PAC: New approach needed to tackle failures in duty of care to prisoners

REPORT SUMMARY

Record high numbers of self-inflicted deaths and incidents of self-harm in prisons are a damning indictment of the current state of the mental health of those in prison and the prison environment overall.

More excuses are not good enough. The Ministry of Justice, HM Prison and Probation Service and NHS England have a duty of care to those in prison, yet do not know where they are starting from, how well they are doing or whether their current plans will be enough to succeed. 

The current level of self-inflicted deaths and self-harm incidents in prisons is appalling and the system for improving the mental health of prisoners isn’t working as it should.

Government does not have reliable or up to date measure of the number of prisoners who have mental health problems and existing screening procedures are insufficient to adequately identify those who need support and treatment.

People in prison are more likely to suffer from mental health problems than those in the community. Yet prisoners are less able to manage their mental health conditions because most aspects of their day-to-day life are controlled by the prison. 

These difficulties are being exacerbated by a deteriorating prison estate, long-standing lack of prison staff and the increased prevalence of drugs in prison.

Improving the mental health of prisoners is a difficult and complex task, but it is an essential step to reducing reoffending and ensuring that those who are released from prison can rebuild their lives in the community.

Despite this, Government’s efforts to improve the mental health of those in prison so far have been poorly co-ordinated, and information is still not shared across the organisations involved, and not even between community and prison GP services. 

COMMENT FROM PAC CHAIR MEG HILLIER MP

“There are deep-rooted failures in the management of prisoners’ mental health, reflected in what is an appalling toll of self-inflicted deaths and self-harm.

“Failing to attend to the mental health needs of inmates can also have devastating effects beyond the prison gates.

“The evidence is stark but there is no realistic prospect of these serious issues being properly addressed unless Government rethinks its approach.

“This must start with a meaningful assessment of the scale of the problem.

“Without adequate data it is simply not possible to determine whether Government action is making a difference – yet, incredibly, the most commonly used estimate of prisoners’ mental health problems is 20 years old.

“This is clearly not good enough and implementing more robust health screening processes must be a priority.

“There are long-standing issues with understaffing in prisons and, as the Government seeks to address these shortfalls, we will expect it to demonstrate swift progress with plans to provide enhanced mental health training.

“But reviews elsewhere in the system are desperately needed: prisoners’ increasing use of psychoactive drugs, for example, has laid bare the weaknesses of treatment and detection programmes. 

“Government must raise its game to understand the problems and we urge it to act promptly on the recommendations set out in our report.”

CONCLUSIONS AND RECOMMENDATIONS

The deteriorating prison estate and long-standing understaffing have created an environment which exacerbates the mental health issues faced by prisoners. Prisoners are less able to manage their mental health conditions because most aspects of their day-to-day life are controlled by the prison. The current restrictive prison regime caused by loss of prison staff, has meant that staff are less likely to identify prisoners with mental health issues and prisoners are less able to self-refer. Prisoners miss an average of 15% of medical appointments, largely because of a lack of staff to escort them. The Ministry of Justice and HMPPS accepted that low levels of staffing have been detrimental to security and order in prisons. HMPPS told us that it was working to address the issues we identified with the prison environment through a range of activities, including recruiting 2,500 additional staff by the end of 2018, providing enhanced mental health training to all new staff including on suicide awareness and providing each prisoner with a dedicated key worker. While this sounds promising, we are not yet convinced that these plans will be enough to improve conditions for prisoners with mental health issues. While all prison officers receive basic training on mental health awareness when they are recruited, 40% of prisons do not offer existing staff any mental health awareness refresher training. We were also concerned to hear of examples where the loss of prison staff is already outstripping recruitment and of delays of 7 months to recruit new staff.

Recommendation: HM Prison and Probation Service should:

By the end of March 2018, reduce the time taken to recruit new prison officers and mental health staff and get them working in prisons;

By the end of January 2018, write to the Committee with details of the number and proportion of prison officers who have participated in the new mental health training; and

By the end of July 2018, write to the Committee with details of the number of additional staff that have been recruited, deployed to prisons, and how many more have resigned since the NAO report.

The failure to establish effective screening procedures means the Ministry of Justice, HM Prison and Probation Service and NHS England do not know the full extent of the number of prisoners with mental health issues. There is no reliable or up to date data on the prevalence of mental health issues in prison. The mostly commonly used estimate, that 90% of prisoners have mental health issues, is now 20 years old. Prison staff screen prisoners when they first arrive in prisons, including for risk of suicide and self-harm, and this is followed by a health screen, but neither of these adequately identify mental health problems. The reception process for new prisoners can be chaotic and not all prisoners with mental health issues are identified at this stage. HMPPS analyses screening data at a national level, but its information is incomplete as prison staff leave some questions unanswered. Prison staff did not enter data on the ‘risk of suicide’ in 68% of screening records, or on the ‘risk of self-harm’ in 59% of records. NHS England has a more complete dataset as it collects information on the number of people who are being treated for mental illness, currently 10% of the prison population. But this does not include those who are waiting for treatment so is very likely to be an underestimate of those that need support.

Recommendation: HM Prison and Probation Service, the Ministry of Justice and NHS England should, by the end of March 2018, write to the Committee to explain how they will improve their screening processes and use the resulting data to make sure they have a complete understanding of the number of prisoners with mental health issues and the treatment they need.

Increased availability of drugs in prisons has contributed to the increase in mental health issues of prisoners. The number of drug seizures in prisons has risen from 2,500 in 2015 to just over 10,500 in 2016. There has been a huge switch in drug use in prison towards psychoactive substances, which existing detection and treatment programmes were not designed to deal with. Spice is now a substantial problem in prison, with the number of seizures going up from 408 in 2015 to nearly 3,500 in 2016. HMPPS told us that dealing with these substances has been very difficult as they were previously legal and easily accessible. It told us that it is was the first law enforcement agency in the world to train dogs to detect psychoactive substances and that it now had a test in place to detect the drug.

Recommendation: HM Prison and Probation Service and NHS England should review their detection and treatment programmes to ensure that they reflect the current behaviours and needs of prisoners.

Poor co-ordination and a lack of sharing information means that prisoners are not receiving continuity of treatment as they move between prison and the community. People in prison are more likely to suffer from mental health problems than those in the community. Many prisoners move in and out of prison, or between prisons, which makes the job of providing healthcare more difficult. Despite this there is a clear disconnect between the information available to healthcare provider on the care patients have received before, during and after their time in prison, which risks making mental health services almost inaccessible for some patients. This lack of continuity risks worsening prisoners’ mental health conditions and undermining their rehabilitation, particularly those with speech and language issues, learning disabilities, autism and dementia. NHS England recognised that healthcare services were not where they needed to be and committed to ensuring that they were better co-ordinated. It told us that it was introducing a system to ensure that prisoners’ medical records from the community and prison were joined-up, which it will start to roll-out from November this year.

Recommendation: NHS England should, by the end of March 2018:

Evaluate the effectiveness of the link between NHS records in the community and in prison; and

Establish and disseminate information sharing protocols between prison, healthcare and probation staff so that all parties are fully informed about the services and support that prisoners will require on their release.

It is a disgrace that too many prisoners wait far too long to be transferred to hospital or secure units. Prisoners with acute mental health problems should wait no more than 14 days to be admitted to a secure hospital, but the majority wait far longer than this. In 2016-17, two-thirds of prisoners who needed treatment waited longer than 14 days to be transferred. We were told of examples where prisoners had waited over a year to be transferred to a secure hospital. NHS England is responsible for ensuring that the 14 day target is met. Yet NHS England does not know how many patients who are currently waiting to be transferred to hospital or secure units have waited longer than 14 days. We are deeply concerned that the failure to make sure these prisoners receive the treatment they need is making them more ill at a time when they are most at risk.

Recommendation: HM Prison and Probation Service and NHS England should, by the end of January 2018, publish quarterly data on the number of prisoners transferred to hospital or secure units, how many prisoners are waiting at the time of publication, and how long both groups have waited. 

NHS England’s oversight of its contracts to provide mental health services has been weak. NHS England does not monitor the quality of mental health care delivered by private providers, or the outcomes these services achieve. The National Audit Office report highlighted two examples where NHS England had continued to pay for services that the contractor had not delivered and had not acted to recoup any costs. Untreated mental health conditions, especially schizophrenia, personality disorders and substance misuse disorders, are associated with higher rates of suicide and self-harm. It is not clear what action, if any, NHS England takes in response to providers who are found to have contributed to a death in custody. NHS England was unable to tell us in our evidence session how many cases there had been where a provider’s failure to provide adequate mental health services had contributed to an individual taking their own life, or in how many of those cases it had taken action against the provider. Taxpayers’ money should not be wasted on services that are not being received or are being delivered to a lower quality than required.

Recommendation: NHS England should write to the Committee by the end of January 2018 to confirm what actions it will take to ensure that it is getting value for money and that taxpayers’ money is not being wasted by paying for services that are not delivered or are well below the standards expected. 

The full text of the Committee’s Conclusions and Recommendations is included in the Report attached to this email.