My Lords, like the other speakers, I, too, should like to thank the noble Baroness, Lady Neuberger, for obtaining this timely debate on a subject on which, as she has already indicated, we share a joint interest as advisers to the trustees of the Sainsbury Centre for Mental Health. She persuaded it to invite me, so I follow her. My particular interest in going there is because the Sainsbury Centre for Mental Health has recently announced that it will concentrate its activities on the treatment of mentally ill people in prison and the problems of finding employment for mentally ill people—two hugely important and sadly neglected subjects.
It may seem rather perverse to raise in-patient care in acute mental health wards for people who are acutely ill and for whom there are no acute mental health wards in prisons. I do so because until 2004 the Prison Service had its own healthcare for which it paid. In 1995, when I took over as Chief Inspector of Prisons, I was amazed to find that prison healthcare was not in the hands of the NHS. After all, all prisoners came from the NHS and would go back to it when they left prison. So why did they go into a sort of medical limbo when they went into prison? That seemed particularly perverse. Prisons, when people are locked up, present an opportunity for identification and treatment of problems both physical and mental. Therefore, to suggest that they had left the care of the NHS to go into this limbo suggested, as I was soon to discover, that that opportunity was not being seized.
In my first inspection of Holloway, which I was told was the largest women's psychiatric prison facility in the country, I discovered large numbers of seriously ill women who were utterly neglected with totally inadequate services. That set the tone for what I found. As a result, in 1996, I produced a paper called Patient or Prisoner, which recommended that the NHS should take over responsibility for those people. Prisons are a public health issue. The health of people when they come out of prison matters to the public. Therefore, it is irresponsible for the Prison Service not to make arrangements to deal with their health while they are inside.
So it was that I was very interested in this debate and I was particularly interested in the reports of the Sainsbury Centre. The noble Baroness, Lady Neuberger, has already referred to a follow up to the original report, called The Search for Acute Solutions, and I should like to quote three short messages from that report which have a great resonance with what goes on in prisons.
"It is important that some short-term investment is made by leaders and managers to enable staff to participate in bringing about change given the potential for long-term gain derived from a more effective service. This does not necessarily mean money. Using existing resources differently and flexibly is possible but good management and leadership are necessary to achieve this. Advanced unit-wide planning, sound organisation, consultation and communication are required so that staff can feel comfortable about taking time to develop and implement change".
Hear, hear to that! Strong leadership, strong management and strong direction, to my mind, are more important than money. We have got to see that existing facilities are used better. I was horrified to find when inspecting prisons that there is only one secure unit in the whole system: it is at Aylesbury and it is used as a classroom because it has not even got a psychiatrist there for the young offenders.
Secondly, as my noble friend Lady Murphy has already mentioned, the report states:
"Inactivity and boredom can delay recovery and can sometimes cause increased levels of aggression and frustration".
Hear, hear to that! What on earth is going to be done for acutely mentally ill people left locked up in prison cells all day? It is doing absolutely nothing for them except, as my distinguished psychiatrist, Dr John Reed, used to say frequently, merely making them worse.
Finally, the report states:
"However, whatever the place that acute in-patient care comes to occupy, there can be no excuse for poor environments and low-quality services.
Hear, hear to that!
Noble Lords may wonder what numbers we are talking about because the numbers in the NHS are huge and the numbers in the Prison Service may not be. Let us look at it proportionally to start with. If you take the percentage of people who suffer from two or more mental disorders, in the general population it is 5 per cent of men and 2 per cent of women; move to prisons and the figures show that 72 per cent of males sentenced and 70 per cent of females sentenced are suffering from two or more mental disorders. Moving on to neurotic disorders—sleep, worry, anxiety, depression and so on—the figures are 12 per cent of men and 18 per cent of women in the general population, but 40 per cent of males and 60 per cent of females in prison. As to the numbers of people who need acute treatment—the ones suffering from psychotic disorders—the figures are 0.5 per cent of men and 0.6 per cent of women in the general population, but 7 per cent of all males and 14 per cent of all females sentenced in the prisons are suffering to that degree. And yet there are no acute mental health wards for them to receive treatment.
To put the numbers into a more reasonable proportion than mere percentages, perhaps I may quote an article by Dr Adrian Grounds, written in 2004. He states:
"The scale of the problem is huge. Based on the best research we've got, it may be that about 4% of the prison population need to be in hospital beds, and, in current terms, that means that something in the order of 3,000 prisoners, possibly up to 3,700"— which is much more likely now given the increase in numbers—
"need to be in a psychiatric hospital".
That is a large number. The trouble is—and I fully sympathise with the NHS and all the people who plan it—that we are not coming at this problem from a good starting point. Because prisons were not part of the NHS, the needs of people in prison were not included in NHS estimates. Therefore a large number of people were coming out—remember that all except just over 30 people in prison will come out—bringing these needs with them into the community, with no arrangements made for them.
As a result, to go on with what Dr Grounds said:
"We commonly see mentally ill men being released at the end of their sentences who, at the very least, should go to suitable accommodation, be registered with their GP and have had follow-up by their local mental health service arranged. Distressingly often, and notwithstanding efforts by their probation officers, they leave with no address, only an instruction to present themselves as homeless to their local housing authority. In the absence of an address, the relevant mental health team either cannot be identified, or will refuse to see the patient, or both. There will be no GP registration. Housing authorities may refuse to accept a prisoner on their waiting lists before he is released because he is not potentially available to take up a tenancy should one arise".
The reason I mention all this is not merely in connection with the acute bed report. The fact is that in our society, as a responsibility of the NHS, are people whose treatment in prison and subsequent treatment after they leave will make them candidates for the over-stretched acute beds and whose needs should be looked at, as well as the people who should be identified by courts and prisons and referred to the acute system even earlier. My contention is that although the cost is large—and I do not pretend that it is not—we cannot afford not to do this, because the cost of not doing it will be greater.
It seems to me perverse that the Prison Service has made £126 million over three years available to treat the 200 to 300 people said to be very seriously disturbed, which works out at £180,000 per person, whereas it has made only £122.5 million available for healthcare, which means £817 only for all the others, a large number of whom are acutely ill. Therefore, I hope that in responding to this very important debate, the Minister will not forget the needs of this part of the population, which is the latest addition to their budget.