Britain's wards of shame

David Pilgrim argues that our scandal-hit maximum security hospitals are unreformable, expensive Victorian relics that should be closed.

Anonymous threats of death and sexual violence are to be expected in hospitals that contain rapists and murderers. What may come as a surprise is the issuing of such threats not by patients but By psychiatric nurses to clinical psychologists.

Such events were recorded in the damning report by Sir Louis Blom-Cooper into complaints of mistreatment in Ashworth Hospital, published in 1992. The Ashworth inquiry was triggered by a television expose of conditions in the hospital. Another TV programme triggered the Boynton inquiry of 1980, which reported brutality at Rampton Hospital. During the 1980s, sudden deaths of black patients in Broadmoor resulted in a number of investigations.

Ashworth, Rampton and Broadmoor make up the English special hospital system. Broadmoor is the oldest of these maximum security hospitals and it is where the Prison Officers Association was formed. The POA, with its authoritarian ethos, remains a strong force in all three institutions today, even though, administratively, they are hospitals, not prisons. The special hospitals contain a mixture of patients, most of them referred to by the courts as "mental disordered offenders". They include patients with learning disabilities, those with a diagnosis of mental illness and those suffering from "psychopathic disorder" under the 1983 Mental Health Act. Some have no criminal record but are difficult to manage in open NHS hospitals.

"Psychopath"Jis a controversial label. Some professionals think the "condition" untreatable, raising legal questions about the legitimacy of placing people so diagnosed in a hospital. The condition is defined legally in a circular way. People are deemed to be psychopathic because they are "abnormally aggressive" or they manifest "seriously irresponsible conduct". These anti-social tendencies are then accounted for by the psychopathic disorder. As an example of the arbitrary nature of the label, arsonists, rapists and paedophiles can be found in both prisons and in the special hospitals.

The inquiries into mistreatment in the special hospitals were predictable. When John Martin came to write his scholarly critique of scandal hospitals, he finished with the worst of these, Rampton, in 1980. His book Hospitals in Trouble was produced in 1984, when the brutalities of Ashworth were being enacted but still awaiting public exposure.

Martin scotched the "bad apple" theory of what he called the "corruption of care" in failed hospitals. While weak and brutish staff may exploit the vulnerabilities of unrewarding residents in long-term institutions, it is the closed and isolated nature of such hospitals which engenders neglect and abuse. Scandal hospitals like Ashworth and Rampton are professionally and intellectually isolated from other parts of the health-care system. Their tight control over visitors makes them isolated from their immediate community. Their large size and complexity means that wards may be isolated, leading to a "fiefdom" mentality on the part of staff. The arm's length approach to their management over many years means that local managers have operated for long periods outside the control of the civil service.

The special hospitals represent a stubborn residue of a discredited Victorian institutional system. They are unreformable not because of a lack of managerial will or money (compared with many mental health facilities they are well financed), but because the organisational features identified by Martin are intractable, woven into their bricks and mortar. Politicians have been wary to grasp the nettle and abolish them because the inmates of such places garner few votes - rather, they arouse public fear and loathing. The job the special hospitals do, which protects them from decisive government action, is that they provide long-term resident detention. They do not provide cost-effective mental health care.

But the politicians' ostrich-like approach to special hospitals cannot survive indefinitely. Scandals will inevitably recur because Martin's checklist of isolating factors cannot be wished away by a PR-sensitive management culture. Since the Ashworth inquiry more problems have been exposed, including staff-patient collusion over the production of pornography. A failure of care on the female side of the hospital was also investigated and an official report produced and suppressed. It cannot be read even by people working in Ashworth. Despite a policy of espoused openness, hospital managers in recent years seem to have simply become more adept at information control. Special hospitals could and should be phased out. "Psychopathic disorder" should be removed from the 1983 Mental Health Act and sex offenders and arsonists sent to prison with a defined sentence. Those serving sentences shorter than life would need to receive psychological treatment to reduce the probability of re-offending. Such treatment is not widely available for sex offenders in the special hospitals. Other patients with learning difficulties, or those deemed to be mentally ill under the Mental Health Act, could be dispersed to mainstream NHS hospitals.

If the new Labour government's health ministers do not address these policy challenges seriously, they will find themselves, like their predecessors, overseeing yet more scandals and financing yet more expensive public inquiries.

David Pilgrim worked as a clinical psychologist at Ashworth Hospital during the 1980s. He will argue for the closure of the Special Hospitals in his keynote address to the Division of Criminological and Legal Psychology at the University of Cambridge on October 1.