Written evidence from the Faculty of Forensic
Psychiatry, Belfast Health and Social Care Trust
The Northern Ireland Affairs Committee has decided
to conduct an enquiry into the Northern Ireland Prison Service.
The terms of reference are: To conduct an enquiry into the operation
of the Northern Ireland Prison Service, in particular to examine
whether the existing prison state is adequate and appropriate
for the secure accommodation of Northern Ireland prisoners, and
whether the Prison Service appropriately meets the health and
education and training needs of prisoners. The Committee will
also examine other such issues as may arise in the course of the
enquiry.
As l am writing on behalf of the Faculty of
Forensic Psychiatry, the focus of this brief piece will be limited
to whether NIPS meets the forensic mental health needs of its
prisoners. Contributions on behalf of other psychiatric specialisms
will be made separately as it is recognised that in addition to
measures to promote mental health, prisoners require regular input
from primary care services, general adult psychiatry, learning
disability, psychotherapy, adolescent and addiction services,
as well as from forensic psychiatry.
The terms of reference almost seem slightly
dated at this juncture. Preceding the inquest into the suicide
of Roseanne Irvine, there have been a number of reports outlining
inadequacies in the provision of NIPS healthcare, for example:
— The Review of Provision of Healthcare
Services for Prisoners (2002).
— Health Care Needs Assessment (2004).
— Human Rights Commission Report on
Women Prisoners (2004).
— Her Majesty's Inspector of Prisoners
and Chief Inspectorate of Criminal justice in Northern Ireland—Report
on Women Prisoners at Ash House, Hydebank Wood Prison (2004).
— Review of Non-natural deaths by Professor
McClelland & Colleagues (2005).
In addition there has been a major review, the
so-called Bamford Review of Mental Health and Learning Disability
in Northern Ireland, looking at policy, services and legislation
in this area. The review began in 2003 and "The Forensic
Mental Health and Learning Disability Services Review" was
published in October 2006.[25]
The reader is referred to this report, and in particular to Chapter
6, which is dedicated to the subject of prisons and provides some
foundation for understanding as to where Northern Ireland prison
services have been and where they are heading in the future.
The shortcomings of the Northern Ireland Prison
Service are succinctly summarised in the report between pages
27 and 43, together with recommendations for future action. DHSS's
formally took on the. responsibility for healthcare provision
within the Northern Ireland prisons on 1 April 2007, thereby bringing
our prisons into line with provisions elsewhere in the UK. This
is to be welcomed, but it is also a matter of some concern that
the transition date has passed with no obvious changes in the
delivery of prison healthcare and indeed to date there has been
no formal dialogue with forensic psychiatrists at all as to the
future development and direction of such specialist psychiatric
care within the prisons.
Much can be learned from the experiences, both
positive and negative, elsewhere in the transfer of responsibility
for healthcare provision from prison to health service. Our present
position is positive in that it enables us to develop on an evidence
base, which has already been prepared for us. The report "Prison
Psychiatry: Adult Prisons in England & Wales" is highly
commended in this regard.[26]
In essence the important points that forensic
psychiatrists locally would like to raise are:
1. Mental health services to prisoners should
be provided as in the community and in line with national policy;
prisoners must have a starting point of equivalence to health
care to that provided in the community.
2. The reader is referred to The National
Service Framework for Mental Health (1999), which sets out some
seven standards to which services should aspire.[27]
These standards are not a legal requirement in Northern Ireland
but we believe they set a benchmark for those who need psychiatric
services, whether in the community or in prisons. Prisoners in
Northern Ireland should have the same aspirational standards as
those prisoners in England and Wales.
3. Staff should be employed with the competencies
necessary to deliver care in the prison environment, or the support
to develop such competency. As referred to in the Prison Psychiatry
Report at Appendix 2, medical appointment panels should only appoint
those psychiatrists with competencies in working in secure environments.
It is likely the bulk of these psychiatrists will be general or
forensically trained.
4. Mental Health referrals from prison primary
care should be made to a generic multi-disciplinary team with
specialist opinions made to tertiary services such as forensic
psychiatry as necessary. Service Level Agreements need to make
it clear that access to specialist psychiatric assessment and
care is guaranteed and in line with the principle of equivalence.
5. The majority of remand prisoner needs
can be met by the in reach model delivered by general psychiatrists
with support as necessary from others. Forensic psychiatry should
be a tertiary service provided to high risk and longer-term prisoners.
For such a tertiary service to be effective relies upon there
being a good staff infrastructure capable of triaging referrals
appropriately. In turn the generic multidisciplinary mental health
team will rely upon high quality committal screening. There is
a need to develop high quality reception-screening tools and to
ensure sufficient competent staff are available at the relevant
times to assess individuals and follow up with further information
collation. A consistently dedicated committal unit would be a
good starting point in the care pathway.
6. Prisoners serving longer sentences, determinate
or life, may need forensic rehabilitation in a secure NHS setting,
as well as complex care planning across agencies within the prison
(probation and psychology). Forensic psychiatrists should also
be involved in sentence planning and working on offence related
needs, especially for individuals who are borderline IQ (70-80)
or mentally ill, so that they are enabled to progress through
the standard prison system. There is a clear breach of human rights
in such prisoners whose treatment needs cannot be met in standard
prison programmes and who are doubly disadvantaged by virtue of
being mentally ill and being unable to access the necessary offence
related work to move them on. Forensic psychiatrists should also
have a particular role in the close supervision/segregation units
in the prison to assist prison staff there to deal with the most
disturbed individuals, especially if chronically so.
7. The Enquiry Committee is also directed
to the paper "Delivering the Government's Mental Health Policies-Services,
staffing and costs", published by the Sainsbury Centre for
Mental Health in 2007.[28]
This gives some useful guidance on the recommended staffing levels
in a range of different prison settings.
8. The therapeutic milieu and prison culture
is important in trying to promote mental wellbeing, particularly
in those serving long sentences. Thought must be given to the
levels of occupancy (gross overcrowding), prisoner mix (remand,
sentenced and lifer prisoners all managed together, in multiple
regimes) and minority groups (women, non English speaking) as
well as to the buildings being fit for purpose. I believe there
is still a very necessary role for the prison "hospital"
in providing mental health care to those patient prisoners who
may not be detainable under current or proposed mental health
legislation, but who are capable of consenting to treatment. The
prison hospital should not be abandoned as a concept but developed
and staffed to meet very particular needs.
9. It is essential that, in future, lines
of communication between health and prison services be improved
at all levels. Clinical governance arrangements, and accountability
for healthcare provision, need to be shared with all staff in
both organisations. In the present transitional phase we would
strongly advise those managing the transition of prison mental
healthcare to liaise with staff (including senior forensic psychiatrists)
who have considerable experience in providing care in the prisons
locally. These staff could have a useful advisory role in taking
developments forward as well as consolidating progress already
made.
Local forensic clinicians are willing to meet
with the Enquiry Committee to provide detail on or further research
the issues raised or to direct to adequately trained/experienced
members in the Forensic Faculty Executive in London for appropriate
advice.
Dr Christine Kennedy
Faculty of Forensic Psychiatry Belfast Health and
Social Care Trust
23 April 2007
25 www.rmhldni.gov.uk/forensicð_ñservicesð_ñreport.pdf Back
26
See www.rcpsych.ac.uk/publications/ Back
27
See www.dh.gov.uk/en/policyandguidance/index.htm Back
28
See www.scmh.org.uk Back
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