Conclusions and recommendations
Understanding the need for mental healthcare in prisons
1.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. (Paragraph 20)
2.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. (Paragraph 21)
Commissioning prison mental healthcare services and models of care
3.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. (Paragraph 26)
4.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. (Paragraph 27)
5.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. (Paragraph 38)
6.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. (Paragraph 39)
7.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. (Paragraph 40)
Mental illness in prison
8.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. (Paragraph 43)
9.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. (Paragraph 44)
10.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. (Paragraph 51)
11.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. (Paragraph 52)
12.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. (Paragraph 53)
13.The NHS should accelerate its work to understand why there is a racial disparity in identifying mental health issues in prison and implement a solution. (Paragraph 54)
14.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. (Paragraph 61)
15.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. (Paragraph 62)
16.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. (Paragraph 68)
17.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. (Paragraph 61)
18.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. (Paragraph 62)
19.HMPPS should build on its existing management guidance and occupational health services to increase its support for the mental well-being of those who work in prisons. (Paragraph 63)
20.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. (Paragraph 78)
21.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. (Paragraph 79)
22.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. (Paragraph 80)
23.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. (Paragraph 87)
24.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. (Paragraph 88)
25.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. (Paragraph 89)
26.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. (Paragraph 90)
27.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. (Paragraph 91)
28.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. (Paragraph 92)
29.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. (Paragraph 93)
Use of prison to accommodate mentally ill people because community care is not available
30.We welcome the proposal in the Mental Health Act Reform white paper to end the use of prison as a ‘place of safety’ and the recognition that this must be supported by investment in alternatives. Problems with access to emergency mental health services (including a shortage of beds on general psychiatric wards) are at the heart of the problem. (Paragraph 97)
31.The Government must, as a matter of urgency, see through its proposal to establish viable alternatives so that prisons are no longer used as a place of safety under the Mental Health Act 1983. We recommend that the Department of Health and Social Care and the Ministry of Justice set a target to eliminate use of prison in this way by 31 March 2022 and monitor progress monthly towards this target in each NHS region in the meantime. (Paragraph 98)
32.The Courts use the provisions in the Bail Act 1976 to remand people to prison for their own protection or welfare only because proper alternatives in the community are not available. We are concerned about the lack of safeguards under this provision, the length of time men, women and children may be remanded, and the unsuitability of prison for them. The use of prisons in this way is wrong in principle. (Paragraph 103)
33.The Government should bring forward legislation by 31 March 2022 to amend the Bail Act 1976 so that it is unlawful to remand anyone to custody simply for their own protection or welfare. (Paragraph 104)
Published: 29 September 2021 Site information Accessibility statement