By Megan Georgiou, Postgraduate Researcher
The COVID-19 pandemic has presented significant challenges to health and social care systems world-wide. Within the prison estate, the challenges are amplified and tough measures have been brought in to contain the spread of the disease (Kothari et al, 2020). Mental health service delivery in prisons is greatly restricted and reports are starting to emerge of the impact of COVID-19 on both prisoners and staff members. This blog brings together some of the key issues and outlines how the current measures are placing prisoners and staff members at risk of harm.
COVID-19 and prisons
Before the COVID-19 pandemic, the prison population was standing at around 83,000 (GOV.UK, 2020). The prison estate in England and Wales has suffered many years of austerity measures, impacted by significantly reduced staffing levels, the highest levels of self-harm and suicide on record and increasingly controlled regimes (House of Commons Justice Committee, 2019).
When lockdown commenced in March 2020, people in prison were subjected to stricter regimes and confinement in their cells of 23 hours a day, visits were terminated, and education programmes were suspended (The Guardian, 2020). There is little opportunity for exercise, showers, telephone contact with family and friends, and there is very little to do (IAP, 2020). Regarding children in prison, three young offender institutions were recently inspected to assess the functioning of the prison estate during the pandemic (HM Inspectorate of Prisons, 2020). Alarming practices were noted, such as children spending just 40 minutes out of their cells each day, and children arriving at prison by themselves having no face-to-face interaction with other children for 14 days. These practices will undoubtedly negatively impact on children’s wellbeing. In light of this, it is deeply worrying that specialist secondary mental health service provision was reported as being limited at these sites during this period.
The restrictions, akin to solitary confinement, raise serious concerns of what impact they will have on prisoners’ mental health. Some prisons have limited or no access to peer support, such as the support network provided by the Samaritans Listener scheme, depending on how restrictive the prison regime is (IAP, 2020). This support is incredibly important, especially in light of the recent acceleration of self-inflicted deaths where five people in prisons were reported to have died by suicide in just six days (The Guardian, 2020). This indicates that the strict measures and prolonged confinement are starting to have an effect and cannot be practical long-term.
Mental illness in prisons
In England and Wales, a recent report found that the Government does not know exactly how many people in prisons have a mental illness (NAO, 2017). As of March 2019, 9,734 people were recorded on mental health caseloads in prisons, although this figure does not reflect the actual number of people with a mental illness in prisons (House of Commons Justice Committee, 2019). This is indicated by a survey conducted by HM Inspectorate of Prisons that found 31,328 prisoners reported mental health or wellbeing issues (NAO, 2017). Managing this population presents many challenges due to the vulnerabilities and complex needs of these individuals and the enduring crisis within our prisons. Managing this population during a pandemic is even harder.
When restrictions were put in place to minimise the spread of the contagion, guidance on how to manage COVID-19 in healthcare settings was extensive. Healthcare professionals in criminal justice settings received tailored guidance on how to respond appropriately (RCPsych, 2020; HMPPS and NHS England, 2020), although it must be acknowledged that there are limits as to what clinicians can achieve in prisons (RCPsych, 2020b). Prison mental health teams have adapted their provision to offer the best service possible in the conditions, such as providing self-help materials, creating distraction packs, and introducing tele-medicine and virtual appointments to enable remote working (RCPsych, 2020b; Kothari et al, 2020). Mental health clinicians from different backgrounds are performing multiple functions to enable a service to operate (Kothari et al, 2020). COVID-19 is bringing about radical changes to the ways in which prison mental health services are working, and some of them could yield positive outcomes should the prison service continue to embrace technology (Kennedy et al., 2020). However, the level of service being provided is dramatically reduced, with clinicians having to prioritise those identified and assessed as most in need (Kothari et al, 2020).
Increasing demands on staff
Another factor to consider is the increase of demands on prison and clinical staff during the COVID-19 pandemic. Mental health service delivery has been greatly impacted, with mental health staff often feeling inexperienced, ill-prepared and poorly supported to manage the COVID-19 pandemic (Tracy, Tarn and Greenberg, 2020). As of 31 May 2020, across 105 prisons, 923 prison staff tested positive for COVID-19 (The Guardian, 2020). The figures relating specifically to health staff in prison have not been published, however this figure demonstrates the scale of the issue. Staff absences compromise service delivery in any situation; the challenges a pandemic brings adds an additional layer of complexity to managing the needs of a high-risk and vulnerable population. Staff members are exposed to situations they feel outweigh their skills, training and experience, leading to psychological distress (Kothari et al, 2020). Furthermore, staff have anxieties about social distancing in such challenging environments, the availability of PPE, their own health and that of their loved ones, and how to provide support to patients requiring immediate mental health support (Kothari et al, 2020). Coping skills training, encouraging social bonds between colleagues and supervisors, and debriefing, may foster resilience and protect mental health among staff members (Greenberg and Tracy, 2020).
The COVID-19 outbreak in prisons has the potential to overwhelm prison health services and place additional demands on community services (Kinner et al., 2020). The situation is ever-changing, and the challenges will evolve as the pandemic continues (Kennedy et al, 2020).
It is important to note that the measures are in place to protect lives by containing the spread, however it is now apparent that they are also placing prisoners and staff at risk (The Justice Gap, 2020). More needs to be done, such as reducing capacity and effective coordination between services, to ease the pressures on the system and to protect lives.
GOV.UK (2020) Prison population figures: 2020. Available at: https://www.gov.uk/government/statistics/prison-population-figures-2020.
Greenberg, N. and Tracy, D. (2020) ‘What healthcare leaders need to do to protect the psychological well- being of frontline staff in the COVID-19 pandemic’, BMJ Leader Month, 0(0). doi: 10.1136/leader-2020-000273.
HM Inspectorate of Prisons (2020) Young offender institutions holding children. Available at: https://www.justiceinspectorates.gov.uk/hmiprisons/inspections/young-offender-institutions/.
HMPPS and NHS England (2020) Prison transfers and remissions to and from mental health inpatient hospitals in relation to COVID-19. Available at: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0338-MH-transfers-remissions-protocol-and-guidance-final.pdf.
House of Commons Justice Committee (2019) Prison Governance. Available at: https://publications.parliament.uk/pa/cm201919/cmselect/cmjust/191/19105.htm.
Independent Advisory Panel of Deaths in Custody (2020) “Keep talking, stay safe”: A rapid review of prisoners’ experience under Covid-19. Available at: https://www.iapondeathsincustody.org/.
Kennedy, H. G. et al. (2020) ‘Forensic Psychiatry and Covid-19: Accelerating Transformation in Forensic Psychiatry’, Irish Journal of Psychological Medicine. doi: 10.1017/ipm.2020.58.
Kinner, S. A. et al. (2020) ‘Prisons and custodial settings are part of a comprehensive response to COVID-19’, The Lancet Public Health, 5, pp. e188–e189. doi: 10.1016/S2468-2667(20)30058-X.
Kothari, R. et al. (2020) ‘COVID-19 and prisons: Providing mental health care for people in prison, minimising moral injury and psychological distress in mental health staff’, Medicine, Science and the Law. SAGE Publications: London. doi: 10.1177/0025802420929799.
National Audit Office (2017) Mental health in prisons. Available at: https://www.nao.org.uk/report/mental-health-in-prisons/
Royal College of Psychiatrists (2020) COVID-19 – Secure hospital and criminal justice settings, Royal College of Psychiatrists. Available at: https://www.rcpsych.ac.uk/about-us/responding-to-covid-19/responding-to-covid-19-guidance-for-clinicians/community-and-inpatient-services/secure-hospital-and-criminal-justice-settings.
Royal College of Psychiatrists (2020b) Quality Network for Prison Mental Health Services (QNPMHS) Webinar #1 – 9 April 2020 – YouTube. Available at: https://www.youtube.com/watch?v=5gh5cbdFUjg&t=849s.
The Guardian (2020) The coronavirus crisis in Britain’s prisons. Available at: https://www.theguardian.com/news/audio/2020/jun/01/coronavirus-crisis-in-britain-prisons-podcast.
The Justice Gap (2020) Five suicides in six days at prisons in England and Wales – The Justice Gap. Available at: https://www.thejusticegap.com/five-suicides-in-six-days-at-prisons-in-england-and-wales/.
Tracy, D., Tarn. M., Greenberg, N. (2020) ‘From moral injury to mental illness: we must protect the wellbeing of frontline covid-19 staff’, The BMJ Opinion. Available at: https://blogs.bmj.com/bmj/2020/04/30/from-moral-injury-to-mental-illness-we-must-protect-the-wellbeing-of-frontline-covid-19-staff/
Please note: Blog entries reflect the personal views of contributors and are not moderated or edited before publication. However, we may make subsequent amendments to correct errors or inaccuracies.