All Party Parliamentary Group on Mental Health

Joint meeting of the Mental Health All-Party Group and the

All-Party Parliamentary Penal Affairs Group

5th December 2006 at 5.00 pm in Committee Room 2

MINUTES

Mental health in prison

Speakers:

Dr David James, consultant forensic psychiatrist in the North London Forensic Service and Academic Secretary of the Forensic Faculty of the Royal College of Psychiatrists

Dr John O’Grady, consultant forensic psychiatrist and Chair, Forensic Faculty of the Royal College of Psychiatrists

Janice Webb, mother of a mentally ill offender who committed suicide

Present:

Attendees:     Geoff Dobson (Clerk to APPG  on Penal Affairs)

                        Julia Braggins (minutes)

Apologies:

Lord Ramsbotham welcomed all present to the meeting. He said that this was a particularly pertinent time for the group to be meeting on this theme.  The prison population had reached 80,000 and continued to rise. The Mental Health and Offender Management bills were before Parliament. Running in parallel were the issues surrounding suicide.  The previous day’s publication of the report Avoidable Deaths, commissioned by the National Patient Safety Agency, and the report by Baroness Corston on women’s issues, coming up in the New Year, were both highly relevant.

There would be three speakers, each of whom would speak for 6 or 7 minutes and then time for questions. It was his pleasure to introduce the first speaker,  Dr John O’Grady, consultant forensic psychiatrist and Chair of the Forensic Faculty of the Royal College of Psychiatrists

Dr O’Grady thanked Lord Ramsbotham for his introduction and mentioned that he would be speaking to the printout of slides, which most members of the meeting had before them.  He continued:

“We must start with first principles, and the first is that of equivalence, which is uncontested: that those in prison are entitled to equal rights of access and standards of health care as the rest of the population. I don’t think we need say any more about that: it’s generally accepted in Britain.

Now when you start looking at the mentally disordered in prison you have to put them in context.  And when you start looking at the comparisons between the general population and the prison population, they are a multiply handicapped group, across all domains. Mental health is only one domain, and it may not even be the most important one. When you start looking at things like being taken into care, in the general population it’s about 2%, but in the prison population it’s 27%. If you start looking at people being excluded from school, that runs at about 2% of the general population but for male sentenced prisoners it’s almost 50%, for female prisoners it’s about 33%. When you start looking at numeracy and literacy below the age of 11, that runs at about 20% or so of the general population but about 65% of the prison population. If you look at IQ it’s skewed towards the lower end of the intellectual spectrum.   Looking at things like unemployment, that’s about 5%-7% in the general population currently, but 65-67%, before imprisonment, in the prison population. Homelessness (on a fairly wide definition) runs at about 1% in the general population, but about 30% in the remand population in particular.

Add to that mental disorder and it’s overwhelming.  About 5% of people in the general population have 2 or more mental disorders – but this rises to 70% or so in the prison population.   So when you start looking at this group they’re a multiply handicapped group of people, with handicaps across all domains: mental health, literacy, ability to find employment, ability to find loving partners, a home to live in, and friends. Most also misuse drugs and alcohol to a very high level which adds to their problems.

Our ability to try and work with this group of people – and I have spent a large proportion of my professional career actually inside prisons working with people, so I speak from experience – is bedevilled by two images. The first is the wicked and dangerous offender who terrorises the local population, who is a prolific offender or a sexual or violent offender, and who deserves imprisonment, containment, and  incapacitation.  The other image we have of people in prison is that of the vulnerable, distressed, multiply handicapped person who self harms and has major mental health problems.

I’m sure you know they are one and the same person. You cannot divide the prison population into sheep and goats in a very easy way. The kind of people in society that most wish to have excluded are those with the highest level of psychiatric morbidity. And that is something we have to live with and work with. Now there are different ways we could do that.  The first and most obvious is to have proper diversion schemes at the very start of the process that allow you to stop people getting into the system. Once you get into the machinery of criminal justice, getting out the other side is formidably difficult, especially if you are mentally disordered. Now why haven’t people thought of that? It’s such an obvious idea. Well they have, but they have failed to implement it and David’s going to speak about that, so I’ll shut up about it now.

The second way that people have approached this is the transfer from prison to the health system of mentally disordered offenders, particularly as in-patients.  And that is one of the jewels in the crown of English legislation. We have section 37 (of the Mental Health Act) in this country which allows people to have a mental health disposal at the point of sentencing. Now people don’t realise that that is quite unique in the world. There aren’t many jurisdictions with such an enlightened and liberal approach to criminality and mental health. We do have the ability to transfer people easily and without difficulty from prison to hospital. But if you look over the last decade, in spite of an expansion in the secure units, in spite of investment and despite everything else, the number of people transferred from prison to hospital has hardly changed. There is very little variation over that time.

Just a few statistics and figures: there are c 78,000 people in prison, annual receptions are c 90,000 and the annual turnover is c 160,000.  Of the people diverted from prison to health in 2004, prison transfers were 831. Now that is hardly denting the mentally ill and disordered portion of the prison population. The expenditure on the secure services part – the in-patients side of our business, and that includes people sent to us on section 37 - is something like £500m. The amount put into prisons, spent on in-reach, is something like £25m. Now there’s obviously a problem here about how we approach the allocation of resources. The way I look at it, in imagery, is to think of prisons as a third world country: an impoverished country with very few facilities, with very little ability to get education, or healthcare or anything else.  And then you have first world countries, and I work in one of them, the medium secure units, where you really do get state of the art treatment, which is about as good as you will get probably anywhere in the world at the moment.

Now it’s formidably difficult to get a visa to move from the third world country to the first world country in health. Section 48 and 49 of the Mental Health Act are the visas which allow you to get in. But most people in prison don’t bother even applying for them because it’s so difficult to achieve. You can also get permanent residence through section 37 of the Mental Health Act but again that is for a small number of people. So what you’re left with is a small group of people getting state of the art treatment in our secure services, and an impoverished third world country, that is prisons, with very little service available and very poorly resourced.

Now I’m among politicians so you won’t be surprised to hear that the third way is the way one has to look at it. I commend to you chapter 6 of the Social Exclusion Action Plan published in 2006. It gets it absolutely spot on in relation to mentally disordered offenders.  What it talks about is the super-excluded: that group in our society that prison acts like a sump to drain off, and put into our institutions. Their characteristics are, that any one of their disorders, their mental health, their drugs, their education, their intellectual abilities are sub-threshold. In other words they don’t meet the criteria for admission to those services. So with mental health, for example, the majority of people in prison will have disorders that most community mental health teams will exclude. They don’t take them on. For drug and alcohol services, most are not dependent on opiates, and therefore don’t get into services that easily.  They are poly-drug, chaotic drug users.  They’re all sub threshold. It’s only when you look at the person as a complete entity that you suddenly see how handicapped they are – right across all the domains.

And I think the Social Inclusion (sic) Action Plan gets it right when it says that the approach to that should be a proper multi-agency one: across criminal justice, health, social services, housing, education – everything. And MAPPA is a good model for that, because it has worked pretty well for that group who are seriously violent in our society.  And we have to get away from the two images: evil and into the criminal justice system or vulnerable and into the health system. We have to deal with the real people, who are actually committing serious criminal offences, and who have multiple handicaps, and work to a MAPPA type approach to meeting their sub threshold needs. None of our agencies can meet their needs by themselves.

And that means too that we have to overturn some of our time honoured principles. We have to get mental health services actually in prisons, working with the people who are in there, and working in conjunction with probation, with prison officers and with the whole system.  A third of the prison population will by 2010 be on life sentences for public protection. Now that means that if we are going to be equitable and do them justice, then their risk is associated with some degree of mental disorder. So mental health must be integrated into the risk management systems for those people society considers to be too dangerous to allow out except under very special conditions. So we have a massive agenda here.

So there, I think, is prison health in seven minutes, which is a record even for me”.

Lord Ramsbotham thanked Dr O’Grady for his presentation, and introduced the next speaker, Dr David James, consultant forensic psychiatrist in the North London Forensic Service and Academic Secretary of the Forensic Faculty of the Royal College of Psychiatrists, who would focus specifically on diversion.

Dr James began by explaining that his focus was on the seriously mentally ill, “those with psychotic disorders characterised by delusions and hallucinations, who are among the most ill and most damaged to enter our criminal justice system. The main point that I wish to make is that it is possible to divert such people out of the criminal justice system before they reach the anonymous chaos of the prison system. And it is possible to do this at two locations: the police station and the magistrates’ court. Over the last 15 years there have been new initiatives at both these locations which have been properly audited subject to Home Office investigation and there have been papers published in specialist scientific journals which demonstrate their efficacy. I will deal with the police station first and then the magistrates’ court.

These are both locations through which people charged with criminal offences will pass. We know from work undertaken in London that at least 1.5% of those passing through police custody suites are suffering from these forms of serious mental disorder. We also know that those with such mental disorder who have committed  relatively minor offences are generally released without the opportunity being taken to place them in contact with health or social services. Indeed the impression is gained from the literature that they are released until such time as they offend sufficiently seriously to cross the barrier that is necessary in order to achieve some form of access to health care.

There are in the community resources which should be available to police at police stations and help that could be accessed by the mentally disordered passing through those locations. There are community mental health teams, there are homeless mental health teams, assertive outreach teams, drug and alcohol teams, there is a host of possible places to which people could be referred. But the custody sergeant in the custody suite has access only to two of them: the police surgeon, or forensic medical examiner, who comes to the police station on an item of service basis, and looks only at two things; fitness to be detained and fitness to be interviewed.  Then there is the approved social worker who can be called to the police station in order to institute an assessment under the Mental Health Act (MHA). These are busy people, and the number of hours that it takes before such a person is able to attend the custody suite at the police station is a disincentive to their being called.

However, in Westminster initially, and then in other parts of London, we instituted an intervention. And this intervention has also been undertaken in various other areas. We took community forensic psychiatric nurses and placed them on call to custody suites at police stations and when the police were worried about someone’s mental  health, this person was called in, took a history,  did a report, and immediately accessed the relevant services.   In our first year in Westminster, a third of the people referred were transferred under the MHA from the police station to local psychiatric hospitals.

If I were allowed to use PowerPoint I would show 2 slides which visualised it.   There is the custody sergeant, surrounded by a whole series of all the options available in the community, but he only has access to the two I mentioned. You place the CPN in the middle of that and suddenly, through him or her, the police have access to all the services. This works.  It’s liked by the psychiatrists and greatly liked by the police.

Next the magistrates’ court: a magistrates’ court is a point where people are funnelled and concentrated from police stations.  Normally at a magistrates’ court if a psychiatric opinion is required on somebody who is detained they are sent to a remand prison, often distant from the area in which their local psychiatric service is located.  It is a complicated process to identify the correct psychiatrist to come and see them in prison and the psychiatrist who gets there will have access to little information about the person’s background, unless he brings it himself, and indeed about the offence.  And it can take a matter of weeks to procure a report and a further matter of weeks until the person goes back to court. And indeed if a person is placed on an order to go to hospital it may takes weeks again until someone has a bed at the hospital to which they can be transferred.  How much simpler, then, to put a psychiatric team in the cells at the magistrates’ court in order to short circuit the entire process, to collect information, interview people, prepare a report for the court and arrange  transfer, under the MHA forensic provisions, of people to beds in local hospitals on the very day that they were sentenced.

Now these schemes were initially encouraged under a piloting arrangement by the Home Office which lasted a few years and a number of results from these were published.   As early as 1991, our paper in the British Medical Journal demonstrated that such schemes increased the recognition of mental illness at the magistrates’ court by 400%. They (this has been  a finding from other groups)  speeded up the admission to hospital in terms of days, from arrest to admission, by a factor of 7. Other research has shown that such schemes can deal with serious cases as well as minor cases and we had a series of homicides that we diverted into hospital beds within days of the homicides occurring through such mechanisms. One of our schemes was so powerful that I personally found myself responsible for 12% of the sec 37 admissions in England and Wales in one year and indeed 6% of the sec 48 transfers of remand prisoners to hospital for treatment, merely though this concentrated mechanism.

Now there were supposed to be 150 of these arrangements around the country, they were encouraged under the National Service Framework for Mental Health, and after the HO funding ran out, local purchasers were encouraged to adopt these practices as a standard part of their mental health provision. Unfortunately reports by NACRO looking at the efficacy of these schemes across the country show that over the past few years the number has declined, the resources put into them have declined, and the picture is one of a system that is declining rather than expanding.

Now I first came and talked to this group, I was reminded, 10 years ago about these matters. And I’m disappointed that in the interim nothing much has happened to improve things. However they remain a cost effective and mechanically very effective way of increasing identification of mental illness and avoiding people being remanded into custody in the first place. They should become a standard part of ordinary psychiatric provision. But we now find that PCTs see them as the soft option: somewhere to make cuts. So unfortunately unless there is encouragement from the centre these effective mechanisms will be on the wane”.

Lord Ramsbotham thanked Dr James for his presentation.  He well remembered that, when Chief Inspector of Prisons, he had tried to find out how many diversion schemes were in operation and he couldn’t get the information from the NHS, or from the courts, or from the police. Eventually he got it from the then National Schizophrenia Foundation, who were the only people who were gathering information – not wholly complete but at least they were making an attempt.

Lord Ramsbotham then introduced the third speaker, Janice Webb, mother of a mentally ill prisoner who had committed suicide in prison, and said how much her attendance was appreciated.  He recalled that, when preparing a report called Suicide is Everyone’s Concern, he had spent the day with ten families who had gone through this experience. It was a day he would never forget.

.

Janice Webb began: “My son lies under a grave stone.  He died by suicide in HMP Manchester, suffocated by a plastic bag while alone in a segregation unit.  He was 33 years old.

13 years before his death in Manchester Prison Richard had graduated from Manchester University with a first class degree in physics.  Sadly at the age of 22 while studying for a PhD in astrophysics he suffered a nervous breakdown.  It began with serious suicide attempts – including setting himself on fire, resulting in serious burns and 6 weeks of treatment and skin grafts in a burns unit.  Schizophrenia was diagnosed soon after this. 

From this time on, Richard was seriously disabled by his mental illness.  He spent the next 10 years in and out of psychiatric wards in Newcastle – sectioned for months and years at a time. The suicide attempts continued and he became increasingly dependent on alcohol as a means of self medicating.  Alcoholism and mental illness are a common dual diagnosis. 

Mental illness is no respecter of background or intelligence.   Richard’s background was middle class. He was a bright, able, highly educated young man. How did a highly intelligent young person with a long and well documented history of serious mental illness end his days in prison?   Our society is failing many vulnerable mentally ill people who cannot cope with living alone.   The long term mental hospitals or asylums (here we should not lose sight of the fact that ‘asylum’ means ‘place of safety’) were closed following the introduction of modern anti psychotic drugs.  The care provided by the asylums has not been adequately replaced.  There is no longer a place of safety for people like my son.

When he was very ill Richard was an inpatient and safely cared for in a hospital environment.  With specialist care and modern drug treatment he would reach a stage when he was considered ready to leave the acute ward.  He would then be discharged home with a written care plan in place.  In reality the care plan provided him with a one hour visit per day from a health care worker.  He lived alone in a council flat. He was often anxious, lacking in motivation, with disrupted sleep patterns and a serious drink habit.  Social isolation and the effects of stigma and fear by his local community increased his fragile mental state.  

There were numerous attempts at rehabilitation and care in the community but the options available for the care of the mentally ill with an addiction are woefully lacking.  Vulnerable mentally ill people are often without sufficient support.  Their disordered and chaotic thinking often results in arrest.  I will describe to you how Richard was arrested.

Richard lived in Newcastle – there he was well known to the mental health services.   Any incident would be dealt with by his care team and would usually result in hospital admission.    A few months before his arrest he met and began visiting a girlfriend at her Manchester home.  During this time he was drinking excessively and smoking cannabis.  While in Manchester he purchased a replica Beretta airpistol.   He was fascinated by guns and the idea of suicide by shooting.  He threatened to shoot himself during a phone conversation with his sister.  She called the police as she was in fear for his safety.   My daughter explained  that her brother was mentally ill and threatening suicide.  She asked the police to remove the gun safely from him and to keep her informed of the outcome.  They did not - and we thought he would be safe in a psychiatric unit.  Richard had no history of violence and had only ever harmed himself.

Five days later we discovered that Richard had resisted arrest and in a struggle the gun was discharged twice.  Richard was taken to a police station and from there to HMP Manchester.  Following his arrest there appear to have been no systems in place to give Richard appropriate care.   His psychiatric history in Newcastle was not investigated – despite the information provided by his sister.  There were serious breakdowns in communications between Manchester and Newcastle. He was not given a list of mental health specialist solicitors.  The criminal justice system was unable to recognise his mental disorder and to respond to it appropriately.

Government policy is to promote the diversion of mentally ill offenders from the criminal justice system to health or social services at the earliest opportunity.  This  diversion scheme was not in place at the Manchester court . For whatever reason: lack of hospital beds, poorly informed lawyers, pressure on the system, communication failures, poorly trained judges, lack of funding – Richard was entirely failed by this “policy”.

Once in the prison system – there was nothing we as a family could do for Richard. 

I wrote letters to the Prime Minister, Home Secretary, Secretary of State for Health and to the MPs in Manchester and Newcastle.   I received almost identical replies from each – describing how diversion schemes were in place to “ensure that people with mental health problems do not go to prison inappropriately” and explaining the policy to provide mental health services within prisons.

Visiting was difficult; applications have to be made in advance, and are restricted to one hour only.  We were unable to telephone him – prisoners are not allowed incoming calls.  The period of remand was far too long - from October through to May.  The judge in the final hearing either through ignorance or prejudice was unable to see beyond the replica firearm.  Richard was sentenced to 5 years.

Richard did not cope well with prison.   Care for the mentally ill should be therapeutic and in surroundings conducive to peace and recovery – not the barred, noisy, stressful and gardenless prison.  Those of you who have visited prisons will be aware of how unpleasant and entirely unsuitable a place they are for the mentally ill.

Prisons spend more than half their health budget on mental health care.  They have health care units, employ psychiatric nurses and have in-reach teams – who do their best, but prison can never be an appropriate place for the mentally ill.  His treatment was drug based and not therapeutic.

Richard was locked up for up to 15 hours a day and had only 2 hours of association with other prisoners per day.  He was bullied and treated with suspicion by most of his fellow prisoners – partly because of his illness and partly through the fact he just did not “fit”.   Middle class graduates are not the norm in Manchester Prison.  Prior to his death Richard was placed in the segregation unit for his own safety after a rumour spread among the prisoners that he was a racist.  I will read an extract from a letter written the day before he died:

“You must understand that one of my beliefs, at a deep level, is that the world is a dangerous and malevolent place – this is common with my illness.  As a result, I do assume that everyone is out to get me - hence the olanzapine (the drug Richard is treated with) - and it does not help when everyone is.  I do not want to go to another jail, except Grendon Underwood where I am supposed to go, and I definitely do want to stay on Rule 45, as I am vulnerable because of my mental illness.

You can see that I am in a terrible situation, segregated, hated by the entire jail it seems and not knowing what will happen next.  Someone could come to my door at any time and tell me I am off to some alien jail, unwanted by this establishment, only to find myself clawing out some kind of existence amongst a new set of threatening criminals.  I hate this kind of life and I have considered actual suicide.  I am by myself and the cell is cold.

The rumour that I am a racist may well travel from jail to jail and I do fear for my life.   I don’t want to be battered or slashed, and I don’t see what I have done to deserve all this.  My crime was a few seconds of behaviour while intoxicated.  The whole penal system is geared towards breaking people down, and segregation is an extra ordeal.  On top of that there is no TV or radio”

The following day he took his own life

Things progress grindingly slowly.  Richard was on remand for 10 months before sentencing.  More than 2 years on we still have no date for the inquest.   I am not eligible for legal aid and I will appeal against this.  In the case of deaths while in care of the Government, legal aid should be publicly funded, not means tested.  It seems entirely improper that bereaved families should be denied legal representation at inquests through lack of funding.

My son was not a criminal.  He was in prison because there was no alternative place for him to be.”

Lord Ramsbotham thanked Janice Webb for her moving address. In return, she responded that she had been most impressed by what both the previous speakers had said. If the diversion schemes of which they spoke had worked, she thought her son would have been alive today.

Lord Ramsbotham then invited questions.

Baroness Gibson said she had been interested in these matters for some years, and had heard these arguments before. The logic was clear. She wanted to know what as politicians, the members present could do to move things forward.

Dr O’Grady said he had been in despair for some years at the lack of progress. However, he had been suddenly encouraged by the social exclusion agenda, and particularly by the Social Exclusion Action Plan, chapter 6 of which was about adults. He thought it was superb, and hoped that some of its suggestions would be followed through. Both health and criminal justice agencies had a blinkered view, and could only see their own budgets. So dealing with these cases became a game of pass the parcel. However if you could develop MAPPA type arrangements around courts and diversion, there could be a way forward – although it would take a deal of imagination from politicians and the agencies involved to make it work. But at least the agenda was there, and provided a way forward.

Alun Michael MP mentioned the institutional gaps already referred to, and also the ways decisions were taken – which were different, and at different levels, in different agencies – how can a proper interface be achieved between health and mental health.  He also wondered what the speakers thought eg about support for people in taking treatment where that was prescribed?

Dr O’Grady confessed he was an optimist.  He referred to the achievements under  MAPPAs.  Because there was a statutory requirement for departments to work together towards a common aim, and to commit resources, people from the different agencies got round the table in a common cause.  That would be a way forward. The important thing was to resist the images which stopped us seeing people as whole individuals, and encouraged us to see them as whole persons not as either health cases, or criminals.

Dr James was also optimistic about new ways of working. He was currently working as a mental health worker within a police unit, the first joint mental health–police unit in the UK. He did not think that would have happened ten years ago. He thought there was a greater understanding of the importance of mental health issues now. Other arguments that could be employed to encourage change included re-offending rates: these were substantially lower for those who received hospital disposals than for those who received custodial disposals or community penalties.

Things tended to be seen in financial terms. Keeping people in prisons was substantially cheaper than keeping them in hospitals: that balance had always been against the diversion and transfer of people.  But if you looked at the wider picture, in terms of social effects, re-offending, and the coherence of the system as a whole, you could see arguments for taking things further. The MAPPA agenda was an exciting one, and a model that other initiatives could take up.

Fiona Mactaggart MP said that having been responsible for this area before, she was aware both of the importance of these matters, and of some of the problems. One was that because prisons were cheaper than hospitals, people often got sent there even when it was clear that hospital would be more appropriate. She had always wondered whether there might be a therapeutic option that was neither a prison nor a hospital: was there a third way?  Like, for example, some of the alternatives to custody for women, such as the Asha project or Centre 218. So that we could request that the HO built those, rather than more prisons? Could we perhaps create asylums in the real sense for people who needed that, rather than prison, but which were slightly less expensive than hospital?  Would there be something we could do in terms of the mental health legislation coming before the House that could make that happen?

Dr James responded that residential accommodation and treatment in the community would depend on a degree of compulsion. As he understood it the proposed community treatment order in the new bill had to be preceded by a period in hospital.

Janice Webb confirmed, at Fiona Mactaggart’s request, that her son had been sectioned.  Her son knew what he needed: a community to live in where he was safe, where he could carry on writing his mathematical formulae, which were his interest, but he wanted to be kept free of alcohol. He knew that addiction was his biggest problem, that he had had to be kept safe from drugs and alcohol, and that that would require some degree of compulsion.   But there was nowhere available.

Dr O’Grady agreed that addiction was one of the major issues, but thought that there were problems with that idea. He invited the politicians to address society’s lack of tolerance of a degree of risk, if we wanted to live in a humane society. Rather than the word ‘asylum’, he preferred the concept of sanctuary. If we were to find sanctuary for numbers of people with multiple handicaps, we would have to tolerate a level of social risk that we were currently not prepared to do.

Alun Michael MP invited Dr O’ Grady to explain that to the media for them. He referred to the infantile level of debate in the press around these issues.

Dr O’Grady sympathised. He said that the same was true for psychiatrists, who were often unwilling to take on some of the more difficult people in our society because they knew that if something went wrong, there’d be homicide enquiries and all that went with them.  So there was a joint problem, in trying to get an understanding that while prisons should be used for the most dangerous offenders, our society had to tolerate a degree of risk around a group of people who needed sanctuary, but who would inevitably commit offences.  Yes prisons were safe, because offenders were locked away, but they were damaging and dangerous places.

The Earl of Listowel said that what really appalled him, working with 16-23 year olds in hostels, paranoid and depressed young people, not bad enough to be in hospital but with serious problems, was the lack of support for staff in these circumstances.  Staff going home in tears, overwhelmed by the experience, and inappropriately supervised. He understood that the same was the case in adult prisons too, although in the youth justice system things were a bit better. He sought guidance on good practice in this area, proper supervision and consultancy, support for staff groups as recommended by Lord Warner in his report on children’s homes, support for groups of governors for example, which would do much to assist.

Dr O’Grady referred to Professor Charlie Brooker’s work on in-reach teams in Grendon Underwood prison. These teams were providing very little, in terms of resources. But when CB went to prison officers and governors and asked what impact these meagre in-reach teams had had, the results were quite startling: ‘It’s transformed my prison, my officers, they feel supported, they’re able to cope with mental health because they have a CPN who talks to them’.    These were terribly simple things.   He couldn’t think of any centres of excellence. However there was also the healthy prisons agenda, and a piece of research from Alison Liebling at the Institute of Criminology, Cambridge, showing how important the atmosphere in a prison was – and that was about simple things too: whether officers were prepared to help prisoners make phone calls for instance. Those prisons with a good atmosphere had a much lower suicide rate, and vice versa.  As to using mental health skills in ways other than treating people, Clive Miux, a forensic psychiatrist, had worked in the most difficult segregation units in the country, providing staff consultancy, and the results showed that the officers in those units were much better equipped to deal with some of the most damaged and demanding people in the Prison Service.

Lord Ramsbotham noted that the Sainsbury Centre for Mental Health had recently announced that they were concentrating on just two themes: the mental health of prisoners and the issue of mental health and employment. This issue of good practice and looking after staff was vital.

The Bishop of Worcester said that, faced with the speakers’ optimism, honesty, and experience, this group had presented itself with a problem. This concerned the rhetoric of punitive violence. A few years ago the bishops and church leaders had decided to visit each of the three party leaders, to see whether they could get agreement on issues of race at the election.   He thought the time was right to take that kind of initiative on this issue. It wasn’t that we didn’t know what to do. It was just that we allowed ourselves to be blown off course by that rhetoric, and we needed as a group to make an effort to get that rhetoric foresworn.  Otherwise we wouldn’t get anywhere until half the population was in prison and the other half was guarding them.

Baroness Masham noted that, in New York where there was a lot of TB, they had a system called DOT, direct observed treatment. She wondered whether something like that could be implemented here, for those with schizophrenia in the community, to ensure medication was taken?  She also wanted to ask about alcohol, which was  big problem: alcohol caused depression, and the combination of alcohol and depression, or schizophrenia,   could result in a serious situation.

Dr O’Grady responded on the issues about the community treatment orders, and said that  ways of coercing treatment were, in his view, unexplored in this country, and we should explore them. In New York there was a system called court-mandated out-patient treatment, which he had visited and which was very successful in managing quite a number of very difficult people, who found sanctuary within that kind of boundary. There were however unintended consequences to that – in that they may be applied differentially to black patients in the community who may find that coercive and difficult to deal with. So there was quite a complex debate to be had around coercion in the community: on the one hand there was a sense of sanctuary around the coercion for many people. On the other hand it may bring people into the net of coercion and compulsion in a way that might alienate them. A difficult debate, but one we had to have.

As regards alcohol, why on earth do we not recognise that the drug that is most clearly implicated in violence, domestic violence, and sexual violence  was alcohol, was beyond him. 

Lord Ramsbotham paid tribute to the speakers for a marvellous evening, with three very excellent, thought-provoking, as well as moving, presentations. As Bishop Peter had said, it was appropriate at this time to receive a rallying call, because the duty that was on all in the two Houses that would be taking these bills was clear:  we had to put this message across, in the strongest terms, based on the evidence. But in return, he asked all involved in organisations and professions working in the field to make certain that parliamentarians had the information they needed. There was nothing more powerful than the personal statement, as we had heard this evening. 

Lynne Jones MP, Chair of the Mental Health Group, wanted to make two final points: one concerned the rhetoric. One of the consequences of that was that it was very difficult to attract good people into these services, if every time there was a homicide someone was pilloried.  The other point was that the focus this evening had rightly been on trying to prevent people with mental health problems going into prison but we had to remember that there were so many of them there already. The Mental Health Group had recently visited an NHS facility in London providing services to prisons. A lot of it was to do with substance abuse, and they made the point that alcohol abuse was not well catered for.  The staff there noted that it appeared to be completely down to prisons whether or not they commissioned services. There did not seem to be any analysis by the Prison Service of the needs within a prison. Some prisons seemed to have a good mental health service, and were commissioning other services from them, whilst in others, where the need appeared greater, there was very little service commissioned. She wondered who was responsible, and whether it was completely down to each prison. Should there not be a requirement to assess the mental health needs of the prison population and commission appropriate services?

Lord Ramsbotham noted that while he had been chief inspector he had repeatedly asked the same questions. Lynne Jones had put her finger on the fact that there was no-one responsible for this. The governor in a prison could change, and when that happened everything else changed. This was something that could be drawn out during debate on the forthcoming bills.

Lynne Jones MP suggested that another meeting might be held on this topic, with the relevant Home Office and Health Ministers invited.

Baroness Masham noted that some members were visiting Belmarsh prison on the next day, when some of these questions could be put.

Lord Ramsbotham concluded the meeting by calling on members to thank the speakers, and a round of applause followed.

--------------------------------------------------------------------------------------------------

back to top

back to mental health