Part 3: Service delivery
3.1
In this Part, we outline our expectations of the agencies in delivering prisoners’ mental health services. We then discuss our findings on prisoners’ access to mental health services, and how the agencies liaise and collaborate to provide care and promote mental health.
3.2
We also discuss how services respond to the needs of Māori, who represent a disproportionately large group within the prison population.
Our expectations
3.3
We expected that:
- prisoners could access a range of mental health services in a timely manner;
- the agencies would liaise and collaborate to ensure continuity of care when prisoners are transferred between jurisdictions;
- the agencies would collaborate in promoting mental health wellness and preventing illness; and
- mental health services would be responsive to the needs of Māori.
Our findings
Access
3.4
We examined how the agencies identify prisoners’ mental health needs and the range of services that are available to prisoners.
3.5
We were satisfied that prisoners receive adequate information on how they can access the available mental health services.
Identifying prisoners who need access to mental health services
3.6
Effective screening of the prison population is essential to identify prisoners with possible mental health needs.
3.7
The Department has procedures for determining prisoners’ health needs when the prisoners arrive in prison. These include a health screen on arrival followed by a more comprehensive health assessment. Each assessment has a component to determine any mental health needs.
3.8
The agencies recognised that they needed a more effective mental health screening tool and set up a collaborative project to develop a mental health screening tool for use in prisons. They intend this tool to identify mild to moderate mental health needs as well as more severe needs. After a possible need is identified, further assessment and referral to the appropriate service is required. At the time of our audit, the screening tool had been trialled and data from the trial was being evaluated. Early indications were that the tool had significantly increased the identification of mental health issues with varying degrees of severity. It had increased the number of referrals for forensic services.
3.9
Departmental policy requires new arrivals in prison to undergo a New Arrival Risk Assessment, which is administered by custodial staff. This assessment is a generic risk assessment that includes questions about mental health. If a prisoner is deemed "at risk", the custodial staff initiate further assessment. Custodial staff also use the assessment for situations other than new arrivals, such as prisoner transfers between units or prisons or when a prisoner receives news of a family death. While the assessment’s scope is broader than mental health, it is another procedure that can identify prisoners’ mental health needs.
3.10
Custodial staff can use the New Arrival Risk Assessment at any time to initiate a mental health assessment if they have concerns about a prisoner’s mental health. However, some Departmental staff queried the assessment’s effectiveness as an ongoing assessment tool because it was designed to assess new arrivals’ risk status. The Department has drafted terms of reference to review this.
3.11
The Department does not have a system for periodically screening the prison population for mental health issues. To identify prisoners with mental illness who are not picked up through initial screening or those who develop mental illness during imprisonment, custodial staff or health unit staff need to recognise signs that mental illness may be present. Staff told us that they are alert for changes in behaviour and are mindful of mental health issues in their contact with the prisoners. The Department advised that periodic screening of the prison population would be difficult because of the turnover of the prison population. It was not aware of any jurisdictions internationally that conduct periodic screening for mental health issues in prisons.
3.12
We recognise that the proposed mental health screening tool has the potential to improve identification of prisoners’ mental health needs. However, in our view, there is a risk that prisoners with mental illness that is not recognised at the initial screening or those who develop mental illness during imprisonment will not be identified and will not get access to treatment. If the Department relies on its custodial staff to recognise signs of mental illness, it needs to ensure that they have enough awareness and understanding of behaviours associated with mental illness. We make a recommendation about this in Part 2 (see Recommendation 5).
3.13
Following our audit, the Department advised that it was consulting staff about implementing two-yearly health assessments for longer-term prisoners.
The range of services available
3.14
The range of mental health services available to prisoners is limited in some areas of primary and forensic services. The situation is similar in the community, where there is variability in mental health services.
3.15
The agencies are aware of service gaps and, in some cases, had identified and started implementing improvements. For example, the agencies are collaborating on the new screening tool to identify mental health needs.
3.16
Areas where services are limited include:
- timely access to inpatient services;
- services for those with mild to moderate illness;
- forensic inpatient services for women;
- services for those with personality disorders; and
- services responsive to Māori needs (discussed in paragraphs 3.50-3.63).
Inpatient services
3.17
Acute mental health needs are provided for but timely access to inpatient services does not occur in some instances. This is the Department’s major concern about mental health services for prisoners.
3.18
Section 45 of the Mental Health (Compulsory Assessment and Treatment) Act 1992 outlines the process for transferring prisoners for inpatient care. Demand for inpatient beds means that prisoners are not always able to be transferred and must remain in prison until a bed is available. This is a particular problem for the Auckland region, but other RFPS indicated they also have high demand for inpatient beds.
3.19
RFPS manage demand for inpatient services through waiting lists and prioritise access based on clinical information. While a prisoner is waiting for inpatient treatment, RFPS staff continue to monitor the prisoner and provide advice to the Department’s health and custodial staff.
3.20
The numbers waiting for inpatient treatment are not large. From July 2006 to June 2007, 59 prisoners were placed on the waiting list in the Auckland region, with the number fluctuating monthly between 9 and 24. Of the 59 prisoners, 34 (58%) were on the waiting list for 40 days or less. Ten prisoners (17%) were on the waiting list for between 41 and 80 days. The remaining 15 prisoners (25%) waited longer than 80 days, with 10 of these prisoners waiting more than 100 days. While the numbers are small, the length of time some prisoners spend on the waiting list is a concern. However, prisoners are prioritised on a clinical basis so those with the greatest needs are treated first. As we are not clinicians, we were not in a position to assess the appropriateness of the priority given to individual prisoners, but we understand that the priority for inpatient treatment is regularly reviewed and we support this approach.
3.21
The Department’s view is that, regardless of the length of time on the waiting list, prison is not the appropriate environment for acutely unwell prisoners. It also considers that it should not be responsible for their care, because its staff have a custodial role not a therapeutic one. The Department is concerned that this situation leaves its staff exposed to legal and health and safety risks. The Ministry recognises that prisoners with acute mental health needs remaining in prison is less than ideal, but is constrained by the number of inpatient beds available.
3.22
In June 2005, the Department and the Ministry agreed a protocol to manage acutely unwell prisoners when no bed is available. The Department intended this to be an interim measure while further inpatient beds were established, but demand for inpatient beds continues to be an issue.
3.23
The Department and the Ministry are continuing to seek an agreement on how to manage the assessment process for prisoners with acute mental health needs.
3.24
RFPS staff mentioned that the length of patients’ stay, as well as the number of patients entering the service, contributed to the demand for beds. Stays with RFPS tend to be lengthy, and the lack of appropriate community facilities for discharge encourages longer stays. Two RFPS we visited were examining how to make improvements in this area:
- Auckland RFPS is conducting some research into waiting list trends to inform the development of new ways through its service; and
- Wellington RFPS stated in its draft five-year plan that it intends to address the lack of community options for discharging forensic patients by creating community housing.
Services for mild to moderate illness
3.25
Providing therapeutic psychological services can help reduce the likelihood of reoffending. There are few mental health services for prisoners with less severe mental health needs. Frequently, Departmental staff told us that its primary health care services lacked treatment options such as counselling for prisoners with mild to moderate illness.
3.26
The Department advised us that it is not funded to provide counselling or therapeutic psychological treatment because these services are not available in a typical general practice in the community.
3.27
Given the combination of the Department’s rehabilitative and custodial duties, the likelihood that the new mental health screening tool will identify more prisoners with mild to moderate mental health needs (see paragraph 3.8), and constraints on prisoners’ ability to obtain health care privately, the Department may need to think about how mild to moderate mental health needs of prisoners can be met. In our view, a lack of publicly funded services in the community does not absolve the Department’s responsibility to ensure that prisoners’ needs in this area are met.
| Recommendation 6 |
|---|
| We recommend that the Department of Corrections examine how it can help prisoners with mild to moderate mental health needs to access services that meet their needs. |
Forensic mental health services for women
3.28
Women prisoners requiring forensic mental health services have different needs from men. The Department identified that the number of women prisoners was increasing, which would place more pressure on forensic providers to deliver services that meet the needs of women. In its 2007 draft forensic framework document, the Ministry acknowledges the special needs of women and seeks input on how RFPS intend to take account of the expected increase in demand from this group.
3.29
RFPS reported that there was a lack of services to meet the needs of women. The Canterbury RFPS in particular identified that it had limited options for inpatient treatment of women. It has included this as a developmental area in its draft forensic five-year plan.
Prisoners with personality disorders
3.30
The estimated prevalence of personality disorders in the prison population is high. A national study1 commissioned by the Department identified that almost 60% of prisoners had at least one diagnosis of personality disorder. The severity of the personality disorders within that 60% would probably vary.
3.31
Prisoners with personality disorders are not well served. However, we acknowledge that the field of personality disorders is complex and that managing people with personality disorders is difficult. Those with personality disorders are not always deemed to be ill, and the condition is not always treatable. Interventions are mainly cognitive and behavioural based.
3.32
It is not entirely clear who is responsible for providing services to this group. In the Ministry’s view, forensic mental health services are not responsible for prisoners with personality disorders unless they have a mental health need as well as a personality disorder. The Ministry considered that primary health services should manage most prisoners with personality disorders. However, the Ministry accepts that personality issues are a priority for the health sector.
3.33
The Department considers that prisoners with severe personality disorders can represent a significant and ongoing risk to themselves and others. As noted previously (see paragraph 2.6), the Department and the Ministry are working on a policy to establish how to manage prisoners in this group. We strongly encourage the agencies to establish the policy.
Liaison and collaboration in care
3.34
The delivery of care is complicated by prisoner transfers between prisons or to RFPS. Systems are needed to ensure continuity of care when prisoners are transferred.
3.35
Overall, there are formal and informal ways for managing care when prisoners with mental illness are transferred between prisons and between prison and RFPS inpatient units.
3.36
The Department has national databases for recording prisoners’ information. This means that staff across Prison Services can access information when prisoners are transferred between prisons. Health information is recorded in a health database accessible only to health unit staff. Paper-based health files also are transferred with prisoners. Custodial staff can access relevant information in the Integrated Offender Management System database. This includes new arrival risk assessment information as well as information from pre- and post-sentence reports, which can indicate that a prisoner has mental health needs. Health and custodial staff can use the Integrated Offender Management System to put a transfer constraint on a prisoner’s file. If the Department is considering transferring that prisoner, the transfer constraint should trigger an alert to seek further information on the prisoner’s situation.
3.37
Procedures for sharing information when prisoners move between Prison Services and RFPS are outlined in service level agreements between the two services. Departmental and RFPS staff commented that information exchange also occurs informally through their daily interactions and that this works well.
3.38
In our view, the use of transfer constraints could be improved. Departmental staff told us that the use of transfer constraints varied. Some staff mentioned that there are situations where a transfer constraint is in place and the prisoner is still moved. RFPS staff mentioned that prisoners they treat in prison are sometimes moved without consultation. We were told of one instance where a forensic service contacted its RFPS counterpart for information on a prisoner coming into its care and discovered that the other forensic service was not aware that the prisoner had been transferred between prisons.
3.39
Therapeutic relationships in mental health require a significant amount of trust and can take a long time to establish. Transferring a prisoner can disrupt a therapeutic relationship, resulting in setbacks for a prisoner’s recovery. We consider that the Department should ensure that it consults RFPS clinicians when it considers transferring a prisoner under forensic care. However, we realise that immediate prisoner transfers are necessary in some instances. In these situations, the Department should ensure that the RFPS receives notification of the transfer as soon as is practicable.
| Recommendation 7 |
|---|
| We recommend that the Department of Corrections ensure that relevant staff are aware of transfer constraints and the process to follow when a prisoner under forensic care is being considered for transfer. This should include seeking advice from the Department’s health staff and the Regional Forensic Psychiatric Service. |
Release planning
3.40
Planning for a prisoner’s mental health care to continue on his or her return to the community is a difficult area for the Department’s health services and RFPS. Once a prisoner has been released, it is difficult to compel that prisoner to maintain contact with community mental health services.
3.41
The Department’s release planning processes require sentence planners to obtain relevant health information to help the prisoner back into the community. However, a number of health staff we spoke to indicated that their involvement in release planning varied and they considered this to be an area that could be improved.
3.42
The Department does not have a standardised discharge process from its health services but intends to introduce procedures to ensure national consistency for discharging prisoners into the community.
3.43
RFPS staff told us that release planning from their service can be complicated by a lack of community beds and reluctance on the part of general mental health services to accept former RFPS clients. The Ministry’s 2001 forensic framework identified this issue. The Ministry’s 2007 draft forensic framework noted improvements in the interface between RFPS and general mental health services and identified that further improvements could be made.
Mental health promotion
3.44
We expected the agencies to promote mental health awareness to the prison population, as well as assist prisoners to maintain good mental health.
3.45
The agencies acknowledged that mental health promotion for the prison population is important. However, they told us that promoting awareness and good mental health to the wider prison population is challenging because of restrictions in the prison environment and the limited time available for these activities.
3.46
We found that mental health promotion and education is an integral part of care for those receiving mental health treatment but that there is minimal promotion for the wider prison population.
3.47
The Department has a general health promotion policy that includes mental health promotion. While it is a national policy, the Department’s individual health units are expected to get involved in local health promotion activities within the wider community. The policy also states that the Department’s health staff are expected to focus on appropriate screening, opportunistic education, and interventions to aid early detection.
3.48
The Department’s specifications for its primary mental health care service include attention to matters such as early intervention, maintenance of health, relapse prevention, problem prevention, and promoting good mental health. We saw Mental Health Commission and Ministry information pamphlets displayed in some health units, but beyond this there was little to suggest that promotion and prevention activities occurred for the wider prison population.
3.49
The Department’s health staff provide education on diet and exercise as ways to keep well, but options for using these in the prison environment are limited. The Ombudsmen’s Investigation of the Department of Corrections in Relation to the Detention and Treatment of Prisoners (2005) outlines these issues in more detail.
Services for Māori
3.50
Responding to the needs of Māori involves consulting with relevant groups when developing services, providing training on the mental health needs of Māori, providing services to promote Māori mental well-being, and monitoring and evaluating services to ensure that they are responsive to the needs of Māori.
3.51
Each agency recognised the importance of providing services responsive to Māori needs as a component of mental health services. Each had some degree of service provision in this area. Departmental and RFPS staff had mixed views on whether mental health services were responsive to the needs of Māori. It was common for people to consider that services were adequate but that more resourcing would improve access and improve the services’ ability to meet the needs of Māori. RFPS staff told us that a barrier to providing services responsive to the needs of Māori was the availability of staff to deliver kaupapa Māori services. The Ministry also acknowledged this in its draft forensic framework.
Consultation and provision of training
3.52
The Department advised that, when it drafts health policies and procedures, it consults internally with its cultural advisers and externally with the Ministry’s Māori Health Directorate. The Department’s health staff receive cultural awareness training as part of their induction, but there is no specific education on the mental health needs of Māori.
3.53
The Ministry seeks advice from its Māori Health Directorate in planning services for Māori. It also seeks input from iwi stakeholders.
Services provided for Māori well-being
3.54
The Department does not provide any specific primary mental health services for Māori. It identifies the provision of Rongoa Māori Traditional Healing Services as part of its primary health care responsibility. The Department intended that these services would be provided by local or regional Māori traditional healing services but had not been able to fund them.
3.55
The Department has a kaiwhakamana visitor policy. This allows kaumatua to be registered as kaiwhakamana and visit prisoners to offer support and assistance. We were told of instances where kaiwhakamana had been used to provide spiritual support and guidance.
3.56
Health and custodial staff told us that they can seek advice from the Department’s cultural advisers or Māori custodial officers if they encounter a situation where cultural input is required.
3.57
Each RFPS we visited provides services for Māori through either a cultural adviser or Māori mental health workers.
3.58
Auckland’s RFPS has several components of its service that are specific to Māori. Staff can make referrals for cultural input, and the RFPS cultural adviser makes assessments using a Māori cultural appraisal form. The RFPS operates a kaupapa Māori unit with practices complemented by Western medical practice. The RFPS offers its prison clients a wānanga programme focusing on te reo Māori, tikanga, and cultural identity. At the time of our audit, the RFPS cultural adviser was proposing a new project to create a suicide screening tool for Māori that would include cultural phenomena that might indicate suicide risk.
3.59
Wellington’s RFPS has kaumatua and kuia, as well as Māori mental health workers. It has a Māori mental health nurse to provide both clinical and cultural assessments.
3.60
Canterbury’s RFPS employs a cultural adviser to work with Māori who come through the service. The RFPS provides cultural clinic sessions at Christchurch Men’s Prison for prisoners under forensic care.
3.61
RFPS in two locations told us that the availability of services responsive to the needs of Māori women is limited.
Monitoring and evaluation of services
3.62
We found that all the agencies involved in delivering mental health services to prisoners did minimal monitoring and evaluation of services to ensure that they were responsive to, and effective at meeting, the needs of Māori.
3.63
We consider that this is an area that agencies need to incorporate into formal monitoring and evaluation of services. Given the disproportionate number of Māori in the prison population, agencies should be considering ways to ensure that services are responsive to the needs of Māori.
| Recommendation 8 |
|---|
| We recommend that the agencies incorporate activities into their formal monitoring and evaluation processes to ensure that prisoners’ mental health services are targeted and responsive to the needs of Māori. |
1: The National Study of Psychiatric Morbidity in New Zealand Prisons: An Investigation of the Prevalence of Psychiatric Disorders among New Zealand Inmates: An Epidemiology Study Commissioned by the Department of Corrections and Co-sponsored by the Ministries of Health and Justice, (1999), Wellington.