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Rapid Responses: Rapid Responses published:
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Impossible task imposed on prisons
- richard J simpson (2 September 2003)
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A missed opportunity for integrated care
- Dr Francis Labinjo (4 September 2003)
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prison consultative apporach welcomed
- Ruth E Martin (4 September 2003)
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Prison Focus Groups: Effecting change
- Jo Nurse, Simon Blasby, Jim Gomersall, Paul Woodcock, Jim Ormsby (26 September 2003)
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A`mental health promotion in prisons checklist exists
- Dr Alexander Gatherer (15 January 2004)
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Should assisted suicide be an option for prisoners?
- Richard G Fiddian-Green (16 January 2004)
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richard J simpson, Senior Medical Officer GDPS Glasgow Primary Car Trust woodside health centre, barr st, Glasgow,G20 7LR
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Editor Nurse Woodcock and Ormsby's paper is a welcome qualitative study providing factual confirmation of a fact that has long been opinion. The HM Inspectors of prisons in Scotland and England and Wales have repeatedly pointed out the detrimental effects of isolation and lack of quality programmes. Having worked in HM Cortonvale prison for 23 years before becoming Deputy Minister for Justice in the Scottish Executive I was very concious of the need for community based solutions particularly to drug related crime where custody often worsened associated mental health problems and also according to Home office research provided opportunities to establish networks for future drug dealing The Scottish Prison Service [SPS] in its 'Key performance indicators' agreed with the Scottish Executive have substantially increased the hours available to prisoners for education work and courses addressing offender behaviour. The SPS has successfully exceeded the targets set. However the increasing numbers of short term prisoners, especially those on remand and the increasing numbers with a drug or drug and alcohol problems has made the task of the SPS more difficult. The other major factor in preventing a solution to this problem in Scotland is the requirement on the SPS to provide an escort service to court. This overriding requirement often removes substantial numbers of officers at short notice from the prison interrupting all programmes. The Scottish Executive have responded by taking the power in the most recent Criminal Justice Bill [2003] to transfer escort duties out of the current SPS. The courts continue to remand increasing numbers of prisoners and to imprison large numbers for two weeks or less for fine default and many more for less than 3 months [in Scotland around 6000/25000 male admissions for fine default and 600/2200 female admissions with similar numbers for remand]. These short term prisoners then re-offend in over 40% of cases young offenders in nearly 70% of cases This approach to remand and sentencing is ineffective both in punishment terms and in preventing re- offending. It is extremely expensive (>£28,000 per prisoner per annum £36,000 for women). For many custody should be replaced by a community based approach which avoids the additional damage done to prisoners especially those with pre- existing mental health problems and will reduce ultimately the damage to society and the burden on prison services caused by short periods of custody. Community solutions should include bail hostels, community reparation orders[proposed in the 2003 manifesto by the Scottish Labour party], 'Time Out ' 'treatment' centres of which the first for women offenders with drug problems will be opened in Glasgow this autumn treating 500 short term offenders annually, and electronic tagging on remand . These measures should be combined with more imaginative custodial approaches including admission for some non-violent offenders at a time when overcrowding permits instead of immediately, overnight custody and weekend prison with sentences calculated in hours rather that weeks or months. All of these measures would reduce overcrowding and allow the prisons improve prisoner management reduce isolation and address re-offending behaviour. Until we stop overcrowding our prisons with those who have drug problems and are in custody for too short a time to benefit from 'treatment'. Until the personal development plans required for each prisoner includes an entitlement [in the absence of contravention of prison rules] to minimum access to out of cell activities, the problem of isolation will continue to be a problem. Competing interests: None declared |
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Dr Francis Labinjo, Consultant in Addiction West Kent NHS & Social Care Trust
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The authors of this study are to be congratulated for highlighting what I knew as a prison senior medical officer and head of health care. Prisoners with dual diagnosis of mental illness and substance abuse have more complex needs, let alone in prison. Despite having the clientele under one roof prisons will miss the opportunity to implement integrated care programmes for comorbid prisoners and to address more complex needs of homelessness, blood borne viruses, suicidality and to make lasting psych-social interventions that would ultimately reduce harm to the individual from illicit drug use, and harm to society from re-offending. The ethics of managing a patient in conditions akin to seclusion apart, the tasks of engaging and retaining of prisoners in treatment and facilitating re-introduction into the unsuspecting community become more difficult. It might be that we as a society need to shift our emphasis to an agenda involving human values of prison staff and prisoner/patients alike, and by focusing more on these we can help both through more appropriate resourcing. We might then right claim to have a moral mandate for putting mentally disordered offenders in prison. References: 1. Jo Nurse, Paul Woodcock, and Jim Ormsby Influence of environmental factors on mental health within prisons: focus group study BMJ 2003; 327: 480-0 2. Models of Care for treatment of adult drug users. Part 2: Department of Health. www.nta.nhs.uk Competing interests: None declared |
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Ruth E Martin, Clinical Assistant Professor UBC Department of Family Practice, 5804 Fairview Crescent, Vancouver, BC, V6T 1Z3, Canada
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I have worked in the medical clinic of a Canadian prison for women (remand, medium security, and high security) since 1994. I concur with the findings of this study, and complement the authors on their work. That high risk behaviour, leading to the transmission of blood bourne pathogens, occurs when addicted men and women are locked up in prison, is well-known. However, the reasons why some inmates become drug addicted during their incarceration, are less well known. This study adds to our understanding. We will only succeed in increasing our understanding of prisoner ill- health if we design consultative studies, such as this one, in which prisoners and prison staff tell us their stories. Similarly, we might succeed in improving prisoner health if we invite prisoners and prison medical staff to give input into the design, and implementation, of prison health interventions. Competing interests: None declared |
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Jo Nurse, SpR in Public Health London School of Hygiene and Tropical Medicine, Simon Blasby, Jim Gomersall, Paul Woodcock, Jim Ormsby
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Dear Editor, Following on from the prison focus group study by Nurse et al (1) conducted in 2000, a number of changes have occurred in Winchester Prison. The initial findings of the focus group study were used to develop a Health Improvement Programme for the Prison based on the views of the community with a health promoting ethos(2,3). This has led to the creation of a prison-based part-time health promotion specialist. A number of initiatives have been introduced that potentially improve prisoner and staff mental health by addressing factors in the wider prison environment: An in-reach Community Mental Health Team has since been developed to work with prisoners with mental health problems and aims for equivalence of care with the NHS. A NGO provides mental health training for prison staff, (though limited prison resources have limited the number of prison officers released for training). An on-going occupational health pilot project succeeded in halving the previously high staff absenteeism rate, which contributed to breaking the circle of stress. ‘Enhanced Thinking Skills Programme’ and the ‘Control Your Anger and Learn to Manage It’ courses, have been introduced to tackle recidivism by challenging the way that prisoners cognitively process their perceptions of the world around them, and allow them opportunities to develop and practise new strategies. These courses have the potential to impact upon the spiral of negative relationships between staff and prisoners. Focus groups conducted in 2002 in the same prison, confirmed that isolation and lack of activity remained key factors impacting negatively on the mental health of prisoners, despite the prison having one of the highest levels of purposeful activity of any local prison in the region. The work which was available was seen as dull and repetitive (e.g. fitting chains to ball point pens). Findings suggested that relationships with prison staff had improved, thereby diffusing the circle of stress. The restricted use of the telephones remained a source of frustration and stress for prisoners, and further meant loss of free time out of cells spent queueing. Poor access to telephones and limited visiting hours exacerbated already strained family ties. The issue of bullying of vulnerable prisoners by other prisoners remained a high priority for this group. There were reports of social distance between members of different ethnic groups, and derisory references to gay prisoners. While progress has been made in addressing prisoner mental health through changes in the prison environment, barriers remain. Winchester Prison has now been included in the Prison Service’s performance improvement strategy and this initiative, at a time of rising population, may in the short term, further contribute to the ‘circle of stress’. References: 1. Nurse J, Woodcock P, Ormsby J ‘Influence of environmental factors on mental health within prisons: focus group study’ BMJ, 2003, Vol. 327, 30th August, pp.480-483. 2. ‘Health Promoting Prisons: A Shared Approach’ Department of Health, www.doh.gov.uk/prisonhealth (accessed 22.09.03) 3. Health in Prisons Project, Europe ‘Mental Health Promotion Statement on Prisons’ WHO, Europe, http://www.hipp-europe.org/events/hague/0042.htm (accessed 24.09.03). Authors: Jo Nurse, Specialist Registrar in Public Health, Health Policy Unit, London School of Hygiene and Tropical Medicine, London, WC!E 7HT. Email: jonurse66@hotmail.com Simon Blasby, Senior Health Promotion Specialist (Prisons), Mid Hampshire PCT Health Promotion Service, Highcroft, Romsey Road, Winchester, Hampshire. Jim Gomersall, The Governor, HM Prison Winchester, Romsey Road, Winchester, Hampshire. Paul Woodcock, Health Promotion Specialist, Public Health Directorate, Western Sussex PCT, Bramber Building, 9 College Lane, Chichester. Jim Ormsby, Consultant Forensic Psychiatrist, Ravenswood House, Knowle, Fareham, Hampshire, PO17 5NA. Competing interests: None declared |
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Dr Alexander Gatherer, retired Cheshire WA4 5QD
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I greatly welcome the initiative of Dr Nurse and colleagues in drawing further attention to an important subject. As their conclusions are of value beyond the UK, I hope that their article is widely disseminated in the prison systems of Europe. It could however have included reference to the "Mental Health Promotion in Prisons Consensus Statement" published in 1998 by the WHO Health in Prisons Project, based in Copenhagen, with its partner organisation Mental Health Europe. This Report includes a management checklist which, if followed, would considerably help to reduce the impact of environmental factors on mental health in prisons.A copy of the Statement and other information about the work of the WHO HIPP can be found at: www.hipp-europe.org Alex Gatherer Competing interests: Acting as temporary consultant to the WHO Health in Prisons Programme |
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Richard G Fiddian-Green, None None
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Judging from the outcry following Shipman's suicide it would seem that there is basic need to see justice being done and for revenge in the case of violent crimes. That is neither a civilised nor a Christian response. The only justification for imprisonment and capital punishment should be the prevention of new crimes. If this were to be accepted by the public the offer of assisted suicide would aid in accomplishing that objective in an humane way. Shipman's suicide was premeditated and very carefully planned and executed judging from the way he managed to give the impression he was looking forward to see his wife for his birthday. He had clearly concluded that he was not going to prove his innocense and was likely to spend the rest of his life in a hell-hole. In making sure that his wife was not left destitute he did the honorable thing. His actions have certainly saved the state a lot of money. Competing interests: None declared |
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