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UPPSALA UNIVERSITET Statsvetenskapliga institutionen Självständigt arbete C Vårterminen 2004 Mad or Bad? Explaining different outcomes of reforming treatment organisation for mentally disordered offenders in Britain and Sweden Author: Wendy Maycraft Kall Tutor: Paula Blomqvist Contents ABSTRACT -3- GLOSSARY OF ENGLISH/SWEDISH TERMS -4- CHAPTER 1: INTRODUCTION -5- 1.1 OBJECTIVES AND SCOPE 1.2 RESEARCH QUESTION 1.3 RESEARCH DESIGN 1.4 SOURCES AND DATA COLLECTION METHOD 1.5 DISPOSITION 1.6 DEFINITION OF KEY TERMS -6-6-6-8- 10 - 10 - CHAPTER 2: THEORETICAL PERSPECTIVES AND HYPOTHESIS FORMULATION 2.1 DECENTRALISATION 2.2 PRIOR RESEARCH ON FORENSIC PSYCHIATRY 2.3 FROM RESEARCH TO HYPOTHESES 2.4 POLITICAL INSTITUTIONS Figure 2.1 Comparison of the Westminster and Nordic models 2.4.1 Formulation of Hypothesis 1 2.5 FORENSIC PSYCHIATRY’S SERVICE CULTURE 2.5.1 Formulation of Hypothesis 2 2.6 CONCLUSION CHAPTER 3: FORENSIC PSYCHIATRIC POLICY IN SWEDEN AND BRITAIN 3.1 FORENSIC PSYCHIATRIC POLICY IN SWEDEN 3.2 FORENSIC PSYCHIATRIC POLICY IN BRITAIN 3.3 DISCUSSION AND CONCLUSIONS: REFORM OUTCOMES Figure 3.1 Policy reform and policy outcomes – a comparison of Sweden and Britain CHAPTER 4 EXPLAINING THE POLICY OUTCOMES 4.1 TESTING HYPOTHESIS 1: THE OUTCOMES ARE EXPLAINED BY POLITICAL INSTITUTIONS 4.1.1 Policy outcomes and political institutions in Sweden 4.1.2 Policy outcomes and political institutions in Britain 4.1.3 Conclusions: Policy outcomes and political institutions 4.2 TESTING HYPOTHESIS 2: THE OUTCOMES ARE EXPLAINED BY SERVICE CULTURE 4.2.1 Policy Outcomes and service culture in Sweden 4.3.2 Policy Outcomes and service culture in Britain 4.3.3 Conclusions: Policy outcomes and service culture 4.4 CONCLUSIONS: HYPOTHESIS TESTING RESULTS Figure 4.1 Summary of hypothesis tests CHAPTER 5: ANALYSIS AND CONCLUDING DISCUSSION 5.1 SUMMARY OF STUDY RESULTS 5.2 ANALYSIS OF HYPOTHESIS TESTING RESULTS Figure 5.1 Diagram: Causes of outcomes 5.3 CONCLUDING DISCUSSION - 12 - 12 - 13 - 13 - 14 - 15 - 17 - 17 - 21 - 21 - 22 - 22 - 26 - 31 - 33 - 34 - 34 - 34 - 35 - 38 - 38 - 39 - 40 - 42 - 43 - 43 - 44 - 44 - 45 - 45 - 47 - REFERENCES - 50 - -2- Abstract Britain and Sweden have had similar backgrounds when it comes to organising treatment of Mentally Disordered Offenders who are sentenced to forensic psychiatric care instead of prison. Traditionally care has been centrally controlled and isolated from mainstream healthcare structures. However since the 1980s, both countries have had similar stated policy objectives of wanting to integrate services for forensic psychiatric treatment into general healthcare structures. Both countries have regionally organised healthcare with decisions on treatment provision made by the regional organisation. The term integration suggests that forensic services would be decentralised to Health Authorities in the same way as other healthcare services. Yet these seemingly similar policy objectives have resulted in very different outcomes. This leads to a puzzle, what is the explanation for the differing outcomes? This study aims to explain the reason(s) for the different outcomes by tracing the causative process using a comparative case-study method. The study demonstrates that both political institutions and service culture explain why Sweden was able to decentralise forensic psychiatric treatment but not Britain. Abstract (Svenska) Storbritannien och Sverige har haft liknande bakgrunder gällande organisationen av behandling för psykiskt störda lagöverträdare som dömdes till rättspsykiatrisk vård istället för fängelse. Traditionellt har vården varit under statens centralstyrning och isolerad från sjukvårdens organisation. Sedan 1980-talet har både Sverige och Storbritannien haft ett uttalat politiskt mål att de vill integrera rättspsykiatrisk vård med den övriga sjukvården. Båda länders sjukvård har en regional organisation och landstingen får besluter om vårdens utbud och omfattning. Begreppet integration tyder på att rättspsykiatrin skulle decentraliseras ner till landsting nivå och organiseras på samma villkor som den övriga sjukvården. Men dessa liknande politiska mål har haft olika utfall. Hur kan dessa olika resultat förklaras? Denna studie har som mål att förklara dessa skilda resultat och spåra de kausativa processerna genom att använda metoden jämförande fallstudie. Denna forskning visar att både de politiska institutionerna och den rättspsykiatriska kulturen förklarar varför Sverige kunde decentralisera men inte Storbritannien. -3- Glossary of English/Swedish terms Official names Board of Health – Socialstyrelsen (Sweden ) Compulsory Psychiatric Care Act – lagen om psykiatriska tvångsvården (Sweden) County Court – länsrätten Court Authority – Domstolsverket Department of health – Hälso och sjukvårds department (Britain) (The) Forensic Medicine Authority – rättsmedicinverket (Sweden) Forensic Psychiatric Act – lagen om rättspsykiatriska vård (Sweden) Health Authority (HA) – Landsting Health and Medical Care Act - Hälso och Sjukvårdslagen (Sweden) Home Office - Inrikes department (Britain) Judicial discharge authority – särskilda utskrivningsprövningen (Sweden) Legal Counsel - rättsliga rådet (Sweden) Magistrate - nämndeman Mental Health Legislative Committee – sinnessjuklagstiftningskommittén General translations Criminal Law – brottsbalken The Criminal Justice system – rättsväsendet Discharge committee - utskrivningsnämnden Expert psychiatrist – sakkunniga läkaren Forensic psychiatry – rättspsykiatrin Government Bill – proposition Home health authority – patientens hemlandsting Home leave – permission Lunatic asylums – sinnesjukhus Mentally disordered offenders – rättspsykiatriska patienter Senior Consultant - chefsöverläkare Serious mental disorder – en allvarlig psykiatrisk störning -4- Chapter 1: Introduction Mad or Bad? Who decides? Who provides? The tragic murder of Anna Lindh brought into sharp focus questions of how societies should respond to mentally disordered offenders, and whether offenders should be regarded as criminals sentenced to prison or ill and in need of care. Cases and crimes involving the mentally disordered are often highly publicised by the media, usually accompanied by demands that politicians should “do something”. This study focuses on the organisation of treatment for the highest risk category of mentally disordered offenders who receive treatment instead of prison; forensic psychiatric services. It is a cmplex area of government policy to categorise functionally as the policy-making concerning treatment and its organisation falls into a grey zone between criminal justice and health policies. The issue of how states should respond to mentally disordered offenders raises important issues for political science; political issues centre on where policy is made and whether it is regarded as a political, legal or medical question. For example: who decides sentencing and release? Which offenders go to prison and which go to hospital? There are also matters of public administration for example, who controls, finances and organises services for mentally disordered offenders? Are services centrally or locally controlled? And are they considered a function of health or prison policy? These issues represent reoccurring themes during policy transition and reform. Britain1 and Sweden are two countries that have had the aim of reforming the organisation of forensic psychiatric services for severely mentally disordered offenders since the late 1980s. The stated policy aims had seemingly similar goals of integrating forensic psychiatry into health service structures, resulting in a decentralisation of management to regional and local levels. However the outcomes have been very different. In Sweden, significant decentralisation has taken place leaving services largely decentralised and integrated with healthcare services. However, in Britain decentralisation did not occur and forensic psychiatry remains somewhat separate with substantial elements of central and Ministerial control. In Sweden services are in the hands of medical and legal professionals yet in Britain, the actual placement and treatment of patients remains controlled by central government politicians. The puzzle is what caused these two governments, with seemingly similar professed aims of 1 I have used the term Britain although the reforms are mainly applicable of England and Wales at this point in time. Scotland is in the process of developing its own forensic service as a result of devolution of powers to the Scottish Parliament. Northern Ireland is governed by separate legislation. -5- decentralisation to achieve different outcomes? Can these differences be explained the political institutions or differences relating to the service culture surrounding forensic psychiatry itself? Why did decentralisation occur in Sweden but not in Britain? 1.1 Objectives and scope The objective of this essay is to analyse the organisational effects of the policy outcomes in Sweden and Britain in order to explain why the similar objectives of integrating forensic psychiatric services into healthcare structures gave different results. Integration of services requires that authority over forensic psychiatry would be decentralised and that forensic psychiatry would be managed in the same manner as other healthcare functions. The areas that this essay will focus upon are whether the result variance lies in differences between the systems of government or relates to the service itself. The study will centre on the organisation of treatment for the most serious mentally disordered offenders; convicted to be treated in high security hospitals, often called forensic psychiatric services. The essay will centre on the reforms to the organisational structures created for treating patients convicted to forensic care in each country. Criminal justice and diagnostic systems will not be evaluated. 1.2 Research question The specific question to be answered is; given that Britain and Sweden had similar stated goals of decentralising and integrating services into healthcare structures, why did Sweden decentralise forensic psychiatric treatment fully into healthcare structures whilst in Britain forensic psychiatry remains under significant central control? 1.3 Research Design2 In this study I will investigate specifically how the seemingly similar aims resulted in different outcomes by examining the policy of decentralising the treatment of mentally disordered offenders in Sweden and Britain, and the organisational structures that were created. The reasons why I selected forensic psychiatry as my case study are several. Forensic psychiatry is a high profile service and has been the subject of many policy and organisational changes; traditionally services have been subject to greater central control and organised separately from healthcare structures. Yet despite this, forensic psychiatry is an area of relatively little political science research. The reasons that I have selected Britain and Sweden for my case study examination are fourfold. Firstly Britain and Sweden are two countries 2 This section is based on the structure set out in George, AL (1979) p 49 - 55 -6- which have publicly funded healthcare systems rather than private insurance based schemes. Secondly, both countries have long standing regional structures for the delivery of health care. Thirdly, Britain and Sweden have had a similar historical development of forensic psychiatry; in the past services were controlled by central government with separate organisational structures. Finally Britain and Sweden have had similar stated policies of integrating forensic psychiatry into general healthcare structures. This implies a decentralisation of forensic psychiatry by devolving responsibilities to local health authorities from centralised, state managed schemes. However the outcomes of these policies have been different; decentralisation in Sweden has integrated forensic psychiatry into healthcare structures, yet in Britain forensic psychiatry is still largely controlled by central government with a strong relationship with prison services. Therefore the aim of this essay is to identify the causative process between the decision to decentralise and the structures established in order to understand why decentralisation occurred in Sweden but to a much lesser extent in Britain. In this study the comparative method will be used, in particular a focussed comparison, which is an intensive analysis of an element of politics or policy in a few countries. In this study the cases have been selected as most similar cases sometimes known as Method of Difference3 where countries have many comparable features yet vary on the particular aspect of interest. By examining two similar countries the study aims to identify and isolate factors that might explain the different outcomes.4 In this study the similarities between Sweden and Britain are held constant in order to isolate how the independent variable (X) led to the dependent outcome (Y). The research design is as follows: Figure 1.1 Focussed comparison: Policy reform forensic psychiatry Sweden Britain Case Characteristics ~ Publicly funded healthcare ~ Publicly funded healthcare (similarities) ~ Regional healthcare delivery ~ Regional healthcare delivery ~ traditionally separate ~ traditionally separate forensic organisation forensic organisation ~ Stated policy of integration ~ Stated policy of integration Independent variable X? Not X? Dependent variable Decentralisation Significant Central Control 3 This method is based on Method of Difference a method developed by John Stuart Mill where cases with similar features yet different outcomes are selected with the objective of identifying the independent variable that caused the different result. (Philosophy Dictionary) 4 Hague; R et al (1998) p 280 -282 -7- Therefore the method for this essay will attempt to identify X; the explanation(s) for the policy reforms having different outcomes. 1.4 Sources and data collection method A variety of sources have been used for this study. Written sources include legal texts, literature, government and official publications. When it came to Sweden the examination of relevant information was relatively straight forward. Copies of the Bills explaining the government’s new policy together with legal texts and literature explaining the reforms to practitioners were used. I also examined the reasons given for reforms set out in government bills, reports commissioned by the government and agencies. Tracing the policy development in Britain has been more problematic. Professor Rhodes recounts the story of when a Conservative Minister attempted to reform ministerial information systems in the 1980’s. The system was so arcane that it was said only three people in Whitehall understood the system, however when the Minister left the Ministry after four years of reform, he’d achieved the remarkable feat that nobody now understood the system.5 Trying to trace the policy reform process for forensic psychiatry in Britain has been a somewhat similar process. Some policy information is classified and unavailable, which together with higher levels of general secrecy means that the government does not always explain the reasons behind its policy decisions. The service provision is very fragmented with policy responsibilities split between two government departments, several government agencies, three strategic health authorities, several mental health Trusts a National Oversight body, the three high security hospitals as well as the Prison Service. Therefore it has not been possible to obtain documents with a comprehensive view across the entire service. I have used a variety of sources, including legal texts, reports of Inquiries and Committees and papers prepared by Ministries and other bodies. I have also utilised secondary research sources where available. Therefore I believe that my documentary sources have a high degree of reliability and validity. One of the problems encountered with my study is that it was not possible to obtain full information from written sources alone, especially relating to implementation. Therefore I carried out some interviews in order to clarify the roles and responsibilities within the new organisations. These interviews represent a very small part of my data collection as they were used to supplement or clarify the written sources. I used a semi-structured interview method 5 Rhodes RAW (1997) p 112 -8- with a schedule of open questions which allowed the respondents to formulate their own replies. According to Wilson, interviews can be a good source as they enable the researcher to obtain greater detail and intensive interviews can lead to a better understanding as the interviewer can focus on the specific element to be researched as well as having the possibility of clarifying answers using follow up questions. However Wilson points out the problems of ensuring representative responses in intensive studies and the risks of the interviewer themselves influencing the outcomes.6 The aim of my interviews was to obtain factual information relating to the roles and responsibilities within forensic psychiatry that was not comprehensive in the written sources. In Sweden I conducted face-to-face interviews with two doctors at the forensic psychiatric unit in Säter who are actively involved with the forensic treatment as well as a County Court appointed expert psychiatrist. Each interview lasted between 30 - 60 minutes. By only interviewing at a single location it is possible that these interviews were not representative, however all three had experience of forensic psychiatric cases in several Health Authorities. In Britain I clarified details relating to the complex organisational structure using structured email interviews with a nursing manager at Rampton hospital and a civil servant in the mental health policy branch, although this did have the disadvantage in not enabling me to pose immediate follow-up questions. My assessment of the interviews was that my interview sources represent central contemporaneous sources. As the nature of the questions focussed on organisations and procedures rather that opinions and values; I believe that my results have achieved good validity and reliability. My study required that I compare the attitudes of society to forensic psychiatry. While I was able to obtain some literature and research on this issue for Britain, I was unable to locate similar material relating to Sweden. Therefore I conducted a small study by reviewing newspaper articles in Dagens Nyheters and Svenska Dagbladets article-database using the search word Rättspsykiatri/n (forensic psychiatry). This resulted in 49 hits. Some were news reports relating to specific cases however I read and analysed seven articles that were of a more general nature7 using the criteria of whether forensic psychiatry was regarded as a healthcare or prison function. The advantage of this method is that it allows me to assess the 6 Wilson, M (1996) p 99 , 111-120 The articles of specific interest are: Dagens Nyheter Psykvård in sönderfall 2/6-03; Engström, Annika, Rättpsykiatrin utan lediga vård platser 10/2-04; Eriksson, Torsten, Brutalt döma psyksjuka till fängelse 11/8-02; Haverdahl, Anna-Lena Våldsverkare nekas psykvård 19/9-03; Haverdahl, Anna-Lena, Isolering istället för sluten vård 24/9-03; Kjöller Hanne; När överkuckut tar till orda; 28/3-01; Svenska Dagbladet, Centern Varnar för maral panic, 2/10-03 7 -9- current attitudes in society when no other information is available, therefore giving good validity. However the disadvantages are, firstly, that the sample was small, and covered a limited number of newspapers and articles which may mean that the results are not fully representative. Secondly, the results of my appraisal are based on my interpretations of the texts; it is always possible that a different researcher might reach different conclusions. Therefore this data may have reduced reliability. However I believe that the data obtained from my appraisal represents the best estimate of the Swedish society’s attitude to forensic care. Although this is an area that could be researched further. 1.5 Disposition The objective of this essay is to explain the different outcomes and why Sweden was able to decentralise but not Britain. The first step will be to review previous political research in order to discuss the key term of decentralisation and examine theoretical arguments that could explain different outcomes in Britain and Sweden and hypotheses will be formulated (Chapter 2). The second stage will be: first, to outline the background to the forensic psychiatry reforms in Britain and Sweden. Secondly the reforms will be described and assessed to determine whether the stated objective was decentralisation and if different outcomes were achieved (Chapter 3). The hypotheses will be tested against empirical data (Chapter 4). Finally the results of my study will be analysed and discussed (Chapter 5) 1.6 Definition of key terms The subject that I have chosen contains a number of specialist terms. I have provided a glossary of translations for key terms. However it is necessary to define the some central terms on both theoretical and operational levels.8 Theoretical definitions9 Forensic psychiatry: The systems for the diagnosis and treatment of mentally ill criminals. Mentally disordered offenders: persons committing an illegal act who suffer from a condition or abnormality affecting their behaviour or thinking ability. Operational definitions The term forensic psychiatry and mentally disordered offenders are in fact vague terms, covering a wide array of crimes and psychiatric conditions; ranging from minor crimes 8 9 A detailed discussion of the term Decentralisation is included in chapter 2 Based on the Oxford English Dictionary; words forensic, psychiatry, mental illness, disorder, offender - 10 - committed by the mildly ill to seriously mentally disordered offenders committing the most serious crimes. Forensic psychiatry: For the purposes of this study I intend to focus on policies relating to high security forensic psychiatric services, meaning patients who are treated in the secure forensic psychiatric hospitals of which there are four in Sweden and three in Britain. Mentally disordered offenders: Criminals who have a serious mental illness and are sentenced to psychiatric treatment in high security settings instead of prison. I excluded criminals suffering from lesser disorders and prisoners who develop mental illnesses at a later time. What is a policy reform? However an important question to consider is what is a policy reform? The word policy means a course of action or principle proposed by the government and reform means a change for the better10. Therefore according to this general definition, any change of government action could be considered a reform. However I intend to interpret the term policy reform more specifically. As we will see many changes have occurred in the two countries, but what separates a policy change from a policy reform? My own interpretation is that a policy reform needs to make fundamental changes to government action and/or services delivered. It includes structural changes in the way that services are delivered; for example a transfer from central to local. It may also include fundamental changes to the way the service is perceived, for example a movement from services being regarded as a prison activity to being regarded as a healthcare service in this instance. Both Britain and Sweden’s main policy reforms occurred during the 1990’s although in both cases there was also reliance on other changes and reforms outside the period. 10 Oxford English Dictionary: policy; reform - 11 - Chapter 2: Theoretical perspectives and hypothesis formulation In this chapter I will review relevant theory and research in order to help me formulate hypotheses as to why similar stated objectives gave different outcomes. In particular I will: Discuss my definition of decentralisation. Review previous research to establish what work has already been done in the field of forensic psychiatric policy and organisation. Utilise relevant research to my essay objectives in order to formulate hypotheses. 2.1 Decentralisation Few political terms have such a positive ring as decentralisation. It sums up a (sometimes idealised) notion of small scale, possibilities for citizens to influence political decisions, local decision making, local service variations and belief in individuals’ sound common sense. If we could only decide ourselves, without the involvement of central bureaucrats and central political directives, the decisions would be sound, and the measures taken right.11 The integration of forensic psychiatry into general healthcare services implies decentralisation; i.e. a shift of power from central government to local health authorities in the case being studied here. One issue that became clear during my research for this paper is the absence of a single, uncontested theoretical definition of decentralisation. The term is often used in vague terms without consistency by political scientists to describe differing phenomena. Pollitt and Summa say that decentralisation is often defined in different ways that have in common the transfer of power from higher to lower authorities, yet in practice there is a disparity in meaning and content.12 Rhodes also defines decentralisation generally, using the term “hollowing out of the State”, as the transfer of power and authority from central government to lower levels or agencies.13 Political scientist Jon Pierre defines decentralisation more specifically, arguing that there are three ways governments can influence the balance between central and local decision making. The first is decentralisation, where political power or decision-making authority is transferred from central government to another legal entity. The second is delegation, meaning decisionmaking authority is transferred to another organisation but the transfer is temporary or subject to conditions or limits. Thirdly deconcentration occurs where organisations or activities are relocated to other geographic locations without any changes to regulations, authority or finance. Pierre argues that there are three dimensions that need to be considered when assessing whether an organisational change can be classified as decentralisation. 11 Pierre, J (2001) p 105 (my translation) Pollitt C and Summa H (1997) p 8 13 Rhodes R (1997) p 48 -54 12 - 12 - Regulation – the lower agency should have freedom over rules and regulations and central government should not make the detailed regulations. Authority –management power should pass to the operational level. Finance – the decentralised body should have control over resources.14 The definitions proposed by Rhodes and Pollitt are abstract and lack sufficient detail to analyse policy outcomes. Therefore Pierre’s specific definitions and dimensions will be used to assess and measure whether decentralisation has occurred in my empirical study. 2.2 Prior research on forensic psychiatry There has been some research from an organisation and management perspective on general health service reforms, however much was not relevant as forensic psychiatry’s traditionally separate organisation was not addressed. Much research focuses on the transition to community care and network issues of offering joined up outpatient services for example Badger et al15 Planning to Meet the Needs of Offenders with Mental Disorders in the United Kingdom discussed the planning of community services. There is historical research that serves as a useful background. For example Swedish psychiatrist and historian Schlaug’s16 book Psykiatri, lag och samhälle analyses the historical development of Swedish mental health legislation, but ends in the 1980s which is where my research begins. There is also a body of sociological gender based research such as Fowell’s17 article Women in the Special Hospitals: a Sociological Approach highlighting the problems of women offenders and treatment based on male norms. Therefore based on my review, I conclude that forensic psychiatry is relatively un-researched from an organisation and policy perspective and little can be utilised to answer my research question. However I did identify several relevant publications and texts from legal, management and political science researchers that I will make use of to develop my hypotheses. 2.3 From research to hypotheses Having searched and reviewed relevant academic literature, I identified two major arguments that could explain the differing policy outcomes in Britain and Sweden; both relate to cultural18 differences between countries. The first concerns political institutions, meaning that 14 This section is based on Pierre, J in Rothstein (ed) (2001) p 105 – 126 Badger et al (1999) 16 Schlaug, R (1989) 17 Fowell, J (2001) 18 I have interpreted the term Culture is using Baldock’s definition of culture as “shared beliefs, values and behavioural norms of a community” (Baldock in Manning and Shaw (2003)p123) 15 - 13 - differences in the British and Swedish political institutions influence policy outcomes and organisational structures. The second argument is that differences in service culture can explain the different policy outcomes. By this I mean that different legal, social and welfare state backgrounds in Britain and Sweden lead to different perceptions, norms and expectations among the public and politicians about forensic psychiatry. These theoretical and research arguments will be discussed and used to develop hypotheses at the end of each section together with relevant measures to test them. 2.4 Political Institutions It is not easy to define the term political institutions. Rothstein outlines the ongoing debate amongst political theorists concerning where the boundaries should be drawn with some theorists preferring to restrict the term institutions to formal state structures whereas others incorporate broader ideas of culture, behaviour and social norms.19 John and Cole define the term as the: national political and administrative arrangements which is a definition that incorporates centreperiphery relations.20 I will use this narrow definition and consider only the role of formal institutions.21 The question is; how do the political institutions of a country influence the outcome of policy reform? According to John and Cole this argument focuses on the importance of history, key events as well as legal and administrative systems as influences upon the decision making process.22 This is reiterated by Rhodes who contends that political institutions provide a historical-legal approach to explain the constraints and context for political decision-making. This achieved by evaluating the historical background that shaped the system of government as well as tracing the legal basis of the powers and procedures adopted by the institutions Institutional theories seek to explain the relationship between structure and policy by looking at the way in which rules, procedures and formal organisations influence policy-making..23 Therefore the political institutions provide a contextual framework for analysing policy differences. Pollitt and Summa assert that public management reforms should take into consideration that countries have different starting points. Some have the tradition of highly centralised structures whereas others are decentralised. These starting points give different 19 Rothstein B (1996) p 145 -146 John P, & Cole, A (2000) p 255 21 By this I mean formal national institutions and not local structures relating to forensic psychiatry. 22 John P, & Cole, A (2000) p 255 -256 23 Rhodes R, (1997) p 63-68 & 79 20 - 14 - structural reform opportunities. Therefore according to Pollitt and Summa the political institutions form the underlying organisational context within which policies are formulated and implemented. Reforms are adapted by political leaders in order to “fit in” with the general organisational patterns and politics that are the “norm” of the individual country.24 Pollitt and Summa argue that the different outcomes of public sector administrative reforms can be traced to the political institutions. In their study, the countries fell into two categories; the Westminster model and the Nordic model. The Westminster Model is characterised by strong central control over policy and lower levels. Policy is made by central government, usually majority governments. The centre can impose reforms on lower levels and there is no tradition of independent agencies. The Nordic model’s main features are decentralisation and autonomous local government and administrative agencies. Policy-making is more consensual and reforms negotiated. The model is summarised in the figure below: 25 Figure 2.1 Comparison of the Westminster and Nordic models26 Model State Political system Westminster ~ Central control ~ central control of local/ regional levels ~ two party ~ adversarial Nordic ~corporatism ~ local government independence ~ coalition ~consensual Administrative system ~ centralised system ~ central government can impose reform on lower levels ~ No tradition of independent agencies ~ decentralisation ~ high administrative ~ autonomy In Pollitt and Summa’s study. Britain was categorised as a Westminster Model country and Sweden as a Nordic model land. Therefore according to Pollitt and Summa’s model there is a greater probability of central government control in Britain whereas Sweden has a tradition of local government independence and “arms length” government via autonomous and decentralised administrative systems.27 24 Pollitt C and Summa H (1997) p 7- 8 Pollitt C and Summa H (1997) p 7- 11 26 This table has been created based on the information contained in Pollitt and Summa (1997) p 14 -15 27 Pollitt C and Summa H (1997) 25 - 15 - Christensen, Lægreid and Wise studied administrative policy28 reform and conclude that political institutions influence policy outcomes in the Nordic countries. The system of government with minority and coalition governments, political parties and public negotiation of policy is a central factor as policy reform is subject to negotiation and consensus. The strong position of autonomous agencies in the interpretation and implementation of policy means that the central government does not dominate. The result is that the administrative systems of the Nordic countries are characterised by equality, negotiation and the balancing of competing interests.29 According to Petersson the “architecture” of Swedish political institutions results in a tradition of strong central government balanced with local autonomy. Over recent decades decentralisation has been an important theme with the lower levels assuming an increasing number of responsibilities previously undertaken by central agencies. However according to Petersson this has not been regarded as a zero sum game; meaning that decentralisation in Sweden has led to complementary responsibilities; central government sets the framework while the lower levels formulate operational and organisational policy.30 In Britain the political institutions emphasise a greater degree of central control. 6 and Peck examined the government’s mental health modernisation policy, and found that although the aim was to decentralise services, the actual structure achieved was a “Hybrid between hierarchy and individualism”.31 Central government maintained a hierarchy by controlling lower levels via detailed standard setting and controls while the individualism related to the local managers’ ability to manage within the confines of centrally set goals. This conclusion reinforces Melon’s earlier research into previous reforms Britain; the creation of Executive Agencies and the recruitment of private sector managers to run them. She concluded that political institutions and culture hindered decentralisation and revealed a gap between the stated objectives of decentralisation and structures created. She concluded that it was difficult to change deep rooted political structures. Despite a policy of autonomous agencies, the central Ministries were unwilling to “let go” and there was direct Ministerial and departmental interference in operational matters. The reforms adopted a “market-speak” of decentralisation which was mostly political rhetoric and did not exist in the actual institutions created. 32 28 This study focused on Sweden, Norway and USA. I have focused on their finding relating to Norway and Sweden using the tern Nordic countries. Their finding relating to USA are not relevant to this study. 29 Christensen et al (2002) p 161-162 30 Petersson (2001) p 72 -74 &97 -98 31 6, P and Perri, E p 101 32 Melon, E, (1993) - 16 - Therefore the political institutions could aid or hinder the reform. Christensen et al, Petersson and Politt and Summa demonstrate that Sweden’s political institutions are in many instances decentralised and autonomous. Therefore the decentralisation of a service may not have been controversial. On the other hand Britain, as a Westminster model country, has a tradition of centrally controlled political institutions. 6 and Peck and Mellon have shown that there is a tendency of the centre to retain control, even where the stated objective is decentralisation. 2.4.1 Formulation of Hypothesis 1 Hypothesis: Political institutions aided decentralisation of forensic psychiatry in Sweden but not in Britain Did the Westminster model in Britain and the Nordic Model in Sweden influence the reform outcomes? This hypothesis assumes that the outcomes can be explained by the political institutions easing or hindering the decentralisation of forensic services into healthcare. In order to test this hypothesis, I will evaluate the formal political institutions of each country using Pollitt and Summa’s model and their impact on decentralising forensic psychiatry. 2.5 Forensic Psychiatry’s Service culture Instead of examining the political institutions some researchers look to political and sociological arguments concerning perceptions about the service itself, in this instance, forensic psychiatric services. According to Bevir, Rhodes and Weller, the formation of policy is influenced by the historical and social knowledge of a society which they refer to as traditions. Political culture and social traditions shape the context within which reform policies are formulated and implemented resulting in the same aim having different results.33 However service culture is difficult to determine as it is rarely expressed explicitly, instead has to derived and interpreted from a variety of sources; sociological, legal administrative etc. The following section uses prior research to attempt to define this nebulous area. Esping-Andersen’ typology of welfare states, The three worlds of welfare capitalism, alludes to different perceptions of public services. Although his research focussed mainly on labour market policy, the principal values and assumptions about states may explain different policy outcomes. Anglo-Saxon countries such as Britain are classified as liberal welfare states. The underlying philosophy is individual responsibility and freedom with the market responsible for services or the state providing stigmatised services. Social protection is considered undesirable and leading to moral corruption. Any state intervention should emphasize self 33 Bevir, Rhodes and Weller (2003) p 1-7 - 17 - help e.g. education. Scandinavian countries like Sweden generally conform to the social democratic model by focussing on the issues of equality and the social origins of poverty with the state’s role being to rectify inequalities and a minimum living standard.34 Specifically related to crime, Braithwaite argues that the social norms that shape modern society provide new ways of regarding crime and its control. He argues that some countries perceive crime as a social welfare problem to be dealt with by employing police, social and welfare workers whereas other countries focus on risk management and preventative governance.35 It may be that these different attitudes to crime and criminals could explain the different policy outcomes. For example Sweden may focus on crime and criminals as a social welfare issue; whereas British policy may centre on public protection and risk management. These underlying welfare state theories (Esping-Andersen and Braithwaite) may influence both policy makers and attitudes towards users among both public and politicians. There is also the impact that legal differences may have on attitudes and perceptions of mentally disordered offenders. Nordenfelt contends that under Anglo-Saxon law, offenders are excused of all responsibility for the crime, there may be no trial and the offender is ordered detained at Her Majesty’s pleasure36 by the court. It is not the mental disorder that leads to treatment, but the concept of being unable to comprehend right from wrong. Under Swedish Law, offenders are always considered responsible and stand trial and the issue of a mental disorder is only raised at sentencing. Nordenfelt asserts that the insanity defence was criticised and regarded as a “let-off” in 19th century Britain.37 Although there may be no difference in the resulting treatment order, my interpretation is that this could be an important distinction. The Anglo-Saxon (British) system absolves offenders of responsibility which may lead the public and politicians to demand greater restrictiveness and more control over treatment whereas in Sweden offenders are always responsible despite a mental disorder. The attitudes of society, for example the general public and politicians, to mentally disordered offenders are also important, albeit difficult to determine, as they are seldom articulated. However there is also an issue of how societies expectations of risk management and 34 Esping-Andersen, G (1990) p 40 -46 and 61 - 65 Braithwaite J (2000) p 222 -227 36 This is the commonly used term although Nordenfeldt does not use this actual term. It means that mentally disordered offenders do not stand trial and are not technically convicted of the offence. Instead offenders are detained in high security mental hospitals until the Home Secretary (Minister in Charge of the Home Office) authorises their release. 37 Nordenfelt L (1992) p 11 - 16 35 - 18 - treatment are balanced in the policy making process. Philosophy researcher, Joakim Molander, discusses how Swedish culture and compassionate attitudes have influenced pubic opinion towards mentally disordered offenders. He argues that there is a general consensus among Swedes of the fundamental goodness of human nature and that evil deeds are carried out by the sick. He summarises the Swedish philosophy as being that if criminals are sick, then they should be treated not punished. According to Molander, the treatment ideology runs deep in Swedish perception, possibly as a result of social democracy’s strength and its philosophy that criminality can be explained by failures within society and that the mentally ill should not be punished by society. Instead these criminals should be taken care of and rehabilitated…the individual does not bear moral responsibility if he is ill. 38 However, Molander adds that the Swedish philosophy of the basic decency of people could be challenged by dramatic events (like the murder of Anna Lindh) if society starts to question its basic assumption of the human goodness of mankind.39 In Britain, nursing researcher Anderson concludes that there has been a growth of empirical research focussing on public fear surrounding mental illness and crime. According to Anderson there is a general public perception that mentally illness equals violence and that having former mental patients in society increases “ordinary” people’s risk.40 Professor of Public Policy, Nancy Wolff studied psychiatric policy in Britain and argues that policy towards the mentally ill is heavily influenced by a society’s attitude toward risk. There is a political problem as policy is framed in terms of risk not illness. Therefore there is a tendency for policy formulation to focus on risk management and public protection rather than therapy. Mental health policy can be framed in terms of mental illness as an illness or mental illness as a risk factor. Currently it is framed in terms of a risk factor…But this approach alters the balance between security and care in the management of the illness…Focussing attention on the illness first offers opportunities to develop a balances system of care when directives and incentive are shaped in a balanced non-discriminatory way.41 The operational risks of modernisation were borne by local agencies. Wolff’s evaluation led her to five conclusions concerning mental health policy in Britain42: 38 Molander, J (2003) Molander J (2003) 40 Anderson M (1997) p 247 41 Wolff N (2002) p 824 42 This section is based on Wolff N (2002) p 812 -821 and 825 39 - 19 - 1. Expectations – Mental health reforms promote unrealistic public safety expectations that forensic patients would not lead to public risk. 2. Instability and activity – moral panics cause governments to seek to demonstrate action. Lower levels are swamped by initiatives, creating uncertainty and fragmentation. 3. Lack of accountability at the top – decentralisation shifts accountability and risks from central to local levels. For example Ministers could claim not to be involved in operations yet were not held accountable for overall policy. 4. Risk aversion – risks that have not been decentralised such as the movement of restricted patients require the Home Secretary’s signature. This is a political risk for the Home Secretary and can lead to a tendency to keep offenders in higher levels of security than needed rather than expose himself to risk. 5. Agenda setting and public opinion – British mental health policy is much influenced by the media and public opinion: Prisoner health does not appear on the policy agenda for resource allocation, in part because prisoners have lost their right to vote while in prison and in part because those citizens who do vote have little sympathy with the plight of offenders. 43 Therefore Wolff describes politicians and public opinion as being unfavourable towards offenders. Health professionals regarding risks as low in absolute terms, whereas the public perception, formed from media reports is that risks are high, creating a moral panic. Therefore risk adverse politicians look for strategies to balance the issues of public protection and patients’ rights by keeping policies broadly in line with public opinion. Governments focus on the public protection elements of policy with patient care a secondary issue. By avoiding risk and focusing on public protection issues creates a service culture that regards offenders more as prisoners than patients.44 The issue of forensic psychiatric service culture is whether the public perception differs or whether the public demand different solutions? For example is the British perception that forensic psychiatry is a criminal justice issue that should be controlled centrally in the same way as prison policy, whereas in Sweden the treatment for mentally disordered offenders is regarded as a healthcare issue? Or, perhaps in Britain there is a greater expectation that politicians should manage this risk directly whereas in Sweden it is regarded as a professional issue to be managed by doctors and the legal system? 43 44 Wolff N (2002) p 821 Wolff N (2002) p 802 - 807 & 821 - 20 - To draw these threads together, I conclude that a picture emerges of two societies with differing underlying principles concerning the provision of services. The British political system is based in individualism and legal doctrines restrict the definition of who is considered mentally unfit to stand trial, I detect an assumption that treatment is considered a lenient option and should therefore be reserved for a few. In Britain there is also a perception that public protection should be the highest priority. In Sweden the public services are based on the concepts of welfare and solidarity and society bears some responsibility for individuals’ problems and therefore forensic psychiatry is a social care issue. Even where there is a general perception of risk, treatment not punishment is the preferred option in Sweden. Therefore there appears to be a discrepancy between Britain and Sweden concerning whether mentally disordered offenders should be regarded as patients and prisoners. 2.5.1 Formulation of Hypothesis 2 Hypothesis: Different service cultures influenced the decentralisation of forensic psychiatry into healthcare structures in Sweden but not in Britain. How did the service culture impact on the policy outcomes? This hypothesis assumes that outcomes can be explained by the service culture easing or hindering decentralisation by affecting how the policies were formulated in practice. Does one country emphasize the humanitarian arguments and the other public safety? In order to test this hypothesis, I will evaluate information relating to how services are perceived by public and policy makers. The indicators I will look for are: Whether services are regarded as a function of healthcare. What evidence exists on the attitudes of politicians and the public to services being a function of healthcare rather than prison and how these factored into the policy-making process? 2.6 Conclusion In this section I have reviewed and discussed theoretical and research literature and found that there are differences between the political institutions and service culture of Sweden and Britain. I have used this theoretical and research information to form two hypotheses. These hypotheses will be tested in Chapter 4 in order to determine if they explain the different outcomes of the forensic psychiatric policy reforms in Sweden and Britain. - 21 - Chapter 3: Forensic psychiatric policy in Sweden and Britain The aim of this chapter is discuss the background of forensic psychiatry’s organisation in Sweden and Britain and to examine and analyse the reform process in each country. This is to establish: firstly, that both countries stated the aim of decentralising and integrating forensic psychiatric services into healthcare structures and secondly that different outcomes occurred. 3.1 Forensic psychiatric policy in Sweden In Sweden the state assumed responsibility for detaining and treating mentally disordered offenders in the late 19th Century. Until after the Second World War forensic psychiatry was characterised by central government control. Treatment was in separately administered units, with detailed regulations covering admission, care and discharge. This centralised structure aimed to provide a national organisation.45 There was some overlap of responsibilities between prison and healthcare e.g. psychiatric examinations could occur both in prisons or Medical Board units.46 The ethos was of closed care in isolated, prison-like units. In the 1960s two new Acts47 on compulsory treatment and forensic psychiatric evaluations started the modernisation process. These Acts allowed Health Authorities to run mental institutions for the first time. General mental hospitals were transferred from state to Health Authority (landsting) control.48 It was the first step towards decentralising psychiatry and incorporating it into the general healthcare structures. However these changes did not fully integrate forensic psychiatry and high risk patients remained under state control. Separate national units were retained for the most difficult and dangerous patients in special units in Säter and Västervik, called permanent pavilions49. These remained under significant state control. The Board of Health (Socialstyrelsen) was responsible placing patients there and took an active role in supervising treatment.50 Discharge committees that decided when patients should be released were appointed by central government.51 However this organisation was unwieldy. In 1981 a report by The 45 This section is based on Gylling Lindkvist C et al (1992) p 13-14 Socialstyrelsen (1981) p 61 47 The two Acts were SFS 1966:293 Lagen om beredande av sluten psykiatriska vård i vissa fall, and SFS 1966:301 Lagen on rättspsykiatrisk undersökning i brottmål 48 Gylling Lindkvist, C et al (1992) p 14-15 49 My translation from the Swedish term ”fasta paviljongen” – the term was used for the national maximum security hospitals that treated the most difficult and dangerous patients. The classification of “difficult and dangerous was made by The Board of Health (Socialstyrelsen). There were two located at Säter and Västervik. 50 Källberg, G interview 6/4-04 51 Lagen om beredande av sluten psykiatrisk vård i vissa fall (1966:293) 46 - 22 - Board of Health concluded that there lacked continuity and coordination between the national units and “home Health Authorities (landsting).52 The period between the 1960s and 1980s was characterised by general psychiatry being integrated into health structures, but the traditional, centrally controlled locked unit remained the model for forensic psychiatry. By the 1980s there was as growing general policy emphasis on decentralisation in the public sector. The 1982 Health and Medical Care Act (Hälso- och sjukvårdslagen) was considered a breakthrough as it established that forensic psychiatry was to be considered as a part of healthcare, in the same way as other disciplines.53 The 1982 Act obliged Health Authorities (landsting) to offer healthcare, including forensic psychiatry to residents within its boundaries. For the first time forensic psychiatry was no longer regarded as a separate entity, but instead given equal status to other kinds of healthcare under this act.54 However, even though this was seen as a step towards integration, the issue of central control was not addressed. Although many patients were transferred from large mental institutions to local units, the Board of Health (Socialstyrelsen) managed the placement of forensic patients. Permanent pavilions were phased out during the 1980s, replaced by four55 special units for dangerous and difficult patients. However those patients convicted to forensic psychiatric treatment could also receive treatment in local Health Authority units.56 In Sweden the Swedish Criminal Legal code prohibits mentally disordered offenders from being sentenced to prison.57 The major reform to Swedish forensic psychiatry occurred in 1991 with three new acts which were as follows: the Compulsory Psychiatric Care Act (Lagen om psykiatrisk tvångsvård), Forensic Psychiatric Act (Lagen om rättspsykiatrisk vård), and Forensic Psychiatric Examination Act (Lagen om rättspsykiatrisk undersökning I brottmål). These combined together with the Health and Medical Care act of 1982 and addressed the legal rights of forensic patients and confirmed the position of health authorities. The most important Act for this study is the Forensic Psychiatric Act. Offenders can only be convicted to psychiatric treatment when a person has been convicted of crimes with sentences more serious that fines and a Court ordered examination have found a serious mental disorder to be present.58 52 Socialstyrelsen (1981) p 18 Gylling Lindkvist, C et al (1992) p 15 54 This section is based on Hälso- och sjukvårdlagen (1982:763) and Gylling Lindkvist, C et al (1992) p 22-23 55 These centres are organised geographically with each unit taking patients from several health authorites. 56 Statskontoret, (1989) p 53 - 55 57 Brottsbalken Kap 30 § 6 58 Lagen om rättspsykiatrisk undersökning 1991:1137 53 - 23 - As early as 1981, a report by the Board of Health and Welfare (Socialstyrelsen) identified structural problems and the need to decentralise. They identified problems with poor management in the care chain because central control over patient movements was inflexible and hindered effective organization. There was little coordination and continuity when patients moved between national and local units. The report recommended abolishing national control for high risk patients and proposed that care should conform to the “closeness principle”, and occur as near to home as possible. There should be local decisions on placement and security as well as a reduced role for the Board of Health (Socialstyrelsen) in direct operations. 59 These recommendations were included in the 1991 reforms. There were several objectives stated by the government for the reforms. The first was modernisation. Psychiatry lagged behind other areas of healthcare and was dominated by; oldfashioned attitudes to mental illness and treatment, a lack of legal safeguards and inflexible structures.60 The 1991 Acts were based on a revised definition of mental illness compared with earlier legislation. In order for offenders to be sentenced to forensic psychiatric treatment, they must suffer from a serious mental disorder61 not any mental disorder. The reasons changing the definition were to strengthen legal safeguards for patients and restrict the use of coercive treatment.62 The social-democratic Justice Minister, Freivalds, had expressed fears about the previous system because of the risk of widespread use of coercive treatment sentences for minor crimes committed by those with minor mental illnesses.63 The second stated objective was full decentralisation. The governments considered the 1991 Forensic Psychiatry Act to be a complement to the 1982 Act and confirmed that forensic psychiatric care provision was the responsibility of Health Authorities. (landsting). 64 Home health authorities obtained the power to decide forensic psychiatric treatment and its organisation. Responsibility for placing and planning treatment for forensic patients passed from the board of Health to the Senior Consultant (Chefsöverläkare), responsible for forensic psychiatry in the patient’s home health authority. The Senior Consultant decides whether to treat the patient locally or to place the patient at one of the regional forensic psychiatric 59 Socialstyrelsen (1981) Chapter 7 Proposition om psykiatriska tvångsvård mm 1990/91:58 p 62 - 78 61 The previous definition was vague and referred to “psychiatric illnesses and abnormalities” SLS 1966:293 1§ 62 Socialstyrelsen (1991) p 9-10 63 Proposition om psykiatriska tvångsvård mm 1990/91:58 p 447 64 Proposition om psykiatriska tvångsvård mm 1990/91:58 p 62 - 78 60 - 24 - treatment units for dangerous and difficult patients. 65 Health authorities (landsting) became responsible for the structures to provide local and regional66 care. They assumed full financial responsibility for patients and could enter-into contracts with other authorities to provide care, for example at one of the units for dangerous patients. The Board for Health and Welfare took up a strategic monitoring role. 67 The third objective of the reforms was to increase legal safeguards. The 1991 reforms increased the regional Judiciary’s powers. Discharge authority passed from the centralgovernment appointed discharge committees to the County Court (Länsrätten). The County Court (Länsrätten) re-authorises treatment twice a year, and hears appeals by patient against decisions relating to admission, discharge and home leave.68 The County Court panel consist of a judge and two lay jurors (nämndemän) and is advised by an expert psychiatrist. The treating Senior Consultant makes recommendations, the patient or their lawyer can present their case, and in addition the prosecutor may also give an opinion to the Court.69 In Sweden there appeared to be a political consensus surrounding the policy of decentralisation and integration. I have found no evidence of political opposition to the reforms which I confirmed with my interview subjects. There was also functional consensus that mentally disordered offenders should be regarded as patients, not prisoners and that their treatment provided as a health authority function, without the involvement of prison services. The Health Minister (Thalén) emphasized that forensic psychiatric treatment was no longer regarded as a state function; therefore there was no need for central control.70 The Justice Minister (Freivalds) concurred that forensic psychiatric patients should be regarded as a healthcare rather than a prison service responsibility.71 This important change established forensic psychiatry as a healthcare function in Sweden. 65 This section is based on an interview with the Kall, E Senior Consultant in charge of forensic psychiatric treatment at Säter forensic psychiatric unit 17/3-04 66 geographical Regional high security units were to be created by agreement between several health authorities. 67 Proposition om psykiatriska tvångsvård mm 1990/91:58 p 195 - 198 68 This section is based on Lagen om psykiatrisk tvåndvård 1991:1128 and Socialstyrelsen Tillämpning av lagen om rättpsykiatrisk vård (1991) 69 Interview Dr. Barbro Larsson, County Court expert psychiatrist 1/4 -04 70 Proposition om psykiatriska tvångsvård mm 1990/91:58 p 195 - 198 71 Proposition om psykiatriska tvångsvård mm 1990/91:58 p 447 - 451 - 25 - 3.2 Forensic psychiatric policy in Britain The late 19th century saw the establishment of Broadmoor, Rampton and Ashworth hospitals, which even today form the basis of high security services. Broadmoor hospital was built in 1863 to house the “Criminally Insane” followed by Rampton and Ashworth. These hospitals were managed directly by the Home Secretary.72 However forensic psychiatric hospitals were owned, managed and staffed as prisons. The creation of the National Health Service in 1946 changed the control of forensic psychiatry. Rampton and Ashworth transferred to the Ministry of Health, but Broadmoor hospital was managed separately, as a prison service by the Home Office until its transfer to the Department of Health in 1948. However the Home Secretary retained control of admissions and discharges for high security patients even after 1948. 73 The culture at this time was that hospitals operated much as prisons. By the late 1980’s the organisation of forensic services remained separate from healthcare. Special hospitals were managed centrally by both the Department of Health (DoH) and Home Office and run by civil servants who made policy decisions including resources, manpower and senior recruitment. Day to day hospital operations were managed at the local level. This structure caused conflict as local managers lacked the authority to make policy but the central board was not involved in operational matters. This led to a power struggle between civil servants, local managers and those hospital staff who were Prison Officers.74 In 1988 around 2/3 of Broadmoor’s staff were trained prison officers, not nurses and the culture was prisonlike with patients locked in without access to care for long periods.75 The hospitals’ origins within the criminal justice system and their subsequent exclusion from the mainstream of mental health services explain the curious anomaly that their dominant staff union is the Prison Officers’ Association. This union, or perhaps more accurately its membership within the hospitals, has played a fundamentally destructive role in the struggle to turn the hospitals into therapeutic institutions…This group has filled the vacuum created as hospital management teams had their authority increasingly undermined and invalidated by senior civil servants and ministers, both in the Home Office and Department of Health. Professor Elaine Murphy76 The need to integrate forensic services into healthcare also recognised in the 1980s as in Sweden. Yet organisational change did not end the isolation of forensic services from healthcare structures. In 1989 a new organisational structure was established; the Special 72 The Home office is the central government department responsible for Prison and Law and Order policy and the Home Secretary is the Minster in charge. 73 This section is based on Fallon et al (1999) para 1.18.0 – 1.18.9 74 Fallon et al (1999) para 1.18.9 – 1.18.10 75 Murphy, E (1997) 76 Murphy, E (1997) - 26 - Hospitals Service Authority (SHSA), which had two aims; to integrate the Special Hospitals more fully into the NHS and maintain public safety. Despite the new organisation’s supposed emphasis on local accountability, the hospitals remained separate and tensions arose between central control and local freedom.77 In the early 1990s changes swept through the NHS with the introduction of internal markets; splitting functions into purchaser and provider. The Special Hospitals were, again, to come closer to the NHS by developing these new arrangements and prepare the hospitals for Trust78 status.79 The three hospitals became Special Health Authorities (SHA); still separate from other NHS Trusts/Health Authorities. The SHA’s were directly financed by the Department of Health, therefore local healthcare purchasers did not bear the cost of care. There was a separate organisation for purchasing, providing and monitoring care with Ministers in overall control of policy for mentally disordered offenders. However the new organisation was complicated and the division of responsibilities meant that accountability for services was unclear between central and local levels. There was also overlap between Health and Prison services which created uncertainty over whether the objective was treatment or public safety. The Fallon Inquiry80 concluded: What is clear is that the tension between central control and oversight and local freedom and autonomy will remain under the current arrangements. 81 One thing that must be made clear is that the policy process in Britain is much harder to comprehend than in Sweden. This is due to the fact that forensic psychiatric services have been reorganised on a regular basis by governments. However until Labour Government came to power in 1997 after 18 years of Conservative rule, despite several organisational changes, forensic services remained separate from healthcare under central government control. In Britain legislation for the detention of patients and the organisation of care is split between different Acts. The detention legislation has remained unchanged for decades; the National Health Service Act 1977 and the Mental Health Act 1983. The 1977 Act makes the Secretary of State for Health responsible for providing forensic treatment. He must: Provide and maintain establishments (in this Act referred to as special hospitals) for persons subject to detention under the Mental Health Act who in his opinion require treatment under conditions of special security on account of their dangerous, violent or criminal propensities. 82 77 Fallon et al (1999) para 1.18.11 – 1.18.17 An NHS Trust is a self managing organisation responsible for providing healthcare services to patients, for example hospital or outpatient care. 79 Fallon et al (1999) para 1.18.18 80 The Fallon Inquiry was a punlic investigation into serious problems at Ashworth Speical Hospital although the inquiry assessed and made recommedations on forensic psychiatric treatment generally. 81 Fallon et al (1999) para 1.18.32 82 National Health Service Act 1977 Section 4 78 - 27 - The Mental Health Act 1983 governs the detention; forced treatment and the Courts’ powers to remand accused or convicted persons to hospital for treatment or assessment. A Restriction Order may also be imposed under section 37. The movements and discharge of patients is restricted by requiring the personal authorisation of the Home Secretary.83 A Labour government took power in 1997 and had modernisation high on its reform agenda. Many reforms and changes were introduced to the National Health Service, Mental Health policy,84 plus specific changes concerning forensic services. The Government had the stated aim of wishing to decentralise and integrate treatment into healthcare structures via the 1999 Health Act.85 However the reform process has been complex and obscure with many initiatives implemented simultaneously. General policies, such as “Shifting the balance of power”86 aimed to change NHS culture by developing patient centred services and decentralising power to local levels,87 as well as specific policies relating to individual services. Mental health had become something of a Cinderella service; regarded as healthcare’s poor relation when Labour took office. Services lacked resources and users were stigmatised. Yet the top priority listed in reports was public safety and public protection.88 The latter part of the 1990s also saw several reports and inquiries into forensic psychiatry scandals. These increased pressure on the government to reform forensic psychiatry. However it was unclear whether the emphasis should be on treatment or detention. Two of the reports, the Fallon Inquiry (1999)89 and the House of Commons Health Select Committee Report on Mental health (2000)90 recommended a radical restructuring and genuine decentralisation of high security forensic services. The other, The Tilt Report (2000) examined physical security (fences, locks searches) and recommended that hospitals should be classified as Category B91 prisons.92 Therefore in Britain there did not appear to be a consensual view of whether mentally disordered offenders should be regarded as patients or prisoners. The reforms implemented can be seen as an extension of this confusion. 83 Mental Health Act 1983 Part III and section 37 6, P and Peck E (2004) In their article I have identifies reference to 15 different reports and initiatives affecting mental health between 1997 -2001 not including: implementation guidelines, official inquiries or the specific reforms relating to the forensic psychiatric services. 85 Secretary of State for Health, Dobson, Department of Health (1999) response to recommendation 49 86 This an initiative based on a report of the same name. It emphasises the transfer of power from centre to local. 87 Department of Health (2001) p 11 88 This section is based on Department of Health (2002) The Journey to Recovery p 5-8 and 17 89 Fallon et all (1999) recommendations 90 House of Commons Select Committee (1999/2000) para 190-196 91 A Category B prison is a prison with a high security classification. 92 Tilt et al (2000) Recommendations 84 - 28 - The key reform was the 1999 Health Act that enabled the special hospitals to integrate into NHS Trusts.93 The Government stated the intention of decentralising and integrating treatment provision so that forensic psychiatry could become part of the general healthcare provision: The changes introduced by this Government throught the Health Act 1999 will end that isolation. It will bring Ashworth, Rampton and Broadmoor back into the NHS fold and ensure that the high security psychiatric service is treated in the same manner as all other services provided by the mainstream NHS.94 The consequence of the Health Act was that the special hospitals would be decentralised and integrated into existing NHS Trusts. The announcement that special hospitals would be integrated into healthcare came early in the new millennium, however this was introduced as a Statutory Instrument95 when the mergers were finalised and the special hospitals became part of existing NHS Trusts.96 There was no new mental health Act and no debate in Parliament about the role and organisation of forensic services. The government’s policy seems clear in the quotation above. The phrases “integrated service development within the wider NHS” and “address the current problems of isolation by allowing the high security hospitals to join with other mental health NHS trusts” imply strongly that the aim was to decentralise services so that they could be organised in a similar way to other Mental Health Services. However the organisation created did not display decentralisation as a key feature was central control. I have summarised the key outcomes of the policy and its organisation below, organised by function for the sake of clarity. The new organisation is complex so elements not relevant to the research question have been omitted to avoid confusion: 93 Health Act 1999 section 41 Secretary of State for Health, Dobson, (1999) Press statement (electronic)The Secretary of State for Health’s response to the Committee of Inquiry into the personality disorder unit, Ashworth Special Hospital 95 House of Commons information office Statutory instruments factsheet 2003 A Statutory Instrument (SI)is a form of delegated legislation that allows existing legislation to be amended without the full scrutiny of parliament. In this case the 1977 Act was amended in order to transfer the special hospitals to NHS trusts. (Statutory Instrument 2002 No.559) . 96 The specific SI’s relating to the Special Hospitals were: Statutory Instrument 2001 No. 714 The Rampton Hospital Authority (Abolition) Order where Rampton became part of the Nottinghamshire Healthcare Trust; Statutory Instrument 2001 No. 834 The Broadmoor Hospital Authority (Abolition) Order where Broadmoor hospital joined the West London Mental NHS Trust and Statutory Instrument 2002 No. 559 The Ashworth Hospital Authority (Abolition) Order where Ashworth hospital became part of the Mersey Care NHS Trust 94 - 29 - Summary of Key outcomes97 Forensic psychiatric policy: Policy is still centrally controlled; determined by a National Oversight Group consisting of representatives from Department of Health, Home Office, NHS agencies, and hospitals. Ministerial responsibility is unclear: the Secretary of State for Health is responsible for hospital services and the Home Secretary controls the movements of restricted patients. Therefore the Trusts cannot decide their treatment/discharge policies. Admission, movement and discharge: Each hospital has an admissions panel which prioritises the waiting list for high security care. There is a shortage of places therefore many convicted to care must “wait” in prison or inappropriate care. However the Home Secretary has the formal power to insist that a particular patient is accepted. Patients cannot be moved to lower security levels or discharged without the express approval of the Home Secretary. Purchasing of care: The purchase of forensic care moved from central to regional control. The aim was to improve coordination by devolving funding to regional groups. Previously forensic services had been a “free good” which had hampered the development of appropriate regional services. There had been little incentive for health authorities to invest in local services when special hospital forensic care was free. This had led in the past to some patients being held at higher security levels than necessary. However even after the reforms, there was still a separate organisation and input from central government, so purchasing was not integrated with the normal procedures. In addition Health Authorities are financed via an allocation from the Department of Health which restricts financial discretion. Provision of care: The role of treatment provider transferred to Health Authorities and Trusts. The aim was to decentralise and integrate with other health services. However there was still direct political involvement in decisions regarding the placement and treatment of patients. The Select Committee on Health found evidence of a conflict between doctors and the Home Office. Doctors felt that treatment was being directly controlled by politicians yet the Home Office justified this by arguing that doctors lacked objectivity in their assessments and public safety considerations made central political control necessary. A Home Office official stated that the Secretary of States Role was: purely that of safeguarding the public interest in the risk dimension…we are able to exercise an objective and discretionary judgement without the danger of becoming too close to the individuals and losing track of some factors that may still be quite prominent in the individual case which the care team might lose sight of”98 97 This section is based on a variety of Sources to give a complete picture: Department of Health (2002) New arrangements for performance monitoring and commissioning of high security psychiatric services p 3 – 11 as well as e-mail interviews with Preston M 30/4-04 and 25/5-04, and CartonG 11/5-04, House of Commons Select Committee (1999/2000) para 182as well as the NHS homepage 98 House of Commons Select Committee (1999/2000) para 182 Boyle, M Home Office Prison Unit - 30 - 3.3 Discussion and Conclusions: Reform outcomes The historical background of forensic psychiatry prior to the reforms reveals similarities. Services were controlled by central government and patients were placed in remote asylums, isolated both physically and organisationally from general healthcare services. In Sweden decentralisation occurred according to Pierre’s99 definition. Policy transferred from central agencies to Health Authorities who were free to establish their own treatment organisation. Using Pierre’s three dimensions of decentralisation it appears that Regulatory decentralisation occurred as central government was responsible only for framework legislation. Authority decentralisation occurred with Health Authorities able to form their own organisation and treatment policies. Finally Financial decentralisation occurred as treatment was financed through local health taxes. Other outcomes were; professionalisation of services as decision making authority passed from central government agencies to local frontline100 medical and legal professional. Secondly coordination of services improved as forensic care was synchronised with health and social care services, thereby improving continuity of care. However the most important outcome of the reforms in Sweden was that treatment of mentally disordered offenders was firmly positioned as a healthcare function Those persons sentenced to treatment were afforded rights as patients, not considered prisoners. Legal safeguards, and a further decentralisation, were achieved by removing the discharge or patients from central government appointed tribunals to County Courts (Länsrätten). One slightly strange aspect of the reform in Britain was that it passed, almost un-noticed without parliamentary scrutiny, as a consequence of the 1999 Health Act. I requested that the Department of Health might direct me to any available reports prepared about the reform but they said none existed.101 One possibility is that a new Mental Health Act, planned since 1998, has yet to be finalised. Another possibility is that the reform ignored the Fallon Inquiry102 and the Select Committee on Health103 both of whom recommended that forensic services should be re-built from scratch. Therefore the reform was less radical than expected and seemed to focus more on transferring existing hospitals to new management, rather than policy making power. 99 Pierre, J in Rothstein (ed) (2001) p 105 – 126 The use of the term frontline in this context means staff dealing directly with patients. 101 Preston Mike (e-mail) 25/5-04 102 Fallon et al (1999) recommendation 47 103 Select Committee of Health (1999/2000) recommendation yy 100 - 31 - In Britain, full decentralisation did not occur as the state retained considerable influence. Using Pierre’s104 three dimensions of decentralisation; regulatory decentralisation did not occur as policy-making is undertaken by the National Oversight Group which is dominated by Central government (The Department of Health and Home Office). Authority was not fully decentralised as local management cannot determine placements as there is still direct Ministerial involvement such as the personal authorisation of the Home Secretary required to move or discharge patients. Financial decentralisation did occur to some extent however as patients are no longer funded directly by central government as a “free good“. However Health Authorities are not totally free to choose which services to buy and there is still central involvement in purchasing as the purchasing organisation for forensic services is separate from other purchasing. In addition British health authorities are financed by central government as there is no local healthcare taxation. Therefore although there was some financial decentralisation, I do not believe it represents full financial decentralisation. Using Pierre’s criteria I conclude that the outcome in Britain could be characterised as a partial decentralisation or as a form of delegation105, meaning that the transfer of authority was subject to limits or conditions, rather than the stated policy of decentralisation and integration. Other outcomes of the reform in Britain were the confused boundaries between health and prisons. Firstly there were split policy responsibilities between the Department of Health and Home Office and an important outcome was that the reform failed to settle the issue of whether patients should be regarded as patients or prisoners. Secondly, direct political control was retained. Even in the new organisation the Home Secretary had significant involvement in an individual patient’s treatment and discharge. Forensic psychiatric services remained deprofessionalized as politicians’ decisions weighed heavier than doctors. There appear to be two interesting issues here, first that the Home Office does not trust clinicians to make the “right” decision and share its risk management strategy, secondly is that doctors may “loose track of some factors that may still be quite prominent in the individual case”106 I interpret this as suggesting that public opinion and political considerations are important factors when deciding the release and movement of patients. There are several implications of the British reforms. Firstly, for the first time, forensic psychiatry in Britain was not a separate entity, which makes this outcome an organisational 104 Pierre, J in Rothstein (ed) (2001) p 105 – 126 Pierre J in Rothstein B (ed) (2001) p 108 106 Mike Boyle Head of Mental Health Unit, The Home Office House of Commons Select Committee (1999/2000) oral evidence: question 620 report para 182 105 - 32 - reform. However there remains a substantial element of central control over forensic psychiatry despite a stated aim of decentralising services into NHS structures. Direct Ministerial involvement in the individual cases of offenders means that the system is politicised. There is a risk that decisions could be subject to ideological/political rather than medical/legal considerations. It is unclear whether mentally disordered offenders are regarded a patients or prisoners owing to the split between the Department of Health and Home Office. Public protection plays a prominent role in the literature on forensic psychiatric services and the Home Secretary’s continued control over patients’ placements and movements must indicate that prison culture remains deeply rooted in the service. The results of my study have shown that despite the stated intention of decentralisation, the reforms have had different outcomes. The reforms in Sweden appear to have led to decentralisation and integration with mentally disordered offenders being regarded as patients and services are provided Health Authorities. However the British reforms resulted only in partial decentralisation and integration into healthcare structures and did little to clarify the boundary between the health and prison services. This has led to a prison culture dominating over therapy in Britain. In Sweden, the main aim of services was treatment whereas in Britain detention was predominant. My findings are summarised in a figure below: Figure 3.1 Policy reform and policy outcomes – a comparison of Sweden and Britain Country Reform objective ReformOutcome Sweden Integration into Health structures Decentralisation Integration Professionalisation Function of healthcare Britain Integration into Health structures Partial decentralisation Political steering Central control Overlap Health/Prison Patient status Patient Prisoner? Patient? The question is: why was decentralisation and integration of forensic psychiatry into healthcare structures achieved in Sweden but not in Britain? - 33 - Chapter 4 Explaining the Policy outcomes In this Chapter I will test my two hypotheses to assess whether the different outcomes observed can be explained be differences in political institutions (Hypothesis 1) or service culture (Hypothesis 2). 4.1 Testing Hypothesis 1: The outcomes are explained by political institutions In this section I will test my first hypothesis by combining the theoretical arguments with the empirical information on the policy outcomes in order to determine whether the different policy outcomes can be explained by the institutional arrangements in each country. Hypothesis 1: Political institutions aided decentralisation of forensic psychiatry in Sweden but not in Britain 4.1.1 Policy outcomes and political institutions in Sweden The model constructed by Pollitt and Summa, identified Sweden as a Nordic model country. According to this model, the composition of central/local government structures is characterised by decentralisation, local government independence and administrative autonomy.107 Therefore according to the Nordic model the healthcare structures would be highly decentralised prior to the forensic psychiatry reforms. The organisation of Swedish government and healthcare historically features decentralisation. There is a tradition of lower levels of government having autonomy. However even central government has something of a decentralised character. Central Ministries are small and policy focused with implementation overseen by autonomous agencies (ambetsverk/styrelse) which are independent from the Ministries that supervise their work. This creates an “arms length” relationship between Ministers and Civil Servants Health authorities have independent policy making and taxation powers as well as an elected legislative body.108 Health Authorities are also free to establish their own priorities and organisation.109 I have identified several features that may be factors in explaining policy outcomes in Sweden. My analysis of the reform process in Sweden demonstrated a smooth transition from central control to decentralised structures, thereby coordinating services with other healthcare functions. The first institutional feature concerns the tradition of decentralised services 107 Pollitt, C and Summa H (1997) Public Money and Management p 7-11 Peters B G (2001) p 147 109 Petersson O (2002) p 73 - 74 108 - 34 - administered by democratically elected health authorities. There were “ready made” democratic local Health Authorities to take full authority for policy, management, finance and placing of forensic patients. This made decentralisation simple to implement. The second issue is that there was not direct political control of services prior to the reforms. Although the transfer of forensic services came with the 1991 Act, responsibility for mental health services had gradually passed from central agencies to health authorities since the 1960s. The tradition of no Ministerial intervention in service management issues means that Sweden does not have the custom of Ministers being involved in the day to day running of services, nor is there a public expectation of this. Before decentralisation, services were controlled by an agency, the Board of Health and Welfare (Socialstyrelsen) not central government politicians. Therefore it may not have been considered a huge step to decentralise responsibility for forensic services for politicians who were not involved in operational issues. Thirdly I identified that there was clarity over forensic psychiatry’s position within government structures. The consensual nature of Swedish politics, identified in the model, meant that the reforms had broad support. There was a political consensus that forensic psychiatry was a healthcare function to be provided by healthcare services. The justice department agreed to did not seek any formal contacts between prison services and forensic psychiatry. Politicians were in agreement that decision-making could be decentralised to professionals; with treatment decisions being made by doctors and local County Courts (Länsrätten) responsible of deciding discharges. Having weighed up these issues, my conclusion is that the political institutions in Sweden aided the decentralisation and integration of forensic psychiatry into healthcare. 4.1.2 Policy outcomes and political institutions in Britain According to Pollitt and Summa Britain belongs to the Westminster Model where the main feature is central control. Central government dominates local and regional levels and the administrative systems. Central government can compel lower levels to comply with its directives. There is not tradition of autonomous administrative agencies and there is always direct influence from central government.110 Previous British research, carried out by Mellon, has shown that some reforms use the term decentralisation, where in reality the transfer of 110 Pollitt, C and Summa H (1997) Public Money and Management p 7-11 - 35 - power from central to local levels has been limited as reforms did not alter the political institutional structures of central control.111 The organisation of British healthcare, although delivered by geographically based health authorities, has been characterised by central policy and control. The National Health Service (NHS) was established in to provide free access to healthcare. Strategic policy for treatment is determined by the Department of Health who set national standards for services. Healthcare is purchased by Trusts and Health Authorities and provided by a variety of Trusts that offer services on a functional basis (Primary Care, Hospital Care, Mental Care etc). These are organised on a regional basis. However Health Authorities and Trusts are accountable to the Department of Health and are monitored by departmental agencies that set performance targets for Trusts and Health Authorities.112 Services are financed by general (central) government taxation which is allocated to care purchasers by the Department of Health using a special formula.113 The members of NHS Trusts and Health Authorities are not elected in Britain but instead are appointed using guidelines from the Department of Health and a central agency, the NHS Executive.114 Doctors are also expected to treat patients in accordance with treatment guidelines from central government. 115 Therefore unlike Sweden services continue to be controlled in detail by the centre as state appointed Health Authorities must comply with government directives and are financially dependent on the state. I believe that the Westminster model leads to key aspects of British healthcare organisation being centralised such as policy, financial allocations and operational standard setting. It is interesting that even though there is a regional structure, the centre dominates which is a contrast from Sweden where policy decisions have been decentralised to Health Authorities. Trusts have to achieve centrally determined performance targets and follow national treatment guidelines; in addition Health Authorities are not elected. Majority governments mean there is less public-policy debate and negotiation. Therefore the impact of the Westminster model is of a regionally based structure controlled by central government. The decision to decentralise and integrate forensic psychiatry, must be seen in the context of the overall structure, it may be that politicians never envisaged a full decentralisation as full decentralisation is contrary to the Westminster model’s trait of the centre maintaining control. 111 Mellon, E (1993) Executive agencies: leading the change from the outside-in NHS homepage: Section: About the NHS 113 The Guardian 26/4-02 - NHS Finance 2002-03: the issue explained 114 the Department of Health (1997) Appointments to the most senior posts in the NHS 115 National Institute for Clinical Excellence: Section about NICE 112 - 36 - The British reforms created a bewildering organisational structure with many different institutional actors involved, for example, the Department of Health, the Home Office, a National Oversight Group, Regional Commissioning (purchasing) teams, Health Authorities, Trusts, Department of Health Agencies (Monitoring and Standard setting), the Prison Service etcetera are all involved in policy coordination The new structure did nothing to resolve the overlapping organisational responsibilities between the Department of Health and the Home Office. The reforms involved transferring various aspects of policy to a variety of different organisations while Ministers retained considerable strategic and operational control. This could be due to a Westminster Model tradition of direct involvement by Ministers in service management as the legislation116 confers a personal responsibility upon Ministers. Although this structure is very confusing and difficult to interpret, it is clear that the new organisation did not represent a decentralisation from central to lower levels. Central government intervention was preserved in the new institutional arrangements. This can be seen by the two central government departments retaining control over key elements of policy, issuing detailed guidelines and even Ministers being involved directly in placement decisions. There is also some evidence that forensic psychiatry is regarded as a national rather than regional service, despite this being contrary to the nature of the reforms, I have found some evidence to support this with certain providers specialising in certain types of care. For example Rampton is to become the sole national provider of high security women’s services.117 High Security Services are increasingly operating as a National Network. As a result of a number of recent Government initiatives, the services at each of the three sites are beginning to change and specialise.118 My analysis of the British reforms revealed that the forensic psychiatry organisation displayed continued government intervention as well as a lack of professional control for medical staff. This is also reflected by management researchers 6 and Peck who identified mental health as an area of strong central control. The Labour Government introduced many guidelines and central directives which were unpopular with clinicians as these limited doctors’ professional autonomy. However psychiatry has a traditionally weak status with less power; service users are stigmatised and media attention is focussed on scandals and murders. According to 6 and Peck mental health modernisation created an institutional “hybrid between hierarchy and 116 Legislation meaning the 1977 NHS Act and the 1983 Mental Health Act Rampton Homepage section on forensic services 118 Department of Health (2002) New arrangements for performance monitoring and commissioning of high security psychiatric services p 7 117 - 37 - individualism”, 119 which can also be seen in forensic psychiatry. A Hierarchy, as there was detailed standard setting and control by central government and individualism because responsibility to manage services was passed to lower levels albeit within the confines of centrally set goals.120 This confirms my analysis; despite the stated aim of decentralisation, there remained a significant level of central control and a lack of professional authority for doctors within forensic psychiatry. Certainly the Professionalisation of services, with decisions devolved to clinicians and the judiciary, which occurred in Sweden, did not occur in Britain. Decisions remained firmly rooted in the political arena. Therefore my assessment is that in Britain the political institutions did not aid decentralisation. 4.1.3 Conclusions: Policy outcomes and political institutions The Nordic and Westminster institutional models’ institutional arrangements influenced the outcomes of the reforms. In Britain, in contrast to Sweden, services were not decentralised to “ready made” decentralised structures and Ministers do not have the “arms length” relationship via autonomous agencies. This appears to be a major difference, as political institutions in Sweden supported decentralisation and integration but not in Britain. Therefore political institutions could certainly be an explanation but is it the only one? One question that occurs to me is that although the tendencies of Westminster model institutions to exhibit central control, it fails to explain why forensic psychiatric services are treated differently to other British healthcare institutions by giving Ministers so much control. Therefore I will now assess whether differences can depend on cultural attitudes to the service itself. 4.2 Testing Hypothesis 2: The outcomes are explained by service culture In this section I will test my second hypothesis to determine whether the different policy outcomes can be explained by the service culture in Britain and Sweden. One problem is that service culture is rarely expressed explicitly and must be interpreted from a variety of sources in order to obtain a complete picture of attitudes towards forensic services. Hypothesis 2: Differing service cultures influenced the decentralisation and integration of forensic psychiatry into healthcare structures. 119 120 6, P and Peck E (2004) p 101 This section is based on 6 Pand Peck E (2004) - 38 - 4.2.1 Policy Outcomes and service culture in Sweden The arguments put forward by Molander about Sweden emphasise that mentally ill offenders should be taken care of by society rather than punished. He contends that the reason for this is rooted in the social democratic perception that regards criminality as a social welfare problem requiring care.121 Esping-Andersen’s classification emphasises that social democratic countries such as Sweden emphasize the social origins of societies problems and the role of the state to reduce inequality and assist those who cannot take care of themselves. It is not easy to assess public attitudes to mentally disordered offenders and I was unable to locate any research on this subject. However I carried out a brief review of newspaper articles relating to forensic psychiatry and found general agreement with Molander’s assertion that the public are supportive of mentally disordered offenders receiving care. There was some criticism, usually in connection with a particular tragedy, however even here the contention was that this was a failure of the state or psychiatric care. The general tone was that more offenders should receive state care rather than that they should be treated as prisoners.122 When it come to the reforms, the language used in the Bills proposing both the Health and Medical Care and Forensic Psychiatric Acts demonstrates that politicians stressed humanitarian values and care. Although there were some references to public protection, the caring arguments dominated, emphasising the integration of psychiatry into somatic care, albeit with some differentiation to take account of the particular needs of patients.123 The government position outlined in the 1991 bill emphasises society’s duty to offer care : The fundamental solidarity in society and healthcare builds on that we do not have responsibility only for ourselves, but also for others. …In situations where a person, because of their mental condition, obviously lacks the capacity to take care of their own interests, or exposes others to risks for life and wellbeing, it demands that the fundamental solidarity between people should give help, even if the recipient resists it. 124 Another important factor of the service culture is that healthcare services assumed full responsibility for treating patients. The service was professionalised with treatment decisions being made by doctors. This suggests an expert dominated culture based on scientific judgements by clinicians rather than political considerations. The comments made by the 121 Molander Outhärdligt om mördaren vore frisk 12/10-03 I am basing this conclusion upon a review of newspaper articles in Dagens Nyheter and Svenska Dagbladet using the search word Rättspsykiatri/n (forensic psychiatry) which resulted in 49 hits. I concentrated on general articles rather than those relating to particular cases. Of particular interest were Dagens Nyhter 2/6-03 11/8-02, 12/6-04 and Svenska Dagbladet 19/9-03, 24/9-03 2/10-03 and 10/2-04. However it’s important to note that the timing of many of these articles was in response to the murder of Anna Lindh. 123 Proposition om psykiatrisk tvångsvård mm 1990/91:58 p 62 -65 124 Proposition om psykiatrisk tvångsvård mm 1990/91:58 p 65 (My translation) 122 - 39 - Justice Minister concerning the 1991 reform confirm that the treatment of mentally disordered offenders was to be considered a health, rather than a prison issue: I will therefore emphasize that the prison service ought not to have the primary responsibility for persons who have an expressed need to psychiatric treatment.125 In Sweden I conclude that the treatment of mentally disordered offenders is strongly established as a healthcare function. Once sentenced to forensic psychiatric care, there is no involvement of the prison service or Justice Ministers in decisions involving patients. The service ethos is of professional medical care, with medical professionals deciding treatment and the discharge authority belonging to the judiciary via the Court system. Hospitals are staffed exclusively with healthcare professionals. Therefore the culture and status of offenders is very much as patients and the attitudes of politicians and the public can be summed as generally supportive of mentally disordered offenders receiving care instead of prison.. There are similarities between the arguments put forward by Molander and Esping-Andersen, namely that social democratic principles have emphasised a caring, not a security oriented culture for this service. Therefore my assessment is that the service culture in Sweden aided the decentralisation and integration of forensic psychiatry into healthcare as the service ethos centres on treatment and rehabilitation 4.3.2 Policy Outcomes and service culture in Britain The public’s perception of mentally disordered offenders is not easy to assess, however many of my sources have refereed to the British Public’s perception of mentally disordered offenders as a public danger. Compared to Sweden there is little emphasis on the fundamental goodness of man but instead that criminal actions are the individual’s responsibility rather than society’s. (A) recent British prime minister, John Major, urged the population to care a little less and condemn a little more.126 Opinions in the media are that forensic psychiatric treatment should be used only sparingly in restricted cases because “wickedness should not be treated as an illness”.127 Anderson notes that many empirical studies into public attitudes to mental illness reveal that the public 125 Freivalds, Justice Minister Proposition om psykiatrisk tvångsvård mm 1990/91:58 p 451 Gunn, J (2000) p 335 127 Palmer; A, 25/8-02 126 - 40 - emphasize public safety issues.128 Wolff contends that the perception of fear and public indifference towards mentally disordered offenders have been given the highest priority in the government’s policy formulation.129 Therefore I believe that in Britain the public’s perception is that mentally disordered offenders are a risk factor, and that public protection should be the main aim of services. This compares with the Swedish perception of care, and where possible, rehabilitation. Public perception is shaped by media coverage of scandals and tragedies according Charles Kaye, Former Chief Executive of the special hospital service authority: The current public mood: increasing distrust of doctors; growing desire for revenge and explicit punishments; greater accountability; and, above all aversion to risk.130 I would argue that public attitudes and perceptions have formed the underlying basis of service culture and policy-making. Public safety and protection rather than treatment and rehabilitation are central to British policy. My examination of the British reforms revealed that there was a duality between healthcare and prisons in government policy with a strong prominence given to safety as the overriding concern. Carton says: It is difficult to separate out patients’ treatment and civil rights from public safety. 131 Historically there has been a tendency to hold patients at higher than necessary levels of security to ensure public protection.132 I found that safety and risk reduction appears first on the list of government priorities,133 even though this seems to conflict with the general Mental Health reforms stated objectives of reducing the stigma and exclusion of mental illness. Therefore there is a lack of clarity concerning the government’s attitude to the mentally ill and the culture of services. On the one hand the government claims the aim of de-stigmatising patients, yet the top priority confirms the mentally ill as a public danger. This double culture is also evident in the organisational structures created to treat mentally disordered offenders. There is confusion concerning whether the forensic psychiatric hospitals are regarded as a healthcare function. Even after the reforms, forensic psychiatric policy is formulated jointly by the Departments responsible for health and prisons. The Select Committee on Health commented, following a visit to Broadmoor hospital that the culture was “more custodial than therapeutic”134 with patients being treated unsympathetically.135 This view was also 128 Andersson M (1997) p 247 - 248 Wolf, N (2002) p 821 130 Kaye; C 28/3-01 131 Carton, G 11/5-04 132 Select Committee of Health (1999/2000):recommendation xx 133 Department of Health (2002) The Journey to Recovery 134 Select Committee on Health (1999/2000): para 195 129 - 41 - confirmed by the Royal College of Psychiatrists who contended that there is a divided culture that emphasised security regimes. The College assert physical security is prioritised and clinical judgement marginalised. The Tilt Inquiry was cited as being dominated by the Prison Service with no practising doctor participating.136 Therefore I found that the dominant thinking and inputs into the policy making-process come from the Prison rather than Health Service. I believe that the fact that it is unclear whether forensic psychiatry is a health or prison service is an important facto in explaining the difficulties in decentralising in Britain. It is hard to integrate forensic psychiatry into healthcare structures if it is not in fact regarded as healthcare. The evidence from my case study shows that the prison culture dominates over therapy. The Home Secretary has the ultimate decision-making power over patient treatment rather than the Secretary of State for Health. Doctors have limited powers and many hospitals continue to have significant numbers of Prison Officers staffing the wards. My conclusion on service culture in Britain is that forensic psychiatry is not firmly established as a function of healthcare and lives something of a double life being controlled both by the Department of Health and the Home Office. This overlap and uncertainty may account for the outcome; forensic psychiatry has not really integrated into healthcare structures because it is not really considered a healthcare function. In many respects it is regarded as a prison function with centralised Home Office control, similar to prison policy. The attitude of politicians is bow to public opinion and let the prison element of policy dominate over treatment. Therefore my assessment is that the service culture in Britain hindered decentralisation and integration of forensic psychiatry into healthcare as the service culture was dominated by prison ideology which emphasised detention and security over therapy when shaping policy. 4.3.3 Conclusions: Policy outcomes and service culture My evaluation of service culture also reveals that there are major differences in the service cultures of Britain and Sweden. In Sweden the emphasis is on mentally disordered offenders receiving care and the state providing treatment as a function of the social democratic welfare state. In Sweden, service culture is based on forensic psychiatry being a function of healthcare and there was general political consensus about this for the 1991 reforms. In Britain service 135 136 Select Committee on Health (1999/2000): para 195 Royal College of Psychiatrists - 42 - culture focuses on protecting the public from mentally disordered offenders through policies that produce safe, secure. “risk-free” treatment. British service culture emphasizes prison-like regimes with strong areas of policy overlap and input from prison services. Therefore service culture is also an explanation for the different outcome of forensic psychiatric reforms. 4.4 Conclusions: hypothesis testing results In this section I have tested two hypotheses and the results can be summarised as follows: Figure 4.1 Summary of hypothesis tests Sweden Britain Difference Hypothesis 1: Political Institutions aided decentralisation Yes No YES Hypothesis 2: Service culture aided decentralisation Yes No YES These two hypotheses have both shown significant differences between Britain and Sweden that could explain the policy outcomes. Therefore I conclude that the political institutions and service cultures both explain the policy outcomes. But how should these differences be interpreted? These issues will be analysed and discussed in the concluding Chapter. - 43 - Chapter 5: Analysis and concluding discussion In my final chapter I will analyse my hypotheses and results in greater detail and discuss more generally the implications of forensic psychiatry’s organisational reforms 5.1 Summary of study results In this study I examined why the organisational reforms of forensic psychiatric treatment in Sweden and Britain resulted in different outcomes. I established that in both countries politicians had stated the aim of decentralising and integrating forensic services into healthcare structures; an objective achieved in Sweden but not in Britain. My analysis of these policies showed that translating the political aims into concrete structures led to very different organisations being formed. The purpose of this study was to explain these different outcomes by testing two hypotheses. The first hypothesis was that political institutions influenced the outcomes. My study revealed that there was a difference between the two countries. Swedish decentralisation was aided by a well established system of autonomous, decentralised Health Authorities. These decentralised political institutions meant that there already existed “ready-made” decentralised structures, which coupled with the traditional “arms-length” relationship between central policy-making and implementation, resulted in a favourable environment for achieving decentralisation. In Britain however, centralised institutions and a tradition of direct political intervention hindered the decentralisation process. In fact, full decentralisation never occurred and central government continues to play a significant role. The study results support the hypothesis that political institutions influenced the outcomes. The second hypothesis was that service culture aided decentralisation in Sweden but not in Britain. This was harder to assess as service culture tends to be implicit rather than explicitly stated. However my study revealed that in Sweden’s social democratic welfare model results in a social policy that emphasises equality and the state’s role in caring for those unable to care for themselves. Thus the service culture regards forensic psychiatry as a therapy-based social care task and a function of healthcare. However in Britain, the dual nature of forensic psychiatry, regarded as a combination of healthcare and prison results in a service culture centred on public protection; with therapy considered secondary. My appraisal also supported the hypothesis that the outcomes were influenced by service culture. Therefore I conclude - 44 - both political institutions and service culture explain the different outcomes for forensic psychiatry in Sweden and Britain. 5.2 Analysis of hypothesis testing results The results of the hypothesis tests revealed that both institutional and service cultures influence policy outcomes. Therefore the results are as follows. Figure 5.1 Diagram: Causes of outcomes Forensic psychiatric POLICY POLITICAL INSTITUTIONS POLICY OUTCOME Forensic psychiatric POLICY SERVICE CULTURE POLICY OUTCOME However the question remains, are these effects independent of each other, or is there a relationship between the variables? Firstly, I believe we can dispense with the premise that the culture of forensic psychiatric services has somehow influenced the formation of national political institutions in a country as this is illogical. It would mean, for example that the relationships between; central and local government, Ministers and Civil Servants etcetera was somehow determined by the culture of forensic psychiatric services. Although obviously it’s clear that the service culture could influence forensic psychiatric services are organised. Therefore the question is do the political institutions have an influence on the service culture? One difficulty is that political institutions and service culture consist of several variables. It would require further research to evaluate each of these; however I intend to take the main themes of service culture used during my hypothesis testing in order to estimate whether they could have been influenced by the political institutions. Service culture could be shaped by political institutions as the way in which functions are interpreted, categorised and located within government structures is influenced by the political institutions and the assumptions of how the state should be organised. In some respects a degree of association is logical. In Sweden the consensus that forensic psychiatry is a health function has existed for many decades and may have influenced public/political - 45 - attitudes. In Britain overlapping structural responsibilities between prisons and health, added to which the Minister responsible for prisons (Home Secretary) decides on discharges, must influence attitudes. However the evidence from my hypothesis testing showed that attitudes to forensic psychiatry are influenced more by the underlying social attitudes and norms in society such as attitudes to crime, risk and the role of the state. This leads me to suspect that the political and public opinion, which creates the service culture, must also have an independent effect. My conclusion is that service culture is influenced in part by the institutional culture, but that the service culture, in addition, has its own independent effect therefore both institutional and service culture have an independent explanatory effect. However it is possible that one of these factors is a stronger explanation than the other. I my study I have not measured the intensity of the relationship, therefore more research would be required in order to make a definitive conclusion on the strength of the respective explanations, but I will discuss the evidence obtained to make a preliminary assessment. In the case of Sweden it was difficult to assess which hypothesis was the stronger explanation as both the political institutions and service culture appeared equally favourable to the policy of decentralisation. The case of Britain is more complex as there is generally more central control over healthcare; however forensic psychiatry is subject to greater central control than normal healthcare services. One of the problems that I have encountered is that there is a disparity between what the British government says and what it does. The government stated the policy of ending the isolation of forensic psychiatry and ensuring that the “high security psychiatric service is treated in the same manner as all other services provided by the mainstream NHS”.137 However, the government did not develop an organisational policy that led to this being carried out in practice. I believe that if the government genuinely wished to decentralise, they could have treated forensic psychiatry in the same way as other healthcare functions as genuine decentralisation has occurred in other government sectors. For example privatisation transferred the Nationalised Industries to private ownership. This altered public expectation about the public and private sectors’ roles. Some social care functions, such as geriatric care have been transferred from Health Authorities to Local Government and the private sector. There is also the issue that several inquiries and reports had specifically called for genuine decentralisation and the Select Committee on Health commented that the decision not to decentralise and integrate forensic psychiatry was “prompted more by political 137 Secretary of State for Health, Dobson, (1999) The Secretary of State for Health’s response to the Committee of Inquiry into the personality disorder unit, Ashworth Special Hospital - 46 - expedience”.138 This leads me to conclude, on the basis of my study, that service culture would appear to be stronger than political institutions in determining the outcomes of the policies for re-organising forensic psychiatry. 5.3 Concluding discussion In Sweden forensic psychiatric services have been integrated into healthcare structures. As a result, forensic psychiatry is not a national service. One consequence is that there is no longer a requirement of equal treatment or that patients with the same illness/risk will receive similar types of treatment. There are also implications of forensic psychiatry having to compete with other local spending priorities, unlike offenders sentenced to prison. This situation is complex as not all health authorities have the same structures as for treating patients. Decision-making and financial responsibility has passed from the state to local politicians and clinicians. Organisational structures are determined in the context of local priorities and party ideologies; for example some authorities utilise a purchaser-provider model whereas others do not, this could result in some authorities basing their policy on cost rather than quality of care. In Britain, forensic psychiatry has not been integrated and continues to have a special status. Although the government stated the objective of decentralising forensic psychiatry and integrating it into healthcare, this did not happen in reality. It is not clear why the gap between stated policy and outcomes occurred. One of problems of studying British policy-making is that the reasons behind policies are not always clearly articulated and openly discussed as in Sweden. Rothstein asserts that policy formation is often conflict charged. These conflicts lead to compromises having to be made when the policy goals are operationalized. This process in turn leads to the goals and formation of policy becoming unclear and sometimes contradictory.139 I believe that this may explain the outcomes of the British reform process; that the political conflicts that had to be resolves led to compromises that diluted the original stated goal. Or perhaps there was never a real intention to decentralise i.e. that the British government uses the terminology of decentralisation without intending that central control should diminish. Previous research, such as Mellon,140 has shown there can be a tendency of British governments to use managerial market-speak to give the impression of modernisation, without the centre relinquishing control over activities. This is an area where further study would be interesting. 138 Select Committee on Health (1999/2000): para 196 Rothstein, B (2002) p 100 -101 140 Mellon E (1993) 139 - 47 - Another problem in Britain is the lack of clarity over responsibilities. Forensic psychiatry is not fully regarded as a healthcare function because of the dual roles of health and prison services in the decision-making process. Therefore it is not surprising that forensic psychiatry has not been integrated into NHS healthcare structures when it is unclear whether it is actually a healthcare function. The consequences of this are that it remains unclear which actor has decision making authority in Britain as there is overlap between different central departments, agencies and regionally based health authorities. Central government dominates the decisionmaking process. Although detailed regulation results in a standardised service, it is also highly politicised with ministers taking the major decisions with medical expertise becoming marginalised. As Wolff observes, patients may “pay” a disproportionate amount of the risk when politicians focus on appeasing public opinion141. Therefore I contend that one consequence is that policy-making is more influenced by media scandals that clinical judgement. Despite the terminology of decentralisation the centre has not given up control. Central government, and particularly the prison service dominate policy-making and the role of doctors is subordinate in the system. One noticeable aspect of the documents that I reviewed for this essay is that there has been a hardening on public opinion in both countries as a result of a few heavily publicised major incidents. Both countries are considering tightening legislation, such as detaining the Mentally Disordered even if no crime has been committed (Britain) or transferring patients to prison if they recover too quickly (Sweden). However such proposals are controversial and may not be adopted. Much is focussed on perceived failure of forensic care; however some commentators question whether the problem is more a policy-making failure, where politicians have created unrealistic expectations that their policies will eliminate public risk. You can’t expect that the staff from Karsudden and the other regional units should knock on doors up and down the country to round up suspects in advance. Hanne Kjöller142 One issue to be addressed by societies is that many of the mentally disordered cannot gain access to psychiatric services until they offend. Many of the articles from Sweden emphasised the point that mentally disordered offenders had tried, but been unable to obtain general mental health services shortly before crimes being committed. During times of public service cutbacks, psychiatry is often subject to heavy resource reductions as cutbacks in psychiatry are seen as an easy option, perhaps as service users cannot, or will not, articulate and fight for 141 142 Wolff N (2002) p 825 Hanne Kjöller 12/6-04 – my translation - 48 - services; perhaps because of the nature of their illnesses and/or the stigma attached to service users. Therefore to answer the research question: the reason that Sweden was able to decentralise and Britain was not is explained by political institutions and service culture. In Sweden patients are consider “mad” (mentally ill) and are an object for the care of health authority professionals, whereas in Britain there is a duality with patients considered more ”bad” (criminal) than “mad” with treatment heavily influenced by central government structures and prison culture. 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