[The first part of this report - Medicine within prison part one, can be found - click]
Psychiatric Disorders in Prison
Dr Anthony Maden is a senior lecturer in Forensic Psychiatry at the Institute of Psychiatry , London. He recently completed a major survey of psychiatric disorders among sentenced prisoners, along with Mark Swinton under the supervision of Professor John Gunn sometimes known as the Psychiatric Profile of the Prison Population. This study was funded by the Directorate of the Prison Medical Service.
The Gunn, Maden, Swinton report investigated the prevalence of mental disorder amongst the 37,000 men and 1,200 women sentenced prisoners in England and Wales (NB it does not include the 12,000 custodial remand prisoners).
The 5% cross-sectional sample of male sentenced prisoners was carefully chosen to be random within each prison yet representative of the entire prison male population. Each subject was seen by one of the two psychiatrists and assessed for the existence a psychiatric disorder
Outline of research protocol
Examine the prison file of each case
Interview the prisoner
examine the prison medical notes and accounts of prison medical officers
Make a psychiatric diagnosis (up to 3 labels) based on current state - with the exception of substance abuse which referred to the 6 months before entry
Decide, with help of the prisoner, which treatment is the most suitable
The investigators found that one third of the total male prison population has a psychiatric disorder but only 2% have a psychosis
• Psychosis 2%
• Neurotic disorder 5 %
• Personality disorder 8%
• Sexual deviation 2%
• Substance abuse 20%
• Organic disorder 1%
• Total (any diagnosis) 39%
The categories with the largest numbers were: substance abuse, personality disorders and to a lesser extent neurosis - in most cases not the kind of problem that would require in-patient treatment. The pattern was the same in women but the prevalence rate of psychiatric disorder was nearly doubled at 60% - the bulk being made up of personality disorder and drug dependence (26% - usually opiates).
Once a diagnosis of mental disorder was made the optimum treatment, having taken into account the wishes of the prisoner, was determined. As, to an extent, the psychiatrists' judgments were matters of opinion and, in order to involve other disciplines, a research panel was set up to verify both the diagnoses and treatment. Five treatment options were considered:
• 3% - NHS hospital inpatient treatment
• 10% - O.P/GP treatment (as in community but provided within prison
• 6% - Therapeutic community using Grendon as the model
• 5% - further assessment (in prison
• 10% - no treatment
3% of the total prison population were found to need treatment in NHS hospitals. That figure includes the majority of the people with a psychosis, those with severe personality disorders and/or sexual deviation, and the few people with severe neurotic disorders. Most psychotic people had already been referred but had been rejected by the NHS. The researchers found that doctors in general (not just prison doctors) commonly take too narrow a view of the type of psychiatric disorder that warrants treatment outside prison - tending to look only for people with hallucinations and delusions. When someone has a severe intractable neurotic disorder which renders them a suicide risk and has failed to respond to treatment in prison, then the NHS should be willing to consider transfer; legislation exists to allow that to take place.
Of the remainder, 10% of the population should be receiving Out Patient/ GP treatment, 5% should be treated within a therapeutic community and about 5% needed further assessment. The narrow view is also a factor affecting the care of personality disorder/sexual deviation. The NHS does not have good facilities to treat them and part of the problem over the failure to refer these cases is that the prison medical officers have learnt that there is no point because the NHS will not accept them.
The 10% who need treatment within prison are those with substance abuse and those with neurotic disorders. The provision of these services would be better organised by the doctors as currently its delivery, often by people such as probation officers, prison officers or psychologists , can be haphazard. Although especially true of substance abuse, much of this treatment depends upon well motivated individuals who may only receive limited support - the service collapsing if that individual leaves.
Some of those with personality disorder /sexual offenders receive treatment at Grendon. For once the NHS contrasts unfavourably with the prison service because there is little comparable treatment in the community for people from this group. Offenders do not spend the majority of their lives in prison and the treatment needs in prison for these cases should not be seen in isolation from the services needed outside. In practice they usually receive a terrible service once they leave prison.
People with an active psychosis cannot be looked after in prison . There has been a call, mainly from doctors outside prison, to change the Mental Health Act so that it applies in certain prisons 'hospitals'. But one of the few things that can almost guarantee getting a psychotic patient out of prison at the moment is if they refuse their medication the NHS feels unable to turn them away. To change the Act in this way would be to hopelessly blur the boundary between what prisons are supposed to do and what NHS hospitals are supposed to do. There are good reasons for improving the facilities in prison 'hospitals' but not in such a way as to make them into second rate psychiatric hospitals.
Issues of confidentiality are important. If, as a prisoner, you want to communicate your suicidal feelings or the fact that your wife has left you, you want to be sure that information is not shared with everyone else in the prison. The study showed that a perception of poor confidentiality was a major reason for prisoners not seeking help from prison staff.
The prison service should be praised for eliminating the use of drugs without consent. Some inmates claim it still takes place but nobody admitted to having any personal experience . If anything there is evidence that underprescribing takes place - in the treatment for depression in particular.
3% requiring NHS treatment may not seem very many but it represents 1000 beds. Most suffered from chronic schizophrenia, usually previously recognised and often eventually having been rejected by the NHS after a long history of treatment. Typically there have been several admissions to a District General Hospital for not very violent or for difficult behaviour (shoplifting, smoking cannabis ). There would have been repeated appearances in court; on the first couple of occasions a hospital would be prepared to take them - the third time they say 'No, we have had enough'. These people need quite skilled long term care - not in great supply in the health service.
The security needs of people needing transfer spanned the range from high to medium to low, but all needed long term care and had the characteristics of a ‘difficult to place patient’. There are only 600 medium secure beds in the country although the recommendation made in 1975 was for 2000 . The then Government accepted a figure of 1000 and the shortfall represents an enormous bottleneck in the current care of the mentally disordered. A example of the reality is that of the facility which should be providing an emergency medium security bed for Brixton prison , which has been full for 6 weeks. There is no point in Brixton referring any cases during that time as the hospital could not take them.
The ethical conflict over the competing demands of clinical care versus the needs of the institution are not restricted to prisons. Having to manage NHS hospital resources may result in the patient who does not fit into the service you provide being left in prison. Even those who are accepted may have to wait - Dr Adrian Grounds surveyed the transfer of prisoners from prison to special hospitals. First the doctor delayed visiting and then there was up to a further 6 months holdup in prison waiting for a bed. Dr Phil Joseph found that mentally disordered remand prisoners accepted on a 28 day order were usually only transferred on day 27 or 28. Another study of remand prisoners demonstrated that most psychotic patients referred by prison doctors were not accepted. In this way the health service uses prison as a warehouse to store very difficult psychotic patients that they would rather not be looking after. Jeremy Coid has described the characteristics of difficult to place psychotic patients:
• Substance abuse
• Possible personality disorder
• Chronic illness
There is an enormous funding issue between the Department of Health and the Prison Service. Patients who remain in prison costs the health service nothing and there is no incentive to admit difficult patients. A register of prisoners needing NHS care would provide evidence of the unmet need - none exists at present.
Better training is required for all doctors working in prison. Psychiatric reports should be written by psychiatrists only. Even then, as with the Judith Ward case, psychiatrists reports are sometimes inadequate and there is a problem for the profession over ‘policing’ itself and auditing psychiatric reports
Dr Rosemary Wool is the medical director of the newly named Prison Health Service. She emphasised that the aim is to deliver a high quality care comparable to that of NHS. As a health service, she argued, everyone will contribute. The governor, as manager of the prison, will be accountable for the provision of health care so the tensions inherent in allocating scarce resources will be removed from medical personnel. And there has been progress, she added; 60% of full time prison doctors have been in the service for less than 5 years, the Royal Colleges are to recommend standards of training , 37% of nurses are now fully trained and only 16 prisons currently follow the VIR (infection) regulations.
Dr Adam Lawrence, a genito-urinary physician from of St Stephens Hospital, has experience of working in both Wandsworth and Brixton prisons. He finds that custodial requirements and a prisoner’s medical needs frequently conflict. In particular the remand transfer system makes continuity of care very difficult.
More resources are not necessarily a priority Adam Sampson claimed. 5,000 places could be made available through identifying that 40% of remand prisoners who eventually either receive non-custodial sentences or are acquitted when they come to trial. Eliminating them from prison system would, more than anything else, help to relieve the pressure on doctors in prison.
Sheila Gore of the MRC Biostatistics Unit pointed out that any improvement in standards will need to be monitored. That means defining standards in a measurable way and then publishing statistics for each prison for comparison.
A medical officer from Wormwood Scrubs bemoaned the fact that prison doctors, who should be in a position to act as the conscience of society, are not allowed to reject a prisoner on ethical grounds when he is medically unsuitable to be in prison. He has found that if more than one prisoner are referred to the NHS then it is always the most difficult one who is rejected. He made two other points: that prison doctors on average have more qualifications than those in the NHS and that governor’s freedom to govern the prison is constrained by the unions.
Dr Dorothy Speed , a Principal Medical Officer based at HM Prison Headquarters and renowned for her ‘the mad, the bad and the sad’ description raised what she sees as a hobby horse of hers. Prisons exist because the judiciary sentence, and those sentenced are increasingly being managed in a harmful environment. As Europeans we should adopt a similar pattern to that in France, Holland and elsewhere whereby prisons are managed by a Ministry of Justice. In this way those who sentence would be responsible for the introduction and monitoring of standards But Whitehall is, she thinks, unlikely to want to lose part of its power base - the Home Office consisting of four departments ; immigration, the fire service, the police and the prison department. She would like to see the prison service managed by to the Lord Chancellors department.
Although a consultant pathologist Dr P O’Gorman spoke as a member of the board of visitors at Bellmarsh prison, where, he suggested, adequate resources and imaginative planning have succeeded in providing a proper service. The cells are open from 7.30 am until noon and 2 .30 to 8pm - allowing for employment, education and association. Three psychiatrists attend the prison, there is a registrar on a rotation into the prison recognised by the Royal College of Psychiatrists as well as a senior registrar. The ready transfer of patients into psychiatric NHS beds is largely, he commented, a matter of local arrangements and contact.
Fleur Fisher heads the Professional Division of the BMA and was until recently a general manager in the NHS for 6 years. She was responsible for a psychiatric hospital and a mental handicap hospital both of which had secure units which received referrals from courts and prisons. She raised two points - that patients referred from prison often need medium and long term care and the current policy of closing psychiatric institutions reduces the most suitable beds, and the problem of losing NHS resources which even at current levels are not adequate.
In winding up the first session, the chairman Richard Smith, speculated that someone might be writing about the state of our prisons in 100 years in much the same way John Howard did 200 years ago. No single solution to the problems of the prison health care service exist he said. It has to do with the attitudes of our society, the failings of our criminal justice system - not only the prisons but the policing and the judiciary. They are complex problems which are very much interlinked and there just are no easy answers. Twice the resources, or half as many prisoners tomorrow, would not mean the problems would be solved overnight although he thought they might be a step in the right direction. In concluding he considered there to be good reasons for saying that handing some of the services over to the NHS would also be a step in the right direction. That very much seemed to be the logical conclusion of the Efficiency Scrutiny.
Mothers and Babies in Prison
Dr Sonya Leff has 25 years experience as a community paediatrician. She started work in a multiracial deprived inner city area later moving to Sussex. Since then she has worked on staff training , service development , audit and protocols of good practice. In 1990 during one year’s secondment to the Children’ Policy Division at the Department of Health she served as the paediatric member of the inspection team which visited England’s three prison Mother and Baby Units.
Donald Hurd, the then Home Secretary, invited the Department of Health to undertake a series of three inspections, at two yearly intervals, of the Mother and B
Prior to the inspections taking place the Children Act was passed obliging local authorities to support families bringing up ‘children in need’. The inspection team concluded that children within Mother and Baby units are ‘children in need’ and determined that the regimes should be child centred - assisting the mothers in their parenting responsibilities and looking toward supporting the mother on her return to the community.
In preparation for the visits the team studied data and reports about the units over the previous 12 months and information about the prisoners, such as their ages, marital status and ethnicity. The closed unit at Styal catered for mothers and babies of up to 9 months. Half the mothers were under 21 and none were married. The majority were white but 15% were of Afro- Caribbean background mirroring the ethnic mix of the general prison population. There were a sizable minority of mixed race babies (19%). The other closed unit for mothers with babies is at Holloway where a third of the mothers are under 21, 94% are single and 24% are non-white while 60% of the babies are non-white. Askham Grange in contrast is an open prison where toddlers up to 18 months can be accommodated. The mothers were older but only 29% were white.
The overseas origin of some mothers reflects the number of women convicted for importing drugs. Their children’s needs are specialised and the legal complexities problematic such that the Social Services Inspectorate are to carry out a special inquiry into the issue. The inspection report recognises inherent tensions that exist between the custodial requirements of the prison and the needs of the babies - a truth recognised by everyone, from governor to the mothers themselves.
Doctors in Prison - a contemporary account.
Dr Vin Chiang joined the prison medical service in in 1980. In 1983 he became Senior Medical Officer and was responsible for the provision of medical services at HMP Wandsworth. Since 1990 he has been headed the medical services at HMP Brixton.
Dr. Chiang spoke about his experience working as a doctor in prison emphasising that what he had to say was a personal view and should not be taken to reflect the view of the Prison Health Care Directorate. A lot of positive initiatives are in the pipeline and the new Director General of Her Majesty's Prison Service, Mr. Joe Pilling, is prepared to bring about organisational change for the betterment of prisoners and staff, he said
A doctor’s duties are divided into four areas - reception work, outpatient work, inpatient work, and statutory duties and other tasks that doctors get involved with as a managing medical officer. When a prisoner is admitted he receives a reception medical at which his medical needs are assessed. Those who need no active medical intervention at that stage are taken into the main prison and form the bulk of the outpatient population. Those that are admitted into the health care centre (the new term for the prison hospital) form the bulk of the inpatient population and include one of the following groups: patients with physical or mental illness, patients on capital charges for observation and preparation of their court reports and lastly patients specifically remanded for the purpose of preparation of a court report.
The outpatient facilities comprise a daily sick parade available Monday to Saturday, usually carried out by a part time visiting prison doctor or a local general practitioner . There may be special callups within the health care centre of outpatients to be seen by a full time prison doctor, who are usually referred by the part time doctor or general practitioner. There are clinics run by visiting specialists as well as facilities such as radiology, physiotherapy, chiropody, optician and even sometimes a speech therapy. Within the health care complex the inpatient facilities will vary depending in the type of establishment.
In most cases the managing medical officer is expected to do a daily round. In large prisons such as Brixton the inpatients would expect to be seen daily by their own full time prison doctor. Sometimes a doctor may find it necessary to arrange to see patients in his own office, for example when he needs to interview and examine a patient for a medical report. Daily statutory duties include a kitchen round and general inspection of the state of cleanliness and hygiene of the prison, a visit to the segregation block to examine inmates regarding their mental and physical fitness to undergo a governors or a board of visitors adjudication for any misdemeanour committed in the previous 24 hours under the discipline code. He is expected to physically see prisoners on punishment and sort out their medical needs and to visit to the high security wing where this is applicable or visit the rule 43 wing (now renamed the vulnerable persons unit). He is also required to examine the food refusal entry book for the previous 24 hours and act accordingly. Other tasks may include attending the governor’s daily meeting; preparing reports for the governor, board of visitors, local review committee, parole board, headquarters; answering queries from Social Services; arranging and participating in training needs of staff at all levels; participating in multidisciplinary groups; dealing with prisoners’ complaints procedure involving health needs; preparation of a hygiene report twice a year and preparation of an annual report on medical and nursing services. There is more - involvement in any occupational health initiatives; preparation of the medical officers on call duty rotas; chairing meetings with a medical or nursing implication; visiting patient/prisoners in outside hospitals and liaising with colleagues in the NHS; and attending courts and HQ meeting when required.
Dr Chiang went on to discuss some of the problems as he sees them. Many stem from the austere and punitive approach and from the buildings, both of which have been inherited from the Victorians. Although the problem of prison buildings is being addressed their poor physical state and years of neglect in their proper maintenance and upgrading has led to a poor standard of housing for the prisoners and, equally, an unsavoury and unwholesome place in which to work. Other problems stem from operational pressures generated by a cultural preoccupation with security and control aspects which is entrained into some staff and is which is difficult to erase - causing conflict. This issue can be especially relevant when staff advise a pliable part time medical officer who subsequently assumes the role of the managing medical officer.
There has been relentless rise in the prison population over the last few years. The facilities and services are already considerably overstretched with very poor conditions and with inadequate resources in many dispersal and remand prisons. Overcrowding just adds to the problem. It is time that doctors shouted loud and long so as to have these matters addressed. There is a need to change these impossible circumstances and help the government to provide productive areas for this group of disadvantaged people Dr Chiang thought.
Other issues have contributed to problems. There have in the past been poor selection procedures . An emphasis on recruiting older doctors and people with a psychiatric background may not always be relevant or necessary. Because of busy schedules all staff have very little time left to attend courses and when there is an opportunity it is difficult to generate an interest in doctors of the older generation. Happily the training requirements of full time medical officers is to be looked at in the near future.
Another issue is poor appraisal of performance. There is an assessment form called an ASR that although used to evaluate all staff is not relevant to medical assessment. There is a perceived feeling within the field that there is an inability at HQ to deal effectively with conflict between staff, especially between governors and doctors, as well as a reluctance to involve staff more with policy changes and keep them up-dated. Recently there has been a plethora of paperwork about change for which there is only limited time - it would be better to have seminars to get information across.
Sadly, the prison medical service has put up with unprofessionalism and low standards in the past Dr Chiang admitted. There is great difficulty in maintaining confidentiality in custody. Confidential information can only protected by the medical officer keeping all the information to himself. New doctors may only have access to advice on this and other matters from non-medical staff. Many part- time doctors do not wish to rock the boat. They have busy practices to manage and some, it has to be said, rush in and rush out because they are only there for the money, so long established procedures may prove difficult to change . The traditional arrangements often provide very little privacy for the doctor/patient interview. In future doctors will have to insist on a private interview and when a patient asks that information remain confidential a separate confidential file should be used. Doctors must take the lead over this matter.
Things are improving; new prisons are being built and with constructive criticism and support from outside agencies everyone can contribute . The average prison doctor can feel threatened and become defensive . But there is a new spirit of hope, prison doctors are actively applying the provisions of the Mental Health Act 1983 more effectively but why, Dr Chiang asked , do visiting consultants psychiatrists have to wait,on average, 2 weeks before seeing a referred case and why are they rarely prepared to admit early rather than waiting until the last days of the 28 day section.
Dr Chiang commented on a number of proposals designed to improve prison health care. Prison hospitals should not be upgraded so as to be able to apply the Mental Health Act; the involvement of more outside agencies such as Samaritans in prisons can only be of benefit; the system of buddies befriending distressed or depressed inmates as developed in Swansea should be taken up more generally; and although there should be more active interchange with NHS facilities it is not appropriate to substitute NHS doctors wholesale for the prison medical officers. To suggest that outside doctors are bought in to deal with, say, problems such as a busy Brixton reception for up to a hundred inmates, he thought, would not be the right answer.
He finished by urging his colleagues to be proud that they are prison doctors but to shout loud when they find themselves unable to tolerate bad medical practice .Prison inmates are wholly defendant upon prison doctors and nurses for their medical care - the necessary improvements in the quality of that care must be self engendered.
Dr Wool encouraged prison officers to use the power they have as advisors to influence their prison governor. Under the fresh start management arrangements the head of medical services at each prison has a right to sit on the governors top management team when talking about any issues connected with that prison. The best health care, she said is provided at prisons where the head of medical services plays a full management role and has an input into everything going on in that prison.
BACCH ( the British Association for Community Child Health) is the largest subgroup of the British Paediatric Association with over 600 members. Dr Marion Crouchman is an executive member of BACCH and a consultant paediatrician at University College Hospital, London. The Association is flummoxed, she said, by the judiciary’s attitude to children and prisons. The members question the need for children ever to go into prison and interpret any enforced separation of mothers and children as child abuse under the new Children Act. Dr Crouchman anticipates that a private prosecution will, at some stage, be brought on behalf of some child and commented that many medical expert witnesses will be pleased to support it.
Now a member of the audience, Dr Richard Smith described the way that his belief the NHS should assume responsibility for the provision of prison health care developed. Over many years, as a result of the invariable failure of the current system to avoid attracting critical inspection reports, initial scepticism gave way to a recognition that an alternative had to be found . The nascent purchasing skills of commissioners of health care form a significant new factor in the equation now making the proposition feasible. For the Prison Service to spurn the expertise developed by purchasing health care for whole populations would be to perpetuate the isolation which has impeded proper prison medical care in the past.
Dr Chiang would rather see one secure hospital for London, run for instance by Dr Wool, with whatever medical expertise needed brought in from the community. He complained that, traditionally, medical influence on planning in the prison service is a of little consequence and cited the example of the VIR policy which was cobbled together at head office by people who did not understand the problems it would create. This is precisely why, Richard Smith rejoined, outside agencies should be employed with their bigger clout.
Dr Wool , having the last word, voiced her conviction that the hearts and minds of the governors and discipline staff must be won before satisfactory health promotion can be practised. Whether that would be easier with an independent agency running the service she thought debatable.