1.Care UK is the prime contractor for prison healthcare and subcontract provision of mental healthcare to Barnett, Enfield and Haringey NNHS Trust and Forward (previously RAPT).
2.The mental health team provides a wide range of primary and secondary services including, one-to-one psychology service, occupational therapy, psychological education (anger management coping skills etc.), speech and language therapy, and a specialist learning disabilities service and day care, which provides meaningful activity for those who don’t engage with education or employment.
3.There is also a 17-bed in-patient facility, although five of these beds are in a dormitory so can rarely be used given the nature of the patients that need them. The inpatient unit deals with mental health, physical health and end of life care.
4.The prison is operating a limited regime on one wing due to prison officer shortages. The rate of recruitment is not matching loss of experienced staff. Pay is a barrier given London’s job market.
5.There are similar shortages of healthcare staff and concerns about time taken to on-board staff, given security clearance requirements (DBS and then prison service screening), which can take 5–7 months. The example was given of a nurse recruited to fill a vacancy that existed since September 2016, who was due to start in April 2017, but pulled out given extended delays. The result is that best recruits get poached. Security clearance must be refreshed every three years but no priority is given to new recruits.
6.NHS has commissioned training and support that can be used for prison officers to improve their mental health awareness but there are challenges in releasing officers for enough time to undertake training. The prison recently had no regime for one day to deliver mandatory training on suicide, self-harm and restraint.
7.The prison’s healthcare team operate a triage system with two tiers of screening followed by a full, on-wing assessment by the Mental Health In-reach team for those with identified mental health issues. The screening suggests around 70% of men have an underlying mental health need (compared to 10% who are receiving treatment across the whole prison system). The team does not cross-refer to other services but provides wrap-around care by drawing in other services through triage meetings three times a week.
8.Information received from community healthcare is variable. Community and prison IT systems don’t link up (plans to link to community SPINE are still in progress but mental health info often not on SPINE) so prison healthcare staff have to chase information. Some community trusts are slow to cooperate or demand payment upfront for letters (£25 per letter, paid out of prison healthcare budget). Result is that investment in building patient information asset is wasted. This is a particular challenge for the scrubs given high churn in prisoners.
9.Ensuring continuity of care is very challenging as there is often no notice of when a prisoner is being released. If their case is discontinued they can leave immediately even though they may have significant mental health needs. If they are released on licence, the Community Rehabilitation Company oversees them but may have had very little notice to establish support.
10.This is a particular issue for prisoners with learning disabilities. The threshold for care in the community is much higher due to limited resources so social services will not support many of the prisoners released. They quickly end up back in prison.
11.Links with social services need to be improved. An example was given of an older prisoner who had had a series of mini strokes that led to reduced cognitive function. His sentence finished last November but he is still in prison because the CRC can’t find him accommodation through social services. He is too young to go into elderly care. Another example was given of an 80 year old prisoner convicted of arson who now had dementia. He couldn’t find accommodation after his sentence was completed as he was deemed too high risk because of his background.
12.There are problems getting patients transferred into secure hospitals because of a shortage of secure beds in the community. One current prisoner has been waiting for a secure bed since June and his condition is worsening. He is Psychotic and refuses his medication. The prison healthcare staff cannot compel him to take it but staff in a secure hospital could. An example of a prisoner in Brixton who waited 20 months was also given. He got progressively more unwell over this time, self-harming and even pouring boiling water over himself.
13.This may worsen under the ‘new models of care’ initiative which is bringing regional commissioners together to identify ways to provide new community mental health provision. The consequence will be fewer beds in medium secure settings. As well as making transfers out of prison harder, this could potentially increase the flow of severely mentally unwell people into prison.
14.Although prison presents an opportunity to address complex needs of a vulnerable group of people, the environment is detrimental to mental health and well-being, increasing the challenge. There are ways for the environment to be more psychologically informed; Feltham has certain rooms that are accredited as autism friendly and HMP Aylesbury has had some success bidding for funding for enabling environments through the Offender Personality Disorder funding pot. This is good but funding is limited so it only allows change on a very small scale. PIPEs (Psychologically informed planned environments) are also well regarded. These examples are the exceptions not the norm.
15.The Prison Estate Transformation Programme presents an opportunity to address this in new build prisons. Netherlands, where focus is on rehabilitation, does this very well. HMP Grenden was given as an example of a true therapeutic community, with a rehabilitative focus and had received the best HM Inspectorate of Prisons rating possible. It serves a particular type of offender though and would not be suitable for all.
16.Her Majesty’s Prison and Probation Service is rolling out training on ‘rehabilitative culture’ that is a watered down version of having an enabling environment. It is intended to be cost neutral and there are some concerns about whether it will make a difference. The prison environment cannot be changed cheaply.
11 December 2017