HMP Healthcare - Prison

It may not come as a surprise that healthcare within our prisons faces many of the same issues as the rest of the beleaguered NHS. That is; underfunded, understaffed, and living with the ever-present threat of further cuts.

In many ways prison healthcare is a chilling foretaste of the future of the NHS, the swingeing cuts to civilian mental health services, specialist care, and elderly care are sharply amplified for prison inmates.

Despite the obvious similarities, where prison healthcare differs from its civilian counterpart is in largely in attitude and competence. Anyone who has ever received treatment from the NHS (so most of us), will attest to an overall impression of a highly competent, caring professionals, who often work “everyday miracles” with very little. Not so prison healthcare professionals.

By contrast, the prison health care I experienced was characterised by near comical levels of incompetence, open disdain towards patients and breath-taking arrogance. In fact, by the end of my sentence my disgust with my own treatment and that of my fellow penitents, was such that I refused to have anything more to do with the department than a fortnightly prescription.

Were you to complain about the “attitude” displayed by healthcare professionals outside of prison, the complaint is likely to be a minor one. The surly manner of a nurse perhaps or a doctor who rushed through your case. Unfortunately, the issues in disposition displayed by prison staff are of a different hue. Many of the incidents I witnessed and experienced, would likely have been cause for disciplinary action had they happened anywhere but a prison.

Take, for example, an exchange I witnessed early in my time at HMP Standford Hill. A prisoner unknown to me politely asked the institution’s Head of Healthcare why his appointment to see a doctor had been altered for the fourth time. She responded with “let me explain this in words of two syllables so that even you can understand,” before launching into a brutal tirade, which aside from not adhering to her syllabic rule, attacked the prisoner for daring to question the vagaries of appointment scheduling and questioned his intelligence and worth to humanity. All this in front of other prisoners awaiting their appointments. An answer to the inmate’s original question wasn’t forthcoming.

Perhaps there was more to that exchange than met the eye. This prisoner may well have been a thorn in the side of the Head of Healthcare. Despite this, shouldn’t a polite question have at least elicited a polite response? The exchange left me with the suspicion that the reason for such obvious and disproportionate disdain, was a case of status. The prisoner was treated in the way he was treated, not because of any wrong-doing, but precisely because he was a prisoner, ergo not deserving of common courtesy.

This suspicion was to be confirmed for me time and time again throughout my time in prison. A particularly comical example was an exchange between a close friend of mine Steve and another member of the healthcare department. Steve, a former stock broker and a graduate of a leading university, provoked the ire of an administrator by politely informing her he would not be able to attend his next appointment. Before he could explain why, another rant was delivered, like the other prisoner, attacking Steve personally and questioning his intelligence. The accusation being that he was trying to avoid attending his healthcare appointment so that he could go out on home leave instead. This continued for around 20 minutes before Steve was finally allowed to explain himself. The reason he couldn’t attend? The date of his appointment was a bank holiday, and clinic he was due to attend closed.

Were this to happen outside of a prison, the least to be expected is an apology. However, Steve was “only a prisoner.” So, after declaring that the appointment being booked in for a bank holiday wasn’t “possible,” which was Steve’s point too but for wholly different reasons, we were quickly ushered from the office.

Nor is the derision shown to prisoners confined to everyday courtesy, the rudeness displayed in over fairly trifling administrative questions, mask something far more sinister.

Amongst elderly prisoners, who are also most in need of healthcare, I witnessed what can only be described as a culture of fear. It was well-known by inmates that disagreement with the diagnosis of the healthcare team could have potentially dire consequences. Most of the rooms assigned to healthcare were fitted with panic buttons, the reasoning behind this is self-explanatory, but it’s also a system open to abuse.

The prison grapevine was full of tales of inmates who’d disagreed with their diagnosis or requested a second opinion, only to have the button pushed for their “threatening behaviour.” The consequence being a likely upgrade in risk status and a transfer to Swaleside the closest category B prison, an institution known among inmates for its violence.  Several prisoners were transferred during my 18 months at Standford Hill, with this being the rumoured reason.

Whether this is true, and I saw enough in my own dealings with Healthcare to believe it is, hardly matters, the consequences were severe. I witnessed several elderly prisoners, with chronic health conditions refuse to seek medical attention out of fear. Their logic isn’t hard to grasp; the risk of further complications with their illness was outweighed by their terror at potentially being sent to a higher category prison, which they justifiably suspected would shorten their lifespan anyway.

To guard against this, I and some of the other inmates took to asking the prison Chaplain to attend healthcare meetings with us. As an independent and impartial witness of sorts, but not all prisoners had this option.

This led to some horrific cases such as Stephan, who suffered from chronic circulation problems, so much so that he risked developing gangrene. Stephan was so afraid of the healthcare team, that he refused to seek treatment. Instead, he suffered, often in agony, in complete silence.

Even inmates who do seek medical attention can’t be sure of being taken seriously. From my own experience, my chronic back problems were described as “non-existent,” despite being diagnosed by top orthopedic specialists prior to my time in prison. I persisted in reporting my pain and was promised a referral to a pain clinic, however after 4 months of repeat appointments no referral was made, nor was I informed how long it would take other than “a while.”

I consider myself one of the lucky ones. Horrific stories abound of inmates enduring unspeakable cruelty at the hands of healthcare staff. One such example is Steven Griffiths, whose story appeared in Inside Time in August 2014, after he became so desperate that the letters page of a newspaper was his only recourse.

Steven has a colostomy bag after suffering from bowel cancer, for proper sanitation this needs to be changed every 3-5 days. Failure to do so brings with it the risk of infection and sepsis, as well as the obvious embarrassment and discomfort it causes the patient. While housed at HMP Oakwood, Steven made two applications for fresh bags, each time the request was either ignored or the wrong size ordered. The inevitable happened and Steven ran out of bags, the reaction of Healthcare staff according to Steven's account? “What do you expect me to do, it’s the weekend.”

How about the inmate I knew who suffered chronic incontinence, due to a litany of health issues? The problem became so severe that the prisoners on laundry duty refused to clean his clothes or bedding, the result being that he had the choice of sleeping in soiled bedclothes or going without. All it would have taken to afford this man the base level of human dignity was a change in diet. However, when he suggested to healthcare staff that a kosher diet would likely improve his condition, he was informed that “Gentiles were not permitted access to a kosher diet.”

I consider myself fortunate that this is the worst I witnessed, however, it’s some way from the worst prison healthcare have meted out to inmates. Former inmate and writer Alex Cavendish recalls a dreadful story about a young man who had to be castrated due to the ineptitude of staff:

I’ll give you another example of a young prisoner known to me personally. He was on the methadone programme to manage his addiction and he suffered from a range of other health problems, including being unstable on his feet at times. One night, he climbed out of his top bunk to use the toilet and slipped. He fell and landed on the back of a metal-framed chair, crushing his testicles. Although he was screaming in agony, and his cell-mate pressed the call bell to get staff assistance, the night screw (‘the clocky’) just told him to get back into bed and shut up.

The next day he was in a very bad way and was unable to walk. Delays in getting an appointment with healthcare meant a three-day wait before he was seen by a nurse, then it took almost a further week until he was taken, handcuffed, to the local hospital. Of course, by then it was far too late and his condition was so serious that he had to be castrated. Yes, you read that correctly. 

When he was finally returned to the prison, after surgery, the powerful painkillers he had been prescribed at the hospital were confiscated and he was given paracetamol instead. News about what had happened went around among the staff and a couple of the screws he encountered found his predicament extremely funny. Just try to put yourself in his position – or imagine that this youngster was your own son”.

Such accounts read like something more akin to the treatment inflicted upon the political prisoners of a third world despot, or first-hand accounts from the darkest days of the Second World War. Not the penal program of a modern liberal democracy.

Yet this callous indifference to the welfare of inmates is commonplace. Which is not to say that caring and professional staff do not exist, but in my own experience and that of countless others, the prevailing attitude was one of utter disdain. The prejudice often displayed is almost Victorian in its assertion that convicted criminals are in some way pathological abnormal or mentally defective. Furthermore, there appears to be an all too real implication that the loss of liberty also equates to an inmate surrendering their humanity.

The attitude displayed towards inmates is matched only be the questionable levels of competence displayed by many of the healthcare staff I dealt with. Having been transferred from B category HMP Thameside, I arrived at Stanford Hill, thinking perhaps that healthcare provision would be better in a prison closer (in risk category) to the real world. Unfortunately, I was to be sorely disappointed.

Upon arrival at Standford Hill, my “thorough medical assessment” consisted of me explaining my complicated medical history, including previous battles with cancer and my chronic back pain. The nurse on duty failed to note any of this down and by the time I left prison some 18 months later, to my knowledge, no attempt had ever been made to source my medical history from my GP.

As my treatment for back pain included the use of Tramadol, Valium, and Co-Codamol, I was told that my case would have to be referred to an offsite pain clinic, to continue receiving any meaningful pain medication. After waiting 4 months for a referral to a pain clinic, no explanation was forthcoming until I put in an application for a 7-foot bed (I am 6 ‘3”) to aid with the pain. To my surprise, I was told that Healthcare had no record of my back pain, by the same nurse who interviewed me no less, and that accordingly, I wasn’t on the pain clinic waiting list.

Moreover, when the nurse asked what my back problem was, she dismissed it as “non-existent” stating that she’d never heard of it. The arrogance of this statement is breathtaking, having seen leading specialists in orthopedics for my condition before my imprisonment, I’m secure in the knowledge that my condition is real. The pain is certainly real enough. That a medical professional would dismiss the judgement of an eminently more qualified specialist is hard to fathom.

More worrying still, during this time I was still receiving my prescription of strictly controlled pain medication each day, despite the prison having “no record” of any corresponding medical issue. Which rather begs the question, how many other prisoners are receiving highly addictive (and valuable) substances for conditions which have not been properly substantiated? With this in mind, is it a surprise that the black market for pharmaceutical drugs is endemic within our prisons?

That my back condition wasn’t reported simply isn’t credible. My medical records arrived at Standford Hill HMP from Thameside HMP the same day as I did, and I’d been receiving controlled substances from Healthcare for months. What is clear is that induction nurse lied to mask her incompetence and was duly protected by the healthcare department. My formal complaints to the Department were met with “we’re sorry you feel that way.”

Nor am I alone in my experiences of rank incompetence from healthcare staff. I witnessed diabetics left without medication for dangerous periods of time, prisoners who were being treated for gangrene after their easily treatable conditions had gone ignored for too long, prisoners who had operations cancelled after “communications mix-ups,” even a prisoner who had been diagnosed with dementia at a previous prison but was refused treatment at Standford Hill because (you guessed it) they had “no record of it.”

Another inmate was told by the triage nurse that there was “nothing wrong” with his foot, despite him ending up in an emergency operation just a few days later when the gangrene spread. Or how about the horror story relayed by Alex Cavendish regarding the complex fracture of an inmate’s leg:

“I’ve witnessed other horrific incidents. A lad broke his leg playing football and even though it was a complex fracture and the bones were visibly breaking through the skin, was told by healthcare staff that it was “just a bad sprain.” Fortunately, the gym screw – who I suspect had more humanity in him than the whole of the healthcare team – had been an Army paramedic and he told them what he thought of their triage diagnosis in no uncertain terms before contacting the duty governor and getting an ambulance called to take the bloke to hospital for appropriate treatment.”

There is no way to describe this incident than in the terms that suit it: complete disdain for the welfare of the prisoner and wilful incompetence on the part of the healthcare team. It’s hard to imagine a similar scenario occurring in an everyday setting because it wouldn’t. If it did, the media reaction would be hysterical and the professionals involved would likely face disciplinary action. It’s worth considering for a moment why the situation should be any different for prisoners?

Perhaps the most worrying impact of staff incompetence is upon mental health patients. It’s long been known that the prison population is far more susceptible to mental health issues than the general populace, in 2015 alone the rate of self-inflicted deaths among the prison population was 120 per 100,000 people, in comparison with a rate of 10.8 among the general populace.

Yet, the healthcare professionals appear ill-equipped to deal with it. 2016’s Prisons and Probation Ombudsman (PPO) Prisoner Mental Health Report found that while 70% of prisoners who died from self-inflicted means while in prison had already been identified with mental health needs, this concerns had only been flagged with reception in just over half of cases. Furthermore, The PPO’s investigation found that nearly one in five of those diagnosed with a mental health problem received no care from a mental health professional while in prison. In severe cases, where inmates were deemed enough of a risk to themselves or others that transfer to a mental health institution was required, in 71% of cases the transfer took longer than the 14-day limit set by the Department of Health.

All the while prison suicide figures continue their upward trajectory (as of 2016 they stand at record levels). My own experiences bear out the figures: inmates with mental health issues were often left to their own devices at both Standford Hill and Thameside HMPs. While mental health issues to some extent “come with the territory” when people have lost their liberty, rhetoric about the “vicissitudes of prison life” is not enough to explain the sheer scale of the problem facing prison healthcare.

Mental health is simply not the priority it should be for prison healthcare. This is partly down to poor funding and scarcity in resources, like provision for the general populace mental health is poorly understood and resource lags far behind demand. It’s also a case of competence, too much of the communication and care regarding mental health is disjointed and half-baked.

There is also a growing body of evidence that mental health issues are not being caught early enough. From 2011 to 2014 the number of male inmates transferred from prison on mental health grounds increased by 21%, yet in the same period the number offenders initially hospitalised instead of being sent to prison fell by 26.5%. Given the previously mentioned statistic that 70% of inmates who die from self-inflicted means were identified as having mental health issues prior to incarceration, if things were working one would expect to see a rise in the number of hospital orders. That the opposite is happening, suggests that perhaps mental health issues are being left to ferment in a prison environment rather than being caught early.

 As former Prison Reform Trust director Juliet Lyon said in 2016 quote to the Guardian: “If you’re thinking about someone that’s got mental health needs, it’s hard to imagine a less conducive environment to getting better than a prison. There’s a tension with what’s currently happening in our prisons: the lack of activity, the shortage of staff, the appalling rise of suicide and self-harm, and violence in prisons. I think the only way really to effect change is to establish the last resort principle that you use prison as a place of absolute last resort in the justice system.”

While government is talking a good game: the MoJ stating in 2016, “We are investing £1.3bn to transform the prison estate, while also training staff to respond effectively to prisoners experiencing suicidal, self-harm and mental health issues,” far more than rhetoric is needed for what’s fast becoming a crisis. That there were (according to statistics released by the MoJ) 34,586 incidents of self-harm in UK prisons last year, an average of one every 15 minutes, brings into stark relief that it hasn’t done anything like enough yet. The prison service needs more mental health professionals, better training for general staff (both in recognising and dealing with potential issues of mental health), and a markedly different outlook on importance of mental wellbeing for prisoners who are likely to be released back into the community at some stage. Sadly, many more men and women may turn to the most desperate of measures long before we reach that point.

The problems facing mental health in prisons are symptomatic of the wider problems with prison healthcare, so how and why have things got so bad? More importantly, what can be done about it?

The how and why is, for the most part, simple to explain. Like the NHS the prison system is poorly funded and suffers from many of the same problems but with some subtle but key differences.

Firstly, the nature of prisons does nothing to help breed efficiency. Given their incarceration, prisoners cannot utilise the options for care available to the general public, they can’t pick up a prescription from a chemist, nor use an A & E department, nor visit their local GP. Meaning that everything from a common cold to a cerebral haemorrhage must go through the same system, placing enormous strain on already overloaded staff. Add into this the general effect of prison on inmates’ health and an aging prison population that much more likely to suffer from acute health conditions and it’s not difficult to see why so many vital services are missed.

The second key issue is one of quality. It is hard to escape the conclusion that many of the healthcare staff I experienced in prison were the dregs of the medical profession, who perhaps would have struggled for employment elsewhere. This was proven time and again by horrific feats of incompetence like those described above and the derision shown towards the opinions of specialists outside of prison. To put it another way, would the healthcare professional who proclaimed bone protruding through tissue a “bad sprain” las long in an A & E department? Unlikely. On a more fundamental level, it’s unlikely prison healthcare, with its multitude of problems and the risk it entails, is particularly attractive to any nurse or doctor with other options open to them. As such the service draws some an extremely shallow pool of talent.

Thirdly, prisoners are a truly captive market. When healthcare slips below an acceptable standard there is very little recourse open to them. Essentially the wronged inmate has four options: the official complaints procedure (which in my own experience is often redundant), riot or cause a disturbance which comes with the risk of re-categorisation, try and survive or in extreme cases, commit suicide. The lack of recourse available to prisoners, remember the majority cannot afford legal representation and lawyers willing to take on cases pro-bono is decreasing all the time, hardly incentivises healthcare professionals to maintain acceptable standards of care.

Fourthly, many of the healthcare providers the National Offender Management Service (NOMS) contracts prison healthcare out to are so-called “community care” providers. Or in layman’s terms, private entities. Often driven by questionable motives (namely their bottom line), as we’ve seen in other areas of prison life such as catering, these companies are often driven by little more than providing the cheapest possible service, rather than anything of quality. This is exacerbated by the propensity of NOMS to continually award contracts to the same select group of contractors (think Serco, G4S and in the case of healthcare, Care UK), despite repeated failings in standards, leaving no incentive for improvement or indeed disincentive to continue in the same vein.

Finally, the attitude towards prisoners is markedly different than that shown towards regular patients. During my final months in prison, I received a response to my complaints from Sue Worrall Head of Workforce Development at Stanford Hill. In it, she described the staff’s commitment to treating all patients with “decency, dignity, and respect.” Noble rhetoric perhaps, but as I hope I’ve demonstrated, this just isn’t reality. Time and time again staff’s attitude and treatment of inmates confirmed my suspicion that we were seen as less than worthy of the basic human needs such as decent healthcare, for the simple reason that we were convicted criminals.

So, what can be done to improve prison healthcare?

The overarching goal is a simple one. Prisoners should be subject, as per Rule 24 of the UN Nelson Mandela Rules for the minimum treatment of prisoners, to an equal standard of care as available in the community. Not theoretically, not rhetorically and the parameters defined clearly by the state. 

It’s worth noting that were the prisoners not serving time, the cost of their care would still likely need to be met by the NHS in their community, why should their incarceration change the level of care they are due? It’s also completely illogical to scrimp on prisoners’ care, working on the assumption that most the prison population will one day be released back into the community, not addressing their health concerns in prison simply presents the NHS and the wider community with a costly health time bomb, which will require attention at some point anyway.

Some headway is being made on this count, health watchdog the National Institute for Health and Care Excellence (Nice) released new guidelines last year in response to a growing problem. The guidelines which seek to define what healthcare should look like in custodial settings include carrying out a healthcare assessment on arrival with questions on physical health and mental health as well as substance abuse, screening for TB within 48 hours of entering prison, and offering advice on smoking, sexual health, and diet.

While the production of guidelines is a welcome step towards parity for prisoners, it isn’t a panacea for the problem. Guidelines from watchdogs are usually just that, without the teeth to punish those prisons who fail to adhere, it’s unlikely to make huge strides in the reality of the healthcare prisoners receive. Remember that the UN Mandela guidelines are largely ignored in practice.

Furthering this point, given their woeful record, private care providers should no longer be permitted to provide prison healthcare. Without the government first installing greater levels of accountability for failings and minimum standards of care. It is axiomatic that a captive market (which prisoners undoubtedly are) should not be entrusted to a private entity driven by profit, to do so goes against the very justification for privatisation of anything.

Finally, less collective head burying and greater transparency are needed. The issues present in prison healthcare are summed up by the irony in Standford Hill’s Healthcare department being declared “top of the tree” in an HM Inspectorate report while I was housed there. If the appalling service I witnessed there are the highest branches of the tree, what godforsaken place must the roots be? Until prison healthcare is measured and compared against the same metrics as those which apply to the NHS, we are unlikely to see parity in quality.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

It may not come as a surprise that healthcare within our prisons faces many of the same issues as the rest of the beleaguered NHS. That is; underfunded, understaffed, and living with the ever-present threat of further cuts.

 

In many ways prison healthcare is a chilling foretaste of the future of the NHS, the swingeing cuts to civilian mental health services, specialist care, and elderly care are sharply amplified for prison inmates.

 

Despite the obvious similarities, where prison healthcare differs from its civilian counterpart is in largely in attitude and competence. Anyone who has ever received treatment from the NHS (so most of us), will attest to an overall impression of a highly competent, caring professionals, who often work “everyday miracles” with very little. Not so prison healthcare professionals.

 

By contrast, the prison health care I experienced was characterised by near comical levels of incompetence, open disdain towards patients and breath-taking arrogance. In fact, by the end of my sentence my disgust with my own treatment and that of my fellow penitents, was such that I refused to have anything more to do with the department than a fortnightly prescription.

 

Were you to complain about the “attitude” displayed by healthcare professionals outside of prison, the complaint is likely to be a minor one. The surly manner of a nurse perhaps or a doctor who rushed through your case. Unfortunately, the issues in disposition displayed by prison staff are of a different hue. Many of the incidents I witnessed and experienced, would likely have been cause for disciplinary action had they happened anywhere but a prison.

 

Take, for example, an exchange I witnessed early in my time at HMP Standford Hill. A prisoner unknown to me politely asked the institution’s Head of Healthcare why his appointment to see a doctor had been altered for the fourth time. She responded with “let me explain this in words of two syllables so that even you can understand,” before launching into a brutal tirade, which aside from not adhering to her syllabic rule, attacked the prisoner for daring to question the vagaries of appointment scheduling and questioned his intelligence and worth to humanity. All this in front of other prisoners awaiting their appointments. An answer to the inmate’s original question wasn’t forthcoming.

 

Perhaps there was more to that exchange than met the eye. This prisoner may well have been a thorn in the side of the Head of Healthcare. Despite this, shouldn’t a polite question have at least elicited a polite response? The exchange left me with the suspicion that the reason for such obvious and disproportionate disdain, was a case of status. The prisoner was treated in the way he was treated, not because of any wrong-doing, but precisely because he was a prisoner, ergo not deserving of common courtesy.

 

This suspicion was to be confirmed for me time and time again throughout my time in prison. A particularly comical example was an exchange between a close friend of mine Steve and another member of the healthcare department. Steve, a former stock broker and a graduate of a leading university, provoked the ire of an administrator by politely informing her he would not be able to attend his next appointment. Before he could explain why, another rant was delivered, like the other prisoner, attacking Steve personally and questioning his intelligence. The accusation being that he was trying to avoid attending his healthcare appointment so that he could go out on home leave instead. This continued for around 20 minutes before Steve was finally allowed to explain himself. The reason he couldn’t attend? The date of his appointment was a bank holiday, and clinic he was due to attend closed.

 

Were this to happen outside of a prison, the least to be expected is an apology. However, Steve was “only a prisoner.” So, after declaring that the appointment being booked in for a bank holiday wasn’t “possible,” which was Steve’s point too but for wholly different reasons, we were quickly ushered from the office.

 

Nor is the derision shown to prisoners confined to everyday courtesy, the rudeness displayed in over fairly trifling administrative questions, mask something far more sinister.

 

Amongst elderly prisoners, who are also most in need of healthcare, I witnessed what can only be described as a culture of fear. It was well-known by inmates that disagreement with the diagnosis of the healthcare team could have potentially dire consequences. Most of the rooms assigned to healthcare were fitted with panic buttons, the reasoning behind this is self-explanatory, but it’s also a system open to abuse.

 

The prison grapevine was full of tales of inmates who’d disagreed with their diagnosis or requested a second opinion, only to have the button pushed for their “threatening behaviour.” The consequence being a likely upgrade in risk status and a transfer to Swaleside the closest category B prison, an institution known among inmates for its violence.  Several prisoners were transferred during my 18 months at Standford Hill, with this being the rumoured reason.

 

Whether this is true, and I saw enough in my own dealings with Healthcare to believe it is, hardly matters, the consequences were severe. I witnessed several elderly prisoners, with chronic health conditions refuse to seek medical attention out of fear. Their logic isn’t hard to grasp; the risk of further complications with their illness was outweighed by their terror at potentially being sent to a higher category prison, which they justifiably suspected would shorten their lifespan anyway.

 

To guard against this, I and some of the other inmates took to asking the prison Chaplain to attend healthcare meetings with us. As an independent and impartial witness of sorts, but not all prisoners had this option.

 

This led to some horrific cases such as Stephan, who suffered from chronic circulation problems, so much so that he risked developing gangrene. Stephan was so afraid of the healthcare team, that he refused to seek treatment. Instead, he suffered, often in agony, in complete silence.

 

Even inmates who do seek medical attention can’t be sure of being taken seriously. From my own experience, my chronic back problems were described as “non-existent,” despite being diagnosed by top orthopedic specialists prior to my time in prison. I persisted in reporting my pain and was promised a referral to a pain clinic, however after 4 months of repeat appointments no referral was made, nor was I informed how long it would take other than “a while.”

 

I consider myself one of the lucky ones. Horrific stories abound of inmates enduring unspeakable cruelty at the hands of healthcare staff. One such example is Steven Griffiths, whose story appeared in Inside Time in August 2014, after he became so desperate that the letters page of a newspaper was his only recourse.

 

Steven has a colostomy bag after suffering from bowel cancer, for proper sanitation this needs to be changed every 3-5 days. Failure to do so brings with it the risk of infection and sepsis, as well as the obvious embarrassment and discomfort it causes the patient. While housed at HMP Oakwood, Steven made two applications for fresh bags, each time the request was either ignored or the wrong size ordered. The inevitable happened and Steven ran out of bags, the reaction of Healthcare staff according to Steven's account? “What do you expect me to do, it’s the weekend.”

 

How about the inmate I knew who suffered chronic incontinence, due to a litany of health issues? The problem became so severe that the prisoners on laundry duty refused to clean his clothes or bedding, the result being that he had the choice of sleeping in soiled bedclothes or going without. All it would have taken to afford this man the base level of human dignity was a change in diet. However, when he suggested to healthcare staff that a kosher diet would likely improve his condition, he was informed that “Gentiles were not permitted access to a kosher diet.”

 

I consider myself fortunate that this is the worst I witnessed, however, it’s some way from the worst prison healthcare have meted out to inmates. Former inmate and writer Alex Cavendish recalls a dreadful story about a young man who had to be castrated due to the ineptitude of staff:

 

I’ll give you another example of a young prisoner known to me personally. He was on the methadone programme to manage his addiction and he suffered from a range of other health problems, including being unstable on his feet at times. One night, he climbed out of his top bunk to use the toilet and slipped. He fell and landed on the back of a metal-framed chair, crushing his testicles. Although he was screaming in agony, and his cell-mate pressed the call bell to get staff assistance, the night screw (‘the clocky’) just told him to get back into bed and shut up.

 

The next day he was in a very bad way and was unable to walk. Delays in getting an appointment with healthcare meant a three-day wait before he was seen by a nurse, then it took almost a further week until he was taken, handcuffed, to the local hospital. Of course, by then it was far too late and his condition was so serious that he had to be castrated. Yes, you read that correctly. 

 

When he was finally returned to the prison, after surgery, the powerful painkillers he had been prescribed at the hospital were confiscated and he was given paracetamol instead. News about what had happened went around among the staff and a couple of the screws he encountered found his predicament extremely funny. Just try to put yourself in his position – or imagine that this youngster was your own son”.

 

Such accounts read like something more akin to the treatment inflicted upon the political prisoners of a third world despot, or first-hand accounts from the darkest days of the Second World War. Not the penal program of a modern liberal democracy.

 

Yet this callous indifference to the welfare of inmates is commonplace. Which is not to say that caring and professional staff do not exist, but in my own experience and that of countless others, the prevailing attitude was one of utter disdain. The prejudice often displayed is almost Victorian in its assertion that convicted criminals are in some way pathological abnormal or mentally defective. Furthermore, there appears to be an all too real implication that the loss of liberty also equates to an inmate surrendering their humanity.

 

The attitude displayed towards inmates is matched only be the questionable levels of competence displayed by many of the healthcare staff I dealt with. Having been transferred from B category HMP Thameside, I arrived at Stanford Hill, thinking perhaps that healthcare provision would be better in a prison closer (in risk category) to the real world. Unfortunately, I was to be sorely disappointed.

 

Upon arrival at Standford Hill, my “thorough medical assessment” consisted of me explaining my complicated medical history, including previous battles with cancer and my chronic back pain. The nurse on duty failed to note any of this down and by the time I left prison some 18 months later, to my knowledge, no attempt had ever been made to source my medical history from my GP.

 

As my treatment for back pain included the use of Tramadol, Valium, and Co-Codamol, I was told that my case would have to be referred to an offsite pain clinic, to continue receiving any meaningful pain medication. After waiting 4 months for a referral to a pain clinic, no explanation was forthcoming until I put in an application for a 7-foot bed (I am 6 ‘3”) to aid with the pain. To my surprise, I was told that Healthcare had no record of my back pain, by the same nurse who interviewed me no less, and that accordingly, I wasn’t on the pain clinic waiting list.

 

Moreover, when the nurse asked what my back problem was, she dismissed it as “non-existent” stating that she’d never heard of it. The arrogance of this statement is breathtaking, having seen leading specialists in orthopedics for my condition before my imprisonment, I’m secure in the knowledge that my condition is real. The pain is certainly real enough. That a medical professional would dismiss the judgement of an eminently more qualified specialist is hard to fathom.

 

More worrying still, during this time I was still receiving my prescription of strictly controlled pain medication each day, despite the prison having “no record” of any corresponding medical issue. Which rather begs the question, how many other prisoners are receiving highly addictive (and valuable) substances for conditions which have not been properly substantiated? With this in mind, is it a surprise that the black market for pharmaceutical drugs is endemic within our prisons?

 

That my back condition wasn’t reported simply isn’t credible. My medical records arrived at Standford Hill HMP from Thameside HMP the same day as I did, and I’d been receiving controlled substances from Healthcare for months. What is clear is that induction nurse lied to mask her incompetence and was duly protected by the healthcare department. My formal complaints to the Department were met with “we’re sorry you feel that way.”

 

Nor am I alone in my experiences of rank incompetence from healthcare staff. I witnessed diabetics left without medication for dangerous periods of time, prisoners who were being treated for gangrene after their easily treatable conditions had gone ignored for too long, prisoners who had operations cancelled after “communications mix-ups,” even a prisoner who had been diagnosed with dementia at a previous prison but was refused treatment at Standford Hill because (you guessed it) they had “no record of it.”

 

Another inmate was told by the triage nurse that there was “nothing wrong” with his foot, despite him ending up in an emergency operation just a few days later when the gangrene spread. Or how about the horror story relayed by Alex Cavendish regarding the complex fracture of an inmate’s leg:

 

“I’ve witnessed other horrific incidents. A lad broke his leg playing football and even though it was a complex fracture and the bones were visibly breaking through the skin, was told by healthcare staff that it was “just a bad sprain.” Fortunately, the gym screw – who I suspect had more humanity in him than the whole of the healthcare team – had been an Army paramedic and he told them what he thought of their triage diagnosis in no uncertain terms before contacting the duty governor and getting an ambulance called to take the bloke to hospital for appropriate treatment.”

 

There is no way to describe this incident than in the terms that suit it: complete disdain for the welfare of the prisoner and wilful incompetence on the part of the healthcare team. It’s hard to imagine a similar scenario occurring in an everyday setting because it wouldn’t. If it did, the media reaction would be hysterical and the professionals involved would likely face disciplinary action. It’s worth considering for a moment why the situation should be any different for prisoners?

 

Perhaps the most worrying impact of staff incompetence is upon mental health patients. It’s long been known that the prison population is far more susceptible to mental health issues than the general populace, in 2015 alone the rate of self-inflicted deaths among the prison population was 120 per 100,000 people, in comparison with a rate of 10.8 among the general populace.

 

Yet, the healthcare professionals appear ill-equipped to deal with it. 2016’s Prisons and Probation Ombudsman (PPO) Prisoner Mental Health Report found that while 70% of prisoners who died from self-inflicted means while in prison had already been identified with mental health needs, this concerns had only been flagged with reception in just over half of cases. Furthermore, The PPO’s investigation found that nearly one in five of those diagnosed with a mental health problem received no care from a mental health professional while in prison. In severe cases, where inmates were deemed enough of a risk to themselves or others that transfer to a mental health institution was required, in 71% of cases the transfer took longer than the 14-day limit set by the Department of Health.

 

All the while prison suicide figures continue their upward trajectory (as of 2016 they stand at record levels). My own experiences bear out the figures: inmates with mental health issues were often left to their own devices at both Standford Hill and Thameside HMPs. While mental health issues to some extent “come with the territory” when people have lost their liberty, rhetoric about the “vicissitudes of prison life” is not enough to explain the sheer scale of the problem facing prison healthcare.

 

Mental health is simply not the priority it should be for prison healthcare. This is partly down to poor funding and scarcity in resources, like provision for the general populace mental health is poorly understood and resource lags far behind demand. It’s also a case of competence, too much of the communication and care regarding mental health is disjointed and half-baked.

 

There is also a growing body of evidence that mental health issues are not being caught early enough. From 2011 to 2014 the number of male inmates transferred from prison on mental health grounds increased by 21%, yet in the same period the number offenders initially hospitalised instead of being sent to prison fell by 26.5%. Given the previously mentioned statistic that 70% of inmates who die from self-inflicted means were identified as having mental health issues prior to incarceration, if things were working one would expect to see a rise in the number of hospital orders. That the opposite is happening, suggests that perhaps mental health issues are being left to ferment in a prison environment rather than being caught early.

 

 As former Prison Reform Trust director Juliet Lyon said in 2016 quote to the Guardian: “If you’re thinking about someone that’s got mental health needs, it’s hard to imagine a less conducive environment to getting better than a prison. There’s a tension with what’s currently happening in our prisons: the lack of activity, the shortage of staff, the appalling rise of suicide and self-harm, and violence in prisons. I think the only way really to effect change is to establish the last resort principle that you use prison as a place of absolute last resort in the justice system.”

 

While government is talking a good game: the MoJ stating in 2016, “We are investing £1.3bn to transform the prison estate, while also training staff to respond effectively to prisoners experiencing suicidal, self-harm and mental health issues,” far more than rhetoric is needed for what’s fast becoming a crisis. That there were (according to statistics released by the MoJ) 34,586 incidents of self-harm in UK prisons last year, an average of one every 15 minutes, brings into stark relief that it hasn’t done anything like enough yet. The prison service needs more mental health professionals, better training for general staff (both in recognising and dealing with potential issues of mental health), and a markedly different outlook on importance of mental wellbeing for prisoners who are likely to be released back into the community at some stage. Sadly, many more men and women may turn to the most desperate of measures long before we reach that point.

 

The problems facing mental health in prisons are symptomatic of the wider problems with prison healthcare, so how and why have things got so bad? More importantly, what can be done about it?

 

The how and why is, for the most part, simple to explain. Like the NHS the prison system is poorly funded and suffers from many of the same problems but with some subtle but key differences.

 

Firstly, the nature of prisons does nothing to help breed efficiency. Given their incarceration, prisoners cannot utilise the options for care available to the general public, they can’t pick up a prescription from a chemist, nor use an A & E department, nor visit their local GP. Meaning that everything from a common cold to a cerebral haemorrhage must go through the same system, placing enormous strain on already overloaded staff. Add into this the general effect of prison on inmates’ health and an aging prison population that much more likely to suffer from acute health conditions and it’s not difficult to see why so many vital services are missed.

 

The second key issue is one of quality. It is hard to escape the conclusion that many of the healthcare staff I experienced in prison were the dregs of the medical profession, who perhaps would have struggled for employment elsewhere. This was proven time and again by horrific feats of incompetence like those described above and the derision shown towards the opinions of specialists outside of prison. To put it another way, would the healthcare professional who proclaimed bone protruding through tissue a “bad sprain” las long in an A & E department? Unlikely. On a more fundamental level, it’s unlikely prison healthcare, with its multitude of problems and the risk it entails, is particularly attractive to any nurse or doctor with other options open to them. As such the service draws some an extremely shallow pool of talent.

 

Thirdly, prisoners are a truly captive market. When healthcare slips below an acceptable standard there is very little recourse open to them. Essentially the wronged inmate has four options: the official complaints procedure (which in my own experience is often redundant), riot or cause a disturbance which comes with the risk of re-categorisation, try and survive or in extreme cases, commit suicide. The lack of recourse available to prisoners, remember the majority cannot afford legal representation and lawyers willing to take on cases pro-bono is decreasing all the time, hardly incentivises healthcare professionals to maintain acceptable standards of care.

 

Fourthly, many of the healthcare providers the National Offender Management Service (NOMS) contracts prison healthcare out to are so-called “community care” providers. Or in layman’s terms, private entities. Often driven by questionable motives (namely their bottom line), as we’ve seen in other areas of prison life such as catering, these companies are often driven by little more than providing the cheapest possible service, rather than anything of quality. This is exacerbated by the propensity of NOMS to continually award contracts to the same select group of contractors (think Serco, G4S and in the case of healthcare, Care UK), despite repeated failings in standards, leaving no incentive for improvement or indeed disincentive to continue in the same vein.

 

Finally, the attitude towards prisoners is markedly different than that shown towards regular patients. During my final months in prison, I received a response to my complaints from Sue Worrall Head of Workforce Development at Stanford Hill. In it, she described the staff’s commitment to treating all patients with “decency, dignity, and respect.” Noble rhetoric perhaps, but as I hope I’ve demonstrated, this just isn’t reality. Time and time again staff’s attitude and treatment of inmates confirmed my suspicion that we were seen as less than worthy of the basic human needs such as decent healthcare, for the simple reason that we were convicted criminals.

 

So, what can be done to improve prison healthcare?

 

The overarching goal is a simple one. Prisoners should be subject, as per Rule 24 of the UN Nelson Mandela Rules for the minimum treatment of prisoners, to an equal standard of care as available in the community. Not theoretically, not rhetorically and the parameters defined clearly by the state. 

 

It’s worth noting that were the prisoners not serving time, the cost of their care would still likely need to be met by the NHS in their community, why should their incarceration change the level of care they are due? It’s also completely illogical to scrimp on prisoners’ care, working on the assumption that most the prison population will one day be released back into the community, not addressing their health concerns in prison simply presents the NHS and the wider community with a costly health time bomb, which will require attention at some point anyway.

 

Some headway is being made on this count, health watchdog the National Institute for Health and Care Excellence (Nice) released new guidelines last year in response to a growing problem. The guidelines which seek to define what healthcare should look like in custodial settings include carrying out a healthcare assessment on arrival with questions on physical health and mental health as well as substance abuse, screening for TB within 48 hours of entering prison, and offering advice on smoking, sexual health, and diet.

 

While the production of guidelines is a welcome step towards parity for prisoners, it isn’t a panacea for the problem. Guidelines from watchdogs are usually just that, without the teeth to punish those prisons who fail to adhere, it’s unlikely to make huge strides in the reality of the healthcare prisoners receive. Remember that the UN Mandela guidelines are largely ignored in practice.

 

Furthering this point, given their woeful record, private care providers should no longer be permitted to provide prison healthcare. Without the government first installing greater levels of accountability for failings and minimum standards of care. It is axiomatic that a captive market (which prisoners undoubtedly are) should not be entrusted to a private entity driven by profit, to do so goes against the very justification for privatisation of anything.

 

Finally, less collective head burying and greater transparency are needed. The issues present in prison healthcare are summed up by the irony in Standford Hill’s Healthcare department being declared “top of the tree” in an HM Inspectorate report while I was housed there. If the appalling service I witnessed there are the highest branches of the tree, what godforsaken place must the roots be? Until prison healthcare is measured and compared against the same metrics as those which apply to the NHS, we are unlikely to see parity in quality.

Written by Rob Stafford and Kreg Mills

For more information on HMPs, Criminal Justice and Custodial Care please see:

http://www.prisonreformtrust.org.uk/
https://howardleague.org/
https://insidetime.org/