BMJ  2006;333:989 (11 November), doi:10.1136/bmj.39028.469965.DB

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Care of mentally ill prisoners is "clearly dysfunctional"

¹ London

MPs and peers have said that a "fundamental shift" is needed in the way offenders with mental health problems are treated in the United Kingdom if levels of crime are to be tackled and the prison population reduced.

"Massive investment" is needed to bring mental health services in prison in line with those offered in the community—something that the government has promised but that is still far from being achieved, they say.

In an interim report focusing solely on mental health the all party parliamentary group on prison health has labelled prisons as "clearly dysfunctional" in the way they deal with prisoners' mental health problems.

Lord Ramsbotham, former chief inspector of prisons, said: "Prison health is a public health issue. In far too many cases [prisoners'] mental health will have deteriorated under our current system."

The government has said it wants to see a mental health service in prisons equivalent to that available in the community. As part of its five year strategy to reduce reoffending it has introduced mental health teams to work in prisons and shifted the responsibility of commissioning mental health services for prisoners away from the prison service and into the hands of primary care trusts.

However, after visiting a number of prisons the group has concluded that "we are very far from being able to say that this [an equivalent mental health service inside and outside prisons] has been achieved."

A shortage of psychiatrists working in prisons, delays in getting prisoners transferred to psychiatric hospitals, poor transport arrangements to take prisoners to hospitals for appointments, and the fact that prisons are exempt from the auspices of the Mental Heath Act all contribute to failing mental health services for prisoners, the group says. In addition, the emphasis on security in prisons rather than a healing environment as found in community services can jeopardise the success of interventions, with as many as a third of prisoners not turning up for appointments in prisons.

"Perhaps future generations will look back on our generation which has criminalised a large section of its mentally ill as being just as misguided as previous generations which exhibited the mentally ill as freaks," says the report.

The group has called for a "major boost" to community based mental health services to help people at risk of offending to stay in education or work and to maintain family and social relationships to help prevent them turning to crime. "Massive investment" is also needed in a stepped care model of services, so that prisoners have good quality primary care for minor problems such as anxiety while those with more severe problems can get specialised care.

It also wants to see real alternatives to prison for people with severe mental health problems. In addition, better links are needed between mental heath services inside and outside prisons so that prisoners who need compulsory treatment are taken to hospital and not kept in prison until a bed becomes available.

Fabian Hamilton, the Labour MP who chairs the all party group, said, "The evidence is overwhelming. We are trying to deal with people with mental health problems in a dysfunctional system.

"What is needed is a massive investment that provides high quality support outside prison; but with the current crisis of overcrowding and the cost of keeping an individual in prison running at £37 000 [55 000; $70 500] a year we believe that will be money well spent."

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