2Continuity of care and oversight
Co-ordinating and planning mental health services for prisoners
17.Many prisoners move in and out of prison, or between prisons, which makes the job of providing healthcare more difficult. Sharing information about a patient’s medical history with health bodies who have also treated the patient is crucial to ensuring that they receive the treatment that they need. Despite this, there is a clear disconnect between the information available to healthcare providers on the care patients have received before, during and after their time in prison. We heard that currently many prisoners arrive in prison without an accompanying medical history, which slows down and reduces the accuracy of their initial assessment, meaning that this first opportunity to provide someone with the type of support they need may be missed. The British Medical Association told us that without access to medical records, prison GPs might prescribe medication without the patient’s history of pre-existing conditions or drug use, including whether they have a history of overdose.17
18.Healthcare records for prisoners appear to follow patients through their mental health journey in very few cases. The NHS IT system within prisons is unable to ‘talk to’ the NHS IT system in the community. It is difficult to see how treatment can be effective if this is the case. We were concerned that this lack of continuity of information makes mental health services almost inaccessible for some patients and risks worsening prisoners’ mental health conditions and undermining their rehabilitation. We heard from the Royal College of Psychiatrists, which told us that access to specialist mental health services for prisoners is inadequate and is getting worse.18
19.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. It has signed a contract to deliver a single IT system, which will bring together health records from before a prisoner enters prison and during their time in prison, with prison records, so that all information about a prisoner is held in a single place. It told us that the new IT system would start to roll-out across the prison estate in November 2017 and would be everywhere within 12–24 months.19
20.Dementia is a growing problem within prisons. The fastest growth in the number of prisoners has been among prisoners aged over 50. Dementia Access Alliance told us that there are currently 10,000 prisoners over the age of 60 and that this number is set to increase unless there are major changes in sentencing trends.20 As the number of older prisoners rises, so too will the prevalence of dementia among prisoners. Despite this, there is currently no national strategy for prisoners with dementia. We were also concerned to hear at Wormwood Scrubs, and from our constituencies, of a revolving door in prison for people with speech and language issues, learning disabilities and autism. NHS England told us that it was increasing the amount that it spends on mental health services, and that spending in this area was going up at a faster rate than the overall NHS budget. It told us that this would be used to expand the range of services available for people with the issues described.
21.Issues with security and resources mean that referring a prisoner to an external specialist or hospital can be complicated and time consuming. The British Medical Association told us that its members say that individuals experiencing a serious mental health crisis will frequently be placed on bed watch, with a member of prison staff there to observe and ensure that they do not attempt suicide or self-harm, but unable to provide therapeutic or clinical support. 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, 1,081 mentally ill prisoners in England were transferred to secure hospital. Some two-thirds of these waited longer than 14 days to be transferred and 7% waited more than 140 days. We were told of examples where prisoners had waited over a year to be transferred to a secure hospital and, in one case, over 20 months. We were similarly concerned to hear from witnesses of examples of a lack of regional and national coordination in transferring prisoners to secure hospitals which means that patients become stuck in a cyclical loop of rejected referrals. Delays in being transferred to secure hospitals can have a substantial negative impact on the mental health and well-being of prisoners. It is unacceptable 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. If the number of self-inflicted deaths and self-harm incidents was not already an indictment of poor performance, this is also a disgrace.21
22.NHS England is responsible for ensuring that the 14 day target is met as part of its responsibility for both health services in prison and for commissioning high, medium and low secure psychiatric services. In the first six months of 2017–18, 305 patients who were transferred to a secure hospital waited longer than 14 days. In 16 cases, the patient had to wait over 140 days to be transferred. While unacceptable performance, this under reports the true extent of how long patients are being forced to wait for treatment because it does not include 220 people NHS England told us are currently waiting. NHS England do not know how long these 220 people have waited so far. NHS England told us that the 14 day target is currently being reviewed by clinicians to determine whether a single target is still the most appropriate to meet the needs of patients or if a more nuanced target is needed. If clinicians decide a more nuanced target is appropriate, it will be essential that NHS England makes sure that enough data is available to track progress against the 14 day target and compare results.22
23.NHS England accepted prisoners needing treatment should be transferred much more quickly than is currently the case. It told us that it had undertaken work to better understand the process for transferring prisoners to secure hospital and identifying blocks in the process as part of wider work examining the care provided to patients in prisons. In particular, it told us that it was reviewing where there are gaps and need in mental health beds in low, medium and high secure units for those who have an assessment under the Mental Health Act. This is the second time that NHS England has undertaken such a review, which is due to complete by the end of the year. Given it is being conducted so rapidly, there is a risk that the new review could repeat the work of the first review and we will await the results to form a view on whether it is sufficient to address the problems identified.23
NHS England’s oversight of mental health services in prisons
24.As part of its responsibilities for health services in prisons, NHS England is responsible for ensuring that its contracts with private providers deliver value for money and the services required are delivered. In 2016–17, NHS England spent £400 million providing healthcare in adult prisons in England, of which it estimates £150 million was spent on mental health and substance misuse services (including pharmacy costs). It was not able to provide this figure at the time of the National Audit Office’s (NAO) report, but subsequently conducted a survey of providers of mental healthcare in prisons to produce the estimate. NHS England could not provide an exact figure as three-quarters of its contracts for healthcare in prisons rely on a single provider model, so costs are based on best estimates and historical figures. While it provided us with a list of the indicators it uses to monitor the performance of private providers contracted to deliver healthcare in prisons, NHS England does not monitor the quality of mental health care delivered by private providers, or the outcomes these services achieve.24
25.The NAO’s 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. In one of the cases highlighted by the NAO, NHS England had continued to pay a provider in full even though it had not provided a psychiatrist in line with the service specifications. NHS England asserted that in some cases of recruitment issues, alternative staff are put in place and it would be inappropriate to cut health services and funding for that period of time. It agreed to review the examples of service failure highlighted by the NAO to ensure that they related to isolated smaller issues with payment of services and discrepancies in the recoupment of costs rather than a systemic failure to manage and oversee these contracts properly. NHS England subsequently told us that the two cases, which related to HMP Gartree and HMYOI Glen Parva, were the result of personnel changes and a lower prisoner population respectively. It did not however, provide a convincing response to why it had continued to pay for these services in full when they were not being delivered. NHS England also told us of a different case, at HMP Downview, where HMPPS had changed the prison from a male prison to a female prison and NHS England continued to procure healthcare services during the interim to ensure continuity of service.25
26.It was not clear during our evidence session what action, if any, NHS England takes in response to providers who are found to have contributed to a death in custody. We heard of an example in Chemlsford prison where financial considerations resulted in the healthcare provider downgrading the service provided to a prisoner who subsequently took their own life in prison. NHS England confirmed that the provider in question was no longer contracted to provide healthcare at HMP Chelmsford, but that it does hold other prison contracts within the NHS. 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. It subsequently told us that there have been five instances since 2013 where failures in the provision of mental or physical healthcare, or the downgrading of services, have been referred to in the coroner’s verdict as contributing factors to an individual taking their own life. Any death as a result of such circumstances is entirely unacceptable. Taxpayers’ money should not be wasted on services that are not being received or are being delivered to a lower quality than required.26
17 Qq 11–12, British Medical Association (MHP0005), C&AG’s Report para 1
19 Qq 73, 75, 100
20 Qq 131–132, 187–189, Dementia Access Alliance (MHP0002), Royal College of Psychiatrists (MHP0006)
21 Qq 38–40, 142–149, 206, British Medical Association (MHP0005), C&AG’s Report para 3.35, NHS England (MHP0008)
22 Qq 142–146, 157–164, 177, NHS England (MHP008)
23 Qq 148–151, 153–156
24 Q 52, 168–170, 172, 176, 198, C&AG’s Report paras 9, 2.22, NHS England (MHP0008)
25 Qq 194–195, 197, C&AG’s Report para 2.27, NHS England (MHP0008)
11 December 2017