Tim Exworthy

Variations in prison mental health services in England and Wales.

In responding to high levels of psychiatric morbidity amongst prisoners and recognising earlier poor quality prison mental health care, prison mental health in-reach teams have been established in England and Wales over the last decade. They are mostly provided by the National Health Service (NHS), which provides the majority of UK healthcare services. Over the same period, the prison population has grown to record levels, such that prisons in England and Wales now contain almost 90,000 of the worlds overall prison population of over 10 million people (roughly the size of Paris or Istanbul). This study provides an overview of mental health in-reach services in prisons in England and Wales, including variations between them, through a telephone survey of senior staff in all prisons and young offender institutions in England and Wales. 73% of prisons took part; of them 13% had no in-reach team at all (usually low security establishments) and the majority of services were run by NHS teams, usually according to a generic community mental health team (CMHT) model rather than other specialist models. Team size was unrelated to prison size. Each nurse covered around 500 prisoners, each doctor over 3700. Many provided few or no healthcare cells and 24-h psychiatric cover (including on-call cover) was uncommon. Despite developments in recent years, mental health in-reach services still fall short of community equivalence and there is wide variation in service arrangements that cannot be explained by prison size or function. The aim of community equivalence has not yet been reached in prison healthcare and a more sophisticated measure of service improvement and standardisation would now be useful to drive and monitor future development.

The development of equivalence as a mechanism to improve prison healthcare

Over the past two decades landmark reforms havetaken place in England and Wales to moderniseprison mental healthcare. Spearheaded by thereport Patient or Prisoner?, subsequent Departmentof Health guidance The future organisation of prisonhealthcare and Changing the Outlook, brought thestate of prison healthcare to the front of the politicalagenda with two essential principles: continuity ofcare and equality.

Mental health care for foreign national prisoners in England and Wales

Abstract Background: The foreign national prisoner (FNP) population in England and Wales has disproportionately increased in size, but mental health research in this group has been limited. Aims: Define the FNP group, review their understood characteristics, identify service challenges and make onward recommendations. Methods: A literature search of Pubmed and Google Scholar was undertaken. Relevant articles/reports were identified and reviewed. Results: Many FNPs face challenges: isolation (with limited family contacts); language barriers; difficulties accessing services; prejudice and discrimination; active legal issues regarding immigration. These are compounded by poor quality interpreting services, institutional barriers including racial assumptions propagated by forces of legislation, the disrupted local care pathways and common mental health problems (including post-traumatic stress disorder, depression and anxiety). Pre-detention trauma, self-harm and suicide are over-represented. Conclusions: Further prevalence and unmet needs research is urgently required. A validated screening tool could assist identification and service access for FNPs with mental health problems. Services providing relatively inexpensive interventions specific to the needs of FNPs (e.g. narrative exposure therapy) should be piloted.

Integration and offender mental health

Integrated care can introduce seamless coordinated pathways that are focused around the individual needs of patients, helping to prevent missed opportunities for intervention. Within offender healthcare, sequential funnelling through designated areas where screening can take place, along with co-location of services, lends itself to integrated working, at least in theory. However, within the offender healthcare pathway, service fragmentation and autonomous, disconnected (often referred to as siloed) working, has historically been the norm. If commissioned and designed to ensure and incentivise connections between services, whilst developing high quality service-focused research activities, pathways could enable clinical and social interventions, and outcomes, on a public health scale for these highly morbid populations. As such, offender healthcare offers a real opportunity to model integration for wider introduction across other health and social care areas. Discussed within is the call for integration, its concept, and its role within offender healthcare.

Mental health in-reach in an urban UK remand prison

PURPOSE Prison mental health in-reach teams (MHITs) have developed in England and Wales over the last decade. Services have been nationally reviewed, but detailed descriptions of their work have been scarce. The purpose of this paper is to describe the functions of one MHIT in a busy, ethnically diverse, male remand prison in London, UK. DESIGN/METHODOLOGY/APPROACH Clinical and demographic data were collected for prisoners referred to the MHIT using a retrospective design over an 18-week period in 2008/2009 (n=111). FINDINGS Foreign national prisoners and sentenced prisoners were significantly under-referred. Most referrals were already known to community mental health services, although around a quarter accessed services for the first time in prison. Around a third presented with self-harm/suicide risks. Substance misuse problems were common. Although the MHIT had evolved systems to promote service access, prisoner self-referrals were limited. PRACTICAL IMPLICATIONS Foreign national prisoners require enhanced investment to improve service access. MHITs identify people with mental disorders for the first time in prisons, but better screening arrangements are needed across systems. An evaluation of multiple MHIT models could inform a wider delivery template. Originality/value - One of the first ground-level evaluations of MHITs in England and Wales.

Improving access to psychological therapies in prisons

ANDREW FORRESTER, FRANCES MACLENNAN, KAREN SLADE, PENELOPE BROWN AND TIM EXWORTHY, Forensic Psychiatry, South London and Maudsley NHS Foundation Trust and Institute of Psychiatry/King’s College London, London, UK; HM Prison and YOI Holloway, Parkhurst Road, London N7 0NU, UK; Forensic Psychology, College of Business Law and Social Sciences, School of Social Sciences, Nottingham Trent University, Nottingham, UK; Forensic Psychiatry, Institute of Psychiatry/King’s College London, London, UK; Forensic Psychiatry, St Andrew’s Healthcare and Institute of Psychiatry/King’s College London, London, UK

Influencing the care pathway for prisoners with acute mental illness

BACKGROUND Despite improved mental health services in prisons in England and Wales, there are often delays in transferring acutely mentally ill prisoners to hospital, particularly in the London area. AIM To establish whether clinical pathway interventions can reduce such transfer delays. METHODS Two clinical pathway interventions - one based in a medium secure forensic hospital and the other in a remand prison (pre-trial/sentence) - were independently introduced to manage referrals of prisoners with acute mental illness in London, UK. Time taken to transfer to hospital was measured for each and compared with the best available estimates for time to transfer prior to the new pathways. RESULTS Both interventions produced significant reductions in prison to hospital transfer times. CONCLUSIONS/IMPLICATIONS FOR PRACTISE The nature of the projects precluded ideal research design, but despite small sample sizes, provision of modestly funded small but dedicated elements of service to target the specified problem of transfer to hospital delays showed a significant advantage for such provision, whether hospital or prison based, psychiatrist or nurse led. Further research is now required to examine the whole pathway. More secure psychiatric beds may be required, at least in the short term, to support diversion policies and enable compliance with national policy directive, and to establish whether redesigned pathways can enhance treatment and behavioural outcomes for acutely mentally ill prisoners on a larger scale.

A right to be fat? A survey of weight management in medium secure units

Obesity is a significant problem among patients in mental health services, with implications for morbidity and mortality. This is particularly challenging in forensic services where patients often remain in hospital for prolonged periods, may be on higher doses of medication and often have less access to exercise opportunities. This survey was conducted to investigate weight management strategies in medium secure units (MSUs) and to identify potential barriers to effective prevention and management of obesity. More than half of the MSUs do not currently have an effective strategy for managing obesity, although most have a reasonable range of weight management options available. There is dissonance among clinicians about the ethics of restricting patients’ access to food in order to reduce obesity. Whilst more coercive strategies may prove challenging in terms of maintaining the balance with human rights, it is clear that hospitals need to rigorously pursue education and health promotion.

A gilded cage is still a cage: Cheshire West widens ‘deprivation of liberty’

The Supreme Courts recent judgment in Cheshire West has clarified, and broadened, the legal definition of deprivation of liberty, with the new definition reflecting the fact that human rights apply to everyone in the same way. The widely criticised Deprivation of Liberty Safeguards need to be replaced: recommendations for reform are set out.

The ‘Hybrid Order’: origins and usage

The hospital direction (Hybrid Order) was inserted into the Mental Health Act (MHA) in 1997 (Crime (Sentences) Act, 1997). It enables higher courts to direct hospital admission for offenders, whilst still imposing a prison sentence. The origins of the ‘Hybrid Order’ and its patterns of usage are examined. Comparisons are made with its Scottish equivalent, Section 59A of the Criminal Procedure (Scotland) Act 1995. Both the ‘Hybrid Order’ and Section 59A have been used infrequently. This may reflect the fact that they were strongly resisted on ethical grounds at their point of inception and that they force the psychiatrist into the position of ‘punisher’, rather than ‘treater’. Since the 2007 Amendment of the MHA in England and Wales which expanded the remit of the ‘Hybrid Order’ to include all legal categories of mental disorder, not solely psychopathy, its use has unsurprisingly increased – this article delineates the considerations that need to be given in its recommendation.