This is a joint post by myself and Professor Charlie Brooker (@charliebrooker9) summarising a new article just published on Prison mental health in-reach teams, serious mental illness and the Care Programme Approach in England in the Journal of Forensic and Legal Medicine.

History and context

We look back at the delivery of prison mental health services in England over the last 12 years. We found that resources for services grew significantly during this period and improved organisational models for the delivery of services were put in place.

Prison mental health in-reach teams, on average, now have eight team members on average. In one service this figure rose to 20 team members. The average caseload, per in-reach team member is 17.6. NHS England, who commission such services, now expect that all those with a Serious Mental Illness (SMI) should be placed under the Care Programme Approach (CPA).

What is the Care Programme Approach?

The four main components of the original CPA were:

1. Systematic arrangements for assessing the health and social needs of people accepted into specialist mental health services;
2. The formation of a care plan which identifies the health and social care required from a variety of providers;
3. The appointment of a key worker to keep in close touch with the service user and to monitor and co-ordinate care; and
4. Regular review and, where necessary, agreed changes to the care plan.

The emphasis on the ‘care co-ordination’ element of the original CPA was originally thought to be crucial for prisoners who on release from prison were reported to often lose contact with mental health services. However it is also important to note that the CPA embraced all
those referred to specialist mental health services, or, those with a serious mental illness. The CPA was revised in 2008 and amended to focus on only those with the most severe mental illness. The new guidance in 2008 also stated the following for the first time:

It is now DH policy that, following appropriate training for staff, exploration of violence and abuse is routinely undertaken in all mental health assessments.

The notion of Routine Enquiry is a critical concept for CPA in general and prisoners in particular, many of whom will have had a history of sexual abuse or violence.

CPA is extremely important for prisoners with a serious mental illness to ensure that they are released with a care plan so that their care can be picked up immediately by mainstream community mental health services.

Findings

Our survey – via Freedom of Information (FOI) requests sent to all 53 English Mental Health Trusts (to which 49 = 92% responded) provided the following results:

• 24% of the responding Mental Health Trusts declared themselves to be providers of mental health in-reach teams in prisons (n=12). These Trusts provided mental health inreach services to 68% of existing prisons in England (n=81).
• The number of prisons served by these in-reach teams varied from 1-10 prisons (One Trust served 10 prisons with a staff complement of 63 full-time multidisciplinary team workers).
• The average number of prison mental health in-reach team members per prison across England was 8.0. This ranged from 2.2 staff members to 20 staff members.
• The average prison mental health in-reach caseload was 17.6. Thus, there were 7,462 prisoners on in-reach caseloads if this figure is extrapolated to all prisons it can be estimated that there are 9,850 prisoners on prison mental health in-reach caseloads in England. Caseload size ranged from 13-25.
• The proportion of prisoners with a SMI on caseloads averaged 38% (range 12-92%). The proportion of those with a SMI subject to the CPA averaged 72% (range 0-100%). It can therefore be estimated that the proportion of the total mental health in-reach caseload subject to the CPA was 27% (or an estimated 2,660 prisoners).

Mental health trusts were also asked an open question that concerned the practical difficulties of implementing the CPA in prisons. Many issues were identified that related to: the nature of the prison environment; geography; and communication with mainstream services. It was rare for services to be fully integrated with mainstream mental health services and the host CPA system and electronic data collection system but this did occur occasionally.

Conclusions

We argue in the paper that a history of sexual abuse or violence are common amongst prisoners and the Care Programme Approach (CPA) provides the vehicle to assess these histories through the use of routine enquiry.

We conclude that commissioners of prison mental health services now need to ensure that teams are delivering cogent trauma-based interventions where relevant and that the outcomes are measured. At the very least NHS England should be ensuring, through audit, that Routine Enquiry takes place for all prisoners with a SMI on the CPA.

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