Commentary

Anyone who has provided psychiatric care to prisoners will know that delivering a decent standard of care is very difficult. In this issue John Reed examines some of the most frequently encountered problems faced by psychiatrists working in prisons and he suggests some practical solutions to overcome these difficulties (Reed, 2002). The problems associated with health care in prisons are complicated, but the reason why prisoners receive substandard health care is fairly simple: the prison service is not set up to deal with the complex needs of mentally disordered offenders (MDOs)and the National Health Service (NHS) has been reluctant to help out.

The role of the prison service

Prisons are not there to provide care for MDOs who have fallen through the net of NHS services: their purpose is to punish offenders, protect the public from crime, enforce court orders and stop people who are involved with the courts from running away. Physical methods of confinement, regimes and strict rules used to maintain prison security hamper the delivery of health care and create an environment that is detrimental to mental health.

The prison estate consists of an assortment of buildings, many of which are old and unsuitable for a modern prison service. This is particularly true of prison health care facilities. Twenty-four-hour staffed in-patient health care centres are located in larger, more secure prisons. They provide a cottage hospital service for a cluster of nearby prisons with less comprehensive facilities.

There are around 140 doctors employed by the Prison Service to work as prison medical officers. Very few have backgrounds or specialist training in mental health, and only a handful hold qualifications in psychiatry. These doctors and other Prison Service employees, including nurses, health care officers (prison officers with some health care training) and health care managers, who constitute the Health Care Service for Prisoners (formerly known as the Prison Medical Service), together with approximately 220 general practitioners who are contracted to work on a part-time basis, provide primary medical care to prisoners.

The Health Care Service for Prisoners is the oldest civilian medical service in Britain. Historically, prison doctors concentrated on reporting on the state of inmates' health, rather than actually treating the sick. They also supervised punishments (Sim, 1990). This legacy continues to exert an influence on doctors working in prisons today.

The responsibility of the NHS

Until very recently responsibility for providing health care in prisons rested solely with the Prison Service. In 1999 a joint working party from the NHS Executive and the Prison Service published a report on the future organisation of prison health care (NHS Executive & HM Prison Service, 1999). This report recommended adopting the principle of ‘equivalence of care’ advocated by the Health Advisory Committee for the Prison Service (1997) and the creation of a formal partnership between the NHS and the Prison Service so that these organisations would become jointly responsible for delivering health care to prisoners, with the Prison Service delivering primary care and the NHS providing secondary care. The government accepted these recommendations and reform began with the abolition of the Home Office Directorate of Prison Health Care and the creation of a new Health Care Policy Unit and Task Force in April 2000 based at the Department of Health.

The current state of psychiatric care for prisoners

Needs assessments are being completed through-out the prison system, but NHS input into prisons in most regions has not increased. Only a handful of prisons have contracts with NHS trusts. Where psychiatric services exist these typically take the form of sessions provided by visiting forensic psychiatrists. Multi-disciplinary input is rare. This means that prison doctors are often left to look after people with mental illness with complex needs in facilities that are unfit for this purpose.

Health care in prisons remains focused around reception, where health screening is carried out, and the health care centre. Although there are plans to change this, very few prisons have health care services that reach out to the main prison, where most of the prisoners with mental health problems and unmet needs are located (Birmingham et al, 1998).

Solutions for delivering psychiatric care to prisoners

The present-day reform of prison health care has only just begun. The Prison Service and the NHS will have to work closely together to improve health care facilities in prisons and create a culture that allows prisoners better access to health care. What needs to change?

To begin with, the NHS and the Prison Service must have a clear and common understanding of the distinction between primary and secondary care. The NHS must take full responsibility for providing secondary care to prisoners and it must integrate with the Prison Service so that a seamless interface between primary and secondary levels of care can be achieved. Ideally, prisons should develop contracts with NHS trusts to provide multi-disciplinary psychiatric care to prisoners. This should involve general as well as forensic psychiatric services.

Multi-disciplinary in-reach services, providing assessment and treatment for prisoners in the main prison, should be developed, and all prisoners with significant mental health problems should be subject to the Care Programme Approach. Prisoners with serious mental health problems should be transferred without delay to suitable NHS in-patient facilities.

Medical and nursing students should be exposed to prisons during their training. Vocational and psychiatric training schemes should also include prison placements as a matter of routine. Doctors and other health care workers employed by the Prison Service should be appropriately qualified and they should be provided with the same opportunities as their NHS counterparts to participate in training and continuing professional development.

There is clearly a lot to be done. The NHS may have entered into a health care partnership with the Prison Service, but I believe that the situation for prisoners will not improve until there is a real commitment to deliver a good-quality service at a local level, and until there are adequate resources to support this.