This article was downloaded by: [Anadolu University]On: 21 December 2014, At: 14:54Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number:1072954 Registered office: Mortimer House, 37-41 Mortimer Street,London W1T 3JH, UK

The Journal of ForensicPsychiatryPublication details, including instructionsfor authors and subscription information:http://www.tandfonline.com/loi/rjfp19

The Future Organisationof Prison Health CarePaul Bowden aa Emeritus Consultant ForensicPsychiatrist , Maudsley Hospital , DenmarkHill , London , SE5 8AZPublished online: 09 Dec 2010.

To cite this article: Paul Bowden (2000) The Future Organisation of PrisonHealth Care, The Journal of Forensic Psychiatry, 11:2, 473-476, DOI:10.1080/09585180050142697

To link to this article: http://dx.doi.org/10.1080/09585180050142697

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say-so of a psychiatrist, however eminent. Kraepelin and Bleuler tried to vali-date their schemes with both neurological and psychological theories. In thisenterprise they were entirely correct, although neither the neurological northe psychological theories at their disposal were up to the task. That was nottheir fault. On the contrary, they homed in on the most contemporarytheories that they knew about. What is peculiar about recent attempts atnosology, including this book, is that virtually no acknowledgement is givento either neurological or psychological theories advanced since the start ofthe twentieth century.

Nosological entities, or rather ‘proposed’ nosological entities, must belinked with either philosophical, psychological, or neuropsychological facts,or, preferably, all three. Otherwise, as in Munro’s formulation, they are either‘valid’ because an eminent psychiatrist, however eminent, says that they arevalid; or because they have a response to treatment that is allegedly differentfrom that of the ‘typical’ psychoses, an argument that Munro makes much ofhere; or because they have a different outcome from their ‘typical brethren’.All these issues were dealt with admirably years ago in Kendell’s (1975) bookon diagnosis. What needs to be currently addressed is the completely revol-utionary way in which the nosology within psychiatry is being tackled. Thethree ways, overall, comprise the philosophical, the psychological and theneuro-psychological. There are numerous books on the matter, none ofwhich is covered here.

Cambridge University Press, having eschewed any British contribution totheir library here, have been left with an outdated, nineteenth-century book.When will British publishers learn to respect their compatriots and appreci-ate what the twentieth century was all about?

Dr John Cutting, MD, FRCPsych, consultant psychiatrist, 7 Devonshire Place,London W1N 2PA

REFERENCE

Kendell, R. E. (1975) The Role of Diagnosis in Psychiatry. Oxford: Blackwell.

HM Prison Service and NHS Executive, The Future Organisation ofPrison Health Care, London: Department of Health, 1999, free(p/b), 101 pp.

National television news on the evening of 3 October 1999 showed the HomeOf�ce minister for prisons and the director of prison health care in the gate

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lodge at Brixton Prison. The minister had visited the prison in response to acri de coeur from the prison governor: there were more than twenty seriousincidents of serious self-harm at the prison in the previous month; medicalstaf�ng was grossly inadequate; the prison planned to refuse receptions ofmentally ill or substance-abusing prisoners. The minister made it clear thatthere would be no new monies to throw at the problem. Having made theprison health care directorate and the responsible health trusts aware of thesituation at Brixton almost a year ago I turned to the Report for help in under-standing the situation, in particular section 8, ‘Time Scale for Change’.

It is important that the pace of this change is realistic. . . . The feasibility,functions and manpower review of the proposed prison health PolicyUnit would commence December 1998. A Health Needs AssessmentTemplate would be commissioned and need to be completed bySpring/Summer 1999. The Task Fore should be appointed early 1999and a programme of work de�ned no later than Spring 1999. A key rec-ommendation of this report is that Governors and Health Authoritiesshould:

� Undertake an assessment of the health needs of the prison population� Devise a health improvement programme covering both prevention

and care provision� Draw up a commissioning plan. . . .

It would be reasonable to expect needs assessments to begin Summer/Autumn 1999 and work on health improvement programmes to begin inearly 2000. (37)

Writing this piece in early October 1999 I consider it not unreasonable tosuggest that the Review can be judged, at least in part, by the way in whichthe time-scale has been observed, although I �nd it dif� cult to reconcile theminister’s presence with success in this area.

This Report can also be judged in the light of the fate of its predecessors overthe last 30 years or so: to be ignored or found to be unworkable. The Reviewis the fruit of a joint prison service and national health service working group.Its main proposal is that health authorities should work in partnership withprison governors to bring about change, with a task force ensuring that ithappens. The current prison service directorate of health care would becomea prison health policy unit, located, perhaps, in the NHS executive.

The working group endorsed an (in my view unachievable and perverse) aimfor prison health care: ‘to give prisoners access to the same quality and rangeof health care services as the general public receives from the NHS’. Here I amreminded that prison itself is an environment prejudicial to health, for is notthe de�nition of crime both transgression of the law and an invitation to

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impose a sanction in the form of punishment, and how can punishment beimposed without compromising health? And what of the fate of paedophiles,foreigners with no one, the atmosphere of violence, the hospital appointmentsmissed because escorts are unavailable, and the discrimination against prison-ers by outside services? Will the Patient’s Charter come to be applicable toprisons, and will their health care centres (for some, a euphemism if ever therewas one) be designated hospitals under the National Health Service Acts sothat their hospitals can be covered by the Mental Health Act 1983 in order thatthose mentally ill non-consenting prisoners, refused by the NHS, can betreated? And what of the use of health care facilities for so-called disciplinarypurposes, the absence of on-call medical staff, and the prescription of must-have tranquillizing medication over the phone?

In a Report which refers to ‘Stakeholder Views’ (prison governors, medicalof�cers and health care managers, and invitees to a seminar) I am not sur-prised to come across the following: ‘Given the problems posed by prison-ers with mental health problems . . .’ (ii). And then the bullet points:

� The care of mentally ill prisoners should develop in line with NHSmental health policy and national service frameworks including newarrangements for referral and admission to high and medium securepsychiatric services.

� Special attention should be paid to better identi�cation of mentalhealth needs at reception screening.

� Mechanisms should be put in place to ensure the satisfactory func-tioning of a Care Programme Approach within prisons and todeveloping mental health outreach work on prison wings.

� Prisoners should have the same level of community care withinprison as they would receive in the wider community and policiesshould be put in place to ensure adequate and effective communi-cation and joint working between the NHS mental health servicesand prisons. Health Authorities should ensure that service agree-ments with NHS trusts include appropriate mental health services fortheir local prisons. (ii and iii)

And later: ‘The NHS will need to take this into account in its planning andresource allocation . . .’ (41).

Two anecdotes may illustrate that the working group were living in cloudcuckoo land. In a London prison at the time when the group was deliber-ating, actively suicidal, mentally ill prisoners were not being observed regu-larly because of staff shortages; the health care centre-based padded cell wasused as overflow accommodation at night because nowhere else was avail-able. The opening sentence of this review referred to the failure of previousinitiatives in this area. In my view those failures were due to proposals beingthe product of the well-meaning but ill-informed. The culture clash between

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those administering health care and those administering punishment cannotbe ignored. Local initiatives should be encouraged and supported; a solu-tion cannot be imposed. Policy changes bring despair to those motivated bythe ideal of reform, and in a world where it is likely that the provision offuture community-based mental health services will be determined by staffavailability, why work in prisons?

Psychiatry’s investment in prison mental health care can be judged both bythe involvement of academic forensic psychiatry in the area and by the sig-ni�cance which the Royal College of Psychiatrists’ forensic section places onthe matter. I suggest similar motivations for the frequency of both prisonreviews and prison research of the ‘How many mentally disordered are therein prison?’ variety. First, they serve political purposes; second, they are self-serving; third, they function as a useful defence mechanism in that anyonebut a fool knows that the standard of health care is below an acceptable levelbut, unwilling to risk our own necks, we undertake displacement activities torelieve our guilt.

Paul Bowden, MPhil, FRCPsych, emeritus consultant forensic psychiatrist, Maudsley Hospital,Denmark Hill, London SE5 8AZ

Carolyn Hoyle, Negotiating Domestic Violence: Police, CriminalJustice and Victims, Oxford: Oxford University Press, 1998, £35(h/b), 248 pp.; Stephen Schulhofer, Unwanted Sex: the Culture ofIntimidation and the Failure of the Law, Cambridge, MA:Harvard University Press, 1998, $27.95 (h/b), 318 pp.

There is still considerable debate about the value of using the criminal justicesystem to reduce men’s violence against women. The law reforms introducedin the 1980s and early 1990s to control men’s violence towards their partners– speci�cally mandatory arrest, mandatory prosecution and mandatoryimprisonment in their various guises – seem to have had little impact. Arrest,prosecution and imprisonment rates continue to be low. Similarly, the lawreforms introduced in the 1980s and early 1990s to control men’s sexual vio-lence – for example, the introduction in many jurisdictions of ‘rape shields’(restrictions on the introduction of the victim’s prior sexual history), theabolition of corroboration requirements, increased penalties and the removalof the marital rape exemption – also seem to have had little impact in prac-tice. Sexual violence continues to have a high rate of non-reporting by victimsto the police and, even when it is reported, prosecution rates are low andacquittal rates are high.

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