Faced with huge numbers of mentally ill offenders, London's forensic mental health services are struggling to cope. Rebecca Norris reports

In trying to care for the needs of mentally ill offenders, health agencies are unanimous in agreeing London "is a very different beast from the rest of the country". The reasons are manifold. London's nine prisons lock up 9 per cent of the UK's 80,000-plus prison population. Most are full to bursting under the current prisons crisis, with much of the estate suffering from 19th century infrastructure.

When inspectors came to call at HMP Brixton in 2006, for example, they found severely mentally unwell patients being held in cold basement cells with concrete floors in "wholly unacceptable", "dirty" and "unfit for purpose" conditions, although a new health centre is being built.

The numbers of prisoners who need mental healthcare are considerable. John Enser is director of forensic and prison services at Oxleas foundation trust, a mental health provider that offers an in-reach service to HMP Belmarsh. He says: "Just in terms of the numbers, 49 per cent of the people transferred [to NHS secure beds] under part 3 of the Mental Health Act [giving courts or the justice secretary the power to order mentally disordered offenders into hospitals for treatment] come from London prisons. That is a massive number."

Again, the reasons for such high levels of need are many. Sean Duggan, director of the Sainsbury Centre for Mental Health's prisons and criminal justice programme, says the catchment areas of London prisons are plagued by inner-city socio-economic problems.

Chief inspector of prisons Anne Owers adds that London's high concentration of "local prisons" - essentially remand prisons with a high population turnover - "is often where people are very vulnerable". The inspectorate's reports list variable and often poor standards of mental healthcare in the city's prisons, young offender institutions and immigration removal centres.

Alison Armstrong, director of mental health, offender health and substance misuse on behalf of London primary care trusts, lists further unique challenges facing the city's forensic services.

"Many patients do not have English as a first language; many have used substances, particularly cannabis, before admission and have also been linked with violent crime, firearms, knives or drug dealing," she says.

The capital is also home to 30 per cent of NHS medium secure units in England and Wales. As many as 471 extra medium secure places will be needed in London by the end of March 2011, revealed care services minister Ivan Lewis last July.

Spending on mentally ill prisoners is a third of what is spent on mentally ill people in the community, according to recent Sainsbury Centre research. And there is a weak area between the criminal justice system and the NHS which affects the fate of mentally disordered offenders.

Consultant psychiatrist Nigel McKenzie, who heads Camden and Islington foundation trust's mental health in-reach team at HMP Pentonville, says requests to transfer mentally ill patients to NHS secure beds are often met with delays, despite new transfer recommendations issued by the Department of Health in 2005. In his patch, the guidance led to waits being cut by 24 days, but to a still-lengthy average of 53 days.

"The main reason is lack of beds," he explains. "There are high pressures on medium secure beds, while psychiatric intensive care units [providing enhanced care for acutely unwell patients], which have lower levels of security but very good facilities, may be concerned about accepting a patient they deem a high risk, such as someone charged with murder or arson."

During transfer waits, in-reach teams rely on patients voluntarily agreeing to take medication. However, a study on transfers by Dr McKenzie (published in Psychiatric Bulletin, January 8) found 50 per cent of prisoners refused to take their medication during waits. As mental health legislation does not apply in prisons, they cannot be treated against their will.

"By refusing to take medication, prisoners may be more likely to be involved in incidents of harm," says Dr McKenzie. "If the situation becomes acute and they're an immediate risk to themselves or others, there are provisions to rapidly tranquillise them under common law. But what you can't do is give them a course of treatment to address their illness as you can do under the Mental Health Act. And psychiatrists are often reluctant to use rapid tranquillisation in prison as it involves restraint by a group of officers."

Unacceptable delays

Dr McKenzie is concerned where that leaves offenders. "Are we going back to a situation of 100 years ago, before anti-psychotics were invented, where all you could do was lock up mentally ill people and not treat them? If people are in prison and they're refusing medication, that is essentially what is happening to them."

His study concluded that hospital transfers should be subject to the same 14-day time limit that usually applies to civil sections in the community.

Prison inspection reports confirm that "unacceptable" transfer delays, sometimes of over a month, are common across London. In one case a male prisoner awaiting transfer had been medicated under restraint and without consent three times.

Peter Mason, chief executive of Secure Healthcare, the social enterprise that leads the consortium of HMP Wandsworth's health providers, warns of recent waits of up to 60 days. He has called for mental health trusts to be fined£300 for every day they breach transfer limits, in the same way the NHS fines social services for their part in delaying the discharge of elderly patients from hospitals.

"Something needs to bring focus to this debate. If the forensic mental health system focused on outcomes, in terms of being able to specifically identify the changes it is able to bring about for people, we would not have people languishing for long periods of time. We need to make sure the system, from high, medium and low secure units to psychiatric intensive care units, links together."

Mental health trusts predictably resist the idea of fines. Mr Enser of Oxleas foundation trust says: "The problem with fining is that we work in a finely balanced community with long-standing and valued relationships that we want to nurture and maintain, including with our PCT commissioners. If there are unacceptable blocks being put by PCTs and there is a case so urgent that clinicians feel it would be abhorrent to leave that person in custody, then I've no doubt we would be supported by our trust board to let that person in.

"But if there are people you feel are safe in custody, even if it's not desirable, we would monitor that and bring them in as soon as we possibly could, by working with our PCTs.

"If you brought everybody in who potentially could require an inpatient service or at least an assessment, there would be a cost shunt onto the health economy. There's a balance to this that we recognise and have to achieve."

The DH is tackling the transfer dilemma by piloting schemes that will move prisoners with "acute, severe mental illness" into the NHS within 14 days. But London PCTs director of offender health Ms Armstrong says London "didn't want to focus on numbers and targets. We wanted to look at service redesign and improvements".

That means eight medium secure units in London are concentrating on ensuring offenders "are effectively treated with a proper package of care, including programmes to address their offending behaviour so they don't get behind when they get back [to prison]. We also try and keep in touch with the prison they've come from - it could be outside of London - to keep that pathway open and make sure they can return when they need to."

PCTs have also been funded to collate and provide monthly data reports on transfers.

"We look at who is waiting and why they have been waiting, whether there is a difficulty with a bed, a commissioning issue, or a victim issue. Many people in London prisons have nothing to do with London PCTs and belong to other parts of the country."

Sharing information

Ms Armstrong says London's NHS secure units want the prison service to share more information about risk factors of offenders, which may currently be withheld because they are high-profile individuals or because files are held by security rather than prison healthcare staff.

"For example, if you have someone who is a local person in a local prison and is in custody for drug dealing, it may in the interests of others [such as their drug suppliers or buyers] to help them out of the NHS facility. In that case, we would be keener to move that person somewhere less accessible. Otherwise it makes the person, our patients, our members of staff and the public - all of whom we have a duty of care towards - vulnerable."

She adds that the capital has successfully met the commitments of a 2003-2007 London-wide plan to build extra bed capacity, including a new medium secure unit for women and two units to house those with personality disorders. The number of London secure patients placed in costly out-of-area beds has also been cut from nearly 400 to below 100.

So if the capital is not meeting transfer targets - Ms Armstrong prefers to say the region is "working towards" them - it is "not because we don't want to or we don't have the beds, or because we are not investing, but because of the numerous circumstances I've described. We have huge conundrums and we should not underestimate the types of people we are dealing with and our duty to protect everyone."

A new London plan revising the 2003-2007 one, planning work up to 2011 and drawn up by a strategic group comprised of clinical and service directors, lead commissioners, probation service, the prison service and the Ministry of Justice, is due to be published by November.

As well as transfer efforts, it is likely to focus on improving primary mental healthcare services within prisons and developing step-down and community services. Work by South London and Maudsley foundation trust to develop a "culturally competent" workforce to address the over-representation of young black men within forensic services will also be rolled out to other trusts. Medium secure staff will also receive specialist substance misuse training.

Another incoming influence is the independent Bradley review, due to report jointly this summer to the Department of Health and Ministry of Justice. Lord Bradley was asked by justice secretary Jack Straw to examine whether more offenders with mental health problems or learning difficulties could be diverted from the criminal justice system to other services and what barriers currently prevented this from happening.

Range of needs

Ms Owers says that while prison mental health in-reach teams and the handing over of commissioning responsibility to PCTs has improved care in all prisons, an underlying problem is the absence of sufficient forensic psychiatric care and indeed community mental healthcare to prevent people becoming a problem for the criminal justice system.

"It is still the case that too many people - particularly in black and ethnic minority communities - are accessing mental healthcare through criminal justice," she says.

"A report from the Social Exclusion Unit pointed out very powerfully that a lot of the people who are ending up in prisons have a whole variety of needs at a sub-acute level.

"These include mental health, employment, social issues and economic problems, but as these are never actually bad enough or the person ill enough to get the care they need in the community, all these come together, maybe through offending or criminal justice."

Court diversion schemes, intended to identify mentally unwell offenders in need of treatment before they enter the prison system, are few and far between and lack consistency, Ms Owers adds.

Hard evidence on the impact of diversion schemes on reoffending rates is weak, admits Mr Duggan of the Sainsbury Centre. Yet he still feels they are worth pursuing. "My view is that it's not just appropriate to look at the court stage; we need to look at pre-arrest, the point of arrest and in police custody."

The case for diversion is strengthened by the centre's work showing that prison healthcare services are much more expensive to provide than community mental health services.

Another idea put to Lord Bradley - by Secure Healthcare chief Mr Mason - is the building of "semi-secure purpose-built community mental health observation and treatment units" near remand prisons or as annexes to medium secure units, to take people who are bailed for assessments. Whatever Lord Bradley recommends, Ms Owers concludes that despite the "difficult time in terms of public finances, unfortunately, unless we do put in investment to this area, we will find that these people keep coming back and back into prison. If only we could pick up those problems earlier, then in the end that would cost us less."

In-reach at HMP Belmarsh

Oxleas foundation trust stands apart from other mental health trusts in London through the glowing report it received from the chief prisons inspector in 2007 for the in-reach team it runs inside HMP Belmarsh. Trust director of forensic and prison services John Enser says the achievements are down to three key factors.

"Firstly, we have a long-standing history with HMP Belmarsh, going back to the 1990s, which started with a visiting consultant service and has gradually developed. The second key ingredient is a partnership approach where we fully recognise the constraints and boundaries that exist within the prison system and try to find a way of assisting people through the pathway. We are also very strong on having a multidisciplinary team; in Belmarsh the team goes from consultant psychiatrists, through nursing, social work, occupational therapy and counselling."

Mr Enser says a jewel in the crown of the Belmarsh service is its Cass Unit day centre run for the past decade in the prison, which is critical to the life of vulnerable offenders, as it offers a haven away from the main prison house blocks.

"It delivers a very clearly defined therapeutic programme, which has been audited annually, where prisoners can address some of their personal and mental health issues and explore coping strategies within a custodial setting."

The trust is trying to reduce transfer delays to mental health secure beds through a new internal rota system for psychiatrists, to ensure offenders are assessed within 48 hours of referrals. It has also launched a pilot in partnership with Central and North West London foundation trust to pilot a scheme inside the Old Bailey criminal court, to divert people to services as early as possible.

"There is one community psychiatric nurse there five days a week and a psychiatrist one day a week. They are there as a service to the court, able to offer advice to either judges or the court itself in terms of giving an early indicator as to whether this person would benefit from a more detailed report. It's not a reporting service per se but a signposting and advice service."

For more on prison mental health, read Angela Greatley's article on hsj.co.uk.

Transforming Forensic Mental Health Services is an HSJ conference in London on 24 June. For more details, visit www.hsj-forensicmentalhealth.co.uk