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BMA response to the Justice Select Committee inquiry into Prison Reform
About the BMA
The British Medical Association (BMA) is a professional association and independent trade union,
representing doctors and medical students from all branches of medicine across the UK and supporting
them to deliver the highest standards of patient care. We have a membership of over 168,000, which
continues to grow each year.
This BMA response to the Justice Select Committee inquiry into prison reform has been developed with our
civil and public services committee. It encompasses expertise from across our membership, and focusses
on the health needs of those within the secure estate, and the challenges that this can also pose.
Executive Summary
In writing this submission the BMA has taken account of the Secretary of State for Justice’s appearance
before the Justice Select Committee on 07 September, and subsequent announcement that new
government plans for justice reform would be released in the upcoming weeks. Our response, therefore,
seeks to address previous government plans on prison reform, but given the current uncertainty as to the
potential future of a prison reform bill, does not relate exclusively to them. In particular our response
addresses the importance of healthcare within the secure estate. We explore the link between health and
reoffending, and how reform of prisons can be best shaped to meet prisoner health needs in a more
efficient and targeted way. This response specifically addresses the impact of mental health and substance
misuse, and the need for transparency and accountability to effect change, Key points contained within this
submission are:
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Prison regimes should be required to provide equivalence of care to prisoners, ensuring that they
receive the same level of care as that available to their contemporaries in the community.
There is a need for an overall recognition by government and prison commissioners of the value
of promoting effective healthcare to improve outcomes for reoffending and prisoner wellbeing.
There needs to be greater transparency for health outcomes throughout the secure estate, such
as information on staffing levels and hospital transfer times.
Specific targets should be introduced to reduce all deaths in the secure estate, including suicides
and premature deaths through natural causes.
Prisons should take an evidence based approach to promoting health programmes aimed at
reducing reoffending, such as initiatives to manage substance misuse and addiction.
Guidelines should be introduced to protect those with language barriers including ensuring that
prisoners’ health is not put at risk by rationing of translator services for healthcare.
There is a need for improved planning and support for ex-offenders accessing health care upon
return to the community, particularly for vulnerable individuals and those with chronic
conditions.
What should be the purpose(s) of prisons?
How should i) the prison estate modernisation programme and ii) reform prisons proposals best fit
these purposes and deal most appropriately with those held?
1.1. The BMA considers that it is outside of its remit to take a position on the purpose of prisons, be that:
safeguarding, rehab, punishment and deterrent or a mixture of these approaches. We do however
believe that whatever the purpose of prison, there should be a duty of care to ensure that all prisoners
receive equivalence of care to the wider community. In some instances, such as supporting an
individual to overcome an addiction, or in providing mental health support, health interventions can
reduce the likelihood of reoffending and may, therefore, be seen as a key priority for commissioners.
This response will seek to further expand on the role of health care in the secure estate.
1.2. We have significant concerns regarding the following areas of health provision within the secure estate:
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Mental health support
Deaths in custody
The aging prison population
Support for substance misuse
Access to a doctor of the same gender
interpretation services
1.3. Greater support for mental health: The BMA believes that prison reforms must address the growing
number of prisoners suffering from mental ill health. Mental ill health is hugely prevalent amongst the
prison population with the Prison Reform Trust reporting that 90 percent of inmates have one or more
of the five main psychiatric disorders (psychosis, anxiety disorder, personality disorder, alcohol
dependence and substance misuse)1. In addition to this both suicide and self harm rates are rising,
with instances of self harm at its highest ever recorded level2. It is crucial that more is done to meet
the mental health and safeguarding needs of the prison population. Government plans to invest in
new reform prisons, may prove an opportunity to achieve this. Specifically, we would welcome
measures to increase transparency and reporting of issues such as self harm in a ‘league table’ type
format, which we consider will improve accountability of individual prisons.
1.4. Deaths in custody: The BMA has significant concerns regarding the rising number of deaths in prison,
between June 2015 and June 2016 there was an increase of 30% compared to the previous year3. This
encompasses increases in both the number of suicides in prison (28%) and in natural deaths (26%),
which have been attributed to poor lifestyle and a lack of lifelong interaction with healthcare services4.
The average life expectancy of a prisoner reported by the Prisons and Probation Ombudsman is only
56;5 the BMA considers this to be a worrying reflection of the overall wellbeing of those in the secure
estate. While we recognise that being in prison is, in most instances, not the only cause of these health
indicators, the prison environment is not an optimum one in which to provide health care, particularly
for vulnerable prisoners suffering mental ill-health and long term or chronic conditions. We
recommend that specific targets are introduced to reduce deaths in the secure estate.
1.5. Many older facilities in the prison estate present a serious risk for self harm and suicide, and there is a
need to modernise many facilities to reduce opportunities for this. While CCTV and ACCT (Assessment,
Care in Custody and Teamwork) observations are a useful tool in preventing self harm and suicide, we
are concerned by reports from doctors working in prisons that monitoring patients in this manner has
had a perverse incentive of reducing active engagement with these vulnerable prisoners. The BMA
believes that all staff need to work together to prevent self harm and suicide, and recommends
increased suicide awareness training, communication and shared working of prison with healthcare
staff to facilitate this.
1
Prison Reform Trust http://www.prisonreformtrust.org.uk/Portals/0/Documents/Bromley%20Briefings/Summer%202016%20briefing.pdf
Prison Reform Trust http://www.prisonreformtrust.org.uk/Portals/0/Documents/Bromley%20Briefings/Summer%202016%20briefing.pdf
3Safety in Custody Statistics Bulletin, P. 8 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/543284/safety-incustody-bulletin.pdf
4 Safety in Custody Statistics Bulletin, P. 8 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/543284/safety-incustody-bulletin.pdf
5 Prison and Probation Ombudsman report, natural cause deaths in prison, 2012, p.5 http://www.ppo.gov.uk/wpcontent/uploads/2014/07/learning_from_ppo_investigations-natural_cause_deaths_in_prison_custody.pdf#view=FitH
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1.6. The aging prison population: Since 2002 the percentage of younger prisoners has decreased, while
those 50 years or over has increased; as of the end of March 2016 the number of prisoners aged 50 or
over was 161% higher than in 20026. Given the aging prison population that now exists we believe that
there is a need to explore further the health needs of this prisoner cohort, and for those with
debilitating conditions or terminal diagnosis. In particular, the government should explore if it is
feasible to support growing numbers of prisoners with multiple and complex conditions within the
secure estate, and if it is not there should be consideration given whether some prisoners, those who
are no longer considered a danger, because of the severity of their health conditions, should be treated
in community settings. Alternatively government may want to explore if specific secure facilities should
be commissioned for the care of these patients.
1.7. Addressing substance misuse: Substance misuse and addiction can be a cause or contributing factor to
an individual being sent to prison, with one survey estimating that 70% of offenders have reported
misusing drugs before entering prison7 and just under one third of prisoners claimed it is ‘easy’ to get
drugs in prison 8 . This includes novel psychoactive substances (NPS), which the Royal College of
Psychiatrists emphasises can have a significant impact on a person’s mental health9 and which have
been reported in some instances as a trigger for self harm10.
1.8. The BMA strongly believes that the secure estate presents an opportunity to offer help to those with
substance misuse issues, who often fail to engage in the community. This approach while clearly in the
best interests of the individual is also beneficial to the state and wider community, in that recovery
can reduce the individual’s likelihood of reoffending. A 2013 study by the Home Office found heroin
and crack cocaine users were responsible for 45 per cent of all acquisitive crime in England and Wales
(excluding fraud) 11 , by removing the drive to commit crime it becomes more likely that these
individuals will have the opportunity to recover and reintegrate with society. The BMA advocates
focusing sufficient resource on addressing substance misuse within the secure estate, coupled with
ongoing and consistent support upon release.
1.9. Access to a doctor of the same gender: The BMA considers that in line with the ability to choose a
doctor of the same gender outside of prison, there is a need to ensure that this right is also available
in the secure estate. The BMA has been concerned by member reports that this is not always an option
open, particularly to female prisoners, and believes that this issue should be addressed. We therefore
call on government to require the secure estate to ensure access in a timely period to a doctor of the
same gender for all prisoners as part of its reform of prisons.
1.10. Communication with prisoners: Language can be a significant barrier to seeking medical attention.
Members report instances where other inmates act as an interpreter, a method which can work well,
but which impedes the confidentially of a patient’s discussion with their doctor. In addition we have
concerns that those who do not speak English may struggle to communicate to prison staff when in
6
House of Commons, Briefing Paper, Number SN/SG/04334, 4 July 2016 Prison Population Statistics p. 12 http://www.parliament.uk/briefingpapers/sn04334.pdf
7HM Chief Inspector of Prisons for England and Wales Annual Report 2011–12 p.109
http://www.justice.gov.uk/downloads/publications/corporate-reports/hmi-prisons/hm-inspectorate-prisons-annual-report-201112.pdf#page=109http://www.publications.parliament.uk/pa/cm201213/cmselect/cmhaff/184/18409.htm#note224
8
Her Majesty’s Chief Inspector of Prisons for England and Wales, Annual Report 2013–14, London: Her Majesty’s Inspectorate for England
and Wales, 2014, p30 [accessed via: https://www.justiceinspectorates.gov.uk/hmiprisons/wp-content/uploads/sites/4/2014/10/HMIPAR_201314.pdf
(19.02.15)]
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Royal College of Psychiatrists – legal highs
10 Prison and Probation Ombudsman report self harm, 2015, http://www.ppo.gov.uk/wp-content/uploads/2015/07/LLB_FII-Issue9_NPS_Final.pdf#view=FitH
11 Understanding organised crime: estimating the scale and the social and economic costs: Research report 73, London: Home Office, 2013, p133:
http://www.no-offence.org/pdfs/55.pdf
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need of medical support. We believe that tools such as ‘language line’, can enable conversations
between non-English speaking prisoners and doctors, but are not universally applicable to scenarios
such as CSU (care and separation unit) or prisoners who are immobile. We recommend that
government provide guidelines to governors which ensure that prisoners’ health must not be put at
risk by rationing or delays in securing translator services for healthcare.
1.11. Literacy: 46% of people entering the prison system have literacy skills of, or below, that expected of an
11 year old child12, three times higher than the population as a whole. While this is a worrying statistic
on its own, from a medical perspective there is an additional danger that prisoners are not able to read
and understand details contained in medical documentation, leaflets and print offs, on specific
conditions, or more widely the directions and allergy information contained on medication. While a
doctor or relevant medical professional will of course go through this information with the individual,
it is important that patients are supported on an ongoing basis where their literacy may be a barrier
or pose a barrier to their treatment. We therefore believe that prisoners who may be vulnerable in
this way are identified and supported by prison staff they are in daily contact with. In addition, wider
education reform and support in the secure estate to address the root cause should also be
encouraged.
1.12. We would also like to draw the committee’s attention to the needs of other particularly vulnerable
groups who are currently underserved in prisons: young offenders, transgender prisoners, those with
learning difficulties (as well as the very low rates of literacy), HIV and sex offenders. Limited access to
education, association, exercise, clinic appointments and interpretation seriously impact these groups
and exaggerate pre-existing health inequalities.
What are the key opportunities and challenges of the central components of prison reform so far
announced by the Government, and their development and implementation?
2.1 Reform prisons and greater autonomy: The BMA broadly welcomes the government’s announcement
of reform prisons, including devolving autonomy for prison governors. We feel that this approach,
coupled with government assurances of increased transparency and reporting on key indicators such as
reoffending and self harm, provide a significant opportunity to improve health provision in the secure
estate, by enabling governors to tailor the support which they provide to meet the characteristics and
needs of their individual prison populations.
2.2 Reform prisons also represent a key opportunity to ensure that prison governors have the flexibility to
design or reshape prisons with the health needs of prisoners and the safeguarding of medical staff in
mind. These designs should take an evidence based approach to inform the planning and design of inpatient facilities that are fit for purpose, cost-effective and support the delivery of key service objectives
and policy drivers13. In addition medical and nursing staff operating in the secure estate should have ease
of access to inpatient facilities when it is required. There should not be instances where such prison
inpatient facilities are shut and medical professionals subsequently have to wait to gain access to a
patient, such as during lockdown.
2.3 To support the devolution of responsibility, but also to ensure prisoners are safeguarded, we recommend
that prisons are issued guidance and that there is a minimum standard of delivery for key health services,
particularly in relation to mental health. The BMA’ therefore’ recommends that prisons are incentivised
to sign up to the Royal College of Psychiatrists, College Centre for Quality Improvement Quality Network
for Prison Mental Health Services. This network implements a framework which can be used to assess
the quality of prison mental health services via a process of self and peer-review. Such a measure is in
line with government’s intention to improve transparency and accountability for governors of prisons.
12Prisoner
Education Trust http://www.prisonerseducation.org.uk/media-press/new-government-data-on-english-and-maths-skills-of-prisoners
Department of Health, Health Building Note 03-01: Adult acute mental health units
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/147864/HBN_03-01_Final.pdf
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2.4 The BMA notes that people in prison have increasingly complex medical needs, but face far more
obstacles in accessing specialist or multidisciplinary care than in the community. There is a strong case
for providing such services on an inreach basis in prison, such as on site radiology, physiotherapy, GUM
and the provision of dedicated units for palliative care, dialysis and more cells for the physically impaired.
Reform prisons should explore incorporating these inpatient facilities to ensure that prisoners can access
appropriate health support in a timely way and avoid the barriers which currently exists in many prisons
of not having sufficient escorts to transfer prisoners to outpatient facilities.
2.5 Improving reoffending: We support government’s intention to prioritise reducing reoffending, and their
intention for reoffending rates to be published. As outlined previously in this response, the BMA
recognises that causes of reoffending can be related issues such as substance misuse, mental health
problems and homelessness, which are in turn linked to the social determinants of health. Evidence also
suggests that between 20% and 40% of violent offenders have potentially treatable psychiatric
disorders 14 while 29% of prisoners had experienced abuse as a child 15 . Given this we believe that
government should see incentivise prisons to work with inmates to address these issues, to
simultaneously reduce the likelihood of reoffending.
2.6 In many prisons there is minimal support for those with a range of addictions that genuinely addresses
the root causes. The BMA believes that more must be done to facilitate substance misuse support
services to operate uniformly within the secure estate. One way that this could be promoted is through
building on the success of the Justice Data Lab pilot16, which gives organisations working with offenders’
access to central reoffending data and provides this information to help organisations to assess the
impact of their work on reducing reoffending. Such an approach will further support prison managers in
their commissioning of inpatient services, including substance misuse.
2.7 In addition, the BMA is keen to strengthen evaluation of liaison and diversion services, which are being
used successfully in some areas to divert those in need of medical support away from the prison service.
We believe that government should further explore this as an option, based on ongoing evaluation, and
with a view to expanding them across the country.
What can be learnt from existing or past commissioning and procurement arrangements for i) private
sector prisons and ii) ancillary prison services which have been outsourced?
3.1 Security first approach: BMA members have reported to us on the impact of a security first approach to
delivering health services in the secure estate. They report that at times this approach, whilst
understandable, can result in health care not being delivered in the most clinically effective way, and
not respecting the principle of equivalence of care with the wider community. This can include doctors
being required to routinely cancel both inpatient and out-patient treatment in NHS hospitals. This is
often due to a lack of transportation and escorts with only a certain quota of those prisoners who require
hospital treatment being able to be taken there each day. BMA believes that it is unacceptable for
necessary treatment to be delayed on this way, with doctors forced to triage decisions. All patients who
require treatment in NHS hospitals should be entitled to it in a timely manner, without doctors having
to choose between them. While we do not advise against the security first approach, we consider that
where this approach results in a prisoner being denied timely care in line with the community setting,
then changes must be made as part of government’s prison reform agenda, ensuring greater
transparency and accountability for the governor.
14
Chang, Z., Larsson, H., Lichtenstein, P., & Fazel, S. (2015). Psychiatric disorders and violent reoffending: a national cohort study of convicted
prisoners in Sweden. The Lancet Psychiatry, 2(10), 891-900.
15 MoJ, Prisoners’ childhood and family backgrounds Results from the Surveying Prisoner Crime Reduction (SPCR) longitudinal cohort study of
prisoners p. 9
16 Justice Data Lab Statistics https://www.gov.uk/government/collections/justice-data-lab-pilot-statistics
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3.2 Promoting wellbeing: In terms of ancillary services, given the lower than average life expectancy for
prisoners, it is crucial catering services take into account of the significant role nutrition has in many
conditions such as diabetes, renal impairment, obesity and ischaemic heart disease. The BMA believes
that prison facilities currently provide inadequate exercise and healthy food options, therefore causing
preventable deterioration in pre-existing health conditions among prisoners. In addition, approximately
four times as many people in prisons smoke than in the general population, which is associated with
and further exacerbates health inequalities for this group. In addition to this approximately four times
as many people in prisons smoke than in the general population, which is also a contributor to health
inequalities for offenders17. We therefore also recommend that government explore further how this
can be address through measures such as extending a smoking ban throughout the secure estate and
improving prisoner access to smoking cessation services.
3.3 Join up between commissioned services: It is not unusual for prisons to commission different agencies
to support prisoners with different aspects of their health. While in principle this is not an issue, the
BMA does consider it crucial that these agencies engage with each other and that there is join up and
continuity formalised in the shape of a healthcare plan. For example, a single prison may have general
practice, mental health provision and addiction services all operating simultaneously but not necessarily
in conjuncture with each other and prison staff.
3.4 Clinical risk: BMA members have raised concerns regarding clinical risk due to lack of access to care for
prisoners. They are particularly concerned that it is doctors who may be medicolegally responsible for a
patient’s wellbeing, when it is the culture of prisons through a security first approach, lack of escorts
and restricted access to care which may be responsible for a prisoner not receiving appropriate
treatment quickly enough. The BMA therefore believes that increasing transparency for DNAs and
improving accountability for prison governors, as proposed by the previous Secretary of State for Justice,
is a necessary step to improve access to care and reduce instances of prisoners waiting unnecessarily for
primary care services, including x-rays and blood tests.
What principles should be followed in constructing measures of performance for prisons?
Are existing mechanisms for regulation and independent scrutiny of prisons fit for purpose?
4.1 Equivalence of care: The BMA recommends a fundamental principle of reducing health inequalities, and
as far as possible providing equivalence of care within the secure estate. We have concerns regarding
access to secondary care and investigations within prisons, which is a barrier to offering equivalent care,
and subsequently exacerbates health inequalities experienced by prisoners, as well as putting doctors
at medicolegal risk. Members have reported that even urgent appointments are commonly breaching
the two week wait, leading to clinical risk. Despite NHS recording DNAs (Did Not Attends), it is often very
hard to establish the cause of these delays, and people in prison commonly complain that escorts to
clinics are critically insufficient. The BMA recommends recording and reporting attendance at planned
appointments, to be used as a key performance indicator of the basic duty of care provided by a prison.
4.2 There is also a need to ensure that prisoners who are admitted to NHS hospitals are not released earlier
than those patients admitted from the community would be, and when they do return to the secure
estate that they receive the necessary follow up care as would be available to patients in the
community. Concerns have also been raised by members about ‘medical wings’ being unfit for purpose,
with limited capacity for intravenous medications or other intermediate care.
17
Public Health England, Reducing Smoking in Prisons Management of tobacco use and nicotine withdrawal
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/412567/Reducing_smoking_in_prisons.pdf
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4.3 Joined up health care support: We recommend that health care providers have regular contact and
meetings with each other and also with the governor and senior managers of a prison, to discuss and
review processes and individual cases. This can, for example, be done through complex case meetings
and ACCT reviews. Currently there are few incentives for prisons to prioritise meetings between health
professionals and other staff, however we believe that this will become even more crucial if prison
governors are given greater autonomy.
4.4 Reporting and transparency: The BMA has also been particularly concerned by reports from members
of cuts to specialist addiction and substance misuse services. We understand that some specialist
services have had their provision cut because the prison does not have sufficient escorts to supervise
prisoners during their treatment. Such reports are greatly concerning, as it suggests that measures to
reduce the likelihood of reoffending are becoming sidelined by immediate funding concerns, without
taking into account the long term savings to the Treasury of supporting an individual not to reoffend.
The BMA recommends that, in line with announcements made by the previous Secretary of State, prison
governors’ performance should be evaluated partially on reoffending rates, which will act as an incentive
to facilitate appropriate support.
4.5 Current health providers' performance in the secure estate is measured using HJIPs (Health and justice
indicators of performance) produced by Public Health England. While this data is useful in identifying
the trends in health and wellbeing of prisoners they do not reflect access to care or the quality of
medical care which is provided. They are therefore not comparable to care in the community which is
measured through a QoF (Quality Outcomes Framework) allowing GPs performance to be measured.
Currently large amounts of data is collected centrally for HJIPs including reporting on shingles
vaccination, abdominal aortic aneurysm screening, bowel cancer screening, hepatitis B and C screening,
for which there is little prospect of treatment in many prisons. While the BMA believes data collection
is important, we are also concerned that this information cannot be used to drive change, when the
reality is that the current system is failing in a far more basic duty of care to provide timely GP
appointments, urgent outpatient appointments or x-rays for fractures. We believe that until there is
monitoring through a QoF type approach; joint commissioning and accountability for escorts and access
to healthcare, these existing issues will not be adequately addressed to meet the needs of prisoners.
4.6 In addition to reporting on reoffending, the BMA believes it is crucial to incentivise better mental health
support, and to reduce health inequalities through greater transparency and accountability for health
specific KPIs (key performance indicators) including:
 Evidence of onward service linkage when an individual returns to the community after time
spent in the secure estate, this could include GP registration and/or connection with
community services
 Adherence to treatment through increased accountability for governors based on measuring
waiting times for primary care services and transfers to out patient facilities
 Continued measuring of DNAs, for when prison medical appointments are missed, and the
reason for the absence
 Introducing improved wellbeing using rating scales
September, 2016
For further information, please contact:
Gemma Hopkins, Senior Public Affairs Officer
T: 020 7383 6287 |E [email protected]
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