Published: 07/10/2004, Volume II4, No. 5926 Page 27

The reforms afoot for prison healthcare will require major cultural and educational changes - but these cannot be ducked, says Peter Mason

A big shift in thinking in the next few years is needed as service managers become aware of the full implications of their responsibility for prisoners' health. The current reforms present a huge opportunity to improve the quality of prison healthcare, but the NHS, prisons and prisoners must learn to understand each other better and find better ways of working together if they are to be successful.

Delivering healthcare in prisons is different. The prison environment is alien and two very different cultures come together within it - one promoting care, the other control. This leads to conflicts on both sides and gives rise to thorny questions:

How do you ensure that prisoners have the right to quality care, delivered to NHS standards?

How will NHS choice and patient liaison requirements be delivered to prisoners?

how will primary care trusts ensure that they do not come under public pressure to spend less on those seen as 'undeserving'?

These were some of the big questions in the minds of senior staff from health and prisons who were starting to grapple with the ethical dilemmas around prisoners' healthcare rights at a recent debate organised by the Centre for Public Innovation.

One clear message was that the NHS will need to regard sick prisoners as NHS patients who are temporarily living at a different address.

Healthcare workers have a duty to be the prisoners' health advocate. They will have to preserve the unique patient relationship and negotiate their space within the prisons to ensure standards are adequate. Get this wrong and the NHS could face litigation from prisoners challenging the system to prove they are getting equivalent care.

The move to modernise prison healthcare means changes are already afoot to stop outmoded activities and tasks that are not really the duties of doctors and healthcare staff, like the issuing of mattresses, boots and dietary supplements.

Prisoners, too, will need to get used to change as NHS standards and ways of working take hold. One big move is the introduction of nurse-led services and care, which will challenge their notion of always seeing the 'medical officer'. There is also an opportunity for prisoners to look after themselves - even with simple measures, such as more in-possession medication and having access to the range of safe products that might be found in a chemist's shop.

How the NHS tackles the very real issue of mental illness in our prisons is not yet clear. Both health and prison representatives agreed that mental illness is a growing problem on the inside.

Surely the NHS in its new role as healthcare champion for prisoners will be unable to condone the practice of locking up large numbers of mentally ill people. It must lobby for effective noncustodial treatments for these patients and for their early diversion into community facilities.

The changes in prison healthcare delivery and the move to normalise it within prisons requires a major education programme for NHS staff, prisoners and prison staff. But it will be worth it.

Peter Mason is chief executive of the Centre for Public Innovation.