Failing prisons fail us all, says Professor Pamela Taylor, Chair of the Royal College of Psychiatrists’ Forensic Faculty.

A 26-year-old, alcohol dependent young man recently told me: “Most help is for people who have reached absolute rock bottom - the thought of having to wait until I’m there to get any help terrifies me.”

He was frightened that he would not get the help he needed to turn his life around, and would start using more dangerous drugs. This was in a prison which officials say is declining but still reasonably good in many respects. If he can’t get effective treatment, it is more likely than not that he will re-offend. How would he cope in a prison like HMP Liverpool?

Suicide, self-harm and a lack of safety

Liverpool and Nottingham prisons hit the headlines last week. Liverpool was deemed the worst the Prisons Inspectorate could remember, with government failing to support local staff. The Chief Inspector’s 2017 Annual Report gives a comparator: ‘there was not a single [prison] establishment that we inspected in England and Wales in which it was safe to hold children and young people’. The Chief Inspector was so concerned about Nottingham prison that he issued a notification letter to the Justice Secretary demanding action within 28 days. The one functional element of Nottingham’s work was healthcare. By contrast, Liverpool prison is in danger of having no healthcare service at all.

"There are too many people with mental disorders in prison. More prisons should join the Royal College of Psychiatrists’ Quality Network for prisons – a voluntary scheme which aims to set, agree and monitor standards of healthcare in prisons."

Prison conditions have been deteriorating since, under Chris Grayling, the Ministry of Justice spend on voluntary early severance for prison officers surged from £3-6 million per annum 2010-2012 to £56million in 2013. Prison staff numbers fell by nearly 30% across the service – presumably with the expectation of saving money. Since then, prisoner deaths from all causes have risen, as has self-harm and violence to others. HM Inspectorate of Prisons has published report after report on failing prisons. Consequent new prison officer recruitment has been minimal.  Nottingham’s rare success in numbers was lost in inexperience.

Many prisoners are in poor health, but conditions as bad as in Nottingham or Liverpool create the perfect environment for new illnesses and injuries and making existing ones worse. The need for good healthcare in prisons has never been higher. So what can we do?

Fund treatment

First, it is more important than ever to keep offenders with mental disorders out of prison whenever it is safe to do so. The Royal College of Psychiatrists has been calling for courts to take up the little used Mental Health Treatment Requirement, which can be coupled with community sentences or suspended prison sentences. This would put people on the cusp of a brief prison sentence back in the community with supervision and psychiatric treatment and less chance of re-offending. Parliament is committed to reducing the prison population, and this seems an obvious and simple way to do just that. There are too many people with mental disorders in prison. Here is a solution – but it will need appropriate funding. Secondly, prisons - and health services in them - will have to be made fit for purpose in the meantime.

  • The Mental Health Treatment Requirement (MHTR) is one of three possible treatment requirements which may be made part of a Community Order. The MHTR is intended for the sentencing of offenders convicted of an offence(s) which is below the threshold for a custodial sentence and who have a mental health problem which does not require secure in-patient treatment. It is a three way contract between the offender, the probation officer and the clinician (usually a psychiatrist). The offender must agree to received regular mental health treatment as part of the requirement, if they are to avoid being in breach of the contract.

More prisons should join the Royal College of Psychiatrists’ Quality Network for prisons – a voluntary scheme which aims to set, agree and monitor standards of healthcare in prisons. Nottingham prison has signed up to this. It probably helped, as their healthcare was recognised as good, despite generally bad prison conditions. Liverpool prison is not part of this network. Currently only about 40% of prisons in England and Wales are – that could be improved, to everyone’s benefit.

NHS England and NICE (National Institute for Health and Care Excellence) have provided excellent new guidance on healthcare in prisons - the College contributed substantially - but achieving the ambition will mean avoiding false economies. We have seen how these affect core prison staffing and safety. In Liverpool, Lancashire Care NHS Trust has given notice that it can no longer provide healthcare after March 2018. The contract for providing healthcare at Liverpool prison has now been put up for tender – at £200,000 less than the contract which Lancashire NHS Trust found insufficient. Liverpool prison is dangerously close to having no healthcare at all.

When prisoners are released, their untreated illnesses, injuries and other disorders are released with them – making them more likely to re-offend and go back to prison. We must all do better.

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