Prison mental health in Northern Ireland

Whilst a recent inspection has reflected improvements in HMP Maghaberry, significant scope remains for the improvement of mental health provision across the prison system, according to a recently published report by the Royal College of Psychiatrists.

The report acknowledges that prison mental health continues to be the most significant challenge to the delivery of forensic mental healthcare in Northern Ireland; a place described in the report as having “evolved differently to those in other jurisdictions within the United Kingdom”.

According to the report’s authors, it is “difficult to ensure matters other than security are the operational priority” at HMP Maghaberry, HMP Magilligan and Hydebank Wood College, due to the fact that “the threat to the security services remains severe”: a point supported in its statement that “the last two members of the security forces to be murdered by terrorists were prison officers”.

The report, published in November by the Forensic Faculty of the Royal College of Psychiatrists, comes at a time in which mental healthcare provision in prisons face greater scrutiny following controversies around self-harm and drug abuse, with Northern Ireland Prison Service (NIPS) data showing 3,855 incidences of self-harm reported between 2012 and 2017. Several points of concern are identified, including issues related to models of care; the lack of a residential healthcare facility and consequent segregation of mentally ill prisoners; the safety of prisoners transferred to hospital; a poor understanding of the prevalence of mental ill health; suicide; mental health screening; therapeutic provision; and regional issues.

Model of care

Many of the central concerns of the report surround the model of healthcare offered to service users in Northern Ireland’s prison system, with the current approach to patient care described as not considering “the prevalence of mental illness in the prison population or the nature of the living environment in custody”. The employment of a “home treatment” model is similarly criticised, in that it allegedly gives little consideration to the “different demographics seen in prisons, or the present, and often toxic, environment”.

The report recommends that the South Eastern Health and Social Care Trust implement an evidence-based model of care in line with national guidelines and quality care guidelines. It is also recommended that prison mental health services join the Prison Quality Network and participate in a peer review process, with prison psychiatry job descriptions and job plans conforming to national guidelines following consultation with the Regional Advisor in Forensic Psychiatry.

Residential healthcare

In regard to residential healthcare, it is claimed that the closure of HMP Maghaberry’s acute medical wing has exacerbated issues in forensic mental healthcare, with mentally unwell patients kept in solitary confinement as a consequence of a lacking, specialised facility: a condition described as “remarkable” by the report’s authors. The report notes that admission data from the regional secure unit demonstrates that the number of transferred prisoners increased four-fold after the closure of the healthcare unit, recommending that such a facility be established “with regards to the established best practice”.

The report has identified several failings concerned with the transfer of prisoners to hospital facilities. One such failing concerns the disproportionate employment of Psychiatric Intensive Care, with the routine practice labelled as “inappropriate and unsafe”, and “not a substitute for security”. It is also noted that there is currently no protocol for assessing the needs of prisoners who are transferred to hospital. To this end, it is recommended that all prisoners to be transferred must be considered by a regional bed management forum, with nationally recognised instruments such as the DUNDRUM Toolkit used to reinforce clinical decision-making.

The practice of transferring prisoners to hospital against the advice of prison clinicians is also noted as a failing in the report. This is criticised as wasting a useful healthcare resource, with the report recommending that the practice of transferring patients against clinician advice is ended immediately.

The prevalence of mental ill health and intellectual disability within Northern Ireland’s prison system is criticised as “poorly understood” in the report, with the region demonstrating a 25 per cent higher overall prevalence of mental illness than seen in England. The authors of the report reflect a concern that such a poor understanding will lead to inappropriately structured and resourced services.

The report recommends the commissioning of research into the prevalence of mental ill health in Northern Ireland to assess the current mental health need.

Suicide

Inaccuracies in suicide risk management have also been highlighted as a major concern in the report. The authors of the document highlight that the majority of prison suicides are committed in the context of social circumstances, in which case a psychiatric-led model in suicide prevention is not always appropriate “and may contribute towards an adverse consequence”. To this end, it is recommended that individual prison suicides should not be framed in terms of predictability and preventability. It is also recommended that the contribution of mental health workers to ‘Supporting Prisoners at Risk’ reviews should continue.

Screening of prisoners for mental health problems is not carried out in accordance with National Institute of Clinical Excellence guidelines – an issue highlighted as a significant failure in the report. The lack of adequate screening “often results in prisoners with mental illness not being identified in a timely fashion”, reaping consequences for the prisoner’s mental health and increasing their vulnerability. Addressing this criticism, the report recommends that screening prisoners for mental health problems be introduced by the South Eastern Health and Social Care Trust, in accordance with National Institute of Clinical Excellence guidelines.

Whilst there is “some limited provision” for cognitive behavioural therapy and psychotherapy for psychological trauma, it is remarked that “There is no provision of specific therapeutic interventions for personality disorder”, with the absence of such treatments noted as failing to change the number of prisoners presenting with mental illnesses. In response to the lack of therapeutic opportunities, the report recommends that they be provided by the South Eastern Health and Social Care Trust in accordance with the National Institute of Clinical Excellence guidelines.

Regional issues

The report criticises a significant “disconnect” between prison mental health care and the wider forensic mental health community. “Prisoners cannot be treated in isolation and there is a need to incorporate all aspects of care into an operational policy,” reads the report. It is highlighted that the provision of police custody healthcare, together with the capacity of the regional secure unit, have significant implications for prisoners with mental illness. To address this issue, the report recommends the establishment of a steering group and Regional Forensic Mental Health Service to decide the delivery of prison mental health care, including forensic psychiatry in the form of the Regional Advisor in Forensic Psychiatry for the Royal College of Psychiatrists in Northern Ireland.