Part 1: Introduction

Mental health services for prisoners.

1.1
In this Part, we describe:

  • prisoners’ mental health service delivery;
  • why we did the audit;
  • our expectations;
  • how we conducted the audit; and
  • what was outside the scope of the audit.

Prisoners’ mental health service delivery

1.2
Responsibility for meeting prisoners’ mental health needs is split between the Department of Corrections (the Department), the Ministry of Health (the Ministry), and district health boards’ Regional Forensic Psychiatric Services (RFPS).1 We refer to these organisations as “the agencies” throughout this report.

1.3
The Ministry estimates that prisoners are three times more likely to require access to specialist mental health services than people in the general population. The Ministry’s estimates indicate that 10% of the prison population could experience a mental illness requiring specialist care. Almost a third of the prison population could experience mild to moderate mental health problems.2

1.4
Figure 1 shows the general composition of the prison population.

Figure 1
Prison population statistics as at 18 November 2007

Prisoner population 7895
Gender Female 5%
Male 95%
Ethnicity Asian 3%
European 34%
Māori 50%
Pacific peoples 12%
Unknown/Other 1%

Source: Department of Corrections Weekly Prisoner Statistics.

1.5
Delivering mental health services to prisoners is a complex and challenging area. As a population, prisoners often have high and complex health needs because they tend not to access health services while in the community. Drug and alcohol dependency is a common problem in those with mental illness. This complicates identification of needs and treatment.

1.6
Delivering mental health services is also complicated by the constraints of operating in a prison environment. For example, it can be difficult to administer medication outside the usual prison routines or there can be delays in getting prisoners to clinics because there are not enough officers available for escort duties. There are also ethical constraints around using compulsory treatment in a prison setting. Prisoners under compulsory treatment orders3 must be transferred to a hospital setting, which compounds prisoner demand for forensic inpatient services.

1.7
Delivering health care is further complicated by the transfer of prisoners. Prisoners can be moved between prisons to manage prison musters and to attend court hearings. After a court hearing, a prisoner may not return to prison depending on the outcome of their case. Those with mental illness requiring inpatient care can move between prison and forensic mental health inpatient units. Prisoners also return to the community from prison and forensic mental health inpatient units.

1.8
Furthermore, prisons are under pressure from increasing growth in the prison population and forensic facilities are struggling to keep up with demand from prisons for inpatient beds. It takes a long time to build new forensic facilities, so it is not always easy to respond to significant increases in demand.

The Department’s responsibilities

1.9
The Department must ensure that every prisoner is assessed promptly after arriving at prison to identify any immediate physical or mental health, safety, or security needs. It must address any needs identified by that assessment.4 A prisoner is entitled to receive any medical treatment that is reasonably necessary, and the standard of health care must be reasonably equivalent to the standard of health care available to the public.5

1.10
The Department is responsible for providing primary health care, including primary mental health services, to all prisoners. The Department funds and provides these services either directly or through contracts with external providers. Figure 2 outlines the Department’s specifications for primary mental health services in the prison setting. Services are delivered through health units at each prison.

Figure 2
Primary mental health care in prison

The Department’s specifications for primary mental health services include:
  • screening and referral to specialist services;
  • managing prisoners with mild to moderate mental disorders that would normally be dealt within the primary care setting;
  • providing medication and other treatment in accordance with treatment plans;
  • ongoing monitoring of symptoms and treatment;
  • providing access to cultural components of service in accordance with assessed need; and
  • attending to matters in relation to early intervention, maintenance of health, relapse prevention, problem prevention, and promotion of good mental health.

Source: Schedule 3: Corrections Prison Health and Disability Support Service Specifications (May 2002), Part Two, page 13.

1.11
The Department has a psychological services group that focuses on providing psychological services to address prisoners’ offending. This includes programmes such as violence prevention. The Department’s psychological services group is not involved in providing therapeutic services to prisoners with mental health needs.

The Ministry’s responsibilities

1.12
The Ministry sets the strategic direction for health and disability services, and is responsible for planning and funding forensic mental health services.

District health board responsibilities

1.13
District health boards organise forensic mental health services regionally, which they deliver through five RFPS. These regional services use multidisciplinary teams to provide forensic mental health services to mentally ill offenders or those who pose a high risk of offending, as described in Figure 3.

Figure 3
Forensic mental health services

The aim of a forensic mental health service is to provide effective assessment, treatment, and rehabilitation for:
  • people charged with criminal offences who have, or may have, a mental illness;
  • offenders with a mental illness; and
  • people whose potential danger to themselves and others is such that community mental health services cannot manage them.
Forensic services include:
  • a court liaison service that provides advice, assessments, reports, and recommendations to the judiciary;
  • a prison liaison service that provides outpatient mental health clinics within prison, assessments, transfer of mentally ill prisoners to secure hospital facilities, and consultation/support services for prison staff; and
  • inpatient care and community follow-up.

Source: Ministry of Health (2001), Services for People with Mental Illness in the Justice System: Framework for Forensic Mental Health Services, Wellington.

Why we did the audit

1.14
We conducted a performance audit to assess the effectiveness of the agencies’ systems for delivering mental health services to sentenced and remand prisoners (prisoners).

1.15
Our audit looked at three areas:

  • service planning;
  • service delivery; and
  • service monitoring and evaluation.

Our expectations

1.16
To assess the systems for delivering mental health services to prisoners, we set audit expectations. In preparing our expectations we considered:

  • NZS8143:2001 National Mental Health Sector Standard;
  • the Mental Health Commission’s Blueprint for Mental Health Services in New Zealand: How Things Need to Be;
  • Effective Prison Mental Health Services: Guidelines to Expand and Improve Treatment, from the US Department of Justice, National Institute of Corrections; and
  • Delivering Efficiently: Strengthening links in public service delivery chains, from the National Audit Office and the Audit Commission in the United Kingdom.

1.17
We expected the agencies to:

  • have sound governance and management arrangements with well-defined roles, responsibilities, and accountabilities in delivering mental health services for prisoners, as well as capability and capacity to respond to prisoners’ mental health needs;
  • have a range of mental health treatment and support services that prisoners could access in a timely manner;
  • liaise closely and co-ordinate when delivering mental health services to prisoners, promoting mental health, and preventing illness;
  • provide mental health services that are responsive to the needs of Māori; and
  • monitor mental health service performance, evaluate these services, and make service improvements as a result of these activities.

1.18
We set out our expectations in more detail in Parts 2, 3, and 4.

How we conducted the audit

1.19
To assess the effectiveness of the agencies’ systems for delivering mental health services to prisoners, we reviewed their policies, procedures, and protocols. We interviewed staff at the Department’s national office, the Ministry, and three RFPS.

1.20
We also interviewed health and custodial staff in nine prisons throughout the country. We selected the prisons to give a sample that represented different regions throughout the country, men’s and women’s prisons, and different sizes and levels of security classification.

Outside the scope of the audit

1.21
Our audit did not seek to assess or evaluate:

  • the effectiveness of any treatment provided to individual prisoners;
  • RFPS’ liaison roles with the courts, police, or community;
  • mental health services for offenders managed by the Department’s Community Probation and Psychological Services Group – such offenders are expected to access services available within the community;
  • mental health services for those within the youth justice system;
  • the Department’s systems, policies, or procedures for managing prisoners at risk of self-harm, except where we would expect these to be integrated with mental health services; or
  • the Department’s and the Ministry’s provision of drug and alcohol programmes, except where we would expect these to be integrated with mental health services.

1: "Forensic psychiatric services" are mental health services delivered by a multidisciplinary team to mentally ill offenders or those who pose a high risk of re-offending.

2: Ministry of Health (2001), Services for People with Mental Illness in the Justice System: Framework for Forensic Mental Health Services, Wellington.

3: A compulsory treatment order is a court order requiring the patient to undergo treatment for their disorder. The Court can make either a community treatment order or an inpatient order. Prisoners do not have the option of community treatment as their "community" is prison, and it is not ethical to administer compulsory treatment in the prison environment as prisons are not designed to provide therapeutic treatment.

4: Corrections Act 2004, section 49.

5: Corrections Act 2004, section 75.

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