1.The deteriorating prison estate and long-standing understaffing have created an environment which exacerbates the mental health issues faced by prisoners. Prisoners are less able to manage their mental health conditions because most aspects of their day-to-day life are controlled by the prison. The current restrictive prison regime caused by loss of prison staff, has meant that staff are less likely to identify prisoners with mental health issues and prisoners are less able to self-refer. Prisoners miss an average of 15% of medical appointments, largely because of a lack of staff to escort them. The Ministry of Justice and Her Majesty’s Prison and Probation Service (HMPPS) accepted that low levels of staffing have been detrimental to security and order in prisons. HMPPS told us that it was working to address the issues we identified with the prison environment through a range of activities, including recruiting 2,500 additional staff by the end of 2018, providing enhanced mental health training to all new staff including on suicide awareness and providing each prisoner with a dedicated key worker. While this sounds promising, we are not yet convinced that these plans will be enough to improve conditions for prisoners with mental health issues. While all prison officers receive basic training on mental health awareness when they are recruited, 40% of prisons do not offer existing staff any mental health awareness refresher training. We were also concerned to hear of examples where the loss of prison staff is already outstripping recruitment and of delays of seven months to recruit new staff.
Recommendation: HM Prison and Probation Service should:
2.The failure to establish effective screening procedures means the Ministry of Justice, HM Prison and Probation Service and NHS England do not know the full extent of the number of prisoners with mental health issues. There is no reliable or up to date data on the prevalence of mental health issues in prison. The mostly commonly used estimate, that 90% of prisoners have mental health issues, is now 20 years old. Prison staff screen prisoners when they first arrive in prisons, including for risk of suicide and self-harm, and this is followed by a health screen, but neither of these adequately identify mental health problems. The reception process for new prisoners can be chaotic and not all prisoners with mental health issues are identified at this stage. HMPPS analyses screening data at a national level, but its information is incomplete as prison staff leave some questions unanswered. Prison staff did not enter data on the ‘risk of suicide’ in 68% of screening records, or on the ‘risk of self-harm’ in 59% of records. NHS England has a more complete dataset as it collects information on the number of people who are being treated for mental illness, currently 10% of the prison population. But this does not include those who are waiting for treatment so is very likely to be an underestimate of those that need support.
Recommendation: HM Prison and Probation Service, the Ministry of Justice and NHS England should, by the end of March 2018, write to the Committee to explain how they will improve their screening processes and use the resulting data to make sure they have a complete understanding of the number of prisoners with mental health issues and the treatment they need.
3.Increased availability of drugs in prisons has contributed to the increase in mental health issues of prisoners. The number of drug seizures in prisons has risen from 2,500 in 2015 to just over 10,500 in 2016. There has been a huge switch in drug use in prison towards psychoactive substances, which existing detection and treatment programmes were not designed to deal with. Spice is now a substantial problem in prison, with the number of seizures going up from 408 in 2015 to nearly 3,500 in 2016. HMPPS told us that dealing with these substances has been very difficult as they were previously legal and easily accessible. It told us that it is was the first law enforcement agency in the world to train dogs to detect psychoactive substances and that it now had a test in place to detect the drug.
Recommendation: HM Prison and Probation Service and NHS England should review their detection and treatment programmes to ensure that they reflect the current behaviours and needs of prisoners.
4.Poor co-ordination and a lack of sharing information means that prisoners are not receiving continuity of treatment as they move between prison and the community. People in prison are more likely to suffer from mental health problems than those in the community. Many prisoners move in and out of prison, or between prisons, which makes the job of providing healthcare more difficult. Despite this there is a clear disconnect between the information available to healthcare provider on the care patients have received before, during and after their time in prison, which risks making mental health services almost inaccessible for some patients. This lack of continuity risks worsening prisoners’ mental health conditions and undermining their rehabilitation, particularly those with speech and language issues, learning disabilities, autism and dementia. NHS England recognised that healthcare services were not where they needed to be and committed to ensuring that they were better co-ordinated. It told us that it was introducing a system to ensure that prisoners’ medical records from the community and prison were joined-up, which it will start to roll-out from November this year.
Recommendation: NHS England should, by the end of March 2018:
5.It is a disgrace that too many prisoners wait far too long to be transferred to hospital or secure units. Prisoners with acute mental health problems should wait no more than 14 days to be admitted to a secure hospital, but the majority wait far longer than this. In 2016–17, two-thirds of prisoners who needed treatment waited longer than 14 days to be transferred. We were told of examples where prisoners had waited over a year to be transferred to a secure hospital. NHS England is responsible for ensuring that the 14 day target is met. Yet NHS England does not know how many patients who are currently waiting to be transferred to hospital or secure units have waited longer than 14 days. We are deeply concerned that the failure to make sure these prisoners receive the treatment they need is making them more ill at a time when they are most at risk.
Recommendation: HM Prison and Probation Service and NHS England should, by the end of January 2018, publish quarterly data on the number of prisoners transferred to hospital or secure units, how many prisoners are waiting at the time of publication, and how long both groups have waited.
6.NHS England’s oversight of its contracts to provide mental health services has been weak. NHS England does not monitor the quality of mental health care delivered by private providers, or the outcomes these services achieve. The National Audit Office (NAO) report highlighted two examples where NHS England had continued to pay for services that the contractor had not delivered and had not acted to recoup any costs. Untreated mental health conditions, especially schizophrenia, personality disorders and substance misuse disorders, are associated with higher rates of suicide and self-harm. It is not clear what action, if any, NHS England takes in response to providers who are found to have contributed to a death in custody. NHS England was unable to tell us in our evidence session how many cases there had been where a provider’s failure to provide adequate mental health services had contributed to an individual taking their own life, or in how many of those cases it had taken action against the provider. Taxpayers’ money should not be wasted on services that are not being received or are being delivered to a lower quality than required.
Recommendation: NHS England should write to the Committee by the end of January 2018 to confirm what actions it will take to ensure that it is getting value for money and that taxpayers’ money is not being wasted by paying for services that are not delivered or are well below the standards expected.
11 December 2017