The health of prisoners

We should be doing something to improve the current appalling situation

Prisons are a public health issue because all except 23 of the 67 500 prisoners currently in prison in England and Wales are going to come out and return to society. The Office of National Statistics reported in October 1998 that 70% of them were suffering from some form of identifiable personality disorder. When the United Kingdom government produced its white paper on the subject of the 2500 people who were alleged to be suffering from a dangerous and severe personality disorder, it reported that 400 of these were in the three special hospitals, 700 somewhere in the community, and 1400 in prison. At least 60% of prisoners were using class A drugs at the time of reception, which implies the risk of blood transmitted viruses such as HIV and hepatitis C. Thirty four per cent of all young offenders were living alone, and many prisoners were living rough before reception, so it is small wonder that tuberculosis in prisons is on the increase, and so on.

A guard checks on an inmate; the quality of medical care for prisoners is questionable

When I took over the post of Her Majesty's Chief Inspector of Prisons in December 1995 I was dumbfounded to find that, alone in the United Kingdom, prisoners were not allowed access to the National Health Service. Prison service health care was not part of the NHS and never had been, allegedly claiming in 1947 that it was the oldest health care service in the country and so it did not need to join. The end result was that only 10% of prison senior medical officers were qualified to act as GPs in the NHS, and health care centres were woefully understaffed with qualified staff.

When I remonstrated with the director general that the director of health care was not doing anything to resolve this, I was told that he was not the director but adviser to the Prisons Board. The Prisons Board, none of whose members were medically qualified, directed health care. Small wonder that it was so poor.

In November 1996 I published a discussion document Patient or Prisoner? in which I advocated that the NHS should be made responsible for prison service health care as quickly as possible.1 The result of this was the eventual setting up of a working party, followed by the establishment of a joint NHS/prison service task force, which was charged with ensuring that every prison had a primary, secondary, and mental health contract, with the nearest appropriate provider, within three years. So progress is being made, but it is all painfully slow.

Does this matter? I submit that it does. The statement of purpose of the prison service (which has been on every prison notice board since 1983) states that its duty is to keep secure those sentenced by the courts, to treat them with humanity, and to help them to lead useful and law abiding lives in prison and on release. There can be no argument with this. When I inspected prisons, I judged them according to whether they were healthy or not. A healthy prison was one in which everyone felt and was safe, everyone was treated with respect as a fellow human being, all prisoners were encouraged to improve themselves and given the opportunity of doing so through access to purposeful activity, and all prisoners were enabled to maintain contact with their families and prepare for release. Health care was looked at under the heading of safety because, among other aspects, we did not want centres to become safe havens for those who were being bullied. Antibullying policies should prevent that, and centres should be used only by those who needed 24 h nursing.

But, under the heading of respect, we looked to see whether the word “equivalence” applied. This is the word that the prison service uses to describe its health care provision compared with what could be expected in the community. I believe that this not only means equivalence of access and provision but equivalence of professional qualification and skills in doctors and staff. Thankfully the royal colleges have entered this particular fray, and there are now award diplomas to both prison doctors and nurses.

But there is still a long way to go, particularly in the treatment of those with personality disorders and other mental health problems. Nothing is worse for these people than to be locked up alone in a cell all day with nothing to do, the lot of far too many prisoners. I was distressed every time a nurse or practitioner told me that all they could do was watch people's condition deteriorate, meaning that they would be worse when they went out than when they came in, which brings me back to the public health issue. Nothing could be more irresponsible than to make people worse, particularly when that was so far removed from the aim of the criminal justice system, of which prisons are a part, namely to protect the public by preventing crime. If the mental condition has contributed to the crime, and prison has made that worse, prison is an accessory before the resulting further offence.

There is a general ignorance about prisons, accompanied by such suggestions that there are no votes in them. I contend that the public does need to know what goes on in them because they are their prisons, from which prisoners will return to their communities. Their physical and mental health when they return does matter and is something that they should both know and protest about if their future safety is affected.

David Ramsbothom, former chief inspector of prisons, United Kingdom


studentBMJ 2002;10:1-44 February ISSN 0966-6494

1. Home Office. Patient or prisoner London: Home Office, 1996.