Cabinet Secretary for Justice

From:Mike Ewart

Chief Executive, SPS

1December 2008

Copy to:Annex A

PUBLICATION OF HMIP THEMATIC REPORT – ‘OUT OF SIGHT - Severe and Enduring Mental Health Problems in Scotland’s Prisons’

Purpose

1.To comment on HMIP’s Report on HMIP Thematic Report – ‘Out of Sight - Severe and Enduring Mental Health Problems in Scotland’s Prisons’ which is scheduled to be published on Thursday4 December 2008.

Timing

2.Routine.

The Report

3.The SPS welcomes this report which is a fair reflection of the current arrangements and challenges for managing prisoners suffering from severe and enduring mental health problems.

The main finding from the Thematic Inspection was that ‘The use of imprisonment is inappropriate for people with severe and enduring mental health problems. Their primary need is their mental health and the appropriate place to address this is a hospital.’

The inspection focused on six specific areas relating to mental health issues in Scotland’s prisons, the finding are summarised below (4 to 9):

The scale of severe and enduring mental health problems in Scotland.
The processes involved.
The impact on the prison.
Prison-based and community interventions.
Issues on release.
Reasons for use of prison for people with severe mental health problems.

4.Prevalence:The report indicates that there is a 4.5% prevalence amongst prisoners held in Scotland’s prisons suffering from severe and enduring mental health problems, with 323 reported. This figure excludes HM YOI Polmont, if there is a comparable prevalence at Polmont that would add a further 31 to this figure resulting in anapproximate total of 350 prisoners.

However, HMIP also reports that ‘A very large proportion of prisoners have some form of mental health problem. Of these, only a small proportion have severe and enduring mental health problems.’

Therefore, the scale of mental health problems in Scotland’s prisons is potentially significantly higher.

The most common types of severe and enduring mental health problems in Scottish prisons are schizophrenia and bi-polar affective disorder. There are also a significant number of prisoners with a personality disorder. The majority of prisoners with mental health problems also have substance misuse issues.

5.Processes: The main ways of identifying mental health problems are through observation by prison staff and other workers during reception and induction processes, observation by other prisoners and through self-referral. There are also information sharing issues, HMIP reports that:

‘There are a number of gaps in the identification of mental health problems and needs. These include: problems with the transfer of information from courts and the community; difficulties for prisoners in disclosing issues; problems with processes and operational issues; and problems with staff being able to identify issues. These difficulties can mean that some prisoners with severe and enduring mental health problems may not access assessment and referral.’

6.The impact on prisons: Prisons are not a suitable environment to address severe and enduring mental health problems. Although prisoners suffering from these conditions have committed offences the prison environment could potentially cause real harm to these individuals and their conditions.

There is also an impact on the general running of a prison as this group is both resource-intensive and potentially a cause of disruption. This can impact on prison staff, the majority of whom are not trained to deal with the physical and emotional demands required to manage the difficult behaviour and respond to the complex needs of this group of prisoners.There is a further impact on other prisoners as resources that could be used for other work is absorbed dealing with these issues.

7.Prison-based and community interventions: Once identified, there is a range of treatments, interventions and supports available in prisons for prisoners identified with severe and enduring mental health problems, this includes access to a psychiatrist, medication, and input from a mental health nurse. This however varies across the prison estate.There aregeographical variations and capacityof support servicesavailable in the community which effects throughcare arrangements.

8.Issues on release: HMIP reports that there is some work being carried out in prisons to assist prisoners in preparing for their release and in accessing support. HMIP recognised that some of the problems experienced on release relate to aspects of prisoners’ lives in the community: chaotic lifestyles; drug and alcohol use; lack of access to economic and social participation; and stigma.

9. Reasons for use of prison for people with severe mental health problems: Apart from having committed offences the only other reason for holding prisoners who are suffering from severe and enduring mental health problems in prison is a lack of suitable support services in the community.

10Recommendations: HMIP makes 20 recommendations, the majority of which are accepted by the SPS. These are summarised in Annex B along with the SPS position.

Publication

11.SPS Communications will provide a media handling plan and publish Action Plans on our website in the usual way.

Mike Ewart

Chief Executive

1 December 2008

Room 341

Calton House

Ext. 48522

Annex A

Copy List: / For Action / For Comments / For Information
Portfolio Interest / Constit Interest / General Awareness
Cabinet Secretary for Justice / X
Minister for Community Safety
DG Justice and Communities
SPS Executive Group
PS/SPS
Mr Fox, SPS
Communications Justice

Annex B

HMIP THEMATIC REPORT – OUT OF SIGHT

Severe and Enduring Mental Health Problems in Scotland’s Prisons

HMIP made 20 recommendations which are summarised below along with proposed action by SPS.

SPS will:

1.Review and update its current mental health strategy, “Positive Mental Health”, and sustain and develop its health care standards for mental health care, its systems for audit and monitoring quality of care, and its commitment to service improvement (Recommendations 2, 8, 9 and 20);

Recommendation 2:Current provision in prison is varied and inconsistent and dependent on the resources available to individual establishments.

Recommendation 8:Minimum standards of treatment, intervention and support should apply to all prisoners with severe and enduring mental health problems, regardless of where they are located, and staff should have relevant training and be provided with information to ensure that they are able to deal with issues arising.

Recommendation 9:Prisoners with severe and enduring mental health problems must have access to a regime which meets their needs.

Recommendation 20:A wide range of conclusions is highlighted at the end of each chapter of the report. All organisations involved in the care, treatment and management of prisoners with severe and enduring mental health problems should take account of these conclusions and develop their own practice to address them.

2.Work to mitigate the worst effects of overcrowding on the most vulnerable people in prison custody, including those with severe and enduring mental health problems, through the use of, for example, mental health and suicide risk assessment, individualised Case Management and Care Planning (Recommendations 4, 9, 11, 12 and 18);

Recommendation 4:Overcrowding affects people with severe and enduring mental health problems.

Recommendation 9:Prisoners with severe and enduring mental health problems must have access to a regime which meets their needs.

Recommendation 11:The number of places likely to be required in a high dependency setting and the best means of meeting the needs for these places should be established.

Recommendation 12:The practice of using segregation units to house prisoners with severe and enduring mental health problems must stop and alternatives for holding these prisoners for long periods of time should be found.

Recommendation 18:The provision of mental health specialist staff varies widely across prisons. Some prisons have a full time resource, others have little or none. Overcrowding in particular has led to increased pressure on healthcare staff generally. Mental health specialist staff and resources should not be diverted to other duties at the expense of the provision of mental health support.

3.Promote the multi-disciplinary mental health team system (MDMHT) as a positive feature of Scottish prisons, and audit servicedelivery to ensure that the system operates effectively in all prisons (Recommendations 6 and 7);

Recommendation 6:All new cases where severe and enduring mental health problems are suspected should be brought to the Multi Disciplinary Mental Health Team, and should be regularly and systematically reviewed at subsequent meetings.

Recommendation 7:The input of non-healthcare staff should be sought as part of the assessment process in all prisons.

4.Work toward formal integration of the Care Programme Approach (CPA) to mirror NHS practice: and continue to invest in Case Management and Care Programme processes, thatimprove ways to prepare prisoners with all types of need in order to re-integrate them successfully into community life after release (Recommendation 17);

Recommendation 17:A formal standardised multi agency planning process should be put in place to identify the release needs of prisoners with severe and enduring mental health, and to ensure that arrangements are made for continuity of care.

5.Sustain programmes that support its commitment to Care and Opportunity, including greater involvement of prisoner-patients in discussions about their recovery and decisions about their care; and work with partner agencies (local authorities, NHS Boards and voluntary sector providers) to secure wider availability of independent advocacy services (Recommendations 13 and 14);

Recommendation 13:Prisoners should be given the opportunity to identify their own needs and provide feedback.

Recommendation 14:Prisoners with severe and enduring mental health problems should be made aware that they have the right to access advocacy services which should be available and understood.

6.Work with NHS colleagues to arrange prompt transfer of those people with severe and enduring mental health problems admitted to prison asa “Place of Safety”; continue to assess new admissions to prison and referrals to MDMHTs to identify prisoners with acute mental health difficulties that require transfer to hospital; work with Police, Courts and NHS partners to improve information systems that will aid assessment on admission into prison ; develop better systems of referral; and audit and monitor the flow of people with severe and enduring mental health problems who require hospital care (Recommendation 1 and 5);

Recommendation 1:Prison is not the most appropriate environment for individuals with severe and enduring mental health problems.

Recommendation 5: The identification of severe and enduring mental health problems in the Reception is not consistent and coherent. An early, systematic, exploration of mental health issues should take place in an environment which supports and enables the disclosure and identification of severe and enduring mental health problems

7.Audit the health care facilities available to conduct psychiatric assessments; and,in partnership with the Forensic Network,look to a future Prison Psychiatry Special Interest Group to develop standardised service and referral criteria (Recommendations 5, 15 and 16);

Recommendation 15:Psychiatrists need to have adequate access to prisoners with severe and enduring mental health problems, or to appropriate facilities to conduct assessments.

Recommendation 16:A clear and well understood policy regarding the criteria used by psychiatrists in determining whether or not a prisoner with severe and enduring mental health problems should be transferred to hospital should be communicated to all staff.

8.Through our MDMHT Case Management process endeavour to meet the needs of offenders with severe and enduring mental health problems who are in custody and not eligible for hospital care, ensuring they have an individual and agreed Care plan in place (Recommendation 1);

Recommendation 1:Prison is not the most appropriate environment for individuals with severe and enduring mental health problems.

9.Work withexternal partners and academic institutions to identifyprevalence and levels of need within prison; and continue to work with outside agencies to offer services and support to vulnerable prisoners to assist them in addressingconsequences of their past abuse (Recommendation 10);

Recommendations 10:Structured and sustained support should be provided to both male and female prisoners with severe and enduring mental health problems who are survivors of childhood sexual abuse.

10.Minimise the use of the segregation unit as a setting for acute management of offenders with severe and enduring mental health problems, recognising the constraints of accommodation made necessary by overcrowding:(Recommendation 12);

Recommendation 12:The practice of using segregation units to house prisoners with severe and enduring mental health problems must stop and alternatives for holding these prisoners for long periods of time should be found.

11.Sustain its commitment to the most effective use of health care staff to ensure that prisoner needs are met; and through our Nurse Training and Learning Strategy and Competency Framework for Nursing Staff ensure healthcare staff are equipped with the knowledge and skills to deliver appropriate care within the prison environment (Recommendation 18); and

Recommendation 18:The provision of mental health specialist staff varies widely across prisons. Some prisons have a full time resource, others have little or none. Overcrowding in particular has led to increased pressure on healthcare staff generally. Mental health specialist staff and resources should not be diverted to other duties at the expense of the provision of mental health support.

12.Encourage all staff to be aware of, and informed about, people with mental health problems. The SPS invests at all levels of the organisation in mental health awareness and training, incorporating suicide risk management, which is principally a mental health and distress-related subject. The majority of prisons have Mental Health First Aid Trainers on site who are required to deliver a set number of training courses. All establishment staff and a range of headquarters staff are expected to undergo Suicide Risk Management Training.

Recommendation 3:There is no shared understanding across SPS about the nature and scale of severe and enduring mental health problems. This lack of shared understanding should be addressed.

Recommendation 19:Structured training and support should be provided to prison staff working with prisoners with severe and enduring mental health problems.

13.The following recommendation is not accepted:

Recommendation 11 (not accepted) The defacto nature of the HMPrison, Barlinnie Unit is a perception largely of Barlinnie and the West of Scotland prisons. It is not the case in actual fact for other prisons. An ideal regime in any prison of sufficient scale would be to have an area for people with higher than average health and social care needs. Overcrowding results in a lack of opportunities to re-create a similar environment in other prisons.

Recommendation 11:The residential care unit in HMPrison, Barlinnie is starting to become a defacto national resource. The number of places likely to be required in a high dependency setting to that provided in the Barlinnie Residential Care Unit, and the best means of meeting the needs for these, should be established."