The future of Britain's high security hospitalsBMJ 1997; 314 doi: http://dx.doi.org/10.1136/bmj.314.7090.1292 (Published 03 May 1997) Cite this as: BMJ 1997;314:1292
The culture and values won't change until the Prison Officers' Association is ousted
- Elaine Murphy, Chairmana
- a City and Hackney Community Health Services Trust, St Leonard's, London N1 5LZ
- Professor Murphy was vice chairman of the Mental Health Act Commission from 1988 to 1994 and a member of the panel of inquiry into events at Ashworth Hospital.2
Until a decade or so ago, the vast majority of mentally disordered offenders who posed a threat to public safety in Britain were consigned to one of the country's three “special hospitals”, Broadmoor, Rampton, and Ashworth (previously Moss Side and Park Lane). This is no longer the case. Most patients on whom a crown court judge has imposed a restriction order (under section 37/41 of the Mental Health Act 1983) are now cared for in regional secure units, general NHS psychiatric inpatient acute units, and independent sector hospitals. These institutions operate far more liberal regimes but with no less safety and without the problems that have dogged the special hospitals. Now that their role is much diminished, do these troubled hospitals have any role in the future of forensic mental health care? And if they do, how can they become clinically excellent institutions?
The special hospitals were run directly by the Home Office and staffed like prisons until 1948. They were then transferred to the Ministry of Health but did not join the new NHS, being managed directly by civil servants. After increasing concern in the late 1980s about standards of care and security, the Special Hospitals Service Authority was established in 1989 to oversee the service at arm's length from the Department of Health. The undersecretary responsible for the service at that time, Cliff Graham, made no secret of his disquiet about the proposed continuation of a centralised management structure, but he felt it was a reasonable interim solution while the hospitals prepared themselves for greater self governance. One of the authority's main problems was to establish management control over a large group of staff that Mr Graham and others perceived to have a damaging influence on standards of care through their rigid, authoritarian, and denigrating attitudes to patients. A widely leaked internal report (the Olliff report, Department of Health, 1988, unpublished) suggested that, unless these staff members could be controlled, the only solution to the persistent problem of poor quality care was rapid closure of all three hospitals.
Ashworth Hospital Inquiry (1992)1 investigated the circumstances surrounding four specimen untoward incidents: a patient's sudden death, an alleged sexual assault by staff on a patient, and serious physical assaults. The events spanned several years. The Panel found:
a culture of denigration of patients
frequent physical and mental bullying of patients by staff
overt racist attitudes and staff membership of right wing, racist political groups
victimisation and bullying of RCN members
poor quality nursing care
frequent use of seclusion as a punishment
a rigid, over restrictive regime
circulation of hate mail and offensive literature to patients and victimised staff
lack of therapeutic optimism, poor clinical team work
The authority was thus to be a transitional body with a maximum life of five years to effect the modernisation of the service and explore the possibility of closing the institutions. In the event, the authority survived seven years, and the hospitals did not close. They finally joined the NHS as three separate health authorities only in April last year. However, a central commissioning role was retained in the form of the High Security Commissioning Board within the Department of Health.
The hospitals' origins within the criminal justice system and their subsequent exclusion from the mainstream of mental health services explain the curious anomaly that their dominant staff union is the Prison Officers' Association. This union, or perhaps more accurately its membership within the hospitals, has played a fundamentally destructive role in the struggle to turn the hospitals into therapeutic institutions. The service has been dogged for 50 years by recurrent scandals pointing to an environment and culture which reflects on the uncaring and demeaning attitude to patients.1 The 1992 Ashworth Hospital inquiry report reflected at length on a regime that seemed to have learnt little from the 1980 Boynton inquiry on conditions at Rampton.2 Biennial reports of the Mental Health Act Commission since 1984 have repeatedly commented on the impoverished regime, overly restrictive and often petty security regulations, the emphasis on mechanical security rather than on the safer strategy of getting to know patients well, and the lack of therapeutic optimism of staff.3
The blame for such conditions has been attributed repeatedly to a core group of members of the Prison Officers' Association which has exercised enormous power. This group has filled the vacuum created as hospital management teams had their authority increasingly undermined and invalidated by senior civil servants and ministers, both in the Home Office and Department of Health, who, in the words of one civil servant, wanted to keep the lid on things. Local managers have repeatedly been prevented from taking the tough measures necessary to root out union ringleaders for fear of provoking industrial action that could then spread to prisons. Latterly, a ministerial culture of obeisance to tabloid press public opinion has added a further unhelpful dimension.4
What those involved find particularly depressing is that heroic attempts have in fact been made in recent years to improve the hospitals; first rate chief executives were appointed, some joint academic appointments have been made, some new ward managers were brought in from outside. Most importantly, the sole negotiating rights on terms and conditions of service held by the Prison Officers' Association were ended, and staff who wished to ally themselves with the quite different culture and values of the Royal College of Nursing and Unison were at last able to sit in at the staff-management negotiating forum. Furthermore, patients' councils have been established in the past five years, and the complaints machinery has improved. There has also been steady, hard won progress towards a 24 hour nursing regime to replace the old 10 hour, night time lock up in single rooms and dangerously claustrophobic dormitories. This has required staff to accept unwelcome major changes to their shift patterns and working practices.
An increasing majority of nursing staff now belong to the Royal College of Nursing or Unison. In Broadmoor in 1988, 800 of the 1200 staff were members of the Prison Officers' Association, compared with 500 today. There remain, however, about 1000 members in the three hospitals, and many staff have dual membership. Working in the special hospitals is highly stressful and occasionally dangerous. The work requires exceptional personal skills and qualities. But the same is true of regional secure units, and indeed the most disturbed and difficult acutely ill offenders are cared for without support from the Prison Officers' Association.
Since the three new authorities were established last year, the new boards have increased their efforts to persuade the Prison Officers' Association to accept a liberalised and safer regime, but the union's response has been, in the words of a senior staff member at Broadmoor, to go back to their old ways. In all three hospitals a hard core of staff–at Broadmoor estimated to be 150 or so–are believed to be behind a new wave of hate mail, intimidation of new staff, victimisation of non-members, and threats to senior managers (a toy grenade was found under a senior executive's car last month). Frank Jordan, the chairman of the union's Broadmoor branch, resigned in late March, it is widely thought because of his lack of sympathy with the old guard and a feeling that he could not oust the troublemakers. There are many decent men and women in the union, but their voices are swamped by the vociferous minority.
The government's 1994 review of high security services concluded that the special hospitals no longer meet future requirements, and a wide range of smaller units providing different styles of care and rehabilitation would be needed.5 Plans for new services for those long term patients who need lesser degrees of security are now well advanced, and the transfer of these patients will leave the hospitals with the most difficult groups to manage. The three new hospital boards have the management talent and imagination to provide a diverse range of improved services for these difficult patients. But they must have the unequivocal support of the NHS Executive and ministers to remove NHS patients from the care of an inappropriate union. Put bluntly, if such a union has a role in a civilised society, it is surely not working in hospitals caring for seriously mentally ill people. The choice is a stark one: either the hospitals must change or they must close completely. Many observers believe that the culture and values will never change until the Prison Officers' Association is ousted. De-recognition of the union's right to negotiate on its members' behalf would be a first step to removing it from the institutions, a move which all the authorities would welcome.
Last year, the three special hospitals' chief executives asked Ken Jarrold, the NHS Executive director responsible for policy on human resources, whether the executive would support de-recognition of the union. Mr Jarrold sympathised but felt that such a move would only be supported by ministers after the election.
The election has come and gone. Let us hope that the new secretary of state for health will have the courage to support such a decision.