Published: 17/11/2005 Volume 115 No. 5982 Page 29 30

With 80 per cent of prisoners suffering mental health problems, PCTs are facing an enormous task when they take on prison health services in April next year. Emma Forrest looks at how specialist teams are preparing for the task ahead

The numbers of prisoners suffering mental health problems is staggering - an astonishing 80 per cent, with a high prevalence of psychotic conditions, according to the Office for National Statistics. A social exclusion unit report last year revealed that 70 per cent of prisoners had two or more mental health conditions. With prisoner numbers recently found to have peaked at a record 77,702 in mid-October, the issue of prison mental health is neither small nor diminishing.

Each prison, with its local primary care trust, has carried out a mandatory mental health needs assessment of its inmate population. By April next year (the target for provision of all prison healthcare to be transferred to PCTs), every prison should have relevant mental health services.

Technically, an offender with a severe mental health problem should not be sent to prison in the first place. There are 139 court diversion and criminal justice liaison teams which should ensure such people are sent to a hospital, but commentators believe they are failing on this.

'There are not enough locked wards in psychiatric services to give reassurances to the courts, ' says Peter Mason, chief executive of crime research and training organisation the Centre for Public Innovation. 'Diversion schemes are clearly not diverting as much as they should because they have not been resourced to a level where they can be effective.' The care model for mentally ill prisoners was outlined in the Department of Health's 2001 Changing the Outlook strategy document. It provided a model for in-reach teams to help prisoners suffering from severe and enduring mental illness. There are now 100 in place, employing over 300 staff. They are intended to be roughly based on community mental health teams. They should have access to local psychiatric input and the opportunity to transfer prisoners to a hospital setting if necessary.

DoH lead for offender mental health in prisons Sean Duggan says he has an 'extremely favourable' impression of in-reach teams' performance. 'We have invested£20m in in-reach services since 2001, and they have been successful in assessing and treating the most needy. We have been pleasantly surprised at the rate of progress.' Yet mental health commentators say that in the rush to set up the new, desperately needed teams, effective models of care have not always been put in place first. Teams are often on the receiving end of inappropriate referrals and find themselves dealing with every prisoner with a mental health problem, however mild.

'This takes up so much time that they cannot -30 concentrate on the prisoners with severe problems.

'Many teams have been given the in-reach remit with little investment or support and have had to deal with everything, ' says Liverpool prison community mental health team manager Denis Cullen. 'This can lead to them folding under the level of work.' Mr Cullen says he took time early on to put a referral system in place that would enable the team to avoid work overload. 'A fluid referral system creates a very reactive service. We try to ensure that the services reflect what you or I would expect to receive in the wider community, ' he says.

His team uses a single point of referral from a multi-agency meeting that meets weekly. 'Before it was established there was no dialogue between the different agencies. It is simple but works effectively.' Team managers argue it is difficult to stick to the model of only dealing with severe and enduring illness when confronted with so much unmet need. 'Despite the suggested model, we undertake work which would not be part of a community mental health team's services, and cover the mental health needs of the whole prison, from moderate problems to severe ones, ' says Manchester prison's in-reach team manager Dale Griffiths.

'There are 1,300 prisoners in this jail and I am not sure we could meet their mental health needs with a community mental health team model.'

Appropriate action

Worcestershire Mental Health Partnership trust has a different way of dealing with the problem.

'When we first started we received loads of referrals and responded, but we are now working with the prison primary care services to work on appropriate referrals and liaise back where they are inappropriate, ' says in-reach team manager Elaine Howard, whose team works across four establishments. 'Primary care now deals with mild to moderate conditions.' Interventions carried out by the team vary according to population need. For example, at maximum security Long Lartin, which has a stable population, work tends to focus on relapse prevention.

Elsewhere, psychological interventions have proved effective at Blakenhurst prison, which holds remand and category B prisoners.

Kevin Cryans, manager of the mental health in-reach team at Preston Prison (category B), agrees that referrals to primary care are more effective for less severe problems.

'We cannot take them, we would be swamped. We get around 38 referrals a month, of which around 12 will be suitable for assessment.

A lot of referrals are still inappropriate, but we have to respond when a prisoner requests to see someone. It is about education; these things take time, ' says Mr Cryans.

It is also important for in-reach teams to decide early on whether they are going to be based inside or outside the prison; either way it is considered important to send out the right message.

'We need to be visible. It is about meeting the needs of the prison and becoming part of the prison process, ' says Mr Griffiths, whose Manchester team is based inside the prison.

But at Liverpool prison, which with 1,500 prisoners has the biggest jail population in western Europe, the team shares accommodation with a local community mental health team.

'I had concerns about being located within the prison, ' says Mr Cullen, who felt the team would work less effectively by being too far away from mental health services.

The DoH has carried out a national evaluation of in-reach teams and is expected to publish its findings next month. Mr Duggan hopes it will establish what work the teams are being expected to carry out, and give a breakdown of professional backgrounds of staff.

'It will be able to answer questions around who the teams are assessing, who they are treating and if they are dealing with the demand successfully.' he says. 'Building up needs assessments partnerships with local providers has taken time and there is more work to be done, but the level of understanding about prison mental health is a lot better than it was.' There are, however, several issues common to in-reach teams that are a result of working within the prison system. The continual turnover of prisoners can make it difficult to establish continuity of care while in the system or aftercare in the community. Around 50 per cent of prisoners serve sentences of less than six months and being moved to another facility is common; a prisoner might live in six establishments during a 12-month sentence.

This means that teams can struggle to establish effective care pathways. They report instances in which they have investigated when a prisoner does not attend an appointment, only to find that they have been transferred or released and noone has told their mental health worker. As a result, caseloads vary from week to week and discharge planning is difficult, particularly as prisoners often have nowhere to go on release, and no GP.

Transfer of prisoners into the NHS is another issue brought up time and again by in-reach staff.

'The reality is that experience of transfer is not positive. On average it takes 12 weeks; an astonishing number, ' says Mr Cullen. 'There is invariably an issue with finding a bed and the case must be heard by the referral panel. So even if someone is acutely unwell it is not possible to move them the same day. The private sector always has beds, but then you have to find a commissioner who will pay those charges.' The DoH says it acknowledges the issues around transfers. 'The whole process of transfer - commissioning the care, finding a bed, the actual transfer and follow-ups - is complicated, ' admits Mr Duggan. 'But we are now producing much more robust data around who is waiting for a bed, what their problems are and what level of care they require in the NHS.'

Work in progress

A two-year programme on improving the transfer process, involving the DoH, National Institute for Mental Health in England, Home Office and Prison Service began in April. Its aims include establishing who is responsible for funding transfers and setting a national waiting-time protocol for transfers. An interim set of guidance is expected by the end of the year.

Work on mapping the capacity of secure psychiatric services suitable for transferred prisoners is also underway.

'The problems are not correctible at prison level; they need addressing upstream, ' says Mr Mason. 'Prisons are bad for your mental health and if you have a pre-existing condition it is likely to be exacerbated. We need to go back to basics and ask what the mental health needs are, work out how to deal with different levels of severity, and promote how to look after your mental health.' Meanwhile, current delays can make providing suitable care extremely difficult. When mental health teams are looking after someone who is acutely ill, they must do so without the legal entitlements that allow them to treat someone without their consent, as section three of the Mental Health Act does not apply in prisons. This can mean a prisoner who refuses to take medication can get steadily worse and be confined to their cell.

As a result, in-reach work is described on occasion as distressing and distasteful. 'We are dealing with acutely unwell guys whose behaviour can be unpredictable, ' says Mr Cryans, who adds that it can be challenging to work in an environment in which healthcare has not historically been a priority. 'The environment can be discomforting and is definitely not for everyone. But you have to accept that the regime and the discipline is part of the game.' Prison mental health is clearly anything but an easy life. One thing these teams have on their side is that recruitment into them has avoided many of the recruitment and retention difficulties associated with mental health.

There are plenty of people eager to work in prison in-reach, provided they are prepared to stay in their current job until the extensive security checks needed for working in the prison service are completed.

In-reach managers working in the sector clearly relish the challenges, but are conscious of the difficulties that have still not been addressed.

'Despite the challenges of the environment, we have seen in excess of 200 people with severe mental illness in the past year [to] who we think we have provided a good service, ' says Mr Cullen. 'I am very proud of my team and encouraged by the progress we have made.' .


'Recently we got someone transferred to a secure unit, he then absconded and was rearrested and sent back to us. Then I was told that we would have to arrange for him to be transferred again. That is barking.' So says Brixton prison governor John Podmore, who is frustrated at the number of acutely mentally ill offenders who get sent to his prison. 'I should not be put in this position. There needs to be better collaboration between the courts, health service and prisons to ensure this does not happen.

'I am here to protect the public, ' he says. 'People who are severely mentally ill should be in hospital, not prison. They should not be having to receive mental health treatment in prison.' Overseeing the sectioning of, on average, 90 people a year, Mr Podmore has spoken publicly about breaking the law by refusing to obey a court order to release a remand prisoner he knew was too ill to be let out. 'I was working on sound advice that I could not protect him or the public otherwise.' He says similar situations have reoccurred since, and is critical of the transfer system that sees mentally ill offenders sent to NHS care. 'The time it takes to get a transfer is usually between three and six months. When I started here three years ago it was between six and 12. It is improved, but it should be 24 hours.' Mr Podmore believes courts need more options on where to send offenders with mental health or drug and alcohol problems. 'There needs to be the expertise in court to make judgments about people who are mentally ill, and there needs to be alternate places for them to go.

Court diversion schemes are not working, so they are ending up in prison.' He is also concerned about what he sees as a lack of work being done around dual diagnosis; people with mental health problems who misuse drugs and alcohol. He argues that services are unprepared for changing patterns in drug use and the effects it will have both on users' mental health, offending patterns and prison populations.

'Around 75 per cent of Brixton's inmates class crack as their drug of choice, ' says Mr Podmore.

'There has been a lot of research around opiates but drug use is shifting towards stimulants. We are yet to fully understand the crack and cocaine issues, and methamphetamine is a real spectre in our society.'

Key points

Four out of five prisoners suffer mental health problems.

There are 139 liaison teams responsible for ensuring offenders are directed to hospitals where appropriate, but they are under-resourced and stretched to capacity.

Mental health teams are working to reduce inappropriate referrals.

HSJ readers can access information and good practice on this subject by visiting

www.goodmanagement-hsj. co. uk/ prisonmentalhealth