Prison health services
204. The current position in the prison healthcare
system seemed to us to link in with our concerns in this inquiry
in two ways. Firstly it was drawn to our attention on a number
of occasions that there is an enormous unmet need among prisoners
for secure mental health services. When Broadmoor described to
us how they managed their waiting lists, they highlighted the
demand for their services from prisons,[493]
and Department of Health officials emphasised to us in oral evidence
that many of the places freed up in Special Hospitals when patients
were more appropriately placed elsewhere would be filled from
the prisons.[494]
Secondly, Sir David Ramsbotham, the Chief Inspector of Prisons,
and his Chief Medical Inspector, Dr. John Reed, submitted very
powerful evidence to us on the low standards of psychiatric care
within prisons, arguing that there are de facto two parallel
systems for caring for mentally disordered offenders: one in prison
and one in hospital. We felt that it would be impossible to look
at the overall capacity of the general and secure mental health
services, without looking in more detail at the current situation
in prisons.
205. The evidence we received on the standards of
prison healthcare shocked us. Dr. Reed told us that "care
for mentally disordered people in prison is frankly a disgrace.
There is no other word to describe it. It is appalling".[495]
Sir David reiterated his medical inspector's description, telling
us that the staff in prison healthcare centres "are neither
trained nor resourced to look after them appropriately and the
result is, as I say, damage or deterioration, or both".[496]
Sheila Foley of Rampton Special Hospital made similar comments
on the staffing problems in prisons:
"There is a shortage
of staff and it is not ... a particularly good place to go and
work. The career options within a prison setting are fairly limited."[497]
The organisation INQUEST described standards of care
in prisons as "appalling" and argued that "in our
view imprisoning people with mental health problems is inhuman,
dangerous and can exacerbate their condition". As an example
of how inappropriate an environment prison can be to individuals
in mental distress, they cited the tendency to see self-harming
behaviour as a discipline problem, rather than a symptom of a
health need.[498]
206. Sir David Ramsbotham's written evidence drew
our attention to a survey carried out by Dr. Reed of 13 healthcare
centres, in which he concluded that standards were well below
those in the NHS, despite the fact that the policy of maintaining
equivalent standards has been in place for almost a decade.[499]
Examples given included low levels of staffing, staff with inadequate
qualifications, very limited therapeutic activity and considerable
use of seclusion. Dr. Reed argued that this was particularly disturbing
given that the prisoners experiencing these low standards of care
were not limited to those who were awaiting transfer to hospital
under the Mental Health Act 1983, but also included many
mentally ill prisoners who did not meet the criteria for transfer,
even though they might need 24 hour nursing care. Thus, under
current policies, this latter group of patients would not be transferred
to hospital, even if the beds were available. Two possible ways
forward were outlined: either raising psychiatric care standards
considerably which would involve major upgrading of healthcare
centres; or developing a new strategy of transferring all
prisoners requiring specialist mental health care and full time
nursing care to the NHS. Under this alternative, prisoners who
did not meet the requirements for transfer under the 1983 Act
could be transferred on temporary licence, in the same way as
patients with physical health needs. Dr. Reed concluded that "this
approach is more likely to provide an adequate service to patients,
ensure uniform standards and avoid wasteful duplication".
He estimated that this policy could lead to around 500 prisoners
being transferred to the NHS, with the consequent closure of one
third of the beds in the prison health care system.[500]
207. As a result of his medical inspector's research,
Sir David had asked West Midlands forensic psychiatric service
to review all inpatients in prison healthcare centres in the West
Midlands and Trent regions to see if this sample corresponded
to Dr. Reed's findings. This study showed that 32% of such patients
needed transfer to a psychiatric facility and a further 20% needed
accommodation in a unit in the prison providing psychological
and emotional support.[501]
Sir David's conclusion was that:
"Continuing the present
arrangements of having two inpatient services for mentally disordered
prisoners, one in the NHS and one in prison, seems to me unsustainable.
In my view, mentally ill prisoners requiring 24 hour nursing care
should be in the NHS not in prison."[502]
208. We were also concerned to learn that there is
no statutory provision for the compulsory treatment of mentally
disordered offenders in prison. Mr. Boateng told us that there
is a common law power to intervene in a crisis, but commented
that "one of the reasons why there is a reluctance even to
use the common law power is because there is a recognition that
conditions in prison are less than ideal for the administration
of treatment against the will of the individual concerned".[503]
The fact that treatment in prison is given under common-law provisions
and is not covered by the Mental Health Act 1983 also means
that prisoners treated without consent do not have access to the
safeguards found in the 1983 Act, such as the Mental Health Act
Commission.
209. We have already described the new arrangements
agreed by the Home Office and the Department of Health which aim
to improve the standards in prison healthcare centres: namely
the creation of a formal partnership between the NHS and the Prison
Service, with a Policy Unit set up in the NHS Executive and a
Task Force working with individual Health Authorities and prisons
to improve services (see above paragraph 21) Sir David Ramsbotham
told us that he "strongly welcomed" these changes[504]
and commented that "at last there is genuine dialogue between
the NHS and the Prison Service".[505]
We were certainly very impressed with the arrangements that we
witnessed when we visited Belmarsh Prison where the psychiatrists
providing services to prisoners are from the Bracton Clinic (part
of Oxleas NHS Trust) and primary care services are provided under
contract by a local GP practice.[506]
This system both provides good links between the prison and the
wide range of mental health services provided by Oxleas, and addresses
the problem that medical officers working in prisons tend to be
very isolated with little career structure or professional support.
It also enabled other specialist professionals, such as an occupational
therapist and community psychiatrist nurse to provide "in-reach"
services within the prison.
210. We hope that the new partnership between
the NHS and the Prison Service will encourage developments on
the lines of the system we saw at Belmarsh Prison and Oxleas NHS
Trust. But we would agree with Sir David Ramsbotham that it is
inappropriate to attempt to provide two parallel systems of specialist
mental health services, one in prisons and the other in the NHS,
especially as those remaining in the prison service do not enjoy
the safeguards included within the Mental Health Act 1983.
We recommend that all prisoners assessed as needing specialist
mental health services should be eligible for transfer to the
NHS, if necessary under temporary licence. We also therefore recommend
that Dr. Reed's estimate of the number of prisoners involved (approximately
500 at any one time) should be taken into account when planning
the number, and type, of secure mental health beds required in
the NHS.
211. Dr. Reed's estimate of 500 prisoners in need
of transfer at any one time was based on
prisoners already placed in healthcare centres. Sir
David, however, drew our attention to a recent survey by the Office
of National Statistics which demonstrated that there was a "vast
amount of psychiatric morbidity that existed within the prisons
of this country".[507]
The figures quoted in the ONS report are certainly striking: of
those given a clinical interview, 63% of male remand prisoners,
49% of male sentenced prisoners and 31% of female prisoners were
assessed as having anti-social personality disorder, while the
figures for functional psychosis were 10% male remand, 7% male
sentenced and 14% for female prisoners.[508]
Dr. Reed expanded this point, telling us;
"They are not detected
by the system, so they do not get treated. You get seriously mentally
ill people, people with schizophrenia, who are out on prison wings
on general medication, in an unfortunate place, quietly mad, behind
their cell door, not getting any treatment."[509]
Dr. Peter Snowden of Mental Health Services of Salford
NHS Trust quoted a figure of only one in four individuals with
mental disorder being identified by the health screening tool
used by prisons on their initial health assessment.[510]
He suggested that this was because the tool used is "next
to useless", but told us that work was being done in Newcastle
at present to develop "a more sensitive screening instrument
that asks the questions that we would want to ask".[511]
A number of other witnesses raised with us the importance of adequate
mental health assessment: both Professor Richardson, who chaired
the Expert Committee on the review of the Mental Health Act
1983 and the Law Society argued that prisoners should have
a right to a mental health assessment.[512]
It is clearly crucial that prisoners should be able to have such
an assessment not only when they first enter prison, but also
when appropriate during their sentence. Sir David told us that
the Prison Service had set a deadline of July 1997 for every prison
to complete a health needs assessment but "to date not a
single prison has completed it, nor has the Prison Service demanded
it".[513] Paul
Boateng MP, Minister of State at the Home Office, told us the
following week that these health needs assessments were now being
"prioritised".[514]
212. We recommend that the Expert Committee's
recommendation that all prisoners should have a right to a mental
health assessment should be accepted. We also urge the Home Office
to ensure that the health needs assessments promised for 1997
are completed as a matter of urgency, so that the data can be
used to inform planning for capacity in the NHS.
213. Much of the evidence we received on the inappropriate
placement of mentally disordered offenders in prison focused on
the problems in finding a bed once a prisoner had been assessed
as requiring a transfer to hospital.[515]
However, a number of other factors were raised with us. The National
Schizophrenia Fellowship highlighted the problems caused where
areas do not have court diversion schemes in their brief case
study of a young schizophrenic man who committed suicide after
being remanded to Wandsworth prison, despite being a known suicide
risk.[516]
Sir David Ramsbotham also raised concerns about the lack of court
diversion schemes in some areas,[517]
while Peter Snowden cited research showing that such schemes only
pick up one in five individuals with serious mental illness.[518]
We recommend that it should be made a requirement that courts
liaise with local mental health providers to ensure that all courts
are covered by court diversion schemes. We also recommend that
the Home Office should commission research on best practice in
court diversion schemes, to improve their efficacy in identifying
vulnerable offenders.
214. The practicalities of transfers were raised
with us by a number of witnesses. The Home Office told us that
their target "which we virtually without exception achieve"
is to process all the necessary paperwork within 24 hours of being
told a bed is available.[519]
Dr. Peter Snowden, however, highlighted the problems involved
in first making the assessment that a patient needs a transfer:
if the prisoner is housed in a prison a long way from the hospital
to which he is likely to be transferred, it is a considerable
commitment of clinician time for a multi-disciplinary team to
travel to the prison to make the assessment, particularly as there
are limits placed on when the assessments can take place, in order
to fit in with the prison regime.[520]
Dr. Snowden commented on the good practice found in Manchester
Prison, whose director of healthcare allows prisoners to be transferred
from other prisons to his healthcare centre, so that local clinicians
can make the assessment without needing to travel.[521]
The Law Society also endorsed a suggestion made by the Expert
Committee on the review of the Mental Health Act 1983,
that prison governors should be given the authority to permit
the transfer of prisoners to hospital on the recommendation of
three professionals, thus removing the role of the Home Office
altogether.[522]
215. The importance of close working relationships
between the NHS and the criminal justice system was emphasised
by a number of witnesses. Dr. Snowden's comments on Manchester
Prison, cited above, seemed to us a good example of how many time-wasting
difficulties can be resolved through sensible co-operation. Sir
David Ramsbotham also pointed out that prisoners with mental health
care needs do not appear out of nowhere: "they have gone
from treatment in the National Health Service and they are going
back to it".[523]
Indeed, prison could be seen as good opportunity to engage people
with mental health problems who have formerly slipped through
the net. Sefton Health Authority Regional Secure Commissioning
Team told us that, while they were seeing "positive attempts
to develop closer and more integrated inter-agency working",
this would be enhanced if the flexibility to pool budgets were
extended to other statutory bodies:
"Currently the Prison
Service funds all primary care within prisons. Secondary care
is funded by the NHS and provided within their own structures.
We believe that for the achievement of a comprehensive service
providing public safety and individual rehabilitation, we will
require mental health services across the NHS, Local Authority
and Prison sectors to meet the spectrum of individual and societal
needs. A project that was jointly funded - for example a joint
NHS/prison mental health needs assessment and treatment unit -
would strengthen the partnership interface between the two services,
provide a stronger dynamic to the exchange of skills between the
services and maintain a stronger focus on cost."[524]
The Department told us in a supplementary memorandum
that they were undertaking an "evaluation process" of
the impact of the new flexibilities for health and local authorities
to pool budgets and that "the evaluation will indicate the
extent to which other services might usefully be included in any
future powers".[525]
216. The final point to be raised with us on the
prison health system was that of funding. South London and the
Maudsley NHS Trust argued that although the Department of Health's
lead role in prison health care was welcome, current failings
in the resource allocation system made it hard for trusts with
large local prison populations to offer an adequate liaison service.[526]
We are aware that the Department is currently reviewing the
formula used for allocating resources to Health Authorities[527]
and urge them to pay particular attention to the distortions caused
in the local health economy by the existence of one or more large
prisons. We also recommend that the Department give serious consideration
to the possibility of extending the authority to pool budgets
to the NHS and the prison service.
415 
