Prison mental health inreach services

Prison mental health inreach teams have been established nationwidein England and Wales over the past 3 years to identify andtreat mental disorders among prisoners. This paper summarisesthe policy content and what has been achieved thus far, andposes challenges that these teams face if they are to becomea clear and effective component in the overall system of forensic mental healthcare.

INTRODUCTION

TOP

INTRODUCTION

As many as nine out of every ten prisoners in the UK displayevidence of one or more mental disorders (Singleton et al, 1998).Despite this, detection of mental illness on reception to prisonhas been found to be ineffective, with many prisoners' mentaldisorders left both undetected and untreated (Birmingham, 2003).Better and more accessible services need to be provided tomentally ill prisoners. This is not a new problem (Gunn et al, 1978).The standard of prison healthcare has been of concern since the earliest reports on prison welfare, with frequent campaignsfor the National Health Service (NHS) to take responsibilityfor prison healthcare from the Home Office (Royal College of Psychiatrists, 2007).This was the main recommendation of Patient or Prisoner, publishedin 1996, which highlighted the shortcomings in the prison healthcaresystem; it also argued for equivalence, namely that `prisonersare entitled to the same level of healthcare as that providedin society at large' (HM Inspectorate of Prisons, 1996). Recommendationsmade in The Future Organisation of Prison Health Care (HM Prison Service & NHS Executive Working Group, 1999)were accepted by the government, which led to the Departmentof Health and the Home Office sharing responsibility for prison health. In 2003 it was announced that responsibility for theprovision of healthcare would be completely transferred fromthe Home Office to the Department of Health from April 2006.

IMPACT AND POTENTIAL ADVANTAGES OF PRISON MENTAL HEALTH INREACH TEAMS

TOP

IMPACT AND POTENTIAL ADVANTAGES...

At the same time as inreach teams have been introduced, therehas been a reduction of 18% in prison suicides for 2004-5 (Howard League for Penal Reform, 2006).It is not clear whether this is due in part to the new inreachteams, as a series of concurrent factors are likely to have contributed to this finding. These include risk-reduction initiativeswithin prisons, such as the Safer Locals strategy and the implementationof the Assessment, Care in Custody and Teamwork (ACCT) programme.Another probable factor is the `dilution' effect seen in theUSA whereby a rising imprisonment rate means that on averagea less unwell or disabled population is sentenced or on remand,and because a larger proportion of the prison population serves long sentences it tends to be more clinically stable (Gore, 1999).In this respect the pattern of imprisonment in the UK is progressivelychanging to resemble American trends.

Mentally disordered offenders in prison could be managed throughthe same channels as those in the community, if inreach teamswere to form part of a joined-up approach to care in whichthere were functioning crisis teams and assertive outreachteams in the custodial environment. Secure hospital care couldtherefore be arranged within the course of fixed sentences through transfers under sections 47 and 48 of the Mental Health Act1983 (Department of Health, 2006). This would enable the moreappropriate use of scarce and valuable secure beds.

THE REMIT AND CHALLENGES OF INREACH TEAMS

TOP

THE REMIT AND CHALLENGES...

Prison inreach teams were intended to be the main vehicle forimprovements in mental health services for prisoners, especiallythose with severe and enduring mental illness. In fact, formsof such teams have existed for several decades at some prisons,for example Belmarsh and Pentonville, and were provided bynon-forensic specialists. The current mental health inreachteams are different in that they are intended to provide careto all prisons in England and Wales. The original intentionwas stated in this way:

`For those persons judged to have the greatest need, the NHSwill fund the establishment of multi-disciplinary teams, similarto community mental health teams (CMHTs) offering to prisonersthe same sort of specialised care they would have if they werein the community' (Department of Health & HM Prison Service, 2001).

The key point is that, upon joining the NHS, these new inreachteams should bring the mainstream NHS framework to apply equallyto prisoners.

Despite nationwide inreach teams being a relatively new initiative,the challenges to such services are already clear. There arealready signs of `mission creep'. The original intention wasto restrict inreach services to treating people with severeand enduring mental illness, but already national policy hasbeen broadened to include all those in prison with any mental disorder (Brooker et al, 2005). Prisoners often present acomplicated clinical picture as they frequently have complexand comorbid problems. Are the general mental health staffin such teams, who do not necessarily have any forensic training, sufficiently expert to provide effective care? In fact a perverseincentive may now operate, in that inreach teams are less likelyto want create referrals for themselves. The role of inreachservices in relation to people with personality disorders isnot yet clear. Now that the evidence base for effective interventionsfor personality disorder is growing, meeting the treatmentneeds of people who frequently present with personality ratherthan illness-driven problems has to be addressed in practicethroughout the prison establishment. Should this fall withinthe remit of an inreach team, be provided in specialist personalitydisorder units, or should there be a combination of the two?Does the general psychiatric in-patient sector have the capacityto accept transfers of people identified in prison as requiring hospital assessment and treatment? Are inreach teams effectivefor both sentenced and remand prisoners, and can such teamsoperate rapidly enough to connect the latter successfully,given high turn-around rates and unpredictable court decisionsand release dates? To date all these questions about the remitof inreach teams remain unanswered.

Evidence of treatment models that have been found to be effectivein the community, such as community mental health and assertiveoutreach teams, cannot be directly applied to the prison populationbecause issues of criminality can complicate the picture (Brooker et al, 2002). Constraints within the prison environment - such as securityissues, information sharing and treating prisoners withouttheir consent - have an impact on the translation of community-basedtreatments into secure settings. Conflicting views on the balancebetween care and control within a prison environment may alsoaffect the outcome of using these treatment models in prison.

Drug and alcohol misuse and dependency need to be a core focusof such clinical interventions in prison. The greatest healthissue (and the real solution to suicide risk) is to addressthe substance misuse issues of prisoners (Gore, 1999). Yet paradoxically there is relatively little evidence for effectiveinterventions for people with `dual diagnosis', i.e. concurrentsubstance misuse and severe mental illness. Such patients areoften excluded from studies of the general adult psychiatricpopulation, and so caution should be exercised when translatingthe research findings from the general adult services to the prison population (Brooker et al, 2002). Drug and alcoholtreatment services in prisons, using the Counselling, Assessment,Referral, Advice and Throughcare (CARAT) system are alreadywell established. Through a more formal collaboration betweeninreach and CARAT services, some form of dual diagnosis servicecould be implemented. Drug-free wings might be a therapeuticsetting in which to treat prisoners with such comorbidity.

Clinical experience to date suggests that inreach services areoperating using limited and idiosyncratic models of care. Theaverage team size, for example, is three members of staff.Official guidance has been deliberately non-prescriptive, andinnovative commissioning by primary care trusts will thereforebe required to sustain the initial momentum to deliver an equivalent standard of care nationwide.

CONCLUSION

TOP

CONCLUSION

Giving the NHS direct responsibility to commission mental healthcarefor prisoners allows us to reconsider what services shouldbe provided on the basis of equity and effectiveness. Shouldhome treatment and crisis response teams be as available toprisoners as to everyone else? Should assertive outreach teams,and specialist drug and alcohol treatment teams, similarly supplementgeneric inreach teams by taking on patients who need such intensive treatment and who happen to be in prison? In other words, shouldprisoners receive care that is either identical or equivalentto the care that they would receive if they were in the community?Should we continue to insist that prisoners cannot be treatedwithout or against their consent? How best can people withmental illness be assisted to engage with community servicesafter release from prison? In fact, inreach teams are onlyone element in a complex and rapidly changing landscape, includingnew arrangements for care pathways (Department of Health & National Institute for Mental Health in England, 2005),treatment of women in prison, and policy changes to expeditetransfers to hospital under sections 47 and 48 of the MentalHealth Act in less than 1 week by 2008 (Royal College of Psychiatrists, 2007).This new national policy in England has therefore prompted awholesale renaissance in the treatment of mentally ill prisonersin recent years: the next challenge is to assess the impactof these changes in practice.

REFERENCES

TOP