Presented by: Shaun Kenny, Adult Service Manager Melanie Jones, Project Lead and Graduate Primary Care Mental Health Wor

1. Presented by: Shaun Kenny, Adult Service Manager Melanie Jones, Project Lead and Graduate Primary Care Mental Health Worker

2. Acknowledgements Isabelle Gibbard, Counsellor, HMP Garth and Wymott Deborah Howe, Healthcare Manager, HMP Wymott Natalia Hunt, Mental Health Lead, HMP Garth Catherine Morton, PCGMHW, HMP Wymott Siobain Penpraze, Healthcare Manager, HMP Garth

3. Workshop Aims By the end of this session it is hoped that: You will have an understanding of the feasibility of integrating the GPCMHW role into the prison environment. You will have an understanding of the challenges that the environment and prison population present to developing the GPCMHW role in prisons.

4. Policy Context NHS Plan (2000). Changing The Outlook (DoH, 2001). Shifting The Balance of Power (DoH, 2002). Nice Guidance for Anxiety & Depression. Local Health Needs Assessment.

5. The Traditional Role of the Graduate Primary Care Mental Health Worker Low intensity, brief CBT-based interventions. Regular telephone / face-to-face contact. Individual one-to-one work for common mental health problems based on problem-solving and other self-help methods. Group work for common mental health problems. Medication management. Liaison with the wider community.

6. Why Carry Out A Project? To assess the feasibility of integrating the GPCMHW role into the prison environment. To address the challenges that the environment and population present to developing the GPCMHW role successfully in prisons. Challenges to the role include: Literacy difficulties Learning difficulties Language barriers Relevance of resources Emergency planning GPCMHW remit Capacity due to prisoner movements Supervision of GPCMHW�s Peer support for prison GPCMHW�s

7. Key Areas For ConsiderationLiteracy How Can Literacy Needs Be Met? Self-help materials need to be matched to the abilities of the prison population by identifying the varying levels of literacy across the general prison population. Alternative methods of delivery of self-help could be made available including CD�s and cassettes.

8. Key Areas For ConsiderationLiteracy Difficulties Progress So Far Patients asked to complete a satisfaction questionnaire requesting feedback about the usefulness of self-help materials. So far, illiterate patients have not been identified. However, the Books on Prescription Scheme (BPS) includes books, CD�s and cassettes which will enable illiterate patients, or those with low levels of literacy, to use audio self-help materials where possible. Written materials have been made available to match varying levels of literacy, from brief self-help materials such as Northumberland Trust guides to more demanding materials such as Chris Williams� Overcoming Anxiety and Overcoming Depression.

9. Key Areas For ConsiderationLearning Difficulties How Can Learning Difficulty Needs Be Met? Resources can be adapted to ensure they are accessible to all (such as making adaptations suggested by The British Dyslexia Association). Progress So Far Reproduction of any written resources (such as handouts) to meet those recommendations made by the British Dyslexia Association, where possible. People with a learning disability are more likely to have more complex health needs than the general population and this includes a greater prevalence of mental illness (DoH, 2000). There is a need to ensure that resources are plentiful. Under the Disability Discrimination Act 1995, service providers are obliged to make reasonable adjustments in order to ensure accessibility for all. People with a learning disability are more likely to have more complex health needs than the general population and this includes a greater prevalence of mental illness (DoH, 2000). There is a need to ensure that resources are plentiful. Under the Disability Discrimination Act 1995, service providers are obliged to make reasonable adjustments in order to ensure accessibility for all.

10. Key Areas For ConsiderationLanguage Barriers How Can Language Barriers Be Overcome? Match self-help materials to the BME population in the prisons. Consider multi-lingual translation IT package �vs.� private company translation for requests. Self-help materials made available in other languages. Liaison with other PCT�s with a high BME population to share resources. The proportion of non-English or Welsh nationals has changed rapidly over the past decade. Their number increased by an estimated 152% between 1996 and 2004 and they now account for approximately 12% of the overall prison population (Prison Reform Trust, 2004) . Foreign national prisoners come from 168 countries, but over half are from just six countries (Jamaica, the Irish Republic, Nigeria, Pakistan, Turkey and India). A quarter are Jamaicans, by far the largest single group (Prison Reform Trust, 2004). At Garth, foreign nationals currently account for roughly 5% of the prison population. The proportion of non-English or Welsh nationals has changed rapidly over the past decade. Their number increased by an estimated 152% between 1996 and 2004 and they now account for approximately 12% of the overall prison population (Prison Reform Trust, 2004) . Foreign national prisoners come from 168 countries, but over half are from just six countries (Jamaica, the Irish Republic, Nigeria, Pakistan, Turkey and India). A quarter are Jamaicans, by far the largest single group (Prison Reform Trust, 2004). At Garth, foreign nationals currently account for roughly 5% of the prison population.

11. Key Areas For ConsiderationLanguage Barriers Progress So Far 7% non-UK foreign nationals and 22% BME population, for example, at HMP Garth. Language Line provision from HMPS for verbal translation. Assistance will be provided by both the PCT and HMPS in the event that a request is received to translate self-help materials to other languages that are not already available. Computer translation packages are generally costly with a low level of accuracy. Therefore, purchase of such program rejected. Receipt of Northumberland PCT materials in languages including: Chinese, Arabic, Bengali, Farsi, Punjabi, Hindi, Urdu, Gujarati, Cantonese, amongst other languages through partnership working with PCT�S with high BME populations.

12. Key Areas For Consideration Relevance of Resources How Can Resources Be Made Appropriate To The Environment? Resources referring to the external environment require adapting to the prison environment in order to ensure that suggestions for behavioural activation, for example, do not include methods solely available to those in the wider community.

13. Key Areas For Consideration Relevance of Resources Progress So Far Resources have been adapted where possible to ensure they are not exclusive in any way. Worksheets are currently being produced to accompany all BPS books that require written input. This way self-help tasks can be completed without damage to BPS books. �1000 per prison was allocated for the BPS. HMP Garth caseload has established the suitability of self-help materials and influenced the choice of titles for the BPS. The permanent location of resources needs to be further explored re: location. However, consultation with patients so far has found that patients would prefer to borrow titles from the Healthcare Centre, rather than request titles from the prison library.

14. Key Areas For ConsiderationEmergency Planning Key Concerns Riot, fire, lock-down procedure when patient in session. Procedure in event of risk of suicide / self-harm. Risk assessments. Personal protection. Progress So Far Formal procedures established for GPCMHW�s to follow in an emergency such as riot, lock-down, fire or suicide / self-harm. Thorough risk assessments carried out using a variety of data collection methods before patients are offered an initial assessment. Attendance on �personal protection� session.

15. Key Areas For ConsiderationRemit of the Prison GPCMHW Potential Duties Of The Prison GPCMHW Individual one-to-one work for common mental health problems (Remedial). Group work for common mental health problems (Remedial / Prevention). Healthy living classes with learning and education centre on topics such as drug and alcohol awareness (Prevention). Awareness raising events delivered via alternate methods such as theatre (Prevention). Staff awareness sessions including guest speakers, e.g. male rape and sexuality awareness (Prevention). Signposting through-care for those leaving prison (Remedial / Prevention).

16. Key Areas For ConsiderationAllocation and Capacity Staff Allocation and Capacity for HMP Garth and Wymott 2 x WTE (1 full-time worker allocated per prison). HMP Garth � Melanie Jones, Tues-Fri, Mondays on MSc Advanced Practice Interventions in Mental Health course at University of Manchester. Current caseload of 25 patients, based on 12 patients seen per week over 3 days. 1 day at University, 1 day admin work, meetings, project work. Currently full to available capacity. HMP Wymott � Catherine Morton, 0.5 WTE. Full-time worker splitting time between both prison and GP surgery. Current caseload of 8 patients seen over 2 days. 0.5 day spent per week on admin work, meetings, project work. Currently full to available capacity. HMP Wymott - Current vacancy for 0.5 WTE (shortly to be recruited).

17. Key Areas For ConsiderationAllocation and Capacity Capacity 1 hour (assessments) and 45min / 1hr (subsequent appt�s). Full capacities so far suggests that the service will be in demand. Projected turnover: 100 refs p.a. (1 in 8 of Garth, 1 in 12 of Wymott). Average caseload 35 � 40 patients (one-to-one work), based on 5 days. Unidentified time Clinical time limited due to prisoner movements. Risk ass., database, display work, replenishing resources, liaison with others and meetings identified as making most effective use of non-clinical time.

18. Key Areas For ConsiderationSupervision of Prison GPCMHW�s Supervision Clinical supervision proven vital and provided by prison Counsellor for both GPCMHW�s. Case supervision provided so far by Mental Health Lead at HMP Garth, and likely to be also provided by PCT CBT therapists in the coming months. Peer supervision will be take place between the GPCMHW�s at both prisons. Support also provided by Shaun Kenny and both Siobain Penpraze, Healthcare Manager (HMP Garth) and Deborah Howe, Healthcare Manager (HMP Wymott).

19. Key Areas For ConsiderationPrison GPCMHW Network Prison GPCMHW Network Aim to establish a network between all of the existing prison GPCMHW�s in the country. Current provision located at HMP Haverigg, HMYOI Thorn Cross, HMP Risley and HMP Liverpool, as well as HMP Garth and HMP Wymott. Email support bulletin board established for prison GPCMHW�s to share good practice and useful resources as well as supporting isolated workers. Attempt made to contact other prison GPCMHW�s country-wide so far proven unsuccessful.

20. Service DevelopmentHelpline Services As a volunteer operator for the Lancashire Mental Health Helpline, I have enabled all HMP Garth prisoners access to the helpline during Helpline opening times when their wing telephone is available. All prisoners to receive leaflet for the service in April 2007. Established suicide and self-harm protocol for the Helpline staff to follow in an emergency, which has involved partnership working between Lancashire Care Trust, Central Lancashire PCT and HMPS. In my free time, I have provided helpline staff with training evenings to aid their understanding of prison environments. Helpline service likely to be rolled out to other prisons in the locality including HMP Wymott, HMP Preston, HMP Lancaster, HMP Kirkham and HMYOI Lancaster Farms.

21. Project Findings To Date Satisfaction Questionnaires All 5 questions rated either poor, fair, good, very good or excellent: Levels of courtesy and respect received � 100% Excellent. Length of time waited to be seen - 30% Excellent, 70% V. Good. Range of treatments offered � 60% Excellent, 40% V. Good. Helpfulness of the treatment given � 70% Excellent, 30% V. Good. Overall satisfaction with service � 100% Excellent. Patients asked to state whether less able, about the same, or more able to deal with difficulties following treatment � 100% stated �more�. Patients asked to comment upon helpful and unhelpful aspects. Most respondents stated that having someone to talk to has reduced their isolation. Others commented positively upon CBT models of working. Patients have not, so far, commented upon anything unhelpful (all findings based on 10 returned questionnaires at HMP Garth).

22. Project Findings To Date � Self-Help Materials & Clinical Outcomes Comments refer to texts including Chris Williams� �Overcoming� workbooks, Northumberland Trust Guides, Trevor Powell's �Mental Heath Handbook�, CCI Worksheets and Constable Robinsons� Overcoming Series (all findings based on 10 returned questionnaires, and 10 discharges following treatment at HMP Garth). Both questions rated either poor, fair, good, very good or excellent: Overall layout (pictures, text) � 40% Excellent, 60% V. Good. Overall content � 60% Excellent, 40% V. Good. Easy to read � Yes / No � 100% Yes. Right Length � Yes / No � 100% Yes. 90% patients discharged following treatment demonstrated improvement in their HADS depression score and 100% patients in their HADS anxiety score.

23. Conclusions Project work so far has identified specific challenges facing the implementation of the GPCMHW role in prisons and ways to overcome barriers. Project work has established the development of the role in prison is feasible and, so far, proving effective when challenges overcome. Likely to be a strong emphasis on health promotion in the prison environment with the opportunity to complete preventative work as well as remedial. Project work is not only maximising the impact of the role in prisons but also ensuring that GPCMHW�s are protected and safely implemented into this complex environment using extensive risk assessment.

24. Report Deadlines Interim Report � Presented w / c 4th December 2006. Final Report � Likely to be completed late Spring 2007.

25. Questions & Answers Any questions? Thank You

26. References Department of Health (2000) The NHS Plan: A Plan for Investment; A Plan for Reform. London: Department of Health. Department of Health (2001) Changing The Outlook: A Strategy for Developing And Modernising Mental Health Services In Prisons. London: Department of Health. Department of Health (2002) Shifting the Balance of Power: The Next Steps. London: Department of Health. National Institute for Clinical Excellence (2004) Anxiety: Management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care. Clinical Guideline no. 22. London: NICE. National Institute for Clinical Excellence (2004) Depression: management of depression in primary and secondary care. Clinical Guideline no. 23. London: NICE.