Joint written evidence from Department of Health and Social Care and NHS England and NHS Improvement

The Department of Health and Social Care (DHSC) are responsible for setting national policy and strategy to improve the health outcomes and reduce health inequalities for people in prison.

As a signatory to the National Partnership Agreement for Prison Healthcare, DHSC is committed to working with the Ministry of Justice (MoJ), Her Majesty’s Prison and Probation Service (HMPPS), NHS England and NHS Improvement (NHSE/I) and Public Health England (PHE) to ensure safe, legal, decent and effective care people in prison.

From 1 April 2019, NHSE/I have been working together as a new single organisation to better support the NHS to deliver improved care for patients. There is a single operating model which is designed to support the delivery of the NHS long Term Plan published in January 2019.

Since 2013, NHSE/I have been directly responsible for commissioning healthcare services for people in prison, this includes mental health services. 

As the organisations responsible for setting policy and direction, and directly commissioning services we are submitting evidence to the inquiry which sets out the current picture from a health perspective of mental health needs and services for people in prison.

The Committee is seeking views on:

1. 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.

When considering health needs for people in prison they may present with a health profile 10 years above their chronological age. They are, in general, less physically and mentally healthy, and more likely to engage in high-risk personal behaviour than the general population therefore making higher demands on the health services in prisons. They are also less likely to have accessed community provision pre-incarceration. 

NHSE/I has commissioned an England wide prison needs analysis with the aim of providing comprehensive diagnostic and socio-demographic profiles of the mental health, psychological, trauma and emotional wellbeing caseloads in each prison. This covers all services commissioned by NHSE/I and includes services with personality disorder and neurodiverse caseloads (e.g. services for people with learning disabilities, autism, speech and language difficulties, ADHD, acquired brain injury).

2.       The appropriateness of prison for those with mental health needs.

NHSE/I commission integrated mental health services in prison which meet the need for mental health conditions that may emerge during incarceration. For some, identification and treatment of their mental health condition may occur for the first time upon arriving in prison and undergoing comprehensive health screening. This is especially the case for people that may have been masking symptoms, including trauma, with alcohol or substances. The integrated approach with primary care and substance misuse services enables a holistic approach to meet mental health needs.

As an alternative to custody, the increased use of Mental Health Treatment Requirement (MHTR) provides the judiciary with robust and effective treatment options, by addressing the underlying mental health and social issues which may be contributing towards offending behaviours. MHTRs form part of the Community Sentence Treatment Requirement (CSTR) Programme, which was developed in partnership by DHSC, NHSE/I, MoJ, HMPPS and PHE.

3. How mental health issues are identified on arrival at prison and/or while a prisoner is serving a custodial sentence.

Standardised health screening tools on the electronic records system (SystmOne) were launched in 2018. These include mental health screening tools, providing a consistent approach to determining the threshold for referring an individual for a mental health assessment within the first days of arriving in prison.

Referrals to mental health teams continue to be encouraged at all stages of the prisoner journey. Every integrated mental health team will have clear referral criteria, including details of how to make a self-referral.

NHSE/I has worked with partners in HMPPS and PHE, to improve and redesign services for people in prison with serious mental health conditions which require a person to be hospitalised. This includes revising approaches to secure hospital transfers (and remissions) where a person will be assessed, diagnosed and placed in a coherent, timely and appropriate manner.

4. Support (clinical and non-clinical) available to those with mental health needs, whether it meets the needs of those in prison and if there are any gaps in provision.

Integrated mental health teams utilise a stepped care approach for common mental disorders which mirrors care used in the community and draws upon evidence-based disease management models that commence with the most cost effective and least intrusive treatment. 

Stepped care provides a model for early identification of vulnerability by GPs, other healthcare professionals and prison staff. It can include: non-clinical activities such as education, meaningful occupation, access to chaplaincy and worship or meditation; low intensity interventions such as facilitated self-help for mild to moderate presentation; more high intensity interventions, including structured therapies and medication for moderate to severe presentations; and assessment for referral under the Mental Health Act (MHA) for those presenting with complex, treatment resistant presentations where the individual is in acute crisis of risk to life.

Commissioners in NHSE/I regional teams undertake health needs assessments (HNA) on a three-yearly cycle, with annual refreshes. These are used to inform commissioned services for each establishment. HNAs are not the only mechanism for NHS commissioners to consider health needs: a constant dialogue with providers and prison governors is part of the process of managing healthcare contracts, and resources are adjusted to take account of changing circumstances.

5. The effect of physical prison environment on mental health.

There are many factors within prisons that can have a negative impact upon an individual’s mental health.

These include noise and overcrowding, fear of violence, bullying and other abuse, access to substances (including other peoples prescription medicines), prolonged solitude and lack of privacy, limited meaningful activity, lack of choices, isolation from social networks, insecurity and perceived lack of control over current and future prospects (work, relationships, etc). The increased risk of suicide in prisons, often related to depression together with the means to make it happen can be a common manifestation of the cumulative effects of these factors.

There are also factors of the prison environment that can positively affect mental health, e.g. time out of cell in purposeful activities; access to employment, education and training opportunities; and access to exercise and nutritious diets.

A safe and secure prison system cannot be successfully delivered without effective mental health and learning disability services and, these in turn cannot be delivered without the full support and partnership of the prison regime and its staff. Both the physical environment within which a person lives and receives care and the service provided contribute towards general wellbeing within the prison.

6. The effect of Covid on prisoner mental health, including on access to services.

The effect of COVID on mental health has been widely predicted but as yet is not fully quantified.

Modelling of additional mental health need in the community may be mirrored in the justice estate with a risk of widening health inequalities of the prison population.

The COVID effect on mental and emotional wellbeing will be transient and work is underway with HMPPS and PHE to promote a holistic multi agency approach to recognising, normalising and containing understandable anxieties and emotional responses to unprecedented circumstances, and whilst people will require support, an automatic steer to a medical model is not always required.

NHSE/I implemented a telemedicine approach for health care providers. This prevented delays and reduced the need for long distance travel for assessment under the MHA. Mental health services have also been able to use in-cell telephony for consultations and maintaining contact in 60% of prisons where it is available.

NHSE/I commissioned a series of 12 prison radio programmes where people that are or were in prison during lockdown talk about the impact this has had on their mental health.

Providers and commissioners have responded to the changing needs identified within different prisons/regions, e.g. deployment of mental health support workers as ‘wing walkers’ providing a mental health presence and accessibility to residents.

7. The quality and availability of mental health support in prison compared to that in the community.

The purpose of health care in prison, including care for people with mental health problems and/or learning disabilities, is to provide an excellent, safe and effective service to all prisoners equivalent to that in the community. Prison mental health services provide timely access to evidence-based, person-centred care, which is focused on recovery and is integrated with primary care, substance misuse services and other sectors.  Mental health teams have a public health perspective and focus on reducing harm and promoting recovery and rehabilitation. The integrated mental health teams work closely with the substance misuse treatment provider and others where dual diagnosis is identified and with primary care and others where co-morbid physical or social care needs are present and will utilise a “stepped care” model as appropriate.

Patients within secure settings should receive the same level of healthcare as those people in the community (albeit necessarily provided differently) – both in terms of the range of interventions available to them which meet their needs, and the quality and standards of those interventions. A limited number of escort slots are available for healthcare appointments, resulting in delays in accessing care. [1]Patients travelling offsite are not permitted to know the time and date of their appointment due to security risks and may wait for a long period of time. This may create preventable pain or anxiety. Many also report feelings of stigma, shame and embarrassment about attending community-based locations in handcuffs.[2]

8. The mental health care pathway in prison to the community.

NHSE/I programmes support access to and continuity of care through the prison estate, pre-custody (through Liaison and Diversion services) and post-custody (through RECONNECT) into the community.

RECONNECT provides a care after prison custody service to support patients through all healthcare pathways including mental health and substance misuse treatment in their transition into the community, with care coordination. Enhanced patient information exchange with primary care and community services underpin continuity of care. This provides a personalised plan and care coordination check points on care on release. 

9. Whether current commissioning of mental health services in prison is working.

In 2016, NHSE/I published its Five Year Forward View for Mental Health to ensure mental health is seen in “parity of esteem” with physical health. 

NHSE/I reviewed the service specification for prison mental health services in 2017-18. The review was published in March 2018, with all new services commissioned against it from April 2018. 

Local Delivery Quality Boards, led by the Prison Governor, monitor operational healthcare performance in each establishment. Contract and performance management is carried out by Health and Justice Commissioners through regular reviews of intelligence and reporting on clinical effectiveness safety and patient experience. Each Commissioner works to ensure there are resources, systems and processes in place through internal and external partnership across the prison estate. Patient safety risks and other high priority issues can be escalated to the local Partnership Board if they cannot be resolved locally.

As part of the procurement process local commissioners look to achieve at least equivalence of outcome with community services.