Mental health services for prisoners.

Prisoners have a high need for mental health services. The Ministry of Health (the Ministry) estimates that prisoners are three times more likely to require access to specialist mental health services than people in the general population. Providing treatment for mental illness in prisons can deliver significant benefits not just for prisoners but also for prison staff and people in the wider community.

Delivering mental health care to prisoners is a complex and challenging area. There are constraints that come with operating in a prison environment. Delivering services is complicated further by the high level of health need among prisoners and the transfer of prisoners within the justice system.

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

We conducted a performance audit that focused on the effectiveness of the agencies’ systems for delivering mental health services to sentenced and remand prisoners (prisoners). The audit looked at three areas – service planning, service delivery, and service monitoring and evaluation.

The system is subject to a number of pressures, such as increasing prison musters, high demand for inpatient beds, and, for some groups, a lack of services to meet their needs. We found a number of areas where mental health services for prisoners could be improved. However, the agencies were aware of their service issues and they were at various stages of identifying and introducing improvements. Where this was the case, we have noted that this work was under way. We support and encourage the introduction of the improvements. We make eight recommendations to supplement the agencies’ work.

Our findings

Service planning

We expected the agencies to have defined roles, responsibilities, and accountabilities for delivering mental health services to prisoners, as well as capability and capacity to respond to prisoners’ mental health needs.

We found that the agencies have identified their roles and responsibilities for delivering most mental health services. It was not clear who was responsible for prisoners with personality disorders, but the Department and the Ministry had identified this service gap. At the time of our audit, they were working out how to provide for this group.

Planning services to meet the growth in prison musters is a challenging area for the agencies. The agencies’ ability to plan services effectively is limited by the quality and currency of data, particularly on service use and the number of prisoners with mental health needs. In our view, the proposed screening tool would assist the agencies in gathering information on the range of prisoners’ mental health needs and enable the agencies to target services to meet these needs. There is scope for the Department and the Ministry to work closely to ensure that they have current and accurate data to meet their joint planning needs.

The Ministry plans forensic mental health services in a five-yearly cycle. The Ministry’s ability to respond to changes in demand during its forensic planning cycle is limited. This creates a risk that services may not keep pace with demand. In our view, it would be useful for the Ministry to set up a regular progress review within its planning cycle to ensure that planned services are meeting prisoners’ mental health needs.

Service delivery

We expected that prisoners would have timely access to a range of treatment and support services, that the agencies would liaise closely when delivering care and promoting mental health, and that services would respond to the needs of Māori.

We saw some service gaps but agencies were aware of them. Areas where services were limited included 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 that were responsive to Māori needs. For the Department, timely access to inpatient services was its biggest concern.

In a number of these areas, the agencies had identified and started implementing actions for improvement.

The agencies’ mental health screening tool project represents an important step in improving the identification of prisoners’ mental health needs for a range of severity. The new mental health screening tool could identify more prisoners with mild to moderate illness, so the Department should be considering how these needs can be met.

The Department did not have a system for periodic mental health screening of the prison population. Beyond initial screening procedures, identification of a mental health need relies on custodial staff recognising signs that mental illness may be present. In our view, there is a risk that prisoners with mental health needs that are not picked up through initial screening or those who develop mental illness during imprisonment will not be identified and get access to treatment. The Department needs to ensure that custodial staff have enough awareness of behaviours associated with mental health issues to enable them to recognise situations where they should seek input from health staff . Following our audit, the Department advised that it was consulting staff about implementing two-yearly health assessments for longer-term prisoners.

Liaison and collaboration between the agencies in delivering care is important. There are formal and informal mechanisms for managing care between prisons and RFPS. However, use of these systems could be improved, particularly when transferring prisoners under forensic care between prisons.

Mental health promotion is limited because of restrictions in the prison environment and the limited time available for these activities. Mental health promotion and education is an integral part of care for prisoners receiving mental health treatment, but there is minimal promotion for the wider prison population.

Each agency recognises the importance of providing services responsive to Māori needs as a component of mental health services and provides some degree of service in this area. A barrier to providing these services is the availability of staff to deliver kaupapa Māori services.

Service monitoring and evaluation

We expected that the agencies would have mechanisms for monitoring and evaluating prisoners’ mental health services.

The agencies have some systems in place to monitor and evaluate services. Both the Department and the Ministry were implementing systems or had work planned to improve service monitoring and evaluation. Given that improvements were in the early stages of implementation, we were unable to determine their effectiveness. However, they appeared to provide a good basis from which to progress.

Our recommendations

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 (recommendation 1); and
  • share current data on prison musters and service demand to meet their joint needs in planning prisoners’ mental health services (recommendation 3).

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 (recommendation 4).

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 (recommendation 2);
  • 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 (recommendation 5);
  • examine how it can help prisoners with mild to moderate mental health needs to access services that meet their needs (recommendation 6); and
  • 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 (recommendation 7).

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 (recommendation 8).

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