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Prisons: Healthcare

My Lords, I spent yesterday morning with the healthcare team at Brixton Prison. As a consequence I am still reeling from the contrasting images that I came away with. My overwhelming impression was of enthusiastic and committed NHS and prison staff supported by able, effective governors working to address almost insurmountable problems in gravely inadequate facilities. The setbacks and successes of Brixton provide a microcosm of the progress of the NHS in prisons, but with the added problems caused by the exceptional high turnover of prisoners on remand at that prison. What is going right? Lambeth Primary Care Trust is very enthusiastic and totally committed to this venture. Nigel Evason, the healthcare commissioner, is working hand in glove with the prison head of healthcare, Andrew Ransome. There is no doubt that the recent introduction of a local family GP practice providing primary care with specialist skills in mental health and substance misuse is a major plus. The ““in reach”” mental health team is a plus too, and is truly multidisciplinary in a way that the Sainsbury Centre/London Development Centre report on prisons in London—which I believe is to be published shortly—has found only too rarely in London prisons. Mental health day care services can now provide a very active range of therapeutic activities, although only for a tiny fraction of those who could benefit, and at present the ““in reach”” team takes on only those with the most severe disorders. However, links to external hospital services are working well and the TB and communicable diseases services are motoring. So there is much that is going right. I have seen major changes from when I previously visited Brixton Prison on a professional basis about 10 years ago. What is not yet right? To my surprise, I found that the funding streams are still not clarified. Ministers talk as if the transfer of health services is all but complete, but I found that both the prison governor, John Podmore, and the primary care trust were frustrated by the lack of clarity about who should be accountable for funding what. Services are working on the ground because of the personal qualities of those determined to improve the situation, but I can see how much funding fudges might prove a sticking point elsewhere. My noble friend Lord Chan mentioned in his introductory speech that mental health problems dominate like a massive black cloud. Some 85 per cent of healthcare centre inpatients have profound psychoses and should not be there. I walked around the unit and really felt extraordinarily distressed that people in that degree of disturbance should be kept in 8 x 6 toilets—and that is the situation. Transfers are still taking too long—months. The transfer process is labyrinthine, and that is not due to lack of effort on the part of the services in trying to improve it. The NHS, by which I mean consultant psychiatrists, I fear, are not always as responsive as they should be—because patients are safe, are they not, in prison? The physical environment is horrible and totally inappropriate. Brixton Prison has just heard that the £5m capital development unit that it was promised for 2006 has been shelved again, which is disgraceful. The assessment protocol on reception is improving, but there is a high risk that it is sketchily done because prisoners arrive back from court late into the evening, sometimes at midnight, which is a source of great frustration for the governor. The three-person substance misuse team struggles to cope: there is no funding for specific alcohol dependence problems, which of course are more ubiquitous and are the direct cause of more violent crime than drugs. I did not hear a good word for the National Treatment Agency for Substance Misuse, which does not seem to think that prisons are its business and is fixated on heroin addiction when crack cocaine and poly-drug misuse are the crucial issues. Perhaps the Minister will explain why we do not do needle exchange in prisons—you may think that it is an obvious issue of security, but the governor, John Podmore, could not see a problem and was willing to engage in it. Nor did I hear much praise for the Prison Ombudsman’s sometimes mediocre and often dilatory reports of inquiries into deaths in custody, which often focus on process but sometimes fail to explore the fundamental social and psychological personal distress issues. The reports are so similar that they could all have been written by the same person. What I saw in Brixton was at the good end of the range of progress in improving healthcare in prisons, and yet what we are providing is still only an elastoplast on a festering boil. I know my noble friend Lord Ramsbotham will address the need for a proper strategy for improving health in prisons which recognises that they act as a sump for the collection of profoundly vulnerable and challenging people, whose problems can never be addressed by shovelling them in their thousands into an inappropriate setting. We could pour massive resources into the current system and it would still not cope. A prison, especially a local prison, is part of the community. It gathers a subset of the population at greatest risk of the scourges of public health: smoking; sexually-transmitted diseases; HIV/AIDS; mental health problems; TB; substance misuse and profoundly disturbing personality traits. Prisons are like swamps providing the breeding grounds for the mosquitoes of disadvantage. John Podmore was wisely calling for an understanding by local public health departments that his captive population belong to their home communities, and that the revolving prison gate feeds further public health problems back into localised communities. If we are serious about narrowing the health inequalities of our most disadvantaged communities, prisons are a very good place to start. The NHS is making just a tiny little bit of an improvement at the moment, but we must address the larger picture of what prisons are doing.