future of the special hospitals

Future of the special hospitals

JAMES HIGGINS Consultant Forensic Psychiatrist, The Scott Clinic, StHelens WA9 5DR

Special hospitals have always had a dated and semi-detached feeling to them.They emerged in 1863 with the opening of Broadmoor as the first criminallunatic asylum, followed by Rampton in 1914, Moss Side in 1933, Park Lanein 1974 and Ashworth by the amalgamation of the last two in 1990.

They were first managed on behalf of the Home Office via the Board ofControl and although they became part of the National Health Service in 1948they continued to be managed by the Board of Control until 1959 when theywere transferred to the equivalent of what is now the Department of Health.However, they remained centrally managed, via the Special Hospitals ServicesBoard, a group of professional and lay civil servants. In 1989 their managementwas transferred to the Special Hospitals Service Authority (SHSA).

There were expectations that the Special Hospitals Services Board wouldhave bequeathed the SHSA a set of tactical guidelines and a strategic plan toindicate how the hospitals should be run, into what they might develop andto what they might aspire. This proved not to be the case. It was all too obvi-ous early on that the hospitals had been both under-managed and over-managed. They had been under-managed in that no central goals had been seton standards, clinical or managerial, just on security. Decisions had often beendriven by knee-jerk responses that were bureaucratic, defensive and over-conciliatory to reactionary and conservative forces in the hospitals often byconcessions and the injection of further wasted resources. The hospitals hadbeen over-managed in that any individuality, innovation or principled standat hospital level had been frustrated by central vacillation or obstruction. Thehospitals retained a very hierarchical style of management with a medicaldirector at the head, the director of nursing in charge, but not necessarily incontrol of the majority of the staff and the other major disciplines, psychologyand social work, performing within an often distant departmental model. Itwas very difficult to be convinced that the hospitals were being run in theinterests of the patients rather than the different and sometimes very self-interested and often adversarial interests of the parties mentioned.

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The early days of the SHSA were, therefore, taken up with the introduc-tion of general management in institutions far from prepared for it. The nextstage, and by far the most important, was to develop a set of operational poli-cies which would turn the hospitals in the direction of being run on behalf ofthe patients, e.g. the institution of 24-hour care (virtually completed); theending of slopping out; setting of standards for domiciliary accommodation;closure of dormitory accommodation (again virtually completed); seclusionpolicies; complaints policies; patient advocacy services etc. and, most impor-tant of all, the reorganisation of the work of the clinical professionals toensure multidisciplinary working actually took place. All these changes had tobe made under serious financial constraints, ministerial insistence that secur-ity was not being compromised, and against the passive and sometimes activeresistance of interested and threatened parties.

Criticism from outside bodies and individuals continued. However welljustified, such criticism is a two-edged sword. It can properly expose and high-light gross deficiencies in practice and provide impetus for change. But, equal-ly, it can be very demoralising and can force attention on issues which comelower in priority that others in a coordinated strategic plan of change. TheAshworth Inquiry (Blom-Cooper et al., 1992) was one such but, equally, theSHSA itself must have been an irritant to the individual hospital manage-ment groups by repeated enquiries into practice, occasionally very formal andintrusive. At points in the early 1990s it seemed that a leak was plugged inone hospital only for another, or even worse, the same one, to spring in anoth-er hospital. The hospitals, however, started going in vaguely the right direc-tion when the game changed, leaving the special hospitals behind again. Thistime it was the introduction of trusts and commissioners and thepurchaser/provider split. How were the SHSA and the three hospitals torespond to this: again remain different and become dated or seek to be thesame as the rest of the NHS, despite the difficulties of being a national servicewith revenue and capital funding coming from a separate budget within theDepartment of Health?

The SHSA was in no doubt that many of the difficulties in the hospitalsarose precisely because they were so special. They were differently managed.They were differently funded. They had different terms and conditions of ser-vice for staff. They had persistent staffing difficulties with shortages in med-ical, psychological and social work personnel and stasis in nursing. There wasserious professional isolation. The hospital beds were a ‘free good’ to other ser-vices which were, therefore, much keener to admit patients to special hospi-tals than to accept patients back again. The cost of a bed was perverselycheaper than those in medium security, not just because of economics of scalebut also because of a poorer range and intensity of treatment options.Hospitals were prepared to admit types of patients, principally those with per-sonality disorders, that other units would not consider admitting, not just ongrounds of security but much more importantly because of diagnostic uncer-

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tainty or reservations about treatability. Therefore, the only way to even startto remedy these special aspects was for the SHSA and the hospitals to attemptto follow the changes occurring in the rest of the NHS.

Fortunately, this was also the view of the Working Group On HighSecurity and Related Psychiatric Provision (1994). This working group wasinteresting for its title alone, with its implications of services rather thanstructures and of an integrated spectrum of secure care. Among the main rec-ommendations of the working group were that: the guiding principlesendorsed for the treatment and care of all mentally abnormal offenders shouldalso apply to those in high security services; future planning of high securityand related services should be underpinned by (individual) multidisciplinaryneeds assessments; purchasing contracts should aim to meet the needs ofpatients who may have a need for longer term medium security; high securityservices should be based in hospitals of no more than 200 beds with closerlinks to local services; high security services should be based on the purchas-er/provider model; the special hospitals should become trusts.

Moving from such a strategic plan to implementation has not been easy.The publication of the working group report was delayed by the Departmentof Health for more than a year. The SHSA and the local hospital manage-ment groups nevertheless had to proceed with arrangements for changebecause when (if) permission was granted for a split between a purchasingauthority, however organised, and more localised service provision, howeverorganised, both purchasers and providers would need time to develop systemsto make such a model a viable one. This involved the SHSA starting to splitits existing two functions, those of purchaser and provider, in order to develop‘purchasing’ skills and to encourage the hospitals to develop ‘provider’ mecha-nisms. Much work has been done, no matter how preliminary and crude, todifferentiate between different groups of patients and their needs: those withchronic mental illness; those with personality disorders; those with learningdisabilities; female patients and more minor groups such as those with braindamage and adolescents. Estimates of security requirements have been made,drawing on the work of Maden et al. (1995) in special hospitals, Gunn et al.(1991) in the prisons and Reed in the regional secure units (RSUs) (1995),with the view to estimating how many individuals require high security, long-term medium security, short-term medium security, long-term low security orno security at all. Attempts have been made to refine the costing of what iscurrently being provided in special hospitals. So far this has only been possibleat the level of sophistication of groups of patients in a ward, not yet at thelevel of a type of patient or properly at the level of the individual patient,though this is the goal.

The SHSA and the hospitals, therefore, now have a much clearer pictureof how the costs of a special hospital are allocated, what types of patients arethere, what sort of service they are getting, what the deficiencies are and where improvements need to be made now and in the future. The ‘core

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business’ of a high secure service has been drafted out, with strategies for themanagement of the major groups mentioned above. This has been agreedwith the three hospitals and it is to be hoped that the processes and theresults will be given much wider circulation soon. But, although the highsecurity services now have an increasingly clear picture of the role they feelthey should play, this can only develop in concert with other provider unitsand equally importantly with the purchasers or commissioners. So, when theWorking Group on High Security report eventually emerged in the summerof 1994 ministers agreed that the three hospitals would be separate and independently managed provider units, not trusts because of a legal impediment which it would require primary legislation to amend, but specialhealth authorities, each with its own board answerable to the Secretary ofState via his local NHS office.

A complementary commissioning body was formed, the High SecurityPsychiatric Services Commissioning Board (HSPSCB), designed to representthe interests of all relevant parties. The membership consists of a representa-tive of the purchasing side of each of the seven NHS regional offices, of theHome Office, the prison department, the probation service, social services andthe Mental Health Act Commission, plus observers from Wales and the NHSExecutive. There are also five independent members, all ex-SHSA, one ofwhom, the current chairman of the SHSA, is also the chairman of the HSPSCB. The vice-chairman, the chief executive of a regional office, is also amember of the NHS Executive.

This body, which had already had its first meeting, only formally came intoaction on 1 April 1996, as did the three special health authorities. The SHSAthen ceased to exist. In the meantime the three special hospitals were in atransitional stage with sub-boards of their own. The HSPSCB then appointedits executive officer, a director of commissioning, to develop a central pur-chasing strategy.

The terms of reference of the HSPSCB, however, go much further thanjust purchasing for special hospitals. They are: the development of trainingand research within special hospitals and other secure psychiatric services;the development of a coordinated strategy for commissioning high and long-term medium secure psychiatric services within the NHS; the developmentof services for patients currently in special hospitals and elsewhere who needlonger term secure care at levels below high security. The timetable is verytight. By late 1996 the HSPSCB will attempt to produce recommendationsfor the development of a strategy for coordinating purchasing of NHS highand medium secure psychiatric services and by early 1997 will produce areport on the need for high security and longer term secure psychiatric services in England and Wales. Thereafter it must provide an annual reporton the commissioning strategy and funding for the next year, together withan assessment of the contract performance of the three new special healthauthorities.

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How easy it will be for such a large body with varying local interests tocomplete these tasks remains to be seen. The knowledge base of the membersof the Board varies considerably. Commissioning of high security services willno longer take place in isolation but will gradually move to be integrated intothe commissioning strategies for local medium secure psychiatric services ofthe seven NHS regional offices.

With such major changes one can only speculate about what might happenin the future. However, one is now compelled to think of the purchaser/providersplit in relation to special hospitals, or rather, high security services as they arenow called, and the tensions that this new arrangement will produce for all par-ties, the high security services and all other secure services.

Let us look at possible future developments, first from the purchasing per-spective. The remit of the HSPSCB makes it abundantly clear that specialhospitals are now in the mainstream of the NHS and that they are but one ofthe providers of secure care, part of the spectrum of secure services for the areacovered by an NHSE regional office. Being part of an integrated service willinevitably lead to pressure for integrated monies, not very soon, but then notvery long away. The trend will be for monies to be attached to individualpatients, or specific groups of patients; not to hospitals, nor to special hospi-tals, regional secure units, long-term low and long-term medium secure unitsnor even local intensive care units and all their associated services. But wherewill the necessary monies for such an extensive and extended range of servicescome from? It is very unlikely that they will come from community and acutepsychiatric services which clearly need to get more money rather than loseany. The medium secure services are chronically overstretched with substan-tial sums of money profitlessly diverted to even more expensive provision inthe private sector.

So will there be any residual monies from the special hospitals as theyrealign their work to deal with their ‘core business’ of high secure care?Despite the expectations of some this is unlikely. Even if the special hospitalpopulation declines from the current 1500 to the projected 1000 or even less inthe current three hospitals, let alone the five or six suggested by the WorkingGroup on High Security, it is unlikely that there will be many savings. Theremaining patients requiring true high security care will all need the top end ofwhat is the current high security patients’ costs, which are higher than thecosts in most RSUs. There will also be reduced effects of economies of scales.And then, and much more important than these two factors, special hospitalshave traditionally been a cheap way of providing secure care, with 25+ beddedwards, a consultant to about 40 patients, other staff in similar proportions; farfrom the norms in regional secure units. So if the special hospitals becomepurely high security hospitals, part of the spectrum of secure psychiatric care,with more movement in and out, with more active social, psychological andpharmacological therapies for the most disturbed of patients, then the cost perpatient is likely to rise considerably. The perverse revenue incentive will then



vanish, as will any pot of gold for development of local long-term mediumsecure services.

It has not yet been decided how the initial artificial dispersal of specialhospital funds will take place. The plan is that the current monies will be allo-cated to the NHS regions and then returned to the HSPSCB pro tem, but forhow long? It has not been decided how this distribution will take place. Thiscould be done in proportion to the patient population currently in specialhospitals – but this would unfairly advantage those regions that overuse spe-cial hospital places for want of local developments and would penalise virtu-ous regions which already pay for virtually the full number of RSU beds andeven a low secure network and consequently have proportionately fewer spe-cial hospital patients. Another way could be to use a weighted populationmeasure, associated with numbers and relevant morbidity. There might evenbe a way which pleases all parties!

However, as the new system develops it would seem essential that allthose involved in commissioning for mentally abnormal offenders in what-ever setting appreciate that special hospitals are no longer far away. Theyare no longer a free good. They are now an integral part of local services.

Speculating about the future from a provider perspective, how are thespecial hospitals likely to develop? They will undoubtedly seek to refine further their core business and contract in size. At least two of them arealready in the process of doing this. They will seek to maintain their ident-ity if only because of staffing and employment issues, at Ashworth and particularly at Rampton. They will pursue contacts with local forensic psy-chiatry services more avidly, seeking an even quicker turn round of patients,and be more willing to take patients for short periods, and for assessmentrather than treatment. Their contact with prisons will increase even moremarkedly than of late. The core business will centre even more markedly onthe treatment of mental illness in men, particularly those suffering from treatment-resistant chronic schizophrenia. Personality-disordered patientswill be considered even more carefully before admission (also by commissioners who will want to know if they are getting ‘value for money’)and there are likely to be more admissions for assessment or for treatmentunder section 47/49 of the Mental Health Act 1983 than under a hospitalorder. Personality-disordered patients are likely to be admitted only toactive research-orientated assessment and treatment units, speciallydesigned for such patients. These, in view of the likely level of staff input,will be very expensive. Learning disabilities services will contract further, toa dedicated specialist service at Rampton. Few, but still some, femalepatients will require high security but finding alternative placements will bedifficult for women with borderline personality disorders who require inten-sive specialist treatment in conditions of less than high security. Strenuousefforts will be made to obstruct the entry and ensure the transfer of patientsrequiring only long-term medium security. But such patients are a very

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heterogeneous group with quite different needs and it is as yet far from certain that these needs can be met humanely at a local level. And what islocal? What size of unit and complexity of services could be provided efficiently at a local level?

If special hospitals do go down these lines they will be much more excitingplaces to work in. The staffing difficulties are then likely to lessen but atwhose expense at a time of considerable shortage of consultant psychiatristsand clinical psychologists?

There are even more radical scenarios. If the special hospitals contract toapproximately 1000 beds in total and the working group recommendationsabout high security units of no more than 200 beds come to fruition, then thethree existing hospitals are too large. At least two new hospitals will berequired based not just on smaller size but even more importantly on betterintegration with other more local secure services. The working group evensuggested where such additional units might be located: the South West, theWest Midlands, the North East and Wales; I would also add north London.Where are the capital monies to come from; perhaps the private sector?Where are the revenue monies to come from? Economies and efficiencies willbe cited, as always, as possible solutions, but existing funding is clearly inadequate for such a highly integrated, much more dynamic and much moretherapeutic arrangement. But this is exactly the sort of service which shoulddevelop: a devolved, integrated, secure psychiatric service driven by individual patient need and provided in different ways determined by localcircumstances, the special hospitals no longer being special other than in thequality of care they provide and the research they undertake at the sharpestend of the business.

The new purchaser/provider system has a capacity to provoke debate,confront issues and stimulate developments. There is, however, scope for ill-informed confrontation and competition and ill-thought out schemeswith a risk that the needs of this most vulnerable group will prove too difficult to meet and that the system may break down with many of thepatients being worse off than they currently are. But if commissioning isproperly informed by expert professional advice and has an appropriatedegree of funds provided then there is scope for a more personalised, morelocal, more integrated style of service with a high security component andthe special hospitals playing an important, active and intrusive part – nolonger semi-detached or dated.

REFERENCES

BLOM-COOPER, L., BROWN, M., DOLAN, R. & MURPHY, E. (1992). Report of the Committee of Inquiryinto Complaints about Ashworth Hospital, Cmnd. 2028. London: HMSO.

GUNN, J., MADEN, A. & SWINTON, M. (1991). Treatment needs of prisoners with psychiatric disor-ders. British Medical Journal 303, 328–341.


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MADEN, T., CURLE, C., MEUX, C., BURROW, S. & GUNN, J. (1995). Treatment and Security Needs ofSpecial Hospital Patients. London: Whurr Publishers.

REED, J. (1995). Changes in funding and organisations. In: High Security Psychiatry Services.London: NHSE.

WORKING GROUP ON HIGH SECURITY AND RELATED PSYCHIATRIC PROVISION (1994). Report.London: Department of Health.

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future of the special hospitals

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