Prisons and Courts Bill

Written evidence submitted by the Royal College of Psychiatrists (PCB 05)

Prison and Courts Bill Committee

The Royal College of Psychiatrists (RCPsych) is the professional medical body responsible for developing and supporting psychiatrists throughout their careers, and for setting and raising standards of psychiatry in the United Kingdom.

Evidence for this submission has been compiled by Dr Pamela Taylor, Chair of the Forensic Psychiatry Faculty in consultation with prison psychiatry colleagues. The College would be very happy to provide any further evidence the Committee needs, in writing or in person.


· Prisoners are over three times more likely to suffer from depression, 12 times more likely to suffer from a personality disorder and 16 times more likely to suffer from psychosis than the rest of the population. [1]

· There are also significantly higher rates of neurodevelopmental disorders such as ADHD, Autistic spectrum disorder, learning disabilities, dependence and harmful use of drugs and alcohol. [2] , [3]

· New statistics from the Ministry of Justice this year revealed a record of 119 deaths by suicide in prisons in 2016. This is the highest number in England and Wales since records began in 1978. [4]

· Death by suicide accounts for about 35% of all deaths in prison; deaths from other causes are also rising.

· Untreated mental disorders, especially schizophrenia, personality disorders and substance misuse disorders, are also associated with serious risk of harm to others. [5] , [6]

· Access to specialist mental health services for prisoners is inadequate and is getting worse.

The Prison and Courts Bill provides an important opportunity to address the current epidemic of mental health issues in our prisons.

1. Statutory purposes of prison

1.1 The Prison and Courts Bill outlines for the first time the statutory purposes of prisons. This is to ensure that, according to the White Paper, "the role of the Secretary of State for Justice is clear, including how she will account to Parliament for her performance".

1.2 Given the extent and consequences of mental disorders and substance abuse among prisoners, the College proposes that an additional purpose be included:

Clause 1, page 1, line 14, insert-

‘(e) make provisions to ensure that the mental health and physical health needs of prisoners are met.’.

1.3 The Bill currently proposes the statutory purposes of prisons should be: (a) protect the public, (b) reform and rehabilitate offenders, (c) prepare prisoners for life outside prison, and (d) maintain an environment that is safe and secure. All of these are interlinked and none can be achieved without the others. The same can be said about good mental and physical health. Good health is an essential variable in ensuring the success of the four existing purposes. Prisons would have a much better chance of reforming and rehabilitating offenders, if they are also required to attend to their mental health.

1.4 Systems for identifying and treating mental health disorders in prisons are not currently reaching prisoners adequately. This can have a dangerous long-term impact, as evidence shows that untreated mental illness in prisoners is linked to increased levels of violence. It may also lead to an increase in the prison population, by preventing those serving indeterminate sentences from being released and leading to prisoners on licence being called back to prison after breaking the terms of their release.

1.5 As the Government has already committed to improving physical and mental health services in prisons this should not require any extra expenditure, but would be a way of holding the system to account.

1.7 This amendment would be a step towards breaking the vicious cycle of inadequate treatment of mental disorders in prisons and increased rates of reoffending.

2. Diverting those with mental health disorders away from prison

2.1 While the importance of improving mental health services in prisons cannot be overstated, the College considers that many of the problems facing prisons could be alleviated by preventing people from being inappropriately imprisoned in the first place. Currently far too many people with mental health disorders are given custodial sentences, despite the evidence showing the effectiveness of community sentence alternatives.

2.2 Given that at least 3-4% of prisoners have a psychotic illness, 10-14% a major depressive illness and up to 2/3 have a personality disorder, opportunities are clearly being missed to divert people away from prison.

2.3 There is an urgent need for courts to better understand how to treat and manage offenders with mental health disorders in the community, and for them to be able to access appropriate community services.

2.4 An existing alternative to prison for those suffering from mental ill-health is a Mental Health Treatment Requirement (MHTR), which may be added to a community or suspended prison sentence after conviction for a criminal offence. Only 652 (0.5%) community sentences in 2007 included an MHTR. [7] Our members say their use has changed little since then.

2.5 Research into MHTRs has shown that they are not used because of a widespread lack of knowledge about what they are and how they can be implemented, even by the courts [8] . In our experience, magistrates welcome input from psychiatrists in their training, but this tends to occur as a result of local links rather than systematically. The College would be happy to engage in extending this work.

2.6 Mental health legislation allows for Guardianship and, through the criminal courts, Guardianship Orders and Supervision Orders. These appoint someone – usually a social worker or a relative - to oversee the person’s care and ensure access to treatment. Use of these orders has been falling, possibly because of insufficient social care resources to oversee the orders.

2.7 The College wants to see the extension of successful clinical models for diversion of people with mental disorders from the criminal justice system at the earliest possible stage.

2.8 Increased knowledge and skills in the Criminal Justice System for safe diversion, such as through specialist drug courts, mental health courts or problem-solving courts is crucial.

2.9 Whenever someone is detained on suspicion of committing an offence and mental disorder is also suspected, all parties in the process should at all its stages pay more attention to diversion options.

2.10 The College would like to know why there is no statutory dutyplaced onthe courts to divert people away from prisons, although it is in courts where the pressures on prisons could most effectively be alleviated.

2.11 If the Government wants prisons to meet the statutory purposes for which this Bill legislates, courts must be given a duty to, where possible, divert people with mental health disorders away from prisons. This would to give offenders the best chance of reform and rehabilitation by handing them the most appropriate sentence.

3. The prison environment and prison officer numbers

3.1 A recent College survey of members who work in prisons found that as many as three quarters believe they are no longer able to provide adequate mental health services in prisons.

3.2 The main reasons they gave were inadequate prison officer staffing, increasing demands on prison mental health services and health service processes for retendering of services.

3.3 The effectiveness of rehabilitative interventions (mental health, education etc.) in prisons depends on the safety and appropriateness of the prison environment. Without adequate prison officer numbers, it will be impossible to deliver adequate mental health care, prevent violence and prevent and respond to drug abuse. As we have seen from the growing number of prison riots, it is becoming impossible even to maintain the physical security of the buildings.

3.4 The average number of prisoners per prison officer has increased by 38% in the last ten years. [9]

3.5 The College's survey found that almost all our psychiatrists have had appointments with prisoners cancelled, either because of a lack of prison staff to support them, or because of lockdowns caused by increasing numbers of security incidents. This has led to real difficulties in accessing acutely disturbed prisoners. This is dangerous, and is consistent with the findings of the April 2016 survey by the Centre for Mental Health (CMH), commissioned by the Department of Health and the Ministry of Justice. [10]

3.6 The same survey of prison psychiatrists found that most prison psychiatrists don’t feel able to deliver a basic level of care, forcing many to consider leaving their jobs. Anecdotal reports suggest that other staff are leaving prison mental health teams and that replacements are harder to find. Some psychiatrists are report that they y are routinely verbally abused, and in one case they were physically assaulted.

3.7 The College is pleased to see that 2,000 new senior prison officer positions will be created and that training will include more on specialist mental health. In 2016, the College’s Quality Network for Prison Mental Health Services found that only 17% of services could confirm that the majority of their prison staff had received mental health awareness training [11] .

3.8 We propose the Bill be amended to provide for a minimum sufficient prison officer: prisoner ratio.

3.9 We suggest this ratio would be calculated on analysis of the numbers required to re-establish and maintain the procedural and relational security, as well as perimeter security, required for largely drug-free prisons which provide the discipline and atmosphere necessary for achieving rehabilitative change. This ratio would ensure that there are sufficient officers to prevent problems arising from staff shortages, such as the rise in suicide rates we saw in prisons following the prison officer cuts in 2013. The RCPsych College’s Quality Network for Prison Mental Health Services would be happy to work with the Government in developing this ratio.

3.10 Even before staff reductions in prisons, it was difficult for prison officers or clinical staff to build the kind of relationships that would ensure identification of most suicidal ideation. Now, the chances of doing so are very substantially reduced.

4. Maintaining relationships between prisoners and families

4.1 Too little is known about maintaining and improving the family relationships of prisoners, but the collective research evidence to date suggests that not only do they enhance prisoner well-being, but they also tend to improve in-prison behaviour and diminish the risk of recidivism. [12]

4.2 The Joint Commissioning Panel for Mental Health guidance for forensic mental health services in the NHS recommends that family support and maintenance and reestablishment of family relationships should occur where possible. [13]

4.3 A joint report from HM Inspectorate of Prisons and the Youth Justice Board found that boys who suffered from emotional or mental health problems were less likely to usually have a visit at least once a week from family and friends that those without mental health problems (25% compared with 37%). [14] If the research suggests that contact with family and friends can improve the mental wellbeing of prisoners, but those with mental health disorders are less likely to have this contact, there is clearly significant room for improvement.

4.4 With a move towards fewer and larger prisons, more and more people are having to travel long distances to see family members in prisons. Many prisons are not fully accessible by public transport and require additional and costly taxi arrangements. Visiting relatives in prisons is therefore likely to become unaffordable, unless action is taken to address this.

4.5 The College proposes that the bill make provision for financial support, not only to facilitate family access, but also to promote good family relationships.

4.6 It is important to recognise, however, that prisoners often have difficult or changing relationships with their families, and we have referred above to changes in the relationship which they regard as most important to them being relevant to the development of later depression in prison. [15] It is therefore vital that more is done to help prisoners to build and maintain positive relationships.

5. How prisons can improve mental health services

5.1 The College runs two systems which aim to improve mental health provision in prisons.

5.2 The first is the CCQI (College Centre for Quality Improvement) Quality Network for Prison Mental Health Services. This allows prison mental health teams to measure their performance against nationally agreed standards, facilitating quality improvement and change through a model of openness and engagement. We are very pleased that four of the Reform Prisons, HMP Holme House, HMP High Down, HMP Kirklevington Grange and HMP Wandsworth, are already part of this Network.

5.3 The extent to which this service can ensure improvements, however, is currently under some threat because of the nature of the commissioning process. Cycles of improvement require commitment from stable, expert healthcare providers. In the current system, short-term contracts mean that it is much harder to maintain improvement work, as services constantly have to bid for contracts which too often seem to be decided on the basis of which is cheaper.

5.4 The second is the Enabling Environment Award scheme. This award looks at more than just mental health provision, and rewards organisations that create environments which foster wellbeing and good mental health. HMP Drake Hall is the first, and current the only, prison to receive the award.

5.5 The recent Centre for Mental Health report Mental health and criminal justice, commissioned by the Ministry of Justice and Department of Health, calls on all prisons to move towards a standard where they too could be granted the award. We hope that the Government, when moving forward with this Bill, will be mindful of this call.

5.6 The National Institute for Health and Care Excellence (NICE) has recently published Clinical Guidelines for the mental health of adults in contact with the criminal justice system. The guidance recommends that there be an immediate referral to the prison’s mental health in-reach team of all those individuals entering prison who are deemed to be at risk of a mental health disorder, before they are allocated to a cell. [16] The College strongly supports this recommendation.

6.7 Together with the NICE guidance for physical health, these will help to hold the Secretary of State to account for ensuring that all prisons meet these evidence-based standards of healthcare.

6. Identification of mental health disorders in prison

6.1 There are difficulties in identifying suicidal ideation on arrival to prison, yet there is evidence that this is a particularly risky time.

6.2There is no alternative to brief screening when people first arrive in prison. Communication of suicidal ideation, however, generally requires some trust to have developed between a prisoner and their psychiatrist before it is disclosed. In addition, a person’s mental state is not fixed, and substantial changes in mental state can be observed even after just 3-4 weeks in prison. Screening should, therefore, not be regarded as a one-off event, but repeated at intervals (NICE recommends a second stage health assessment within 7 days of admission o prison, and reassessment following significant changes in custodial or health status).

6.3 An evaluation of in-reach services showed that, while availability of mental health service personnel time available to prisoners had increased, only about 25% of prisoners with serious mental illness were being assessed and 13% taken into treatment. [17] There was a much lower availability of service for people with personality disorder. [18]

7. Mental health support after leaving prison

8.1 People leaving prison are almost seven times more likely to commit suicide than the rest of the population. [19] It is vital that people get support at this incredibly difficult time.

8.2 It is a real challenge, however, for mental health services to provide the support people need, as many people leave prison with no fixed abode, making it very hard to allocate them services in the right geographical area.

8.3 Even when community mental health teams do know the whereabouts of someone who has been released from prison, they often struggle to be able to offer them support, because their workload is already massively overstretched.

8.4 Many community mental health teams can only offer help to people who are already facing a mental health crisis, as they simply do not have the resources to provide help to everyone who needs longer-term support.

8. Substance misuse issues

9.1 There is little mental health care available for prisoners with substance misuse disorders. The prison-based Counselling, Assessment, Referral Advice and Throughcare (CARAT) triage system is the designated route to assistance, but fails to reach many problem users.

9.2 One study found that over half of those who were dependent on alcohol and who recognised the problem and wanted help were unable to access a CARAT worker. [20]

9.3 It is likely that access is now even worse, as these figures precede the 2013 reduction in prison officer numbers, on average by 40-45% across the prison estate.

March 2017

[1] Singleton, N., Meltzer, H. & Gatward, R. (1998) Psychiatric Morbidity among Prisoners in England and Wales. London: Office for National Statistics.




[5] Taylor PJ (2009) Psychosis and violence: stories, fears and reality. Canadian Journal of Psychiatry 53: 647- 659.

[6] Taylor PJ and Estroff SE (2014) Psychosis, violence & crime. In Forensic Psychiatry: Clinical, Legal and Ethical Issues. J Gunn and PJ Taylor (Eds). CRC Press: Boca Raton, FL. 334-366.

[7] Solomon E and Silvesti A (2008) Community Sentences Digest. Centre for Crime and Justice Studies, King’s College: London.





[12] De Claire K and Dixon L. (2015) The effect of prison visits from family members on prisoners’ well-being, prison rule breaking, and recidivism: a review of research since 1991. Trauma, Violence and Abuse DOI: 10.1177/1524838015603209



[15] Taylor PJ, Walker J, Dunn E, Kissell AE, Williams A & Amos T. (2010) Improving mental state in early imprisonment. Criminal Behaviour & Mental Health 20: 215-231.


[17] Shaw J, Senior J, Lowthian C et al (2009) A National Evaluation of Prison Mental Health In-Reach Services. OHRN: Manchester.

[18] Shaw J, Senior J, Lowthian C et al (2009) A National Evaluation of Prison Mental Health In-Reach Services. OHRN: Manchester.

[19] Singleton, N., Meltzer, H. & Gatward, R. (1998) Psychiatric Morbidity among Prisoners in England and Wales. London: Office for National Statistics.

[20] Kissell AE, Taylor PJ, Walker J, Lewis E, Hammond A and Amos T. (2014) Disentangling Alcohol-related needs among pre-trial prisoners: a longitudinal study. Alcohol and Alcoholism 49: 639-644.


Prepared 28th March 2017