Every so often hospital staff see patients literally chained to another person for much or all of their appointment. Radhika Holmström asks is this how prisoners’ healthcare is arranged, and how they get access to hospital?
The pressure on the NHS needs no restating. Prisoner patients, however, are at the receiving end of an additional set of pressures, most recently highlighted in an investigation published in The Observer which revealed the 'crisis state of prisons in England and Wales'. The Prison Reform Trust points out that for well over a decade around a quarter of the prison population has been held in overcrowded accommodation – usually doubling up in cells intended for one person; and that at the end of May 2017, 76 of the 117 prisons in England and Wales were holding, between them, nearly 9,500 more people than they were designed for. The prison professionals agree, with the president of the Prison Governors Association describing the combination of an increasing prison population and staff shortages as a ‘toxic mix’ of pressures on the service in England and Wales.
Yet quite separately from this, prisoners’ health poses its own problems. The prison population has a disproportionately high level of people with mental health problems – particularly in women prisoners; HMI Prisons has found that around two-thirds of people in custody reported ‘mental health or well-being issues’. This is one major reason why rates of self-harm and suicide are hugely higher in prisoners (10 times higher in 2015, compared to the wider population). Separately from that, a significant proportion of the population – possibly as high as 30 per cent – has some level of learning disability. For a combination of reasons – lifestyle, poverty, lack of access to health information and possibly the condition that caused their learning disability – people with learning disabilities are often in poor health; they are particularly prone to epilepsy, cardiovascular disease and/or hypertension, and they are also much more likely to develop dementia (especially people with Down’s syndrome).
Not that they are the only ones: the fastest growing age group in prison, according to the Prison Reform Trust, is the proportion aged over 60, including prisoners who are over 80. That group is now 16 per cent of the population, and clearly it has its own health challenges.
In short, says Frances Crook, chief executive of the Howard League for Penal Reform, the prison population is made up of some of the most unhealthy people in the country:
They come from the poorest and the most ostracised, the most vilified population. Their teeth and diet are terrible, and if they have an underlying condition it’s very unlikely it will have been diagnosed. The relatively high death rate from diseases which probably could have been dealt, with is quite alarming. And people are dying in their 40s and 50s from diseases like cancer or heart disease, whereas in the wider population you’d expect this to be happening 20 years later.
A summary of NICE guidance published in the BMJ last year set out the most prevalent health problems, including substance misuse, personality disorder, depression, anxiety, respiratory disease, diabetes, and other chronic health conditions. Unsurprisingly, most prison officers do not have the skills – and are not given the training – to recognise and/or tackle the health needs of this complexly deprived population.
You’re old at 50, officially, in prison, because it’s such an unhealthy environment.
And, just to compound the whole issue, Crook points out that prison itself is a health risk.
There’s a poor and sparse diet, very little exercise and no fresh air, and very little mental stimulation. You’re old at 50, officially, in prison, because it’s such an unhealthy environment. People who go in reasonably healthy are still expected to show the signs of deterioration and ageing ahead of the rest of the population. It’s probably worse for men, partly because most women spend a relatively short time in prison.
Some prisoners actively make the situation worse, notably through using the synthetic psychoactive drug ‘spice’ and/or by violence against others as well as themselves.
When someone is first admitted to prison, they are expected to have their health needs identified, and after that they receive their primary health care within the prison. Primary care is commissioned directly by NHS England – much of it to Care UK but also to smaller companies like Hanham Health in South Gloucester. If they need to see a doctor, they make an application and are taken to their appointment. If they need care that the healthcare team cannot deliver, either a specialist is brought in or they are taken to hospital.
Jake Hard chairs the RCGP’s Secure Environments Group, is an expert witness in this area and works in one men’s and one women’s prison. ‘My job is to ensure they are safe,’ he says of his day-to-day work. ‘A lot of what we do is rationing and gatekeeping, but also investigating – very much normal general practice and the day-to-day stuff. Week by week I tend to be dealing with mental health issues and access to medication. There’s a lot of musculoskeletal pain and pain generally – people are isolated and in distress.’
Every prison, he explains, has its own demographic but there are some common factors. ‘The prevalence of hepatitis B and C is much higher and the risk of getting it greater, and viral things like u can spread very quickly – otherwise the only major infection we’re concerned about is TB.’
The system does not work so well in some other prisons. Ryan Harman manages the Prison Reform Trust’s advice and information services and while he does not want to draw broad generalisations he does flag up concerns:
We speak to people who have quite severe needs that haven’t been sorted from the beginning – in particular, getting their prescribed medication. One explanation for that is that the prison services have to wait for the GP confirmation but clearly that isn’t working very well, and we’ve heard of that in conditions as serious as epilepsy: people quite often have to wait for up to a week.
Then when they are in prison, getting an appointment isn’t always easy he adds:
You have to make an appointment and people report that they haven’t heard back for a long time, or haven’t heard back at all. Then your appointment may be cancelled because staff are needed elsewhere, or they’ve had to take someone else to hospital, or staff shortages mean the whole prison is on lock-down. The thing we hear the most in this regard is simply “I can’t get to see healthcare”, which is frustrating for everyone. Right from the start there are barriers to getting specialised secondary care.
Other primary care professionals certainly echo these concerns.
Last August The Guardian reported that a number of NHS doctors working in prisons felt their working conditions were so unsafe that their services would be shut down anywhere else: there was very little capacity to manage health conditions within the prison, and problems with getting people to secondary care.
‘When we refer someone to hospital because they are acutely unwell, they’ll go out on the same day,’ says Hard. ‘That physical transport is done by the prison authorities. That’s the point at which we rub up against the prison authorities – they have to release people.’
For a non-acute appointment, the details are arranged by prison staff and then staff, again, have to be released to take them – and the prisoner is not told when their appointment is, to cut down the risk of absconding:
Where the system becomes more challenging is when there are a lot of referrals going out and limited staff to take them: I have to decide what is urgent and what can be moved. Or you may have to rearrange because they can’t be taken. For the most part we have a good consistent flow of people and I’m lucky where I work, but there are delays in referrals and delays in taking people at some prisons. It is a peculiarity with the prison system, because in the wider community it’s an issue of people not turning up for their appointments.
Harman flags up some other problems. ‘Cases have been identified by the ombudsman where healthcare staff did not make urgent referrals, and that is concerning.’ That is backed up by a number of legal and other high-pro le cases where people have not been referred at all, or their referral has come much too late.
Harman is also concerned about the number of referral appointments cancelled at the last minute, pointing out that HMI Prisons has touched on this too. ‘We had one man who needed an adapted vehicle for his journey, and his escort was arranged twice without that vehicle. Even if you’re getting as far as those appointments being set up you can be delayed and disappointed.’ On top of that, there are the people who need ongoing hospital treatment:
We had someone who sustained very serious injuries and clearly needed physiotherapy and hydrotherapy after the car crash that caused him to end up in prison. His sentence immediately disrupted all his treatment and it was pretty clear that he’d almost certainly miss the next few appointments and there was a question about whether he would get the same level of care. That’s an example of how disruptive it can be, and how the same quality can seem to be inaccessible if you’re in custody.
Even if someone is dying, they’ll be chained somehow – possibly quite a long chain, but they are always chained.
The cumulative effect of these hurdles mean that some patients may present at hospital later than they should. That aside, however, from now on in, they are much the same as other patients – with one notable exception. They will be accompanied, and they will also subject to ‘restraints’ to make sure they do not use this as an opportunity to get away. Several reports from the Prisons & Probation Ombudsman [sic] (PPO) have mentioned concerns with the use of restraints, mostly in relation to prisoners who died in hospital.
This also means, inevitably, that someone else (and not necessarily someone who is particularly supportive) is always there at every appointment, although a screen can be used to allow some privacy. ‘There is a security- conscious approach to this, rather than putting the individual’s needs first,’ says Harman.
The decision should be balanced with the risk the individual has. In a treatment situation if the restraints are impeding treatment we’d encourage medical staff to make that clear. We’d really like to see those decisions over restraints looked at more closely.
Crook is even more forceful. ‘Even if someone is dying, they’ll be chained somehow – possibly quite a long chain, but they are always chained.’ And there is scope, she points out, for doctors to challenge this.
If it conflicts with their responsibility to care for the patient – either because of medical confidentiality, or someone is just too poorly to be a danger or try to escape – they can and should change this obsession with security.
Finally, Crook has some recommendations for doctors whose patients are going back to prison:
If they need a walk every day to recover, say so. Give the same advice that you would in any other patient, and give the same advice to the custodial officers. They have a responsibility to make sure that information gets back, about the diet they’ll need or the exercise regime, whatever is appropriate to support recovery and a healthy lifestyle. Make sure the patient’s properly cared for, rather than complying with the prison regime. Your immediate responsibility is to them.
‘See the patient first, not the prisoner,’ she concludes. And Hard adds: ‘They’ve been deprived of their liberty. That is already their punishment.’