The Justice Committee has just published a report looking at those imprisoned with mental health issues. The report concluded that the Government must establish viable alternatives so that prisons are no longer used as a “place of safety” under the Mental Health Act.
What is the problem?
In 2005 the NHS took over the responsibility for healthcare in prisons, but there are still longstanding problems. According to the report, the most urgent problem is that mentally ill people are sent to prison due to a shortage of mental health services in the community. Further improvement is needed in improving the flow of medical information and the continuity of mental healthcare after release.
Covid 19 restrictions have impacted prisoner mental health, causing an unprecedented level of demand. No action plan or additional resources appear to be in place to deal with this increased demand.
What has happened since 2005?
The National Audit Office reported on mental health in prisons in 2017 and found no clear picture of how much was spent, whether it was well spent or the extent or nature of the issues. Since then, the DHSC and NHS have said that a “needs analysis” is being carried out by the Centre for Medical Health to help understand the prevalence of mental health in prison.
The first report from the Centre said that progress had been made since 2005, but the same problems remained. The HM Inspectorate of Prisons reported that 71% of female prisoners and 47% of male prisoners self-reported mental health problems.
Adequacy of care
Prisoners told the Committee that the scale of the issue was “colossal, far bigger and worse than anyone can comprehend or wants to admit” and that the “person who shouts loudest gets the psychiatrist and/or the medications”.
The Committee concluded that there is a high unmet need for treatment and that there is inadequate provision. As many as 70% of prisoners may have some form of need, and around 10% are recorded as receiving treatment.
Mental healthcare services
A mix of private and public providers are used for healthcare services, a split that can cause people to receive no care. A prisoner may not be serious enough to be seen by secondary care, but the primary care team may not have the right skills or resources to deal with him. A serving prisoner provided the example of a prisoner with complex PTSD being seen by a cognitive behavioural therapy practitioner. The practitioner acknowledged they could not provide the help needed, but the only person who could assist didn’t have time to do so.
The complex commissioning arrangements also cause communication failures, it being difficult to pass on information. The Independent Advisory Panel on Deaths in Custody fear that this could mean a failure to pick up on a suicide risk.
The Royal College of Psychiatrists felt that the commissioning process did not improve the quality of services as it was driven by cost. As a result, clinical quality and sustainability was not a priority.
Mental Health Treatment Requirement orders only make up 1% of community sentences, and the Ministry of Justice has said it is committed to increasing their availability. The issue raised is that such an order may be an option for certain offenders, but when the order is not available, the offender is sent to prison instead.
The Committee stated that the government target of the orders being available in 50% of areas by 2023 is “insufficiently ambitious”.
Screening in prisons
The NHS contract requires providers to carry out a first-day screening for all prisoners arriving in prison, with a follow-up assessment within seven days.
While this sounds like a good idea, in practice, not all prisoners are screened, and the process itself may not be sufficient. If a person arrives at a prison for the first time, they may not be ready to discuss mental health issues and may not be in a fit state to discuss them.
The Committee found that one in 12 prisoners did not have a screening and that BME prisoners with a mental health condition were less likely to have that identified than white prisoners.
Subsequent identification of problems
Prison officers currently receive training about mental health, but greater expertise is needed given the scale of the issue. This is important where a problem is not disclosed at first screening or a prisoner’s mental health deteriorates while in custody.
There is a shortage of mental health beds meaning that the NHS target of transfer to the beds within 14 days is not being met. Acutely ill people are being kept in prison without the necessary treatment as a result. For a high-security bed, a transfer took, on average, 159.6 days.
Continuation of services
Longstanding difficulties remain with continuity of services as prisoners move between prisons and then also when released. This issue links with the communication failures detailed above with complaints that information frequently takes too long to arrive.
Places of safety
Some prisons are used as emergency places of safety under the Mental Health Act if there is nowhere else for an acutely mentally ill person to be sent. The proposal is for such use to end, but it must be recognised that there must be an investment in alternatives in doing so.
The NHS should use the “need analysis” to make plans and allocate resources to ensure, at the minimum, that the mental healthcare in prisons is the same as in the community. It also needs to take into account the specific needs of the prison population.
There needs to be a bridge between existing gaps in care, and the problems resulting from fragmented service have to be resolved to ensure access to appropriate and adequate care. Although cost is an essential criterion on which to judge procurement bids, so is quality. Cost is not to be prioritised at the expense of quality.
The Ministry of Justice and the NHS should increase the availability of community sentence treatment requirement orders so that they are an option across the UK by 2023.
Mental health screening is to be reviewed, finding out why some establishments don’t carry them out in the appropriate timescale. The NHS should specify that the screening has to be carried out by a competent professional with experience in the criminal justice system. Work into understanding why there is a racial disparity should be accelerated.
The Prison Service should develop training for officers on identifying mental illnesses, and how to support prisoners and signpost them to treatment.
Statutory time limits should be introduced for the limits for transferring prisoners to mental health inpatient beds (although this would not solve the problem of bed shortages).
As a matter of urgency, the relevant agencies are to introduce arrangements for the swift availability of prisoner medical records between prisons and the community. Liaison should also take place with the Parole Board to identify areas where there are problems arranging mental health treatment packages for prisoners being considered for parole.
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[Image credit: “Into the Prison” by Bill Nicholls is licensed under CC BY-SA 2.0]