out of sight, out of mind: the state of mental healthcare in prison

Out of Sight,Out of Mind

The state of mental healthcare in prison

Professor Charlie Brooker and Ben UllmannEdited by Gavin Lockhart

£10.00ISBN: 978-1-906097-27-1

Policy ExchangeClutha House

10 Storey’s GateLondon SW1P 3AY

www.policyexchange.org.uk

Our prison population is at its highest ever. Of the 82,000prisoners in England andWales it is estimated that nine out of tenhave one or more mental health disorders. Although treatment ofmental illness in prison has improved over the past decade,mental healthcare is not given the attention it deserves. The ratesof mental illness among prisoners suggest that the PrisonService has become a catch-all social and mental healthcareservice, as well as a breeding ground for poor mental health.

In 1996, Lord Ramsbotham, then Chief Inspector of Prisons,wrote a report that was heavily critical of prison healthcareservices. And although matters have improved since then,progress is slow. Out of Sight, Out of Mind argues that LordRamsbotham’s findings are as relevant today as they were 12years ago: research contained in this report suggests that a thirdof the spending on mental health services in prison is spentinefficiently and that prison mental healthcare remains verypoor. Professor Charlie Brooker and Ben Ullmann argue thatlevels of staffing would need to be tripled in order to reachservice levels equivalent to that of the wider community but thatrates of reoffending would have to fall by less than one per centto make this improvement cost effective.

Out

ofSight,O

utofMind

Professo

rCharlie

Brooker

andBen

Ullm

ann,Edited

byGavin

Lockhart

Policy

Exchang

e

OOSOOM Cover_HDS 30/6/08 12:45

Policy Exchange is an independent think tank whose mission is to develop and promote new policy ideas which willfoster a free society based on strong communities, personal freedom, limited government, national self-confidence andan enterprise culture. Registered charity no: 1096300.

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Charles Moore (Chairman of the Board), Theodore Agnew, Richard Briance, Camilla Cavendish, Richard Ehrman,Robin Edwards, Virginia Fraser, George Robinson, Andrew Sells, Tim Steel, Alice Thomson, Rachel Whetstone.

Out of Sight,Out of MindThe state of mental healthcare in prison


OOSOOM_HDS 26/6/08 18:57 Page 1

About the authors

Professor Charlie BrookerProfessor of Criminal Justice and Health,University of LincolnCharlie Brooker leads a research group atthe University of Lincoln that focuses sole-ly on research in the criminal justice sys-tem and associated health issues. He was afounding collaborator of the NationalPrison Health Research Network and he isdeeply interested in the relationshipbetween policy, health status and reoffend-ing. He is the lead author of Short-changed:Spending on Prison Mental Healthcare, arecent publication from the SainsburyCentre for Mental Health, which high-lights inequities in the NHS funding forprisoners who experience mental healthdisorders.

Ben UllmannResearch Fellow, Crime and Justice Unit,Policy ExchangeBen Ullmann joined Policy Exchange in2007 after graduating with a degree inMathematics and Philosophy from theUniversity of Bristol. His previous publica-tions for Policy Exchange includeUnlocking the Prison Estate, an economicanalysis of rebuilding and improving theprison estate.

Gavin LockhartHead of Crime and Justice Unit, PolicyExchangeGavin Lockhart has responsibility forcrime and justice research at PolicyExchange. After graduating in 2002 with afirst-class degree, Gavin worked as a man-agement consultant before joining PolicyExchange in August 2006. He has alsoedited a number of previous PolicyExchange reports including Measure forMeasure, Fitting the Bill and Footing theBill.

© Policy Exchange 2008

Published byPolicy Exchange, Clutha House, 10 Storey’s Gate, London SW1P 3AYwww.policyexchange.org.uk

ISBN: 978-1-906097-27-1

Printed by Heron, Dawson and SawyerDesigned by SoapBox, www.soapboxcommunications.co.uk

2


www.policyexchange.org.uk • 3

Contents

Acknowledgements 4Executive Summary 6

1 Introduction 92 Public attitudes to offenders with mental illness 153 The offender mental healthcare journey 194 Assessment of prison mental healthcare 275 Spending, staff and savings 336 Recommendations 38

Glossary 40Appendix 1: List of prisons served by the PCTs and mental health in-reach teams surveyed 42Appendix 2: Full results from the YouGov survey on behalf of Policy Exchange 43


Acknowledgements

Policy Exchange thanks the Hadley Trustfor its generous support of this project.The authors would like to thank those whocontributed their time and expertise to thisreport including the mental health in-reach team leaders and PCT prison healthleads who took part in our surveys. Specialthanks should go to those who gave theirtime and expertise and provided us withtheir insight into this important topic.

� Aly Valli: Oxfordshire Primary CareTrust

� Angela Perrett: Bristol Primary CareTrust

� Anne Owers CBE: HM ChiefInspector of Prisons

� Carole Lawrence-Parr: DorsetPrimary Care Trust

� Catherine Clay: South StaffordshirePrimary Care Trust

� Colette Rimmer: Preston PrimaryCare Trust

� Coral Sirdifield: University ofLincoln

� Dave Spurgeon: Nacro� Dina Gojkovic: University of Lincoln� Elizabeth Tysoe: HM Inspectorate of

Prisons� Graham Durcan: Sainsbury Centre

for Mental Health� John Ellis: Cambridgeshire Primary

Care Trust� John Podmore: Offender Health

� Julian Corner: Revolving DoorsAgency

� Juliet Lyon: Prison Reform Trust� Katherine Onion: University of

Lincoln� Lesley Dibben: Gloucestershire

Primary Care Trust� Lord Ramsbotham GCB CBE:

Former HM Chief Inspector ofPrisons

� Lucy Smith: Nacro� Michael Parsonage: Sainsbury Centre

for Mental Health� Nicola Singleton: UK Drugs Policy

Commission� Paul Jenkins OBE: Rethink� Professor Luke Birmingham:

University of Southampton� Richard Bradshaw: Offender Health� Rochelle Harris: West Yorkshire

Probation Board� Sarah Cocker: West Yorkshire

Probation Board� Sean Duggan: Sainsbury Centre for

Mental Health� Vanessa Fowler: Formerly

Department of Health

Finally the authors would like to thankPhilippa Ingram,RichardCarter, JulianChant,Emily Dyer, Natalie Evans, Simon Horner,Jonathan McClory, Mike Morgan-Giles, TomShakespeare and all those who commented ondrafts of this report.

4


Acknowledgements


Expert panelThis report would not have been possiblewithout the generous assistance of ourpanel of eight experts who agreed to beinterviewed. Their inclusion here does notnecessarily indicate an endorsement of thereport’s contents but quotations are includ-ed with their agreement.

Anne Owers CBEAnne Owers has been Her Majesty’s ChiefInspector of Prisons for England and Walessince 2001. Before this post she wasDirector of JUSTICE, the UK-basedhuman rights and law reform organisation.

Lord Ramsbotham GCB CBEDavid Ramsbotham was Her Majesty’sChief Inspector of Prisons for England andWales from 1995 to 2001. He sits in theHouse of Lords as a crossbench peer.

Sean DugganSean Duggan is the Director of Prisons andCriminal Justice Programme at theSainsbury Centre for Mental Health.Previously he was director of health andsocial care for criminal justice at theLondon Development Centre and offend-er health consultant for the Department ofHealth.

Julian CornerJulian Corner is chief executive of theRevolving Doors Agency, a leading UKcharity dedicated to improving the lives ofpeople who are caught up in a damagingcycle of crisis, crime and mental illness.

Paul Jenkins OBEPaul Jenkins has been chief executive ofRethink, a leading national mental healthmembership charity, since January 2007.Previously, he was director of service devel-opment at the NHS Direct Special HealthAuthority.

John PodmoreJohn Podmore is a former governor ofHMP Brixton, HMP Swaleside and HMPBelmarsh. He is now a senior adviser to theOffender Health directorate at theDepartment of Health.

Richard BradshawRichard Bradshaw is the director ofOffender Health based at the Departmentof Health.

Juliet LyonJuliet Lyon is the director of the PrisonReform Trust. She has worked in mentalhealth and in education as head of a psy-chiatric unit school.


6

Executive Summary

Our prison population is at its highest ever.Of the 82,000 prisoners in England andWales it is estimated that nine out of tenhave one or more mental health disorders.Although treatment of mental illness inprison has improved over the past decade,mental healthcare is not given the atten-tion it deserves. The rates of mental illnessamong prisoners suggest that the PrisonService has become a catch-all social andmental healthcare service, as well as abreeding ground for poor mental health.The general public are largely unaware

of the amount of mental illness in prison,although data on the subject has beenavailable for some time. When asked toestimate the proportion of people in pris-ons in the UK with a mental health prob-lem only 1% answered correctly; the vastmajority underestimated the figure. Nearlyhalf (45%) thought that it was 30% or less.There is significantly less public sympa-

thy for prisoners with mental illness thanfor those in the community. While 90% ofpeople believe that we have a responsibilityto provide the best possible care for thosewith mental illness, rather less, 64%,thought this applied to offenders. This sitsawkwardly with the fact that 60% believethat anyone can have a mental illness andcommit a crime.The current assessment of prison mental

healthcare by those who deal with it everyday is bleak. In our surveys of prisonhealthcare professionals, who includedmental health in-reach leaders and PCTprison health leads, more than half saidthat prison mental healthcare was averageor poor – surprisingly low for a self-assess-ment. Our panel of experts also acknowl-edged that prison mental healthcare is stillnot working properly despite someimprovements.Spending on mental health services in

prison is currently £20.4 million (it will

rise to £24 million in 2008-09). Ourresearch found that over a third, £8.6 mil-lion, is not being spent efficiently. This isdue to shortfalls in staff recruitment – justover 10% of the total budget is not beingspent – and confusion over the role ofmental health in-reach teams. These teams,which were originally supposed to dealexclusively with cases of severe mental ill-ness, are working in practice with a muchbroader caseload: 30% of cases have nei-ther a severe mental illness nor a personal-ity disorder.Spending is not only inefficient but also

insufficient. The proportion of the totalhealth budget spent on mental healthcarein the community is 15%. The proportionof the total prison healthcare budget spenton mental healthcare is only 11%, eventhough mental illness is much more com-mon in the prison system than the com-munity at large.Primary care trusts (PCTs) are responsi-

ble for the healthcare budgets of prisons intheir area. As far as we know no rationalbasis has been established for the allocationof monies to PCTs for prison health. Thecurrent funding reflects a negotiated settle-ment with the Prison Service based onwhat it was receiving from the HomeOffice before prison health services becamethe responsibility of the Department ofHealth. In other words, budgets are basedon past practice rather than any definitionof current need. A sophisticated needsassessment should be undertaken in orderto find how much is really required to pro-vide for the prison community.One consequence of underfunding is

chronic understaffing. Mental health in-reach teams, on average, consist of just fourclinical staff; they are intended to be mul-tidisciplinary but usually have no psychia-trist, psychologist or social worker. We alsoknow that staffing of in-reach teams varies



Executive Summary

across prisons, with some consisting of tenor more staff while others have only twoclinical nurses.

If Department of Health (DoH) guid-ance for community mental health teamswas applied to prisons and took intoaccount the much greater prevalence ofmental illness there, in-reach teams wouldhave the equivalent of three to four com-munity psychiatric nurses; two to threesocial workers; a minimum of one full-time clinical psychologist; a support work-er and administrator; and two full-timepsychiatrists: in total between 12 and 14professionals. This suggests that the aver-age in-reach team is only a third of the sizeit should be and does not contain the cor-rect range of skills.

The co-ordination of mental healthcarealso leaves much to be desired. In-reach,primary care, drug services and otherteams work separately. The line betweenwhat is primary and secondary care isblurred and prisoners are passed betweenthe two or even lost completely. A singlemental healthcare delivery team, with thesame range of skills and practitioners as inthe community mental health teams,would go a long way to improving thequality of care. In fact, some teams struc-tured in this way already exist and areproving to be effective.

Whatever improved level of funding forprison mental healthcare was decided on,we believe the extra cost would be offset bya reduction in reoffending. Former prison-ers who suffer social exclusion, whichincludes factors such as homelessness,unemployment and family breakdown, aremore likely to reoffend. Mental illnessincreases the risk of social exclusion andtherefore of reoffending. Recent studiesestimate that the £20.4 million currentlyspent on prison mental healthcare wouldneed to be tripled in order to reach servicelevels equivalent to that of the wider com-munity. If we accept this figure as a sensi-ble estimate, rates of reoffending would

have to fall by only 0.3% to make theimprovement cost effective. A relativelysmall increase in spending might result in amuch larger reduction than this and, sub-sequently, in the costs of reoffending.

The second report in this series will con-tain lessons from abroad and detailed rec-ommendations. However, there are fourareas that the Government must look aturgently: prison overcrowding; resettle-ment plans; improved awareness trainingfor prison officers and prison governors;and integrated policymaking.

A key element of the Bradley Reviewinto court diversion schemes due later thisyear must be to implement a robust andproperly funded system for divertingoffenders with mental illness away fromprison. Not only would this ease the crisisof overcrowding, but also ensure thatoffenders with mental illness were provid-ed care and treatment in an appropriatesetting, whether in the community or asecure health facility.

If reoffending and mental illness are tobe properly addressed, they must be seen inthe wider context. The biggest drivers ofreoffending – lack of employment, suitableaccommodation and access to healthcare –need to be carefully considered in anoffender’s resettlement plan. Ensuring thateveryone with a mental health problemwho is released from prison has a propercare plan is crucial in decreasing reoffend-ing rates. This should already happen forprisoners with a severe mental illnessthrough the care management approach(CPA) but our survey of in-reach teamssuggests that it is not always the case.

Although the clinical staff are vital in

“ Ensuring that everyone with a mental health problem

who is released from prison has a proper care plan is

crucial in decreasing reoffending rates”


Out of Sight, Out of Mind

8

delivering effective mental healthcare,prison officers will have the most contactwith prisoners day-to-day. It is essentialthat they have the skills to identify anddeal with mental illness. Current trainingis not sufficient and in some cases is notcompulsory. In surveys conducted for thisreport in-reach team leaders and PCTprison health leads said that one of thebiggest improvements that could be madewould be to increase mental health aware-ness training for prison officers. Prisongovernors play the most important role ofall in determining the atmosphere of aprison and their training too shouldinclude mandatory mental health aware-ness training.

The structure of policymaking makes ithard to introduce mainstream healthdevelopments, such as the programme forincreasing access to psychological thera-pies, into prisons. Responsibility for prisonhealthcare was transferred fully from thePrison Service to the Department of

Health in 2006 but offender health is man-aged by a separate directorate of the DoH.Primary care trusts, which are responsiblefor prison healthcare budgets, would bemore likely to consider prison populationsas part of their local communities if a moreintegrated approach to policymaking wasevident from the top.

In 1996, Lord Ramsbotham, then ChiefInspector of Prisons, wrote a report thatwas heavily critical of prison healthcareservices – their lack of suitable training formedical and nursing staff; isolation fromnew clinical developments; inadequate carefor the mentally disordered in prison; fail-ure of continuity of care between prisonand community; and a lack of considera-tion of the care needs of specific groups ofprisoners such as women and young peo-ple. And although matters have improvedsince then, progress is slow. This reportargues that Lord Ramsbotham’s findingsare as relevant today as they were 12 yearsago.



1Introduction

SummaryHowever else the people who populate ourjails may differ from the community at large,there is one distinguishing characteristic ofwhich we can be certain: prisoners are farmore likely to suffer from mental ill-healththan the general population. Nearly halfhave at least three co-existing mental healthproblems compared to less than 1% in thecommunity.1 Some 70% of sentenced pris-oners suffer from two mental conditions, ofwhich the most common are personality dis-orders, neurotic disorders, drug dependencyand alcohol dependency.2 Between 6% and13% have a severe schizophrenic or delu-sional disorder and 1% to 2% psychosis.3

Faced with such figures the obviousquestion is whether the prisoner has amental disorder from the outset or whetherprison life leads to its development. Muchof the available research measures the pro-portion of people in a population whohave a disease or condition at a particulartime – it is a snap shot or what epidemiol-ogists term “point-prevalence” – so it is notpossible to be sure. However, we know thatthe prison experience itself does have an

effect on mental health. In a 2003 studyprisoners reported that long periods of iso-lation with little mental stimulus led tointense feelings of anger, frustration andanxiety; they used drugs to relieve the longhours of tedium.4

Black and minority ethnic communitiesPeople from black and minority ethnic(BME) communities make up about 10%of the UK population5 but about 20% ofthe prison population.6 The rate of diag-nosed mental health problems is lower inBME communities than among whiteprisoners, perhaps because of lower rates ofreferral and recognition.7 The ChiefInspector of Prisons, Anne Owers, recog-nised this inequality in her 2007 report onmental health:

“In general, we found that services wereinsufficiently responsive to diverse needs.Neither substance use nor mental healthservices were sufficiently alert to the differ-ent needs of BME prisoners; nor were theymonitoring access effectively.” 8

1 Corner J, Jones E, Honeyman

R, Prisons: Britain’s ‘Social

Dustbins’, Revolving Doors

Agency, 2007

2 Prison Factfile, Bromley Briefing

May 2007, Prison Reform Trust

3 Ibid

4 Nurse J, Woodcock P, Ormsby

J, “Influence of environmental fac-

tors on mental health within pris-

ons: focus group study”, British

Medical Journal 327 480, 2003

5 Office for National Statistics,

2001 Census. See www.statistics.

gov.uk/cci/nugget.asp?id=263

6 Rickford D and Edgar K,

Troubled Inside: Responding to

the Mental Health Needs of Men

in Prison, Prison Reform Trust,

2005

7 Durcan G, Knowles K, London’s

Prison Mental Health Services: A

review, Policy Paper 5, The

Sainsbury Centre for Mental

Health, 2005

8 The Mental Health of Prisoners:

A thematic review of the care and

support of prisoners with mental

health needs, HM Inspectorate of

Prisons, 2007

9 Singleton N et al, Psychiatric

morbidity among prisoners in

England and Wales, Office for

National Statistics, 2007

10 Singleton N, Bumpstead R,

O’Brien M, Lee A, Meltzer H,

“Psychiatric morbidity among

adults living in private households,

2000”, International Review of

Psychiatry, 15 (1), 65-73, 2003

Table 1: % Rates of mental illness among prisoners and the general population

% Prisoners9 % General population (adults of working age)10

Psychosis 6-13 0.4

Personality disorder 50-78 3.4-5.4

Neurotic disorder 40-76 17.3

Drug dependency 34-52 4.2

Alcohol dependency 19-30 8.1


WomenWomen make up approximately 5% of theprison population.11 They serve shortersentences, but during that time their chil-dren may be taken into local authority careand they may lose both their job and theirhome. There are relatively few women’sprisons, so family visits often involve along journey and may be very difficult toarrange for any children involved. Allthese factors increase the likelihood ofmental stress.

In fact, women prisoners are twice aslikely as their male counterparts to havereceived help for a mental or emotionalproblem in the 12 months before theirimprisonment.12 It is estimated that 14%suffer from psychosis; the equivalent figurefor the community is less than 1%.13

Antisocial personality disorder is estimatedat 31% among women prisoners. They arealso more likely than male prisoners to suf-fer from common mental health problems.It has been estimated that 66% exhibitneurotic disorders such as depression andanxiety compared to 16% of women in thegeneral population.14

Of all groups, women in prison have thehighest levels of emotional and psycholog-ical distress, often related to past abuse andexacerbated by distance from home andchildren. Primary mental healthcare, rela-tionship support and survival counsellingare particularly important to meet theirneeds.15

The Corston Report for the HomeOffice recently recommended completelyreplacing the women’s prison estate withlocal, smaller-scale alternatives.16 (PolicyExchange has made a similar recommenda-tion for the whole prison estate.17)Research by SmartJustice, an advocacygroup that campaigns for alternatives tocustody, shows that there is broad publicsupport for this measure. Given a choicebetween prison and various alternatives, itssurvey found overwhelming support(86%) for the idea of local community

centres where women would be sent toaddress the root causes of their crimes inaddition to doing compulsory work to rec-ompense the community.18

Young PeopleAlmost 14% of the prison population isunder 21 years, a fifth of who are only 15-17 years.19 Young people in prison are evenmore likely to suffer poor mental healththan adults; 95% have at least one mentalhealth problem and 80% more than one –disturbed sleep, anxiety and depressionbeing the most common.20

Older PeopleThere are more than 1,765 prisoners aged 60and over, 2% of the total prison population.21

Fazel and Danesh reviewed the treatmentneeds of older prisoners and found that,although mental health conditions wererecognised and recorded in the clinical recordof half of older prisoners, only 18% of thosewho needed medication received any.22

Suicide and self-harmRates of self-harm and attempted suicidein prison are high. Although suicide andself-harm is not necessarily associated withmental illness, both are highly correlatedwith clinical depression, psychosis and per-sonality disorder. There were 67 prison sui-cides in 2006 and 22,324 incidents of self-harm were recorded during 2005-06.23

Attempted suicide over a 12-month periodranged from 7% (in male sentenced pris-oners) to 27% (in female remand prison-ers).24 The greatest risk of suicide or self-harm is among newly arrived prisoners intheir first seven days in prison.25

According to figures for England andWales released by the Ministry of Justice,there were 92 suicides last year, amongthem a boy of only 15 years. Before 2007suicide rates in prison appeared to be declin-

11 Ministry of Justice, Population

in Custody, Monthly Tables,

March 2008, England and Wales.

See www.justice.gov.uk/docs/

population-in-custody-mar08.pdf

12 Justice for Women: The need

for reform, Prison Reform Trust,

2000

13 O’Brien M, Mortimer L,

Singleton N, Meltzer, H,

“Psychiatric morbidity among

women prisoners in England and

Wales”, International Review of

Psychiatry, 15 (1) 153-157, 2003

14 Ibid

15 The Mental Health of

Prisoners: A thematic review of

the care and support of prisoners

with mental health needs, HM

Inspectorate of Prisons, 2007

16 The Corston Report: A review

of women with particular vulnera-

bilities in the criminal justice sys-

tem, Home Office, 2007

17 Lockhart G, McClory J,

Ullmann B, Unlocking the Prison

Estate, Policy Exchange, 2007

18 “Public say: Stop locking up

so many women”, SmartJustice,

2007

19 Population in Custody, Monthly

Tables, March 2008, England and

Wales, Ministry of Justice, 2008

20 Lader D, Singleton N, Meltzer

H, Psychiatric morbidity amongst

young offenders in England and

Wales, Office for National

Statistics, 2000

21 Statistical Bulletin: Offender

Management Caseload Statistics

2006, Home Office Dec 2007

22 Fazel S and Danesh J,

“Serious mental disorder in

23,000 prisoners: a systematic

review of 62 surveys”, The

Lancet, 359 (9306) 545-50, 2002

23 Prison Factfile, Bromley

Briefing May 2007, Prison Reform

Trust

24 Brooker C, Sirdifield C,

Gojkovic D, Mental Health

Services and Prisoners: An updat-

ed review. University of Lincoln,

2007

25 Shaw J, Baker D, Hunt I,

Moloney A, Appleby L, “Suicide

by Prisoners: National Clinical

Survey”, British Journal of

Psychiatry, 184: 263-7, March

2004


10



Introduction

ing, so the sudden increase last year givescause for concern.

One possible explanation is that theHome Office safer custody initiative, togeth-er with the introduction of the assessment,care in custody and teamwork approach – acase management system that aims to identi-fy individual need and offer individualisedcare and support to prisoners in advance of,during and after a crisis – and the mentalhealth awareness training initiative for prisonofficers, all helped to reduce the rate of sui-cide. The 2007 increase is likely to be a func-tion of greater overcrowding. Juliet Lyon,director of the Prison Reform Trust, com-mented:

“Fis massive increase in prison suicides ofalmost 40% on 2006 figures is a result of thepressures of chronic overcrowding across theprison estate. Far too many people with seri-ous and enduring mental health problems areheld in custody, which despite the best effortsof prison staff can only make their illnessworse.”

History of policy developmentIn 1996 the responsibility for all healthcarerested with the Home Office and the PrisonService not the Department of Health andNHS as one might have expected. In thatyear, David Ramsbotham, then Chief

Inspector of Prisons, published a highly criti-cal report, Patient or Prisoner? which drewattention to the inadequate care for the men-tally disordered in prison; the lack of suitabletraining for medical and nursing staff andisolation from new clinical developments; thelack of continuity of care between prison andcommunity; and ignorance of the needs ofspecific groups of prisoners such as womenand young people.26 Despite these unsatisfac-tory standards, his report pointed out thatmental healthcare in prison was more thantwice as expensive per person than that pro-vided by the National Health Service for thegeneral population. He noted that prisoncould exacerbate mental health problemswith long-term impact on the individualconcerned and the community into which heor she was released.27 Patient or Prisoner?declared:

“Prisoners are entitled to the same level ofhealthcare as that provided in society at large.Fose who are sick, addicted, mentally ill ordisabled should be treated…to the same stan-dards demanded within the National HealthService.” 28

It recommended that the NHS should takeover responsibility for prison healthcare andoutlined several ways of doing so. Lookingback recently on what prompted him towrite the report, Lord Ramsbotham said:

0 -

20 -

40 -

60 -

80 -

100 -

120 -

140 -

160 -

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Num

ber/

Rat

epe

r10

0,00

0

Number of suicides Rate of Suicide per 100,000 General Population rate per 100,000

- - - - - - - - - - -

Figure 1: Number and rate per 100,000 of suicides in prisons 1997-2007compared to the rate per 100,000 in the general population, 1997-2005

26 HM Chief Inspector of Prisons,

Patient or Prisoner? HM


27 Ibid

28 Ibid


29 Health Advisory Committee for

the Prison Service, The Provision

of Mental Healthcare in Prisons,

Home Office, 1997

30 Birmingham L, “The mental

health of prisoners”, Advances in

Psychiatric Treatment, 9, 191-

201, 2003

31 Joint Prison Service and

National Health Service Executive

Working Group, The Future

Organisation of Prison Healthcare,

Department of Health, 1999

32 Ricketts T, Brooker C, Dent-

Brown K, “Mental health in-reach

teams in English prisons: Aims,

processes and impacts”,

International Journal of Prisoner

Health 3(4) 234-247, 2007


Belshaw L, A Review of Mental

Health Service Provision in the

Lincolnshire Prisons, University of

Lincoln, 2008

34 CPA is an approach to case

management adopted by all sec-

ondary care mental health servic-

es in the community (ie outside

prison) in England. A care co-ordi-

nator is appointed to co-ordinate

various elements of care and to

organise multidisciplinary reviews

of care. CPA should involve both

users and carers in planning and

reviewing care

35 Changing the Outlook: A strat-

egy for developing and mod-

ernising mental health services in

prisons, Department of Health,

2001

12


The principle of equivalenceThe following year, the Health AdvisoryCommittee for the Prison Service publishedits report, The Provision of Mental Healthcarein Prisons.29 This also drew attention to thepoorly co-ordinated delivery of healthcare inprisons and the need for more effectivethrough-care and aftercare arrangements.30

Prisons, it said, should “give prisoners accessto the same quality and range of healthcareservices as the general public receives fromthe NHS.”

These two documents paved the way forthe transfer of responsibility for healthcare inprisons from the Prison Service to theNational Health Service. The desire was toprovide services to prisoners that wouldmatch those received by the general popula-tion. In Chapter 4 we assess to what extentthis has been achieved.

The transfer of prison healthcare to theNHSTo address the issues raised by Patient orPrisoner?, a joint Prison Service and NHSexecutive working group was established todevelop practical proposals for change. Theresulting report, The Future Organisation ofPrison Healthcare, conceded that prisonhealthcare varied considerably in terms oforganisation, delivery, quality, effectivenessand links with the NHS.31 It acknowledgedthat an extensive programme of change wasrequired but rejected calls that the NHSshould assume sole responsibility for allprison healthcare on the ground that differ-ences in workplace culture might lead to

healthcare staff working in prisons beingmarginalised. It therefore recommended thatthe two organisations should be jointlyresponsible for identifying the health needsof prisoners in their area and, thereafter, forthe planning and commissioning of appro-priate services.

The working group was clear that systemsfor dealing with the high incidence of mentalhealth problems in prisoners were underde-veloped. Two major deficits were screeningarrangements to identify the need for mentalhealthcare at reception and the inadequatelevel of care-planning that takes place gener-ally within prisons.32 Its report recommendedthat to improve this situation the care ofmentally ill prisoners should develop in thefollowing manner:33

� In general all future improvementsshould be in line with NHS mentalhealth policy, in particular the NationalService Framework (NSF) for mentalhealth (see Box 1);

� Special attention should be paid to thebetter identification of mental healthneeds at reception screening;

� Mechanisms should be put in place toensure the satisfactory functioning of thecare programme approach (CPA)34 todevelop mental health outreach work onprison wings;

� Prisoners should receive the same level ofcommunity care within prison that theywould receive in the wider community;

� Policies should be put in place to ensureadequate and effective communicationbetween NHS mental health services andprisons.

The advent of mental health in-reachTwo years later, Changing the Outlook devel-oped a more specific policy for modernisingmental health services in prisons.35 The fore-word reaffirmed the principle of theNational Service Framework underpinningthe strategic direction of service develop-ment and set out a vision for the next three

“How could the prison service have ahealth system which was not part of theNHS? Gey were missing an opportuni-ty, when people were in prison, to iden-tify their physical and mental healthproblems and do something about them.So I made it my business to get prisonhealthcare into the NHS as quickly as Icould.” (Lord Ramsbotham)


36 Brooker C, Repper J, (Eds),

Implementing Mental Healthcare:

A review of the National Service

Framework for Mental Health,

Elsevier forthcoming September

2008

37 The community mental health

teams are fully integrated teams

of people from a variety of profes-

sional backgrounds, aiming to

provide one point of access to

mental health services for people

assessed as suffering from a

severe mental health problem.

Their services are aimed at adults

of working age

38 Narey M, “Human Rights,

Decency and Social Exclusion”,

Speech to The British Institute of

Human Rights, 2002






Introduction


to five years. It recognised that this was like-ly to be a major challenge given that mentalhealth services in prisons were ineffectiveand inflexible, and “struggling to keep pace”with developments in the NHS at large.The report called for a “move away from theassumption that prisoners with mentalhealth problems are automatically to belocated in the prison healthcare centre”;suggesting greater use of primary care, in-reach services, day care and wing-basedtreatments that mirror community-basedmental health services.

To enable prisoners with mental healthproblems to remain on their normal locationrequired the establishment of multidiscipli-nary mental health in-reach teams, funded bylocal primary care trusts, to provide specialistmental health services to prisoners in thesame way as community mental health teamsdo to patients in the community.37 Althoughit was anticipated that all prisoners wouldeventually benefit from the introduction ofin-reach services, the early focus of the teams’work was to be on those with severe andenduring mental illness. They would use theprinciples of the care programme approachto help to ensure continuity of care betweenprison and the community upon release fromcustody of these individuals. A target was setthat promised 300 more staff to provide in-reach services by April 2004, so that 5,000

more prisoners with a severe mental illnesswould receive better care and treatment andhave a care plan on release.

In a speech in 2002, Martin Narey,Director-General of the Prison Service, com-pared these extra 300 psychiatric nurses fromthe NHS to the “cavalry coming over thehill”, though he admitted that, because men-tal illness in prisons had risen sevenfold sincethe late 1980s, the situation they faced was“near overwhelming”.38

There are now 70 in-reach teams workingin prisons consisting of a core of psychiatricnurses, although access to other professionalssuch as psychiatrists, clinical psychologists,occupational therapists, drugs workers andcounsellors is scant.39

Since April 2006 responsibility for prisonhealthcare has been transferred fully to theNHS. There has clearly been some improve-ment in mental healthcare provision and agreater acknowledgement of the health needsin prison. Our report assesses the story so farand gives an idea of how far is yet to go. (ADepartment of Health strategy review,Improving Health, Supporting Justice, currentlyin progress, is undertaking the same task.)

In Chapter two the authors describe publicattitudes to offenders with mental illness.Using our own public opinion polling con-ducted by YouGov, (a professional researchand consulting organisation, pioneering the

Box 1: A National Service Framework for Mental HealthNational Service Frameworks are policies set by the Department of Health to define standards of carein the NHS for serious conditions such as cancer, coronary heart disease, diabetes and mental illness.A National Service Framework spells out how services can best be organised and the standards thatservices will have to meet. The National Service Framework for Mental Health was published in 1999and accompanied policy developments in prison health. It laid out a list of standards for mainstreamservices that were to be provided – mental health promotion, services in primary and secondary care,services for carers and suicide prevention. It was hoped that these would be achieved within a ten-year timeframe. The framework emphasised the need to improve the quality of mental health servic-es in prisons by creating closer partnerships between prisons and the National Health Service at local,regional and national levels. However, mental health in prisons has constituted a very small elementof the overall range of developments demanded across all National Service Framework standards formental health.36


use of internet polling), and similar data col-lected by the Department of Health, we com-pare differences in public attitudes to offend-ers with mental illness and to members of thegeneral community with mental illness.

Chapter three examines the experience ofoffenders with mental health illness as theytravel from the courts, through to screeningon reception in prison and then onward torelease and resettlement. We look at the lackof primary mental healthcare provision with-in prisons and assess the success of in-reachteams, the most significant policy initiativesince 1996.

Chapter four analyses the state of prisonmental healthcare, and assesses the successesand failures of various policy initiatives andthe delivery of mental healthcare in prisons.

The analysis draws on our own surveys of in-reach team managers and PCT prison healthleads, as well as in-depth interviews with thelatter.

Chapter five discusses the economic fac-tors surrounding prison mental healthcareincluding current spending, which it com-pares with spending in the community. Itanalyses the economic consequences of poormental healthcare provision in prison andsuggests that the cost of increased spendingwould be offset by even a small drop in reof-fending rates.

Chapter six sets out some broad policy rec-ommendations for improving mental health-care in prison and provides the frame of ref-erence for our second report later this yearthat will focus on policy solutions.

14



2Public attitudes tooffenders withmental illness

SummaryOne of the aims of our research was tounderstand the differences between the waythe public viewed offenders with mental ill-ness and the law-abiding with mental illness.Our research includes two sets of data. Thefirst involves public opinion polling, com-missioned for this report, on the public’s atti-tudes to offenders with mental illness.40 Thesecond is a Department of Health/TNS sur-vey on public attitudes to people with men-tal illness in general.41 Using these two datasets it is possible to compare the public’sknowledge and attitudes to offenders withmental illness and those with mental illnessin the community.The research produced two significant

findings: the majority of people grosslyunderestimate the prevalence of mental ill-ness in prison, and there is much less pub-lic sympathy for offenders with mental ill-

ness than for non-offenders. Both mayhave implications for the delivery of equiv-alence in care.

Public perceptions on prevalence ofmental illnessOur survey asked respondents to estimate theproportion of people in prisons with a men-tal health problem. The answer is 90%, butonly 1% of respondents were correct.The vast majority of respondents (74%)

estimated that the proportion of prisonerswith a mental illness is 50% or less.A similar question was used in the

Department of Health/TNS survey.Respondents were asked what proportion ofpeople in the UKmight have a mental healthproblem at some point in their lives. Theactual lifetime incidence of mental healthproblems is estimated to be around 1 in 4.42 40 All figures on public perception

of prisoners with mental illness

are from YouGov unless otherwise

stated. Total sample size was

2,067 adults. Fieldwork was

undertaken between 12th and

14th May 2008. The survey was

carried out online. The figures

have been weighted and are rep-

resentative of all British adults

(aged 18+). The full data can be

found in Appendix 2

41 The data on public percep-

tions of mental illness in general is

taken from the study Attitudes to

Mental Illness 2008 Research

Report commissioned by the

Department of Health and con-

ducted by TNS UK

42 Attitudes to Mental Illness

2008 Research Report, TNS UK,

2008


25 -

20 -

15 -

10 -

5 -

0 -

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port

ion

ofre

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s(%

)

0 10 20 30 40 50 60 70 80 90 100

Proportion with mental health problems in prison (%)

0

10

17

23

18

15

75

31 1

ACTUALPREVALENCE

Figure 2: Public perception of the prevalence of mental illness in prisons


Again, respondents tended to underesti-mate; a quarter of respondents thought theproportion is 1 in 10; 35% of respondentsthought it is less than this; 14% correctlystated the overall proportion is 1 in 4, and9% thought it was higher (18% answered“don’t know”). There is clearly a huge gap inpublic knowledge of the prevalence of men-tal illness, particularly in prisons.

Public attitudes to mental illnessand crimeThe Department of Health survey also poseda series of questions on attitudes to peoplewho have a mental illness. Respondents wereasked how much they agreed or disagreedwith eight statements. Our survey asked thesame questions but added the phrase “whocommit crime”. We deliberately mirrored thequestions from the DoH survey in order tocompare the results (see Box 2).

Our first question aimed to measure peo-ple’s perception of the general susceptibilityto mental illness and committing crime:60% either agreed or strongly agreed that vir-tually anyone can become mentally ill andcommit crime, whereas only 18% disagreedor strongly disagreed. In the DoH survey,89% of respondents agreed that virtuallyanyone can become mentally ill (Figure 4).

The answers to the rest of our questionscan be best represented using these attitudi-nal differences.

For example, in Figure 5, the first bar rep-resents the 29% difference in public attitudesto people with mental illness in general andpeople with mental illness who commitcrime.

A more tolerant attitude and the bestpossible careWhen asked whether we need to adopt amore tolerant attitude towards people with

43 Attitudes to Mental Illness

2008 Research Report, TNS UK,

2008

16


30 -

25 -

20 -

15 -

10 -

5 -

0 -

Pro

port

ion

ofre

spon

dent

s(%

)

Proportion of people who may have a mental illness at some point in their lives

ACTUALPREVALENCE

1 in 3 1 in 4 1 in 10 1 in 50 1 in 100 1 in 1000

9

14

25

14 13

7

Figure 3: Public perception of the prevalence of mental illness in thecommunity43

Box 2: Our SurveyTo what extent do you agree or disagree with each of the following statements?

� Virtually anyone can become mentally ill and commit a crime� We need to adopt a more tolerant attitude towards people with mental illness who commit crime� We have a responsibility to provide the best possible care for people with mental illness who com-

mit crime� People with a mental illness who commit crime are a burden on society� Increased spending on mental health services for people who commit crime is a waste of money� There are sufficient existing services for people with mental illness who commit crime� People with mental illness who commit crime are far less of a danger than most people suppose


Public attitudes to offenders with mental illness


mental illness, 84% agreed. When thephrase “who commit crime” is added onthe end, the number falls to 32%. Whenasked whether we have a responsibility toprovide the best possible care for peoplewith mental illness, 90% are in agree-ment. The figure falls to 64% when relat-ed to those with a mental illness whocommit crime. This may not seem partic-ularly surprising and is merely registeringpeople’s attitude to crime in general.However, we know from the previousquestion that a large proportion (60%)believes that anyone can become mental-ly ill and commit crime. If that is thecase, we need to explain why there is

there such a low tolerance for a disposi-tion that “virtually anyone” is capable of.

A burden on society and increased spendingMost people (78%) disagree that peoplewith mental illness are a burden on soci-ety. This number falls to 33% whencrime is entered into the equation. Mostpeople think that those with mental ill-ness who commit crime are a burden onsociety. Additionally the majority of peo-ple don’t believe that increased spendingon mental health services is a waste ofmoney (87% for mental health servicesin general and 57% for mental healthservices for people who commit crime).

So the majority view is that people witha mental illness who commit crime are aburden on society but that increasingspending on mental health services forthem is not a waste of money. This suggeststhat there is some sympathy with the viewthat the social costs of reoffending trig-gered by mental health problems can bereduced by investing in appropriate mentalhealth treatment.

This result is supported by the followingsurvey question. Only 11% of people believethat there are sufficient existing services forpeople with mental illness who commitcrime and this number rises to only 19% forthose agreeing that there are sufficient exist-

‘Virtually anyone can become mentally ill’

89

60

0102030405060708090

100

‘Virtually anyonecan becomementally ill’

‘Virtually anyonecan become

mentally ill andcommit a crime’

Pro

port

ion

ofre

spon

dent

s(%

)

-29

-51

-25-28 -26

-9

-40

-60

-50

-40

-30

-20

-10

0

‘Virtually anyonecan becomementally ill’

‘We need to adopta more tolerant

attitude towardspeople with mental

illness’

‘We have aresponsibility toprovide the bestpossible care for

people with mentalillness’

'People with amental illness are aburden on society’

‘Increasedspending on mentalhealth services is awaste of money’

'There aresufficient existing

services for peoplewith mental illness'

‘People with mentalillness are far lessof a danger than

most peoplesuppose’

Pro

port

ion

ofre

spon

dent

s(%

)

Figure 4: Public attitudes onsusceptibility to mental illness

Figure 5: Differences between public attitudes to people ingeneral with mental illness and to prisoners with mental illness


ing services for people with mental illness ingeneral. The majority of people believe therearen’t sufficient existing services either forthose with mental illness or for those withmental illness who commit crime.

Danger of mental illness17% of those surveyed agree that peoplewith mental illness who commit crime arefar less of a danger than most people sup-pose, while 50% disagree and 33% wereunsure or neither agreed nor disagreed.58% agreed with the DoH survey state-ment, “people with mental illness are farless of a danger than most people sup-pose”.As can be seen, there is a significant dif-

ference between the way the public see men-tal illness in general and when it is linked tooffending. In every question, respondentswere much less sympathetic towards thosewith mental illness who have committed acrime, although opinion varies according toage group and gender.

Differences in response by age and gender54% of young people (18-24) agree that wehave a responsibility to provide the best pos-sible care for people with mental illness who

commit crime compared to 68% for peopleover the age of 55.43% of men agree that people with men-

tal illness who commit crime are a burdenon society compared with 27% of women.

35% of young people (18-24) disagree thatthere are sufficient existing services for peoplewith mental illness who commit crime com-pared with 57% of people aged over 55.

18


0102030405060708090

100

Age (years)

18to

24

25to

34

35to

44

45to

54

55+

5461 64 67 68

Pro

port

ion

ofre

spon

dent

s(%

)

43

28

0

10

20

30

40

50

60

70

80

90

100

Male FemaleP

ropo

rtio

nof

resp

onde

nts

(%)

35

5157

62

0102030405060708090

100

Age (years)

57

18to

24

25to

34

35to

44

45to

54

55+

Pro

port

ion

ofre

spon

dent

s(%

)

Figure 6: Proportion who agreewe have a responsibility toprovide the best possible carefor people with mental illnesswho commit crime

Figure 7: People who agree thatpeople with mental illness whocommit crime are a burden onsociety

Figure 8: Percentage of peoplewho disagree that ‘there aresufficient existing services forpeople with mental illness whocommit crime’


3The offender mentalhealthcare journey

SummaryAn offender with mental illness who is sentto prison comes into contact with multipleservices and providers along his journey fromentry into prison to release. This may includea mixture of court diversion schemes, mentalhealth screening on reception, primary men-tal healthcare, being placed on an in-reachcaseload, referral to drug services, transfer toa secure health facility and then receivingthrough-care services on release. In the exist-ing system, each part of this journey has thepotential for problems.

Court diversionCourt diversion schemes were introducedin 1989 with joint Home Office andDepartment of Health funding. Manyschemes were put in place in the 1990safter the 1992 Reed Report advocateddiversion away from prison for offenderswith mental health issues.44 Their primaryaim was to steer mentally ill offendersaway from the criminal justice system andinto acute mental health services or to

liaise with other services in order to pro-vide care in the community. Court diver-sion is important for a number of reasons,not least that it ensures that offenders aredirected to the appropriate care.Diversion lies at the heart of the debatesurrounding the solution to prison over-crowding.

In 1997 there were 190 diversionschemes but by 2004 they had fallen to140.45 In practice few have been consideredsuccessful. In an article on court diversionin 1999, David James, a respected forensicpsychiatrist, said that “most court diver-sion services are currently inadequatelyplanned, organised or resourced, and aretherefore of limited effect.”

A 2005 report found that there wereinsufficient schemes to divert offenderswith mental health problems out of thecriminal justice system and into appropri-ate health services.46 In the same year aHome Office and Department of Healthreview of ten schemes concluded that theireffectiveness depended on adequateresources and an appropriate structurethat met both mental health and socialcare needs. But few schemes were based onneeds analysis or were delivered jointly byhealth and social care agencies. The DoHfound that targets, performance manage-ment and outcome analysis were generallynot in place and that many areas inEngland and Wales had no court diversionservices at all.47 Others relied on just onelone worker – usually a community psy-chiatric nurse. Survey respondents said

44 Review of Health and Social

Services for Mentally Disordered

Offenders and Others Requiring

Similar Services. Final Summary

Report, Department of Health and

Home Office, Cm 2088,

Stationery Office, 1992

45 Findings of the 2004 Survey of

Court Diversion/Criminal Justice

Mental Health Liaison Schemes

for Mentally Disordered Offenders

in England and Wales, NACRO,

2005

46 Ibid







Box 3: Overview of offendermental healthcare journey

� Court diversion� Reception screening� Primary mental healthcare� Mental health in-reach� Transfer to secure health unit� Release and resettlement


48 Ibid

49 Singleton N et al. Psychiatric

Morbidity among Prisoners in

England and Wales, Office for

National Statistics, 1998

50 Winstone J and Pakes F,

Mental Health Effective Practice

Audit Checklist (MHEP-AC):

Results of a pilot study involving

nine mental health teams, Office

for Criminal Justice Reform, 2007

51 Bradley K, Independent Review

of the Diversion of Individuals with

Mental Health Problems from the

Criminal Justice System and Prison,

Department of Health, forthcoming

52 Durcan G and Knowles K, op cit

that underfunding coupled with the lackof clear government guidance was leadingto serious gaps in service provision. Forexample:48

� Only 23% of schemes had been subjectto some form of evaluation since theirestablishment;

� 72% cited lack of beds as a barrier tosuccess;

� 50% have no input from either a psy-chiatrist or a psychologist and 41%reported difficulties in obtaining psy-chiatric reports;

� 34% said they were using the policestation as their sole “place of safety” forpeople detained;

� 25% had seen a decrease in staffing lev-els within the past year;

� 36% of schemes did not have a policyon information sharing.

The 1997 psychiatric morbidity surveysuggested that between 7% and 14% ofthe prison population has a severe andenduring mental illness, or roughly 6,000-12,000 offenders.49 Later studies have con-curred.

There is also a large group of offenderswith low-level mental disorders, oftencombined with drug or alcohol addiction.Depending on the severity of the crime, webelieve that many of this group should alsobe diverted to community sentences, drugand alcohol treatment, counselling andtalking therapies and various other alterna-tives to prison that are available to thecourts.

A more recent study in 2007 came to thesame conclusions as David James did in1999. Schemes continue to be underfundedand insufficiently embedded in both crimi-nal justice and mainstream mental healthprovision. Three out of four magistrates’courts have no court diversion schemes intheir area to access. And the fact that thereis no overarching organisational frameworkcontinues to impede their effectiveness.50

At the time of writing, Lord Bradley isconducting an independent review of thediversion of offenders with mental healthproblems or learning disabilities away fromprison.51 The review will “explore diversionat any point of the offender pathway,including diversion away from the crimi-nal justice system itself, whilst continuingto safeguard the public.”

Reception screening in prisonAny prisoner thought to be in need of amental health service undergoes an assess-ment process. Most prisons use the stan-dardised Don Grubin health screening testto assess the mental health of prisoners atreception.

Participants in a recent review of London’sprisons thought that these questions were notalways effective in identifying mental healthor substance misuse problems.52 However, ata national level there is mixed evidence aboutreception screening – many healthcare pro-fessionals say that it is good at picking upsevere and enduring mental illness but lesssensitive at identifying low-level disorders.Anne Owers told us:

20


Box 4: The Don Grubin Screening Test questions� Is the inmate charged with homicide?� Has the inmate ever received treatment from a psychiatrist for any form of mental health prob-

lem (not including treatment only in prison or one-off assessments)?� Has the inmate ever received antidepressant or anti-psychotic medication (outside prison

only)?� Has the inmate ever deliberately harmed himself?



The offender mental healthcare business

We believe that reception screening is fail-ing to pick up the extent or diversity ofneed for a variety of reasons. First, screen-ing is not properly executed or followed upby appropriately skilled staff. Secondly, thescreening itself is not sensitive enough topick up real, and particularly unacknowl-edged, need. This is unsurprising: theGrubin test asks only four questions relat-ed to whether the offender has had a previ-ous mental illness or been treated for one.It is easy for those who are unaware of their(often low-level) mental illness to bemissed and for those who do not want todeclare their history of serious mental ill-ness, for whatever reason, to simply answer“no” to any of the screening questions.

There are other tools that may be moreappropriate: the Inspectorate of Prisonsused the 12-item version of the GeneralHealth Questionnaire in a recent study ofmental health in prisons. This picked uphigher levels of need throughout the prisonpopulation and particularly in black andminority ethnic groups and male prisonerswho respectively are much less likely toaccess mental healthcare in the communi-ty and who are less likely to acknowledgeneed.53

Thirdly, reception itself can be a chaoticprocess in which large numbers of peoplearrive at one time. Screenings are conduct-ed by primary healthcare staff who may ormay not have mental health training. As aresult of all these factors, prisoners with

mental health problems are often not iden-tified and are therefore placed on an ordi-nary prison wing.54 Once there it is evenless likely that a mental health problemwill be identified.55

Paul Jenkins, head of the mental healthcharity Rethink, said that he was con-cerned about the “simple lack of identifica-tion of people with previous history” and“the inability to integrate people’s previoustreatment plans and medication”:

Primary mental healthcarePrimary mental healthcare is defined asmental healthcare that is provided by GPs.In the general community the distinctionbetween primary and specialist mentalhealthcare is often based on whether a serv-ice user has either a common mentalhealth problem, such as anxiety or depres-sion, or a serious mental illness, such aspsychosis.

According to the National ServiceFramework for Mental Health anyone notin contact with specialist services should betreated in primary care. But there is a longway to go if this principle is to be imple-mented in prisons.

� In-reach teams are able to cope withonly a small fraction of serious mentalillness, thus prisoners diagnosed withserious mental illness often end upbeing treated in primary care. Studieshave shown that primary mentalhealthcare staff in prisons have to deal






54 Parsons S, Walker S, Grubin

D, “Prevalence of mental disorder

in female remand prisoners”,

Journal of Forensic Psychiatry, 12,

194–202, 2001

55 Birmingham L, Mason D,

Grubin D, “A follow-up study of

mentally disordered men remand-

ed to prison”, Criminal Behaviour

and Mental Health, 8, 202–213,

1998

“Ge current reception screening is betterthan what preceded it but it’s not goodenough. Gere are lots of things thataren’t pulled out. One of the things wefound is that there’s a lot of tick box stuff,which is not followed up. Ge box thatsays ‘further information required’ wasoften not ticked, and many prisoners didnot have a secondary health screen to fillout their medical history.” (Anne Owers)

“If somebody with a significant mentalhealth problem is coming to prison, thenat least getting the medication right atthe outset and continuing any treatmentor intervention that they have been hav-ing strikes me as a pretty fundamentalprinciple. I think there are a lot of argu-ments for standardising the approachand putting more effort into getting thatinitial assessment.” (Paul Jenkins)


with cases displaying symptoms as severeas those treated by mainstream commu-nity mental health teams;56

� Prison primary care staff attend to manycommon mental health disorders oftenwithout specialist staff; some do possessmental health expertise but the extent towhich they can use it is highly variable;

� There is very little data concerning pri-mary care mental health staff in prisons,both in terms of their professional disci-plines and training;

� It is common for primary care staff toboth provide reception screening and totriage (or assess) all referrals to in-reachteams. Not only is this time-consuming,but it also demands a high level of clini-cal skill.

John Podmore, a former governor of Brixton,Swaleside and Belmarsh prisons, described atypical situation:

Findings from the recent review of mentalhealth service delivery in prisons highlight anumber of these issues.57 None of the nineGPs interviewed in the review had any train-ing in working with prisoners with specialistmental health needs. In addition, the reviewelicited that few primary care services in pris-ons had specialist mental health nurses whocould assist with screening or triage. Thereview recommended that there should be“sufficient resources in primary care teams tomeet the high level of primary mental healthneed in prisoners and greater co-ordinationbetween them and in-reach to ensure thatreferrals are appropriately allocated andresourced.”

In another 2007 survey, of prison in-reach,team leaders rated primary care triage ofmental health referrals as “inadequate”, par-ticularly in high security and category B pris-ons.58 One in-reach team leader said:

“We have a lot of people that we pick upaccidentally and they’ve never been referredalthough they have a psychiatric history.Primary care acknowledges the problem butthey don’t refer them. Fey do assess them, inthe sense that they tick the box, but no in-depth analysis takes place.”

Mental health in-reach teamsMental health in-reach teams – perhaps themost significant policy initiative from the late1990s – were first envisaged in the 2001Department of Health report, Changing theOutlook:

“For those persons judged to have the greatestneed, the NHS will fund the establishment ofmultidisciplinary teams, similar to communi-ty mental health teams (CMHTs) offering toprisoners the same sort of specialised care theywould have if they were in the community.” 59

In-reach teams are employed by local NHSproviders, rather than by prisons. Theteam, made up of mental health profes-sionals, may receive referrals from a rangeof sources. There are now 70 in-reachteams working in prisons, consisting of acore of psychiatric nurses, with supportfrom other professionals such as psychia-trists, clinical psychologists, occupationaltherapists, drugs workers and counsellors.60

The composition of the teams varies acrossprisons, team sizes range from two regis-tered mental health nurses to 19 whole-time equivalent staff. Their original taskwas to deal with cases of severe and endur-ing mental illness, yet the majority findthat even this is too big a brief given thesize and composition of their team. Oneexpert told us:

56 Senior J, Hayes A, Pratt D,

Thomas S, Fahy T, Leese M,

Bowen A, Taylor G, Lever-Green

G, Graham T, Pearson A, Ahmed

M, Shaw, J, “The identification

and management of suicide risk in

local prisons”. Journal of Forensic

Psychiatry & Psychology 18(3),

368-380, 2007






58 Brooker C, Gojkovic D, Shaw

J, “The second national survey of

mental health in-reach services in

prisons”, accepted for publication,

Journal for Psychiatry and

Psychology

59 Changing the Outlook: A strat-

egy for developing and mod-

ernising mental health services in

prisons, Department of Health,

2001






22


“If you’re a prisoner in a small catego-ry C training prison and you’re notfeeling well, not feeling good aboutyourself, you may well end up seeing asessional GP who is unlikely to look atyour primary mental healthcare in anystrategic way.” (John Podmore)


Our research suggests also that 35% of theircaseload is made up of people who have apersonality disorder but no accompanyingsevere mental illness, and just under a thirdhave neither a severe mental illness nor a per-sonality disorder. Our experts agreed that in-reach teams were often used to deal with dif-ficult and disruptive prisoners, rather thantreating those with the most severe cases ofmental illness whose behaviour may draw lessattention. John Podmore agreed. He said:

The changing role of mental healthin-reach teamsWhen in-reach teams were originally estab-lished there was a clear sense that theirfunction was to work with people with aserious mental illness. However, by 2007,this perception had changed. Findingsfrom the national survey of in-reach, forexample, show that the majority (96%) ofin-reach teams have operational policiesand many of these have been changed toreflect a greater emphasis on working with

primary care.61 It is also noticeable thatthere has been a decrease (from 52% to38%) in teams with operational policiesthat exclude those with common mentalhealth problems.

This change in orientation, driven partlyby the Department of Health through thecare services improvement partnership(CSIP) is reflected in the qualitative dataobtained in the survey of in-reach teams.Particularly when working with people withpersonality disorders who sometimes self-harmed, there was a lack of clarity about in-reach’s role. One team leader said thatalthough the target population was alwaysgoing to be people with serious mental ill-ness, he opposed black and white dividinglines because “if someone in prison has gota personality disorder or some mental ill-ness, substance misuse, that kind of stuff,that to me is a serious mental illness.”

This issue has not been resolved. A con-sultant psychiatrist said that the problemwas especially acute with women, whooften have severe personality disordersrather than severe mental illness. “There’s adebate as to whether in-reach take on thesesorts of women or just stick to womenwho’ve got severe mental illness.” A nurseon an in-reach team commented:

“Fere is debate even among the teamabout who should receive secondary mentalhealth services. I work on the premise thatpersonality disorders are complex needs andthat they are included in community men-tal health teams and we should be replicat-ing that service in prison…Not everybodyshares my view on that.”

In this sense, “mission creep” has beenoccurring because there has been a percep-tion, driven partly by policy, that closerintegration between primary care and in-reach would be beneficial.62 The data pre-sented here seems to indicate that this hasled to confusion about the principal func-tion of in-reach teams.

61 Brooker C, Gojkovic D, Shaw,

J, op cit

62 Steel J, et al, “Prison mental

health in-reach services”, British

Journal of Psychiatry, 190 373-

374, 2007



“Too often we find a mental healthcarein-reach team consists of two RegisteredMental Health Nurses, for example, anda forensic psychiatrist who might noteven work for the same mental healthtrust. Gere are not that many teamsacross the country that have the fullrange of occupational therapists, clinicalpsychologists, talking therapists or evena social worker. Gere isn’t that samesort of multidisciplinary team that theremight be in the community.”

“Where mental illness is being dealtwith, it can often be targeted where itpresents in prisons in a disruptive way.If poor mental health presents itself inwithdrawal and personal exclusionthen there is a real danger it will bemissed.” (John Podmore)


63 Counselling Assessment

Referral Advice, CARAT, is a drug

service available in prison


Gojkovic D, Mental Health

Services and Prisoners: An updat-

ed review, University of Lincoln,

2007

65 Steel J et al, “Prison mental

health in-reach services”, British

Journal of Psychiatry, 190 373-

374, 2007

24


Although prison mental healthcare wascovered by the National Service Framework,no specific guidelines were provided for in-reach teams. This has probably been a causeof the teams’ confusion regarding their brief.Whereas, the Department of Health haspublished detailed guides for the operationand staffing of community assertive outreachteams and early intervention in psychosisteams, no such guidance has been forthcom-ing for in-reach teams in prisons. Assertiveoutreach teams provide intensive support forthe severely mentally ill people in the com-munity who are “difficult to engage” in moretraditional services. Many will have a crimi-nal record and more than one disorder. Careand support is offered in their homes or someother community setting, at times suited tothem. Team staff may be involved in directdelivery of practical support, care co-ordina-tion and advocacy as well as more traditionaltherapeutic input.The aim of the service is tomaintain contact and increase engagementand compliance. Early intervention in psy-chosis teams work with people aged between14 and 35 years, who have experienced a firstepisode of psychosis.

Sean Duggan, director of the prisons andcriminal justice programme at the SainsburyCentre for Mental Health, told us that in-reach teams have been “overburdened”.

One of the biggest difficulties that in-reachteams face is their separation from other serv-ices. Policy initiatives in this area, as in manyother areas of government, have been rolledout separately. This leads to isolation andpoor co-ordination across services even with-in prisons. Julian Corner, chief executive of

the Revolving Doors Agency, a charity dedi-cated to people caught up in a cycle of crimeand mental illness, said that there was achronic lack of integration between differentservices:

Further, the modelling of in-reach on com-munity mental health teams seems mis-placed. Any evidence of treatment modelsthat have been found to be effective in thecommunity, such as community mentalhealth and assertive outreach teams, cannotbe directly applied to the prison populationbecause issues of criminality can complicatethe picture.64 Constraints within the prisonenvironment – such as security, informationsharing, levels of literacy and treating prison-ers without their consent – all undermine thetranslation of community-based treatmentsinto secure settings.65

Transfers to secure health facilitiesSome prisoners with mental health problemswill require in-patient treatment that cannotbe delivered by the prison. These prisonerscan be transferred to secure health settings inorder to receive the appropriate care.

Under the terms of the Mental Health Act1983, the Home Secretary may direct thetransfer of a prisoner to hospital for psychi-atric treatment on receipt of two separatemedical reports. One of the two doctors ormedical officers must be approved under sec-tion 12(2) of the Act as having recognised

“We gave them too much pressure; wedidn’t provide a national standard forin-reach. I think that’s regrettable, weshould have done that. We need a blueprint for the operation of in-reach and anational design to inform localcommissioning.” (Sean Duggan)

“Mental health teams are struggling tocross a cultural divide through to therest of the prison, and this comes downto does the mental health team knowwhat the drugs team is doing, does itknow what the housing advice team isdoing, or many of the others? Most ofthe cases are going to be dual diagnosis,so what on earth are CARAT teams andmental health teams doing operatingseparately?”63 (Julian Corner)


66 “Procedure for the Transfer of

Prisoners to and from Hospital

under Sections 47 and 48 of the

Mental Health Act 1983”

67 Rutherford M, Duggan S,

Forensic Mental Health Services:

Facts and figures on current pro-

vision, Sainsbury Centre for

Mental Health, 2007

68 Ibid

69 Durcan G, From the Inside:

Experience of prison mental

healthcare, Sainsbury Centre for

Mental Health, 2008

70 Durcan G, “Equivalent to

what? Mental healthcare in

Britain’s prisons”, The Journal of

Mental Health Workforce

Development, Volume , Issue 4,

2006


Briefing May 2007, Prison Reform

Trust



special experience in the diagnosis or treat-ment of mental disorder.

The key to successful secure transfers isminimal waiting times for assessment andtransfer.

In November 2005, Louis Appleby,National Director of Mental Health andJohn Boyington, Director of Health andOffender partnerships, wrote to all strategichealth authorities and PCT mental healthcommissioners about unacceptable delays inthe transfer of acutely mentally ill prisonersto and from hospital under Sections 47 and48 of the Mental Health Act 1983. A docu-ment was included that outlined the proce-dures for transferring prisoners under the Actin order to “secure and sustain significantimprovements”.66

The following year, 1,440 mentally disor-dered offenders were moved from the penalsystem into forensic psychiatric services.About one third of those (473) were initiallysentenced to time in prison and later trans-ferred to hospital; 21% (303) were divertedinto forensic psychiatric care at the point ofsentencing.

An audit by the Department of Health in2006 indicated that at any one time acrossthe prison estate there are 282 prisonersawaiting initial psychiatric assessment by anin-house or visiting psychiatrist who routine-ly works in the prison. Six prisons each hadmore than 12 people waiting for an initialassessment.

Some prisoners who are recommended bythe prison for transfer to forensic services arenot accepted and are kept in prison. Whentransfer requests have not been accepted aftera second mental health assessment by anexternal provider’s consultant psychiatrist,33% of the time it is because the prisoner is“not meeting the criteria for transfer underthe Mental Health Act 1983”. Where prison-ers are not accepted for transfer, 55% aremanaged on the main wing of the prison and35% in the prison’s in-patient unit.67

When a transfer has been agreed, lack ofbed availability is the most common reason

for delay in transfers (73%). However, inJune 2007, the Government stated that:“There has been a significant decrease in thenumber of people waiting over 12 weeks fora transfer – in the quarter ending March2007, 40 prisoners [who had been waitingmore than 12 weeks] were waiting, downfrom 51 in the same quarter in 2005.”68

It is crucial that transfers to forensic psy-chiatric units are used where necessary andare subject to minimal delays. Removingthose prisoners whose needs exceed the capa-bilities of the prison staff and support servic-es could not only cut costs, but also relievepressure on the system as a whole. A prison-er with a mental illness will incur high costsin addition to those incurred providingprison services for a healthy offender such asdrug treatment or behavioural interventions.

Release and resettlementThe final part of the offender journey isrelease and resettlement.This is a critical stagein the future of the offender and often deter-mines whether he will go on to reoffend.

A study by Graham Durcan found thatwhile most prisoners who were in contactwith in-reach teams were more confidentabout their futures than those who were not,the experience of virtually all of those whohad had experience of leaving prison previ-ously was negative. They reported that ele-ments of care were not put in place to supportthem.69 Nearly half of people with a mentalhealth problem have no permanent residenceon release, while 50% have no GP.70 ThePrison ReformTrust found that 96% of men-tally-disordered prisoners were released with-out supported housing, including 80% ofthose who had committed the most seriousoffences; more than three quarters had beengiven no appointment with outside carers.71

The prisoners interviewed in Durcan’sreport were negative about what they saw asthe basics: “decent” accommodation, supportin getting benefits, registration with a GP,referral to a mental health service or adequate


72 Durcan G, From the Inside:

Experience of prison mental

healthcare, Sainsbury Centre for

Mental Health, 2008

73 A crisis resolution team pro-

vides prompt intensive support,

including medication, for people

with mental health crises, in their

own home. The idea is to prevent

hospital admissions and it stays

involved until the problem is

resolved

74 Durcan G, op cit, 2008

26


support for substance misuse. Several prison-ers said that although they received little sup-port for their mental health in prison, theprison met their basic requirements and tookresponsibility for many decisions concerningtheir day-to-day needs and activities. Butwhen they left prison they were “suddenlyback in charge”, in most cases with no sup-port, and with no history of having “man-aged it all well before”.72

Mentally disordered prisoners are enti-tled to the same arrangements as mentallydisordered persons being discharged fromhospital. As at other stages of the criminaljustice system, the prison process allows anopportunity for intervention and linkingan individual with, or back into, services inthe community. The process is facilitatedby the in-reach team, which liaises with theappropriate community-based services.

If the prison does not have an in-reachteam, this role may be taken on by the vis-iting psychiatrist, criminal justice mentalhealth liaison schemes, the prisoner’s careco-ordinator in the community, or theprison staff – most usually healthcare staffor probation officers. In some areas the cri-sis resolution team has been extended toundertake assessments of prisoners.73

Durcan found that while the in-reachteams did give consideration to what hap-pened after a prisoner was released, those

prisoners not in contact with these servicesreceived very little support. Healthcare staffattempted to connect some prisoners withGPs, but for many the most they wouldreceive on release was a card with the NHSDirect phone number.74

The care programme approach (CPA) shouldlink the prisoner, once discharged, to appro-priate community services. Otherwise anywork achieved within the prison is lost, theoffender’s mental health is likely to deterio-rate and the chances of reoffending are high.These care plans should include suitablesecure occupational activity, adequate hous-ing and appropriate entitlement to welfarebenefits. Care plans need to be attended byall the key professionals. The principle ofequivalence requires that a severely ill prison-er should receive a follow-up contact with aclinician within seven days, as would be thecase in the community.

“Ge fundamental point of principle isthat, whatever prisons are there for, whenoffenders come out you ought to givethem their best chance not to go back.Gis is something I feel very passionatelyabout. You need to address the range ofneeds that people face. So if they’ve gotdrug and alcohol problems or housing,employment or mental health issues,there should be access to ongoing sup-port and treatment when they come out.It points to a need for some kind of casemanagement approach.” (Paul Jenkins)

“We are talking about individuals whomnobody else wants to work with whenthey are in the community, and whenthey offend the criminal justice systempicks up the responsibility. In a way thatsuits everybody fine because you’ve got allthese awkward customers off your booksand they are out of harm’s way for awhile. So there is an argument for mak-ing sure somebody is responsible andcan’t wash their hands of individualshowever challenging their needs andhowever difficult they are.” (Paul Jenkins)

“Gere isn’t the care available before orafterwards for many people that we see.Either their first contact with mentalhealthcare is through criminal justice, orelse they have not been dealt with beforeand they won’t be dealt with well after-wards. Gey are too often seen as a burdenand they are very costly. Gey take a bigchunk out of your budget.” (Anne Owers)


4Assessment of prisonmental healthcare

SummaryWe asked people working in the field fortheir assessment of prison mental healthcare.Their answers were bleak. The majority ratedit as either average or poor. As well as describ-ing problems with co-ordination, they high-lighted staff shortages, commissioning servic-es, overcrowding, and a lack of training. Allof these factors impact heavily on the deliveryof mental healthcare and make it harder todeliver on the promise of equivalence withhealthcare in the community.

Self-assessment of mental healthcarein prisonsThe research team surveyed two groupsdirectly involved in delivering prison mental

healthcare; in-reach team leaders and PCTprison health leads. Both groups were askedto assess the current status of mental health-care in prisons.75 54% of in-reach leaders saidthat mental healthcare was either average orpoor; 34% said it was good. No respondentsrated it as either excellent or very poor. 60%of PCT prison health leads said that mentalhealthcare was either average or poor; 40%said it was good, and none rated it as excel-lent, very good or very poor.

When this data is combined the per-centage of respondents who assessed men-tal healthcare in prisons as either average orpoor is 54%. It is of concern that over halfof all health providers in prison assessprison mental healthcare as average or poor– particularly for a self-assessment.

75 The surveys were conducted

in March 2008 with a response

rate of 49% and 35% respectively.

For the mental health in-reach

teams the sample size was 70

and the number of respondents

was 34. For the PCT prison health

leads the sample size was 60 and

the total number of respondents

was 21


12

33

27 27

0

40

35

25

0

5

10

15

20

25

30

35

40

45

Excellent Very good Good Average Poor Very Poor

Mental health in-reach leads PCT prison health leads

Pro

port

ion

ofre

spon

dent

s(%

)

Figure 9: What is your general assessment of mental healthcare in prisons?


StaffingStaff shortagesOur interviewees repeatedly referred tostaff shortages. The majority of the mentalhealthcare budget is spent on salaries. If, aswe argue later, there is inadequate fundingfor prison mental healthcare, we wouldexpect this to be reflected in the level ofstaff resources.

The Prison Reform Trust report on themental health needs of men in prison high-lights the inequities in staffing betweenprison and the community.76 In the report,Adrian Grounds argues that a typical largelocal prison, with 1,000 places and aturnover of 5,000 receptions a year, willhave about the same caseload of seriousmental illness as a town of 20,000 with100,000 people arriving and leaving eachyear. According to Department of Healthguidance for community mental healthteams, a typical team, with a caseload of350 service users (only half of who presentcomplex problems) would consist of threeto four community psychiatric nurses; twoto three social workers; a minimum of onefull-time clinical psychologist; a supportworker and administrator; and two full-time psychiatrists: in total between 12 and14 professionals.

A recent Sainsbury Centre report cal-culated that working-age adult communi-ty mental health service staffing repre-sented 55% of what was needed to imple-ment the Government’s mental healthpolicies.77 The same paper estimated thata typical category B men’s prison with550 inmates would require an in-reachservice of 11 full-time equivalent special-ist mental health staff to meet the needsof its population.

Those prisons for which information isavailable indicate that the average size of anin-reach team in 2007 was just over fourfull-time clinical staff.78 Provision relativeto need is therefore only a third of what isrequired and in many cases characterisedby teams consisting solely of nurses rather

than the multidisciplinary teams envisagedby policymakers.79 A large local prison islikely to have at least the caseload thatwould be served in the community by afull community mental health team, andin the prison there will be additionaldemands such as providing assessments forcourts, arranging aftercare for those leavingcustody, and trying to look after seriouslyill prisoners who should be in hospitalthough places are unavailable. However, anin-reach team is very unlikely to have thepersonnel that would be found in commu-nity mental health services.

We believe that multidisciplinary teamsare of crucial importance to such an isolat-ed service. For example, very few socialworkers contribute to in-reach teams,when the evidence shows that social needson release are a crucial determinant of reof-fending.80

Overcrowding and its effect on mentalhealthcareOvercrowding affects all prisoners, andparticularly those with mental health prob-lems. The Inspectorate of Prisons noted inits 2007 review that it was:

“Activity and support from staff and otherprisoners that were the two things thoughtto be most helpful by prisoners with mentalhealth and emotional problems, and theabsence of these crucial elements wasthought most likely to make things worse.In overcrowded, under-resourced prisons,these essential elements of care are, howev-er, at a premium.” 81

It is worth understanding the sheer scale ofthe overcrowding problem and how itspecifically impacts on the delivery ofmental healthcare. On 22nd February2007, the prison population in Englandand Wales reached 82,068 – 96 over itsusable operational capacity and exceedingits highest normal level for the first time.

76 Rickford D and Edgar K,

Troubled Inside: Responding to

the Mental Health Needs of Men

in Prison, Prison Reform Trust,

2005

77 Boardman J and Parsonage

M, Delivering the Government’s

Mental Health Policies: Services,

staffing and costs, Sainsbury

Centre for Mental Health, 2007

78 Gojkovic D and Brooker C,

Secondary analysis of prison

mental health in-reach survey

data In submission, PhD Thesis,

University of Lincoln, 2008






80 Social Exclusion Unit,

Reducing Reoffending by Ex-pris-

oners, Office of the Deputy Prime

Minister, 2002






28




Assessment of prison mental healthcare

The useable operational capacity of thePrison Service is the sum of all prisons’operational capacity less 1,700 places.83

The figures meant that for the first timethe Prison Service had almost 100 moreinmates in jail than the numbers governorswant to hold to ensure a controlled andsecure regime.

According to the Prison Service’s stan-dard of certified normal accommodation(CNA) – the decent standard of accom-modation that the service aspires to pro-vide all prisoners – the prison population isnow 8,000 more than it should be.

The bloated size of the prison popula-tion is undermining any work the PrisonService is trying to do in terms of makinglife inside constructive for the majority ofprisoners. In 2001-02 the Prison Servicefailed to meet its own target of providingprisoners with at least 24 hours of pur-poseful activity a week. Only three out of40 of the local prisons for men (thoseholding predominantly remand and shortsentence prisoners), which suffer theworst overcrowding, managed to meetthis target.

But a lack of “purposeful activity” is notthe only consequence of overcrowding. In adesperate attempt to find empty beds, pris-oners are being transported all over the

country. In 2001, 37,000 prisoners werebeing held over 50 miles away from home;5,000 of these were being held more than150 miles from their home town. This dislo-cation has cost the taxpayer millions ofpounds in transportation and delays to thecriminal justice system as a result of latearrivals for court appearances. It also jeopar-dises family relationships and the chances ofsuccessful integration back into the commu-nity on release – two of the most importantfactors in reducing reoffending.

In an interview with The Times on 12thJuly 2007, Jack Straw, Secretary of State forJustice, stated: “We cannot just build ourway out of crowding.” He called for anational conversation on the use of prisonand said that he would still want this totake place even if he could “magic an extra10,000 places” into being.84

82 Population in Custody, Monthly

Tables, March 2008 England and


83 This 1,700 is known as the

operating margin and reflects the

constraints imposed by geo-

graphical distribution and the

need to provide separate accom-

modation for different classes of

prisoner (ie by sex, age, security

category, conviction status, and

risk assessment)


Briefing, May 2007, Prison

Reform Trust

Table 2: The ten most overcrowded prisons in England and Wales at March 200882

Establishment In use CNA Operational Capacity Population Total Percentage Overcrowding

Kennet 171 342 333 195

Shrewsbury 175 340 319 182

Swansea 240 422 421 175

Preston 429 750 734 171

Altcourse 794 1,024 1,315 166

Lincoln 436 738 708 162

Dorchester 145 259 234 161

Durham 577 981 931 161

Leicester 210 385 329 157

Northallerton 153 252 232 152

“Ge present overcrowding means thatfar too many are away from their base.To me the resettlement process doesn’treally work unless the person who isgoing to be responsible for the resettle-ment makes contact with the personbefore they are released and then is readyto receive them.” (Lord Ramsbotham)


CommissioningSince the transfer of the prison healthcarebudget to the Department of Health, thecontrol of spending has been delegated toprimary care trusts. All PCTs are now respon-sible for commissioning (purchasing) servicesfor prison health but the Government admitsthat it has not yet seen the benefits of thischange. A source from the Department ofHealth told us: “We have transferred thecommissioning responsibility, but we are yetto fully modernise the service whether it’smental health or drugs or communicable dis-eases.There is still some way to go. I think it’sgoing to take a few years for the PCTs to real-ly bite on that.”

A prisoner who is diagnosed with twomental disorders may be involved with asmany as five different providers. Healthcarecommissioning in prisons is complex and thesystem has not proved sophisticated enoughto deal with such issues. Local PCTs usuallycommission primary care, specialist sub-stance-misuse workers and mental health-care. Providers still work in “silos” and com-munication about basic issues, such as the

assessment of complex disorders, is inade-quate. Julian Corner told us that matters aremade more difficult for community commis-sioners because the profile of a prison is like-ly to change every year or so and so may bevery different from the local population.

More thought needs to go into the ways inwhich integrated mental healthcare shouldbe commissioned in prisons. Structures andsystems which promote far greater co-ordina-tion between agencies and services are essen-tial. Our experts were very clear that there isstill a reluctance in PCTs to deal with thesepotentially difficult clients and a tendency toemploy various ways of ensuring that theystay off their books.

85 All figures from Prison Factfile

Bromley Briefing May 2007,

Prison Reform Trust, unless other-

wise stated

86 Population in Custody Monthly

Tables June 2007 England and


87 Population in Custody Monthly

Tables March 2008 England and


30


Table 3: Prison overcrowding in England and Wales in the last 15 years(mid-year)85

Year Number of places (CNA) Number of prisoners Percentage overcrowding

1994 48,291 48,929 101

1995 50,239 51,086 102

1996 53,152 55,256 104

1997 56,329 61,467 109

1998 61,253 65,727 107

1999 62,369 64,529 103

2000 63,346 65,194 103

2001 63,530 66,403 105

2002 64,046 71,112 111

2003 66,104 73,627 111

2004 67,505 74,468 110

2005 69,394 76,079 110

2006 70,085 77,962 110

200786 71,374 79,734 112

200887 72,512 81,759 113

“It is important to examine whereprisons are in relation to PCT’s priori-ties, and where mental health fits. GePCT is key. If we’re going to deal withmental health issues, drugs and alco-hol, prisons need to be much higherup their agenda.” (John Podmore)


Prison staff trainingOne of our interviewees suggested that theclosest prisoners get to having a “carer” inprison is through contact with individualprison officers (POs). Despite the veryhigh incidence of mental health disorder inprisons, mental health awareness is still nota mandatory component of POs’ basicintroductory training. Although healthcarestaff are in charge of the clinical care ofprisoners, the discipline staff clearly alsohave an important role to play. Andalthough there have been various mentalhealth awareness training schemes deliv-ered in the past, interviews with ourexperts, in-reach leaders and PCT prisonhealth leads suggest that there is still a needand desire for more.

The very nature of prison and its primefocus on security can hinder the neces-sary spread of awareness about mental ill-ness and its treatment. Prison officershave to care for a very vulnerable groupof people but are not recruited on thatbasis nor are they trained to create a ther-apeutic, healthy environment – though a

number end up with that kind of role. Ifthe primary task of the prison is aboutsecurity, then that will drive every aspectof what happens to an inmate. If the pri-mary task is to provide a secure healthyenvironment then that task will filterdown to everything that goes on includ-ing who gets recruited, who gets trained,and what the skills of the senior manage-ment team are. Ensuring that this overar-ching primary task is enforced is theresponsibility of the prison governor butit is not always easy.

GovernorsPrison governors have overall responsibil-ity for determining the culture in aprison. However, the knowledge that gov-ernors possess about mental health is vari-able. Paul Tidball of the PrisonGovernors’ Association recently stated inevidence to the Home Affairs SelectCommittee:

“…a substantial majority of people inprison had significant mental health, drugand alcohol abuse problems and many hadcommitted only minor offences. More treat-ment and support services in the communi-ty were needed to convince the courts thatnon-custodial sentences for them wereviable.”

It is often difficult for a governor to drivechange in a prison because of the shorttime he or she will stay in the post (cur-rently an average of two years).

Assessment of prison mental healthcare


“A lot of prison officers say to you thatthey can’t get access to training, theydidn’t have the training, but theywould like it and so I don’t think it’sworking properly.” (Sean Duggan)

“Ge governor doesn’t stick around todrive change over a sufficiently longperiod of time. How can you trans-form an institution from one state ofaffairs to another if the average stay ofa prison governor is two years?”(Julian Corner)

“Ge Prison Officers’ Association andthe professional association, the PrisonGovernors’ Association are united –and they are not always – in wantingto stop being asked to look after peo-ple who are mentally ill if they haveoffended very seriously and warrantimprisonment. Time and again theysay how bad it is for their members tohave to do jobs they are not trainedfor.” (Juliet Lyon)


Governors play the most importantrole of all in determining the atmosphereof a prison. As with prison officers, webelieve that all future prison governors’training should include a mandatory ele-ment of mental health awareness training.

The principle of equivalenceTwelve years after David Ramsbothammade the case for equivalence, it is still along way from being achieved. But even ifGovernment provided the same level ofmental health services in prison as in thecommunity it would not achieve equiva-lence because of the psychiatric morbidityof the prison population.

One of the core documents to guide theprovision of equivalent services is theNational Service Framework (NSF) forMental Health which it was envisaged would

encompass prisons as well as the general com-munity. But the reality has fallen short of thetheory.

The numbers of prisoners with a mentalhealth disorder is not fixed. Improvements inthe diversion system, for example, will neces-sarily reduce them and the system must beflexible enough to accommodate suchchanges.

32


“We don’t have crisis teams generallygoing into prisons, we don’t have earlyintervention teams for psychosis andassertive outreach teams, and those arethe big parts of the psychological service.Gose are the big parts of the NationalService Framework, that should apply toprisons and they don’t.” (Sean Duggan)


5Spending, staffand savings

SummaryThe proportion of the community healthcarebudget spent on mental health is 15%. Theproportion of the total prison healthcarebudget spent on mental health is only 11%,even though mental illness is much morepervasive in prison than the community atlarge.88 Our research shows that shortages instaff recruitment and confusion over in-reachcaseloads lead to inefficiencies in spending.We estimate that more than a third (£8.5million) of the total mental healthcare budg-et is not being spent efficiently.

Various studies have suggested that thecurrent spending of £20.4 million onprison mental healthcare would need to betripled in order to reach levels equivalentto that spent within the community. We

argue that, coupled with more efficientspending, this extra cost would be offset bya reduction in reoffending, which isstrongly associated with social exclusion(mental illness is a factor). A less than 1%reduction in reoffending rates would coverthe cost of tripling spending.

SpendingRegional variation in mental healthcarespendingThe total expenditure on prison mentalhealthcare in England in 2007-08 is £20.8million equivalent to an average of £306 perprisoner in publicly run prisons.89 When bro-ken down by region, there are some differ-ences in the amount spent per prisoner.

88 Brooker C, Duggan S, Fox C,

Mills A, Parsonage M, Short-

changed: Spending on Prison

Mental Healthcare, Sainsbury

Centre for Mental Health, 2008

89 Ibid

90 Ibid, reproduced by kind per-

mission of Sainsbury Centre for

Mental Health


£0 £100 £200 £300 £400 £500

England

West Midlands

South West

South Central & South East

North West

North East, Yorks & Humber

London

East Midlands

East England

Reg

ion

Spend per head per year (£)

Figure 10: Prison mental health spending per head of prison population byregion90


Expenditure per head ranges from a lowof £182 in the East Midlands and theSouth West to a high of £416 in London.Although costs in London are higher thanin other parts of the country, this explainsonly a small part of the observed differ-ences in spending. It is also notable thatexpenditure per prisoner is more thantwice as high in the North East, Yorkshire& Humber region as in the East Midlandsand in the South West.92

It is unlikely that the regional prevalenceand severity of mental health problemsvary on a scale sufficient to explain the dif-ferences in spending per head.

Variations in overall health spendingOne possible explanation is that theyreflect differences in overall spending onprison healthcare, covering physical as wellas mental health conditions. Plannedspending on all types of healthcare in pris-ons amounted to £189 million in Englandin 2007-08, equivalent to £2,769 per pris-oner.

Apart from London, there is much lessvariation between regions in overall healthspending per prisoner than there is inspending on mental health. In the case of

mental health, the highest spending regionoutside London spends more than twice asmuch as the two regions with the lowestspending. In the case of general healthexpenditure, the corresponding differenceis less than 30%.

London is a clear outlier, spending near-ly twice as much on prison healthcare perprisoner as any other region in the country.This is why the capital appears to be a lowspender on prison mental health when thisis measured as a share of total prison healthexpenditure.

The North East, Yorkshire & Humberand the North West regions are highspenders on prison mental health, whetherthis is measured in absolute or relativeterms, and the South West and EastMidlands are low spenders, again on bothbases of comparison.

This suggests that, except in the case ofLondon, regional variations in mentalhealth spending per prisoner cannot beexplained by corresponding variations inoverall prison health spending. For exam-ple, the South West region spends moreper head on prison healthcare generallythan the North East, Yorkshire & Humberregion, but less than half as much on men-


34

91 Ibid

92 Ibid, reproduced by kind per-

mission of Sainsbury Centre for

Mental Health

England

West Midlands

South West

South Central & South East

North West

North East, Yorks & Humber

London

East Midlands

East England

0% 3% 6% 9% 12% 15%

Reg

ion

Proportion of spend (%)

Figure 11: Proportion of mental healthcare in total healthcare spending byregion91


93 Mental Health Strategies, The

2006/7 National Survey of

Investment in Mental Health

Services. Department of Health,

2007

Spending, staff and savings


tal healthcare. Although this is an extremeexample, it does imply that there are majorinequities in the funding of prison mentalhealth services around the country thatmerit further investigation.

The differences in spending are notexplicable on the basis of regional varia-tions in general prison health spending orany other objective factor. It is hard toavoid the conclusion that standards ofmental healthcare in prisons vary substan-tially. This result chimes with findingsfrom our polling of in-reach team leadersand PCT prison health leads, whichshowed that while some rated prison men-tal healthcare as “good” more than halfrated it as either “average” or “poor”.

Comparison of mental healthcarespending in prisons and the communitySpending on prison mental healthcare isestimated at £306 per person in prison.This is almost twice the average level ofmental health spending on working-ageadults living in the community. Based onthe latest annual survey of investment inadult mental health services carried out forthe Department of Health, total expendi-ture on mental healthcare for adults ofworking age in the general population isestimated at £169 per head in 2007-08.93

The £20.8 million spent on prison men-tal healthcare represents 11% of the totalspent on prison healthcare. To comparethis directly with the figure of £306 forprison mental healthcare would not, how-ever, be a like-for-like comparison, as thecommunity figure includes spending on arange of services that is not covered in theestimate for prisons, most obviously in-patient and residential care.

In general terms, prison in-reach teamsare intended to provide broadly the sametype and mix of services to prisoners as areavailable to people with severe mentalhealth problems who are living at home. Inthe absence of a precise definition of whatthis should include, two alternative meas-

ures are suggested here: a broad one includ-ing spending on all outpatient/residentialservices in the community and a narrow onecovering only expenditure on community-based mental health teams.

Using these measures, spending on adultmental health services for the general pop-ulation is estimated at £79 per head on thebroad definition and £42 per head on thenarrow definition. Per capita spending onprison mental healthcare is between fourand seven times as large as per capitaspending in the general adult population.However, given the much greater preva-lence of mental illness in prison, this figurewould need to be around 20 times as largeto provide equivalent care.

Allocation of resourcesIn addition to the problem of under-resourc-ing and varying standards across regions,budgets are not being spent in the most effi-cient way. This is most obvious in two areas:the recruitment of staff and the compositionof the caseloads of in-reach teams.

When the in-reach teams were first estab-lished, funding was provided for a certainnumber and type of staff. In practice, due toshortfalls in recruitment, the money hasn’talways been spent. Table 4 shows the averagenumber of whole-time-equivalent (wte) staffper prison who were budgeted for on theestablishment in comparison with the num-ber of staff who were actually recruited.

The difference between the establishmentwhole-time-equivalent total and the actualwhole-time-equivalent is 0.5. This meansthat 10.4% of the total allocated spending onprison mental healthcare, or £2.1 million of

“We are way behind what we wouldneed to provide decent mental healthservices. If we are going to provideequivalent services as in the communityand take into consideration the higherrates of mental disorder within prison,then we’re 70% adrift.” (Sean Duggan)


the total £20.4 million, is not used due toshortfalls in staff recruitment.94

This is not the only inefficiency: the£20.4 million for prison mental healthcareis not being spent in line with the declaredpolicy objectives (as laid out in the NHSplan). As discussed in Chapter 3, in-reachcaseloads hold up to a third of prisonersthat have neither a serious mental illnessnor a personality disorder.

Using these figures it is estimated thatover a third of the budget, or £6.4 million,is being spent on prisoners who have nei-ther a severe and enduring mental illnessnor a personality disorder.

Reducing reoffendingEven with savings from greater efficiency itis likely that the overall budget will need tobe increased to provide equivalent servicesfor prisoners with mental illness. We

believe that the resulting reduction in reof-fending would make such an investmentcost effective.

In 2002 the Government’s SocialExclusion Unit published a report on reduc-ing reoffending by former prisoners.95 Itnoted that prison sentences are not succeed-ing in turning the majority of offenders awayfrom crime. Of those prisoners released in1997, 58% were convicted of another crimewithin two years, and more than a third hadbeen re-imprisoned. The system strugglesparticularly to reform younger offenders:72% of 18-20 year-old male prisoners werereconvicted over the same period; 47%received another prison sentence.

Building on criminological and socialresearch, the Social Exclusion Unit identifiednine key factors that influence reoffending:

� education;� employment;

36


Table 4: Comparison of in-reach staff establishment and actual recruitment

Establishment wte per prison Actual wte per prison Percentage of the establishment

which is staffed

Nursing 3.4 3.04 92

Social workers 0.24 0.21 87.5

Psychiatry 0.29 0.28 96.5

Clinical psychology 0.25 0.17 68

Occupational Therapist 0.21 0.18 86

Probation 0.01 0.01 100

Support workers 0.11 0.10 91

Admin/secretarial 0.65 0.58 89

Other members of staff…. … …

Total wte 4.80 4.3 90

members of staff members of clinical staff

(median value) (median value)

Table 5: Comparison of in-reach teams caseload composition96

Severe and enduring Both severe mental illness Neither severe mental illness

mental illness alone and personality disorder nor personality disorder

Caseload proportion 32% 9% 31%

94 It is worth noting that in main-

stream nursing in community psy-

chiatry, the vacancy rate is only

1.5%.




Minister, 2002

96 Brooker C, Gojkovic D, Shaw

J, “The second national survey of

mental health in-reach services in

prisons”. Accepted for publica-

tion, Journal for Psychiatry and

Psychology, 2008


� drug and alcohol misuse;� mental and physical health;� attitudes and self-control;� institutionalisation and life skills;� housing;� financial support and debt;� family networks.

For example, being employed reduces therisk of reoffending by between a third anda half; having stable accommodationreduces the risk by a fifth.

If untreated, mental health problems inprison can become worse and will reducethe chances of finding a home and keepinga job later. Time in prison can present avaluable opportunity to address some ofthese health issues. However, even whereprogress is made, further community sup-port is needed on release.

All of our experts accepted that there wasa link between poor mental health and reof-fending, via the medium of social exclusion.

Stigmatisation of people with mentalhealth problems is pervasive throughoutsociety. Despite a number of campaigns,there has been little significant change inattitudes. Fewer than four in ten employerssay they would recruit someone with a men-

tal health problem. Many people fear dis-closing their condition, even to family andfriends, and this can be particularly true forprisoners living in crowded conditions,often with people they do not choose.

The costs of reoffendingThe Social Exclusion Report estimated thatthe financial cost of reoffending by formerprisoners, calculated from the overall costsof crime, is staggering and widely felt. Interms of the cost to the criminal justice sys-tem of dealing with the consequences ofcrime, recorded crime alone committed byex-prisoners comes to at least £13 billion ayear (adjusted for inflation).97

The costs of reoffending are varied andinclude the direct costs of keeping someonein prison to the indirect costs of unemploy-ment benefits, childcare provision and soon. If there is a link between poor mentalhealth and reoffending, then by increasingand improving mental healthcare provisionin prisons, it would be possible to drastical-ly reduce that £13 billion.

Various studies have suggested that the£20.4 million spent on prison mentalhealthcare would need to be tripled in orderto reach levels equivalent to that spent with-in the community. A conservative reductionof only 0.3% in reoffending rates (a costreduction of £40 million) would berequired to make the tripling of the mentalhealthcare spending cost effective.




Minister, 2002

Spending, staff and savings


“Regardless of whether we have a strongevidence base, it seems to me to be palpa-ble common sense that there is a strongrelationship between unmet mentalhealth need and offending. It impacts onsomebody’s ability to maintain stableaccommodation, to move into stableemployment, to keep away from drugs orto kick drug habits. It is also heavily asso-ciated with all manner of crises such asfinancial crises, family relationships etc. Itseems to me to be the pervasive factor inwhether you can get all the other stufftogether and I just don’t see how some-body can do this, if mental health needisn’t properly sorted out.” (Julian Corner)

“What we are aiming to do in prisonsis to bring about much greater socialinclusion on release – and improvingmental health is essential to that aim.If former prisoners can get a job, havea positive social relationship and gen-erally be socially included, then re-offending is less likely and expenditurewithin the Criminal Justice Systemmuch more effective.” (John Podmore)


38

6Recommendations

SummaryA follow-up report, to be published byPolicy Exchange later in 2008, will look atbest practice in England and Wales, as wellas various international models, in order toformulate a number of policy recommen-dations to improve mental healthcare inprison. But it is already clear which areasthese recommendations will focus on. Theinvestment in mental healthcare in prisonsis too low and varies widely and arbitrarilyacross regions. The provision of primarymental healthcare is severely lacking andthe integration with in-reach teams is vari-able often resulting in poor care co-ordina-tion for service users.

The authors’ preliminary recommenda-tions are:

� Multidisciplinary teams – all mentalhealth staff should be integratedinto one multidisciplinary teamThe relative isolation of each team (in-reach, primary care, CARATs) workingseparately is resulting in poor co-ordina-tion of services and a lack of through-care. The blurred line between what isprimary and secondary care results inprisoners being passed between the twoor even lost completely. A single mentalhealth delivery team, with the range ofskills and practitioners of communitymental health teams would go a longway to improving the quality of care.

� Training for Prison Staff – all prisonofficers and prison governors shouldhave some form of mandatory men-tal health awareness training

Prison officers have the most contactwith prisoners day-to-day and as suchcan act as their primary carers. Withsuch a high prevalence of mental ill-ness it is essential that prison officershave the skills to identify and dealwith mental illness. Training is notsufficient and in some cases is notcompulsory. Prison officers do notfeel qualified to deal with prisonerswith mental disorders and in order togain that confidence they must all begiven thorough and continuous train-ing. Prison governors play the mostimportant role of all in determiningthe atmosphere of a prison. As withprison officers, the authors believethat all future prison governors’ train-ing should include a mandatory ele-ment of mental health awarenesstraining.

� Release planning – every prisonershould have a co-ordinated care planon release.The biggest determinants of reoffend-ing need to be carefully considered inan offender’s resettlement plan. If noone takes responsibility for organisingthe basics (access to a GP and accom-modation) for an ex-offender on releasethen it is more likely that he will go onto reoffend. Ensuring that everyonewith a mental health problem who isreleased has a proper care plan is crucialin reducing reoffending rates. Thisshould already happen for prisonerswith a severe mental illness through theCPA.



Recommendations

� Increased funding – funding formental healthcare in prisons shouldincrease to a level that correspondsto the mental health needs profile ofprisoners.Funding should be based on rationallyassessed needs, rather than historicalprecedent from the days when theHome Office allocated funds to thePrison Service. The staffing levels ofprison in-reach teams are far belowtheir equivalent in the communitywhere there is much less mental illness.A sophisticated health needs assessmentshould be undertaken in order to findthe real funding necessary for providingfor the prison community.

� Further research into the linkbetween mental health andreoffendingAlthough it is easy to call for increasedfunding, it is not always economicallyviable or politically palatable. However,in this case there is a case to be madethat improving mental healthcare inprisons would have a significant effecton reoffending rates – and thus thecosts associated with reoffending.Research on the link between untreatedmental illness and reoffending is scarce,but most experts the authors inter-viewed agree that there is such a link.There is a need to commission more

research in this area in order to under-stand the possible economic conse-quences of effective mental healthtreatment for prisoners.

� Improve court diversion – imple-ment a robust and properly fundedcourt diversion scheme for offenderswith mental illnessAlthough not dealt with specifically inthis report, the need to divert a largenumber of prisoners with mental illnessaway from prison is clear. Not onlydoes it ensure that they are treated in anappropriate setting, but it would alsogo some way to alleviating overcrowd-ing and the myriad problems chronicovercrowding causes the Prison Service.The authors look forward to the rec-ommendations of the Bradley Reviewon this issue.

� Integrating mental health policyThe structure of policymaking(Offender Health is a separate direc-torate within the Department ofHealth) makes it difficult to integratemainstream health developments inprisons, such as increasing access topsychological therapies. PCTs would bemore likely to consider prison popula-tions as part of their local communitiesif a more integrated approach to policy-making was evident at the top.


40

Glossary

ACCT: Assessment, Care in Custody andTeamworkThe ACCT approach is a case manage-ment system which aims to identify indi-vidual need and offer individualised careand support to prisoners in advance, dur-ing and after a crisis. It replaces the currentF2052SH risk management system.

Assertive Outreach teamsAssertive outreach teams provide inten-sive support for the severely mentally illpeople who are ‘difficult to engage’ inmore traditional services. Many will oftenhave a forensic history and a dual diagno-sis. Care and support is offered in theirhomes or some other community setting,at times suited to them. Workers can beinvolved in direct delivery of practicalsupport, care co-ordination and advocacyas well as more traditional therapeuticinput. The aim of the service is to main-tain contact and increase engagement andcompliance.

BME: Black and minority ethnic com-munity

CARAT worker: Counselling, assessment,referral, advice, and through-care workerCARAT workers co-ordinate the care ofthose prisoners on their caseloads; workerscan also provide basic information aboutdrugs and their effects and ways to reduceharm; they may offer some structured one-to-one support and group work to prison-ers who want to give up or cut down ontheir habit. They can also refer a prisonerto a drug treatment rehabilitation pro-gramme.

CMHT: Community mental health teamsThese are multidisciplinary teams aimingto provide one point of access to mentalhealth services to those diagnosed with a

severe mental health problem. Their servic-es are aimed at adults of working age withmental health problems that seriouslyimpair their ability to function.

CPA: Care programme approachCPA is the case management systemadopted by all secondary care mentalhealth services in the community (ie out-side prison) in England. A care co-ordina-tor is appointed to link various elements ofcare and to organise multidisciplinaryreviews of care. CPA should involve bothusers and carers in planning and reviewing.

Crisis Resolution TeamA crisis resolution team provides intensivesupport for people in mental health crisesin their own home: they stay involved untilthe problem is resolved. It is designed toprovide prompt and effective home treat-ment, including medication, in order toprevent hospital admissions and give sup-port to informal carers.

CPN: Community psychiatric nurse

DoH: Department of Health

Early Intervention TeamsEarly intervention teams work with peopleaged between 14 and 35 years, who haveexperienced a first episode of psychosis.

In-Reach: See mental health in-reachteams

Mental health in-reach teamsModelled on the CMHTs, mental healthin-reach teams are designed to provideassessment, care and treatment for those inprison who are experiencing serious mentalhealth problems and form part of a nation-al policy aimed at improving mentalhealthcare within prisons.


HMIP: Her Majesty’s Inspectorate ofPrisonsHer Majesty’s Inspectorate of Prisons forEngland and Wales (HMI Prisons) is anindependent inspectorate which reports onconditions for and treatment of those inprison, young offender institutions andimmigration removal centres.

NacroNacro is a charity that focuses on crimereduction. Its mission is to make societysafer by finding practical solutions toreducing crime. Since 1966 it hasworked to give ex-offenders, disadvan-taged people and deprived communitiesthe help they need to build a betterfuture.

NHS: National Health ServiceThe NHS provides healthcare to anyonenormally resident in the UK with mostservices free at the point of use for thepatient though there are charges associatedwith eye tests, dental care, prescriptionsand many aspects of personal care.

NSF: National Service Framework (forMental Health)National Service Frameworks are policies setby the National Health Service to definestandards of care for major illnesses such ascancer, coronary heart disease, mentalhealth and diabetes. A National ServiceFramework spells out how services can bebest be organised to cater for patients withparticular conditions and the standards thatservices will have to meet. NSFs are alsodefined for some key patient groups includ-ing children and older people.

PCT: Primary care trustPrimary care trusts covering all parts ofEngland receive budgets directly from theDepartment of Health. Since April 2002,PCTs have taken control of local health-care while strategic health authorities mon-itor performance and standards. Since thetransfer of the prison healthcare budget tothe Department of Health, the control ofspending has been delegated to PCTs. AllPCTs are now responsible for commission-ing (purchasing) services for prison health.


Glossary


Appendix 1

List of prisons served by the PCTsand mental health in-reach teamssurveyed

HMP AltcourseHMP AshwellHMP BelmarshHMP BlakenhurstHMP BlundestonHMP BronzefieldHMP ColdingleyHMP DorchesterHMP DovegateHMP DownviewHMP Drake HallHMP DurhamHMP Edmunds HillHMP EverthorpeHMP FeatherstoneHMP FranklandHMP GartreeHMP GloucesterHMP High DownHMP HighpointHMP Hollesley BayHMP HollowayHMP HullHMP KennetHMP Lancaster CastleHMP Leeds

HMP LeicesterHMP LiverpoolHMP Long LartinHMP Lowdham GrangeHMP ManchesterHMP NottinghamHMP PeterboroughHMP PrestonHMP SendHMP ShrewsburyHMP StaffordHMP StockenHMP Stoke HeathHMP The MountHMP The VerneHMP WakefieldHMP WealstunHMP WellingboroughHMP WhattonHMP WoldsHMYOI BrinsfordHMYOI DeerboltHMYOI FelthamHMYOI Glen ParvaHMYOI Lancaster FarmsHMYOI Low NewtonHMYOI NorthallertonHMYOI OnleyHMYOI PortlandHMYOI Warren Hill

42


Appendix 2


YouGov Survey Results: Sample Size: 2067, Fieldwork: 12th - 14th May 2008

Gender Age Social Grade

Total Male Female 18-24 25-34 35-44 45-54 55 + ABC1 C2DE

All GB Adults 2067 992 1075 227 384 350 372 734 1116 951

Unweighted Sample 2067 976 1091 261 371 331 376 728 996 1071

% % % % % % % % % %

The next question is about mental illness…

To what extent do you agree or disagree with each of the following statements? [Please tick one option on each horizontal row]

Virtually anyone can become mentally ill and commit crime

Strongly agree 15 15 16 13 15 19 15 15 15 16

Agree 45 44 46 37 39 42 49 49 45 45

Neither agree nor disagree 17 18 17 18 17 17 18 17 16 19

Disagree 14 15 13 17 17 14 13 12 15 13

Strongly disagree 4 4 4 3 5 3 3 4 5 3

Don’t know 5 5 4 12 6 4 2 3 4 5

We need to adopt a far more tolerant attitude towards people with mental illness in our society who commit crime

Strongly agree 7 8 6 6 8 7 7 8 7 7

Agree 25 22 29 22 23 22 25 29 24 26


Disagree 25 26 25 23 28 28 22 25 26 24


Don’t know 4 4 4 10 5 4 2 2 3 5

We have a responsibility to provide the best possible care for people with mental illness who commit crime

Strongly agree 17 17 17 12 19 19 17 16 18 15

Agree 47 46 48 42 42 45 50 52 48 46


Disagree 9 10 7 10 9 7 9 9 8 9


Don’t know 4 3 4 9 5 4 1 3 3 5

People with mental illness who commit crime are a burden on society

Strongly agree 6 7 4 7 5 5 7 5 6 5

Agree 29 36 23 27 28 29 24 33 32 26


Disagree 25 20 29 21 26 21 28 25 24 25


Don’t know 3 3 4 9 6 2 1 2 2 4



44

Increased spending on mental health services for people who commit crime is a waste of money

Strongly agree 3 4 3 2 3 4 4 4 3 4

Agree 11 12 9 12 10 11 9 11 8 13


Disagree 39 37 40 35 40 34 42 39 40 36


Don’t know 5 6 4 11 6 4 2 4 4 6

There are sufficient existing services for people with mental illness who commit crime

Strongly agree 2 2 2 1 1 1 2 3 2 2

Agree 9 10 8 8 9 7 8 12 8 11


Disagree 34 32 35 25 37 34 34 35 36 31


Don’t know 15 17 13 34 18 14 10 11 15 15

I would not want to live next door to someone who has been mentally ill

Strongly agree 7 9 5 7 5 8 8 6 7 6

Agree 17 19 15 17 21 16 14 16 17 17


Disagree 26 23 29 24 26 27 28 26 28 24


Don’t know 4 4 4 12 4 3 3 2 2 6

People with mental illness who commit crime are far less of a danger than most people suppose

Strongly agree 4 4 4 3 5 5 3 4 5 3

Agree 13 12 14 10 12 8 14 16 14 12


Disagree 34 35 34 34 34 34 31 36 34 35


Don’t know 8 8 7 15 7 6 6 7 7 9

Which of the following is closest to the proportion of people in prisons in the UK that you think might have a mental health problem?

0% (no-one in prison) 0 0 0 0 0 0 0 0 0 0

0.1 9 11 7 14 6 7 9 10 8 11

0.2 15 20 11 16 14 18 16 13 15 15

0.3 21 21 20 15 25 24 17 20 21 20

0.4 16 15 17 18 16 16 18 14 17 15

50% (half of those in prison) 13 12 14 9 13 14 13 14 12 14

0.6 7 5 8 7 7 4 8 6 7 6

0.7 5 3 6 6 6 5 5 4 6 4

0.8 2 2 3 3 2 3 2 2 3 2

0.9 1 0 1 1 1 1 1 1 1 1

100% (all of those in prison) 1 1 0 0 1 0 1 1 0 1

Don’t know 11 10 11 10 8 9 10 13 9 12


Out of Sight,Out of Mind

The state of mental healthcare in prison


£10.00ISBN: 978-1-906097-27-1

Policy ExchangeClutha House

10 Storey’s GateLondon SW1P 3AY

www.policyexchange.org.uk

Our prison population is at its highest ever. Of the 82,000prisoners in England andWales it is estimated that nine out of tenhave one or more mental health disorders. Although treatment ofmental illness in prison has improved over the past decade,mental healthcare is not given the attention it deserves. The ratesof mental illness among prisoners suggest that the PrisonService has become a catch-all social and mental healthcareservice, as well as a breeding ground for poor mental health.

In 1996, Lord Ramsbotham, then Chief Inspector of Prisons,wrote a report that was heavily critical of prison healthcareservices. And although matters have improved since then,progress is slow. Out of Sight, Out of Mind argues that LordRamsbotham’s findings are as relevant today as they were 12years ago: research contained in this report suggests that a thirdof the spending on mental health services in prison is spentinefficiently and that prison mental healthcare remains verypoor. Professor Charlie Brooker and Ben Ullmann argue thatlevels of staffing would need to be tripled in order to reachservice levels equivalent to that of the wider community but thatrates of reoffending would have to fall by less than one per centto make this improvement cost effective.

Out

ofSight,O

utofMind

Professo

rCharlie

Brooker

andBen

Ullm

ann,Edited

byGavin

Lockhart

Policy

Exchang

e

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