Examination of Witnesses (Questions 220
MONDAY 9 FEBRUARY 2004
Q220 Lord Lester of Herne Hill: I
am sure we are glad to hear that but given what I have just said
about other mechanisms, are you reviewing the power of the MHAC
or its successors to provide a statutory basis for a full independent
inquiry because, on the face of it, it is very odd that there
should be a full independent inquiry into these other contexts
but not in this one. Are you looking at reviewing the powers of
the Commission as a matter of priority?
Dr Ladyman: At the moment, I would
have to say it is something that we are not minded to do but we
are open minded about it.
Q221 Lord Lester of Herne Hill: Why
are you not minded to do it?
Dr Ladyman: Because, as I say,
I think that there are mechanisms in place at the moment which
adequately allow the investigation of deaths in mental health
environments, but again the report of this Committee will be helpful
in formulating our future views.
Q222 Lord Lester of Herne Hill: Do
you think it satisfies Article 2 of the European Human Rights
Convention for the status quo to exist?
Dr Ladyman: I do.
Q223 Lord Lester of Herne Hill: You
think it does?
Dr Ladyman: I do.
Q224 Chairman: Minister, we are aware
that the National Health Service assumed responsibility for the
prison healthcare system in April of last year. How would you
say the prison healthcare system has changed since that date and
what changes would you envisage in the future?
Dr Ladyman: I think the partnership
between the National Health Service and the Prison Service actually
had some serious benefits even before April of last year. I do
not know if the Committee is aware but we put in a traffic lights
system for assessing the quality of health services in prisons
where red is a healthcare service with serious deficiencies, amber
gives cause for concern and green is considered to be adequate
and, from 1999 to 2003, we went to a situation where there was
a significant number of prison healthcare services at red to a
situation in 2003 where there were none at red and the vast majority
were at green. Only 24 remained at amber and 114 at green by 2003.
So, a significant improvement already as a result of the partnership
work. So, what would I expect now between 2003 and 2006 when we
fully take over or PCTs take over full commissioning? I would
expect to build on that foundation; I would expect to see a general
improvement in healthcare services everywhere but, more importantly,
I would expect to see what we call mainstreaming of services.
So, to see services delivered in prison as they would be if people
were not prisoners in the sense that, if you were not a prisoner,
you would receive treatment for something in your home, then we
should be able to deliver the same standard of treatment to you
in prison in your cell on your wing which is the equivalent of
your home whilst in prison. If it requires you to be hospitalised
whilst you are not a prisoner, then it would require you to be
hospitalised if you are an inmate. So, we would want to see the
same strategies and the same quality of health service in prison
and outside prison.
Q225 Chairman: Would you say that
the high rate of the imprisonment of mentally ill people indicates
a failure of or a function of the failure of mental healthcare
available in the community generally?
Dr Ladyman: I would not take the
view that it is a failure of healthcare in the community. I think
it is inevitable that more prisoners will be people with mental
health problems than in the general community. I agree with you
that it is a horrifying level of people that have a mental health
disorder in prison. There are five categories of health disorder
and 90 per cent of people have at least one of those disorders.
That is a horrifying level, I agree. I have to say that I think
it gives us a huge opportunity that hitherto I do not think we
have fully exploited and that is that, if we can help people whilst
they are in the Prison Service system to overcome that mental
illness, whether it is drug abuse and alcohol misuse or any of
the other mental disorders, and support them whilst they are in
prison, then we are going to make dramatic improvements to the
offending rates when people leave prison. So, it is something
that worries me and which shocked me when I first took over this
role and discovered how high the levels were in prison but, no,
I do not think it is a reflection on mental health treatment in
Q226 Chairman: In some of their evidence
to us, Mind have suggested that people's general level of mental
health tends to deteriorate while they are detained in prison;
would you agree with that statement?
Dr Ladyman: I think that is generally
accepted but, equally, I think we have to ask ourselves what we
mean by that. Prisons are not supposed to be fun places to go
to. By definition, you are being punished. You either have the
prospect of a trial or you have the memory of your trial, you
have then a period of incarceration with your liberty curtailed,
you have to deal with what your family and friends and what the
community you have left may be thinking about you and what you
did or what they perceived you did. It is a place that is bound
to exacerbate any underlying mental health condition that you
have had and to expose any that has not been spotted before you
came into the prison environment. So, yes, I think it is generally
accepted that mental health will deteriorate in prison, but I
do not believe it is necessary for it to deteriorate to serious
levels while you are in prison.
Q227 Lord Judd: Surely you are quite
right when you imply and more specifically say that prisons are
not fun places to go to but, on the other hand, surely one of
the principle objectives of prison is not only punishment but
rehabilitation and, if there is a question of mental health deteriorating
at all, this is working right against the whole objective of rehabilitation
and is something to be taken extremely seriously.
Dr Ladyman: Absolutely and we
are taking it extremely seriously and that is why we are transferring
prison health services to the National Health Service in order
that we can take it even more seriously in the future. What I
mean to say is that, when you go to prison, there is bound to
be an element of depression about it. If it was not depressing
you, it would not
Lord Judd: If I may say so, I thought
you described that rather well.
Q228 Chairman: The Chief Inspector
of Prisons, Anne Owers, recently said there is a need for what
she called a new generation of institutions which focused on treatment
and interventions where mentally ill people can be detained rather
than going to prison; do you agree with that?
Dr Ladyman: As I said earlier,
I would need a lot of convincing that it is necessary. Yes, 90
per cent of people have characteristics of one of the five mental
disorders whilst they are in prison, but a much smaller proportion
of them are seriously mentally ill. I think we have estimated
that there are about 5,000 people in prison who are seriously
mentally ill and the question I would have to ask is, what sort
of level of mental illness is it that she is proposing we build
new institutions for? If it is people with very serious mental
illnesses that she is proposing that we build new institutions
for, then are we not in danger of recreating the old asylums,
which I expect everybody would immediately criticise us for, quite
rightly, if we tried to go down that route. Given that we are
in the middle of a process of mainstreaming prison health services,
doing things we have never done before in this country to drive
up the quality of prison health services and to take issues like
mental health of prisoners far more seriously than we ever have
in the past, I think that, before we go down the route she is
proposing, we would be very well advised to see how well the route
we are following at the moment works, bearing in mind that we
do not even have the first primary care trusts taking over prison
health services until this April. We are at a very early stage
in a process which may address the problem and I think will address
the problem that she has identified.
Q229 Chairman: We also heard from
the Chief Inspector that the average period between the diagnosis
which could lead to sectioning under the Mental Health Act to
allocation to a secure hospital is generally about three months
and she said to us that those are three months in which a prisoner
could deteriorate quite dramatically. Is there going to be a focus
on trying to shorten that period?
Dr Ladyman: Yes. I think we have
to focus on that. I think we estimate that, at any one time, there
are about 40 people waiting three months or more for a transfer
and we need to make sure that the gap is as short as possible
and that, for the period they are awaiting a transfer, the health
services we are providing them within the prison environment where
they are is as appropriate as possible.
Q230 Mr Stinchcombe: Minister, I
would like to take you to some more general healthcare issues
outside of the mental health remit. Firstly, drug detoxification.
Do you agree that drug addiction is one of the most significant
healthcare problems facing the Prison Service?
Dr Ladyman: Absolutely. We estimate
that it is 40 to 50 per cent of male inmates have substance abuse
problems and about 60 per cent of the women.
Q231 Mr Stinchcombe: To what extent
is patient maintenance treatment available to prisoners with addictive
Dr Ladyman: I would have to write
to you with the percentage of people to whom it is available.
In general terms, I would have to say that the non-clinical services
we provide to people with substance abuse problems in prison are
fairly generally available across the prison estate but the clinical
services at this time are much more patchy.
Q232 Mr Stinchcombe: What precise
steps have you taken to improve detoxification programmes within
Dr Ladyman: We are generally looking
at the extension of clinical services and the opportunity for
different prescribing options to be made available according to
the clinical judgment of people who are caring for prisoners and
we are making detoxification facilities available much more widely
across the prison estate, but I am the first to say that it is
Q233 Mr Stinchcombe: To what extent
are you protecting those who have been detoxified in prison by
providing them with Naltrexone to block the impact, for example,
of heroin, whilst they are in prison and of course when they are
Dr Ladyman: I think that there
is an issue there. As I say, we do not think that the availability
of clinical services is widespread enough in the Prison Service
yet, so we need to extend that and I accept that entirely, and,
from my experience of talking to professionals within the healthcare
service, one of the things that we have yet to get right is the
length between the detoxification programmes and the treatment
programmes we have put on whilst people are in post and the support
we provide for the aftercare after they are released. What governors
typically tell me when I go to visit prison health centres is
that, if somebody is in prison for a few months, then they can
usually get them off drugs or help them with their substance abuse
programme during that time but, quite often, they are immediately
released back into the environment from which they came, often
without a proper care plan and they quite often find themselves
going back to sleep in the same flats and the same places where
the people who got them into trouble in the first place are.
Q234 Mr Stinchcombe: Could you drop
a line to the Committee with the figures as to the percentage
of prisoners who are specifically offered Naltrexone treatment.
Dr Ladyman: Yes.
Q235 Mr Stinchcombe: Can I turn quickly
to communicable diseases. I think you will agree that a percentage
of inmates suffer both HIV and Hepatitis B and C significantly
higher than the outside community and presumably that is because
those inmates had the disease transmitted to them in the normal
way either through sharing needles or through having unprotected
Dr Ladyman: Yes.
Q236 Mr Stinchcombe: I take it that
the Department of Health is promoting needle exchanges and sterilisation
of needles and also condoms in the wider community.
Dr Ladyman: Yes.
Q237 Mr Stinchcombe: Will it also
promote those programmes inside prison?
Dr Ladyman: Certainly, there was
an attempt to introduce disinfecting tablets which was withdrawn
and is now being reintroduced under a pilot programme which we
carried out some analysis on. So, we think disinfecting tablets
for those people who are using equipment inside prisons is an
important way forward. Our experience so far of the needle sharing
schemes in prison has not been particularly successful but I am
open minded about anything. Condoms in most places are available
on a confidential basis in prisons where we think it is necessary.
Q238 Lord Lester of Herne Hill: Minister,
we would be grateful if you would provide us with evidence rather
than assertion as to why Anne Owers is wrong because I think that
is what you are saying when she says that there is a real need
for a new generation of institutions with focus on treatment and
intervention so as to get people out of prison who should not
be there because of their mental disorder. Can your department
provide evidenceI understand the assertionbecause
we have to form a judgment in the end as to whether we accept
her evidence or not? So, if you have evidence to the contrary
I have evidence that supports her from my own experience and you
clearly must have visited prisons yourself, but can you hereafter
provide us with chapter and verse, please.
Dr Ladyman: I will certainly write
to you and give you a considered view on it. I do not think that
the Chief Inspector was actually putting this forward as a proposal
for an immediate start. I think she was flagging it as an option
that we ought to be looking at as well. I am happy to give you
a response on it.
Chairman: Minister, thank you very much
for appearing before us today. It has been very helpful to us
as we continue our examination of the very serious issues that
arise from deaths in all forms of custody. Thank you very much.