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The future of prisonhealth careAdrian Grounds aa iUniversity Lecturer in ForensicPsychiatry , Institute of Criminology,University of Cambridge , Cambridge , CB39DT , UKPublished online: 09 Dec 2010.

To cite this article: Adrian Grounds (2000) The future of prisonhealth care, The Journal of Forensic Psychiatry, 11:2, 260-267, DOI:10.1080/09585180050142507

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The future of prison health care

AD RIAN GROU ND S

A year ago The Future Organisation of Prison Health Care was published byHM Prison Service and NHS Executive (1999). The report was produced bya working group established following trenchant criticism of the prison healthcare service by the Chief Inspector of Prisons, who observed that the prisonservice patently fails to deliver a standard of health care equivalent to the NHSin three key respects: health policy, standards of care and access to care. ThePrison Inspectorate advised that it was fundamentally unsound and disadvan-tageous to maintain a prison health care service separate from the NHS andthat a time-table should be agreed for the NHS to assume responsibility forcommissioning and providing health care in prisons (HM Prison Inspectorate,1996, 1998). The Joint Prison Service and NHS Executive Working Groupundertook to consider these views and set out options for the future.

The Working Group’s report is candid about the de�ciencies in theorganization of prison health care. However, its report rejects the solution ofintegration with the NHS because of concerns that such a change would bedisruptive, that it could be divisive within prisons, and that the NHS mightnot in practice be able to give suf�cient priority to prison health care. Insteadthe Working Group advocates an approach based on formal partnershipbetween the prison service and the NHS. Future arrangements should bedesigned to ensure that health care standards in prison are the same as thosein the NHS, isolation of clinical staff is minimized, and continuity of care ismaintained on entry to and exit from prison.

To these ends, health authorities should work with prisons in their geo-graphical areas to carry out joint health needs assessments, agree a prisonhealth improvement strategy and jointly plan and commission services. Theprison service would remain responsible for the provision and funding of

The Journal of Forensic Psychiatry Vol 11 No 2 September 2000 260–267

The Journal of Forensic PsychiatryISSN 0958-5184 print/ISSN 1469-9478 online © 2000 Taylor & Francis Ltdhttp://www.tandf.co.uk/journals

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primary health care and the NHS would continue to be responsible for thedelivery of secondary health care. NHS regional of�cers and prison servicearea managers should jointly review the progress of health improvement pro-grammes and make plans for commissioning tertiary services, includingmedium and high secure psychiatric care. To oversee and manage the newarrangements the Prison Health Care Directorate would be replaced by twonew bodies working closely together, a new Prison Health Policy Unit,responsible for strategic direction and the application of Department ofHealth polices and objectives, and a task force responsible for ensuring thathealth needs assessments and other radical changes are delivered in practice.

At the heart of the report is the simple and radical aspiration that prisonhealth care should be based on the principle of equivalence. Policy, organiz-ational arrangements and health care standards in the prison service shouldbe equivalent to those operating in the NHS. The key task of the new policyunit is to devise means of achieving this goal. The principle of equivalencewas adopted from the Health Advisory Committee for the Prison Service,which noted that it implies that ‘any target set for the health of the nationshould apply to the prison population’ (Health Advisory Committee for thePrison Service, 1997: para 8).

What are the challenges facing the new policy unit and task force, and howshould they be met?

An immediate preliminary task is to provide a sense of cohesion, con� -dence and shared purpose among prison health care staff and those who werepreviously part of the Prison Health Care Directorate so that there is clarityand enthusiasm about their place in the new structures. Secondly, a closeworking relationship between the policy unit and the task force will becrucial for the future, and at an early stage they should carry out a joint analy-sis of their shared task, setting an agreed agenda and plans. They need toidentify barriers to the achievement of their goals and strategies for over-coming them, and to obtain support at the highest level for doing so.

The physical location of the policy unit and task force in Department ofHealth of�ces is symbolically important and should be re�ected in theirapproach and mind-set. Their perspective should be health service-based.Health service policies and structures represent the norm, and where prisonhealth care conventions differ from them, the prison arrangements should bebrought into line, rather than the NHS policies being selectively adapted anddiluted to �t with conventional prison health care practice.

NHS POLICY FRAMEWORK

In their general outline, current policies for the NHS provide a conceptuallyimpressive and coherent framework that must be extended into prison health

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care. The White Paper The New NHS: Modern, Dependable (Department ofHealth, 1997) and its progeny see the NHS as a system based on partnership,quality and performance. Partnership implies that problems should beaddressed ‘without the constraints of Departmental structures’ (Departmentof Health, 1999a: para. 6.7). The central emphasis is on quality of care: excel-lence should apply to all patients and, in particular, there should be equaltreatment for disadvantaged and socially excluded groups (Department ofHealth, 1999b). The delivery of health care should be measured againstnational standards, and variations in quality should not be tolerated.

The approach to ensuring quality of health care is outlined in A First ClassService – Quality in the New NHS (Department of Health, 1998a). Theapproach has a number of components. National service frameworks willprovide evidence-based standards and models for services; the National Insti-tute for Clinical Excellence will promote effective, high-value and consist-ently applied forms of treatment; professional standards will be supportedthrough clinical governance, and the Commission for Health Improvementwill visit and review the standards of services, reporting to government onneeds for remedial action when there are serious de�ciencies. A nationalframework for assessing performance will be used to judge how well theNHS is delivering quality against speci�c indicators (NHS Executive, 1999).The policy framework also emphasizes that NHS and health organizationsshould systematically build in patient involvement to the way they operate,with particular attention being paid to under-represented groups. TheNational Survey of NHS Patients will regularly obtain patients’ views aboutthe services they receive (Department of Health, 1999c).

Current health service policy also includes a national strategic frameworkfor the workforce of the NHS, because it is recognized that there must bestaf� ng of the right quality, size, skill and diversity to meet the objectives ofthe service. This framework includes arrangements for training, recruitment,retention and involvement of staff in service planning (Department of Health,1998b). An important aspect of NHS workforce policy is the recognition thatemployees should be able to raise concerns about malpractice in a respons-ible way without damage to their careers. Trusts and health authorities shouldhave designated managers responsible for protecting whistleblowers, and‘gagging’ clauses in contracts should be prohibited (Department of Health,1999d). The minister announcing this policy said:

Whistleblowers protect the patient’s interest. I want all staff to feel theycan speak out about NHS malpractice, whether it be poor clinical per-formance, safety at work, �nancial malpractice, fraud, poor governanceor risk to patients, without fear of being frozen out by colleagues or�nding staff closing ranks against them.

(Department of Health, 1999e: 2)

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Finally, in the health service there is recognition of the central importanceof scienti�c research. The NHS has a well developed research and develop-ment strategy with the aim of ensuring that policy and practice have a soundknowledge base and are research-driven (Department of Health, 2000).

The current health service policy framework outlined above provides adaunting and challenging set of values, strategies and administrative arrange-ments that must be extended into prison health care and applied with equival-ence. In meeting this objective the new Prison Health Policy Unit shouldpursue two broad avenues of work: � rst, quality and progress should beevaluated by systematic comparisons with the NHS; second, the unit shouldpursue linkage and integration with NHS structures.

SYSTEMATIC COMPARISONS WITH NHS

The purpose of systematic comparisons with the NHS would be twofold:�rst, to highlight un�inchingly the extent of the de�ciencies in the prisonhealth care system that need to be remedied and, second, to persuade NHScolleagues at all levels to recognize and include prisons in their planningassumptions and service developments. The value of the health needs assess-ments to be carried out jointly with health authorities will depend on whetherthey are properly resourced and conducted with adequate methodology andconsistency. Previous prison morbidity surveys indicate disproportionatelyhigh rates of reported chronic illness and disability, drug and alcohol prob-lems and mental illness (Of� ce of Population Censuses & Surveys, 1995;Singleton et al., 1998). In relation to the mentally disordered, the HealthAdvisory Committee for the Prison Service (1997) found basic de� cienciesin practice, such as inadequate access to mental health services, lack of careplanning, and absence of after-care arrangements. More recently the HMInspectorate of Prisons (2000) noted the absence of psychiatric support in theunits that take the most disruptive and disturbed prisoners in the prisonsystem.

The expected quality of health care in the prison system should be de�nedand monitored by using the same methods and standards that apply in thehealth service. For example, chronic care management, cost-effective pre-scribing, mental health practice and suicide prevention should be measuredagainst the indicators in the National Framework for Assessing Performance(NHS Executive, 1999) and relevant national service frameworks (Depart-ment of Health, 1999f). The principle of equivalence additionally implies thatthe bodies responsible for external assessment of health care standards, suchas the Commission for Health Improvement and the Hospital AdvisoryService 2000, should extend their oversight to prison health care.

Funding arrangements for prison health care should also be challenged by

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the principle of equivalence. The Health Advisory Committee for the PrisonService (1997) noted that prison health care budgets are set locally by gover-nors, and this should change to be in line with the health service, i.e. capita-tion funding with appropriate weighting for the characteristics of the prisonpopulation. On the NHS side, �nancial allocations to health authorities donot give suf� cient weight to the clinical needs of prisoners in their areas(Department of Health, 1999g), and this requires review so that there isweighted funding to re�ect their higher morbidity and service needs. When,as a matter of policy, signi� cant additional investment is made in the NHS(for example, ‘modernization funds’ for mental health services, and the sub-stantial increases announced in the spring 2000 Budget), there should bearrangements to ensure that prison health care is not excluded, and receivesequivalent gains where relevant.

LINKAGE AND INTEGRATION

Over the medium and long term, the Prison Health Policy Unit shoulddevelop greater linkage and integration with NHS structures in relation topolicy, research and development, specialist services commissioning, and train-ing and recruitment. It will be important to be proactive, identifying the newand developing areas of health policy and securing prison service represen-tation where relevant. Prison health needs should be strongly represented inrelation to the development and commissioning of specialist services such ashigh secure psychiatric provision. Prison health issues should also be morewidely re�ected in the NHS Research and Development Strategy, in relationboth to the Policy Research Programme and to the regionally led programmes.To facilitate better linkage, within the NHS executive structure prison healthcare advisors should move their location to NHS executive regional of� ces,and there should be �rm encouragement of developments that promote withinhealth authorities and primary care groups a sense of ownership of the healthcare needs of prisons in their geographical areas.

Perhaps the most important challenge for the future is to revolutionizetraining and recruitment. To meet the objective of improving the quality ofpersonnel in the prison health care service, there should be a determined strat-egy to achieve proper integration by extending NHS training structures intothe prison context. The chronic de�ciencies in recruitment and training ofprison doctors have been sorrowfully recorded in a series of reports over thelast four decades (Home Of�ce, 1964; House of Commons, 1986; RoyalCollege of Physicians et al., 1992). There is an immediate need to remedy thepresent anomaly that the medical manpower needs of the prison service arenot included in assessments of NHS medical manpower needs. The require-ments of the prison service have not been considered, for example, in the

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calculations of the Speciality Workforce Advisory Group which has set thenumbers of training posts in medical specialties. Training schemes in themedical specialties most relevant to prison health care – i.e. general practice,psychiatry and public health medicine – should include prison experience andprison placements as a matter of course. A strong central lead would be neces-sary to persuade the Royal Colleges, NHS teaching centres, post-graduatedeans and prison health care centres to implement such a change, but it wouldprovide the best means of improving the quality of prison medical personnelover the long term. Trainees would discover how unexpectedly worthwhilethe health care of prisoners can be; and employment arrangements could beadapted in two respects to encourage trainees to return to prison work: �rstby means of joint prison and NHS posts; second, by making the more con-genial working hours of prison health care a strong selling point. The pioneer-ing arrangements made at Belmarsh Prison, through quiet and imaginativeentrepreneurship, integrating prison experience into an established psychiatrictraining scheme, represent an excellent model that merits wider application.

Similar considerations apply to other professions and should be adoptedin psychiatric nurse training and clinical psychology training. Conversely,forensic psychology training schemes for prison psychologists should bebroadened to incorporate placements in NHS mental health settings, in orderto improve expertise in the management of mentally disordered prisoners,particularly those with personality disorder.

It has to be recognized that the principle of equivalence will sometimeshighlight fundamental points of con�ict between health and prison serviceobjectives which are not capable of easy resolution. A particular example isthe welfare of children. One of the core objectives of the Department ofHealth (1998a), as part of its public service agreement, is ‘to maximise thesocial development of children within stable family settings’ (para. 1.13). Thisis dif� cult to square with the prison service policy of separating children atthe age of 18 months from imprisoned mothers, after enabling them to staytogether until that age. Notwithstanding recent improvements (HomeOf� ce, 1999a, 1999b), it is dif�cult to imagine a practice more contrary to theneeds of children for secure and sustained attachment, and it would be incon-ceivable that such a rule would operate in a health and social care setting.However, from a prison service perspective, the development of mother andbaby units that enable this degree of contact is seen as a laudable achievement.

CONCLUSION

In summary, The Future Organisation of Prison Health Care sees the prin-ciple of equivalence as fundamental for the way forward. There is a choice:applying the principle will have radical and uncompromising implications;

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discarding the principle will be unacceptable. It is to be hoped that all con-cerned will have the vision to pursue the former course.

Adrian Grounds, DM, FRCPsych, university lecturer in forensic psychiatry, Institute ofCriminology, University of Cambridge, Cambridge CB3 9DT, UK

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