One day in early August, 36-year-old Gavin bumped into an old friend outside That’s Entertainment music and DVD shop in Preston market.
“He pulled me to one side, but I didn’t recognise him,” Gavin (a pseudonym) says when we meet a week later. “He was like, ‘How you doing? I’m just going to get some stuff, make some money.’ He’s opened his bag and it’s full of razor blades. He’s selling razor blades for a tenner a pop, all of that business.”
Gavin says that he and the man were former “grafting partners”: commercial burglars and thieves, working around Lancashire. But in the six years since they had last seen one another, their lives had taken divergent paths.
“He’s ended up on the gear, shoplifting,” Gavin says. “I was like, ‘See you later mate.’ I felt guilty, tight, leaving him, but I thought: ‘What would happen if I’m with him and he gets pulled over and I’m in the hospital?’ I’d be in a lot of trouble, wouldn’t I? I gave him a couple of quid to buy himself a couple of pies, a cup of tea, and he wandered off … I sat there and thought: ‘If I’d not been in here, it’d be me doing that.’”
Gavin relates the story inside a meeting room at Guild Lodge hospital, in the Lancashire village of Whittingham, where he has lived for the past three years. Guild Lodge is one of 60 medium-secure mental health hospitals in England and Wales that house people deemed to be a danger either to themselves or others on account of their mental illness. Most of the 149 patients have committed offences while mentally ill, or have been diagnosed with a mental illness while already in prison. Some have been in higher-security institutions; almost all are being held under the terms of the Mental Health Act.
Gavin, who has schizophrenia, describes a life of substance abuse and crime, sometimes with violence, that took him in and out of prison and secure care settings for the past 18 years – his entire adult life. He was most recently admitted to a medium-secure ward at Guild Lodge in 2013, and is now in low-secure, from which he is permitted release to go into town, as he waits first for a tribunal hearing that could clear him for discharge and then, crucially, for a bed in supported accommodation.
“It might not work if I was just kicked out like I was in the prison system. I would have nowhere to go,” Gavin says. “I’d be on the street, in a hostel, back in crime or something. When I’ve been released from prison, it’s been a few weeks at the most. I’ve been straight back in for something else.”
From 1873 until 1995, the leafy park that surrounds Guild Lodge’s complex of modern buildings concealed Whittingham Hospital, which was Britain’s largest psychiatric institution and a centrepiece of the notorious Victorian asylum system. But Guild Lodge, which opened in 1999, is a striking representation of the advancements in secure-care provision across the UK – particularly at a security level one step below Broadmoor, Ashworth and Rampton, England’s three high-secure forensic psychiatric services.
From the outside, the pale bricks and long windows of the medium-secure area of Guild Lodge could pass for a leisure centre. Even the high mesh fence that surrounds it could be for tennis courts or a five-a-side football pitch. The low-secure area that sprawls outside looks and feels like a business park. There is little to distinguish buildings containing administration offices and meeting rooms from the wards in which patients sleep.
Service users (the preferred term for patient) considered low-risk are free to wander through the adjacent woodland, around an Anglican church, a cemetery and even a cricket pitch. One service user, who told me he spends much of his days watching wildlife and listening to music on a wind-up radio, insisted that a relative of local hero Andrew Flintoff was the groundsman.
As with all hospitals, the aim is that patients will one day be discharged from Guild Lodge with their illnesses under control. It is recovery-focused rather than punitive, and although the Ministry of Justice retains a controlling interest in the onward progression of many patients (some will go back to prison), funding for medium-secure hospitals comes entirely from NHS England’s special commissioning budget.
The unique challenge is to balance care with custody; to maintain the public’s security while effectively treating patients’ illnesses. For thousands of people like Gavin, who is genial, articulate and rational when his schizophrenia is under control, secure care units can prove the difference between what might be considered a worthwhile life, and one wasted as hostage to an unpredictable and often dangerous illness.
Such endeavours are not cheap. According to figures from NHS England, expenditure on medium- and high-secure mental health services during the past year was £1.23bn, which accounts for 74% of the special commissioning budget and is one fifth of all public spending on adult mental health care. Accurate figures on a patient-by-patient basis are difficult to obtain, but conservative estimates put the cost of a bed and care for a year in a medium-secure hospital at £150,000, nearly five times as much as a male inmate in a category B prison.
Partly because of their cost, forensic psychiatry hospitals are under almost constant review. Medium-secure services in particular have remained a focal point for mental health campaigners, who say patients are often too readily admitted to an unnecessarily high level of security and then stay too long. The most recent government taskforce report on mental health – titled Five Year Forward View for Mental Health, released in February – made fresh commitments to “prevent avoidable admissions”, support recovery in the “least restrictive setting” and “address existing fragmented pathways in secure care”. In essence, it emphasises a need to get patients hastily into secure care when mental illness is the root cause of their offending, but also to discharge them quickly and safely, with adequate continued care, to get on with their lives.
Yet there remain frequent claims that the Ministry of Justice is overly cautious in approving discharge from secure hospitals, and that there is inadequate onward housing provision for patients reintegrating into communities. In general, treatment for mental illness has progressed significantly since the days of the asylums, but age-old misconceptions persist about psychiatric institutions. Patients still suffer familiar prejudice on account of their illness, compounded by their detention in hospital.
“It’s very, very risk-averse stuff,” says Jenny Shaw, the recently retired clinical director for specialist services at Lancashire Care Foundation Trust, which oversees Guild Lodge. “Even having conversations with some of my friends, who should know better, [I hear] ‘How can you ever let people who have committed those kinds of offences out?’ It’s a complete lack of understanding of what we’re trying to do. I think there’s still a massive stigma around mental health, and people with mental health problems and who are offenders – it’s a massive double whammy.”
I visited Guild Lodge twice earlier this year, touring the medium-secure unit and talking to some service users about treatment programmes and the challenges they face. Journalists are rarely permitted inside secure care environments: service users are often vulnerable and their recovery programmes easily undermined by external distractions. Administrators are also wary of the sensationalist reporting mental health hospitals have been known to attract, while victims and their families stand to gain little by repeated exposure to the perpetrators of the crimes against them. All names have therefore been changed and details of offences omitted.
In general, people who have committed offences as a result of a mental illness tend to be blighted by extreme guilt for their actions. Many people hear voices or suffer delusions that have encouraged their offences. Hospitals house people suffering from a vast range of illnesses – schizophrenia, psychosis, acute depression, bipolar disorder – from hugely varying backgrounds, many of whom have suffered extreme trauma. The propensity to self-harm is also high.
The area “over the fence” – as one service user described the medium-secure part of the hospital – has the atmosphere of a vocational college, albeit one in which most doors are permanently locked. Staff and visitors pass through an air-lock security door, past a small office where patients can meet guests, and then into a courtyard, with various separate buildings situated either side of an access road and areas of green lawns. After appropriate risk assessment, service users are allowed access to an art room and wood and metal-working workshops, or to learn gardening skills in an on-site greenhouse and nursery. There is also a music room, and a service-user band regularly plays gigs both in and outside the hospital.
My visit to the medium-secure unit coincided with lunch, when the common areas were almost entirely deserted. Patients were in gender-specific wards, where they sleep in single-occupancy rooms, with washing facilities, and are locked in overnight. Although neither staff nor service users denied that tempers can flare, and that patients’ moods and illnesses can often raise tensions inside the hospital, I saw no threatening behaviour. Patients at different stages of recovery demand varying levels of supervision, but I met service users for interview in the low-secure area to which they brought themselves and left unescorted.
Many patients in secure care have co-morbidity issues – drug or alcohol misuse, or personality disorders – and programmes work to tackle these, as well as to improve patients’ physical health. Smoking is entirely prohibited inside Guild Lodge, and service users are encouraged to use an on-site gym and sports hall. Weight gain remains one of the most damaging side-effects of many psychotropic medications, leading both to physical ailments and reduced self-esteem.
Guild Lodge is also relatively unusual in that its administrators have won a battle to permit computer use for service users. Access to technology brings out the most risk-averse tendencies of lawmakers, who fear that vulnerable patients may be drawn to the darkest fringes of the internet. (Mobile phones are also strictly forbidden.) But a lack of even rudimentary IT skills may be damaging to a patient’s prospects of reintegrating to the job market on release. Service users can suffer an extreme sense of isolation, as though they are separate from the community in which they hope to reintegrate. Any further barriers, such as a lack of basic skills, only compound anxiety issues surrounding discharge.
One low-secure service user named Janet, who was not at Guild Lodge and who met me in a coffee shop in London, described a scenario where she was required to go online to arrange her own onward housing in order to be discharged from a hospital, but was not permitted access to the internet before she left.
“In the five years I’ve been in hospital, the world has moved a lot,” Janet says. “One of the people I live with has been in hospital for 16 years. She is about to be discharged and she has got no concept of how to use the internet. None at all.”
She adds: “No matter how confident you are as an individual, your confidence just plummets. Even the most arrogant individuals in hospital – it’s quite interesting watching them go out into the community, all that arrogance and bravado seems to quite quickly crumble. It’s fearful. We have a bridge at the front of the hospital. It’s called ‘life beyond the bridge’. Patients fear crossing that bridge.”
In recent years, studies into the effectiveness of treatments for mental illness, including schizophrenia, have centred on involving patients themselves in planning their own recovery. Research has shown that patients respond better to treatment when they are engaged in it and given more control over the direction of their own care.
In the secure environment, attempts to empower patients in this way can be seen to run counter to the demands of security, but initiatives are now in place that focus on service-user involvement and are aimed at hastening recovery and expediting discharge. “These things are related,” says Ian Callaghan, a former service user, with experience of both low- and medium-secure hospitals, who now works for Rethink Mental Illness. “As soon as a person’s mental health is stabilised, things should change. Stabilising mental health and managing risk go hand-in-hand.”
Callaghan is the national service user lead for a Department of Health initiative named My Shared Pathway – a programme followed throughout a patient’s stay in hospital. My Shared Pathway is tailored to an individual’s specific needs and defines closely their shared relationships with the clinicians, support workers, other service users and eventually the community they hope to return to. Meanwhile, a scheme launched by Rethink Mental Illness’ Innovation Network is aiming to involve service users in planning their futures in a far more detailed way than has been the norm.
These initiatives aren’t to everyone’s taste. One 57-year-old service user, who had spent many years in Ashworth high-secure hospital before transferring to Guild Lodge seven years ago, said: “They have meetings about when to organise meetings.” The same service user was also not a supporter of the smoking prohibition, and said fellow patients squirrelled cigarettes just outside the fence.
Nevertheless, initial feedback from staff and patients has mainly been good, and further trials are also currently under way to enhance the role of peer-support workers in secure hospitals. The idea is that experienced service users can volunteer their support and advice to other patients, building on informal relationships on some wards and broadening networks of trusted individuals. Service users are known to respond well to people who have been through the secure-care system and have successfully returned to the community. Janet says: “It does sometimes take somebody who has recovered to let you see the light a little bit.”
Service users and staff both told me that it can be detrimental to recovery if, after being cleared for discharge by a clinician, a patient is denied release either by the Ministry of Justice, or by a lack of onward accommodation provision. After the taskforce recommendations, NHS England is trialling a reorganisation of budgets to allow local administrators to manage pathways out of hospital and into community mental health care teams. The aim is that medium-secure services be used only to address the most pressing clinical needs, rather than by patients for whom there is simply nowhere else to go.
Gavin says that the severity of his illness did not allow him to understand the benefit of his treatment during previous admissions to secure hospital. He returned to the prison system and stopped taking medication, leading to a deterioration in his condition. (Prisoners can reject medication, but some sections of the Mental Health Act, under which service users will be in hospital, allow for doctors to administer it without consent.) Eventually, after returning again to secure care, a course of therapy helped him manage his illness and turn over a new leaf.
“You get to a certain point where [you think], ‘What’s been going on? What have I been doing with my life?’” he says. “I just want to leave now. I don’t smoke anymore, I’ve not done drugs, I’ve not drunk alcohol and I don’t intend to. I don’t want to go back to that life.”
Better than prison: life inside the UK"s secure hospitals
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