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. ^{Reference Forrester, Henderson, Wilson, Cumming, Spyrou and Parrott1}

The recently published, government commissioned Bradley report ² recommended that the Department of Health should develop a new minimum target for the National Health Service (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 the Mental Health Act, it is difficult to justify using the Mental Capacity Act 2005 to treat a mentally ill individual repeatedly.

The study calculates, based on unit costs, ³ the ‘saving’ to the NHS of £6.759 million. Although this ballpark figure is a good starting point, the true costs to the NHS as a result of delayed transfers may well be higher based on the following factors.

The longer the patient remains in prison the longer their psychosis remains untreated. Marshall et al ^{Reference Marshall, Lewis, Lockwood, Drake, Jones and Croudace4} 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, 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 potentially significant effect 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 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.

The apparent initial ‘savings’ made from prisoners waiting to be transferred are negated by clinical and financial costs to the NHS in the long term. Finally, from the perspective of equivalence, prisoners should have the same timely access to appropriate mental health services as mentally disordered individuals in the community.