The special edition

In this edition, Andrew Carroll and Adam Brett deal with this issue head-on, argue that ‘Jailing is failing’^{Reference Carroll and Brett3} and describe a key role for psychiatry in a revised system through tiered models of prevention. While it is the case that we as psychiatrists have much to offer in the onward management of people with offending behaviour and mental illness, there is an abiding sense that we are not as fully engaged, or used as effectively, as we might be. How to solve this issue is likely as much about testing new service models working across health and justice areas as it is about our willingness to engage and become part of the solution.

Lara Arsuffi et al^{Reference Arsuffi, Ozcelik, Bingham, Taylor and French4} go on to describe one such model – Mental Health Treatment Requirements (MHTRs) – which we know can be successful when applied to people who have primary care-level mental health needs. Yet despite this, there is much to learn, and although MHTRs offer an alternative to imprisonment for appropriate cases – providing a framework through which onward care and supervision can be applied – there are some abiding questions. How and when should we apply them to people with severe and enduring mental illness, what barriers might prevent their proper use and how might such recommendations best sit within existing liaison and diversion services?^{Reference Ryland, Exworthy and Forrester5,Reference Chaplin, Lord Keith Bradley, McCarthy and Forrester6} Here, there is a clear role for future research.

A further model is described by Manuela Jarrett et al,^{Reference Jarrett, Mills, Mallion, Sykes, Wills and Chaplin7} who have evaluated the application of screening and brief interventions for alcohol-related conditions in police custody. While the use of health screening in police custody has significant support within the literature,^{Reference McKinnon, Moore, Lyall and Forrester8} the authors found that considerable challenges apply when attempting to implement a public health intervention model in these settings, and that any further changes are likely to require a significant training investment.

In further work aimed at improvements on a public health scale, Rebecca Crook at al^{Reference Crook, Lennox and Awenat9} have described a logic model with implementation strategies, as part of their project that aims to reduce and prevent suicide in prisons. Here, again, the complexity of clinical work in prisons is apparent, with a range of outer or environmental considerations (e.g. environmental instability, or the prioritisation of security concerns over the delivery of healthcare services) and internal, or individual, factors (e.g. previous experience of healthcare, or trust in institutional and health delivery systems). This model has a real potential strength, in that it tries to capture the complexity that is apparent in real-life systems and interactions, and promising further developments are suggested. In any case, there is no doubt that improvements are required in this area, given the most recent statistics from England and Wales, showing 371 deaths in custody in 1 year, of which 86 were self-inflicted.¹⁰

In a further demonstration of the complexity that characterises this broad field, Bradley Hiller et al^{Reference Hillier, Carthy and Kalk11} identify issues that arise with chemsex, with evidence of a subgroup who engage in offending behaviour and also experience harm. To date, although there has been increasing recognition of the difficulties arising in this area, there has been no over-arching multi-agency strategy. So, Hillier et al have set about trying to change this by taking a three-pronged approach to key recommendations. These recommendations – training, research and network development – have broad support, and now require a framework to move forward.

There are also two further international contributions to this edition. The first – from Roland Jones and Alexander Simpson^{Reference Jones and Simpson12} – considers issues arising with Medical Assistance in Dying (MAiD), when this is used amongst people in prison. While this area is ethically complex, the main arguments in support of access have been based upon the principle of equivalent care – that is, that prisoners should have the same standard of healthcare that is available in the wider community.¹³ The authors go on to describe four powerful cases, and argue that although this is an evolving area, considerable caution is required. Their clear recommendations deserve further thought.

The second – an interview of Professor Guillermo Rivera, who is Professor of Abnormal Psychology in Santa Cruz, Bolivia, by Claire McKenna^{Reference McKenna14} – provides a fascinating glimpse of prison conditions and prison mental health services, in Bolivia. However, despite well documented and often dangerous prisons, and de facto self-governing prison systems, Rivera draws our attention to significant humanitarian efforts being made on the ground to improve and reform existing conditions. From a psychiatric perspective, only 1 of the 90 prisons in Bolivia has a psychiatrist who is funded by the State, and most prisons have no mental health staff at all. Yet, Rivera faces these issues head-on and takes an admirably practical approach to continuous improvement. His work is important.

In working to improve services within criminal justice and correctional settings, we set out clear progressive intent, and in undertaking this work we assert the right of the individual to healthcare services that should be available, accessible, acceptable and of good quality, irrespective of their legal status.^{Reference Exworthy, Samele, Urquía and Forrester15} Where, how and when this can best be delivered is likely to remain the subject of societal and political debate, yet medicine – and psychiatry in particular – must play a significant role in shaping this debate as it moves forward.