Prison medicine: a crisis waiting to break
February 2004
Introduction by Dr P J Keavney, chairman of the BMA Civil Service Committee
There is a crisis looming in general practitioner recruitment and retention. It has already arrived at the Prison Service. Yet patients within prison are amongst the most needy in the country in relation to their health care needs. Over 90% of patients who reside within our jails come from deprived backgrounds. Their average length of stay is around 6 months, before they return to their deprived communities.
The Government has put the provision of equity and equitable services at the top of their health care agenda. Surely this should also apply to patients within our penal institutions? And yet the Prison Service is being consistently starved of adequate funding to meet this clinical and social care agenda.
The Prison Service itself does not help matters by its insistence on an agenda for its governors which concentrates on process instead of clinical outcomes. The lack of understanding of clinical governance is a bar to the delivery of adequate health care within our penal institutions. It is a recipe for conflict and stress between clinicians and governors. These problems, together with poor remuneration, terms and conditions of service, are at the root of this present crisis.
Transferring prison health care to the private sector, as has happened in Scotland, is not a solution to the problem as it does not address the central core of the issues at fault. What is needed is a ‘Needs Analysis’ program similar to that which is currently being progressed by health authorities throughout England and Wales.
In the end, a system focusing simply on ‘process’ to satisfy short term political and media concerns will fail to resolve the clinical needs of patients nor address the recruitment and retention crisis for clinicians. Nor can these problems be resolved alone by a central policy or task force. Clinicians have to be involved at the sharp end to deliver caring and appropriate services, which are relevant to their patients and the communities from whence they came.
A neglected problem
In the run up to an election, and at a time when many sectors of the UK medical profession are suffering from multiple problems in relation to morale, recruitment and retention, overwork, under-resourcing and increasing expectations regarding quality assurance, one particular sector has consistently been overlooked by politicians of all parties – healthcare for prisoners.
In this document, we draw attention to some of the serious problems which are faced by prison doctors and nurses every day, and we highlight the enormous missed opportunity that a captive population presents to improve its health and prevent reoffending. Politicians’ failure to address these challenges makes the work of prison medical staff increasingly stressful and isolated and risks affecting their ability to do the job.
Why is there a crisis now?
We have called this brief report “A Crisis Waiting to Break” but, in fact, the prison medical service has been in an acute crisis for some time. Criticisms of individual prison healthcare services and of the prison healthcare culture have repeatedly appeared in reports by the Chief Inspector of Prisons, Sir David Ramsbotham, and his predecessor, Judge Stephen Tumin. A decade ago, in 1991, for example, Judge Tumin drew attention to the very serious inadequacies in the medical services in Wormwood Scrubs. He said that the profound defects in the services there were “made tolerable only by a sensitive, sensible staff” (BMA publication, Medicine Betrayed, 1992, p.189).
Some positive changes might have been expected by the time prison medicine moved into the 21st century but, as Paul Boateng’s condemnation of services in Brixton in 2000 indicated, little has changed.
In 1996 an important discussion paper by Sir David Ramsbotham, Patient or Prisoner? (Patient or Prisoner: A new strategy for health care in prisons. HM Inspectorate of Prisons for England and Wales, 1996), which was strongly endorsed by the BMA, emphasised that “prisoners should be 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.” This paper recommended integration of the prison health care services with the NHS, a recommendation which was supported by the BMA, and which is being slowly implemented through joint working.
The recent Chief Inspector’s report, issued perhaps appropriately on the Ides of March, reflected a continuation of that dismal outlook. In his report on HM Prison Birmingham, the Chief Inspector of Prisons heavily criticised the regime, although noting that significant improvements had been made in the health care accommodation and management of drug offenders.
These problems are not the fault of prison doctors, who are as much victims of the under-funding and poor managerial support as are the prisoners themselves.
Much of the difficult working environment for prison healthcare staff stems from the lack of co-operation, and in some cases active opposition, of prison administrators, particularly certain prison governors. Many of the complaints made to the BMA from its own members who are prison doctors concern unacceptable interference by prison governors in their doctors’ clinical judgement about the needs of their patients. Structural changes in the service in the 1990s also increased the status of governors relative to prison doctors and further undermined clinical independence.
In addition, because of the general shortage of resources in prisons, prison medical officers often have inadequate support from an appropriately qualified healthcare team. Complaints are still made, for example, that in England and Wales too much reliance is placed on unqualified ‘hospital officers’ who are given responsibility for aspects of clinical care of prisoners that in the NHS would only be given to clinical staff with appropriate training.
In England and Wales, prison doctors are required to be responsible not only for “the care of the health, mental and physical, of the prisoners in that prison” as stated in the prison rules, but also to ensure that the particular circumstances of a prisoner’s incarceration are not having a deleterious effect on his or her physical or mental health. (Longfield, M. (1999) 'Opportunities for doctors in the prison service', British Medical Journal Classified, 23 January, p. 2). They are, in brief, assigned the role of patient advocates and required to ‘ensure’ that prison conditions do not adversely affect prisoners’ health. Demands are also made on them by prison authorities and staff that can conflict with their ethical obligations. Contractual duties or regulations governing their employment can also impede doctors who need to act as their patients' advocates by drawing attention to poor standards or to brutality in prisons.
The special healthcare needs of the prison population
The demands that prison doctors are subjected to are unique, both from the prison authorities and from the patients they treat, who often have a multiplicity of health problems. Prison doctors often have little support in responding to the complex health needs of prisoners who, as a population, are notoriously unhealthy and also often have a multiplicity of other problems. Many are poorly educated and have a history of being marginalized within society. In the UK, minority ethnic or migrant groups are over-represented in the prison population. (Levy, M. (1997) 'Prison Health Services', British Medical Journal, Vol. 315, pp.1394-5.) Prisoners have higher than average rates of mental illness. (Gunn, J., Maden, A., Swinton, J. (1991) 'Treatment needs of prisoners with psychiatric disorders' British Medical Journal, Vol. 303, pp.338-41) and substance abuse. (Mason, D., Birmingham, L., Grubin, D. (1997) 'Substance misuse in remand prisoners: a consecutive case study', British Medical Journal, Vol. 315, pp.18-21).
In England, repeated surveys have shown that a large proportion of young offenders in particular come into prison from unstable living conditions. Many have experienced homelessness and have lived on the streets. A 1997 survey by the Prisons Inspectorate, for example, found that a quarter of young prisoners were homeless on reception into prison.. Cavadino, P., 'House arrest', Guardian, 8 December 1999.
In 1999, some 26% of all prisoners and 38% of those under the age of 21 had previously been in the care of the local authority, compared with 2% of the general population. ( Ibid).
Prevalent in the prison population are problems common to marginalized peoples such as infectious and sexually-transmitted diseases, HIV infection and AIDS. (Weild, A., Curran, L., Parry, J., Bennett, D., Newham, J., Gill, O. N. ,'The prevalence of HIV and associated risk factors in England and Wales in 1997; Results of a national survey', 12th World AIDS Conference Geneva 28 June (1998) Abstract 23510.)
In the UK, children and young people constitute a quarter of all known offenders and they are also among those likely to have health problems. In 1999, the National Association for the Care and Resettlement of Offenders (NACRO) published a report indicating that children and young people suffering from poor health, including those with mental health problems, were more likely to get drawn into crime than their peers. (NACRO (1999) Children, Health and Crime, London.)
Although the link between poor health and crime in young people was acknowledged to be a complex one, the report concluded that the factors which indicate a young person is at risk of offending overlap to a significant degree with those which predispose young people to adopt unhealthy lifestyles. NACRO called for the development of specialist services for children and specified that these should be clearly distinct from adult services. It also recommended that the National Health Service should assume responsibility for the health care of all children and young people in prison.
Pressure to compromise clinical judgement
Prison doctors have dual responsibilities: to their patients and to assist the authorities who employ them in the efficient and economic running of the prison. Efficiency and economy may be interpreted to mean cutting corners and prescribing cheaper drugs rather than those most appropriate for the patient or not referring to a hospital outside the prison since this incurs the costs of accompanying guards. In recent years, the BMA has seen a large increase in enquiries and complaints from prison doctors in the UK who are encountering increasing obstacles to the exercise of their clinical judgement. The majority of such cases involve conflicts between prison doctors and governors, the roots of which lie in inadequate resources for prison healthcare.
Non-consultation on prescribing protocols
Doctors report that they are prevented from prescribing the most appropriate medicines for their patients. In some cases, for example, doctors have not been allowed to prescribe the most effective migraine relief for prisoners who suffer recurrent migraine attacks. The consequent erosion of the prisoner’s ability to function for repeated periods of time can lead to depression and mental illness. Trust between doctor and patient suffers when a less effective medication to that available in the community is prescribed.
It is common for prescribing protocols to be agreed in many areas of medical practice in order to make best use of scarce resources. In some prisons, however, doctors feel that they have been excluded from the process of drawing up and agreeing suitable protocols that balance prisoners’ needs with economy. They are in the very difficult position of being accountable to their professional body, the General Medical Council for the standard of care, which includes the medications they prescribe, but at the same time they are often restricted by prison budgets in exercising their clinical judgement about prescribing.
In-patient hospital care for prisoners
Hospital treatment of prisoners is now provided in NHS hospitals rather than in prison healthcare units. Doctors must apply to transfer sick patients to hospital for essential specialist treatment but prison authorities are often reluctant to pay the cost of accompanying prison officers even though the lack of specialized care will have serious health implications for the prisoner. In one case a prison governor expressed indifference to the likelihood of the prisoner dying as a result of failure to transfer him to hospital. Clearly, security is an appropriate concern for the prison authorities, but it is unacceptable that doctors’ assessments of their patients’ needs should be challenged in this way.
The clinician responsible for the patient’s management should have independence, as far as is practically possible, in deciding the patient’s care, although in practice clinical autonomy is not absolute. Doctors are generally aware of resource limitations but are torn between the ethical obligation to provide standards of care equivalent to that in society at large and containing costs in the treatment of a population for whom the public often has little sympathy. While it is clearly an ethical duty to use the most economic and efficacious treatment, prison doctors are aware that they are often the only advocates their patients have. It is unacceptable for doctors’ clinical judgement, in whatever field, to be overruled by management decisions which discount medical opinion and do not accord with patients’ best interests.
Doctors in the UK have also complained about the lack of provision of holistic services, in particular the lack of access to psychiatric nurses, occupational health workers, substance abuses councillors and clinical psychologists, who are much more likely to be needed in dealing with the mental health problems that predominate in many prisons.
Not all the blame can be attached to the prison system and the authorities that run it. Lack of support from colleagues in the NHS can put prison doctors at risk of feeling extremely isolated professionally. NHS hospitals are often reluctant to take prisoners who need more specialised services than are available in prison hospitals. For this reason, and because of the prison service’s obsession with security, there are often delays in securing admission of prisoners to hospitals which can adversely affect the prisoners’ health. These delays are extremely demoralising to the doctors caring for those prisoners, their patients.
Mental illness in prisons
‘It is government policy that prisoners on remand who have a serious mental disorder should be transferred to psychiatric hospital, but this is often not done. Even when a prisoner is transferred there are delays, during which the prisoner remains in prison and is at increased risk of self harm and suicide. Studies conducted in one London remand centre showed that two thirds of psychotic men were rejected for hospital admission and the outcome was even worse for other diagnoses.’ Psychiatrists in London, 1996. (Brooks, D., Taylor, C., Gunn ,J., Maden, A. (1996) ‘Point prevalence of mental disorder in unconvicted male prisoners in England and Wales’, British Medical Journal, Vol.313, pp.1524-7).
The general prison system is no place for the mentally ill. Research on the prison population, however, confirms that many prisoners suffer from psychiatric disorders. The high incidence of mentally ill individuals in UK prisons was noted by a series of studies and reports throughout the 1990s. A study undertaken by the Office of National Statistics, for example, found that 7% of sentenced men, 10% of men on remand and 14% of women in both categories suffered from psychotic illness in the previous year as compared to 0.4% of the general adult population. (Fryers, T., Brugha, T. (1998) 'Severe mental illness in prisoners', British Medical Journal, Vol. 317, pp.1025-6). A 1996 study indicated that over 60% of unconvicted male prisoners held on remand were suffering from mental disorder and some of these were judged to have an immediate treatment need that was not being met. (Brooks, D., Taylor, C,. Gunn, J., Maden, A. (1996) ‘Point prevalence of mental disorder in unconvicted male prisoners in England and Wales’, British Medical Journal, Vol.313, pp.1524-7.)
Extrapolating from the results obtained, the authors concluded that about 680 men held on remand in England and Wales needed to be transferred to hospital for psychiatric treatment, including about 380 with serious mental illness.
Effective diversion schemes which effectively separate out people with mental illness at the beginning of any custodial process and in advance of judicial proceedings are essential. In the UK, it is government policy that, wherever possible, mentally disordered offenders should receive care and treatment from health and social services. (Department of Health and Home Office (1992) The Reed Report, London.)
Although diversion schemes have been established for adult offenders, health professionals continue to express concern about the lack of similar diversion schemes for adolescent offenders. A study published in 1999, for example, indicated the existence of previously undiagnosed psychosis, neurotic illness and emotional disorders among children and adolescents appearing before the Manchester Youth Court. (Dolan, M,. Holloway, J., Bailey, S., Smith, C. (1999) ‘Health status of juvenile offenders. A survey of young offenders appearing before the juvenile courts’, Journal of Adolescence, Vol.22, pp.137-44.)
Seventeen percent of the young offenders were not registered with a general practitioner and generally the young people had a low level of contact with primary health care. Regular psychiatric clinics were subsequently established in the Youth Court and these worked with other agencies to improve health care provision for young offenders.
Research has found that in the UK mentally ill prisoners, once detained, frequently fail to receive appropriate psychiatric care. It is also vital that appropriate specialist care is available for prisoners who become mentally ill during the course of imprisonment. Although many prisoners have significant mental health problems, they do not necessarily meet the criteria for transfer to the National Health Service under the Mental Health Act 1983. As Reed et al point out, outside prison these patients would be under the care of a consultant psychiatrist whereas in prison they are often under the care of a prison doctor who has little training in psychiatry. (Reed, J., Lyne, M. (1997) 'The quality of health care in prison: results of a year's programme of semi-structured inspections', British Medical Journal, Vol. 315, pp.1420-4.)
Even where the patient is considered to need treatment under the Mental Health Act, obtaining a transfer may prove difficult. In 1998, the Prison Service of England and Wales estimated that 2,000 prisoners should be transferred to National Health Service psychiatric care but could find places for only about 700. (House of Commons Hansard Vol 308. No. 142. 19 March 1998. Col 1513). In September 1999, the UK Chief Inspector of Prisons conceded that many mentally ill prisoners were not receiving appropriate care but stated that mental health care was now a priority for the Prison Service. Closer collaboration was needed, he said, between the Prison Service and National Health Service and there needed to be more incentives to attract health professionals to work in prisons.
Revalidation
Like all other doctors, prison doctors will shortly have to fulfil the requirements of revalidation and show that they are keeping their clinical skills up to date in order to remain on the Medical Register. It is unclear, however, how the prison healthcare service will make the necessary facilities available for doctors to maintain their professional skills. Prison doctors’ ability to engage in continuing professional development activities alongside their NHS colleagues has been a long standing problem.
The risks of doing nothing
Law and order
If prisoners continue to be allowed to return to society with untreated mental illness or chemical dependency problems, this will inevitably impact upon the level of criminal activity, which in turn will result, for example, in increased insurance premiums. These ‘causes of crime’ are frequently ignored by politicians who are nevertheless keen to be seen as ‘tough on crime’.
Demoralisation and erosion of services
Reports from the Chief Inspector of Prisons are so commonly highly critical that there is a risk that the public will accept as inevitable the gross problems of overcrowding, poor resources, excessive prisoner to staff ratios and the resulting poor morale of medical practitioners working with prisoners. Complacency, however, must be challenged. We are losing experienced prison doctors, and new doctors are being deterred from entering the service, with the resultant risks of further deterioration of the medical services provided to those in prison.
Public health
Failure to support prison doctors will inevitably affect both prisoners’ health and the wider public health in the long run. People who come out of prison after serving their term, if they are still suffering from inadequately diagnosed or insufficiently treated conditions, will inevitably affect the wider public health. Many prisoners also contract HIV or other communicable diseases while in prison which could be treated much more quickly and effectively in prison.
Recommendations
- Government recognition of the need for greater financial support for prison health services to maintain an efficient and high quality prison medical service and to enable it to compete with the NHS for high quality doctors and nurses.
- Changes to prison doctors’ terms and conditions of service to give them guaranteed study and training time, organised by local NHS groups, in order to keep their skills up to date.
- A comprehensive health needs analysis of the prison service should be commissioned.
- As far as possible, prison doctors should be recognised as having the same duties and rights to exercise clinical independence as other doctors. Prison doctors are generally aware of resource limitations but must have a voice in deciding how services should operate within those restraints. It is unacceptable to exclude them from priority setting and the drawing up of protocols governing their prescribing practice.