6.There is no clear picture of the extent or nature of mental ill health in prisons, nor on how much is spent on treatment and whether the money is well spent. The head of the National Audit Office, when it reported on mental health in prisons in 2017, said:
The data on how many people in prison have mental health problems and how much government is spending to address this is poor. Consequently government do not know the base they are starting from, what they need to improve, or how realistic it is for them to meet their objectives. Without this understanding it is hard to see how government can be achieving value for money.
7.The Ministry of Justice admitted that it had little information on the extent of mental illness in prisons:
We do not have a complete understanding of the overall prevalence of mental health needs of prisoners, due to the cessation of NHS health and justice indicators of performance. In addition, prisoners can experience mental health issues at any time during their sentence but we only systematically assess need at reception into prison.
8.It went on to say that understanding the extent of the need for mental healthcare was clouded by a lack of a clear definition, prisoners’ complex needs and incompatible IT systems.
9.The Department for Health and Social Care and NHS England and NHS Improvement (NHSE/I) jointly said a ‘needs analysis’ is being carried out for them (by the Centre for Mental Health) to help them to understand mental health and neurodiverse prevalence in prison:
with the aim of providing comprehensive diagnostic and socio-demographic profiles of the mental health, psychological, trauma and emotional wellbeing caseloads in each prison. This covers all services commissioned by NHSE/I and includes services with personality disorder and neurodiverse caseloads (e.g. services for people with learning disabilities, autism, speech and language difficulties, ADHD, acquired brain injury).
10.The Centre for Mental Health published a report on 25 June 2021 covering the first part of this work which covered the themes and findings from consultation and a literature review carried out over the summer of 2020. In that publication it said:
This review was the first part of a two-stage process. NHS England and NHS Improvement has also commissioned Centre for Mental Health to conduct a mental health needs analysis across the English prison estate which will quantify the levels of service provided, need and (where possible) unmet need.
11.In this first report the Centre for Mental Health said that much progress had been made in the 15 years that it has been reviewing this mental healthcare in prisons but that problems remain that “have been known and consistently reported for the last two decades.”
12.Kate Davies, Director for Health and Justice at NHS England, told us that the NHS conducts yearly audits of mental health needs in prison, but this did not take place in 2020 because of the covid-19 pandemic. The only NHS audit relating to prisoners’ mental health that has been published was in 2017 and only covered prisoners waiting for assessment and transfer under the Mental Health Act 1983.
13.Even without up-to-date NHS data it is clear from the evidence submitted to this inquiry that a significant proportion of prisoners have a mental illness and this is often combined with other difficulties. HM Inspectorate of Prisons reported that 71% of women and 47% of men surveyed by inspectors in prison self-reported having mental health problems.
14.The Centre for Mental Health has summarised the existing research, (all of which is more than five years old and some much older), on the prevalence of mental health diagnoses and other vulnerabilities:
Most prisoners experience more than one vulnerability… 70% of prisoners meet the criteria for two or more diagnoses. With the single possible exception of autism, all of the vulnerabilities […] have a prevalence rate in prison very much higher than in the general population. Additionally, the experience of trauma and adverse childhood experiences is very common amongst prisoners […] It is therefore reasonable to state that by default, prisoners are vulnerable and have multiple and complex needs.
15.Kate Davies told us that:
70% of our men and women at any one time will have a need around mental health, which might be exacerbated when they have been in prison for days, weeks or months.
16.Evidence from HM Inspectorate of Prisons was that prison mental health treatment was not always adequate to meet the need for it. It set out some of the reasons for this:
Prior to the COVID-19 pandemic, although inspectors found effective mental health support and services in some prisons, overall inspectors found that prisoners had inadequate access to mental health treatment at approximately half the adult male prisons inspected in both the 2018–19 and 2019–20 reporting years. Provision was not adequate to meet the high levels of need in some women’s prisons. Inspections identified various reasons […] including inadequate service specification, chronic recruitment and retention issues, inadequate staff supervision, difficulties accessing patients due to the restrictions of the prison regime and a lack of suitable therapeutic spaces in which to offer services.
17.A serving prisoner who is the Listener coordinator (peer support, trained by the Samaritans), Healthcare Rep, and Healthcare Council Member (for charity Uservoice) on the Albany site of HMP Isle of Wight, wrote to tell us of his experience:
The scale of mental health issues in prisons is colossal, far bigger and worse than anyone can comprehend or wants to admit. There is nowhere near enough in place to determine the scale of the problem. The current self-referral process is not fit for purpose. People with genuine problems either don’t want to burden mental health staff after hearing how overworked they are or have no faith in the staff or the system.
18.Another prisoner told us: “In the community I had a CPN [Community Psychiatric Nurse] with regular contact and a prescriber when I needed my medications changing. Inside, it seems to be the person who shout the loudest gets the psychiatrist and/or medications!”
19.In its 2017 report, the National Audit Office said that NHS England collected information on the number of prisoners in treatment for mental illness, which at that time was 10% of the prison population in England. It added “there may be more people in treatment who are not captured in these data”.
20.While there have been improvements in prison mental healthcare, provision is still not adequate. The high unmet need for treatment for mental illness in prisons is surprising and disappointing. Around 10% of prisoners were recorded as receiving treatment for mental illness with one suggestion that as many as 70% may have some form of mental health need at any one time. NHS work is long overdue to quantify the gap between mental health treatment needs and the services provided.
21.The NHS should use its prison mental health treatment ‘needs analysis’ to quantify shortfalls in mental health services, make plans and allocate resources so mental healthcare in prisons is at least equivalent to services outside prisons, having taken account of the specific needs of the prison population.
6 National Audit Office, , webpage accessed 13 July 2021
7 Ministry of Justice ()
8 Ministry of Justice ()
9 Department of Health and Social Care ()
10 Centre for Mental Health, The future of prison mental health care in England, June 2021
11 Ibid p 4
12 Ibid p 7
14 The 2017 NHS Benchmarking Audit of Prisoner s waiting for MHA assessment, transfer and remissions, , 2018, webpage accessed 26 July 2021
15 For example, learning disabilities, autism, speech and language difficulties, ADHD, acquired brain injury and substance abuse
16 HM Chief Inspector of Prisons annual report: 2019 to 2020, October 2020
17 Centre for Mental Health, The future of prison mental health care in England, June 2021
19 HMI Prisons ()