Editorials

Prisoners: an end to second class health care?

Eventually the NHS must take over 

Prisoners in England and Wales receive inferior health care.^1-3 Soon they should have the same health care as everybody else. At the moment their health care is the responsibility of the Home Office, the government department that oversees the criminal justice system. Soon it should be the responsibility of the National Health Service. Last week a joint report from the NHS and the prison service recommended a "formal partnership" between the two services to improve the health and health care of prisoners.²* The report stopped short of adopting the recent recommendation of the chief inspector of prisons that the NHS should take over prison health care completely.³ But many of those who have watched the excruciatingly long and slow minuet between the prison service and the NHS will think that the final step of the NHS taking full responsibility must and should come soon.

The joint report summarises the familiar problems well. "Health care in prisons is characterised by considerable variation in organisation, and delivery, quality, funding, effectiveness and links with the NHS."² Prison medicine is out of date, with a very "medicalised model of care," focusing on illness not health, and with little attention to prevention, guidelines, multidisciplinary work, audit, continuing professional development, or information. Ironically, those who pine for the NHS of the 1950s might feel comfortable working in an English prison, even down to the nursing staff calling them "Sir." But the staff are central to the problem. Although some nursing staff do remarkable work in difficult conditions, many are security officers first and nurses second; and they have primitive training.

This shaky system has had to try to manage serious, often intransigent, problems in dreadful circumstances. Prisons in England and Wales are overcrowded, insanitary, and dangerous, and there is a very high prevalence of mental health and substance abuse problems among prisoners. Suicide rates are orders of magnitude higher than in the community. Prison is the main sump of British society, and many of those who fall through inadequate mental health services in the community end up in prison. The joint report recognises that the prison service is dealing not just with the 65 000 people in prison at any one time but with the more than 200 000 who pass through prison each year. These people are some of the most deprived in Britain, and a good health service within prisons could help achieve the government's declared aim of reducing inequalities in health.

Prisons have had their own medical service since 1877, making it the oldest civilian medical service.⁴ The service was not incorporated into the NHS when it was founded in 1948, and the prison service has consistently resisted incorporation into the NHS. Many medical bodies, including the Royal College of Physicians, argued to a Home Office working party in 1964 that the NHS should take over.⁵ Nothing happened. The Royal College of Psychiatrists argued the same in 1979, saying that a separate system for a minority group tends to sink to a poor standard.⁶ Again nothing changed. An efficiency scrutiny in 1990 recommended that the prison medical service should be reorganised along purchaser-provider lines,⁷ but this achieved little, concedes the present report.² Most recently, the chief inspector of prisons argued in 1996 that running parallel health systems was worse than pointless.³ The smaller system would always lag behind the larger, and many prisoners are going backwards and forwards from prison to the community. "Only by the NHS accepting responsibility for health care in prisons," said the chief inspector, "can two essentialsequality and continuity of carebe ensured."³

Why didn't the new report go the whole hog and suggest that the NHS take over? Realpolitik is the answer. The Home Office is reluctant to give up control. The NHS has limited stomach for taking on such difficult problems, particularly when it has severe problems of its own. And nobody is keen to negotiate with the Prison Officers Association, which represents most prison nurses and enjoys a formidable reputation for macho trade union behaviour. So "for the time being" a formal partnership is the answer. Funding and departmental accountabilities remain broadly as now. Health authorities and prisons together will conduct needs assessments and develop prison health improvement programmes. A "prison health policy unit" will replace the current "prison service directorate of health care," and a small team will continue the minuet by discussing whether the new unit should be in the NHS or the prison service.

I applaud the joint report for defining specific action points and setting a timetable, and it is by no means easy to create a seamless health service between prisons and the outside community, as I discussed in detail in 1984.¹ But it is hard to escape the simple argument of the chief inspector of prisons and the Royal College of Psychiatrists that any separate service for a marginal group will prove inferior. Fusion is surely the long term answer.

Richard Smith, Editor. 

BMJ

Acknowledgments

*The report does not cover prison health services in Scotland and Northern Ireland, where arrangements are different.

1. Smith R. Prison health care. London: BMA , 1984.
2. Joint Prison Service and National Health Service Executive Working Group. The future organisation of prison health care. London: Department of Health , 1999.
3. Her Majesty's Chief Inspector of Prisons. Patient or prisoner?A new strategy for health care in prisons. London: Home Office , 1996.
4. Gunn J, Robertson G, Del S, Way C. Psychiatric aspects of imprisonment. London: Academic Press , 1978.
5. Home Office. The organisation of the prison medical service. London: HMSO , 1964.
6. The college's evidence to the prison services inquiry. Bull Roy Coll Psychiatr 1979; May: 81-84.
7. Report on an efficiency scrutiny to the prison medical service. London: Home Office , 1990.