Part 2: Service planning

Mental health services for prisoners.

In this Part, we outline our expectations for planning prisoners’ mental health services, and present our findings on how the agencies met our expectations.

Our expectations

We expected the agencies to plan prisoners’ mental health services effectively. Specifically, we expected the agencies to:

  • identify accountabilities for delivering services;
  • assess the level of demand for services;
  • have effective communication systems and working relationships to deliver co-ordinated services;
  • document and implement policies and procedures to ensure that prisoners receive timely access to services;
  • identify the training and development that staff need in order to be aware of prisoners’ mental health needs; and
  • account for how agencies use funding to provide mental health services to prisoners.

We also expected the Ministry and district health boards to provide for prisoners’ mental health services in national and regional mental health strategies.

Our findings

Service accountabilities

The Department and the Ministry have set out their respective responsibilities for providing prisoners’ health services, including mental health services, in a Memorandum of Understanding (MoU).

Overall, it was clear which agency is responsible for providing services in each particular area. However, there was one exception to this.

The MoU does not cover prisoners with personality disorders, and it is not clear who is responsible for providing services for them. However, at the time of our audit, the Department and the Ministry were establishing responsibilities for managing prisoners with personality disorders. We discuss services for prisoners with personality disorders further in paragraphs 3.30-3.33.

In our view, once responsibilities are established, they should be documented to ensure that the Department and the Ministry are clear on where these lie.

Recommendation 1
We recommend that the Department of Corrections and the Ministry of Health outline the roles and responsibilities for managing prisoners with personality disorders in their Memorandum of Understanding for health services, once they have established those roles and responsibilities.

At a local level, Prison Services1 have service level agreements with the RFPS in their area. These agreements set out roles, responsibilities, and procedures to manage the interaction between Prison Services and RFPS.

Assessing demand for services

In our view, adequate forecasting is essential to effectively manage the delivery of services. However, we recognise that estimating demand for prisoners’ mental health services is difficult. Variables, such as changes to sentencing legislation, can increase the need for services.

The agencies were aware that prison musters are increasing and that there would be a flow-on demand for mental health services. The Department had assessed the likely effects of implementing the proposed mental health screening tool (see paragraph 3.8) in terms of resources, but it was not clear whether the Department had assessed the effect that increasing prison musters would have on its primary mental health services.

At the time of our audit, the Ministry and RFPS were beginning a new planning cycle and were drafting plans to take account of increased demand for forensic services. Their draft planning documents also took account of anticipated demand increases arising from the new mental health screening tool.

In our view, to assist in assessing demand, quantifying the number of prisoners with mental health needs is important. We also consider that information on prison musters and forensic service access should be reasonably current. Having such data would assist the agencies to identify trends, estimate future demand more accurately, and target services towards prisoners’ mental health needs.

We found that data collection is fragmented in both the Department and the Ministry. It is difficult for the Department to quantify the number of prisoners with mental health needs. For the Ministry, it is difficult to obtain accurate information on prison growth to inform its planning of forensic services.

The Department keeps records on the number of prisoners waiting for forensic inpatient services and has current data on prison musters and trends in prison muster growth. However, the Department could not quantify the number of prisoners with primary mental health needs because its information systems do not record this data.

The Department’s health information system can report on prisoners with severe mental illness, but the usefulness of reports depends on accurate data entry in the database. An internal audit in 2006 identified data entry in the health database as an area for improvement. At the time of our audit, the Department was planning to provide training on data entry for its health staff. We recognise that difficulties in obtaining accurate health reporting are not specific to the Department’s health service. It is also an issue in the wider health system.

Implementing the proposed mental health screening tool should help the Department and the Ministry to improve the available data on prisoners’ mental health needs.

If the proposed tool is implemented, the Department should consider how it can collect and record information on prisoners’ mental health needs as a means of obtaining data to meet the agencies’ planning needs. It should discuss the Ministry’s and RFPS’ planning needs and how the data collection system can incorporate them.

Recommendation 2
We recommend that the Department of Corrections improve the information available for identifying trends in prisoners’ mental health needs and for planning services by establishing a system to collect and record prisoners’ mental health information as part of the implementation of the proposed mental health screening tool.

Because implementing new forensic services is costly in terms of time and budget, the Ministry plans forensic mental health services in a five-yearly cycle. Producing forensic framework documents and conducting censuses of forensic mental health service users are important parts of the Ministry’s service planning.

At the time of our audit, the Ministry was drafting its second framework for forensic services, covering the period 2008/09 to 2013/14. The Ministry intends this document to highlight the main issues for forensic services over that period. As part of this process, the Ministry required RFPS to produce five-year plans to coordinate national and regional planning. The Ministry anticipated that these plans would enable it to get a better sense of future service needs and to evaluate the costs of these. We agree that these plans have the potential to provide a sound basis for delivering the required services. They may also provide a useful measure for assessing progress in service implementation.

The Ministry has conducted two censuses of forensic mental health service users, published in 2001 and 2007. The most recent census was based on data from 2005. As part of the census, the Ministry sought RFPS’ views on future service direction and the major concerns facing them. Reported issues included:

  • a lack of services to meet the needs of women;
  • demand for inpatient services;
  • difficulties in obtaining staff who can provide services responsive to Māori;
  • the need for appropriate screening tools; and
  • the level of primary mental health care available within prisons.

The Ministry’s 2001 census identified similar issues, such as the inadequacy of forensic facilities for women, workforce issues with providing services responsive to Māori, and a need for more effective screening for mental illness in prisons.

The Ministry has done work to identify aspects of services requiring improvement. Drafting forensic framework documents and conducting censuses provide good opportunities for assessing services and demand. However, we have two concerns about the Ministry’s use of the framework documents and censuses in planning forensic services.

First, we observed that there was some delay between obtaining census data and using this information in service planning. The Ministry’s 2007 draft forensic framework document quoted 2005 census data. In our view, using two-year-old data limited the effectiveness of the Ministry’s forensic service planning, particularly as it was well known that prison musters were increasing, with a likely increase in demand for forensic services. If the Ministry does not use up-to-date information in its service planning, there is a risk that services may not keep pace with demand. We consider that the Ministry should use more current data in its service planning to provide a more accurate picture from which to estimate future demand.

We understand that the Department has readily available statistical information on prison musters and forensic inpatient service demand that it can provide to the Ministry and RFPS for their service planning. We know of one occasion where this information has been shared, and we suggest that the Ministry and the Department collaborate to share current data on prison musters and service demand, and use it in service planning on an ongoing basis.

Recommendation 3
We recommend that the Department of Corrections and the Ministry of Health share current data on prison musters and service demand to meet their joint needs in planning prisoners’ mental health services.

Our second concern relates to the Ministry’s ability to respond to significant changes in demand during its planning cycle. The Ministry acknowledged that capacity is an issue for inpatient services because they require a lot of resources and it takes a long time to establish extra capacity. In our view, the Ministry should have some flexibility in its five-year planning cycle to respond to changes in demand and to ensure that services keep pace with demand.

Recommendation 4
We recommend that the Ministry of Health incorporate regular progress reviews within its forensic service planning cycle to ensure that planned services are meeting prisoners’ mental health needs, and to enable planned services to be modified in response to changes in service demand.

Communication and relationships

The agencies have communication systems in place to co-ordinate services.

The Department and the Ministry have formal processes for communication outlined in the MoU and through a joint prisoner health working group, the Offender Related Health Action Group. This group has a broad health scope that includes resolving issues and barriers to the effective delivery of health services, identifying gaps, and identifying opportunities for improving the delivery of forensic mental health services. The group’s membership consists of Department and Ministry management. It meets monthly to discuss issues and track projects of common interest.

Locally, relationships between Prison Services and RFPS appeared to function well. Frequently, Departmental staff told us that RFPS staff members are readily available and that information is shared appropriately. There was a significant amount of goodwill between both services to make the system work. In a number of places, there are staff who have worked in the prison system as well as in RFPS. They considered that this gave them valuable understanding of the different systems.

Policies for getting access to mental health services

The agencies have documented and implemented policies to ensure timely assessment, treatment support, and review of prisoners with mental health needs.

The Department’s Policy and Procedures Manual outlines the procedures for health and risk assessments on arrival in prison.

Regional service level agreements between Prison Services and RFPS include referral and response processes.

At the time of our audit, the agencies were working to identify and address gaps in services and improve their responsiveness. For example, the Department and the Ministry were reviewing and revising a protocol for managing prisoners requiring acute inpatient treatment and discussing how to provide for prisoners with personality disorders.

Education and training

In our view, ensuring capability is an important aspect of service planning. We expected the Department to identify the training and development that staff need for them to be aware of prisoners’ mental health needs. We also expected that Departmental staff involved in identifying prisoners’ mental health needs would have enough training for this identification and that, more generally, custodial staff would receive mental health awareness training.

Staff we spoke with considered that the Department supports their training and professional development needs. At the time of our audit, the Department was reviewing its mental health awareness training for custodial staff and piloting a primary mental health care course for its nurses.

The Department does not require its nurses to have mental health experience because they provide primary health care (including primary mental health) services rather than specialist mental health services. Nurses have some mental health knowledge, as this is included in undergraduate nursing training. However, RFPS staff and nurses with mental health experience considered that training beyond this would be useful in the prison environment. We were pleased to see that the Department was considering how to provide further primary mental health training for its health staff.

All custodial staff attend an initial training course that includes training in administering the New Arrival Risk Assessment (see paragraph 3.9) and suicide awareness education. In keeping with their custodial function, the focus of suicide awareness training is on managing risk. It does not specifically focus on, but includes some information about, behaviours associated with mental illness.

Prisoners with mental illness are often managed by custodial staff in At Risk Units.2 There is no specific training for staff working in these units, because the Department provides generic training for its custodial staff. A number of staff mentioned that they pick up a lot of mental health knowledge through their informal discussions with RFPS staff and interactions with longer-serving staff in At Risk Units. Some RFPS staff commented that staff in At Risk Units are very good at managing mentally ill prisoners despite having little training in this area.

Some staff in At Risk Units had attended education days co-ordinated by the local RFPS, and local mental health awareness courses. They mentioned that these were useful. One RFPS staff member told us that these courses often led to useful discussion between staff in At Risk Units and RFPS staff on the behaviours of prisoners in the At Risk Units.

In our view, RFPS and Prison Services collaborating to deliver mental health awareness training is a valuable opportunity for improving understanding of mental health. It also contributes to strong working relationships between the services.

Given the prevalence of mental health issues in the prison population, it is likely that custodial staff will frequently interact with mentally ill prisoners. Custodial staff should therefore have a reasonable understanding of mental illness and associated behaviours, as well as an awareness of behaviours that may indicate risk of suicide. We consider that the Department should continue to monitor training needs in this area.

Recommendation 5
We recommend that the Department of Corrections ensure that the training it provides to its custodial staff has enough coverage of behaviours associated with mental health issues to enable them to recognise situations where they should seek input from health staff.


We intended to examine broadly how agencies accounted for funding used to provide mental health services to prisoners. After discussions with the agencies it became apparent that we would not be able to do that. The Ministry does not record funding information in a way that would allow us to identify the mental health service funding for prisoners (the target population of our audit) as distinct from forensic services for people in the community deemed at risk of offending. The Department does not identify primary mental health spending within its national health budget. In our view, the way that agencies accounted for mental health service funding did not impinge on the delivery of those services.

Providing for prisoners’ mental health services in health strategies and plans

Prisoners’ mental health services are part of the wider mental health system, so we expected that prisoners’ mental health services would be included in health strategies and plans.

The Ministry’s 10-year plan for improving mental health3 sets the strategic goals for the mental health sector. The plan acknowledges the need for agencies to work together to meet the special needs of those within the criminal justice system. It mentions women, in particular, as having specific cultural and gender needs when they access forensic mental health services.

Te Kōkiri: The Mental Health and Addiction Plan 2006-2015, published by the Ministry, identified three actions for forensic services:

  • evaluating how the forensic framework has been implemented;
  • examining options for the role of the Ministry and district health boards in planning, funding, and delivering forensic services; and
  • continuing to develop and support inter-sectoral initiatives and frameworks to ensure that the needs of people in the criminal justice system are met.

Regionally, Auckland’s RFPS has a strategic plan to develop services, while the Central Region’s district health boards have produced a draft Regional Mental Health and Addiction Strategic Plan that includes some detail on progress made with forensic services. The plan does not include any actions for forensic services specifically, although broader actions such as workforce development and responsiveness of services will have some effect on forensic services.

We were pleased to see that the South Island Regional Mental Health Strategic Plan 2005-2008 noted a need to report on the effect of the new prison at Milton and provide recommendations for new or additional services.

1: Prison Services is the group within the Department responsible for providing safe, secure, and humane containment and for managing the sentences of prisoners.

2: At Risk Units are areas of the prison designated for housing prisoners who are at risk of harming themselves or others. Prisoners in At Risk Units are monitored frequently by custodial staff.

3: Minister of Health, (2005), Te Tāhuhu - Improving Mental Health 2005-2015: The Second New Zealand Mental Health and Addiction Plan, Wellington.

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