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Health care in prisons 2004: criticisms
HEALTH CARE IN PRISONS

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Introduction

Every four years or so, the UN Committee against Torture (CAT), meets with each State Party to discuss that State’s compliance with the UN Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment.

Since the revelations of torture and ill treatment of detainees in Iraq, Guantanamo Bay and other places of detention within the territorial jurisdiction of some of the international community’s most vehement opponents of torture, the importance of CAT’s role has been enhanced.

As soon as undeniable evidence of torture and ill treatment appeared, in May 2004, PHR-UK faxed the UN Committee against Torture expressing its concerns. The UK, which had been scheduled to discuss its compliance with CAT in May 2005 was invited to meet with CAT in November 2004.

Timed to coincide with the UK’s meeting with CAT, PHR-UK published this Report listing its disquiet about health care in prisons. PHR-UK also submitted a shadow report to CAT cataloguing a number of its concerns about UK compliance with the Convention, and the substance of this Report is contained in that shadow report’s section on health care - Health provision in places of detention, including prisons

PHR-UK has decided to make this shorter Report available, because prison health care is an area in which it has maintained a sustained interest. A major theme of our 1992 conference, was the importance of giving the NHS responsibility for prison health care. Medicine within prison

Now this has happened; but as this Report discusses, there remains a need for primary care trusts to be trained for their new role.

In essence, the message of this report is simple - Prisoners are entitled to the same standards of healthcare as the general public. PHR-UK would be glad to hear from anyone who supports this aim, and we can be found on the website www.phruk.org

1. PSYCHIATRIC CARE IN PRISON

1.1 Prison suicides

Prison suicides have continued to increase in recent years.[1] 32% of suicides take place within 7 days of reception. 49% occurred among remand (unsentenced) prisoners. 17% of suicides happened in prison health care centres. 60% of these died within 7 days of admission and 42 % were under medium or high levels of supervision.[2]

Suicide prevention methods should be particularly concentrated in the first seven days following reception.

1.2 Environmental factors in mental illness amongst prisoners

In a recent research study, prisoners reported that the prison environment contributed to poor mental health, and intense feelings of anger, frustration, and anxiety. Prisoners said they misused drugs to relieve long hours of tedium.[3] 28% of male sentenced prisoners with evidence of psychosis reported spending twenty-three or more hours a day in their cells. This is twice as long as those without mental health problems.[4] Prolonged periods within cells do not meet standards required by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT).[5]

Prisoners should be afforded exercise and recreational opportunities appropriate to their health needs.

1.3 Delays in obtaining appropriate care for prisoners

Research suggests that there are up to 500 patients in prison health care centres with mental health problems sufficiently severe to require immediate admission to National Health Service (NHS) hospitals. Prisoners diagnosed as having a severe mental illness requiring transfer to an NHS facility, often wait months to be transferred. During the delay they do not receive the same standard of psychiatric care they will receive afterwards.[6] Delays in transfer do not meet the standards of health care required by the CPT.[7]

Courts should divert mentally ill offenders away from custodial sentences or into appropriate hospital or other treatment facilities.

Psychiatric services for prisoners should be equivalent to what they would receive in the NHS. Prisoners with severe mental illness should be transferred as soon as possible to NHS psychiatric facilities.

1.4 Inappropriate staffing and inadequate staff training

Health personnel are often not specially trained in mental health, thereby providing inadequate levels of care.[8] Prison Officers are being taken off suicide watch and replaced by less qualified staff because the system is overwhelmed by an epidemic of self harm. Uniformed “operational support staff” often cover for fully trained officers at night - the very time when prisoners, locked in their cells, are most at risk of killing themselves.[9] Inadequate staff training does not the meet standards of health care required by CPT.[10]

Sufficient prison personnel with adequate psychiatric training should be on duty at all times, especially when prisoners are at greatest risk.

1.5 Insufficient information on prisoners’ mental health history

Transfer of information is of vital importance. A national survey showed that, of those patients with a history of contact with NHS mental health services, an attempt was made to gather clinical information in only 17% of cases. Information from their primary care physician was only obtained in 16% of cases.[11]

The full medical history, including mental health record of each prisoner should be available to prison health personnel at all times.

2. CONTAINING POTENTIALLY FATAL DISEASES

2.1 Risks arising from shared needles

Prison is a high risk environment for the spread of potentially fatal diseases, particularly Human Immunodeficiency Virus (HIV), Hepatitis B and Hepatitis C. The infecting agents, especially HIV, are most commonly spread worldwide during unprotected sexual activity, but also by contaminated needles.

A large number of people in prisons report drug misuse. On average 24% of prisoners report that they have injected drugs of whom 30% continue to inject whilst in prisons. Three quarters of those who injected shared needles or syringes.[12]

Since April 2004, sterilising bleach tablets have been introduced to clean needles. There are, however, no needle exchange programmes in UK prisons. Health professionals consider that disinfecting tablets are not as effective as sterile needles in preventing spread of HIV and Hepatitis B. There is no evidence that introduction of a needle exchange programme leads to an increase in injecting drug use in prisons.[13]

The government should make clean needles available to prisoners to prevent the spread of potentially fatal disease in prison.

2.2 Risks arising from unprotected sex

Condom use is a simple public health measure to minimise the spread of sexually transmitted infections, including HIV, Hepatitis B and Hepatitis C.

In Canada, condoms are easily and discretely available in all prisons. Inmates can collect them from baskets without needing to interact with prison staff and so avoid embarrassment.[14 ]

The Aids Advisory Committee in 1995 recommended in its Prison service review that “condoms and lubricants be made easily accessible to prisoners throughout their period of detention”.[15] The reality is that condoms are not readily available and having to obtain condoms on prescription does not meet this requirement.[16] Restricted access to unused needles and condoms does not meet the standards of health care required by the CPT.[17]

The government should make condoms readily available to prisoners to prevent the spread of potentially fatal disease in prison.

2.3 Risks from inter-prisoner violence

There is also a lack of preventative measures to prevent rape and sexual abuse. This is exemplified by one prisoner’s experience.

“I was 25 when I was banged up. I was also on anti HIV combination therapy before I went to jail. After months of regular beatings this big, mean and menacing bloke has summoned me to his cell. He said he’d decided to take me under his wing. You can’t say no - I wouldn’t be here if I had. In the beginning we would have sex every day, sometimes three times a day. Now condoms are hard to come by in prison. As I went down to the medical quarters twice a day (to get my medication), I used to ask there. But I was rationed to one a day. I was told that if I took the dirty condom back to prove it had been used they would give me more. But even taking dirty condoms back didn’t always guarantee fresh supplies. I doubt the authorities would admit it, but prisoners are constantly treated for sexually transmitted diseases. It goes on daily. If I hadn’t gone in with HIV, I’d have been damned surprised if I hadn’t come out with it.[18]

The failure to monitor violence in order to protect prisoners does not meet the standards required by the CPT.[19]

The government should implement measures to prevent inter-prisoner violence that can spread potentially fatal disease within prison.

3. PRIMARY HEALTHCARE PROVISION IN PRISONS

3.1 Need for specialized preparation for prison health care

In a reorganisation of health services in England in April 2002, over three hundred primary care trusts (PCTs) were created with responsibilities for providing primary health care, improving health, and commissioning secondary (specialist) care services. Two years later, as part of a planned transfer of responsibility from the former prison medical service, the first wave of PCTs took on commissioning responsibility for prisoners’ health care.

Prisoners should be provided with a broadly equivalent range and quality of services as the general public, yet PCTs “have not yet had time to become effective negotiators in their commissioning relations with acute care providers or to develop their planning and purchasing capacity.”[20] For example, the House of Commons Science and Technology Select Committee recently concluded that PCTs do not have the necessary expertise to commission specialist services effectively.[21] Primary care trusts need to have adequate training and experience to provide the specialist services required within the prison environment.

To ensure that the transfer of responsibility of care for prisoners to PCTs is effective, the government must ensure adequate training, collaboration and monitoring.

3.2 Need for access to prisoners’ medical histories

Electronic patient records and access to electronic information resources are the cornerstones of delivery of modern primary care. However modern information technology is lacking in prison primary care. The main perceived barriers being concerns about potential breaches of security and discipline in prisons, anxiety about data security and a culture that gives low priority to health in prisons.[22]

Those responsible for the health care of prisoners must have access to information about the medical histories of those in their charge. Improving health information by introducing electronic records should not be obstructed by issues of security if equivalence of care is to be given.

The full medical history, including the mental health record of each prisoner should be available to prison health personnel at all times.

3.3 Health care of older prisoners and those with chronic diseases

In 2002 there were 1,359 prisoners aged over sixty, 85% of whom had one or more major illnesses, which usually require multiple drug regimes and careful monitoring. A number of academic studies and a report by the Prison Reform Trust and the Centre for Policy on Ageing have concluded that the health needs of older prisoners are not being satisfactorily met.[23]

In 1997 a young remand prisoner was shackled to his bed shortly before death.[24] The failure to release a prisoner who was near death, and the withholding of palliative care does not meet the standards of health care required by the CPT.[25]

The government should ensure that the health needs of older people or those with chronic disease in prison are investigated and met.

4. THE HEALTH CARE OF PRISONERS DETAINED UNDER THE ANTI-TERRORISM, CRIME AND SECURITY ACT 2001

4. 1 Conditions of detention influencing the mental health of detainees

The mental heath of the detainees has been harmed by the conditions of detention. Each one of the fourteen men then incarcerated in Belmarsh Prison indefinitely as terrorist suspects had developed a serious mental disorder by June 2004.[26]

The mental health of detainees was put at risk by the following conditions of detention found by the CPT during its inspection of detainees held on February 17 2002:

(1). inadequate access to psychological support and psychiatric care especially as some detainees had a history of mental disorder, of being tortured, or were under threat of torture if returned to their own country;

(2). the stress involved in being unable to contest detention and the indefinite nature of detention; and

(3). the limited nature or lack of out-of-cell time and purposeful activities of a varied nature.[27]

Every effort should be made to reduce those restrictions that harm the mental health of those detained under ATCSA 2001

4.2 The standard of health care

Allegations were made that medical treatment which had been initiated before detention was discontinued following arrival in prison, and that medical confidentiality was not respected in that some consultations and examinations took place in the presence of custodial staff.

Some medical records were inadequately maintained giving no indication of the reasons for prescribing psychotropic (for mental disorders) drugs, their dosage, or the person who had prescribed them.[28]

Detainees should continue to receive the medical treatment provided before detention unless it is unnecessary or contraindicated, in which case the patient should be fully informed, and the decision recorded.

Medical confidentiality should be respected and, unless there are compelling reasons, medical consultations should be in private. A full record of prescribed and administered treatment should be maintained.

5. CONCLUSION

PHR-UK makes no apology for raising the issue of prison health care in a report on torture and other cruel, inhuman or degrading treatment or punishment. Criminals who are sentenced to prison should not also be sentenced to a breakdown of either their mental health, possibly leading to suicide, or their physical health, possibly leading to their succumbing to a potentially fatal disease. Neither should prisoners experience health care, including preventative or palliative treatment, that is less than they could expect from the National Health Service were they outside prison. An individual should not lose his or her right to have their full medical history taken into consideration by their prison health care practitioner because they are imprisoned, or be deprived of their regular medications. They should not be exposed to a prison environment that worsens their health condition through lack of recreation and exercise or appropriate monitoring for violence, whether self-inflicted or by another prisoner. The normal conditions of medical consultancy, confidentiality and patient record keeping should be maintained.

References:

1. Prison suicides hit record high, BBC news, September 3, 2004 http://news.bbc.co.uk/2/hi/uk_news/england/3622920.stm (accessed 23/10/04).

2. Suicide by Prisoners. National Clinical Survey, Shaw J et al, British Journal of Psychiatry, 2004 Mar; 184: 263-7.

3. Nurse J, Woodcock P, Orsmby J. Influence of environmental factors on mental health within prisons: focus group study, British Medical Journal 2003; 327: 480.

4. Prison Reform Trust Factfile, July 2004 p18. London.

5. European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment. The CPT standards. para 47 p 17, para 53 p 34 http://www.cpt.coe.int/en/docsstandards.htm. (accessed 22/10/2004).

6. John Reed, Mental Health Care in Prisons, The British Journal of Psychiatry (2003) 182: 287-288.

7. European Committee for the Prevention of Torture and Inhuman or Degrading Treatment of Punishment. The CPT standards. para 37 p 31, para 43 p32 http://www.cpt.coe.int/en/docsstandards.htm. (accessed 22/10/2004).

8. John Reed, Mental Health Care in Prisons, The British Journal of Psychiatry (2003) 182: 287-288.

9. Bright M., Prison suicides soar as jails hire “babysitters”, The Observer, October 17, 2004.

10. European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment. The CPT standards. para 43 p 32, para 57 p 35 http://www.cpt.coe.int/en/docsstandards.htm (accessed 22/10/2004).

11. Suicide by Prisoners, National Clinical Survey, Shaw J et al, British Journal of Psychiatry, 2004 Mar; 184: 263-7.

12. Prevalence of HIV, hepatitis B and Hepatitis C antibodies in prisoners in England and Wales, Weild et al, Communicable Disease and Public Health, 2000 Jun; 3(2): 121-6.

13. H Stover, Monograph: Drug and HIV/AIDS Services In European Prisons, Oldenburg: BIS-Verlag, 2002, 240 S.

14. Fighting AIDS in America’s prisons, Brent Staples, International Herald Tribune, October 21, 2004.

15. National Aids Trust, The UK response to the HIV epidemic. An assessment of the U.K’s compliance with the UNGASS declaration of commitment on HIV/AIDS Section 2.3.3.

16 Personal communication from Dr. Simon Wilson Consultant Forensic Psychiatrist. Her Majesty’s Prison Brixton on file with PHR-UK.

17. European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment, The CPT standards. para 31 p 29 http://www.cpt.coe.int/en/docsstandards.htm (accessed 22/10/2004).

18. +ve online, October 2000, Prisoner Cell Block HIV ( www.howsthat.co.uk/000/10/001005.htm).

19. European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment. The CPT standards. para 60 p 35 http://www.cpt.coe.int/en/docsstandards.htm (accessed 22/10/2004).

20. Primary Care Trusts, Walshe K, Smith J, Dixon J et al., British Medical Journal, 2004; 329: 871-872

21. Cancer patients failed by local trusts, say MPs, S Boseley, The Guardian, October 27, 2004.

22. Delivering primary care in prison: the need to improve health information, Anaraki S et al., Information in Primary Care, 2003; 11(4): 191-4.

23. Prison Reform Trust Factfile, July 2004 p16 London.

24. Developing effective palliative care within a prison setting, Wilford T., International Journal Palliative Nursing, 2001 Nov 7 (11): 528-30.

25. European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment. The CPT standards. para 31 p 29, para 70 p 37 http://www.cpt.coe.int/en/docsstandards.htm (accessed 22/10/2004).

26. I Robbins, Physicians for Human Rights – UK Conference presentation - The health and human rights of unlawful detainees, Middlesex Hospital, London, June 26, 2004.

27. Report on the visit to the United Kingdom carried out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment - 17 to 21 February 2002. CPT. Strasbourg, February 12, 2003.

28. Report on the visit to the United Kingdom carried out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment - 17 to 21 February 2002. CPT. Strasbourg, February 12, 2003.



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