All Party Parliamentary Group for Mental Health

Notes of meeting: July 2002

Tuesday 2 July 2002

Speakers:

Dr John O’Grady, Member of DoH’s Mental Health in Prisons Expert Group

Andy Smith, Inner London Forensic Mental Health Co-ordinator, MACA

Members present: Dr Lynne Jones MP, Oliver Heald MP, Dominic Grieve MP and David Drew MP

In attendance: Martin Aaron (JAMI), Nick Bosanquet (Inner Cities Group Imperial College), Linda Butler (Association of Colleges), Jonathan Calder (British Psychological Society), Nicky Edwards, (British Psychological Society), Dr Wolfram Engelhardt (psychiatrist working in Holloway Prison), Dr Roger Freeman (Royal College of Psychiatrists), Gary Hogman (Rethink), Simon Lawton Smith (MACA), Maureen Ng (Janssen-Cilag Ltd), Dr William Obomanu (MACA) and Christopher Walden (Royal College of Psychiatrists).

Dr John O’Grady

 Dr O’Grady explained about the organisation of health care within the prison system. Minister of Health is jointly responsible for the health of prisoners with the relevant Minister in the Home Officer. The NHS works in partnership with the Prison Service. He said there had been significant advances in the last ten years – there was not one report on prisons before 1990 which mentioned prisoners mental health. Now the NHS Plan targets included prisons and were part of local networks and steering groups. However, Dr O’Grady was concerned that the establishment in April 2002 of Primary Care Trusts would hinder some of the progress made.

Other recent changes included reception screening for new intake of prisoners and in-reach teams. The latter were working in 22 prisons and they were expected to be in all prisons by 2006. There were, however, problems with GP recruitment in prisons and the Community Mental Health Teams working in prisons had a narrow remit and would only work on severe mental illnesses such as schizophrenia.

Dr O’Grady compared the prison system to managing high risk and seriously ill patients in a poorly staffed cottage hospital. There were a multiplicity of problems and some patients were in segregation units and could be violent and disruptive. Added to these problems was the turnover in the prison population. Average General Practice patients in the community changed 15% a year however in prisons it was 15% a week. This led to problems of information about the prisoner patients not being passed on as they went to a different prison or into the community.

Dr O’Grady firmly believed in the concept of a ‘healthy prison’ where there was commitment from the Governor and staff, safety was considered everybody’s responsibility and prison and community teams work to different remits but towards the same objective.

Finally, Dr O’Grady asked that politicians keep prison health on the agenda and ask searching questions about investment. He also wanted to see legislation which would bring together budgets for prison health care.

Andy Smith

Andy Smith raised some concerns from MACA’s operational perspective of providing community based forensic mental health services across 13 London Boroughs. He believed that consistent, accessible, flexible and collaborative multi-agency services would produce increased knowledge and awareness of individuals needs, deliver better and speedier interventions and thus contribute to reduced risk.

Offenders as a ‘client’ group were traditionally antagonistic towards and suspicious of authority and the stigma of mental health problems is reflected in prison slang. This, in part, explains the disengagement from services.

There was a wide variability in services available once an offender is either discharged from custody or is an offender being supervised in the community. There were systems, such as the care programme approach, which worked well and some offenders did get the right packages of care. However, for every offender who is the recipient of a good quality service there were many others who are missed and there condition can deteriorate. These offenders often experience the ‘five Ds’:

Deterrence – characterised by gate-keeping by primary care, unfriendly staff, inconvenient appointment times, poor quality care environments and prolonged duration between appointments.

Deflection – passing referrals to other agencies

Dilution – thinly spread service provision and adopting minimal standards of care

Delay – long waiting lists for consultations and specialist psychological treatments

Denial – which involves not providing a treatment or service at all for more or less justifiable reasons

Mr Smith was concerned about the high incidence of personality disorder and that full clinical assessments are not carried out, and within this group are men and women who may be mentally ill and for a variety of reasons fall within the personality disorder category. He and his colleagues were also becoming increasingly concerned about offenders with mental health problems who were victimised both in prison and once back in the community. They report, being robbed, sexual and physical assaults and often become depressed and entertain self injury and self-harm.

In conclusion, Mr Smith said that if you have assertive out-reach services that seeks to meet the client halfway, its important to have options that meet their needs and are consistently delivered. For the services to be effective, an active network of services have to work in concert with sufficient capacity to deliver. He looked forward to the projected increase in community mental health services for offenders with mental health difficulties which would hopefully address better access and the issues of accommodation and dual diagnosis.

Questions

Lynne Jones MP said that meeting was very timely as mental health had been in the political spotlight for the last few days because of the launch of the draft mental health bill. The needs of prisoners were very much part of the proposals. She asked if Care Plans for prisoners were carried from prison to prison when the prisoner was moved?

Dr O’Grady said that unfortunately this was not usually the case because of often a lack of imagination from those working in the Prison Service and the problems of overcrowding.

Dominic Grieve MP, the Conservative Party spokesman on prisons, said that his prison visiting and research had demonstrated yet again that many people in the prison system should not be there at all because of their mental health problems and perhaps could be dealt with in the community. Dr O’Grady said that people on custodial or community sentences often had similar problems. The problems start in the community and then develop when the person goes to prison. He hoped that the increase in financial support would provide more ‘user-friendly’ services and encourage people to come for help when needed.

Simon Lawton Smith asked about the effect of the proposal in the draft mental health bill about introducing compulsory treatment in prisons and also CTO in the community. Andy Smith said there was already a difficulty engaging people in the community and he was concerned that CTOs would have the effect of many people ‘disappearing’ from services. The message that Government wanted to give often got distorted by the public safety agenda. With regard to the compulsory treatment in prisons Dr O’Grady said it could create a problem. Equivalence should mean that the citizen has the same rights as prisoners but this certainly could not be the case at the moment. He felt it could only work if the prisoner had access to the full range of services available in the community and was a truly mental health based service.

Martin Aaron from JAMI asked about the value of education and training in the rehabilitation of offenders. Dr O’Grady said that there were some formal systems of rehab within the prison service and they were beginning to make links. He agreed that it was an extremely pressing problem as the levels of numeracy and literacy were staggeringly low. Andy Smith referred the APG to a section of the MACA website www.maca.org.uk) called D2W which provided advice on work for offenders.

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