§ 9.33 p.m.
§ The Earl of Longford rose to ask Her Majesty's Government whether they are aware of the failure to make progress with the establishment of regional secure units as recommended by the Butler Committee on abnormal offenders.
§ The noble Earl said: My Lords, I beg leave to ask the Unstarred Question standing in my name on the Order Paper. I must begin by thanking the noble Lord, Lord Glenarthur, for handling this debate personally despite the long and arduous duties that he has already performed. I thank also—because I have no right to speak at the end of the debate—all noble Lords who are taking part. I am glad to think that I am followed by the noble Lord, Lord Windlesham, who must be in happy mood. As chairman of the Parole Board the noble Lord is able to point to the fact that he will soon have 2,000 people under his care who otherwise would be in prison. Although credit goes in the first place to the Home Secretary and in the second place to the noble Lord. Lord Windlesham, I think that the All-Party Penal Affairs Group should perhaps also be mentioned in this connection.
§ I am sure that we are all pleased that the noble Lord, Lord Allen, is to speak in this debate. As Permanent Under-Secretary at the Home Office he was intimately concerned with the setting up of the Butler Committee on abnormal offenders. In 1974 that committee produced an interim report calling urgently for the establishment of regional secure units. Its final report appeared in 1975. In the 10 years that have elapsed since then we have seen Labour Governments and Conservative Governments. I am going to dole out my strictures, such as they are, with an impartial hand.
§ My main concern tonight is with the present and the future, rather than the past. I continue to believe that these secure units could not only provide a new and valuable form of treatment for a number of mental offenders and others in like case, but could improve as the experiment develops. Our whole approach to the mentally ill could be improved. I should like to think that our debate would strengthen the hands of those inside and outside official circles who have been pressing, and will continue to press, for a much more rapid development of these units. I hope also that our debate will encourage those dedicated doctors, nurses, and others who are staffing, or are preparing to staff, the units in question.
§ My first task must be to press the Government for a full report on progress. It may be that some of the details may require to be spelt out later in Written Answers. In the spring of 1978 the noble Lord, Lord Allen, initiated a debate on mentally abnormal offenders in which the questions about regional secure units received disappointing answers. I myself reported at that time that I had tried to find even one regional secure unit. I had visited the only one 376 recommended by the ministry, a unit at Knowle Hospital, and found that it was not secure in any ordinary sense. There was no locked door. The patients could leave at any time. One can say that six years ago, four years after the original Butler recommendations, there was no sign of visible progress.
At that time the noble Lord. Lord Wells-Pestell, who played such a distinguished part in our previous debate this afternoon, was a Minister, and he was answering for the Department of Health and Social Security. I quote the following passage from a speech of his:
the report of the Butler Committee on the urgent need for regional secure psychiatric units was accepted by the Government. There is no intention on the part of the Government to put the report conveniently aside and at a suitable moment to torpedo it out of sight. There are reasons why the Government have not made the progress they would have liked to make".—[Official Report, 22/3/78; col. 1849.]
§ I think that to most of us present that seemed an understatement.
§ I should mention here, perhaps, the reasons supplied by the noble Lord, Lord Allen of Abbeydale, at that time for the failure. He said that first there had been staff and trade union difficulties. I encountered those myself when I visited Knowle Hospital. The noble Lord. Lord Allen, went on to say that there had been objections from local residents, and most important, he thought, had been the reservations quite genuinely felt by the psychiatrists themselves. Whatever the causes, the results were plain. They were all too painful.
On 6th May last year the noble Lord, Lord Allen, was at it again. He put this Queston to Her Majesty's Government:
how many places are now available in permanent psychiatric secure units."—[Official Report, 6/5/83; col. 271.]
The information supplied was described, not surprisingly, by the noble Lord, Lord Allen, as disappointing. That, again, was a fairly mild term. Coming nine years after the Butler Committee had submitted an interim report recommending the units, it was a rather deplorable story.
§ The noble Lord, Lord Allen, then asked whether the Government were still committed to an overall figure of 1,000 places in the units in the first instance. He asked when did the Minister think that the programme would be achieved. The noble Lord, Lord Trefgarne, then the Minister involved, replied that the Government were still committed in principle to achieving 1,000 places in regional secure units. He hoped that by the end of 1985, 11 years after the original recommendation, about 600 places would be available in such units.
§ On 7th March this year Mr. Austin Mitchell asked the Secretary of State to publish the number and location of regional secure units planned and in the course of construction. That was a wider question than that asked by the noble Lord, Lord Allen, in the previous year. The answer given in the Official Report mentioned 14 such units, but it would seem that a few months ago, in March of this year, only half a dozen of those had become operational. The Minister will put me right there, as he will have the latest information, but reading the answer given in March, it would 377 seem that the permanent facilities were not being made use of by more than 200 patients; but the Minister may have a better tale than that to tell in July.
§ I can assure him that no one would be happier than I if he can demonstrate to us that at last things are really moving—much better later than never. Perhaps the Minister will tell us whether the difficulties about which we heard from the noble Lord, Lord Allen, and others in 1978 have been overcome? What is the attitude of the trade unions and the shop stewards today?
§ I was told when I visited the secure unit at Rainhill, Merseyside, that the interim unit, which was superseded by a permanent unit last autumn, had been blacked until them, but I was told that the relationship with the trade unions now seemed to he satisfactory. At Runwell Hospital, near Southend, I was told that there had been no trouble of this kind. The fact that the hospital was local as distinct from regional was thought to be part of the explanation. No doubt the Minister will tell us how far difficulties with the trade unions are holding matters up.
Although I have given the Minister notice, I have not given him much notice, that I will refer but briefly to an article that appeared in the Sunday Times on 3rd June by a gentleman called Mr. Brian Deer. It was quite a thorough article. It begins in this way:
The most ambitious project ever devised in Britain to prevent mentally ill patients from being detained needlessly in top-security hospitals and prisons is in risk of collapse because health authorities say they do not have the money to run them.
That would seem to imply that the Government were at fault. But in the same article Mr. Kenneth Clarke, the health Minister, is reported as accusing health authorities of,
diverting money for secure units into other projects".
I hope that when the Minister replies he will tell us how far it is true that the cuts imposed by the present Government are holding matters up and how far it is the fault of the health authorities by diverting money to other projects.
§ The issue here is not merely quantitative. I hope that the Minister will take the opportunity today to tell us what the Government have in mind when they say that they are in favour of regional secure units. That phrase is a hit of an incantation. It is high time that the Government restated their true objective. The matter cannot be settled today in 1984 by reference to the Butler Committee. We want to know what today in 1984 is considered to be the point and purpose of regional secure units by Her Majesty's Government. After all, these units, quite correctly, are relatively expensive. The staffing ratio is high: two nurses to every patient, which seems to be the accepted proportion. It is difficult to make an exact comparison with special hospitals but it is a very much higher ratio of nurses to patients than special hospitals can provide. The cost per patient seems to be between £600 and £700 a week, but for that money one could go to any private nursing home outside the top bracket.
§ One great merit of these units is the specialist staff. There is an additional training for all nurses who work in them. There is no doubt that the results in these imaginative units should be better than those in the 378 average mental or special hospital. It is too early to say that this has already been demonstrated; there has not been enough experience but I am confident that as time goes on it will be. But we, the general public, are entitled to ask what are the aspirations of the Government? When the economic difficulties and any problems with staff and psychiatrists have been overcome, where do they hope this great experiment will finish?
§ I gathered recently from visiting two of these units that a wider measure of autonomy is conceded to the regions. In fact, I am under the impression that marked variations between one region and another are already evident. I do not say that that is wrong. If we see the present stage as one of experiment, as indeed I do, it may be that we shall learn more by studying a number of different approaches than if there were some monolithic arrangement. I will mention one or two topics and ask whether the Minister has any guidance to offer.
§ Who do we think ought to be treated in these units? In Rainhill, Merseyside, I was told that 90 per cent. of the patients came from the courts in one way or another. They could be called forensic patients. The other 10 per cent. had probably at some time been in trouble with the law. However, at Runwell Hospital near Southend, 10 out of 24 patients in secure conditions were forensic and 14 were non-forensic. I do not say that Rainhill is necessarily right and Runwell wrong or vice-versa. These represent completely different compositions. Incidentally, I may say in passing, for perhaps it is just worth mentioning, there were vacancies at Runwell in the section reserved for women. It may mean that women are not coming forward or proving to be quite the people required to the extent expected.
§ The staff at Rainhill were proud, and, I am sure, justly proud, of their dynamic approach. The average time spent by a patient in the unit is something like nine months. From the beginning, the patient is made to be aware of a movement forward towards freedom in contrast with what is sometimes referred to as the more static atmosphere of a special hospital. At Runwell, there is less emphasis on a fixed period. Some patients may come for a few days only; others may expect to stay almost indefinitely. As the number of units increases, we may expect to see an increase in these variations.
§ On all sides—and here, I am sure, there is unanimity—it is stressed that there has been a lot of fresh thinking on all these matters since the publication of the Butler Report. Much emphasis is laid by everyone on the need to see these units not in isolation but as part of an elaborate network of services affecting offenders and non-offenders alike. When I visited Rainhill, for example, a probation officer was present who provides liaison with former patients who are now being looked after in the community. At Runwell, there are 24 secure places but 18 other places were treated as a kind of back-up for the patients on their way to the community. Here, as at Rainhill, much contact is preserved with patients after they leave the hospital.
§ At Rainhill and at Runwell, as, I am sure, with other units as they develop, progress is intended to be continuous. If all goes well, at a certain point the 379 patient will be allowed parole and will be allowed to go shopping on his or her own. I take it that all such developments are approved by the Minister and his advisers.
§ My Lords, I must come to an end, but cannot do so without paying my tribute to the enthusiasm, confidence and pioneering spirit that I found among the staff in the units that I visited. They deserve to succeed. They will succeed. They have chosen a very difficult but infinitely rewarding vocation. They have devoted their lives to the care and treatment of a large number of afflicted human beings on the borderline between sin and sickness. From the conversations that I had with patients in the two units I visited, I feel confident that the efforts of doctors and staff are truly appreciated. But the Government have still a large responsibility. I hope and believe that the Minister will discharge some part of it at least by what he tells us this evening.
§ 9.49 p.m.
§ Lord Windlesham
My Lords, I welcome the noble Earl's initiative in putting down his Unstarred Question for debate this evening. There may not be, at this hour, many people in the Chamber but there is no doubt that a debate of this kind in your Lordships' House does have the effect he is seeking in supporting and encouraging the very important work that is taking place in the penal system or in the hospitals. I should also like to thank him for his generous reference to me at the start of his remarks.
The mentally abnormal offender, the disordered offender, as he tends to be called now, who was the subject of the Butler report a decade ago, tends to fall into a no man's land lying between the special hospitals, the open psychiatric hospitals and, only too often, the prisons. It is difficult to decide in many cases whether such people will respond to treatment or not. Each case has to be considered individually, as has the degree of security that is necessary for the protection of the public. Just how many men and women in prison are mentally disordered, whether or not their state constitutes actual mental illness, nobody knows. But anyone familiar with the penal system can be in no doubt that there are considerable numbers of people in prison who would be much better off in hospital.
Here I should declare an interest: I am chairman of the Parole Board, although I have no direct responsibility for mentally disordered offenders inside or outside the prisons. However, I am naturally—as many others who are aware of the situation—deeply concerned about those offenders who are recognised by the courts as being mentally ill and needing treatment, but who are sent to prison because there is nowhere else for them to go.
The power to transfer an inmate, once he is there, from prison to hospital already exists, providing certain conditions are fulfilled. But the problem has been to find a hospital that will take a mentally ill offender. The reluctance of many hospitals and some doctors to receive such patients is quite understandable. They tend to be highly disruptive and on occasion can present a threat to other patients and 380 to the staff. They are rarely welcomed in ordinary psychiatric wards and in any event some form of secure provision is essential. Until comparatively recently, with the opening of small secure units on an interim basis in most of the regions, the problem had got worse since Lord Butler reported in 1974. The addition of a fourth special hospital has relieved the pressure of numbers, and the disgraceful overcrowding, to which Lord Butler and his colleagues referred, in the special hospitals. On the other hand, the consequence of the "open-door" policy in psychiatric hospitals, desirable as it may be in itself, has led inevitably to a marked reduction in the number of locked wards. As a result, the courts have sometimes had no alternative but to sentence mentally ill offenders to imprisonment because no hospital place is available. Once in prison, they have usually been denied the treatment that they require, as well as affording a great deal of difficulty to an already overstretched prison service.
So that is a pretty black picture. But for once, my Lords, it is a problem with a solution; only a partial solution, it is true, but a solution which is now in sight. Painfully slow as it has been, the establishment of the secure units in most regional health authorities represents an important step forward, as the noble Earl. Lord Longford, recognised in his own speech. We cannot tell whether the scale will be adequate but, where they exist, the facilities, the treatment. and the approach all seem to me to be admirable. From inquiries I have made as to the extent of the current provision, the general picture seems to be that there are six permanent regional secure units providing a total of 216 places that are now open, with a further two units which have been completed but are not yet open. These contain 68 places. Four regional secure units providing another 249 places are under construction, with four more permanent units planned. These will provide an additional 175 places. All in all, there should he provision in regional secure units for up to some 500 or so patients by the end of 1984 or early next year, rising to 650 in 1986–87.
I shall look forward with interest to what the noble Lord, Lord Glenarthur, has to say about these figures, particularly as they fall short of the target of 1,000 that the noble Earl mentioned earlier. I, too, understand that, because of staffing and other difficulties, not all the places that have been completed are in fact in use. In the meantime, several interim secure units have been established in converted existing accommodation: and these are likely to be replaced when the new purpose-built units are completed and brought into use.
It was one of these interim units, located in Ealing, which I visited in preparation for this debate. I was greatly encouraged by what I saw. In a small but well laid-out unit of 14 beds, there was an effective but not unduly obtrusive standard of physical security. The medical and nursing staff seemed to be keen and enthusiastic, with a high nurse-to-patient ratio. Each patient—both men and women—in the unit had a single bedroom with excellent toilet and recreational facilities. When we reflect that some of the patients in a unit such as this come (and in the future, we must hope, will increasingly come) from prison, the contrast is with a completely different world.
381 The Minister, the noble Lord, Lord Glenarthur, who is to reply to this debate tonight, and I both heard the most reverend Primate, the Archbishop of Canterbury, in another context say yesterday that he has learnt to judge most of the institutions that he visits fairly quickly by their atmosphere. That struck me as a very true remark; and at St Bernard's Wing of the Ealing Hospital the atmosphere was encouraging and positive. The staff are well aware that they have a difficult but immensely worthwhile task to do, and they gave every evidence of relishing the opportunities.
Of course the regional secure units, even if and when the programme is complete, cannot solve all of the problems of mentally disordered offenders who are imprisoned. Nevertheless, for the first time in my experience I left a mental hospital uplifted rather than downcast in spirit.
Let me end by asking the Minister two questions: one on an important matter of policy, and the other on a more detailed point. Is it anticipated that virtually all the places in the regional secure units, initially at any rate, will be taken up by patients, whether received from the courts or from special hospitals or from prisons, who have committed criminal offences in the past and who continue to be a danger to others; or, if only a proportion of the patients in these units are to be offenders, what proportion is that likely to be?
I submit that the first priority should be given to mentally ill offenders, to people who have been in front of the courts and who have been found to require treatment and are expected to respond to it. They can only receive treatment in a secure environment. I believe their need is greater than that of long-stay patients, who are less susceptible to treatment, or of non-offenders, who should receive treatment in psychiatric hospitals within the National Health Service, with whatever degree of security is appropriate to their condition. I recognise that that is easier to say than to do, but in the case of the convicted offender there is no choice. It has to be either a special hospital or a prison or a regional secure unit. Those of your Lordships who have seen the conditions in prisons in which mentally disordered patients needing treatment are confined will, I feel sure, understand why I wish to see that particular group of people given priority.
The second question is this. When is it intended to give effect to the new powers contained in the Mental Health Act 1983 which allow a court to remand an accused person to hospital for a report on his mental state or for a period of treatment? Until now, a court has had the power only to remand in custody or on bail. When this provision is brought into effect it will be a useful additional power for the courts. I believe the courts will make good use of it. There is little doubt that a number of judges in the Crown Courts as well as magistrates should welcome it, and I hope that the regional secure units will co-operate in receiving mentally disordered persons who have appeared before the courts and have been remanded to hospital for reports.
The delays in implementing this programme have undoubtedly been deplorable, whatever the reason. The obstacles have not yet been overcome. Staffing shortages, the attitudes of regional health authorities 382 and some doctors, health service union disputes and other factors, itemised by the noble Earl, Lord Longford, all remain to be resolved. But, that said, slowly and arduously, a new development of fundamental importance is taking shape. It is one which can have a significant impact on the penal system of Britain, where real improvements in standards are few and far between.
§ 10.3 p.m.
§ Baroness Robson of Kiddington
My Lords, I should like to join in thanking the noble Earl, Lord Longford, for introducing this debate tonight. Before coming to the House I, too, armed myself with some statistics obtained from the Department of Health. They relate to October of last year, so I was delighted to hear from the noble Lord, Lord Windlesham, that the situation as it now exists is an improvement on the figures that I have.
Out of the 1,000 places planned in the country, in October 294 had been built and created. That appeared to me quite cheering when I first looked at it, because it was an improvement on the position as, I had known it before. But when you start to read down the notes in the margin against the places that are built and ready, you find that in October of last year only 145 of them were staffed and occupied. Inevitably, one of the tragedies is that the revenue allocations to regional health authorities in support of the regional secure units have been such that they are unable to staff them. In my experience, the main difficulty is not that of finding staff: the main difficulty is the lack of revenue.
A lot of the blame for the slowness of the development of regional secure units is frequently put at the door of regional health authorities themselves. It is often said that they are not totally convinced that these units are necessary. I believe that that is unfair, and I should like to use the few minutes at my disposal to give an example of the development that took place in the region of which I was chairman until 1982.
When the announcement first came that the Department of Health and Social Security were finally prepared to set aside special funding for the regional secure units, that announcement was welcomed within my region and. I believe, in most regions. As has already been said, at that time the psychiatric services in every region followed generally the open door policy. It was therefore almost impossible for the regional authorities to provide a place for the mentally ill offender. I can remember vividly my regional medical officer sitting up late in the evening ringing one hospital after another trying to find a place for a mentally ill offender for whom the court had told us we had to find a hospital place. So it was obviously with enthusiasm that the regions received the allocation of special funds for the creation of regional secure units.
In my own region, we immediately set up a working party. We looked through the region and we found one hospital, the Royal Earlswood Hospital, where we believed that we could provide the secure beds that it was our responsibility within our region to provide. We went through all the planning procedure and through all the consultation with the local residents, and throughout we kept the Department of Health and 383 Social Security informed about what we were doing. It culminated in a submission to the Secretary of State for a go-ahead.
Early in 1979, when we felt that we had achieved the right answer and that any day the go-ahead would be given by the Secretary of State, to our horror we were told that it was refused. We were given two reasons why it was refused. One was that it was felt to be inappropriate to have within the same unit, although properly divided, psychiatrically ill patients and mentally handicapped patients. There may have been something in that, but our proposal entailed a complete division between the two types of patients. We were also given the answer that one of the health service unions, COHSE, was on the point of producing a report on the treatment of psychiatric offenders, and that therefore it would he preferable not to go ahead with our development. That was obviously a great disappointment after all the work that had gone into planning the scheme.
In retrospect, it may have been a good thing that we did not go ahead quite as quickly with that unit, because the creation of one large regional secure unit in virtual isolation from the rest of the psychiatric service in the region could have run the risk of labelling the patients as "impossible", and might just have created a special group of forensic patients in mini-special hospitals not too different from Broadmoor in the minds of most people outside.
As a result of the refusal to proceed, the region had to rethink its policies in order to cope with its responsibilities towards these special patients. This resulted in a decision to develop a much smaller regional secure unit at Netherne Hospital with about 25 beds, and at the same time create secure wards or, if you like, interim units in some psychiatric hospitals on a district basis.
The advantage of such a scheme is that the regional secure unit does not become isolated but becomes an integral part of the psychiatric services of the region. The unit then becomes an assessment unit as well as a short-term secure unit aimed at integrating patients into the full psychiatric services of the region, with the aim of the movement of patients from the regional secure unit to normal psychiatric hospitals, and finally back again into the community.
I have become convinced that the regional secure unit itself must not be too large and that the integration of the service between the psychiatric hospitals and the hospitals for the mentally handicapped, and the creation of a limited amount of secure accommodation in those hospitals, will provide a better service. I believe that many regions in England are thinking along those lines today.
I should like a statement from the Government as to whether they are still wedded to the rather larger regional secure units or whether they accept that a more integrated system is preferable. I look forward very much to hearing what the Minister has to say about those alternatives.
§ 10.13 p.m.
§ Lord Allen of Abbeydale
My Lords, like the previous speakers, I am most grateful to the noble Earl 384 for giving us this fresh opportunity to discuss this important subject which, unlike the subject we discussed earlier, is apparently one in which the voice of the Cross-Bencher can appropriately be heard. I am bound to say that the history of this subject does not make it one of the most glorious chapters in our island's story. It is certainly a topic that seems to benefit from parliamentary stimulus from time to time.
I agree with the noble Earl that not very much is to be gained by going into detail about the lamentable earlier history, and that it will be more profitable to consider where we go from now on. All the same, I am bound to say that it is quite distressing to recall that a working party in the old Ministry of Health recommended as long ago as 1960 the setting up of secure units. The department commended that proposal, but nothing happened, with the single possible exception of one faltering experiment which turned itself into a specialised adolescent unit.
I cannot deny that I then had some personal involvement with the setting up of the Butler Committee, and though I had left public service quite soon after. I was not all that surprised when the committee submitted their interim report, to which reference has been made, proposing as a matter of great urgency the setting up of secure units to provide 2,000 beds, so as to fill the yawning gap between the overcrowded special hospitals and the open-door policies of the ordinary psychiatric hospitals. That is the second yawning gap of which we have heard today. We shall discuss how far progress has been made in filling that gap.
It is, incidentally, a matter of some mild interest that in these days of enhanced prices of Government publications, that report of the Butler Committee cost a modest 14p.
Once again the recommendation was accepted and this time money was promised for staff and buildings—and once again for years nothing happened. It was an issue on which the late Lord Butler felt very deeply, and one of his very last appearances in this Chamber was when he came, at some personal inconvenience, to support a question asking about the lack of progress.
There are certainly signs that things are at last on the move. I am bound to say—even if this sounds a bit carping—that progress never quite seems to keep up with the forecasts held out to us. I leave aside any discussion of the interim arrangements, apart from saying that the rather glowing account given by the noble Lord, Lord Windlesham, makes one regret all the more the delays in getting the programme under way.
The list of regional projects for permanent units listed in Mr. Patten's reply in another place (to which the noble Earl referred) shows that there are plans for a sizeable total of beds. According to that reply—and so far as I know this is the latest information given to Parliament, whatever other estimates have been given to noble Lords, or whatever the noble Baroness may know about—there do not seem to be all that many actually in use. We were told that in March there were four purpose-built units open and that on 30th September 1983—which seems to be the last date for 385 which figures were available—there were 75 beds available in those four units. What we were not told is whether or not all 75 beds were occupied, or whether or not there were problems of being unable to use them due to lack of staff or staff disputes for one reason or another. No doubt there has been progress since March and the noble Lord the Minister will be able to give us complete figures when he comes to reply. But figures are by no means the end of the story. Various references have been made to staffing problems. I go along with those, but I say that it would be helpful to know whether or not there are problems regarding recruitment, union disputes, and so forth.
What about training? It would be interesting to know what training is provided in handling disturbed behaviour—an art which for understandable reasons has tended to die out in the ordinary hospitals. Who arranges that training? In running the units, are educational and work facilities provided, as recommended by the Butler Committee? Are the units used, or are they planned to be used, for assessment purposes, and are staff provided accordingly?
I take it, incidentally, that the new Mental Health Act Commission will in due course be addressing itself to the operation of these units, but I imagine it has had its hands full and has not yet been able to get round to these units in any detail.
I do go along with the thought that the most important question is whether the Government themselves are quite clear as to the purposes to be served by these units and whether the profession and those responsible for running the units are themselves fully aware of what the Government consider those purposes to be. The number of patients is so small, so far, that it is obviously premature to come to any overall judgment. For example, there has been no effect at all yet on the population of Broadmoor, but there are some slightly disquieting pieces of evidence.
In the Parliamentary reply by Mr. Patten which was referred to, it was stated that in the Oxford region planning was proceeding for a 20-bed unit but the hospital hoard, it was said, was reassessing policy on security for mentally ill people in the light of its strategic shift towards community based services. One wonders, just what does that mean? Is there a national Government policy to press on with secure units or not? If there is can a region, if it wishes, opt out, as it were, from Government policy? How far is this policy of local experiment to go?
This question of admissions, to which reference has been made, is pretty crucial. The Butler Committee itself, if one looks back at the interim report, thought from the outset that the units should have a mixture of offenders and non-offenders, but, having regard to what the noble Earl and the noble Lord, Lord Windlesham, have said, may I ask whether there is any national policy and are guidelines laid down as to how this mix should best be achieved if, indeed, it is policy to have such a mix? As regards admissions generally, I think it is not unfair to say that the 1980 report of the Royal College of Psychiatrists found it a good deal easier to say which patients would not be suitable, rather than to say exactly which patients should be admitted.
386 We have heard quite a bit about differing practices in the different units. For my part, I understand that some of them have already adopted the policy that they will refuse admission to anyone thought likely to need more than a year's treatment; whereas I recall that, in an address which the noble Lord, Lord Trefgarne, gave to a symposium in Chester last year, he referred to an important part of the unit's role as bringing together patients who may be amenable to 18 months to two years of specialist treatment. One is bound to ask: who is right? Who finally determines the policy, whatever it may be? Here again, what are the limits within which local experiments can be made? On other aspects, is there any central guidance about involving the local social services department and the probation service and, indeed, about involving the local community whether through a league of friends or a visiting committee, or whatever?
In conclusion, I just say this. I think that the main danger, which must somehow or other be avoided, is that of treating these units as isolated institutions outside the main stream of psychiatric treatment. It seems to me that they must rather be looked on as providing their own specialised contribution to the whole range of facilities for dealing with one of the most difficult problems facing our society. We shall be in a pretty sorry state unless there is a clear concept of how each part of the pattern fits together—the special hospitals, the ordinary NHS hospitals, the prisons, the community services and now the regional secure units. I am among those who wait with great interest to hear how the Government see that last element fitting into the continuum of care.
§ 10.25 p.m.
§ Baroness Masham of Ilton
My Lords, I too add my thanks to the noble Earl. I would just like to say that it is a great pleasure to follow my noble friend Lord Allen of Abbeydale. He and I are the only two Cross-Bench Peers who have spoken the whole day. I have a feeling that the House would not want me to speak for long; it has had a long working day. But as I come from the North I just wanted to say a few words.
Credit should be given where credit is due. The Northern Region went ahead of all the other regions and established the first secure unit. This is in the grounds of St. Luke's Hospital in Middlesbrough. I have spent a day at that unit. As the regional health authorities were supposed—as the noble Earl's Question states—to establish those units, the Northern Region should be congratulated on obeying the instructions that all regions were given.
There is no doubt that some of the units have many problems that have to be overcome or lived with. They are very expensive to run. They are a combination of a prison and a hospital unit within a hospital. Other hospital staff may look at the unit with suspicion. Because it is such a secure unit with double locked gates, the staff within the unit could become isolated from other hospital staff. Within the units there is a very high ratio of staff to patients. Because patients and staff live at very close quarters, it is important that the selection of staff should be carefully considered. I would say that, unless there is a very good team approach and compatibility among staff, there might be problems.
387 The more secure the units are the more rehabilitation is required to get the patients back into a normal environment and eventually back into society. Are not the units meant as short-term and assessment units? May I ask the Minister how long patients are meant to reside in those very close quarters? Many of them are difficult patients to place. May there not be a tendency to leave them there for years and thus block the beds for other patients who might benefit from an intensive, well staffed programme?
This year I visited St. Andrew's Hospital, Northampton. That is an independent hospital, set in large spacious grounds. For years that hospital has taken, on a contractual basis, difficult patients from many regions. I tried to ascertain why it had coped where other hospitals had not. One reason may be the high ratio of staff to patients. The secure units have that too. But the other reason may be a reward system for patients. Has the NHS studied that means?
The Yorkshire Region is about to open its secure unit at Wakefield. The hold-up has been staff negotiations. I think it is important to look very carefully at the existing units to monitor the successes and failures, to learn from the mistakes and be sure that there are plenty of recreation and therapy facilities. These were inadequate at the St. Luke's unit.
These are difficult patients. Many of them are young. One should hope that assessment and short-term treatment will be the main aim, so that the stay in these units will not be for too long.
All penal institutions have a board of visitors. I wonder whether these secure units should not have attached to them a board comprised of a few interested lay people who would be seen and would represent the interests of the patients and those of the unit, which I feel will need some outside representation. Community health councillors do not have the time and are not so closely attached to individual units as are boards of visitors. I would ask the DHSS to look into this. It must not be forgotten that these are special units with very special problems. They need a great deal not only of monetary but also of moral support.
I hope the Minister, after his long hours in this Chamber, will be able to answer some of our questions, the main ones being approximately how long patients should stay and which patients qualify for treatment in these secure units.
§ 10.32 p.m.
§ Lord Prys-Davies
My Lords, the House, as well as the disturbed or dangerous mentally disordered offender, and possibly the non-offender, who could benefit from psychiatric treatment in hospital, owe a debt of gratitude to the noble Earl, Lord Longford, for initiating this important debate. The noble Earl has explained the concern about the future, which prompted him to initiate the debate. His concern has been echoed by every other speaker. We believe that concern to be well-founded.
The position of this relatively small group of unfortunate patients is quite unacceptable. Moreover, they are patients who do not, by the nature of their affliction, generate a sympathetic response from the 388 community at large, particularly when NHS funds are under pressure.
The noble Lord, Lord Allen of Abbeydale, has outlined the deplorable record of the last decade. Ten years have gone by since the powerful Butler Committee recommendation that there be 2,000 beds in secure units. That recommendation was accepted 10 years ago. The Government of the day committed themselves to the provision of a minimum of 1,000 beds. But, as at 30th September of last year, the total number of permanent places staffed and available—though I am not quite sure whether that term means that they are fully operational—in the 14 regions of England was 87. In addition, there were six or 10 places available in Wales. So progress, in the words of the noble Lord, Lord Windlesham, has been painfully slow.
The provision of the secure units is clearly a regional planning issue in England and a Welsh Office planning issue in Wales. Central Government departments may say that the regions or the health authorities have fallen down on their task. It is equally arguable that central Government have also fallen down on their task.
I take the point made by the noble Baroness, Lady Robson, that there is some evidence that some dedicated doctors and staff in some districts are, in retrospect, possibly gratified that it has not been possible for their districts to move forward faster, and that, meanwhile, important lessons have been learnt through trial and error. But, on the other hand, it is difficult to resist the conclusion that some of the health authorities may have lacked the necessary enthusiasm, or awareness of what can and should be done, and that the central departments have not been exercising their role in a sufficiently positive way to ensure the provision of the facilities along the lines recommended by the Butler Committee and modified in the light of experience.
The noble Lord, Lord Allen of Abbeydale, has already referred to the important statement by the Under-Secretary of State for Health and Social Security in the other place on 7th March. The information in that statement referred to the position as at 30th September. According to those statistics, 284 beds had been provided, 209 beds were under construction, tenders for 40 beds were under consideration, and planning was proceeding for 165 beds. When this programme is completed, whenever that may be, there will be about 700 beds available. I say "whenever that may be" because it is possible, on the evidence of a Welsh Office consultative paper, issued about a fortnight ago, that some of the beds would not be available until the eighth year from now. The Welsh Office consultative paper, issued on 14th June, relates to 60 new places in secure units to be planned and made available in Wales. But it acknowledges that half of those places, which have been talked about at this stage, will not be available until the eighth year after the decision to proceed is taken.
Another question has to be asked. Even when the beds are available, how soon will it be before they are fully operational? Again, the noble Lord, Lord Allen, has underlined the significance of the Under-Secretary of State's statement on 7th March. I am sorry if I 389 appear to be descending into details, but I think that the details are important. Only the 10-bed Runwell unit has been described as being fully operational. Of the 30 beds in Middlesbrough, only 20 were staffed and available. Perhaps the Minister will explain the distinction between the term "fully operational" and the beds being "staffed and available". Of 60 beds at the Towers Hospital, Leicester, only 15 were staffed and available. Of 30 beds at the Langdon Hospital, Dawlish, only 10 were staffed and available. Of 50 beds at Rainhill Hospital, only 30 were staffed and available. In other words, of the 180 places described as being available, just over half are not staffed.
These occupancy figures demonstrate that there are difficulties in getting the units operational. Reference has been made to the difficulties. We have been told that there has been community resistance in some areas, union resistance, difficulties in training or recruiting trained staff, and possible clinical disagreement locally about the criteria for admission or about management. There may also be administrative inertia. The House, I am sure, will want to know whether the departments, after the experience of the last few years with interim units and permanent units, have now identified the problems that appear to have plagued the units. Have they found ways of resolving them? If the problems have not been identified correctly, and if they have not been resolved, they will continue to obstruct, inhibit, or even prevent progress.
We wish also to have more information, though not necessarily tonight, about the units which are described as being fully operational. How many patients are admitted in a year? What has been their average length of stay? Again, the question has been asked: what percentage of the patients who have been admitted are offenders, and what percentage are non-offenders? How many patients have passed in progressive steps from the units into the community, freedom and normal existence? Those are questions which have been raised this evening by a number of noble Lords.
We want more rapid progress with the implementation of the policy, if there is a commitment, a continuing commitment, to it. We should be mindful that the consequence of not having psychiatric secure units is that people who are in need of treatment are detained in prison. Some patients who are in special hospitals could be transferred to such units and so ease the conditions in the special hospitals. The courts are unable to make appropriate hospital orders and have become increasingly impatient.
As we have said, the position is unacceptable and worrying. Therefore, in the short term specific action is expected of the departments. It is for consideration whether the DHSS and the Welsh Office should establish a task force or a catalyst group (call it what you may) within the departments, with special responsibility for monitoring closely the progress towards establishing permanent regional secure units, to consider, discuss and promote possible ways in which the establishment of the units can be speeded up substantially, and to monitor the operation of the units, once established, including the extent to which prisons and special hospitals could transfer offenders 390 to the units. I should be grateful if the department could consider the desirability of setting up such catalyst groups at the DHSS and the Welsh Office.
§ 10.43 p.m.
§ Lord Glenarthur
My Lords, I should like to thank the noble Earl for raising this important issue, and to assure him that the Government are fully committed to the RSU programme. The establishment of a network of regional secure units is an integral part of a comprehensive range of services for care and treatment and it should not be seen in isolation from the mainstream of psychiatric care.
I think your Lordships might find it helpful if I put the regional secure unit programme in a national context. We have heard tonight quite a lot of statistics and figures, and at this hour even I am getting slightly confused, having already had quite a lot today. But the position nationally is that six permanent RSUs are now open and two further units are completed though not yet open; but they will open later this year. Three permanent RSUs and a five-unit multi-site scheme are under construction. All but one of these are expected to be complete this year, and, in addition, four more permanent RSUs are at various planning stages. The six that are open, when fully staffed, will provide 216 places. The places are being brought into use on a phased basis, and I think that that is an important point to bear in mind when we talk about staffing versus availability. I understand that currently 100 beds are staffed and available for use.
So far as concerns the noble Earl's suggestion that lack of co-operation could be delaying the establishment or staffing of RSUs, I can say that that is not the case. There might have been some difficulties in the past, but these were general difficulties with unions in mental hospitals receiving difficult patients.
I also said, I think, that two further units were completed but not yet open. Both are expected to admit their first patients during this year. In order to get the statistics right, perhaps I should add for the benefit of the noble Baroness, Lady Robson, that the latest available information is, as I have said, that 100 beds in six permanent RSUs are staffed and available. So far as timing on the 100-bed unit at Rubery Hill, Birmingham, is concerned, it has slipped. The region's present plans suggest that by the end of 1985 about 500 places countrywide in 14 permanent units will be available; by the end of 1986 about 580 beds are planned to be available; and more beds will become available in 1987 and later years. I shall of course check those statistics—we have heard quite a lot of them bandied about this evening—and if I have been in any way inaccurate I shall let your Lordships know.
I am well aware that there has been widespread criticism about delays in establishing RSUs; that there have been allegations that the Government's attitude towards them is lukewarm, and that resources set aside have not been properly used by some health authorities. I want to say a few words about those criticisms and perhaps dispel some of the myths which have arisen, but I should first like to say how we see RSUs fitting into the rest of the psychiatric service.
As I mentioned earlier, our aim with the programme of regional secure units is to form part of 391 a comprehensive service. This consists of community services, including, for example, primary care, inpatient care in a variety of settings, regional secure units and special hospitals. They are all inter-related and inter-dependent. It is essential that regional secure units should not be seen and treated as isolated units outside the main stream of psychiatry, and I hope that that reassures the noble Lord, Lord Allen of Abbeydale. This is, to a certain extent, what happened in the past to the special hospitals. It resulted in unnecessary difficulties in placing patients in facilities that met their current needs, and it also created gaps in the system instead of continuity.
First, there is the question of delay. We and our predecessors have been criticised about the rather long-drawn-out timescale of this operation. My noble friend Lord Windlesham described it as painfully slow. Local anxieties have given rise to opposition in places, and this, in turn, has led to delays. But RSUs were a new concept, and detailed discussions have been needed with health authorities, and by them with professions, staff, other statutory bodies and the public. Services for mentally disordered people are, regrettably, not among the most popular, not necessarily because it is a time of tight resources—as the noble Lord, Lord Prys-Davies, seemed to suggest—in every case. Facilities for those who may have offended and come before the courts are even less popular. It is not surprising that people need reassurance, and that they are anxious and sometimes hostile about the setting up of a secure unit near to their homes, especially when confronted with some of the rather misleading articles and headlines they see in the press. If the price of obtaining local understanding and agreement is a certain delay, it is a price worth paying, particularly if the community can later adopt the very important supportive role for the unit.
There is undoubtedly an urgent need for regional secure units—no one would deny that. Ever since the inception of the National Health Service it has been part of its responsibility to provide facilities to treat all types of patient with mental disorder. But with the advent of the "open door" philosophy, to which my noble friend Lord Windlesham also referred, in some psychiatric hospitals and the emergence of district general hospital psychiatric departments, it became increasingly difficult for the National Health Service to care for some patients. It is against the interests of patients who do not need the high security of a special hospital to place them there; and the overcrowding if we did would be against the interests of the special hospital patients who do, unfortunately, need to be there.
Secondly, as the noble Earl, Lord Longford, said, health authorities have been criticised for not using the whole of the RSU revenue allocations for the RSU programme. Ministers have been criticised for not directing them to do so. Let me put the record straight: these allocations were set aside from funds voted for health services: the money is therefore NHS money and not a new source of funds; if it had not been set aside in this way it would have gone to the NHS anyway. So where health authorities have not been able to use all of it on secure facilities they have been encouraged to use it on psychiatric services generally. I am pleased to say that returns from regional health 392 authorities show that practically all these revenue allocations are now being used on psychiatric services and an increasing and substantial proportion on secure facilities as these are brought into use.
In the meantime, until permanent regional secure units become operational throughout the country, regional health authorities have been asked to designate particular hospitals to provide treatment and facilities in conditions of security. A range of facilities has been developed, including the provision of designated interim secure units in which about 300 places are currently available as well as over 900 beds in other types of secure facilities, including special care wards.
So far as finance for RSUs is concerned, between 1976–77 and 1983–84 regional health authorities received over £66 million central revenue support as a contribution towards the running costs of regional secure units and interim secure facilities: nearly £12 million has been made available for 1984–85.
The noble Earl, Lord Longford, referred to the Sunday Times article and the use to which RSU revenue is put. Since 1976 the Department has identified a special recurring amount in RHAs' general revenue allocations for the funding of the revenue costs of RSUs and of the interim secure facilities pending the establishment of RSUs. The RSU revenue allocation is derived from general funds voted from the National Health Service, but it was always recognised that RHAs might not be able to spend the whole of this amount on secure facilities.
After a slow take-up in the first year the proportion spent on psychiatric services rose from over 60 per cent. in 1977–78 to 90 per cent. in 1982–83, and the proportion spent on secure facilities also rose steadily and in 1982–83 was 60 per cent. Department officials are currently trawling regional health authorities on the use to which the 1983–84 revenue allocations were put. The decision in 1976 to leave the revenue funds within the general allocation was taken in order to avoid money being lost to the health service when local delays, such as adverse decisions by planning authorities, prevented the expansion that was intended. Moreover, some health authorities have also been putting to one side, and carrying forward, some of their revenue to be used when their permanent units begin to operate. I hope that answers some of the noble Earl's points about the assertions which the article made.
§ The Earl of Longford
My Lords, I quoted what the article said that the Minister had said. I do not know whether the article was correct in the quotation from the Minister of Health.
§ Lord Glenarthur
My Lords, I have not seen the quote but I shall certainly look into it and let the noble Earl know. On the capital side, some £55 million has been set aside for the building of permanent regional secure units, of which over £23 million has now been allocated. A further £5 million is likely to be allocated in the current financial year.
Turning very briefly to research, the regional secure unit programme breaks new ground. To that extent it is an experiment. But it is an experiment founded on 393 a lot of earlier experience, and with clear and specific objectives. An integral part of the process will be research and evaluation of how the units are functioning, the extent to which they are meeting needs and whether they have brought to light any other gaps in our psychiatric and related services. The department is funding a three-year research study under the leadership of Professor Gwynne Jones into just these sorts of questions. His study is now about half way through, and the findings should help all those involved, in both planning and running RSUs, to build on the lessons learned.
On the question of who should be admitted to RSUs—this point was taken up by several noble Lords—those responsible for the patients' care have to make individual decisions with regard to the particular behavioural problems of individual patients and their likely response to treatment. After treatment in an RSU many patients will be transferred to ordinary mental hospital wards and some will be discharged direct into the community. For those who are discharged into the community, detailed arrangements for future care would of course be discussed and agreed before discharge, with the appropriate aftercare services. Social services, probation services and community psychiatric nursing services all play a major part and this is why it is essential that RSUs should form part of a continuing process of care and not be thought of as isolated units outside the mainstream of psychiatric care. I very much take the message from this short debate that that is what your Lordships would wish.
Some of your Lordships seemed to be under the impression—and perhaps this answers the point raised by my noble friend Lord Windlesham—that RSUs are provided solely, or almost entirely, for offender patients. I ought to make it clear that RSUs are not intended solely for mentally disordered offenders. They provide intensive treatment and rehabilitation in conditions of security—high staffing ratios, as well as physical security—for men and women who are judged by experienced professionals as likely to benefit from the kinds of treatment offered. This applies irrespective of whether or not these men and women are offenders. They are admitted from a variety of referring agencies, including prisons and special hospitals, or direct from courts, other psychiatric hospitals, and the community. It is impossible. I am afraid, to predict what proportion of offender and non-offender patients will be admitted. This will vary from one unit to another and, over time, in any particular unit.
I turn briefly to staffing and a point raised by not only the noble Earl, but also the noble Baroness, Lady Masham. Naturally, in the early years of the new RSUs there are likely to be relatively few nursing staff who have extensive experience of nursing patients in these secure conditions, but in many cases there will be a number of nurses in RSUs who have previously worked in interim secure units and who have acquired some relevant experience there. I am also aware that the Joint Board of Clinical Nursing Studies sponsors short training courses in psychiatric nursing in secure environments.
The number of nurses qualified and unqualified in 394 psychiatric services has increased gradually in recent years and the target for mental illness services of 100 nurses per 100,000 population in the 1975 White Paper entitled Better Services for the Mentally Ill was exceeded some years ago. There may be some difficulties in recruiting trained nursing staff in some parts of the country, but I do not believe that these problems cannot be overcome. I have no reason to believe that there will be any insuperable problems in recruiting suitably qualified medical, paramedical, or other staff for RSUs.
There are many signs that in a couple of years we shall be able to count the introduction of the RSUs as a success story, if perhaps a rather slow-moving one. I think a main reason for this is that this new challenge has attracted high quality medical, nursing and other staff into what previously was rather a neglected sphere.
I, too, should like to take this opportunity to pay tribute to the doctors, the nurses and the other staff of the secure units. They have a difficult and demanding job, and without their skill and dedication the National Health Service could not possibly provide the caring and effective service which is now developing across the country.
I have a few points which I think it would be useful for me to answer now. I hasten to add that these are in no particular order. The noble Baroness, Lady Masham, asked about the need for better facilities. I should say that currently the department is carrying out an evaluation of the design of the unit at St. Luke's. As the noble Baroness knows, I have been there and seen it for myself. The design team is considering space standards generally and the need for facilities of various kinds, including those for leisure and recreation. As she knows, the unit at St. Luke's was the first to be opened, and nobody pretends that it is by any means perfect.
The noble Lord, Lord Allen, asked about the difference in approaches to the provision of RSUs being adopted by regions. The two reports, the Butler Report and the Clancy Report, gave general advice on the types of patients for RSUs and on the siting of RSUs. There can be no rigid model for all regions, although the principle of a range of facilities will be generally applicable. The policy will be reappraised in the light of the experience of running both the permanent and the interim units. Different sizes of RSUs are either completed, under construction, or being planned in different regions which were arrrived at in the light of local needs and circumstances after much consultation and consideration within the planning team.
I have visited three of these units. I hope to visit more soon. I cannot say that in visiting any of them, although they have all been different, I have noted any particular weakness in the design of them in the way that perhaps the different approaches by different regions might seem to suggest. So far as Oxford is concerned, the department is in close touch with the Oxford Regional Health Authority about its plans for a secure unit. I understand that consideration is currently being given to the establishment of RSUs in one or two districts in the region. Planning for a unit, primarily for mentally-handicapped patients, at Borocourt Hospital is already under way.
395 Several noble Lords asked about the length of time that a patient would he in one of these units. Up to two years, yes. It is impossible to be absolutely categorical about this because it varies from patient to patient. One would not envisage them being there for longer than two years and, hopefully, for less. I think the important point to make is that in most of these units—certainly all that I have seen—the people who are there are looked after in different degrees of security, depending upon the progress they make throughout their time there. So far as the Mental Health Act Commission are concerned, yes, they are concerned with all detained patients and they have already visited RSUs.
The noble Baroness, Lady Robson, referred to the planning of secure facilities in South-West Thames. I can tell her that the department has given consideration to the paper submitted by the region for the development of a regional secure treatment centre and regional forensic psychiatric service and accepts in principle the proposals which have been put forward. The next step will be for the department to agree a formula with the region based on mutual agreement of certain criteria by which the comprehensiveness of the region's proposed service can be judged. I fully accept the noble Baroness's point about the need for a fully integrated service. A letter confirming the department's approval in principle of the region's proposal was sent to the region last week.
My noble friend Lord Windlesham referred to people seen by the courts as needing treatment. I would like to refer to the provision in the new Mental Health Act for giving the courts powers to remand mentally disordered persons in hospital and to make interim hospital orders. As was explained during the proceedings on the Mental Health Amendment Bill of 1982, because of resource considerations it was not possible to implement the remand hospital and interim hospital order provision on 30th September 1983, at the same time as the rest of the Mental Health Act 1983 came into force. We propose to implement these sections on 1st October this year 1984, and we are currently considering comments received from health authorities and others. When the new provisions are brought into force, it is likely that RSUs will accommodate a number of those who will be subject to new provisions and will provide for assessment of a person's response to treatment and need for security.
I close by raising what seems to me to be a crucial issue. After talking to many people and dealing with a great deal of correspondence on the subject, and having undertaken several visits to them and to other parts of this particular psychiatric service, I have a strong feeling that there is still a great deal of uncertainty and a great deal of unnecessary anxiety about the role and functions of RSUs. Some people regard them as mini special hospitals. Others see them as a panacea for resolving all the problems in placing disturbed and mentally-disordered patients and offenders. There are many other misconceptions, and I shall not attempt to catalogue them now. But all the misconceptions create problems for those seeking to set up and run services, particularly where services need to work closely together.
396 It is essential to the success of the programme that we increase the level of understanding of the aims and objectives of RSUs and how they fit into the pattern of treatment and care that I have described. We need more understanding among the public and among some of the professionals in the health service, local authorities and other services. I am sure that the discussion this evening will add to the general understanding, and I would again express my thanks to the noble Earl for the opportunity he has created for this interesting and helpful discussion.
§ Lord Allen of Abbeydale
My Lords, I know the noble Lord has had a very long day, but could he say one word about the point the noble Baroness, Lady Masham, and I raised about the involvement of the community and the possibility of having boards of visitors, or whatever you may call them?
§ Lord Glenarthur
My Lords, I think that is a good point. I should like to look into that; I think it makes sense. It works well so far as the special hospitals are concerned, and I am thinking particularly of Rampton. I see no reason why it should not work and I shall look into it and let the noble Lord know.
House adjourned at seven minutes past eleven o'clock.