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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES 6. - Prison Medicine
RADIO 4
TUESDAY 18/01/05 2100-2130
PRESENTER:
MARK PORTER
CONTRIBUTORS:
JANET WILKINSON
JULIET LYON
BERNARD GESCH
PRODUCER:
GERALDINE FITZGERALD
NOT CHECKED AS BROADCAST
PORTER
Hello for today's programme I've left the relative comfort of Broadcasting House and I'm standing outside the gate of a much starker institution - Her Majesty's Prison, Chelmsford. I'm here to find out more about the provision of healthcare inside prisons - how do staff deal with problems like self-harm and drug abuse that are both far more common in prisoners than the rest of the community? And what happens if you have an ongoing medical problem, like diabetes, or you need an operation to repair a hernia or replace an arthritic hip?
I'll also be discovering how diet can influence prisoners' behaviour - can simple vitamin and mineral supplements really reduce antisocial behaviour, if so what are the implications for society as a whole? But first I've got to get in.
In 2003 around 75,000 people were held in prisons across England and Wales. Ninety four committed suicide - and a further 211 had to be resuscitated by staff.
Prisoners are eight times more likely to take their own lives than the rest of the population - a third of all suicides occur in the first 60 days of imprisonment - 1 in 10 within the first 24 hours.
John and Joel run a self-harm support group here at Chelmsford. Called the 2052 group, after the prison service form that has to be filled in when someone is deemed to be at high risk of self-harm, they meet regularly in the day centre in the healthcare block. John and Joel's input is based on first hand experience - they were both desperate when they first arrived at Chelmsford prison, and promptly set about planning ways to end it all.
JOHN
I was suicidal 'cos being my first time in prison. I was actually on healthcare meself for six months, in strict conditions, on constant watch for two months.
PORTER
To prevent you harming yourself?
JOHN
Yeah, yeah and I was doing things just to - saving cling film, tied together - even though I had someone watching me I still was doing things because that's how low I felt.
PORTER
You were on suicide watch, which basically meant that you were on your own in a safe cell where you couldn't do yourself any harm. Despite that you were collecting cling film and other things - what were you going to do with the cling film?
JOHN
I was actually tying it together.
PORTER
To strangle yourself?
JOHN
Yeah, yeah.
PORTER
I mean you don't get much more desperate than that. How did things change? Did they have you on medication?
JOHN
Yeah I was on medication and they referred me to day care. And to be honest with you I haven't looked back since - since day care.
PORTER
Had you had a problem with your mental health - with depression - before you came in?
JOHN
I was depressed but didn't know it.
PORTER
And presumably the dramatic change of circumstances. And it's not an uncommon problem in people coming in - do you see many - do you recognise it in many of your fellow prisoners?
JOHN
I do - I do now, yeah, I mean obviously working upstairs ...
PORTER
Yes because you work here as an orderly in the healthcare block.
JOHN
Yeah, I think me and Joel we have more to do with other inmates here than the actual officers because we work with them all the time.
PORTER
Joel did you have problems when you came in?
JOEL
Yeah I had - just prior to me coming in I went through depression, very, very strong, I've never felt anything like that before. I lot of my depression was to do with my daughter being taken off me. And then suddenly I found myself in prison, it was very daunting, I was suicidal and I thought that's the end of everything, there's nothing worth living for.
PORTER
Did you actually harm yourself at all - did you have any attempts?
JOEL
Yeah I attempted to - well I attempted three times to slash my wrists.
PORTER
I can see the scars on your arm there.
JOEL
Yeah they're quite bad scars.
PORTER
How did you manage that inside here then because presumably you were - you don't have access to things that you could damage yourself with?
JOEL
It's quite easy to get access to a razor. There are other ways of doing things to yourselves - I've seen a lot of things happening here that basically shouldn't happen - you should see the problem before it's going to happen which John and I do nowadays - we tend to understand what these people are going through, it is very daunting. And there's a couple of people that I know of that have tried to take their own lives - being on remand.
PORTER
What's actually happening here at Chelmsford to help people like you who have come in and are suffering from serious cases of the blues or indeed trying to harm themselves?
JOHN
I was in Belmarsh for three months before I came to here. I've got so much more from here than I did.
PORTER
But what sort of things - I mean when I came in here you were sitting in a group having a chat, I mean is it something that's openly talked about?
JOHN
We've got - I mean we have a support group here ...
JOEL
Yeah we do the 2052 support group, which basically are people that have self-harmed and how do they deal with not self-harming again. And we basically go through a process of the fact that they could be in here for a long time, how do they deal with it and then basically just review that really, keep reviewing it.
PORTER
Now you've both obviously had quite major problems when you came - that adjustment period - what about now?
JOHN
What how I feel - oh I'm back to normal, I'm all good now. And now I'm putting something back in. I actually facilitate the 2052 groups now and sometimes I have actually run them on me on. So I can relate to them.
PORTER
Because that's one of the problems when you're depressed, isn't it, that actually everything - there is no future, you can't see any way out of it and actually having someone like you sitting there and saying look I was in your situation.
JOHN
Yeah, well they can see that you can come through the other side. No one's been on a constant watch longer than me, I was the longest. So you can come through, you can come through and that's what I try to put across to them.
PORTER
John and Joel talking to me at Chelmsford prison. My studio guest today is Dr Janet Wilkinson who's lead GP at Holloway prison.
Janet - Holloway's a woman's prison - is self-harm as much of a problem among female prisoners?
WILKINSON
Sadly the needs of women are even more complex. Sixty to seventy percent of them arrive with mental health problems already and that's often associated with substance misuse problems too. So we already have a very complicated group of ladies coming into prison. And obviously from their arrival in prison they're even more likely to develop depressive symptoms with coping with imprisonment.
PORTER
Because they make up a disproportionate number of suicide attempts don't they.
WILKINSON
Yes, well they make up 6% of the prison population but in all the suicide - successful suicides - are probably double that and the instance of self-harm and attempted suicide are unfortunately about half the number of attempts throughout the prison service.
PORTER
So they account for half the number of attempts but only account for 6% of the population. What sort of methods are they using - we hear there somebody saving up cling film, presumably getting a razor out of a razor blade to use on their wrists - what sort of methods are people using?
WILKINSON
Well I think you have to draw a distinction between self-harming and suicide attempts. Self-harming is mostly done by cutting in women's prisons, they use anything - we don't have metal cutlery, we have plastic cutlery throughout the prison but they can still snap that and use those to cause problems with their wrists, they even, some of them, mutate their breasts and genitals. So it's a huge problem in women's prisons. The way that they will often express their unhappiness in prisons is by tying a ligature, as we call it, and that can be anything from a shoe lace just casually tied round their neck to somebody actually ripping bed clothes, ripping their own clothes and hanging themselves from the rails in the prison cell.
PORTER
It must be very difficult to assess these people - whether it's a sort of cry for help or whether it's a serious attempt - I mean it's difficult enough in the community.
WILKINSON
Yeah we have a lot of support with mental health teams in the prison. We have very good access to Camden and Islington Mental Health Trust who will see patients for us the same day or the day after if we want to, if there's a real crisis. We also have good access to psychologists as well. And all these support mechanisms make it easier for the GPs within the prisons to identify who is at serious risk of suicide and who is really making a cry for help.
PORTER
We heard there John and Joel talking about suicide watch - being put on suicide watch, what does that involve?
WILKINSON
Really they transfer to inpatients in Holloway and an agency nurse often will sit outside the patient's room - we don't like to call them cells - but outside the patient's room and just observe the patients throughout a period of often 24 hours. We don't like to use this often in Holloway because it seems to us that what the patient is doing is actually expressing a need for contact and it's much better if we can spend our resources talking to patients rather than just sitting outside with a lady who often changes every eight hours and who the patient really can't make any - form a relationship with.
PORTER
How many women would you have on suicide watch in Holloway at any one time?
WILKINSON
Out of the 470 women we have at the moment probably about 50-60 are on suicide watch or an F2052, as we call it.
PORTER
That's a lot of people.
WILKINSON
That's a lot of people.
PORTER
Well drug abuse is another huge problem in gaols and protocols for managing addicts seem to vary from prison to prison. Chelmsford has one of the stricter approaches - all new prisoners are put through a rapid detoxification programme.
Nicky is the nurse running that programme and I asked her how the prison deals with people who are regular heavy users of hard drugs and likely to suffer serious withdrawal effects.
NICKY
Here we have a very strict protocol and we use BritLofex. It's a non-opioid, non-addictive drug, it's not like methadone or subutex - BritLofex is non-opioid, non-addictive. Basically it slows down the production of noradrenaline, so that when they're withdrawing it's not as adverse as it would be. And of course with that we give symptomatic relief as well - so that they get Buscopan, Diclofenac, something to help them sleep for five nights. If they take benzodiazepines, we put them on a reduction regime here.
PORTER
So basically everybody who comes in gets a crash withdrawal - a supported withdrawal - but a fairly rapid one?
NICKY
Yes.
PORTER
You would expect them to get drug-free at what sort of stage typically?
NICKY
Between 7-10 days, unless of course they're withdrawing from methadone, which is a longer period, more difficult to withdrawal from. And they get a slightly extended regime, which would be over 14 days.
PORTER
But it's prison policy to put everyone through that supportive withdrawal, rather than to maintain them on some form of substitute as may happen in the community.
NICKY
Yes, it is - that is our protocol at present. That's not the protocol for every prisoner, we don't have any sort of real consensus amongst the prisons within the area - some prisons might use methadone, some might use substitutes, but here we're funded for BritLofex at present.
PORTER
How do the prisoners react to that withdrawal - do some of them - I mean obviously it's a golden opportunity for them when they're in an environment where the drugs aren't as readily available to come off, I mean do they appreciate that?
NICKY
The majority of them do. The advantage of BritLofex is that they can be on ordinary locations - the medication that they have has no currency value.
PORTER
So they can't trade it with other prisoners.
NICKY
No, and we try and support them very much through the initial period of their detox, so I will endeavour to regularly review them and I think that that psychological support is very important to the drug using population that we have here.
PORTER
Nicky, who runs the drug and alcohol detoxification programme at Chelmsford prison. You're listening to a Case Notes special on healthcare in prisons - I'm Dr Mark Porter and my guest is Dr Janet Wilkinson lead GP at Holloway.
Janet, do you use a similar approach to Chelmsford - i.e. getting people off as quickly as possible?
WILKINSON
No, one of the differences I think in women's prisons is a. the length of stay of women, the average length of stay is just 21 days. The other issue is that most women present with poly-drug use, so they arrive with problems with heroine dependence, crack misuse, diazepam dependence and an alcohol problem as well. So what we try to do in the short space of time that we have is to maintain - detox the patients who wish to be detoxed but if we can't, try to stabilise those patients who wish to be stabilised on methadone and then try and link them into drug treatment agencies in the outside.
PORTER
How big a problem is it - I mean how many people coming into Holloway Prison have a drug problem as they arrive?
WILKINSON
Again it's about 60-70% of all our patients have either an alcohol or ...
PORTER
Of your patients or of people coming into prison?
WILKINSON
Of all the new reception screens that we see.
PORTER
So all the prisoners coming in.
WILKINSON
Yes.
PORTER
What about use in prison - I mean we've been reading in the press this week about drug use in prisons in Liverpool - how do drugs get in, I think most of our listeners would think of it as a secure unit - the one place you aren't going to get drugs is in prison, but that's not the case is it?
WILKINSON
No I think - well men and women will always find ways of getting drugs into prison. When patients arrive in Holloway we're not allowed to give them intimate searches obviously, so many women if they know they're going to be arrested will actually put drugs in the vagina before they arrive at the prison.
PORTER
So they're bringing in a supply with them.
WILKINSON
Yes, to sell on in prison or to use for themselves.
PORTER
But if they're in prison for a year or two years maybe and most of your people stay for quite a short time, they've obviously got to get re-supplied, where's the re-supply coming from?
WILKINSON
I think it can come from any source - it can come from visitors, it can come from - some of the women have had babies in prison and have had - we've had baby walkers who take the babies out and have even put drugs in the babies' nappies to bring back into prison. So you know if they want to there's no - unfortunately no hundred percent way that we can stop drugs coming into the prison.
PORTER
And what sort of drugs are we talking about - the full gamut of drugs that you'd find on the street?
WILKINSON
Mainly heroine and crack.
PORTER
And so - I mean with heroine are they injecting that?
WILKINSON
Very few are injecting within prison because they don't really have access to the needles. Most of our drug patients are actually injecting before they come in. But the amount of drugs that they can get in and the type of equipment that they can get their hands on usually means that they are smoking heroine and crack.
PORTER
Well Juliet Lyon is from the Prison Reform Trust and she's also quick to admit that drug use is rife in our gaols - a recent Home Office study found three out of four prisoners interviewed admitted using drugs while inside. But how?
LYON
There are all sorts of efforts made to prevent people bringing in drugs. The fact is that prisons are seen as a place that can be targeted by dealers and they will use any means possible, if they see it as a way of raising money. So they'll use prisoners, they'll intimidate prisoners' families, they'll even use some members of staff, if they can find people who are willing to bring in drugs.
PORTER
Are we making inroads into the supply of drugs in prison or is the problem worse than it was?
LYON
I think there are some inroads being made but the issue really is the whole prison environment - the whole environment - can it be made into a constructive useful place? And in the course of that can we reduce the amount of drugs that are being brought in?
PORTER
Do you think the courts are seeing prisons as an opportunity to "detox" some of the people that are coming through the courts and perhaps inappropriately sending them into prison?
LYON
I think that's a real worry we have at the Prisoner Reform Trust, that prison is our punishment of absolute last resort and the danger, I think, of making some improvement in prison healthcare, ironically, is that you can actually give the courts confidence to use it, for example, for psychiatric assessments - particularly for women on remand - and as a result it can be stretched - its purpose can be stretched. That's not fair - that's not fair to prisons, it's not fair to the staff who work hard to respond to the needs of the most serious offenders.
PORTER
Do you think we should have a dedicated prison healthcare service or one that's fully integrated with the services that are available in the community?
LYON
I think it's very important to have it fully integrated. A lot of people arrive, they don't have a GP, they need to have that provision made, they need to get a chance to see what their health needs are, maybe even begin to address those health needs and then once they're back outside in the community to go on getting some help for their health needs, which are pretty huge.
PORTER
We heard earlier - on my visit to Chelmsford - I was quite impressed by the facilities they've had there. What does the Trust think of healthcare generally across the country in prisons?
LYON
We're definitely seeing improvements but there's a very long way to go I think before we get anywhere near equivalence.
PORTER
Equivalence in what way because the facilities I saw in Chelmsford were certainly better than mine and I cater - my practice caters for around 10,000 patients and that was something like 500 prisoners - big difference?
LYON
Yes, I think as you said earlier on it's about very patchy healthcare, some prisons really are getting there and others have got a long way to travel. And I think the other thing that we really need to pay attention to is court diversion and liaison schemes. Are court diversion schemes working in the way that they should be?
PORTER
And by court diversion schemes you mean?
LYON
These are schemes administered by the PCTs which are designed to divert people who haven't committed serious offences and clearly health needs are what's prevalent - what really matters - and to divert them into health treatment.
PORTER
So we're looking at drug and alcohol - those problems largely I suspect.
LYON
And also mental health. And those schemes, where they do operate, appear to operate well but they appear to be very patchy. So on the one hand you're getting people washing into the prison system who really don't need to be there, either because they haven't committed a crime that's really serious enough to warrant a prison sentence and they could serve their time in the community with supervision, also the very high numbers going on remand, I mean last year there were around about 60,000 people held on remand.
PORTER
Just clarify what we mean by remand.
LYON
That means that they're held in prison waiting trial.
PORTER
They've not been convicted or anything.
LYON
They haven't been convicted and when they get to court one in five of them were acquitted altogether and half went on just to serve a community penalty. So consequently what we're seeing is a resource that is a scarce and important resource being overused.
PORTER
And these people - many of them - have quite important healthcare problems - drug abuse, alcohol problems, mental health issues - and because they're incarcerated they're not being looked after properly, is that what you're saying?
LYON
That's right. I mean prison isn't a treatment centre and although prison is improving its healthcare that's not its primary purpose. In relation to alcohol of course although there have been improvements on drug treatment and in terms of mental healthcare. Alcohol, there is a policy but absolutely no resources.
PORTER
What about young offenders who've got families, I mean particularly I'm thinking here of women, presumably they're going into prison, many of them will have young children?
LYON
One of the stresses and strains you see, particularly in women's prisons, is the loss of children and the efforts women make to try and maintain contact with their families. That's probably the biggest single difference that staff have identified between a men's gaol and a women's gaol - that the women try and parent from prison, they're trying to - you so often will hear women saying - have you gone to school, have you got your trainers - they're on the phone all the time, they're trying very hard to make an effort to keep that role going. We know that around about 17,500 children are separated each year from their mothers.
PORTER
How many of those will get back with their mothers afterwards?
LYON
A high proportion do get back together, it's around about - it's under 10% go into local authority care, most are farmed out to family and friends. It's one of the great worries, I think, is maybe that process isn't managed as well as it could be.
PORTER
Juliet Lyon from the Prison Reform Trust.
Janet - you must see a lot of desperate mothers?
WILKINSON
Yes I think in women's prisons it's more difficult as well because there are fewer women's prisons in the country, so that women are often moved around the country and maybe miles - hundreds of miles from their children. Holloway has a catchment area of - as far north as the Wash and right down to the South coast, even despite the fact that another prison has recently opened down there. So to try and keep in contact with your children is very difficult for the mothers inside.
PORTER
Can children visit?
WILKINSON
Yes they are allowed to visit, obviously dependent on the crime or social services problems. But the officers do their best to try - sometimes ladies will be allowed to bring their children in to use to the swimming pool, just to have a couple of hours together, doing the normal things that you would do maybe on a Saturday morning.
PORTER
What about women who come in pregnant and are due to give birth while they're in prison?
WILKINSON
Many women deliver in Holloway in prison but we only have 17 mother and baby beds in Holloway. A decision has to be made as to whether it's in the child's interest to be with the mother in prison. Obviously if the mother's got a long sentence of 12 years then we allow babies up to the age of nine months in prison and it may be more traumatic for the mother to part with the baby at nine months than it would be for her to part with a baby at birth. But either way it's obviously a very distressing position to be in.
PORTER
It must be awful, so what we're basically saying is you have your child while your in prison, the child will be taken away from you at some stage.
WILKINSON
Yes. In the best scenario women have families outside who are prepared to care for them, so at least they can maintain contact. But often, particularly with the ladies who are accused of importation, so they get long sentences and their families are back in Africa or the Caribbean and so they have absolutely no prospect of maintaining contact with a child.
PORTER
Janet, thank you for now.
Good nutrition is vital for optimum health, but it's an area that is often overlooked, particularly in prisoners in whom it may have some surprising benefits. Bernard Gesch is a senior research scientist at Oxford University and director of the charity Natural Justice, and the man behind pioneering research in the UK which suggests that poor nutrition contributes to antisocial behaviour. Two hundred and thirty one men from HM Young Offenders' Institute in Aylesbury were included in his trial which was designed to discover if nutrition could influence their behaviour. Gesch began by assessing what they were eating in the prison canteen.
GESCH
We found that many of the prisoners had made poor food choices from the food available from the kitchen serveries. So what we postulated was that the possibility was that part of their behaviour could be as a result of these poor diets because in effect what we eat comprises an important component of our brain chemistry. So all we tried to do was to reinstate the nutrients which were missing from their diets, using food supplements.
PORTER
The aim being to provide the required daily quotas of vitamins, minerals and fatty acids - and the prisoners took the supplements for an average of five months.
GESCH
Well the results were quire remarkable. What we found was two things: one was that the people who received the fake capsules - the placebos - there was no change in their behaviour. However, when we looked at the people that took the active capsules with the extra nutrients in, even with the most conservative analysis there was a reduction in offending of about 26%. The more serious offences could involve very serious assaults against another person, down to typically incidents where, for example, someone failed to comply with an instruction and was insolent.
PORTER
A larger repeat study is planned to confirm the findings, and work out which of the supplements are influencing behaviour - and how. In the meantime could simply improving the prisoners' diet help?
GESCH
There's certainly evidence to suggest that if you simply improve people's diet it will also benefit behaviour. But one of the things we found at Aylesbury was that the prison diets provided by the kitchens were actually reasonably close to government dietary standards. The problem was that the prisoners were not eating them. Now it occurs to us there's at least two ways you can address this problem: if you're going to go down the dietary route you have to include dietary education because many of the prisoners hadn't heard, for example, of vitamins, let alone what they did, so they were not in many cases remotely equipped to judge what an adequate diet was. Alternatively, you could do what we did, which is to provide a form of supplementation and I think there are strengths and weaknesses to each approach but let's face it the ideal is for the people to choose a healthy diet.
PORTER
Bernard Gesch.
Janet, is nutrition taken seriously at Holloway?
WILKINSON
Yes, I mean at the moment we're spending something like 拢600 a month on nutritional supplements to the patients. What we're trying to do though however is to look at the diets, we feel that with 拢1.72 pence to pay - to play with for ...
PORTER
That's the average amount you spend on a day's food.
WILKINSON
That's the amount that the kitchen has to play with to spend on patients' food. And what we're trying to do is we've recently got a dietician from Islington PCT to come in and to look at the diets, to take those away and it's actually going to be a project for a local university to come up with a four week rolling cycle of a diet for the prisoners which will be healthy and hopefully reduce our need for nutritional supplements.
PORTER
Optimum nutritional 拢1.72 a day - that's a tough call.
Let's move on to a more general issue, quickly to end with - what happens if someone, who's a prisoner at Holloway, needs a specialist appointment, I mean maybe they've got a problem with their eye and I'd simply refer them up to the local hospital as a GP, do you do the same?
WILKINSON
Yes exactly the same - we send our patients to the local Whittington Hospital, they get appointments through the post, of course they're not allowed to know the appointments and then we ...
PORTER
Because they might make a plan to sneak out the back door of the hospital while they're there.
WILKINSON
Well the greatest level of risk of escape is when a prisoner goes to a hospital appointment, so we're not allowed to tell them that. But other than that it's just done in exactly the same way - that they go to hospital, see the consultant, albeit with two officers, and then come back to the prison in the usual way.
PORTER
And they wait like the rest of us - there's no short cuts?
WILKINSON
Well I think - they're probably pushed in a little bit quicker.
PORTER
Two burly prison officers standing next to them. What about emergencies - I mean my appendix ruptures and I'm in prison - what happens then?
WILKINSON
Same thing again - during the day we have access to local GPs and the same at night. We have the local Camidoc deputising service that come into the prison if there's a problem within - at night.
PORTER
The only implications being of course if a prisoner has to leave a prison they always have to be escorted - are they handcuffed?
WILKINSON
It depends where they're going really, it depends - the officers are well aware of the areas of the hospital which patients are most likely to make escape.
PORTER
Experience has taught them that.
WILKINSON
Yeah.
PORTER
That's all we have time for. Dr Juliet Wilkinson - thank you very much.
If you have any queries about today's programme then do visit our website bbc.co.uk/radio4 for useful contacts and where you can listen to the programme again. Or you can call the Radio 4 Action Line on 0800 044 044.
Next week's programme looks at premature labour, and the results of a new landmark study into the effects on a child's development. What is the long term outlook for the one in ten babies that are born early?
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