Prison health Contents

4People’s journey through prison

37.The evidence to our inquiry paints a dismal picture of conditions inside English prisons. This picture too frequently is one of overcrowded, unsanitary and outdated establishments. These establishments, due to staff shortages, severely restrict, and too often compromise, the safety and wellbeing of prisoners and staff alike and fail to provide an enabling environment consistent with the rehabilitative purpose of prisons. This section describes the problems raised with us through different points of a person’s journey through prison, along with some of the potential solutions to these problems.

Entry into prison

Liaison and diversion

38.The solution to some of the problems inside English prisons begins with people’s first contact with police and when they are charged. Liaison and Diversion schemes across police stations and courts are able to carry out assessments, refer people to treatment and support and provide information on alternative responses to prison, such as community sentences and out of court disposals. This approach helps to ensure that people are only imprisoned when it is appropriate. The Bradley Report in 2009 placed a renewed emphasis on the use of liaison and diversion,54 but nine years on such schemes only cover 82% of the population, with full roll-out expected in 2020/21.55

39.Identification of vulnerabilities or need by liaison and diversion services does not necessarily translate into changes in sentencing practices. For example, since 2011 there has been a 25% decline in the use of hospital orders which allow defendants to be sent for medical treatment.56 This is despite an initial evaluation of liaison and diversion finding an increase “in the number of people with vulnerabilities who were identified”.57 We heard that a lack of suitable community alternatives, including, for example, the provision of community mental health services to divert someone to, may be limiting the effectiveness of liaison and diversion. As the BMA explained:

Effective liaison and diversion from the criminal justice system are, however, dependent on the community services being in place to enable appropriate care and support, and we are concerned that this is not always the case. A chronic shortfall in funding for mental health services (particularly child and adolescent services) continues to create problems of access for those in need of support.58

40.We are disappointed that nearly a decade on from the Bradley report in 2009, liaison and diversion services do not yet exist in nearly 20% of the country. In the response to this report, the National Prison Healthcare Board should set out the remaining areas where it needs to roll out these services, the reasons for the delay and how the roll-out of these services to the rest of the country will be achieved.

41.We are also disappointed by the decline in the use of hospital orders, despite liaison and diversion services identifying more people with vulnerabilities who may be more appropriately directed to other services besides prisons. The Board should set out the reasons for the decline in hospital orders, what action it is taking to reverse that decline, and by when that action will be completed. There must also be sufficient resourcing of community mental health services so that people are not sent to prison because of a lack of appropriate community mental health care.


42.Prisons are meant to screen new inmates for health conditions, and other health and care needs, upon arrival and again a few days later. Her Majesty’s Inspectorate of Prisons expects that “immediate health, substance use and social care needs are recognised on reception and responded to promptly and effectively”, and that prisoners then “receive a second health screen within seven days to look at wider health issues”.59 This can be a challenging process to manage, as Kate Davies from NHS England described:

[ … ] a lot of people are very chaotic and are coming in at weird times of the day and night, and often there may be one or two—even more—vans queued outside, so it is quite a challenging time to get that screening right.60

43.Most newly arrived prisoners, according to HMIP, receive a prompt initial health screening, despite late arrivals from court affecting the effectiveness of this process.61 In contrast, the second health screen, according to HMIP, “was not consistently occurring in some prisons we inspected due to high non-attendance rates, difficulties accessing patients and staffing shortages”.62 The reception area of a prison, as described above, can be busy and stressful, potentially resulting in a rudimentary assessment upon arrival,63 thereby making the second screen even more important.

44.The view of many stakeholders is that this process needs to be more comprehensive and robust to include a broader range of vulnerabilities prevalent among the prison population and the risks associated upon a person’s entry into prison. In addition, we heard further training, particularly of prison officers, is needed to ensure screenings are carried out by staff with the right knowledge and skills to effectively identify a person’s needs.

45.The National Prison Healthcare Board informed us that “new templates have been introduced to encourage a systematic and consistent approach to assessments on reception, medicines management, and release planning”.64 Kate Davies from NHS England also noted that over the last 18 months commissioners now require 72-hour follow-up, self-referral and a target response. Referring to these changes, Ms Davies said:

We are monitoring it very closely to see how that reduces things like self-harm, but particularly deaths in custody, and improves the uptake of immediate understanding of people’s needs, particularly a high level of learning disability, medication needs and continuity of medication management.65

46.Problems with the conduct of health screenings inside prisons, including the location of the screening, mean that both the NHS and the prison service are missing opportunities to identify and begin to address the health and care needs of a vulnerable population, including previously unrecognised and unmet needs. These missed opportunities affect prisoners, but also wider society. For example, current screening processes inside prisons, along with inadequate training of prison staff, means opportunities to spot and address the following conditions are being missed:

47.Imprisonment represents an opportunity to identify, effectively diagnose and treat health and care needs, some of which may be drivers of behavioural problems, which may have gone unrecognised and/or unmet. We recommend that over the next 12 months the National Prison Healthcare Board, in collaboration with stakeholders, particularly those representative of health and care professions, develop a more comprehensive and robust approach to health screening in prisons, capable of testing for a broader range of health and care needs. Once a new approach is designed its implementation must be supported by a training programme for staff carrying out assessments.

48.In its next annual report, we recommend that Her Majesty’s Inspectorate of Prisons comment specifically on the quality of health screenings, including the extent to which prisons are conducting a second health screening within 7 days.

Prison environment

49.A quarter of the prison estate was built before 1900.67 These older prisons, CQC told us, negatively affect prisoners’ wellbeing and the safe delivery of care.68 Parts of the prison estate are unfit, even with reasonable adjustments, to cater for the needs of older prisoners, yet continue to hold them. Northampton Healthcare Foundation Trust described typical conditions in these ageing buildings:

premises are designed to hold a younger population and accommodation is often completely unsuitable, with most cells having narrow doorways rendering it impossible to enter in a wheelchair; cells are tiny with fixed furniture, either bunk beds or very low fixed beds. Shower and washing facilities are inadequate.69

50.Overcrowding in prisons, coupled with staff shortages, over recent years has been one of the major drivers of deteriorating standards and conditions. Throughout 2016–17 and 2015–16, just under 25% of prisoners were held in a prison cell shared by more people than it was originally designed to hold. This is, we were told, Her Majesty’s Prison and Probation Service definition of crowding.70 However, prisons also have a certified normal accommodation (CNA) level. A prison’s CNA is a standard of decent accommodation the prison service aspires to provide to all prisoners. Just under 60% of prisons at the end of March 2018 exceeded their certified normal accommodation.71

51.Letters from prisoners we received via Inside Time reflect concerns raised by stakeholders, including Her Majesty’s Inspectorate of Prisons, about the poor, unsanitary, and even squalid, conditions inside some prisons. One example can be seen in the box on this page. In another case, we heard that a prison had no hot water for five months. One of the older prisoners, who was in poor health, was having to wash and shower in cold water during this time. His health deteriorated over this period and he later died in hospital.

One prisoner wrote to us saying “living conditions in prison are very poor. Sanitation and hot water are often unavailable and the ever-growing population of rats running around the communal areas are an ongoing risk of disease. The quality of food is a daily drain on mental wellbeing and the very old, torn and unsupportive mattresses make sleep very difficult or impossible.”

52.Prison cells are cramped spaces in which people detained in prison often sleep, eat and go to the toilet. The CQC reported that:

Overcrowding and lack of personal space are acknowledged stress factors for both prisoners and staff that impact on the delivery of an effective health service. The significant impact on prisoners’ general health and wellbeing includes increased risks associated with privacy/confidentiality, communicable diseases, sleep hygiene and anxiety/depression.72

Box 2: Our visit to a prison cell

At our visit to HMP Belmarsh, we were shown a three-bed cell, consisting of a bunk bed on the left-hand side and another bed up against the opposite wall, with a metre-wide gap between the two beds. There was little room to move; if all three men were standing up there was not enough space for them to pass each other without touching. To the right-hand side of the entrance there was a sink, a plastic bin and a tiny mirror, about the size of a small paperback book. There was a toilet in the right-hand corner of the room. The toilet had a small door with a gap below and above. However, not all cells, we were told, have a toilet door. The main door to the room was not barred, but the wall on the other side had a fairly large window, providing some natural light in the cell. There were two cupboards either side of the window, both broken.

Source: Visit to HMP Belmarsh, see Annex 1

53.In response to this report, the Government should set out what its plan is to ensure that all prisons are clean and sanitary all of the time and by when and how they expect to stop overcrowding.

Prison regime

54.In recent years, prisoners have spent the vast majority of their time in their cells. HMIP expect prisoners to be unlocked for at least 10 hours a day, but over the last two years have found this to be the case for only a minority of people in adult male prisons (16% in 2017/18 and 14% in 2016/17). Instead, one fifth said they spent less than two hours out of their cells on a weekday.73 A high proportion of people detained in local prisons74 and prisons catering for young adult males, in particular, report spending less than two hours out of their cells per day.75 One prisoner who wrote to us had recently seen his association time reduced to 1hour 40minutes per day, which in his view “affects mental health greatly” and is inconsistent with the Government’s aim to rehabilitate offenders. Too many prisons, according to HMIP, fail to provide “sufficient activity places and activity that is truly purposeful.”76 Too much time spent locked up without any purposeful activity, or access to sunlight and fresh air, is not only inconsistent with the rehabilitative aim of prison, but a risk to the safety of the environment.77 As CLINKS describe:

A lack of access to rehabilitative services and purposeful activity may have a cyclical impact, leading to increased boredom and frustration which can lead to violence, self-harm and drug use, which in turn leads to further lockdown and an exacerbation of the current difficulties.78

55.Time spent out of cells includes time to work, undergo education and training, access healthcare appointments and resettlement services, and carry out daily activities: showering, eating and speaking on the telephone. Prisoners frequently have to choose whether to spend their allotted time exercising, taking a shower or on the phone.79 One prisoner told us:

There is also the issue that recreational facilities, such as outside exercise and opportunities to go to the gym, are the first things to be withdrawn if the prison have staff resource issues or if anything else happens. This type of entertainment is considered a privilege rather than a right!

56.The Howard League told us “exercise, showers, family contact and recreation time are all used as rewards for good behaviour or sanctions that can be taken away when behaviour is poor.”80 Jackie Doyle-Price, the Parliamentary Under-Secretary of State for Mental Health and Inequalities, responsible for prison health within the department, told us that these activities and facilities are “tools that affect people’s behaviour.”81 However, while this might be the case, we agree with the Howard League that prisons should encourage prisoners to make healthy choices and, most importantly, not deprive them of regular access to facilities and activities that enable them to achieve a basic standard of wellbeing.

57.In response to this report, we request that the Government set out its future plans for the recruitment of prison officers, including a date by when it expects to have enough prison officers in post to ensure the overwhelming majority of prisoners can be unlocked for the recommended 10 hours per day.

58.The Government’s approach to prison reform emphasises the importance of harnessing incentives. Incentives should encourage prisoners to lead healthy lives. In addition, incentives should not deny prisoners regular access to facilities and activities that enable them to maintain basic standards of health and wellbeing. This point should be made clear in guidance on how prisons and prison staff use incentives. People in prison should not in effect be sentenced to a reduction in life expectancy or worsening health.


59.People’s diet in prison is constrained by resources. Prison establishments, according to HMIP’s latest annual report, frequently struggle to provide meals of a reasonable quantity and quality with the daily food budget of £2 per person.82 Prisoners have little choice over what they eat and healthy eating is difficult to promote.83 We also heard that prisoners often receive their breakfast the night before.84 Examples from the correspondence we received from prisoners themselves appear in the box on this page.

One prisoner told us “there is also limited thought or concern given to nutritional or dietary needs, it is a carb overload all the way!!”, while another prisoner pointed out that “the diet is unhealthy and many elderly men are grossly obese and are not encouraged to exercise.”

60.The Government must urgently ensure that all prisoners have access to a reasonable quantity and quality of food which supports health and wellbeing rather than adversely affecting it. Public Health England should carry out an assessment to determine whether the daily food budget of £2 per person can realistically deliver this objective and review the national food standards in prison, which should be consistently implemented across the prison estate.

Experiences of safety

61.Violence in prisons is at a record high, including prisoner on prisoner assaults and assaults on staff, thereby creating an environment in which many prisoners and staff alike feel unsafe. Half of prisoners report having felt unsafe at some time, according to HMIP’s annual report, which rises to 70% for prisoners in large inner city local prisons (e.g. HMP Liverpool, HMP Leeds and HMP Pentonville).85 Exposure to persistent threats of violence and/or bullying, as well as other stressors in prison, creates an environment that is harmful to people’s health. The threat of violence can heighten anxieties of prisoners with health conditions, who can feel vulnerable to attack. We heard accounts from prisoners with health problems who had isolated themselves through fear of being bullied or assaulted. According to HMIP’s annual report, “much of the violence seemed to be linked to drugs and debt, as well as mental health and poor prison conditions.”86 In his oral evidence to us Peter Clarke, the Chief Inspector of Prisons, emphasised the impact of illicit drug use, saying:

The issue of illicit drugs has clearly contributed not only directly to ill health in terms of the impact of the drug on the person when they take it, but to the environment as well, with the violence, the fear, the debt and the bullying it places many people in. They self-segregate and self-isolate, and instances of self-harm and suicide tragically flow from that.”87

62.Almost half of the adult male prisons HMIP inspected over the last year had a main recommendation for addressing problems with violence, either due to high levels of violence or, in some respects more worryingly, a “lack of effective response from managers.”88

Experience of health and social care

63.Demand for healthcare, as identified in Chapter 3, is high among people detained in prison. User Voice found almost 100% of prisoners in Kent, Surrey and Sussex required some form of treatment during their time in prison. They also found the majority (72%) report struggling to access services, while over half report being dissatisfied with the quality of care they received.89 This section describes some of the common problems prisoners experience. The points below are based on prisoners’ reported experiences of health and care services, including responses to our call for evidence in Inside Time. Boxes show some particular examples of the experiences reported. We have gone into more detail further on in this chapter about problems prisoners experience in accessing appointments and with support for mental health and social care needs.

64.Prisoners often struggle to get health concerns acted upon in timely way. Prisoners frequently report long delays in having their health concerns acted upon. This can include worrying symptoms not being responded to in a timely manner, if at all. Letters we received from prisoners include accounts where deaths of fellow prisoners were preceded by long delays in prison and healthcare staff responding signs of ill health

One prisoner wrote to us describing the case of a fellow prisoner, saying: “on the 20th November 2017 Stephen (not his real name) was having issues eating and drinking. He went to healthcare with these problems, but these issues got worse over the coming weeks. Then in March 2018 he was taken to our local hospital where, after doing tests, he was told he had cancer.”

65.Prisoners can experience problems getting help in an emergency. This includes prisoners experiencing suspected stroke or heart attacks, those with serious health conditions (e.g. a cancer diagnosis) or prisoners in a mental health crisis.90 Prisoners frequently complain about waiting a long time for call bells to be answered or not having calls answered at all.91 Getting help in an emergency is particularly difficult during periods of low staffing (e.g. at night).92

“So I rang my emergency call bell for medical attention and was given a behaviour IEP for the pleasure! When I was seen 12 hours later I was rushed to hospital.”

66.Prisoners report having to convince prison staff that they need urgent treatment. Even if they do, healthcare staff are not always available to assist them and when staff are available responses still can be poor.93 When emergency services are called they can often experience long delays in gaining access. For example, the Prison Reform Trust told us of an occasion in which an ambulance, responding to a serious medical emergency, had to wait 30 minutes outside the prison gate.94

One prisoner wrote to us saying “both staff on the wing and in healthcare here in my experience are wholly inadequate in dealing with urgent or emergency care. Prisoners who have self-harmed are described as a nuisance. I have heard prison staff on the wing stating they wish people would kill themselves more efficiently. ‘Let him hang for longer’, ‘let him cut up,’ and ‘I used to gut fish for a living so I can show him how to do it properly’ is just some of the dialogue I have personally heard.”

67.We received reports of flippant and dismissive attitudes among prison staff and healthcare staff to prisoners experiencing an urgent health or mental health problem. The Prison Reform Trust told us prisons have refused to speak to them, and families of prisoners, when they have sought to report urgent health concerns about detainees.95

68.Prisoners experience problems getting medicines they need. Prisoners can experience delays in getting access to medicines, including medicines they’ve been prescribed before they enter prison or when they are transferred to another prison. The Prisoner Advisory Service (PAS) informed us that prisoners can be left without vital medication including “beta blockers, insulin, mental health medication and pain relief.”96 According to the PAS, this problem is “endemic in certain prisons” and has resulted in hospitalisation on occasions.97 Like illicit drugs, there is a market for prescription medications inside prisons. This can result in prisoners being bullied for their medicines. Healthcare professionals, wary about the possibility of bullying, choose not to prescribe medications.

Another prisoner who wrote to us said “last week I was told by the doctor that while he understands I might need pain relief, he can’t prescribe tablets to me, as I might be bullied. So the doctor is doing the bullies’ job now by denying me them.”

69.Prisoners often struggle to see a dentist, GP, speech and language therapist or an optician. User Voice found that over 70% of prisoners reported finding it difficult or very difficult to see a dentist, with just over 50% reporting similar problems accessing a GP and an optician. We heard of cases where prisoners waited many months to access specialist dentistry services or optical care. For example, the PAS informed us of prisoners waiting months for urgent dental treatments, such as a tooth extraction, or specialist treatment for eye conditions.98 On the latter, prisoners who are unable to access treatment for eye conditions can be left feeling very vulnerable, particularly because of high levels of bullying and violence in prisons. Dentists, according to the User Voice survey, were reported to offer the lowest quality of service. Over 40% of prisoners who accessed dentistry services reported these as being poor or very poor.99

The Prisoner Advisory Service informed us that they “recently assisted a prisoner who was denied contact lenses, although he was partially sighted and his condition meant he could not wear glasses. He could hardly see on the prison wing and felt very unsafe. The matter was resolved but not without months of anxiety and distress for the individual concerned.”

70.Prisoners report problems when making a complaint. Prisoners’ complaints often go unanswered, as do complaints made on their behalf. The Prisoner Advisory Service told us it is not sure whether unanswered complaints are recorded in the first place. This concern was also voiced by prisoners who responded to our advert in Inside Time. As such, prisoners often end up making numerous complaints about the same problem. Prisoners are often unware that healthcare services have a different complaints procedure, so, as well as being ignored, they report being passed from pillar to post between different agencies.100

One prisoner told us that he can prove the head of healthcare at his prison puts prisoners’ complaints in the bin. He describes that when prisoners complain, and their complaints are not binned, the response they get from the NHS is a “fob off”, which leaves them back at the point they started at. According to the prisoner, there is a rogue doctor operating within the prison. He goes on to say that hundreds of prisoners have complained about his treatment of them, but the head of healthcare just gets rid of them.

Medical appointments

71.Missed appointments, either in or outside prison, are common. Non-attendance for internal appointments, based on reports by Independent Monitoring Boards, is on average around 20–30%.101 HMIP provided examples of similar trends in the prisons it visited. For example, at Brixton, HMIP found that between November and December 2016 the ‘did not attend’ rate for the GP clinic was 28% and that 25% of hospital appointments between October and December 2016 had to be rescheduled. In both cases, it was restrictions in the regime that was the underlying cause.102

72.Getting an appointment can be difficult in the first place. For example, it is common for staff to fail to pass on messages or for applications made electronically to go missing.103 Waiting times can sometimes be excessive, according to HMIP. For example, waiting times to see a GP ranged from 8–12 weeks in Holme House.104 This is due to staff shortages, high demand, high rates of non-attendance, prisoners not being unlocked for, or escorted to, appointments or prisoners choosing to use the time for other activities if there is only limited time out of their cells.105

73.Similarly, prisoners can also wait too long for external appointments, as people detained in closed prisons require a prison escort, usually a prison officer. HMIP told us they ‘found some prisoners waited too long for external appointments as a result of too few escorts to meet demand and also cancellations due to a lack of escort staff’.106

74.Medical emergencies within prisons also affect pre-arranged appointments. For example, increases in emergencies, such as those fuelled by the use of novel psychoactive substances, mean escorts are allocated to those in most immediate need rather than someone who may have an appointment, such as a cancer investigation or treatment appointment that is urgent but not immediately life threatening .107 We were also told that further follow ups may then be cancelled or simply not rearranged as a result of poor communication.

75.The Government in its response should set out how it intends to drastically reduce the number of missed appointments both in and outside prison across the prison estate to ensure that clinical need is always met.


76.Cannabis, opiates, steroids, other diverted medicines, synthetic cannabinoids and other novel psychoactive substances are heavily misused in many establishments.108 These substances, and the internal market for them, compromise the safety of prisons by fuelling high levels of debt, violence and self-harm. The Independent Advisory Panel on Deaths in Custody note that drug-related deaths in prison appear to have been increasing and argue for clear recording of such deaths, to highlight the extent of the problem.109

77.Many prisoners report having a drug problem on arrival (42% of women and 28% of men). Worryingly, 13% of men and 8% of women reported they had developed a problem with illicit drugs while in prison.110 However, from our oral evidence it was clear that without mandatory drug testing prisons do not, and cannot, know the extent to which people have a problem on arrival or develop one during their sentence.111

78.The widespread use of novel psychoactive substances over recent years, we heard, has presented a major challenge to an already overstretched service. Dr Jake Hard, a GP and Chair of the Royal College of General Practitioners Secure Environments Group, distinguished NPSs from other illicit drugs, describing their rise as a “real curve ball.”112 These substances have unpredictable and severe physical and psychological effects (changes in blood pressure, seizures, reduced drive to breathe and extreme strength, agitation, paranoia and psychosis). The psychological effects can sometimes be severe or enduring enough to require intervention under the Mental Health Act.113

79.These substances also negatively affect staff, diverting health and prison staff away from their usual roles, leading to assaults and regularly draining NHS resources, especially ambulances and emergency services.”114 The Royal College of Nursing told us that their members “report suffering the effects of inhaling the drug” being used by those they are treating, including at least one case where a nurse was taken to A&E by ambulance after being knocked unconscious by the psychoactive fumes.115

80.We agree with the Independent Advisory Panel on Deaths in Custody that drug-related deaths in prison should be clearly recorded. We recommend that in the Government’s official response to this report the Ministry of Justice set out the steps it intends to take to ensure that happens.

81.We recommend the approach to health screening is modified to enable prisons to get a much more comprehensive understanding of people within their prison who have a pre-existing substance misuse problem. The approach to screening should also enable prison healthcare providers to identify, and assist, those who develop such a problem during their sentence.

82.The National Prison Healthcare Board’s Partnership Agreement states that it will “continue work at all levels to reduce the impact of substance misuse (including from the use of psychoactive substances), to address the risks of misuse and resultant harms, and to ensure the right help is available at the right time.” This statement of intent is very vague. In its place we recommend the National Prison Health Board commit to reducing substance misuse in prison, as well as its impact, and set clear and ambitious targets for:

a)reducing the supply of, and demand for, illicit drugs in prisons; and

b)improving the recovery, and associated health outcomes, of people in prison with a substance misuse problem.

Mental health in prisons

83.Numerous concerns have been raised with us about the demand for, and provision of, services catering for people with all severities of mental health need in prison. The environment, culture and conditions within prisons frequently compromise the mental wellbeing of prisoners and staff alike. For example, in men’s prisons, over the last two years, the vast majority of HMIP’s inspection reports (90% in 2017/18 and 75% in 2016/17) have been critical of the establishments response to one or more of the key factors that contribute to self-harm and suicide. One fifth of reports in 2016/17 and a third in 2017/18 included a main recommendation relating to these issues.116However, the inspectorate’s latest annual report notes that “despite similar recommendations in the past, prisons had made insufficient effort to help prisoners in crisis.”117

84.HMIP recommended improvements in the provision of mental healthcare in just over half of all prisons inspected in 2017/18.118 To begin with, there is a gap in mental health services commissioned in prisons, particularly services catering for people with mild to moderate mental health needs (e.g. psychological services, counselling etc).119 This point was reiterated in CQC’s evidence to us.120 There is also a difficulty with ensuring continuity of mental health care when prisoners are transferred to other prisons.

85.For those with severe mental health problems, guidelines introduced in England and Wales following the Bradley Report stipulate that prisoners should be transferred to a mental health unit within 14 days of the first medical recommendation for transfer. A second medical opinion and all administrative tasks, including finding a bed, should also be completed in those 14 days. However, this is rarely the case. Instead, in England and Wales in 2016–17, only 366 (33.7%) of the 1083 transfers from prison to hospital were completed within 14 days. 717 (66.3%) took longer than 14 days and 76 prisoners (7.1%) waited 140 days or longer.121 HMIP found excessive delays in 27 male prisons in 2017/18.122

Self-harm and suicide

86.Rates of self-harm in custody have reached record highs over recent years and continue to rise.123 In 2017, there were 44,651 reported incidents of self-harm, up 11% from the previous year. The number of self-harming individuals increased by 6% to a new record high of 11,630.124 Self-inflicted deaths in prison also remain at very high levels.125 The Prison and Probation Ombudsman told us that:

We have seen a very welcome reduction in self-inflicted deaths in 2017/18, although numbers started to increase in the second half of the year. It is important that we work together to understand the reasons behind this. We should all recognise that levels remain unacceptably high and that it is far too early to conclude that “our work here is done”. Combating self-harm and self-inflicted deaths must remain a key concern.126

87.Every death by suicide is a tragedy with appalling long-term consequences for loved ones, those around the individual who has taken their own life and staff. Suicide must be regarded as preventable.127 Risk of suicide is dynamic: anyone can become at risk of suicide at any time during their sentence.128 However, it is unacceptable that deaths by suicide continue to occur for people who are known to be at high risk and for whom appropriate action, including the removal of all ligature points, which could have saved their lives, has not been taken. Particular attention also needs to be paid to periods of greater risk, including on entry to prison, on release from prison, while in segregation and while awaiting transfer to a secure mental health hospital.

88.There are well known risks relating to suicide and self-harm for people in prison. While rates of self-inflicted deaths in prisons have fallen since reaching a peak in 2016, there is no room for complacency as incidences of self-harm remain at a record high. We expect to see a concerted effort from Government to reduce suicide and self-harm in prison, supported by ambitious targets and a clear and credible plan for achieving them. The newly identified role of a minister with responsibility for suicide prevention is welcome, but we expect the Government within its response to report on how this role will extend to suicides and self-harm within prisons and on release.

89.The National Prison Healthcare Board’s agreement states that between 2018–21 it plans to “continue to work collaboratively to improve practice to reduce incidents of self-harm and self-inflicted deaths in the adult secure estate, by strengthening multi-agency approaches to managing prisoners at serious risk of harm and further embedding shared learning.” Like the reference to substance misuse described above, this is too vague. The Board should set clear reduction targets and measures of success for this period, including improving access to psychological therapies, especially for those with mild to moderate mental health needs.

90.We are deeply concerned that the majority of people requiring treatment in secure mental health facilities are not transferred within the 14-day target and that a small minority wait over 140 days. The most cited reason for delays is a lack of access to secure hospital beds.129 We were informed of aspirations to increase capacity, but that this will not be achieved for some years.130 Currently, the National Prison Healthcare Board is working hard to reduce waiting times by improving the flow through the system, thereby using the current capacity more efficiently.131The question remains to what extent the 14-day target is achievable within the current capacity of secure beds. In response to this report, we recommend that the Board set out the level of reduction in waiting times for transfers to secure mental health facilities it plans to achieve in each of the remaining years of its partnership agreement (2018/19, 2019/20 and 2020/21). We also recommend that the Board set out its plans for expanding the number of secure hospital beds, including dates by which extra capacity will be operational and the contribution this extra capacity will make to reducing waiting times.

Social care in prisons

91.There is an underserved need for social care in English prisons due to high prevalence of learning disabilities, autism and other difficulties with communication. People with these difficulties often fall below the eligibility criteria for state funded social care support.132

92.For those who may qualify for social care, there are pockets of good, even excellent, practice across the prison service, although overall the identification, assessment, commissioning and provision of social care in prisons varies significantly. Where problems with social care arise, they may be the fault of local authorities (e.g. failing to commission services or delays in local authorities carrying out assessments) or of providers (e.g. inadequate staffing, poor care planning and communication).133 However, the majority of the issues reported to us were with the prison service.134

93.Referrals to local authorities for assessment of an individual’s social care needs vary significantly between prisons. For example, in 2016/17 six prisons generated over 100 referrals, while eight prisons did not generate any.135 These variations may stem from differences in the ability of prison staff to identify people in need of social care and/or a lack of contact with social care staff and a corresponding lack of knowledge about the local authority’s role and how to contact them.136 In addition, very few areas, 7 out of 50, have a memorandum of understanding in place between the prison and the local authority, despite the inclusion of such an MoU being stated within official Prison Service Instructions.137

94.Prisons add to the cost of providing social care in two critical ways. Firstly, in a sector which already experiences a high staff turnover (30%), the long waits for security clearance often mean prospective employees have found another job before their vetting is completed. In addition, the time taken to get in and out of prison doubles the cost of providing social care in prison compared to the community, according to ADASS.138

95.We recommend a target should be introduced for all of the 50 local authority areas with prisons to have a memorandum of understanding on the provision of social care in place with each prison in their area in the next year.

Release from prison

96.Release from prison is a challenging time for prisoners, associated with significant risks to their health. During this transition the risk of suicide increases and those who misuse substances are at risk of overdosing.139 We heard that “healthcare provision at present is often disjointed between prison and the community” and that “uncertainties at the time of release, for example regarding future home address, can make communication between integrated and community healthcare services more difficult”.140

97.Problems arising upon release from prisons include prisoners leaving without or with the wrong medication, without being registered with a GP in the community, and without an assessment of their social care needs, despite receiving care in prisons. Dr O’Moore from Public Health England also told us only a third of people on structured drug treatment programmes in prison are picked up by drug services when they leave.141 In addition to problems with continuity of health and care, many prisoners are also released homeless.142

98.We were particularly concerned to hear from INQUEST about the number of people dying during post-release supervision in the community. INQUEST informed us that almost 1,400 people died during post-release supervision in the community between 2010/11 and 2016/17. 554 of the 1,378 deaths were of natural causes, 401 were self-inflicted and 229 await classification. Analysis by INQUEST of official data from the MoJ showed the increase in deaths post-release (274%) has been far in excess of the increase in caseloads (62%).143 We share INQUEST’s concern that “there seems to be a complete absence of any form of investigation and follow-up when something happens to somebody on post-custody supervision.”144

99.A lack of continuity of care on release and problems securing provision for ex-offenders may be caused by a poor sharing of information between services, disputes, for example between commissioners, over who is responsible for the ex-offender’s needs, and scarce resources in the community (e.g. a lack of social housing).145

100.We recommend that the Government undertake a thorough investigation of deaths during post-release supervision in the community, including the reasons for the rise in death rate that has been described. We further recommend that the Government clarify where responsibility for oversight of such deaths should lie and set out a plan to reduce this death rate.

55 DHSC, MoJ, HMPPS, NHS England and PHE (PRH0032), para 2.10.1.

56 UK National Preventative Mechanism (PRH0030), para 7

57 British Medical Association (PRH0019), para 1.4

58 British Medical Association (PRH0019), para 1.4

59 HMI Prisons (PRH0039)

60 Q184,Kate Davies

61 HMI Prisons (PRH0039)

62 HMI Prisons (PRH0039), para 25

63 British Medical Association (BMA) (PRH0019)

64 DHSC, MoJ, HMPPS, NHS England and PHE (PRH0032), para 2.10.3.

65 Q184 Kate Davies

66 RCSLT (PRH0026)

67 National Audit Office, Short guide to the Ministry of Justice, October 2017

68 Care Quality Commission (PRH0004)

69 Northampton Healthcare Foundation Trust (PRH0035)

70 DHSC, MoJ, HMPPS, NHS England and PHE (PRH0032), para 3.5.1.

71 The Howard League (PRH0029), para 4.6 and UK Prison Population Statistics, House of Commons Library Briefing Paper, Number CBP-04334, 23 July 2018

72 Care Quality Commission (PRH0004)

73 HMI Prisons (PRH0039) para 45

74 Her Majesty’s Inspectorate of Prison for England and Wales, Annual report 2017/18, July 2018, HC1254

75 Her Majesty’s Inspectorate of Prison for England and Wales, Annual report 2017/18, July 2018, HC1254

76 HMI Prisons (PRH0039), para 45

77 See Annex 1

78 Clinks (PRH0005) para 19

79 Her Majesty’s Inspectorate of Prison for England and Wales, Annual report 2017/18, July 2018, HC1254

80 The Howard League (PRH0029)

81 Q177, Jackie Doyle-Price

82 Her Majesty’s Inspectorate of Prison for England and Wales, Annual report 2017/18, July 2018, HC1254

83 Care Quality Commission (PRH0004)

84 See Annex 2 on Prison Health Stakeholder Discussion

85 Her Majesty’s Inspectorate of Prison for England and Wales, Annual report 2017/18, July 2018, HC1254

86 Her Majesty’s Inspectorate of Prison for England and Wales, Annual report 2017/18, July 2018, HC1254

87 Q61 Peter Clark

88 Her Majesty’s Inspectorate of Prison for England and Wales, Annual report 2017/18, July 2018, HC1254

89 User Voice (PRH0031)

90 Prisoners Advice Service (PRH0044),Prison Reform Trust (PRH0038)

91 Prisoners Advice Service (PRH0044)

92 Prison Reform Trust (PRH0038)

93 Prison Reform Trust (PRH0038)

94 Prison Reform Trust (PRH0038)

95 Prison Reform Trust (PRH0038)

96 Prisoners Advice Service (PRH0044)

97 Prisoners Advice Service (PRH0044)

98 Prisoners Advice Service (PRH0044)

99 User Voice (PRH0031)

100 Prisoners Advice Service (PRH0044)

101 AMIMB (PRH0043)

102 HMI Prisons (PRH0039)

103 Prison Reform Trust (PRH0038)

104 AMIMB (PRH0043)

105 HMI Prisons (PRH0039), para 27

106 HMI Prisons (PRH0039), para 31

107 AMIMB (PRH0043)

108 HMI Prisons (PRH0039)

109 Independent Advisory Panel on Deaths in Custody (PRH0040)

110 HMI Prisons (PRH0039), para 43

113 Royal College of GPs (PRH0023), para 30

114 Royal College of GPs (PRH0023), para 30, Prison Reform Trust (PRH0038)

115 Royal College of Nursing (PRH0037), para 2.5

116 HMI Prisons (PRH0039)

117 Her Majesty’s Inspectorate of Prison for England and Wales, Annual report 2017/18, July 2018, HC1254

118 HMI Prisons (PRH0039)

119 HMI Prisons (PRH0039)

120 Care Quality Commission (PRH0004)

121 UK National Preventive Mechanism (PRH0030)

122 Her Majesty’s Inspectorate of Prison for England and Wales, Annual report 2017/18, July 2018, HC1254

124 INQUEST (PRH0027) para 10

125 Q28 Rebecca Roberts

126 Prisons and Probation Ombudsman (PRH0017)

127 House of Commons Health Committee, Suicide prevention, Sixth report of Session 2016–17, 16 March 2017, HC1087

128 Clinks (PRH0005)

129 UK National Preventive Mechanism (PRH0030)

130 UK National Preventive Mechanism (PRH0030)

132 Association of Directors of Adult Social Services (ADASS) submission (PRH0051) and Revolving Doors Agency (PRH0046)

133 Care Quality Commission (PRH0004)

134 Care Quality Commission (PRH0004) and Association of Directors of Adult Social Services (ADASS) submission (PRH0051)

135 Association of Directors of Adult Social Services (ADASS) submission (PRH0051)

136 Association of Directors of Adult Social Services (ADASS) submission (PRH0051)

137 Association of Directors of Adult Social Services (ADASS) submission (PRH0051)

138 Association of Directors of Adult Social Services (ADASS) submission (PRH0051)

139 Royal College of Psychiatrists (PRH0014)

140 University of Manchester (PRH0003), para 1.9.1.

141 Q222 Dr O’Moore

142 On our visit to HMP Thameside we were informed that 45% of prisoners are released to no fixed abode.

143 INQUEST (PRH0027)

144 Q56 Rebecca Roberts

145 Q214 Digby Griffiths

Published: 1 November 2018