Amlan Basu: Behind the scenes of Broadmoor

Amlan BasuThe landmark documentary Broadmoor aired on ITV on Wednesday 5 and 12 November. For the first time, the NHS allowed a camera crew into a high secure psychiatric hospital to film the lives of patients and staff.

One of the biggest challenges of being clinical director of Broadmoor Hospital is changing the public perception of severe mental illness and improving understanding of its causes, treatment, and outcomes.

That is why it has been so heartening in the past year to be involved in making the ITV documentary about the hospital.

Now in its 151st year, Broadmoor Hospital in Berkshire cares for around 200 offenders with severe mental disorders in conditions of high security. Patients are referred from courts, the prison system, and other secure services to the hospital from London and the south of England. Rampton and Ashworth hospitals care for patients in the north of England, and the State Hospital Carstairs cares for patients in Scotland. In all, 811 staff look after Broadmoor’s patient population.

There are so many myths and misunderstandings about the hospital, its staff, and patients—no doubt a legacy of its founding as a “criminal lunatic asylum,” where patients were sent with little hope of a return to society. Today’s hospital is a far cry from its origins, and we wanted to give people a feel for the contemporary hospital, its care, and treatment. Our motivation was to show the human side of our patients and staff, and try and reduce the stigma associated with serious mental illness.

A really common misconception is that patients who come to Broadmoor are so irreparably damaged that they can’t move on. In fact, patients stay at the hospital on average just under five years and with a far lower repeat offending rate than is found in the prison population.

The hospital’s model of care aims to motivate and engage patients, while providing them with intensive treatment centred on therapeutic activities. We treat men whose illnesses fall into two categories: mental illness such as schizophrenia and personality disorders. Many patients have more than one diagnosis and require a range of medications and therapeutic treatments.

The diagnosis of mental illness and the associated assessment of risk are not always straightforward and so, once an admission is agreed, patients are placed on an admissions ward for anywhere between three to nine months to confirm their diagnosis and assess their treatment needs.

Depending on the nature and severity of their illness, patients may be treated in intensive care, high dependency, or move from assessment to assertive rehabilitation wards, which prepare patients to move on from the hospital.

Detailed care plans, with contributions from across the multidisciplinary team, ensure that the programmes of treatment are carefully tailored to each patient’s needs, and that they start looking towards recovery and planning for discharge from day one.

So when we were agreeing the approach with ITV, we were keen to make sure that patients were as fully involved in the documentary as possible while protecting their interests. Our priority was that all patients had to give informed consent to participate in the documentary. Despite this, I think the final film does a great job at capturing a full picture of the hospital.

The use of restraint is an issue that is often seen as one of the most controversial aspects of mental health, yet we try to prevent such incidents as much as possible and de-escalate situations before they become a problem. However, there are times when we do need to use restraint; we do so as a last resort and we apply restraint for the shortest time and in the safest way possible. Our violence reduction team are experts in their field, and provide training and advice to other NHS, public, and private sector organisations. The hospital is actively involved in a national review of the use of restraint to improve prevention of violence and to promote the safe use of restraint.

Another issue that the documentary explores is the administration of medication against someone’s will. People who don’t recognise their own illness can be reluctant to take medication. Most of the time, we can talk to patients to encourage them to take their medication. However, there are some occasions where patients are so unwell that they cannot act in their own best interests. In such cases, where the risk to others or the patient themselves becomes considerable without medication, the clinical team will decide if medication against someone’s will is needed to stabilise their condition. This decision is not taken lightly and requires authorisation by a second approved doctor, who is wholly independent of the hospital and is appointed by the Care Quality Commission (CQC). When patients are well, we try to decide in collaboration with the patient what interventions would be appropriate in the event that they should relapse in the future.

People may think that the treatment for patients at Broadmoor includes only mental healthcare, but, importantly, the NHS is moving towards integrating physical and mental healthcare, and Broadmoor has an in-house GP to assess patients’ physical healthcare.

Patients with mental health problems are more likely to experience heart disease, diabetes, obesity, and respiratory problems—and life expectancy can be as much as 20 years shorter. We banned smoking at Broadmoor Hospital in line with the NHS moving towards smoke free environments. This is an important area for improving care here and elsewhere in mental health services, and our aim is to provide the same level of physical healthcare that patients would expect in the community.

The hospital is also active in researching how better to assess complex and high risk individuals, and evaluate the effectiveness of new medicines and psychological treatments. Current research at the hospital includes a study to evaluate predictors of treatment outcomes for violent, mentally disordered offenders by investigating which patients are likely to respond positively to their offered treatment, and which patients are not (and therefore may need a modified or new treatment plan).

As we see in the film, treatment for the type of patient cared for in Broadmoor often progresses in small steps, and while some patients will suffer a relapse, those small victories are a constant reminder of why we do the job. This, for me, is the most rewarding aspect of my role and working here. I see the most challenging patients in the country recover.

As well as being the first look inside the iconic Victorian Broadmoor Hospital, the ITV documentary is likely to be the last, as the gatehouse and terrace overlooking the Berkshire hills are soon to become part of the hospital’s historic past.

Over the next two years, the hospital will complete construction of a new £242m high secure hospital on the existing Broadmoor site. Building a state of the art, high secure hospital is exciting as it offers us the opportunity to design increased safety, effectiveness, and greater efficiency into the fabric of the new hospital.

Amlan Basu is clinical director of Broadmoor Hospital. He joined the hospital as a consultant forensic psychiatrist in 2009 and became clinical director in April 2014.

I have read and understood BMJ policy on declaration of interests and declare the following interests: none.