Official Report: Minutes of Evidence

The Chairperson (Ms Bunting): I welcome Professor Andrew Forrester from Cardiff University. Hello, Andrew.

Professor Andrew Forrester (Cardiff University): Hello. It is nice to see you.

The Chairperson (Ms Bunting): You too. It is good that you can see and hear us. Andrew will give us a briefing on mental health and the criminal justice system, and then we will take some questions from members.

At this stage, we have not coordinated our questioning, so I will hand over to you to give us all the information that you intend to give us, and then we will take questions. I apologise that we have kept you waiting, but we had some housekeeping that we needed to work through. Apologies for that, and thank you for your patience.

Professor Forrester: That is OK. Thank you for asking me to come here today to give evidence. I want to start with a brief presentation of perhaps five to 10 minutes in which I will talk about the international context and what we know about mental health in prisons. I will focus mainly on prisons today, but we can also talk about courts and police custody.

We know that the world prison population is probably in the order of over 11 million people. That has gone up by about 25% since 2000. The prison population is growing pretty much across the world. There are huge rises in some areas, such as Oceania and parts of Latin America, where there have been increases of over 100% in some countries. There have been some reductions in the prison population in parts of Europe, mainly in eastern Europe and in the Russian Federation, but, across the world, the story is one of increases.

A number of international problems arise across jurisdictions, one of which is overcrowding. The most recent look at overcrowding internationally was done by Penal Reform International. It found that 120 countries in the world had reported at some point more than 100% capacity in their prisons, meaning that, whatever their capacity, more than 100% of the places in the prisons were full. Another international problem is pretrial detention. Something like 14 million people are said to be held in pretrial detention per annum. That is more than the overall prison population because of the churn in prisons, but it means that people are held on remand for excessive periods before they come to trial. Governance and staffing are huge international problems — that means staff recruitment and retention — as is the over-representation of ethnic and religious minority groups, indigenous people across the world and foreign national groups in prisons.

There are lots of other international issues that are worth a brief mention. Violence in prisons is endemic in many countries. There are problems with the basics, like poor nutrition, ventilation, water and things like that. Torture happens in some states, and, of course, the death penalty is present in some states. We know quite a lot about mental health morbidity amongst people who are in prison. We know less about people who are in courts or police custody, but it is safe to say that levels are high across the board in the criminal justice system. I will drill into that briefly for a minute.

When we talk about psychosis — I mean schizophrenia, for example, and other psychotic illnesses — those are said to have a prevalence of about 3·6% among men and 3·9% among women. That compares with a community prevalence of approximately 1%. Depression occurs in about 10% of male prisoners and 14% of female prisoners. Intellectual disability, meaning a learning disability, occurs in about 1% of prisoners. In the literature, the screened prevalence of attention deficit hyperactivity disorder (ADHD) is 25% or thereabouts. Post-traumatic stress disorder (PTSD) arising from serious traumatic stress in life is said to be present in 7·7% of male prisoners and complex post-traumatic stress disorder (CPTSD) in about 17% of male prisoners and perhaps in 21% of female prisoners. Finally on mental health, the latest estimate for personality disorder (PD) was of the order of 65% amongst prisoners, so a majority of prisoners are said to have personality disorder.

I will not say too much more, but I will take a minute to talk about vulnerable groups. There are well-recognised vulnerable groups among people in the criminal justice system. There are people with neurodevelopmental conditions, which includes people with autism spectrum disorder (ASD) who often struggle in prison environments and in institutional environments generally, people with ADHD and people with learning disability. Cognitive impairment is said to be present in perhaps 8% of prisoners, and dementia in maybe something like 2% to 3%. We are not entirely sure about that, but those are the sorts of figures that are likely. Something like 60% of prisoners report a history of brain injury, and, of those, up to 17% have a history of moderate to severe brain injury.

We know that, in vulnerable groups, foreign national prisoners tend to under-access mental health services in prisons. That is probably because of a language barrier but also because of mistrust of the state in which they are imprisoned. Finally, across the world, indigenous people are over-represented in mental health issues and substance and alcohol misuse.

The last thing that I will say is that, in putting services together in prisons, there has been an international consensus around following the principle of equivalence. That means that, if services exist in the community, it is thought that they should exist in prisons in the same way. In other words, prisoners are entitled to the same range and quality of services as they would have if they were in the community. It is important to say that that is sometimes misunderstood as, "if they were in hospital", but that is not the test of equivalence; it is about whether they are receiving the same service as they would, if they were in the community.

I will stop there and see what questions you have.

The Chairperson (Ms Bunting): Thank you very much, Andrew. That has been really interesting thus, and I look forward to pursuing the discussion. Does anybody have any questions?

Mr Beattie: Thank you, Andrew. You might not be able to answer this question, but, when you look at the prisoners and their mental health, do you look at the effect that it has on the staff who have been employed to look after them but are not necessarily trained for a mental health role? You could look at prison officers in Northern Ireland, who are not trained but have a high prevalence of inmates with mental health issues. Do we know what effect that has on the prison staff?

Professor Forrester: There is limited information about that, but we know some things. We know that it is incredibly difficult to deal with people when you feel that you are out of your depth and do not have the expertise to manage a mental health situation. We know that people can, over time, be traumatised by it and that there tends to be an institutional response to mental health. The bottom line is that, really, we are expecting prison staff to do a job that they are not trained to do because prisons are increasingly full of people with mental health conditions. That is an issue not just in Northern Ireland; it is an international issue. It seems only fair that we provide staff with appropriate training before they end up in situations where they are uncertain how to proceed. It is an issue. People do their best in what are often difficult circumstances, and people are sometimes traumatised by what they find and are not sure how to manage it.

Mr Beattie: Can that have a knock-on effect on the prison staff's mental health? Is anybody taking the time to monitor that? You have given some really stark statistics, but I wonder if those statistics show in the staff.

Professor Forrester: There has been qualitative research looking at prison officers and their responses. Basically, what I just said is that in a nutshell. Looking at their mental health over time and perhaps thinking about ways to improve it is in development, and I cannot easily talk to that. There might be papers out there that I am not aware of, but we have a long way to go with prison officer training and making sure that they have the knowledge that they need to do the job.

Mr Beattie: Thank you.

Mr McNulty: Thank you, Chair, and thank you, Andrew, for the interesting presentation and discussion so far. What information do you have relating specifically to the North of Ireland?

Professor Forrester: In the North of Ireland, I was part of a review with the Regulation and Quality Improvement Authority (RQIA). In 2021, we looked at prisons in Northern Ireland and found that many committed people were doing great jobs in difficult circumstances, for sure. We also found that on the whole, it was probable that mental health services, substance misuse services and psychology services in prisons were under-provided. We recommended that there be some needs assessment and some benchmarking so that we could work out what the needs were and provide accordingly. It is some years since that review. It was done during the pandemic, and I am not the person who can tell you what has happened since then, but that is where we were at the point of the review.

Some other things were concerning, one of which was that people were waiting a long time to be seen by mental health services. The standards for being seen by mental health services are in the RQIA report. I cannot tell you those off the top of my head, but people were waiting for something like five days for an urgent assessment, as opposed to the standard of two days elsewhere. The standards needed to be reviewed, and people needed to be seen earlier than they were being seen.

Another difficulty was waiting times for transfer to hospital when people had acute mental health problems. It would be unfair to say that those problems exist only in Northern Ireland; they certainly do not. They are UK-wide problems and are probably international problems; nonetheless, they were also happening in Northern Ireland at the time that we did that report.

A final thing to say is that, unfortunately, some people with mental health problems, including those with acute mental health problems, were being held in care and separation units. That is unfortunate, because those are not healthcare units, and people were being held there in the absence of a suitable alternative, with the suitable alternative being transfer to hospital in a timely manner. I hope that that answers your question.

Mr McNulty: Yes. That was very informative, Andrew. Thank you very much for your evidence.

Miss Hargey: Thanks very much, Andrew. You might have answered this in part. The over-representation of certain groups in prison systems globally is reflected here throughout the justice system more broadly. Is there any best practice on how to prevent that and tackle it at the front end, rather than dealing with it when people get to prison, by lensing the work on intervention and prevention with the people in those groups, be they from a working-class or ethnic minority background or one of the other groups that are over-represented in the system?

There have been investigations and coroners' inquiries into the deaths of people with vulnerabilities, addiction issues and mental health conditions. The Department says that a person-centred delivery model has been established over the last number of years. Again, is there best practice on what a bespoke needs assessment would or should include for each prisoner?

Professor Forrester: Thank you very much. I will try to answer that. There are some models that are useful to look at when thinking about prevention and what might happen upstream. If we think about the point before people come into police custody, we find that other jurisdictions have liaison and diversion services. In the States, there are mental health court models. Those models are meant to divert people who might be vulnerable or have a mental health condition from custody. Those people have perhaps committed low-level crimes, so the idea is that those services are in place to divert them. Whether they do as they are meant to is an open question; the literature is not clear on that. The mental health court model in the States has a robust evidence base, but the liaison and diversion model has less of a robust evidence base on diversion. To be clear, what I mean by "diversion" is the diversion of people to hospital care, if they need it, or to community sentences, if, for example, some kind of mental health treatment is involved and is required.

There are also liaison and diversion models a bit earlier in the criminal justice pathway, if we can call it that, into police custody. In other words, that is about identifying and screening people in police custody. There is good evidence on the effectiveness of screening in police custody as early as possible when people come into the criminal justice system. Uptake of proper clinical screening, which is an international issue, has been poor UK-wide. It is a work in progress to get that to happen. A group in Newcastle has been working on that for some time and continues to advocate proper health screening in policy custody.

Before that, there is street triage. That is a way in which the police sometimes come together with healthcare workers — for example, community psychiatric nurses (CPNs), psychiatrists and maybe GPs — to intervene before people even get to police custody. That model has been trialled. Again, there are arguments that it is useful, and there are arguments against it. Nonetheless, it is a model that is there.

On your wider question about prevention and vulnerable groups, those questions are not really for psychiatry but for society. What things promote good mental health? They include a lack of poverty, education, inclusion in society, not being homeless and the avoidance of drug use. That is a really wide question that is probably beyond my remit to answer today. It goes to the nature of the society that we have and how it is put together. Perhaps there are ways of including so-called vulnerable and marginalised groups earlier in developmental and preventive work. There is an argument for research in that area, including trialling specific methods, for example, to see what might be useful.

Miss Hargey: Is poverty a key driver for a number of those in over-represented groups?

Professor Forrester: For sure. Poverty is a key driver of poor mental health. Absolutely.

Your final question was about how we do an assessment of need and what should be included in that. There a number of ways of doing that. There are well-established methods of doing that in other parts of the UK, or research methods could be used. There are ways of using research diagnostic instruments to look at the prevalence of mental health conditions. One way might be useful for thinking about and planning services, if you want to do it in a service planning and delivery sort of way, perhaps if you are thinking about the money that should be available for services and what that should look like. In the prevalence data that I presented to you, I spoke about the rate of psychosis being 3·6% in men, for example, and a rate of nearly 17% of complex PTSD amongst male prisoners. Those figures all come from research prevalence studies. If you want to know the answer in the best way that we can know it, you have to look at people and you have to do prevalence studies like that to understand the percentages.

There is a lot of crossover diagnostically, so an individual prisoner might not have just one condition. I am no longer doing a prison clinic; I stopped it in May this year. When I was doing my prison clinic, it was common for me to see people who had three or four conditions. Maybe they had schizophrenia. They also had depression that came and went. Perhaps they had a history of ADHD, and then they had a history of heroin and cannabis dependence in the background too. You are dealing with often quite complicated and complex people and presentations.

Miss Hargey: On your point about trying to do some of that at the custody end of things, including trying to prevent and getting an early indication, is it your view that doing that earlier is better when trying to prevent people going into the prison system in the first place? Is there a reluctance to do that? Is it an issue of resourcing for the police or of access to health professionals? What do you find to be the reluctance in trying to do that work?

Professor Forrester: I will speak about England and Wales, because that is the jurisdiction that I am most familiar with. In England and Wales, there are liaison and diversion services in place. Those services work in courts and in police custody, and they are now said to be present 100% of the time, so there is 100% coverage of those services across those areas. The services are in place, and they see people in police custody when they are referred, but still we know that the gold standard should be to screen everybody using validated clinical screens when they come into police custody. We should do that because a lot of people who come into police custody have serious physical and mental health conditions, including diabetes, asthma and epilepsy. They may be alcohol-dependent, which, if not treated correctly, can have a mortality rate of up to 5% or even more. People come in with serious conditions that really need to be identified.

You asked me why those clinical screens have not been put in place. I do not think that I can answer that question. It has been a work in progress for years. It is still not as it should be, given what the research tells us, but here we are, years later, and we are still not doing the screening as probably we should. It is probably a mixture of trying to coordinate things nationally and the research evidence being widely known. It is partly something to do with computerised systems, and there are real practical issues about how you do it.

None of that, however, is an excuse for not doing what we should be doing.

Miss Hargey: Thank you.

Mr Bradley: Thank you, Andrew, for your presentation. You said that you deal mainly with situations in England and Wales, but, in Northern Ireland, we have a gross shortage of social housing. If prisoners have nowhere to go when they are released, they could end up back in the situation that led to prison in the first place. How does that impact on reoffending?

Professor Forrester: It is hugely problematic. The period after people come out of prison is a high-risk period. We know that there is an excess of mental health and physical health morbidity. We know that there is an excess of death in the period after people come out of prison. The lack of access to mental health and physical health services and so on contributes to all of that. If people have nowhere to live, it makes sense that that is a huge factor that is brought to bear on all of that. It is enormously important for people's stability and, likely, their onward mental health that they have a place to go when they come out of prison.

Ms Ferguson: Thank you, Andrew, for your presentation. When you gave an overview of what happens internationally, you mentioned governance as an issue, alongside staffing and over-representation. I am interested in hearing a bit more about governance.

Furthermore, you noted a range of mental health issues. One of the alarming ones for me is personality disorder. Did you say that 65% of prisoners have a personality disorder?

Professor Forrester: I will deal with those issues in turn. There are multiple models of governance in place across the world. Every state has a different idea about it. There are, however, some things that are important clinically. It is important to have mechanisms in place for the monitoring and management of people who are at risk of self-harm and suicide. Those things are vastly over-represented among people in prison. How that is managed in a governance sense is really important. The World Health Organization, for example, states that processes should be in place to manage that, that they should be well delineated and that they should have a clear mechanism of governance for managing them, but, if you look across the world, you will see that that is not the case in many states.

There are also issues internationally with recruitment and retention. This partly relates to the earlier question, but prison staff are thrown in at the deep end. They go into prisons with little knowledge of mental health conditions. Many of them are highly capable and do a difficult job in difficult circumstances, but they probably need more mental health training. That has a bearing on recruitment and retention.

Your second question was about PD. Yes, I did say 65%. It is an astounding figure. Of course, that is the literature-screened prevalence, so, if you screen on people, that is what comes out. Whether that is the same as a clinical diagnosis is a different matter, but, nonetheless, there is a broad understanding that the majority of prisoners have personality disorder.

Ms Ferguson: I will come back in on the governance issue. Doug mentioned the difficulties that prison officers have in trying to cope with the mental health issues that they have to deal with day-to-day. Owing to those circumstances and the difficulties with managing them, prison could exacerbate prisoners' mental health issues. Is there research available in that regard?

Professor Forrester: Yes. The research shows different things. Some research shows that people come into prison custody and their mental health is all over the place at the beginning, but, in time, it starts to stabilise. If we look at a cohort, we see that mental health improves over time in prison. That may be as a result of treatment for drugs or alcohol dependence or as a result of re-stabilising on medication that had not been taken in the community. On some occasions, it may be because they have seen a psychiatrist in prison, which is difficult to do in the community. That is not how it should be, but that is sometimes how it is.

My clinical experience is that prison can also harm mental health in many ways, and there is literature that tells us that. For example, there is prison violence, prison bullying, which is endemic, the use of drugs in prison, which is also endemic. Going into a care and separation unit for long periods can also harm mental health. Many things can be harmful to an individual's mental health in prison. The rates of self-harm and suicide are higher in prison than they are in the community. All those things are important. Does that answer your question?

Ms Ferguson: Yes. Thank you. Finally, from your research to date, is there anything different, good or bad, in the North from your experience of looking at prisons around the world? Does anything here stand out?

Professor Forrester: There are good examples of really committed people doing great work, such as the supporting people at risk evolution (SPAR Evo) system that looks at self-harm and suicide. I thought that that was excellent. The other thing that stood out for me is that clinicians on the ground are mostly in contact with and trying to learn from one another, and that was great. There are many difficulties as well, but those are some of the strengths.

Mr Dickson: Where in the world can we find best practice for dealing with mental health in prisons, and what does best practice look like?

Professor Forrester: That is a good question. We do not entirely know the answer to that question. We know some of it. The literature in the area is starting to cleave into different components. I will talk about prisons in particular. In prison, there is the screening, triage, assessment, intervention and reintegration (STAIR) model, which was put together by Professor Alexander — Sandy — Simpson in Toronto. Toronto is a good place to look for high-quality examples of best practice.

The STAIR model has screening at the beginning, and there is a good international evidence base that we should and must screen people when they come into prison custody. That definitely happens in Northern Ireland. Triage comes next. It is an administrative process in which people are moved into the different clinical pathways. For example, if they have diabetes, they are put on the diabetes pathway, or, if they have schizophrenia, they are put into the care of the mental health team. Assessment is the next part. For mental health, that means an in-depth assessment of people who have serious mental health conditions. About 15% of your population should receive a full, in-depth mental health assessment by a mental health team and a psychiatrist.

Intervention is next, and that means making sure that all the drug treatments, such as antidepressants and antipsychotics, that exist in the community also exist in the prison. It also means psychological therapies such as cognitive behavioural therapy for depression. When we did our report on Northern Ireland, there was certainly a deficit in the area of psychological treatments. There was also an under-provision of general mental health care in prisons. More of it was needed.

The final bit of the STAIR model is reintegration. The international literature tells us what that should probably look like. When people come out of prison, we know that it will be a difficult time for them, so we should engage with them before they come out and mentor them through the prison gates. It does not have to be a clinician who does that, but it is useful if somebody helps them with the process of coming out to the other side. We should then probably stay in touch with them for a period.

I do not know how long that period should be. It may be that it should be as long as three months, while they re-stabilise themselves on the other side. We have talked about accommodation and so on. That helps with things such as having mobile phone access, having general practitioner access and getting to hospital appointments. That last bit about reintegration is common sense in a way. Those are some things that we should do. The best place to look to for that as an example at the moment is probably Toronto.

The Chairperson (Ms Bunting): Thank you very much, Andrew. I have a couple of follow-up questions. The focus of our attention is on the extent to which the justice system picks up the demonstrable healthcare pressures. What are you seeing happening in other places? What activities are under way to redress that balance, particularly in places with budgetary difficulties?

Professor Forrester: The justice system almost certainly picks up pressures that are not being managed in the healthcare system, and there is literature to support that. That is because of changes in the way in which healthcare has been provided to deal with mental health in the community. Overall, it is probably about a winding-back of the services and about the way in which they work.

I am speaking mainly about England and Wales. I cannot easily speak to how services operate in Northern Ireland, but I can say that, in England and Wales, we have seen services operating in a gatekeeping capacity. By that, I mean that a referral will be made, but, if they do not engage a few times, a person may be discharged from the service. There is a problem with that, in that, if they have schizophrenia, a person may not have insight into their condition. Perhaps the person is paranoid about the mental health team or does not think that they should take medication, so why on earth would they engage? Sending out a referral and writing to them twice or phoning them once before then discharging them does nothing at all.

If you were to ask me what I think, I would say that it is likely that the justice system picks up some of the problematic practices in health and on some of the winding-back of care for mental health that has taken place generally in the community over the past 10 to 15 years.

The Chairperson (Ms Bunting): Have you seen examples of that being addressed in circumstances of budgetary pressure?

Professor Forrester: I cannot easily say that I have. There is a process of discussing that under way. We are going through a process, internationally, of understanding what that mental health care should look like. It is not an easy question to answer. How do you provide care for mental health without having the budget to provide it? I do not know the answer to that.

The Chairperson (Ms Bunting): That is fair enough.

Professor Forrester: The answer may be that you need to have the budget.

The Chairperson (Ms Bunting): I am not asking you to work a miracle.

Professor Forrester: It is a work in progress. Perhaps others can answer that question, but it is not obvious to me how you would do it. There might be other models that could be employed, such as telephone access or remote care provision. There are ways of thinking about it. For example, models such as street triage have proved helpful. The problem with those models, however, is that they tend to be research-funded models. The research may show that some things work and others do not, but, when the research period ends, there is no funding to take anything forward. It then becomes a problem. If you were to ask me what I think, I would say that there is no substitute for funding mental health services properly.

The Chairperson (Ms Bunting): That is helpful. Thank you.

In answer to Doug's question about training for prison officers, you mentioned the training that prison officers are afforded in other countries. Will you give us some examples of what that training entails?

Professor Forrester: Yes. I will talk specifically about Norway. In Norway, prison officers do a degree programme. I do not know how many years it is done over, but it is either three or four years of theory and training, after which they take up a job as a prison officer. To have that level of training before starting the job is a different ball game. I do not know how long training for prison officers takes in Northern Ireland, but I know that it is a matter of weeks in many jurisdictions. I spoke to the College of Policing for England and Wales a while back, and it told me that what prison officers get is just a matter of days of mental health training: one or two days during their overall training. There is definitely a need for more.

The way of thinking about it may be wrong. Perhaps the training does not all need to be done at the beginning. People can be in post and then have periods in which they are released for further training. Perhaps one week a year or something like that, they could be released for training and thus do it that way. There may be other ways of thinking about it.

The Chairperson (Ms Bunting): They could do it through continuing professional development (CPD).

Professor Forrester: Exactly.

The Chairperson (Ms Bunting): I will follow up on Ciara's question about personality disorder. You will be aware that there are issues in Northern Ireland, because personality disorder is not recognised here. In what ways could things be different here if PD were to be recognised?

Professor Forrester: Do you mean that it is not recognised in mental health legislation?

The Chairperson (Ms Bunting): Yes.

Professor Forrester: I will talk about the offender personality disorder programme in England, which is a large-scale attempt to manage people with personality disorder. It involves therapeutic areas, by which I mean psychologically informed environments in prisons, in the community, in probation hostels and so on. Moreover, there are some hospital wards in which people can be detained — I think that there are two or three in England but none in Wales — so people have a range of interventions available to them.

Before thinking, however, that, because it exists elsewhere, it is the right route to go down, it is important to understand something. The qualitative work has been done. Everybody is supportive of the projects. The people who have been through them think they are great. The people who have been working on them talk about increased supervision, better knowledge and all of that. If we look, however, at the quantitative work done so far and ask whether it prevents reoffending behaviour and violence, there is no demonstrable effect as yet. I say "as yet" because such things can take a long time to materialise in a system. It is tempting to think that those things are obvious solutions and that they work, but, when they are put under the microscope, we must ask whether they do work. The jury is out on whether the offender personality disorder programme works or does not work. If you look closely at levels of violence, for example, there is a small uptick — a non-significant but small uptick — in violence among the treated group, so there is an argument against the programme that needs to be considered as well.

There is also an argument for people with personality disorder going into hospital in some situations, and there are hospital units in England that operate as such. People can be detained in hospital with a diagnosis of personality disorder in a way in which they cannot in Northern Ireland. Again, In the literature, the verdict is out as to whether those units have done what they are meant to do. Have they prevented violence and reoffending? That question is still to be answered.

The treatment of personality disorder is complicated, because it often involves people being brought onside and wanting to engage in therapy. That then means that they start to take responsibility for themselves. If people are held under legislation, it is difficult for them to take responsibility for themselves in those circumstances. You can argue that it may be a useful addition, but, equally, you can argue that including that provision in mental health legislation could be problematic. Those are my views, by the way. Other people have different views on that area, but those are mine.

The Chairperson (Ms Bunting): Thank you for that. Does treatment potentially fall down in the system as opposed to upon diagnosis of PD? You say that the evidence demonstrates that there is a slight uptick in violence among the people who have been through the system that you outlined as opposed to among people who received a diagnosis and a different style of treatment?

Professor Forrester: What I am saying is that a whole treatment pathway was put in place for people with personality disorder by way of an experiment to see whether it would work. If you look at the treatment pathway, people are positive about it. They all think that it is great, but, if you look at them, what the statistics show, among the group that has been treated, is a small uptick in violence. That is not evidence of effectiveness, so that is something that we have to be aware of when we think about treating and managing people with personality disorder.

I am saying that the whole area is complicated and that we do not have the solutions really, but that does not mean that we should not try to do some things. We know that, when people with personality disorder present with comorbidities, such as depression,

or psychosis, treating those comorbidities is a useful thing to do. I suspect that the issue in Northern Ireland at the moment is that there are lots of people in the system who have undiagnosed personality disorder, because they have not been looked at in the way that, perhaps, they might have been.

The Chairperson (Ms Bunting): We will receive a briefing in a few weeks on the principle of Right Care, Right Person (RCRP). You mentioned a balance: can you give us an example from what you have seen of where the issue of people being in prison to be punished has been balanced well against their receiving the right care — the care that they need — and a decision on whether prison is the right place for them?

Professor Forrester: That is not an easy question to answer, because those struggles exist in every state all the time. The essential question is this: how do you punish and treat at the same time? That is a difficult thing to do. There is evidence that, if you can keep your organisations — by "organisations", I mean the prison system and the healthcare system — a bit separate and healthy but keep them friendly with each other but able to criticise each other in a friendly way, through adopting almost a critical friend approach, there is some evidence that that prevents the development of a monoculture. By "monoculture", I mean that there can be a tendency for people who work in healthcare to go into a prison and become part of the prison culture, because that is the place in which they work day in, day out. It is an almost natural human response, if you like. To prevent that and to keep health where it is, all sorts of things can be done. It is about robust governance, training, CPD, supervision, clear policies and procedures — so that people know what they are meant to do and when they are meant to do it — and, crucially, the ability to raise issues when they arise in a way that means that people do not get defensive about them.

Creating systems that operate in that way is not easy. Doing so requires lot of goodwill, the right people and a broadly positive approach. We know, however, that that is the right way to go to create a system that is healthy.

The Chairperson (Ms Bunting): That is helpful. In those circumstances, we have seen some difficulty with information sharing. We have seen a willingness to work together but some difficulties with information sharing that we will need to probe further as we move on to the scoping exercise.

I have one final question, Andrew. You have been generous with your time and information. On the basis of the statistics, what is the best provision that you have seen to address issues such as addiction, substance abuse, alcohol abuse and so on with prisoners?

Professor Forrester: The best provision that I have seen comes from having integrated services. What I mean by that is that there is a temptation for substance misuse services to be provided by substance misuse professionals, mental health services to be provided by mental health professionals and physical health services to be provided by physical health professionals.

What you get in prisons is, in a way, unexpected, because sometimes those professionals all work together in the same building — sometimes in the same corridor and sometimes in adjacent rooms — yet they work in separate ways. The best way for those teams to work is for them to come together — we will call it "integration" — so that they can work in an integrated way. Then, you do not get substance misuse professionals doing their thing, mental health professionals doing their thing and physical health professionals doing their thing.

From what I have seen of substance misuse services, it is important that there is a connection to the community at the other side, because people will come out of prison and often go straight back on drugs. It is important that they can get the care and treatment that they need at the other side. Local provision to deal with substance misuse can be important.

The Chairperson (Ms Bunting): Thank you very much, Andrew, for taking the time to join us. Your evidence today has been really insightful and informative for us as we move forward in this work. Thank you very much indeed.

Professor Forrester: Thank you very much. It was nice to meet you all.