A survey of referrals to a special hospital ( Rampton Hospital )

In 1989, the responsibility for managing the three special hospitals of England and Wales (Broadmoor Hospital, Ashworth Hospital and Rampton Hospital) moved from the Department of Health to a special health authority, the Special Hospital Services Authority (SHSA). His torically, referrals for admission to the special hospitals were decided by a multidisciplinary central admissions panel at the Department of Health in London. Following the introduction of the SHSA, local admissions panels were estab lished for each special hospital to consider cases referred for admission. In addition to the local admissions panels a central admissions panel (based at the SHSA) was set up:

In 1989, the responsibility for managing the three special hospitals of England and Wales (Broadmoor Hospital, Ashworth Hospital and Rampton Hospital) moved from the Department of Health to a special health authority, the Special Hospital Services Authority (SHSA).His torically, referrals for admission to the special hospitals were decided by a multidisciplinary central admissions panel at the Department of Health in London.Following the introduction of the SHSA, local admissions panels were estab lished for each special hospital to consider cases referred for admission.
In addition to the local admissions panels a central admissions panel (based at the SHSA) was set up: (a) to monitor the operation of the local panels at each special hospital (b) to consider difficult and sensitive ad mission applications which the local panels referred for advice or guidance.
The current procedure for admission to the hospital is as follows.
(a) Referrals to Rampton Hospital derive from the courts.Her Majesty's Prisons and NHS hospital including regional secure units.Such referrals may be to a named con sultant on the staff of a hospital, but are usually directed towards the director of medical services or the hospital's unit general manager.The Report of the Committee of Inquiry into Complaints about Ashworth Hospital (1992) recommended that "medical staff should under take an audit of the Admission Procedure and adopt a more forceful role in protecting the over all therapeutic aims of the establishment" (Rec ommendation 41).This review of the admission procedure at Rampton Hospital represents the first stage in such an audit.

Objectives
How do the recommendations made up by the consultant psychiatrist compare with the local Psychiatric Bulletin (1994), 18, 221-223  The study Case files are kept on all referrals to Rampton hospital whether accepted for admission or re jected.Data were collected from this source for a retrospective survey of all referrals to Rampton Hospital during the two years from 1 January 1990 to 1 January 1992.

Findings
There were 353 referrals to Rampton Hospital for 316 patients during the sample period.Just over one third of these referrals (117) resulted in the offer of a bed.The vast majority of patients were referred once, one patient was referred four times.Of all the referrals, 66 (19%) cases were unable to be analysed further for the following reasons: in 38 cases the referral was simply for advice so the referral did not progress to the local admis sions panel; 15 referrals were withdrawn by the referring agency; in six cases the patients were admitted as emergencies so no panel decision was taken upon them at the time; in four cases the patient was acquitted at court or sentenced to imprisonment; in two cases the patients were recalled to the hospital, having been condition ally discharged in the past and in one case the referral involved a transfer from another special hospital.
Of the 287 remaining referrals, 261 (91 %) were considered 'non-controversial' in so far as the consultant psychiatrist and the local admissions panel agreed on the recommendations for the patients.In 101 cases, the consultant psy chiatrist and the local admissions panel agreed on admission for the patient.In 160 cases the consultant and the local admissions panel agreed on rejecting a referral for admission to the hospital.
The local admissions panel and the consultant psychiatrist disagreed on 26 (9%) referrals corre sponding to 24 patients.Table I shows how these decisions differed.
In five cases (17%) the local admissions panel deferred a decision until advice had been sought from the central admissions panel.This advice was followed in all cases.In five cases the central admissions panel reviewed the decisions of the local admissions panel and intervened by ad vising that the decision not to offer a bed be reversed.In all but one of these cases, the con sultant's recommendation was equally over turned.In one case, the Home Office intervened and directed the transfer of the patient.This occurred after the consultant psychiatrist had recommended admission, but both the local ad missions panel and the central admissions panel had rejected the referral.

Comment
Differences in opinion fell into two main categories -clinical and security.Two thirds of the differences in opinion were for reasons of security.
Two main issues arose from the 'controversial' referrals.These were treatability and security.Although treatability was rarely in dispute, oc casionally patients diagnosed with 'psychopathic disorder' led to vigorous debate over whether or not a patient was 'treatable' and should be admitted to a special hospital.The degree of security required led to differences in opinion.
Special hospitals are provided for "Patients subject to detention who require treatment un der conditions of special security on account of their dangerous, violent or criminal propensities" (NHS Act, 1977).In assessing a patient for ad mission to the hospital, special hospital consult ant psychiatrists not only have to assess the nature of the mental disorder from which the patient is suffering, but also the degree of 'dangerousness' with which the patient presents.Predictions of dangerousness are fraught (Prins, 1986) and issues surrounding treatability in psy chopathy have led to vigorous debate (Robertson, 1992).
In view of the fact that the local admissions panel consists of one medical member and three to four individuals from different professional backgrounds and that the panel deals with an average of three to four referrals weekly from a staff of up to ten consultant psychiatrists, it is not surprising that differences in opinion arose from time to time.
In the light of the 1992 Ashworth Inquiry's injunction that medical staff adopt a more force ful role in protecting the overall therapeutic aims of the establishment, it is reassuring to note that the opinions and recommendations of the consultant psychiatrists stood up well to in dependent multidisciplinary scrutiny.Few other medical procedures are subjected to such close scrutiny.It is of some interest that the admis sions procedure for the only special hospital in Scotland, Carstairs Hospital, which also takes admissions from Northern Ireland, is markedly different from the three English special hos pitals.In Carstairs Hospital, consultant psy chiatrists on the staff of the hospital receive direct referrals from their consultant colleagues in the wider NHS.There is no local or central admissions panel.
Perhaps the results of this survey support a view that consultant psychiatrists working in Rampton Hospital could take direct admissions to hospital thereby reducing the bureaucracy and delays inherent in the local admissions procedure.Such a change could lead to a more sensitive and speedy response to patient need with the consequent development of closer work ing relationships with forensic colleagues and serving to further reduce the isolation and often perceived impenetrable barrier of the special hospitals.A change in the procedure allowing for direct admissions would be a fruitful area for clinical audit and the findings of this survey could serve as a useful baseline measure for such an audit.

Table 1 .
RMO recommendations and local admissions panel decisions in 'controversial' cases admissions panel decisions?How often does the central admissions panel at the Special Hospital Services Authority (SHSA) intervene in decisionmaking and what form does this take?How often does the Home Office direct an admission or transfer of patients?What are the reasons give for differences in opinion?Are they based on clinical issues or on the grounds of perceived dangerousness (i.e.security issues)?