Solution to treating prisoners in hospital is financial

EDITOR,--The situation that N Needham-Bennett and I Cumming describe in a prison health care centre1 is all too familiar,2 despite successive initiatives to improve provision for mentally disordered prisoners.3 4 We take issue, however, with the authors' proposal that the Mental Health Act 1983 should be revised to allow compulsory psychiatric treatment in prisons.

In March 1992 the Department of Health and the Home Office invited proposals from the four Thames regional health authorities to provide a better service for mentally disordered male prisoners remanded into custody. Our successful proposal combined a medical and nursing prison based assessment service and a 14 bedded locked ward exclusively for the inpatient care of mentally ill men who would otherwise have been remanded into custody. In its first year the service saw 150 referrals and admitted 62 patients, who had been charged with offences ranging from murder to shoplifting. A full description of the service is in preparation, as is a report of an independent audit of the impact of the service on the remand population at Wormwood Scrubs prison. More than half of those seen were referred within two weeks of their remand into custody. More than two thirds of those referred were assessed within five days of referral. Of those for whom admission was recommended, one fifth were admitted within five days and more than half within two weeks of assessment.

The independent evaluation has confirmed the success of our service. We are currently funded entirely through regional health budgets, without any contribution from the Home Office. A major determinant of our costs has been the delay in concluding cases dealt with at crown courts: the mean length of admission for cases dealt with at magistrates' courts is 42 days and at crown court 95 days. We are therefore constrained in the clinical management of patients by external judicial processes over which we have no control and which substantially increase the cost per admission. In addition, we are responsible for transporting and escorting our patients for court appearances; this cost would otherwise be met by the Home Office. Should local purchasers be responsible for these costs in future?

We are convinced that the proper place for mentally disordered prisoners requiring hospital treatment is hospital. We have shown that the problems described by Needham-Bennett and Cumming are not insoluble; the solution is not legislative but financial. The delays inherent in the resolution of serious cases inflate our costs. We have expressed our concerns to the Home Office but have received only an acknowledgement. In the absence of any acceptance of joint responsibility by the Department of Health and the Home Office for funding services for mentally disordered remand prisoners, we believe that the current situation is a disaster that is already happening.