1.On the basis of a report by the Comptroller and Auditor General, we took evidence from the Ministry of Justice, Her Majesty’s Prison and Probation Service and NHS England on mental health in prisons. We also took evidence from Dr Andrew Forrester, Consultant and Honorary Senior Lecturer in Forensic Psychiatry at the Institute of Psychiatry, Sarah Hughes, Chief Executive Officer of the Centre for Mental Health, Mark Johnson, Founder of User Voice, and Dr Huw Stone, from the Prison Quality Network at the Royal College of Psychiatrists.
2.There were 84,674 adults in prison in England and Wales on an average day in 2016–17. Her Majesty’s Prison and Probation Service (HMPPS) is responsible for the management and operation of prisons in England and Wales and ensuring that the prison environment is safe, secure and decent. The Ministry of Justice is responsible for prison policy and commissioning services in prisons. NHS England is responsible for healthcare in prisons. As part of these arrangements, prisoners should receive an equivalent health and well-being service to that available to the general population, with access to services based on need. They should experience an improvement in their health and well-being, and receive continuity of care between prisons and between prison and the community.
3.There is currently no agreement in place which outlines responsibilities for the mental health and wellbeing of people in prison. A partnership agreement between the National Offender Management Service (now HMPPS) and NHS England expired in April 2017 and has not been replaced. The high-level objectives in the old agreement were not good enough, and there was a disconnect between these objectives and any sensible joined up plan to deliver them. Both HMPPS and NHS England committed to having the new partnership agreements in place by April 2018. We would welcome a shared, single plan that recognises the roles of each organisation, and commits them jointly to improving the mental health and wellbeing of prisoners. The Ministry of Justice told us that the agreement will be a step improvement on the last one, and both NHS England and the Ministry stated it would set out proper measures that are quantifiable, and look at both clinical healthcare and the role of the prison.
4.People in prison are more likely to suffer from mental health problems than those in the community. NHS England estimates that 37% of its spend on adult healthcare in prisons is on mental health and substance abuse, which it told us is more than twice the proportion that is being spent within the NHS budget as a whole. Complex social and personal issues such as a history of unemployment, substance misuse or trauma are more common among the prison population, and being in prison can exacerbate poor mental health and well-being. In turn, untreated mental health conditions, especially schizophrenia and personality disorders, and substance misuse disorders, are associated with higher rates of suicide and self-harm. There is no one size that fits all solution to these issues.
5.There were 120 self-inflicted deaths in prison in 2016. Seventy per-cent of those who took their own life in prison between 2012 and 2014 were known to have a mental health condition. A substantial proportion of prisoners are also known to self-harm and the number of self-harm incidents amongst prisons has risen significantly. Just over 12% of men in prison and 28% of women in prison self-harm. The number of self-harm incidents in prisons has increased by 73% to 40,161 incidents in 2016, the highest in any year on record. Witnesses agreed that the levels of self-inflicted deaths and self-harm in prisons were appalling and a damning indictment of mental health services within our prison system.
6.Despite the rise in the number of self-inflicted deaths and self-harm incidents, government has no reliable or up to date estimate of the number of prisoners with mental health issues. The mostly commonly used estimate, that 90% of prisoners have mental health issues, is now 20 years old. The Institute of Psychiatry told us that it estimated that over half of prisoners have common mental disorders, including depression, post-traumatic stress disorder and anxiety. It similarly estimated that around 15% of prisoners have specialist mental health needs and around 2% are thought to have acute and serious mental health problems.
7.The Ministry of Justice was not able to tell us the percentage of those currently in prison who have mental health issues. The only figures it has are from a survey 10 years ago which showed that around 50% of prisoners were prone to anxiety, which has not been updated. Prison staff are responsible for screening prisoners when they first arrive in prisons, including a basic screening to identify risks to prisoners on their first day, such as whether an individual is at immediate risk of suicide and self-harm. This is followed by a health screen, which is conducted by a healthcare professional. The reception process for new prisoners can be chaotic and not all prisoners with mental health issues are identified at this stage. Prisoners can be unwilling to admit to mental health issues for fear of negative consequences, for example on their eligibility or conditions for parole. The Institute of Psychiatry told us that the current screening process only detects around a quarter of those that it should, and there is a long way to go before the screening process adequately identifies those it should.
8.HMPPS analyses data from screening by prison officers at a national level, but its information is incomplete as prison staff leave some questions unanswered. The initial assessment conducted by prison officers consists of over 120 questions, most of which are voluntary. 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 collects month-by-month data on the number of prisoners who are being treated for mental illness. It told us that 10% of those in prison were currently receiving treatment for mental health issues. But this only includes those who are currently in treatment. It does not, for example, include those who are waiting for treatment.
9.Prisoners are less able to manage their mental health conditions because most aspects of their day-to-day life are controlled by the prison. A lack of staff within the prison system has meant that the prison regime has become more restrictive and staff are less likely and able to identify prisoners with mental health issues and prisoners are less able to self-refer. Establishing proper one-to-one engagement between prisoners and prison officers is incredibly important to maintaining the mental health of prisoners, partly because prison staff can identify problems and partly because it can prevent prisoners from feeling so isolated and alone. But existing staffing levels have meant that prisoners have less regular contact with prison staff. We were surprised on our visit to Wormwood Scrubs to be told that just seven prison officers were responsible for 300 prisoners across four floors. Prisoners miss an average of 15% of medical appointments, in large part because of a lack of prison staff to move them from the wing to healthcare appointments. In Wormwood Scrubs, we heard that a lack of prison staff means that more than 40% of medical appointments are missed.
10.The Ministry of Justice acknowledged that the level of staffing has been detrimental to the security, stability and order in prisons, including the mental health of prisoners. It told us that it was committed to improving the quality of care provided to prisoners with mental health issues and reducing the number of self-inflicted deaths and incidents of self-harm. As part of this, the Ministry of Justice committed to bringing more prison officers back onto prison wings and establishing more regular one-to-one contract between prisoners and prison staff. HMPPS told us that it was on track to recruit an additional 2,500 prison staff by the end of next year which would mean that it would be able to significantly improve the ratio of prison officers to prisoners from one officer for every 30 prisoners to 1 officer for every 20 prisoners. It told us that it was also introducing a system so that each prisoner had a key worker and each key workers looks after around six prisoners.
11.While the Ministry of Justice and HMPPS’ plans sound promising, we were not yet convinced that they will be enough to improve conditions for prisoners with mental health issues. The Ministry of Justice told us that it had introduced mental health training and training on suicide awareness for all prison staff and that 7,000 members of staff had undergone the training to date. The NAO report, however, found that 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.
12.We were similarly concerned to hear of examples where the loss of prison staff is already outstripping recruitment and the process of recruiting new prison officers and mental health staff can take seven months. Part of the delay is the need to ensure new staff go through security vetting prior to taking up their posts. The Ministry of Justice and HMPPS recognised that retention of prison officers has been a problem, particularly in areas of the country where the labour market is buoyant, and that it taken too long to recruit new staff. They told us that they were confident that they were improving prison retention and that recruitment of new staff would outstrip resignations. They asserted that the recruitment of new staff has been a particular success, with 1,290 additional prison officers now in place compared to October 2016.
13.The physical prison environment is important to ensuring both the mental health and well-being of prisoners and that services designed to support this are delivered. This is made more difficult by the fact that the majority of the prison estate was not built to provide healthcare. Over a quarter was built before 1900 and some of the newer buildings were not designed with modern healthcare in mind. Much of our prison environment is out of date and need to be upgraded. HMPPS told us that it was working to ensure that new prisons are designed based on international best practice and engagement with external organisations to mitigate mental health issues and promote wellbeing. HMPPS has planning permission for three sites at present: the former prison at Glen Parva; a site at Wellingborough; and a site at Full Sutton. It told us that it has worked with the Royal College of Psychiatrists to develop better environments in prisons for those with personality disorders and has committed £40 million to fund this initiative in prisons and communities.
14.The increase in self-inflicted deaths and self-harm incidents in prisons is also attributable in part to the use of drugs in prison. Drug use in prison is a serious issue and can severely compromise prisoners’ mental health. The number of drug seizures in prisons has risen from 2,500 in 2015 to just over 10,500 in 2016. Prisoners can gain access to drugs in a range of ways, including through them being brought in by visitors, put in correspondence, being thrown over prison walls or being flown in by drones.
15.There has been a huge switch in drug use amongst prisoners towards new psychoactive substances (also known as Spice) which existing detection and treatment programmes were not designed to address. These have changed the nature of how prisoners behave when under the influence of drugs and are a very real danger to both prisoners and prison staff. 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. Figures for the first half of 2017 show that there have already been 1,600 seizures of Spice in prison. Psychoactive substances such as Spice were originally classed as legal and relatively easily accessible in the community and consequently in prisons.
16.HMPPS accepted that it took some time to be able to address the challenge posed by psychoactive substances in prison, but that the increase in the number of drug seizures was in part due to better detection methods. It told us that it was working with law enforcement agencies to disrupt supply routes and ensure prisoners have access education and treatment programmes. Testing for psychoactive substances can be difficult and HMPPS did not initially have a test that could detect them. It told us that it now had a test in place and that it was the first law enforcement agency in the world to train dogs to detect psychoactive substances.
1 C&AG’s Report, , Session 2017–19, HC 42, 29 June 2017
2 , paras 4, 1.9
3 Qq.73, 86, 119–120, Q 124, paras 4, 1.11
4 Qq 1–3, 6, 175–176, Royal College of Psychiatrists (), paras 1, 1.3, 1.5
5 Qq 45, 58, 60, 67, paras 2, 1.6–1.7
6 Q 2, para 1.3
7 Q 2–3, 6, 82–84, 99–101, 107, British Medical Association ()
8 Qq 6, 9, 79–81, 130, paras 9, 1.4, 3.10
9 Qq 5–6, 29, 61, 72, 85–86, paras 1, 3.24
10 Qq 61, 72, 106
11 Q 61, para 3.21
12 Qq 72, 100, 108, 110, 112, 114, 117–118
13 Qq 33, 138–140, para 3.4
14 Qq 27–28, 52, 54–57
15 Qq 27, 52
16 Qq 52–53
11 December 2017