Mental health services for prisoners

Mental health services are provided to sentenced and remand prisoners by three agencies (the agencies) – the Department of Corrections (the Department), the Ministry of Health (the Ministry) and the Regional Forensic Psychiatric Services (RFPS – run by district health boards).

The Department is responsible for primary mental health care that is reasonably equivalent to the standard of health care available to the public. The Ministry is responsible for the strategic direction of mental health services, and RFPS is responsible for providing specialist mental health services for those in the criminal justice system.

The scope of our audit

We considered the effectiveness of the agencies' systems for delivering mental health services to prisoners. At the time of our audit, these systems were under significant pressure from increasing prisoner numbers and a high demand for in-patient beds.

The audit looked at:

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

Our findings

It was difficult for the agencies to plan services to meet the growth in prisoner numbers because they had limited information about the mental health needs of prisoners. The Ministry had limited ability to respond to changes in demand during its five-year planning cycle for forensic care. The agencies had identified their roles and responsibilities for delivering most mental health services. One exception to this was a lack of clarity about which, if any, of the agencies had responsibility for prisoners with personality disorders.

Our audit noted some gaps in service delivery, which included:

• timely access to in-patient services;
• forensic in-patient services for women;
• services for those with mild to moderate mental illness;
• services for prisoners with personality disorders; and
• service responsiveness to Māori.

The agencies were aware of these services gaps and were at varying stages of identifying and introducing improvements.

Systems for managing care between prisons and RFPS needed to improve, particularly when transferring prisoners under forensic care between prisons.

The Department and the Ministry were planning or putting in place improved systems for monitoring and evaluating services. However, at the time of our audit, it was too early to assess the effectiveness of these improvements.

We made eight recommendations for the agencies, and their responses are detailed below.

At the time of our audit, the Department was working with the Ministry and RFPS staff to improve its processes for mental health screening. This involved creating and trialling a mental health screening tool. Although the Ministry was successful in securing funding for this tool, the Department's budget bid was unsuccessful. The Department continues to seek funding for the tool's implementation, and the necessary resources to ensure that it is effective, but the project cannot go ahead until both the Department and the Ministry have funding for it.

The response to our findings and recommendations

We made our eight recommendations on the basis that the mental health screening tool would be implemented after our audit. Because this tool has not been implemented, the Department's ability to implement some of our recommendations has been affected.

Only one of our recommendations has been fully implemented. Implementation of one has stalled because the mental health screening tool is not in place. Two have been partially implemented, and the agencies are in the process of implementing another. Three of our recommendations have not been implemented.

Overall, we are not satisfied with the entities' response to our recommendations. We remain particularly concerned about the risk that services will not keep pace with demand, and the Department's ability to identify prisoners with mental health needs.

Identifying trends in prisoners' mental health needs

We recommended that the Department improve its information for identifying trends in prisoners' mental health needs to support service planning. Implementing the mental health screening tool would have helped with this. However, without the tool, the response to this recommendation has stalled.

Basic screening for mental health issues occurs as part of the Department's initial health assessment process, but without the mental health screening tool there is a risk that prisoners with mental health needs will not be identified or treated. We encourage the Department to improve how it identifies, collects, and records information about prisoners' mental health needs. This would allow it to better quantify and identify needs, then plan and adapt services accordingly.

We consider better mental health screening by the Department to be a priority for improving mental health services. However, the Department has prioritised other work above this. We found no evidence that the Department will be able to improve how it collects data about prisoners' mental health needs until it funds the mental health screening tool.

Incorporating progress reviews in the forensic service planning cycle

We recommended that the Ministry incorporate progress reviews in its forensic service planning cycle so that it could adapt services in response to changes in demand. The Ministry meets regularly with regional forensic clinical directors (who, through RFPS, deliver forensic psychiatric services), providing an opportunity for changes in demand to be noted. However, we found no evidence that any action in terms of service provision has resulted from noting such changes in demand.

We encourage the Ministry to implement our recommendation. If it does not, there is a risk of services not keeping pace with demand. We note that RFPS is responsible for delivering regional psychiatric services, but the Ministry has a role in overseeing service delivery nationally.

Improving mental health awareness training for custodial staff

We recommended that the Department ensure that its training for custodial staff include enough coverage of the behaviours associated with mental health issues that staff can recognise when to seek input from health staff. At the time of our audit, the Department was reviewing its mental health awareness training for custodial staff. As a result of this review, the level of mental-health-related content in custodial staff training has increased. This should help custodial staff to better understand mental illness and associated behaviours. We encourage the Department to ensure that its review of At Risk Units is completed promptly, because the Department told us that it is highly likely that the recommendations from the review will address custodial staff's skills and knowledge in the area of mental health.

At the time of our audit, the Department was also piloting a primary mental health care course for its nurses. The Department is awaiting formal evaluation of this course, but informed us that, anecdotally, it is successful. This course is expected to improve nursing staff skills in managing mental health in the primary care setting.

Improving prisoner access to services

We also recommended that the Department look at how it can help prisoners with mild to moderate mental health needs to access the services they need. We found no evidence that the Department has done this. We considered this important because the proposed mental health screening tool had the potential to identify more prisoners with this level of need. It is important that the Department ensure that it does this if the mental health screening tool is implemented in the future.

We note that the Department is required to provide such services at a standard roughly equivalent to that available to the general public. The Department believes that it does so. However, we consider that the combination of the Department's rehabilitative and custodial duties places some responsibility on the Department to ensure that prisoners' needs in this area are met, regardless of the comparable level of access to such services in the community.

Transfer constraints and processes

We recommended that the Department ensure that transfer constraints and transfer processes are followed by staff when prisoners under forensic care are transferred. Department managers now encourage staff more strongly to apply these transfer constraints and follow these processes more strictly. The Department told us that improvements have resulted from this.

Clarifying agency roles and responsibilities

We recommended that the Department and the Ministry clarify their roles and responsibilities for managing prisoners with personality disorders. There is still no official agreement between the Department and the Ministry on this. However, the agencies are trying to better understand this complex area of clinical practice through the Multiple and Complex Needs project.

This project involves collaborative work between the Department, the Ministry, and RFPS to manage and care for prisoners with multiple and complex needs, including those with personality disorders. We consider the response to our recommendation to be in progress because part of this project will include clarifying who is responsible for managing prisoners with personality disorders.

We note that managing prisoners with personality disorders is a difficult area of clinical practice, and there is unresolved debate about whether it is the responsibility of the Department or RFPS. However, we encourage the entities to complete this project promptly.

Sharing current data on prison musters and service demand

We also recommended that the Department and the Ministry share current data on prison musters and service demand. This recommendation has been partially implemented in that the Department and the Ministry are sharing this data to meet their joint planning needs and both are comfortable with the level of data sharing between them. However, we continue to have concerns that the Ministry is not using current enough data about service demand in its planning.

Responsiveness of prisoners' mental health services to the needs of Māori

We recommended that the agencies adapt their monitoring and evaluation processes to ensure that prisoners' mental health services are responsive to the needs of Māori. Since the time of our audit, neither the Ministry nor the Department have adapted their processes. However, the Department is working on a tool for increasing the effectiveness of its response to the needs of Māori.

We are pleased that the agencies have improved other aspects of their mental health services for prisoners, unrelated to our recommendations. Figure 2 discusses these other pieces of work.

Figure 2
Other work by the agencies to improve mental health services for prisoners