Written evidence from NHS England and NHS Improvement

This submission focuses on aspects of the committee’s inquiry relevant to NHS England and NHS Improvement (NHSE/I) as commissioner of justice health services.

What progress has been made on commitments to reduce the number of women in custody since the publication of the Female Offender Strategy?

  1. From a health service perspective there are two key initiatives that support the government to meet its commitment to reduce the number of women in custody.

NHSE/I Liaison and Diversion Services

  1. NHSE/I Liaison and Diversion (L&D) services divert those with mental health needs from the Criminal Justice System (CJS). Clinical staff are located at police stations and courts across England to provide assessments and referrals to treatment and support. Offenders may be diverted away from the CJS altogether, or to a community sentence with a treatment requirement. Roll out of L&D services started in April 2014, an ambition to achieve full coverage across England was met in March 2020.


  1. All L&D services have an appointed female lead, to develop the pathways and sensitively address holistic needs of female offenders. To do this, services offer to see all females who come into custody, provide choice of gender for the practitioner offering them ongoing support, offer a gender-sensitive approach to screening and support effective onward referrals to gender specific and sensitive services. They also endeavour to work in partnership with police forces to develop out of court disposal pathways and to create female-specific conditional cautions.


Community Sentence Treatment Requirements


  1. Providing appropriate intervention and treatment at the right time, in the right place is vital to improving outcomes for people with mental health issues and problems with substance misuse, and to reducing reoffending. 


  1. Currently the numbers of women in custody are high factoring that their offence is related to drug and alcohol misuse.  It would be preferable to offer these offenders trauma informed health interventions in a non-custodial setting with supportive accommodation and community-based rehabilitation.


  1. Community Sentence Treatment Requirements (CSTR) aim to reduce reoffending and short-term custodial sentences by addressing the health and social care issues of offenders. There are three types of CSTRs: Mental Health Treatment Requirements (MHTRs), Drug Rehabilitation Requirements (DRRs) and Alcohol Treatment Requirements (ATRs).

What more can be done?

  1. A significant number of people who encounter the CJS experience mental health and/or substance misuse problems but the use of Community Sentence Treatment Requirements (CSTRs) to address these needs as part of a community sentence is very low.


  1. However, there is a requirement that CSTR’s offer an alternative to custody across the country. Therefore, additional investment is being made in community mental health and substance misuse provision. This is primarily to enable women sentenced with minimum wait times, flexibility to access services closer to their home and to support women with carer responsibilities so they are not constrained if they want to access services.


What has been done to reduce the number of women serving short prison sentences?

  1. CSTR’s are an alternative to short custodial sentences and the L&D pathway specifically for women identifies them early in their interaction with the CJS so an assessment is secured and they can engage with community-based services. This supports a commensurate community sentence, ensuring that any woman who can be managed and supported for their rehabilitation in the community has the opportunity to do so. 

Since the publication of the Female Offender Strategy, what work has been done to improve conditions for those in custody?

  1. The NHS Long Term Plan commits to improving access to and delivery of health services across the population. There is a specific emphasis on mental health services as well as ensuring best health outcomes for vulnerable patient groups, which includes people in prisons.

Perinatal mental health services

  1. As part of its LTP commitments, NHSE/I is developing perinatal mental health services. Recently, coverage of these services has been extended to develop co-commissioned, general maternity and perinatal services for women in prisons. This includes development of a service specification to underpin perinatal mental health services across the female estate. The aim is to provide a consistent and qualitative approach to the care of pregnant women and new mothers in prison.

National Women’s Prison Health and Social Care Group

  1. In 2021 NHSE/I stood up a multi-agency National Women’s Prison Health and Social Care Group. This group is independently chaired and has membership from the third sector, HMPPS, commissioners and healthcare providers. It has a remit to consider improvements to the built environment and health offers for women in custody and builds on existing improvements.

National Women’s Prison Review

  1. The National Women’s Prison Review is an initiative led by HMPPS with NHSE/I, DHSC and local authority involvement. It aims to improve health and well-being, reduce health inequalities and improve outcomes for women in prison. It also aims to ensure that on release women have access to the full range of high-quality health and social care services in the community.


  1. Women ‘experts by experience’ will inform the Review and its recommendations. ‘Operational authenticity’ will be determined through ongoing discussions with front line prison, health and social care personnel. Lived Experience expert advisors are also in post to inform, advise and deliver on a workplan to incorporate the needs of women, highlighting where health inequalities across the estate require focus and action.

Does the female prison estate take a Whole System Approach (that considers all of the offenders needs) to those in their care?

Whole System Approach

  1. A whole system approach to healthcare across the women’s estate would ensure that the physical and mental health of a women in custody is seen as an integral part of their management.  The clinical presentation of an individual must remain within clinical bounds of confidentiality, unless an individual gives their consent for information to be shared.  However, what can be considered is for the whole system to operate as a trauma informed environment that ensures awareness of any issues an individual has at every point of their contact with CJS.  

Women’s pathways

  1. Women prisoners often fear the negative consequences of admitting mental health problems or substance misuse issues, particularly if they have dependents or are in an abusive relationship. NHSE/I is currently enhancing ‘women’s pathways’ across all L&D services. 


  1. These pathways are being co-designed with women with lived experience of the CJS to enable a gender sensitive approach to services.  Consideration will also be given to addressing the barriers that groups, such as sex workers and foreign national women, face in accessing services.

What does this look like in practice?

  1. Case Study: Checkpoint - A Police Assessment and Out of Court Disposal. This deferred prosecution scheme in Durham, saw positive outcomes working with female offenders out of court. Using a multi-agency approach, Checkpoint supports those eligible with a ‘navigator’ who conducts an in-depth needs assessment based on their risk of reoffending, sets the conditions for the treatment requirement and manages the woman throughout a four-month period. The offender must agree and engage with the contract or risk prosecution for the offence. Over 90% of those who participated completed the scheme successfully and did not receive a criminal record.

Are there any barriers in achieving a Whole System Approach to female offending?

  1. Community orders with treatment requirements attached can be a better option for offenders who might otherwise serve a custodial sentence. For dependent drug and alcohol users and offenders with mental health problems these orders can address vulnerabilities which can be a factor in their offending or how they engage and respond to interventions.


  1. The proportion of offenders with such vulnerabilities is substantial, but in 2017, fewer than 1% of all offenders starting a court order had a Mental Health Treatment Requirement, 4% had an Alcohol Treatment Requirement, 7% had a Drug Treatment Requirement and fewer than 1% received a residential requirement.


  1. Assessment of women’s needs for Pre-Sentence Reports (PSRs) must take account of the difficulties they face and support them to disclose key information. Working with L&D services, where consent is given, key information from these assessments is shared with relevant criminal justice partners to inform decisions on charging and sentencing. Of those with an assessment, 22% of women supervised under a court order have a mental health issue, 29% an alcohol misuse issue and 32% a substance misuse issue.  For some of these, a CSTR may produce better outcomes than a custodial sentence.


  1. Recently published MoJ research suggests that sentences including mental health treatment, where mental health issues are identified, are associated with significant reductions in re-offending, compared with similar cases without treatment. The reoffending rate was around 3.5 percentage points lower over a one-year follow up period.


  1. MoJ and Public Health England (PHE) linked data also showed that among those who committed an offence in the two years prior to engaging with community-based substance misuse treatment, there was a 33% reduction in the number of offences committed in the following two years, and 44% did not go on to reoffend in the subsequent two years. This was especially striking for those engaging in alcohol treatment only, with 59% of these not reoffending in the two years after treatment, while for opiate treatment this figure was 31%.

What factors contribute to the high levels of self-harm in the female estate?

  1. We know that there is a higher prevalence of need amongst female offenders, such as mental health problems, and self-harm. Many experience chaotic lifestyles often as a result of abuse and trauma. For example, almost 60% of female offenders have experienced domestic abuse.


  1. Causation and contributing factors for self-harming are complex. Many reasons that women self-harm can be the same as men: loss of control with harm being a way of taking some control; a way of responding to intrusive thoughts; and expressing or coping with high levels of emotional distress. In women this distress is more likely to manifest from previous physical and sexual abuse and other trauma.


  1. Women in prison are more likely to have depression, anxiety or borderline personality which can make them vulnerable to self-harm. They are also more often the primary carer of children or elderly relatives and being separated from family they care for can lead to high levels of distress.

What is being done to address the high levels of self-harm in the female estate?

  1. A Women’s Self-Harm Task Force was set up in April 2020 in response to increasing concerns about the level of self-harm in the Women’s estate. Several local and national strategies both clinical and non-clinical are being implemented as part of this.  This includes strategies to prevent self-harm through increasing meaningful activities to provide distraction and increased access to video calls and phone credit to maintain family contact.


  1. There are also several interventions being led by University of Manchester, including the WORSHIP III project. This is a randomised controlled trial which looks at the clinical and cost effectiveness of Psychodynamic Interpersonal Therapy for women in prison who self-harm. COVER is another randomised control trial, which examines the use of Medical Skin Camouflage for women in prison with self-harm scars.


  1. The updated Assessment and Care in Custody Team (ACCT) (version 6), is also piloting across several women’s prisons. This HMPPS document is designed to foster a multi-agency approach to identify and plan for the management and care of vulnerable women who pose a risk to themselves and/ or others.

Does the custodial estate offer a trauma-informed environment for females? (a trauma informed environment, being that which is about putting experience, behaviours and needs first, and creating a safer, healing environment that aims to reduce and prevent trauma and retraumatising an individual)

  1. A trauma informed position is essential to improving engagement with patients and understanding the gender specificity of many areas of health delivery, ensuring healthcare providers respond to their needs accordingly.


  1. The Primary Care, Mental Health, Dentistry and substance Misuse health specifications have all been reviewed and updated in recent years. The baseline is that every intervention with a woman in custody should be trauma informed so every intervention is mindful of previous experience of trauma a person may have had. For example, reception screening for women’s prisons includes trauma informed questions and any potential acquired brain injuries to be flagged as a result of possible domestic violence.  Also, all women of reproductive age are also offered pregnancy tests.

Could more be done? If so, what?

  1. Post Covid-19 all health specifications will be reviewed and updated to consider the impact of Covid-19 on the patient population from a health and wellbeing perspective.


What support is available to ensure that women are successfully resettled into the community upon release and reduce reoffending?

  1. RECONNECT is a Care After Custody Service, working pre and post release to ensure those leaving prison engage with community-based health services to support them to maintain and improve their own health and avoid returning to the CJS.


  1. In January, the Government announced that an additional £2.5 million will be invested in an Enhanced RECONNECT service. This will support male and female offenders with complex needs to ensure they get the right treatment from mental health, substance misuse and other services, for up to a year after release. Offenders will be supported by expert care navigators working with health and probation services.


Are there any barriers to effective resettlement, and reduced reoffending?

  1. From a health perspective, continuity of care is key to maintaining rehabilitative outcomes. RECONNECT supports the patient to secure an uninterrupted pathway from custodial health services to ones in the community.

What support does the female adult estate offer to girls transitioning from the youth custodial estate?

Transitions to inpatient settings 


  1. On average 10 children transfer to secure hospital under the Mental Health Act 1983 Part III from the Children & Young People Secure Estate each year. Of these, most transfer in a timely way, however there are a small number of cases where the child either has a complicated presentation that requires an extended assessment period, or where the child does not fit the criteria for admission and/or detention.  


  1. Over the last few years, a small group of children have been identified as extremely high harm high risk who often create or contribute to systems failures. To better understand these children and their needs, NHSE/I commissioned a clinical review of these cases to support future policy and commissioning. It will be reviewing the evidence and recommendations together with its partners to evaluate next steps 


  1. Revised procedures for the transfer or remission of children under Parts II and III of the Mental Health Act 1983 III (Children and Young People Secure Estate) will be published in Summer 2021.


Transitions to the community 


Collaborative Commissioning Networks (CCN)


  1. The NHSE/I Collaborative Commissioning Networks (CCN) project commenced in 2016, as part of the NHSE/I Children and Young People Mental Health Transformation Programme. The CCN project supported a collaborative approach to the commissioning of services locally that ensured full clinical pathway consideration for CYP transitioning into and out of NHSE/I Health & Justice commissioned services. These services include:



  1. Local CCNs have been implemented across the country to support the transition between services and bridge the gaps in pathways for this cohort of children and young people. The initiatives set up were not gender specific however some may have benefited girls more due to the nature of the service. Two examples are: the recruitment of a dedicated CYP crisis worker within the SARC (Lancashire) and dedicated ‘Frankie Workers’ to provide outreach therapeutic counselling to children and young people under 18 years who are traumatised as a result of being missing, exploited, trafficked or sexually abused (Portsmouth and Isle of Wight).


  1. In February 2020 NHSE/I and the Youth Custody Service (YCS) co-commissioned Centre for Mental Health to conduct a review of the needs of, and pathways for, girls placed in the Children and Young People Secure Estate (CYPSE) in both welfare and justice placements. The final report was presented in December 2020 and is due to be published in Summer 2021.


  1. Findings showed that girls in CYPSE settings have higher adverse childhood experience risk profiles than boys and have histories of sexual abuse, poly-victimisation and gender-based violence. To support this cohort, gender-based and trauma-informed approaches are advocated. In addition to these findings, the report makes recommendations to improve girls’ experiences of CYPSE settings, with a view to making them safer and more effective.


  1. To ensure that all girls are supported and receive a high-quality, empowering service whilst in our care, a joint NHSE/I and YCS Girls Care Strategy is being drafted which considers these recommendations. To inform this, an extended period of consultation with key stakeholders is being conducted.


  1. Further, NHSE/I is considering the recommendations that are relevant to the community provision to inform work in line with our Long Term Plan (LTP) commitment to support children and young people with complex needs, the Framework for Integrated Care in the Community.

PSP and YCS Transitions Project 


  1. The transition of children and young people from YCS into the adult estate has been the subject of criticism for some time and despite the best intentions of stakeholders has resulted in the transition journey of children and young people not always being consistent, or support given to them as effective, as expected. Reliance on local relationships between establishments often drives the process rather than planning and meeting the needs of the individual child or young person. The YCS Placement and Casework Team’s concerns about transition have been increased by the growing volume of 18 year-olds within the YCS estates.


  1. Young Adult sites and the YCS are working collaboratively to identify and overcome the barriers to effective transition. A Young Adult Project Board was established in December 2018 to coordinate and streamline the response of HMPPS to The Justice Select Committee and also relevant recommendations arising from the Lammy Review. The transition of a child or young person from YCS into the adult estate can be a critical period in the young person’s journey through custody, and indeed on his or her life journey. It is imperative that this is carefully planned, is focussed on the child or young person, meets their needs and takes place in a joined-up way with the child or young person at the centre of it. 


June 2021