Sir David Ramsbotham, her majesty's chief inspector of prisons for England and Wales, does not have a high opinion of civil servants. Or anybody, indeed, who fails to take responsibility for getting things done.
The former army general told a rapt audience, at a conference on the future of prison healthcare last week, about his legendary inspection of HMP Holloway less than two weeks after arriving in the job.
That meant the woman in the mother and baby unit who asked if it was 'fair' that she had been chained up to give birth. And the 15-year-old girls in the antenatal wing 'because nobody else knew where to put them' and the 'psychotic and disturbed' who were there for the same reason.
His findings famously prompted him to stop the inspection. Eventually they also prompted him to launch a report on prison healthcare, Patient or Prisoner?, that led to a wider review when the present government took power.
'My thesis in Patient or Prisoner? was that it was high time that the NHS assumed responsibility for healthcare in the same way that it was responsible for all other healthcare,' Sir David said.
But a prison service/NHS Executive report on the future of prison healthcare services, issued in April, opted instead for partnership, with a national taskforce and a prison service health policy unit to replace the directorate of healthcare.
Even so, Dr John O'Grady, a member of the working party that produced the report, said the NHS was now 'locked into prison care' and would 'never get out again'.
'The only logical pathway is that if partnership does not work then the next step is takeover by the NHS,' he told the conference organised by Southampton University and Ravenswood House, a medium-secure unit run by Southampton Community Health Services trust.
The prison service is already supposed to provide a health service 'equivalent' to the NHS. The question widely addressed by conference speakers was how to make this work in practice.
Dr O'Grady, a consultant forensic psychiatrist at Ravenswood House, argued for a 'conceptual shift' within prisons, so healthcare workers were seen as a specialist primary care team, operating facilities analogous to those run by a GP cottage hospital. That would mean patients needing inpatient psychiatric care being 'rapidly' moved into the NHS.
But the 'sting in the tail' for mental health services was that 80 per cent of morbidity in the community was dealt with by primary care services - so prison healthcare services could not expect to shift it all into secondary care.
At a national level, Dr O'Grady argued that policy changes such as health improvement programmes and clinical governance should act as 'a powerful force for change'.
But despite the palpable enthusiasm at the conference, questions remain unanswered. One, as a local reporter put it, whether the government was 'going to open its purse' to fund the plans. The April report warned that£30m might be needed to bring prison services up to scratch.
'A lot of nonsense' was being talked about funding, said Sir David, and it was 'complete rot' that the new strategy was unaffordable because the prison service would no longer be trying to provide services already provided by the NHS.
Dr O'Grady identified waste and duplication in the current system, and insisted improvements could always be made that did not cost anything. As an example, he cited the 'full complement' of GPs provided at nearby Winchester prison, which meant prisoners could be offered an appointment with a GP of their choice.
But one delegate said it was difficult to persuade health authorities to invest in services 'at the expense of cardiology'.
And Southampton and South West Hampshire public health consultant Dr Ruth Shakespeare, who was otherwise enthusiastic about prison HImPs as drivers for change, said it was not in a situation 'where there has been adequate investment in health services in this country'. The new national service framework for mental health would reveal 'gaps' so 'equivalence could mean gaps'.
'The real wicked problem is that as we start to do this sort of work, we will find more and more unmet need, so we are going to have to find some way of moving resources into this area,' she said.
The taskforce established under former East London and the City HA chief executive Peter Coe is now trying to complete needs assessments for prisons, to feed intothe next comprehensive spending review round which starts in April. It is also going to look at clinical governance.
But other problems lie ahead, such as competition with the NHS for scarce staff which, Dr O'Grady conceded, could be 'the thing that could derail this'. Others were issues around multi-agency work - a good thing, speakers agreed, but not easy to achieve - concern about the government's plans for people with 'dangerous, severe personality disorder'; consent and sectioning; and dealing with residency issues.
Prison service healthcare adviser Dr Cliff Howells said it boiled down to money again - whether HAs paid for people from their area in prison, or whether the HA 'hosting' the prison was responsible. And a balance was needed between acute and long-term care, so doctors could arrange rapid acute care for prisoners without spending 'five hours on the phone' trying to find someone clinically responsible for their long-term care.
To move forward, he said, prisons needed more links - to trusts, primary care groups, other prisons - and they needed to 'grab' the opportunities offered by clinical governance.
It made no sense to do otherwise, Sir David said. Of the 60,000 or so people in prison, only about 30 would never be released. Everybody else would eventually be covered by the NHS, so it made 'no sense to release them in a worse state' than when they began their sentences.