Submission to the Justice Select Committee’s inquiry into mental health in prisons from Her Majesty’s Chief Inspector of Prisons

1. Her Majesty’s Inspectorate of Prisons (HMI Prisons) is an independent inspectorate whose duties are primarily set out in section 5A of the Prison Act 1952 and include reporting on the conditions for and treatment of those detained in prisons and young offender institutions (YOIs) in England and Wales. In England, we inspect health and social care outcomes in partnership with the Care Quality Commission (CQC). When inspecting prisons and YOIs in Wales, we work alongside Health Inspectorate Wales (HIW). The General Pharmaceutical Council assists us in both England and Wales.
2. Our below response sets out our findings regarding prisoner’s mental health needs and the support they receive; the identification of needs; the impact of the prison environment; and transfers to community settings. The information set out below is based on our:
   • findings from full inspection reports published during 2019-20;
   • findings from Short Scrutiny Visits and Scrutiny Visits which were conducted in response to the COVID-19 pandemic using an adapted methodology;¹ and
   • findings from our thematic review, What happens to prisoners in a pandemic?, which explored prisoners’ experiences of the restrictions that were introduced in response to the pandemic.
   • Additional context from earlier reporting years has been included where this may help to illustrate the scale or ongoing nature of a problem.

3. In our survey, HMI Prisons asks prisoners whether they have any mental health problems and, if so, whether they been helped with those problems in the prison they are in. Table 1, below, sets out survey results and our inspection findings, and illustrates that there is a high level of mental health need in prisons which is often unmet.
4. Prior to the COVID-19 pandemic, although inspectors found effective mental health support and services in some prisons, overall inspectors found that prisoners had inadequate access to mental health treatment at approximately half the adult male prisons inspected in both the 2018-19 and 2019-20 reporting years. Provision was not adequate to meet the high levels of need in some women’s prisons. For example, in the 2019-20 reporting year, while at HMP Eastwood Park the service provided a responsive and good level of intervention and women at HMP & YOI Foston Hall with higher levels of need were managed well, we found staff vacancies had led to significant gaps in the provision at HMP & YOI New Hall. Inspections identified various reasons for a lack of planned or implemented care, including inadequate service specification, chronic recruitment and retention issues, inadequate staff supervision, difficulties accessing patients due to the restrictions of the prison regime and a lack of suitable therapeutic spaces in which to offer services.
5. Subsequent to the outbreak of the pandemic, prisoners who spoke to inspectors during Scrutiny Visits and our thematic review described a decline in their mental health and well-being. At many prisons, healthcare practitioners told inspectors there had been an increase in prisoners requiring support with their mental health. Long periods of isolation without purposeful activity and the lack of contact with families and meaningful support has had a profound effect on well-being. During our thematic review, some prisoners told us that they had been diagnosed with clinical depression and prescribed antidepressant medication during the pandemic. However,
   despite increased levels of need, the range of mental health services was limited and we found evidence of unmet need in most prisons. Most services had ceased routine assessments and interventions, focusing on urgent and acute care only, which meant many prisoners often faced considerable waits to see mental health practitioners. Individual and group-based therapy had been suspended at the beginning of the pandemic, which had negatively impacted on the mental
   health of prisoners’ who were previously accessing these therapies. Some prisoners were due to be released without completing their prescribed therapy. Several prisoners were using unhealthy coping strategies like drugs and self-harm to manage the prolonged periods of isolation. During our Scrutiny Visit to HMP Hewell, prisoners told us they felt they had to self-harm to gain mental health support.

6. At a prison-wide level, mental health need is identified through independent Health Needs Assessments.⁴ On full inspections, inspectors have found that most prisons have a comprehensive assessment. However, these are sometimes several years out of date and no longer reflect the needs of the population.
7. At an individual level, prisoners are initially screened on arrival, and referrals are made to mental health services if required. During full inspections, we found that most prisons undertook an initial screening for those arriving, which included mental health. However, in a quarter of prisons inspected in the 2019-20 reporting year, initial interviews were not held in private, which potentially reduced the likelihood of prisoners disclosing important information. We found better secondary health screening of new prisoners during 2019-20 than in the previous year, with most prisons meeting the national guidelines.
8. During the pandemic, new arrivals at most prisons continued to receive an initial screening. We continued to find that initial interviews were being held in non-confidential environments at some prisons. Inspectors found some good practice of identification of mental health needs. For example, at a few prisons, initial screenings were carried out jointly with mental health practitioners, which helped to identify any additional needs. At HMP Bure, inspectors found that staff had introduced a process to acquire data from sending prisons regarding any new prisoners with mental health problems, to better identify their needs on arrival. However, we found that access and waiting times for a mental health assessment had been negatively impacted, as most mental health providers had ceased routine assessments and focused on urgent cases. For
   example, some women at HMP & YOI Peterborough had waited five weeks to be assessed for primary mental health services, which was too long.

9. There are a number of factors which help to achieve good mental health, including exercise, time in green space, meaningful relationships, good sleep quality, autonomous decision making and being able to keep clean. Prior to the pandemic, we found that these basic pre-requisites to good mental health were not available in many prisons. The pandemic has subsequently exacerbated these issues.
10. At the beginning of the pandemic, prisoners often got as little as 45 minutes per day out of their cell. During our Scrutiny Visits, we found this had increased, with prisoners spending, on average, about 90 minutes a day out of their cells and most could spend 30 to 45 minutes in the open air each day. However, at some prisons, prisoners had to choose between basic aspects of a decent regime such as outdoor exercise and other tasks (such as showering or having meals). For some
    prisoners on a reverse cohort unit or who were shielding or isolating, regimes were much more restricted. Opportunities for physical exercise were reduced. In interviews for our thematic review, prisoners told us that they were really worried about the long-term health implications of their inability to eat well or get enough exercise. They also told us that it was impossible to sustain meaningful in-cell activities for so many months. Prisoners were frustrated and fed-up and described going “stir-crazy”. Women in particular told us they missed activities which they used to find gave them a purpose and helped to manage their feelings, such as walking and working in the gardens and grounds and, where they had them, looking after the prison’s animals.

11. Prisoners in crisis and those who present a risk to themselves or others should be transferred to secure community services for assessment and treatment. However, inspectors continue to find delays in transferring prisoners to a secure hospital within the 14-day guideline. In the 2018-19 reporting year, there were delays in the vast majority of adult male prisons inspected, and in 2019-20 this was the case in over half. We also continue to find some prisoners waiting for periods that are completely unacceptable. For example, we found a prisoner had waited seven months for transfer during our 2018 inspection of HMP Swinfen Hall. Inspections have found some delays in the women’s estate; our inspection of HMP Low Newton found that, in 2017, the average transfer time was seven weeks but one woman had waited 15 months. At HMP Bronzefield in 2018, over the six months prior to the inspection, only one of the nine women awaiting transfer had been transferred within two weeks.
12. During our Scrutiny Visits, inspectors found one prisoner had been waiting over 100 days for transfer and another over 250 days at HMP Leicester, and four prisoners at HMP Lowdham
    Grange had waited between 76 and 230 days despite efforts to escalate the issue. At HMP & YOI Peterborough (women), three prisoners had been transferred in the six months prior to our visit, waiting between five and eight weeks. However, there were a few prisons where there were no reported delays for transfers. Inspectors visiting HMP Hewell were pleased to find a new approach to transferring prisoners, including weekly monitoring with commissioners, had proved effective at reducing the number of prisoners waiting.

13. The level of mental health need in prisons is high and for too many years has not been met. This situation has been exacerbated by the COVID-19 pandemic. Given the high levels of need for mental health support, we are currently working on a thematic inspection of mental health services across the criminal justice system, together with the CQC, HIW, HMI Constabulary Fire & Rescue Services, HM Crown Prosecution Service Inspectorate, and led by HMI Probation. The report of this work is expected to be published in the autumn.

Charlie Taylor
Chief Inspector of Prisons
June 2021