- Email: [email protected]
The medium-secure project and criminal justice mental health – Authors' reply
Correspondence
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Karamanoli E. Dept crisis strains Greece’s ailing health system. Lancet 2011; 378: 303–04. Stuckler D, Basu S, McKee M. International Monetary Fund and aid displacement. Int J Health Serv 2011; 41: 67–76. Stuckler D, King LP, Basu S. International Monetary Fund programs and tuberculosis outcomes in post-communist countries. PLoS Med 2008; 5: 1079–90. Gupta S. Response of the International Monetary Fund to critics. Int J Health Serv 2010; 40: 323–26. Paparrigopoulos T, Liappas I. Greek academic psychiatry and neurology before the firing squad? Lancet 2011; 378: 313.
The medium-secure project and criminal justice mental health
Photolibrary
Simon Wilson and colleagues (July 9, p 110)1 make cogent arguments for improved community-based services for offenders with mental disorders in the UK. However, although the principles of quality communitybased services are laudable, Wilson and colleagues put the cart before the horse. What we need upstream of community services is a more effective use of medium-secure services and their full integration with communitybased treatment programmes. Commissioners need to stop restricting prisoners’ access to medium-secure hospital beds and include the National Health Service and independent sector in calculating the total number of available beds. Men and women in prison identified as needing treatment in medium security should be transferred out of prison to hospital within 14 days— this is what Bradley recommended2 and there is capacity to achieve this. In London there are 60 mediumsecure beds in the independent sector immediately available, but the average time taken to effect a transfer from prison to hospital is measured in months, not days. Commissioners should get smarter. Admission to hospital should be for short periods for symptom stabilisation and establishment of treatment. 1460
Patients returning to prison should be supported by the care programme approach (CPA) and their needs met by prison in-reach teams. Proper and effective CPA can follow the prisoner at release, reducing the likelihood of relapse and recidivism. The current UK Government is committed to saving money, controlling costs, and reducing offending. In Waiting on the wings,3 Judy Renshaw suggests that effective treatment in hospital for mentally ill offenders can save society up to £600 000 over an offender’s lifetime—a compelling argument for better, not less, use of our medium-secure estate. I declare that I have no conflicts of interest.
John Taylor [email protected] Partnerships in Care, Borehamwood WD6 1JN, UK 1
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Wilson S, James D, Forrester A. The medium-secure project and criminal justice mental health. Lancet 2011; 378: 110–11. Bradley K. The Bradley Report: Lord Bradley’s review of people with mental health problems or learning disabilities in the criminal justice system. http://www.dh.gov.uk/prod_consum_ dh/groups/dh_digitalassets/documents/ digitalasset/dh_098698.pdf (accessed Oct 5, 2011). Renshaw J. Waiting on the wings: a review of the costs and benefits of secure psychiatric hospital care for people in the criminal justice system with severe mental health problems. http://www.laingbuisson.co.uk/portals/1/ media_packs/Fact_Sheets/Waiting_on_the_ Wings_2010.pdf (accessed Oct 4, 2011).
Authors’ reply John Taylor’s plea for more effective use of medium-secure services makes sense. However, our message is broader than the secure psychiatric estate. It concerns the whole offender population. The medium-secure programme in the UK was established with the best of intentions. Sadly, it has become focused on removing a small number of individuals with psychosis from the criminal justice system into specialist units, neglecting the problems of the majority. The bigger picture is being missed. The system of provision needs to be substantially rebalanced to bring a fresh focus on relatively neglected
parts (probation, prisons, courts, and police stations) and to encourage the expansion of preventive services. Such expansion involves providing better support for those with a range of problems, not simply psychosis, and a return to a focus on problem behaviours (ie, provision of services to assess and treat those who threaten, stalk, exhibit poor anger control, or develop sexually deviant interests). The way forward is through the dismantling of the current artificial barriers between forensic psychiatry services and the criminal justice system, and a move towards a convergence of care efforts, while maintaining agency integrity. This integration would be more likely to produce equitable mental health delivery for all in the system, not just the lucky few, through ensuring better interagency cooperation and coordination of care. In doing so, it would also aid in preventing people from entering or reentering the criminal justice system, and so further their own interests as well as those of public protection. We declare that we have no conflicts of interest.
*Simon Wilson, David James, Andrew Forrester [email protected] Department of Forensic & Neurodevelopmental Science, Institute of Psychiatry, London SE5 8AF, UK (SW); North London Forensic Service, Chase Farm Hospital, Middlesex, UK (DJ); South London and Maudsley NHS Foundation Trust, London, UK (AF); and Institute of Psychiatry, Healthcare Department, HM Prison Brixton, London, UK (AF)
Department of Error Khan AS. Public health preparedness and response in the USA since 9/11: a national health security imperative. Lancet 2011; 378: 953–56—In this Viewpoint (Sept 3), the fifth sentence of the second paragraph in column two on p 955 should have read: “Similarly, advances in laboratory reporting are tempered by the reality that in 2010, 12 (24%) states could not submit 90% of Escherichia coli test results to CDC’s PulseNet database within 4 working days, compromising rapid identification.12” This correction has been made to the online version as of Oct 21, 2011.
www.thelancet.com Vol 378 October 22, 2011
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Karamanoli E. Dept crisis strains Greece’s ailing health system. Lancet 2011; 378: 303–04. Stuckler D, Basu S, McKee M. International Monetary Fund and aid displacement. Int J Health Serv 2011; 41: 67–76. Stuckler D, King LP, Basu S. International Monetary Fund programs and tuberculosis outcomes in post-communist countries. PLoS Med 2008; 5: 1079–90. Gupta S. Response of the International Monetary Fund to critics. Int J Health Serv 2010; 40: 323–26. Paparrigopoulos T, Liappas I. Greek academic psychiatry and neurology before the firing squad? Lancet 2011; 378: 313.
The medium-secure project and criminal justice mental health
Photolibrary
Simon Wilson and colleagues (July 9, p 110)1 make cogent arguments for improved community-based services for offenders with mental disorders in the UK. However, although the principles of quality communitybased services are laudable, Wilson and colleagues put the cart before the horse. What we need upstream of community services is a more effective use of medium-secure services and their full integration with communitybased treatment programmes. Commissioners need to stop restricting prisoners’ access to medium-secure hospital beds and include the National Health Service and independent sector in calculating the total number of available beds. Men and women in prison identified as needing treatment in medium security should be transferred out of prison to hospital within 14 days— this is what Bradley recommended2 and there is capacity to achieve this. In London there are 60 mediumsecure beds in the independent sector immediately available, but the average time taken to effect a transfer from prison to hospital is measured in months, not days. Commissioners should get smarter. Admission to hospital should be for short periods for symptom stabilisation and establishment of treatment. 1460
Patients returning to prison should be supported by the care programme approach (CPA) and their needs met by prison in-reach teams. Proper and effective CPA can follow the prisoner at release, reducing the likelihood of relapse and recidivism. The current UK Government is committed to saving money, controlling costs, and reducing offending. In Waiting on the wings,3 Judy Renshaw suggests that effective treatment in hospital for mentally ill offenders can save society up to £600 000 over an offender’s lifetime—a compelling argument for better, not less, use of our medium-secure estate. I declare that I have no conflicts of interest.
John Taylor [email protected] Partnerships in Care, Borehamwood WD6 1JN, UK 1
2
3
Wilson S, James D, Forrester A. The medium-secure project and criminal justice mental health. Lancet 2011; 378: 110–11. Bradley K. The Bradley Report: Lord Bradley’s review of people with mental health problems or learning disabilities in the criminal justice system. http://www.dh.gov.uk/prod_consum_ dh/groups/dh_digitalassets/documents/ digitalasset/dh_098698.pdf (accessed Oct 5, 2011). Renshaw J. Waiting on the wings: a review of the costs and benefits of secure psychiatric hospital care for people in the criminal justice system with severe mental health problems. http://www.laingbuisson.co.uk/portals/1/ media_packs/Fact_Sheets/Waiting_on_the_ Wings_2010.pdf (accessed Oct 4, 2011).
Authors’ reply John Taylor’s plea for more effective use of medium-secure services makes sense. However, our message is broader than the secure psychiatric estate. It concerns the whole offender population. The medium-secure programme in the UK was established with the best of intentions. Sadly, it has become focused on removing a small number of individuals with psychosis from the criminal justice system into specialist units, neglecting the problems of the majority. The bigger picture is being missed. The system of provision needs to be substantially rebalanced to bring a fresh focus on relatively neglected
parts (probation, prisons, courts, and police stations) and to encourage the expansion of preventive services. Such expansion involves providing better support for those with a range of problems, not simply psychosis, and a return to a focus on problem behaviours (ie, provision of services to assess and treat those who threaten, stalk, exhibit poor anger control, or develop sexually deviant interests). The way forward is through the dismantling of the current artificial barriers between forensic psychiatry services and the criminal justice system, and a move towards a convergence of care efforts, while maintaining agency integrity. This integration would be more likely to produce equitable mental health delivery for all in the system, not just the lucky few, through ensuring better interagency cooperation and coordination of care. In doing so, it would also aid in preventing people from entering or reentering the criminal justice system, and so further their own interests as well as those of public protection. We declare that we have no conflicts of interest.
*Simon Wilson, David James, Andrew Forrester [email protected] Department of Forensic & Neurodevelopmental Science, Institute of Psychiatry, London SE5 8AF, UK (SW); North London Forensic Service, Chase Farm Hospital, Middlesex, UK (DJ); South London and Maudsley NHS Foundation Trust, London, UK (AF); and Institute of Psychiatry, Healthcare Department, HM Prison Brixton, London, UK (AF)
Department of Error Khan AS. Public health preparedness and response in the USA since 9/11: a national health security imperative. Lancet 2011; 378: 953–56—In this Viewpoint (Sept 3), the fifth sentence of the second paragraph in column two on p 955 should have read: “Similarly, advances in laboratory reporting are tempered by the reality that in 2010, 12 (24%) states could not submit 90% of Escherichia coli test results to CDC’s PulseNet database within 4 working days, compromising rapid identification.12” This correction has been made to the online version as of Oct 21, 2011.
www.thelancet.com Vol 378 October 22, 2011