Written evidence from anonymous submitter

I thank the Justice Committee for their attention to this extremely important public health concern. I am submitting as an individual. I have 10 years experience working at the interface of mental health and justice as an occupational therapist. My PhD involved working with people on probation with a mental health condition (personality disorder). I thank you for your time and request my name is not published online.

I respond to each of the questions in turn but first make some clarifying remarks and a suggestion for how to consider mental health.

Clarifying 1: Health inequalities are relevant to mental health. People who experience greater social disadvantage are more likely to have poor mental health. As the prison population disproportionately hails from socially disadvantaged neighbourhoods – there is likely to be high levels of mental illness and distress prior to imprisonment.

Clarifying 2: Mental health and mental health issues are vague conceptualisations. It is important to differentiate mental health and mental illness. The latter is a psychiatric diagnosis that typically receives a medical model response. The former is crucial for the human rights of everyone in prison, and preventing deterioration to the point of illness.

I suggest considering ‘mental health’ in three ways.

1. All people in prison: A public health approach to mental health. Everybody has mental health that fluctuates in response to our circumstances. Population level interventions that support mental health should include things required by all humans: Social connection, access to meaningful/purposeful activity, access to nature, opportunities to care for others, opportunities for physical exercise. The ‘five ways to wellbeing’ are a guide here.

2. People at risk of mental illness: Some people will be unable to engage with mental health supportive activities. This might be due to environmental or person factors. Eg. Movement restrictions, remand status, exclusion due to behavioural or risk concerns, suspicion about participating, staff shortage, poor social skills, disability, fear of failure/fear of being harmed. This group may benefit from personalised input to enable their participation. For example, Occupational Therapists focus on enabling people to participate in the activities that keep them well through established assessment and intervention techniques. The committee might investigate if occupational therapists are being optimally deployed, for example in a  consultant capacity, in prisons or if they are constrained to medical model practice as junior team members.

3. Those experiencing mental illness: Many people will meet diagnostic criteria for mental illnesses. It is important to recognise the range of mental health conditions and the different approaches to treatment required. It is critical that mental health teams are adequately staffed with multidisciplinary staff: including nursing, occupational therapy, psychology, speech and language therapy, psychiatry and social work at a level of seniority that enable them to work effectively. They should  have the skills to work with affective disorders (depression, anxiety, bipolar disorder), psychotic disorders (schizophrenia), personality disorders and learning disabilities (including neurodivergent presentations like autism). They should access and work seamlessly with specialist support, e.g. substance use and learning disability.

The scale of mental health issues within prisons in England and Wales and whether enough is in place to determine the scale of the problem.

There has been no robust assessment of mental health need in prisons for over 20 years (Singleton et al 1998). Rigorous academic work with a representative sample using validated screening and diagnostic tools is needed to understand levels of mental illness, and prevalence of distress indicators. This will provide evidence for data-driven responses to ensure service provision is adequate.

Appropriateness of prison

Everybody has mental health needs. Prison is undoubtedly detrimental to mental health by its nature – it restricts access to activities that support good health, natural environments, and social connections.

For those with mental illness or disorder – prison can be the first place that they have access to and receive mental health care. However, when unwell, there is little about prison that promotes recovery, particularly on remand where the environment is unstable and inconsistent. When people are sufficiently unwell as to warrant a transfer to hospital, waiting times are too long. Hospitals often exclude people whose primary needs are personality disorder related, as specialist support for this group is lacking – particularly in acute crisis. Not everyone with a mental illness needs hospital treatment. But it is difficult to conclude that prison is an appropriate environment.

Identifying mental health issues on arrival/while serving a sentence

Anecdotally, screening processes are limited to one or two questions that focus on suicidal thoughts. People are not necessarily honest because of a mistrust of the prison system. These screens should be done with empathy and more depth by an appropriately qualified health professional, and with clarity for the individual about what will happen if they do disclose symptoms of mental illness or distress.

If people are known to mental health services – it is not clear to what extent, if any at all, their care is smoothly handed over to a prison mental health team.

Support available to those with mental health needs, whether it meets the needs and if there are any gaps in provision.

Huge gaps in the provision of non-medical mental health care. Some prisons have an excellent multidisciplinary offering, but these often have long waits. Others have a visiting psychiatrist and nursing dispensing medication, but little psychological, occupational therapy or social work. This must be addressed.

The Offender PD Pathway is excellent for people with severe personality disorder – but these services are exclusive, limited and minimally focused on life skills for the future. Wings that operate Psychologically Informed Planned Environments have much to offer the rest of the estate.

The effect of physical prison environment on mental health.

The evidence is clear that a poor physical environment is detrimental to mental health. But we should not neglect the social environment. Wings that operate Psychologically Informed Planned Environments have much to offer the rest of the prison estate. Examples of how prisons are operated in Scandinavian countries have clear benefits, being smaller, more flexible in access to basic activities and the natural environment.  These should be explored, not large super-prisons that do nothing but warehouse people and neglect the need for social connectedness, safety and support.

Effect of Covid on mental health, including on service access

Service providers were redeployed to acute physical health care, leaving mental health services across the board and in prisons without key staff. This is particularly true of dual trained rehabilitation professionals such as occupational therapy and social work. The perception of what was essential did not treat mental health with parity of esteem. In future, the mental health workforce should not be seen as less essential.

Further, we saw excessive lockdown conditions implemented to prevent prisoners associating. Whilst this may have controlled viral spread, it did nothing for the wellbeing of prisoners.

Quality and availability compared to the community

Comparing to the community is not desirable given i) levels of unmet need in the community and ii) prison population are at higher levels risk given the nature of imprisonment. We need up-to-date evidence of the level of need. This should be the starting point, not comparison with what is available to a different group of people.

Care pathway from prison to the community

It is imperative that we think not just about treating people in prison – but ensuring the social determinants of health are addressed before release, (poverty, housing, employment) so that someone doesn’t return to a high stress situation, and that support to sustain mental health is in place from appropriately qualified professionals and people with lived experience. Current evidence is that people are inadequately supported on release, given the extreme mortality from suicide and substance overdose. There are some interventions designed in Australia (Kinner et al) to bridge this gap, but attention is needed for English and Welsh contexts. We cannot expect people released to an unfamiliar area without transport or even a home, to prioritise making an appointment.

Continuity of care is highly problematic, and is exacerbated by fragmentation of providers, poor notice given of release, and insufficient capacity in prison and in the community mental health services. In mental health services, anyone discharged from inpatient care is proactively followed up within 72 hours due to the heightened risk of death in this period. Given the same risk among people released from prison, this could be a vital intervention. Ideally contact would be by a mental health professional whom they have already met. This person should have a handover and justice system experience.

Is commissioning of mental health services in prison is working?

No. A wholesale review of commissioning is needed. The complex needs of people in prison do not sit neatly into a pre-defined service model. Separating addiction, mental health, learning disability and personality disorder services makes information sharing hugely challenging. This is exacerbated by provider change, meaning governance processes need to restart. For services to work effectively, relationships need to be built between them and their staff. The current commissioning model means this is frequently disrupted, contributing to mistrust. Each time there is change, a new service and team takes time to become established before they can deliver. This wastes time and resource, impacts on quality and continuity of care and risks people falling through gaps. Tendering and commissioning cycles that benefit no one should be reduced, if not eliminated.

May 2021