The future of mental health care in prison

Work with offenders looks at an important new report from the Centre for Mental Health

As many readers will know, poor mental health is exceptionally common in prison. 45% of adults in prison have anxiety or depression, 8% have a diagnosis of psychosis, and 60% have experienced a traumatic brain injury. Being imprisoned can exacerbate mental health difficulties, and there are too many avoidable remands and short sentences where a community alternative could have been viable. In recent years prison suicides have reached record levels, and so too have recorded self-harm and violence.

For this reason NHS England and NHS Improvement commissioned Centre for Mental Health to conduct a review of mental health care in prisons which was published last week.

The good news is that the review concludes that the model of mental health care commissioned by NHS England and NHS Improvement is working well. The researchers found examples of good and innovative practice from the NHS and independent and voluntary and community sector (VCS) providers.

The bad news is that they also found marked variation in provision from prison to prison, and a paucity of psychological therapy offers in some areas and for some categories of prisoners. Screening and assessment processes are not robust and much need is likely to go unidentified.

In particular, the researchers found that the pathways in and out of prison are problematic. There are too many avoidable remands and short sentences where a community alternative could have been viable (the number of community orders with Community Sentence Treatment Requirements remains particularly low for those in need of mental health support). People coming into prison on remand and short sentences tend to be those with the highest levels of need. But with short and unpredictable prison stays, and persistent difficulties in communication with services in the community, the report says that continuity of care has been difficult to achieve for this group in particular.

Continuity of care for people leaving prison is also problematic. Many prisoners who need support are not receiving it. NHS England and NHS Improvement have commissioned a pilot programme, RECONNECT, targeting the most vulnerable people leaving prison, which is starting to address at least part of this need.

The researchers find hope in the reforms in the commissioning of healthcare in England which they say should offer opportunities for ensuring better continuity of care when people go into prison and when they leave.This can include the meeting of more niche specialist needs. These are Integrated Care Systems (ICSs, which are collaborations between health and social care) and Provider Collaboratives (PCs, which are alliances between local NHS organisations and possibly independent sector providers, to foster closer cooperation between them). These new bodies have the potential for closing gaps in and between mental and physical health care, and in connecting better with social care to address more complex need.

This review was the first part of a two-stage process. NHS England and NHS Improvement has also commissioned the Centre for Mental Health to conduct a mental health needs analysis across the English prison estate which will quantify the levels of service provided, need and (where possible) unmet need. These two exercises combined will inform the future of prison mental health care and any revisions to the national specification for mental health care in prisons. Much of the data about the mental health needs of prisoners is out-of-date and many people working in the forensic mental health sector will welcome this work.

The report makes a number of recommendations including that all prisons should become trauma-informed environments and that there needs to be a major investment in the mental health training of all prison staff.