22.Healthcare services can be fragmented between a range of public and private providers offering primary or secondary care, physical or mental healthcare or combinations of all or any of these alongside substance abuse services. Practice Plus Group said that the split can result in people receiving no care:
In a primary / secondary split a patient may not be sufficiently ‘serious’ for secondary care even though their complexity means a primary care team may not have the right skills and resources. Sadly this can result in people receiving no care and this is a theme seen in deaths in custody.
23.A serving prisoner told us how this happens in practice:
I see people every day with deep-rooted issues like complex PTSD, who only have a CBT [cognitive behavioural therapy] practitioner for support, even then they keep getting pushed off of mental health’s books. “I can’t give you the help you need, the only person who can help you does not have time to see you”.
24.Juliet Lyon, Chair of the Independent Advisory panel on Deaths in Custody told us another drawback of complex commissioning arrangements was communication failures:
The complexities of having so many different commissioning arrangements seem to make it very difficult to communicate and pass on information. From the IAPDC perspective, we know that is one of the main risks. If clear information is not passed on, that is when you can have somebody failing to pick up on suicide risk. It is really important that we get this right.
25.We also heard concerns about how the commissioning process can affect the quality of healthcare services. The Royal College of Psychiatrists, for example, said:
The competitive tendering process for awarding healthcare contracts in prison has not had the desired effect of improving the quality of services. It is our experience that too often the main criterion for awarding contracts is cost, to the detriment of clinical quality and sustainability.
26.Healthcare services can be fragmented, meaning people receive no or inadequate care. NHS England and NHS Improvement should set out how they intend to bridge existing gaps in care and resolve the problems that result from fragmented service provision to ensure that all patients receive access to appropriate and adequate care.
27.Cost and quality are essential criteria on which to assess bid submissions in procurement processes. All commissioned services need to be cost effective and provide value for money, but cost should not be prioritised at the expense of quality. NHS England should set out how they balance cost and quality criteria when procuring services.
28.NHS England’s national specification for prison mental healthcare outlines that all prisons should provide an integrated model, with self-help at the bottom step and specialist mental health services for those with marked mental illness at the top but the evidence is that this is not a reality in many prisons. The Centre for Mental Health (CMH) in its work for the NHS has found that:
Integrated mental health services were very limited in their offer to people who did not meet the criteria for secondary mental health care, […] (typically little or no psychological intervention).
29.CMH also found large disparities in what is provided across the English prison estate. “We found variation of mental health provision even within a single provider across different establishments.”
30.Integrated care is an NHS concept where barriers within the healthcare system are broken down so that primary and secondary, mental and physical care can be delivered seamlessly in a patient-centred way. Within the prison sector there is another related but separate concept known as the ‘whole prison approach’. The Ministry of Justice, the Department for Health and Social Care, HMPPS, NHS England and Public Health England have committed to the ‘whole prison approach in their national partnership agreement, where it is described as an “approach to health and wellbeing that ensures that regime, activities and staffing facilitate an environment that promotes good health and wellbeing and reduces violence for all prisoners, including those with protected characteristics”.
31.Practice Plus Group, while recognising that the purpose of imprisonment is to punish as well as rehabilitate, described for us the range of issues that need to be addressed if a ‘whole prison approach’ is to be effective in promoting mental health and well-being:
Prisons are intended to punish. The emphasis in the wider prison system on rehabilitation only partially mitigates the impact of this inherently detrimental environment and doesn’t yet deal effectively with less intended and controlled factors such as a lack of personal safety, exposure to widespread drug misuse, ageing and inappropriate buildings, the lack of meaningful work and, often, uncertainty over sentencing and opportunities for release.
Our experience is that those presenting with mental health deterioration often report ‘prison issues’ as at least part of the cause [...]
32.The Prisoner Governors’ Association also described ‘prison issues’:
Prisons are loud, unsafe places for vulnerable people who are often targeted by more confident and bullish prisoners. They are awash with drugs and the associated bullying and taxing of this illicit trade. Staffing levels are inadequate to supervise large numbers of unlocked prisoners resulting in those at risk or in crisis being missed in the melee of day to day prison life.
33.Some prisons are safe, secure, and respectful environments that support inmates to progress towards release. For example, HM Inspectorate of Prisons’ reports show that ‘prison issues’ such as illicit drugs, debt, threat, violence and disrespect are managed effectively at Warren Hill and Grendon. Both these prisons house prisoners on long sentences for serious crimes. Prisons with continual ‘churn’, such as the major local prisons, face other challenges.
34.There are initiatives within HMPPS and the Youth Custody Service that seek to adopt a ‘whole prisons approach’, for example the ‘trauma-informed approach’ for women prisoners, ‘SECURESTAIRS’ for children and young people, and in specialist units for some prisoners with personality disorders and other serious psychiatric problems.
35.The Ministry of Justice’s 2018 Female Offender Strategy set out that women in prison were twice as likely as male prisoners to report mental health problems. The strategy contains commitments to adopting a trauma-informed approach in women’s prisons taking account of the very many women prisoners who are victims of abuse. The trauma-informed approach is only beginning to be introduced in women’s prisons. We are currently conducting a separate inquiry into women in prison that will look in depth at the issues relating to women prisoners and what progress has been made with the Female Offender Strategy.
36.We have previously reported on children and young people in custody. In those reports we welcomed the fact that the Youth Custody Service, NHS England and NHS Improvement were working to improve mental health and emotional wellbeing services across the youth estate with the ‘SECURESTAIRS’ framework. The Ministry of Justice submitted evidence that “SECURE STAIRS is a psychologically informed, trauma-based framework for integrated care that creates a single plan around the child. It is based on the idea that “every interaction matters” and input from every member of staff is fundamental. It is focused on the child’s story, not on their diagnosis, offence, or other label.” In evidence to that inquiry Barnado’s said that their workers see increasing cases involving children with mental health needs and that: “At the current time custody often acts as a barrier to obtaining appropriate mental health support for young people.” With the exception of Oakhill, all 19 secure children’s home, secure training centres and youth offender institutions are eligible for SECURESTAIRS programmes. More than 600 staff have been trained, and staff have been fully recruited to more than half those institutions.
37.In 2011, the NHS and HMPPS jointly introduced a new Offender Personality Disorder (OPD) pathway. According to the Centre for Mental Health (CMH) around 1,700 prisoners are ‘receiving interventions’ under OPD with most of them participating in intensive treatment programmes often in specialist units. These include ‘Therapeutic Communities’ and ‘Psychologically Informed Planned Environments’ that are based around a whole prison approach. However, the CMH reported concerns that lower risk prisoners with less severe personality disorders were not receiving appropriate treatment:
Many prisoners who pose low or moderate risk will also have personality disorder and most will receive little or no intervention and will be managed by staff who are often not adequately trained for this task.
38.Initiatives such as integrated healthcare, the trauma-informed approach in the women’s estate, SECURESTAIRS in the youth estate, and the intensive programmes used on the Offender Personality Disorder pathway, are all welcome as far as they go. The comparatively few such services as yet provided within the youth estate have been relatively recently introduced.
39.The NHS should expand on its work to commission integrated healthcare across all three estates so that prisoners can access proper physical and mental healthcare services at primary and secondary level as appropriate and without undue delay.
40.As the covid-19 restrictions in prisons are released, HMPPS (including the Youth Custody Service), should have plans ready for how it will reinvigorate its measures to control unwelcome and unintended issues such as substance abuse and violence in prisons.
22 Practice Plus Group is commissioned to provide healthcare including mental health in over 50 prisons in England
23 Practice Plus Group ()
26 Royal College of Psychiatrists ()
27 Centre for Mental Health, The future of prison mental health care in England, June 2021, p 16
28 Ibid p 16
29 , p 9
30 Practice Plus Group ()
31 Prison Governors Association ()
35 Justice Committee, , accessed 15 July 2021
36 Children and Young People in Custody (part 2): The Youth Secure Estate and Resettlement, Sixteenth Report of Session 2019–21, HC 922, February 2021, pp 12–16. See also Children and Young People in Custody (part 1): Entry into the youth justice system, Twelfth Report of Session 2019–21, HC 306, November 2020
37 Ibid, p 14
39 Centre for Mental Health, The future of prison mental health care in England: A national consultation and review, June 2021, p 34