BMJ No 7120 Volume 315
Papers Saturday 29 November 1997
The quality of health care in prison: results of a year's programme of semistructured inspections
John Reed, Maggi Lyne
Abstract
Objectives: To assess, as part of wider inspections by HM Inspectorate of Prisons, the extent and quality of health care in prisons in England and Wales.Design: Inspections based on a set of "expectations" derived mainly from existing healthcare quality standards published by the prison service and existing ethical guidelines; questionnaire survey of prisoners.
Subjects: 19 prisons in England and Wales, 1996-7.
Main outcome measures: Appraisals of needs assessment and the commissioning and delivery of health care against the inspectorate's expectations.
Results: The quality of health care varied greatly. A few prisons provided health care broadly equivalent to NHS care, but in many the health care was of low quality, some doctors were not adequately trained to do the work they faced, and some care failed to meet proper ethical standards. Little professional support was available to healthcare staff.
Conclusions: The current policy for improving health care in prisons is not likely to achieve its objectives and is potentially wasteful. The prison service needs to recognise that expertise in the commissioning and delivery of health care is overwhelmingly based in the NHS. The current review of the provision of health care in prisons offers an opportunity to ensure that prisoners are not excluded from high quality health care.
Introduction
Health care in prisons has long been a matter of concern.(1,2) Research has shown high levels of mental disorder(3-5) and drug misuse(6,7) and general poor health among prisoners.(8) Health screening on entering prison is only moderately effective,(9) and the Health Care Service for Prisoners is at times seen by prisoners as more interested in the needs of the prison as a secure institution than their needs as patients.(10) The practice of shackling patients - especially women - has been widely criticised.(11-13) On the other hand, it has been claimed that the Health Care Service for Prisoners provides quicker access both to primary and specialist care than the NHS does, and all prescription are free.(14)
HM Inspectorate of Prisons
Since 1791 prisons have been subject to inspection, but only in
1979 was a truly independent inspectorate of prisons
established.(15) The inspectorate's work comprises
announced inspections lasting a week, shorter unannounced inspections,
and a series of thematic reports. Inspection reports are public
documents available from the inspectorate or on the internet
(www.penlex.org.uk).
In 1996 a review of prison health care by the inspectorate concluded that it was no longer sensible to have a healthcare service for prisoners separate from the NHS, and that disadvantages arose from having two parallel systems.(16)
We report some results from the inspection of 19 prisons (for men, women, and young offenders) in England and Wales from September 1996 to August 1997. The prisons have a population of some 7,250 prisoners, about 12% of the total prison population.
Methods
The inspectorate works to a set of "expectations" of the level and quality of service that it expects to find in prisons. Expectations for health care(17) are based on existing healthcare quality standards in the prison service,(18,19) and, for areas not covered by these standards or for which the published standards are not explicit, they reflect the standards in the NHS as the prison service has a commitment to provide "the same standards of health care as those provided by the NHS." (20)
Healthcare inspections - carried out by a doctor and, when necessary, a nurse - last one to three days and involve (a) visits to all healthcare areas, (b) discussions with staff (both those employed by the prison and visiting specialists), (c) review of the annual reports on health care in the prison and of local guidelines and protocols, and (d) meeting patients both individually and, when appropriate, in a group. During a full inspection 10% of inmates are asked to complete a questionnaire about aspects of prison life. The sample is not random, though attempts are made to ensure that all categories of inmate get questionnaires. The questionnaire allows responses on a five point scale from 1 (very bad) to 5 (very good) to the question, "how would you describe the quality of the healthcare service?" It also asks about health screening on entry to prison and provides space for comments on any aspect of life in prison.
Inspection reports make recommendations to the prison and to a range of bodies such as prison service headquarters (including the Directorate of Health Care - equivalent in function to the NHS Executive) and to external bodies.
Results
Questionnaires
Questionnaires were circulated in the 10 prisons receiving full
inspections. The figure shows the ratings given by prisoners to the
quality of their prison's health care. The ratings varied considerably
between prisons. All prisoners must undergo health screening on the day
of entry and be examined by a doctor within 24 hours. Questionnaire
results showed that 85.9% of prisoners reported having had a
healthcare assessment and that 84.9% felt free to tell the nurse or
the doctor of any problems (figure). In 3 of the 10 prisons, however,
less than 80% of inmates felt able to talk freely to healthcare staff
on entry; the prison with the lowest percentage (68%) also scored
worst in the overall rating for quality of health
care.
Responses of prisoners in 10 prisons who completed questionnaire about health care at their prison
Assessing need
Health Care Standards (No 3) requires prisons to
conduct an assessment of need for health care and suggests seeking
specialist advice. None of the 19 prisons had conducted a needs
assessment, though two had made some preliminary moves in that
direction. None had sought advice.
Budgets
No prison knew its overall budget for health care, though all knew
the locally held budget for drug treatment and visiting specialists.
Budgets were decided on the basis of the previous year's budget,
taking account of planned changes and of a reducing overall prison
budget.
Managing health care
Ten prisons had a clear healthcare management structure, with a
managing medical officer who sat on the prison senior management team.
In other prisons a junior governor represented health care on the
senior management team. Clinical, academic, or management meetings
involving all healthcare staff were unusual.
Primary care
Most health care in prisons is primary care. The inspectorate
expects that primary care in prisons will be given by or under the
supervision of doctors who are qualified to work as principals in NHS
general practice. In 10 prisons all primary care was delivered by
doctors who were so qualified. In the remaining prisons much primary
care was given by doctors who had not completed primary care training.
Mental health care
The inspectorate expects that mental health care other than
primary care will be given by or under the direction of a doctor whose
name is on the relevant specialist register. All prisons except two had
arrangements for visits by local psychiatrists (either forensic or
general) mainly to facilitate transfer out of prison. However, many
prisoners have important mental health problems but do not meet the
criteria for transfer to the NHS under the Mental Health Act 1983.
Outside prison they would often be under the care of a consultant
psychiatrist; in prison they are often inpatients in the healthcare
centre.(21) No prison had arrangements for all mentally
disordered inpatients to be under the care of a consultant
psychiatrist, and none provided a full multidisciplinary mental health
team. At one prison, considered by the prison service to be a national
resource for the care of mentally disordered prisoners, neither of the
doctors responsible for the care of inpatients had completed specialist
training in psychiatry or primary care.
Referral and transfer to the NHS
Except in Wales, transfer of mentally disordered patients to the
NHS was reported to be easier than in the past, though still delayed by
disputes about security required in the NHS. Physically ill patients
requiring either a consultant opinion or transfer to NHS inpatient care
were often advantaged over NHS patients; the wait for an appointment or
admission was generally not long. However, 18 of the 19 prisons
reported frequent problems in obtaining staff to act as escorts to
outpatient departments or as "bed watches" for NHS inpatients. This
led to frequent last minute cancellation of appointments at substantial
cost to the NHS. After the criticism last year of the shackling of
patients transferred to hospital, new security procedures were
introduced in January 1997. Inspections will assess the impact of these
changes.
Supervision and support for healthcare staff
Only four prisons had established clinical supervision in the
prison for their nursing staff. Visits by senior nursing colleagues
from the Directorate of Health Care were rare; the prison service for
England and Wales is covered by only two nursing advisers.
Most doctors were unsupported except by visits every three to six months from their area medical advisers. Few doctors were members of medical royal colleges, and those who were, often thought their colleges irrelevant to their work. Two doctors had serious (but previously undetected or unresolved) health problems that might have affected their professional capabilities.
Hours of work
Most prisons had established sensible hours of work for their
staff, but difficulties in recruiting staff, especially nurses, meant
that these hours often could not be maintained. Several prisons had
failed to make adequate arrangements for medical cover, so that doctors
had excessive on call commitments. At three prisons the medical officer
was on duty continually unless he or she made arrangements for cover;
one of these prisons had failed even to provide the doctor with a
mobile phone. At two other prisons the doctor was on duty every day and
every other night and weekend.
Continuing professional development
All prisons had a commitment to continuing professional
development for doctors and nurses, but all except one reported serious
shortage of money to fund such programmes. At one prison, for six years
staff had to use annual leave to attend courses and meetings. Twelve
prisons were meeting the postgraduate education and practice
requirements of the United Kingdom Central Committee for Nursing and
Health Visiting (UKCCNHV).
Pharmacy and supply of drugs to patients
Although Health Care Standards (No 9) requires a
legal and ethical pharmacy service, the prison service claims Crown
immunity in this area; at the time of these inspections the
inspectorate team did not include a pharmacy inspector.
Prescribing patterns varied widely. At one prison two thirds of the prison population was estimated to be receiving regular drug treatment, usually benzodiazepine tranquillisers or hypnotics. In contrast, six prisons operated a policy of not prescribing benzodiazepines or hypnotics except for withdrawal and were highly successful in weaning patients off treatment; one of these prisons was frustrated by the speed with which patients re-established benzodiazopine prescriptions from NHS general practitioners after release before re-entering prison after a further offence.
Nursing staff often found it difficult, owing to staff shortages, to
meet the UKCCNHV's standards during treatment rounds. At one prison,
nurses had to give patients treatment based on unsigned treatment cards
as doctors often failed either to cancel or to renew p Audit Health care is, understandably, a secondary function for prisons,
though they aim to achieve equivalence with the NHS.(20)
Some health care in prisons is of good quality and broadly similar to
good NHS care, but the quality of care varies. Several areas cause the
inspectorate particular concern: entry procedures, ethical standards,
the experience and training of medical staff, the external support
available for healthcare workers, and the arrangements for purchasing
health care and for audit and monitoring.
Entry procedures Ethical standards Limited guidance on ethical practice is available. Standing
Order 13, which is not mandatory, requires medical officers
"at all times observe the United Nations Code of Medical Ethics and
principles relating to health personnel in the protection of prisoners
and detainees." The Health Care Standards require
"strict adherence to professional standards and ethical codes." The
United Nations's Declaration on the Principles of Medical
Ethics,(22) the World Medical Association's Declaration of
Tokyo (1975), and the World Psychiatric Association's Declaration of
Hawaii (1983) are not commonly available to doctors working in prisons
who face difficult ethical decisions daily. What these principles mean
to the practice of health care in prisons in England and Wales needs
wide debate, with published guidance for staff.
Experience and training of doctors Managing medical officers are required to ensure that staff training
needs are met, and the prison service as a whole has a target of five
days' training a year for each staff member. This is broadly similar
to the time required to gain the postgraduate educational allowance by
NHS general practitioners; it compares less well with the
recommendations of professional organisations, some of which have
recently reviewed the need for continuing professional development. The
Royal College of Psychiatrists, for example, recommends 150 hours
annually of continuing professional development. A statement of the
qualifications and experience required for working in prisons, together
with mandatory standards for continuing professional development, is
urgently needed.
Support for staff Purchasing health care Audit and monitoring Conclusion Prisoners retain the right, as set out in the United Nations's
declaration, to have health care equivalent to that available to those
outside prison.(24) But for many prisoners this right is not
met, and the chain of responsibility and accountability to ensure that
it is met has become more uncertain now that individual prisons are
responsible for purchasing health care. The position would be clarified
if responsibility for health care was separated from their custodial
function and transferred to the Department of Health's ministers. Back
in 1962 a Home Office working party, set up to consider how the prison
medical service was organised and how relations with the NHS could be
improved, was told by all major healthcare bodies, except the BMA, that
the prison medical service should be integrated with the NHS. The
working party recommended no change.(25) Similar advice,
given to the May Committee in 1979, was again rejected.(26)
The "efficiency scrutiny" of the prison medical service in 1990
received evidence about many of the concerns reported in this paper and
recommended the development of a purchaser-provider split in prison
health care, assuming that much care would be contracted in from the
NHS and that concerns about quality could be met in the contracting
process.(27) This has not always been the case.
The response to the inspectorate's 1996 review overwhelmingly
favoured integration of the NHS and the Health Care Service for
Prisoners, and it showed that health authorities were keen to play a
part in purchasing health care in prisons.(16) Recently
France has shown that integration of prison health care into the wider
national health service can succeed. The announcement by ministers in
both the Home Office and the Department of Health that the provision of
health care in prisons will be reviewed means that an opportunity now
exists to resolve this longstanding problem.
We thank the governors, staff, and inmates of the prisons
inspected for their unfailing openness and cooperation.
Funding: HM Inspectorate of Prisons.
(Accepted 11 November
1997)
HM Inspectorate of
Prisons,
Correspondence to: Dr Reed
email: JohnReedCB@compuserve.com
References
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15 Stockdale E. A short history of prison inspection in England.
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16 HM Inspectorate of Prisons. Patient or prisoner?
London: Home Office, 1997.
17 HM Inspectorate of Prisons. Expectations of the
availability and quality of health care in prisons in England and
Wales. London: HMIP, 1996.
18 HM Prison Service. Standing order 13 - health
care. London: Home Office, 1991. (As amended, 1994).
19 HM Prison Service, Directorate of Health Care. Health
care standards for prisons in England and Wales. London: Prison
Service, 1993, 1996.
20 Home Office. Custody, care and justice: the way ahead
for the prison service in England and Wales. London: HMSO,
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21 Prison Service Report of the Director of Health Care
1995-1996. London: Stationery Office, 1997.
22 United Nations. Declaration on the principles of medical
ethics. New York: United Nations, 1981.
23 Department of Health, Home Office. The government's
response to the advisory committee on mentally disordered offenders'
recommendations. London: DoH, Home Office, 1997.
24 Committee on the Prevention of Torture and Inhuman or Degrading
Treatment or Punishment. Report to the United Kingdom government
on the visit to the United Kingdom. Strasbourg: Council of
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25 Home Office. The organisation of the prison medical
service. London: HMSO, 1964.
26 Committee of Inquiry into the United Kingdom Prison Service.
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27 Home Office. Report of an efficiency scrutiny of the
prison medical service. London: Home Office, 1990.
Only four prisons were conducting audits of any aspect of their
activity. Discussion
Questionnaire results show that a large majority of prisoners feel
able to talk freely at entry, in contrast with research findings in
individual prisons.(9,10) But this result hides wide
variations, which may reflect differing case loads. Although entry
procedures can work well in quiet prisons, in busy prisons with up to
100 prisoners arriving each day, effective screening and medical
examination is virtually impossible with current working patterns.
One prison had produced a "patient's charter" setting out
what inmates could expect from the healthcare service and what the
service expected of its patients. But in some prisons healthcare staff
adopted over-punitive attitudes. One NHS general practitioner doing
sessional work in prison said of mentally disturbed prisoners: "One
or two nights in the special unfurnished rooms tends to bring them
to their senses." A nurse in charge of a ward said: "What they
young prisoners respond to best is a good shouting at." One
doctor sanctioned the "nursing" of a suicidal patient naked in an
unfurnished room in early spring. Some staff are acutely aware of the
ethical dilemmas they face. As one doctor put it, "I am working in a
substandard service, but at least I know it's substandard. Who knows
who would come here if I resigned?"
Many doctors were fully trained to undertake the work they did,
but in some cases doctors were not sufficiently trained to be eligible
to deliver the same care in the NHS. Often they had started but not
completed training in general practice or a specialty. Current criteria
for appointing doctors are not sufficiently exacting: one prison
specified only that they required a "registered medical
practitioner" to run its primary care service.
Healthcare staff in prisons do not have the external professional
advice and support enjoyed by those working in the NHS, though many
nurses said how helpful they found the Royal College of Nursing's
special group for nurses working in prisons. No similar group is
available to doctors, and for many the Directorate of Health Care is
their only source of advice. A better external supporting structure is
needed urgently.
Since 1992-3 governors have been responsible for purchasing health
care for their individual prisons, with the Directorate of Health Care
providing advice on strategy, policy, and standards. Effective
purchasing of health care depends on an understanding of the needs of
the population and on expertise in such purchasing. Needs assessments
have not been done, and prison governors do not have healthcare
purchasing skills. The present policy of seeking to achieve "better
health services and better value for money by contracting with the NHS
and other providers" (21) is unlikely to be successful
unless it is backed by much greater expertise in needs assessment and
purchasing. Creating such expertise in individual prisons or even in
the Directorate of Health Care when it is already available in NHS
health authorities would be wasteful duplication.
The Health Care Standards cover important areas of
practice from entering to leaving prison; if the standards were fully
implemented, they would greatly improve health care in prisons. But
implementing many standards has important resource consequences, and
with a rapidly increasing prison population and a reducing budget it is
not surprising that many prisons have not reached the standards
required. The Directorate of Health Care has tried to audit the
implementation of the standards through the annual reports from
managing medical officers, but inspection showed that annual reports
not infrequently said that standards had been met when they had not.
More effective audit is needed, and failures to reach the standards
should be considered by the Prisons Board,(23) which agreed
their introduction as a way of raising standards.
The Health Care Service for Prisoners is a small, isolated service
that is seen as an unattractive place to work. The work need not be
unattractive - much is fascinating. Many staff are well qualified and
care deeply for their patients despite adverse surroundings and a
difficult clientele. Some health care in prisons is of high quality,
particularly where provision of health care has been contracted out to
a local NHS general practice with a lead general practitioner acting as
managing medical officer. This arrangement often included additional
clinical services (one practice, at no additional cost to the prison,
brought in the practice midwife and community psychiatric nurse). But
some health care is bad; some staff are poorly qualified, and some fail
to operate within a proper ethical framework. These faults require
urgent correction.
Key Messages
The standard of health care in prisons in England and Wales
varies widely - a few provide a quality of care close to that in the
NHS, but many provide low quality care The commissioning of health care and the monitoring of
services in prisons are inadequate More exacting standards for appointing doctors, a mandatory
system for continuing professional development, and better support for
healthcare staff are needed A better ethical framework is essential The NHS should be more involved in both the commissioning and
the provision of health care in prisons
Conflict of interest: None.
Home Office,
London SW1H 9AT
John Reed,
medical inspector
Maggi Lyne, nursing
inspector
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