Prison population: mental health needs

Mental health services for individuals in prison: Service mapping

• Available support for the mental health of individuals in prison is multi-agency and multi-disciplinary. A mapping exercise found wide variation between prisons in NHS service size and configuration, with per prison resident input somewhat arbitrary from allied health professionals, psychiatry and clinical psychology professionals. Several prisons reported unfilled nursing vacancies and difficulties in recruiting staff.
• Providers stressed the importance of adequate transition planning and throughcare support to those leaving prisons, citing that limited support can have a detrimental impact on mental health and community reintegration.
• Multiple barriers to supporting the mental health of Scotland's prison population beyond those relating to service provision were identified, including barriers to information sharing and coordination between agencies supporting the care of individuals within prisons, between prisons and between the community and prisons.

Mapping exercise approach

NHS Scotland is responsible for the provision of healthcare including mental healthcare to those in prisons but it is recognised that other partners including SPS, prison-based social work teams and third sector organisations work together and independently to support the mental health of individuals in prison. A mental health services mapping exercise conducted in 2012 by the Forensic Network on behalf of the NPHN Mental Health Subgroup (2014) found that service provision in nursing and psychiatry was related to historical factors rather than a true assessment of need, and there was a serious lack of clinical psychology input. There has not been a national mapping exercise conducted since this time.

The aim of the present service mapping exercise was to understand current provision available to people across all of Scotland's 15 prisons as well as prison leavers. The mapping exercise was undertaken by the Forensic Network, selected for its experience in conducting the previous national mapping exercise and for its links with prison health centres in relation to the care of individuals who require transfer from prison to secure hospitals. Electronic proformas were sent to prison health centre managers and prison-based social work team leads across all 15 prisons for completion and return in September 2021. A 100% completion and return rate was achieved. To gather third sector input into the mapping exercise, the research team and the Forensic Network partnered with the Criminal Justice Voluntary Sector Forum (CJVSF), a network of over 30 third sector organisations working in criminal justice settings in Scotland. Input was gathered through proforma response and from a virtual discussion event hosted by CJVSF with attendance from organisations which support the mental health of individuals in and leaving prison.

Findings

Service size and configuration

Integrated primary and secondary mental health services are available in 13 of the 15 prisons in Scotland. In HMP Greenock and HMP Dumfries services are offered through primary care only. Mental health and substance use services are integrated in six establishments. In nine prisons these services are not integrated (NHS Tayside prison mental health services, serving HMP Perth and HMP Castle Huntly, were reported to be in the process of integrating mental health and substance use services) though work closely and collaboratively.

Service staffing, according to number of qualified or registered professionals, across nursing, allied health professionals, psychiatry and clinical psychology as reported by health centre managers is set out in Appendix B. Responses which identified unfilled vacancies within the service are also described in the table. Workforce figures are reported using the standard by discipline; namely whole time equivalent (1 WTE = full time / 37.5 hours per week) for nursing and allied health professionals (AHP), and number of sessions per week (one session = ½ day, 10 sessions per week) for psychiatry and clinical psychology.

Across the prison estate there are 91 WTE nurses employed, with 76 being mental health nurses. HMP Barlinnie, HMP Perth and HMP Kilmarnock mental health teams also include substance use or learning disability nurses. There are 90 prison residents per nurse overall (of any nursing specialty). There is substantial variation across Scotland's prisons in the resident-to-nurse ratio, with the most favourable staffing complement in HMP YOI Cornton Vale and HMP Inverness. NHS Tayside prison mental health practitioners work across HMP Perth and HMP Castle Huntly, with a minimal service operating at HMP Castle Huntly, Scotland's only operating open prison. Individuals who are acutely mentally ill or experiencing a mental health crisis would not remain in the open estate. In such instances, the individual would be transferred back to closed conditions where their needs can be more closely and safely monitored and their mental health stabilised.

There were mental health nurse vacancies noted at six prisons, including multiple posts unfilled at HMYOI Polmont, HMP Kilmarnock and HMP Perth. AHPs, including occupational therapists and speech and language therapists, form part of the core multidisciplinary mental health teams in just over half of establishments, though there is wide variation across these prisons in terms of input per resident. Across the entire estate there are fewer than 10 WTE AHPs (854 residents per 1.0 WTE) within prison mental health services, a quarter of them employed at HMP Kilmarnock. In establishments where AHPs are not part of the mental health team they may nevertheless be providing support to individuals with mental health needs.

Psychiatry provision across the prison estate totals to 39 sessions, equivalent to just under four full time psychiatrists. This equates to an average of 210 residents per one half-day psychiatry session. The only vacancy noted is in HMP Grampian, where sessions for learning disability and substance use specialties remain unfilled (65:1 if all sessions were filled). The number of funded psychiatry sessions per week appears relatively arbitrary in relation to prison size, with too few sessions at the largest prisons including HMPs Edinburgh, Barlinnie and Addiewell.

There are presently 164 clinical psychology sessions funded across the estate^[1], an average of 50 residents per one half-day session. Relative to other establishments, clinical psychology input into HMP Low Moss, HMP Greenock, and HMP Grampian is substantial. In comparison, the input into HMP Glenochil and HMP Shotts is low with over 100 residents per session. HMP Dumfries, HMP Inverness, and HMP Castle Huntly do not currently offer a clinical psychology service.

Service delivery

Screening and referral

All people being received into prison in Scotland complete a standardised health screening by a member of the prison nursing team, most often a general rather than mental health nurse. The mental health portion of the screening asks about previous history of mental illness, self-harm, prior contact with mental health services, previous inpatient admissions for psychiatric care and any medication currently prescribed. The nurse who completes the screen will complete a referral to prison mental health services if there is a current mental health concern or the individual is in receipt of medication for a mental health or substance use problem. Responses from several establishments recognised that the process could be more thorough, or that a mental health nurse should deliver that mental health screening. Social work and third sector colleagues highlighted the need for a more robust process in place to identify mental health needs for those coming into prison, however NHS teams on the whole did not identify issues with the existing process.

Multidisciplinary case management

Discussions for where mental health is the focus occur primarily in two multi-disciplinary forums. The prison multidisciplinary mental health team (MDMHT) meeting occurs fortnightly or monthly, and is chaired by SPS and features wide professional representation including, typically, forensic psychology, substance use nurses, social work and prison staff in addition to representation from the NHS mental health team. The purpose of these meetings is to discuss any mental health concerns amongst the individuals within the prison establishment, review management of individuals on the Talk to Me programme, and discuss potential hospital transfers. The NHS mental health team meets either weekly or fortnightly, with representation from health professionals that comprise the core service in each establishment. Existing cases are reviewed, relevant complex care concerns identified and access to further assessments and interventions by the mental health team are discussed.

Distinct from these two forums, respondents detailed a range of multi-disciplinary meetings convened to support individuals, at which mental health or substance use concerns are discussed where relevant, on a case-by-case basis. These include Care Programme Approach^[2] meetings for the coordination of transitional care, Talk to Me Conferences, integrated case management meetings, and risk assessment and management meetings.

Interventions

Respondents described specific interventions delivered by members of the multidisciplinary team (MDT) offered to support individuals' mental health. Most establishments reported a range of individual and group interventions for common mental health and substance use problems, according to a tiered approach. Interventions vary in intensity and in the staff who deliver them. For example, information and self-help interventions, such as self-help pamphlets and literature and relaxation CDs, are available to individuals in prison without the need for referral. Other low intensity interventions involve direct clinical content, initiated usually by clinical psychology, though they are facilitated or co-facilitated by nursing staff and other non-health colleagues, including prison-based social work and SPS staff in certain establishments (for example, HMP Inverness, HMP YOI Cornton Vale and HMYOI Polmont). These low intensity interventions typically target common and less severe mental health problems, for example anxiety management, mindfulness, psychoeducation and coping skills. High intensity interventions are typically delivered by clinical psychology and can include cognitive behavioural therapy, acceptance and commitment therapy, and trauma therapy. Interventions for personality disorder are delivered by clinical psychology, are driven by the individual's case formulation, and span a range of therapeutic models including cognitive analytic therapy, schema therapy, mentalisation-based therapy and cognitive behavioural therapy. All establishments cited the Talk to Me programme as the only service in place for the prevention of suicide. There were few specific interventions described as part of a service for personality disorder, which if available is led by clinical psychology. There was little evidence of differential access to interventions for certain groups of individuals (for example, by the individual's gender or legal status) within prison, except for psychological interventions which in many cases is not initiated for individuals with less than six months to serve before their earliest date of liberation.

Discharge planning and throughcare

Discharge planning and throughcare follows a matched-care approach. The prison mental health team will make a referral to the relevant community mental health team if ongoing support is required, for example in cases where the individual is receiving antipsychotic medication or would benefit from further psychological intervention. On a case-by-case basis, case conferences are held to plan for the transition of care, to which community providers are sometimes invited. Social work teams described a significant role for their profession in liaising with community agencies and third sector services on behalf the wider MDT. If ongoing support is not required, the individual is provided with information and advice on community mental health services and signposted to their general practitioner (GP) as the first point of contact for any developing problems. Individuals on medication-assisted treatment for substance use problems are provided with an appointment to attend the community substance use team on the day of or the day following liberation.

Issues and challenges

We asked professionals to consider service gaps and other barriers beyond service provision to supporting the mental health of people in prison. Their comments have been organised into the following themes.

Funding and service provision

Responses received from both NHS and social work teams recognised that the mental health needs of individuals in prison appeared to far outstrip current resources. The current resources dictate that prison mental health services must direct much of their limited resources to a relatively small proportion of the prison population who are acutely unwell, acknowledging that there are many more who have less severe, or less complex needs which would benefit from care but who are not 'unwell enough' to progress past long waiting lists. Individuals in the community with mild or transient mental health problems would more easily be able to seek out and access self-help materials and digital health interventions, whereas these options are limited in prison. Several prison-based social work teams, citing that this has a limiting effect on their ability to support individuals with mental health needs, also highlighted inadequate funding. A social work team from a mid-size prison reported that due to insufficient resources it is not possible, except on rare occasions, to attend MDMHT meetings despite this being a recognised as core to their service.

Staffing

Respondents noted that staffing deficits, which existed prior to the pandemic, have been exacerbated by COVID-19 related sickness absence and self-isolation requirements. Due to staff shortages during the pandemic, mental health nurses have had to cover shifts in the wider health team. This resulted in the cancellation of clinics and assessments or reviews of individuals in prison. Mental health nurses being pulled from their duties away to support wider health services was also an issue prior to the pandemic. In several establishments, mental health nurses were also required to complete the medication rounds and attend medical responses, pulling them away from their usual duties. Distinct from COVID-19 related issues, several mental health teams highlighted difficulties in recruiting staff to posts, primarily mental health nurses (see vacancies in Appendix B), though previous recruitment challenges in psychiatry and clinical psychology were also highlighted by some respondents. All respondents who highlighted staffing issues stressed that these shortages are detrimentally affecting patient care in their service.

Substances

Responses reflect the considerable challenge for mental health service provision from issues relating to access to and use of substances within prison, and the high proportion of people in prison who have dual diagnoses. NHS teams reported that changes in patterns and prevalence of substance use drives mental health referrals, some providing anecdotal evidence that increased use of NPS during the pandemic fuelled increased need for prison health and mental health services.

Information sharing

NHS and social work teams alike highlighted difficulty accessing relevant health information on individuals in prison. The experience of information sharing and handover between services based in the community and in prison was highlighted as poor in many cases, describing delays and the need for attempts to chase up reports retrospectively. Social workers highlighted frustrations regarding barriers to non-health staff accessing information from their health colleagues, reporting that as a result social work is sometimes required to complete risk assessment and management tools with limited or inaccurate information relating to an individual's mental health. For national service prisons such as HMP YOI Cornton Vale and HMYOI Polmont, which receive individuals in prison from a number of NHS Boards, accessing prior health records from other NHS Boards and held on other clinical information systems is difficult and time consuming.

Non-English speakers

Several social work teams described barriers to accessing prison mental health services linked to residents whose first language is not English. They described difficulty accessing translators for some appointments.

Partnership working

Challenges in effective partnership working was a recurrent response in relation to barriers to meeting the mental health needs of individuals in prison. Several social work teams suggested that an increased awareness of the roles and responsibilities of all professionals involved in care of people in prison would better facilitate joint working. This was also highlighted by third sector organisations, who reported difficulties getting access into prisons to deliver services due to the inflexible structures in place, and an under-recognition by NHS and statutory colleagues of the value of non-clinical services offered by third sector organisations.

Transitions

Service providers highlighted the impact that the process of transitioning from prison to the community can have on someone's mental health is under-recognised. Upon liberation, people are often returning to similar circumstances in the community as they were in before prison, and which may have been made worse by or during imprisonment. Several respondents indicated that current support for employment, housing, and existing pre-release planning and throughcare support for mental health and substance use (limited largely to referral to community services) is inadequate and sets the individual up to fail.

Facilities and prison regime

NHS teams at several prisons indicated that limited available physical space within the establishment to undertake clinical work with their patients and house staff offices was an operational challenge. This was worsened at times during requirements for people to maintain a necessary minimum physical distance due to the pandemic. Some establishments have explored temporary solutions, for example the use of a portakabin at HMP Shotts, however in this case the request was denied by SPS.

Multiple services highlighted that the limited window of two hours available each morning and afternoon for health centre clinics, on account of working within the time constraints of the SPS regime, was problematic. While health staff can see their patients on the prison halls outside of these clinics, this does not offer the necessary privacy.

Training

NHS teams reported good availability of training relevant to mental health through a range of sources including their local NHS Board, NHS Education for Scotland, and the Forensic Network's School of Forensic Mental Health. However releasing staff to access these training events is difficult in the present context of substantial staffing pressures. Social work teams overwhelmingly stated that they would welcome funding for and access to training related to mental health. Responses indicated there was no mandatory training relating to mental health (with the exception of training on the Talk to Me programme), despite the recognised high prevalence of mental health needs among people in prison. Social work teams viewed a foundation level of training on mental health as integral to good risk assessment and management planning. The need for funding to attend training relating to specific needs including trauma, personality disorder, and dementia was highlighted. There was consistent recognition that some level of mental health training should be mandatory for all staff working in prisons including and in particular, prison staff as this staff group spend the most time with people in prison.

COVID-19

The pandemic was noted to have exacerbated many of the pre-existing challenges in service delivery. It also strained MDT working (through reliance on video conferencing and physical distancing requirements affecting team meetings). It appears many prisons were able to adapt to using the Near Me system to facilitate one-to-one psychiatry and clinical psychology sessions, though in NHS Boards where access to Near Me within prisons was more limited (e.g. NHS Greater Glasgow & Clyde) this halted some types of direct patient therapeutic activity for a prolonged period during the pandemic. Group psychological and psychosocial interventions were suspended in many establishments for much of 2020, and for at least one prison this pause on group work was still ongoing at the time of data collection (September 2021). Finally, staff have reported an increase in use of illicit drugs in prison and report an increase in mental and physical health problems in the prison population resulting from this, further stressing services.

With these challenges however, have also come positive learning points. Several third sector providers that adapted to working virtually reported that they planned to operate a hybrid model, continuing some remote delivery, which was found to be beneficial. A third sector organisation working with individuals in HMYOI Polmont stated that by moving their services remotely by offering phone and digital support they were able to reach more people in need of support than they had been able to using a face to face approach.

Summary

An updated prison mental health services mapping exercise found considerable variation in NHS service provision across Scotland's prisons. NHS staffing resources in prison do not appear to be closely linked with the size and characteristics of the prison population in individual establishments, which would be a parallel approach to how NHS Scotland resources are geographically allocated to individual NHS Boards (Public Health Scotland, 2021). This largely arbitrary variation leaves the people who live in several prisons unfairly disadvantaged. There has been a notable increase in the staff mix within services, with greater input from the clinical psychology and AHP workforce since the previous mapping exercise. Staffing vacancies, particularly among mental health nurses, is a serious barrier to meeting the mental health needs of individuals in prison.

Providers also highlighted wider challenges to supporting people in prison. They cited limited services for non-English speakers, mental health nurses being pulled away to support physical health and substance use services, problems in information sharing between professionals working in prisons, and constraints from prison facilities and regime on daily service delivery.