by Professor Andrew Forrester, Professor of Forensic Psychiatry at Cardiff University. EC Member Crime In Mind.
This article appears in our latest newsletter (Winter 2024) which can be downloaded here.
Given the high prevalence of mental health conditions among people in prison, it seems obvious that services should be in place to meet their needs. However, this has not always been the case. A key turning point came with the publication in 1976 of the seminal report Patient or Prisoner, which highlighted significant shortcomings in healthcare for prisoners. At the time, these services were run by the Home Office and staff faced issues such as unclear career structures, professional isolation, and a lack of connection with the broader National Health Service (NHS). The report’s solution was clear: transfer responsibility for prison healthcare to the NHS.
This transition took nearly a decade to complete. In the interim, there was an opportunity to rethink how
prison mental health services should be structured. The eventual model, mental health in-reach teams, was grounded in the principle of equivalence, as outlined in the Mandela Rules (Rule 24, 2015):
“The provision of health care for prisoners is a State responsibility. Prisoners should enjoy the same standards of health care that are available in the community, and should have access to necessary health care services free of charge without discrimination on the grounds of their legal status.”
The idea was to replicate community mental health teams within prisons, assembling multidisciplinary
teams with expertise from psychiatry, psychology, nursing, occupational therapy, and sometimes social work, supported by administration. By around 2006, these teams were operating across the prison system.
Early Gaps and Subsequent Changes
While these teams were designed with the best intentions, a crucial element was missing: no research had been conducted to inform their composition or, after implementation, their utility or effectiveness. Over the years, various adjustments were made, including the addition of primary care mental health services, sometimes working in parallel with existing services, sometimes within a more integrated framework. In time, these services evolved to include greater input from psychology and an emphasis on talking therapies, aligning with national initiatives like the NHS Improving Access to Psychological Therapies (IAPT).
Substance misuse services, which initially operated separately, were gradually integrated into mental health in reach teams in some areas. Other initiatives sought to incorporate specialist services, such as memory clinics for older adults or support for neurodevelopmental disorders like autism, ADHD, or intellectual disabilities. Recently, a shift toward fully integrated service provision has emerged, aiming to meet the needs of all prisoners regardless of diagnosis.
Many of these changes were implemented by commissioners working centrally, with a focus on contracts,
limited clinical advisory input and little supporting evidence. While well-intentioned, recurring challenges have persisted, including:
- Clinical Complexity: Prisoners often have multiple diagnoses and complex needs, requiring integrated, multidisciplinary approaches.
- Severe Mental Illness: People with illnesses like schizophrenia require intensive support, but services can become overwhelmed by primary care needs, leaving these vulnerable patients overlooked.
- Ineffective Diversion Policies: While some individuals benefit from diversion schemes that steer them away from the criminal justice system, when considered across the board, these services have largely failed to do what was intended.
The Path Forward: Research and Reassessment
Rather than rushing into another uninformed redesign, it is time to pause and reassess. High-quality research is now needed to guide future improvements and several key questions must be answered:
- What is the optimal design and composition of prison mental health teams?
- Should services, and their component parts, operate in parallel with the wider NHS or as fully integrated units?
- How can diversion schemes (e.g., police or court-based programmes) be improved for greater effectiveness?
- Many of these changes were implemented by commissioners working centrally, with a focus on contracts, limited clinical advisory input and little supporting evidence. While well-intentioned, recurring challenges have persisted, including:
1. Clinical Complexity: Prisoners often have multiple diagnoses and complex needs, requiring integrated,
multidisciplinary approaches.
2. Severe Mental Illness: People with illnesses like schizophrenia require intensive support, but services can become overwhelmed by primary care needs, leaving these vulnerable patients overlooked.
3. Ineffective Diversion Policies: While some individuals benefit from diversion schemes that steer them
away from the criminal justice system, when considered across the board, these services have largely failed to do what was intended.
- What is the optimal design and composition of prison mental health teams?
- Should services, and their component parts, operate in parallel with the wider NHS or as fully integrated units?
- How can diversion schemes (e.g., police or court-based programmes) be improved for greater effectiveness?
- Are additional interventions, such as peer support, or enhanced access to activities such as gym, other exercise and occupational therapy, needed?
- How should prison healthcare wings operate, what are they for, and how should they be managed?
- How should mental health teams approach areas of particular concern and vulnerability in prisons, such as segregation?
Now is the time to focus on evidence based models and rigorous research to ensure the needs of people in prison are met effectively. Only by putting our own house in order, through research, can we achieve lasting progress in this critical area.
References:
Home Office. (1996). Patient or Prisoner. Home Office, London.
United Nations Office on Drugs and Crime. (2015). The United Nations Standard
Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules).
UNODC, Vienna.
Research can transform lives. We want to support discoveries about what helps people with mental disorder who have been victims of criminal behaviour, or perpetrators of criminal behaviour, and their families, and the clinicians and others who treat them and, indeed, the wider community when its members are in contact with these problems. More effective prevention is the ideal, when this is not possible, we need more effective, evidenced interventions for recovery and restoration of safety.
Please help us by donating to Crime In Mind – DONATE TO CRIME IN MIND HERE
If you would like to become a Member of Crime In Mind please visit our website here.
Download your Membership Application Form Here
Membership entitles all Members to the following benefits:
- Access to private members page on dedicated website containing Members discussion forums, document archive and resource libraries.
- Access to recordings of our previous webinars and seminars.
- Free attendance at suitable events awarding up to 10 CPD hours per annum
- Opportunity to join the Executive committee subject to the conditions of the Articles of Association.