Special hospitals

BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7113.949a (Published 11 October 1997) Cite this as: BMJ 1997;315:949

We received three other letters making this point.—Editor

Special hospitals are not prisons…

  1. Jeremy Kenney-Herbert, Consultant forensic psychiatrista,
  2. Martin Humphreys, Senior lecturer in forensic psychiatryb
  1. a Reaside Clinic, Birmingham B45 9BE
  2. b University of Birmingham, Birmingham
  3. c St George's Hospital Medical School, London SW17 0RE

    Editor—Clare Dyer reports on several important issues that are raised when patients discharged by psychiatrists commit a serious offence.1 In referring to the case of Mr Martin Mursell she seems to have confused the very different roles of prisons and special hospitals. Mr Mursell is reported to be “serving a life sentence in Rampton special hospital.” Mr Mursell is a patient in Rampton Hospital under the Mental Health Act 1983. If he was convicted of murder and given a life sentence then he would have been transferred from prison to hospital under sections 47/49 of the Mental Health Act 1983 for treatment, but not to serve a life sentence. When such a patient no longer fulfils criteria for detention in hospital then he or she is returned to prison to serve the remainder of the sentence.

    This point is more than one of mere semantics. Special hospitals are not prisons. They are maximum security psychiatric hospitals. The people receiving care and treatment within them are patients and not inmates, as they are at times called in the media.

    It is important that the general public is not misinformed about the role of special hospitals by receiving wrong messages from the media. Patients admitted to special hospitals should not be unnecessarily stigmatised by the incorrect use of terminology which may have pejorative connotations. In this respect medical journals such as the BMJ have a vital role in using the correct terminology to serve as a model for the general media.


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    …but have a history of problems

    1. Annie Bartlett, Senior lecturer and consultant in forensic psychiatryc
    1. a Reaside Clinic, Birmingham B45 9BE
    2. b University of Birmingham, Birmingham
    3. c St George's Hospital Medical School, London SW17 0RE

      Editor—In her editorial Elaine Murphy blames problems at special hospitals for mentally disordered offenders on the members of the Prison Officers' Association who staff the hospitals; she is not the first to do this.1 The association is an easy and often appropriate target, but it is not the whole problem. The Department of Health has known of problems in patient care in the special hospitals for 20 years (NHS Hospital Advisory Service on Broadmoor Hospital, unpublished data, 1975) but failed to make radical changes until 1989. No bureaucrat seems to have been blamed for this inertia. The isolation of staff and patients has long been recognised, yet the rest of the health service has not rushed to move patients out of the special hospitals. Instead it has been all too happy to have dangerous patients cared for elsewhere.

      Current thinking is to move patients into enlarged, local, medium security units for long stay care. Local high security services have been mooted too. Calls for closure of the special hospitals neglect to address the realities of establishing these services where the “not in my back yard” mentality prevails. Money allocated in the 1970s to medium security units was siphoned off; bed numbers grew painfully slowly. The movement of patients is dependent on local purchasers of health care who may find that there is an uncomfortable shortfall between the money attached to treating particular patients and the cost of local services. Economies of scale seem inevitable.

      We should worry about repeating history. Forensic services alone build new institutions designed, as before, to deal with society's uncertainties about mentally disordered offenders. Local secure services may need to temper their entrepreneurial enthusiasm and ask themselves if they really can provide better care than their equally well intentioned predecessors. For instance, little psychotherapeutic skill exists in medium security units to deal with psychopaths (who are one third of the special hospital population). Attention should be given to whether the beneficial aspects of special hospitals—kitchen gardens, on site education, work experience in bricklaying, and social events—can be created in local secure settings. Long stay patients in medium security units will spend little time, if any, off site; their quality of life is important.

      Vigilance will be required if and when patients are moved into local medium security units. Patients will face risks similar to those they face now; these stem from long length of stay, few community contacts, intractable problems, and the dangers of therapeutic nihilism. They will also face new risks from living on mixed wards. The existence of the Prevention of Professional Abuse Network, a charity that helps patients cope with abuse by therapists, and the long history of inquiries into non-forensic hospitals2 indicates that members of the Prison Officers' Association have no monopoly on inadequate patient care.


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