Prison Mental Health Care in England: A Guide for Health and Care Staff

Prisons hold some of the most vulnerable people in the country, and many of them have mental health needs that began, or went untreated, long before they were sentenced. Health and care staff meet these needs in prisons, but also before custody, after release and when someone is transferred to hospital. This guide summarises what the best recent evidence says about mental health in prisons in England and what it means for staff. It draws on a report from the Centre for Mental Health, commissioned by NHS England, published in 2023 on a survey carried out in summer 2021.

How common are mental health problems in prison?

The Centre for Mental Health report's executive summary states that nine out of ten prisoners have at least one mental health or substance misuse problem. It notes that this figure echoes the landmark 1998 survey by Singleton and colleagues, which found that 90% of the custodial population had at least one mental health or related problem. The report also points to the 2007 Inreach Review Team estimate that at least 23% of prisoners would meet the criteria for secondary mental health care. Because the evidence is old, the report's sixth recommendation is a robust new prevalence study.

What mental health teams are seeing

For people on prison mental health caseloads, the report found the most common recorded diagnoses were anxiety or depression (29.0%), psychosis (21.9%), personality disorder (17.3%), ADHD (8.9%) and PTSD or trauma (8.0%). Neurodiverse needs were recognised in 17.4% of the caseload, though the report notes that research suggests the true figure is much higher. Our guide to psychosis and schizophrenia is relevant here, as is the overlap with substance misuse.

Risk factors on caseloads

The same survey found that 54.0% of people on the caseload had a history of self-harm, 40.0% had a history of attempted suicide, and 39.0% had a dual diagnosis of mental health and substance misuse problems. Thirteen percent of the caseload was on an ACCT, the prison's suicide and self-harm risk process. These figures show why self-harm and suicide risk are central to prison healthcare; our guide to suicide and self-harm awareness covers the foundations.

How services are organised

The report describes an integrated mental health team model that provides tiered care from primary to secondary level. It found a lot of variation: prisons typically had two or three providers, sometimes up to eight, and about 40 different caseload labels were in use across prisons. Interventions offered most often were talking therapy (21.6%), assessment (16.7%), medication (13.4%) and psychiatry consultation (11.1%). The report also lists gaps in support for speech and communication difficulties, acquired brain injury and neurodiversity, with regional differences in the availability of psychiatrists, nurses and therapists.

Transfers to hospital under the Mental Health Act

People who are seriously unwell in prison may need to be transferred to hospital under the Mental Health Act. The report cites a proposed 28-day standard from referral through assessment to transfer. In the 12 months before the survey, it found 919 assessment applications across England and 704 successful transfers, a 76.6% success rate. Among people waiting at the time of the survey, 23.5% had waited more than 28 days, and the range of delays extended from two days to more than a year beyond that limit. After transfer, any leave from hospital is governed by section 17 of the Act.

Release and resettlement

The report found that 27.3% of the caseload was due for release within 12 months. Release is a high-risk time: support with housing, benefits, employment and ongoing treatment can be lost. The report recommends resettlement support, along with better screening at reception and on the first night, strictly enforced 28-day transfers, improved data sharing between systems, action on regional staffing gaps and a new prevalence study.

What this means for health and care staff

• Ask about custody. Someone recently released may have untreated mental health needs, medicines gaps and no stable address. Check what continuity of care has been arranged.
• Share information safely. Health and care providers, probation and housing services need to work together. Public protection arrangements may apply, as explained in our guide to MAPPA.
• Notice neurodiversity and brain injury. The report highlights both as under-recognised in prisons; screening and reasonable adjustments help.
• Take self-harm seriously. A history of self-harm is common, and release is a vulnerable moment.
• Do not treat prison status as a reason for lower standards. Equivalence of care means people in custody should receive care comparable to what they would get in the community.

A note on the evidence

These percentages come from a survey of mental health teams in 2021, not a general population study, and they describe people on caseloads rather than all prisoners. Services have changed since, so treat the figures as a guide and check current data from NHS England and the Centre for Mental Health.

Frequently asked questions

Are mental health services in prison the same everywhere? No. The report found major variation in providers, caseload definitions and staffing.

Where can staff train? Learnsignal's CPD courses for health and care staff cover mental health, risk and the law.