The government has recently agreed to consider re-fashioning In-reach Psychiatric Services, so that they can focus on prisoners with severe mental illness.
A recommendation to that effect was made by the Labour peer and former Home Office Minister Lord Bradley, in his review of how the criminal justice system treats people with mental health problems or learning disabilities. The Bradley Review was wide-ranging and its analysis has been received favourably, not least in Whitehall.

Lord Bradley was responding to concerns raised by in-reach professionals, who told him they were unable to concentrate on the most seriously mentally ill prisoners because they also had to provide a service to others, such as those with personality disorder or who had self-harmed. A recent evaluation found that 60 per cent of prisoners receiving in-reach services were not severely mentally ill, although more than 40 per cent of them did have a personality disorder (and 70 per cent had substance misuse problems). The government has set up a programme board to implement many of Lord Bradley’s recommendations, and amongst other things, the board will consider this recent evaluation and act upon its conclusions.

Primary Care
Lord Bradley suggested that in-reach services might be better able to fulfil their purpose if other services were of higher quality. It seems that, like most of those outside the wall, the majority of prisoners with a diagnosed mental health problem can be treated adequately and safely in primary care. The government has therefore accepted that there must be less reliance on inpatient care, and that robust primary mental health services must be developed. It has asked Offender Health – the partnership between the Department of Health and the Ministry of Justice – to make the change, working with regional offender health commissioning groups and appropriate third sector organisations.

At one end of the spectrum, there is, of course, a dedicated programme for those with Dangerous and Severe Personality Disorder (DSPD), which includes pilot services in two high-security prisons, HMP Frankland and HMP Whitemoor; two high secure hospitals, Broadmoor and Rampton; the women’s prison HMP Low Newton and three medium secure hospitals. Between them, these services provide 350 assessment and treatment places, but Lord Bradley was concerned that they might not be sufficient, and that the DSPD programme as a whole is not fully integrated with other related work. He concluded: “there is currently not a coherent and agreed inter-departmental approach to the management of personality disorder within the criminal justice and health systems”. Lord Bradley recommended that the government evaluate both the treatment options for prisoners with personality disorder and the DSPD programme itself, and also that it develop a strategy for the management of personality disorder within both the health service and the criminal justice system, and covering offenders in both prison and the community. The government has agreed to produce such a strategy by February 2010.

Transfer to hospital
Another controversial issue is prisoners who require treatment for acute mental illness and the speed with which they can be transferred to hospital. In 2005, the Department of Health found that at any one time, an average of 282 prisoners are awaiting initial assessment by a psychiatrist. Significant progress has been made of late, but some prisoners still have to wait a long time to become patients.

Lord Bradley recommended that the Department develop a new target, requiring the NHS to receive a prisoner with acute, severe mental illness into an appropriate healthcare setting within 14 days. Although at first sight striking, this target is not new: it is being used even now in the Department’s own pilot scheme, which has been running for some time, but has yet to be evaluated. The government “agrees with the goal behind this recommendation” but will only say that the position is “under review”, and the programme board will consider whether further guidance should be issued. Some thought will also have to be given to security, especially in low and medium-secure mental health facilities.

Lord Bradley said it was important to provide an appropriate level of physical, procedural and relational security, “so that the public can feel fully confident in the diversion of acutely mentally ill patients from prison custody”. The government has accepted in principle that there might be a need for such things as standardised risk assessments, and the programme board will deliver its own conclusions by April 2010.

Reception screening
That is also the date by which the government hopes to have developed an improved prison-reception screening tool. Lord Bradley expressed concern that the existing tool, though much improved on its predecessors, was not being properly implemented, and in particular, that it could not identify individuals with learning disabilities. Echoing concerns expressed by HM Chief Inspector of Prisons in 2007, he suggested there was a particular problem with the second part of the tool, which “is supposed to be undertaken away from the constraints of the reception environment”.

Prisoners with a dual diagnosis
Lord Bradley also expressed concern that where a prisoner has a dual diagnosis – in other words, he or she both suffers mental health problems or learning disabilities and misuses drugs or alcohol – the services provided do not work well together. He found there were separate national policies for each service, and that, far from being a prompt for careful treatment, a dual diagnosis is often regarded as a reason to exclude someone from services. Accepting Lord Bradley’s recommendation in principle, the government has agreed to consider improving services to prisoners affected in this way. The programme board will look at the resource implications of doing so, both for the criminal justice system and for the NHS, and meanwhile, work is underway to improve the management of dual diagnosis among offenders and to give staff the relevant assessment skills.

Training
Action is also to be taken to improve prison officers’ awareness of mental health and learning disability issues. Those who are wing-based currently receive three days’ awareness training. Two years ago, an evaluation found that this training had been poorly implemented, and that finding was again echoed by the Chief Inspector.

Lord Bradley recommended, therefore, that all prison officers receive mental health and learning disabilities awareness training, and that this training be provided jointly with other services and involve service-users. The government says that appropriate responsibility will be given to offender health regional teams.

Care Programme Approach
The Care Programme Approach (CPA) is to be fully implemented in prisons as a matter of urgency. This recommendation, which was also among those made by Lord Bradley, dates back to at least 1999 and the report of a Prison Service and NHS working group. The CPA is the process for ensuring co-ordination and continuity of care for people with mental health problems and it has been fundamental in the NHS for more than a decade. A recent study found that only 27 per cent of prisoners had their in-reach mental health services co-ordinated at the main level of the CPA. Lord Bradley also recommended, and the government now accepts, that offender managers should be aware of their place within the CPA, and also that there should be proper, CPA-compliant planning for the care a prisoner will receive once he or she has been discharged.

Some more general points raised by the Report include that as far as sentences of imprisonment imposed for public protection (of which the latest figures suggest there have been almost 5,000) are concerned, the government has agreed to carry out a study of their relationship with mental health or learning disability issues. The role of the Appropriate Adult is also to be reviewed. It seems they are used far less often than they should be, possibly because of problems identifying the need for them or of locating someone who can perform the role effectively. Lastly, the government is to consider whether healthcare given to people in police custody should be the responsibility of the NHS, not individual forces. Lord Bradley’s recommendation to this effect seems to reflect widespread dissatisfaction with Forensic Medical Examiner services.

Although the government has welcomed Lord Bradley’s report, the implementation of a few crucial recommendations has been left to other, arm’s length bodies and appears to be contingent upon the availability of suitable time – and sufficient money. For those reasons, therefore, a third cheer should perhaps be held in reserve.

Lord Bradley’s review may be found at www.dh.gov.uk/en/Publicationsandstatistics/
Publications/PublicationsPolicyAndGuidance/DH_098694 and the government’s response at www.justice.gov.uk/publications/bradley-mental-health-cjs-gov-response.htm

Dr David Hewitt is a partner in Weightmans LLP and one of the firm’s health and social care law specialists. He is also a Tribunal Judge and a Visiting Fellow at the universities of Northumbria and Lincoln: david.hewitt@weightmans.com