INSIDE STORY

Who would choose to work locked in with some of Britain's most dangerous criminals? Emma Forrest visits HMP Full Sutton's health team.

Imagine working in a place where you may not see daylight once during a 12-hour shift. Where private consultations with patients are impossible because, for your own safety, there must always be someone else present. Where you treat people who some believe should not even be entitled to medical help. Welcome to prison healthcare.

Traditionally delivered by staff dubbed inadequate by NHS colleagues, aided by prison staff without healthcare training and deprived of professional training, prison healthcare has had an unenviable reputation. Gaps in workforce and training are exacerbated by the gulf in cultures between the prison service and the NHS.

But since funding for prison health was transferred to primary care trusts last April, the two worlds have been forced to get along. All commissioning of prison-based health services will be switched to primary care trusts by 2006, so there is a lot to learn.

Although every prison is different, security remains the dominant concern and it clashes with basic access to healthcare. This is even more apparent when the jail is maximum security, like HMP Full Sutton on the outskirts of York. It has more than 600 inmates and its primary function, according to its website, 'is to hold, in conditions of high security, some of the most difficult and dangerous criminals in the country'. In some ways it is in the vanguard - it has the country's first prison walk-in centre. If NHS healthcare can work in Full Sutton, it can work anywhere.

'There is a tension between the laissez-faire, guidance-driven culture of the NHS and the security-driven philosophy of the prison service, ' says Mark Johnson, director of offender mental healthcare strategies at consultancy Mental Health Strategies, who has been evaluating the walk-in centre.

Officials close to the Full Sutton project say that if the governor had not been on board from the start, it would have been very difficult to get the centre off the ground. 'There can be resistance to change and although the health and prison staff are now working together well, getting anything done can be very difficult, ' says one. 'Getting hold of a drawing pin can be a major exercise.' Full Sutton healthcare manager Liz Littlewood acknowledges that there are prison officers who do not believe healthcare has a place in a prison setting. 'They are there to monitor safety and security, are about order and discipline and have a lack of understanding about healthcare. But the service is becoming more about rehabilitation.

Full Sutton employs officers with that mindset.' NHS staff who work in a prison environment may face prejudice from colleagues. 'When I decided to come here people said I was going to damage my career and that no-one would want to employ me again if I left. There is a story that good-quality nurses do not work in prisons, that they do not attract good-quality staff. But I wanted to work somewhere I could make a difference, ' she says.

Ms Littlewood joined Full Sutton from a private, medium-secure psychiatric unit and has employed several of her former colleagues - so many of them are used to the secure environment.

But she has also taken on staff who have never worked in such conditions before.

'You have to be careful not to scare people in interviews, but you have to give them the truth. It is a very austere environment and I make sure people get shown round at the time so they can see for themselves. It doesn't suit many people. At interview we find out how they would feel about working with sex offenders and people who have committed quite heinous crimes, ' says Ms Littlewood. She has learnt to tell who is not going to be right for the job. 'You just develop a sense for these things.' Working conditions are a pressing issue in a maximum-security environment. After just a few hours there, it is easy to see how spending 12 hours a day in Full Sutton could get depressing.

Despite a rather bland outward appearance - it is not until you get close that you can hear the guard dogs and see signs warning visitors of what they can and cannot take into the prison - the interior of the 18-year-old building feels surprisingly Victorian. The long corridors, reminiscent of some older NHS hospitals, are difficult to navigate - everything looks the same.

Just like in a hospital, everywhere is either very hot or very cold.

Bleak house

Not every wing looks the same: some have long, open-plan landings (think Bad Girls) while others are smaller, more claustrophobic and, according to prison officers, more difficult to watch over.

But every wall is painted in varying shades of grey, beige or pale blue and, aside from a few anti-drugs posters in the healthcare unit, there is no decoration. The general sense of bleakness is exacerbated by the tattiness, as you might expect from a building that has more than 1,000 pairs of feet tramping through it every day.

And of course there are hundreds of locked doors and a conspicuous lack of windows. Where daylight does penetrate, it is through thin slits of frosted glass. It must be difficult to tell what time of day it is or even what the weather is like as most cannot be opened.

Healthcare staff say getting into work can be an arduous business: the prison's size and the number of secure doors mean it can take at least 15 minutes to get to the healthcare unit.

Mr Johnson says: 'Every unit is in some way isolated; you cannot move freely around and you cannot just go for a walk if you feel like a break. And the security authorities have the right to restrict your movements. If there is an incident and the prison goes into lockdown [where all prisoners are confined to their cells] no staff can leave; I've been kept in Belmarsh for hours after a visit.' While being shown round Full Sutton, I mention I had decided not to tell my mother where I had gone until I was safely home again.

This is met with laughter. There are constant assurances that, despite what anyone who watches a lot of television might think, a maximum-security prison is one of the safest -32 31- environments a person could find themselves in. 'Far safer than your average NHS hospital' or 'far safer than A&E' are oft-repeated remarks.

Staff say their families do not worry about them, and there is no palpable sense of menace.

Ms Littlewood does decline, however, to show me the segregation unit, where violent or disruptive prisoners are housed. I didn't argue.

Walk-in centre nurse Linda Hoskins says she is used to 'very macho, basic environments'.

'I used to be a paramedic and I have worked in Jamaica and in the East End of London. This is a different culture again. I found it very different at first, but I sometimes get treated better here than I did when I worked at the walk-in centre in York.' Staff are frequently asked how they can stomach looking after criminals. Half of Full Sutton's inmates are deemed vulnerable prisoners; of those, most are sex offenders. The 'hierarchy' of crimes (raping a woman is 'better' than raping a child) among inmates means they are considered to be at risk from each other.

The answer seems to be, 'You have to treat them the same as any other patient. If you didn't you would never be able to do it.' Often, if it is not essential to be told what crime a prisoner has committed if workers choose not to find out: 'By choosing not to know what they are in here for I can stay objective, ' says Ms Hopkins.

Switching off

But not all workers, such as mental health nurses, have that option. 'I have had people ask how I can bear to work with sex offenders, but you cannot let that influence your work. If you do not switch off you could let it influence your life, ' says inreach worker Tina Liversidge, whose enthusiasm for her job could be an advertisement for prison work. She believes it should be part of mental health nurse training. 'This is an experience that you will never find anywhere else.' Ms Littlewood adds that she encourages an 'off-load' culture (so staff forget about work when they go home) and makes sure any incidents or concerns are immediately reported to a line manager. She would like to be able to provide employee counselling, but cannot do so yet.

Mr Johnson says stress levels are often not any worse than those felt by NHS staff. 'Choosing to not know what people have done can be a defence mechanism. Mental health nurses cannot do that, but they tend to have different coping strategies.

There is less of a soldiering on mentality and they are more likely to recognise feelings of stress and deal with them.' In an institution housing some of the country's most notorious criminals, there is also the chance that workers may recognise some of their clients.

Ms Liversidge admits that she has recognised some inmates, but says it does not happen as often as when she worked in a remand centre.

'There you would see someone on the news one week and they would be in front of you the next.' Some of the pressures of the job are more unexpected. Ms Littlewood says she did not appreciate how litigious prisoners are; many inmates read up on the Human Rights Act and prepare long lists of complaints.

Find out more HM prison service

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Health services management centre on prison health

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Centre for Public Innovation

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'They complain about not getting access to treatment and not getting appointments. You or I would face the same waits, but prisoners do not accept them; they think they are used as punishment. I do have a problem with that, ' she says. 'You also have to become wise to those who are playing the system. They can be manipulative.' However, an element of mutual respect is essential. 'Treat people like animals and they will act like it' is a common attitude.

Most staff said it was rare not to be treated with respect by the prisoners; something Mr Johnson attributes to nurses being seen as 'administering angels'. But Ms Littlewood points out that if gratitude is felt, it is rarely expressed.

Job satisfaction must be gained in other ways.

'You never get a thank you. You are never going to get a box of chocolates from grateful patients or their families. There is no gloss in this job, ' she says.

Bringing health and prison cultures together has meant a steep learning curve for prison health staff. Mr Johnson says that until recently, prison culture was like the NHS 20-30 years ago, with a family atmosphere perpetuated by staff living on site and visiting the social club after work. Now the club is gone and staff drive to work.

'It is not that the prison service is not open to change, but it is not used to having change imposed upon it, ' he says.

Full Sutton's healthcare staff report that they do feel part of the team. But balancing the need to fit in with a desire to remain independent will be vital; prison workers can become isolated and an insular, confined atmosphere can develop.

In the meantime there are still obstacles.

Prisons can be pretty far down a PCT's list of priorities and still struggle to access NHS resources. Announcing millions to be spent on new facilities for prisoners is never going to be a vote-winner. Some have suggested that the PCTs involved, Yorkshire Wolds and Coast and Selby and York, only recently acknowledged Full Sutton's healthcare needs and enabled changes to take place; not least because of the governor's determination to see prison healthcare improved.

But the facilities are still basic. Ms Littlewood wants the healthcare unit modernised.

'I would like a better working environment for staff... It is very cramped, and needs dedicated interview rooms and office space. Some places are getting dedicated new builds but you come in here and It is like [the film about life on death row] The Green Mile.' You could never call it dull. This is one of the most challenging healthcare environments around and if there is one thing that unites the staff, it is a fondness for the challenge.

'This is not the right place for everyone. But we are about the delivery of healthcare; we are attending to a need, regardless of the person who is being attended to, ' says Ms Littlewood. 'You can't be judgmental. Who you deliver care to really should not matter.'

Full Sutton walk-in centre was a finalist in this year's HSJ Awards. See the attached supplement

HE CHANGING FACE OF PRISON HEALTH SERVICES

From guards to nurses Until the transfer of prison healthcare to the NHS, few nurses actually worked in prisons. Healthcare guards who had received basic training were essentially doing nursing jobs, sometimes even running units.

Though still involved in delivering services such as smoking cessation and counselling, the role has been effectively demoted so they have no say in deciding if a prisoner is eligible to visit the healthcare unit or, at Full Sutton, the walk-in centre.

Instead, they are present at all consultations - healthcare staff cannot be alone with a prisoner - and carry out tasks such as distributing medications.

Security, scissors and small talk Security measures are part of everyday life in a place like Full Sutton.

Every member of staff goes through security measures before they start a shift. No more than one pair of scissors can be used at any one time and the use of other props, such as gloves, is closely monitored.

Staff must think twice before they use even the most basic equipment. All tools are locked away and checked after every session at the centre.

Prisoners waiting at the healthcare centre are kept in a locked room. Of the prison's eight hospital beds, two are 'specials', meaning they are kept under 24hour camera surveillance.

In any consultation with healthcare staff there must be an officer present. And staff are advised not to give away personal information when dealing with clients; nurse Linda Hoskins says she avoids the informal chat used when talking to patients in a typical NHS workplace and any mention of staff's children is forbidden.

Waiting in the prison wings Rules on prisoners' movements dominate the conditions under which healthcare staff and prisoners can gain access to each other.

Full Sutton's inmates are divided between the vulnerable prisoners (VPs) and those badged the 'main' prisoners.

The two groups must not meet under any circumstances, which can make day-to-day management more difficult. If a main prisoner wants to go to the walk-in centre but there are three VPs waiting to be seen, the main prisoner cannot move until the VPs have been escorted back to their wing, which can mean long waits.