Mental health and criminal justice · USERVOICE () for their help in organising meetings with...

REPORT

Views from consultations across England & Wales

Dr Graham Durcan

Mental health and criminal justice

Centre for Mental H

ealth REPORT Mental health and crim

inal justice

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Contents

Acknowledgements 3

Executive summary 4

1 Introduction 8

2 Methodology 10

3 Overview of the system 12

4 Consultationfindings-commissioning 15

5 Consultationfindings-prison 17

6 Consultationfindings-probationandrehabilitation 30

7 Consultationfindings-furtherissues 34

8 Consultationfindings-Wales 37

9 Discussion 39

10 Conclusion:Addressingtheneedsidentifiedintheconsultation 42

References 44

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Acknowledgements

SarahPalmer-MinistryofJustice

AngelaHawley-DepartmentofHealth

USERVOICE(www.uservoice.org)fortheirhelpinorganisingmeetingswithexpertsbyexperience-andinparticularGailBlandoftheNorthEastUservoicegroup.

LindaVentress,AlexisFairclough&DrJayanthSrinivas-SouthStaffordshire&ShropshireHealthcareNHSFoundationTrust

MikeHardy&FarhanKhan-DepartmentofHealthandSocialServices/WelshGovernment

JaynePainter-Gofal(www.gofal.org.uk)

MeganGeorgiou-RoyalCollegeofPsychiatrists-CollegeCentreforQualityImprovement

VanessaFowler-NHSEngland(Kent,Surrey&SussexAreaTeam)

SineadDervin-NHSEngland(LondonRegion)

AndrewCass-NHSEngland&Probation(NorthWest)

DavidDakin-EmergingFuture(NorthWest&Cheshire)

RuthCoates-Sova(Birmingham)

KateWeaver&SarahConnor-Sova(London)

StanSadler,SallyTatton&DrNickKosky(ChairofNICEGuidelinesgrouponmentalhealthofadultsincontactwiththecriminaljusticesystem)-DorsetHealthcareUniversityNHSFoundationTrust

DrAndrewBickle&RachaelHolt-NottinghamshireHealthcareNHSFoundationTrust

MaxineClift-InstituteofMentalHealth,NottinghamUniversity

DrLisaGardiner&WendyScott-Earl-Cambridge&PeterboroughNHSFoundationTrust

DuncanCooper-WakefieldCouncil&OfficeforPolice&CrimeCommissionerforWestYorkshire

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Itisestimatedthatasmanyas90%ofprisonershavesomeformofmentalhealthproblem,personalitydisorder,orsubstancemisuseproblem.Inseekingtodeterminehowthementalhealthoftheprisonpopulationcanbeimproved,CentreforMentalHealthwascommissionedbytheDepartmentofHealthandtheMinistryofJusticetoconductaconsultation.Theconsultationreviewedtheexperiencesofpeoplewithpersonalorprofessionalknowledgeoftheinterfacesbetweenthecriminaljusticesystemandmentalhealthservices.Theconsultationwasconductedvia17eventsheldacrossEnglandandWales,andalsobyasmallnumberofonetooneinterviewsandmeetingswithsmallgroupsofstakeholders.Over200peopletookpartinthereview.Theviewsreportedarethoseofthestakeholderswhotookpart,wheretherewasageneralconsensusofviews.Wecannotclaimthatthe‘findings’ofthisconsultationareentirelyrepresentativeofthewholeinterfacebetweencriminaljusticeandmental health. However, there was a marked consistencyinwhatwasreportedacrossalleventsheldinEnglandandWales.

TheeventsalltookplaceinFebruary2015,butCentre for Mental Health has conducted other workinandaroundprisonsmainlyintheWestMidlands and London since then, which do notindicateanysignificantdifferencestoouroriginalfindings.

Key Findings

Commissioning

Fewclinicalcommissioninggroups(CCGs)prioritisehealthcareprovisionforpeopleleavingprison,courtsorpolicecustody,orforthoseincontactwithprobationservices.

Thereareanumberofcommissioningorganisationsresponsibleforoffenderswithmentalhealthdifficulties,andthiscanleadtoclashesorgapsbetweenthem.

Impact of cuts

Cuts in criminal justice services were widely citedinoureventsashavinganegativeimpactonthecareandtreatmentofvulnerablepeople,

particularlythoseinprison:forexamplebyreducingnumbersofprisonofficersavailabletoescortprisonerstoappointments.Thereareof course other factors, such as increased and changingdemandinprisons.Whilstreducedstaffingwasconsistentlyreportedbythoseworkinginprisons,onlyaminorityofprisonswererepresented(approximately20).

Training in mental health awareness

Professionalsworkinginprisonswhoattendedoureventsreportedthatmentalhealthawarenesscoursesforprisonstaffarepoorlyattended,forarangeofreasons.Trainingforpoliceofficerswasmorepositivelyreceived.Probationstaffwhohadbeentrainedinmentalhealthalsoreportedthatithadbeenhelpfultothem,butaccesstotraining,especiallyforthoseworkingintheCommunityRehabilitationCompanieswasreportedtobelimited.

Information sharing

Wefoundthatinformationexchangewithinandbetweenmentalhealthandcriminaljusticeserviceshasimprovedmarkedly,whereLiaison&Diversionservicesareinplace.Theseserviceswerereportedasprovidingsentencerswithrelevant information which was felt to reduce delaysandtheneedforremandtoprison.Wheresuchserviceswerenotinplace,delayswerereportedtobecommonandmentalhealthadvicewashardtocomeby.

Prison mental health care

Primary mental health care remains the weakest elementofmentalhealthsupportwithinprisons.Thecomplexityandseverityofneedamongprisonersrequiresalevelofresourcingandspecialismthatiscurrentlylackinginthehealthcareoftheprisonsrepresented.Fewoftheprisonsrepresentedreportedbeingabletoofferpsychologicalinterventions

Transfers to hospital

Transferstohospitalremainamajorprobleminmanyprisons,withdelaysof3-4monthsfrequentlyreported,especiallywhenseekingan‘outofarea’bed.

Executive Summary

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Services for people with personality disorder

Servicesforpeoplewithpersonalitydisorderandwhoposeahighriskofharmwerehighlyregardedamongthepeoplewemet.SomenowprovidePsychologicallyInformedPlannedEnvironments(PIPEs)withhigherstaffinglevelsandmultidisciplinaryteams.OtherprisonsandapprovedpremisesaredevelopingEnablingEnvironmentstoprovideasupportiveenvironment for staff and residents (Standards forEnablingEnvironmentsareadevelopmentbyTheRoyalCollegeofPsychiatrists,andarenotspecifictooffendersorthosewithpersonalitydisorder).

Resettlement

Leavingprisonremainsproblematicforpeoplewithmentalhealthproblems,withlittlecontinuityofcare.‘Throughthegate’interventionsarewidelysupportedbutaccesstothese is limited.

Probation

ProbationserviceshadbeendisruptedbyTransformingRehabilitationreformsbutinmostareasweresettlingdownbyearly2015.Dedicatedmentalhealthresourceswerethoughttobeessentialforallprobationservices.

Mental Health Treatment Requirements

MentalHealthTreatmentRequirementsforpeopleoncommunityservicesremainrare.Thebiggestbarrieristhelackofmainstreamcommunitymentalhealthcareavailableatthepointofsentencing.

The interface between mental health & criminal justice in Wales

InWales,the2010MentalHealthMeasurehadimprovedaccesstomentalhealthservicesbutitwasreportedthatthelackofanequivalenttothenationalLiaison&DiversionprogrammeinEnglandmeantthatpeoplewhocouldbedivertedwerebeingmissedinpolicecustody.WhereWelshLiaison&Diversionschemesdidexist, these were largely focused on adults with severementalillnessratherthanthebroadrangeofvulnerabilitiesandall-ageresponsegivenbythenewservicesinEngland.

Key themes

Some consistent themes emerged regardless of thepartofpathwaythatwasbeingdiscussed.Ourparticipantsfelttherewasaneedfor:

• Robustscreeningandassessmentprocessesforarangeofvulnerabilitiesinalljustice settings;

• Wideravailabilityofsupportandcareforpeople’svulnerabilitiesregardlessofsetting;

• Providingpragmaticandpracticalsupport(e.g.withhousinganddebt)atcriticalperiods(e.g.onreleasefromprison);

• Adoptingapsychologicalandtraumafocusedapproachacrossalljusticeservicesandprovidingtrainingintheseforallwhowork in them;

• Increasingaccessinboththecommunityandcustodialsettingstopsychologicalinterventionsthatareadaptedtoreflectcomplexandmultipleneed;

• Increasingtheuseofmentorsandpeers,and the voice of service users in the planningandprovisionofservices.

Achievingsuchchangesandreformsisdifficulttoachieveatanytimeandespeciallyduringsuchastraitenedfiscaltime.Butitislikelytobringaboutbettervalueformoneybothshort-termandoverpeople’slifetimes.Jointworking,jointbudgetsandcreativethinkingarecalledfor.AnditisvitalthatCCGsandlocalauthoritiesengage in meeting the health and care needs of someoftheirmostvulnerablecitizens.

Thefollowingideasforchangesandimprovementsemergedfromtheconsultationfindings:

1. Commissioning

Clinicalcommissioninggroups(CCGs)needto take the lead role in commissioning health servicesforpeopleleavingcustodialsettingsintheirlocalareas.ThiswouldbefacilitatedthroughcloserworkingbetweenCCGsandtheirlocalprobationproviders.TheroleofCCGsinsupportingprobationandoffendersinthe community (on community sentences and

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followingreleasefromprison)couldbewrittenintothenextNHSMandate.NewguidancefromNHSEnglandcouldsetoutclearexpectationsforCCGs.OneexpectationwouldbeCCGsenablinglocal community mental health services to give sufficientprioritytotheprovisionofMentalHealthTreatmentRequirements,throughvariation in local contracts where necessary. ThereisaneedforsomenationaloversighttoensureaconsistentandequitableapproachistakenandthisisarolethatcouldbefilledbyNHSEngland.TheWelshAssemblyshouldprovidesimilarguidanceandoversighttoWelshhealthboards.

2. Training and workforce development

ThereshouldbeajointcommitmentacrossMinistryofJustice,HomeOffice,DepartmentofHealth,NHSEnglandandtheWelshAssemblythatallprofessionalsincriminaljusticeshouldreceive mandatory mental health awareness training(andperiodicupdates)thathelpstoachieveapsychologicallyinformedapproachtomanaging offenders.

3. An operating model for prison mental health care

ItwouldbehelpfulforNHSEnglandandtheWelshAssemblytodevelopanationalframeworkforprisonmentalhealthcare,similarto the English Liaison & Diversion services. Theconsultationexercisesuggestedthatthefollowingelementswouldbehelpful:

A. Basedonastepped-caremodel,offeringprimaryaswellassecondarycareandarangeofNICEapprovedpsychologicaltherapies.GuidancepublishedbytheRoyalCollegeofPsychiatristsandforthcomingNICEguidelinesmayprovideastartingpointforthis framework.

B. Thisshouldincludedesigningevidence-basedpathwaysandprogrammesforarangeofvulnerabilitiesincludingmentalhealthproblems,ADHD,learningdisabilities,personalitydisorder,acquiredbraininjury,dementiaandautisticspectrumdisorders.Theframeworkshouldalsoaddresstheneedsofyoungpeopleintransition,olderprisoners,women,peoplefromdifferentethnicandcultural communities and foreign nationals.

C. Theaimshouldbetoensureparityofesteemforpeopleinprisonwithmentalhealthproblemsandrelatedvulnerabilities.Parityinthiscontextmeansbothequivalenceto the care offered outside the criminal justicesystemandequalitywithphysicalhealth care.

D. ThevehiclesformonitoringqualityshouldreflecttheFrameworkandbeinformedbyserviceusermeasuresofquality.

E. GuidanceshouldbeproducedbyNHSEnglandandtheWelshAssemblyontheprisonmentalhealthroleinresettlement,'throughthegate'support,andonhowClinicalCommissioningGroups(CCGs)shouldworkwithprobationproviders.Thisshouldmonitoredbytheappropriateregulatorybodies.

F. NHSEngland,theWelshAssemblyandMinistryofJusticeshouldworktogethertomakementalhealthreportsforParoleBoardsa commissioned activity.

4. Transfer to secure mental health care

NHSEngland,theWelshAssemblyandtheMinistryofJusticeshouldtakeurgentstepstospeeduptransfersfromprisontosecurecare,particularlywheretheseoccuroutsidelocalareas.

A. Arationalisedprocessofassessmentshouldbeincludedinthisreform,whereasinglecompetentgatewayassessmenttakesplaceratherthanmultipleassessments,regardlessofwhereabedisbeingsought.Atimelimitfortheassessmenttobeconductedshouldbesetatthepointofrequest.

B. If an assessment indicates a need for transfer,thisshouldhappenwithinasettimelimit (14 days).

C. NHSEnglandandtheWelshAssemblyshould oversee and monitor the timely transfer under the Mental Health Act.

5. All prisons as Enabling Environments

TheMinistryofJustice,DepartmentofHealth,NHSEnglandandtheWelshAssemblyshouldjointlyworktowardsallprisonsachieving

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theRoyalCollegeofPsychiatrists’EnablingEnvironmentsstandards.Thiscouldincludea far greater role for service user involvement includingpeermentoringtypeinterventionstosupportprisonerswithvulnerabilities.Itshouldinclude training of mentors and research into theimpactoftheseEnablingEnvironments.

6. Release from prison as a ‘time of crisis’

Releasefromprisonshouldbetreatedasatimeof‘crisis’forpeoplewithmarkedvulnerabilities,andcoveredbytheCrisisCareConcordatinEnglandandanequivalentpolicydirectiveinWales.Targeted‘throughthegate’supportforpeoplewithpoormentalhealthandrelatedvulnerabilitiesshouldbethejointresponsibilityofNHSEngland(tothepointofrelease),CCGs,andtheNationalProbationServiceandCommunityRehabilitationCentres.Thisshouldincludeapre-releaseengagementandtime-limitedsupportpost-releasethatincludestheprovisionofhealthandcaresupport(includingpsychologicalinterventionsadaptedforpeoplewithcomplexneed)andhelpwithbasicneedsandadvocacy.Mentoringandpeermentoringshouldformpartoftheresponsetosupportingpeopleleavingprison.SimilarsupportshouldbeprovidedforpeopleinApprovedPremises.

7. Mental health support for probation providers

CCGsshouldcommissioneffectivementalhealthsupportforprobationprovidersintheirworkwithpeoplewithmentalhealthproblemson community sentences. At the very least consultationsurgeriescouldbeprovided,buttimelyaccessforprobationclientstoatherapyservicemayrequireavariationincontractforlocalmentalhealthproviders.

8. Court reports

Courtpsychiatricreportsshouldalwaysbeprovidedbypsychiatristswhoworkwithoffenders, understand the needs of the courts and who work locally and can make connections withlocalservices.HerMajesty’sCourtService,NHSEnglandandWelshAssemblyshouldwork together to achieve new contracting arrangementsortemplatesforthem,thatensureconsistencyandqualityofpsychiatricreportstocourts.

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Centre for Mental Health was commissioned bytheDepartmentofHealthandMinistryofJusticetosupportareviewoftheinterfacesbetweenthecriminaljusticesystemandmentalhealthservices.ThereviewwasabroadonecoveringallpartsofthepathwaybeyondthedevelopmentofnewservicessuchasLiaison&Diversionincourtsandpolicecustody.

ThereviewhadbeenpromptedafterministerialconcernswerevoicedoverthestateofprisonmentalhealthcareinSeptember2014,whichsawareportedincreaseinsuicidesbyprisoners.

Centre for Mental Health was asked to run consultationeventsforpeoplewithexperienceof the criminal justice system and its interface with mental health services across England and WalesduringFebruary2015,andtoprovideanindependentreportonthefindings.

Scale of the issue

ItisalmosttwodecadessincethemostrobuststudyofpsychiatricmorbidityinprisonswasconductedacrossEnglandandWales(Singletonet al., 1998), and almost a decade since some smaller-scalerobuststudieswereconducted(Harding et al.,2007andStewart,2008).Allofthesetoldusthatprisonerssuffersignificantlygreaterpsychiatricmorbiditythanthegeneralpopulation(seetable1)andthatevenwithinprisonsthereisvariation;forexample,thatmaleremandandfemaleprisonershavegreaterlevelsofneed(seetable2).Recentanalysisof data on a longitudinal survey of newly sentencedprisoners(1435peoplesentencedin2005-2006;Stewart,2008)foundthat16%ofthesamplereportedsymptomsindicativeofpsychosis.Thiswasconsiderablyhigherinfemaleprisoners,25%ofwhomreportedsymptomsindicativeofpsychosis(males=15%).Maleprisonerswithpsychoticsymptomswere 10% more likely to reoffend within a yearafterreleasethanothermaleprisonersinthesample.Therewerenodifferencesinreconvictionratesbetweenwomenwithandwithoutsymptoms(Lightet al., 2013).

However,wehavelessinformationaboutother

partsofthecriminaljusticesystem.Asinglestudyoftheprobationservicefoundthataround40%ofpeopleonprobationhaveacurrentmentalhealthproblem(CentreforMentalHealth, 2012a). A survey of those on community orders(betweenOctober2009-December2010)foundthat35%ofoffendershadaformalmentalhealthdiagnosisand29%reportedhavingacurrentmentalhealthproblem.Forfemaleoffenderstheproportionreportingacurrentproblemwasmuchhigher(46%)(Cattellet al.,2013).Dataonpolicecontactwithpeoplewithmentalhealthproblemssuggestthatbetween15-40%ofpolicecontactsarewithpeoplewithmentalhealthproblemsandrelatedvulnerabilities(HomeOffice,2014andICMHP,2013).

Personalitydisorderfeaturesprominentlyintheprisonpopulationandislikelytobehighlyprevalentinbothprobationcaseloadsandpolicecontacts.Prisonersseldomhaveasingleproblemorvulnerabilityandtypicallywillhavemultipleandcomplexneeds.Historiesoftrauma,unhelpfuluseofsubstances,poorrelationships,poorlifeskills,learningdifficultiesandlearningdisabilities,acquiredbraininjury,pooreducationandworkhistoriesareallcommonamongprisoners,andmaketheprovisionofcareandsupportallthemorechallenging.

Chapter 1: Introduction

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Table 1: Mental illness among prisoners and the general population

Prisoners (%)¹ Generalpopulation(%)²

Psychosis 8 0.5

Personality disorder 66 5.3

Depressionoranxiety 45 13.8

Drugdependency 45 5.2

Alcoholdependency 30 11.5

¹ Singleton et al., (1998)

² Singleton et al., (2001)

Table 2: Mental illness among sentenced and remanded prisoners

Sentences Remand

Male (%) Female (%) Male (%) Female (%)

Psychosis 6 13 9 13

Personality disorder 64 50 78 50

Depressionoranxiety 40 63 59 76

Drugdependency 34 36 43 52

Alcoholdependency 30 19 30 20

Suicideattemptinlastyear 7 16 15 27

Self-harm(notsuicideattempt) 7 10 5 9

Singleton et. al. (1998)

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The events

Atotalof17eventswereheldacrossEnglandandWales.

Thetimetablefortheconsultationswaslimitedand the events were organised over a three weekperiod.ExistingCentreforMentalHealth,MinistryofJustice,DepartmentofHealth,WelshAssemblyandNHSEnglandcontactswereusedtoestablishtheeventsandinvitelists.AdditionallylocalareaNHSEnglandcommissioners were contacted and invitations weresentviatheRoyalCollegeofPsychiatrists’QualityNetworkforPrisonMentalHealthServices (the College had conducted a recent nationalconsultationintoprisonmentalhealthstandards).

• London (x4 covering London and South East)

• Birmingham(x2)

• Cambridge

• Dorset

• Huntingdon

• Leeds

• Newcastle

• Nottingham

• Stafford

• Swansea (x2)

• Warrington

• Wrexham

In addition, 19 key stakeholders (who were unabletoattendtheeventsbutstillkeentoparticipate)wereinvolvedinone-to-oneinterviewsandsmallgroups.Justover200peoplecontributedtotheconsultationoverall.Theevents,smallgroupsandinterviewswerefacilitatedbyasingleinterviewerandallconsultationstookplaceinFebruary2015.

Allevents,groupsandinterviewswererecorded(inexcessof60hours)andmind-mappedforeaseofanalysis.Themind-mappingtookplaceinitiallyasaformofnote-takingduringtheconsultations,andwerefurtherdevelopedbyrepeatedlisteningtotherecordingsaspartoftheanalysis.Theinterviewerconductingthedata collection also conducted the analysis.

Thequestionssetoutinthetopicssection(page11)wereusedtoprovideaninitialcodingframework for analysis and the data were exploredtofindevidenceabouteachitemandfor additional themes that emerged during the discussions.Thesequestionsweredevelopedinitiallyfollowingabriefliteraturereview,particularlyofcertainareasofcurrentpolicy,andthendevelopedinconsultationwiththosesteeringthereview,andrepresentativesfromMinistryofJustice,DepartmentofHealthandNHSEnglandinparticular.

Allthosetakingpartwereassuredconfidentiality.Inplaces,quoteshavebeenalteredtomaintainconfidentiality.

Limitations

Theevidenceforthisreportwaslargelycollectedat17events,andisthereforerepresentativeoftheviewsofthosewhoattended.Itmaynotapplymorewidely,asifothereventshadbeenheldelsewhereourfindingsmighthavediffered.

However,therewasasufficientconsistencyofexperiencereportedacrossallevents,andoverlapwithotherCentreforMentalHealthreview work (see Durcan et al., 2014, Durcan 2014a&2014b),forustoconcludethatthefindingsarelikelytobereflectiveofthe‘stateofplay’acrossbothEnglandandWales.

Since concluding the last of the events, Centre forMentalHealthhashadtheopportunityto review at least some of the issues and findingsraisedintheconsultationsthroughotherprogrammesofwork,particularlythoserelatingtoLiaison&Diversion,prisonsandresettlement.ThisworkhasbeenconductedinSouthWales,LondonandtheEastandWestMidlands.

Chapter 2: Methodology

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• Formerprisonersandmentalhealthserviceusers;

• Prison governors;

• Police and Crime Commissioners;

• Police;

• Sentencers and Court services;

• NationalProbationService;

• CommunityRehabilitationCompanies;

• Carers;

• Inspectionbodies;

• Voluntarysectorandspecialinterestgroups;

• Local health commissioners;

• Specialist&offenderhealthcommissioners;

• Publichealthservices;

• Mentalhealthteamsinprisons(primarymental health care, inreach and other teams –e.g.psychologicaltherapyservices);

• Forensic mental health;

• Prison health care;

• Community offender health services;

• Professional organisations;

• Localauthorityrepresentatives;

• Mentors,includingpeers.

Topics and themes explored in the consultation

TheconsultationcoveredabroadrangeofissuesandalthoughCentreforMentalHealth’sbriefdidnotincludeStreetTriageandLiaison&DiversionfromCourtsandCustody,participantsat all events wanted to include these in their discussionstodescribea'wholepathway'approach.Atalleventstherewasanemphasisoninterveningasearlyaspossibleandat“criticaltimepoints”,suchasmeetingthepoliceatatimeofcrisis,onarrestorwhenincourt,butalsoonreleasefromprison.

Thefollowingtopics/areaswerecoveredintheconsultation events:

• StreetTriage;

• Liaison & Diversion;

• Prison mental health care;

• Enhanced regimes, e.g.:

o Personality disorder –PIPEso 24 hour health careo Specialistmentalhealthcareo TherapeuticCommunities

• Transitions;

• Transfersto&fromhospital;

• Leavingprisonandcontinuityofsupport;

• 'Throughthegate'interventions;

• Workingwithprobation;

• Alternatives to custody & courts;

• Reportsforparoleboardsandcourts;

• MentalHealthTreatmentRequirements.

Foreachofthetopicswediscussed:

• Whatisthecurrentexperience?

o Strengthso Weaknesseso Gapso Goodpracticeexamples

• Whatneedstobeinplace?

• Whatistheexperiencefordifferentgroups,e.g.:

o Womeno Veteranso Youngadultso Olderprisonerso PeoplefromBMEcommunitieso ForeignNationalso Peoplewithparticulardiagnosesorchallenges(e.g.autismspectrumdisorders,hearingproblems,learningdisabilities,acquiredbraininjury,attentiondeficithyperactivitydisorder).

Theeventstookbetweentwoandfourhours.

Who took part?

Averybroadrangeofstakeholderscontributedtotheconsultationeventsandinterviews:

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Stage of pathway

Service Definition

Early Intervention

StreetTriage Aninterventioninvolvingmentalhealthpractitionersworkingdirectlywithpolice,eitherviajointpatrols,orviaradioandphonefrompolicecontrolcentresorviadedicatedphoneservice.Thoughprimarilyaimedatreducing the use of section 136 of the Mental Health Act, ithasbeenreportedtoCentreforMentalHealththatitcanalsopreventotherarrests.

Liaison & Diversion

Liaison & Diversion services are those that work in courts,policecustodyandinyouthoffendingteamsto‘divert’peoplewithmentalhealthproblemsandrelatedvulnerabilities.Theseservicesdatebacktothelate 1980s and are found across the United Kingdom. However,NHSEnglandradicallyreformedtheseservicesinaprogrammeofdevelopmenttocreateforthefirsttimeastandardisedmodelthatcoversmultiplevulnerabilities,allagesand(sinceApril2015)50%oftheEnglishpopulation.PeoplewithdrugandalcoholproblemsmayalsobesupportedbyLiaison&Diversionteamsorbyadedicatedspecialistservice.

Practicalsupport Liaison & Diversion services may also have community support/linkworkersaspartoftheirservice.Thisisinrecognitionthatpeopleincontactwiththejusticesystemoftenhavecomplexandmultipleneeds.Theseworkerswillprovidesometime-limitedsupporttohelpoffendersengage with a range of services (e.g. health and housing). ThereareothergoodpracticemodelssuchasthatprovidedbyCommunityAdvice&SupportServices(CASS)in magistrates courts in Devon and Cornwall (see Durcan, 2014b).

Adaptedpsychologicaltreatment

LargelyunavailablebutwouldformpartoftheIncreasingAccesstoPsychologicalTherapy(IAPT)offerinalllocalities.Essentially,easyaccesstotheprovisionofevidence-basedinterventionsthatareadaptedtoreflectthecomplexneedsoftheuser.

Fromourconversationswithparticipantsandotherrecentreviewandresearchwork,apicturehasemergedofwhatan‘endtoend’systemforprovidingservicesforpeoplewithmentalhealthproblemsinthecriminaljusticesystemcouldlooklike(withsomecommentaryonthecurrentstateof services).

Chapter 3: Overview of the system

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Stage of pathway

Service Definition

Alternatives to custody and community

Mental Health TreatmentRequirements

Theleastusedofthe3treatmentrequirementsavailableaspartofacommunityorder.Onthewhole,whereavailable,theseareprovidedbyamainstreamcommunitymentalhealthservice.Thisisdescribedmorelater.

Probationcaseloads

TheavailabilityofpsychologicalandothermentalhealthinterventionsdirectlytopeopleunderprobationwitheithertheNationalProbationService(NPS)oraCommunityRehabilitationCompany(CRC).Probationserviceshavefounditdifficulttoengagementalhealthservicesinprovidingthissupport(oftenduetohighentrythresholds)exceptviaaspecificcontract.Akeyofferwouldbeadapted,evidence-basedpsychologicalinterventions.

Probationconsultation

Severalprobationserviceshavecontractedmentalhealthservicestorunconsultationsurgerieswhereprobationofficersseekadviceonthemanagementofcases.

Custody Mental health inreach

Mental health inreach teams were originally intended toprovideanequivalentservicetoacommunitymentalhealthteam,i.e.theyhaveasecondaryorspecialistrole to work with those who have severe mental health problems,includingthosewithsevereandenduringpoormentalhealth.Thisislargelystilltrue,thoughsomehavemergedwithprimarymentalhealthcare.Thenotionofmission‘creep’or‘stretch’isdiscussedlater.

Primary mental health care

Primaryhealthcareservicescomprisethesameelementsasinthecommunity,withgeneralpractitioners(GPs),nurses,dentistsandsoon.Thementalhealthcareelement, for those with mild to moderate mental health problems,isprovidedbyGPs(formedication)andlargelyotherwisebynurseswhoinmanyprisonshavegeneralnursingresponsibilities,aswellasamentalhealthqualification.Thecomplexandmultiplenatureofneedinprisonersprovidesmajorchallengesforthistypeofprovision,andprimarymentalhealthcareserviceshavebeenseenastheweakestelementofthepathway.

Adaptedpsychologicaltreatment

Alimitednumberofprisonshaveaccesstoclinicalpsychologistsornursetherapistswhocanofferadaptedevidence-basedpsychologicalinterventions,fordifferentlevelsofneed(includingtheequivalentofIAPT-styleservicesforpeoplewithcomplexandmultipleneeds).

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Stage of pathway

Service Definition

Specialregimes:•PIPEs•Enabling

Environments•Therapeutic

Communities•24 hour health

care

Psychologically Informed Planned Environments (PIPEs) aredescribedlaterbutconsistofasmallnumberofunitsprovidedwithinprisons(andsomeothersettings)forthoselikelytohaveaseverepersonalitydisorderwhoposeahighriskofseriousrepeatoffending.Likewise,servicesthathaveachievedtheEnablingEnvironmentsQualityMark(RoyalCollegeofPsychiatrists)andTherapeuticCommunities(inprisons)arelimitedinnumberanddescribedlater.

Someprisonshavewingsthatprovideatypeofinpatientbedandatleastsomelimitedhealthcareprovisionatnight and at weekends as well as during the working week.Prisonswithoutthesecanreferprisonerstoonewithin their region.

Release from Custody - resettlement

Throughthegate

Follow-up

Thereareavarietyof‘throughthegate’initiativesandmostprisonshaveaccesstoatleastsomelimitedpost-releasesupport.ThisshouldincreasewiththeintroductionofCRCswhohaveapost-releaseresponsibilityforanypersonreleasedafterasentenceforamildormoderateriskoffence.‘Throughthegate’initiativesofteninvolvesomeengagementpriortorelease,mayinvolvebeingmetatthepointofreleaseandofferingsometime-limitedsupportpost-release.Peermentoringcanformpartoftheoffer.Averysmallnumberhavespecificallytargetedpeoplewithmentalhealthproblemsandlearningdisabilities.NHSEnglandhaspilotedsuchaninitiativeforpeoplewithdrugandalcoholproblemsintheNorthWestofEngland.Inadditionthereareavarietyofpost-releasesupportinitiatives.ThesecanincludequiteintensivecommunitysupportsuchaswasprovidedbyElmoreCommunityServicesinOxfordbutalsoincludevolunteermentorssuchasthoseprovidedbySova.

‘Engager’,a'throughthegate'andpost-releaseinterventionforprisonerswithcommonmentalhealthproblemsisdescribedlater.

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TreatmentRequirement(MHTR).Thiswillbediscussed in more detail later.

“…this is a very difficult area for CCGs to see [what] they need to do…as far they are concerned they commission community mental health teams to provide community care so the MHTR is covered…it is hard to engage them long enough to see [that] some sort of priority needs to be given for MHTRs to work…”

(Probationparticipant)

“…it’s hard to demonstrate the saving to health, though doubtless there is one….so they see the courts benefitting and think they should fund them…..it’s the same to a degree with Street Triage…”

(Manager of community criminal justice mental health service)

“…The sad thing is they are going to spend money on these people in any case, on Section 136, at A&E….but it’s difficult to persuade CCGs to invest in earlier intervention and not just in crisis … surely it would save money…”

(Policeparticipant)

Other local commissioning bodies

“…the people I work with have lots of problems and issues….they’re complex… it’s not just the NHS but also councils….they all have to see they have a part to play…”

(Prison inreach service manager)

“…the single biggest problem is housing, nearly all of them are homeless or on the verge of it…there is a massive role for housing departments and councils here…”

(Voluntarysectorparticipantworkingwithpeoplereleasedfromprison)

Amoremixedviewwasgivenbyourparticipantsofthepartplayedbylocalauthorities,butitwasrecognisedthatcouncilshadexperiencedsignificantcutsinfundingandthatthiswouldcontinuetobethecasefortherestofthisdecade “at least”.

“…it begs the case for joint budgets…” (Localauthorityparticipant)

The role of clinical commissioning groups

Allofourparticipantsatthe14consultationevents in England saw clinical commissioning groups(CCGs)ashavingacrucialroleinsupportingcontinuityofcare,diversionandearlyinterventionwithpeopleincontactwiththe criminal justice system. Commissioning in England(whencomparedtoWales)iscomplexandtherehasbeenmuchreforminrecentyears.Thismayhaveresultedinsomeconfusionovercommissioningresponsibilities.

CommissionersfromCCGsattendedsomeofthe consultation events and several of them were funding initiatives for diverting former offenders.Forexample,severalwerejointfundersofpilotStreetTriageschemes,andwerepersuadedbythebenefitsofinvestingin‘diversion’.However,byandlarge,theperceptionofmostparticipantsattheconsultationeventswasthatCCGsdonotseeitastheirroleorasaprioritytoinvestinservicesforpeopleleavingprison,policecustodyorthecourtsorforthoseinvolvedwithprobation.

“…CCGs have lots of competing demands on their resources…”

(CCGparticipant)

Similarstatementstotheaboveweremadebyarange of stakeholders across several events.

Ataroundhalfoftheevents,participantsreportedthatlocalCCGcommissionersconsidered‘offenders’tobethedomainofNHSEngland.NHSEnglandisresponsibleforcommissioningservicesprovidedinpolicecustody,courtsandprisons,anditwastheperceptionofourparticipantsthatsomeCCGsdonotrealisetheyareresponsibleforresidentoffendersoncepeoplehaveleftthesesettings.

“…I don’t think they get that an ex-offender in the community is their business….if they hear “offender” they think it’s NHS England’s job…”

(Prisonhealthparticipant)

Aparticularareaofconcernateventsattendedbyprobation,CRCs,courtofficialsand sentencers was that of the Mental Health

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Different strands of commissioning within NHS England

Atoneeventitwaspointedoutthatitwouldbedesirabletocommissionpathwaysforindividuals,andparticularlythosewhorequireentrytosecurementalhealthcare.Participantsstatedthatfundsneedtofollowtheperson.Thiswasdifficultwhenanindividualmovedtoservicesfundedbydifferentcommissioners,e.g.NHSEnglandtoaCCG;butitwasalsothecasewithinNHSEnglandifapatientmovedbetweenservicesfundedbydifferentcommissioningstrands (e.g offender health funding and secure care);thefundsfailedtofollowthepatient.

“…you hit these barriers every time you move between services…”


“…It would be great if the funding followed the person or funded the pathway…”

(NHSEnglandparticipant)

“…we can say “no they don’t need secure care” and state that they need some other form of care…but we can’t make that happen because we don’t fund it…”


The impact of procurement

Allprisonmentalhealthservicesrepresentedateventshadrecentlyexperienced(withinthelast 18 months) or were currently undergoing procurementexercises,whereNHSEnglandwasputtingouttotenderthecurrentprisonhealthcontracts.Thesewereuniversallyreportedas“incredibly disruptive”.

Thetenderprocesswasreportedastaking12-18months,duringwhichitwascommonlyreportedthattherewouldbestafflosses.

“…I know good staff are always going to move on, but if there is any uncertainty, they are not going to hang on….I lost three really experienced people…”

(Inreachmanagerparticipant)

“…procurement has a negative impact during the process and after….even if you win the contract…”

(Inreachparticipant)

“…all local commissioners should sit down and prioritise the top 100–150 people with complex needs and commit to jointly fund services for these people…” (NHSEnglandparticipant;Policeparticipant–

nearlyidenticalquotesatdifferentevents)

TherolethatPoliceandCrimeCommissionersplaywasgenerallycommendedandinmostareastherewasreportedinvestmentfromPCCsor at the very least an interest in investing.

“…it’s funny…they are the new kids on the block…but they seem to have ‘got it’ straight away…”

(Liaison&Diversionparticipant)

Commissioning clashes

“…we are meant to be working together but NOMS commissioning doesn’t seem to take any or enough account of health…”

(Seniormentalhealthprisonclinician)

Such“clashesofcommissioning”werereportedatalleventswhereprisonmentalhealthprofessionalswererepresented,whichwasthemajorityofevents.However,representativesofcriminaljusticeservices(albeitwithlessconsistency)alsoreportedthathealthcommissioning did not take into account the needs of the criminal justice services that health serviceswerebeingcommissionedin.

Severalexamplesweregiven.Onewasthe‘re-rolling’ofaprisonbyNOMStoserveadifferentpopulation:

“…the needs of [the new population] are very different to those of [the prison’s current population]… and we are expected to make the changes to our team in a matter of weeks…there appeared to be no understanding of what was involved for us…”


Likewise,criminaljusticepractitionersandrepresentativeswhospokeaboutNHScommissioningcomplainedofalackofconsultation and acknowledgement.

“…we have lots of people on our caseloads with some sort of mental health problem….we can’t get them into mental health services…health commissioners need to find a way to provide a service to us…”

(ProbationManager)

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The context of prison mental health care

Atalleventstherewassignificantdiscussionaboutthecontextinwhichprison(andother)mentalhealthcarewasprovided.Thefollowingarecommonlycitedissueswhichbothhealthandjusticerepresentativesreportashavinganimpactontheabilitytoworkeffectivelywithpeoplewithmentalhealthproblems,learningdisabilitiesorothervulnerabilities.

“…we have too many people in prison….it’s hard to organise anything that’s not chaotic….it’s hard to do mental health care….it’s hard to do anything…”

(Seniorprisonserviceparticipant)

Thoughfallingoutoftheremitoftheconsultation, two events had lengthy discussionsaboutsentencingpolicyandtheneedtodrasticallyreducetheprisonpopulationin order to work effectively.

However,atallevents,significantcutsto criminal justice services were cited as negativelyimpactingonthecareandtreatmentofvulnerablepeople.Fromalltheprisonsrepresentedattheevents,participantsreportedthattherehadbeen“drastic cuts”toprisonofficernumbers.

“…there are very few staff on the wings now…” (Inreachparticipant)

“…all the most experienced guys in our prison have taken redundancy and left…there are fewer staff and they are much less experienced…”

(Prison health care)

“…there is a lot less time spent out of cells…” (Formerprisoner)

“…I can’t see that being locked up in a small space most of the day is good for your wellbeing…”

(Formerprisoner)

“…in the past I could go and have a chat with my personal officer….that had all gone out the window this last time (most recent spell in custody)…there are not enough staff and they have no time…”

(Formerprisoner)

InCentreforMentalHealth’sexperience,non-attendanceratesformentalhealthappointmentsinprisonshavealwaysbeenhigh,andparticipantsattheseeventsreportedthatrateshavebecomeevenhigher.Anon-attendancerateof30–50%wasreportedatourevents.Escortingbyprisonstaffwasseenasmajorissue.Staffshortageswerereportedasthe main reason for this, as these affected the abilityofstafftoescortprisoners.

Thedesignofsomeprisonsmorenaturallyallowsforwing-basedhealthconsultations(i.e.roomsthatarebothsafeandallowforconfidentialexchanges,whichreducesthereliance on staff escorts) whilst others are not.

Prisons and other criminal justice services should “see poor mental health and supporting mental wellbeing as part of their mainstream business…and not just the responsibility of a visiting service…”(seniorprison-basedclinician).

Mental health awareness

Mentalhealthawarenesstrainingforprison-basedstaffwasreportedaspoorlyattendedatalleventswherementalhealthpractitionersworkinginprisonswererepresented(mostevents).Accordingtoourparticipants,plannedtrainingwasoftencancelledduetoundersubscription,anditwasprisonwing-basedstaffwhoweredeemedtomostneedtrainingandbeleastlikelytoattend.Viewsacrossourparticipantsweresplitastowhythiswas,butcutsandshortageswerefrequentlycited.

“…staff just can’t be released to attend training…”


“…to be honest I am not sure what good awareness training would be at the moment…there are so few staff and much less prisoner-officer interaction than in the past…”

(Seniorprison-basedclinician)

Butnotallparticipantsentirelyagreedthatthiswas the reason.

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Aboutathirdoftheprobationservicesrepresented(bothNPSandCRC)haddirectaccesstomentalhealthpractitionerseithercurrentlyorintherecentpast,and(likethepolice)reportedpositivelyontheimpactoftheirwork, claiming greater awareness as a result of beingabletodirectlyconsultpractitioners.Mostof these contracts, if still current, were due to endbyApril2015withuncertaintyastowhatwould follow.

New Psychoactive Substances

Theuseofsyntheticformsofcannabis(so-called 'legal highs') and other drugs was reportedasanissueforbothcustodialandcommunitysettings,butmostofthediscussionattheeventsconcernedtheimpactonprisons.AtoneeventintheNorthofEngland,prisonhealth care staff stated that two inmates had experiencedseizuresthatdayandthat‘legalhighs’weresuspected.InotherCentreforMentalHealthworkintheMidlands(aprojectthatworkswith7prisons),itisapparentthatthiscontinuestobeanissue.

Severalhealthpractitionersinprisonsdescribedthe use of legal highs as a “crisis” and that theirusewasseenashavingrisensignificantlyinthe6-12monthspriortotheconsultation.Atthetimeoftheeventstherewerenoreliablemeans of detecting and testing for their use. Knowledgeofthedrugusecameoccasionallybydiscoveryofthedrugsthemselves,butmainlyfromself-reporting.

Theperceivedimpactofsuchdrugswereseizuresandincreasedratesofpsychosis-

“…it’s frightening how rapidly people can become psychotic…”


“…they are making people very unwell…I’d much prefer people took skunk…”

(Prisonhealthcareparticipant)

Intwoprisons,representedattwoseparateevents,itwasreportedthatnewsubstances(so-called‘legalhighs’)hadbeentestedonvulnerableinmatesfirstbyotherinmatesbeforetheywouldrisktakingasubstancethemselves.

“…mental health is not prioritised… our prison regularly goes into lock-down to allow release of staff for training… but mental health awareness training is never on the list…”


“…it’s down to the governor…..if they are interested then things tend to be better…”


Somementalhealthpractitionersreportedengaginginwhatoneparticipantlabelled“smart awareness training”.AsoneparticipantworkinginaprisonintheSouthEastreported,this involved the mental health team visiting a particularwingandspendingmuchofashiftthere,spendingtimewithofficersandofferingmore ad hoc awareness training.Awarenesstrainingforpolicewasreportedmorepositively;inallforceareaswevisited,policewere engaged in training.

“…a significant factor is it’s mandatory….but officers recognise they meet people with vulnerabilities every day…”

(Policeparticipant)

StreetTriageschemesandLiaison&Diversionserviceswereseenashavingasignificantimpactonpoliceawareness.

Thepictureforprobationwasamixedone.Insomeareas,manyifnotmostofficershad undergone some form of awareness training,andinparticulartheKnowledgeandUnderstanding Framework (KUF) awareness trainingonpersonalitydisorder.Thiswasseenasvaluableandveryuseful.Aparticipantwhohad delivered training on the KUF to staff in a probationhostelreportedhowpositivelyithadbeenreceived:“it was like a [road to] Damascus moment for these staff”.Theyrecognisedwhatwasbeingdescribedandfounditusefultohaveanexplanationofwhysomeoftheirclientsreactedandbehavedastheydid.Someprobationofficersattendingeventshadalsoreceivedbroaderawarenesstraining,butthiswasreportedatonlytwoevents.

“…the bulk of people my team work with have some form of mental health problem or personality disorder…without training we are working in the dark…”


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Prison primary care

“…the prison mental health care at [a women’s prison] was excellent …but for only people at the apex…there is very little for people below this level, many of whom have marked need…”


“…where is that person that states that ‘we have this proportion of people with this problem’ and ‘this proportion of people with that problem’ and then setting up a service to meet that [sic]… instead we have prison inreach, where most [of] the people don’t meet the entry criteria…what is the use in that?…”


Prisonprimarymentalhealthcarehaslongbeenidentified(Durcan,2008)astheweakerelementofprisonmentalhealthservices.Prisonsprovidechallengesforprimarycarethatareunique,notleastthosewhichcomefromthepopulationitserves.Prisonersarealmostexclusivelydrawnfromthemostdeprivedcommunities,andhavesignificantlyhighermorbidityforpoorphysicalandmentalhealth.Thisiscoupledwitha‘default’towardsacomplexityandmultiplicityofneed.Ahistoryoftraumaiscommon,asissomelevelofunhelpfuluseofsubstances.Manyprisonershavesomeleveloflearningdifficultyandasignificantproportionwillhavealearningdisability(PrisonReformTrust,2015estimatebetween20-30%havealearningdisabilityorborderlinelearningdisability).Historiesofpoorrelationshipsarecommon,andmanyprisonersarepoorlyskilledinactivitiesofdailyliving;arepoorlyeducated;havelimitedworkexperience;andsufferdebt,homelessnessandunstablehousingwhenoutsideprison.

Itistheconcurrenceofsomanyproblemsthatprovidesthechallengeforprisonprimarycareandprobablyrequiresalevelofresourcingandspecialismthatnoneoftheprisonsrepresentedattheeventshadavailabletothem.

“…the level and breadth of need is astounding…”


Theconsistentviewacrossalleventswasthatprimarymentalhealthcareremainsweakandwithverylimitedprovision.

Information flows and exchange

Siloworkingandpoorinformationexchangehavelongbeenacomplaintofallagenciesworkingincriminaljusticeandinparticularintheprisonestate.However,inrecentyearstherehavebeensignificantimprovements.ItwasreportedthatthetransferofhealthinformationbetweenprisonswasseenasamuchlessdifficultissuesincetheintroductionoftheTPPSystmOne electronic information system, which providestransferofhealthinformationbetweenprisons.

WheretherewereNHSEnglandNationalLiaison&Diversionpilotsinplace(coveringareasrepresenting22%oftheEnglishpopulationatthetime,extendedsinceApril1st2015to50%(NHSEngland2015)),theexchangeofinformation,particularlyconcerninghealthbetweenprisonsandcourts,hadreportedlyimproved.PractitionersinthenewpilotsinEnglandhavemadeanefforttodevelop(previouslynon-existent)linksbetweenthemselves, inreach and health care services inthelocalprisonsthatprimarilyservethecourtstheyworkwith.ButformostofEnglandandWales,asrepresentedattheseevents,theinformationexchangebetweencourtsandcustodywasdeemedtobepoor.

Obtaininginformationfromcommunitymentalhealthserviceswasoftendifficultforcriminaljusticestaff.Onecourt-basedprobationofficerstated:

“…it can take days and sometimes longer just to find out who I need to speak to…”


Theavailabilityofmentalhealthpractitioners,such as via a court Liaison & Diversion service, made an “enormous difference” to accessing health information:

“…X has access to the Trust’s information system, plus she knows who to phone…it’s unusual for her not to get the information on the same day…”


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“…there is some great work done, but we can’t do much with most of the people who need something from us…”


Therewerealsoanumberofcommonlyreportedgapsinservicesforpeoplewithspecificdiagnoses(seeTable3).

Prescriptionpracticesforprisonerswithmentalhealthproblemsvariedhugelybyprison.Severalexamplesweregivenofmedicationsbeingavailableinoneprisonbutnotinotherprisons,causingdistresstoprisoners.

Someprisonmentalhealthserviceshadtosome extent merged secondary care with primary,andthismorereadilygaveaccesstoabroaderrangeofclinicalskillsandbetterclinicalsupervisionarrangements.

Therewaswidespreadsupportforthedevelopmentofastepped-caremodelofprovisionandmostprisonmentalhealthserviceswereattemptingtodevelopsuchamodelofprovision,oratleastdesiredto.

“…mental health promotion should be a big part of what we provide in prisons…getting in there before there is a problem or helping it get recognised early…not just waiting for things to happen…”


Therewasalsodiscussionatseveraleventsontheuseofprisonsegregationdepartmentsfor“…housing people with the sort of vulnerabilities we are talking about…” Participantssawthisasunacceptable.

Table 3: Prevalence rates of mental health disorders/learning disabilities in prisons

Diagnosis/vulnerability Prevalenceintheadultprisonpopulation

Learningdisability(LD) 7%oftheprisonpopulationisestimatedtohaveamarkeddisabilityand25%tohaveaborderlinedisability.¹

Acquiredbraininjury(ABI)

ThelargestUKstudyfoundthat47%ofadultprisonersreportatraumaticbraininjuryand30%hadexperienced5ormore.²

Autisticspectrumdisorder (ASD)

ArecentUKstudyindicatedaprevalencerateof4%,significantlyhigherthaninthegeneralpopulation.Someinternationalstudieshavefoundtheprevalencetobeevenhigherinprisonpopulations.³

Attentiondeficithyperactivitydisorder(ADHD)

Prevalencerangesfrom24-45%acrossseveralstudiesofprisonpopulations.⁴

Personality disorder (PD) 64%ofmaleprisonersareestimatedtohavepersonalitydisorder,butremandprisonpopulationprevalenceis78%.50%offemaleprisonershaveapersonalitydisorder.⁵

¹Talbot,(2008)² Pitman et. al., (2013)³King&Murphy,(2014)⁴ Eyestone & Howell, (1994), Rosler et al., (2004)⁵ Singleton et al., (1998).

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“…I’ve worked with several veterans…but also load of guys who have undergone abuse in the past…quite a few have Post Traumatic Stress Disorder…and then there are loads of other ways that trauma can manifest itself…”

(Prison-basedclinician)

“…I think we should adopt a trauma informed focus to intervention with offenders….so many have had significant history of trauma in their lives…”

(Prison-basedvoluntarysectorparticipant)

Providinginterventionsforvictimsinprisonsisrecognisedaschallenging,particularlyforthosewithshorterspellsinprison,butveryimportantand in “desperate need of development” (voluntarysectorparticipant).

Avarietyofpsychologicalapproacheswerereportedasbeingusedbothinsideandoutsideprisonswithoffenders,severalofwhichhaveresearchsupportingtheirefficacyforpeoplewithcomplexproblemsandpersonalitydisorder. Most are derived from Cognitive BehaviouralTherapyandthosementionedincludedinparticularSocialProblemSolvingTherapy,MentalisationBasedTreatmentandDialecticalBehaviourTherapy.

Psychological interventions

Theavailabilityofpsychologicalinterventions(eitherviaprisonprimarymentalhealthcareorprisonsecondarymentalhealthcare)appearstobearelativelyrarecommodityifthese17eventswererepresentative.Afewoftheprisonshadeitherclinicalpsychologistsornurseswithsignificanttrainingindeliveringpsychologicalinterventions,andwereabletomakeasignificantpsychologicalinterventionoffer. However most were not so resourced and could not.

Animportantpartofpsychologicalpracticeisthedevelopmentofpsychologicalformulations.Thesegosomewhatfurtherthanadiagnosis,and are rather a narrative that looks at a wider contextindefininganindividual’sissuesandalso therefore in designing interventions. As aresultofbothcontextsandtheoutcomesofintervention,suchformulationsaresubjecttochangeandassucharea‘movablefeast’.Ourparticipantssawthisasaparticularlyusefulwayofapproachingandsupportingpeoplewithmultipleandcomplexneeds.Suchformulationsarequitewidelyusedinmentalhealthcare.

Theperceptionofourparticipantswasthataverylargenumberofprisonerscouldandshouldbenefitfrompsychologicalinterventions.

“…you have to adapt the approaches…because these are not like community populations…”

(Prison-basedclinician)

“…there are loads of prisoners with mild to moderate mental health problems…who may or may not get some medication but that’s about it…”


Examplesweregivenofsuccessfullysupportingpeoplewithmarkedpersonalitydisorderandofreducingbehavioursthathadledpreviouslytofrequentpunishments.

Livingwithtraumawasseenasasignificantissueandprison-basedparticipantsreportedveryhighnumbersofprisonerswhohadsufferedfrompasttrauma.

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Prison mental health care - Inreach

Therehasneverbeenablueprintoroperatingmodelforprisonmentalhealthinreachservices,andmanycurrentservicesbeganaslargelymono-disciplineservices,consistingofnursessometimeswithsomepsychiatrysessions.Theseserviceshaveonthewholegrownandmanyarenowmoremultidisciplinarythantheywereinthepast.Somehaveincorporatedprisonprimarycareservices.However,thereremainshugevariabilityofprovisionandthiswasevidentfromtheprison-basedsecondarycarepractitionersandmanagerswhoattendedevents.

Ourparticipantswerekeenforsomeequivalenttemplateforprisonmentalhealthcaretothat

whichisavailableforLiaison&Diversion,i.e.NHSEngland’sOperatingModel.Twootherprojectsthatmaysupportthedevelopmentofmorestandardisedprisonmentalhealthcarewerecitedintheevents.Thesewere:

• ThedevelopmentofPrisonMentalHealthCareStandardsbytheRoyalCollegeofPsychiatrists’QualityNetworkforPrisonMental Health Services (Royal College of Psychiatrists,2015);

• TheNationalInstituteforHealthandCareExcellence(2012)projectdevelopingguidance for offender mental health care.

Stakeholdersinvolvedinbothofthesedevelopmentscontributedtothereview,and

Adopting a psychologically informed approach

Apsychologicallyinformedapproachtoworkingwithoffenderscanbeseenasonewhichseekstounderstandthemotivationsandthinkingoftheperson,andwheresuchknowledgeinformshowstaffmembersreactandrespondboththroughday-to-daycommunicationandthroughspecifictherapy.Developingsuchanunderstandingcanallowworkerstobeproactive.

PsychologicalinformednessisoftenusedspecificallywhendiscussingpeoplewithpersonalitydisorderandspecificenvironmentssuchastheEnablingEnvironmentconcept(developedbytheRoyalCollegeofPsychiatristsanddescribedbyJohnson&Haig,2012)andPsychologicallyInformedPlannedEnvironments(developedbyDepartmentofHealth,NOMSandNHSEngland),bothofwhicharedescribedinthisreport.However,apsychologicallyinformedapproachalsoinvolvesusingformulationstounderstandtheindividual.Formulationscanbedescribedashaving the following characteristics:

• Asummaryoftheserviceuser’scoreproblems;

• Asuggestionofhowtheserviceuser’sdifficultiesmayrelatetooneanother,bydrawingonpsychologicaltheoriesandprinciples;

• Theaimtoexplain,onthebasisofpsychologicaltheory,thedevelopmentandmaintenanceoftheserviceuser’sdifficulties,atthistimeandinthesesituations;

• Indicationofaplanofinterventionwhichisbasedonthepsychologicalprocessesandprinciplesalreadyidentified;

• Beingopentorevisionandre-formulation.

(Johnstone&Allen2006,citedinBritishPsychologicalSociety(BPS)2011,p.6)

Formulationsareanattempttounderstandanindividualintheircontext,andtodosousing‘plausibleaccount’(Butler,1998citedinBPS,2011)intheformofasharednarrativeratherthanacategoricaldiagnosis.Theformulationprovidesahypothesistobetestedanditsnarrative changes as the individual does.

Apsychologicallyinformedapproachhasawiderapplicationthanjusttothosediagnosedwithpersonalitydisorder,whichisinanycasehighlyprevalentinoffenderpopulations.Aspectsofapsychologicalapproach,suchasformulations,lendthemselvesparticularlywelltoworkingwithpeoplewithcomplexandmultipleneeds.

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thoseinvolvedintheongoingNICEprojectwerekeentobeinvolvedinwhatemergesfromthisreview.

Someprisonmentalhealthserviceswereableto deliver a range of interventions including adaptedpsychologicalinterventions,whileothers could only make a more modest offer. Onthewholetheavailabilityofpsychologicalinterventionswasreportedtobelow.

Allparticipantsreportedthattheprisonmentalhealthinreachhadundergonemission“creep”or“stretch”overtheyears.Thiswasreportedlyduetopressurefromtheprisonsforteamstotakeoncases,butalsoduetorecognitionoftherolementalhealthteamscouldplayinsupportingpeoplewithcomplexandmultipleneeds.

Inalltheprisonsrepresented,thedemandformental health inreach was far greater than the resourceavailable,andthiswasreportedlyduebothtotheweaknessinprimarymentalhealthcareandthehighlevelsofpsychiatricmorbidityintheprisonpopulation.

“…we are only ever going to be small teams…we can’t take it all on…we need to share what we know with prison staff…”


Atseveraloftheeventsparticipantsexpressedsupportfordevelopingmoreofamentalhealthconsultancyapproach:

“…we do a bit of it already….I think some interventions could be delivered by prison staff….but they need skilling up…consultancy would spread our resource more widely…"


Itwasalsorecognisedthatthecutstostaffinginprisonsmakesuchinterventions“challenging”.

Transfers to psychiatric care

ThereasonsfordelaysintransferringprisonerstohospitalwerereviewedbyCentreforMentalHealth(2011)andtheissuesreportedduringthis consultation differ somewhat to those the Centrepreviouslyreported.However,lengthydelaysintransferarestillbeingreportedandwere so at all our events. Previously each unit thataprisonmentalhealthteamreferredtheir‘patient’towouldconductanassessment;this

sometimesresultedinmultipleassessmentsanddelays.Thisiscurrentlynotthecaseformostinter-regionreferralsandasinglereferralissufficient.However,ifthereisnobedwithintheregionandareferraltoanout-of-regionresourceisrequired,thisresultsinfurtherassessmentsanddelays.RegionalGatewaysarecurrentlyreportedtobetheproblem.Anyformofspecialisedbed(e.g.forsomeonewithlearningdisabilitiesorsomeonewhoisdeaf)isreportedtoresultindelay.Waitsofthreeandfourmonthswerereportedacrossevents,andone wait of nearly 12 months.

Difficultiesintransferringtosecurementalhealth care were not necessarily related to shortagesinbeds;indeedinoneregionitwasreportedthattheyhadclosedsomebedsasoccupancyhadbeenquitelow.

ApsychiatristatoneoftheEnglisheventsstatedthatapatientofhiswasfloridlypsychotic,inneedofintensivetreatment,andnotsuitablefortreatmentinprison.However,ittookseveralweekstotransferhimtohospital,bywhichtimehisconditionhadsignificantlydeteriorated.

Prison-basedpsychiatristsreportedthattherewasanissueofcliniciansfromthe‘receiving’unit‘nottrustingassessments’evenfromveryqualifiedprison-basedclinicians(thiswasalsothecasein2011).ThiswasfarlessofanissueforlocalandinternalNHStrustreferrals(i.e.wherethesamementalhealthproviderisintheprisonandreceivingunit).

Thedefaultforreferralisnowtolow-securefacilities, unless the level of risk determines otherwise.CentreforMentalHealthpreviouslyfoundthatthedefaulthadbeentomedium-securefacilities(2011).Italsoappearedtobethedefaulttorefertoaunitintheprisoner’sareaoforigin.Thiswasfelttomakesenseiftheprisonerwastobereleasedfromthisunitortransferredfromthisunittoalocalprison.However,severalincidenceswerereportedwhereprisonershadbeentransferredtolowsecureorpsychiatricintensivecareunits(PICUs)someconsiderabledistanceawayfromtheprisononlytobetransferredbackwhenrecovered.Thismadeliaisonwiththereceivingunitdifficult.Allcliniciansreportingthisstatedthat it made more sense to refer to a local unit (iftheprisonerwaslikelytobetransferredback

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tothereferringprison),whichtheycouldworkwithandbeinvolvedinthetreatmentoftheir'patient’.

“…it makes no sense….when we have a unit in this trust within a mile of here….it would be easier to ensure continuity of care and to work with the team at our local unit…we can’t attend case reviews if they are placed miles away...”


“…PICUs are funded by CCGs….we have had a PICU from the area of the prisoner’s origin saying we should refer the prisoner to our local one. The local one refused saying ‘they are nothing to do with us’…and whilst we were trying to resolve this we had to admit the patient to a medium-secure [facility] as that’s where we had a bed and we had big concerns about him…"


Atoneeventitwasreportedfromamedium-secureunitthatoverthepastyearithadbecomedifficulttotransferpatientsbacktothereferringprison.Thisappearedtoberelatedtoapolicyoftryingtoplaceprisonersinprisonsclosertotheirareaoforigin.Theprisonoforigin informed the medium secure unit that theprisonerwasnolonger‘theirs’andthenewprisonrefusedtoacceptthereturntransfer.Theunitreportingthisfoundtheprocessofreturningthe‘patient’toprisonlengthyanddifficultasitwasfarfromclearastowhichprisonnowhad‘ownership’.

PIPEs and the personality disorder pathway

Servicesforprisonerswithseverepersonalitydisorderand/orwhocontinuetoposeaseriousriskofrepeatedsexualorviolentoffendingwerehighlyregarded.Onetypeofapproachis the Psychologically Informed Planned Environment(PIPE).Theseareunitswhereallofthestaffhavebeentrainedinprovidingapsychologicallyinformedapproach,wherethewholeunitexperienceisdesignedtosupportthosewithcomplexneedswithaneffectivetransitionthroughapathwayofservices.Crucially, criminal justice staff received training inworkingwithpeoplewithpersonalitydisorderandworkinginapsychologicallyinformedway.At several events, staff who had undergone this

trainingreportedpositivelyonit,andsawthetrainingashavingamuchwiderapplication.

“…all prison work should be psychologically informed…"

(Voluntarysectorparticipant)

PIPEsdifferedfromotherprisonregimesinotherways,mostsignificantlyinstaffinglevels.PIPEs have a higher staff to resident ratio and moreofamultidisciplinaryteam.

“…I don’t think all prisons need to become PIPEs but it would be great if we could all aspire to achieve status as Enabling Environments"

(ParticipantwithrecentexperienceofreviewingseveralprisonsincludingPIPEs)

EnablingEnvironmentsarenotspecifictoprisonsorevenhealth;rather,theyaresettingsthat strive to achieve a set of standards that havebeendevelopedbytheRoyalCollegeofPsychiatrists(2013).TheseEnablingEnvironment standards are:

1. Thenatureandqualityofrelationshipsareofprimaryimportance.

2. Thereareexpectationsofbehaviour,andprocessestomaintainandreviewthem.

3. Itisrecognisedthatpeoplecommunicateindifferent ways.

4. Thereareopportunitiestobespontaneousand try new things.

5. Everyonesharesresponsibilityfortheenvironment.

6. Supportisavailableforeveryone.

7. Engagementandpurposefulactivityisactively encouraged.

8. Powerandauthorityareopentodiscussion.

9. Leadershiptakesresponsibilityfortheenvironmentbeingenabling.

10. Externalrelationshipsaresoughtandvalued.

TherapeuticCommunitieswerealsotalkedaboutpositively,buttherewasverylimitedexpertiseontheseattheevents.Therearearange of other services within the Personality Disorder Pathway and not all were discussed at ourevents.Oneofthesmallgroupswasheldwithmentorssupportingpeoplereleasedintothecommunityaspartofthepathway.Thisgroupalsostressedthebenefitsofknowledgeofpersonalitydisorderandoftakingapsychologicallyinformedapproach.

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TheissueinapplyinglessonsfromthePIPEsandEnablingEnvironmentswasin‘scalingup’in a climate where resources were very limited.

Mental health prisons and wings (MHPs)

Mentalhealthprisonsdonotcurrentlyexistbuthavebeenmootedattimesandexistinotherjurisdictions. Unless changes were made to the MentalHealthAct,MHPswouldbeforvoluntaryprisoners/patients(aprisonisnotaplaceofsafetyundertheAct).Theseunitswouldmostlikelybeforthosewithsevereillness,wouldbeexpectedtohaveahigherstaffratioandafullercomplimentofpsychiatricdisciplines.OneproponentofMHPssuggestedtoCentreforMentalHealthpriortothereviewthatMHPswouldconcentratepsychiatricresources.

At all of the events, the notion of MHPs was discussedandtwoparticipantsvoicedsomesupportforsomeformofMHP.Bothwereclinicians and saw a role in such units in interveningearlytopreventthenecessityof transfer to external secure mental health care,butalsoforobservationanddetailedassessment. However, the majority of participantssawlittleroleforMHPs.

“…it misses the point…the vast majority of prisoners have issues with their mental wellbeing…”


“If a prisoner is willing to accept treatment, then there isn’t an issue…we can treat them on the wings…”


“…a small number of people have such severe illness that requires they be transferred to a secure unit [NHS commissioned secure hospital]….but actually we are pretty good at caring for people with severe and enduring mental illness…”


“…I think the people we… and the prisons… struggle to cope with are people with complex needs…with personality disorder….it’s a huge number and most would fall well below the threshold for a secure unit and even a community mental health team… they are [in] the realm of primary care…”


Ratherthanspecialunits,mostclinicianssawthevalueofinvestmentinanddevelopmentofprogrammestosupportpeoplewithvulnerabilitiesforwhichtheyfelttheyofferedlittleatpresent(seediagnoses/vulnerabilitieslisted earlier).

Cliniciansfeltscreeningforthepreviouslylistedvulnerabilitiesneededtobeimproved;indeed,itwasreportedthatonlyverylimitedscreeningtookplaceinanyoftheprisonsrepresentedattheevents.Participantsatoureventssawthevalueofsupportingnotjustprisonerswiththesedisordersbutalsoprisonstaffwhoworkedwiththem:

“…guys… especially those with ADHD are just seen as discipline problems….they get punished and nothing changes…I think we could make a real difference…”

(Prison-basedclinicianparticipant)

24-hour prison-based health care

Themajorityofcliniciansstatedthattheyvalued24-hourhealthcareprovision,butfewhaditintheprisonstheyworkedin.

“…if you can get someone in quickly then they are really useful for a bit of intensive work and really good for observation…”


Mostprisonmentalhealthcarestaffreporteddifficultyinaccessingthesebedsandthiswasespeciallydifficultifthe24-hourfacilitywaslocatedinanotherprison.

“…I don’t think I have ever managed to get anyone in…we need more of these…”


Someprisonhealthcarestaffreportedthatsuchunitsremainedunderthecontroloftheprisongovernorandinsomeprisonstheyhousedpeoplethatdidnotwarrant,intheirview,abed.Itwasreportedthatinmostcasessuchusagewasforpeoplewhowerenotcopingwithordinaryprisonregimesbutwhodidnothavea‘health’relatedproblem.

“…it was worse in the past….all sorts of folks would get placed in the health care unit…but it still goes on…I think they (24 hour units) have a real role to play and if you could get someone in quickly then they can avert a crisis…”


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Leaving prison

Ourparticipantssawleavingprisonasacriticaltransitionpointandahugelyproblematicarea.Itwasnotedatoneeventthatthefirstfewdaysandweeksafterreleaseposemanychallengesfor those released and are a time of heightened risk,notleastofself-harmandsuicide.Arecentsystematic review of the research of suicide inthepost-releaseperiodfoundthatsuicideswere6.76timesmorelikelythaninthegeneralpopulation(JonesandMaynard,2013).Ensuringcontinuity of care was deemed “incredibly difficult”,andpeopleleavingprisonwhobyandlargehavemultipleandcomplexneedsoftenleftprisonwithnoorverylimitedsupport.

Manyprisonershad,ineffect,nofixedabodeonleavingprisonandsoatbestmightbelivingatahostelonrelease.Itwasacommonexperiencetonotknowwheretheywouldbelivinguntilthedayofrelease.ObviouslythisdatawascollectedpriortoCommunityRehabilitationCompanies(CRCs)beingfully'upandrunning'andnewpathwayworkand'throughthegate'contractsbeingawarded,sothismayalreadyhaveimproved.However,CentreforMentalHealth’sworkonaresettlementandpost-releaseemploymentprojectintheWestMidlandssuggestsitmaystillbeproblematic.IthasbeenreportedthatasmallnumberofpeoplereleasedunderthesupervisionofCRCsandreferredtotheprojecthadnoaccommodationfoundpriortorelease,andno'throughthegate'supportotherthanthatofferedbytheproject’semploymentspecialists(notapartoftheirroleortheproject’s'offer').Thesemayofcoursebeisolated,atypicalincidents.

AtalleventsinbothEnglandandWalestherewasaperceptionthatcommunitymentalhealthserviceshadreportedlyraisedtheirentrythresholdsinthepast12-18months.

“…most of the people we work with in here would not meet the criteria for secondary care. (In the community)…it has always been difficult to pass some on to a community mental health team, but it is much more difficult now…”


“…we struggle to get people who have severe and enduring mental health problems into community teams...but the community has even

less to offer if you have a learning disability or ASD [autistic spectrum disorder] …”


Withregardstolearningdisabilitiesitwasacknowledgedtherewaslimitedprovisioninprisons,andthatprisonmentalhealthcareoftentookpeoplewithlearningdisabilitiesontotheircaseloads.Severalprisonmentalhealthteamshadrecruitedstaffwithlearningdisabilityqualifications.Theleavingexperienceforthesepeoplewasdescribedas“dismal”byoneparticipant,andthisviewwasgenerallyshared.

“…there is nowhere in our area I can refer prisoners with learning disability to…”


“…I have had some quite profoundly disabled young men… but these days they do not meet the criteria for [community] LD services…”


TheimpactoftheWinterbourneViewHospitalabuseandsubsequentinquirywasdiscussedatmosteventsanditwasfeltbyparticipantsthattheresponsetoWinterbourneViewhadbeenafurtherreductioninresourcesforpeoplewithlearningdisabilitiesandparticularlybeds:

“…there is a danger of the baby being thrown out with the bath water…”


Formostcategoriesofprisonmentalhealthcarepatient,ensuringcontinuityofcareinthecommunityonreleasewasdescribedasdifficult.Itwaspreviouslyreportedthatwhereprison-basedserviceshadbeenabletoofferadaptedpsychologicalinterventionstherewasoften no community service willing to offer a similaradaptedapproach.

“…most IAPT teams wouldn’t touch our folk…” (Prison-basedclinician)

“…it would be great if the period after release could be deemed a ‘crisis’….because it often is…and if the Crisis Care Concordat [HM Government, 2014] covered that…”


“…an awful lot of the people who leave here have nowhere to go to and we don’t know where they will be released to, but it will be a hostel somewhere… this makes it impossible for us to

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connect that person….even with primary care….the best we can do is send them out with a letter detailing their needs and treatment, they give this to their GP when they find one…”

(Prisonhealthcareparticipants)

ThishasalsobeentheexperienceofanotherCentreforMentalHealthproject(whichgaveevidence to this review). Centre for Mental HealthandpartnersEnable,Sova,UniversityofNottinghamandtheSouthStaffordshireandShropshireHealthcareNHSFoundationTrustareworkingonaresettlementprojecttestingoutanemploymentinterventionwithpeoplewithmentalhealthproblemsbeingreleasedfromsevenWestMidlandsprisons.Thevastmajorityoftheseprisonershadnoreleaseaddressuntilclosetothedayofrelease,makingitdifficultto deliver the intervention. Only a minority are beingsupportedbycommunitymentalhealthteams and although virtually all are under probationsupervisionaftertheirrelease,thesupporttheyreceiveisreportedasminimalatbest.

Thecomplexityandmultiplicityofneedwasalsohighlighted at our events.

“…the first couple of weeks after release are the most difficult…and the first couple of days are a nightmare…I’ve had everything done for me in prison…then suddenly you’re on your own…and there is the stress of getting to your first probation appointment, Job Centre Plus…”

(Formerprisoner)

“…being met at the gate and provided with a bit of support might have stopped me going back to prison…”

(Formerprisoner)

“…you have to meet someone’s basic survival needs first, accommodation, access to funds and so on…then you can worry about treatment…”

(Voluntarysectorparticipant)

Therewasverywidespreadsupportfor‘throughthegate’typeinterventionsthatprovidevulnerableprisonerswithsupportandadvocacyforacriticalperiodafterrelease.However,access to such schemes was very limited. Surprisinglyinonecase,thementalhealthteaminaprisonwhichhadahighprofileschemehadexperiencedverylimitedcontactwiththescheme and had very vague knowledge of it.

At the time of the review, whilst Community RehabilitationCompanies(CRCs)wereinexistenceandindeedrepresentedatmostevents,theirserviceswerenotdeveloped.CRCsarecommittedtoproviding‘throughthegate’supportandwillbeprovidingsupportandsupervisionforagreaternumberofpeoplepost-releasethanprobationserviceshadpreviously.However,mostofourparticipantsfeltthatpeoplewithpoormentalhealth,alearningdisabilityoranotherrelatedvulnerabilityrequiredatargeted,enhancedversionofwhateverthegeneral‘offer’wouldbe.Thepsychological'informedness'(akeyfeatureofwhatisofferedtothesmallnumberofoffendersinthepersonalitydisorderprogramme),wasseenbymanyparticipantsasthe"model"to follow, as this resulted in a more tailored approachtotheindividual.

“…with the change in probation…we now have the CRC coming in here…and they do the ‘through the gate’ stuff, they work with prisoners up to 3 months prior to release…but they work with everyone and there is nothing specific for people with mental health problems…”

(Prison-basedprobationparticipant)

“…I think it’s important to have someone working with them who understands mental health, who can give them the time because they have small caseloads….even if only for a couple of weeks after release…”

(Prisonserviceresettlementpaticipant)

Severalgroupsofprisonersprovidedgreaterresettlementchallenges,forexample:

• Women–(largelyduetothetypicallylongdistancebetweenprisonandareaoforigin,and therefore a lack of knowledge of local services in that area);

• MenandwomenreturningtoWales(thiswasaproblemwheretherewasnotwell-establishedcommunicationwiththeEnglishprison);

• ForeignNationalprisoners.

Onleavingprisonitwasthepracticeofallprisonmental health services to send information toaprisoner’sGP,andanyservicetheyhadreferredthepersonbeingreleasedto.However,thereleaseaddressformanyprisonerswas

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unknownatrelease,soprisonmentalhealthserviceswouldprovideguidanceonhowtoregistertotheprisonerupontheirrelease,witha letter on any treatment received and ongoing health needs.

Oneprisonmentalhealthinreachteamreportedfollowinguponallreleasedformercases,usuallyamonthafterrelease.Thiswasviaanyservicetheprisonerhadbeenreferredto,theirGPorsometimestheformerprisonerthemselves.Thiswasfeltbyparticipantstobeanexampleofgoodpracticeas(attheveryleast)itprovidedsomedataonthechallengesofthepost-releaseexperience.

Liaison&DiversionservicesaspartoftheNationalPilotProgrammeemploycommunitysupportworkers.InLondonthesearecalledCommunityLinkWorkers(CLWs–managedbyTogetherforMentalWellbeing).TheCLWshavearolebeyondtheLiaison&Diversionremit,inthattheyoffertime-limitedsupportaftercourtorpolicecustody.CLWsworkwithpeoplewithcomplexneedsandparticularlyinsupportingtheir engagement into a range of services, for examplementalhealthservicesorhousing.Theconsistentviewacrossoureventswasthatasimilaroffer,suchasanoutreach-styleservice,oughttobeavailableonrelease,orthatacommunity-basedserviceshouldprovideanequivalentresponse.Peoplewithmentalhealthproblems,learningdisabilities,personalitydisorderandrelatedvulnerabilitieswerefelttoneedenhancedsupport,i.e.somethingbeyond“the standard offer on release”. ThecommissioningofsuchaservicewouldmostlikelyprimarilybetheresponsibilityofCCGs.Thereweresomeexamplesofthisforpeopleleavingprison.Oneinreachservicehadanoutreachworkerwhoprovidedsometime-limitedpracticalsupport,andsupportaround service engagement (London), whilst anotherhadaccesstoa‘throughthegate’serviceforpeoplewithmentalhealthproblems(Nottingham).

Reports for parole boards

Alltheprison-basedmentalhealthpractitionerswemet(particularlypsychiatrists)hadsomeexperienceofproducingreportsforprisonparoleboards.Andallreportedthesame

challenges.Theparticipantsexpressedthatthiswasanimportantandvaluableactivity,but:

“…I don’t think the board has any idea of the level of resource it takes to complete a report…I am a very small resource and completing a report effectively withdraws access to a psychiatrist in the prison…”


“…they are not included in the contracts we have here…so there is no time allocation for them…”


“…I actually do want to do the best for my patients and I do want to report to the parole board…but I think there is an education job to be done with them about what to expect and how to ask for reports…”


Ourparticipantsallagreedonthefollowing:

• Paroleboardmembersrequiredmentalhealth awareness training.

• Paroleboardreportsoughttobeacontracted activity with time allowances for completion.

• Morenoticeofrequestswasrequired.

Alimitationofoureventswasthatparoleboardswerenotrepresented.

Foreign national prisoners

Thelattergroupwereparticularlydifficultasiftheyweretobe‘removed’followingrelease,communicationwithfutureserviceprovisionwas “near impossible”. However, many foreign nationalprisonerswerenotremovedfromtheUK at the end of their sentence.

“…it’s a real concern….it’s heartbreaking…they have little or no entitlement on release.”


MentalhealthprovidersatanImmigrationRemovalCentre(IRC)reportedveryhighlevelsof severe mental illness and that they had transferredamuchgreaternumbertosecurementalhealthcarethanwouldbeexpectedfromabusylocalprison.

“…we were quite shocked by the level of need…it’s our most demanding service…”


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SomeprisonhealthcareservicestalkedaboutthestruggletoprovidingmeaningfulsupporttopeoplewhodidnotspeakEnglish.

Lessons from Engager: towards developing principles for the resettlement of people with vulnerabilities

Engagerisaprogrammeofresearchandpracticedevelopmentfocusedonpeopleleavingprisonwithcommonmentalhealthproblems.ItisledbytheUniversityofPlymouthandManchesterUniversityinpartnershipwithanumberoforganisationsincludingCentreforMentalHealth¹.Thefollowinglessonsforsuccessfulresettlementhaveemergedfromtheexercise:

• Liaisewithkeyservicesbeforereleasetofindoutwhenkeyappointmentsare.

• Releasedayisavitaltimeforbuildingtrustandengagement:Meetthereleasedpersonatthegate,accompanythemtotheirreleasedayappointments(thisisparticularlyimportantforsupportingdrink/drugabstinenceonreleasedayandthusengagementwithotherkeyservices).

• Informalcommunicationsuchastextingisimportanttomaintaincontactandengagement.

• Assertivecontactinthecommunityeveninthefaceofsetbacks(e.g.substancemisuse).

• Useofinevitablesetbackstogaintrustanddevelopcopingskillsanda‘sharedunderstanding’ofbarriersandchallenges,andhowtheymightbeovercome.

Developing a ‘shared understanding’ between the released person and the practitioner

• Worktogetherwiththereleasedpersontounderstandthethoughtsandfeelingsthatarerelatedtobehaviourstheyconsiderproblematic(e.g.offendingordrinking).

• Usedaytodaycrisestounderstandwhathappensinrecurringproblemsinthecommunityandtosupportasharedunderstanding.

• Usethisunderstandingtodeveloppersonalgoals.

• Developawrittenrecordofthissharedunderstandingthatcanbesharedwithotherkeyagencies.

Working on goals and developing a ‘shared action plan’

• Matchpersonalgoalstoavailableresources(thereleasedpersonthemselves/thepractitioner/otherservices&practitioners/family/friends/peers).

• Liaiseandadvocatetogetotherpeopletoworkaroundtheperson’sgoals.

• Useawritten‘sharedactionplan’tocommunicatetootherpractitionershowtheirworksupportstheperson’sgoals.

Working on relationships

• Supportgoodcommunicationbetweenparticipantsandinvolvedpractitioners.

• Modelgoodrelationshipsandcommunication.

• Traininsocialandcommunicationskills.

¹ TheotherpartnersinvolvedwiththeEngagerresearchprogrammeareExeterUniversity,UniversityCollegeLondon,CityUniversity-London,King'sCollege,UniversityofSouthWales,StGeorge's-UniversityofLondon,LeedsCommunityHealthcare,Avon&WiltshireMentalHealthPartnershipNHSTrust,DevonPartnershipNHSTrust.

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Probation

Mosteventshadattendancefromprobation,bothNPSandCRCs,anditwasagreedthattheimpactofthereformprocessunderTransformingRehabilitationhadbeenverydisruptivebutwasnowsettling.Bothnewbranchesofprobationwerelaunchedorbeingestablishedatthetimeoftheevents.TherewasstillalackofclarityoverwhatwouldbetheCRCs’prioritiesandhowthesewouldbereflectedinthecontractstheyagreed with other organisations. At the time of the events, organisations currently contracting withprobation,suchasamentalhealthserviceprovidingsessionsforprobationofficersanda'throughthegate'interventionforpeoplewithmentalhealthproblemsandlearningdisabilities,wereduetohavetheircontractsfinishonMarch31st2015.Ifthesecontractsweretobe“picked-up”thenthiswouldnotbeuntilafterMay1stwhenCRCswereduetoannounce such arrangements.

Centre for Mental Health met with two service usersinthecommunityinWalesandtheirsupportworkersaspartofthisreview.Theseserviceuserseachhadlearningdisabilitiesandmentalillness.Theyhadhistoriesofseriousoffendingbutwerenotcurrentlyunderanyprobationsupervision.Theywerenotsupportedbyeithermentalhealthorlearningdisabilityservices.Theonlysupporttheyreceivedwasfromavoluntarysectorsupportservicethatengagedbothoftheminprisonbeforerelease.Bothwerereportedtohaverespondedwelltothesupportandwereveryappreciativeofit.TheprojecttheywerereceivingsupportfromwasduetoendonMarch31standtheirsupportwithdrawnthereafter.Theprognosisforbothwasfelttobepoor.Ithassincebeenconfirmedthat this service did come to an end.

InsomecasestheNPShadagreedtocontinuewith any element of an existing contract for peopleposinghighharmandontheircaseload.

Mostprobationofficers,bothCRCandNPSworkinginthecommunity,expressedafeelingthat they were “…neglected…” in criminal justiceandmentalhealthpolicy.

“…don’t get me wrong…it’s great what’s been done in prisons but we have the bulk of offenders…most of the people I work with have poor mental health and I have nowhere to go with them…”


“...we always focus on the tiny group of offenders in prison and forget that most live in the community…”


“…the Liaison & Diversion folk are great, but they kind of stop at the court door and can’t help us…”


Some,butnotall,oftheprobationservicesrepresentedattheeventshadpreviousexperienceofhavingsomededicatedmentalhealthresource.Thistooktwoformsandsomeserviceshadexperiencedboth:

• Directanddedicatedsessionsforpeopleonaprobationcaseload(inonecasethisincludedaformofIAPTservicewithadaptedpsychologicalinterventions);

• Probationconsultancysurgeries(wherementalhealthpractitionersprovidedadviceandconsultancytoprobationofficersaboutany case they were concerned with).

Theaddedvalueofhavingsuchaccesstoamentalhealthpractitionerwaseasieraccesstoinformationontheirclients,andasimplerrouteinto mainstream mental health care.

CCGswouldneedtocommissionsuchprovision:

“It’s shocking how few CCGs realise that they have a responsibility at all for probation, and until…they do and put in place any of your [the review’s] recommendations, [they] are going to be firing into an empty space…rather than one structured to receive your recommendations…”

(Seniorprobationparticipant)

Researchondeathswhilstonprobationsupervision(HowardLeagueforPenalReform,2012) reveals that there is a higher mortality ratewithintheprobationcaseloadpopulationwhencomparedtothegeneralpopulation,

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andthatasignificantproportionoftheseareduetosuicide(13%).Thisincludesthoseon community sentences as well as those onlicense.Thesuiciderateformenunderprobationsupervisionisaround70per100,000 (calculated from Howard League, 2012)comparedto9.8per100,000malesinthegeneralUKpopulation(WorldHealthOrganisation,2014)andforwomenis30per100,000underprobationsupervisioncomparedto2.6per100,000intheUKgeneralpopulation(same sources).

Reports for courts

TheEnglishandWelshexperiencesaresomewhatdifferentandtheWelshexperienceisdescribedlater.AteventsinEngland,thoserepresentingcourtswhowereinreceiptofservicesfromthefirstwaveofNHSEnglandLiaison&Diversionpilotsreportedpositively.

“…in the past I might have had to wait weeks…but the diversion people can now get me what I need to know the same day…”

(Sentencer)

TheNationalLiaison&Diversionpilotswereperceivedashaving:

• reducedtheneedforpsychiatriccourtreportrequests;

• increasedaccesstotimelyreportsforsentencersandprobation;

• providedthetypeofreportingthatmetthecourts’needs:

o theywereshortandtothepoint;o they made grounded recommendations;

• increased timely access to health care informatio

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