23rd October 2017
Scope of the inquiry
Despite setting ambitious objectives for providing mental health services to prisoners, the Government does not know how many people in prisons have a mental illness, or how much it is spending on treating them, according to a National Audit Office (NAO) report.
The NAO estimates that c.£400 million was spent in 2016–17 on prisoners’ healthcare in England. This included treatment for 7,917 mental health patients. However, surveys carried out by HM Inspectorate of Prisons found that 31,328 prisoners (37% of the prison population) reported mental health or well-being issues.
Incidents of self-harm and self-inflicted death in prisons are increasing with 120 self-inflicted deaths in 2016—the highest on record. The Prisons and Probation Service estimated that 70% of prisoners who ended their own life between 2012 and 2014 had mental health needs.
Clinical care to prisoners is considered good, but identification of those who need mental health services is not consistent. Prisoners are screened upon arrival but staff do not have access to GP records. With a 30% reduction in public prison staff between 2009 and 2017 it is harder to detect changes in prisoners’ health, whilst in private prisons HM Prisons and Probation Service does not monitor the quality of healthcare provided.
The Public Accounts Committee will ask NHS England, HM Prisons and Probation Service and Ministry of Justice about how they are working together to secure reliable data on incidences of mental illness among prisoners, why reliable data does not yet exist, and how at a time of budgetary pressure they will ensure to provide healthcare provision to those prisoners who need it.
Questions from Gillian Keegan MP
Q10 Gillian Keegan: Possibly this question picks up on something Dr Stone said about how commissioning can make a real difference; some facilities are very good and so on. We visited one recently, and it seemed that the health staff were very good. But how would you actually know? The thing that strikes you about this whole thing, despite all the process breakdowns on the way in, is the disconnect between the objectives and any plan to deliver them, whether that involves sentencing, screening, access to the right staff and then the environment, or whatever. All the way through, the plan does not hang together, so how would you actually know? What would you suggest? It is a complex area, but how would you be able to improve this to have a more outcome-based process?
Dr Huw Stone: I think the commissioning process has not included a proper evaluation of the services that those commissioners are commissioning, and an important component of that is the quality of the service. I am here today representing the quality network for prison mental health teams, which the Royal College of Psychiatrists runs. We would encourage all commissioners to ensure that their prison mental health teams are members of a quality network such as ours, where this is
done on the basis of a peer review, with the network learning from the teams that are really good and those that are struggling perhaps learning how to improve the way they are working. Also, as the NAO Report pointed out, in terms of the whole commissioning process, the retendering of services has had a drastic effect on prison mental health teams. If you talk to anyone working in prison mental health teams, they will describe the disruptive nature of this process, where every few years the service is re-tendered out. It can take 12 to 18 months to complete that process; it can cost a lot of money. I think that it is something that really could be done very quickly, to say that that sort of rapid turnover of tendering should cease. We would recommend that services should be provided for at least 10 years before a re-tendering exercise is undertaken.
Q11 Gillian Keegan: If you look at the continuity from the prisoner or the patient’s viewpoint, it seems to me that even if you have better quality service and the way in which it is tended is not as disruptive, the record follows the patient through their mental health journey in very few cases. At the end of a prison sentence—a short one, in most cases—how can the treatment continuing afterwards ever be effective?
Dr Huw Stone: I think that things have actually become more effective in the prison system, in that there is now an electronic patient record that goes across all prisons. When a prisoner arrives at a prison, the staff can immediately look up all of the prisoner’s records—not just from that sentence but perhaps even from previous sentences. I have seen a huge change in that during my lifetime working in prisons.
Q12 Gillian Keegan: But the NHS records are the missing piece.
Dr Huw Stone: You’re quite correct. As you say, there is a big disconnect between what happens in the community, both before someone comes into prison and after they are released from prison. That is when there is a big disconnect.
Q28 Gillian Keegan: We have talked about the rise in self-harm and suicide. How much of that do you think is linked to Spice?
Dr Andrew Forrester: That is a difficult question to answer. The increase in self-harm and suicide rates is probably attributable to a range of factors, of which Spice is one. The deteriorating prison environment also has to be put into the mix; as numbers of officers have gone down, and as incidents of violence have gone up, so things such as time out of cell have become difficult. There are some reports of prisoners spending less than an hour out of their cell per day. All those things within the environment are important as regards self-harm.
Q29 Gillian Keegan: We were quite surprised when we went to a wing with 300 prisoners—
Chair: Just to be clear, we went to Wormwood Scrubs—
Gillian Keegan: In Wormwood Scrubs, we went to the wing with the less engaged people who were not going out to work, etc. There were seven prison officers for 300 prisoners on four floors. It seemed obvious that that would keep people in their cells more, but there is also an impact when the care is available: less than 60% of the appointments were met because people could not get there. It seems to me that the whole system and the design do not hang together. Even in the bits that you use, you are looking at one individual element of it and there is no holistic plan— with the exception of you, perhaps, Mark—to have the patient at the centre of the care. What would you recommend in terms of a prison environment that would—
Mark Johnson: If I can be really honest here, political decisions were made a couple of years ago that, I believe, played quite a big role in causing this problem.
Q30 Gillian Keegan: What was the decision?
Mark Johnson: The reduction in prison staffing levels and in interventions and stuff as well. I am talking about direct interventions. Not only that, but no new way or innovation was put in place instead. The old, archaic controls, etc., are still there. I see prison from a different perspective; I see that prisoners run prisons. They do. That is a fact. Yet we still control them and lock them up. There are no staffing numbers, but there are peer-led interventions that we could do that are proven worldwide. They create an enabling environment so that prisoners can play a more active role in their own rehabilitation. We have a very colonialist approach to administering rehabilitation, when—speaking from lived experience—it is very different from that. The frustrating part for me is that prison governors are measured on how many people break out of their prison, and not on how many people come back in. We need to change the dynamics of that and create a whole revolution and drive towards people being equipped with what they need in order to never go back into prison.
Q31 Gillian Keegan: Going back to self-harm, how easy is it to self-harm in prison? How can they protect prisoners from that kind of environment? We saw lots of broken windows and things. What is your view?
Mark Johnson: Prison is a place of isolation. Anybody would tell you, and I am sure the doctors would tell you, that there are three types of abuse— mental, physical and sexual—but it is not the event that causes the damage, it is the sense of isolation. Prison is a place of isolation. Nobody talks about this stuff. If you have seven prison staff in a wing of 300, is that suggesting that they are even qualified to understand what mental health is, never mind being able to physically do anything about it?
Q32 Chair: But in terms of actual harm, things like broken windows and ligature points—
Mark Johnson: It is easy. It is absolutely easy. It is like drugs. People say, “There are no drugs in my prison.” There will always be drugs, because when there is a market and a need, there is a drive to want to go and find it. Razor blades, plastic, you name it; any implement can be used to self-harm. The question is why. That is the question. Why? What environment are we putting these volatile people into in the first place that is exacerbating the problem of their doing this stuff?
Q33 Chair: Dr Forrester, on that point?
Dr Andrew Forrester: One key thing is that many of our prison environments are completely out of date and need an upgrade across the board. Ligature points are a huge issue for suicide in prisons. It is difficult to address in older Victorian prisons that were built in 1843 and so on, but we must be able to find a way to solve the ligature points issue.
Q34 Chair: You say, “You must be able to,” but have you got any ideas about how that could be done? In other inspectorates they have to identify ligature points in other settings. Dr Andrew Forrester: There are ways of doing things around safer cells, for example. Perhaps building different prisons is a way forward.
Chair: That is under way, I suppose.
Q35 Gillian Keegan: That is under way, but I worry about whether this thinking is actually inputted into the planning process for the new prisons.
Mark Johnson: It’s not.
Q36 Gillian Keegan: You don’t believe it is.
Mark Johnson: I don’t believe it is.
Q37 Gillian Keegan: Dr Forrester, have you seen any evidence?
Dr Andrew Forrester: To an extent. Sometimes bodies such as the Royal College might be asked to comment and so on, but I think that more expertise could be put in to these new designs.
Sarah Hughes: I think that there is something about recognising selfharm too. Some people who are repeatedly self-harming are at a greater risk of suicide because of physical health and so on. It is not just about going immediately to the ligature points, although that is incredibly important. Ritualistic self-harm on a daily basis needs to be understood, and the only people who can are the people on the wings—peer workers and officers.
Q73 Gillian Keegan: Mr Stevens, you mentioned a hotch-potch of services that were there previously. Rarely have I seen such disconnect between the high-level objectives—providing health and wellbeing services in prisons, and looking to improve health, tackle health inequalities and reduce reoffending—and any semblance of a sensible, joined-up plan. You talk about little bits and parts of tackling each individual piece as a solution. None of those will be effective without a sensible joined-up plan. What are you doing to achieve that?
Simon Stevens: Kate is obviously our prisons expert here. Looking at the history of this, I think in 2005 responsibility for prison health was transferred to the NHS but was largely the responsibility of local primary care trusts. Then in 2013, for the first time, we were able to take a national point of view on that. As contracts have come up for renewal, we have been able to drive more consistency into the way in which those contracts are being let. I do not say that we are at the end of the line on that. There are clearly some intersections that are not working as they need to. Those are, in many cases, rightly pointed out in the NAO Report. But in terms of both the investment and the quality of care, let us remind ourselves that the NAO Report says in several places, “clinical care is broadly judged to be good”. I think that is correct.
Q74 Gillian Keegan: That might be true, but the process disconnect almost makes the service inaccessible. There is the continuity of records—of NHS health records and GP records—going to the prison and a treatment plan that is joined-up and has the prisoners’ needs at the centre of it. Then there is the problem with the records following the patients—the screening and diagnosis—and then, when you have got an appointment, when you have a treatment plan, there are not enough prison officers to take you out of your cell and deliver it. The appointment rate is 60%. If you have not got records to follow this up, it is not working.
Simon Stevens: Fundamentally, yes, but your stat is wrong. I think 15% of appointments are not kept, as measured off the most recent information set for the performance.
Q75 Gillian Keegan: We went to one prison on Friday. They said that only 60% at best were kept, and they thought they were doing well.
Simon Stevens: That was Wormwood Scrubs, was it?
Gillian Keegan: Yes.
Simon Stevens: If that is the Wormwood Scrubs position as of Friday, that is significantly worse than the national position. The underlying point is correct, which is why we have taken action. In fact, we signed a contract on the Friday just gone for the equivalent of a GP medical records set that will be available for prisoners. We will be able to import their medical records for their prior treatment in the community and subsequently export their in-prison healthcare experience. We signed that contract on Friday, and it will take between 12 and 24 months to get a complete roll-out across the whole of the adult prison estate, youth prisons and other parts of the criminal justice system, but that is going to make a hell of a difference. If you had come with me to Belmarsh prison, where I was a few weeks ago, you would have seen some of the improvements that have been made more recently, such as the smart card that enables prison health teams to get access to the summary care record, which was previously not available. Previously, faxes were flying around the system with bits of information.
Chair: Sorry, we were just laughing at the idea of the faxes. Our fax machines are gathering dust.
Simon Stevens: Well, indeed. Was that a pretty screwy system? Yes. Have we taken action to tackle it at root? Yes. Will we see the clinical benefits of that over the course of the next 12 to 24 months? Yes.
Q76 Gillian Keegan: How are you measuring your clinical benefits? In your new agreement, have you got measurable outcomes?
Simon Stevens: There is a chicken-and-egg aspect to this. If we have not got the longitudinal medical record, it is hard to track what is actually happening to prisoner health status. Once we have that record, we will be able to do that.
Q77 Gillian Keegan: So you accept that we have no idea whether the £400 million we have spent so far has been effective or not.
Simon Stevens: No, I think that is a generalisation.
Q78 Gillian Keegan: Give me a specific example of how it has been effective. We can’t see anything that you can measure—reducing reoffending, for example.
Simon Stevens: Here is the indicator set that we use—I can leave this with you, although you may have got it—to track what is happening inside the health services in prisons. It is pretty extensive. Is it all-singing, alldancing? No, but to say that there is nothing here in this phone directory’s-worth of information would be a mistake.
Q95 Gillian Keegan: How do you do that assessment if you do not know how many people have a mental health issue, you do not have a proper screening process and you do not have the GP records beforehand? How do you do it?
Chair: Practically?
Kate Davies: If we are talking about data, there are a number of elements as well as the data we have, including the substance misuse data from the national drug treatment misuse service and mental health data from both primary and secondary care. The data also include the healthcare data that we have locally within prisons; all our healthcare providers also support us with a local matrix of information. They also include the P-NOMIS information that we work with within our prison system, particularly the important information on gender, race, ethnicity or age, and particularly some of the information that is key—
Q96 Gillian Keegan: Just to stop you, when we went to Wormwood Scrubs we heard how inadequate the mental health professionals felt the records that they had were. They were asking for GP records that they never received, and having to pay £25 to get one, if it ever came. They did not have any information at all. The screening had almost half the questions not answered. So you don’t have the information to start.
Simon Stevens: That is why we are procuring the new health information system—the electronic medical records system—for all prisons. Kate Davies: That includes the new clinical templates. I completely agree—
Q97 Gillian Keegan: But you are talking about the last four years. You spent £400 million or something.
Kate Davies: But we really wish we could have had that in earlier. We have had to take that and develop it. It is a new £30 million service around the health and justice information system. We are really proud to have been able to put that in for the first time in England and, as far as the World Health Organisation is concerned and has fed back as part of the global, it is something that we are absolutely keen has to be improved. There is no doubt about that, but alongside substance misuse, mental health and vulnerability, including learning disability, it is absolutely essential that we now put that in place and commission it in the way that we have.
Q108 Gillian Keegan: When we were at Wormwood Scrubs, they explained to us that the loss of staff and people leaving was outstripping recruitment. That was the first issue. The second was that your process for the recruitment itself takes seven months to clear somebody—both mental health professionals and prison officer staff. Trying to plan your career with a seven-month wait is impossible. Are you creating the problem of not having enough staff in prisons or in mental health provision in prisons?
Chair: Who is that question addressed to?
Gillian Keegan: Mr Heaton and Mr Stephens.
Richard Heaton: Retention of officers is a problem, particularly in areas of the country where the labour market is buoyant. However, our staff in post—not just numbers of recruits but net numbers of staff in post—is going up. We are outstripping a retention problem, and we are also improving retention in those prisons with the worst numbers. It is disappointing that it takes sometimes too long to get prison officers in post—
Gillian Keegan: Seven months.
Richard Heaton: I am not sure how representative that number is. We have worked very hard to reduce the time to hire.
Q109 Gillian Keegan: What is your objective?
Richard Heaton: I cannot give you a number.
Gillian Keegan: You need a number.
Richard Heaton: I cannot give you a number right now.
Q112 Gillian Keegan: Were you aware that it was taking seven months to clear mental health professionals to work in the service?
Simon Stevens: Yes, we are aware that there are delays, and we have been in discussion with the Ministry of Justice about that, because in just the same way as the operational—
Q113 Gillian Keegan: And when did you become aware? Simon Stevens: We get constant feedback from staff and from our healthcare providers in different parts of the country.
Kate Davies: It is something that we were working on for a number of months. In fact, I know that, at the moment, we have 67 staff waiting for clearance after being employed. As increased levels of staff in a number of prisons—
Q114 Gillian Keegan: We have also heard of third parties that do a similar service and that do it in a couple of months. They do not create any delay whatsoever. Is it just your inefficiency or failure to address the problem? It will clearly never lead to the staff you need.
Richard Heaton: There are various pinch points in the process and we have addressed some of them. For example, one of the pinch points is in our shared service provider. We have recruited additional staff, seconded to the share service provider, to help that part of the process. The other pinch point is vetting, where we have used—
Q115 Gillian Keegan: Have you given them a service level? So they would have to do it in x months or x days or whatever?
Richard Heaton: We certainly have an aspiration for how short the time to hire needs to be. I wish I could give it to you now.
Q118 Gillian Keegan: Prison staff are key to delivering this aspirational service that you have. If you do not get this right, I think you may as well not bother with the rest of it.
Richard Heaton: We are successfully addressing the recruitment challenge.
Q119 Gillian Keegan: It is the joined-up thinking that is completely missing again. Does your new partnership agreement address that joined-up thinking? Do you have a single plan that will actually be able capable of addressing this?
Richard Heaton: On staffing?
Gillian Keegan: On everything.
Richard Heaton: Yes. I hope the new partnership agreement will be a step improvement on the first one, which, as has been said, was better than the multiple arrangements that pre-existed NHS England taking on this work. I am hoping that the new partnership agreement will set out proper measures that are quantifiable for health and wellbeing across the prisons—not just in the clinical parts, but in the prison service parts.
Q138 Gillian Keegan: Can we just move on to the prison environment? Another thing that is quite important is actually the prison itself, and enabling mental health and wellbeing services to be delivered—and, indeed, places that would promote mental health and wellbeing. How involved are the NHS or the mental health professionals in the design of the new-build prisons to optimise the building with mental health in mind?
Michael Spurr: We have had a wide range of involvement from, certainly, NHS colleagues but also wide international and academic input into the design of prisons. The new prisons that have been designed: I am very confident about those designs bringing together the best practice internationally, at trying to design environments that will mitigate the issues—the pains of imprisonment, as it is called in criminological terms— to try and promote wellbeing.
Q139 Gillian Keegan: When can we expect to see this? When will we expect to see these new prisons?
Michael Spurr: We have got planning permission for three sites at the moment: the former prison at Glen Parva, which was closed in the summer, a site at Wellingborough, which held a prison some time before, and at Full Sutton. We are pursuing the position in terms of developing tenders for contract at the moment. We have still got to get through the final parts of the business case, but I would anticipate that, within the next few months, we will be proceeding with some of those sites.
Q140 Gillian Keegan: We had heard that actually you were not really taking that input in the prison design. Is it one of these open-ended consultations, or are you absolutely convinced that you have had the right experts giving you right advice, again going back to joined-up thinking?
Michael Spurr: Yes, we have had an extensive amount of engagement with a range of different bodies, individuals and academics. I am very happy to take people through how we have done that—it is not appropriate here—but yes, I am absolutely confident that we have engaged widely. The environments are really important. Just to say, we have worked very closely with the Royal College of Psychiatrists about developing better environments in prisons—therapeutic environments. Psychologically informed planned environments—PIPEs—for particular personality disordered offenders are a real success story over the last few years, where we have had something like £40-something million diverted from wider secure health settings to support personality-disordered offenders in prison and in the communities and in approved premises. We have been working to develop enabling environment award standards in the way that we deliver services in approved premises in probation. One whole prison, Drake Hall female prison, has gained that award from the Royal College of Psychiatrists. So we have been working very closely with professionals about environment and wellbeing.
Q141 Gillian Keegan: The cost of reoffending is estimated to be between £7.4 billion and £10 billion a year, so there is a clear business case for you to get this right. Do you look at it in that way? Do you analyse and measure it?
Michael Spurr: Yes. You asked previously about reoffending. Of course, there is too much reoffending. I have spent my whole career trying to reduce the risk of reoffending. The numbers have actually improved—not as much as we would have wanted, but from prison specifically the 2015 figures, the latest available, are that 43.4% of people who left prison reoffended within a year. Of course that is too high, but that is 2.1% better than the previous year and five percentage points better than it was 10 years before that. I accept that that is not good enough. That is why the whole reform agenda—the White Paper agenda—needs to take that forward. But of course it matters. We talk about preventing victims by changing lives. It matters, because if we can prevent somebody offending, that prevents a crime and a victim in the community. So absolutely it matters.
Q165 Gillian Keegan: As well as a lack of clear targets or a clear sense of who is responsible for them, there is something else bothering me. I think the way this works is that there is a fixed contract price, with mental and physical health all going into the same area. How on earth are you going to make sure that the budget is sufficient to deliver the service that we have talked about today?
Simon Stevens: By setting a specification for the service to be delivered at a particular prison and running competitive procurements to choose the most advantageous provider.
Q166 Gillian Keegan: But you are going to be spending more, aren’t you?
Simon Stevens: Actually, the effect of some of the competitive procurements has been to create some savings in aspects of the way these services have been provided. But looking over the next several years, my expectation is that we will be spending more in this area. If you look at our health and justice programmes, not just in prisons, but in the round—including liaison and diversion, sexual assault services, immigration removal centres, young offenders institutions and so on—NHS England has been increasing investment in those programmes faster than the increase in the overall NHS budget.
Q167 Gillian Keegan: Are you going to ring-fence mental health services?
Simon Stevens: Within the prison? Definitely not, because that would cut across the integrated clinical model that most people think makes sense. Most people who actually try to run those services—a GP, a counsellor or someone in substance abuse services—say that it would be deeply unhelpful to somehow partition the physical and mental health and wellbeing or addiction services they provide.
Kate Davies: As Mark Johnson said earlier, we need to ensure that 100% of men and women within our prisons, including children and young people, are receiving a levelling assessment around mental health, vulnerability and substance misuse at all levels, as part of that service. That does not mean—this was quite rightly part of your question—that we should not also commission services that are required and needed for mental health or substance misuse or other elements of healthcare. What is really important, certainly from the feedback we have got from all our service users and patients in the last 18 months, is that they want to see that assessment and that need run through all services on mental health, substance misuse and vulnerability.
Q168 Gillian Keegan: Well, it’s going to be a step change from the way that you work today. You don’t know how much you are spending today.
Simon Stevens: That is not true. I think I wrote to you a year ago, Chair, saying that we thought we would be spending £150 million out of the £400 million last year on mental health-related services, and subsequent to the NAO Report, when we went and kicked the tyres, that is indeed what we were spending. It was £148 million, in fact, so we do know.
Q169 Chair: Just to be clear: that is in on mental health services in prisons.
Simon Stevens: Mental health and substance abuse in adult prisons.
Q170 Gillian Keegan: But we have talked about the inadequacy of the records, of the screening and of the treatment, and the fact that people cannot get to the treatment—
Simon Stevens: Yes, but you just said a different thing, which is that we do not know what we are spending, and we do.
Q171 Gillian Keegan: So you are happy that what you are spending is meeting the objectives that you set out, which are to provide equivalent health care and to make sure that people have the support that they need to reduce reoffending. Are you happy that you are spending enough to achieve the objectives? This is the whole point: the objectives are not clear and the spend is not clear. They are not tied together.
Simon Stevens: As we said earlier, I agree with the NAO and others when they say that clinical care is broadly judged to be good. I note that the speed at which prisoners get access to GP services, mental health services and substance misuse services within prisons is as good as and, in some cases, faster than would be the case if they were outside prison. I also believe that there is a net need for a number of these services in just the same way as there is across the country as a whole, so for that reason I expect that we will be spending more on these services in the years to come. The NAO Report says that improving the mental health of those in prison will “require a step change in…resources”.