Oral evidence: Mental Health in Prisons, HC 400

Oral evidence, 23 October 2017.

Witnesses

Dr Andrew Forrester, Sarah Hughes, Mark Johnson and Dr Huw Stone.

Chair

Good afternoon, ladies and gentlemen, and welcome to the Public Accounts Committee. It is Monday 23 October 2017. Today, we are considering the National Audit Office’s excellent Report on mental health in prisons, which in my view is seminal. It underlines the huge challenges in our prison system for prisoners with mental health problems. Two things that have arisen from the Report are the fact that the National Audit Office and others have looked at this, and the range of the number of prisoners with mental health problems is anything from 10% to 90%, depending how you measure it; and the fact that 2016 was the highest year on record for people killing themselves in prison and for self-harm in prison. In a sense, that in itself introduces the subject; I don’t think I need to say any more. I am going to ask Shabana Mahmood to kick off, but I am going to introduce the panel first. From my left, we have Sarah Hughes, who is the chief executive of the Centre for Mental Health. Welcome to you, Ms Hughes. Dr Huw Stone is the co-chair of the Prison Quality Network for Mental Health Services at the Royal College of Psychiatrists—that is quite a mouthful, Dr Stone. Mouthfuls seem to be quite the thing in psychiatry, because Dr Andrew Forrester is a consultant and honorary senior lecturer in forensic psychiatry at the Institute of Psychiatry and, I understand, the Maudsley. Is that right?

Dr Andrew Forrester

And the University of Manchester.

Chair

My word, you’ve had a lot of jobs! Thank you for giving up some time to come here. Finally, but not least, we have Mark Johnson, the founder of User Voice. I have to say that it is a very big issue for this Committee to reflect user voices where we can. One of the main points of our existence—we think—is to connect people at the receiving end of public services funded by the taxpayer with the people who make the decisions about how those services are formed. Over to you, Ms Mahmood.

Shabana Mahmood

Thank you, Chair. Welcome to the panel, and thank you all for coming to speak to us today. We have seen figures for the number of prisoners with mental health issues that range from 10% to 90% of the prison population. What would you say in your experience, with your professional hats on? How would you pitch the scale of mental health issues within the prison population?

Dr Andrew Forrester

We know quite a lot from the international evidence about the prevalence of mental health problems in prison. From evidence over the last 20 to 30 years, we can expect 2% of the prison population to have acute and serious mental health problems; about 15% to have specialist mental health needs; about 50% to have substance abuse problems and so on; and perhaps 50%-plus to have common mental disorders—depression, post-traumatic stress disorder, anxiety and so on. We are talking large numbers of people.

Mark Johnson

I would say 100%. I don’t think people who go to prison make healthy choices. They often have not made the moral choice to commit a crime—I think their predisposition from life experiences, et cetera, determines who we have got. I would like to say that the figures you have just mentioned are around what we measure—it is in the Report as well, about lack of assessment. So those figures are just who we assess, never mind whether people tell the truth on those assessments. There is that issue around, “If I’m honest about what is really going on, I get tret punitively, rather than getting the care that will affect my life and give me better mental health.”

Shabana Mahmood

That fear of possibly attracting punitive treatment while in prison, is that something people report often to you?

Mark Johnson

One-hundred per cent. Psychological services in prison are pretty much there to measure someone’s likely risk to society, not to solve the problems—it is about power and empowering. If we have a very siloed approach to how we commission mental health services, clinical services or whatever, then if I am honest with a clinician, that can be used against me, which can affect my parole and my likelihood of actually getting out, so there is an agenda for me to want not to tell the truth.

Chair

Dr Stone or Dr Forrester, do you want to pick up on that point?

Dr Huw Stone

Yes; I think it is a very good point. Looking at mental health in prisons is very complex, as I am sure everyone is aware. It is not as simple as someone going to their GP and saying, “I feel bad today and this is the reason,” as Mark has just explained. It emphasises also the whole problem of trying to deliver any type of health intervention in a setting that is not a therapeutic setting in that way—a prison is not therapeutic. It does emphasise some of the challenges that prison mental health teams face when they are trying to deliver mental healthcare in prisons. But certainly I would support Dr Forrester’s view that the prevalence of mental health disorders—each one that he mentioned—is much higher in prison than in the community. That is the key point. When we ask why there are so many more people in prison now with mental health problems, part of the answer is that there are more people in prison, full stop, therefore the number with mental health problems in prison will have also increased.

Sarah Hughes

It is an important point that you have just made. We cannot understand the scope or scale of this issue until we start reducing the numbers of people in prison. We all accept that the vast numbers of people in prison are in prison for less than 12 months for low-level crime. We know from the Report and from our own evidence that successful interventions in that time are virtually impossible to achieve. Fewer people in prison is the first point of call.

Layla Moran

Dr Stone, as you rightly pointed out, the more people who are in prison, the greater the likelihood that absolute numbers increase. In terms of the proportion, compared with the general population, have we seen a spike? Is the prevalence in the general population not going up while it is in prisons, or is it a general trend across the population that is being mirrored?

Dr Huw Stone

One of the really interesting things about this area is that, if you look internationally, there are very consistent and fairly stable figures for these proportions. If you take the most severe mental illness—some form of psychosis, such as schizophrenia—you find in developed countries across the world that between 4% and 5% of the prison population will have that illness. It is actually something that has remained quite constant for a number of years now. That is why I am saying the prevalence has not increased. The absolute numbers have increased, but as far as we know the prevalence has not actually increased.

Shabana Mahmood

Staying on screening, usually prisoners will have the reception screening and then a health assessment. What can be done to ensure that those assessments capture as much data as necessary to ensure that prisoners get the treatment they need, apart from setting up something that feels less like a formal interview and feels more like it will lead to therapy rather than punishment in prison?

Mark Johnson

As it said in the Report, we are dependent on limited assessments. And, as Sarah said about reducing the numbers of people in prison, there is a quite prominent point in the Report around restricted regime within that. Often, you can have a very good service that exists—that is, on entry into prison—but if you cannot get access to it, it is pretty pointless having it. For me, the elephant in the room—not just for this Committee, but for one I did a couple of months ago, which I think Harriet Harman was chairing, on the same issue—is around the restricted regime and addressing that before anything else; before you go into, “How can you improve assessments?”, et cetera. That restricted regime means there is a loss of prison staff, and the qualification of prison staff to pick up various mental illnesses on the wings—or even the ability to self-refer. We are talking about having a very colonialist approach to a professional diagnosing somebody coming through the door with a mental illness, but what about self-referral? If I am ill, I know I can go somewhere and I will get a standard of care like everybody else does.

Chair

Which of the doctors wants to go first? Dr Stone, you look like you are itching to get in there.

Dr Huw Stone

I know Dr Forrester will have a lot of helpful things to say about screening, which I think is a key thing, but one of the really important things to remember is the reception process. What happens when somebody comes into prison is that there is what they call reception, and a number of different tasks have to be carried out there, including a health screening. Probably, reception is one of the most chaotic parts of any prison—which also has its own problems as well. So, getting people through there and completing all those tasks can be a real challenge. One of the things that we are suggesting is that there should be a second specialist mental health assessment or screening done very shortly after reception—perhaps in what is called the first-night centre, where prisoners move to after reception. What the mental health teams tell us is that some of them can do that, and they find it very helpful, but others simply do not have the staff to do it. One of the issues which we thought the NAO Report was particularly strong on was commissioning and the consistency in commissioning. I am amazed at the differences in the resources available to some prison mental health teams compared to others. That really is a situation where if you have more resources and more staff, you can actually make a real difference in terms of their involvement with mental health in the prison.

Chair

Dr Forrester, do you want to come in briefly on that point? I will then bring in Sarah Hughes. We can’t have everyone answering on everything, or we will be here all day.

Dr Andrew Forrester

I think screening is a vital part of the pathway. Unfortunately, at the moment, from the work of Jane Senior and others, we are finding that we are detecting only about 25% of the people that we should be detecting through screening, so we have a long way to go before screening hits where it should be hitting. That is one of the reasons why it is important to do a second screen, as Dr Stone said, within the first 72 hours or thereabouts. I agree with Mark about open referral systems: I think they are vital in ensuring that we offer services to everybody when we can.

Sarah Hughes

I think this also speaks to an issue about the workforce. We know that in the prison system there is a reduced workforce number, but I think there is also something about skills and training and ongoing support and supervision for those individuals undertaking these assessments. This Report found that some of the questions were not being asked by prison officers, and that is because this is a really complex area. The nuances of self-harm and suicide are complicated; there is no one size that fits all, and I think the Report says that. So there is also something about prison officer training, recognising prison officer pressure, recognising what they are dealing with, and recognising the complexity—this is a complex issue that needs a complex solution; it is not easy.

Geoffrey Clifton-Brown

Could I ask our two professionals who the right person to be doing this assessment is—whether it should be prison staff or medical staff supplied by NHS England? Who are the right people to carry out the assessments?

Dr Andrew Forrester

I think the right people to do health screening are health professionals—usually nursing staff—at the point of reception into prison.

Geoffrey Clifton-Brown

So NHS England needs to be geared up to provide enough professionals to be able to do this work for the entire prison population.

Dr Andrew Forrester

Yes, I think everybody should be screened by a nurse when they come into prison.

Dr Huw Stone

We would go a bit further and say that we think that that nurse should be a mental health nurse, particularly for the second stage of the screening. They need to be part of the mental health team within the prison, so that they can immediately signpost somebody to treatment if they require that, and ensure it is delivered.

Geoffrey Clifton-Brown

At the risk of incurring the wrath of the Chair, may I follow up with a very brief question? At the moment, the assessment has 120 questions, most of which are voluntary and are probably not answered in most cases, for the reason that Mark pointed out at the beginning. How far is it reasonable to carry out an assessment and ask some pretty probing questions?

Dr Andrew Forrester

It can be difficult, in reception areas, to answer questions fully. Sometimes people might have only a certain number of minutes—10 to 20 minutes—per reception screen, which is usually difficult. That is the reason why it is important to go back and have a second look, with triaging, up to 72 hours later, when things are often a bit calmer.

Chair

We will now hear from Gillian Keegan and then Heidi Allen—everyone wants to come in, basically.

Gillian Keegan

Possibly this question picks up on something Dr Stone said about how commissioning can make a real difference; some facilities are very good and so on. We visited one recently, and it seemed that the health staff were very good. But how would you actually know? The thing that strikes you about this whole thing, despite all the process breakdowns on the way in, is the disconnect between the objectives and any plan to deliver them, whether that involves sentencing, screening, access to the right staff and then the environment, or whatever. All the way through, the plan does not hang together, so how would you actually know? What would you suggest? It is a complex area, but how would you be able to improve this to have a more outcome-based process?

Dr Huw Stone

I think the commissioning process has not included a proper evaluation of the services that those commissioners are commissioning, and an important component of that is the quality of the service. I am here today representing the quality network for prison mental health teams, which the Royal College of Psychiatrists runs. We would encourage all commissioners to ensure that their prison mental health teams are members of a quality network such as ours, where this is done on the basis of a peer review, with the network learning from the teams that are really good and those that are struggling perhaps learning how to improve the way they are working. Also, as the NAO Report pointed out, in terms of the whole commissioning process, the re-tendering of services has had a drastic effect on prison mental health teams. If you talk to anyone working in prison mental health teams, they will describe the disruptive nature of this process, where every few years the service is re-tendered out. It can take 12 to 18 months to complete that process; it can cost a lot of money. I think that it is something that really could be done very quickly, to say that that sort of rapid turnover of tendering should cease. We would recommend that services should be provided for at least 10 years before a re-tendering exercise is undertaken.

Gillian Keegan

If you look at the continuity from the prisoner or the patient’s viewpoint, it seems to me that even if you have better quality service and the way in which it is tended is not as disruptive, the record follows the patient through their mental health journey in very few cases. At the end of a prison sentence—a short one, in most cases—how can the treatment continuing afterwards ever be effective?

Dr Huw Stone

I think that things have actually become more effective in the prison system, in that there is now an electronic patient record that goes across all prisons. When a prisoner arrives at a prison, the staff can immediately look up all of the prisoner’s records—not just from that sentence but perhaps even from previous sentences. I have seen a huge change in that during my lifetime working in prisons.

Gillian Keegan

But the NHS records are the missing piece.

Dr Huw Stone

You’re quite correct. As you say, there is a big disconnect between what happens in the community, both before someone comes into prison and after they are released from prison. That is when there is a big disconnect.

Chair

So to pick up on Ms Keegan’s point, what can be done to make that work better? That question is for any of you—Sarah Hughes, you seem keen to answer.

Sarah Hughes

We believe that it is important that there is now just one commissioner for healthcare in prisons, which has been a fairly recent development in the grand scheme of things. That is a step forward, which gives us a better chance of making the information links.

Chair

That’s within prisons, but what about the link between prisons and the NHS? What about that continuity?

Sarah Hughes

I think that is a process that is about to happen. We need to recognise liaison and diversion, and that there has been an improvement in information sharing. The bigger issue for us is about when people leave prison and sharing of information through the gates, so that there is continuity of care at that point. It is improving when people are coming into prison, but we would say that there is still a problem when people are leaving prison.

Heidi Allen

This is a question to anybody really. It seems to me that for any good process to work you need the data, targets, the right number of staff, the right training for staff, the right processes in place and the right sharing of information, such as NHS records. Have any of you seen it working well anywhere in your careers? Sorry—that is far too doom and gloom. I saw it in prisons when I was looking at work readiness, from a work and pensions point of view. Some places are really good. The governor seemed to be the key ingredient to delivering a better service to their prisoners. Have you seen it anywhere and, if so, what does it look like?

Chair

Quick fire—has anyone seen it, first of all?

Dr Andrew Forrester

The place I saw it working best was where the same provider was working in police custody, in the local magistrates courts, in the local prisons, and back out in the community, because that offered continuity of record, movement and professional—

Chair

Presumably that commissioning was done through separate pots. It wasn’t one commissioner commissioning the same provider.

Dr Andrew Forrester

Well, at the time the commissioning was done differently. It wasn’t done by NHS England, but that does not exist in the same way in many places now.

Chair

Could that happen under the current commissioning system?

Dr Andrew Forrester

I think that is a question for the commissioners who come later, but possibly, yes.

Chair

Mr Johnson.

Mark Johnson

I could probably give you 12 examples of where it is working, with the NHS. It is working by putting the patient at the centre of the room and having monthly meetings with all the services in every establishment.

Heidi Allen

And where is that happening?

Mark Johnson

In 12 prisons across Kent, Surrey and Sussex at the moment. The problem is that we are actually commissioned to do 17, but in two years we have not even been able to get into five because of the systemic failures of security, and so on, of actually getting into work—

Chair

Could you write to us with that full list—the ones you are in, not the ones you are not in?

Mark Johnson

I just have to say, that is a consistent theme. Never mind actually getting into work; if people with lived experience—and we are absolutely driving patient voice and offering something of quality to the system—are not being allowed in because of their past, there is a problem. It is working in 12 prisons. On the procurement, it is working right the way through commissioning. On the commissioning of services that get into prison, we have a 10% procurement score for the prisoners themselves. There are two examples where they have almost been kingmakers in the contracts, saying that actually one service was needed more than another. I think that the monthly meetings and the process that is given for everybody to be involved in what services they get are profoundly transformative, because everybody is involved in it.

Heidi Allen

Does that continue when a person moves prisons—to a resettlement prison, for example?

Mark Johnson

There is peer-to-peer drive, which is what User Voice stands for, but I’m not doing a sales pitch here as we have no market competition strangely enough, of people with lived experience having a proper stake in this. If I have a mental health issue, then surely the ultimate answer is that I am given the skills to take control and responsibility of my own condition; that if I need help, I can go and get it; that I can go to prison and reach an enabling environment, where I am going to address the reasons that got me in there in the first place and not come back once released. Surely that is the purpose. Yet, what we often have is this systemic failure. Through the 12 commissioned areas in Kent, Surrey and Sussex, I think that there is a chance for it to be addressed, because people are getting to talk to each other more.

Heidi Allen

We would certainly be interested in more detail.

Mark Johnson

I would absolutely invite anybody to come in to have a look.

Chair

If you could write to us with that list that would be really good.

Mark Johnson

Absolutely.

Chair

Sarah Hughes, could you please answer that question? Sarah Hughes: A point connected to where things are going well is where interventions that are provided by both primary and secondary care are designed to meet complex needs. Currently we have IAPT in prison and secondary care in prison, and sometimes the people that we are talking about are improving access to psychological therapies.

Chair

Could you spell it out?

Sarah Hughes

That scheme is open to people with fairly mild to moderate conditions. Taking your point about the complexity of people going in, in terms of substances, self-harm and other issues, sometimes IAPT is not able to address their needs. We certainly advocate for interventions that are designed to work with people with complex needs and for not necessarily helicoptering in things that are working okay in the community.

Layla Moran

Mr Johnson, at the top level of commissioning, does someone with lived experience currently sit at that table?

Mark Johnson

No.

Layla Moran

Do you think it would help if they did?

Mark Johnson

Yes. Absolutely, 100%. Getting closer to the problem, one of the big things that startles me really is what is mental health? You described the layers; I think it is very important to set that out. I would say that the biggest, especially around the drug and alcohol community and the recovery community, is the ability to have the space to just talk about stuff. I think that it should be allowed to happen in prison, because it’s free. There are recovery groups outside in the community that want to get in but cannot because of the systemic security and failures to get them in. That is something that this Committee and the people in the room could actually do and achieve. Then let’s see what happens after that.

Chair

Thank you, Mr Johnson.

Shabana Mahmood

I would like to pick up on issues around drugs in prison. There has been a huge increase in drug finds in prison. Seizures of different drugs in prison have gone up from 2,500 in 2015 to more than 10,000 last year. In particular, there has been a huge increase in Spice in prisons. Do you think that that is connected to the increased levels of self-harm and violence in our prisons?

Mark Johnson

100%. We did a report on it last year, commissioned through the NHS. Prisoners call it the bird killer—that was the expression that was used. Basically, it kills your bird—your time—because there is nothing else to do. That is not just about workshops and not even about boredom either. There are a few different reasons actually: accessibility and the fact that there is not a test that is fit for purpose. We have a new emergent theme right now because of smoke–free prisons and the probably unintended consequence through what I believe is poor design—I might get shot down a little bit. Tobacco is bigger contraband than Spice right now and it would cost more to buy than Spice. I think it is a ticking time bomb not only in prison but actually out in the community, where people who have been in for the second or third time come back out and they have changed their drug of choice now—it is not crack and heroin. There is a question mark on whether the services are designed for this new type of drug use.

Dr Andrew Forrester

I agree that drug use in prison is a huge issue and can seriously compromise people’s mental health when they are in prison. I see people all the time in my clinics who have been using lots of Spice on the wing and have become acutely mentally ill, sometimes requiring transfer out to hospital, because of that Spice use in prison.

Gillian Keegan

We have talked about the rise in self-harm and suicide. How much of that do you think is linked to Spice?

Dr Andrew Forrester

That is a difficult question to answer. The increase in self-harm and suicide rates is probably attributable to a range of factors, of which Spice is one. The deteriorating prison environment also has to be put into the mix; as numbers of officers have gone down, and as incidents of violence have gone up, so things such as time out of cell have become difficult. There are some reports of prisoners spending less than an hour out of their cell per day. All those things within the environment are important as regards self-harm.

Gillian Keegan

We were quite surprised when we went to a wing with 300 prisoners—

Chair

Just to be clear, we went to Wormwood Scrubs—

Gillian Keegan

In Wormwood Scrubs, we went to the wing with the less engaged people who were not going out to work, etc. There were seven prison officers for 300 prisoners on four floors. It seemed obvious that that would keep people in their cells more, but there is also an impact when the care is available: less than 60% of the appointments were met because people could not get there. It seems to me that the whole system and the design do not hang together. Even in the bits that you use, you are looking at one individual element of it and there is no holistic plan—with the exception of you, perhaps, Mark—to have the patient at the centre of the care. What would you recommend in terms of a prison environment that would—

Mark Johnson

If I can be really honest here, political decisions were made a couple of years ago that, I believe, played quite a big role in causing this problem.

Gillian Keegan

What was the decision?

Mark Johnson

The reduction in prison staffing levels and in interventions and stuff as well. I am talking about direct interventions. Not only that, but no new way or innovation was put in place instead. The old, archaic controls, etc., are still there. I see prison from a different perspective; I see that prisoners run prisons. They do. That is a fact. Yet we still control them and lock them up. There are no staffing numbers, but there are peer-led interventions that we could do that are proven worldwide. They create an enabling environment so that prisoners can play a more active role in their own rehabilitation. We have a very colonialist approach to administering rehabilitation, when—speaking from lived experience—it is very different from that. The frustrating part for me is that prison governors are measured on how many people break out of their prison, and not on how many people come back in. We need to change the dynamics of that and create a whole revolution and drive towards people being equipped with what they need in order to never go back into prison.

Gillian Keegan

Going back to self-harm, how easy is it to self-harm in prison? How can they protect prisoners from that kind of environment? We saw lots of broken windows and things. What is your view?

Mark Johnson

Prison is a place of isolation. Anybody would tell you, and I am sure the doctors would tell you, that there are three types of abuse—mental, physical and sexual—but it is not the event that causes the damage, it is the sense of isolation. Prison is a place of isolation. Nobody talks about this stuff. If you have seven prison staff in a wing of 300, is that suggesting that they are even qualified to understand what mental health is, never mind being able to physically do anything about it?

Chair

But in terms of actual harm, things like broken windows and ligature points—

Mark Johnson

It is easy. It is absolutely easy. It is like drugs. People say, “There are no drugs in my prison.” There will always be drugs, because when there is a market and a need, there is a drive to want to go and find it. Razor blades, plastic, you name it; any implement can be used to self-harm. The question is why. That is the question. Why? What environment are we putting these volatile people into in the first place that is exacerbating the problem of their doing this stuff?

Chair

Dr Forrester, on that point?

Dr Andrew Forrester

One key thing is that many of our prison environments are completely out of date and need an upgrade across the board. Ligature points are a huge issue for suicide in prisons. It is difficult to address in older Victorian prisons that were built in 1843 and so on, but we must be able to find a way to solve the ligature points issue.

Chair

You say, “You must be able to,” but have you got any ideas about how that could be done? In other inspectorates they have to identify ligature points in other settings.

Dr Andrew Forrester

There are ways of doing things around safer cells, for example. Perhaps building different prisons is a way forward.

Chair

That is under way, I suppose.

Gillian Keegan

That is under way, but I worry about whether this thinking is actually inputted into the planning process for the new prisons.

Mark Johnson

It’s not.

Gillian Keegan

You don’t believe it is.

Mark Johnson

I don’t believe it is.

Gillian Keegan

Dr Forrester, have you seen any evidence?

Dr Andrew Forrester

To an extent. Sometimes bodies such as the Royal College might be asked to comment and so on, but I think that more expertise could be put in to these new designs.

Sarah Hughes

I think that there is something about recognising self-harm too. Some people who are repeatedly self-harming are at a greater risk of suicide because of physical health and so on. It is not just about going immediately to the ligature points, although that is incredibly important. Ritualistic self-harm on a daily basis needs to be understood, and the only people who can are the people on the wings—peer workers and officers.

Shabana Mahmood

I want to ask about transfers to secure hospital settings and the 14-day target, which is obviously hardly ever met. We saw examples at Scrubs of people who had been waiting for months, and we were told of other examples in other prisons where people had been waiting for over a year—in one case, 20 months. How can we fix this problem? That is a scandal.

Dr Huw Stone

As with many of the problems, there is not one thing that is stopping it from happening. One of the things that we as psychiatrists need to do is be better at working with people in prisons. When I started working in prisons, I found that you saw a completely different side when referring somebody to the secure hospital, which I also worked in, compared with when you were sitting in that secure hospital. It is about understanding between the two so that there is not, for example, a repeat of assessments. If an assessment is undertaken by psychiatrists in the prison, it should be accepted by a receiving hospital. That is one way it can be reduced. This is an example of where the whole pathway needs to be looked at. It is not, as somebody said just now, one bit of it in the prison. What are the issues with secure hospitals and the problems with getting beds in those at present? It is something that NHS England has to look at. The point in the NAO Report that there are different commissioning streams from NHS England is really important, and perhaps there is a case for bringing those two together.

Chair

The fragmentation certainly comes through.

Shabana Mahmood

Do you think the changes to commissioning will lead to a decrease in the number of secure beds available? Are we about to see this crisis get worse?

Dr Huw Stone

Are you talking about the changes to new care models within—

Shabana Mahmood

Yes.

Dr Huw Stone

I think that is one of the most exciting things that is going to happen. I am involved in our local area, the south-east of England, in the new care models development. For the first time it actually gives the people who understand the issue, including people with lived experience of it, a chance to have a say in shaping that service. It is not just led from a higher-up commissioning level, so I think that has the opportunity to make big changes.

Geoffrey Clifton-Brown

We saw 120 self-inflicted deaths in 2016—an increase of 97% since 2012. Further to Ms Mahmood’s question, the Department of Health guidelines say that people should be sent to a secure hospital within 14 days. Some are up to 140 days. Surely we ought to have a mechanism? Maybe it is that those properly qualified mental health staff, which you talked about at the beginning, ought to be brought in quickly to get those people out of prison quickly when there is a really serious problem. After all, if those people were in the civilian population, in the worst circumstances they would be sectioned and got into hospital within a matter of hours or possibly days. If that happens within weeks or months in prisons, no wonder they get so many cases of self-harm or, even worse, death.

Dr Andrew Forrester

There is an issue about developing liaison and diversion services in particular, so that vulnerable people do not get into prison in the first place. Last I heard, there was 50% national coverage of liaison and diversion services. We certainly need to get up to 100% coverage so that we divert people as early as possible. The second point I would like to make about hospital transfers is about lack of co-ordination. There is often a lack of regional and national co-ordination about these referrals. As a doctor working in a prison setting, I would often make a referral to a medium secure unit, for that to be rejected, to make a referral on to a psychiatric intensive care unit, for that to be rejected, to make a referral back to the same medium secure unit, and on and on—it goes round and round. I am a section 12 approved practitioner, and I can determine whether someone requires hospital admission or not. That is a problem that we need to solve.

Sarah Hughes

Liaison diversion is, I think, at near 70% with an achieved target by 2020, so it is moving at pace. The point of the matter is that these people should not be in prison in the first place. Liaison and diversion is critical to making that happen.

Geoffrey Clifton-Brown

Is there a role here for the Ministry of Justice and the justice system considering these problems in the round before they make a sentence?

Sarah Hughes

For sure. Absolutely, we would argue that these decisions need to be made with full information at hand: with a full, complete assessment of somebody’s needs. We know there is a huge number of people that should not be in prison. Liaison diversion has been designed and set up to alleviate the pressure. It is not rolled out 100%; it is near that. But it is also about integration and people understanding and respecting those assessments and diverting people away to community services. Mental health treatment orders are not quite at optimum level yet, either.

Layla Moran

Dr Stone, to come back to the question I asked at the beginning, I sense there is a general picture that things are getting worse, yet you said that the proportion was not really changing. Have I misunderstood that?

Dr Huw Stone

No. I think the proportion of people in prison with severe mental illness is, as I say, remarkably constant. However, you could argue, “Why isn’t it reducing? Why isn’t it improving?” Over the last 10, 15 years, we have had a big expansion of the secure hospitals, so there are far more beds now then there were 10 to 15 years ago. So the question is: why isn’t it getting any better? One of the reasons why things are getting worse now is, I would say, everything in prison is getting worse. We have heard very graphically from Mark about what it is like in prison, and that is our experience as well, working in prisons: everything is getting worse. So when things are getting worse within the environment, then mental healthcare is bound to get worse as well, I am afraid.

Layla Moran

If we called you back in one or two years’ time, in terms of that proportion, what would success look like, numerically speaking? What would be an achievable goal?

Dr Huw Stone

I do not think it is possible to put a figure on it. What success would look like is well-resourced mental health teams working to a service specification specific to the area they are working in. NHS England is currently working on a service specification for mental health teams, but I understand it is a one-size-fits-all. Will that be sufficient, say, for a women’s prison compared to a male prison, compared to a young offenders' institute, compared to a remand prison? There needs to be greater emphasis on looking at what the specific needs are within the different prisons that exist at the moment.

Caroline Flint

I want to ask you about the staff working in prisons. All of you have mentioned that there are just not enough staff. I am interested in your comments. What is the responsibility for mental health support for some of those staff as well, if they feel under enormous pressure all the time from having seven people to 300? Or they may have been victims of an attack, which is going to affect their mental health in terms of returning to work. Have you done any research on that that correlates to the needs of prisoners and also the staff?

Sarah Hughes

We did some work with the Howard League at the beginning of the year and published four reports talking about this very issue. What we would say is that the pressure on prison officers is vast. It is not just about the risk of assault, actually. It is about the risk of trauma: finding somebody who has self-harmed or tried to take their own life, or has indeed succeeded in doing so. This is a daily occurrence. So we cannot overestimate the impact of that. We, working in clinical services, will have clinical supervision, ongoing training and monitoring—all of those things. Prison officers do not have that. They are being faced with highly complex issues on a daily basis, and I do not think we can develop an understanding of need without really thinking about the officers that are doing the work.

Chair

Thank you all very much. That was really useful evidence. The transcript of this bit of the hearing and the next bit will be up on the website, uncorrected, in the next couple of days. You will be sent information about that, as witnesses. Our report will be coming out, we hope, by Christmas—I cannot guarantee that. We will send you a copy just ahead of that. Thank you very much indeed. Examination of witnesses

Witnesses

Kate Davies, Richard Heaton, Michael Spurr, and Simon Stevens.

Chair

Good afternoon, and welcome back to the Public Accounts Committee on Monday 23 October 2017. For the benefit of the new witnesses—and particularly Mr Stevens, who is a frequent flyer, to make sure he is on the right topic today—we are looking at the National Audit Office’s Report on mental health in prisons. As I said earlier, we do not need to say much more than that 2016 was the worst year for self-inflicted death and self-harm in prisons since records began, which is pretty stark. I will not repeat what is in the NAO Report—you have seen it, and we have seen it—but this is a very big issue. Before we go into the main hearing, I will introduce our witnesses, and I want to ask Mr Heaton and Mr Spurr about a couple of issues relevant to your area in the last couple of weeks. We have Michael Spurr, who is the chief executive of Her Majesty's Prison and Probation Service—I think we last met each other just over a year ago in Doncaster; Richard Heaton, who is the Permanent Secretary at the Ministry of Justice; Simon Stevens, who is the chief executive of NHS England; and Kate Davies, who is the director of health and justice, armed forces and sexual assault services commissioning at NHS England. That is a very long job title, Ms Davies. It is good to have you here. I think this is your first time in front of us.

Kate Davies

It is, yes.

Chair

Welcome. We are a very friendly group of people. Our hashtags today are #mentalhealth and #prisons, if anyone is following on Twitter. I want to ask, Mr Heaton, about what is happening at Long Lartin. It was a pretty horrific set of events in October. Was that because of cutbacks on prisons officers?

Richard Heaton

No. As far as I know, Long Lartin was fully staffed, and I don’t think what happened there—

Chair

You say it is fully staffed, but is the complement enough to prevent this sort of thing from happening in future?

Richard Heaton

On the day, I do not think there was a staffing issue. I do not think that was one of the proximate causes at all, but Mr Spurr may be able to help.

Michael Spurr

Long Lartin is a high-security prison. It has a large staff group. There are vacancies in that staff group, but staffing was not an issue in terms of the incident that happened recently. The prison has been able to run a full regime. There were a set of issues that we are looking into, and we will investigate what happened at Long Lartin, but it was much more about the dynamic between prisoners themselves and the way that staff were managing the prisoner issues than anything to do with the regime or staffing numbers at Long Lartin.

Chair

How many vacancies were you carrying at Long Lartin then and how many do you have at the moment?

Michael Spurr

I was not expecting that question, but it is around 22 prison officers out of a complement of, I think, 280. Those are large numbers, but they will be covered through potential for overtime payment plus and so on. It is about the same number—20-some—of vacancies for operational support grades, who are the next grade down from prison officers, out of 100-plus. Again, that is an overtime grade and will be covered through overtime.

Chair

Thank you for that. Sorry, I thought we had notified you of that question; forgive me if I did not do that. This question is also to you, Mr Spurr. It is on community rehabilitation companies. You yourself came out quite boldly, saying they have not achieved as much as they could. We discussed this when we were in Doncaster on that nice sunny day last summer. Are you now changing tack on how you deliver these—

Michael Spurr

No, I was answering a straight question with a straight answer. It was a question about resettlement services. I referred to the chief inspector of probation’s report on the Through the Gate programme, which indicated that that was not working as had been anticipated, and I confirmed that is the case. It is not working as well as we would have wanted was my precise phrasing, and that is the case. But what we have been doing—I said this as well—is working with the CRC providers, in terms of looking at what the service provision is and what we can do to improve that service; we are continuing to do that at the minute.

Chair

We did flag up some of these concerns in our report, so what has changed since that you are now beginning to act? Were you doing things after that report came out?

Michael Spurr

To be fair, one of the key issues that was flagged by the NAO and, indeed, by your report was the changing volumes for CRCs. I recall that you said specifically, and the NAO Report said, that we needed to address that. That is one of the things we have been doing; indeed, it is one of the reasons why we made some changes to payments and how we would structure payments in the summer. I know the NAO, again, is looking at that. It was precisely to address an issue around a change in the case mix that CRCs have faced, and not just numbers in terms of volumes, but the different types of cases that they are having to manage. We have restructured contracts to some degree to try to address that.

Chair

But if you are restructuring contracts frequently, does that perhaps mean that the flexibility is not in the system for people to deliver what they need to deliver for the individual who is sitting in front of them at the time?

Michael Spurr

This was a first-generation outsourcing contract of a pretty large nature and involving complex service provision, so it would have been a surprise, and I think that, again, it was recognised in the NAO Report and in your previous engagement that we needed to look at and manage this. We delivered, as the Report said, the implementation of the policy pretty effectively, but it was always going to be about how the policy worked in practice, and we are into that very key area at this moment.

Chair

Okay, we will leave that for now. I am going to hand over to Shabana Mahmood to pick up on wider issues.

Shabana Mahmood

The number of drug seizures in our prisons went up from 2,500 in 2015 to just over 10,500 in 2016. The number of Spice seizures in prison went up from 408 in 2015 to nearly 3,500 in 2016; and in the figures that we have for half of 2017, the number of drug finds for Spice is already over 1,600. I think it is fair to say that drugs are rife in our prisons and there appears to be a bit of a Spice epidemic. Why is there such a failure to prevent drugs from getting into our prisons?

Michael Spurr

As Mark Johnson said in the evidence earlier, there has been a huge switch in drug use over recent years towards psychoactive substances, which has been a very difficult thing for us to deal with in prisons. Those substances were for a period classed as legal. That is why we had the terminology of “legal highs”, and they were relatively easily accessible in the community, which meant that people—initially, friends and so on—began to try to supply these drugs, but they were quickly seized upon by serious organised criminals, who saw a market in prisons. They have targeted that market quite mercilessly, in our view. We have been working with police colleagues and others to try to address that. We have done a whole range of things to address the threat that these drugs have created for us in prisons. There were over 300 different compounds, which meant that testing for them was difficult. We do now have a test, and we are testing regularly for these drugs. We could not detect them. We were the first law enforcement agency anywhere in the world to train dogs to detect psychoactive substances. We could not previously do that. For a period, that meant that prisoners were getting access to these drugs in a whole range of ways, including through throw-overs; even though it is illegal, they were coming over the wall. We were picking them up. That is why the numbers of finds were much increased. We found an awful lot of this, but some gets through. It gets brought in by visitors; it gets brought in through a whole range of measures, including technological aids like drones, which have been bringing drugs in. It took us some time to begin to address this real change that has spread across the prison system in England and Wales so swiftly. They are very dangerous types of substances, as Mark and, indeed, the doctors themselves quite rightly said in the previous evidence. They have changed the nature of how people, when they have taken drugs, respond in prisons. It has been extremely difficult for us, but we are working with our law enforcement partners—the police—in communities to try to deal with the supply routes, as well as actually working with our NHS colleagues on treatment and education. We have a huge education programme in prisons through prison radio and a whole range of arrangements.

Shabana Mahmood

Your interventions do not appear to be impacting on the number of finds, which have not actually gone down; for the six months of this year, they are already at least half of finds in the whole of the previous year. How would you say you are succeeding in all of the measures you are taking?

Michael Spurr

You can look at finds in two ways. The fact that we are detecting them means that we are actually stopping them getting to prisoners. A lot of those finds will be ones we have taken before they get anywhere near prisoners; some will be from prisoners’ cells and so on. Detection, disruption and finding, and now being able to charge prisoners internally for having possession of drugs as well, which we could not do initially because we weren’t able to detect them, is part of a strategy that says you have to try to attack the supply of the drugs coming into prisons from external sources; to make clear to prisoners that that is an unacceptable practice—clearly it is illegal and you cannot have illicit items in prisons, including drugs; to tackle it with the individuals; and to then provide treatment options for them to come off those drugs. You need a holistic strategy, much as we do in communities, to be able to address that whole problem.

Shabana Mahmood

On the issue of supply, the drugs are either thrown over the perimeter into the prison estate or are flown in by drones— my understanding is that lots of the NPSs are flown in, in particular. Why has it proven so challenging to stop the drones getting on to the prison estate?

Michael Spurr

We are doing a lot to try to prevent drones coming close to prisons. At the moment, that is a minority way of coming in; it is high profile when people see it, but it is the minority way of coming in. It is difficult because prisons are very often in communities, so it is often about air space and stopping things and about what you do that does not prevent other people legitimately doing things like using their mobile phones outside a prison and so on. There are lots of ways that drugs get in, as I said. Another route people have been sending them in by is simply putting it on correspondence; there is a way of getting psychoactive substances on to letters and then smoked or sniffed and so on. There are a whole range of different ways that we are constantly looking at to try to disrupt and prevent drugs entering prisons.

Shabana Mahmood

On drones in particular, my understanding is that you have the data about how many drones that were about to bring drugs into a prison that you were able to stop, but you do not release that data. Is that true?

Michael Spurr

We record a whole range of things about drone sightings and so on.

Shabana Mahmood

But specifically about drones bringing psychoactive substances into a prison? You know how many you have stopped, but you don’t share that information?

Michael Spurr

I am not sure we would have information about what drones we have stopped bringing psychoactive substances into a prison.

Shabana Mahmood

Any type of information on any type of drug?

Michael Spurr

I am not sure we would differentiate between drones bringing things into prison. We have data about drone sightings and on where we were able to stop drones. I am not sure what we have done in terms of putting that into the public domain; I am happy to look at that and write to you.

Shabana Mahmood

Moving on to rising self-harm and suicides in prison, self-harm incidents have increased by 73% and we have the highest numbers on record of people taking their own life in prison. That is a pretty damning indictment of mental health within our prison system, especially when you consider that 70% of those who took their own life were known to have a mental health condition. Do you agree that that is a damning indictment of the state of mental health services within our prison estate?

Michael Spurr

The level of self-harm and the deaths in prison are a dreadful thing. Yes, it is a damning indictment that anybody takes their life or dies in prison, and levels of self-harm going up like that is something that worries all of us who work in prisons. Every time I hear of a death, which I do for every single one, it is, of course, dreadful.

Shabana Mahmood

It is more than dreadful—it is a sign that the system has utterly failed, is it not? When 70% of those people are known to have had a mental health condition, it is a sign that mental health services in prison have utterly failed.

Michael Spurr

As was said earlier, it is a sign of a whole range of things that are not working how we would want. I think there is a whole range of factors that have led to increasing self-harm and suicide in prisons. Some of them were referred to earlier in your evidence.

Chair

A lot of those things are within your control or the control of the prison system, Mr Spurr.

Michael Spurr

Some things are in our control, absolutely. I am not denying the whole issue about changes in the prison regime and changes in numbers of staff, but there is equally an issue, as we have just described, about changing drug use and the changing nature of people who are coming into prisons as well. In particular, I would say from my experience that the psychoactive drugs have had a wider impact, as mentioned in the earlier evidence, than you are perhaps reflecting on. There is no question but that the levels of self-harm going up have been a real issue. In effect, just over 12% of men in the system are self-harming, and 28% of women are self-harming. That is a significant proportion of people, and the incidence of self-harm has increased significantly. In terms of the number of deaths, 2016 was a horrible year. Thankfully, the figures released in June for the year from June 2016 to June 2017 are better. We have been working incredibly hard to address and reverse the increase in the numbers of deaths. Those June figures were better, but not where we would want them to be, and the rate at 1.1 per 1,000 is much too high. We want to reduce them and are working hard to do that.

Shabana Mahmood

Given the increase in self-harm and suicide, what is the specific plan that has been put in place to see those numbers come down? I address that to Mr Heaton and Mr Stevens in particular, because you, in effect, hold the pen on a strategy for getting these numbers down.

Richard Heaton

This is about how the Prison Service performs, as well as the NHS. Let me make that absolutely clear. We are responsible for the care of the individuals who take their lives and, as Michael said, it has been a very dreadful thing. I will mention a few things. The first is mental health training generally, and training on suicide awareness, among our staff. All our staff will go through that. Already some 7,000 members of staff have started going through that training. Secondly, I know we mention this a lot, but the level of staffing has been detrimental to the security, stability and good order in prisons, including the self-confidence and resilience of offenders. It was the case that offenders had regular human contact with prison officers more often than has been the case in the past three years. Bringing some prison officers back on to the wings and establishing proper one-to-one engagement with prison officers is incredibly important. That is partly because they can pick up problems and is partly because conversations can happen and the human space can operate whereby people do not feel alone. Then—as Mr Spurr has not said this, I will—there is the matter of responding better to recommendations made by the ombudsman, by the inspector and by this and other Committees. We have not been as good as we should be on responding and keeping up to date with the recommendations against us—the ones that we have accepted—so we are working very hard to ensure that when observations are made about the failures, they are acted on. Those are three things, but maybe Mr Stevens—

Chair

Before we go to Mr Stevens on this, you mentioned the response to the ombudsman. A lot of these responses to the regulatory bodies, inspectorates and so on are not statutory requirements. Is that right?

Richard Heaton

The ombudsman is not a statutory being, correct.

Chair

What about the inspectorate? Is it statutory?

Richard Heaton

The inspectorate is statutory, yes.

Chair

So you have to respond?

Richard Heaton

We had clauses in the Prisons Bill before the election that would have strengthened the inspectorate. We are replacing that with administrative measures, which come to the same effect. We are going to treat it as such.

Chair

But administrative measures are not statutory. You have hit the nail on the head about why I am probing on this.

Richard Heaton

You’re right, but, for example, we are introducing a system with the inspector where, if the inspector sees something really serious, he can bring it to the immediate attention of the Secretary of State who has to act. There is no statutory force behind that, as there would have been had it been in a Bill, but we are doing it anyway, and that stuff will be rolled out within weeks.

Chair

Is there a reason there is no statutory measure? Why has it been dropped from the new Bill? Is that a policy decision?

Richard Heaton

There is a pressure on legislative time because of the Brexit legislation and other things.

Chair

I shall bring in Mr Stevens, and then I have others coming in too.

Simon Stevens

I agree with everything that Richard has just said. May I also start with a personal declaration of interest? My partner is an unpaid member of the independent monitoring board of a prison in London. I just want to put that on the record. From the NHS point of view, we would say that the range and the quality of prison health services have improved over the last several years, relative to the hotch-potch that it was when it was all locally commissioned by PCTs. However, we do not think that we are where we need to be, so there is quite a significant programme of work both to expand the availability of services and to get better join-up between the prison system, the specialised mental health services and continuity of care for prisoners before and after. One of the foundational assets of that, alluded to in the NAO Report, will be a health information system coming online. That will mean that when prisoners are screened at point of reception—that is a couple of hundred thousand people a year—we will be able to do a more comprehensive longitudinal assessment of their mental health and ensure that they then get the services they need. I agree with Richard that the teams of staff providing healthcare in prisons are part of the broader team. The very welcome efforts that the Prison Service is making to increase staff numbers will help with getting prisoners to the health appointments made for them within the prison estate.

Kate Davies

You asked, Chair, what the plan was for the reduction of deaths in custody. I absolutely agree—it is an appalling situation to be overseeing health and justice commissioning with that horrible, stark stat. One thing that is really important is focusing on operational issues as well as strategic and partnership responses. The panel before us was questioned about this. We have improved and put as a mandatory requirement all levels of screening within our healthcare commissioning services. Our healthcare services have a requirement to screen on reception within five hours. They also have a requirement to screen within 24 and 72 hours. That improvement has been showing dividends as part of the improvement in healthcare and the risk factors within our prisons. I know that some of the panel have seen some of those. We have to look at the point made about the right people getting into prisons, particularly on remand and in the new reception centres. We have a massive churn in prisons. We have 87,000 people currently in our adult prisons and about 200 going through the churn of the system at any one time. In reception prisons particularly, we need an emphasis on more access to healthcare and more support—for example, the Samaritans’ listening service. We are very pleased to be working on that in partnership with Her Majesty’s Prison and Probation Service. It is also about designing more peer support and getting to people much sooner, before they are at risk. We know there are absolutely massive levels of self-harm, and one of the issues is working with a number of people who are self-harming. There are large numbers, but there are also clusters, so it is about identifying those. I know that—

Chair

I am not trying to demean your evidence, but you are describing the problem. What we are really after, in the time we have, is solutions. We have all read the Report and were pretty shocked—that is a word we do not use too often in this Committee, otherwise we would be shocked every week, but this is really shocking. I think we all agree on that, so let’s take that as read.

Heidi Allen

That is exactly where I was going with my question. Kate, you were starting to give me hope, but Richard, I have to say that I was bitterly disappointed. I do not for one minute think this is one single person’s responsibility to fix. Committees clearly have an important role to play, as well as the NAO and so on, but all you gave us was more training. I appreciate that staff numbers going down has played a massive part in this—I don’t underestimate that at all—but I want to hear why you are not looking at the whole process end to end and re-engineering it, rather than waiting for Committees to tell you their recommendations.

Richard Heaton

We are absolutely not waiting for this Committee to make recommendations. This has been top of our operational and strategic attention during the last two years. The most vulnerable time in a prisoner’s journey is in reception, in the first few days in custody, so we are improving prisoners’ experience in the first few days in custody. We have a system to assess someone’s susceptibility to suicide, and we have improved that. The attention that we have been paying to this will show through in the October figures, which I hope will show a further improvement. The June figures were an improvement on the horrific figures we had last year.

Heidi Allen

Do you have some target numbers?

Richard Heaton

I would not like to set a target that could be suggested to be an acceptable number of prison suicides. That would be wrong. Every prison has to make appreciable reductions in the self-harm and suicides in their prison. That is something we measure and look at in every performance and accountability board we have.

Chair

At Bristol prison, there were three deaths in 18 months. Our colleague, Alex Chalk, has raised that with concern in this House and with us in advance of the hearing. Since then he has had an answer from the Minister saying that 31 additional prison officers have been appointed to that prison. But why did it take three deaths to say that there was a problem at Bristol, when people were aware of the problems there before that?

Michael Spurr

We were certainly aware of that. We had identified Bristol as a prison of serious concern when we published our assessment ratings of prisons in the summer.

Chair

Was that after the three deaths, or before?

Michael Spurr

Deaths, tragically, can come in clusters. That occurs in the community and it certainly occurs in prisons. You can have deaths, very sadly, in prisons that are running well, and sometimes prisons that are not good manage not to have deaths. The complexity of why you have particular deaths in places is very difficult.

Chair

So how do you identify the problem in Bristol before that?

Michael Spurr

You look at other measures, self-harm being a particular issue. There is a much greater volume of self-harm than individual deaths, which statistically are still quite small, though each one is tragic. I want to come back to the point about what we are doing and looking at. Lord Harris did a review a couple of years ago on the whole issue of deaths of 18 to 24-year-olds. His main recommendation to Government was reinvigorating and providing a case worker for each of the young people whom they could relate to. In putting an initial 2,500 staff into prisons, we have taken the model that Lord Harris looked at. We are looking to introduce that across the system, with key workers for every individual prisoner and around six prisoners for each key worker to look after and manage. That was the rationale for the additional resource that we were able to secure. It is absolutely the right way to try to address the deficiencies we have at the moment, with people feeling more isolated, and to make sure regimes are more consistent—something that was raised previously. That is a very specific and clear change we are bringing into place. We are on track to recruit those 2,500 officers. The latest figures, published last week, show 1,290 additional officers compared with October last year.

Gillian Keegan

Mr Stevens, you mentioned a hotch-potch of services that were there previously. Rarely have I seen such disconnect between the high-level objectives—providing health and wellbeing services in prisons, and looking to improve health, tackle health inequalities and reduce reoffending—and any semblance of a sensible, joined-up plan. You talk about little bits and parts of tackling each individual piece as a solution. None of those will be effective without a sensible joined-up plan. What are you doing to achieve that?

Simon Stevens

Kate is obviously our prisons expert here. Looking at the history of this, I think in 2005 responsibility for prison health was transferred to the NHS but was largely the responsibility of local primary care trusts. Then in 2013, for the first time, we were able to take a national point of view on that. As contracts have come up for renewal, we have been able to drive more consistency into the way in which those contracts are being let. I do not say that we are at the end of the line on that. There are clearly some intersections that are not working as they need to. Those are, in many cases, rightly pointed out in the NAO Report. But in terms of both the investment and the quality of care, let us remind ourselves that the NAO Report says in several places, “clinical care is broadly judged to be good”. I think that is correct.

Gillian Keegan

That might be true, but the process disconnect almost makes the service inaccessible. There is the continuity of records—of NHS health records and GP records—going to the prison and a treatment plan that is joined-up and has the prisoners’ needs at the centre of it. Then there is the problem with the records following the patients—the screening and diagnosis—and then, when you have got an appointment, when you have a treatment plan, there are not enough prison officers to take you out of your cell and deliver it. The appointment rate is 60%. If you have not got records to follow this up, it is not working.

Simon Stevens

Fundamentally, yes, but your stat is wrong. I think 15% of appointments are not kept, as measured off the most recent information set for the performance.

Gillian Keegan

We went to one prison on Friday. They said that only 60% at best were kept, and they thought they were doing well.

Simon Stevens

That was Wormwood Scrubs, was it?

Gillian Keegan

Yes.

Simon Stevens

If that is the Wormwood Scrubs position as of Friday, that is significantly worse than the national position. The underlying point is correct, which is why we have taken action. In fact, we signed a contract on the Friday just gone for the equivalent of a GP medical records set that will be available for prisoners. We will be able to import their medical records for their prior treatment in the community and subsequently export their in-prison healthcare experience. We signed that contract on Friday, and it will take between 12 and 24 months to get a complete roll-out across the whole of the adult prison estate, youth prisons and other parts of the criminal justice system, but that is going to make a hell of a difference. If you had come with me to Belmarsh prison, where I was a few weeks ago, you would have seen some of the improvements that have been made more recently, such as the smart card that enables prison health teams to get access to the summary care record, which was previously not available. Previously, faxes were flying around the system with bits of information.

Chair

Sorry, we were just laughing at the idea of the faxes. Our fax machines are gathering dust.

Simon Stevens

Well, indeed. Was that a pretty screwy system? Yes. Have we taken action to tackle it at root? Yes. Will we see the clinical benefits of that over the course of the next 12 to 24 months? Yes.

Gillian Keegan

How are you measuring your clinical benefits? In your new agreement, have you got measurable outcomes?

Simon Stevens

There is a chicken-and-egg aspect to this. If we have not got the longitudinal medical record, it is hard to track what is actually happening to prisoner health status. Once we have that record, we will be able to do that.

Gillian Keegan

So you accept that we have no idea whether the £400 million we have spent so far has been effective or not.

Simon Stevens

No, I think that is a generalisation.

Gillian Keegan

Give me a specific example of how it has been effective. We can’t see anything that you can measure—reducing reoffending, for example.

Simon Stevens

Here is the indicator set that we use—I can leave this with you, although you may have got it—to track what is happening inside the health services in prisons. It is pretty extensive. Is it all-singing, all-dancing? No, but to say that there is nothing here in this phone directory’s-worth of information would be a mistake.

Shabana Mahmood

From that document, can you tell us how many people in prison today have a mental health issue? Does that document capture that information? I have not managed to find it anywhere else.

Simon Stevens

Yes. We have that on our mental health registers, which show the month-by-month prevalence of severe and enduring mental health problems. I have got the figures here for June, but no doubt we have got the data. The answer is 9.5% at the severe end of the spectrum. Over and above that, there is a figure in the NAO Report of 37%, which I think is an HM inspectorate of prisons number. As we get the comprehensive screening in place using the new systems we have got, we will be able to produce that on a real-time basis.

Chair

I want to clarify that number, but I think Mr Stevens might have just done that for us.

Oliver Lodge

My understanding is that that is the number of people in treatment.

Shabana Mahmood

My question was not about the number of people receiving treatment for mental health issues. It was about the number of people with a mental health concern in prison.

Simon Stevens

We think the number of people with severe mental health problems is the number of people—

Chair

To be fair, Mr Stevens might know more about the treated people, because that is his responsibility. Mr Heaton, how many people in prison have got—

Richard Heaton

I see the gap as follows. We know, from the 10% number, the number of people who are in treatment—

Chair

Sorry. Let’s cut to questions and answers. Do you know the percentage of prisoners with a mental health problem? Have you got any figures you work from?

Richard Heaton

No. The only figures we have are about 10 years old. They are from an in-depth survey we did, which showed that roughly 50% are prone to anxiety or depression.

Chair

So you don’t know the scale of the problem, and yet you have got—

Richard Heaton

We know in scale terms, but we don’t have precise data showing how many people are prone to anxiety in 2017. We can’t give you that figure.

Chair

You choose anxiety, but there are different grades of mental health problems. Do you have any figures for any of them? You have got the high end, because those are some of the people Simon Stevens’s side of things is treating.

Richard Heaton

No. At a national level, we have some good intelligence but we don’t have sophisticated data on gradations of healthcare needs or mental health needs in our prisons, as far as I know.

Shabana Mahmood

So we don’t have a full understanding of the scale of the problem. Do we know how many people request treatment but do not receive it? That is to either Mr Stevens or Mr Heaton—whoever is responsible for that data.

Simon Stevens

Kate will come in here, but we have the missed appointments, which by definition are people who are supposed to be coming, and that is running at about 15%.

Shabana Mahmood

That is not the same as those who have requested treatment and then not received it. We understand that that happens across—

Simon Stevens

The health service works on the basis of care according to need, not on the basis of care for people who request care. A clinical judgment is made as to what the appropriate medical response needs to be. But Kate will speak on prevalence.

Kate Davies

On prevalence, when we talk about a plan, it is also important to say that we started commissioning this with no indicators or measures of performance. It was really important to have that plan and to get those indicators in place, and we have done that in partnership with Public Health England and the MOJ. We always said that those indicators of performance that we are measuring at the moment would be there for three years, and we are reviewing them now. We will refine them; the 20 indicators for mental health within those indicators are being reviewed as I speak. They will be improved and go live for April 2018. That will also include a stronger emphasis on the aspect of mental health that I think you are talking about in terms of numbers—that is, on anxiety and depression. Lastly, I slightly dispute what was said in the NAO Report: all our healthcare commissioners do health needs assessments, and it is from those health needs assessments that we know that the prevalence is around 18%. We also know about mental health needs through our service users and lived experience panels.

Shabana Mahmood

How long has NHS England been in charge of delivering mental health services in prison?

Kate Davies

We have been commissioning since April 2013.

Shabana Mahmood

So you have had some years to try to get some of these basic metrics and indicators in place, and there has been a failure to do that. That is a material point, isn’t it?

Kate Davies

I would argue that there has not been a failure to do that. What was absolutely important was, for the first year, to ensure that we had the quality, as was mentioned earlier.

Shabana Mahmood

Would you agree that, if you start with no indicators, as you said in your previous answer, and we still do not know the scale of mental health issues in prisons, we have basically failed to get the most important indicator in place?

Kate Davies

We have that indicator for severe and enduring conditions, and we have that—

Shabana Mahmood

You have just said in your answer that you will move towards looking at what you describe as the lower end: anxiety and depression.

Kate Davies

Yes, absolutely.

Shabana Mahmood

You accept that they are part of the mental health piece in prisons?

Kate Davies

Yes, I accept that that needs to be improved.

Shabana Mahmood

When you took over those contracts in 2013, it ought to have been clear that we should get some indication of all these elements of mental health-issue indicators in place right at the start.

Simon Stevens

One indication is how quickly people are able to get the mental health appointment inside prison. If we are talking about equivalence, the comparison is between that and how quickly someone might be able to get a mental health appointment outside prison. The figures we have show that the appointment times are fewer than six days on average, and indeed, for an urgent GP appointment they are faster in some respects in prison than outside.

Shabana Mahmood

With respect, we have not yet moved on to the quality of the service or what we mean by equivalence.

Simon Stevens

I thought quality was what we were debating.

Shabana Mahmood

We are talking about the basics of data collection, so that we can work out whether you know the scale of the problem and how much it will cost to fix it, or whether we have a dysfunctional and more expensive system in place. Right at the start, when you took over these contracts, it should have been obvious, should it not, that a proper understanding of the scale of mental health issues across the piece—not just the most serious issues, but anxiety and depression—should have been core business bullet point 1?

Simon Stevens

I disagree, because that is to misunderstand the way these contracts came up for renewal. When we inherited them, there was a duration—a run-off—on these contracts. What you have heard from Kate Davies but have not taken account of is that, as the contract comes up for renewal, a health needs assessment is done for that prison, taking account of the mental health and other health needs of those prisoners. That is then reflected in the contract that is let. It is happening on a rolling basis.

Gillian Keegan

How do you do that assessment if you do not know how many people have a mental health issue, you do not have a proper screening process and you do not have the GP records beforehand? How do you do it?

Chair

Practically?

Kate Davies

If we are talking about data, there are a number of elements as well as the data we have, including the substance misuse data from the national drug treatment misuse service and mental health data from both primary and secondary care. The data also include the healthcare data that we have locally within prisons; all our healthcare providers also support us with a local matrix of information. They also include the P-NOMIS information that we work with within our prison system, particularly the important information on gender, race, ethnicity or age, and particularly some of the information that is key—

Gillian Keegan

Just to stop you, when we went to Wormwood Scrubs we heard how inadequate the mental health professionals felt the records that they had were. They were asking for GP records that they never received, and having to pay £25 to get one, if it ever came. They did not have any information at all. The screening had almost half the questions not answered. So you don’t have the information to start.

Simon Stevens

That is why we are procuring the new health information system—the electronic medical records system—for all prisons.

Kate Davies

That includes the new clinical templates. I completely agree—

Gillian Keegan

But you are talking about the last four years. You spent £400 million or something.

Kate Davies

But we really wish we could have had that in earlier. We have had to take that and develop it. It is a new £30 million service around the health and justice information system. We are really proud to have been able to put that in for the first time in England and, as far as the World Health Organisation is concerned and has fed back as part of the global, it is something that we are absolutely keen has to be improved. There is no doubt about that, but alongside substance misuse, mental health and vulnerability, including learning disability, it is absolutely essential that we now put that in place and commission it in the way that we have.

Caroline Flint

Ms Davies, you have a long-standing career in this area: the National Treatment Agency, drugs and so forth. I would have thought that taking that experience into NHS England would be paramount to dealing with the problems identified on page 31 of the Report. Paragraph 3.10 says: “Staff did not enter data on the ‘risk of suicide’ in 68% of screening records, or on the ‘risk of self-harm’ in 59% of records.” In fact, a number of the questions associated with potentially discovering the state of someone’s mental health are optional rather than mandatory. In your experience, Ms Davies, how can that enable NHS England—I will come to Mr Spurr and his 40-odd-year career in the prison service—to understand better what is going on in terms of identifying the data needed?

Kate Davies

I have answered the question once, and I think you are quite right, particularly about my personal experience with the National Treatment Agency. That is why one of the first things that we have done is look at what the baseline information and data need to be, and get those systems commissioned and in place within a prison system, particularly around self-harm and suicide. We have also done that alongside service users and lived experience and said, “What is it that would help that isn’t there already to support that information and those data?” That is something we have been developing constantly over the last two and a half years. The first year was very much about making quite sure that we had the level of services, not just in mental health but in secondary and primary care, dental and physical care, within all our prisons. Some of those particularly—

Chair

I think Ms Flint was asking particularly about the questions being asked or not asked.

Caroline Flint

The questions are not even being asked.

Chair

That brings us to Mr Spurr, because this is at the prison end. Aren’t the prison officers well-enough qualified to do this?

Richard Heaton

It is a prison service screening, not a health screening. It is a day one screening. You would never expect to get healthcare data from lay screenings done by prison officers. It is done for a different purpose: to determine, for example, day one risks and cell-sharing risks.

Caroline Flint

But when I look at figure 6 on page 32, you are quite right—it does say “Prison officers conduct Basic Custody Screening”—but then it says, “Healthcare staff conduct healthcare screening”. For goodness’ sake, Mr Heaton, surely there should be joined-up thinking between the interviews related to the basic screening and those related to the healthcare screening assessment, to make sure that as soon as possible—maybe not on the first night, because that might not be appropriate, but at least within the 72 hours indicated in this lovely diagram—the figures are being met. You can’t just say, “That’s our job, not NHS England’s.” The pair of you need to sort it out.

Richard Heaton

You’re absolutely right. The investment that has been mentioned is incredibly important. You are right: NOMIS, the prison service IT system, does not talk to the NHS system outside or inside the prison, and it is a huge disjoint. The one system that can bring together health records from before a prisoner enters prison, health records inside the prison and, crucially, prison officer records, so that all the intelligence and observations about an individual, whether they are done by a lay officer on a wing or by a healthcare professional—

Chair

But Mr Heaton, you may not remember, although I am sure Mr Spurr will, the Magee review of data within the justice system, which mapped all the data that could or should be shared and showed the gaps between prison, probation and courts. Some of the stuff that you are dealing with now in the court system—that was nearly a decade ago, and yet we are still not sharing information, not even within the same Department.

Richard Heaton

Some of the Magee recommendations have been fixed. This one hasn’t, but it is being fixed now, which is a great leap forward.

Chair

It was a whole decade ago. Mr Spurr, did you want to add anything?

Michael Spurr

To be fair to NHS colleagues, that specific paragraph is about the basic screening tool conducted by prison staff. The NAO Report says that 58% of the time, the question of whether someone is at risk of suicide is not completed—that is about a basic screening and an officer not being able to determine whether that individual is at risk of suicide at that moment. There is an issue around contact with mental health services, which is a mandatory question that has been completed. That is the very basic screening tool that officers use at the first point of reception. The individual is then seen every time by a healthcare professional with the potential for that individual to be seen again.

Chair

Could you be clear? Ms Flint asked why some of these questions are not compulsory. Can we have a quick-fire answer on whether they should be compulsory at some point in those 72 hours?

Michael Spurr

Some are compulsory for answering and some are about taking answers from an individual. At that point it is not an assessment of a person’s suicide risk when a basic screening—

Chair

Should they be compulsory at some point in those first 72 hours?

Michael Spurr

Yes, but the health screening is absolutely compulsory, which follows that.

Caroline Flint

I understand that the first 72 hours is the most important time in which to assess whether someone is at risk. I totally understand that you might not want to do that within hours of them arriving, because it would be destabilising, but some follow-up in the next 72 hours and clarity on who is asking which questions seem vital. Why is that not happening?

Michael Spurr

It is happening.

Kate Davies

That is happening from a health perspective. One of the things to do probably is to join up the way that that works in every different prison and within the healthcare provider. One of the essential things is joint planning between individual prison governors and the healthcare providers, to join up that compulsory information as part of health screening.

Caroline Flint

I get that, but why is that not happening? The lack of joined-up thinking is nothing new. Mr Spurr, you joined the prison service in 1983 as a prison officer. You have moved up the ranks and you must have a massive amount of experience. You have mentioned the staffing problems. At any time from 2010, in your position either as director of operations for NOMS or as its chief executive, did you raise concerns or ask for a direction from Ministers about the impact of staffing cuts on the provision of services, with respect to the issues we are discussing?

Michael Spurr

I have not asked for a direction from Ministers. We have tried to deliver the Government’s expectations to run with a reduced budget, as many Departments were required to do. We tried to introduce the staffing changes in a way that would continue to deliver adequate and proper services to all our prisoners. The Justice Committee did a review of our staffing review of benchmarking just before the 2015 election, which said that the rationale and the way we were doing that had merit. It questioned—rightly and perceptively at that point—whether our staffing ratios were going to be sufficient given the change in need. That proved to be right. That is why we made the case for additional funding, which we have now received, to increase our staffing ratios.

Geoffrey Clifton-Brown

Mr Spurr, when will the difference between the benchmarking and the staff in every prison be closed?

Michael Spurr

Our aim is to have new staff in post by the end of next year, which will certainly mean that everyone will be operating above what they were on benchmark. Our aim is to go well above that with the 2,500 additional staff and to introduce different ratios for staff to prisoners. There are 11 different benchmarks—there is not one for every prison. There are different ratios and ways to operate depending on different types of population, such as women, high security prisoners and young people. They differ depending on geography, because you have to operate with the geography of an individual prison. In basic terms, the ratio change that we are introducing with the extra 2,500 staff is a move from a starting point of one to 30 prisoners to a position of one to 20 prisoners, which is a significant improvement in the staff-to-prisoners ratio.

Geoffrey Clifton-Brown

Mr Heaton, you said very clearly that the screening was your responsibility. You heard my question in the previous session. Do your staff have sufficient training, probably from NHS England, to be able to carry out this screening on a proper, professional basis?

Richard Heaton

They are not healthcare professionals, so they are not trained to be healthcare professionals. The screening is, in healthcare terms, fairly rudimentary, which is why it is so important to follow it with professional healthcare screening, which is not the responsibility of HMPPS staff.

Gillian Keegan

When we were at Wormwood Scrubs, they explained to us that the loss of staff and people leaving was outstripping recruitment. That was the first issue. The second was that your process for the recruitment itself takes seven months to clear somebody—both mental health professionals and prison officer staff. Trying to plan your career with a seven-month wait is impossible. Are you creating the problem of not having enough staff in prisons or in mental health provision in prisons?

Chair

Who is that question addressed to?

Gillian Keegan

Mr Heaton and Mr Stephens.

Richard Heaton

Retention of officers is a problem, particularly in areas of the country where the labour market is buoyant. However, our staff in post—not just numbers of recruits but net numbers of staff in post—is going up. We are outstripping a retention problem, and we are also improving retention in those prisons with the worst numbers. It is disappointing that it takes sometimes too long to get prison officers in post—

Gillian Keegan

Seven months.

Richard Heaton

I am not sure how representative that number is. We have worked very hard to reduce the time to hire.

Gillian Keegan

What is your objective?

Richard Heaton

I cannot give you a number.

Gillian Keegan

You need a number.

Richard Heaton

I cannot give you a number right now.

Chair

Can you write to us with a number?

Richard Heaton

I can write to you with a number. We are working very hard. This is a volume recruitment and it is proving very successful. We are getting people in and through training. You are right that we have had to tackle the time to hire. We need to do decent levels of security vetting—we do not want that to not happen—but you are absolutely right. There are processes that happen sequentially that can happen in parallel, and so on.

Chair

If you could, write to us with not just the current time for vetting but the trends, and also if you have any suggestions about how you might speed that up, because that is helpful to us when we are writing our report.

Richard Heaton

I will certainly write to you with that.

Simon Stevens

From our point of view, we agree completely. As these process improvements happen, that will be of great benefit to the healthcare providers as well.

Gillian Keegan

Were you aware that it was taking seven months to clear mental health professionals to work in the service?

Simon Stevens

Yes, we are aware that there are delays, and we have been in discussion with the Ministry of Justice about that, because in just the same way as the operational—

Gillian Keegan

And when did you become aware?

Simon Stevens

We get constant feedback from staff and from our healthcare providers in different parts of the country.

Kate Davies

It is something that we were working on for a number of months. In fact, I know that, at the moment, we have 67 staff waiting for clearance after being employed. As increased levels of staff in a number of prisons—

Gillian Keegan

We have also heard of third parties that do a similar service and that do it in a couple of months. They do not create any delay whatsoever. Is it just your inefficiency or failure to address the problem? It will clearly never lead to the staff you need.

Richard Heaton

There are various pinch points in the process and we have addressed some of them. For example, one of the pinch points is in our shared service provider. We have recruited additional staff, seconded to the share service provider, to help that part of the process. The other pinch point is vetting, where we have used—

Gillian Keegan

Have you given them a service level? So they would have to do it in x months or x days or whatever?

Richard Heaton

We certainly have an aspiration for how short the time to hire needs to be. I wish I could give it to you now.

Chair

An aspiration is not a service-level agreement; it is just wishing when your contract is in.

Richard Heaton

It is an aspiration agreed by all parties to this process. I cannot give you the number now.

Chair

What are the consequences to your contractors of not meeting your aspiration?

Richard Heaton

Some of the partners are contractual, some are Government partners.

Chair

That is a laden comment. Is it that the Government partners are the reason for the delays?

Richard Heaton

Security vetting is a Government function. Shared services is a contracted function. We are bringing pressure to bear and working with partners in both of those fields.

Gillian Keegan

Prison staff are key to delivering this aspirational service that you have. If you do not get this right, I think you may as well not bother with the rest of it.

Richard Heaton

We are successfully addressing the recruitment challenge.

Gillian Keegan

It is the joined-up thinking that is completely missing again. Does your new partnership agreement address that joined-up thinking? Do you have a single plan that will actually be able capable of addressing this?

Richard Heaton

On staffing?

Gillian Keegan

On everything.

Richard Heaton

Yes. I hope the new partnership agreement will be a step improvement on the first one, which, as has been said, was better than the multiple arrangements that pre-existed NHS England taking on this work. I am hoping that the new partnership agreement will set out proper measures that are quantifiable for health and wellbeing across the prisons—not just in the clinical parts, but in the prison service parts.

Chair

Can you give us a date for when that will be published?

Richard Heaton

The next one is in April 2018, I believe.

Kate Davies

April 2018.

Chair

But the last one ran out in April, am I right?

Kate Davies

Because of elections and also a change in Government policy—

Chair

Sorry—have elections had such an impact on something that was a work in progress?

Kate Davies

There were changes in the way that the MOJ and HMPPS, which was NOMS, were working. We have had a partnership agreement—we have a working partnership agreement—but going back to the question, we have also done work to set measurable objectives and metrics. That includes continuity of care within the new partnership agreement.