WEDNESDAY 24 MAY 2000

THE RT HON ALAN MILBURN MP, MR JOHN HUTTON MP AND THE RT HON PAUL BOATENG MP

  720. Finally, I would like your comments on Peter Fallon's recommendation for reviewable sentences. Do you think that is a reasonable option? Somebody could have their risk assessed on an on-going basis and, if necessary, their sentence reviewed and extended and extended, if they were felt to be at significant risk before they were released, rather than under the current situation where they are often released knowing they are a danger.
  (Mr Boateng) What one would say to that is, of course, that is not inconsistent in any event in terms of what potentially might happen with the discretionary life sentence. It is not inconsistent with that. We do not believe that that proposal deals with the whole situation because it does not enable us to develop the sort of services we are very anxious to develop—Health and Prison Service together—around the needs of people with severe personality disorder. One of the great advantages, whether it is an Option A or an Option B, is a whole range of service enhancement gains. So although my first concern has to be the safety of the public, one of the reasons why Health and the Home Office have worked so well in this area is because we do see here too the needs of the offender, the needs of the person who suffers from the severe personality disorder, being better met as a result of this joint work, the development of a risk assessment tool, the piloting which is going on in our two services. Peter Fallon's proposal, while one understands why he makes it, does not enable that to happen, nor does it deal with that group of people whom I have described, some 300 to 600, who are currently out in the community whom we need to deal with if we are to protect the public.

  721. I am getting increasingly confused because you are describing two quite separate circumstances. One is someone who has offended, been through prison, refused therapeutic intervention quite often, and at the moment you have not got the powers and you want to acquire powers and I think that is perfectly right under the criminal justice system. But we are really talking about another group where I was surprised that you said this was a criminal justice issue which is to pre-empt danger to the public, after risk assessment, and compulsorily detain someone under the criminal justice system. That, I think, is quite a different issue. Your comments on the European Convention of Human Rights were interesting because that does also make reference to therapeutic intervention and this is why clearly in the Netherlands they have gone very strongly for that. I must say I seldom agree with anything the Home Secretary says but his opinion of psychiatrists I do rather agree with. The actual question is, do you not think you have to base your criminal justice legislative framework on a therapeutic intervention possibility, because otherwise you do not have a hope in hell's chance of it actually sticking? It is not really a criminal justice issue, it is a therapeutic and therefore health issue.
  (Mr Boateng) I am not sure this is a particularly helpful approach to the problem which I accept exists, and this is a very complex area, with that very, very small group of people who are out there in the community at the moment, who do not and would not necessarily access this system, whether we go for Option A or Option B, through the current criminal justice process or through the current or indeed even an amended, to remove the condition of treatability, Mental Health Act. There is a small group of people, very small, who are out there in the community. We would not intend that that group should be detained in anything other than an environment that, whilst it was not a hospital, was not a prison either. So there would be a context in which they would be held and subject to a range of interventions, some of them of a therapeutic rather than an overtly clinical nature.

  722. But surely the justification for holding them would be that there is an intervention that is likely to be therapeutic?
  (Mr Boateng) No. The justification for holding them, and this is why I make the remark I do about the necessity in some instances for a form of preventative detention, is that they present a real and present danger to the public and cannot be released until such time, if ever, that risk has been minimised.

  Dr Brand: Mr Chairman, I think this may be a very good issue for pre-legislative scrutiny because I can see great difficulties in this. No doubt you have had lots of advice but it would be very helpful, if we can use that process for something as uncontroversial as the Food Standards Agency, to have a one-off Select Committee look at this because it does raise incredibly important civil liberty issues. Whereas I have every confidence in a British Government applying this sort of reasoning reasonably—

  Chairman: We could have Mr Boateng back again!

  723. —even where Mr Boateng is so powerful in the Home Office, it does open up all sorts of worries. This is how Russia ran their mental hospitals.
  (Mr Boateng) I think that is slightly over-egging the pudding, Dr Brand, if I may say so; uncharacteristically so. It is almost inconceivable that this would apply to somebody who had never had any previous contact with the criminal justice system. I do think that point ought to be made. It is almost inconceivable that this would apply to someone who had not had previous contact with the criminal justice system, but the evidence, such as it is, is that it might be possible for somebody who had not to be caught under the provisions that we propose under the new regime, either in relation to Option A or Option B. But if that were the case, then the justification would be subject to the most rigorous scrutiny through the review and the appeals procedure, would in any event be subject to that scrutiny, but would in any event be subject too to a process whose justification would be public protection. This is an issue around public protection rather than an issue in relation to treatability or mental health. I would end my answer on the basis, because it is very important to understand the rationale behind the provision, that the mental disorder link with public protection and risk to the public is justifiable under the ECHR.

  Chairman: I am conscious that we were hoping to try and finish by half past six and there is a whole range of areas we would still like to touch on.

  724. Before doing that, Chairman, and I do not want the three members to comment on it, can I just say that we had an excellent visit to Belmarsh, which was opened in 1991, yesterday, and Bracton, opened in 1984. Although we will not expand on it, they certainly were concerned about the whole issue you have just been discussing, and I think there was some sort of video link after it had taken place whereby it was suggested that heads be knocked together because they were not singing the same song, but I want you to reflect on the views from those two excellent establishments. Gentlemen, you are only too well aware there seems to be a shortage of services for helping young and adolescent people, and in particular there is a problem when people move on from the adolescent stage to the adult services; a big gap there. Those problems are compounded by the cut-off age of 16, 18 or 21. Officials have given us evidence telling us that they did not necessarily think, when it was suggested we had a cut-off point of 18, that was good. They suggested that the present system was suitable because of the flexibility that it enjoyed although we seemed to have contradictory evidence about that. I just wondered what your views would be on the youth service which would deal with late adolescents and people in their early 20s when conditions of schizophrenia and others seem to develop. I think the overall view of the Committee was that youngsters seem to be slipping—and this is not an original statement—through the system and this is particularly impacting in the realms of offending.
  (Mr Hutton) I think there is a problem here and we acknowledge that but I would say there is a number of difficulties we need to make some further progress on before we can be confident that the options you are proposing and others are proposing will sort this out. Firstly, there is no absolute consensus about what the cut-off or the transitional age should be between youth services or children services and adult services. The other problem is, should we be using rigid chronological ages as being the threshold for transition from young person services into adult services because, of course, as we all know from our own experience, somebody who is 16 may actually have very different emotional needs from someone who is 18 and in fact the person who is 18 may actually present as a person with much younger problems. So there is a problem about that, we are looking at a range of proposals which have been put forward by groups like Young Minds and others to see what further progress we can make there. I would just draw the Committee's attention, very briefly, to the National Service Framework which made a number of recommendations to get local agreements in place to cover some of these concerns. I think we will make more progress in this area thanks to the significant investment which is going into child and adolescent mental health services, £90 million over three years, a big investment, and it will allow us to turn round some of the historic problems we inherited. I have to say that one of the problems we inherited when we came into government was that the actual number of beds, just one aspect of the service, had almost halved in number in the preceding two years. We have to turn that round. There are other issues we need to address too, but I think the new money and the new focus in the National Service Framework and the desire generally on our part to address these issues means we will make some real progress.
  (Mr Boateng) I would endorse what John Hutton has said because it does have, as Mr Amess indicated, implications for young, young offenders, and it will be very important, and we are working hard to ensure this happens, that the youth offending teams are able effectively to draw on the experience and expertise of the local health service in terms of their work and their intervention in the youth justice system. But also, and the Secretary of State was referring to this earlier, as we get the community mental health teams working more in prisons—and they are going to be coming in, working not only in the health centres but, particularly importantly, on the wings—it will be important that we target that group of people who do not necessarily fit in between the old definition of 18 to 21 but who may be 23, 24, 25 but who are held within the prison system who do have very real mental health needs which are currently not always picked up, either by the Prison Service or by the NHS.
  (Mr Hutton) One issue we are very keen to address is the inappropriate placement of young people on adult acute psychiatric wards. That is a very serious issue and some of the extra money which is going into these service areas will hopefully minimise that, but it is something which is of very real concern and I think we are making good progress in providing extra capacity in that part of the service, and that is a very positive development.

  725. With only three minutes left, Chairman, I will not be provoked about shortage of beds, just simply to reflect that we visited two excellent establishments founded in 1991 and 1984, and I am sure you get the point I am making there. You are not ruling out the youth service?
  (Mr Hutton) No, but I think it may not be quite as simple as that.

  726. But it is not being ruled out?
  (Mr Hutton) The important thing is to get the transition right from young person's services to adult services and I think there may be a variety of different—
  (Mr Milburn) That is why the NSF, for example, stipulates to the local health services on this cusp between adolescent services and adult services, but there have to be protocols for managing the transition between the two and, in particular, this crucial issue about young people being inappropriately placed on adult wards. The message which the NSF sends out is that should be minimised. Of course it should, it is just inappropriate. But over time we can solve that problem as we grow the capacity.

  Mr Gunnell: There is some good work in North Birmingham where they have an integrated approach, where young people move smoothly into getting help when they need it, at the point when they start to need it.

  727. A final point about Young Minds, they said that even to use the term "adolescent psychiatric services" was a misnomer, because they thought that specialist services were so rare in that group. Would you agree that this amounts to a form of treatment by post code and how do you intend to deal with the enormous variation in service—in one and a half minutes?
  (Mr Hutton) I will try and keep a very straight face as I try and deal with that question because I have to say that was the legacy we inherited. We are addressing exactly that problem. It was, I am afraid to say, Mr Amess, your party's contribution to the National Health Service and we are going to be the ones to sort that out.

  Chairman: Can we just squeeze in a couple of quick questions on the special hospitals and secure services? I know Eileen wants to speak briefly on women and I think Peter wants to say something. What I wanted to press you on was the concern I have had over a long period of time that we have had report after report, the Reed Report in particular, we had Dr John Reed here at the Committee last week, we had the Fallon Inquiry which made specific recommendations with regard to effectively breaking up the Specials and moving towards a regionalised provision. Is it right that I draw the conclusion that that will never happen under any Government because of the political difficulties of developing regional secure units within localised areas? That is my question but what I would like to do is to bring my colleagues in and perhaps you can answer all the questions at the same time.

  Mrs Gordon: I could go on for hours about women's services and I am glad, Secretary of State, you mentioned that earlier as being one of the priorities. One of the things which is most depressing and shocking is the number of women in special hospitals inappropriately who really should not be there, and some in pre-discharge wards certainly in Broadmoor for years. It is just awful. Part of the problem is that there is a kind of gender blindness, that they are just lumped in with the men's services without any special consideration for their special needs. One of the terrible things is that one of the new security directives is limiting child access. This was obviously done for a good reason after Ashworth and the inquiry there and obviously that needed to be done but it applied to a specific group of men and yet it is being applied to women as well so they are now having limited access to children and relatives. It just seems a gross misjustice that they are being covered with this blanket security when they did not cause the problem in the first place and indeed most of them should not be there to begin with. I wondered if you would look at that, the access to their children and the whole direction of looking at women's needs. The other thing is that I understand there was a move to produce a strategy on women's secure services, a national strategy, and I would like to know what has happened to that and when it is going to come into being.

  728. Very briefly because it relates to that, we have already discussed inappropriate placements, the Secretary of State said there would be an extra 200 beds on top of the 500, as I understand, and that of course is extremely welcome, but I am disappointed that in the memorandum from the Department we have got costings for the cost of a secure bed but it is not possible for us to have a figure for a medium secure or low secure facility. If you are planning them, you are costing them, and presumably there are some figures available. There are no figures for the average cost of treating a psychiatrically-ill person in a prison. It would be quite helpful if a little more work was done on that, because I know a lot of resources are spent sectioning prisoners with suicide risk, so we can also strengthen the economic argument as well as the clinical argument. The evidence we have had from Dr Reed confirms that there are 500 people probably in the Prison Service who ought to move on and that there are at least 400 people—this is from the people running the special hospitals—in the special hospitals, so the shortfall is more likely to be 900 than 700. But one cannot ask for everything all the time, even I would not do that.
  (Mr Milburn) That is very generous of you, if I may say so!

  729. Until we have the extra penny.
  (Mr Milburn) That will solve all the problems, as you keep telling us. On this issue of the number of people who are wrongly placed in the system, that was our starting point this afternoon, and it is certainly true. Just a word of caution, yes, there are problems with those who are, if you like, in the discharge system within the three high security hospitals, that is true, but there is, as you know, a huge process which has to be gone through to ensure that they can be discharged, and there are rather fewer who have gone through that process and are waiting for placement—around 60, I think, who have got Home Office approval overall. So we do recognise that there is a problem, of course there is, and there is a lot of people who are inappropriately placed there. There are some people who are inappropriately placed in prisons—

  730. But they cannot be discharged because there is not a suitable place to discharge them to, and that is probably why the Home Office have limited the—
  (Mr Milburn) That is precisely why there is a focus on the intensive care medium secure and low secure beds as well. As far as costings are concerned, we can have another look at that certainly. There are costings, as you know, leaving aside specialist medical treatment. Keeping somebody in prison for a year costs between £20 and £25,000, to keep somebody in one of these hospitals costs well over £100,000, but in the end what should inform judgments is not so much the cost, it should be the appropriateness of the treatment and the care and indeed the security which is necessary for some people. The starting point was Mr Hinchliffe's question about the potential closure down the line of some of these hospitals. The reason we have not gone for that option is not actually the so-called political problem issue, it is the fact that actually these organisations have built up a level of expertise dealing with in some cases very difficult, very disordered and sometimes very dangerous people indeed. The worst thing possible, in my view, would be to lose that expertise and that experience. What we do have to do, however, is to overcome if you like the isolation of the three hospitals. It is perfectly clear, and indeed it has been a continual line of inquiry both in the hearing this afternoon and in your previous evidence, that because of the hospitals' isolation and because of the perverse incentives of the funding arrangements—remember, right now, it is a free choice for health authorities to stick somebody in one of these hospitals—that is precisely the reason why we have devolved decision-making down to a more localised level so that the clinical decision is matched by some financial responsibilities as well on the part of service commissioners. I think the model we now have with, if you like, a National Oversight Group ensuring co-ordination, backed up by more regional specialised commissioning arrangements involving not just high security but medium security, is the right way to go on that. That will help us overcome this problem, particularly for around 110 women who are in these hospitals at the moment who all the evidence suggests need not be there but probably do need a degree of security and secure environment but probably not the level they are receiving at the moment.
  (Mr Hutton) Can I just respond to Mrs Gordon's question about strategy for women in a high secure state? The National Oversight Group are actually looking at that right now and we have asked them to go away and bring that work forward as quickly as possible. As the Secretary of State has said, there is no question at all that those women inappropriately placed in the high security estate will be amongst the principal beneficiaries of the additional resources we are making available to improve the operation of the system. In relation to your queries about the child directions, I think we have to be clear about the child directions. They are aimed at the generality of child visiting but there are specific issues around particular categories of offenders who have a record and a history of either abusing other children or their family members as well. I think you have to be absolutely clear that we need to exert very careful control over inappropriate child visiting to the high security estate. Judge Fallon was very clear about that in his report. At Ashworth, I accept, it was in relation in the main to male offenders in the personality disorder unit, but I think his point about offenders and the reason why a person might be in a high secure unit applies equally to men and women, particularly those women who have been convicted of serious violent offences against children and other members of their family too. The child directions I believe certainly chime with Judge Fallon's recommendations and I think they are an attempt to try and address what he described as a totally inappropriate pattern of child visiting into the high secure hospitals, but we have tried to do it in a way which is fair to all patient groups and prisoners. The basic principle and purpose of this exercise was to safeguard the children themselves. Rather like in relation to public safety, I think it is absolutely right that that should be our principal concern.
  (Mr Boateng) There are issues for women generally which go beyond the special forensic service and I think Mrs Gordon is absolutely right to draw attention to the need for, in some instances, a gender-specific approach. If I can give you an example, 40 per cent of women prisoners have received some form of help or treatment for mental or emotional problems in the 12 months before entering prison. That figure for men is 20 per cent. Two in five women in prison have at some time attempted suicide. What that is telling us, amongst other pieces of information we have, is that there are high levels of mental ill health amongst women in the general prison population which we need to address, and one of the ways in which we are doing that is to prioritise the health needs assessments which we are now developing with the NHS in the Prison Service. For instance, Holloway has been given a very high priority, it has now completed its health needs assessment. There are issues there to be addressed and we are seeking to address them but one of the ways in which we are doing that is by putting the women's estate under one single area manager now, so there will be a particular focus on women in the Prison Service. What we need to do is to make that a safer and more decent experience for them, and one in which these underlying problems in relation to mental illness as well as substance and alcohol abuse, which are also there and often related to it, are addressed. So Mrs Gordon's point is well-taken in terms of the general prison population.

  Chairman: I will resist the temptation to ask my colleagues if there are any further questions and end by saying that there are a number of areas we would have liked to touch on in more detail and some we have not touched on at all, but on behalf of the Committee I express our gratitude to you for coming today in what has been a very helpful session.