Screening prisoners for psychiatric illness: who benefits?

Until recently the provision of health care within prisons was the sole responsibility of the prison service. The Prison Health Service (formerly known as the Prison Medical Service) is the oldest civilian medical service in Britain. In addition to being much older than the NHS the Prison Health Service is much smaller, less well developed and less well resourced. Prison health care was coordinated by the Directorate of Health Care at the Home Office; the Department of Health and the NHS had no direct input. As a result, prisoners were afforded a standard of health care well below that provided by the NHS, and without radical reform there was little prospect of improvement. However, in recent years things have begun to change and last year collaboration between the prison service and the NHS resulted in the creation of a partnership between these two organisations (Joint Prison Service and NHS Executive Working Group, 1999). Although the intention is to improve health care standards for prisoners, the formal nature of this partnership also has the effect of making the NHS more directly responsible for health care in prisons.

Why screen for mental illness?

There are valid reasons for screening prisoners for mental illness, but unfortunately reception health screening in many prisons is carried out primarily because it has to be done. An assessment of the physical and mental health care needs of prisoners on first reception into prison is a statutory requirement according to Prison Service Standard 24: Health Services for Prisoners (H.M. Prison Service, 2000). The historical legacy behind this dates back to the 1865 Prison Act, which introduced legislation making the medical examination of all new prisoners mandatory and instructed doctors to be alert for signs of insanity because health problems, especially psychiatric disorders, were so prevalent among prisoners (Smith, 1981; Hardy, 1995). The same is true today: prisoners with mental health problems continue to pose major problems for the Prison Service and prison health care centres are crowded with people with mental illness who are often more disturbed than those in secure psychiatric hospitals. Recent studies of psychiatric morbidity in prisons in England and Wales (Gunn et al, 1991; Maden et al, 1995; Birmingham et al, 1996; Singleton et al, 1998) indicate that serious mental illness is common, comorbidity is the norm and many prisoners have complex psychiatric treatment needs. Based on the findings of the 1997 Office for National Statistics survey of psychiatric morbidity in prisons (Singleton et al, 1998), it would be reasonable to expect the prison population today to contain 5000 people with schizophrenia and related psychotic disorders. This prison survey did not concern itself with psychiatric treatment needs. Estimates based on previous national point prevalence studies (Gunn et al, 1991; Maden et al, 1995) suggested at the time these surveys were carried out that there were over 2000 sentenced and remand prisoners with serious mental health problems requiring transfer to NHS psychiatric hospitals and many more who required treatment in prison.

Apart from the common finding of psychiatric morbidity, another good reason to screen new prisoners for mental illness is that this provides a unique opportunity to identify and engage an otherwise elusive group of people with serious mental health problems. These are individuals who in the community are often seen as unpopular patients, who do not make good use of services and who, as a consequence, have complex unmet needs (Birmingham, 1999). Indeed, research suggests that over one-quarter of unconvicted men on remand entering prison are suffering from mental disorder (excluding drug- and alcohol-related disorders) and one in 20 has acute psychosis (Birmingham et al, 1996).

Screening: the ideal

Screening for mental illness in prisons should be properly coordinated and form part of an integrated health service for mentally disordered offenders. Screening should operate in conjunction with court diversion and remand prison liaison schemes, psychiatric services visiting prisons, local mental health teams and secure psychiatric services. Close liaison between health, prison and court services is also necessary to prevent prisoners with mental health problems from slipping through the net.

Reception is an ideal place to screen new prisoners and triage those with mental health problems. However, reception screening will inevitably miss some psychiatric morbidity and other prisoners may develop mental health problems later on during imprisonment. Therefore, psychiatric outreach services that extend on to the prison wings (normal accommodation) and into other areas of the prison, such as the segregation unit, need to be set up in order to ensure that the needs of prisoners with mental illness who are not identified by reception screening are not overlooked.

In my opinion it does not make sense for a doctor to examine every new prisoner. It seems much more sensible to use trained nurses to carry out a preliminary health screen with a view to identifying prisoners in need of a more detailed mental health assessment. This could then be carried out by a doctor.

Screening: the reality

Although a clear opportunity exists to intervene in the case of people with mental illness unfortunate enough to find themselves in prison, the only structured health screening that takes place — on entry into prison — is cursory and ineffective (Mitichison et al, 1994; Birmingham et al, 1996, 1997). Poor facilities, pressure of time and prisoners' perceptions of prison staff (and vice versa) mean that in many cases this intervention is little more than an institutionalised procedure. Consequently, the majority of newly received prisoners with mental illness are not identified as such and they are consigned to standard prison accommodation where their treatment needs are liable to remain unrecognised (Birmingham et al, 1998).

Under the traditional model of prison health care, opportunities to identify psychiatric treatment needs in prisoners are limited. Health services are isolated in prisons and, after reception, prisoners placed in standard accommodation are unlikely to see a member of health care staff unless they specifically request this. Many are worried about the consequences of disclosing information to health care staff, who are seen as part of the establishment, and some prisoners have concerns about the standard of medical treatment on offer; consequently few are willing to disclose details about mental health problems. As mentioned above, Prison Service Standard 24 (H.M. Prison Service, 2000) requires that a doctor carry out a physical and mental health assessment on each new prisoner within 24 hours of reception. In local remand prisons, in particular, the large number of new receptions each day and other demands on the doctors' time mean that, in most cases, the assessment is little more than cursory.

Why change?

Effective health screening with prompt access to treatment for prisoners who suffer from mental illness is likely to reduce the suffering experienced by these individuals, help to guard against adverse outcomes, including suicide, and may improve the prognosis for those who would otherwise remain with untreated acute psychosis. Additional benefits include continuity of care for those who remain in prison and psychiatric after-care following release. For non-mentally disordered prisoners, a reduction in the number of prisoners with acute mental illness would have the effect of reducing disturbance on prison wings and free up staff, who could supervise more periods of association.

Less disturbance, less drain on overstretched staff and possibly fewer prisoner suicides are just some of the potential benefits for the prison service arising from improved health screening coupled with resources providing treatment for prisoners with mental illness. When it comes to considering the position of the NHS it is more difficult to identify ways in which the health service would benefit from the demands of more people with mental illness identified by better health screening in prisons. Perhaps the only real answer to the question of ‘why change?’ from the perspective of the NHS is that, having formally committed itself to improving health care for prisoners, the NHS no longer has any choice in the matter: it must now take responsibility for prisoners and health standards in prisons must improve.

Obstacles

Many prisoners have either had first-hand experience of substandard health care in prisons or they are wary about prison health services because of what they hear from fellow inmates and friends who have been in prison. They not only feel that they may not be taken seriously and may not receive proper treatment from prison health care staff, but they express concerns about confidentiality. Fear of discrimination is also a barrier. Disclosing information about a mental health problem may affect a prisoner's standing among his peers, but the greatest obstacle is usually prisoners' concerns that telling prison staff will result in a more restricted regime, being suspected of substance misuse or, worse still, being placed in unfurnished accommodation. Based on the above some prisoners make a calculated judgement about how much information to disclose at health screening: one reason that screening may fail. Prison staff, especially those working in health care, face a dilemma when confronted by the conflicting needs of the prison service and those of individuals with mental illness who are also prisoners. Some prison staff are altruistic individuals who respect those in their custody, but in every prison there are staff who thrive on the historical legacy of the prison service, uphold traditional values and resist change at all costs. A further obstacle to change within the prison service is the fact that the Prison Health Service is poorly resourced, under-funded and likely to remain that way because, in the eyes of the Home Office, health care for prisoners will always come second to other requirements in prison, such as security.

The commitment by the NHS to improve health care for prisoners cannot be met from existing resources, yet the new partnership between the prison service and the NHS has not been underpinned by additional funding. Perhaps part of the reason why so many people with mental illness end up in prison is because psychiatric hospital beds are in such short supply and psychiatric services, especially those in inner-city areas, are overstretched. In terms of clinical need alone, many people with mental illness in prison who require transfer to hospital could be managed in open psychiatric units. However, once they adopt the status of a prisoner the Secretary of State, who sanctions the transfer of mentally disordered prisoners to hospital, may insist on a secure placement. Secure beds are even harder to come by, and transfer to medium security, if required, can incur considerable delays because medium secure units throughout the country are silted up with patients who have nowhere to move on to. Therefore, in order to provide better screening for mental illness in prisoners and ensure that the needs of those who are identified are met, the NHS will have to do much more than just provide more resources in prisons. Psychiatric beds will be required to accommodate prisoners with mental illness who need to be transferred to hospital, and more effective ways of managing mentally ill offenders who are released into the community will need to be developed to reduce the risk of them simply returning to prison.