The Psychiatrist -- eLetters for Forrester et al., 33 (11) 409-412

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Original papers:
Andrew Forrester, Christopher Henderson, Simon Wilson, Ian Cumming, Miriam Spyrou, and Janet Parrott
A suitable waiting room? Hospital transfer outcomes and delays from two London prisons
Psychiatric Bulletin 2009; 33: 409-412 [Abstract] [Full text] [PDF]

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The real cost of waiting in a prison for a hospital psychiatric bed: Pratish B Thakkar, Dr Ranjit Kini (Consultant Forensic Psychiatrist) Dr Phillip Brown (Consultant Forensic Psychiatrist) (16 November 2009)

The real cost of waiting in a prison for a hospital psychiatric bed 16 November 2009

Pratish B Thakkar,
ST6 Forensic Psychiatry
Tees Esk and Wear Valley NHS Trust,
Dr Ranjit Kini (Consultant Forensic Psychiatrist) Dr Phillip Brown (Consultant Forensic Psychiatrist)
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Re: The real cost of waiting in a prison for a hospital psychiatric bed

pratish.thakkar{at}tewv.nhs.uk Pratish B Thakkar, et al.

Forrester et al’s study on the delays in hospital transfer from prison focuses on an important clinical issue, given it is common knowledge that there is a shortage of secure beds in the country. The recently published, government commissioned Bradley report1 recommended that the Department of Health should develop a new minimum target for the NHS of 14 days to transfer a prisoner with acute, severe mental illness to an appropriate healthcare setting. There are plans to include the minimum waiting time in the local mental health contracts for prisons.
The study highlights an important issue of prisoners remaining in inappropriate environments while waiting for a transfer. In prison settings, without the protection of Mental Health Act it is difficult to justify using the Mental Capacity Act 2005 to treat mentally ill individual repeatedly.
The study calculates, based on unit costs2, the ‘saving’ to the National Health Services. The study comments that the aggregate wait in their study resulted in a total saving of Ł6.759 million to the NHS. Whilst this ball park figure is a good starting point, we suggest that the true costs to the NHS as a result of delayed transfers may well be higher based on the following factors.
The longer the patients remain in prison the longer their psychosis remains untreated. Max Marshall et al3 concluded in their systematic review that a longer period of untreated psychosis was associated with more severe overall symptoms, depression/anxiety, negative and positive symptoms, and worse overall function. Furthermore they inferred that people with longer duration of untreated psychosis were less likely to experience remission at 6, 12 or 24 months. We suggest that “delayed transfer patients” could have longer in-patient stays and require higher levels and more frequent episodes of observation due to the higher degree of their mental disorder; thereby potentially increasing the ‘costs’ to the NHS.
The other potential significant impact of delayed transfers is escalation of self injurious behaviour and risk to others, in the context of deteriorating mental health. Arguably, the escalation of risk behaviours may result in some prisoners eventually requiring placement in higher levels of security than if they had been transferred earlier in their phase of illness. The evidence for this is reflected by higher prevalence of constant watch, higher incidence of the use of safer cells, care and separation units and transfers to general hospital for treatment. They are also seen more frequently in clinics by visiting psychiatrists and mental health in-reach teams. This increases the demand on meagre resources and arguably increases the overall cost of patient care.
We therefore conclude that the apparent initial “savings” made from prisoners waiting to be transferred is significantly negated by clinical and financial costs to the National Health Service in the long term. Finally, from the perspective of equivalence, prisoners should have the same timely access to appropriate mental health service as mentally disordered individuals in the community.
References:
1. The Bradley report: Lord Bradley's review of people with mental health problems or learning disabilities in the criminal justice system. Department of Health
2. Department of health, National Schedule of Reference Costs. 2006- 2007 for NHS Trusts Department of Health.
3. Association Between Duration of Untreated Psychosis and Outcome in Cohorts of First-Episode Patients : A Systematic Review Max Marshall, MD; Shon Lewis, MD; Austin Lockwood, RMN; Richard Drake, PhD; Peter Jones, PhD; Tim Croudace, PhD Arch Gen Psychiatry. 2005;62:975-983.