Feature

Part of the problem, not the solution

The inquiry into abuses at Ashworth has provoked calls for reform of the special hospitals. But the only way to avoid yet another scandal of abuse is to close the hospitals down, says David Pilgrim

The recent report of the maltreatment of patients at Ashworth special hospital on Merseyside is merely the latest indictment of the special hospital system. In 1980 the Boynton Report reviewed the abuse of patients at Rampton after nearly one thousand cases had been referred to the director of public prosecutions, and a series of black patients died at the hands of trained psychiatric nurses in Broadmoor hospital during the 1980s.

Both the Ashworth and the Rampton inquiries followed investigative television documentaries, suggesting that in the absence of journalistic interest, the special hospitals would have remained a closed and sinister world. Neither the professional bodies of hospital staff nor the Mental Health Act Commission (MHAC), the independent watchdog set up by the then DHSS in the wake of the 1983 Mental Health Act, have reversed an established pattern of neglect and abuse.

What is the future for secure psychiatric treatment, given this sad state of affairs? First, policymakers of all political persuasions must reject any role for the Prison Officers Association (POA) in psychiatric care. The POA refused to co-operate with the Ashworth inquiry and was cynical and hypocritical in its reaction to the report. When complaints have been made against individual members, the POA’s policy has been either to refuse to co-operate with investigations, or to respond only to police inquiries. The whole ideology of the union is anti-therapeutic, custodial and authoritarian.

Second, the majority of the medical and nursing staff in the special hospitals have now been shown to be indifferent to the norms of the callous regime which pays them. While only a minority have been implicated directly in assaults on patients, most have acted with a degree of complicity. In March of this year, Detective Inspector Barnfather of the Nottinghamshire police said: ‘During the last six years, to the best of my knowledge, not one staff member in Rampton hospital has been prepared to acknowledge openly the fault or wrongful actions of another. No staff member has ever made a statement to the police which would be construed as supportive of a patient’s complaint.’

The Department of Health (DoH) must address not only the role of the POA, but also this regressive staff culture, which would probably persevere under any trade union umbrella. New staff, untainted by the old culture, must be recruited. A policy of openness needs to be engendered, with staff rewarded rather than punished for being ‘whistleblowers’. Of course, the recent treatments of Graham Pink in Stockport and Chris Chapman in Leeds do not augur well for the future. A tiny minority of staff from all disciplines at Ashworth have spoken out over the past few years, but they have had to suffer abuse and threats from ‘colleagues’ as a result.

Third, the effectiveness of the MHAC should be reviewed. It may have become part of the problem rather than part of the solution. Since Victorian times, governments have had a recurring but unfounded faith in inspection bodies. For all the visits, the documentation, and the expense account living of its members, the value of the MHAC remains unproven. As the evidence now shows, since 1984 patients in special hospitals have been abused, and have died under suspicious circumstances. Because its remit is to investigate only individual cases, the MHAC diverts attention from the need to ask wider organisational questions. One such question, which has had to wait until the Ashworth inquiry, is whether or not, in principle, the special hospitals are reformable at all. The cumulative evidence now points unambiguously to a system which is oversized, physically and professionally isolated, and impenetrable to public scrutiny and corrective action.

It is now clear that the special hospitals should be closed down and replaced by smaller units, accountable to local health authorities and offering flexible levels of security. At present, about one fifth of the 1,700 patients in the special hospitals are awaiting discharge. The system has had a net outflow of patients over the last 20 years, and could be said to be running itself down in any case. This run down could be encouraged by two policy initiatives.

First, all those offender patients admitted with a ‘psychopathic disorder’ should from now on be contained in prison, with a designated sentence. This group, mainly murderers, sex offenders and arsonists, are not insane, but they lack control over their anti-social impulses. The response should be one of preventative detention -- sentencing -- and education about their bad habits, if they seek it during or after their sentence. Medical treatment of such people is only minimally effective. Indeed, many mental health professionals consider psychopathy untreatable.

Second, those patients who have learning difficulties, many of whom have never offended but were difficult to manage in NHS settings, should not be in conditions of maximum security. These patients have mainly accumulated on the two worst sites of a bad system, Rampton and Ashworth South (previously Moss Side hospital). The DoH has an obligation to ensure that people with learning difficulties and challenging behaviour are not locked up like prisoners. This would leave the third main legal category of people, those with mental illness, to be dealt with by an expanded role for the regional secure units.

Unless the special hospitals are closed, it is only a matter of time before we witness yet another damning report, like the Ashworth inquiry, detailing horrific and shameful examples of patient abuse.