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Mental health in prisons

Minutes of the Meeting of the All-Party Group on Penal Affairs, held on 25 October 2016 in Committee Room 21


Kate Davies OBE, Head of Health and Justice, Armed Forces and Public Health,  NHS England
Fiona Grossick, National Quality and Lead Nurse for Health and Justice, Medical Directorate, NHS England
Professor Huw Williams, Co-Director of the Centre for Clinical Neuropsychology Research Centre (CCNR), Exeter University
Dr Kimmett Edgar, Head of Research, Prison Reform Trust


Lord Ramsbotham (in the Chair)
Lord Bradley
Lord Fellowes
Baroness Healy
Baroness Howe
Kate Green MP
Dominic Grieve QC MP
Lord Judd
Lord Ponsonby
Andrew Selous MP

Lord Ramsbotham welcomed everybody to the meeting.  He said that this topic had long been a special interest. Before his time as Chief Inspector of Prisons, he had been appointed Chairman of Hillingdon Hospital, where the Director of Mental Health had suggested he should train as a lay assessor. He was grateful for that training, which had enabled him to see, on his first inspection of Holloway Prison, that all was not well with the way that women with mental health problems were treated in the Prison Service. With his principal medical inspector, a psychiatrist, he worked to get prison healthcare taken over by the NHS – though that took longer than World War Two.  There had been notable improvements subsequently, especially in some prisons, but care was still patchy.  The promised White Paper on Prisons, the first since 1991, was shortly to be published.  He sincerely hoped that there would be a great deal about the treatment of prisoners with mental health problems in it, and if not, that ministers would amend it to include this important issue. It was particularly appropriate that we should have a briefing from experts in the field.

He introduced the first speaker, Kate Davies, who had made a tremendous impact on all parts of the system since she took up her role.

Kate Davies OBE began by thanking the Chair for his introduction. ‘It is really good to be able to address what is an incredibly important subject, and also a very timely one.  There has been much deliberation across government departments, and I guess that’s where I start, around what and who has accountability and responsibility for looking at mental health in prisons.  As Director for Health and Justice NHS England, part of the national team, my role is to ensure that the healthcare for patients within secure and detained settings is equivalent, whether that is for someone who is on remand for a few days or weeks, or someone serving a long sentence for a serious offence.

The secure settings within which we are responsible for healthcare include 116 adult prisons, the children’s secure estate – YOIs and STCs and secure children’s homes and welfare beds - and also IRCs, the Immigration and Removal Centres. So what does that mean for adult prisoners, for children and young people, and what does that mean for detainees, who are there because of their asylum or immigration status?  Very importantly, the work we have been doing over the past three years as commissioners, with ministers like Andrew Selous, is about pushing the continuity of care. What we do in prisons is great, though not always consistent – and I take that challenge on board – but what is more important is reducing the number of men and women in custody, particularly when their mental health is a key reason for their behaviour.  That could be related to offences, or behaviour which then results in a prosecution or offence, or is the reason why someone is detained.

We are very hopeful about the new White Paper.  Obviously it is not my White Paper but the Ministry of Justice’s, and  I am working very closely with  my colleagues, round the clock for the past few weeks, to ensure that it does give an opportunity for the first time since 1991 to describe the reality of mental health in prisons at the moment.  

I am not one to start on a negative but unfortunately I will. Because I think the reality for us as commissioners, commissioning just over half a billion pounds’ worth of healthcare across the secure and detained estate, and also for our providers, providing those services for health care, mental health and substance misuse, is that it is the most challenging time that we have ever had.  I have worked in and out of prisons for about three decades now, sadly, and it really is quite something to say.  Quite often the reason why it’s a challenge is because we have men and women locked up in different parts of the secure setting for long periods of time.  It is much more difficult to pursue the interventions, following good mental health assessments, both on agreement and sometimes on conditions, as part of the intervention that we commission. And quite frankly that is a waste of public money, if we cannot ensure that we can pursue them at the depth and the quality that we need to.

So what we have been doing is very much targeting around mental health.  If we can’t do everything, we have to know where the biggest areas of risk are.  My overview has changed slightly.  The reason why my lead nurse Fiona Grossick is by my side today, as she so often is, is that the reduction of deaths in custody, self-harm and suicide is one of our biggest priorities as part of mental health interventions and early screening.  If we get the right assessment for people of their mental health needs as well as their physical health needs, at the earliest opportunity, not only do we get the right pathway to care however long they may be detained, we get the right pathway to care as part of their release.  That pathway should not start a few days before they are released but should start on the day they come into custody.

Most importantly it is about early screening and interventions. The increase in deaths in custody over the last couple of years has frightened many of us who work in this field.  Mental health cannot be discussed in isolation from integrated provision in healthcare.  Quite often people tell me that it is much too complicated.  But I challenge you: in the community we expect that integration as part of our family care, our emergency admissions, our sexual health, our substance misuse. That should be the same for those in detention.  There shouldn’t be silo interventions.  So as commissioners we have painstakingly done a lot of work on two things over the last couple of years.  One is coming up with core service specifications that raise the standard, remove that uncomfortable word ‘patchy’, and say ‘this is the minimum that anyone should be delivering in healthcare and mental healthcare within criminal justice, detained and secure settings’. 

And secondly as part of those standards we also have to ensure that we have flexibility to change and support the need of prisons, because they are changing constantly at the moment.  Why? One reason is because of the changing face of drug and alcohol abuse, particularly drug use within our prisons, and the mental health consequences.  As part of the whole designer drug element – spice, or whatever anyone wants to call it – we have got probably one of the worst situations we have experienced within our prisons in terms of how that has affected not only the mental health but also the health and wellbeing of the men and women – particularly the men. It is slightly different in the women’s estate, the children and young people’s estate and the immigration and removal estate. It’s not non-existent, but it is certainly an acute need in the adult male estate.

The other element that is really important is primary care assessment.  We have made a lot of investment in NHS England to ensure our health information, our management of people’s patient records, and the parity of esteem of the standards that we have brought in for NHS England for mental health also exist for patients within the prison estate.  That is really important because there is quite a low expectation within our prisons, and particularly within our immigration and removal centres, about what is appropriate and what is justified.  Some of the work that we have also been doing, with our local commissioners and our local governors, is challenging the status quo of mental health services and asking: is that right? For example, a prison like HMP Wandsworth has a very high level of foreign nationals, and a very high level of movement within the prison.  Is it perhaps different for HMP Downview, a women’s prison which is growing in size and which is struggling to have the right state and structure physically for mental health to be supported?

I will now round off and give you a few headlines particularly on the priority of deaths in custody and clinical assessment. It is slightly different from the overviews I have given in the past, when I would talk about the work that we have done, particularly around children and young people and screening for neuro-disabilities, or the services around sexual assault and sexual abuse.  I could give you the long list.  But I have steered away from that today because the White Paper, which is probably days or weeks away, is very much the time for mental health services to look at opportunity and innovation, and early intervention.  I want to be quite brave and say: could we not change the sentencing options around mental health and substance misuse in the community, to reduce the prison population and to shift some of the focus onto the services that are in the community for some of our most vulnerable men and women?

From NHS England’s point of view, I came this morning from the Crisis Care Concordat third annual event where the Health Secretary Jeremy Hunt gave his first public address on mental health publically and I am really pleased to say that prisons and criminal justice were part of his address, as part of the parity of esteem.  The police say that we have worked very hard to support that intervention.  The challenge for this room and for the debate today is how we maintain that level. We have had no new investment on mental health.  We have restructured some of our healthcare services to prioritise mental health provision.  But I hope we can actually increase the commissioning and the funding around some fairly new opportunities and new dynamics. I would like to say one last thing about deaths in custody if that’s ok.  Fiona.

Fiona Grossick I am the quality and lead nurse for health and justice in Kate’s team and the main objective of my role is to support the reduction of deaths in custody. We have a death in custody working group where we have recently done a review of self-inflicted deaths with some recommendations which we are taking to our clinical reference group. The main recommendations very much fit with what Kate said.  It’s around ensuring that consistent and comprehensive healthcare assessments are undertaken within those very early days on entry into prison, how to make sure that that is consistent across the whole estate, and that the right needs are identified, and met, to enable the rehabilitation of the offenders.  We are also doing a key piece of work around medicines optimisation, to ensure that there is continuity not just of care but of medication, as people enter into prison, and then back on release into the community, and to ensure that the GPs records all match up so that there is easy access for information. 

Lord Ramsbotham thanked Fiona Grossick and introduced Professor Huw Williams, who he saw regularly as Chair of the Criminal Justice and Acquired Brain Injury interest group. There was no-one who knew more about neuro development than Huw Williams.

Professor Huw Williams thanked the chair for his introduction. ‘I guess it would be useful to give a bit of background as to why brain injuries and neuro-developmental disorders are important.  Also in context with what Kate has described as the need for integrated services, and the need to pick up and screen early what the issues are, so that we can then hopefully try to contain the people who will be more at risk within the systems that they are in. Bear in mind that many of the people who end up in the prison system have had very adverse lives, from childhood all the way through to teenage years, and then they have tended to develop psychological and psychiatric problems, particularly traumatic stress type disorders from those backgrounds and brain injuries, and then may well be self-medicating for those issues.  So everything is in a bit of a combination for these people.  It is useful to try to come up with interventions, and the earlier the better.

As Lord Ramsbotham has mentioned, the rate of traumatic brain injury in the prison population may be quite high. Within the general populations we expect one in ten people to have had some kind of brain injury.  Most of those, 80%, would be mild injuries and another 20% might be moderate to severe injuries. In the prison population it is more like 50-70% of people who have had some kind of brain injury, and 20% of the population would have had a moderate to severe brain injury. In other words, something that has changed the way their brain functions.  Another 30% would have had quite a number of mild injuries that change the way the brain functions.

If you think about things like what’s your brain useful for? It’s about things like being able to pay attention, which is what you are all doing now - thank you very much for doing that, and not being too distracted by the bells - and being able to hold your emotions in, to think things through, and to plan ahead. So brain injuries tend to impair the parts of the brain, particularly the frontal lobes, that are important for initiating, planning, thinking things through, and also holding yourself back, and not doing something that might get you into trouble.

Obviously these brain injuries happen in various ways.  Typically in people in prison it is through violence, and falls on drugs and so on, and typically they happen young.  Typically many of these people have suffered brain injuries as children and young adolescents.  We know that a brain injury relatively early in life is associated with an increased risk x4 in adulthood of mental health problems and of ending up in the prison system.  So if you take one thing away, please think about whether a brain injury has happened in somebody’s life, and what increased risk that has for their mental wellbeing, paranoia, depression, and anxiety.  Suicidality is increased in people with brain injury as well, and unfortunately violence and crime.

There’s a story about how the injuries in the young happen, say for someone between five and ten. It may then start to be seen as a problem in school; they may start to be seen as  having behavioural issues.  By the time they are in their teens they start to end up in the criminal justice system. So there is something we can do earlier, if we integrate things more. But many of the people who have ended up in the criminal justice system have these issues which then complicate the interventions that might be provided to them.  They may find it harder to use the CBT that has been provided, to use the problem solving skills, and all the systems that thankfully have been provided.  But it might be harder for them to benefit from those interventions.  Unfortunately brain injury has been associated with 2-3 times higher levels of resettlement problems too. It is in the constellation of factors; there are the adversity issues and the drug misuse as well.  But brain injury is an important factor, because without your brain to help you think things through, remember what to do and all the rest of it, then you are not going to be a good advocate for yourself, and you are not going to remember what to do, when to do it, and why not.

There has been really good progress in the youth estate, looking at assessment of neuro disability, autism, ADHD, brain injury and so on. There are much better systems for picking these things up which has made it much easier to then bring about multi-agency working. There are some projects which are putting link workers into prisons to help prison staff to screen for these issues, and where appropriate to help them to resettle people after prison, and that has been quite effective and is being expanded in a number of areas.  There is promise in doing that, and promise in working more effectively around looking at brain injuries and other neuro-disabilities. 

At the moment there is an excellent opportunity with a White Paper coming up. Tomorrow there is going to be the launch of the Justice Committee report to the Lord Harris review on suicide and deaths in custody of 18-25 year-olds. I wouldn’t want to prejudge what is in the report, but I imagine it will be very interesting reading from the point of view of anybody interested in how the prison system could be involved to have more of a rehabilitation focus and to bring about change in these relatively young people’s lives – the people who end up in prison tend to be young – and in so doing also to help with the public finances.  We have looked with the Centre for Mental Health at the cost of brain injury in association with crime. A typical 15-year-old, one of the 90% who has had a not particularly severe brain injury, will cost £85,000 each in terms of their management and loss of their productivity at school or wherever, and the effect on parents.  Unfortunately there is another £65,000 worth of cost from the increased risk of crime.  If that individual is already in contact with the criminal justice system, the extra cost is something like £250,000.  If you start to roll that out across the system, in terms of the numbers involved, that is a lot of money over a long period of time.  Earlier and better, more integrated, multi-agency interventions would probably save a lot of money.

As I said it’s a very good time to try to see how these long-term savings could be accrued, not just because the Justice Committee is bringing out a very interesting report tomorrow, but because the NICE guidelines for managing mental health issues are also currently out for comments.  It would be very helpful for this group to send comments in to that. They cover where we can screen more effectively and that does include brain injuries, and what interventions could be used, and where to take these issues into account.  At the same time another initiative that Kate seems behind is complex needs in young people in the youth estate, with new indications of improved services. In the Scottish Parliament too there is another report being launched in November on traumatic brain injury in the prison systems in Scotland which might give some very useful areas which we could invest in in terms of screening and earlier intervention.’

Lord Ramsbotham thanked the last speaker and welcomed Kimmett Edgar from the Prison Reform Trust.

Kimmett Edgar thanked the Chairman for his introduction and said he would be speaking specifically about segregation and mental health.  ‘Segregation is harmful to mental health. We know a lot about its effects – increased anxiety, depression, insomnia, risk of self-harm. We also know why it has these effects – the social isolation, the lack of activity, the powerlessness it imposes.  The South African poet, Breyten Breytenbach quoted a prisoner who said that while no one should break the law, neither should the law break a person.

Let me say something about safeguards.  It is NOMS’ policy that segregation should not be applied to prisoners who are: being assessed for, or awaiting transfer to, a secure hospital; at risk of self-harm; taking prescribed anti-psychotic medication, or within four weeks of the start of de-toxification.

On admission to a segregation unit, people must be screened by a health care professional, whose duty is to: “assess the physical, emotional and mental well-being of the prisoner and whether there are any apparent clinical reasons to advise against the continuation of segregation.”  Through the ‘safety screen’ the policy encourages medical experts to use their discretion, thus allowing interpretations of who should be protected from segregation which are wider than the four criteria above.

A manager said to us:  “Prisoners go stir crazy through the isolation. Mr Evans – he can’t do bang-up. It’s time to ruminate, and his behaviour goes off. He’s smashed cells; he won’t shower; he’s not looking after himself. Staff identified that he wasn’t quite right. A cycle of him being more and more withdrawn. He won’t engage with staff, so he gets less and less. Staff pull away. That can’t help but affect his mental health.”

Our report Deep Custody, which I co-authored with Dr Sharon Shalev, was based on a study made possible by support from the Barrow Cadbury Trust. We visited 14 segregation units, and interviewed 67 segregated prisoners (17 of whom were in close supervision centres) together with unit officers and managers.  Over half of the individuals interviewed (33/63) reported that they had three or more of the following: anger, anxiety, insomnia, depression, difficulty in concentration, and self-harm.

One said: “All my mental health problems start kicking in – been really depressed listening to all the voices a lot more, just stuck in my thoughts.”  Another described the lack of activity:  "Some days are slow. It’s boring. There’s nothing to do. If you can’t read, you just sleep; then you can’t sleep at night."

Our report described the typical regime in a segregation unit as impoverished. Confinement within a single cell for 22 hours a day, broken by meals, a phone call, some exercise though not up to UN standards, and a shower.  Few have access to education or the gym, and almost none have any association with others.

The policy is very clear. It states that segregation should not be used for people at risk of self-harm unless there are exceptional circumstances, including a risk of violence to others. We found that people whose segregation was directly related to violent behaviour on the wings were more likely than other segregated prisoners to cope poorly with segregation and to have problems with self-harm.  So the very people for whom segregation was being used were the most likely to be harmed by that experience.

One man, who was segregated following an assault on an officer, said the isolation caused him to self-harm. He explained:  "I had alcoholic parents who used to lock me in a room and go out drinking. It’s happening again in here.” The three components inherent in segregation - social isolation, inactivity, and powerlessness - combine to create a toxic environment, known to have negative effects on health and wellbeing. 

So what of the mental health care?  In some of the prisons we visited, mental health in-reach teams were closely involved in the segregation unit, provided personal support to prisoners, and contributed to segregation reviews, self-harm support plans and other case conferences. In other prisons, mental health professionals conducted cursory (if any) consultations with prisoners; showed deference to officers’ judgments about risk of self-harm and indeed mental health; and demonstrated a lack of concern about privacy and medical confidentiality.

The service that medical staff should provide to segregation units is clearly defined in international standards. The UN Standard Minimum Rules require medical staff to: have no involvement in decisions to punish people in custody; visit segregation units daily and provide mental health support as needed;  report immediately any adverse effects of segregation on the physical or mental health of any prisoner and advise if segregation should be stopped or the conditions changed for the person's health; and recommend changes to the segregation of a person to ensure that the isolation does not exacerbate his or her mental health.

Some examples of good practice: in one or two of the prisons we visited, a psychologist was working with officers on reflective practice – to help staff think about situations to learn how they might have handled it better. There was a weekly multi-disciplinary meeting in one prison where the needs of particular residents could be discussed and a consistent plan agreed. But these were exceptions I am sorry to say.

So what should be done? Firstly, and most obviously from what I have said, use segregation less, for fewer prisoners and for shorter periods of time. Make better use of other options to resolve the problems for which segregation is currently imposed. Secondly, training and support for prison health care staff should help them to become more resilient and pro-active in their roles, so that they consistently put the patient's therapeutic needs first. They should object more often and with greater authority to the segregation of people whose mental wellbeing is being damaged both on admission and when it's clear that continued segregation is causing deterioration in health. Thirdly, reduce the harms of segregation. Nothing in official policy states that segregation units must impose inactivity, isolation and powerlessness - but these are the conditions that lead to a deterioration in mental wellbeing. Practice must change. All segregation units must work out how to deliver purposeful activities, social interaction, and an increase in autonomy for the segregated person’.

Lord Ramsbotham thanked Kimmett Edgar and mentioned inspection visits he had recently undertaken to prisons in Abu Dhabi and Dubai, and three years previously in Kenya.  In Abu Dhabi there had been one suicide since 1995. He had learned that one of the reasons was that all landings were locked but no cells. So that by day all prisoners had free access to all facilities, and only slept in their cells.  He had mentioned this to Liz Truss, the Justice Minister.  The contrast with our prisons, with no activities and a soaring suicide rate, was instructive.  He opened the floor to questions.

Andrew Selous MP wanted to know clinicians’ views about using other prisoners, families and friends, to assist individuals on a preventative basis. If prisoners received bad news inside, they could suddenly plunge. He had read a user voice report about a prisoner setting up an informal counselling service on the wing.  He wondered if we were missing a trick in not using prisoners and their families more, in this sort of way.

Kate Davies said that NHS England had been insistent on the need to commission peer support and a lived experience approach.   There were some great models already. But it was important to ensure this was not seen as cheap labour, and was properly funded.  She was pleased to announce that, thanks to Revolving Doors, her department was now commissioning peer support as part of the core service specification for liaison and diversion. There was plenty of evidence that this could make all the difference for individuals.

Families were key, but it should be recognised that often family was part of the problem for many prisoners. Particularly for women and the children and young people’s estate, but also increasingly for the adult estate, sexual and physical abuse had been a significant issue. She hoped that the new reception centres which featured in the White Paper would help to provide better contact and support. She also hoped that there might be the funding for a block contract to commission the Samaritans, as confidentiality was a key issue.

Professor Huw Williams agreed that the facility to share stories safely could enable prisoners to process what was happening to them. However this required proper training and supervision, and would need investment. He mentioned some promising work along these lines with young people in New Zealand. As regards involving families, he shared Kate Davies’ concerns about some of the problems, as well as the benefits, to this approach, mentioning one young offender who had become suicidal at the prospect of being returned to his mother, with whom he had had major issues.

Kimmett Edgar mentioned one segregated woman he had interviewed who had told him that because no-one seemed to care whether she lived or died, neither did she.  He stressed the value of Samaritan-trained Listeners, whose care could convince prisoners that their lives mattered, and who had saved many lives in prisons.

Lord Ramsbotham mentioned the success of the Shannon Trust and the Toe by Toe literacy scheme, also involving peer mentors. Whilst in Kenya, he noticed that prisoners were teaching others all sorts of skills.  He also commended Safe Ground and the Prisoners’ Advice and Care Trust, for their work with families – especially in the Visitors Centres.

Kate Parradine from Women in Prison sought the panel’s views on sentencing alternatives, given that the key was to reduce the numbers of those suffering from mental ill health in the prison population, and especially in respect of the rise in self-inflicted deaths.

Kate Davies said she would love the White Paper to set a target of reducing the prison population by 40%, especially in the women’s estate. She noted the success in reducing the numbers of young people in custody over the past four years. She also mentioned so-called generational offending, the impact of family patterns. Magistrates felt their hands were tied, particularly around property offences. New justice and legal reforms around sentencing, giving a strong message, were needed.  Alternatives to custody for offending involving mental health and drugs and alcohol issues had been around for decades, but the approach had been scattergun rather than strategic, depending on funding and leadership.  60% of the prison population, especially in the women’s estate, were still serving less than six months, often repeatedly.

Professor Huw Williams agreed. He was pleased that more trauma-focused interventions were being used for women who ended up in the secure estate, but that often involved being away from children and families.  Many studies had indicated the high proportion of childhood abuse found amongst these women. A recent initiative in Wales involved a clinical psychologist in the sentencing of young persistent offenders, which had assisted both offender managers and also magistrates and judges to take a longer-term view.

Kimmett Edgar said how noticeable the presence of mental health issues were on segregation units, especially in the sounds, for instance of women screaming to silence the voices in their heads. One reason such individuals often ended up in segregation units was that the wing was so ill-equipped to care for them. This made it doubly important to divert such people from custody, wherever possible.

Kate Davies added that it was just as important for colleagues working in the health service to understand about working with offenders in the community.

Lord Ramsbotham said he was glad that this had been mentioned.  Research had revealed the disappointingly low number of clinical commissioning groups who realised that they had a responsibility for offenders on probation. Additionally there was some confusion over the Community Rehabilitation Companies and their relationship with sensitive information.

Kate Green MP noted that in her constituency, in Greater Manchester, there was shortly to be an elected mayor, with health and justice (though not prisons) amongst their responsibilities, and a new combined authority. This made it imperative that there should be greater clarity in the changing landscape, between NHS England and the MoJ, about who was responsible for commissioning what, against a backdrop of huge pressure on community mental health care services generally. She had heard a lot in Manchester about the opportunity for the new mayor to take responsibility for health and social care, and mental health as part of that, but she had not heard very much about the interface with the justice system.

Kate Davies said that she was very nervous about this. Devolution was a great opportunity, but there was a long way to go before appropriate pathways of care were clarified.

Sara Hyde, from Working Chance, wanted to draw attention to the previous week’s murder in Pentonville prison, together with the distressing number of self-inflicted deaths in our prisons. What more could be done to change things?

Fiona Grossick agreed that immediate action was needed to address this. There were a number of work steams in NOMS around self-inflicted deaths and self-harm at present. It was recognised that urgent work needed to be done.

Kate Davies added that there were new policies on ligature points, constant supervision, and lessons learned from reports, and governors, ministers and healthcare providers were being lobbied. At the moment conditions in prison, and the sentencing of some very vulnerable people, had created a perfect storm in respect of deaths in custody.

Lord Ramsbotham added that the conclusion to his prisons inspectorate report entitled ‘Suicide is Everyone’s Concern’ was that full, purposeful and active days for prisoners were the best antidote. He concluded by thanking all present, especially the speakers, and giving notice of an upcoming joint meeting with the APPG on Human Rights, about the use of solitary confinement, to be held on Wednesday 2nd November.