The treatment and security needs of patients in special hospitals

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Abstract
The treatment and security needs of a 20% cross‐section of patients in the three maximum‐security hospitals of England and Wales are described. Data were collected from case notes and interviews with each patient and with the clinical team. Patients were described in term.s of their diagnosis, source of admission and reasons for admission, past psychiatric treatment, present clinical features and estimated needs for psychiatric treatment and secure containment. The sample consisted of 296 cases. Most patients had been admitted from prison, although only 10% were serving a sentence; 21% were detained under non‐criminal treatment orders. The most common diagnosis was schizophrenia (55%) and 14% suffered from other psychoses. Most patients had long histories of psychiatric treatment and 39% were inpatients at the time of the behaviour which lead to their admission. The problem mentioned most often in admission reports was repeated assaults (56%), with the most frequent victims being other patients or hospital staff. Both the research and clinical teams rated over 80% as needing medium or higher security, with the research team identifying a need for maximum security in 37%, whilst the clinical team put this figure at 50%. A similar range of diagnoses and clinical problems was identified in patients rated as needing medium or maximum security, suggesting differences in severity only, with many patients on the borderline between these categories. The most common clinical problems were lack of insight, difficulty relating to other people and failure to respond to medication. Absconding risk was identified as an obstacle to transfer to lesser security in only 9% of patients. Only 2% of patients were expected to show any improvement in their clinical condition over the next year and only 5% were expected to improve in the next 5 years. These predictions are consistent with the long histories of hospitalisation in many patients. Between one‐ and two‐thirds of patients rated as needing medium security would require this level of security for more than 2 years, making them unsuitable for most units. Many special hospital patients’ do not require all aspects of maximum security but most have a high level of chronic psychiatric disability and extensive treatment needs. The success of any attempt to move them out of the special hospitals will depend on providing care elsewhere, particularly long‐term medium secure care, which is lacking at present. The quality of life and chances of transfer of many special hospital patients could be improved by a greater emphasis on treatment and rehabilitation within the hospitals. This has important resource implications.