Editor's Choice | This Week in BMJ | Press releases
BMJ No 7099 Volume 315 Personal view Saturday 5 July 1997
Should prisoners have a say in prison health care?The prison service is rarely out of the media spotlight. One issue is the delivery of health care, which was the subject of a report by Her Majesty's Chief Inspector of Prisons, entitled Patient or Prisoner? A new strategy for health care in prisons.The prison medical service may have taken on a new look for the 1990s and changed its name to the healthcare service for prisoners following the efficiency scrutiny seven years ago, but it seems that this face lift has achieved little and fooled no one. With continuing cutbacks, an escalating prison population, and a growing suicide rate in prisons, is it any wonder that morale among prison staff is low and that there should be an increasing gap between health services provided inside and outside prisons? Many prisoners have only limited contact with healthcare services. Official reports scrutinising the needs of prisoners draw information from many sources, but the opinion of the prisoner is seldom sought. An opportunity to work with remand prisoners has led me to believe that more attention needs to be paid to prisoners' opinions. Policies which are implemented without taking these views into consideration are one sided and are unlikely to be effective. As part of my research looking at mental disorder in remand prisoners, I visit a large local remand prison on a regular basis. Over a seven month period a research colleague and I spent part of every working day in the prison. We approached each newly remanded prisoner and with their consent interviewed them to screen for mental disorder. Between us we saw nearly 570 men; only 19 refused to be interviewed. In the knowledge that the information was confidential, most were willing to take part in the study and discuss their problems, despite knowing that we could do nothing directly to help them. I was struck by the number who were concerned about the standards of health care and who thought that research was worth while. Many of the prisoners had problems, with over one quarter suffering from a diagnosable mental disorder and over a half regularly consuming drugs or alcohol to abuse or dependency levels. A substantial number of those with mental disorder had not been receiving any treatment before they were remanded and many of them were not registered with a general practitioner. Most prisoners had previous, personal experience of prison health care and quite a number of others had some knowledge of it gained from friends or relatives who had been in prison. A substantial number commented about health care in prisons. Although some were favourable, the vast majority were not and in many cases their concerns seemed justified. Comments such as "They [prison health- care staff] are just part of the system that's here to punish us" epitomised the view, widely held among prisoners, that the prison medical staff were part of the establishment and that they did not have the health or other interests of prisoners as a priority. One acutely psychotic young man who was taken away to see the prison doctor while I was in the middle of interviewing him returned after a few minutes. "The officer in the room told me to stand in front of the desk," he said. "The doctor didn't look up, he said something or other, but I don't think he asked me any questions so I didn't tell him anything and that was it." Other prisoners were even more reluctant to disclose information and some said they had deliberately withheld information from prison medical staff for fear of the consequences. "I learnt my lesson the last time I was inside," one prisoner said. "I was suicidal after my brother died. I told them and they put me in strips. You wouldn't treat a dog like that. I wouldn't tell them anything now." A considerable number of prisoners suffering from mental health problems realised their need for treatment and had realistic views concerning this. Many, however, did not trust the prison healthcare system enough to help them and so elected to try and manage their problems themselves while in prison. One inmate, who gave a clear history of recurrent major depression, told me, "They don't want to know and they don't listen. If you make a fuss you make it worse for yourself. You're better trying to get your head down and get it sorted on the out." He went on to tell me about a previous remand to another prison where he had ended up in segregation because he had lost his temper with the doctor who had discontinued his antidepressant medication. As a result, he told me that he intended to try and manage his depression himself, using illicit drugs if necessary, until he was released. Health care for prisoners stirs up strong emotions which can result in controversial and contrasting opinions. Some people may be concerned about the potential for prisoners to misuse improved healthcare services. But adequate health care for prisoners is not a privilege, it is a basic necessity. There will always be some who abuse the system, and disruptive, antisocial, manipulative individuals are certainly over-represented in the prison population. The attitudes and self destructive behaviour of these prisoners make them difficult to manage and can serve to reinforce prejudice towards those with mental health problems. But many prisoners do have concerns which are valid, expectations that are realistic, and suggestions that if listened to could help resolve at least some of the problems that hamper the delivery of health care in prisons. We can no longer treat prisoners as the passive recipients of health
care. If the healthcare service is to provide an effective service then
prisoners need to play an active role. Prison is supposed to be about
rehabilitation as well as punishment. Rehabilitation involves promoting
health, so p My experience has appalled me, but it has also spurred me on in an
academic career and made me consider further research specifically
focused on the way in which health care is delivered to prisoners.
Luke Birmingham, clinical research associate in forensic
psychiatry, Newcastle upon
Tyne
|