Scottish Government

4. PROVISION FOR PRISONERS WITH SEVERE AND ENDURING MENTAL HEALTH PROBLEMS IN PRISON

4.1 This chapter examines the ways in which prisons address severe and enduring mental health problems, from identification to provision of treatment, interventions and other support.

IDENTIFYING NEEDS

4.2 The first stage in the process of addressing severe and enduring mental health problems is the identification of needs, and this can take place at various stages.

Reception and Induction

4.3 The processes at reception and induction are important in identifying if a prisoner has severe and enduring mental health problems, and there are a number of ways in which this takes place.

4.4 Firstly, information about mental health needs may be received upon reception, although this varies. For example, there may be written reports from court (including psychological, psychiatric or social enquiry reports), there may be information from RCS (the escort services contractor), or the prison may be notified by the court, a social worker or other individuals or organisations in the community. This is more likely to be the case where there is a long-standing mental health problem. Additionally, if a prisoner has been in prison previously, his records may contain some relevant mental health information. However, some prisoners arrive with no background information at all.

4.5 Secondly, the reception or induction process itself may highlight problems, as well as providing an opportunity to pass on information to prisoners about the mental health team. The processes most commonly used for identifying needs were the provision, at reception, of a nursing assessment and the Act2Care process. In some prisons, the nurse at reception is always, or almost always, a mental health nurse, whose expertise can assist in the process of identification of needs.

4.6 A very small number of prisons made specific reference to exploring mental health issues in more depth. For example, one noted that the World Health Organisation Assessment was completed by a mental health nurse on admission for every prisoner. Another noted that all prisoners were seen by a mental health nurse on admission, and a third that prisoners were asked a range of specific questions about previous mental health issues.

4.7 A small number of other aspects of the process were also identified as additional means of identifying problems; one establishment uses a "first night checklist", and another uses some "general questions" which could help to indicate mental health issues. The use of follow up medical assessment was also highlighted, and some participants mentioned the use of the cell sharing risk assessment, the risk management process or the Integrated Case Management process in this context.

4.8 Thirdly, the prisoner may disclose his or her mental health problems at some stage during reception or induction. Self-disclosure has become more likely in recent years. Prisoners can also be provided with information about how to access services at induction, which could assist in enabling them to disclose the issues which they face.

4.9 Some officers have received Mental Health First Aid training. Where prisoners had been in the prison before, staff may already be aware of the issues which they face.

During a Sentence

4.10 During a sentence, the main means of identifying severe and enduring mental health problems are: observation by staff; self-disclosure by prisoners; information provided by other prisoners; information provided by other organisations; and issues raised in multi-agency discussions.

4.11 The process of observation by prison staff is one of the key means of identifying severe and enduring mental health needs, and staff ability to recognise potential mental health problems has improved. Staff highlighted that they would look for behavioural changes, and there were some examples of identifiable behaviour which might be taken to indicate need such as where a prisoner does not come out of their cell at meal times, refuses to eat, refuses an order to leave their cell or attend a meeting, wants to stay in bed all day, or carries out an assault.

4.12 There may, in some cases, be direct disclosure of mental health problems by a prisoner during a sentence, or instances where they self-harm or attempt suicide. Good relationships between staff and prisoners can assist with staff identification of issues and in enabling disclosure by prisoners, as can specific awareness raising events to encourage people to identify the issues which they face.

4.13 Information may also be provided by another prisoner where there are cell sharing problems, or where a prisoner has identified someone who is "struggling", and examples of this were also given. External agencies, Listeners and visitors may also refer people to the mental health team.

4.14 In addition to these means, some prisoners will be the subject of multi-disciplinary discussion outwith the MDMHT, for example, if they are in a segregation unit for a period of time, and this can provide a means of identifying mental health problems. Every prisoner held in segregation for a month should be subject to a Mental Health Nurse Assessment, regardless of any previous referral. There should also be suitable healthcare representation at the initial case conference to pick up on the necessary referral to the Mental Health Team. However, these did not appear to be happening on every occasion. The role of the MDMHT is examined in detail later in this report.

Issues and Gaps in the Identification of Needs

4.15 The processes for the identification of needs are varied, and have improved as the understanding of mental health problems has increased. One overarching concern, however, identified particularly by the voluntary sector, was the lack of a clear, systematic and specific process for identifying mental health needs.

4.16 Additional issues and gaps in the identification of needs were identified. Although it is not suggested that these problems exist in all prisons, they serve as examples of ways in which some prisoners with severe and enduring mental health problems may not be identified.

4.17 There can be problems with the passage of information from courts and the community:

• Although some courts were seen to be generally good at sending information, one MDMHT noted that court reports could be "hit or miss".
• There are no formal procedures for receiving information from the community, and there are variations in the level of provision.
• Without written information, there is a reliance on prisoners disclosing issues at the early stages of sentence.
• Information from initial screening is not always shared with other staff.

4.18 There can be difficulties for prisoners in disclosing issues:

• People with communication or language support needs may find it difficult to disclose mental health problems.
• Prisoners may not feel able to tell staff about their mental health, because of the nature of the relationship, or embarrassment.
• Some prisoners hide their symptoms due to cultural and social pressures.
• Disclosure can be a problem where mental health problems are related to previous abuse.
• Prisoners may feel that disclosure will not result in action.
• Prisoners may be deterred by the belief that there is an assumption, when someone is unwell, that they are trying to get medication, or get to hospital.
• Prisoners may fear the consequences of disclosure: including the impact on their liberation date; the impact on their progression; the possibility of transfer to suicide cells for observation, or the possibility of ridicule.

4.19 There can be problems with processes and operational issues:

• Reception of a prisoner can involve a largely "tick box" approach unless there is a specific trigger such as medication. Prisoners in some prisons are not asked routinely about their mental health needs, and the existing processes are not linked explicitly to identifying severe and enduring mental health problems.
• Pressure on time at reception can lead to difficulties in identifying complex needs and in processing information.
• Late admissions can constrain the process of identifying mental health needs.
• The conditions at reception may exacerbate problems particularly in prisons where there are still small cubicles.
• In overcrowded prisons where prisoners are locked up for long periods it is more difficult to identify mental ill health.

4.20 There can be problems with staff identifying issues:

• A reliance on previous knowledge of a prisoner creates difficulties, as this can lead to short interviews and complacency in exploring mental health issues, while their needs may have changed.
• Nurses in reception who do not have mental health training and experience might not pick up some signs of less visible mental health problems.
• There are variations in staff skills, training and willingness to engage with these issues.
• There is a lack of an overall shared understanding of mental health problems. For example, sometimes mental health problems are seen as primarily behavioural and control issues.
• A lack of resources, staff time and overcrowding can lead to a focus on those people with the most visible problems, or those who cause problems for the management of the prison.
• Prisoners who do not draw attention to themselves, who are "quietly compliant" or "quietly mentally unwell", can be missed.
• People who have been in good mental health, but whose behaviour is poor, can become ill and may be missed. For that reason, segregation unit prisoners should be monitored closely.
• Substance misuse can make it difficult to identify mental health problems.
• Where prisoners are not out of their cells much, this can make interaction and observation difficult.
• Medical confidentiality can mean that officers do not know what they should be looking for, unless there is a specific issue with suicide or self-harm.

4.21 The impact of a lack of identification of needs will clearly vary in individual cases, but these difficulties can mean that some prisoners with severe and enduring mental health problems may not access the next stage in the process which is assessment and referral, as a precursor to their receipt of treatment, interventions and other support.

REFERRAL AND ASSESSMENT

4.22 Following the initial identification of needs, a referral is generally made to the mental health team in the prison, either by a staff member, or directly by the prisoner. There are generally forms available on which to do this, although many mental health teams also take verbal referrals, and some participants identified the development of strong and positive working relationships between mental health nurses and prison officers as an important element in the identification of needs.

4.23 Prison staff tend to "err on the side of caution" in making mental health referrals, and some officers stressed that they would be unwilling to take risks. This was particularly the case where mental health issues were linked to suicide or self-harm.

4.24 Following referral to the mental health team, most processes involved an initial assessment by a mental health nurse. This is sometimes, but not always, prioritised and carried out within a specific time period. Most prisons had some prisoners awaiting initial assessment by the healthcare team, and the time for this varied within prisons and between prisons, particularly in terms of the maximum waiting period, although this was generally no more than three weeks, and most prisoners whose needs were considered urgent would be seen within 24 hours. One prison had no assessment provision available at the time of the inspection, although the MDMHT was exploring ways of addressing this. It was also noted that specific forms of support, such as Cognitive Behavioural Therapy ( CBT) or Speech and Language Therapy could involve a longer waiting period and in many prisons was not available.

4.25 There was also variation in the means of consideration of new cases by the MDMHT. In some prisons, all first referrals would be considered and their treatment and throughcare planned in this way, but this is not always the case. In one instance the nurse would make a decision about whether or not to refer the prisoner to the MDMHT for further consideration, and some nurses would input support or develop a care plan without the full team being involved. In one prison the whole MDMHT would only see a case where there was a need to make a referral to another of the team members. Another works on a shared assessment process involving social workers, healthcare centre staff, Phoenix Futures and others.

4.26 In general, the main parts of the process are the involvement of the mental health nurse in assessment, then referral to the MDMHT where the care required would be discussed and planned and, in some cases, a case manager identified from within the MDMHT.

4.27 All prisons seek additional information from organisations in the community should a prisoner experience severe and enduring mental health problems. The range of organisations identified varied between prisons, but included health contacts, social workers, addictions workers and other organisations, as well as, in some cases, families.

4.28 There may also be a process of further onward referral to a psychiatrist or other forms of support.

Issues and Gaps in Referral and Assessment

4.29 Although there was overall satisfaction with the processes of referral and assessment in prisons, a small number of issues and problems were also highlighted.

4.30 Some of the problems related to difficulties in referral are:

• Prison staff can find it difficult to describe a prisoner's problems when making a referral: "how do you say they're not quite right?".
• Some MDMHTs consider some staff "too quick to make a referral" or that they make inappropriate referrals.
• Some officers believe that health staff do not accept their views of a prisoner, and that they can often make a referral and no action will be taken.
• There can be a lack of feedback from mental health staff about inappropriate referrals, making it difficult to improve practice.
• Prisoners may be confused or unclear about the nature of their own mental health problems.
• Not all prisons had a functional MDMHT or nominated mental health nurse.

4.31 Some of the problems related to difficulties in assessment/diagnosis are:

• There can be a lack of assessment tools.
• It can be difficult to assess remand prisoners and those serving short sentences because of a lack of time and a perceived unwillingness of these prisoners to disclose mental health problems.
• The level of demand on mental health nurses and shortages of staff can lead to a gap in time between referral and assessment.
• Some mental health problems are difficult to diagnose.
• Drug taking can mask mental health problems.
• There is no routine assessment for specific issues such as alcohol-related brain damage, learning disability and personality disorder.
• Information about individual prisoners in residential areas is not always written down.
• Information "alerts" may be more focused on suicide risk.
• Information from community sources is not always received in time to contribute to the process, and there is a lack of a formal system to ensure the provision of historical records.
• There can be differences of view between the psychiatrist and others about whether or not a prisoner has a diagnosable mental health problem. Particular concerns were raised about the issue of personality disorder, as well as with a perceived unwillingness to diagnose severe and enduring mental health problems amongst young offenders.

4.32 Although it is not suggested that these problems occur in every establishment, they are likely to impact upon whether or not a prisoner receives timely and appropriate treatment, intervention and support.

TREATMENT, INTERVENTIONS AND OTHER SUPPORT

The Nature of Treatment, Interventions and Support in Prison

4.33 Once prisoners have been identified as having severe and enduring mental health problems, but do not require transfer to hospital, the treatment which they receive in prisons generally includes:

• Medication.
• Access to a psychiatrist.
• Input from a mental health nurse (where available).

4.34 There are a number of additional forms of treatment, intervention and other support which may be available, although these vary considerably between prisons. In some prisons there is some access to Cognitive Behavioural Therapy ( CBT). There is also variation in other aspects of psychological support, and in access to one-to-one support and "counselling". In one prison psychologists work alongside personal officers while, in others, psychologists may be involved only in programme work.

4.35 There was a clear absence of specific regimes for prisoners with severe and enduring mental health problems. One prison had established a self-help group for mental health service users with input on issues such as communication skills, but while this was described as "practical good practice", such provision was uncommon.

4.36 A small number of prisons have specific facilities considered relevant to prisoners with severe and enduring mental health problems, such as: a Residential Care Unit (Barlinnie); a "Safer Custody Unit" for vulnerable prisoners (Kilmarnock); single cell accommodation within the healthcare department for closer observation and 24 hour care (Kilmarnock); a Personal and Social Development Unit and supportive work party (Polmont); daycare provision (Barlinnie); a multi-sensory room (Cornton Vale - although this was not being used at the time of the inspection) and input from specialist staff organisations, such as a local Stress Centre (Barlinnie); a speech and language therapist (Polmont); a Community Learning Disability Nurse (Cornton Vale); addictions staff or organisations working with survivors of abuse ( e.g. work in Edinburgh, and work developing further in Cornton Vale and Greenock). There had been Occupational Therapy provision in Cornton Vale in the past, but this is no longer available. One prison, at the time of the inspection, was trying to develop a therapeutic day centre. Where these forms of provision exist (and are made available), they are seen to be beneficial, and prisoners generally expressed positive views.

4.37 There was also use made of other facilities in a flexible way. For example, some prisons identified a particular hall where prisoners with mental health problems would be located; Greenock has a two and three bed unit, which was seen to provide a "good halfway house" from the anti-ligature cells; and there are "buddy cells" in Edinburgh. There were examples of Independent Living Units identified as being helpful to prisoners with mental health problems, and the National Induction Centre in Shotts was seen to provide an opportunity for support to very long-term prisoners.

4.38 Although officers have a good deal of day-to-day contact with prisoners, they have limited involvement in providing treatment, interventions and other support following referral to the mental health team. Officers were often unaware of the treatment provisions available, or the actions taken with individual prisoners, and received little information about this, with the exception of prisoners on Act2Care.

4.39 Despite their lack of involvement, the attitudes and approach of prison staff can make a difference to people with severe and enduring mental health problems. The importance of staff commitment is clear. Some prisoners identified specific officers they could trust and talk to, and highlighted the value of staff who were willing to listen and provide support. Some officers also stated that they adopt a flexible approach to people with mental health problems: they would "make allowances" and "go that extra mile for vulnerable prisoners". A number of prisoners also said that they received support from other prisoners.

4.40 A small number of other individuals and organisations were also identified as providing treatment, interventions or other support, and some prisons also identified access to throughcare as part of the treatment, support and interventions available. Some of the other organisations highlighted included: addictions services; chaplains; counsellors; listeners, and other voluntary sector services working in the prison.

4.41 A small number of prisoners were identified as awaiting treatment at the time of the inspection, and the waiting times again varied between prisons and between types of input. Medication could generally be made available quickly, but some forms of support, such as psychologists and specialist organisations sometimes involved a longer wait.

Segregation and Restraint

4.42 Segregation units/separate cells are used at times for some people with severe and enduring mental health problems by most prisons, and most reported a small number of circumstances in which they may do this. These were: when they were violent or disruptive; displaying anti-social behaviour; posing a risk to themselves or others; or during an acute psychotic episode. Most of the prisons visited had prisoners in the segregation unit within the caseload of the MDMHT, and a small number stated that their segregation units were being used, at least in part, as quasi-care units.

4.43 Staff were aware of the difficulties in making distinctions between mental health and behavioural/ management problems and recognised that the behaviour leading to the use of segregation maybe linked to mental health problems.

4.44 There were concerns expressed about the use of segregation in these circumstances, and one MDMHT did note that if they had people with a mental health problem in segregation, they would generally push for them to go to hospital. It was also suggested, however, that the nature of the staff involved, and their sometimes greater level of understanding, could provide some support to some prisoners, and there were some good examples of people having been well looked after in segregation. One prisoner also expressed a personal preference for segregation and "my own space". Constraints to this were also highlighted, however, particularly when staffing is low, and segregation was often seen to be used inappropriately because of a lack of alternatives to deal with prisoners whose problems led to disruptive behaviour. As one prisoner stated:

"You've got to think of the guys who've flipped - where are they going to put them? They don't know how to deal with you so they put you to the digger [Segregation Unit]. That makes you worse."

4.45 There is a small number of prisoners managed nationally by the ECMDP (Executive Committee for the Management of Difficult Prisoners). Such prisoners may have severe and enduring mental health problems, or may be "difficult" for other reasons. The basis of their management is that they are rotated around a number of prisons on a regular basis, and are housed in the segregation unit. During the period such prisoners are in a prison, they would generally become part of the MDMHT caseload, and would be worked with by the mental health team, although their overall management remains with the ECMDP.

4.46 Where prisoners pose a significant risk to their own welfare through their behaviour, intervention usually involves the use of control and restraint techniques by specially trained officers.

4.47 A very small number of examples was given of the use of a body belt in particular circumstances, such as to prevent self-harm/threatened suicide, but this is very uncommon and a "last resort". Some prisons have not had to do this in the period for which records were available.

4.48 There is some variation in understanding of the use of medication in crisis situations. Although there was a common belief that this was not allowed, several psychiatrists stated that emergency medication could be given in some circumstances to deal with an acute and immediate problem. They also noted, however, that it is not permissible to force a prisoner to take medication which has been prescribed for a particular mental health problem. It is clear, however, that there is some measure of uncertainty about these issues.

The Involvement of Prisoners and their Families Advocacy

4.49 There has been a growing emphasis on prisoners identifying their own needs and participating in their own care. In practice, however, this is limited, and variable, ranging from one MDMHT which stated clearly that prisoners would take part in assessments and discussions through to other cases where there was seen to be very little involvement by prisoners.

4.50 Mental health nurses discuss treatment with prisoners. Some MDMHTs involve prisoners in case conferences. The involvement of prisoners in care plans was highlighted by a group of prisoners, while one MDMHT noted that treatment and care plans involved prisoners but added that the mental health nurses did not have care plans in place at present. In one prison a specific group of prisoners have no say in their care and treatment ( i.e. those subject to Rule 37 which requires a medical officer to report to the Governor and Scottish Ministers about any serious concerns they may have about the health and welfare of a prisoner). Prisoners do not appear to receive feedback about discussions which take place at the MDMHT.

4.51 A number of MDMHTs discuss the issue of consent from prisoners to sharing information about their mental health care with non-medical staff. There are some processes in place for this, although these vary. In some cases, a written consent form is completed and there were also examples of consent being given verbally. Some information must be shared with social work staff, such as child protection issues, whether or not there is consent.

4.52 Awareness of the need for, and the nature of, consent was mixed amongst prisoners. There was also evidence of some staff lacking recognition of the need to ensure that consent forms were signed, as well as lacking clarity about what required consent and what did not.

4.53 Practice is also varied in terms of the provision of advocacy support to prisoners with severe and enduring mental health problems. The overall view of the voluntary sector organisations consulted, some of whom were specialist advocacy providers, was that this was rarely provided to prisoners, and it was clear that five prisons had no advocacy available at all at the time of the inspection.

4.54 Some examples were given where prisoners had asked for advocacy support, or where support had been used at case conferences. A small number noted that local advocacy services had been advertised and publicised, or were available on request. One noted having "Advocard" in place, where an advocate would attend, if called.

4.55 It was clear that prisoners generally had little or no awareness of their right to advocacy support under the Mental Health (Care and Treatment) (Scotland) Act 2003.

4.56 There was also variation in the extent of involvement of families. In some cases, this was virtually non-existent, or limited to responding only where a family raised specific issues or concerns. One prison, however, has a strong focus on this, and some examples were identified of work taking place.

4.57 It can be difficult to organise family involvement, particularly where it is difficult to identify a "family", or where family members also have mental health problems, and a number of prisoners stated that they did not want to involve their families. One prison ensured that visits could be arranged through the mental health team and these could be held away from other prisoners.

Internal Transfers

4.58 The issue of transfers between prisons can also impact upon treatment, interventions and other support. Common reasons for transfer were: a prisoner having "a history" with other prisoners; committing offences within the prison; disrupting the regime; overcrowding; requiring care that could not be provided; requiring accommodation that could not be provided; or where transfer is otherwise seen to be in the interests of the prisoner.

4.59 Some of the most problematic prisoners may be transferred to the Residential Care Unit at Barlinnie, and other prisons were often keen to send vulnerable prisoners to the Unit, which, in the view of some had become "like a national facility".

4.60 Where prisoners were undergoing assessment or treatment (such as CBT), some MDMHTs gave examples of instances in which they had had input to, or had influenced decisions, by requesting that the prisoner should not be transferred at that stage. It was acknowledged, however, that people with undiagnosed mental health problems may move between prisons without the involvement of the MDMHT. It was also identified that, in some cases, prisoners may be moved without the MDMHT being made aware of plans to do so.

Issues and Problems with Treatment, Intervention and Support in Prisons

4.61 A number of examples of good practice were highlighted, including some of the facilities and input from staff, and links between some staff. Some prisoners, when stabilised on medication, could cope in the mainstream prison system and were "safe". The care available in prisons for people with severe and enduring mental health problems can also exceed that in the community, with, for example, faster access to treatment, and more regular input from a senior and specialist psychiatrist.

4.62 Against this background, however, there are problems and constraints with the provision of treatment, interventions and other support.

Problems with Existing Practices

4.63 A number of concerns exist with aspects of the nature of existing provision, including:

• The variation in practices, and the availability of different forms of treatment, interventions and other support in different prisons.
• A perceived greater reliance on medication than would be desirable, with limited provision of other forms of treatment, interventions and other support.
• Issues with the receipt of existing medication, such as delays in provision of medication; changes to medication; and perceived differences in prescribing practices.
• The use of segregation and anti-ligature cells which are generally inappropriate, understaffed for this purpose, and identified by many prisoners as making mental health problems worse. Some prisoners perceived this as being "punished" for their mental health problems.
• The lack of routine mental health assessment in segregation; the lack of routine mental health staff input to case conferences for prisoners in segregation and the poor conditions in some segregation areas.
• Inappropriate placement of some prisoners or the use of facilities for vulnerable prisoners which are not equipped to cope with prisoners with severe and enduring mental health problems.
• Difficulties in working with prisoners without a formal diagnosis, due to a lack of options available; difficulties in making provision for people with a personality disorder; and difficulties in working with prisoners exhibiting some behaviours where medication is not appropriate.
• Lack of use of existing facilities which may benefit prisoners with severe and enduring mental health problems.
• Separation of some forms of intervention which should be more closely integrated.
• Lack of availability of 24-hour nursing cover.

Gaps in Types of Treatment, Intervention and Other Support

4.64 Many of the concerns expressed relate to perceived gaps in the types of treatment, interventions and other support available. These include perceived gaps in the following:

• Daycare provision.
• Prison-based in-patient facilities.
• A specific regime for people with mental health problems, with appropriate work and other activities/interventions.
• Specific forms of intervention, such as diversionary and therapeutic activities, targeted programmes, and one to one support.
• Support, in some cases, from a dedicated mental health nurse.
• Clinical psychology support, "talking therapies" and CBT.
• Specialist input for both male and female survivors of childhood sexual abuse.
• Specialist input for other issues such as PTSD; co-morbidity of substance abuse and mental health; and sex offending.
• Access, in some cases, to social work services.
• Occupational therapy.
• Specialist input to meet the specific needs of particular groups, such as women; prisoners in particular age groups; ethnic minority prisoners; LGBT prisoners; prisoners with communication or language support needs; prisoners with learning disabilities; and prisoners with a personality disorder.
• Input from other specialist services based in the community, and access to other community-based support.
• Advocacy support and a lack of information for prisoners.
• Support to people who might, if in the community, require outpatient, rather than in-patient facilities.

Attitudes

4.65 Some problems were highlighted relating to attitudes:

• Lack of understanding and poor attitudes amongst some of those working in prisons to mental health.
• Variations in staff attitudes, with some prisoners identifying poor staff responses which exacerbated their problems.
• A perceived assumption by some prisoners that mental health problems are always drug-induced.
• Some "gatekeeping" by staff, which can lead to difficulties in access to support.
• Perceptions of unfairness amongst other prisoners when a flexible approach is taken by staff to prisoners with mental health problems.
• Issues with the flexibility of some staff in enabling visits by psychiatrists.

Operation, Security and Overcrowding

4.66 As with the identification of needs, aspects of the operation and security of prisons, and issues relating to overcrowding were also seen to limit the provision of treatment, interventions and other support, and concerns include that:

• Regimes restrict the work that can be done, constraining staff time.
• The number of prisoners requiring medication (particularly methadone), and the practicalities of providing this, constrain the time available for other work.
• It is difficult to provide treatment, interventions and support to prisoners serving short sentences.
• Overcrowding and the need for progression may lead to moving people on, and the new location may not be suitable to their needs.
• Movement of prisoners can make it difficult for psychiatrists to keep track of the patients they are working with.
• Transfer between prisons, when prisoners are unwell, is difficult.
• There are some problems with the provision of information between prisons on transfer, which can lead to treatment being interrupted.
• There can be problems with continuity of care for ECMDP prisoners.
• Security, operational concerns and "the needs of the prison" can supersede mental health needs and determine the intervention made, such as the use of segregation.
• Overcrowding leads to a high level of demand for support, and a lack of time for officers to work with individuals, especially where prisoners are locked up for longer periods of time. This affects particularly the opportunity to talk and to listen, which many prisoners identified as beneficial.
• There can be difficulties in locating a large number of vulnerable prisoners in one hall.

Staffing, Information and Other Resources

4.67 Staffing, information and other resource constraints arose repeatedly in relation to problems in providing treatment, interventions and other support. The broad issues raised relating to staffing, information and other resource constraints include:

• Lack of staff.
• Lack of time and other demands upon staff which constrain their opportunity for input and follow-up.
• Lack of skills and training for some staff.
• Limitations to the role and involvement of some staff, particularly uniformed officers, and ambiguity within the role in terms of the balance between care and custody.
• Gaps in provision of specialist staff.
• Gaps in joint working between relevant services/teams.
• Waiting times and availability, in some cases, of specialist staff, or insufficient frequency or length of contact. These issues may also impact upon prisoners' motivation to address issues.
• Staff stress and "burnout" where there is intense involvement with prisoners with mental health problems.
• Staff turnover and staff absence.
• Difficulties with information sharing, lack of feedback of information to hall staff, and issues with confidentiality, causing problems for staff in knowing how to provide support, and prisoners who may have to tell their story repeatedly.
• Inappropriate or limited facilities within prisons and some difficulties with booking arrangements for psychiatrists and collecting prisoners for appointments.
• Lack of tools to measure success.

CONCLUSIONS

4.68 In terms of the identification of severe and enduring mental health problems, the main conclusions are as follows:

4.68.1 Reception and induction processes can provide the first opportunity to identify mental health needs, and there are a number of ways in which these can be highlighted: through information provided, aspects of the reception and induction processes; self-disclosure or a member of staff being aware of such needs.

4.68.2 During a sentence, the main ways of identifying mental health problems are through observation by prison staff, other workers, prisoners, and through self-referral.

4.68.3 There is 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.

4.68.4 Following the initial identification of needs, a referral is generally made to the mental health team in the prison, and there are some differences in processes at this stage, particularly in waiting times and in when the MDMHT becomes involved. Most involve an initial assessment by a mental health nurse, after which there may then be a process of further onward referral.

4.68.5 A small number of issues and problems with the processes of referral and assessment in prisons were identified, including: a lack of a shared understanding of when a referral is required; some technical issues with the processes of assessment and diagnosis; and a lack of evidence and information to inform the process.

4.69 In terms of the treatment, interventions and other support for people with severe and enduring mental health problems in prison, the main conclusions are as follows:

4.69.1 Once prisoners have been identified as having severe and enduring mental health problems which do not require transfer to hospital, the treatment which they receive in prisons generally includes: medication; access to a psychiatrist; and input from a mental health nurse.

4.69.2 There are a number of additional forms of treatment, intervention and other support, which vary considerably between prisons. A small number of prisons have specific facilities considered relevant, as well as some resources such as books and CDs. There was, however, little evidence of input from community-based mental health and other relevant organisations focusing on mental health during sentences.

4.69.3 Segregation units/separate cells are used at times, with difficulties faced in making distinctions between mental health and behavioural/management problems. The use of segregation as a response to mental illness is wrong.

4.69.4 Mechanical restraints are used very rarely in prison but are never used in hospitals. The use of mechanical restraints to control prisoners with mental health problems is unacceptable.

4.69.5 There has been a growing emphasis generally on the involvement of prisoners in identifying their own needs and participating in their own care, but this remains limited and variable.

4.69.6 The provision of advocacy support varies. In some prisons, there was no provision, or it was virtually non-existent. Prisoners generally had no awareness of their right to advocacy support under the Mental Health (Care and Treatment) (Scotland) Act 2003.

4.69.7 The issue of transfer between prisons can impact upon treatment, intervention and support, and most MDMHTs stressed that prisoners would not be transferred to another prison solely on the basis of their difficult behaviour. MDMHTs are generally consulted about any proposed move of a prisoner within their remit.

4.69.8 A number of concerns were expressed with: aspects of the nature of existing provision ( e.g. variations in practice and availability; issues with medication; issues with the use of segregation; practical difficulties; a lack of an holistic approach; gaps in types of treatment, intervention and other support ( e.g. lack of daycare; lack of "talking treatments"; lack of a specific regime; the removal of in-patient facilities; lack of specific forms of intervention and specialist intervention for issues such as sexual abuse); attitudes ( e.g. variation in understanding; and some inappropriate attitudes and behaviour); aspects of the operation of prisons and issues relating to overcrowding ( e.g. pressure and time constraints, and operational demands); staffing, information and other resources ( e.g. lack of staff, time and training).