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7. RESOURCES AND STRUCTURAL ISSUES

7.1 Resources and structural issues impact upon work with prisoners with severe and enduring mental health problems in prisons, in hospitals and in the community. This chapter examines the resources available to prisons and hospitals. It will also examine joint working between prisons and with the NHS and voluntary sector.

STAFFING AND ROLES

7.2 Prisons were asked to provide a summary of the resources available to them for mental health work. This is summarised below. It represents the position at mid-December 2007.

7.3 Aberdeen: Aberdeen has no dedicated mental health staff, other than a psychiatrist for two hours per week. A full-time RMN had been recruited, and was expected to be able to dedicate 15 hours each week to prisoners with severe and enduring mental health problems. The balance of time was expected to be made available for general nursing duties.

7.4 Barlinnie: Barlinnie has an allocation of 111 hours from RMNs, of which 60 hours were available to prisoners with severe and enduring mental health problems. A further eight hours were available from a psychiatrist. A total of seven hours was available from an addictions nurse working on "dual diagnosis", but it is difficult to quantify the time that might be spent with prisoners with severe and enduring mental health issues. Although Barlinnie has access to a psychologist, none of his or her time is specifically dedicated to prisoners with severe and enduring mental health problems, although such prisoners may take part in programmes run by a psychologist. In addition, prisoners with severe and enduring mental health problems are eligible to receive support from voluntary organisations working in the prison, although this was unusual, as these groups tend to work with prisoners with less severe problems.

7.5 Cornton Vale: Cornton Vale has access to 12 hours each week from a psychiatrist, of which 10 hours were dedicated to prisoners with severe and enduring mental health problems. A total of two hours (out of 7.5 hours) of psychologist time were also available. Cornton Vale also has a variety of nurse resources available, including a nurse dedicated to Ross House for remand prisoners (with 25 dedicated hours), an addictions nurse (with 30 dedicated hours) and a further 20 hours available from other mental health nurses. In addition, it is estimated that around 18 hours per week of their time, and a further two hours of the medical officer's time were dedicated to prisoners with severe and enduring mental health problems.

7.6 Dumfries: The total number of hours available from staff at Dumfries consists of three hours from a consultant psychiatrist, six from a psychological counsellor, two from an addictions nurse, and five from an addictions counsellor.

7.7 Glenochil: Glenochil is unusual in having a time commitment from two psychiatrists, one a forensic, the other a general psychiatrist. A total of 11 hours is available. A total of 56 hours is dedicated from mental health nurses, and a further four from the clinical manager, who was also a registered mental health nurse. At the time of inspection, the psychologist's post was vacant. A total of five hours is available from the GP.

7.8 Edinburgh: Staff in Edinburgh found it difficult to assess the time available from the two RMNs which varies depending on staff availability and other tasks. Both staff were full time. Similarly, it was difficult to assess the time commitment of both the psychiatrist (with seven hours in total available) and the psychologist (with 37 hours available).

7.9 Greenock: Greenock has a full time mental health nurse, with 37 hours dedicated to prisoners with severe and enduring mental health problems. Beyond this, two to four hours are dedicated by a psychiatrist and one to two hours from an addictions nurse.

7.10 Inverness: Inverness has no dedicated mental health nurses, and three hours were available from a forensic psychiatrist and three from a forensic liaison nurse.

7.11 Kilmarnock: Kilmarnock has a full-time mental health coordinator, with 37 hours dedicated to prisoners with severe and enduring mental health problems. The prison also has three part-time mental health nurses, each with 7.5 hours per week dedicated to this group. The psychologists are part of the MDMHT. Four hours psychiatric input are available each week.

7.12 Open Estate: The Open Estate has one mental health nurse (30 hours) fully dedicated to prisoners with severe and enduring mental health problems, supported by two to three hours each from a primary care nurse, addictions nurse an Enhanced Addictions Casework Service ( EACS) worker, and a further one to two hours from a psychologist.

7.13 Perth: Staff in Perth were unable to determine accurately the time dedicated to prisoners with severe and enduring mental health problems. The prison had two mental health nurses, a learning disability nurse, a primary care nurse and an addictions nurse, all of whom work with prisoners with severe and enduring mental health problems for varying amounts of time. The prison has access to two psychiatrists for six and three hours each week respectively, and a psychologist for two hours each week. It was not possible to estimate what proportion of this time was dedicated to prisoners with severe and enduring mental health problems.

7.14 Peterhead: Although Peterhead has a mental health practitioner nurse, the time dedicated to prisoners with severe and enduring mental health problems could vary from 0 to 15 hours, depending on other commitments. Beyond this, the prison has three full time practitioner nurses, a medical officer and a psychologist, all of whom work with prisoners with severe and enduring mental health problems "as required". The prison also has access to a psychiatrist for three hours every two weeks.

7.15 Polmont: Polmont has four mental health nurses, with around 140 hours in total dedicated to prisoners with severe and enduring mental health problems. There are 10.5 hours psychiatric input available each week. Polmont also has both a senior psychologist (three hours) and trainee psychologists (four hours), as well as an activities officer (30 hours) almost entirely dedicated to organising and supervising supported work parties and other activities for prisoners in this group. Polmont also has access to 10 hours from a speech and language therapist.

7.16 Shotts: Shotts has two mental health nurses, with variable amounts of time. The prison also has access to six hours from a psychiatrist, and time from a psychologist, although it was not possible to identify how much of this time was dedicated to prisoners with severe and enduring mental health problems.

Overview of Healthcare Staff and Other Specialists

7.17 The provision of healthcare staff, and particularly mental health specialist staff varies widely across prisons. While some have a full time mental health nursing team, some have no specialist nurses. In some prisons, staff are fully dedicated to mental health, in others mental health nurses are expected to distribute methadone and carry out general nursing duties.

7.18 In prisons with a dedicated mental health nurse or nurses, staff and prisoners have an obvious first point of contact; it helps clarify contacts with external organisations, and provides a focus for contact with hospital-based, and community-based forensic teams; and it allows expertise to be built up in this area.

7.19 The general pressure on healthcare staff has increased, and more prisoners are requiring to be seen. This has meant there has been a knock-on impact on mental health, with fewer resources, and staff more likely to be required to undertake general health duties. At a basic level high numbers of prisoners was also creating difficulties of physical overcrowding in health centre facilities themselves.

7.20 Generally, nursing teams are available on a Monday to Sunday basis, although there is little or no mental health nursing cover on-site overnight or at weekends. Concerns were also expressed about the impact of absences caused by illness, holidays and staff shortages.

Other Specialist Staff

7.21 Some prisons have other specialist staff working with prisoners with severe and enduring mental health problems. In one, a speech and language therapist is available. In some an occupational therapist is a useful addition to the team.

7.22 In all prisons, the social work team works with prisoners with severe and enduring mental health problems. The proportion of the caseload represented by these prisoners varies, although this may be very small.

Staff Trained in Specific Interventions

7.23 There were very few examples of staff trained in, or delivering, CBT. In one case, even where a staff member had had training, other pressures meant that this could not be offered. Where psychologists were employed, their time tended to be deployed on either programmes or addictions work. There were few examples of psychologists delivering one-to-one sessions with prisoners.

Other Commitments

7.24 Mental heath staff have a range of other responsibilities including distributing methadone, general administration and report writing, programme delivery and general healthcare duties. The net effect of these other duties is to reduce the time available to work directly with prisoners with severe and enduring mental health problems.

Residential and Operational Staff

7.25 Residential and operational staff are expected to play a greater role in the management of prisoners with severe and enduring mental health issues than in the past. This increased management role is in part due to the increasing number of such prisoners. The removal of healthcare beds also means that prisoners with severe and enduring mental health issues are being located in the halls.

Training and Awareness Raising

7.26 As a result of participation in the national Choose Life initiative, Mental Health First Aid training has been introduced to prisons. To date, relatively few staff have been provided with MHFA training, but where this has been possible, it has been beneficial, with staff feeling more confident in dealing with prisoners.

7.27 Also largely as a result of Choose Life, staff in some prisons have received ASIST (Applied Suicide Intervention Skills Training). This provides higher level training in relation to addressing the risk of suicide. Again, while not directly related to severe and enduring mental health problems, it gives staff a wider insight into these issues.

7.28 A training pack "New to Forensics" has been developed. This was originally for use in the NHS but is being adapted for use in prisons, and will extend the available mental health training into more specialist areas, particularly relating to severe and enduring mental health problems. This has been very well received.

Issues and Problems with Staffing and Roles

7.29 A range of issues was identified in relation to staffing and roles. Firstly, in relation to healthcare staff:

• In some prisons the level of staffing, particularly staff with mental health qualifications, is inadequate to address the needs of prisoners fully.
• Some prisons do not have a dedicated mental health nurse, although there may be staff in other roles who are mental health trained.
• Some prisons either do not have a psychologist in post, or do not have any psychologist time dedicated to mental health.
• The time allocated by psychiatrists to individual prisons varies and concerns were raised about whether demand was always met.
• Contact with a psychiatrist should be within 24 hours if necessary. When someone is distressed, and there is no nursing observation available, it is difficult to manage and medicate them during this period.
• Generally, no members of the mental health team are available overnight, or at the weekend.
• Although some prisons benefit from specialist staff, in some cases, the level of time made available through these arrangements is low.
• In some prisons, there is a relatively high turnover of staff, with long lead times for staff to be replaced. One had four vacancies in its healthcare team, with a fifth member of staff not allowed to have any prisoner contact. Another had been seven nurses below complement in the recent past.
• Qualified mental health nurses are, in some prisons, diverted to other activities, particularly the distribution of methadone.
• Staff in most prisons are not trained to provide talking therapies. Even where staff are trained, other priorities may mean that contact time with prisoners for these activities is either very limited, or impossible.
• There is a lack of clinical psychologists in prisons.
• There is no specialist provision to survivors of childhood sexual abuse.
• While there is a good deal of assessment undertaken, there is too little intervention available.
• Some staff do not feel valued or supported. The comment was made that mental health is the "Cinderella" service in SPS.
• There may be a possibility of prison-based healthcare staff losing aspects of their skills, or skills and knowledge becoming out of date, as a result of lack of access to mainstream NHS continuing professional development.
• There is a lack of clinical supervision for some of the mental health professionals working in a prison setting.

7.30 Issues relating to residential and other uniformed staff included:

• Many staff lack confidence, as well as skills and knowledge in dealing with prisoners with mental health problems.
• In some prisons, staff can lack direction and guidance, and are "just expected to get on with it".
• Staff may be reluctant to take what are perceived as risks, even though they may be reassured by managers that they should follow policy.
• Staff in some prisons find it difficult to access training, or where access to training is granted, this is delivered in a truncated form.
• There is a lack of effective mental health training for new recruits to the Scottish Prison Service.
• While staff working in some segregation units had had training in mental health issues, this was not the case in all prisons.
• Staff shortages in some prisons mean that residential staff do not have time to spend with prisoners with severe and enduring mental health problems.
• The delivery of prisoners to assessment and treatment sessions can be "ad hoc" when there are staff shortages, and was liable to be forgotten if other, apparently higher priority work intervened.
• The effect of rostering can mean that staff cannot attend two-day training programmes.

7.31 In some prisons, concerns were expressed about the attitudes of some staff, in terms of the use of inappropriate language, or through threatening the use of restraints.

JOINT WORKING

Multi Disciplinary Mental Health Teams

7.32 Multi Disciplinary Mental Health Team ( MDMHT) meetings represent an opportunity for staff involved in the management of prisoners with mental health problems to discuss these cases in an open forum. Broadly, MDMHTs have two main purposes:

• To consider new cases brought to the meeting and, through multi-disciplinary discussion, determine the best course of action to be taken forward by means of a clear action plan.
• To review the ongoing treatment and management of prisoners deemed to fall within the remit of the team.

7.33MDMHTs may also be involved as a team in planning the arrangements for a prisoner's ongoing care after liberation.

7.34MDMHTs vary in terms of whether or not the team has any responsibility for strategic issues, including staffing and deployment, as well as reviewing the overall pattern of resources and care. In some cases, due to the number of cases within its remit, the team has to focus on case management.

7.35 The MDMHT generally has a role in considering the transfer of any prisoner within its remit. This does not always happen in practice.

7.36 Meetings are always minuted, and the minutes distributed to all of those members attending, and, in most cases, other relevant staff (for example, where one staff member represents a group of staff). In one prison, the content of the MDMHT is the subject of a briefing between the Deputy Governor and the Duty Governors over the weekend period, to ensure that they are made aware of any issues likely to arise.

The Composition of MDMHTs

7.37 All except two prisons had an operational MDMHT.

7.38 There is considerable variation in the membership of MDMHTs.

7.39 In a majority of cases (9 out of 14), the meetings are chaired by a senior member of staff, often the Governor or Deputy Governor. This was considered to be positive, with the view expressed that this gave the team more "clout", and underscored the "multi-disciplinary", rather than simply "health" view of the meetings. In those prisons where the Governor or Deputy Governor does not attend, another senior member of staff does. In other prisons, the meetings are chaired by the clinical manager or health centre manager.

7.40 In all prisons either or both the clinical manager and health centre manager attend. In all prisons with mental health nurses, one or more nurses attend. Psychiatrists attend in 11 out of 14 prisons, with psychologists in attendance at 10. GPs attend in six prisons. A representative from social work attends at all prisons except one. In all but two either an addictions nurse, or a representative of the addictions contract holder attends.

7.41 In some prisons, some additional people also attend, including representatives of some voluntary organisations, the ACT coordinator, the lifer liaison officer and, in one case, a representative of the community forensic mental health team.

7.42 There is significant variation in whether or not residential staff attend MDMHT meetings. There are strong views for and against this usually related to issues of confidentiality, and sometimes staffing levels mean that it cannot happen in any case.

7.43 Psychiatrists attend in the majority of prisons. Again there were mixed views about the attendance of psychiatrists, with some psychiatrists viewing their attendance as essential, while others viewed this as a lesser priority than their individual prisoner contact (particularly in cases where this is restricted in terms of available hours).

7.44 In most prisons, either Phoenix Futures, or a member of staff with responsibility for drugs issues attends.

7.45 A representative of the prison chaplaincy attends all but one MDMHTs. The extent to which chaplains become involved varies across prisons, with some taking a largely listening role, except where asked to raise issues on behalf of a prisoner.

7.46 Overall, attendance was high at all MDMHTs visited during the inspection.

Benefits of the MDMHT

7.47 There was a strong and consistent view that MDMHTs are a positive initiative: they are the best way of ensuring that prisoners receive the assistance they require consistently, and with no overlap. Staff also bring their own expertise, and learn from each other. The meetings also raise awareness of mental health issues across the prison. The process of ongoing review, where this takes place, also ensures that prisoners cannot be overlooked, or forgotten about.

Other Internal Joint Working

7.48 Other joint working within prisons also takes place. Although there can be tensions in relation to the transfer and sharing of information, in some prisons a "team" approach is taken. In one prison, since the removal of healthcare beds, there is now a greater reliance on residential staff carrying out observation of prisoners, and an onus is on them to report back their findings to healthcare staff. However, residential staff concerned did not always consider that they had the skills or knowledge to do this effectively.

Joint Working with External Organisations

7.49 As described elsewhere in this report, prisons work directly with staff of other organisations, either on joint basis, or where that organisation is contracted to provide a service to SPS (or SERCO in the case of Kilmarnock).

Service Level Agreements

7.50 Some prisons have service level agreements ( SLAs) in place with their local NHS Board. Generally, these cover the provision of psychiatrists, but in some cases, other services such as speech and language therapy or psychological counselling.

Relationships between Hospitals and Prisons

7.51 Relationships between hospitals and prisons relate largely to the transfer of prisoners, although there are also a number of examples of joint working groups of which both prison and NHS staff are members.

7.52 In some prisons, formal liaison arrangements exist between hospitals and prisons, but in others, the relationship is ad hoc, and focused specifically on an individual prisoner. A large range of individual instances of joint working is in place and, among the staff identified as working jointly with some prisons were nurses, occupational therapists, physiotherapists, art therapists, speech and language therapists, as well as psychiatrists and psychologists.

7.53 Generally, relationships were described as good by all parties, although in some cases, it was clear that, at least in part, they could be more effective. One aspect of arrangements which is helpful is where hospital-based psychiatrists also work in the prison. In some locations, other health staff have worked both in a prison and hospital setting.

Relationships with the Voluntary Sector

7.54 The level of joint working between prisons and the voluntary sector is lower than with the NHS, and varies greatly between prisons, although a number of examples of effective joint working were identified. Amongst the voluntary organisations identified were: Samaritans; SAMH; local associations for mental health; Penumbra; a local hearing voices network; training and employment providers; and organisations supporting homeless ex-offenders.

7.55 Some voluntary organisations, however, find it difficult to work with prisons, in part because they lack information and awareness of how the SPS operates, and they may be unable to identify a suitable first point of contact.

7.56 Some voluntary organisations also find it difficult to work with the NHS, and jointly with other voluntary organisations. In part, this appears to be a funding issue.

7.57 One of the main difficulties identified both by voluntary organisations, and to an extent by prison staff, was an assumption that all work with prisoners would be funded by SPS, even where others, generally either the NHS or local authorities, were funding work in the community and in hospital. This can limit work in a number of areas such as introducing advocacy on a wider scale.

Participation by Prison Staff in Wider Forums

7.58 A wide range of examples was identified of participation by prison and NHS staff in wider joint working arrangements. These include the Forensic Network at a national level. At a local level, most prisons are members of forums specifically to discuss mentally disordered offenders and, in some cases, forensic psychiatry networks. Some prisons also take part in multi-agency groups dealing with risk assessments, for example, relating to sex offenders.

Issues and Problems with Joint Working

7.59 A number of issues with internal joint working were identified. The first group of issues relate to the operation of the MDMHTs and include that:

• There is clear variation in the nature and operation of MDMHTs.
• In some cases, there are practical difficulties in relation to the attendance of team members.
• There is a lack of consistency surrounding the attendance of residential staff at MDMHT meetings.
• Non-health staff in some prisons have limited awareness of the remit and composition of the MDMHT.
• Some residential staff expressed frustration at the fact that they had never been asked to contribute to MDMHT meetings, even indirectly, even though they had had direct contact with prisoners over an extended period.

7.60 In some prisons, concerns were raised about other aspects of internal joint working:

• In one prison, staff were described as "working in silos", and aspects of this were also identified in other prisons.
• Staff in a wide range of roles expressed frustration with the lack of information provided to them by health staff as a result of what was perceived to be medical confidentiality.
• Some concerns were also raised about the expectations placed on residential staff in relation to assuming roles they were neither comfortable in, nor considered themselves trained for.

7.61 Some issues were raised about joint working between prisons and external bodies:

• In some cases there was not a well-formed and clear understanding of the roles and responsibilities of, and, in some cases, constraints, facing prison and NHS staff.
• A small number of prisons identified problems with resources, largely time for staff to engage in networking, but also financial resources (in relation particularly to the voluntary sector).
• The sheer volume of prisoners in Barlinnie can make assessment and treatment difficult, as well as "keeping up" with prisoner receptions and liberations.
• A number of psychiatrists raised issues relating to visiting prison, including being unable to pre-book appointments, being unable to see prisoners, being expected to carry out assessments in inappropriate locations, including corridors, and being forced to cut short visits with no notice or explanation.
• Issues were also raised by psychiatrists that their allocated times may not be fully utilised due to delays in the delivery of prisoners and confusion over bookings.
• Some voluntary organisations find it difficult to make both initial and ongoing contacts with prisons, and some find it difficult to continue to work with clients who are serving a sentence.

RECORD KEEPING AND INFORMATION SHARING

7.62 Mental health information is generally kept within prisoners' medical records. Some services, however, keep their own records (psychiatrists, psychologists, social workers, chaplains etc.). In addition, some information is kept on a daily basis in halls.

7.63MDMHT meetings provide a forum for information sharing about individual prisoners' mental health, and issues arising and the treatment provided are usually discussed. The MDMHT members, however, will not generally be provided with a prisoner's medical records, although, where consent is given, the contents may be shared. Additionally, consent can be over-ridden, and the information shared with or without consent where a prisoner is very unwell, where they themselves or someone else is considered to be "at risk" or where it is "in their best interests".

7.64 The process of holding case conferences for some prisoners is also a means of information sharing, and one group of prison mental health staff noted that Integrated Case Management records, which were seen to be relevant, would be maintained in a prisoner's PR2, although it was also noted that the mental health information provided on these records was limited.

7.65 Two prisons have access to GPASS, but the extent of this is very limited, and does not appear to extend to accessing GP records.

7.66 Little mental health information is shared with officers in the halls. Few officers attend MDMHT meetings and the lack of information is an issue for officers, some of whom suggested that the issue of medical confidentiality was being used as a reason not to provide basic details to them.

Issues and Problems with Records and Information Sharing

7.67 Some issues were raised in relation to perceived gaps in provision or sharing of information, including that:

• There can be some problems with the transfer of information from courts and the community, and it can be difficult to get information from GPs.
• There can be difficulties with information following prisoners on transfer and on return to the community.
• The limited information provided to prison staff about prisoners' mental health problems and treatment can constrain the knowledge they have about individual prisoners, and can also constrain their effectiveness in providing support.
• The standards of record keeping vary.
• Time constraints can make it difficult to keep records up to date.
• There may be some gaps in communication between organisations working with prisoners, particularly where organisations are not involved in the MDMHT.

7.68 There can also be some problems with the issue of consent:

• There can be a lack of clarity and consistency about what is confidential and what can be discussed, and a lack of shared understanding of data protection and medical confidentiality.
• There is variation in the means and rigour with which consent for information sharing is sought and recorded.
• Issues relating to confidentiality and consent, and the balance of these issues with safe management, risk and the best interests of prisoners, raise a number of ethical concerns which are not always fully recognised or addressed.

PHYSICAL RESOURCES

7.69 A large majority of prisoners with severe and enduring mental health problems are accommodated in mainstream halls. This is likely to involve sharing a cell in many cases, although a prisoner's mental health is usually taken into account in deciding whether or not to allocate a single cell. The overcrowding issues facing prisons at present are likely to have an impact on prisoners with severe and enduring mental health problems, and to serve to exacerbate their problems.

Accommodation and Facilities

Reception

7.70 The nature and quality of prisoner reception facilities varies across the SPS. Investment is being made to improve conditions, but in some prisons the conditions facing prisoners with mental health problems are not good. For example, in some prisons, individual small boxes remain in use, which effectively isolate a prisoner. As far as possible, doors are left open, and if staff are made aware of a prisoner's needs, they would try to ensure this was the case, or find another location in which to hold the prisoner. In some prisons assessments are conducted in full view of other prisoners.

Healthcare Centres

7.71 All prisons have some form of healthcare centre, designed to meet the general medical needs of prisoners, including prisoners with severe and enduring mental health problems.

7.72 Only one prison (Kilmarnock) has dedicated healthcare beds, and these are in the process of being removed. In Barlinnie previous healthcare beds have been replaced by day care facilities. The lack of day care facilities in most prisons is a source of frustration for staff.

7.73 Barlinnie has a Residential Care Unit, specifically for prisoners requiring additional support, who would struggle to cope in a mainstream hall. Not all prisoners in the Unit have diagnosed or undiagnosed severe and enduring mental health problems.

7.74 At Cornton Vale, most prisoners with severe and enduring mental health problems are located in Ross House. This area has a higher staff: prisoner ratio, and staff have been provided with additional training, including Mental Health First Aid. A mental health nurse is available to Ross House on an almost full-time basis. In addition, a day care facility is being developed within Ross House, which will provide a range of activities.

Interview Rooms

7.75 The conditions under which consultations take place vary greatly. In some prisons, these are wholly inadequate: for example, prisoners are sometimes interviewed by psychiatrists in corridors, or whenever there is space. The standard of interview rooms also varies between and within prisons.

Specialist Cells

7.76 Some prisons have a small number of specialist cells which may be used to house prisoners with severe and enduring mental health problems. These include:

• Ligature free cells designed for those subject to suicide risk management.
• A variety of three and four bed small units variously configured, allowing for vulnerable prisoners to have another prisoner in attendance at all times. In some cases, these units are in quieter locations than would be possible in mainstream halls.
• Some prisons have larger two-person cells which serve a similar purpose: these are sometimes called "buddy cells").

Segregation Units

7.77 In a small number of prisons, segregation units may be used to provide accommodation for prisoners with severe and enduring mental health problems. This is used when it is considered that a prisoner requires time out, or additional observation. Some prisons made it clear that they would not use the segregation for these prisoners.

Accommodation for People Detained for Assessment

7.78 No prison has accommodation specifically for people detained in prison for assessment, which staff generally describe as a "place of safety order". Generally, accommodation is identified within mainstream halls, or in small units or high dependency areas where these exist. In one prison, the only accommodation available is safe anti-ligature cells, which, it is acknowledged are "not always conducive to caring for individuals with severe and enduring mental health problems".

Issues and Problems with Accommodation and Facilities

7.79 The following issues and problems were raised in relation to accommodation and facilities:

• In general terms, almost all prisons consider that the physical resources available to them are inadequate to address the needs of prisoners with severe and enduring mental health problems.
• One of the key issues relating to accommodation is overcrowding.
• There are a number of impacts of overcrowding, including the fact that prisoners with severe and enduring mental health problems may be required to remain in their cells for up to 23 hours per day, with little access to activities or stimulation.
• Some prisons find it difficult to find work for prisoners with severe and enduring mental health problems.
• Most prisons have inadequate resources for group work and one-to-one working.
• Overall, there is considerable pressure on physical resources across the SPS: "There's not a cupboard that's not used for something".
• Some staff in segregation units have not received training in mental health issues, even though a proportion of the prisoners under their care may be likely to have either diagnosed or undiagnosed severe and enduring mental health problems.
• Concerns were expressed by prison and community health staff about the removal of healthcare beds. This has had the result that more prisoners who would previously have been located in a healthcare setting are being located in mainstream halls. This can have an impact on other prisoners, and on the regime.
• Even in prisons with high dependency units, the pressure on these means that some prisoners cannot be allocated places, and remain in mainstream conditions.
• Being located in halls makes it difficult for observation to take place.
• Some staff expressed concerns that "buddy cells" cannot be a substitute for either high risk cells, or healthcare beds.
• Some prisons have no facilities for prisoners taking time out, or requiring a quiet location, as would happen in a day centre setting.
• Most prisons have a lack of accommodation which can be used while a prisoner is awaiting transfer to hospital.
• The conditions in the "back cells" in Ross House in Cornton Vale are inappropriate to house prisoners with mental health problems, although they are occasionally used for this purpose.

CONCLUSIONS

7.80 In terms of resources, the main conclusions are as follows:

7.80.1 The general pressure on healthcare staff is considered to be increasing, with increasing demands arising from addressing general health issues. Overcrowding is seen to play a major part in this.

7.80.2 The level and nature of healthcare staff, and particularly mental health specialist staff varies widely across prisons. Generally, nursing teams are employed on a Monday to Friday basis, and there is little or no nursing cover on-site overnight or at weekends.

7.80.3 Some prisons are experiencing, or have recently experienced staff shortages in healthcare generally, with a knock-on impact in relation to mental health. Staff turnover is also high in some prisons.

7.80.4 Some prisons have a psychologist in post, some do not. Psychologists are more likely to work on programmes than directly with prisoners with severe and enduring mental health problems. Most prisons have access to a psychiatrist, although for a relatively small number of hours.

7.80.5 Overall, there is concern about the level of specialist staffing resources available, the number of competing priorities, and the extent to which existing arrangements have sufficient resilience to cope with, for example, a member of staff leaving, or periods of sickness.

7.80.6 In all prisons, residential and operational staff have a less well-defined, but still important, and increasing role, to play in relation to prisoners with severe and enduring mental health problems. A number of concerns were raised that staff: lack specific training (and find it difficult to access training); may lack confidence; may feel that they have not had sufficient guidance; may have insufficient time to interact with prisoners and may lack information about the prisoner's problems and the impact of any steps they take in working with them. These can lead to significant amounts of pressure and stress being placed on staff.

7.80.7 Healthcare beds have been phased out in virtually all prisons, which has given rise to concerns both within prisons, and among NHS staff. This means that more prisoners who might have been located in these beds are now located in halls, and it makes observation of prisoners' behaviour more difficult.

7.80.8 Some of the conditions in which interviews and assessments have to take place are inappropriate. Overall, there is a lack of space.

7.81 In terms of joint working, the main conclusions are as follows:

7.81.1 The main mechanism for joint working is the MDMHT. In some prisons, the residential unit manager, or individual officers attend, but there were mixed views about the benefits and drawbacks of this. There are variations in the nature and operation of MDMHTs.

7.81.2 The MDMHT's meet to varying schedules, and all discuss a subset of prisoners with mental health problems: in some cases, those giving cause for concern, in others, all prisoners with severe and enduring mental health problems on a rolling programme. There was a strong and consistent view that MDMHTs are a positive initiative.

7.81.3 Joint working takes place within prisons relating to individual prisoners. It involves specialist staff and, in some cases, residential or programme staff. The main concern about this relates to diverging views on information sharing and client confidentiality.

7.81.4 Relationships between hospitals and prisons largely surround the transfer of individual prisoners. There are also examples of joint working groups of which both prison and NHS staff are members. Generally, relationships were described as good by all parties, although in some cases, it is clear that, at least in part, these could be more effective. There are examples of a lack of understanding of each other's roles and constraints. Some psychiatrists considered that they were not afforded sufficient cooperation, or adequate facilities, by some prisons.

7.81.5 There are few difficulties relating to sharing information about prisoners on transfer to hospital, in part because hospital-based psychiatrists may be involved with the prisoner prior to transfer, in some cases for an extended period, and do not, therefore, require access to case notes.

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