England and Wales are two constituent countries of the United Kingdom. While their health, justice and prison policies fall under common legislation, their prison health services differ. The National Health Service England (NHS England) and the National Health Service Wales (NHS Wales) are responsible for prison health in England and Wales respectively. The Mental Health Act (MHA), which applies to both countries, regulates the hospitalisation of offenders who are considered especially dangerous. Depending on the facility, mental health professionals in England may be affiliated with public or private organisations. The Wales Department of Health and Social Care provides the only mental health care in Welsh prisons.

Offenders declared not criminally responsible on account of their mental disorder are subject to treatment orders. A judge can authorise a “hospital order“ to entrust someone to a psychiatric facility, so that person is no longer part of the prison system. There are no psychiatric facilities set up specifically for defendants with mental illness, so care is provided in general psychiatric hospitals, some of which have special units for offenders. Security in these units differs according to the danger posed by the defendants.
A mentally ill defendant may be subject to a treatment order and be sent to a general psychiatric hospital. There are two predominant scenarios:

• A judge may issue a treatment order the moment the sentence is handed down if the facility assigned to the defendant cannot provide appropriate care. Nevertheless, the person may remain in prison if a bed in a psychiatric hospital is unavailable.
• A judge may decide to transfer a prisoner to a psychiatric hospital if the prisoner has experienced a mental health crisis.

Over 35% of prisoners in England suffered from a mental health disorder in 2016 and over 25% of them were treated. Eighty suicides were reported between 2019 and 2020.

Persons with mental illness who have committed an offence are usually held under the ordinary prison regime. Some prisons may have an in-patient healthcare unit that provides treatment to people with severe mental health disorders who are awaiting transfer to a general psychiatric hospital. Prisons without these units can transfer prisoners to other facilities, but this rarely happens in practice. The unit in Pentonville prison has 22 beds.

Some facilities have units reserved for people with severe personality disorders called Psychologically Informed Planned Environments (PIPEs). These units were designed “to offer a safe and facilitating environment to help prisoners develop socially” but they don’t provide any treatment.

Prisoners with mental illness are sometimes placed in “units for vulnerable prisoners”. The main goal is to protect them from other prisoners. As they are normally deemed unfit to work and are left out of activities, they usually remain in their cells.

Prisoners with severe mental illness may be placed on suicide watch, and monitored according to the Assessment, Care in Custody, and Teamwork (ACCT) process. The Committee for the Prevention of Torture (CPT) observed that they are regularly transferred to segregation units in Doncaster, Liverpool and Wormwood Scrubs prisons. Some of them are sent there while waiting to be transferred to a general psychiatric hospital. Time spent in segregation may last up to 23 hours a day, and there are no planned activities. However, visits, phone calls and walks are allowed. In many prisons, the segregation units are dilapidated and unsanitary. Following a visit to the Liverpool prison, the CPT reported that a mentally ill person placed in a segregation unit had inflicted serious self-harm. It deemed this placement inappropriate and recommended an emergency transfer to a psychiatric hospital.

Access to mental healthcare¶

Health screening must be carried out within 24 hours of admission. The nurse in charge of the screening process obtains the defendant’s medical history (health issues, treatments, addictions, and mental health status) through a questionnaire comprised of 120 questions, of which 35% are optional ─mostly those related to suicide and self-harm. Following the screening, the nurse refers the defendant to a doctor for a second visit if necessary.
There are many requests for mental health appointments. A prisoner who makes this request is first seen by a nurse. The lack of healthcare staff is causing long wait times. Patients must be escorted to their appointment by a prison officer. In some prisons, between 30% and 50% of the prisoners cannot attend their appointments because of staff shortage.

Prison boards sounded the alarm about the overcrowded health units and lack of resources. Prisoners in Deerbolt wait up to 27 weeks to access one-on-one psychotherapy. Every month, over 120 people are referred to High Down’s prison health services.

Provision of mental health treatment¶

Any prisoner with mental health problems can receive an individual treatment plan. Those with severe mental illness are given medication. Access to therapy varies from one facility to another. The majority of prisons do not have sufficient resources to provide psychological assessments. Therapy is especially lacking in women’s prisons.

PIPEs offer psychotherapy and group therapy to individuals with personality disorders. In-patient healthcare units provide limited mental health treatment.

Those suffering from substance abuse are carefully monitored and assessed within five days of entering prison. Most prisons offer therapy and substitutes for nicotine and opioids. Half of them have “drug-free” units for these individuals.

Medical staff¶

Ambulatory care is provided by a mental health team consisting of a psychiatrist (sometimes full-time), psychiatric nurses and psychologists. Social workers and occupational therapists are also available. In some prisons, mental health staff are not available during evenings and on weekends.

Medical confidentiality¶

Requests for psychological consultations are made in writing or orally. In some prisons, these can be made directly through cell phones. Doncaster’s prisoners must complete a form online.

The CPT observed that in the healthcare unit of Liverpool prison, assessments are carried out in the presence of prison officers. It noted that healthcare professionals of psychiatric hospitals inform the escorting prison officers about decisions related to patients. The officers then return the prisoner and inform the prison healthcare team. The CPT believes that this practice infringes upon patient confidentiality.

Medications for prisoners with mental health problems are prescribed by a psychiatrist or a general practitioner. Nurses at the Doncaster and Wormwood Scrubs facilities distribute these medications in particularly busy areas. The CPT considers this practice contrary to patient confidentiality as it exposes vulnerable prisoners to potential violence from other prisoners.

Emergency measures¶

In theory, prisoners undergoing a mental health crisis must be transferred to a general psychiatric hospital. Nevertheless, they may be placed in segregation cells while awaiting their transfer. In 2017, about 8% of prisoners waiting for transfer to a mental health facility were kept on suicide watch and moved to a “segregation cell”. The CPT recommended that pending transfer, patients “should be accommodated in the prison health care inpatient unit and not held in segregation.”

Prison officer training¶

A four-hour introductory training programme on mental illness was made available to prison officers in 2016. They are trained to identify a prisoner’s deteriorating mental health and refer to the relevant healthcare personnel. The programme is only for new recruits, and there is no further training for the existing staff. The implementation of these programmes is left up to the discretion of facility directors. Additional mental health awareness training for prison staff is available, but usually cancelled due to low participation rates.

Continuity of treatment¶

From the very beginning of a sentence, special attention must be given to community reintegration. There is no guarantee of continuing care for foreigners, nor those serving short sentences.

”Clinical Commissioning Groups“ (CCGs) are in charge of local health services, and are responsible for the healthcare of released prisoners. Prison facilities use “SystmOne” to ensure the continuity of care. This is an electronic system containing the medical records of prisoners.
Released prisoners in Wales have the right to a psychiatric assessment called the “Mental Health Measure” after which they can access mental health care. Persons incarcerated in England may sometimes have their care interrupted when returning home to Wales.

There are no special facilities dedicated to people who are not criminally responsible or mentally ill. Those who require mental health treatment are placed in general psychiatric hospitals, and this can occur at any point during the incarceration period. A judge may decide on a treatment order known as a remand to hospital during the trial period. If the defendant is found to be not criminally responsible, the judge hands down a treatment order known as a hospital order. This measure may also have a restriction order if the defendant poses a “serious danger”. In this case, the Justice Minister may approve certain terms and conditions of the order such as leave permissions.

If the defendant is found to be criminally responsible, but the judge has not yet decided on the sentence, an interim hospital order may be handed down.

Transfers from prison  ¶

Mentally ill prisoners may be given a hospital order that places them in a general psychiatric hospital. The law provides for two possible scenarios:

• A judge may order a so-called hospital direction if the facility to which the defendant is sentenced cannot provide the necessary care. The defendant must be transferred within a maximum period of 28 days, and may be placed in detention if there is no space in a psychiatric hospital.
• The Ministry of Justice may decide to transfer a prisoner with a mental health crisis to a psychiatric hospital. The transfer request is made to the prison administration and must be presented within two weeks.

It usually takes a long time to get transferred, and there are not enough beds in psychiatric hospitals. Some institutions refuse to admit prisoners and prioritise other patients. Some transfers are done between different regions. The CPT reported that in 2019, prisoners at Doncaster, Liverpool and Wormwood had to wait up to four months. In 2017, 8% of the prisoners had to wait for their transfer in a segregation cell, and 36% remained in their regular unit. Men have better access to healthcare units than women.

Legal framework¶

Persons declared not criminally responsible. Persons under a hospital order plus a restriction order are placed in a psychiatric hospital for an average time of seven years. Placements in “high-security” hospitals can last about eight years compared to two to five years in their “medium-security” counterparts.

Hospital orders are reassessed every three years by a Mental Health Tribunal. People under a hospital order, and their families, can appeal the order to the tribunal, but the appeal must be filed no more than six months after the order was given. They can also ask for the order to be re-examined every year. The tribunal orders a person’s release from hospital if the person no longer needs in-patient psychiatric treatment, and informs the Ministry of Justice of the decision.

Prisoners. Transfers from prison to hospital must be reviewed every six months. They are initially admitted to a high-security hospital before moving on to a medium-security, and then a low-security one. The time required for the transfers to be authorised can prolong their stays. Legally, a remand to hospital must last 28 days, and extensions are decided by hospital officials following a doctor’s request. Expertise is provided by external psychiatrists.

Prisoners cannot contest a transfer to a psychiatric hospital until the transfer has taken effect. At least once a year, the person’s doctor must submit a report for every case to the Justice Minister.

Daily life¶

Incarcerated persons and offenders are not usually sequestered from regular patients. Security measures in psychiatric hospitals vary according to the degree of danger posed by the patients.

Three high-security psychiatric hospitals admit people deemed to be especially dangerous, and they have the most admission requests. Their living conditions are similar to those in prison. They have more staff than other psychiatric hospitals. The team in charge of the Positive Intervention Programme (PIP) at Ashworth Hospital consists of specially trained nurses. This team is usually called upon to administer treatment to recalcitrant patients without their consent, or to contain them in case of crisis. The CPT reported that the team had to intervene 325 times in 2015.

Female prisoners are systematically transferred to Rampton Hospital. Since there is no such facility in Wales, people must be transferred to England when necessary.

Other patients are sent to “low-” and “medium-security” units, usually in private hospitals. These units are equipped with Security Automation Systems (SAS) and a video surveillance system. They are surrounded by wire fences, and have many security guards.

The Justice Minister may decide that those under restriction orders be placed in dedicated units. They may then be transferred to “medium-” or ”low-security” units if the Justice Minister agrees to it. The decision arrives long after the request, thus lengthening the stay.

Placement in long-term segregation happens frequently. A doctor can order segregation if a person presents a serious danger to the guards and other patients. This placement can last several years. Minimal social contact is allowed and the patients can leave their cell only for a few hours a day. Some of them get only 30 minutes of yard time every two days. The CPT reported that long-term segregation is becoming increasingly used in Broadmoor Hospital. It cited the case of a patient at Ashworth who has been segregated for four years without any activity, and cautioned against the risk of inhumane and degrading treatment. Mechanical restraints and handcuffs are allowed when prisoners are transferred to a psychiatric hospital.

Continuity of treatment¶

Patients under a restriction order who have been granted parole must be supervised by two professionals: a healthcare expert and a social worker who submit regular reports to the court and advise on the final release, which the patient may ask for at the end of two years.

Patients who were formerly under a hospital order may have to follow a community treatment order. They must follow the conditions imposed by that order or risk returning to hospital.

Some ambulatory care teams specialise in treating former prisoners suffering with mental illness. They also work with patients who were previously subject to a healthcare order. They may be placed in rehabilitation homes under the supervision of organisations or NHS foundations.