by Donald West
The Mental Health Act Commission
A further taste of life on a QUANGO came about when I was made a Mental Health Act Commissioner. It was in the early days of the organisation. As with the Parole Board, my recruitment came about in a manner that would have been thought improper later on, when formal application in response to public advertisement became the order of the day. A civil servant whom I knew through previous dealings with the Home Office approached me – I think it was at some conference meeting – to ask, since I was retired, if I might like to serve on the new Commission. I expressed interest, but it was still a surprise to receive, out of the blue, notification from the Department of Health that I was now a Commissioner and was expected to attend a forthcoming meeting.
The Commission was set up by the Mental Health Act 1983 to monitor the care of patients compulsorily detained because their illness made them a danger to themselves or others. The legal rights of such patients were contained in the Mental Health Act, 1983, supplemented by a Code of Practice couched in less legal terminology. The Commission was required to arrange inspection visits to mental hospitals, public and private, and to report back to the hospital managers. The Commission had no powers to enforce the recommendations contained in these reports or the policy proposals made in their biennial reports to the Department of Health. Indeed, specific changes suggested in visit reports were quite often found not to have been implemented, especially by some private hospitals, by the time the next visit took place.
Inspection visits were carried out by small teams of four or more Commissioners arriving at times announced in advance. They were expected to check that the rules governing, for example, appeals against detention, the use of physical restraints, solitary confinement and enforced treatments were being followed. They would meet with managers and staff, tour the wards housing detained patients, examine records and conduct interviews with patients individually in private. They would pool their impressions and produce a collective report. The visits were time-consuming. Many hospitals were located away from towns, necessitating car journeys by Commissioners travelling from their own homes and co-ordinating their arrival times. Commissioners, of whom there were about a hundred, came from varied backgrounds. Their experience of working in the National Health Service or their familiarity with the intricacies of the Mental Health Act was varied, and there were only a few psychiatrists.
After long absence from the world of hospital psychiatry, one impression was of a notable improvement in recognition of patients as people with rights and needs who should be talked to and not just ordered about or left to themselves for endless empty hours. Hospital managers had become more numerous and obtrusive. At feed-back meetings with staff at the end of each visit there were, to my mind, too many managers, too few nurses and even fewer doctors. Managers were clearly oriented to offering glowing accounts of their particular hospital. Sometimes we were loaded with glossy brochures claiming great success for the policies and successes of the Health Trust to which they belonged.
Unlike voluntary patients, those detained under the Mental Health Act cannot refuse drug treatments. Anti-psychotic drugs can have unpleasant side effects and many patients complained about having forced injections and being made to continue with medication indefinitely. Although rumours of chemical ‘zombies’ are often exaggerated, we did note some instances of unusually high dosage. Unfortunately schizophrenics, who appear to have recovered and are thinking and behaving normally, frequently relapse into delusions and irrational or violent acts soon after medication is discontinued, so decisions about reducing or discontinuing treatment can be difficult.
The provisions for enforcing ECT (electro convulsive treatment) were being well respected. Patients could only be made to accept ECT if both the hospital doctor and an independent outside doctor, registered competent to give second opinions, agreed on the need. The treatment has had bad publicity, and it can be damaging to the brain if over-used. The patient is not conscious of the process, but the idea of having pads clamped to the head and an electric current passed through is frightening. However, for the minority of serious depressions unresponsive to drugs, it is an effective means of relief and sometimes a life-saving measure.
One concern we had was of injuries from excessive or inappropriate use of force in response to violence or threats of violence, causing us to recommend further training in safe methods of restraint. Small, empty locked rooms, not necessarily the padded cells of the past, were set aside for the temporary seclusion of aggressive or violent patients, for their own safety as well as that of others. Nurses were required to record in a seclusion book the time patients spent in these rooms and the frequency of observation. There were considerable differences between units in the number and duration of seclusions, and occasional breaches of the Code of Practice were found. We also noticed some striking differences in the degree of interaction between nurses and patients. Sometimes patients were left sitting around, unoccupied, while nurses chatted together in a group apart. Rooms set aside for smoking were often heavily polluted and smoking elsewhere impossible to control. Complaints of sexual pestering were sometimes suggestive of poor supervision or lack of provisions for privacy. The investigation of patients’ complaints was another function of the Commission, but carried out separately from the routine visits.
The effectiveness of these visits in improving standards seemed limited and the cost must have been enormous. It confirmed my suspicion that QUANGOs can operate in unnecessarily expensive ways. However, the system was later streamlined. In 2004, pre-arranged state visits by a group of Commissioners were replaced by unannounced visits by a single Commissioner drawn from local teams. In 2009 the Commission was abolished and its functions, together with those of other NHS inspectorial organisations, were taken over by a Care Quality Commission that was given a much wider remit for monitoring the totality of health and social care.
The mentally ill who commit crimes can be dealt with under Mental Health Acts and committed to hospitals instead of being imprisoned. Mental Health Act Commissioners included in their visits the three high security ‘Special Hospitals’ where patients guilty of grave offences are incarcerated, most of them under ‘Restriction Orders’ of indefinite duration. My duties included visits to Broadmoor, the large Special Hospital in Southern England, housing some of the most notorious of murderers, such as Ian Brady. At the time the hospital was in a state of transition and I believe that in this case the Commission did have some significant input into the changes taking place. Some features at Broadmoor would not have been acceptable elsewhere. One concern was the locking-up overnight in a large male ward, unsupervised, save for rare visits by a torch bearing nurse, of a mixture of patients, who might include murderous psychopaths and paranoid psychotics. There was an alarm bell, but whether potential victims of assault, sexual or otherwise, could easily reach it, I had my doubts. This arrangement was put an end to fairly quickly.
Broadmoor has the disadvantage of being the focus of media attention. If a discharged or escaping patient commits another crime it becomes at once a national scandal and psychiatrists are blamed. Psychiatric reports recommending patients as sufficiently safe for discharge were being made with understandable caution. Lacking support from Broadmoor doctors’ reports, patients’ appeals for release to Mental Health Tribunals were for the most part futile exercises. Patients were being retained, albeit sometimes with good reason, far beyond the time they might have expected to remain in prison under a sentence proportionate to their crime. For example, I once had the task of giving supportive psychotherapy to a patient on probation who had been convicted of arson. He was a middle-aged man of pathetically inadequate personality and paranoid disposition who, at times of frustration, had set fire to garden sheds and the like. Because he was unco-operative about taking medication, or keeping appointments, and had managed to find a job working in a large wood-yard, I was obliged to report him for breach of his probation order. The doctors at the local menta
l hospital were unwilling to admit him and so I was reluctantly obliged to go along with a recommendation for committal to Broadmoor where, of course, he was kept many years, although on this occasion he had committed no offence and was scarcely in need of the expensive high security and expertise at a Special Hospital.
One consequence of the difficulties in the way of discharge from Broadmoor was that some patients had become elderly and institutionalised and had lost all their contacts outside, so that it would be almost cruel to let them out to fend for themselves in a world greatly changed since they knew it. In fact there were a few old women living quite contentedly in the hospital under conditions more comfortable and less demanding than anything they might find on welfare dependency outside.
Large institutions tend to develop a culture of their own that resists change. This was especially true of Broadmoor. The population of nurses was unusual in being, like their patients, overwhelmingly male, belonging to the prison officers’ union and many having been recruited from generations of the same local families. There was a history of tension between the requirements of security from hostile patients, dangerous visitors and escape attempts, and the medical need for co-operation with patients and realistic psychotherapeutic interaction. During my time on the Commission there was talk of reducing the size of Broadmoor. The setting up of new, smaller ‘medium secure’ hospital units was in progress, providing a much needed half way path to final release into the community, hitherto impeded by the reluctance of local mental hospitals to accept ex-Broadmoor patients. A remarkable expansion of facilities for offender patients outside of the special hospitals, and of the speciality of forensic psychiatry, has since taken place. Broadmoor, however, is still going strong. In Broadmoor there are admirable workshops and facilities for promoting manual and artistic skills that are particularly appropriate for long stay cases and there are substantial halls for dances, visiting theatricals and other social activities. It becomes economic to provide such facilities in a large hospital, but for fewer patients the expense might be prohibitive.
One feature I thought worthy of criticism was the poorly used procedure for transfers from prisons to Broadmoor. Prisons house many very disturbed men and women, some of whom could be better cared for elsewhere. Transfers are legally possible when a diagnosis of mental illness is made. As Commissioners we were concerned to note that some men, who had languished a long time in prison, were so diagnosed just before the completion of their sentence. A continuing propensity for irrational violence was a likely cause of reluctance to free them, but it seemed a pity this had not been identified sooner. Natural resentment at the unexpected and devastating announcement of the substitution of indefinite detention for immediate release was not a good preparation for a man’s easy acceptance of a psychiatric approach. Prisons are not usually geared to deal as well as a secure mental hospital with troublesome and irrational behaviour in the mentally ill, who may be made worse by the normal disciplinary measures available. Furthermore, not only do such patients have a better chance in hospital of receiving help to restoring capacity for living independently, they do not have to be released until they are ready to cope, which is a protection for them as well as for the community.
FINAL CHAPTERS
Death of a Partnership
During his time working at the university in Stoke-on-Trent, my partner Pietro made great efforts to be with me as often as possible, driving for hours late at night to Cambridge or London. When he began work at Christie’s and moved to London he would return to Cambridge at week-ends. During all this long association, whenever we were having terrible rows about my sexual behaviour, the upsets meant that sex together would temporarily cease. Eventually Pietro decided that we should terminate sexual life together, though we still shared a bed. This did not put an end to mutual dependence. We worried about each other’s welfare, shared our troubles and continued to present a united front to others. Pietro introduced me to his colleagues at Christie’s, where they accepted me as his partner and some of them became good friends, while I took an interest in his work. Although fluent colloquially, he had never quite mastered English composition, and I was able to help when he had to write some articles on ceramics. When he found a flat in Kensington near his work, he set about furnishing it and making it comfortable with, of course, some characteristic artistic flourishes. He was given an office in Christie’s premises which he gradually filled with a collection of art books. He was an avid reader and took immense pains to prepare his lectures to students. One of the characteristic that made him popular as a teacher was an acute perceptiveness and an enthusiastic belief in simply looking and noting every detail of a picture or object as the best way to learn its date and origin and appreciate its quality. He enjoyed accompanying students on visits to museums and galleries abroad, especially to his native Italy. I joined him in Florence at the end of one of these visits. Our time together there revived something of the pleasures of earlier years. He had become a practised guide capable of vivid commentary on the surrounding art treasures. I still have an amusing photo of a group of naked young people, Christie’s students during a visit to Berlin, facing a large shrouded building, actually the Reichstag, then under reconstruction by the British architect Norman Foster.
Slowly the situation changed as Pietro’s health deteriorated. For a long time he had been experiencing anginal pain. As the attacks became more frequent and violent, he would wake up in obvious agony with cold sweat and pallor and need swift vasodilator medication. Much as he tried to make light of these attacks, they left him exhausted. Angioplasty gave only temporary improvement. Although no longer able to tolerate wine, his heavy smoking continued. He could no longer tend the garden in Cambridge that had been his pride and joy. He pursued his work with grim determination, appearing cheerful and confident before his students, but at home he was increasingly morose, unwilling to have friends visit, and less inclined to visit Cambridge or to encourage me to stay in the London flat. There he set up his bed on the sitting room sofa, leaving me to sleep in the otherwise unused bedroom. He was forced to take two short periods of sick leave and his boss contacted me to ask if I thought it would be wise for him to take early retirement. That was the last thing he wanted. I suggested he should retire to Cambridge with me, but he was emphatic he wanted to make London his home. He seemed to want to be more and more independent.
In the end he developed stomach pains of unknown cause and was admitted to hospital. He did not appear acutely ill, receiving cheerfully many visits from students and making plans for a swift return to work. I had booked a trip with our San Franciscan friends that included an Alaskan cruise. Pietro was insistent I should go, and with misgivings I did so, taking Tom with me, as usual without telling Pietro. Tom was delighted with the Alaska trip, particularly when he was able to go fishing and produce a fine catch for the hotel to serve up for dinner. I was glad of this, because Tom’s health was already failing and there would be little opportunity for such pleasures in the future. For me, the trip was beset by unremitting anxiety. In my absence our old friend John kept in regular touch with the hospital, visited Pietro and relayed to me reassuring news, later proved unjustified, that he was not in danger. Unexpectedly, the doctors decided to perform a laparotomy. This failed to locate a cause of his symptoms, and following the operation he had a fatal heart attack.
News of the impending laparotomy reached me shortly before the return flight to London was due. Desperately anxious, I negotiated a first exit from the plane on arrival and literally ran from the tube station to Chelsea and Westminster Hospital. Entering the ward, I saw his bed was empty. A nurse, who must have realised who I was, ushered me into a small office and told me the news. For the first time I experienced the frozen calm a shock can bring. I remember talking in a matter of fact way about practical matters, such as the death certificate, agreeing it was unnecessary to call upon a doctor for further information about cause of death, and afterwards walking back in a daze to the Lo
ndon flat. At the time, and indeed ever since, I have felt guilty about not being around when Pietro was dying, especially since I heard he had been asking for me when he was ill after the laparotomy. He had left his body for medical use, but because of the recent surgery it was not required, so I arranged (through funeral directors occupying the same building as the SPR) a cremation without ceremony, attended only by me and John. When the coffin was delivered there was a moment of silence till I gave the signal and watched it disappear.
