I have been invited to respond to Dr Exworthy and Professor Gunn's critique of the review of security at the high-security hospitals (Reference Exworthy and GunnExworthy & Gunn, 2003, this issue). Our report (Reference Tilt, Perry and MartinTilt et al, 2000) made 86 recommendations, all of which were accepted by the Government.
As I read the critique the main argument is that the team ignored the importance of relational security and was too preoccupied with physical and procedural security. I think this is a serious misinterpretation. The authors do not appear to have taken sufficient account of section 2 of the report, specifically paragraph 2.5, in which we said:
‘In the view of the review team it is important that patients feel engaged and committed to the hospital. The provision of a full and purposeful activity and therapy programme is essential both for treatment purposes and as a significant part of the creation of a secure and safe environment. In the same way, the review team believes that beyond specific individual and group therapy it is important for a patient's daily life to be as active and demanding as possible having regard to the constraints of individual illness/disorders. It is for this reason the review team's recommendations have two main thrusts
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• an increase in therapy and activity for patients
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• an upgrading of physical and procedural security to safeguard the public, staff and patients’ (Reference Tilt, Perry and MartinTilt et al, 2000:p.5).
The Faulk (Reference Faulk and Gostin1985) formula for a successful secure unit cites: (a) sufficient physical security appropriate to the patients; (b) high staff ratios; and (c) a therapeutic policy which encompasses individual programmes.
In my view this does not go far enough. Providing high staff ratios offers very little unless the staff are properly trained, motivated and managed. One of the shortcomings we found in the three hospitals was that although good therapy, expertise and resources were available, they were significantly underused because there was little or no management information or action to ensure that the best possible outcomes were achieved from the resources made available.
In terms of the specific criticism that we neglected relational security, it is worth recording that recommendations 7, 15 and 57 related specifically to this aspect. The authors also assert that there was no clinical member on the enquiry team. This is not correct – one member of our team had extensive clinical experience, including working in high-security hospitals. Beyond that, in each of the three hospitals we spent time consulting many clinicians, including psychiatrists, and were struck by how many suggested to us that the existing security arrangements at that time were inadequate.
I believe firmly, as did all the members of my team, that the key to running successful treatment-oriented high-security hospitals lies in ensuring that the public, patients and staff feel safe about their operation. I believe our recommendations are making a positive contribution to that.
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