41.Sentencers can be faced with offenders who have a multitude of problems including mental illness but who are not so acutely mentally ill that treatment in hospital is required. The circumstances of their offences may be such that a community order would be an option if combined with treatment for their mental illness. To this end, Mental Health Treatment Requirement orders were introduced in 2005, but make up only 1% of community sentences. The Ministry of Justice accepts that these orders have been under-used and is committed to increasing the availability of community sentences with treatment requirements. In its ‘A Smarter Approach to Sentencing’ white paper it says:
In the past the use of the existing treatment options available under a community sentence has been low. We, in partnership with the NHS, are increasing the availability and usage of Community Sentence Treatment Requirements (CSTRs), to deliver tailored interventions and support rehabilitation of those with a range of treatment needs.
42.Alex Chalk, then the Prisons Minister, told us: “We have a target to increase the number of CSTRs [Community Sentence Treatment Requirements] with a mental health treatment requirement to cover 50% of England and Wales by 2023, and we want to go further still.”
43.Too many offenders are imprisoned because community orders with mental health treatment requirements are unavailable in many areas. The Government’s target that community orders with mental health treatment requirements should be available across 50% of England and Wales by 2023 is insufficiently ambitious. It is unacceptable that in many parts of the country and for years to come, sentencers will continue to be obliged to send offenders to prisons simply because appropriate community sentences are unavailable.
44.The MoJ and the NHS should accelerate plans to increase the availability of Community Sentence Treatment Requirement orders, so these orders are available options for sentencers in all parts of England and Wales by 31 March 2023.
45.Arrival in prison, whether for the first time or not, is a dangerous point for prisoners’ mental health with concomitant risks of self-harm and suicide. This area has seen improvements: for example, since 2018 the NHS contract has required healthcare providers to carry out first-day screening for all prisoners arriving in prison. The current NHS service specification also includes a follow-up assessment within seven days of arrival.
46.Kate Davies, Director for Health and Justice at NHS England, told us how important the first night and seven-day follow-up screening is:
It is quite often when men and women go back to their cell, they are in custody for the first time or they may be in custody on repeated occasions, that their drug misuse may well decline or change or become more chaotic. Their own anxieties, their own needs around medication and psychosis then come to the fore, so those two elements are absolutely essential.”
47.A serving prisoner wrote to us about difficulties identifying mental health problems at the initial screening:
The self-referral process involved in identifying mental health problems on initial reception to prison is not fit for purpose. First time prisoners are generally in a complete daze, or on auto-pilot upon initial reception to prison. It takes time for people to build up the confidence to talk about their ailing mental health, let alone self-refer to the mental health team.
48.Kate Davies told us that not all prisoners are screened on arrival and that that a smaller proportion of Black, Asian and other Minority Ethnic prisoners get their follow-up health assessment than do white counterparts: “We know that 92% of men and women in the adult estate receive their first-day screening. Of course, we want 100%. It decreases a little on their second screening appointment,
… for second screening [it] is 65% for black and minority men and women and 73% for our white patients.
49.Lower levels of screening for Black, Asian, and other Minority Ethnic prisoners are especially concerning given that the Lammy Review demonstrated that Black, Asian and Minority Ethic individuals are less likely to be identified with problems such as learning difficulties or mental health concerns on reception at prison than other prisoners. Kate Davies told us: “It is very important that we identify where those outliers [prisons with lower screening rates for Black, Asian and other Minority Ethnic prisoners] are.” It was clear that this work was still to be done.
50.The Royal College of GPs submitted evidence about the levels of training of staff carrying out assessments:
At present, there is a competitive tendering process for contracts and considerable operational variation across UK prisons as a result. First night and secondary screening assessments are undertaken mainly by primary care nurses or health care support workers under the supervision of a primary care nurse. These healthcare practitioners have variable experience in mental health and there is no consistent requirement for mental health training for the workforce in prisons. Additionally, officers at a third of prisons inspected in 2019 had not undertaken adequate mental health awareness training. It is therefore possible that men and women coming into prison with mental health issues are not being picked up either through the health entry screening processes or by prison staff…
51.It is unacceptable that one in 12 prisoners do not have a health screening appointment within 24 hours of arrival and that Black, Asian, and other Minority Ethnic prisoners who have a mental health condition are less likely to have that identified than their white counterparts.
52.The NHS should identify why some establishments have difficulties screening prisoners within 24 hours of arrival and should put in place action plans with the healthcare providers at those establishments to remedy this.
53.The NHS should review its mental health services specification so that mental health screening is always carried out by a competent mental health professional with experience of the criminal justice system.
55.Prisoners may not disclose a mental health issue on arrival or prisoners’ mental health may deteriorate while they are in prison. The Royal College of GPs submitted evidence about the importance of prison staff in identifying prisoners with mental health issues and directing them to mental health services:
While in prison, mental health issues may be identified through behavioural observations by staff and healthcare teams on the wings and by self-reporting of problems by patients. Training of staff is essential to enable timely identification of mental health issues. Additionally, there needs to be reduced stigmatisation of vulnerability and accessible information about mental health services and the range of available support from mental health teams, prison chaplaincy, prison key workers and peer support workers. At present, information is frequently inaccessible to people with lower literacy skills, language barriers and neurodiversity issues which can leave them without a clear understanding of how they can be supported while in prison.
56.Prison officers on residential wings receive introductory training about mental health as part of key-worker training. The prison officer key worker initiative is promising but given the scale of mental ill health in prisons greater expertise would be valuable. Alex Chalk, then the Prisons Minister, told us that training is important but so too is experience:
One of the most effective tools at your disposal is someone providing a bit of common sense and experience […] being able to spot those warning signals, having the judgment to know when they need to refer someone to treatment, when, in fact, it just requires that sensitive and humane conversation. […] I see holding on to prison officers, allowing them to develop that experience […] is so important in providing some of that immediate interface with people who are very often extremely complex, sometimes very damaged and potentially in need of mental health support.
57.The Prison Officers Association told us that mental illness was increasing in prisons and called for better training for prison officers:
The crisis of mental health in our prisons has intensified in recent years, with rising numbers of prisoners suffering from a variety of conditions, ranging from depression to serious personality disorders. An aging prison population is also causing an increase in dementia. With mental health problems getting worse, it is more important than ever that prison officers receive adequate training to support the mental health of all those in their care.
58.MIND in Camden described the impact that the training it provides can have:
In a follow-up meeting after training, the officer told us […] he was able to support a young man who had made attempts to take his own life. The officer was honest in saying that previously he would have said the man was ‘just showing attention seeking behaviour’ […] The detainee stabilised and upon release, told the prison officer ‘you saved my life that time, truly’.
[…] immediate listening humanises the individual’s distress, referrals can take a long time and many are refused. It also increases prison officers’ confidence and job satisfaction, plus frees up overly stretched mental health services […] The officer said he’s used what we taught him many times, and since has been given an award from the prison recognising his achievements.
59.With respect to becoming mentally ill in prison, there are particular concerns about the effect of the (now defunct) Indeterminate Sentences for Public Protection on the mental health of those subject to them. Several serving prisoners wrote to us about the impact that not having a parole date had on their mental health and their difficulties accessing the treatment programmes they needed to complete in order to reduce their risk to the public, leaving them feeling without hope. The Committee will follow this Report with an inquiry into IPP prisoners during the remainder of 2021.
60.The Parole Board set out how unidentified mental illness can hamper and delay its decisions: “All too often, mental health concerns are identified far too late in the parole process, which makes it very difficult to put in place measures to support the prisoner to engage meaningfully in their parole review, and can cause delays.”
61.Prison officers and other operational staff play a vital role in identifying and supporting prisoners who need mental healthcare and signposting prisoners to this treatment. Having the time to talk to and listen to prisoners is a key part of this, particularly those with difficulties absorbing written information due to poor literacy, language barriers, or neuro-difficulties. We agree with the Prisons Minister that experience should complement, not substitute training.
62.HMPPS should (with the Royal Colleges and other experts in the field of prison mental healthcare) develop training for prison officers and other operational staff on how to identify mental illness and how to support and signpost prisoners to treatment. It should establish regular refresher training.
63.HMPPS responded to the covid-19 pandemic by severely restricting social contact for prisoners among themselves, among those working in prison, and with friends and family. Prisoners were largely confined to their cells 23 hours a day, seven days a week and face-to-face visits from family and friends ended. Access to work, education, rehabilitative courses, the chapel, the gym, and library almost all stopped. This undoubtedly saved lives but has taken a toll on prisoners’ mental health. HM Inspectorate of Prisons reported in February 2021
The most disturbing effect of the restrictions was the decline in prisoners’ emotional, psychological and physical well-being … In our fieldwork we saw a sense of hopelessness and helplessness becoming engrained… The cumulative effect of such prolonged and severe restrictions on prisoners’ mental health and well-being is profound.
64.Women prisoners have been particularly affected by a lack of contact with supportive fellow-prisoners and not seeing their families. Male prisoners reported some decrease in anxiety at the beginning of the ‘lockdown’ due to a reduction in issues such as bullying, and a sense of the restrictions being necessary and for their own protection. One prisoner who wrote to us said “The only saving grace has been that we understand that for once, whether in person or the community we are all in the same boat.” However, prisoners across the male, female and children and young people’s estates report feeling worse as time has gone on. HM Inspectorate of Prisons described this as follows:
Some prisoners described their low mood. Others had been diagnosed with clinical depression and prescribed antidepressant medication during the pandemic. Some felt that their unprecedented isolation was already causing them psychological damage. Others were concerned for friends who would go for days without coming out of their cell.
Some adult prisoners described general anxiety about the implications for their health of catching COVID-19. With such prolonged periods behind their cell door without distraction, their anxieties had escalated and were reinforced by the news and conversations with their families. They worried about their health while they waited for COVID-19 test results. They wanted to talk to health care staff about their fears but were not able to see them.
Adult prisoners told us that they had struggled to access mental health services because of the COVID-19 restrictions. Prisoners who had been undergoing individual and group-based therapy before the pandemic said that their mental health had deteriorated when these services had been abruptly suspended. Inevitably, some prisoners were due to be released into the community without completing their prescribed therapy.
65.Many of the prisoners who wrote to us told us how hard they had found it. For example one said “covid-19 means all of us are to one extent or another emotionally scarred.” And from another “at weekends we could be in this solitary confinement for 60 hours at a time”.
66.The POA told us that the conditions in prisons were affecting the mental health of staff even before the pandemic: “The soaring levels of prisoner violence, self-harm and suicides have an appalling effect on staff mental health.” Phil Copple, Director General in HMPPS, drew our attention to the contribution of frontline staff during the pandemic:
I would recognise over that period is just a lot of care and compassion and very strong leadership shown in our prisons by lots of people on the frontline to make sure that the very real risks in terms of mental health, suicide and self-harm were mitigated as far as we could.
67.One of the serving prisoners who wrote to us for this inquiry praised the staff:
Reward the prison officers and nurses who’ve worked during the pandemic. Most of whom couldn’t go home, slept at friends/other officers homes to ensure their families wasn’t put at transmission risk, that the officers could keep coming to work, the prison officers and nurses are overlooked heroes. As are prison chaplains too.
68.We recognise that prison staff have been under extra pressure during the pandemic and may face uncertainty as the prison restrictions are eased. We would like to express our appreciation again of all those who work in prisons.
69.We asked Dame Anne Owers, who is National Chair of the Independent Monitoring Boards, and was Her Majesty’s Chief Inspector of Prisons between 2001 and 2010, what response would be needed following the pandemic. She said:
Resource will be needed. You also need to look at the whole environment. When I was chief inspector of prisons, we did a thematic in mental health. We asked prisoners, who were suffering, as someone just said, a whole variety of mental health conditions from anxiety to depression upwards, what they really wanted. The big answers that came back were “someone to talk to” and “something to do.” Those things have been notably absent from our prisons over the past year and a half.”
70.We asked Alex Chalk and Kate Davies about the deterioration in prisoners mental health and what they planned to do in response. They said they hoped to continue some innovations introduced during the pandemic including video medical appointments and the scheme to prevent prisoners becoming homeless on release. There did not appear to be a plan in place to address the scale of demand for mental health treatment that has built up during the pandemic.
71.Prisoners have shared the anxieties of the general population about possibly becoming ill themselves with covid-19 or their loved ones becoming ill. This has been combined with the most severe restrictions on their daily lives, going beyond those experienced by the general population. For example, family contact was restricted, and in circumstances where enhanced digital access was not available, the restriction on family access would potentially have exacerbated the effect on prisoners’ mental health. We recognise and understand that the restrictions on prisoners during the period of the pandemic will have saved numerous lives, but, we are concerned about the impact of the pandemic on prisoners’ mental health and how well prepared HMPPS and NHS will be for the increase in the need for mental healthcare services as a result.
72.The Ministry of Justice, HMPPS and NHS England should take urgent steps to increase provision of mental healthcare services over the coming 12 months so that prisoners whose mental health has deteriorated because of the pandemic can be treated.
74.The NHS’s 14-day target for transferring acutely ill prisoners to mental health beds is not working because of a shortage of secure mental health beds. As a result, acutely ill people are being held (some for many months) without access to the medical treatment they need. Recent research has found that average transfer times were as follows: to high security beds = 159.6 days; medium security = 58.6 days; low security = 54.8 days; and psychiatric intensive care = 16.1 days. Ill prisoners may be kept in segregation owing to the risk they pose to others. The government proposes introducing a statutory time limit for transfers, but not until new NHS good practice guidance on transfers (issued on 10 June 2021) has been ‘embedded’.
75.Phil Copple, Director-general HM Prison Service set out some of the impacts of delays in transferring prisons with acute and serve mental illnesses promptly to hospital:
we can often have quite serious, sometimes very extreme, issues that they can present of harm to themselves and to other people. It is sometimes the case that staff have to deal with very traumatic incidents in relation to those individuals. I won’t give graphic examples, but some of the self-harming behaviours that staff have to deal with can be absolutely appalling and extreme.
[…] sometimes those individuals can end up being managed in segregation units, which is far from ideal but is necessary because of a lack of any other safe location to hold them during that time. Staff try to work very hard with nursing staff, mental health staff, who provide in-reach service into the prison to try to support people. Essentially, in that scenario, we are struggling with the fact that it is not the right place and we do not have the right range of skills, including in the mental health team because they are not there to deal with that group of people other than in the very short term.
The other thing to bear in mind is that it inevitably pulls resources away from everybody else, including a lot of other people with less acute mental health needs whom the services and the staff are also trying to support.
76.In the white paper on reforming the Mental Health Act 1983, the Department for Health and Social Care and the Ministry of Justice have proposed introducing a statutory time limit for transfers but not until after new guidance (which was issued by the NHS on 10 June 2021) has been ‘embedded’:
… we will introduce a 28 day time limit, split into two sequential, statutory time limits of 14 days each: first from the point of initial referral to the first psychiatric assessment, and then from the first psychiatric assessment until the transfer takes place.
…Stakeholders […] have argued that enshrining the time limit in statute could result in unintended consequences if not carefully managed. For example, clinicians may avoid recommending hospitalisation if they, or their employing authority, are likely to be penalised for not meeting the deadline [...] we will not commence this provision until the new NHSEI guidance is properly embedded.
77.Historically, there was a view that some personality disorders were untreatable, but according to the Royal College of Psychiatrists this is no longer the case: “Recent research makes it clear that mental health services can, and should help people with personality disorders.” We are concerned that the Independent Monitoring Boards said one reason some acutely unwell prisoners are held in segregation is because “some very unwell prisoners fall outside the scope of such [Mental Health Act] assessments, because their behaviours, however extreme, are deemed not to derive from treatable mental health conditions.”
78.It is inappropriate that severely mentally ill prisoners are kept in prison, sometimes in segregation. Despite the best efforts of prison staff this can result in periods of inhumane treatment. We welcome the proposal to introduce statutory time limits for transferring prisoners with acute and severe mental illness to appropriate mental health inpatient beds, but this will not solve the underlying problem which is the shortage of appropriate secure mental health inpatient facilities.
79.The Ministry of Justice should work with the Department for Health and Social Care and the NHS to increase immediately the availability of mental health inpatient beds for prisoners from those prisons that have the most difficulty transferring prisoners within the time limit, including for those who are considered by some of those involved to have ‘untreatable’ conditions.
80.HMPPS and the NHS should gather and publish monthly information for every establishment (without naming establishments to protect patient confidentiality) on the number of prisoners awaiting transfers to inpatient care for mental illness and for how long they have been waiting.
81.There are longstanding difficulties ensuring continuity of medical care for prisoners as they arrive, move around the prison system, and are released. Practice Plus Group told us that it often takes too long for prisoners’ medical information to be made available to those responsible for looking after them when they arrive in prison:
The challenge of supporting people on arrival is exacerbated by the lack of access to information. Mental health services electronic patient notes are not accessible at the point of arrival and information available via the general practice electronic medical records systems is limited.
The importance of getting information to the right people was set out starkly by the Independent Advisory Panel on Deaths in Custody: “Investigations frequently raise problems with information transfer as a cause of death.”
82.Kate Davies, Director of Health and Justice at NHS England, told us that some of the apparent barriers to sharing data had been overcome as part of the response to the pandemic. She said:
I have signed off 2,000 new licences around the way that digital systems can work, from primary care to secondary care, from prison into hospital settings. We had waited years to get those signed off. It took us three months to get them signed off within the pandemic.
83.Further problems arise at release. Martin Jones, Chief Executive Officer of the Parole Board, told us of the difficulties the Parole Board can face making sure that appropriate care is available in the community so that higher-risk prisoners (who are those that the Parole Board decides about) can be released safely.
Of course, we cannot compromise the safety of the public, and there is a balancing act to be struck as part of that. For many of the people whom we see with serious mental health difficulties, if you understand what the condition is that you are managing and you have the right support package, that risk can be managed in the community, […]
It is not at all unusual for us to find that a case will take 18 months to two years to reach a conclusion […]
84.The Parole Board described a vicious circle where it cannot authorise release without community services being in place, but community mental health teams will only accept responsibility after release has been approved:
Parole Board members have experienced serious problems in community mental health teams only accepting responsibility for community management and supervision post-release, when release has been approved by the Parole Board. This is an issue as mental health may be an active risk management factor in the community and the Parole Board is unable to support release until community mental health support is confirmed.
Martin Jones also told us that not providing appropriate support can result in prisoners being returned to prison: “We certainly see people, for example, recalled to custody because of chaotic behaviour and non-compliant behaviour in the community, and when you are looking at the case it is all about unmet need […]”
85.Most prisoners are lower risk and are released without the Parole Board being involved. Many of those who submitted written evidence to this inquiry told us of communication problems and other difficulties that meant that mental healthcare often stopped on release. For example, the Royal College of GPs said:
Prisoners who do not have a fixed address prior to release face real challenges as to who is responsible for taking over care. Even where referrals to community mental health services are made, patients are frequently not contacted by community teams in a timely manner after release.
86.Kate Davies told us of the importance the NHS places on its new ‘care after custody’ programme (known as RECONNECT). She told us of the need to ensure prisoners could continue to get the medications prescribed to them while in prison and be able to continue cognitive therapy or similar programmes when they are released. She told us “unfortunately because of Covid [RECONNECT] has not yet got up to speed as we would have liked.”
there are 11 [pathfinders]. We are now rolling out to have the coverage of RECONNECT services across the board by 2024.
The Ministry of Justice told us that it is piloting Health and Justice Partnership Co-ordinators at five prisons to help improve continuity of medical care on release.
87.Making medical information systems interoperable between prisons and the community is challenging but vital if appropriate care (including the correct medication) is to be provided from arrival in prison through to release. Progress has been made during covid-19 and this should be built on.
88.As a matter of urgency, the Ministry of Justice, the Department for Health and Social care, HMPPS and NHS England should introduce arrangements so that all prisoners’ medical records are swiftly available between prisons and between the community and prison and vice versa. They should set a joint target date for this work to be completed and a timeline towards it.
89.Some parole decisions are delayed because prisoners applying for parole have undiagnosed mental illness that limit their participation in the parole application process. There are further delays due to insufficient co-operation from community mental health teams in arranging packages of services for prisoners for their release.
90.Prison healthcare providers should systematically assess the mental health of prisoners coming up for parole and make sure that any needing support and treatment have it in good time before they make an application.
91.NHS England should liaise with the Parole Board to identify local areas where there are problems arranging mental health treatment packages for prisoners under consideration for parole. NHS England should then work with the new NHS Integrated Care Systems and providers to help them understand and fulfil their responsibilities so that these prisoners may be released safely and promptly.
92.Despite longstanding difficulties arranging continuity of healthcare for prisoners on their release, the NHS RECONNECT programme, which is meant to resolve these problems, is in its infancy. In the meantime, prisoners who have been receiving treatment in prison for mental illnesses are often released to find that there are no services for them in the community, including no medication. The transition from prison to life outside is challenging enough for these prisoners without this sudden withdrawal of their mental health support and treatment. It does not benefit the public if these prisoners fall into chaotic lifestyles, with the increased risk of re-offending that brings, because the support and treatment they had in prison has been removed.
93.The NHS should learn early lessons swiftly from its RECONNECT pathfinder projects and accelerate roll-out of the most important features across all prisons in the interim between now and 2024 when it intends to have completed the full roll-out. Similarly, HMPPS’s five Health and Justice Partnership Co-ordinator pilots should be evaluated as soon as possible and if this evaluation is positive, they should be implemented across all prisons. The findings from the pathfinders and the pilots should be published.
51 Royal College of General Practitioners ()
52 Royal College of General Practitioners ()
55 POA – the Professional Trades Union for Prison, Correctional & Secure Psychiatric Workers ()
56 Mind in Camden ().
57 UNGRIPP ()
58 Parole Board for England and Wales ()
59 HM Inspectorate of Prisons thematic review, What happens to prisoners in a pandemic?, February 2021, p4
60 POA – the Professional Trades Union for Prison, Correctional & Secure Psychiatric Workers ()
62 HM Inspectorate of Prisons thematic review, What happens to prisoners in a pandemic?, February 2021, Section 2
63 HM Inspectorate of Prisons thematic review, , February 2021, pp 24–25
65 POA – the Professional Trades Union for Prison, Correctional & Secure Psychiatric Workers ()
70 The Royal College of Psychiatrists () referred to Craster, L. and Forrester, A. (2020), “Mental Health Act transfers from prison to psychiatric hospital over a six-year period in a region of England”, Journal of Criminal Psychology, Vol. 10 No. 3, pp. 219–231.
72 NHSEI stands for NHS England and NHS Improvement
73 , webpage accessed 5 July 2021
74 Royal College of Psychiatrists, , webpage accessed 15 July 2021
75 Independent monitoring boards ()
76 Practice Plus Group ()
77 Independent Advisory Panel on Deaths in Custody ()
79 The sentences dealt with by the Parole Board include life sentences, indeterminate sentences for public protection, some fixed sentences and recall cases (meaning that the offender was previously released but has been subsequently returned to prison custody). The Parole Board can also advise on moves of some prisoners from a closed to an open prison.
82 Parole Board for England and Wales ()
84 Royal College of General Practitioners ()
85 The NHS Long Term Plan, , para 10, webpage accessed on 12 July 2021.
88 Ministry of Justice ()