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BRITISH JOURNAL OF PSYCHIATRY (2004), 184, 5^7 EDITORIAL The principle of equivalence and the future restrictive environment for a mentally ill prisoner charged with shoplifting? Is a wait of mental health care in prisons of months for transfer to hospital ‘timely’ in accordance with Standard 5 of the National Service Framework? SIMON WILSON Prison health care wings are not hos- pitals, being specifically excluded by the National Health Service Act 1977, and consequently prisoners located there can- not receive medication against their wishes under the Mental Health Act 1983, unlike their counterparts in hospitals in In March 1999 the British Government ordinary location – for example, with the NHS and independent sector. Treat- publishedpublished The Future Organisation of regular input from psychiatric nursing, ment can be given only under common Prison Health Care, setting out the arrange- monitoring compliance with medication law, and this has tended to be interpreted ments for a formal partnership between the and beginning to implement the care in very narrow fashion so that medication Prison Service and the National Health programme approach. is held in reserveuntil an emergency (see Service (HM Prison Service & NHS Execu- The National Service Framework for for more detailed discussion Wilson & tive, 1999). On 1 April 2003, the NHS Mental Health (Department of Health, Forrester,Forrester,2002).2002). In addition, owing to formally took over the provision of health 1999) details principles and standards for the lengthy delays in assessment and trans- care within the 138 prisons in England the provision of psychiatric care: fer to hospital, psychiatrists who have and Wales. For many years there have been worked in prisons will be all too familiar ‘Any service user who contacts their vocal criticisms of the standard of care in primary health care team with a common with the uncomfortable position of con- prisons (Smith, 1984). Are things about to mental health problem should have their mental sidering not treating their prisoner patients change?change? health needs identified and assessed, and be in case they get well before they have offered effective treatments, including referral had the opportunity of hospital treatment to specialist services for further assess--assess (Earthrowl(Earthrowl et aletal, 2003). Does this make ment, treatment and care if they require it’ prison hospital wings suitable ‘alternative (Standard 2). EQUIVALENCE OF CARE places’ for those in need of a period of This already happens in most prisons with ‘care away from home’? There is no equiva- The Government’s policy for prison health a developed psychiatric in-reach team lent of a prison hospital wing anywhere is enshrined in the principle of ‘equivalence and, although not perfect, presents no con- else, and this presents conceptual problems of care’ (Home Office, 1990, 1991; HM ceptual difficulty for the community for the community model of mental health Prison Service & NHS Executive, 1999). model. But what of the health care wing care in prisons, and for the principle of Prisoners should receive the same level of population? equivalence. health care as they would were they not in prison – equivalent in terms of policy, standards and delivery (Health Advisory THE PRISON HOSPITAL WING Committee for the Prison Service, 1997). WHAT ARE PRISON HOSPITAL The prison population is conceptualised as Unlike prisoners with physical illnesses of WINGS FOR? a community and the health care provided comparable severity, those developing a within prison should be equivalent to serious mental illness are usually moved to In taking over prison health care the NHS primary care in the NHS, including specia- the health care wing where they may wait needs to answer the question ‘What are list out-patient services. Any prisoner months for transfer to hospital, after a pro- the health care wings of prisons for?’ requiring more than primary care is to be tracted period of referral to local services, Currently they occupy a limbo between transferred from prison to hospital to assessment, decision-making, seeking a the community of the prison and the hos- receive it.it.receive hospital bed at the appropriate level of pital beds of the NHS and independent Prisons contain large numbers of security and, finally, transfer (Reed & sector. Their continued existence means prisoners with serious mental illnesses Lyne, 2000). that their occupants remain almost invisi- (Singleton(Singleton et aletal, 1998). The developing Standard 5 of the National Service ble – they would not be so difficult to see prison psychiatric in-reach teams provide Framework states: if all prisoners awaiting a hospital bed were a clinical service to two main areas within sent to queue up in their local casualty ‘Each service user who is assessed as requiring a the prison: the residential population on period ofofcare care away fromtheirfromtheirhome home shouldshouldhave have department. The prison hospital wing is ordinary location, including in segregation; timely access to an appropriate hospital bed or tacitly accepted as an ‘alternative place’ – and the population contained in prison alternative bed or place, which is in the least better to be unwell in a prison hospital health care wings. The first area is not prob- restrictive environmentconsistentenvironment consistent withthewith the need wing than in the community. Yet psy- lematic conceptually for the community/ to protect them and the public and as close to chiatric professionals working in prisons primary care model and advances have home as possible’. are unable to treat their patients in equiva- been made in the successful supervision Is the prison hospital wing an ‘alternative lent fashion to their patients in hospital of prisoners with mental disorders on place’? Is a prison hospital wing the least (Needham-Bennett & Cumming, 1995), 55 Downloaded from https://www.cambridge.org/core. 23 Sep 2021 at 20:06:45, subject to the Cambridge Core terms of use. WILSON and the prison is not a safe place to wait for SIMON WILSON, MRCPsych, HM Prison Brixton, Jebb Avenue, Brixton, London SW2 5XF,UK. a hospital bed (Reed, 2003). Tel: 020 8588 6058; fax: 020 8588 6295; e-mail: dr___dr___ simon___wilson@@yahoo.co.uk With the introduction of prison psychi- atric in-reach teams, the detection of (First received 4 March 2003, final revision 20 June 2003, accepted 25 June 2003) mental illness within prison is much improved and is likely not to be responsible for delays in transfers to hospital (although a key performance indicator of prison psy- Health Act Commission. These are essential The principle of equivalence that guides chiatric services will be the transfer times). for ensuring equivalence of clinical care. the ethos of prison health care delivery Either more secure psychiatric hospital beds Making more use of the common law relies on a model of the prison as a com- are needed in Britain or prison health care would simply maintain the status quostatusquo byby munity, with prisoners receiving primary wings need major changes. Will the take- fudging the critical question of what prison care and specialist out-patient services over by the NHS provide an increased hospital wings are for, and certainly does within the prison. This model breaks down number of beds outside the prison? It is not amount to equivalent care. with prison hospital wings that have no difficult to see how. This is a longstanding It might be argued that such treatment equivalent outside the prison. The current problem – Broadmoor Hospital opened as would not be equivalent to the treatment lack of treatment facilities and a clear legal an Asylum for the Criminally Insane in of physical disorders in prisoners, with the framework for the treatment of prisoners 1863 to remove mentally ill prisoners to example of the failure of surgical units with severe mental illnesses within prison hospital. Over 100 years later, epidemio- within prisons in mind (Home Office, hospital wings, and the unacceptable delays logical surveys continue to demonstrate 1990). This would be to misinterpret the in hospital transfers, make the status quostatusquo the high prevalence of severe mental illness principle of equivalence, however. The care unacceptable. Without more secure hospi- in prisons (Singleton et aletal, 1998).,1998). of prisoners with mental illnesses should be tal beds in the NHS or independent sector, equivalent to the care of non-prisoners with prisoners with severe mental illnesses are mental illnesses, not to the care of prisoners far from receiving equivalent care. Is it with physical disorders. However, what it not time to reconsider what prison hospital PRISON HOSPITAL WINGS does illustrate is the need for more than wings are for? Is it not time to enable psy- AS HOSPITALS simply a change in legislation to provide chiatrists who work in prisons to treat their equivalent care – a properly multidis- patients there equivalently to their patients Bringing prison hospital wings, suitably ciplinary team of trained staff will be in hospital? The Department of Health’s staffed and equipped, under the aegis of needed with proper facilities, and a varied taking over of prison health care provides the Mental Health Act 1983 might provide and productive range of therapeutic activ- an excellent opportunity to re-examine the best route to equivalence of care for ities for patient-prisoners. This will not be critically the provision of mental health prisoners. Such prisoner-patients thus an easy task, but it is perhaps not so differ- care in prisons. would be ‘doubly detained’ under the ent from the similar struggles going on in Mental Health Act and the criminal law. many inner-city general psychiatry in- This would be the same as patients patient settings. What mentally ill prisoners DECLARATIONOF INTEREST currently detained in hospital under require are adequately equipped and staffed Sections 35, 36, 38, 47 and 48 of the hospital facilities, whether inside or outside None.None.

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