November 23, 2005: Jailing the Mentally Ill

'Trouble Inside: Responding to the Mental Health Needs of Men' is a new Prison Reform Trust (PRT) report. It concludes that many men who have serious mental health problems slip through the net of care and end up in the prison system. Up to three-quarters of men in prison suffer from two or more mental disorders; about one in ten have a functional psychosis; and an estimated 3000-3700 prisoners at any time have problems sufficiently serious as to require urgent transfer to secure NHS facilities.

The report is a comprehensive review of how mentally ill offenders reach prison and are treated there. It shows that prisons are ill-suited for managing mental illness, staff have profound difficulties coping with the complex needs of mentally ill offenders and the mental health of many deteriorates as a result of the stressful conditions in prison. It considers the needs of specific groups, including people who are deaf, ageing or from a minority ethnic background. There is a marked failure to address their particular needs for mental healthcare as these offenders may also face exclusion, discrimination, misdiagnosis and neglect in prison.

The report is published at a time when the NHS is close to taking full responsibility for healthcare in all public prisons in England and Wales. Despite Department of Health commitments, people in prison often receive treatment which fails to meet anything like an equivalent standard to the quality of healthcare outside. In our overcrowded, under-resourced jails, the gap between prison and community health service is widening. Equivalence of mental healthcare is supported by heroic efforts by health staff, but is unattainable in present conditions because of the high psychiatric morbidity of prisoners, the low level of existing services in prison, the pressure of overcrowding, separation from families and the loss of continuity of care.

According to PRT director Juliet Lyon:

“Many men in prison are mentally ill, much of their offending is a public health concern, not a criminal justice one. The solution is not investing in more prisons, but fixing the gaps in mental health care, drug treatment and diversion from police stations and courts to treatment. The use of prison to warehouse people for their mental illness is a criminal use of our justice system, it makes ill people worse and disrupts the rehabilitative work of prisons. If you had to invent a way to deepen mental health problems and create a health crisis, an overcrowded prison, and particularly the bleak isolation of its segregation unit, would be it.”

The report calls for action:

• The National Service Framework for Mental Health must do more to improve diversion and liaison services.
• Government should require Health and Social Care Commissioners to include offenders in their plans and provide the funding for their needs to be met.
• Mental health services for offenders need urgently to be addressed and matched to the specific needs of particular groups including the aged, those who are deaf or who have learning disabilities.
• The principle of equivalence of health services within prison must be supported by more than rhetoric. The level of funding must be matched to the level of need, with clear lines of accountability and the same inspection and monitoring regimes as exist in the community.
• The principles of patient involvement and representation are still comparatively new in the health service and groundbreaking in the prison system. Having a say is important for people’s mental health and well being and consultation of this kind could have a positive effect on prison culture.

The PRT also notes that  20% of men entering custody say they have previously attempted suicide. According to the Government’s Social Exclusion Unit, more than 50 prisoners commit suicide shortly after release each year. A significant number of prisoners suffer from a psychotic disorder. Seven per cent of male sentenced prisoners have a psychotic disorder; 14 times the level in the general population. A high proportion of prisoners have been treated in psychiatric hospitals - 20% of male and sentenced prisoners have previously been admitted for in-patient psychiatric care. Research also suggests that prisoners are twice as likely to be refused treatment for mental health problems inside prison than outside.

Prisoners with severe mental health problems are often not diverted to more appropriate secure provision. The Chief Inspector of Prisons has estimated, based on visits to local prisons, that 41%t of prisoners being held in health care centres should have been in secure NHS accommodation. Research has found that there are up to 500 patients in prison health care centres with mental health problems sufficiently ill to require immediate NHS admission. The government has committed itself to a programme of standardising and improving court diversion schemes across the country but to date little action has taken place.