§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Pope.]
§ 10 pm
§ Helen Jones (Warrington, North)
I am grateful to have the opportunity in this short Adjournment debate to raise the problems of the prison health service. I recognise that it is not a popular subject for debate and would not be so even if it were not held at 10 o'clock on a Thursday evening. Prisoners are not a favourite cause, and their welfare is not at the forefront of most people's minds. However, the strength of the House can be measured by the way in which it deals with unpopular subjects. Similarly, the health of our society can be gauged by the way in which it deals with those who have offended against its laws.
For that reason, my first premise is that we ought to expect for prisoners the same standards of health care that we expect for ourselves. Their punishment is to serve their sentence. They have not been sentenced to be deprived of adequate health care. Yet it is clear that the present system that operates within our prisons fails to deliver the standard of care that we ought to expect and is fatally flawed. That is recognised by prisoners and by many of the staff who work in the service, and it was recognised most of all by the chief inspector of prisons in his report, "Patient or Prisoner", which was published in 1996. That report ought to be commended not only to hon. Members, but to anyone interested in the Prison Service. I am sure that my hon. Friend the Minister of State will be looking into its conclusions carefully and considering how to take them forward.
From that document and from every other source, it is clear that the prison health service fails on three counts. It fails to provide proper health care for prisoners and an adequate career path for staff, and it also fails to meet the needs of society.
The two major problems that we have to deal with in our prisons are addictive behaviour and mental health. If a prisoner goes into prison addicted to drugs and comes out addicted or goes in with mental health problems that are not dealt with in prison, that prisoner is much more likely to reoffend, and we must bear that in mind.
Instead, we should be creating a system that ensures that those problems do not occur, as far as possible, and are tackled in prison. We must also ensure that staff working in the system—we have to admit that they are working in difficult and sometimes dangerous conditions—are adequately trained and properly managed. While the dedication of many of those staff is not at issue, the real problem with the prison health service is that it lacks proper central direction and is not clear about its aims and objectives.
In some areas, we have no idea what is happening. In a written answer, the Minister said:The aims and objectives of the prison health care service are set out in centrally published Health Care Standards".That is right and commendable, but the answer goes on to say that, while many institutions observe those standards,statistics are not available centrally about the proportion that do this."—[Official Report, 20 January 1998; Vol. 304, c. 518.]Responsibility for health care in prisons is left to the governor, who is not obliged to follow any particular model of care. No patients charter is applicable in prison 1512 to ensure minimum standards. I do not seek to apportion blame for the situation. To be honest, the system has persisted regardless of which party has been in power.
The Prison Service and the national health service have established a joint working group to consider the way forward in prison health care, but it is amazing that we cannot even say which establishments follow the central aims of the Prison Service in that regard.
Another cause for concern is the lack of suitably qualified staff in our prisons. I learned from a written answer in November that there were 14 prison establishments with vacancies for either full-time or part-time medical officers. That is bad enough in itself, but the situation regarding the qualifications of staff in our prisons and the training that they are offered is even worse.
As anyone who has ever visited a health care centre in a prison knows, the staff work with very difficult patients who are demanding and can be violent, so it is essential that they have adequate training and are properly managed, yet medical officers get only a two-week induction course in prison health care, and many prisons still do not have health care managers as recommended in the chief inspector's report.
Data are not collected centrally, but the Minister told me in a written answer thatdata from 122 establishments indicate that…34 per cent. of health care managers"—[Official Report, 13 November 1997; Vol. 300, c. 653.]are registered nurses. We do not know how many nurses or other health care staff are undertaking national vocational qualifications or other courses in health care management. I fail to see how the prison health service can function properly with a lack of NHS-trained managers. The fact that we do not even have adequate data is extremely worrying.
The lack of qualified staff to deal with mental health care and addiction is apparent. Because mental health problems are so widespread, it is important to have staff who can cope with them; yet of 197 doctors employed in the Prison Service, only 21 are members of the Royal College of Psychiatrists or hold a diploma in psychiatric medicine.
The training of other staff in dealing with mentally disordered offenders is very patchy, and only 21 per cent. of all health care officers and nursing grades employed in prisons are registered mental nurses. Under those conditions, the service cannot be expected to cope with the number of prisoners with mental health problems.
There are further grounds for concern about how we deal with mentally disordered offenders. The Mental Health Act 1983 does not apply in prisons, so the code of practice on seclusion does not apply either. The guidelines are issued for guidance to prison doctors, but they are not bound by them. I suggest that that is yet another example of the standards of health care that we expect outside prisons not applying within them.
There is also a real problem with the transfer of prisoners to psychiatric institutions. It is true that, once the warrant is issued, those transfers take place very quickly. However, I have talked to prison staff who have made it clear that it sometimes takes a long time to reach that stage. It is often difficult to get doctors to assess prisoners and find proper placements for them. At one time, 1513 the Prison Service estimated that 2,000 prisoners should be transferred to NHS psychiatric care, but could find places for only about 700. The situation was so bad that the chief inspector recommended the establishment of new units for day care centres and 24-hour nursing. However, there has been little progress towards those objectives.
We all recognise that there is a widespread problem with drug abuse in our prisons, yet only 25 per cent. of doctors who work in prisons are trained to deal with addictive behaviour. While I welcome the research carried out in our prisons into drug treatment programmes and the assessments of the impact of mandatory drug testing on the patterns of drug abuse, much remains to be done. Risley in my constituency is in the process of establishing a drugs treatment centre. The officers involved in that project are very enthusiastic about it. They recognise that, while prisoners are rightly punished for drug use in prison, we are not tackling the real problem unless we do something to break the cycle of drug dependency.
Unfortunately, initiatives such as that are few and far between. The same is true in other areas of prison life. For instance, it is clear from the chief inspector's report that care for young offenders is very patchy. There are also serious problems with the care of pregnant women in prison. The Royal College of Midwives' guidelines for prisoners, on pregnancy and childbirth, have yet to be implemented in many establishments.
A further concern is general health promotion and health education in prisons. Some basic awareness training in the area of HIV and AIDS is provided—usually in the first weeks of imprisonment—but much more must be done to educate prisoners about healthy life style choices, treatment and how to prevent ill health. I was heartened to meet recently some nurses from Winchester and to hear what they are doing. They are working in a wing of the prison rather than in a health care centre, so that they are available for appointments with prisoners and can answer questions about any aspect of health care.
Such initiatives point the way forward. However, the real problem with the current system is that it depends on individual staff and governors to take action. We need consistency and co-operation throughout the service, so that standards can be improved and best practice can spread. That is what we are trying to achieve in the national health service, and we should try to achieve it in prisons as well.
I accept that the problems facing the prison health service cannot be put right overnight. However, we must face the fact that health care for prisoners is below the standard of that received by the ordinary population, in terms of both quality of care and access to services. The question is how we should move forward. We must recognise that recruiting more qualified staff is the key to progress. As things stand, there is little incentive for doctors or nurses to work in prisons. There is no real career path, and there are fewer promotion prospects than there are outside.
We also have to be honest and say that prison staff face real ethical dilemmas concerning privacy, confidentiality and the exercise of their clinical judgment; and whether they might appear in conflict with the prison authority.
There is no continuity of planning between the NHS and the Prison Service, and there are no common standards for health care. That is why it is vital in the long 1514 term that the prison health service is integrated into the NHS. Such a move would have major benefits for the quality of patient care and for the training and professional development of staff.
I also recognise that that is not so easy to achieve. Major resource implications should be recognised. The prison population is a significantly higher user of the health service than people of the equivalent age and sex elsewhere. In addition, as I hope I have pointed out, prisoners have hidden health care needs that are not being met and which will increase costs.
It is clear, too, that other issues will have to be tackled, such as the lines of managerial accountability and the relationship between primary and specialist care, which is probably needed more in prisons than outside.
In that situation, it is not easy to move forward, but I hope that the Government will accept that doing nothing is not an option. I hope that when my hon. Friend the Minister of State replies, she will consider some of the ways in which we could progress. If we cannot arrive at the point that we would wish immediately, I hope that the Government will at least consider some pilot projects from which we could learn, and move on from there.
There are many possibilities. For example, prisons could be linked with local trusts. We could consider linking prisons with psychiatric care outside, perhaps a regional secure unit. Such a system might provide easier transfers and better opportunities for research and staff development.
But whatever we do, we must ensure that qualified staff are attracted into our prisons and that we tackle the major health care problems. There are opportunities as well as problems. For example, there are opportunities to consider multi-disciplinary health care within our prisons, involving nurses much more in health care.
If we do not do something, the service will continue to fail to meet the needs of those in prison and of society. I hope that, in the end, we shall be able to tackle the problem. It is not an easy one and it is not a popular cause, but it must be tackled urgently. I hope that my hon. Friend will suggest some ways in which we might go forward and tell us her thinking on these issues.
§ The Minister of State, Home Office (Ms Joyce Quin)
I congratulate my hon. Friend the Member for Warrington, North (Helen Jones) on her good fortune in securing this Adjournment debate and on her choice of subject. I welcome the opportunity to speak to the House on the subject of the prison health care service and how the Government see its future.
My hon. Friend has taken an active interest in the matter during the past year, particularly through her various written questions on the subject, which I welcome. It is an important subject, in which many hon. Members have a keen interest.
The Prison Service, in its statement of purpose, has the duty of imprisoning those sent to prison by the courts, and also owes a duty of care to the people in its custody. It must also prepare them for release.
I was glad that my hon. Friend recognised that the provision of health care is an important dimension of that duty. However, I do not want the House to be under any illusions about the difficulties involved in that task, or the challenges that it presents to staff.
1515 Perhaps I could give some statistics as a background. In the last financial year, 1996–97, about 200,000 prisoners passed through the prison system. The average daily population rose from 53,740 at the end of March 1996 to 59,161 at the end of March 1997. The most recent figure is slightly over 65,000. During that period, the prison health care service handled more than 2 million health-related consultations with inmates. Around 190,000 of these were with visiting NHS consultants providing treatment and care in a variety of specialisms: psychiatry, dentistry, optometry, radiography, and so on.
On 37,000 occasions, prisoners were sent to NHS hospitals as out-patients or in-patients. That represents a good deal of work. Prisons are closed and secure institutions, and, as my hon. Friend recognised, many of the things that are simple and straightforward in the community take on a more complicated character in prison.
My hon. Friend also recognised that, as a group, prisoners are not typical of the general population. That is perhaps obvious, but it is particularly true in health terms. The prison population is predominantly young and male, with a higher incidence of mental disorder and a higher propensity to suicide. They are more likely to smoke—80 per cent. of prisoners do—and to have a drug-taking habit.
By contrast, the equivalent male age group in the community at large tends to make comparatively few demands on health services. All these factors, coupled with the facts and necessary consequences of custody—security, control of medication, particular care for the vulnerable, depressed or suicidal and mentally disordered—make providing health care in prisons a challenge both to health care professionals and to uniformed staff.
An Institute of Psychiatry survey showed that around 38 per cent. of sentenced prisoners suffer some form of mental disorder, although it is important to recognise that, within that figure, we also include those who have some degree of substance misuse or addiction.
A similar survey completed in 1993–94 found that the incidence of mental disorder in the remand population was much higher, at around 66 per cent. In terms of the current population, that translates to around 20,000 sentenced prisoners and 8,300 remand prisoners having some kind of mental disorder: psychosis, neurosis, personality disorder, substance misuse or addiction.
I am glad that random mandatory drug testing appears to be having an impact on drug misuse. The figures available for this year show that 21 per cent. of tests are proving positive—against 24 per cent. last year. The great majority of positive results are for cannabis, but 4 per cent. prove positive for opiates. The fact remains that some prisoners continue to take part in risky behaviour—taking drugs and sharing needles.
We are in the relatively fortunate position that the human immune deficiency virus is not prevalent in our prisons, but we know from experience in other countries that prisons could readily become reservoirs of communicable diseases—HIV, hepatitis B and C, tuberculosis and others. Therefore, we cannot afford to be complacent. Unless care and precautions are taken, 1516 there is potential for a serious threat to prisoners' health, the health of their families, prison staff and, ultimately, the wider community.
Improving the effectiveness of the health care that prisoners receive makes obvious sense: a large number of prisoners spend relatively short periods in custody, during which time effective health care and the prevention of disease can make a positive impact when they return to their home community.
I should underline that good work is being done in response to those challenges. In my visits to various prisons, I have seen the commitment and dedication of prison staff and those who provide health care in prisons. Indeed, they have managed well against the pressures of a rising population, which makes special demands. None the less, many tasks are being taken forward, and there are plans for the future. I hope that I shall be able to refer to these briefly.
The Prison Service is pressing forward with work to develop prisons as places where the promotion of health measures as well as treatment of health problems can take place so that we can encourage prisoners to adopt healthier life styles. An internal awards scheme, which was run for the first time last year, has shown early positive results, with 20 prisons receiving some form of commendation.
A range of pilot drug treatment and counselling programmes has begun. About £6 million was spent in centrally funded projects in the current year, and about as much again was spent by prisons from local budgets. My hon. Friend referred to that work, and the Government want to increase the number of voluntary testing units, at which people in our prisons can live and be supported in a drug-free environment. About 4,000 places are currently available, and the Under-Secretary and I have visited operational schemes.
Plans are in hand to increase the number of therapeutic community places, similar to those available at Grendon prison, which my right hon. Friend the Home Secretary and I visited recently. A range of research suggests that Grendon-type therapy courses have beneficial effects in terms of psychological change and reoffending behaviour.
The number of prisoners transferred to NHS hospitals for in-patient treatment for mental disorder has increased significantly in the 1990s. It is difficult to cope with demand; there has been a fivefold increase in transfers since 1986. The NHS is playing its part in expanding facilities—a growing number of services in prison are provided by NHS specialists.
A range of training is in place or being developed to improve the skills and knowledge of health care staff and prison doctors. I agree with my hon. Friend that the central collection of statistics could be strengthened to make the position clearer, and the Government are keen to address the patchiness and variability of provision.
Training in dealing with communicable diseases is being stepped up, and prisons are required to have multidisciplinary teams to manage HIV and AIDS treatment. Their training is being extended to other communicable diseases. I have visited good induction schemes for prisoners in which HIV and AIDS awareness plays an important part. The schemes are imaginatively delivered in some prisons via video programmes, which effectively communicate the message to prisoners. 1517 Historically, health care in prison has been the responsibility of the Prison Service, and has been organised outside the NHS. Ultimately, accountability rests with the Home Secretary, alongside that for prisons and the management of prisoners. In practice, as statistics show, the NHS has been drawn into providing some health care, particularly of a specialist nature. Indeed, the pattern of provision is quite varied. The majority of primary care is provided by directly employed staff, but, increasingly, NHS or private sector health care providers play a complementary role.
The pattern of organisation and provision reflects in part an attempt by prisons to meet local needs, but is also in large measure the result of history, and inadequately co-ordinated development. There are good examples, which might serve as models that could be applied more generally, but also rather poor ones.
My hon. Friend referred to the thematic review undertaken by the chief inspector of prisons, Sir David Ramsbotham, who highlighted his anxieties about prison health care in the report, "Patient or Prisoner?" He recommended that responsibility and, ultimately, the budget for the delivery of prisoner health care should move to the NHS. We have not yet reached a view about 1518 whether that is the right way forward—it would raise a range of organisation, management and resource issues for the Prison Service and the NHS—but the working group to which my hon. Friend referred, involving the Home Office, the Prison Service and the Department of Health, is important in that respect. I have received an interim briefing from it, and look forward to receiving its recommendations in the near future.
The group's remit is to consider jointly the future organisation and delivery of health care to prisoners. The objectives are to secure improvements in meeting the health needs of prisoners, to tackle the problems and weaknesses in standards, and to deal with the isolation of health care staff. I agree with my hon. Friend that prison health care staff must feel part of a career structure, and must not be isolated from other health care providers and professionals. Prison health responsibility should be seen not as a career cul-de-sac, but as an important part of career development.
§ The motion having been made at Ten o'clock, and the debate having continued for half an hour, MR. DEPUTY SPEAKER adjourned the House without Question put, pursuant to the Standing Order.
§ Adjourned at half-past Ten o'clock.