Prison health services will be taken over by the NHS from next year
Graham McKerrow, HIV i-Base
The National Health Service is to take over from the Prison Service responsibility for the much-criticised health care services in British prisons. It is hoped the changes could improve HIV care in prisons.
The Department of Health will fund prison health services from April 2003 and over the next five years primary care trusts will take responsibility for the commissioning and provision of health services in prisons.
In addition to the funding currently used by the prison service to provide health care for prisoners, the Department of Health will, over the next three years, allocate further resources to improve these services, rising to around an extra £46m a year by 2005-06.
The health services run by the Prison Service have long been criticised. Aids activists have been particularly angry that standards of care vary from prison to prison. Many prisoners are moved from jail to jail on a regular basis and people prescribed drugs in one institution have had difficulty getting them in another. There are worries that such random interruptions to treatment could result not only in poorer health but also in the development of drug resistant virus.
Gabrielle Brown, HIV coordinator at Brixton Prison, where HIV services are already bought in from the NHS, told HTB: “NHS specialists are very important and the Prison Service is to be congratulated for buying in GU and HIV services. This move [to make the NHS responsible for health care in all prisons] should expand an area of good practice.”
An employee of the Prison Service, who asked not to be identified, highlighted the need for more prevention work. He said: “I would like to see a public outcry about clean needles because the risks of transmission in prisons are as bad as they ever were because clean needles are not allowed.”
Home Office prisons minister, Hilary Benn, said: “Improving health services for prisoners is important for their rehabilitation and resettlement to reduce their chances of reoffending. We know that health problems such as mental illness can contribute to reoffending, so high quality, professional care, which continues on release, is vital.”
Dr Paddy Keavney, a Nottingham GP and part time prison medical officer, welcomed the Home Office announcement but warned that prison health services needed more money. “The resources available at the moment do not come anywhere near meeting the needs of the clinical workload in our prisons. There are tremendous manpower problems in terms of recruiting and retaining doctors. If the recruitment problems in general practice are bad, then they are absolutely diabolical in prisons,” he said.
Prisoners’ health is particularly poor, and Home Office studies have found that 90% of all prisoners have a mental health problem (including personality disorder), a substance misuse problem, or both. More than 80% of prisoners smoke and 24% have injected drugs. One in five women prisoners asks to see a doctor or nurse each day.
Last year Martin Narey, director general of the Prison Service, told an NHS Confederation conference that, despite an 18 month partnership between the NHS and the prison service aimed at improving services, few prisoners had seen any real differences.
He added that conditions for some prisoners were “worse than the kennels in which I leave my dog when I go on holiday.”
Joe Levenson, a policy officer at the Prison Reform Trust, welcomed the move to give the NHS responsibility for prison health and said that prisoners were entitled to the same level of health care as any other member of the public.
He added: “There is not enough psychiatric expertise within prison medical teams. Prisoners are some of the neediest people in society, and they are not receiving the level of care they need. There has been a suicide in prison once every four days this year.”
However, Brian Caton, general secretary of the Prison Officers’ Association, said that prisoners should not be treated like ordinary patients.
“When a prisoner becomes ill we have made the mistake of thinking the prisoner ceases to be a prisoner and is now a patient,” he said. “When people have relaxed on that issue they have found themselves with either an injured prisoner or an injured member of staff. People forget that prisoners are capable of extreme levels of violence.”
Activists and professionals may grumble about HIV care and prevention in society at large, but prisoners should be so lucky. In taking over responsibility for health care in prisons, the NHS is taking on a huge and complex responsibility. It will have to tackle problems handed over by the Prison Service, as well as others of its own making. Many people in our jails are there because the NHS has already failed them. If they needed mental health care outside, that need multiplies on the inside.
The system often fails people with HIV in prisons repeatedly and in a number of ways. Prevention initiatives in society have made enormous progress over the years with the distribution of condoms and clean works to avoid transmitting HIV, hepatitis and other infections. This work has hardly begun in prisons.
In the few institutions where condoms are available, some make prisoners ask a doctor for them, others have them freely available in very public places where everyone can see them being collected. The result is that very few are distributed. The NHS should start by making a thorough survey of the provision of condoms in prisons throughout the country.
The situation with IV drug works is even worse. The Prison Service still operates under the pretence that there are no drugs in prisons – a ludicrous self-delusion as has often been reported, most recently by Lord Archer in his prison diaries – and therefore no need for prevention information let alone clean works. Indeed, it is still argued, as it used to be in society at large, that prevention initiatives would encourage drug use. People arrive in prisons having used clean works outside but face risks in prisons as bad as they ever were because clean needles are forbidden. Further, by testing prisoners for drug use they are encouraging the use of heroin – which can be swiftly flushed from the body – rather than marijuana, which can be traced in the body for some weeks after use.
So, the Prison Service encourages the use of IV drugs and takes steps to make sure they are administered with dirty works. The NHS will have to change this culture completely.
Then there is treatment. Or not. The standard of care varies widely between institutions, and it is just bad luck for a prisoner who is moved from one with good HIV health care provision, to one with poor provision. Some prisoners receive treatment, some don’t and others have treatment started but interrupted. The NHS will have to end a system that denies treatment to people or treats people in ways that lead to them developing virus that is resistant to treatment.
The NHS must take into prisons its excellent record on confidentiality. It must take the healthcare to prisoners, not the other way round: taking prisoners on a regular basis to sit in chains in a public clinic must be halted.
The prison authorities have clung to policies that spread the virus, deny treatment and develop drug resistant strains of HIV. If there were any justice, the people responsible would be locked up.
The NHS has a tremendous opportunity to revolutionise HIV care in prisons and the Home Office must provide the institutional and political backing for these moves. But they should be wary of placing too much trust in GPs. The HIV experience and knowledge of GPs varies almost as much as current health care in prisons, so we cannot assume that handing matters over to primary health care groups will result in uniform improvements.
When society denies someone their liberty we take on a duty of care, and HIV voluntary organisations have a role to play. We must publicise the issues, pressurise the authorities and support individuals.