Prison mental healthcare: pushing up standards

The health and social care of mentally disordered offenders is currently the subject of much thought and effort.

In November 2007 the Department of Health published the strategy and consultation document Improving Health, Supporting Justice and a subsequent evaluation report contained a number of valuable suggestions. And this year Lord Bradley has been reviewing the diversion of people with mental health problems from the criminal justice system and prisons. He is due to report in late 2008, with a detailed strategy expected next year.

As psychiatrists working in London prisons, we are delighted at the renewed interest.

Prison healthcare

The time to reorganise prison healthcare commissioning has arrived. Despite the great strides made in prison healthcare the interaction between commissioning and provider structures is unsatisfactory, but it could, with reorganisation, provide a solution.

In the last 15 years, the number of prisoners has risen from 40,000 to more than 80,000. The prison estate in England and Wales consists of 139 establishments providing a variety of services, including remand, training and rehabilitation and specialist functions such as provision for young offenders and high security.

Before 1996, prison medical officers provided primary care services. The absence of a direct link with the NHS was believed responsible for the poor quality of care and professional isolation identified by the chief inspector of prisons. As a result mental health inreach teams were introduced to prisons in 2001, followed by full primary care trust commissioning in 2006. However, prison inreach services cannot work in the same way as outside as their functions are inhibited by powerful cultural forces in both the NHS and prison service.

The prison population presents particular health problems. Its rates of psychosis, substance misuse and personality disorder are well in excess of community equivalents. Prisoners are not protected by the provisions of mental health legislation and compulsory treatment is not available for those who need it. Primary care mental health problems are endemic and many difficulties remain in getting mental health beds for acutely mentally disturbed prisoners.

Systemic bias

We believe systemic bias against prisoners often lies at the heart of the problem. Prolonged arguments about catchment area responsibility and disagreements over levels of NHS based security remain commonplace. The absence of a mechanism for appealing against clinical or financial disagreement is problematic while getting a transfer warrant can compound delays.

Practically, high levels of turnover of mentally disordered prisoners can overwhelm small clinical teams, especially if they do not have sufficient administrative support.

While some prisoners are admitted to hospital quickly and without fuss, we are particularly concerned about those who wait. The law has a clear role to play under the provisions of the Mental Capacity Act, or article 3 of the Human Rights Act. Unlike the Mental Health Act, which has already been used for successful legal challenge in France on the grounds that inappropriate delay resulted in inhuman or degrading treatment or punishment.

Some excellent proposals have been made to try to remedy the problem. The Law Society has suggested the Ministry of Justice has a duty to order transfer to hospital. Others have proposed a duty to co-operate between health, social care and criminal justice agencies or the inclusion of offender health in primary care trusts annual public health plans.

Unitary commissioning

We add the following proposal: we believe the solution to the problem of delays in securing beds for mentally ill prisoners lies in the unitary provision of commissioning services. We propose the creation of a single commissioning team with its own devolved budget, operating as a "prisoner care trust". This would eliminate the need for existing PCTs or trusts to fund prisoner transfers or hospital care in the NHS.

Central to this proposal are financial incentives. We believe attaching a parcel of money to individuals requiring hospital transfer would make them considerably more attractive to providers. Coupled with financial penalties for missed deadlines, it could revolutionise the priority given to prison diversion.

This new commissioning team could offer an appeal structure and develop a high level of expertise. The problems and inconsistencies of multiple commissioning arrangements could be minimised and the special nature of prison healthcare need and provision would be recognised. Significant progress has been made in prison healthcare. We now have a welcome window of opportunity for substantial change. It is time to make that change happen.