Government¹ does not know how many people in prison have a mental illness, how much it is spending on mental health in prisons or whether it is achieving its objectives. It is therefore hard to see how Government can be achieving value for money in its efforts to improve the mental health and well being of prisoners, according to a report by the National Audit Office. Her Majesty’s Prisons and Probation Service (HMPPS), NHS England and Public Health England have set ambitious objectives for providing mental health services but do not collect enough or good enough data to understand whether they are meeting them.
Rates of self-inflicted deaths and self-harm in prison have risen significantly in the last five years, suggesting that mental health and well-being in prison has declined. Self-harm rose by 73% between 2012 and 2016. In 2016 there were 40,161 incidents of self-harm in prisons, the equivalent of one incident for every two prisoners. While in 2016 there were 120 self-inflicted deaths in prison, almost twice the number in 2012, and the highest year on record. Government needs to address the rising rates of suicide and self harm in prisons as a matter of urgency.
In 2016, the Prisons and Probation Ombudsman found that 70% of prisoners who had committed suicide between 2012 and 2014 had mental health needs. The Ministry of Justice and its partners have undertaken work to identify interventions to reduce suicide and self-harm in prisons, though these have not yet been implemented.
While NHS England uses health needs assessments to understand need these are often based on what was provided in previous years, and do not take account of unmet need. The NAO estimate that the total spend on healthcare in adult prisons, in 2016-17 was around £400 million. HMPPS does not monitor the quality of healthcare it pays for in the six privately-managed prisons it oversees.
The prison system is under considerable pressure, making it more difficult to manage prisoners’ mental well-being, though government has set out an ambitious reform programme to address this. NOMS’ (National Offender Management Service) funding reduced by 13% between 2009-10 and 2016-17, and staff numbers in public prisons reduced by 30% over the same period. When prisons are short-staffed, governors may run restricted regimes where prisoners spend more of the day in their cells, making it more challenging for prisoners to access mental health services. Staffing pressures can make it difficult for prison officers to detect changes in a prisoner’s mental health and officers have not received regular training to understand mental health conditions, though the Ministry plans to provide more training in future.
In addition, NOMS did not always give NHS England enough notice when it has made changes to the prison estate. For example at Downview Prison NHS England was in the process of commissioning health services for a male prison, when NOMS decide to open it as a female prison instead. When NAO visited six months after it opened, the prison was still in the process of developing a healthcare service that could meet the needs of the female population. The challenges of delivering healthcare are compounded by the ageing prison estate, over a quarter of which was built before 1900 and without modern healthcare in mind. The Ministry has a programme to replace the ageing estate with modern buildings.
While clinical care is broadly judged to be good, there are weaknesses in the system for identifying prisoners who need mental health services. Prisoners are screened when they arrive in prison, but this does not always identify mental health problems and staff do not have access to GP records, which means they do not always know if a prisoner has been diagnosed with a mental illness. NHS England is in the process of linking prison health records to GP records to address this.
Mentally ill prisoners should wait no more than 14 days to be admitted to a secure hospital, but only 34% of prisoners were transferred within 14 days in 2016-17 while 7% (76) waited for more than 140 days. The process for transferring prisoners is complex and delays can have a negative impact on prisoners’ mental health and they may be kept in unsuitable conditions such as segregation units.
“Improving the mental health of those in prison will require a step change in effort and resources. The quality of clinical care is generally good for those who can access it, but the rise in prisoner suicide and self-harm suggests a decline in mental health and well-being overall. The data on how many people in prison have mental health problems and how much government is spending to address this is poor. Consequently government do not know the base they are starting from, what they need to improve, or how realistic it is for them to meet their objectives. Without this understanding it is hard to see how government can be achieving value for money."Amyas Morse, head of the National Audit Office
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Notes for editorsAround £400m Amount NHS England spends on providing mental and physical healthcare in prisons in England 31,328 People in prison who report having mental health or well-being issues at any one time, based on HM Inspectorate of Prisons surveys (37% of the average monthly prison population) 7, 917 People recorded by NHS England as receiving treatment for mental health illnesses in prison in England in March 2017 84,674 Average monthly adult prisoner population in England and Wales in 2016-17 202,099 Number of arrivals into prisons in 2016 (this includes people arriving in prison for the first time, being recalled into prison, and moving between prisons). 120 Self-inflicted deaths in prisons in 2016, the highest number on record 40,161 Self-harm incidents reported in prisons in 2016, the highest on record 40% Of prisons did not provide refresher mental health awareness training to prison staff
- The Ministry of Justice, Her Majesty's Prison and Probation Service (HMPPS), Department of Health, NHS England and Public Health England all have responsibilities for health in prisons.
- Around one in four adults are diagnosed with a mental illness during their life and many more will experience changes in their mental well-being. Most research suggests that people in prison are more likely to suffer from mental health problems than people in the community and being in prison can exacerbate poor mental health and well-being. Prisoners whose mental health needs are not addressed may be more likely to reoffend.
- Until 31 March 2017, the National Offender Management Service (NOMS), was responsible for prisons. On 1 April 2017 NOMS was replaced by a new executive agency called Her Majesty's Prison and Probation Service (HMPPS). HMPPS retains NOMS' responsibility for the operational management of prisons, but the Ministry of Justice will take on NOMS' responsibility for prison policy and commissioning.
- NOMS (which has since been replaced by HMPPS) NHS England and Public Health England have signed a joint partnership agreement setting out their objectives for health in prisons. This was signed in March 2015, and in July 2016 was extended to March 2017. It is currently being revised again. The Partnership Agreement is available here: https://www.gov.uk/guidance/healthcare-for-offenders#national-partnership-agreement.
- Press notices and reports are available from the date of publication on the NAO website. Hard copies can be obtained by using the relevant links on our website.
- The National Audit Office scrutinises public spending for Parliament and is independent of government. The Comptroller and Auditor General (C&AG), Sir Amyas Morse KCB, is an Officer of the House of Commons and leads the NAO. The C&AG certifies the accounts of all government departments and many other public sector bodies. He has statutory authority to examine and report to Parliament on whether departments and the bodies they fund have used their resources efficiently, effectively, and with economy. Our studies evaluate the value for money of public spending, nationally and locally. Our recommendations and reports on good practice help government improve public services. Our work led to audited savings of £734 million in 2016