The quality of health care in prison: results of a year's programme of semistructured inspections

Exploring the Intersection of Drug Addiction and Mental Ill-Health in Scottish Prisons: A Qualitative Study of Incarcerated Men

This article presents insights from small-scale qualitative research exploring the intertwining nature of drug addiction and mental ill-health among men in Scottish prisons. Semi-structured interviews were conducted with 24 men in two Scottish prisons. The men’s narratives suggested that increased tension in prison halls had stimulated a huge surge in the use of New Psychoactive Substances (NPS), in turn increasing and deepening existing mental ill-health and violence. They believed health care in the prisons to be of low quality, and that methadone was prescribed as a mechanism for social control. Implications for future policy, practice and research are outlined.

Health-promoting prisons in the female estate: an analysis of prison inspection data

BACKGROUND

Women in prison have comparatively greater health needs than men, often compounded by structures and policies within the prison system. The notion of a 'health-promoting' prison is a concept which has been put forward to address health inequalities and health deterioration in prisons. It has, however, not been fully discussed in relation to women in prison. The paper aims to distil the learning and evidence in relation to health promotion in female prisons using prison inspection reports of women's prisons in England and Wales.

METHODS

Prison inspection reports are one way of ascertaining the contemporary situation in prisons. Prison inspections are often unannounced and use a myriad of methods to draw conclusions around various aspects of prison life. Thirteen prison inspection reports were analysed thematically focusing on health promotion within the institutions. Two analysts conducted the work using NVivo 12.

RESULTS

Five core thematic areas were identified during the analysis of the reports. Saliently, a joined-up approach to health promotion was not a common feature in the prisons and indeed the focus tended to be on screening and 'lifestyle issues' rather than a concern for the underlying determinants of health. There was often an absence of a strategic approach to health promotion. There were some good examples of the democratic inclusion of women in prison in shaping services, but this was not widespread and often tokenistic. There were some examples of inequity and the inspection reports from a small number of institutions, illustrated that the health needs of some women remained unmet.

CONCLUSIONS

The paper suggests that there is potentially some work before conditions in women's prisons could be described as 'health-promoting', although there are some examples of individual prisons demonstrating good practice. The health promoting prison movement has, implicitly at least, focused on the needs of men in prison and this has been to the exclusion of the female prison population. This does lead to several challenges and the potential for exacerbating health challenges faced by an already marginalised and vulnerable group. Greater focus on the health promotion needs of women in prison is required.

Health promotion co-existing in a high-security prison context: a documentary analysis

PURPOSE

There is interest in promoting health in prison from governmental levels, but, to date, understanding how best to do this is unclear. This paper argues that nuanced understanding of context is required to understand health promotion in prison. The purpose of the paper is to examine the potential for empowerment, a cornerstone of health promotion practice, in high-security prison establishments.

DESIGN/METHODOLOGY/APPROACH

Independent prison inspections, conducted by Her Majesty's Inspectorate of Prisons for England and Wales, form a critical element in how prisons are assessed. Documentary analysis was undertaken on all eight high-security prison reports using framework analysis.

FINDINGS

Analysis revealed elements of prison life which were disempowering and antithetical to health promotion. While security imperatives were paramount, there were examples where this was disproportionate and disempowered individuals. The data show examples where, even in these high-security contexts, empowerment can be fostered. These were exemplified in relation to peer approaches designed to improve health and where prisoners felt part of democratic processes where they could influence change.

PRACTICAL IMPLICATIONS

Both in the UK and internationally, there is a growing rhetoric for delivering effective health promotion interventions in prison, but limited understanding about how to operationalise this. This paper gives insight into how this could be done in a high-security prison environment.

ORIGINALITY/VALUE

This is the first paper which looks at the potential for health promotion to be embedded in high-security prisons. It demonstrates features of prison life which act to disempower and also support individuals to take greater control over their health.

The mental health of prisoners

Mental health problems are the most significant cause of morbidity in prisons. Over 90% of prisoners have a mental disorder. The prison environment and the rules and regimes governing daily life inside prison can be seriously detrimental to mental health. Prisoners have received very poor health care and, until recently, the National Health Service (NHS) had no obligations to service this group, which was the Home Office's responsibility. The NHS is expected to take responsibility eventually, following a new health partnership with the Prison Service. NHS psychiatrists will have to be much more active in the development and delivery of health care to prisoners who now have the right to equal health care. There are positive developments but concerted and determined action is required to bring prison health care up to acceptable standards.

The interface between general and prison psychiatry – the consultant's perception

AIMS AND METHOD

A postal questionnaire was sent to 100 Section 12 (2) approved consultant psychiatrists in the West Midlands to ascertain their perceptions of the role of general psychiatric services in the care of imprisoned patients with mental disorder previously cared for by generic services.

RESULTS

Of 59 respondents 90% believed they could contribute to the care of imprisoned patients with mental disorders. Ten per cent would delegate total responsibility to specialist forensic services. Lack of awareness of imprisonment of patients was a common problem.

CLINICAL IMPLICATIONS

Insufficient liaison between prison and general psychiatric services may impede the provision of psychiatric care in prison and prevent discharge planning in line with the Care Programme Approach and current Government guidelines.

Delivering psychiatric care to prisoners: problems and solutions

‘In some few jails are confined idiots and lunatics, –many of the bridewells are crowded and offensive, because the rooms which were designed for prisoners are occupied by lunatics. The insane, when they are not kept separate, disturb and terrify other prisoners. No care is taken of them, although it is probable that by medicines, and proper regimen, some of them might be restored to their senses, and usefulness in life’ (Howard, 1784: pp. 10–11).

A mixed-methods study exploring the characteristics and needs of long-stay patients in high and medium secure settings in England: implications for service organisation

Background

Forensic psychiatric services provide care for those with mental disorders and offending behaviour. Concerns have been expressed that patients may stay for too long in too high levels of security. The economic burden of these services is high, and they are highly restrictive for patients. There is no agreed standard for ‘long stay’; we defined a length of stay exceeding 5 years in medium secure care, 10 years in high secure care or 15 years in a combination of both settings as long stay.

Objectives

To (1) estimate the number of long-stay patients in secure settings; (2) describe patients’ characteristics, needs and care pathways and the reasons for their prolonged stay; (3) identify patients’ perceptions of their treatment and quality of life; and (4) explore stakeholders’ views on long stay.

Design

A mixed-methods approach, including a cross-sectional survey (on 1 April 2013) of all patients in participating units to identify long-stay patients [work package (WP) 1], file reviews and consultant questionnaires for long-stay patients (WP2), interviews with patients (WP3) and focus groups with other stakeholders (WP4).

Setting

All three high secure hospitals and 23 medium secure units (16 NHS and 9 independent providers) in England.

Participants

Information was gathered on all patients in participating units (WP1), from which 401 long-stay patients were identified (WP2), 40 patients (WP3), 17 international and 31 UK experts were interviewed and three focus groups were held (WP4).

Results

Approximately 23.5% of high secure patients and 18% of medium secure patients were long-stay patients. We estimated that there are currently about 730 forensic long-stay patients in England. The source of a patient’s admission and the current section of the Mental Health Act [Great Britain.Mental Health Act 1983 (as Amended by the Mental Health Act 2007). London: The Stationery Office; 2007] under which they were admitted predicted long-stay status. Long-stay patients had complex pathways, moving ‘around’ between settings rather than moving forward. They were most likely to be detained under a hospital order with restrictions (section 37/41) and to have disturbed backgrounds with previous psychiatric admissions, self-harm and significant offending histories. The most common diagnosis was schizophrenia, but 47% had been diagnosed with personality disorder. Only 50% had current formal psychological therapies. The rates of violent incidents within institutions and seclusion were high, and a large proportion had unsuccessful referrals to less secure settings. Most patients had some contact with their families. We identified five classes of patients within the long-stay sample with different characteristics. Patients differed in their attribution of reasons for long stay (internal/external), outlook (positive/negative), approach (active/passive) and readiness for change. Other countries have successfully developed specific long-stay services; however, UK experts were reluctant to accept the reality of long stay and that the medical model of ‘cure’ does not work with this group.

Limitations

We did not conduct file reviews on non-long-stay patients; therefore, we cannot say which factors differentiate between long-stay patients and non-long-stay patients.

Conclusions

The number of long-stay patients in England is high, resulting in high resource use. Significant barriers were identified in developing designated long-stay services. Without a national strategy, these issues are likely to remain.

Future work

To compare long-stay patients and non-long-stay patients. To evaluate new service models specifically designed for long-stay patients.

Study registration

The National Institute for Health Research (NIHR) Clinical Research Network Portfolio 129376.

Funding

The NIHR Health Services and Delivery Research programme.

STRESS-testing clinical activity and outcomes for a combined prison in-reach and court liaison service: a 3-year observational study of 6177 consecutive male remands

BACKGROUND

People with major mental illness are over-represented in prison populations however there are few longitudinal studies of prison in-reach services leading to appropriate healthcare over extended periods.

AIMS

We aimed to examine measures of the clinical efficiency and effectiveness of a prison in-reach, court diversion and liaison service over a 3 year period. Secondly, we aimed to compare rates of identification of psychosis and diversion with rates previously reported for the same setting in the 6 years previously. We adopted a stress testing model for service evaluation.

METHOD

All new male remand committals to Ireland's main remand prison from 2012 to 2014 were screened in two stages. Demographic and clinical variables were recorded along with times to assessment and diversion. The DUNDRUM Toolkit was used to assess level of clinical urgency and level of security required. Binary logistic regression was used to assess factors relevant to diversion.

RESULTS

All 6177 consecutive remands were screened of whom 1109 remand episodes (917 individuals) received a psychiatric assessment. 4.1 % (95 % CI 3.6-4.6) had active psychotic symptoms. Levels of self-harm were low. Median time to full assessment was 2 days and median time to admission was 15.0 days for local hospitals and 19.5 days for forensic admissions. Diversion to healthcare settings outside prison was achieved for 5.6 % (349/6177, 95 % CI 5.1-6.3) of all remand episodes and admissions for 2.3 % (95 % CI 1.9-2.7). Both were increased on the previous period reported. Mean DUNDRUM-1 and DUNDRUM-2 Triage Security Scores were appropriate to risk and need.

CONCLUSIONS

We found that a two-stage screening and referral process followed by comprehensive assessment optimised identification of acute psychosis. The mapping approach described shows that it is possible for a relatively small team to sustainably achieve effective identification of major mental illness and diversion to healthcare in a risk-appropriate manner. The stress-testing structure adopted aids service evaluation and may help advise development of outcome standards for similar services.

Characterization of pharmacy services in Portuguese prisons: a national survey

PURPOSE

The primary purpose of this paper is to collect reliable information to characterize the pharmacy services in Portuguese prisons. The secondary purpose is to develop a set of suggestions for improving these services and, therefore, improve the health services provided to the inmate population.

DESIGN/METHODOLOGY/APPROACH

A three pages survey was developed that included questions covering the characterization of prison health teams, pharmacy services and pharmacy activities. This survey was sent to all Portuguese prisons, with capacity higher than 50 prisoners. The response rate was of 87.5 per cent.

FINDINGS

It was found that only 6.1 per cent of prisons had pharmacists and that in 63 per cent the guards still participated in pharmacy activities. There were not Pharmacy and Therapeutics Committees in 94 per cent of prisons and 94.4 per cent did not present adequate storage conditions for drugs. Only 51.7 per cent of prisons had computers in the pharmacy and only 3.4 per cent had access to the internet. This study found that there is a gap between public and prison pharmacy services, since most prison pharmacies in Portugal are solely locals of storage and distribution of drugs, with no effective management nor promotion of drug rational use.

ORIGINALITY/VALUE

This paper is the first study about pharmacy services in Portuguese prisons. The information collected could be very useful to improve the Portuguese prison pharmacy services provided to prisoners.

Take-home emergency naloxone to prevent heroin overdose deaths after prison release: rationale and practicalities for the N-ALIVE randomized trial

The naloxone investigation (N-ALIVE) randomized trial commenced in the UK in May 2012, with the preliminary phase involving 5,600 prisoners on release. The trial is investigating whether heroin overdose deaths post-prison release can be prevented by prior provision of a take-home emergency supply of naloxone. Heroin contributes disproportionately to drug deaths through opiate-induced respiratory depression. Take-home emergency naloxone is a novel preventive measure for which there have been encouraging preliminary reports from community schemes. Overdoses are usually witnessed, and drug users themselves and also family members are a vast intervention workforce who are willing to intervene, but whose responses are currently often inefficient or wrong. Approximately 10% of provided emergency naloxone is thought to be used in subsequent emergency resuscitation but, as yet, there have been no definitive studies. The period following release from prison is a time of extraordinarily high mortality, with heroin overdose deaths increased more than sevenfold in the first fortnight after release. Of prisoners with a previous history of heroin injecting who are released from prison, 1 in 200 will die of a heroin overdose within the first 4 weeks. There are major scientific and logistical challenges to assessing the impact of take-home naloxone. Even in recently released prisoners, heroin overdose death is a relatively rare event: hence, large numbers of prisoners need to enter the trial to assess whether take-home naloxone significantly reduces the overdose death rate. The commencement of pilot phase of the N-ALIVE trial is a significant step forward, with prisoners being randomly assigned either to treatment-as-usual or to treatment-as-usual plus a supply of take-home emergency naloxone. The subsequent full N-ALIVE trial (contingent on a successful pilot) will involve 56,000 prisoners on release, and will give a definitive conclusion on lives saved in real-world application. Advocates call for implementation, while naysayers raise concerns. The issue does not need more public debate; it needs good science.

Prisoners with psychosis in England and Wales: diversion to psychiatric inpatient services?

The prevalence of psychosis among prisoners in England and Wales is ten times that in the household population and UK government policy is that prisoners should receive equivalent care to those in the community. This study investigated the implications of policy to divert more from the criminal justice system for psychiatric treatment. Psychotic prisoners were compared with psychotic persons in households and with other prisoners in two surveys of psychiatric morbidity in representative samples of the UK population. Psychotic prisoners were younger, more from ethnic minorities, with comorbid anxiety, substance misuse, ASPD, and childhood behavioural problems compared to psychotic persons in households. Less than a third had received previous inpatient treatment. Psychotic prisoners had similar criminal histories and higher psychopathy scores than non-psychopathic prisoners. Diversion is unfeasible without improved screening for psychosis and increasing bed numbers at higher levels of security to accommodate more patients who would pose high risk to the public. Future research should investigate why UK psychiatric services fail to identify psychotic prisoners and provide aftercare.

Patients, prisoners, or people? Women prisoners' experiences of primary care in prison: a qualitative study

BACKGROUND

The development of primary care services within prisons has been central to improvements in the provision of health care in this setting over the past decade. Despite national imperatives to involve patients in the development of services and numerous policy initiatives, there has been no systematic evaluation of changes in the delivery of primary care and little published evidence of consultation with prisoners.

AIM

To explore women prisoners' experiences of primary healthcare provision in prison.

DESIGN OF STUDY

Qualitative study using focus groups and interviews.

SETTING

Two women's prisons in southern England.

METHOD

Six focus groups involving 37 women were conducted, as well as 12 semi-structured individual interviews. Focus groups and interviews were recorded, transcribed, and analysed thematically.

RESULTS

Women prisoners' perceptions of the quality of prison health care were mixed. There were accounts of good-quality care where practitioners were regarded as knowledgeable and respectful, but many perceived that the quality of care was poor. They complained about difficulties accessing care or medication, disrespectful treatment, and breaches of confidentiality by practitioners. They voiced the belief that staff were less qualified and competent than their counterparts in the community.

CONCLUSION

The prison environment presents unique challenges to those providing health care, and much work has been done recently on modernizing prison health care and improving professional standards of practice. However, the accounts of women prisoners in this study suggest that there is a gap between patient experience and policy aspirations.

Socio-demographic determinants of coinfections by HIV, hepatitis B and hepatitis C viruses in central Italian prisoners

BACKGROUND

The coinfections HIV/HCV/HBV are an important health issue in penitentiary communities. The aim of the study was to examine HIV, HBV and HCV coinfections determinants amongst prisoners in the jails of Southern Lazio (Central Italy), in the period 1995-2000.

METHODS

Diagnosis of seropositivities for HIV, HBV and HCV was made using ELISA method. A multiple logistic regression analysis was conducted to verify the influence of socio-demographic factors on the HIV/HBV/HCV coinfections.

RESULTS

HIV/HCV, HBV/HCV and HIV/HBV coinfections were detected in 42 (4%), 203 (17.9%) and 31 (2.9%) inmates, respectively. These coinfections are significantly associated with the status of drug addiction (OR = 16.02; p = 0.012; OR = 4.15; p < 0.001; OR = 23.57; p = 0.002), smoking habits (OR = 3.73; p = 0.033; OR = 1.42; p = 0.088; OR = 4.25; p = 0.053) and Italian nationality (OR = 7.05; p = 0.009; OR = 2.31; p < 0.001; OR = 4.61; p = 0.04).

CONCLUSION

The prevalence of HIV, HBV and HCV seropositivity in jails suggests that information and education programs for inmates could be useful to reduce the spread of such infections.

Can morbidity be inferred from prescription drug use? Results from a nation-wide prison population study

AIM

To estimate psychiatric and somatic morbidity in a nation-wide prison population, as inferred from detailed medication sheets.

METHOD

Medication sheets from 37 prisons, covering 90% of the Norwegian prison population, were collected and examined by experienced clinicians. All inmates on medication were assigned best-estimate psychiatric and/or somatic diagnoses according to the International Classification of Primary Care diagnostic system.

RESULTS

Among the 2617 inmates 919 (35%) had psychiatric disorders, as estimated by our methodology. Depressive disorders (11%) and sleep disorders (11%) were most prevalent. Twenty-six inmates (1%) were prescribed medication indicative of affective psychosis and an additional 77 (3%) received anti-psychotic drugs in doses indicating other psychotic disorders, bringing the sum total of psychosis up to 103 (4%). A total of 848 inmates (32%) were estimated to suffer from somatic disorders. Various pain conditions were prevalent (11%) in addition to obstructive airway diseases and asthma (4%). Both psychiatric and somatic disorders were more prevalent in female prisoners.

CONCLUSION

This study has demonstrated high psychiatric and somatic morbidity in a nation-wide population of prison inmates receiving adequate health services. As the morbidity estimates are inferred from prescription drug use they must be interpreted with caution. However, we do believe that our study, utilizing this unconventional but readily available source of information, has yielded valuable knowledge regarding the physical and mental health of a nation-wide prison population.

Natural deaths in male prisoners: a 20-year mortality study

BACKGROUND

Although morbidity is high in prisoners compared with the general population, uncertainty exists over rates for natural causes of death. We investigated natural deaths in prisons in England and Wales over a 20-year period.

METHODS

All men who died in English and Welsh prisons from 1978-1997 were identified. All deaths received a post-mortem. Death certificates were obtained to provide mortality information according to ICD-9. Standardised mortality ratios (SMRs) for major causes of natural death were calculated in those <60 years.

RESULTS

574 male prisoners died in custody from natural deaths, of which 307 (53%) deaths were from circulatory diseases and 91 (16%) from respiratory causes. Overall, SMRs for natural deaths were significantly lower than the general population (SMR = 0.70; 95% CI = 0.65-0.76). However, SMRs from respiratory pneumonia (SMR = 2.35; 1.75-3.16) and from other infectious causes were higher (SMR = 1.52; 1.03-2.23).

CONCLUSION

There are important methodological challenges in calculating SMRs in prisoners. Bearing these in mind, we found increased mortality ratios for respiratory pneumonia and other infections. These findings highlight the need for the screening and effective treatment of infectious diseases in prisoners.

Prisons and the human rights of persons with mental disorders

PURPOSE OF REVIEW

This paper deals with issues of human rights related to persons suffering from a mental disorder in the prison system. In particular, I consider whether the rights afforded prisoners with mental disorders in various international conventions and resolutions are being implemented in legislation and case law.

RECENT FINDINGS

There have been advances in recent years in the Western world, particularly in the USA and the UK, with regard to prisoners' rights. In the UK, there is now a partnership of responsibility between the National Health Service and the Prison Service so that these organizations would become jointly responsible for delivering health care to prisoners. In the USA, the Prison Rape Elimination Act of 2003 and the Mentally Ill Offender Treatment and Crime Reduction Act of 2004 go a long way in ensuring the basic rights of the imprisoned individual.

SUMMARY

The large number of mentally ill inmates necessitates a continuous safeguarding of the rights of these individuals. It is now widely acknowledged that prisoners should be entitled to expect the same standard of health care as that provided to persons with unrestricted freedom, and have similar access to psychiatric beds. Further research is needed to see whether the improvement in their rights also improves their mental health and the long-term outcome of their illness.

Capturing perceptions: Prisoners assess their health services ‐ Australia, 2001 and 2004

There is little literature on patient satisfaction related to prisoner health services; the little that does exist refers to specific services, or to sub‐groups of prisoner‐patients. We describe a general assessment of prisoner health services conducted on two separate occasions each with a collective sample of 210 participants, three years apart, using the same instrument. We utilised the World Health Organization Rapid Cluster Sample Survey on both occasions. We conclude that prisoners are interested informants for the health services provided to them. They have valid concerns about the confidentiality of their medical records. Programs and work routines have major impacts on accessibility of prison‐based health services. Given the lack of choice in service‐providers for prisoners, greater flexibility is required by health and custodial agencies to accommodate these two competing areas of activity. We demonstrated that a health service targeting an ‘at risk’ population can respond to inadequacies in service provision. Finally, we confirmed that the World Health Organization Rapid Cluster Sample Survey methodology is an efficient and effective means of assessing health services to discrete populations.

Providing treatment to prisoners with mental disorders: development of a policy. Selective literature review and expert consultation exercise

BACKGROUND

Mental disorder is more prevalent among people in prison than in the general population. Prisoners who require transfer to psychiatric hospitals for treatment face long delays. Doctors working in prisons regularly face ethical and legal dilemmas posed by prisoners with mental illness.

AIMS

To develop a policy for providing treatment under the common law to prisoners with mental disorders who lack treatment decision-making capacity, while arrangements are made to transfer them to hospital.

METHOD

The policy was developed through literature review and consultation with the Faculty of Law at Southampton University and health care staff at Winchester prison in the UK.

RESULTS

The policy provides guidelines for establishing decision-making capacity, standards for documentation, and guidelines for implementation based on the Mental Health Act Code of Practice, other best-practice guidelines and case law.

CONCLUSIONS

It can be argued that case law allows more-extensive treatment to be provided in the best interests of the incompetent prisoner, beyond emergency situations. The policy has ethical implications and its use should be carefully monitored.

Impact of a newly opened prison on an accident and emergency department

OBJECTIVE

To determine the impact of a newly opened prison on an accident and emergency (A&E) department.

METHOD

A new category B prison opened in April 1999, the first privately run prison in Scotland and the third largest in population. All prisoners referred to the A&E department for treatment were identified prospectively during the first year after the opening of the prison.

RESULTS

99 prisoners and four members of staff attended during the one year period. Ages ranged from 18-64 years with a mean age of 29.8 years. Presentations were as a result of deliberate self harm (22%), injury after violence (18%), sports injury (15%), surgical condition (15%), medical illness (13%), accidental injury (9%), ENT problem (2%), and miscellaneous (6%). Thirty seven prisoners (35.6%) were admitted to the hospital. Further review at outpatient clinics was arranged for 15 prisoners. One prisoner died, the result of suicide by hanging. The remaining prisoners were returned to the prison for further management by the prison medical and nursing team. Twelve prisoners re-attended a total of 37 times, ranging from twice to a maximum of eight visits. Some 42.3% of attendances were during "working hours" (09.00-17.00) and 57.7% attended "out of hours" (17.00-09.00). Twenty four referrals (23.1%) were deemed inappropriate by the prison medical team on retrospective review. Sixteen of these occurred "out of hours". Forty one prisoners (39.4%) were known to have a history of injecting drug misuse. Including re-attenders, 59 presentations (56.7%) to the A&E department had a history of injecting drug misuse. Of these 41 prisoners, 11 (26.8%) were hepatitis C positive, with eight of these having a positive polymerase chain reaction test. No prisoners had HIV and only one prisoner was hepatitis B positive.

CONCLUSION

The opening of the prison resulted in only a slight increase in the workload of the A&E department. A significant proportion of prisoners were admitted to the hospital highlighting the practical and logistical problems of managing people restrained and in custody. Most cases can be safely referred back to the prison. Increased input is required from the prison medical team when dealing with deliberate self harm, frequent attenders, and "out of hours" referrals. All A&E staff must be aware of the increased risk of hepatitis C infection when dealing with a confined prison population.

Management of diabetes in French prisons: a cross-sectional study

AIMS

To assess by a survey the management of prisoners with diabetes treated with insulin in French prisons.

METHODS

A questionnaire was sent to the head of healthcare services for prisoners of every French prison. Information was obtained on prevalence of insulin-treated diabetes prisoners and diabetes care in prison. The number of episides of ketoacidosis and hypoglycaemia needing hospital admissions were evaluated during the past year.

RESULTS

Among the 163 questionnaires sent, 115 were returned, giving an overall response rate of 69%. At the time of the study the prison population was 38 175 people. One hundred and sixty-nine prisoners were treated by insulin (0.4%). Self-monitoring of blood glucose was available only for 94 (55.6%) insulin-treated prisoners. A total of 130 (76.9%) prisoners performed two insulin injections daily or less, 105 (62.1%) prisoners were not allowed to keep their insulin delivery systems with them. Of the prisoners who treated themselves, 14 (12.1%) used syringes and 42 (36.5%) used pen devices. Ninety-two (55.1%) prisoners had had access to a diabetes specialist during the previous year. Diabetic diets were available in only 65 (60.7%) prisons. From June 1998 to June 1999, there were 20 hospital admissions for a diabetic ketoacidosis and 14 for hypoglycaemia.

CONCLUSIONS

This study shows that prison decreases the autonomy of diabetic prisoners who often cannot self-inject or test their blood. Access to visiting consultant diabetologists and specialist nurses to educate both prisoners with diabetes and prison staff could improve diabetic care.

Inpatient care of mentally ill people in prison: results of a year's programme of semistructured inspections

OBJECTIVE

To investigate the facilities for inpatient care of mentally disordered people in prison.

DESIGN

Semistructured inspections conducted by doctor and nurse. Expected standards were based on healthcare quality standards published by the Prison Service or the NHS.

SETTING

13 prisons with inpatient beds in England and Wales subject to the prison inspectorate's routine inspection programme during 1997-8.

MAIN OUTCOMES MEASURES

Appraisals of quality of care against published standards.

RESULTS

The 13 prisons had 348 beds, 20% of all beds in prisons. Inpatient units had between 3 and 75 beds. No doctor in charge of inpatients had completed specialist psychiatric training. 24% of nursing staff had mental health training; 32% were non-nursing trained healthcare officers. Only one prison had occupational therapy input; two had input from a clinical psychologist. Most patients were unlocked for about 3.5 hours a day and none for more than nine hours a day. Four prisons provided statistics on the use of seclusion. The average length of an episode of seclusion was 50 hours.

CONCLUSION

The quality of services for mentally ill prisoners fell far below the standards in the NHS. Patients' lives were unacceptably restricted and therapy limited. The present policy dividing inpatient care of mentally disordered prisoners between the prison service and the NHS needs reconsideration.

Health, place and British prisons

This short communication considers people's health care needs in prison. It shows that people have a wide range of health care needs that are not always met when they spend time in prison. To locate these issues the paper draws on the "patient or prisoner" debate to understand the challenges that face future policies.

Managing terminally ill prisoners: reflection and action

In 1997 a young remand prisoner was 'shackled' to his bed until shortly before his death. An outcry ensued. This paper discusses issues concerning care of terminally ill prisoners. In Cardiff, the Prison Service, local National Health Service trusts and the hospice have produced joint guidance on the escorting of ill prisoners and managing a bedwatch; these are outlined.