Is the Prison System Failing Mentally Ill People?
Inmates with mental health problems are being badly let down by a system riddled with inconsistencies, reports Louise Tickle in the Herald Society supplement.
When Corinna Penrose was 23 and severely mentally ill with mania, she strode into the middle of a busy road and held up traffic. It was a breach of the peace that resulted in her being picked up by the police and put in the cells. In such a poorly state that she could no longer communicate coherently to explain her condition, she was sent to Cornton Vale prison for psychiatric assessment. This did not happen swiftly; she was held for a week.
Now a service-user commissioner with the Mental Welfare Commission, Penrose explains that though she had been arrested before when displaying erratic behaviour in public, this time she risked being charged with a criminal offence. She believes people with mental health problems should be expertly assessed when they come into contact with the criminal justice system and says the days she spent in an unsuitable prison environment meant her mental health and physical safety were compromised.
“When they're trying to assess you, you're getting no medication, of course, so you can be bad,” she says. “At that time, I was very ill and unaware of the hierarchy with the other prisoners. I was agitating them through my behaviour and, I think, I put myself at risk.”
Because of the deteriorating relationship with her fellow inmates, Penrose was put into solitary confinement. However, for someone in her distressed condition this type of intervention, even if well meant, was dangerously ill-informed. “If you suffer from psychosis, being with other people helps to normalise the situation. If you're completely alone you can go deeper into your psychosis,” she explains.
Though finally released by the court with just an admonishment on account of her age, she notes the someone older could have easily gained a criminal conviction, so affecting their future employment opportunities. And she is most certainly not the only person with a mental illness who has ended up in prison, often for minor offences.
The Scottish prison population currently stands at around 6,700. More than 60% of inmates will enter prison suffering from a mental illness. This compares to 16% of the general population. Dr Andrew Fraser, head of health for the Scottish Prison Service (SPS) notes that 5% of prisoners will be suffering from a severe and enduring mental disorder, four times the background incidence one would expect in the community.
Given the scale and depth of mental distress inside prisons, what is the SPS doing to care for inmates, some of whom will be incarcerated for many years, with others frequently in and out of prison through a constantly revolving door?
It unfortunately appears to be something of a 'prisons lottery' – what you get depends on where you are. Acknowledging the often dire physical and mental state of prisoners entering the system, Dr Andrew McLellan, Scotland's chief inspector of prisons, says that inmates' access to good mental health care is 'very patchy.'
In his report for last year, he found that only one prison in the whole of Scotland – HMP Inverness – offered a standard of healthcare equal to what would have been provided outside. “People with fancy theories about prison medication? Forget it. It's very basic,” McLellan states plainly. “Regarding mental health nursing, you'd think that prisoners have equal access, but they don't.” Equality of healthcare, he notes, would be his preferred standard.
It's also what the SPS wants to offer, confirms Fraser, who is clearly concerned that prisoners get good quality care for their mental health needs. “The mission statement talks about equivalence,” he says. “But it's an issue, because the level of need inside a prison is so great that it can't be met.”
The quality of care doesn't just depend on where you are, it also depends on the severity of your problem. It is generally agreed that the SPS is good at identifying and transferring prisoners suffering from severe mental illness to specialist treatment in NHS hospitals. The number of secure acute beds is insufficient, though adolescents do present an exception. The treatment of less serious, but nonetheless distressing and enduring, mental health problems is another story. Women prisoners and young men are groups of particular concern; the overwhelming majority enter the prison in poor mental health.
The NHS, perhaps surprisingly, does not provide healthcare services in Scottish prisons. Instead, the SPS has always run as a 'total system' with governors in charge of interpreting and delivering the mental health strategy, and operating healthcare contracts independently of the NHS.
How successful this is almost entirely depends on whether the governor gives priority to the mental well-being of inmates. For example, multi-disciplinary mental health teams are supposed to be available in all prisons but the specialist mental health nurses, who are the bedrock of the system, can be easily diverted, by prison management, to other duties. The draft report of the Working Group on Services for People with Personality Disorders – now out for consultation – also questions whether the multi-disciplinary team really do draw on a wide range of expertise.
Fraser appears acutely aware of the need for cultural and operational change. “At the moment, we are revealing the extent of mental ill-health in the system and we are not equipped to deal with it,” he says. “The Prison Service is not a health service. Do we need more resources? Of course we do.”
Clearly, he is working in a context where many prisoners will have multiple, complex problems that community-based health services would also struggle to support. He points out, however, that in England and Wales there has recently been an overhaul in approach to healthcare and the NHS has now replaced the prison service as the central provider; this has meant more integration with community health services and a higher standard of care. McLellan concurs, saying anyone examining Scottish mental health services would also do well to look at the results south of the border since NHS services were introduced.
At the very least, integrating drug treatment and therapeutic regimes for mentally ill prisoners with primary care services upon release would make a lot of sense. In Scotland, however, there is currently no official exchange of medical information between an inmate's GP and the prison's contracted-in GP service. For someone serving frequent short stretches or who is regularly moved between prisons, this means that the continuity of care, so important in the management and alleviation of many mental illness, becomes virtually impossible.
If prisons won't take the initiative, the NHS will have to, says Dr Madeline Osborn, of the Mental Welfare Commission. “Our sense is there is some failure of the NHS to pick up people who are going in and out of prison,” she comments. “Those with mental health problems find it difficult to engage with outpatient services and they will therefore re-offend very quickly and end up in prison again.”
Fraser agrees. “We have yet to create a consciousness in the NHS that some of their people are with us some of the time. The prison system has lost out on the planning for integrated care.”
Delivering better mental health care means looking at the whole system that contributes to a prisoner's state of mind, he emphasises. More staff have now taken on board the principle of rehabilitation. However, prison environments themselves must also improve dramatically. Poor conditions have an effect on mental health; the design of new prison facilities must take revised attitudes to prisoner welfare into account.
“I want to create circumstances where people don't get ill or worse by being in prison,” Fraser says firmly. With prison governors interpreting health policies in different ways, and the existing widespread inconsistency of approach to their care, the thousands of prisoners currently in distress will doubtless be hoping he gets his way.
From the Herald Society supplement, July 19 2005.
2005-08-17 00:00:00
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