The State of Mental Healthcare in Prison

Psychiatry and Psychology CategoryA new report by Policy Exchange reveals over a third of spending on mental health services in prison is wasted and calls for a drastic overhaul in treating mental health in prisons, including mandatory training for prison officers.

Mental healthcare in prisons is widely overlooked as being a problem in the justice system, with overcrowding and high costs trumping mental health for column inches. Yet experts agree that there in a link between mental illness and reoffending in the community. In the latest Policy Exchange report, Out of Sight, Out of Mind, leading experts say that it is time policy makers woke up to the realities of mental healthcare in prisons, and the report authors suggest that only a small reduction in re-offending rates would make a tripling of the prison mental healthcare budget cost effective.

Alcatraz Guard TowerOur prison population is at its highest ever. Of the 82,000 prisoners in England and Wales it is estimated that nine out of ten have one or more mental health disorders.

Although treatment of mental illness in prison has improved over the past decade, mental healthcare is not given the attention it deserves. The rates of mental illness among prisoners suggest that the Prison Service has become a catch-all social and mental healthcare service, as well as a breeding ground for poor mental health.

The general public is largely unaware of the amount of mental illness in prison, although data on the subject has been available for some time. When asked to estimate the proportion of people in prisons in the UK with a mental health problem only 1% answered correctly; the vast majority underestimated the figure. Nearly half (45%) thought that it was 30% or less.

There is significantly less public sympathy for prisoners with mental illness than for those in the community. While 90% of people believe that we have a responsibility to provide the best possible care for those with mental illness, rather less, 64%, thought this applied to offenders. This sits awkwardly with the fact that 60% believe that anyone can have a mental illness and commit a crime.

The current assessment of prison mental healthcare by those who deal with it every day is bleak. In our surveys of prison healthcare professionals, who included mental health in-reach leaders and PCT prison health leads, more than half said that prison mental healthcare was average or poor — surprisingly low for a self-assessment.

Our panel of experts also acknowledged that prison mental healthcare is still not working properly despite some improvements.

Spending on mental health services in prison is currently £20.4 million (it will rise to £24 million in 2008-09). Our research found that over a third, £8.6 million, is not being spent efficiently. This is due to shortfalls in staff recruitment — just over 10% of the total budget is not being spent — and confusion over the role of mental health in-reach teams. These teams, which were originally supposed to deal exclusively with cases of severe mental illness, are working in practice with a much broader caseload: 30% of cases have neither a severe mental illness nor a personality disorder.

Spending is not only inefficient but also insufficient. The proportion of the total health budget spent on mental healthcare in the community is 15%. The proportion of the total prison healthcare budget spent on mental healthcare is only 11%, even though mental illness is much more common in the prison system than the community at large.

Primary care trusts (PCTs) are responsible for the healthcare budgets of prisons in their area. As far as we know no rational basis has been established for the allocation of monies to PCTs for prison health. The current funding reflects a negotiated settlement with the Prison Service based on what it was receiving from the Home Office before prison health services became the responsibility of the Department of Health. In other words, budgets are based on past practice rather than any definition of current need. A sophisticated needs assessment should be undertaken in order to find how much is really required to provide for the prison community.

One consequence of underfunding is chronic understaffing. Mental health in-reach teams, on average, consist of just four clinical staff; they are intended to be multidisciplinary but usually have no psychiatrist, psychologist or social worker. We also know that staffing of in-reach teams varies across prisons, with some consisting of ten or more staff while others have only two clinical nurses.

If Department of Health (DoH) guidance for community mental health teams was applied to prisons and took into account the much greater prevalence of mental illness there, in-reach teams would have the equivalent of three to four community psychiatric nurses; two to three social workers; a minimum of one fulltime clinical psychologist; a support worker and administrator; and two full-time psychiatrists: in total between 12 and 14 professionals. This suggests that the average in-reach team is only a third of the size it should be and does not contain the correct range of skills.

The co-ordination of mental healthcare also leaves much to be desired. In-reach, primary care, drug services and other teams work separately. The line between what is primary and secondary care is blurred and prisoners are passed between the two or even lost completely. A single mental healthcare delivery team, with the same range of skills and practitioners as in the community mental health teams, would go a long way to improving the quality of care. In fact, some teams structured in this way already exist and are proving to be effective.

Whatever improved level of funding for prison mental healthcare was decided on, we believe the extra cost would be offset by a reduction in reoffending. Former prisoners who suffer social exclusion, which includes factors such as homelessness, unemployment and family breakdown, are more likely to reoffend. Mental illness increases the risk of social exclusion and therefore of reoffending. Recent studies estimate that the £20.4 million currently spent on prison mental healthcare would need to be tripled in order to reach service levels equivalent to that of the wider community.

If we accept this figure as a sensible estimate, rates of reoffending would have to fall by only 0.3% to make the improvement cost effective. A relatively small increase in spending might result in a much larger reduction than this and, subsequently, in the costs of reoffending.

In a report due later this year, we will look at examples of best practice from home and abroad and bring together detailed policy recommendations for improving prison mental healthcare. However, there are four areas that the Government must look at urgently: prison overcrowding; resettlement plans; improved awareness training for prison officers and prison governors; and integrated policymaking.

A key element of the Bradley Review into court diversion schemes due later this year must be to implement a robust and properly funded system for diverting offenders with mental illness away from prison. Not only would this ease the crisis of overcrowding, but also ensure that offenders with mental illness were provided care and treatment in an appropriate setting, whether in the community or a secure health facility.

If reoffending and mental illness are to be properly addressed, they must be seen in the wider context. The biggest drivers of reoffending — lack of employment, suitable accommodation and access to healthcare — need to be carefully considered in an offender’s resettlement plan. Ensuring that everyone with a mental health problem who is released from prison has a proper care plan is crucial in decreasing reoffending rates. This should already happen for prisoners with a severe mental illness through the care management approach (CPA) but our survey of in-reach teams suggests that it is not always the case.

Although the clinical staff are vital in delivering effective mental healthcare, prison officers will have the most contact with prisoners day-to-day. It is essential that they have the skills to identify and deal with mental illness. Current training is not sufficient and in some cases is not compulsory. In surveys conducted for this report in-reach team leaders and PCT prison health leads said that one of the biggest improvements that could be made would be to increase mental health awareness training for prison officers. Prison governors play the most important role of all in determining the atmosphere of a prison and their training too should include mandatory mental health awareness training.

The structure of policymaking makes it hard to introduce mainstream health developments, such as the programme for increasing access to psychological therapies, into prisons. Responsibility for prison healthcare was transferred fully from the Prison Service to the Department of Health in 2006 but offender health is managed by a separate directorate of the DoH.

Primary care trusts, which are responsible for prison healthcare budgets, would be more likely to consider prison populations as part of their local communities if a more integrated approach to policymaking was evident from the top.

In 1996, Lord Ramsbotham, then Chief Inspector of Prisons, wrote a report that was heavily critical of prison healthcare services — their lack of suitable training for medical and nursing staff; isolation from new clinical developments; inadequate care for the mentally disordered in prison; failure of continuity of care between prison and community; and a lack of consideration of the care needs of specific groups of prisoners such as women and young people.

And although matters have improved since then, progress is slow. Our report argues that Lord Ramsbotham’s findings are as relevant today as they were 12 years ago.


Brooker, C., Ullmann, B. (2008). Out of Sight, Out of Mind. Policy Exchange.

Ben Ullmann

Ben Ullmann is a Research Fellow in the Crime & Justice Unit at Policy Exchange. He graduated with joint honors in Mathematics & Philosophy from the University of Bristol in 2006 and served as President of its Students Union for a year before joining Policy Exchange. His previous work includes Unlocking the prison estate, an economic analysis of rebuilding the prison estate. He also takes a keen interest in the world of behavioral economics.
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