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What can be done to curb suicide, violence and drug abuse in prison?

What can be done to curb suicide, violence and drug abuse in prison?

The English and Welsh prison system is experiencing a mental health crisis.
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The English and Welsh prison system is experiencing a mental health crisis. Suicide rates are at their highest since records began in 1978. Prison mental health services (PMHS) and their staff are under increasing stress. Yet this is occurring at a time when these services are commissioned nationally and are more professional and organised than ever, operating within a successful quality network and with NICE publishing evidence-based guidelines for their delivery.

The prisons crisis

Barely a week has gone by in the past two years without press coverage highlighting the problem. Most recently, a report about a series of suicides at HMP Woodhill in Milton Keynes has received interest. The Parliamentary Joint Committee on Human Rights rushed out its interim report on mental health in prisons1 a day before the dissolution of parliament on 3 May.

The number of self-inflicted deaths in prison has risen steadily from 58 in 2010 to 119 in 2016, the highest number since records began in 1978. There has been a particularly sharp increase in the number of self-inflicted deaths in the female estate, up from five in 2015 to 12 in 2016, the highest number since 2003. The increase in self-harm and suicide in prisons has been described as ‘shocking’ by the chief inspector of prisons, who said the death toll will continue to rise because prisons are becoming ‘unacceptably violent and dangerous places’.2

Many factors have contributed to the crisis: the cuts in prison officer numbers; the growing prison population; the availability of new psychoactive substances (NPS), formerly known as ‘legal highs’; and the large numbers of life-sentenced prisoners without a definite release date are just a few of these.

While the exact figures and front-line impact are debated, the cuts to prison officer numbers since 2010 are real and acknowledged by the Ministry of Justice. It announced its intention in November 2016 to recruit 2,500 officers and for each offender to have a personal officer.

The reduction in officer numbers has been a major factor in the deteriorating safety of the prison system. The number of security breaches, such as prisoner access to drugs and mobile phones, has risen, as have incidents of violent assault on staff and other prisoners.

This has had knock-on effects on PMHS. A lack of officers available to escort patients makes it more difficult to conduct clinics, while security incidents lead to lockdowns and cancelled clinics and result in staff feeling concerned for their safety. Female staff have reported higher levels of sexually inappropriate comments and psychiatrists have left prison posts. The lack of officers also means it is less likely that prisoners with mental health difficulties can be identified, supported by officers and protected from bullying and exploitation on overcrowded, understaffed wings.

The fact that the problem has been acknowledged and positive actions have been taken should be welcomed. There have been moves to improve officer recruitment, address the dangers of drones and block mobile phone signals.

A drug‑testing regime was included in a prisons and courts bill introduced to the previous parliament, but was lost when the general election was called.

Impact on PMHS

Prisoners have long been recognised as having very high rates of mental disorder, including psychosis, mood disorders, substance misuse disorders and personality disorder. More recently, awareness has grown about high rates of neurodevelopmental disorders and cognitive impairment.

This has led to a change in the nature of work for prison mental health teams, with more time being spent on assessment, care in custody and teamwork (ACCT) reviews, the prison service process for managing self-harm and suicide risk and responding to crises (eg drug-induced psychosis caused by NPS).

As a result, less time is available for the long-term work that is more likely to have ongoing benefits for patients in terms of their mental health and possibly in reducing offending. NPS has led to a rise in short-lived, drug-induced psychosis, exacerbations of pre-existing psychotic illness and new cases of psychosis. All of this places additional, extremely damaging pressures on services.

Staff are under unprecedented levels of stress. Constant responses to crises are debilitating. An underappreciated element is that suicides have an emotional impact on staff, as does subsequent attendance at inquests, often with multiple parties being represented. Cross examination by barristers representing mental health providers, physical healthcare providers, prison staff and relatives is not
uncommon.

These problems can also be considered a consequence of national difficulties in mental health services. Budgets have fallen in real terms, meaning fewer psychiatric beds are available. Bed-blocking is a problem too because of a lack of appropriate discharge accommodation. Community services are increasingly stretched, so patients with histories of contact with the criminal justice system are more likely to ‘fall between the gaps’ in the community and present in forensic settings.

Anecdotally, this has led to more patients with pre-existing mental illnesses being admitted to prison and delays in transfer from prison to hospital. There are recruitment difficulties throughout mental health services, especially prisons in London or areas such as the South East.

Progress

While there is much to be gloomy about, there are also areas where progress is being made. Mental health services in prisons are generally well integrated with physical healthcare and substance misuse, as they are commissioned jointly by NHS England. The common information system, SystmOne, means all healthcare providers use the same records system. Records now pass from prison to prison electronically and almost instantaneously, meaning up-to-date information is available at reception.

Central commissioning has protected PMHS from some of the reductions seen in CCG-commissioned mental health services. However, disparities can still be found, because of the historical development of services, lack of responses to changes in the prison estate and the absence of a national template.

The quality network for PMHS has been developed from the work of the College Centre for Quality Improvement (CCQI) at the Royal College of Psychiatrists. The CCQI runs quality networks for services such as acute in‑patient psychiatric units and medium- and low‑secure forensic units.

After a successful pilot phase involving 18 prisons in 2015/16, the first cycle of the quality network recruited more than 40 prisons in England, Wales and Ireland. CCQI quality networks are professionally led and develop standards by consulting with staff, service users and carers and stakeholders. They operate on a combination of self-assessments against the standards and peer-reviewed visits. Staff from member services visit other units and are visited themselves. This is an excellent way of disseminating good practice. An annual report summarises findings across all member services.3

NICE has recently produced guidelines for the physical health of people in prison (CG57)4 and on the mental health of adults in contact with the criminal justice system (CG66).5 Physical and mental healthcare have the potential to be far more integrated in prisons than in many community settings: services are run in the same setting, share a common information system and are usually included in the same contract, although often multiple providers are involved. Yet they continually fall short of full integration.

The physical and mental health guidelines were developed in parallel, with close co-ordination between the guideline development groups. The first-and second-stage healthcare screens provide multiple opportunities to refer for primary and secondary mental health assessments. The guidelines are important in stressing the need for comprehensive assessment and risk assessment. They emphasise the need to be aware of neurodevelopmental disorders – such as attention deficit hyperactivity disorder (ADHD), autistic spectrum disorder (ASD) and learning disabilities (LD) – and cognitive impairment (acquired brain injury in younger patients, dementia in older patients), which are common but under-diagnosed.

There has long been a tension between PMHS teams, which are often very small and work to deliver basic mental health treatment, particularly for psychosis – and the criminal justice system, which desires a far more comprehensive assessment and treatment focused on reducing risk. This has become a more pressing problem with the large numbers of prisoners serving indeterminate sentences for public protection. These prisoners often have complex mental health needs but not psychosis. There is also an emerging evidence base that mental health treatment can lead to substantial reductions in recidivism.

First, three classes of psychotropic medications (antipsychotics, psychostimulants and drugs used in addictive disorders) were associated with substantial reductions in violent reoffending. Second, the magnitudes of these associations were as strong as and possibly stronger than those for widely disseminated psychological programmes in prison.

These findings could have profound implications for the models operated by PMHS. There is an obvious parallel between the introduction of Improving Access to Psychological Therapy services following LSE’s Depression Report,6 with an economic analysis on improving treatment for depression and anxiety having economic benefits by reducing benefit payments and improving economic activity.

A model that funds PMHS at a higher level based on the economic benefits of reducing reoffending by effective treatment, applied consistently across the prison estate, could provide a way forward for PMHS in an era of austerity.

Problems and opportunities

The crisis in the prison system has direct consequences for mental health in terms of the damage done by widely available NPSs and increases in self-harm, suicide and violence. The cuts in officer numbers have had a direct impact by making prisons less safe, but also by making the task of delivering high-quality services more difficult, due to problems accessing prisoners and fears for staff safety.

The nature of the work has changed, too, with more resources being spent on responding to crises, attending ACCT reviews and dealing with the consequences of NPSs. This is to the detriment of planned interventions and long-term work. Mental health services are under strain nationally and anecdotal evidence suggests greater numbers of patients with pre-existing mental health conditions end up in prison, because of
a lack of community and in-patient mental health services.

Recruitment difficulties in mental health are magnified in less attractive services such as prisons. Staff are under more pressure, feel less safe and move to other services as a result.

Meanwhile, PMHSs are becoming more professional and are successfully developing a quality network. They also have some fantastic NICE guidelines to inform their work. Emerging evidence about the benefits of mental health treatment in reducing recidivism may point to a need for a new funding and operational model for PMHS. What is clear is that the future of an effective criminal justice system must involve good-quality, well-supported mental health services. Otherwise, it is doomed to fail.

Dr Steffan Davies is a consultant forensic psychiatrist at Northamptonshire Healthcare NHS Foundation Trust and co-chair of the court diversion and prison psychiatry networks at the Royal College of Psychiatrists 

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