Chapter 6 Evaluation of the Performance of Prison Health Services CHAPTER 6 EVALUATION OF THE PERFORMANCE OF PRISON HEALTH SERVICES INTRODUCTION THE HEALTH NEEDS OF PRISONERS ARE PRISONER HEALTH NEEDS MET? INSUFFICIENT RESOURCES LOW PROFILE OF HEALTH SERVICES LACK OF COMPREHENSIVE FORWARD PLANNING OTHER FACTORS SUMMARY OF CONCLUSIONS SUMMARY OF RECOMMENDATIONS Report on Deaths in Prisons 85 Chapter 6 Evaluation of the Performance of Prison Health Services INTRODUCTION 6.1 As long ago as 1978 the Nagle Royal Commission in New South Wales recommended that:- “..in all cases the appropriate test for the provision of medical and other health care should be whether it is necessary for the health of the prisoner. Prisoners should receive the same medical and health care as a private citizen. The cost of such provision is no answer to necessity.” (my emphasis) 6.2 The Ministry’s Standards for the Delivery of Health Services (April 1999) state that the aim of its health services is to “ensure the health and safety of prisoners in custody in a just and humane manner…” by means of “…..an integrated, comprehensive health service to meet the identified health needs of individual offenders and specific offender groups….” 6.3 Although not specifically stated in that mission statement, the underlying - and universally accepted - principle by which prison health services are measured is that they should be equal to that available to the community. That means that cost and logistical difficulties created by the prison environment should not generally be used as justification for not providing that equality of service. 6.4 A large proportion – possibly the majority - of submissions to my inquiry raised concerns about the standard and adequacy of prison health services. An equally large number of issues were also raised in the course of interviews with prisoners, prison officers, prison health staff and outside organisations. It is quite clear from the issues identified in individual prison deaths and the number of comments about prison health care in submissions and interviews that there are wide-ranging concerns among prisoners and health services staff about the adequacy of health services. Only one prisoner said that he thought the health service was “excellent”. 6.5 I must emphasise, however, that I have not interpreted the absence of compliments about the service as significant. What is significant is that there were relatively few complaints about individual prison health staff other than a number of comments about verbal abuse and rough treatment by unidentified Hospital Officers at Casuarina and the complaints about a former prison doctor referred to in Chapter 5. Most prisoners were concerned about the adequacy and accessibility of the health services available to them rather than the quality of those that were provided. 6.6 Health services staff were also concerned about the adequacy of the services that they were able to provide and frequently expressed the view that, in the long term, a shortfall in ‘quantity’ would eventually impact on ‘quality’. Taking this a step further, I agree with the view expressed in a submission1 that “……appropriately resourced, committed and responsible provision of health services would contribute to an improvement in patient care and welfare……….” 6.7 The consistency of the theme in submissions and interviews that prison health services are “starved”of funding and under-resourced led me to consider this issue closely in order to establish whether there was substance to this view. Having considered and explored the range of services provided to prisoners and the way in which those services are provided, I have reached the conclusion that health services have been for the most part under-resourced and under-staffed primarily because prisoner health care has been, and still is to an extent , in reality, considered of lesser importance than prison operations and security issues by some sectors of prison administration. 86 Report on Deaths in Prisons Chapter 6 Evaluation of the Performance of Prison Health Services 6.8 It is unclear whether the Ministry accepts in principle the view expressed by the Nagle Royal Commission that “The cost of such [equal to community standards] provision is no answer to necessity”. What is quite clear is that health services have to compete with security considerations for the scarce ‘corrections’ dollar and have frequently come off second best. Competition becomes fiercer because an assessment of the ‘performance’ of the prison system tends to be measured from the negative aspect of the number of escapes and the number of prisoner deaths - rather than from the more positive aspect of successful rehabilitation resulting in a reduced rate of recidivism and a generally healthier and more manageable prison population. In this regard, I note RCIADIC Recommendation 3282 that “sufficient resources be made available to translate the principles [of Standard Guidelines for Corrections] into practice”. In other words, it is not enough to say that the principles of the Standard Guidelines and the RCIADIC recommendations have been implemented if funding and resources are inadequate to permit those principles to be reflected in everyday service reality. The recent increase in funding for health services referred to in Chapter 4 – Table 4.3 and paragraphs 4.33 and 4.34 – is therefore a welcome improvement. 6.9 Security within prisons may be the emphasis demanded by society - and I am not suggesting that the escape of an offender who has been sentenced to a term of imprisonment for the protection of society should not be of concern. However, the fact is that most prisoners are released to the community at some stage and, in my view, whether they continue to present a risk to society after their release should be of equal concern to the community. I interpret ‘risk’ to include not only risk of re-offending but also health risks. Ultimately, society bears the cost of prisoner health care to a very large extent, whether it is provided during a term of imprisonment or after release. 6.10 In relation to the importance of prisoner health to the community, HM Chief Inspector of Prisons (UK) wrote in the introduction to his 1998 discussion paper entitled “Patient or Prisoner?”:- “Prisoners are entitled to the same level of health care as that provided in society at large. Those who are sick, addicted, mentally ill or disabled should be treated, counselled, and nursed to the same standards demanded within the National Health Service. Failure to do so could not only damage the patient but also put society at risk.” (my emphasis) 6.11 Later in the same paper3 the Chief Inspector noted:- “Health for the individual is part of the overall quality of life and health for everyone. Every penal establishment is a small part of the wider local community, which should be seen as an organic whole. Health standards affect all who work and live within the establishment. Staff, prisoners, visitors and contractors all contribute to the overall well being of each other…. .............A prisoner’s health and health care before offending has an impact on what happens in prison, both to the individual prisoner and more widely. A prisoner’s health care in prison can, for example, for those with mental disorder or substance abuse, be a major factor in their well being and chances of re-offending on release. However obvious those statements, they emphasise the interdependence of health care in prisons and in the wider community......” 6.12 I agree entirely with this view. I also believe that the successful rehabilitation of an offender is as important to the safety and welfare of the community as the security of that offender within a prison. In this regard I consider it significant that in 1998/99 almost two thirds of Western Australia’s prisoners had served one or more previous prison sentences as shown in Table 6.1 on the next page:- Report on Deaths in Prisons 87 Chapter 6 Evaluation of the Performance of Prison Health Services Table 6.1 Previous Sentences for Prisoners 1998/99 No. of Previous Aboriginal Non-Aboriginal Total % of Total Sentences Prisoners 0 343 943 1286 36 (37)* 1 211 342 553 15 (15) 2 168 208 376 11 (10) 3-5 329 302 631 18 (17) 6-10 282 148 430 12 (13) 11-15 125 37 162 5 (5) 16-20 45 7 52 1.5 (2) 21-25 18 1 19 0.5 (0.5) 26 and over 24 0 24 1 (0.5) Total 1545 1988 3533 *The figures in brackets are the % of total prisoners for 1997/98 6.13 An analysis of these figures shows that:- • 1318 prisoners (38%) had served 3 or more sentences • 647 prisoners (20%) had served 6 or more sentences • Of the 257 prisoners (8%) who had served 11 or more sentences, 212 (82%) were Aboriginal 6.14 In my view, the ‘health’ of an offender in its broadest sense4 will make a significant contribution to his or her chances of successful rehabilitation. However, the figures in Table 6.1 appear to indicate that a large proportion of prisoners reoffend. In this chapter I set out the reasons why I believe that the Ministry’s Health Service does not meet the health needs of its patients. THE HEALTH NEEDS OF PRISONERS 6.15 Prison health staff have told me, and it is widely acknowledged, that prisoners as a group have probably the worst health of any group in the community due to, inter alia, background and life-style; a generally low level of education; lack of employment; physical, sexual or mental abuse; a perception of low self- worth; and lack of appreciation of the importance of health to their overall wellbeing.