11 Health Care in Prisons*

C:/Postscript/11_HCNA3_D3.3d – 26/1/7 – 14:21 [This page: 791] 11 Health Care in Prisons* Tom Marshall, Sue Simpson and Andrew Stevens 1 Summary Introduction Providing health care for prisoners has historically been the responsibility of the prison service, not the NHS. Prison governors have been responsible for allocating resources to health care leading to considerable variation between prisons in the way in which health care services are provided. Prisons face many problems in the provision of health care, in particular relating to the need for security and inmates’ isolation from their communities. Describing the prison population The prison population has three key features: it is largely young, overwhelmingly male and has a very high turnover. About 60% of inmates are under 30 years old. Fewer than one in twenty prisoners are female. New receptions per year amount to four times the prison population. Local prisons, which receive remand prisoners directly from the courts and prisoners on short sentences, have the highest turnover. Training prisons and high security prisons, which hold prisoners on longer sentences, have a lower turnover. About one in five prisoners are on remand, that is, they are awaiting legal proceedings or sentencing. Prisoners are drawn from lower socio-economic groups and have poor levels of education. Ten per cent of the prison population is black. Prevalence and incidence of health problems The range and frequency of physical health problems experienced by prisoners appears to be similar to that of young adults in the community. However, prisoners have a very high incidence of mental health problems, in particular neurotic disorders, compared to the general population. By ICD-10 criteria, in any week, almost half of prisoners are suffering from a neurotic disorder such as anxiety or depression. One in ten prisoners has suffered from a psychotic disorder in the past year. * This chapter is an updated version of a report commissioned jointly by the Department of Health and the Directorate of Health Care of the Prison Service in England and Wales in 1998/9. C:/Postscript/11_HCNA3_D3.3d – 26/1/7 – 14:21 [This page: 792] 792 Health Care in Prisons Suicide is about eight times more common among prisoners than in an equivalent community population. Suicides most frequently occur within the first weeks and months of imprisonment. Incidents of deliberate self-harm are reported in one in sixty prisoners a year. Half of prisoners are heavy alcohol users and about one in twenty has a serious alcohol problem. About half of prisoners are dependent on drugs (principally opiates, cannabis and stimulants) and at least one quarter have injected drugs. Aminority of prisoners continue to use drugs while in prison. Services available Opportunities for informal care and self-care are very limited in prisons. Per capita expenditure on formal health care services are higher than equivalent expenditure for young adults in the NHS. Directly employed health care staff include health care officers (prison officers with some training in nursing), nursing staff (some whom may also be prison officers) and medical officers. Many prisons also contract with local general practitioners, hospital trusts, medical, dental and other specialists. In addition to access to NHS in-patient facilities, many prisons also have their own in-patient facilities. Asubstantial part of the work of Prison Health Care Services involves routine medical examination at entry and prior to release and preparing medical reports for legal reasons. Per year of imprisonment, prison inmates consult primary care doctors three times more frequently and other health care workers about 80 to 200 times more frequently than young adults in the community. Prison inmates are admitted to NHS hospitals as frequently as young adults in the community, but are also admitted to prison in-patient facilities two to sixteen times more frequently than this. Inmates are also heavy users of medical specialists and professions allied to medicine. Effectiveness of services There is little direct evidence of the effectiveness of health services in a prison setting. Relevant data are available from a range of sources of evidence-based reviews and guidelines. It is known that screening prisoners at reception fails to identify many who are mentally ill. There are effective means of managing many of the health problems of prisoners. There is a range of effective treatments for minor illnesses, some of which are available without prescription. There is a range of medications and some psychological treatments (in particular cognitive behaviour therapy) which are effective for neurotic disorders and symptoms. For a range of health problems, the work of doctors can be successfully carried out by other professionals using clinical guidelines. Recommendations Planning of health care should be based on an understanding of health care needs. Planning of health care should not be primarily driven by a concern for demand (by patients or professionals) and historical precedent. Efforts should be made to increase prisoners’ ability to self-care and to reduce their dependence on the formal health care system. The recognition and management of neurotic disorders using effective pharmacological and psychological treatments should be given a high priority in the primary health care system. To achieve this, staff will need appropriate training. The provision of prison-based in-patient C:/Postscript/11_HCNA3_D3.3d – 26/1/7 – 14:21 [This page: 793] Health Care in Prisons 793 facilities should be reviewed. The management of chronic physical and mental illnesses should follow appropriate clinical guidelines. 2 Introduction and statement of the problem Health care in prisons was for many years a matter of concern.1 Prison medicine was said to be out of date, with a very ‘medicalised’ model of care, focusing on illness not health, and with little attention to prevention, guidelines, multidisciplinary work, audit, continuing professional development, or information.2 HM Chief Inspector of Prisons, working independently of the Prison Service, reports directly to the Home Secretary on the treatment of prisoners and the conditions in which they are held. Adverse reports following inspections led to investigations into health care in prisons. In 1997 the Standing Health Advisory Committee to the Prison Service in its report The Provision of Mental Health Care in Prisons highlighted an uncoordinated approach to the delivery of mental health care.3 More recent publications addressing the main issues of concern include Patient or Prisoner?4 and the joint Prison Service and NHS Executive working group report, The Future Organisation of Prison Health Care.5 Both of these reports made recommendations for the restructuring of the Prison Health Care Service with a view to improving prison health care. Health care delivered in prisons was found rarely to be planned on the basis of need. Both reports also recommended that comprehensive health needs assessment of the prison population should be carried out. Responsibility for the health care of prisoners The health care of prisoners has until recently been funded and organised separately from the National Health Service (NHS), being the responsibility of HM Prison Service. The broad aim of the Prison Health Care Service was: to provide for prisoners, to the extent that constraints imposed by the prison environment and the facts of custody allow, a quality of care commensurate with that provided by the National Health Service for the general community, calling upon specialist services of the NHS as necessary and appropriate. Standing Order 13. Health Care. Home Office. HM Prison Service From 1992 Governors were responsible for purchasing health care for their individual prisons, with the Directorate of Health Care providing advice on strategy, policy and standards.1 This included the payment of staff; the provision of clinics for dentistry; opticians’ services; genito-urinary medicine; and pharmacy.4 The NHS was responsible for funding NHS (secondary) in-patient and outpatient care. The source of funding for NHS visiting consultants and for NHS services which reach into prisons (such as community mental health support) was less clear and varied from one prison to another. In 1996 annual health care expenditure by the prison service averaged approximately £1000 per prisoner (based on the Average Daily Population). However, this figure concealed wide variation in expenditure on health care, with some institutions spending as little as a few hundred pounds per inmate and others as much as £9000 or between 3% and 20% of their total budget on health care.5 In 1999 the establishment of a formal partnership between the Prison Service and the NHS was agreed The partnership was lead by two national joint units – a policy unit and a task force – to help support and drive the reform of prison health care from the centre. The units formally came into being on 1 April 2000. In September 2002, Ministers announced the decision to transfer the budgetary responsibility for prison C:/Postscript/11_HCNA3_D3.3d – 26/1/7 – 14:21 [This page: 794] 794 Health Care in Prisons health from the Prison Service to the Department of Health. In addition a timetable of April 2006 was agreed for full devolution of commissioning responsibility to Primary Care Trusts (PCTs). General features of the health care needs of prisoners Prisoners have general health needs similar to those found in the general population. These are often overshadowed by health care needs related to offending behaviour such as substance misuse and mental health problems. Prisoners also have health care needs which are a consequence of imprisonment. Imprisonment restricts access to family networks, informal carers and over the counter medication; the prison environment can be overcrowded and may be violent; prisoners suffer emotional deprivation and may become drug abusers or develop mental health problems whilst incarcerated. Other health care needs may be made more complicated by imprisonment such as the management of chronic diseases like diabetes or epilepsy.

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