Service delivery

Prison mental health servicesJenny Shaw

Naomi Humber

AbstractThis contribution describes current prison mental health service pro­

vision in the UK and suggests further practice areas for consideration.

Following the commissioning and provision of all healthcare services

in prisons to NHS Primary care Trusts (PcTs), many innovative reforms

have taken place. Prison mental health services have undergone and

are undergoing significant change in order to provide equivalent mental

healthcare to prisoners. evaluation of reform is necessary in the foresee­

able future, firstly to establish whether there are measurable positive

changes from the substantial investment in this work, and secondly

to address the implications of this work in order to inform and guide

future practice.

Keywords Assessment, care in custody and Teamwork (AccT); mental

health in­reach; methadone maintenance programme; National Offender

Management Service (NOMS); offender pathways; prison mental health

services; prison suicide prevention

National Offender Management Service (NOMS)

The NOMS was created in 2004 to bridge the divide between custody and community. Central to the NOMS strategy is provi-sion of end-to-end offender management, including the manage-ment of those serving sentences in prison, the community, or both.1 It incorporates both the prison and probation services to ensure that the whole sentence of the court is planned and de-livered in an effective and integrated way. An offender manager is responsible for an offender and they ensure that the offender’s sentence plan is implemented and intervention programmes are completed.

Jenny Shaw MBChB MRCPsych is Professor of Forensic Psychiatry at the

University of Manchester, and Consultant Forensic Psychiatrist in

Preston, UK. She qualified from Manchester University and trained in

psychiatry in the northwest of England and in Australia. Her research

interests include homicide, suicide and prison mental health. Conflicts

of interest: none declared.

Naomi Humber BSc is a Research Assistant at the University of

Manchester, Manchester, UK. She completed a BSc. (Hons) in

Psychology at the University of Liverpool in 2001 and is currently a

PhD student in Psychiatry at the University of Manchester. Her research

interests include prison psychiatric services, prison suicide and

community mental health service provision. Conflicts of interest: none

declared.

PSycHiATry 6:11 46

As one of the major aims of NOMS is to increase informa-tion-sharing and communication both across and within criminal justice agencies, it is hoped that the individual needs of offenders will be more efficiently and effectively identified and met. Both risk and mental health assessment of offenders are to be included in the communication between agencies, which will inform staff members and ultimately improve the treatment of offenders whilst in the criminal justice system.

Devolution of prison healthcare services to NHS

The Chief Inspector of Prisons proposed that the responsibil-ity for providing healthcare for prisoners should shift from the Prison Service to the NHS.2 A formal partnership between the Prison Service and the NHS was recommended and accepted by the government in April 2000.3 The responsibility for the trans-fer of the commissioning responsibility of healthcare services for prisoners was devolved to Primary Care Trusts (PCTs).4 This transfer of commissioning and provision of healthcare services is now complete.5

Strategies for developing and modernizing mental health services in prisons, which included guiding services within prisons to ensure an equivalence of services to those available in the community, were previously defined by the Department of Health.6

Concerted effort and funding by government bodies has seen major changes to the prison estate in general and specifi-cally to the way in which healthcare is provided to individuals in custody. NHS investment in prison mental health services totalled £10 million in 2003/2004 and doubled to £20 million in 2005/2006.7

Offender pathways

It is now recognized that mental health service developments and improvements need to occur at all stages of the custodial process, including pre-prison; reception screening; induction or ‘first night’ centres; primary and secondary mental healthcare; acute care within prison; acute care outside prison; through-care and pre-release; prison transfer and after-care; and prison to com-munity transition.7 This includes the cooperation of agencies and

• Major reforms have taken place over the last few years in prison mental health services in the UK

• important changes have included the National Offender Management Service (NOMS), which aims to provide end­to­end offender management across the criminal justice system; the devolution of all the healthcare services in prison to the National Health Service (NHS); and an ‘Assessment, care in custody and Teamwork’ (AccT) approach for suicide/self­harm risk assessment, which includes case­management, individualized care planning and multidisciplinary teamwork

What’s new?

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Service delivery

staff in health, social, criminal justice, voluntary sector, housing and education services working together to ensure the effective care and treatment of those individuals with mental health prob-lems coming into contact with the system.

Court diversion/prison transferWhen it is recognized that an individual has acute severe mental illness, he or she should not be sent to or remain in prison. This can be achieved either at the police or court stage, with diversion from custody, or in prison, with transfer to a NHS psychiatric hospital.

The first magistrates’ court diversion scheme was established in London in 1989.8 This was followed by a national expan-sion of local court-based initiatives and by the late 1990s there were about 150 schemes across England and Wales.9 A nation-wide network of schemes was then officially recommended.10 Whilst there have been some evaluations of the efficacy of these schemes,8,11,12 it is apparent that a comprehensive national strat-egy needs to be developed.

There are currently problems with the acute transfer of prisoners to NHS psychiatric facilities under the Mental Health Act 1983,13 with considerable delays in the system. Alterna-tives to custody for those with severe mental illness need to be developed,14 and this is currently a prominent government target in the care and treatment of severely mentally disordered offenders.7

Prison populationIn the UK, the prison population has risen steadily over recent years. There are currently approximately 80 000 people in prison on a daily basis.15 The majority of prisoners are male and nearly three-quarters of the prison population are sentenced. The aver-age length of stay for prisoners is approximately 6 months.16

Prisons contain a high proportion of vulnerable individuals, many of whom possess the characteristics associated with an increased risk of mental health problems and self-harm/suicide. They are in challenging environments, with tension between providing security, healthcare and rehabilitation services. Within this context, prisons have been tasked to provide a robust and effective mental health service for those who come into contact with its agencies.

Compared with the general population, prisoners have vari-ous health and social inequalities,17 an increased prevalence of mental health problems18 and high levels of drug and/or alcohol misuse.19 Research suggests that as many as 90% have some form of mental disorder and/or a drug/alcohol abuse problem.16 The importance, therefore, of a comprehensive and an effective prison mental heath service provision cannot be overestimated.

Reception screeningA pilot study of a new reception health screening tool was con-ducted in six prisons and found that it detected over 80% of new remands who were suffering from mental illness.20 Based on research findings, it is believed that nearly half of all new recep-tions will screen positive for mental illness using this structured screening.21,22

However, it is recognized that a substantial majority of prison psychiatric morbidity is undetected and can be missed at this

PSycHiATry 6:11 46

early stage.23 Pathways to assessment for mental health problems identified at reception have been found to be inadequate,24 and those who are identified seldom receive appropriate treatment.25 Systematic screening earlier in the criminal justice system may therefore be an important strategy.26,27 The other essential step is that there are clear pathways to assessment for those who screen positive for mental ill health.

Transitional periods: pre and post custodyThe transitional periods between the community and prison have been shown to be risky times.28 There are also increased deaths in the first week of custody.29 Contemporary prison men-tal health services must address the transitional periods pre- and post-custody. Currently, post-custody transitional initiatives are being investigated, targeting community treatment in dis-charged prisoners. Shaw and colleagues are piloting the Criti-cal Time Intervention,30 promoting the engagement of mentally ill discharged prisoners into community mental health services. Other post-release initiatives include ‘meet at gate’ transitional care, in which designated caseworkers meet released prisoners to facilitate prompt access to pre-existing community services. Crim-inal justice, healthcare and social service agencies need to work together to facilitate the achievement of these initiatives.

First-night centre and induction wingFollowing an increased suicide rate in the prison population, a number of deaths in local prisons, a thematic review conducted by the Prisons Inspectorate and an internal review of current prison procedures, the Safer Locals Programme was launched and aimed to examine a series of measures to reduce the rate of suicide in six local prisons. A first-night centre and induc-tion wing were two initiatives designed to address the problem of self-harm/suicide in the early stages of reception into prison. The quality of reception procedures and first-night experience for prisoners have been recommended as being of particular im-portance in the initial stages of custody.24 An evaluation of these facilities within local prisons has shown important benefits for the care of prisoners on entry into prison, including reducing distress and improving feelings of safety.31

Primary care servicesPrimary healthcare provision within prisons has been repeatedly criticized as inadequate and undeveloped,32 and, consequently, failing to meet the complex needs of the prison population.33 The provision of primary care varies considerably between prisons, with some provided by prison doctors, often locums, and others by local GP practices. Prison nurses provide a significant amount of primary care through wing-based triage, nurse-led clinics and crisis intervention. Issues of continuity of primary care between the community and prison present great challenges, especially when approximately 50% of sentenced prisoners are not regis-tered with a GP prior to prison.17 Communication with external agencies is necessary to ensure important information exchange, enabling healthcare staff to meet the complex treatment needs of prisoners.

Secondary care servicesTo improve secondary mental health services for prisoners, the mental health in-reach initiative is seen as a fundamental

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component of the prison mental health services’ modernization agenda.6 Mental health in-reach teams within prisons are designed to be similar to community mental health teams (CMHTs). In the community, their remit is to provide commun-ity mental health team-based services to those with severe and enduring mental illness. Prisoners receive assessment, includ-ing care-planning, an individual care coordinator, and treat-ment. The majority of prisons within the UK have developed these services. Recent findings have shown that a CMHT model is difficult to replicate in prison. In view of the inadequate pro-vision of primary care with insufficient triage, in-reach teams are being overwhelmed by referrals. Furthermore, the prison environment makes it difficult for the provision of consistent mental healthcare.34

Drug treatment services: methadone maintenance programmeApproximately 50% of prisoners misuse drugs on a daily basis on entry into prison,16 and many are poly-drug users.35 Detoxi-fication should be a priority for individuals with substance misuse and dependence problems entering the prison system. Many prisons now offer a methadone maintenance programme to a selection of prisoners. The introduction of this mainten-ance programme within prison has been a contentious issue. There are, however, benefits to maintaining prisoners on an opiate substitute programme, as those in withdrawal and post-withdrawal states can be impulsive and at risk of self-harm.36 In addition, those who are on the programme are often more stable and are also able to function more effectively, enabling engagement in prison regimes.37 The development of a single standard and set of protocols for detoxification in the prison estate, which can be adapted to individual prison needs, should be developed to ensure common standards of care between all establishments.

Dual-diagnosis servicesMany prisoners have complex needs, including an identifi-able mental illness and drug and/or alcohol dependence.38 The prison services that provide care for mental health and sub-stance misuse have undergone massive transformations in the past few years,36 but service developments and implementations have often occurred in parallel without consideration given to interlink the services for those who need to utilize both. Integ-rated care pathways between substance misuse teams and men-tal health teams for prisoners need to be facilitated to ensure a continuity of treatment.

Suicide prevention

There were 67 deaths in custody in 2006, representing a 14% reduction in prison suicides from 2005.39 The prison suicide rate has fallen from 127 per 100 000 in 2004 to 90 per 100 000 in 2006.39 However, whilst this is encouraging, the number of sui-cides does fluctuate and it remains to be seen whether this is indeed a trend.

Research has identified certain risk factors associated with suicide in prison, including: • being on remand29,40

• having a history of psychiatric illness40,41

• having a history of drug and/or alcohol abuse29,40,42

PSycHiATry 6:11 46

• having a history of self-harm/attempted suicide43,44

• being in the early stages of reception into prison29,41,42

• being charged with or convicted of a violent offence.40,44

Recent suicide prevention strategies implemented have included an Assessment, Care in Custody and Teamwork (ACCT) approach. Any member of staff can initiate this process if they are concerned that a prisoner is at risk. Once monitored under this system, the prisoner is assessed and a plan of care formulated. The process is supervised by a case manager who ensures that assessments and interventions are completed. Skills-based and suicide awareness training is an integral part of the programme.45

Forum for preventing deaths in custodyA high-level forum was developed in 2005, to enable the shar-ing and learning of lessons from deaths in all custodial set-tings. The development of this forum highlights the emphasis on maximizing learning from deaths in custody by bringing together professionals from different disciplines, such as health-care and criminal justice, to share knowledge, experience and ideas to aid future suicide prevention strategies, policies and pro-cedures. However, further work is required to reduce suicide at other phases of the criminal justice system, such as in recently released prisoners.28

Prisoner peer supportThere is an ongoing recruitment drive for prisoner peer support-ers, including both ‘Insiders’, who help to reduce anxiety and distress experienced by new arrivals into custody, and Samari-tan-trained prisoner ‘Listeners’, to provide emotional support to

Further practice areas

• improvements in diversion and transfer services for those

with acute severe mental illness

• Mental health services matched to the needs of particular

groups (e.g. ethnic minorities)

• Focus on the principles of patient involvement and

representation within prison

• A more coordinated model of care in which primary mental

healthcare supports the work of secondary and tertiary

mental healthcare

• ‘Bridging the gap’ between healthcare, criminal justice and

social services in the provision of prison mental health

services

• A greater focus on transitional periods within custody, i.e.

transfer, pre­trial, sentencing, pre­discharge, pre­ and post­

custody

• Mental health promotion and the recognition that whilst

many prisoners may not develop or have a specific mental

health problem, they may at times feel anxious, stressed and

in need of extra support

• ‘end­to­end’ offender management which ensures that staff

and agencies work with the individual for the entirety of their

sentence: information­sharing, risk management, continuity,

consistency and rehabilitation are of great importance

Table 1

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Service delivery

fellow prisoners. Evidence has shown a reduction in self-harm incidence with the introduction of Listener schemes and that this service improves the existing provision in supporting vulnerable prisoners.46

Suicide in the criminal justice systemSuicide is a serious problem within the criminal justice system. Criminal justice agencies have a duty of care to protect those within this system. The agencies have a complex task of balan-cing issues of security, punishment and justice with appropriate treatment. The assessment and prediction of suicidal risk con-stitutes a difficult task in any setting. This task is made more difficult within the criminal justice system as risk factors for sui-cide are over-represented in those individuals who come into contact with the system.16,29,47 Transitional periods between different stages and agencies within the criminal justice system must be managed effectively, involving comprehensive informa-tion-sharing and communication regarding an individual’s risk of suicide.

Conclusion

Current reforms to the provision and organization of prison men-tal health services are attempting to radically change the stan-dards of care received by prisoners. Major changes have occurred over the last few years and will continue to occur until a demon-strable improvement is witnessed. However, improvements in information exchange and communication must also occur within and across other stages of the criminal justice system, to ensure a continuity of care, including the police, court, NOMS, prison, social and health services. (Table 1 lists further practice areas identified.) ◆

ReFeReNCeS

1 NOMS, Home Office. Offender management model 1, 1 May 2006.

2 Her Majesty’s inspectorate of Prisons. Patient or prisoner? A new

strategy for healthcare in prisons. london: Home Office, 1996.

3 HM Prison Service and NHS executive. The future organisation of

prison healthcare. report by the Joint Prison Service and National

Health Service executive Working Group. london: department of

Health, 1999.

4 department of Health. The NHS plan: a plan for investment, a plan

for reform. cm 4818­i: london: Stationery Office, 2000.

5 department of Health. National partnership agreement between

department of Health and the Home Office for the accountability

and commissioning of health services for prisoners in public sector

prison in england, January 2007.

6 department of Health. changing the outlook: a strategy for

developing and modernizing mental health services in prisons.

london: department of Health, 2001.

7 department of Health & National institute for Mental Health in

england. Offender mental health care pathway. london: department

of Health, January 2005.

8 Joseph PlA, Potter M. Psychiatric assessment at the magistrates’

court. Br J Psychiatry 1990; 164: 722–24.

9 James dv. court diversion in perspective. Aust N Z J Psychiatry

2006; 40: 529–38.

PSycHiATry 6:11 4

10 department of Health and Home Office. review of health and social

services for mentally disordered offenders and others requiring

similar services: final summary report (the reed report). london:

HMSO, 1992.

11 Holloway J, Shaw J. Providing a forensic psychiatry service to a

magistrates’ court: a follow­up study. J Forensic Psychiatry 1993; 4:

575–81.

12 NAcrO. Findings of the 2004 survey of court diversion/criminal

justice mental health liaison schemes for mentally disordered

offenders in england and Wales. london: NAcrO, 2005.

13 isherwood S, Parrott J. Audit of transfers under the Mental Health

Act from prison – the impact of organisational change. Psychiatr

Bull 2002; 26: 368–70.

14 dell S, robertson G, James K, Grounds A. remands and psychiatric

assessments in Holloway. Prison i: the psychotic population.

Br J Psychiatry 1993; 163: 640–44.

15 HM Prison Service statistics, January 2007.

16 Singleton N, Meltzer H, Gatward r, coid J, Peasy d. Psychiatric

morbidity among prisoners in england and Wales. london: Office of

National Statistics, HMSO, 1998.

17 Social exclusion Unit. reducing reoffending by ex­prisoners. london:

Office of the deputy Prime Minister, 2002.

18 Fazel S, danesh J. Serious mental disorder in 23000 prisoners: a

systematic review of 62 surveys. Lancet 2002; 359: 545–50.

19 Gunn J, Maden A, Swinton M. Treatment needs of prisoners with

psychiatric disorders. Br Med J 1991; 303: 338–41.

20 Grubin d, carson d, Parsons S. report on new reception health

screening arrangements: the result of a pilot study in 10 prisons.

london: department of Health, 2002.

21 Birmingham l, Mason d, Grubin d. Health screening at first

reception into prison. J Forensic Psychiatry 1997; 81: 435–39.

22 Grubin d, Birmingham l, Mason d. The durham remand study.

report for HM Prison Service/Northern and yorkshire regional Health

Authority, 1998.

23 Birmingham l, Mason d, Grubin d. Prevalence of mental disorder

in remand prisoners. A consecutive case study. Br Med J 1996; 313:

1521–24.

24 Safer locals report, in press.

25 Birmingham l, Mason d, Grubin d. A follow­up study of mentally

disordered men remanded to prison. Crim Behav Ment Health 1998;

8: 202–13.

26 Shaw J, creed F, Price J, et al. Prevalence and detection of serious

psychiatric disorder in defendants attending court. Lancet 1999;

353: 1053–56.

27 duffy d, lenihan S, Kennedy HG. Screening prisoners for mental

disorders. Psychiatr Bull 2003; 27: 241–42.

28 Pratt d, Piper M, Appleby l, Webb r, Shaw J. Suicide in recently

released prisoners: a population­based cohort study. Lancet 2006;

368: 119–23.

29 Shaw J, Baker d, Hunt i, Moloney A, Appleby l. Suicide by prisoners:

National clinical Survey. Br J Psychiatry 2004; 184: 263–67.

30 Susser e, valencia e, conover S, Felix A, Tsai W, Wyatt rJ. Preventing

recurrent homelessness among mentally ill men: a ‘critical time’

intervention after discharge from a shelter. Am J Public Health 1997;

87: 256–62.

31 liebling A, Tait S, durie l, Stiles A, Harvey J. An evaluation of

the safer locals programme: a summary of the main findings.

cambridge: cambridge institute of criminology Prisons research

centre, January 2005.

68 © 2007 elsevier ltd. All rights reserved.

Service delivery

32 department of Health. The future organisation of prison health care.

Joint Prison Service and National Health Service executive, Working

Group, March 1999.

33 Smith r. Prisoners: an end to second class health care? eventually

the NHS must take over. Br Med J 1999; 318: 994–95.

34 The Sainsbury centre for Mental Health. london’s prison mental

health services: a review. Policy paper 5. london: Sainsbury centre

for Mental Health, 2006.

35 Singleton N, Farrell M, Meltzer H. Substance misuse among prisoners

in england and Wales. Int Rev Psychiatry 2003; 15: 150–52.

36 department of Health. clinical management of drug dependence in

the adult prison setting, November 2006.

37 Palmer, J. Prison service news, February 2006.

38 Maden A, Taylor cJA, Brooke d, Gunn J. Mental disorder in remand

prisoners. london: department of Psychiatry, institute of Psychiatry,

1995.

PSycHiATry 6:11 4

39 HM Prison Service. Press release, January 2007.

40 dooley e. Prison suicide in england and Wales, 1972–1987. Br J

Psychiatry 1990; 156: 40–45.

41 Backett SA. Suicide in Scottish prisons. Br J Psychiatry 1987; 151:

218–21.

42 Topp dO. Suicide in prison. Br J Psychiatry 1979; 134: 24–27.

43 lloyd c. Suicide and self injury in prison: a literature review. Home

Office research Study No. 115. london: HMSO, 1990.

44 Bogue J, Power K. Suicide in Scottish prisons, 1976–1993. J Forensic

Psychiatry 1995; 6: 527–40.

45 HM Prison Service. Safer custody Group. The AccT Approach. caring

for people at risk in prison, 2005.

46 davies B. The Swansea listener scheme: views from the prison

landings. The Howard Journal of Criminal Justice 1994; 33: 125–35.

47 Sattar G. rates and causes of death among prisoners and offenders

under community supervision. Home Office research Study 231, 2001.

69 © 2007 elsevier ltd. All rights reserved.