Legal and human rights issues in the use of electronic monitoring (using GPS 'tracking' technology) in forensic mental health settings in the UK.

Electronic monitoring (EM) of individuals has been used by the criminal justice system for the past thirty years, and in the UK, use is on the increase. Its use has been justified as an alternative to prison to reduce recidivism and allowing early release of prisoners, however, the evidence base for this remains mixed. In 2010, it was employed for the first time in a forensic psychiatry setting. A study investigating the effects of EM on leave episodes concluded that EM may improve the speed of patient progress and reduce the length of admission, leading to reduced costs and increased public safety. However, the intervention generated considerable controversy and sparked discussion about ethical concerns. Here, we consider specifically legal and human rights issues that emerge from use of EM in forensic healthcare settings, scrutinising its use in the context of the Mental Health Act and the Human Rights Act. We conclude that EM is legal and justifiable, providing it is used judiciously and with due consideration of concerns for the individual and the given context.

Liaison and diversion services in South East London: Referral patterns over a 25-year period.

Criminal justice liaison and diversion services identify people with mental health needs and ensure they receive appropriate support. We describe a 25-year period of one such service that deals with a population of 864,540 in South East London that was set up in 1991. We used data from three time periods. A diagnosis of a mental illness was recorded in 70.0-80.3% of court liaison and diversion referrals. The proportion receiving a hospital order declined from 15.4% in 1991/1992 to 1.1% in 2015/2016; 54/199 (27.1%) of referrals to the police liaison and diversion service were detained in hospital. Although the service is designed to support any individual with a mental health issue, these results suggest that it has dealt mainly with people who have severe mental illness. Further research is required to understand how best to benefit a wider range of people with mental health issues who attend the lower (Magistrates') courts, and whether screening for mental disorders can be applied in liaison and diversion settings to aid the implementation of national policy. We also need to understand how disposal decisions are made, and which are most effective.

The mental health of foreign national prisoners.

Foreign national prisoners include people who are subject to criminal proceedings and have been deprived of their liberty in a state in which they are neither a national nor a resident. In the United Kingdom, they constitute approximately 10,000 individuals and represent around 12% of the total prison population. Significant health disparity exists within the general prison population compared to society at large and foreign national prisoners suffer even higher rates of both physical and mental health disorders. The impact of detention; extradition, deportation and administrative removal legislation; and mental health service provision for foreign national prisoners is discussed. The right to health encompasses access to appropriate healthcare independent of legal status and like all human rights, extends to foreign national prisoners. Change is required and the provision of equivalent care for foreign national prisoners requires global attention.

A gilded cage is still a cage: Cheshire West widens 'deprivation of liberty'.

The Supreme Court's recent judgment in Cheshire West has clarified, and broadened, the legal definition of deprivation of liberty, with the new definition reflecting the fact that human rights apply to everyone in the same way. The widely criticised Deprivation of Liberty Safeguards need to be replaced: recommendations for reform are set out.

Mental health care for foreign national prisoners in England and Wales.

BACKGROUND: The foreign national prisoner (FNP) population in England and Wales has disproportionately increased in size, but mental health research in this group has been limited. AIMS: Define the FNP group, review their understood characteristics, identify service challenges and make onward recommendations. METHODS: A literature search of Pubmed and Google Scholar was undertaken. Relevant articles/reports were identified and reviewed. RESULTS: Many FNPs face challenges: isolation (with limited family contacts); language barriers; difficulties accessing services; prejudice and discrimination; active legal issues regarding immigration. These are compounded by poor quality interpreting services, institutional barriers including racial assumptions propagated by forces of legislation, the disrupted local care pathways and common mental health problems (including post-traumatic stress disorder, depression and anxiety). Pre-detention trauma, self-harm and suicide are over-represented. CONCLUSIONS: Further prevalence and unmet needs research is urgently required. A validated screening tool could assist identification and service access for FNPs with mental health problems. Services providing relatively inexpensive interventions specific to the needs of FNPs (e.g. narrative exposure therapy) should be piloted.

Mental health in-reach in an urban UK remand prison.

PURPOSE: Prison mental health in-reach teams (MHITs) have developed in England and Wales over the last decade. Services have been nationally reviewed, but detailed descriptions of their work have been scarce. The purpose of this paper is to describe the functions of one MHIT in a busy, ethnically diverse, male remand prison in London, UK. DESIGN/METHODOLOGY/APPROACH: Clinical and demographic data were collected for prisoners referred to the MHIT using a retrospective design over an 18-week period in 2008/2009 (n=111). FINDINGS: Foreign national prisoners and sentenced prisoners were significantly under-referred. Most referrals were already known to community mental health services, although around a quarter accessed services for the first time in prison. Around a third presented with self-harm/suicide risks. Substance misuse problems were common. Although the MHIT had evolved systems to promote service access, prisoner self-referrals were limited. PRACTICAL IMPLICATIONS: Foreign national prisoners require enhanced investment to improve service access. MHITs identify people with mental disorders for the first time in prisons, but better screening arrangements are needed across systems. An evaluation of multiple MHIT models could inform a wider delivery template. Originality/value - One of the first ground-level evaluations of MHITs in England and Wales.

Influencing the care pathway for prisoners with acute mental illness.

BACKGROUND: Despite improved mental health services in prisons in England and Wales, there are often delays in transferring acutely mentally ill prisoners to hospital, particularly in the London area. AIM: To establish whether clinical pathway interventions can reduce such transfer delays. METHODS: Two clinical pathway interventions - one based in a medium secure forensic hospital and the other in a remand prison (pre-trial/sentence) - were independently introduced to manage referrals of prisoners with acute mental illness in London, UK. Time taken to transfer to hospital was measured for each and compared with the best available estimates for time to transfer prior to the new pathways. RESULTS: Both interventions produced significant reductions in prison to hospital transfer times. CONCLUSIONS/IMPLICATIONS FOR PRACTISE: The nature of the projects precluded ideal research design, but despite small sample sizes, provision of modestly funded small but dedicated elements of service to target the specified problem of transfer to hospital delays showed a significant advantage for such provision, whether hospital or prison based, psychiatrist or nurse led. Further research is now required to examine the whole pathway. More secure psychiatric beds may be required, at least in the short term, to support diversion policies and enable compliance with national policy directive, and to establish whether redesigned pathways can enhance treatment and behavioural outcomes for acutely mentally ill prisoners on a larger scale.

Variations in prison mental health services in England and Wales.

In responding to high levels of psychiatric morbidity amongst prisoners and recognising earlier poor quality prison mental health care, prison mental health in-reach teams have been established in England and Wales over the last decade. They are mostly provided by the National Health Service (NHS), which provides the majority of UK healthcare services. Over the same period, the prison population has grown to record levels, such that prisons in England and Wales now contain almost 90,000 of the world's overall prison population of over 10 million people (roughly the size of Paris or Istanbul). This study provides an overview of mental health in-reach services in prisons in England and Wales, including variations between them, through a telephone survey of senior staff in all prisons and young offender institutions in England and Wales. 73% of prisons took part; of them 13% had no in-reach team at all (usually low security establishments) and the majority of services were run by NHS teams, usually according to a generic community mental health team (CMHT) model rather than other specialist models. Team size was unrelated to prison size. Each nurse covered around 500 prisoners, each doctor over 3700. Many provided few or no healthcare cells and 24-h psychiatric cover (including on-call cover) was uncommon. Despite developments in recent years, mental health in-reach services still fall short of community equivalence and there is wide variation in service arrangements that cannot be explained by prison size or function. The aim of community equivalence has not yet been reached in prison healthcare and a more sophisticated measure of service improvement and standardisation would now be useful to drive and monitor future development.

Asserting prisoners' right to health: progressing beyond equivalence.

The concept of the "right to health," regardless of a person's legal status, is a guiding force in establishing adequate standards of health care for all, including prisoners with mental illness. Prison health care in the United States, however, often falls below acceptable minimum standards. In the United Kingdom, the notion of equivalence has been the main driving force in improving prison mental health care. Although improvements have been made over the past ten years, demand for services continues to outstrip supply, as in the U.S. prison system. In both prison systems, prisoners often present with complex and multiple needs, much greater than those found in community samples. Even mental health care equivalent to that provided in the community falls significantly short of what is required. Further improvements to prison health care, therefore, remain a priority, and a more suitable model needs to be established and implemented. The authors propose an assertive application of a person's right to health with a well-defined framework for health care that is available, accessible, acceptable, and of good quality (AAAQ). The authors explore how the AAAQ framework can move beyond minimal or equivalent standards to deal with complex prison structures, meet health care needs, and measure progress more effectively. The AAAQ framework could lead to more equitable standards of health care that can be applied to international settings.

Commentary: UK perspective on competency to stand trial.

This commentary offers a perspective from another common law jurisdiction, specifically the law in England and Wales, where competency to stand trial on a criminal charge is known as fitness to plead. The commentary begins with a discussion on the principle of proportionality evident in health care decisions by way of comparison with the topic in the criminal arena. Fitness to plead is an historical legal concept and employs an intellectual test that has evolved very little since its appearance in case law. There have been amendments, through statute, to its procedure and outcomes following a determination of being unfit to plead. However, competency to stand trial in England and Wales remains a more marginal issue than in the United States. Recent developments in domestic and European jurisprudence have been related to consideration of the requirements for a fair trial, driven by the demands of the European Convention on Human Rights.