Psychological Medicine, 1977, 7, 141-148
The NHS practice of forensic psychiatry in one region PAUL BOWDEN1 From the Institute of Psychiatry, De Crespigny Park, London
The present paper outlines the number and distribution of forensic patients within one region. In addition, attitudes to both available services and existing legislation are described. Regional and national data are compared so that the results can be used by other regions which are currently planning a development of their own forensic services.
SYNOPSIS
Three acts provide for the management of individuals who are charged with offences and are considered to have mental disorder: as a condition of probation the person can be required to submit to treatment, Section 3, Powers of Criminal Courts Act (1973); in accordance with Part V, Mental HealthAct(1959) (MHA) an order can be made for admission to, and detention in, hospital or, an individual can be found not guilty by reason of insanity or unfit to plead and the court is directed to make an order to admit the apellant to hospital, Sections 1 and 4, Criminal Procedure (Insanity) Act (1964). (The Powers of Criminal Courts Act, 1973 (PCCA), consolidated the relevant parts of the Criminal Justice Act, 1948.) In all cases the name of the hospital at which the patient is to be treated has to be entered on the order and Part 3 of the PCCA, 1973, also demands that the name of the medical practitioner who will direct treatment must be specified. The Butler Committee (Report of the Committee on Mentally Abnormal Offenders, 1975) has stated that the guiding principle in the disposal of mentally disordered offenders by the courts should be to send them wherever they can best get the treatment they need; however, in practice the admission to hospital of a patient concerned in criminal proceedings depends on a psychiatrist's willingness to accept the patient. Some observers believe that this decision is influenced more by prejudice (Bennett, 1973), and lack of resources (Gunn, 1974), than by the severity of a disorder or its amenability to treatment. In 1 Address for correspondence: Dr Paul Bowden, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF.
certain cases nursing unions have prevented the treatment of mentally disordered offenders by threatening a withdrawal of labour if they were admitted to hospital (e.g. R. V. Parker, The Court of Appeal, Criminal Division, 248/R/75). Because of the difficulty in obtaining admission for suitable cases, Lord Justice Ormrod (1975) has warned that there is a real danger that the courts will once again draw away from psychiatry. An earlier study (Bowden, 1975), in the South-East Thames Region traced the run-down of the larger mental hospitals and showed that there had been a 40 % reduction in the number of beds in constantly closed wards within the last 5 years. It was argued that these changes have resulted in a lack of facilities for mentally abnormal offenders; the increasing scarcity of lodging-house accommodation and the failure of the newer psychiatric units to take mentally abnormal offenders as in-patients were said to have resulted in an over-burdening of both the penal system and the special hospitals. These developments were anticipated by the Special Hospitals Working Party, 1961, and different proposals have been made to improve conditions in those areas where problems are most acute (Revised Report on Security in NHS Psychiatric Hospitals, 1974; Scott, 1974). The Butler Committee (1975) recommended that forensic psychiatric services should be established in each National Health Service region which should, wherever possible, be based on new secure units. These units should be integrated with existing hospital and community mental health services and the emphasis should be on community care and out-patient work. However, an expansion of psychiatric services
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Paul Bowden
142
for mentally disordered offenders must rest on an assessment of current practice as well as the contributions made by both individual psychiatrists and the facilities which they serve. METHOD
The survey was conducted in the South-East Thames Regional Health Authority (SETRHA) in early 1975. Eight consultants outside the region completed a questionnaire as a pilot study. Only those specialists who were concerned exclusively with child psychiatry were excluded and only one regional consultant held an appointment jointly between the Home Office and NHS. The 90 regional psychiatrists were asked for information on all patients who were under their care and were subject to either the MHA, 1959; the CP(I)A (Criminal Procedure (Insanity) Act), 1964; or the PCCA, 1973. The prevalent use of this legislation at the time of the survey was therefore ascertained and in this paper individuals subject to these orders are termed 'section' patients. Patients must have been referred from the penal, judicial or probationary systems, or from the special hospitals. It was recognized that some patients from the special hospitals were not offenders in that they had not been placed on an order by, or on, the initiative of a court. Thus, in 1969, 11 % of male admissions to the special hospitals had no criminal record or present offence. The source of patients was determined and consultants were asked how many patients were unsuitable for management in their present situation. In addition respondents described the characteristics of the separate hospitals at which they had in- or out-patient sessions and listed the contacts with prisons, special hospitals and remand facilities in the previous year. In this way it was possible to ascertain a crude 1-year rate of contact with these services; however, double-counting of individuals possibly occurred. Attitudinal questions concerned secure provisions, the use of restriction orders and the role of the special hospitals.
replied. Five reported that they were too busy to provide the necessary information and there were 3 non-responders.
PATIENTS
Of the 282 current patients, 45 % were subject to Sections 60, 65 and 72, Part V, MHA, and 31 % to Sections 25 and 26, Part IV of the same Act. One-fifth of section patients were out-patients and Section 3, PCCA (Powers of Criminal Courts Act) is mainly used for this group (Table 1). TABLE 1 CURRENT IN- OR OUT-PATIENTS BY SECTION
Total
Section
In-patient
Out-patient
72 (MHA 1959) 65 (MHA 1959) 60 (MHA 1959) 26 (MHA 1959) 25 (MHA 1959) 3 (PCC 1973)
2 46 60 62 26
10 9 — —
2 56 69 62 26
25
42
67
221
61
282
or
4 (CJA 1948)
Total
CONSULTANTS
The 82 respondents had a mean of 108 beds under their care of which 25 were short-stay beds. Thirty-four (41 %) did not have access to a permanently locked ward, 8 (9 %) were solely concerned with mental subnormality and 12 (15 %) had no in-patient beds. Excluding this latter group, the subnormality consultants have a mean of 344 beds compared with 98 for mental illness (t = 8-27, df = 68, P < 0001); they also have more section patients, a mean of 7-1/consultant for mental handicap and 2-5 for mental illness (r = 2-72, df = 68, P < 001). The mental subnormality consultants did not report any section out-patients. Thirty-four (42%) psychiatrists did not have any section patients and conversely, 3 psychiatrists accounted for 60 (21 %) of all the section patients. There is a significant correlation between the number of beds designated to a consultant and the number RESULTS of section in-patients under his care (Pearson's Coefficient, All 90 psychiatrists in the SETRHA were Product Moment Correlation circulated with the questionnaire and 83 (91 %) cc = 0-46, N = 82, P < 0001).
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The NHS practice of forensic psychiatry in one region
TYPE OF HOSPITAL
Excluding those consultants with no in-patient beds, non-teaching hospital consultants had a mean of 185 beds, teaching hospital consultants, 57 beds, and Bethlem/Maudsley consultants, 19 beds (Analysis of Variance, F = 29-122, P < 0001). In this context a teaching hospital consultant is an individual who works wholly, or partly, in a hospital classified as 'teaching' (see Management Arrangements for the Reorganised NHS, 1972), but not at the Bethlem/ Maudsley hospitals. Non-teaching hospital consultants have significantly more section inpatients, a mean of 4, compared with 2-9 for teaching hospital psychiatrists and 0-8 for those at the Bethlem/Maudsley (Analysis of Variance, F = 3-026, P < 005). Similarly non-teaching hospital consultants take more patients annually from special hospitals, a mean of 0-4 compared with 0-2 for teaching hospital consultants and 0-1 for Bethlem/Maudsley consultants (Analysis of Variance, F = 2-1, NS). TABLE2 ALTERNATIVE PLACEMENT FOR IN- AND OUT-PATIENTS
Patient
Special hospital
In-patients Out-patients Total
7 2 9
Prison 2 2 4
Regional secure unit 23 14 37
for out-patients, of which only one resulted in admission. There were 14 requests for transfer of patients from the special hospitals in the year; all 5 requests for transfer to out-patient care were accepted by regional hospitals, but only 6 of the 9 requests for transfer to inpatient beds. The number of patients accepted from the special hospitals was related to the number of in-patient beds supervised by the consultant (cc = 0-25, N = 70, P < 005). To assess a patient's suitability for treatment in a regional hospital 33 (40 %) of respondents had visited a remand centre or prison in the previous year. Of the 292 visits done (65 % by only 3 consultants), 208 patients were accepted for treatment, 158 as in-patients and 50 as outpatients. LOCKED WARDS
Excluding the 12 consultants without inpatient beds, 27 (39 %) did not have access to a permanently locked ward. This group has significantly more in-patient beds than their colleagues who have access to a locked ward, a mean of 163 compared with 102 (r = 2-29, df = 68, P < 005). TABLE 3
Total 32 18 50
ALTERNATIVE MANAGEMENT
Whether the patient was on section or not, all respondents were asked how many of their current patients would be better managed by other facilities (Table 2). Sixty-five (78%) indicated that they did not have any patients who needed different management. TRANSFER
Nineteen (23 %) of the consultants had made 24 requests for the transfer of patients to the special hospitals in 1974. Eleven requests (46 %) concerned in-patients of which 4 resulted in acceptance by the special hospital and 13 were
ANNUAL FREQUENCY OF DEFENCE/COURT REPORTS IN PERCENTAGES
None
One or two
Several
Custodial Defence Court
51 42
24 24
25 34
Non-custodial Defence Court
40 33
17 24
43 43
Type
REPORTS
The pilot survey had shown that consultants could not accurately assess the number of reports provided in the previous year, so broad quantitative categories were used (Table 3). Sixty-nine (84 %) had provided reports in 1974 of whom 17 (21 %) had only prepared 'one or two'. When nonteaching consultants were compared with the other respondents, the former group had a smaller proportion in the 'none' category and more in the ' several' group.
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ATTITUDES
Respondents were asked 6 questions (Table 4): (i) Should psychiatrists accept, as in-patients, individuals subject to an order restricting discharge? (ii) Do restriction orders demand a degree of supervision which exceeds the resources of the mental health services? (iii) Do the special hospitals provide an adequate service in accepting dangerous and/or criminal and violent patients from mental hospitals? (iv) Should mental hospitals with 200 beds or more have a permanently locked ward ? (v) Should mental hospitals with less than 200 beds have a permanently locked ward ? (vi) Should secure facilities be provided in a separate regional unit? There was no significant difference in attitudes between the following groups: non-teaching, teaching and Bethlem/Maudsley consultants; those with and without access to a permanently locked ward; consultants who did the greatest number and the fewest court reports; those who had most and least current section patients. TABLE4 RESPONSE TO ATTITUDINAL QUESTIONS IN PERCENTAGES
Question (i) Restriction orders - as inpatients (ii) Restriction orders - excess supervision (iii) Special hospitals - adequate service (iv) Large hospitals - locked ward (v) Smaller hospitals - locked ward (vi) Regional secure unit
Yes
No
Uncertain
35
45
20
59
28
13
26
51
23
55
28
17
20 81
51 11
29 8
DISCUSSION
In 1973 the population of the SETRHA was estimated at 3515085, 8 % of the population of England. At the time of this study there were 6076 beds for adult mental illness and 2752 for adult mental handicap, 1-73 and 0-78/1000 population respectively. The mental illness beds are contained in 12 psychiatric hospitals. The Bethlem/Maudsley hospitals and the 3
regional teaching hospitals together have 485 psychiatric beds. Sixteen institutions deal exclusively with mental handicap and two hospitals share facilities between mental illness and subnormality. Day hospital facilities are available at 13 centres and 34 general hospitals provide out-patient clinics. An analysis of available data on all admissions in the SETRHA shows that 64 % (70 %) 2 were to psychiatric hospitals, 19% (4-3%) to beds classified as 'teaching' and 13 % (18 %) to units in general hospitals. The courts and the police were the source of referral of 2-6 % (4-3 %) of male admissions to the region. For England, 1-3 % of male and 0-2% of female admissions were direct from either prisons, borstals or community homes and a disproportionate number of these were in the 15-35 age group (57 % compared with 34 % for all admissions). Eighty-six per cent (85%) of mental illness admissions to the region were informal: 14% under Part IV, 0-4 % under Part V, 0-3 % under Part IX, MHA, and 005 % on other sections (Psychiatric Hospitals and Units in England and Wales, 1972). Excluding the special hospitals about 4 % of the 5600 admissions of men each year to SETRHA mental illness beds are from the police, courts or penal institutions. Less than 1 % of all admissions and only 7 % of formal admissions are on the sections with which this study is concerned. The DHSS provided information which made it possible to quantify the transfer of SETRHA patients to and from the special hospitals. For the years 1969-74 an annual mean of 28 persons were admitted from the SETRHA to special hospitals: 17 direct from court, 3 from prisons and community homes and 8 from regional hospitals. A distinct trend could be identified, with an increasing proportion being admitted from court. Perhaps these patients are being admitted less from the community to mental hospitals and more frequently gain admission to special hospitals from the courts (Table 5). Hospital consultants are therefore less likely to know the patients whom they are asked to admit from the special hospitals because they were not initially transferred from their care. An increasing proportion of patients who are subject to 8
The figures in parentheses refer to England as a whole.
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The NHS practice of forensic psychiatry in one region TABLES SOURCE OF SPECIAL HOSPITALS ADMISSIONS FROM THESETRHA IN PERCENTAGES
Source
Year...
Courts Prison and approved schools Regional hospitals Community
1968
1969
1970
1971
1972
1973
1974
Af = 27 60 7 33 0
N = 22 56 22 22 0
Af = 21 57 5 38 0
Af = 41 63 10 27 0
Af = 35 63 9 28 0
N = 25 64 12 20 4
N - 22 73 9 18 0
Source of information : DHSS. TABLE6 ADMISSION OF PERSONS DETAINED IN SPECIAL HOSPITALS AND REGIONAL HOSPITALS SUBJECT TO SPECIAL RESTRICTIONS IN PERCENTAGES
Source Year. . .1965 Special hospitnl Regional hospital
1966 1
1967
1968
1969
1970
1971
1972
A' = 418
AT = 434
N = 447
N = 405
A» = 36"'
1974
1973
Af = 454
A = 368
N = 39S
42
43
38
45
43
50
57
48
48
56
58
57
62
55
58
50
43
52
52
44
Af = 405
N « 304
special restrictions are detained in the special the SETRHA, was seen as the most appropriate hospitals) rather than in regional hospitals alternative facility for three-quarters of this group. The finding that 36 % of these patients (Table 6). In 1973 a personal survey was made of 4 large were currently out-patients and yet were concustodial remand centres, Ashford, Brixton, sidered to require management in conditions of Canterbury and Holloway, all of which serve security (special hospital, prison, regional secure the SETRHA and other regions. Of the 79 unit) could reflect on the lack of current secure patients who were referred for treatment to the provisions in regional psychiatric hospitals or SETRHA in that year, 9 (12%) were under Part on the clinical judgements involved. Some conIV, MHA, 48 (60 %) under Part V of the same Act; sultants indicated that patients who were in 22 were subject to Section 3, PCCA. The present need of transfer to a special hospital were too study shows that there are nearly 300 section disturbed to be treated in beds to which they had patients in the region of whom about a third are access, or, having been admitted, that they were subject to Part IV, MHA. The inclusion of discharged from in-patient care when a request those who were accepted for treatment after a for transfer was rejected by the special hospital. In 1970 the DHSS requested each region to non-custodial remand possibly accounts for the disproportionately large number of mentally provide an estimate of the number of in-patients disordered offenders subject to Part IV, MHA, who were 'unsuitable for treatment in ordinary who are revealed by the present study in compari- psychiatric hospitals'. The Glancy Committee son to the 1973 remand centre survey. Sixty-three (Revised Report of the Working Party on per cent of respondents had done 'several' Security in NHS Psychiatric Hospitals, 1974) court or defence reports in the previous year of has commented that the results of this survey which many were on out-patients who, particu- were so varied and inconsistent that it was larly if their offence was non-imprisonable, difficult to make use of them as a reliable base for planning. However, the DHSS has provided would be treated under Part IV, MHA. the return made by the then South-East MetroThere were only 50 patients in the region who politan Regional Hospital Board in December were thought to require management in a different 1970. If only in-patients in those hospitals for setting. The proposed regional secure unit, whom a direct comparison can be made between about which there has been much discussion in PSM 7
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Paul Bowden
1970 and the present study are considered, there were 18 individuals thought unsuitable for treatment in ordinary psychiatric hospitals in 1970 and 25 in the present study who their consultant considered would be better managed in other facilities. Different degrees of authority are vested in the courts by the above mentioned Acts and they represent an agreement to share responsibility between a court and a psychiatrist. This study shows that many patients were under Part IV, MHA, which was not intended to provide for the management of such patients. Consultants, who obviously retain complete clinical independence under Part IV, and Section 60, had three main criticisms of Section 65, Part V, MHA: there were not the resources to supervise patients to the extent demanded by restriction orders; the bureaucracy involved in managing such patients was excessive and slow to take account of a changing clinical situation; the special hospitals did not provide the necessary back-up facilities. These are some of the factors which account for the consultants' reluctance to admit patients who may require transfer from regional hospitals. The SETRHA is atypical because of the relatively large number of beds designated as 'teaching' and since these tend to be in smaller units it could be expected that they would take fewer section in-patients. The ratio of patients on section to those considered suitable for alternative placement is higher for out-patients, 1:0-3 for out-patients and 1:0-1 for in-patients. The management of out-patients could therefore present more of a problem and this proposition is supported by the finding that transfer to special hospitals from out-patients is particularly difficult. There are also fewer day-patient attendances in the region, 1084/100000 population (1730/100000) which could indicate a relative lack of day-patient facilities. Contrary to the national trend, SETRHA hospitals have admitted a decreasing number of individuals who are thought to be mentally disordered and are considered to be in immediate need of care and control (Section 136, MHA). Between 1964 and 1972 there has been a 50% increase in admissions to hospitals in England of patients brought by the police on this section, from 0-56 to 0-84% of all admissions; however,
in the SETRHA, there has been a reduction from 1-3 to 0-3%. Such patients were not included in the present study because they could not be considered to be offenders. TABLE7 MEAN CHARACTERISTICS OF PATIENT POPULATION BY OPEN OR CLOSED HOSPITAL CONSULTANT
Characteristic
Open hospital consultant, W - 27
Closed hospital consultant, N = 43
Section I.P. Section O.P. Better managed elsewhere Annually to SH Annually from SH Annually from remand/prison
3-48 052 117 015 Oil 1-89
2-77 100 0-26 002 019 3-51
Although consultants in mental subnormality take significantly more section patients, when the rates are adjusted per 100 in-patients they are more comparable: 2-1 for subnormality and 2-6 for mental illness. Similarly, although consultants without access to a permanently locked ward have 50 % more beds, there are on average 2-7 section in-patients/100 beds in closed hospitals and 2-1/100 beds in completely open hospitals. Psychiatrists in open hospitals are more reluctant to manage forensic patients; they considered that more of their patients would be better managed elsewhere (e.g. prison, special hospital, regional secure unit) and they admit more patients to special hospitals but take fewer from them (Table 7). Those respondents who, in practice, were least concerned with this aspect of psychiatry did not express the most negative attitudes in the questionnaire responses and it would seem that this group is not involved for reasons other than the attitudes which were revealed in the questionnaire responses. The tendency was for those consultants who took most section patients and did most court work to be most critical of restriction orders and the special hospitals. In summary the patients with which this study is concerned represent only 2-6 % of the inpatient population and, as either in- or outpatient, 8/100000 of the population of the region. A minority of consultants had patients who, in their view, would be better managed
The NHS practice of forensic psychiatry in one region
elsewhere. In the previous year, 84 % had provided a court or defence report; 58 % had current section in-patients, 40 % had visited a prison or remand facility and one-fifth had contacted a special hospital to request the transfer of a patient. The 6 consultants who did most prison or remand facility visiting and who took the greatest number of in-patients on section worked at 4 large regional hospitals with more than 1000 beds: two consultants at each of the two largest hospitals and one at each of the two other hospitals. All four maintained a permanently locked ward. The other regional hospitals with more than 1000 beds did not have a psychiatrist who specialized in this type of work; both were completely open hospitals. The attitudinal responses suggest that respondents clearly associate the need for a constantly locked ward with the size of the hospital. The lack of such facilities in a hospital should not be interpreted as a criticism of the concept of maintaining locked wards, since 93 % of consultants in open hospitals believed that secure wards should be provided on a regional basis. In the past 7 years, 10 regional mental illness and 3 subnormality hospitals have engaged in 134 special hospital transfers, only 10 of which have been to or from hospitals with less than 400 beds. CONCLUSIONS
It is evident that there have been developments in regional psychiatric services which impede the transfer of patients to and from the courts, remand centres and special hospitals. Changes in these services and the exercise of clinical freedom have resulted in a selection of the less demanding patients in favour of regional psychiatric services (Report of the Work of the Prison Department, 1973; Bennett, 1973). A restriction order is imposed by a higher court but only with the agreement of a psychiatrist; such orders are not favoured and perhaps it is the restriction order itself rather than the patient who is subject to it, which is disliked. The increased supervision demanded by restriction orders does however provide greater control, as was shown by the Aarvold Committee (1973) which recommended an extension of the principle, with an additional
147
special assessment of restricted patients who were thought to require specially vigilant management. Although sympathetic to the problems faced by the staff, respondents were critical of the services provided by special hospitals. Patients who would have previously gained admission in the SETRHA under Section 136, MHA, are possibly being charged with offences and being remanded in custody where their transfer to regional hospitals is requested by prison medical officers. These results suggest that a large unfilled demand for psychiatric beds is from remand prisons and a study is at present in progress to determine the characteristics of those offenders who are remanded for a medical report but are not accepted for treatment in the region. The majority of psychiatrists in the region are concerned with the management of offender patients and they should be involved in the recommended development of forensic psychiatry. Some consultants specialize in this aspect of psychiatry; they work in large hospitals which maintain locked wards. The inception of regional secure units could be a catalyst for the development of existing regional services and act as a point of reference for a network of regional facilities; this model has been supported by the Butler Committee (1975) and by the DHSS (Regional Secure Units, 1975). An alternative would be that the new regional secure units would be isolated institutions like the special hospitals, but this would facilitate the disengagement of general psychiatry from the forensic aspect of its practice. Regional secure units are intended to facilitate the treatment of mentally disordered offenders in regional hospitals; to halt, and possibly reverse, the process whereby some patients are deemed unsuitable for treatment in the mainstream of psychiatry. This study shows that only 3-6/1000 in-patients were considered to be unsuitable for treatment in regional hospitals and if the new units are successful this rate should be reduced. No details are as yet available of the resources needed for those individuals who are being inadequately or inappropriately cared for in prisons and special hospitals, and in the community by health and welfare organizations; however, if forensic psychiatry is to develop in the way which has been outlined by
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the Butler Committee, it is these latter areas which the forensic psychiatrist should now investigate. I am grateful to SETRHA psychiatrists for completing the questionnaire and to the DHSS, SETRHA officers and the Special Hospitals Research Unit for providing research information. The study was supervised by Professor T. C. N. Gibbens, who, together with Mrs Elizabeth Parker and Dr John Gunn, gave valuable advice and criticism of the manuscript. The research was supported by a grant from the DHSS. REFERENCES Aarvold Committee (1973). Report on the review of procedures for the discharge and supervision of psychiatric patients subject to special restrictions. Cmnd. 5191. HMSO.
Bennett, D. (1973). An introduction to community psychiatry. Community Health 5, 58-64. Bowden, P. (1975). Liberty and psychiatry. British Medical Journal iv, 94-96. Butler Committee (1975). Report of the Committee on Mentally Abnormal Offenders. Cmnd. 6244. HMSO. And Committee on Mentally Abnormal Offenders. Interim Report (1974). HMSO: London. Glancy Committee (1974). Revised Report of the Working Party on Security in NHS Psychiatric Hospitals. DHSS. Gunn, J. (1974). Disasters, asylums and plans. British Medical Journal m, 611-613. Management arrangements for the Reorganised NHS (1972). DHSS: London. Ormrod, R. (1975). The debate between psychiatry and the law. British Journal of Psychiatry 127, 193-203. Psychiatric Hospitals and Units in England and Wales (1972). DHSS: London. Regional Secure Units. Design Guidelines (1975). DHSS. Report on the Work of the Prison Department (1973). Cmnd. 5767. HMSO: London. Scott, P. D. (1974). Solutions to the problem of the dangerous offender. British Medical Journal iv, 640-641. Special Hospitals: Report of a Working Party (1961). HMSO: London.
The NHS practice of forensic psychiatry in one region PAUL BOWDEN1 From the Institute of Psychiatry, De Crespigny Park, London
The present paper outlines the number and distribution of forensic patients within one region. In addition, attitudes to both available services and existing legislation are described. Regional and national data are compared so that the results can be used by other regions which are currently planning a development of their own forensic services.
SYNOPSIS
Three acts provide for the management of individuals who are charged with offences and are considered to have mental disorder: as a condition of probation the person can be required to submit to treatment, Section 3, Powers of Criminal Courts Act (1973); in accordance with Part V, Mental HealthAct(1959) (MHA) an order can be made for admission to, and detention in, hospital or, an individual can be found not guilty by reason of insanity or unfit to plead and the court is directed to make an order to admit the apellant to hospital, Sections 1 and 4, Criminal Procedure (Insanity) Act (1964). (The Powers of Criminal Courts Act, 1973 (PCCA), consolidated the relevant parts of the Criminal Justice Act, 1948.) In all cases the name of the hospital at which the patient is to be treated has to be entered on the order and Part 3 of the PCCA, 1973, also demands that the name of the medical practitioner who will direct treatment must be specified. The Butler Committee (Report of the Committee on Mentally Abnormal Offenders, 1975) has stated that the guiding principle in the disposal of mentally disordered offenders by the courts should be to send them wherever they can best get the treatment they need; however, in practice the admission to hospital of a patient concerned in criminal proceedings depends on a psychiatrist's willingness to accept the patient. Some observers believe that this decision is influenced more by prejudice (Bennett, 1973), and lack of resources (Gunn, 1974), than by the severity of a disorder or its amenability to treatment. In 1 Address for correspondence: Dr Paul Bowden, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF.
certain cases nursing unions have prevented the treatment of mentally disordered offenders by threatening a withdrawal of labour if they were admitted to hospital (e.g. R. V. Parker, The Court of Appeal, Criminal Division, 248/R/75). Because of the difficulty in obtaining admission for suitable cases, Lord Justice Ormrod (1975) has warned that there is a real danger that the courts will once again draw away from psychiatry. An earlier study (Bowden, 1975), in the South-East Thames Region traced the run-down of the larger mental hospitals and showed that there had been a 40 % reduction in the number of beds in constantly closed wards within the last 5 years. It was argued that these changes have resulted in a lack of facilities for mentally abnormal offenders; the increasing scarcity of lodging-house accommodation and the failure of the newer psychiatric units to take mentally abnormal offenders as in-patients were said to have resulted in an over-burdening of both the penal system and the special hospitals. These developments were anticipated by the Special Hospitals Working Party, 1961, and different proposals have been made to improve conditions in those areas where problems are most acute (Revised Report on Security in NHS Psychiatric Hospitals, 1974; Scott, 1974). The Butler Committee (1975) recommended that forensic psychiatric services should be established in each National Health Service region which should, wherever possible, be based on new secure units. These units should be integrated with existing hospital and community mental health services and the emphasis should be on community care and out-patient work. However, an expansion of psychiatric services
141
Paul Bowden
142
for mentally disordered offenders must rest on an assessment of current practice as well as the contributions made by both individual psychiatrists and the facilities which they serve. METHOD
The survey was conducted in the South-East Thames Regional Health Authority (SETRHA) in early 1975. Eight consultants outside the region completed a questionnaire as a pilot study. Only those specialists who were concerned exclusively with child psychiatry were excluded and only one regional consultant held an appointment jointly between the Home Office and NHS. The 90 regional psychiatrists were asked for information on all patients who were under their care and were subject to either the MHA, 1959; the CP(I)A (Criminal Procedure (Insanity) Act), 1964; or the PCCA, 1973. The prevalent use of this legislation at the time of the survey was therefore ascertained and in this paper individuals subject to these orders are termed 'section' patients. Patients must have been referred from the penal, judicial or probationary systems, or from the special hospitals. It was recognized that some patients from the special hospitals were not offenders in that they had not been placed on an order by, or on, the initiative of a court. Thus, in 1969, 11 % of male admissions to the special hospitals had no criminal record or present offence. The source of patients was determined and consultants were asked how many patients were unsuitable for management in their present situation. In addition respondents described the characteristics of the separate hospitals at which they had in- or out-patient sessions and listed the contacts with prisons, special hospitals and remand facilities in the previous year. In this way it was possible to ascertain a crude 1-year rate of contact with these services; however, double-counting of individuals possibly occurred. Attitudinal questions concerned secure provisions, the use of restriction orders and the role of the special hospitals.
replied. Five reported that they were too busy to provide the necessary information and there were 3 non-responders.
PATIENTS
Of the 282 current patients, 45 % were subject to Sections 60, 65 and 72, Part V, MHA, and 31 % to Sections 25 and 26, Part IV of the same Act. One-fifth of section patients were out-patients and Section 3, PCCA (Powers of Criminal Courts Act) is mainly used for this group (Table 1). TABLE 1 CURRENT IN- OR OUT-PATIENTS BY SECTION
Total
Section
In-patient
Out-patient
72 (MHA 1959) 65 (MHA 1959) 60 (MHA 1959) 26 (MHA 1959) 25 (MHA 1959) 3 (PCC 1973)
2 46 60 62 26
10 9 — —
2 56 69 62 26
25
42
67
221
61
282
or
4 (CJA 1948)
Total
CONSULTANTS
The 82 respondents had a mean of 108 beds under their care of which 25 were short-stay beds. Thirty-four (41 %) did not have access to a permanently locked ward, 8 (9 %) were solely concerned with mental subnormality and 12 (15 %) had no in-patient beds. Excluding this latter group, the subnormality consultants have a mean of 344 beds compared with 98 for mental illness (t = 8-27, df = 68, P < 0001); they also have more section patients, a mean of 7-1/consultant for mental handicap and 2-5 for mental illness (r = 2-72, df = 68, P < 001). The mental subnormality consultants did not report any section out-patients. Thirty-four (42%) psychiatrists did not have any section patients and conversely, 3 psychiatrists accounted for 60 (21 %) of all the section patients. There is a significant correlation between the number of beds designated to a consultant and the number RESULTS of section in-patients under his care (Pearson's Coefficient, All 90 psychiatrists in the SETRHA were Product Moment Correlation circulated with the questionnaire and 83 (91 %) cc = 0-46, N = 82, P < 0001).
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The NHS practice of forensic psychiatry in one region
TYPE OF HOSPITAL
Excluding those consultants with no in-patient beds, non-teaching hospital consultants had a mean of 185 beds, teaching hospital consultants, 57 beds, and Bethlem/Maudsley consultants, 19 beds (Analysis of Variance, F = 29-122, P < 0001). In this context a teaching hospital consultant is an individual who works wholly, or partly, in a hospital classified as 'teaching' (see Management Arrangements for the Reorganised NHS, 1972), but not at the Bethlem/ Maudsley hospitals. Non-teaching hospital consultants have significantly more section inpatients, a mean of 4, compared with 2-9 for teaching hospital psychiatrists and 0-8 for those at the Bethlem/Maudsley (Analysis of Variance, F = 3-026, P < 005). Similarly non-teaching hospital consultants take more patients annually from special hospitals, a mean of 0-4 compared with 0-2 for teaching hospital consultants and 0-1 for Bethlem/Maudsley consultants (Analysis of Variance, F = 2-1, NS). TABLE2 ALTERNATIVE PLACEMENT FOR IN- AND OUT-PATIENTS
Patient
Special hospital
In-patients Out-patients Total
7 2 9
Prison 2 2 4
Regional secure unit 23 14 37
for out-patients, of which only one resulted in admission. There were 14 requests for transfer of patients from the special hospitals in the year; all 5 requests for transfer to out-patient care were accepted by regional hospitals, but only 6 of the 9 requests for transfer to inpatient beds. The number of patients accepted from the special hospitals was related to the number of in-patient beds supervised by the consultant (cc = 0-25, N = 70, P < 005). To assess a patient's suitability for treatment in a regional hospital 33 (40 %) of respondents had visited a remand centre or prison in the previous year. Of the 292 visits done (65 % by only 3 consultants), 208 patients were accepted for treatment, 158 as in-patients and 50 as outpatients. LOCKED WARDS
Excluding the 12 consultants without inpatient beds, 27 (39 %) did not have access to a permanently locked ward. This group has significantly more in-patient beds than their colleagues who have access to a locked ward, a mean of 163 compared with 102 (r = 2-29, df = 68, P < 005). TABLE 3
Total 32 18 50
ALTERNATIVE MANAGEMENT
Whether the patient was on section or not, all respondents were asked how many of their current patients would be better managed by other facilities (Table 2). Sixty-five (78%) indicated that they did not have any patients who needed different management. TRANSFER
Nineteen (23 %) of the consultants had made 24 requests for the transfer of patients to the special hospitals in 1974. Eleven requests (46 %) concerned in-patients of which 4 resulted in acceptance by the special hospital and 13 were
ANNUAL FREQUENCY OF DEFENCE/COURT REPORTS IN PERCENTAGES
None
One or two
Several
Custodial Defence Court
51 42
24 24
25 34
Non-custodial Defence Court
40 33
17 24
43 43
Type
REPORTS
The pilot survey had shown that consultants could not accurately assess the number of reports provided in the previous year, so broad quantitative categories were used (Table 3). Sixty-nine (84 %) had provided reports in 1974 of whom 17 (21 %) had only prepared 'one or two'. When nonteaching consultants were compared with the other respondents, the former group had a smaller proportion in the 'none' category and more in the ' several' group.
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ATTITUDES
Respondents were asked 6 questions (Table 4): (i) Should psychiatrists accept, as in-patients, individuals subject to an order restricting discharge? (ii) Do restriction orders demand a degree of supervision which exceeds the resources of the mental health services? (iii) Do the special hospitals provide an adequate service in accepting dangerous and/or criminal and violent patients from mental hospitals? (iv) Should mental hospitals with 200 beds or more have a permanently locked ward ? (v) Should mental hospitals with less than 200 beds have a permanently locked ward ? (vi) Should secure facilities be provided in a separate regional unit? There was no significant difference in attitudes between the following groups: non-teaching, teaching and Bethlem/Maudsley consultants; those with and without access to a permanently locked ward; consultants who did the greatest number and the fewest court reports; those who had most and least current section patients. TABLE4 RESPONSE TO ATTITUDINAL QUESTIONS IN PERCENTAGES
Question (i) Restriction orders - as inpatients (ii) Restriction orders - excess supervision (iii) Special hospitals - adequate service (iv) Large hospitals - locked ward (v) Smaller hospitals - locked ward (vi) Regional secure unit
Yes
No
Uncertain
35
45
20
59
28
13
26
51
23
55
28
17
20 81
51 11
29 8
DISCUSSION
In 1973 the population of the SETRHA was estimated at 3515085, 8 % of the population of England. At the time of this study there were 6076 beds for adult mental illness and 2752 for adult mental handicap, 1-73 and 0-78/1000 population respectively. The mental illness beds are contained in 12 psychiatric hospitals. The Bethlem/Maudsley hospitals and the 3
regional teaching hospitals together have 485 psychiatric beds. Sixteen institutions deal exclusively with mental handicap and two hospitals share facilities between mental illness and subnormality. Day hospital facilities are available at 13 centres and 34 general hospitals provide out-patient clinics. An analysis of available data on all admissions in the SETRHA shows that 64 % (70 %) 2 were to psychiatric hospitals, 19% (4-3%) to beds classified as 'teaching' and 13 % (18 %) to units in general hospitals. The courts and the police were the source of referral of 2-6 % (4-3 %) of male admissions to the region. For England, 1-3 % of male and 0-2% of female admissions were direct from either prisons, borstals or community homes and a disproportionate number of these were in the 15-35 age group (57 % compared with 34 % for all admissions). Eighty-six per cent (85%) of mental illness admissions to the region were informal: 14% under Part IV, 0-4 % under Part V, 0-3 % under Part IX, MHA, and 005 % on other sections (Psychiatric Hospitals and Units in England and Wales, 1972). Excluding the special hospitals about 4 % of the 5600 admissions of men each year to SETRHA mental illness beds are from the police, courts or penal institutions. Less than 1 % of all admissions and only 7 % of formal admissions are on the sections with which this study is concerned. The DHSS provided information which made it possible to quantify the transfer of SETRHA patients to and from the special hospitals. For the years 1969-74 an annual mean of 28 persons were admitted from the SETRHA to special hospitals: 17 direct from court, 3 from prisons and community homes and 8 from regional hospitals. A distinct trend could be identified, with an increasing proportion being admitted from court. Perhaps these patients are being admitted less from the community to mental hospitals and more frequently gain admission to special hospitals from the courts (Table 5). Hospital consultants are therefore less likely to know the patients whom they are asked to admit from the special hospitals because they were not initially transferred from their care. An increasing proportion of patients who are subject to 8
The figures in parentheses refer to England as a whole.
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The NHS practice of forensic psychiatry in one region TABLES SOURCE OF SPECIAL HOSPITALS ADMISSIONS FROM THESETRHA IN PERCENTAGES
Source
Year...
Courts Prison and approved schools Regional hospitals Community
1968
1969
1970
1971
1972
1973
1974
Af = 27 60 7 33 0
N = 22 56 22 22 0
Af = 21 57 5 38 0
Af = 41 63 10 27 0
Af = 35 63 9 28 0
N = 25 64 12 20 4
N - 22 73 9 18 0
Source of information : DHSS. TABLE6 ADMISSION OF PERSONS DETAINED IN SPECIAL HOSPITALS AND REGIONAL HOSPITALS SUBJECT TO SPECIAL RESTRICTIONS IN PERCENTAGES
Source Year. . .1965 Special hospitnl Regional hospital
1966 1
1967
1968
1969
1970
1971
1972
A' = 418
AT = 434
N = 447
N = 405
A» = 36"'
1974
1973
Af = 454
A = 368
N = 39S
42
43
38
45
43
50
57
48
48
56
58
57
62
55
58
50
43
52
52
44
Af = 405
N « 304
special restrictions are detained in the special the SETRHA, was seen as the most appropriate hospitals) rather than in regional hospitals alternative facility for three-quarters of this group. The finding that 36 % of these patients (Table 6). In 1973 a personal survey was made of 4 large were currently out-patients and yet were concustodial remand centres, Ashford, Brixton, sidered to require management in conditions of Canterbury and Holloway, all of which serve security (special hospital, prison, regional secure the SETRHA and other regions. Of the 79 unit) could reflect on the lack of current secure patients who were referred for treatment to the provisions in regional psychiatric hospitals or SETRHA in that year, 9 (12%) were under Part on the clinical judgements involved. Some conIV, MHA, 48 (60 %) under Part V of the same Act; sultants indicated that patients who were in 22 were subject to Section 3, PCCA. The present need of transfer to a special hospital were too study shows that there are nearly 300 section disturbed to be treated in beds to which they had patients in the region of whom about a third are access, or, having been admitted, that they were subject to Part IV, MHA. The inclusion of discharged from in-patient care when a request those who were accepted for treatment after a for transfer was rejected by the special hospital. In 1970 the DHSS requested each region to non-custodial remand possibly accounts for the disproportionately large number of mentally provide an estimate of the number of in-patients disordered offenders subject to Part IV, MHA, who were 'unsuitable for treatment in ordinary who are revealed by the present study in compari- psychiatric hospitals'. The Glancy Committee son to the 1973 remand centre survey. Sixty-three (Revised Report of the Working Party on per cent of respondents had done 'several' Security in NHS Psychiatric Hospitals, 1974) court or defence reports in the previous year of has commented that the results of this survey which many were on out-patients who, particu- were so varied and inconsistent that it was larly if their offence was non-imprisonable, difficult to make use of them as a reliable base for planning. However, the DHSS has provided would be treated under Part IV, MHA. the return made by the then South-East MetroThere were only 50 patients in the region who politan Regional Hospital Board in December were thought to require management in a different 1970. If only in-patients in those hospitals for setting. The proposed regional secure unit, whom a direct comparison can be made between about which there has been much discussion in PSM 7
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1970 and the present study are considered, there were 18 individuals thought unsuitable for treatment in ordinary psychiatric hospitals in 1970 and 25 in the present study who their consultant considered would be better managed in other facilities. Different degrees of authority are vested in the courts by the above mentioned Acts and they represent an agreement to share responsibility between a court and a psychiatrist. This study shows that many patients were under Part IV, MHA, which was not intended to provide for the management of such patients. Consultants, who obviously retain complete clinical independence under Part IV, and Section 60, had three main criticisms of Section 65, Part V, MHA: there were not the resources to supervise patients to the extent demanded by restriction orders; the bureaucracy involved in managing such patients was excessive and slow to take account of a changing clinical situation; the special hospitals did not provide the necessary back-up facilities. These are some of the factors which account for the consultants' reluctance to admit patients who may require transfer from regional hospitals. The SETRHA is atypical because of the relatively large number of beds designated as 'teaching' and since these tend to be in smaller units it could be expected that they would take fewer section in-patients. The ratio of patients on section to those considered suitable for alternative placement is higher for out-patients, 1:0-3 for out-patients and 1:0-1 for in-patients. The management of out-patients could therefore present more of a problem and this proposition is supported by the finding that transfer to special hospitals from out-patients is particularly difficult. There are also fewer day-patient attendances in the region, 1084/100000 population (1730/100000) which could indicate a relative lack of day-patient facilities. Contrary to the national trend, SETRHA hospitals have admitted a decreasing number of individuals who are thought to be mentally disordered and are considered to be in immediate need of care and control (Section 136, MHA). Between 1964 and 1972 there has been a 50% increase in admissions to hospitals in England of patients brought by the police on this section, from 0-56 to 0-84% of all admissions; however,
in the SETRHA, there has been a reduction from 1-3 to 0-3%. Such patients were not included in the present study because they could not be considered to be offenders. TABLE7 MEAN CHARACTERISTICS OF PATIENT POPULATION BY OPEN OR CLOSED HOSPITAL CONSULTANT
Characteristic
Open hospital consultant, W - 27
Closed hospital consultant, N = 43
Section I.P. Section O.P. Better managed elsewhere Annually to SH Annually from SH Annually from remand/prison
3-48 052 117 015 Oil 1-89
2-77 100 0-26 002 019 3-51
Although consultants in mental subnormality take significantly more section patients, when the rates are adjusted per 100 in-patients they are more comparable: 2-1 for subnormality and 2-6 for mental illness. Similarly, although consultants without access to a permanently locked ward have 50 % more beds, there are on average 2-7 section in-patients/100 beds in closed hospitals and 2-1/100 beds in completely open hospitals. Psychiatrists in open hospitals are more reluctant to manage forensic patients; they considered that more of their patients would be better managed elsewhere (e.g. prison, special hospital, regional secure unit) and they admit more patients to special hospitals but take fewer from them (Table 7). Those respondents who, in practice, were least concerned with this aspect of psychiatry did not express the most negative attitudes in the questionnaire responses and it would seem that this group is not involved for reasons other than the attitudes which were revealed in the questionnaire responses. The tendency was for those consultants who took most section patients and did most court work to be most critical of restriction orders and the special hospitals. In summary the patients with which this study is concerned represent only 2-6 % of the inpatient population and, as either in- or outpatient, 8/100000 of the population of the region. A minority of consultants had patients who, in their view, would be better managed
The NHS practice of forensic psychiatry in one region
elsewhere. In the previous year, 84 % had provided a court or defence report; 58 % had current section in-patients, 40 % had visited a prison or remand facility and one-fifth had contacted a special hospital to request the transfer of a patient. The 6 consultants who did most prison or remand facility visiting and who took the greatest number of in-patients on section worked at 4 large regional hospitals with more than 1000 beds: two consultants at each of the two largest hospitals and one at each of the two other hospitals. All four maintained a permanently locked ward. The other regional hospitals with more than 1000 beds did not have a psychiatrist who specialized in this type of work; both were completely open hospitals. The attitudinal responses suggest that respondents clearly associate the need for a constantly locked ward with the size of the hospital. The lack of such facilities in a hospital should not be interpreted as a criticism of the concept of maintaining locked wards, since 93 % of consultants in open hospitals believed that secure wards should be provided on a regional basis. In the past 7 years, 10 regional mental illness and 3 subnormality hospitals have engaged in 134 special hospital transfers, only 10 of which have been to or from hospitals with less than 400 beds. CONCLUSIONS
It is evident that there have been developments in regional psychiatric services which impede the transfer of patients to and from the courts, remand centres and special hospitals. Changes in these services and the exercise of clinical freedom have resulted in a selection of the less demanding patients in favour of regional psychiatric services (Report of the Work of the Prison Department, 1973; Bennett, 1973). A restriction order is imposed by a higher court but only with the agreement of a psychiatrist; such orders are not favoured and perhaps it is the restriction order itself rather than the patient who is subject to it, which is disliked. The increased supervision demanded by restriction orders does however provide greater control, as was shown by the Aarvold Committee (1973) which recommended an extension of the principle, with an additional
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special assessment of restricted patients who were thought to require specially vigilant management. Although sympathetic to the problems faced by the staff, respondents were critical of the services provided by special hospitals. Patients who would have previously gained admission in the SETRHA under Section 136, MHA, are possibly being charged with offences and being remanded in custody where their transfer to regional hospitals is requested by prison medical officers. These results suggest that a large unfilled demand for psychiatric beds is from remand prisons and a study is at present in progress to determine the characteristics of those offenders who are remanded for a medical report but are not accepted for treatment in the region. The majority of psychiatrists in the region are concerned with the management of offender patients and they should be involved in the recommended development of forensic psychiatry. Some consultants specialize in this aspect of psychiatry; they work in large hospitals which maintain locked wards. The inception of regional secure units could be a catalyst for the development of existing regional services and act as a point of reference for a network of regional facilities; this model has been supported by the Butler Committee (1975) and by the DHSS (Regional Secure Units, 1975). An alternative would be that the new regional secure units would be isolated institutions like the special hospitals, but this would facilitate the disengagement of general psychiatry from the forensic aspect of its practice. Regional secure units are intended to facilitate the treatment of mentally disordered offenders in regional hospitals; to halt, and possibly reverse, the process whereby some patients are deemed unsuitable for treatment in the mainstream of psychiatry. This study shows that only 3-6/1000 in-patients were considered to be unsuitable for treatment in regional hospitals and if the new units are successful this rate should be reduced. No details are as yet available of the resources needed for those individuals who are being inadequately or inappropriately cared for in prisons and special hospitals, and in the community by health and welfare organizations; however, if forensic psychiatry is to develop in the way which has been outlined by
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the Butler Committee, it is these latter areas which the forensic psychiatrist should now investigate. I am grateful to SETRHA psychiatrists for completing the questionnaire and to the DHSS, SETRHA officers and the Special Hospitals Research Unit for providing research information. The study was supervised by Professor T. C. N. Gibbens, who, together with Mrs Elizabeth Parker and Dr John Gunn, gave valuable advice and criticism of the manuscript. The research was supported by a grant from the DHSS. REFERENCES Aarvold Committee (1973). Report on the review of procedures for the discharge and supervision of psychiatric patients subject to special restrictions. Cmnd. 5191. HMSO.
Bennett, D. (1973). An introduction to community psychiatry. Community Health 5, 58-64. Bowden, P. (1975). Liberty and psychiatry. British Medical Journal iv, 94-96. Butler Committee (1975). Report of the Committee on Mentally Abnormal Offenders. Cmnd. 6244. HMSO. And Committee on Mentally Abnormal Offenders. Interim Report (1974). HMSO: London. Glancy Committee (1974). Revised Report of the Working Party on Security in NHS Psychiatric Hospitals. DHSS. Gunn, J. (1974). Disasters, asylums and plans. British Medical Journal m, 611-613. Management arrangements for the Reorganised NHS (1972). DHSS: London. Ormrod, R. (1975). The debate between psychiatry and the law. British Journal of Psychiatry 127, 193-203. Psychiatric Hospitals and Units in England and Wales (1972). DHSS: London. Regional Secure Units. Design Guidelines (1975). DHSS. Report on the Work of the Prison Department (1973). Cmnd. 5767. HMSO: London. Scott, P. D. (1974). Solutions to the problem of the dangerous offender. British Medical Journal iv, 640-641. Special Hospitals: Report of a Working Party (1961). HMSO: London.
