Richard Smith: Is prison health better now it’s an NHS responsibility?

richard_smith_2014In the 1980s people in prison received a second class health service despite having a high prevalence of health problems. I visited many prisons at that time and wrote a series of articles for The BMJ.  In those days the Prison Medical Service was part of the Home Office, and there was an argument that if the NHS took responsibility for the health of people in prison then services would improve. In 2006 that happened. So have services improved?

The doctors and others who spoke at a meeting recently on the history of prison healthcare had no doubt that it had. This, they said, can be backed up by both experience and objective data. One psychiatrist talked of how services are better joined up in prison than they are in the community. GPs, psychiatrists, the drug and alcohol services, and occupational health services are all on one site with one medical record, and the record follows prisoners as they move from one prison to another.

Another psychiatrist noted that some NHS commissioners do a better job at commissioning prison health services, starting with the needs of people in prison, than they do community services, where they simply commission so many psychiatric beds. Improved health services have even been associated with reduced rates of reoffending for some people in prison, particularly those with alcohol and drug problems. The environment of prisons has also improved greatly: the stench associated with slopping out that I smelt in the 80s has disappeared.

But things are far from perfect. I was told in the 80s that people in prison (it’s politically correct now, I learnt at the meeting, to talk of people in prison rather than prisoners, not least because for most people it’s a temporary state) comprise the sad, the mad, and the bad in that order of prevalence. And it’s still the case.

Most of those in prisons come from deprived backgrounds, and their health problems stem from their deprivation. Even improved health services in prison cannot reverse deep problems, and several people at the meeting pointed out that the services available in prison do not extend outside the prison where people often find themselves unemployed and homeless. I find it ironic that this has not improved despite the NHS being responsible for services in and out of prison.

The historical perspective of the meeting showed how people in prison have had high rates of mental illness ever since there have been prisons. Those with mental health problems are more likely to be admitted to prison, and prisons exacerbate mental health problems. Separation from society and family, high rates of abuse, lack of meaningful employment, lack of exercise, long hours of confinement, grief, and remorse all aggravate and cause mental illness. Homicide and suicide rates have always been high in prisons and are currently rising in England. And rates of psychosis remain stubbornly high: in prisons the world over about 3% of inmates have schizophrenia.

Segregation or solitary confinement is especially bad for aggravating and causing mental health problems and continues to be common. We heard how Pentonville Prison, which opened in 1842, employed the regimen developed in the US of separate confinement. Prisoners spent 23 hours a day in single cells, were led from one part of the prison to another with hoods over their heads, and attended chapel in separate stalls. The idea, which was religiously inspired, was that you broke a man down and then built him up again as a good man. Unfortunately only the breaking down worked.

The truly and uncomplicatedly bad, which those who have never been in prisons imagine to be the majority, are a small minority.

There was much discussion at the meeting of the dual responsibility of doctors in prison, to their patients and to the prison. Some of the prison doctors I met in the 80s thought that a special competence they had was to detect patients who were feigning illness or “swinging the lead.” But a doctor at the meeting said he thought that feigning was usually a sign of some unmet health need. Prison doctors have to declare that patients will not be excessively harmed by solitary confinement, and this doesn’t seem very different from declaring them “fit for punishment,” which is thought unethical. Doctors must also monitor those in solitary confinement.

I concluded in the 80s that prisons are unhealthy places no matter how good the environment or the health services. Britain locks up more people than most comparable countries, and we need a continuing debate on what prison is for. I concluded in the 80s that it was effective at keeping dangerous people away from society, but few people in prison are dangerous. It also works as punishment, but the punishment is simply deprivation of liberty not being exposed to horrible conditions. And I couldn’t see much evidence that prisons reform or deter. Sentencing people to community service rather than prison may avoid the harmful effects of prison and the stigma of having been a prisoner and save the taxpayer money.

Working with prisoners is still regarded as a strange career for a doctor, as one of the prison doctors at the meeting made clear. But the same doctor also said that if you are passionate, as he is, to do something about inequalities then there is no better a career for doctors than working with prisoners.

The meeting on the history of the mental health of prisoners was organised by Professor Hilary Marland from Warwick University and Dr Caherine Cox from University College Dublin. They have a Wellcome grant. My book on Prison Health Care from 1984 can now be bought for £1.82.

Richard Smith was the editor of The BMJ until 2004.