HL Deb 18 November 1992 vol 540 cc687-710

7.37 p.m.

The Earl of Longford rose to ask Her Majesty's Government what action they propose to take following the report of the Committee of Inquiry on Ashworth Hospital.

The noble Earl said: My Lords, following the report on Ashworth Hospital of the committee presided over by the eminent Queen's Counsel, Sir Louis Blom-Cooper, I am happy to know that I shall be followed by experts such as the noble Baroness, Lady Macleod and others. I must apologise if I stick rather more closely to my notes than I believe is graceful, because I have to record some views which the authors will probably want to ensure are reported accurately.

The committee presided over by Sir Louis Blom-Cooper was set up in April 1991. It followed a Channel 4 television report in which very grave allegations were made about the maltreatment of several patients in the special hospital at Ashworth. The Special Hospitals Service Authority, which is often referred to as the SHSA, asked the Government for a full inquiry. The Secretary of State duly appointed the committee under Sir Louis.

The committee reported in August this year. It included many adverse comments, although it did pay a well justified tribute to those who gave much devoted work. There were 90 recommendations, nearly all of which were accepted by the management, which is now under the inspired leadership of Mr. Peter Green, who is a qualified social worker with 20 years' experience. I will not attempt to summarise the 90 recommendations.

I shall say a few words about Sir Louis Blom-Cooper's attitude to what I propose to say. I showed him the gist of my remarks and, although others may well expand his comments—I believe that he has made his views known to others—he thinks that at least six of his recommendations should be highlighted. I shall mention only their headings; others may well develop them. The first is, "the establishment of a patient advocacy service". The second relates to seclusion. Sir Louis and his committee were utterly opposed to the supervised confinement of a patient alone in a locked room. Thirdly, he makes important detailed recommendations in regard to medication. Fourthly, he wants the date announced by which slopping out will be abolished. Fifthly, he wants the removal of hateful literature. No one is more opposed to this hateful literature, of which there has been all too much in the recent past, than the leaders of the Prison Officers Association. Finally, he wants a much more effective method of what he calls "incident reporting".

I mention those because I think that Sir Louis would wish them to be mentioned. I should also say that nearly all the recommendations that I have mentioned have been adopted, except for that on seclusion. That recommendation has not been accepted. Sir Louis, however, thinks that insufficient priority has been given in several places. I asked him what he though about my attitude as revealed in the remarks that I proposed to make. He said, "Too optimistic". In speaking from these Benches it is not always my role to be too optimistic, but by Sir Louis Blom-Cooper's standards—and they are high ones—I am. I shall, however, remain too optimistic and shall set out the situation as I see it in a spirit of hope.

Although this is mainly for the record, I also believe that the House should know a little about the Park Lane Hospital. The House is probably aware that Ashworth Hospital was originally two hospitals: Park Lane, which is the more recent hospital, and Moss Side, which is the older hospital. I have often been to Park Lane to visit particular patients—in fact, nearly always one particular patient, who, I am sorry to say, now does not want to see me. The House may understand that. At any rate, I have visited the hospital often. In preparation for this debate, I had prolonged discussions with Mr. Green, his colleagues and a number of patients. In that sense, therefore, I am up to date. Although I am sure that all your Lordships will understand, perhaps I should repeat, in case other people do not, that we are talking about two hospitals dating from different periods. I think that one can say that Park Lane is much more up to date than Moss Side but they are now rolled into one, the Ashworth Hospital.

Again this is for the record, although it may also be interesting to the House if I describe the nature of the patients there. The patients in Ashworth are people who are suffering from mental disorders who require treatment in conditions of special security because of their dangerous, violent or criminal propensities. I shall not go into more detail about that, but the great majority have been convicted of crimes—in some cases, of very serious crimes. There are also some patients who have not been convicted of crimes but who are considered so dangerous and at the same time so disordered that they could not be safely left in an ordinary mental hospital.

Ashworth is a hospital with high ideals. It has always possessed high ideals which, according to the Blom-Cooper report, have not been realised in practice in all too many cases. It exists and its aspiration is to provide a safe therapeutic environment and a centre of excellence in forensic and other branches of psychiatry, psychiatric care and treatment with—I stress this next point—equal priority being given to the care and treatment of patients and the safety of the public. One is dealing with men who are ex hypothesi dangerous. One is aware of that but, at the same time, they are human beings. Each is possessed, like the rest of us, of an immortal soul of infinite worth in the sight of God and the hospital exists to carry out that terrible, difficult double task of treating them with humanity and of preserving the interests of the public.

Ashworth Hospital has an average patient population of 650 people. As I said earlier, all have mental problems and the majority are offenders. I need not describe all the various categories of mental illness, and I shall give just one illustration, although I could give many. On the last occasion when I visited the adolescent unit I met a very fine-looking young man. If I said that he looked like one of the younger members of the opposite Front Bench, they will understand what I mean. One would have thought that he was an hereditary peer, full of promise, young and vigorous. He was very good looking, well grown, and all the rest of it. In fact, he had been sexually abused when he was a small child. I asked him whether it was by his father and he said that it was not, so I do not know who was the abuser. At any rate, he had been sexually abused. He waited a long time—a dozen years or so—and when he reached his full stature (and he was a big young man, bigger than me) he decided to get his revenge. He tried to strangle his assailant, the man who had raped him when he was a small boy. He is now about 22 and he is just one of many patients who, in many cases, have had the most horrible background but who have also done horrible things. I hope that the time will come—there is no reason why it should not—when he will be set at liberty, and I hope that he will be looked after in one way or another when he is set at liberty. That is just one example of the kind of person with whom the staff are having to cope.

I come to the staff. It should be mentioned that nearly all the staff are nurses and nearly all are members of the Prison Officers Association as a result of what I think can be called an historical accident. They are not, therefore, like prison officers, who often have a short period of training before becoming prison officers. These are qualified nurses. They face the most difficult human problems imaginable and they need to be nurses who are also trained in proper prison security. I could not imagine being able to cope with their problems at any time in my life. I do not know whether many noble Lords think that they could make a good job of it. If so, they are fortunate, because they must have a lot of self-confidence.

I find it incredible that anybody undertakes this task at all, but somebody has to and these people dedicate their lives to this service. Every now and again they fall below the proper standards and then we have allegations of misbehaviour—perhaps justified—and then there is a big inquiry. We must all agree that, on the whole, good results follow such an inquiry, but we must always remember that when we talk of the staff we are talking about people who are coping with these human problems.

I am therefore very glad that the point of view of the staff will be put forward by the noble Lord, Lord Dean of Beswick —and no one could do it better. I shall mention just a few headings that were given to me by someone whom I have mentioned before in this House (someone for whom I have special regard), Mr. David Evans, the General Secretary of the Prison Officers Association. He has given me four headings. The noble Lord, Lord Dean, is well qualified to explain them more carefully. Mr. Evans has asked me to explain the kind of thing that he has in mind. The staff is to be renamed to emphasise the role of care in a secure environment; they will set out to work with other nursing bodies; they will try to ensure that the association initiates a working forum with other trade unions; and they will seek to develop a forum for discussions on the clinical needs of patients in the special hospitals. I ask the House to listen carefully to what Mr. Evans has to say. As I told Sir Louis—I do not think that he liked this comment but he swallowed it—his impressive report has fallen short in only one respect. The committee tried very hard to be fair to the Prison Officers Association but I do not feel that it quite managed it.

I now come to what Mr. Green told me in my long discussions with him and what he has set out in letters to me since. This is where I must rely on my notes, because I want to be sure that Mr. Green's views are accurately placed before the House. Sir Louis may say that I am too optimistic. He did not say that I was much too optimistic—just too optimistic. I shall set out Mr. Green's aspirations, and from what I saw on the ground he has already taken some considerable steps to give effect to these aspirations.

Mr. Green was the first to recognise that many of the recommendations required an improvement in management ability. One cannot place the whole responsibility on the nurses if anything goes wrong. One has to think of the management and the medical staff. All concerned must share the responsibility for any shortcomings. Out of the many recommendations—I said earlier that the authority concerned, Mr. Green and the others have accepted nearly all of them—Mr. Green mentioned these priorities. Ashworth must become a hospital able to offer 24-hour care. He recognises that this has considerable financial implications. In all the discussions about improvement in the social services, we always come back to finance. One can mention improvements but one cannot expect them to happen overnight. At any rate, it must become a hospital able to offer 24-hour care. According to Mr. Green, this has considerable financial implications for night regimes but also carries with it the ending of slopping out.

Mr. Green agrees that there should be an active programme for the improvement of the so-called "culture". We know the word "culture" in this connection. It is very vague but one can call it "atmosphere" or "ethos". Everyone agrees that it could be very much improved. Speaking for myself, and without total knowledge but having been close to this in various ways, I think that most people would agree that the culture of Park Lane was a great deal more advanced than the culture of Moss Side. It should be said that Mr. Green has taken one step already in stopping the wearing of uniforms in Moss Side. They were not worn in Park Lane.

One can use many general expressions regarding improvement in the culture but I wish to put a few of them on the record. Ashworth is now setting out to provide a good therapeutic and secure working environment. The management now recognises that patients are people first and foremost. The fact that they are very difficult people to cope with does not stop them being people. Another aspiration which is very close to the heart of Mr. Green and his present colleagues is that every individual should be encouraged to develop realistic aspirations of his or her future opportunities and life style. There should be a comprehensive range of activities. There should be new and effective methods of communication and individuals should be trained in life skills and assured of adequate community support. In case I have not made it plain, it is also accepted that the staff require and deserve much more effective training than they have hitherto received. Mr. Green says that security should never be used as an excuse for not meeting any of the above objectives. Mr. Green summed up his ideal in this way. I am convinced that he means to realise it if he is given the chance. He said:

"If the appropriate finance is made available to Ashworth Hospital, we will become a true centre of excellence and provide a service in which the public can have confidence".

Before I conclude my remarks I must return to the question of the culture. One cannot do more than reiterate the phrase "a great improvement in the culture". If all these aspects of the ideal were given effect to, we should find a completely different atmosphere. It will take time and it will not happen unless the Government and all those who have any influence in the matter back up Mr. Green and his colleagues.

I shall not belabour the Minister with compliments tonight. I paid some last night and noble Lords might think that there was something sinister going on if I kept on congratulating her. I cannot imagine anyone who is better qualified to handle these difficult problems and I can only hope that she will have as big an effect on her colleagues as I know she would wish to have. I hope that the House will send out a message of encouragement to Mr. Green, his colleagues, all the staff and all the patients. I realise that in a way this is just the beginning of a long discussion and that there will be other debates. I am most anxious that the Government should be given the chance to say that they are placing themselves firmly behind the main recommendations of the Blom-Cooper Report and are determined to do all they can to support the present management in their efforts to bring about a great improvement in the future.

7.58 p.m.

Baroness Macleod of Borve

My Lords, the hour is late but, despite that, all Members of your Lordships' House who have listened to the noble Earl, Lord Longford, will be grateful to him for the wise advice he gave the Government and those who are interested in the field. The noble Earl cares. He goes and he sees the hospitals and the prisons. He knows the people. He is one of the most caring people in your Lordships' House. Unfortunately, I have not been able to get to Ashworth, but it was very interesting to hear what the noble Earl found there.

I congratulate Sir Louis Blom-Cooper and his team on their detailed report. When I tried to bring the report into your Lordships' House I found that I could not carry it. I tried to read it. It was very long. I cannot therefore pretend, as some noble Lords may pretend, that I have read, marked, learnt and inwardly digested the whole of the report. But I found it of great interest. Only a highly-qualified lawyer could have led such an expert team and brought out such an impressive and immensely interesting document.

I shall be brief because, as I say, the hour is late. However, I should like to draw your Lordships' attention to two sentences in chapter XXXII, Recommendations. It has a bearing on something else I wish to draw to your Lordships' attention. It reads: the consequences that might be indicated as flowing from findings of criticism of individuals. Recommendations which are prompted by findings of misconduct might either constitute the foundation of a criminal charge or invite disciplinary action. Many years ago I was national chairman of all the leagues of hospital friends and I had about half-a-million people working all over the country for the hospitals. I was asked to go down to Rampton Hospital because two-and-a-half years earlier, as a result of a discussion in the other place, the government of the day had ordered the police to go into Rampton Hospital. They were there for two-and-a-half years, overlooking the work of the dedicated staff. Needless to say, after two-and-a-half years the morale in the hospital at all levels was as low as it could possibly be. The chairman of that league of friends asked me to go down to see if by any chance I could talk to them.

I went there many times. Each time I was more impressed by the work that the staff of all grades at the hospital do for their patients. But the result of the inquiry that was started as a result of a television programme made by Yorkshire Television was that 22 nurses were suspended on full pay for two-and-a-half years. All 22 were taken to the local court at Retford. They went from there to the Crown Court, charged in every case with doing an injustice to their patients. At the Crown Court every one of the nurses except one was exonerated. After two-and-a-half years they were allowed, if they so wished, to return to their jobs. This was not only a terrible waste of precious nurses' time and effort but of course the cost to the country was naturally immense.

It took a long time for Rampton Hospital to recover from that disastrous episode. I am now told that they have recovered, that the board of management is doing very well, and that the morale, which was so low, is now up to the norm, which is high. I am interested in this aspect of it because, as I understand from the report, seven of the nurses at Ashworth have been suspended. Can my noble friend the Minister tell us what is happening to those nurses? I think the services of one were immediately withdrawn, but I am more interested in the seven nurses who might possibly face charges similar to the ones that I have described.

Chapter XIII, as the noble Earl also told us, is about the patients' advocacy service. There again, I wonder whether my noble friend the Minister could let us know when this is likely to be implemented. It is vital that patients should have people they trust—not necessarily staff, whom I am sure in the majority of cases they would trust, but people from outside the hospital. Perhaps, as has been hinted, members of that good organisation, MIND, might go in to listen to any problems that can be brought out by the patients. I wanted also to touch on chapter XIV, which deals with training the police in investigating and interviewing people who have grudges against each other. Special training is needed because one is dealing with people who do not always tell the truth. They can also elaborate on the truth, and do not always tell even a vestige of the truth, but it all boils up to problems within the hospital.

Ashworth and the other two special hospitals are ordinary hospitals. They are there to cure patients. If they are lucky in their cures then the patients go out of the hospitals. They are there to be treated and, we hope, cured. But the regime for these special patients whom I have met at Rampton on many occasions has to be different from the ordinary hospital because of the special needs. Ashworth is not just for special patients. All members of the community of Ashworth are special people. I want to emphasise that, because the nation owes them a great debt of gratitude for taking on this particularly arduous work of nursing and caring for people who, as the noble Earl said, are not the easiest to care for.

I was enormously impressed by the dedication of all the personnel in Rampton from the board of governors, the management teams, the medical staff, the nursing staff, the auxiliaries, down to the gardeners and everybody that I met. Can we from this House say a big thank you to all of them for undertaking and carrying out this particular branch of medicine, which is so vital to all of us.

8.8 p.m.

Baroness Mallalieu

My Lords, I am particularly grateful to the noble Earl, Lord Longford, for initiating this debate and thus prompting me personally to read this superb report of Sir Louis Blom-Cooper and his colleagues. Unlike both the noble Earl and the noble Baroness, Lady Macleod, who both have enormous personal experience in this field, I have never as yet visited any of the special hospitals and have thus no personal knowledge of the regimes that apply in any of them. But as a member of the Bar, I have on a number of occasions in the course of my work come to know—sometimes well—people who have subsequently been sent on to them under hospital orders made by the courts.

Accordingly, I have often wondered about the way of life which lay ahead of them, the quality of treatment they would receive, and the nature of the care which our society provides for some of its most difficult and dangerous people. The answers to those questions as provided by this detailed and disturbing report are what I had hoped not to hear. The allegations of ill-treatment that were made in the "Cutting Edge" programme broadcast in March 1991, which the report deals with in some detail, have led to an inquiry which has laid bare in respect of this particular special hospital underlying difficulties which are clearly of long duration and which require a major review of the approach to the work of special hospitals and not merely cosmetic alterations in procedures.

The essential problem which seems to me to lie at the heart of what is wrong is an historical one. The special hospital system has its origins in the early 19th century with the foundation of the criminal lunatic asylums; and, later, the opening of Broadmoor in 1863. Those institutions—hospitals in name—have sadly remained outside the mainstream psychiatric services of the NHS. Whatever brave pronouncements of their objectives have been made over the years by governments, the prison service, the NHS and the special hospital service itself, those running them, and those responsible for staffing them, have never it seems to me—I shall be told if I am being unfair—made an unequivocal commitment to see them as hospitals and not as prisons.

I had hoped that the disturbed people whom I have seen in the courts over the years would be committed to hospitals where they could hope, in view of the seriousness of their conditions, to receive the best available treatment which would, if possible, fit them for eventual return to the community. So far as concerns Ashworth, the report shows—at any rate, at the time at which the inquiry took place—that that was a hope that was likely to be a vain one.

As a layman, the aspects of the committee of inquiry's findings which caused me the greatest anxiety were, first—despite all the tributes the report pays to many dedicated staff—the unacceptably low level of patient care. I found it frankly shocking that the report should feel it necessary to recommend that higher sights should be set in medical, social, psychological, nursing, education and occupational assessments when a patient is admitted. In other words, just about everything.

The general approach, according to the report, to a patient's prospects of recovery are pessimistic. I find it distressing that, contrary I understand to experience in other countries and with notable exceptions (thank goodness!) the more experienced and better qualified psychiatrists are not attracted into the special hospital service here. Further, I find it staggering that a hospital of this importance, dealing as it does with severely disturbed patients had—and, as I understand it still has —no pharmacist on its permanent staff. Surely, following the report the recommendation for a hospital-based clinical pharmacy service, suitably staffed with specially trained staff, must be a priority.

Secondly, I find it profoundly disturbing that conditions in a hospital into which a third of the patients are admitted, not because they have committed crime but through the civil process, should have living conditions which are, in some respects, worse than those in many of our oldest prisons. The continuation of slopping-out is a disgrace. So far as I am aware, no date has been given for an end to that practice in special hospitals. If the prison service can do it, then surely so must the hospitals.

Thirdly, I am worried about the staffing levels in so far as they affect the way in which staff can carry out their work and also the effects on patients. The absence of any proper night call system, with often one nursing assistant only readily available on duty, has serious implications for staff and patients in an emergency.

The continued use of seclusion—in effect, it is clear as a punishment—may, as the report illustrates in one case which was investigated, have tragic consequences. Yet I suspect that higher staffing ratios, as in the new unit at Broadmoor, would render that treatment unnecessary. I hope that the recommendation that it be discontinued will find favour as soon as possible.

I find it shocking too that a report in 1992 should have had to make a recommendation that mechanical restraints be no longer used. To retain the use of restraining garments and yet have no pharmacist on the permanent staff is all too clearly an illustration of what is wrong. Those procedures and practices are surely more fitted to the 1800s than to the 1990s, and graphically illustrate the prisoner rather than the patient philosophy.

If attitudes are to change, hospital patients, even disturbed or dangerous ones—perhaps I should say particularly disturbed or dangerous ones—must have a voice which is heard in the running of their hospital, and access to advice which is independent and readily and promptly available to them. A properly staffed patients' advisory service would not merely enable misunderstandings to be overcome and avoid escalations into wholly unnecessary bitterness and resentment—especially between patients and staff—it would enable genuine complaints to be articulated properly and thus acted upon swiftly.

A proper system of reporting all untoward events is clearly essential for the protection of patients and staff alike in such an environment. Together with a proper complaints system, I hope that those improvements will go a considerable way towards dispelling the feelings which were widely expressed in patients' letters written to the committee of inquiry that they were treated as sub-human.

Nothing that I have said is intended to overlook or minimise the difficulties which management, nursing staff and doctors must face in hospitals such as this. I do not envy them their work. I can readily see how, faced with staffing difficulties, antiquated facilities and sometimes inadequate training for difficult tasks, what the report describes as the culture of denigration and devaluation of patients may develop, but it needs to be addressed urgently, if that has not been done since the report was published.

I am especially worried by that part of the report which deals with women patients where the current regime was described as, "infantilising, demeaning and anti-therapeutic". In ordinary language, it seems that by its culture instead of helping to make patients better and more independent, the way that the hospital tended to treat women patients may well have worsened their condition.

It may be that the actions of the committee of inquiry and the publication of this report in August of this year have already gone some way towards addressing some of the problems that were highlighted in it. I hope that that is so, and I hope that the Minister will tell us that that is the position.

Next spring, when I understand Dr. Reed's working party and the special hospital task force will report, I hope that we shall see a full review of the way our special hospitals will be run in future. I hope that the House will have an opportunity to debate fully the issues raised.

Those who have to be confined in special hospitals and deprived of their freedom should surely have a right to expect to receive the best treatment that we can offer them, and as good a quality of life as is compatible with the need to restrain them. The report has shown that much is wrong, but it has done more: in its recommendations, it shows vision and it points the way to begin to put those things right. I hope we shall hear from the Minister that the Government will be following its guidance and proposes to do so as soon as possible.

8.18 p.m.

Lord Jenkins of Putney

My Lords, I should like to join those who have thanked my noble friend Lord Longford, not just for asking the Question but for being his invaluable self. My noble friend does the visiting that some of us know we should do but do not do. He has the personal experience, while some of us—here I speak for myself—speak from what we have read or have been told. My interest in the matter has been sporadic.

When Frank (as I like to call him) asked me whether I would participate in the debate tonight I hesitated to do so because of my lack of close knowledge of the matter. But, as he knows, I came into contact with it fairly early in my political career in the other House when I had a constituent named Mr. Peter Thompson. Mr. Thompson had the misfortune to he (as he puts it himself in his book) mad at a certain period in his life. That is not a word we use now but Mr. Thompson was not afraid to use it about himself so I do not hesitate to use it here. He was mentally disturbed for a period. During that period he committed a grave offence. As a result he was found to be mentally unstable and went to Broadmoor. I am not sure whether Mr. Thompson would agree with what I am saying, but it must be something in the nature of a tribute to the institution, and above all a tribute to Mr. Thompson himself, that, having emerged from that institution he has become the director of a very valuable organisation called the Mathew Trust.

The Mathew Trust takes a close interest in these matters and has made recommendations concerning what action should be taken in relation to the current examination. I will not go into those in detail; they can be read. What I will say is that one of the chief concerns of Mr. Thompson and the trust is what happens to the prisoner on discharge. At the moment there is no satisfactory provision. There is no half-way house, which has been suggested as one possibility, between a person being in public life and being in close confinement. The idea that there should be a half-way house existence is one that I find attractive and interesting. I hope that when the noble Baroness comes to reply she may be able to say whether it is one that the Government are ready to accept.

The history of the attitude of mankind to the mentally ill among us has been pretty appalling, has it not? When one looks back in history discovering how people who were "mad" were treated sometimes makes one almost ashamed to be a member of the human race. But we went through a period of reform. I am told that at one time we were in the lead in improving the situation and beginning to cope with this difficult problem, but I understand that we are falling behind and are still operating systems and adopting attitudes—the report confirms this—that belong to the past rather than the present. There are many other more progressive countries which have overtaken us in that respect and are already implementing the kind of recommendations that the Blom-Cooper report highlights.

I must agree with what the noble Baroness, Lady Macleod, said about the difficulties raised by the report. I have the report with me. I had to stagger in with it. The most readable and horrifying part of the report is volume II, which details what happened to four people in this establishment. One cannot read this part of the report without coming to the conclusion that matters are very grave and must be changed. That does not take away from the appreciation one also has of the fact that people who work in these establishments are doing work which most of us would neither be capable of doing nor would wish to do. Therefore they cannot be denigrated as a whole. That does not mean to say that we must not also concern ourselves with what happens to four patients and what happens to some other patients. My noble friend has referred to the "culture"—it is referred to in the report—which means there is a tendency to treat mentally ill patients as less than human.

If we come to the document itself, it is long, important, distressing and difficult to read. It raises many vital questions, one of which is what has happened since the publication of the report in August. I hope that when the noble Baroness comes to reply she will concentrate on that question. Have we made a start? I think we have. We want to know whether we have made a start on tackling those problems and how we are getting on with it. I believe my noble friend knows more about that than we do. Has a new procedure been introduced to deal with patients' complaints? Those questions have been raised by another valuable organisation: MIND. Is there a new system to ensure that there is proper monitoring of complaints so as to deal with issues that are of continuing concern to patients? Is there now the proper implementation of an incident-reporting mechanism to ensure that complaints see the light of day? Has an effective system been set up to monitor how the recommendations of the report are being implemented? The inquiry made a number of other detailed recommendations, some of which have already been mentioned. I hope that when she comes to reply to the debate the noble Baroness will be able to tell us that at least some of the problems are already beginning to be tackled. Is the hospital-based pharmacy being looked at? That must be important. There is also the question of the culture.

Since I do not know enough about the subject myself I have been studying what other organisations who do know about it have to say. The conclusion reached by the Royal College of Nursing is the following: Action is urgently needed to bring change in these special hospitals. Resources are needed to provide the highest standards of nursing care in a secure environment. A cultural change needs to be encouraged, alongside changes in nursing practice, education and industrial relations. The need for change demands resources and commitment. What happens at Ashworth will affect the future not only of the special hospitals, but of psychiatric nursing in every area of health care". I believe that that shows the very great importance of the report, and I am sure that the noble Baroness and her colleagues are dealing with it with that sense of importance.

On page 84 of the report it is stated: … it is the unqualified right of a patient to make a complaint about anything to do with his/her care and treatment and to obtain redress". Again, that is important. It seems to he suggested in the report that there is difficulty in getting complaints heard. I wonder whether that point too has been looked at.

Mr. Blunkett, the Labour spokesman on these matters, referred to the review following the report. I am glad to say that that review is now taking place. I am sure that the noble Baroness will have something to say about it when she comes to reply. Mr. Blunkett urged that the review should consider the whole structure and management of the special hospital and prison medical service to avoid the narrow perspective of previous inquiries.

I am half way between the view which is taken that this problem is so grave that reform is almost an impossibility and the more optimistic view taken by my noble friend Lord Longford in introducing this subject. There are grave problems and grave difficulties here. There are grave difficulties which are tackled by people who on the whole do their best to tackle them within the culture and the environment in which they exist. We must ask ourselves about that culture and that environment. I am sure that in replying to the debate the noble Baroness will address herself to these problems. Once again I wish to say that all of us here and others outside this Chamber owe a debt of gratitude to the noble Earl for raising this issue this evening.

8.31 p.m.

Lord Dean of Beswick

My Lords, I, too, wish to express appreciation to my noble friend Lord Longford for tabling this Question on the subject of this important report. My noble friend does us a profound service in doing so. However, the report is so long and protracted that I think we are only slightly opening the door on the subject today and we shall have to return to this matter to discuss how it has progressed, as it must progress.

I cannot approach this subject on the same basis as my noble friend Lord Longford, who has a tremendous history of showing interest in this field and working within it. He has long been interested in the fate of people who are in trouble and who have to be held in custody. Nor do I have the background of my noble friend Lady Mallalieu, who is a distinguished QC. I approach this matter totally from a layman's point of view.

During my political life, by a geographical accident I represented areas that contained two of the largest prisons in the United Kingdom. The report, in my view, concerns the prison service as a whole. When anything goes wrong, the nearest guy to kick on the backside is the one at the sharp end of the operation. Apparently it is not the Home Office which has made the mistakes, or the Government—whether Tory or Labour—who have not provided adequate funds. The guy who is kicked is the one who is trying to do his job.

I, for my sins, was the Member of Parliament representing Leeds, West where Her Majesty's Prison Armley was situated. I have visited that prison and I have seen prison officers in tears because they had to look after kids of six and seven years of age who were remanded in juvenile custody because the government of the day, whatever their colour, had not provided a proper facility in which those children could be held.

When I moved back to Manchester I was aware of the situation at Strangeways. I am perhaps speaking a little wide of the report we are discussing tonight. Before I left Leeds I was told that the overcrowding and the conditions at Armley prison were so bad that it was a power keg that could explode at any time. I went back to Manchester and the power keg exploded with a consequent cost to the taxpayer of £60 million. The people who had the least input in terms of dealing with that situation were the prison officers who worked there. They assured interested people like myself that they could take control of the prison in two days but that they were stopped by the Home Office. The Home Secretary who was responsible for that decision is now, I believe, sunning himself in Bermuda as the governor there.

It is essential that the people at the bottom of the structure should be able to express their point of view. I liken that situation to an industrial dispute. According to this Government, the faults in production in this country lie always on the shopfloor. According to the Government the fault never lies with management. I think one should also speak up for the staff.

I think there is a misconception as regards the type of patient that is held in the hospital we are discussing. I am told that about 60 per cent. of the patients are dangerous not only to themselves but also to other people and to the staff who look after them. I have discussed this matter with three members of the Prison Officers' Association, who incidentally are certificated nurses. They are not "screws" in the old fashioned sense. They are fully qualified medical staff. I do not think any of those three people would look amiss in the front row of a rugby team. I asked them whether they would be happy with nursing the inmates of the hospital on a one-to-one basis. They replied that they would not be happy with that situation and that they would not feel at all secure.

A short time ago I chaired a meeting in Manchester. The meeting concerned the privatisation of prisons. A Roman Catholic bishop, the Bishop of Salford, was on the platform at that meeting. He discussed the matter of society deciding to incarcerate people. Once the door is locked on prisoners, society is finished with them, but for other people the problem starts. In the normal course of events the staff of prisons will have to spend 12 hours a day incarcerated with the people they have to look after. That is not an easy job. In some prisons the position may be better than in other prisons according to the resources that are made available.

Only a few days after I visited Strangeways a headline in the paper said, "Her Majesty's Chief Inspector of Prisons, Judge Tumim, condemns Strangeways". I assumed that the judge had visited Strangeways, but that was not the case. He had relied on reports from his staff who had visited the prison. Some two days' later he published a report of a prison that holds only 200 inmates. When Strangeways is rebuilt it will accept once again 50 per cent. more prisoners than it was built to accommodate. However, when things go wrong in a prison the authorities always blame those at the bottom end of the structure.

I do not accept that Sir Louis Blom-Cooper is right in every instance. I believe he infers, for example, that the staff are in the wrong trade union. I have been attacking this Government for the past 13 years for telling people which trade union they should join. Most of the staff employed in the hospital we are discussing are qualified psychiatric nurses and they chose to join the Prison Officers' Association. To try to equate the hospital we are discussing with what I would term a normal mental hospital in the widest sense is absolute rubbish. Most of the inmates of the hospital we are discussing are, unfortunately, murderous people to themselves and to the community at large and they must be incarcerated.

I was interested to hear the comments of the noble Baroness, Lady Macleod, about Rampton. She said that a television documentary had been appallingly unjust in its treatment of the staff at Rampton. However, the other night a programme was shown about the House of Lords and noble Lords who featured in the programme were made to look like characters from "Spitting Image". Therefore one cannot take seriously a television programme made about any subject. Television programmes are just a joke.

The Prison Officers' Association—and I have no financial connection with the association—has made it quite clear that it is not prepared to defend members who behave badly. It is asking for a special complaints procedure. I am told that, since the report was issued, if a patient makes a complaint, whoever he may be and however serious or frivolous his complaint, a member of the staff is immediately suspended. So much for British justice. The Prison Officers' Association has assured me that it would be quite prepared to become involved in a complaints procedure so long as it had an input in order to protect the rights of its members. What is wrong with that in a democratic society? I am sure that noble Lords who have spoken in the debate, and Sir Louis Blom-Cooper himself, realise that the defendant is also entitled to the fullest protection. If he is able to be attacked, he should be able to be defended.

I do not believe that the present situation can continue indefinitely. I could give a list of the charges that have been made. There are underlying charges, which have been withdrawn from the report, about the political role of the POA. It is said that it is loaded with Fascists. I have a letter written by the secretary of that association, David Evans, in August which makes it quite clear that the Prison Officers' Association is totally opposed to any such people being in its ranks and that if they could be identified it was the duty of their branch to report them to the executive to deal with the matter.

The Prison Officers' Association is not insular. Perhaps I may mention some of the organisations with which it has affiliations. It is affiliated to the TUC. It holds the chairmanship of the European Justice Trade Group and of the Council of Civil Service Unions. The Prison Officers' Association structure includes a race committee and an equal opportunities committee. Its external activities include membership of the Trades Union Congress health committee, Liberty, the NACRO Committee for Minimum Standards in Prisons, the NACRO Community for Racial Equality and the Penal Consortium for Reform, which includes among others the Howard League, the Prison Reform Trust and NACRO. All the POA asks is that in any changes that take place it is consulted.

It is no good thinking that people can be stamped in the same way as an egg is stamped for inspection. They should not be told that although they used to be prison officers now they are members of another union and they must behave differently. That is grossly resented by the prison officers involved. As I said, most of the people involved are fully qualified medically.

Previous speakers have mentioned slopping out. That does not affect Ashworth alone. They have only just started getting rid of slopping out at Strangeways and Armley. It should have gone years ago, irrespective of whether it was a mental institution or one of Her Majesty's ordinary prisons. It is all a question of resources. Slopping out is part of the normal prison service. You could always tell when you were near Armley or Strangeways: your nose told you. You could smell it. But it had nothing to do with the prison officers. They worked for 12 hours with that situation. They suffered as well, and their families suffered.

I make no special plea. I ask simply that prison officers are respected for the job they do. Most of us would not want to do that job. Society has a right to remove from society people who go before the courts if they are a serious danger. We know that people who have been released from prison after committing rape have committed rape again. People have been released after committing murder and have committed murder again. What do the general public say? They say that we are too soft on crime. One should not get the idea that the general public are overwhelmed by passionate appeals such as the one Sir Louis Blom-Cooper has made. He may well be right, but the general public would view the matter with some disdain. People believe that prisons are for punishment, not for rehabilitation. I take the view that they are for rehabilitation, but in the case of Ashworth I dare to say—and I have no medical knowledge —that the possibility of rehabilitation of most of the people incarcerated there is virtually nil.

I understand that three of the ringleaders of the Strangeways mutiny are now incarcerated in Ashworth. Why were they ever in an ordinary prison such as Strangeways and looked after by prison officers whose own security was at risk? Prison officers were injured and people died as a consequence. That was an issue which the Government could not get away from.

I do not want to join the mutual admiration society for the Minister on the Front Bench tonight, dear though I think she is, but I know that she is a sympathetic listener. It is not the fault of this particular Government that such a situation exists. But, nothing will happen until we as a nation support a government, of any colour, which is prepared to see substantial sums of money spent on eradicating what has happened in this particular establishment. But they must take the staff with them. The solution must not be handed down as a diktat based on an independent report.

I hope that the Government will look at what Sir Louis Blom-Cooper has said. I do not agree with all of it but I go along with most of it.

I end by thanking my noble friend Lord Longford for giving us the chance of debating this subject tonight.

8.46 p.m.

Lord Desai

My Lords, I should like to join my noble friend Lord Dean and other noble Lords in thanking my noble friend Lord Longford for giving us this opportunity to discuss the report on Ashworth Hospital. I thank him particularly because, unlike other noble Lords who have spoken, I have even less experience of the subject. I have not been a prison visitor; I am not a barrister; I have not been a Member of Parliament with either a hospital or a prison in my constituency; and I am not a voter who has had such a problem.

When I read the report it was truly a great education. At the core of the report, leaving aside the beginning and the appendices, there are about 200 pages which could be released in the popular bookshops. People could learn a great deal by reading the report. It is an eye-opener.

Many noble Lords have spoken of the details of the report. Perhaps I may quote from the report what I believe to be the crux of the matter. Of the four case studies which are laid out and which, as my noble friend Lord Jenkins of Putney said, make very serious reading, the report begins by saying: From our studies in depth of these four cases there is a wealth of evidence to demonstrate how, from the moment when society intervened in the lives of each of these four mentally disordered persons, there has been failure upon failure to care for and treat them properly". Therefore, before we discuss what happened in Ashworth Hospital and what may be done, let us remember the broader social context in which such reports must be placed. It is not just one special hospital; nor is it even a system of special hospitals which is at issue here.

The problem of how to treat mentally disturbed patients who may have criminal tendencies and may have offended is one which starts long before those people come to such hospitals. No one is born a criminal. There is plenty of evidence to show that, if some of those people had had viable alternatives of treatment, analysis, diagnosis and advice, they would not have ended up so tragically. So, first, let us remember that the whole issue that we are discussing has a much broader social context. Indeed, not just our society but every Western society so far as I know has failed to treat the problem in a proper, broad social context. We are learning, but it still remains the case that far too often patients are treated like prisoners. That is the essence of the problem.

Many details of the report's recommendations have already been mentioned. I should just like to raise three issues. One is the issue of culture. Many people have already alluded to the problem of culture. What is it? It is not just a problem of ethos, broadly speaking, or a problem of attitude. The report makes disturbing comments—not being an expert in this matter I have to take the report's evidence as valid—about racism, sexism and homophobia. I take on board everything that has been said about the dedication of many members of staff. They do difficult work and are very committed people. I criticise no one individual or even the Prison Officers' Association. The issue clearly concerns the very disturbing attitudes of racism, sexism and homophobia.

In saying that the culture needs to be changed, we mean that it is those aspects which must be removed. They cannot be eradicated easily; after all, they exist in society generally and not just in Ashworth Hospital. We must make a start on whatever is needed to be done by way of education, retraining or whatever to ensure that, to the extent possible, those aspects of the culture are removed as soon as it is feasible to do so. That is my first point.

My second point concerns procedures. Many of the recommendations, such as advocacy for prisoners or a complaints procedure and so on, are matters of improvement to procedure. Improvement of procedure is not very costly. It is a matter of changing practices. It may cost something to implement but does not involve great expenditure. It will be interesting to hear from the noble Baroness what has been done about improving procedures, especially those concerning complaints. As other noble Lords have pointed out, when a person can complain any time that he feels that he has a complaint, for whatever reason, without fear and with the support of an advocate, then we shall be treating people as patients and not as prisoners.

Lastly, and this is tricky, there is the matter of resources. It is quite clear, for example, that if seclusion treatment is to be properly carried out, if slopping out is to be stopped and if many other matters are to be dealt with properly, there is a need for a 24-hour service with more than one person in attendance at night. That has already been mentioned.

The staff provision is clearly inadequate. It would be interesting to know, given all the stringency that is always present, how much in the form of additional resources will be put into this special hospital and special hospitals in general. We should like to be assured that such things will not happen again. I do not want to take up any more of your Lordships' time. Once again I thank my noble friend Lord Longford for having given us the opportunity to discuss this matter and for having given me the opportunity to educate myself.

8.55 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Baroness Cumberlege)

My Lords, as other Members of your Lordships' House, I am grateful to the noble Earl, Lord Longford, for drawing attention to the report of the Ashworth Hospital inquiry. There can be no greater authority on this issue in your Lordships' House and few people in the country who have carried out so much research into the subject. We are indeed fortunate to have the noble Earl among our number. I should also like to thank him for his courtesy in sharing with me his approach to this debate and for his thoughtful speech.

The debate gives me the opportunity to explain to your Lordships how we are addressing the important issues raised in the wide-ranging and searching inquiry which was chaired by Sir Louis Blom-Cooper. I should like to pay a tribute to him and his colleagues for the enormous amount of time, energy and care they put into conducting the inquiry and into producing the final report. The findings have implications which go far beyond Ashworth itself and beyond the special hospital service. In replying to the concerns which the noble Earl and others have raised, I hope to demonstrate how seriously these are being regarded.

The inquiry report reflected some very disturbing aspects of life at Ashworth Hospital. Both the Government and the Special Hospitals Service Authority (which manages all three special hospitals) are resolved to deal with these as a matter of urgency. On publication in August, my right honourable friend the Secretary of State for Health announced that the authority would immediately draw up a detailed action plan for tackling the report's recommendations. That action plan was submitted by the authority and subsequently approved by my right honourable friend. At the same time the authority set up a task force at the hospital which was charged with implementing the agreed action.

The task force is chaired by the hospital's acting general manager, Mr. Peter Green, who has obviously impressed the noble Earl. Mr. Green's commitment is beyond question and he is determined that the hospital should provide treatment, care and a quality service where patients' needs are paramount. The other four members of the task force are well qualified and experienced people from outside the special hospitals: a consultant forensic psychiatrist, a nurse manager, an industrial relations expert and a representative of patients' interests. They report to an authority-level steering group, which in turn keeps Ministers in regular touch. It is through this mechanism that progress towards achieving the report's recommendations will be charted. Like the noble Earl, I too have recently visited Ashworth and was able to see and hear at first hand the positive action that is being taken.

The overriding aim in following up the report must be to ensure that staff, patients and the public at large see Ashworth and the other special hospitals as hospitals. They are not part of the penal system and they do not exist merely to promote containment. The public quite rightly expects to be protected—that protection is one of the key objectives of the authority—but high security must be provided in the context of an essentially therapeutic environment.

We are anxious to promote professionalism in special hospitals and are committed to developing and maintaining the highest possible nursing and clinical standards. We do not underestimate the demands on those who work on a daily basis with extremely difficult and challenging patients; but abuse, degrading treatment, or neglect cannot he tolerated under any circumstances. The Special Hospital Service Authority has made it clear that disciplinary action will be taken in such cases. Indeed, that has already happened.

It is also important to recognise that, while the inquiry report illustrates some obvious failures in what should be a compassionate and therapeutic service, much good work has been and is being done by committed staff at management and ward level. The authority had already taken important steps to tackle many of the problems which confronted it when it was set up only three years ago. Indeed the creation of the authority itself stemmed from a determination to replace the over-centralised and bureaucratic management structure which existed before by a more open model on health service lines. The task ahead is a challenging one, but undoubtedly the introduction of general management and the identification of clear goals has generated an energy and enthusiasm which are accelerating the pace of change.

I would like to address some of the specific points raised by the noble Earl, Lord Longford, and other noble Lords. First, I shall deal with the question of a patients' advocacy service. That issue was raised also by my noble friend Lady Macleod of Borve and the noble Baroness, Lady Mallalieu. This was one of the key areas highlighted by my right honourable friend the Secretary of State when she announced the publication of the report. In particular, she welcomed the proposal for a patients' advocacy service, which the Special Hospitals Service Authority strongly supports. The authority is working enthusiastically with the Ashworth task force to identify different options for advocacy and expects to make a choice early in the New Year. The preferred model will be piloted in Ashworth and, when established, the good practice spread to the other two special hospitals. A member of the task force, Miss Lindsey Dyer, from the patients' advice bureaux at the North-western Regional Health Authority and formerly of MIND, is taking a lead role in this area.

With regard to the grim practice of slopping out raised by the noble Baroness, Lady Mallalieu, I assure her that the Government share her view and that of the committee of inquiry that the practice should be discontinued as soon as possible. The noble Lord, Lord Dean of Beswick, was also concerned about that. I am sure that they will he pleased to learn that the Special Hospitals Service Authority has successfully piloted a scheme at Rampton Hospital demonstrating the practicality and benefits of increasing the level of night staffing and allowing the patients free access from their rooms to toilet facilities and, more importantly, to have regular contact with nursing staff during the night hours. It is the authority's intention from existing funds to introduce the same regime in a limited number of wards, at both Broadmoor and Ashworth hospitals before the end of March 1993. It would also be aiming to extend the arrangement throughout all 79 wards, but it is aware of the significant resource implications in the trebling, or in some cases the quadrupling, of the number of staff on duty at night.

I should now like to turn to the issue of seclusion. Your Lordships will be aware that the subject of seclusion is controversial. Those who support its total abolition tend to work outside the special hospitals, whereas those who have to deal with these difficult patients on a daily basis favour its reduction and strict control. The Government doubt whether the proposal to end seclusion entirely is realistic but they welcome the encouraging trend of its very selective use. I understand that the practice of secluding newly-admitted patients has ceased and over the past two years the number of seclusion hours has been reduced at Ashworth by one-third and the number of patients secluded halved. The authority is actively looking at ways of accelerating that change, a development very much welcomed by the Government.

The noble Baroness, Lady Mallalieu, and the noble Lord, Lord Jenkins of Putney, were concerned that there was no hospital-based pharmacy. The authority and the department support the establishment of a hospital-based pharmacy, and that will be implement-ed as soon as the necessary resources are available. I shall come to resources in a minute.

Perhaps I may raise the question of alternative literature. There has been a great deal of concern about the dissemination of unacceptable literature within Ashworth. At the request of the Special Hospitals Service Authority the retired deputy chief constable of the Cleveland Police Authority is conducting a thorough investigation into the circulation of this offensive and obscene literature. His inquiries are still in progress but his first report is due to be received by the authority in the very near future.

I should now like to turn to the issue of the complaints system, which was raised specifically by the noble Lords, Lord Jenkins of Putney and Lord Dean of Beswick, and other Members of your Lordships' House. A new complaints system was introduced by the authority on 1st April 1992 and I am pleased to be able to tell your Lordships that independent investigators have been appointed and are handling serious complaints. An initial review after six months shows that the new system has been effective in all key aspects. My noble friend Lady Macleod—

Lord Dean of Beswick

My Lords, I thank the Minister for giving way on the question of the complaints procedure. It may be acceptable to everyone except the person who is being complained of because there are circumstances in which frivolous complaints can be made. A marvellous example was given by the noble Baroness, Lady Macleod, about a group of nurses who suffered substantially both financially and professionally by virtue of a television programme. I am saying only that the Prison Officers' Association is prepared to support any complaints procedure provided that it is given an undertaking that it can be part of it so that it is able to defend nurses who are members of the association. I think that that is only common justice.

Baroness Cumberlege

My Lords, I entirely endorse that view and I would be totally opposed to trial by television, which I think takes place in some instances. However, I have to say that in this particular case many of the reforms which I am now citing and which have been adopted by the task force were introduced before that Channel 4 programme. We should endorse the new complaints system, monitor it very carefully and, if there are shortcomings in it, clearly we shall have to make certain amendments to it. But I understand that after a review of the first six months it is proving to be very effective.

My noble friend Lady Macleod of Borve spoke from the considerable knowledge that she has gained over many years as a former president of the National League of Hospital Friends. She illustrated so vividly, as the noble Lord has outlined, the impact which inquiries can have on institutions. She went on to ask what has happened specifically to the nurses who were the subject of disciplinary action. Five nurses have resumed duty following disciplinary action where that was appropriate; one has been dismissed; and one is still suspended pending a disciplinary hearing next week. The cases are not being allowed to drag on as in the case of Rampton, which she quoted. They are being dealt with speedily under the procedures which the Special Hospitals Service Authority has developed.

The noble Baroness, Lady Mallalieu, expressed her deep anxiety about the poor quality of medical staffing. That is an issue which is addressed in the Special Hospitals Service Authority's action plan. Medical members of the SHSA—Dr. Taylor, Dr. Higgins and Dr. Dick—are carrying out a personal review with all the medical staff to ensure that roles are clearly understood and support given where needed. Moreover, a medical audit is also being developed throughout the hospitals.

The noble Lord, Lord Jenkins of Putney, cited one of the many successes of the special hospitals. I am grateful to him for stressing the positive aspect of much of the work which is undertaken. The noble Lord asked specifically about discharges from special hospitals. The report of the mentally disordered offenders review emphasises the importance of follow-up action and care. I shall be referring to that in a moment. That report has been chaired by Dr. John Reed. Action to speed up development of the regional secure units is one of the great keys to getting patients moved from special hospitals. The care programme approach, which is explicitly included for special hospitals, follows through a new placement in the community so there is a continuing responsibility that is going to be exercised in the future.

The noble Lord, Lord Dean of Beswick, outlined graphically the retribution meted out to those at the sharp end who trespass and transgress. It is right that sloppy practice, neglect, poor care or worse—abuse and brutality—at all levels are detected and speedy action taken. I make no apology for that but I do concur with the noble Lord that those who have let such a culture take hold must also bear their share of responsibility, as they have in this case.

It is untrue to say that members of the staff are suspended whenever a patient raises a complaint. That would happen only if the initial management investigation established a prima facie case of misconduct by a member of staff.

I agree with the noble Lord, Lord Desai, that this is a most difficult area and, in some respects, as society's attitudes change, it becomes uncharted territory. Forensic science is a relatively new medical specialism but I am extremely pleased that talented and committed people are entering the specialty. I hope that the leadership that they give will enhance that challenging area of care.

I turn now to the question of resources. Over the past three years resources have considerably increased for the funding of special hospitals. In 1989–90 £80.1 million was spent on this service. In 1992–93 £118.4 million is to be spent so that considerable investment has been made in special hospitals.

Your Lordships will be aware that it is essential that the special hospitals should be viewed not on their own, but as part of a much broader range of care for mentally disordered people, in the NHS and in the community. Because they have locked doors and many of their patients are referred from the prisons or the courts, they run the risk of isolation from mainstream health services. This clearly must be avoided for the very reasons which have been highlighted today about the poor quality of care which previously existed at Ashworth. The authority's priority is to strengthen outside links by building closer working relationships with the wider NHS, the universities, local probation and social services departments. It is also forging partnerships with the voluntary sector. We welcome these developments.

Because the special hospitals are just one part of a much wider pattern of services, my right honourable friend recently announced the formation of a working group to look in detail at the needs of people who need treatment in conditions of high security. As I said before, this is being chaired by Dr. John Reed, who also led the joint Department of Health/Home Office review of services for mentally disordered offenders that completed its work in July. It will report next Spring.

Earlier this year, the noble Earl commented in his book Prisoner or Patient on the interim report of the mentally disordered offender review. As he said, this was a "major document". I am pleased to say that the final summary report of that review is being published later this month. This report will pull together the key features of the nine earlier consultative documents, the broad thrust of which have already been widely supported by the various bodies involved in this field. At the same time we shall be publishing two further discussion papers; one on the needs of offenders with learning disabilities; the other, on racial and cultural issues.

One of the main points in the review is the need to provide services for mentally disordered offenders as near as possible to their own homes. This principle has implications for the centralised pattern of special hospitals—and my ministerial colleagues and I are aware of alternative models that have recently been suggested. Dr. Reed's working group will be looking closely at all the issues, including the level of need for high security and the implications for related services. The working group will be keeping in close touch with another group, also chaired by Dr. Reed, that is looking at services for people with psychopathic disorder. This has long been a difficult and contentious area, but one in which we are determined to see practical progress made. I am confident that both working groups will be able to build constructively on the good work already done by the main review.

I thank the noble Earl once again for his continuing and humane interest in the needs of this relatively small but often problematic group of patients. As he put it in his recent book: We owe a duty to those suffering from these grave handicaps and to those who dedicate their lives to helping them". My right honourable and honourable friends and I are determined, for our part, to do all we can to ensure that these patients receive the best care and treatment in the most suitable surroundings for their individual needs, always bearing in mind the need to protect the safety of the public.

House adjourned at fourteen minutes past nine o'clock.