STRESS-testing clinical activity and outcomes for a combined prison in-reach and court liaison service: a 3-year observational study of 6177 consecutive male remands

Prisons have been described as representing a ‘rare public health opportunity’ for identifying and managing major mental illness in young men [1] and can provide a focal point for arranging diversion to healthcare [2]. In a review of research on the mental health of prisoners, including a number of meta-analyses, Fazel et al. [3] identified the need for longitudinal studies of mental health in prisoners. There remains a need to determine and define the variables measuring the effectiveness of prison mental health services. Further, there is limited research describing sustainable clinical pathways over extended periods for persons receiving mental health care in prisons.

Cross-sectional prevalence rates of psychotic illness in prison populations have been estimated at ten times the community rate [4, 5]. Fazel and Seewald found a pooled prevalence of psychotic illness (including psychosis, schizophreniform disorders and manic episodes) of 3.6 % in a systematic review and meta-analysis of studies involving 33,588 prisoners from 24 countries [6]. Still higher rates have been found in studies of male remands in Ireland [7] and England and Wales [8]. Curtin et al. [9] found 3.8 % (95 % CI 2.2–6.6 %) of a series of 313 male remands in Ireland had a current diagnosis of psychotic disorder (including schizophrenia, psychotic mood disorders, substance-induced psychosis and other organic psychoses).

Pakes and Winstone audited areas of practice in 101 prison mental health services across England [10]. They noted that while screening and mental health assessment was mainly performed adequately, proactive screening was sporadic and services were often unstructured. In particular they reported a lack of coherence in the way data was collected in different sites. Pillai et al. [11], showed that the introduction of a formalised model of care was followed by an increase in the proportion of referrals taken onto clinical caseloads in remand and sentenced settings over a six-year period (2010–2015).

The Bradley Report [12] echoed the Reed Report of 1992 [13] in recommending improved coordination and integration of prison mental health care and diversion services. Quality standards have now been developed as part of a quality network for prison mental health services to support improve and standardise prison mental health services in a measureable way [14]. These standards provide for qualitative comparisons but do not in their current iteration provide for quantitative measurement and comparison of specific outcomes.

Coid and Ullrich [5] have stated that psychiatric services “fail to identify psychotic prisoners and provide after care (pg 99)” and suggested that “proposals to divert more offenders with severe mental illness to mental health services … may currently be unfeasible (pg 107)” due to difficulties in identification, limited resources and the need for the public to be reassured that diversion is risk-appropriate, with diversion of high-risk patients to more secure settings.

Stress testing refers to a deliberate process to determine the stability of a given system or entity. The approach is used in a range of settings including financial systems, information technology and engineering to confirm that intended specifications are being met and to help determine modes of failure [15, 16]. An effectively functioning prison mental health in-reach service should be able to ‘count in and count out’ those using the service, identifying those with the most severe acute symptoms and arrange transfer of care at the point of exit. The service should also allocate patients to the appropriate level of care according to their assessed need (Flynn et al. [23]). This is particularly important for remand settings where a rapid turnover of prisoners can risk individuals with major mental illness being lost to follow up. Inability to achieve or effectively measure such outcomes may reflect a service under stress, and may help advise resource requirements or system recalibration. In prison settings, the greatest turnover is in remand settings, where higher rates of mental illness have been identified [6‐9]. For patients subsequently transferred to sentenced prisons, much of the work of comprehensive assessment including taking histories, collateral gathering and care-planning will be completed in remand settings.

Our research group has previously described a combined prison in-reach, court diversion and liaison scheme in Ireland’s main remand prison which identified the presence of active psychotic symptoms following committal among 20,084 consecutive male remands at rates in keeping with epidemiologically predicted rates, and diverted 572 cases from prison to healthcare over a 6 year period from 2006 to 2011 [17]. Limitations of that study included failure to present a number of key outcome measures, including time to achieve assessment and risk-appropriateness of diversions to different levels of security. We undertook to address these limitations in further research with an approach structured to enable intra-service comparison over time, comparison with similar services and with existing epidemiological evidence.

The aim of this study was to describe the longitudinal activity of a psychiatric in-reach, court liaison and diversion service in a male-only remand prison over a 3 year period, using quantitative routine outcome measures of service outcomes. It was intended that the routine outcome measures used would enable comparisons of service activity over time for our service and act as a basis for comparison with activity and outcomes of similar services elsewhere.

The format we used is divided into six domains: screening, identification and description of service caseload, transfer of care, risk-appropriateness of diversions, efficiency, self-harming behaviours and service mapping. These domains are summarised by the acronym STRESS-Testing. The domains and associated aims of the study are laid out in Table 1, below.

We have shown that data can be routinely collected as part of our service’s normal clinical governance and that this data yields service evaluation. We have adopted a stress-testing model of evaluation and formulated this according to the acronym “STRESS-Testing”. The proportion of remands nationally committed to Cloverhill remained similar over time, at approximately 60 %. The proportion of remands taken onto the PICLS caseload following two-stage screening and referral increased marginally over the two time periods from 16 to 18 % of all remands. Absolute numbers diverted per annum increased between the two time periods. We have shown that year on year the service was able to achieve the intended health gains. At present levels of service resource and population demand, diversions to mental health services were in keeping with epidemiological expectations [9] for rates of active psychosis. The matching of numbers with psychosis detected by systematic screening and numbers diverted may represent a measure of effectiveness while the confidence intervals for these numbers may represent an estimate of capacity. Should demand rise beyond the limits of the confidence intervals described, evidence of service stress might include longer delays before diversion or emerging evidence of cases missed.

The service does not exclude minor mental illnesses or those with substance misuse problems who constituted the great majority of the caseload. The service does regard the ability to identify those with the most severe conditions as its key role. We use the presence or absence of psychotic symptoms as a key measure. This has the advantage of being definable in terms of presence or absence, rather than degree. The proportion of remands to Cloverhill identified as having active psychotic symptoms was higher for the more recent period. Both proportions were within the confidence limits found in the previous study by Curtin et al. which used research diagnostic criteria for diagnosis of an epidemiologically representative sample [9]. This was reassuring in that previous research has found that routine clinical services tended to under-identify severe mental illness among prisoners [26, 27] leading to failure to arrange transfer of care and diversion [2, 28].

The proportion of persons identified as homeless was greater for the later period than for the earlier period. This represents a psychosocial stressor from society at large impacting on patients in the community and in prisons. The addition of a housing support worker represents a service response to this stressor.

Coid and Ulrich [5] predicted that increased prioritisation of psychotic prisoners would have resourcing implications for local and secure psychiatric services, particularly were there to be evidence of increased prevalence rates of psychosis in prisons. Like Fazel and colleagues [3], they identified the need for longitudinal data.

Chow and Priebe [29] described a general reduction in inpatient beds across Western Europe between 1990 and 2012, while forensic beds and prison populations increased. In Ireland they demonstrated that while prison beds increased and general beds reduced between 1990 and 2012, forensic bed numbers per 100,000 inhabitants remained static over the period 2004–2011 at around 2 per 100,000, considerably less than most other developed countries in Western Europe. These represent likely sources of service stress. It may be helpful for similar research to include comparisons of the longitudinal prison in-reach data such as presented in this paper with admission rates to forensic and general psychiatric hospitals and committal rates to prison which in this paper were derived from annual reports of the Irish Prison Service [30‐32]. It is beyond the scope of this paper to test such relationships, which may provide information about sources of stress on prison mental health in-reach services.

Coid and Ulrich [5] also described the need to maintain public confidence in diversion arrangements. We have not presented data regarding recidivism in a paper based on routine mental health data collection. DUNDRUM toolkit scores indicated that patients were diverted to appropriate levels of care based on validated measures of need for therapeutic security and urgency of need. DUNDRUM toolkit scores differentiated between forensic, general and outpatient diversions..

Regarding efficiency, a majority of patients taken onto the caseload were formally assessed after screening within 2 days of committal. The rates of case-management per team member and times to assessment and transfer of care provide a basis for comparison with other services.

Hawton and colleagues [33] have described the largest study of self-harming rates in prison settings. They found predicted rates of 5 % self-harming per remand committal episode, albeit with considerable differences between areas and evidence of clustering in time and location. The rates found for this sample were relatively low. Elements of service structure may have been protective. These included transfer of those identified on or following committal as at-risk to the high support unit on D2 wing, mainly in shared accommodation.

We have described arrangements for transfer of care for our sample and mapped these arrangements with the time taken to achieve outcomes. The ability to ‘count in and count out’ is important for any system to operate safely and measurably, including airline checklists and surgical systems [34, 35].