Measures to improve relations between the NHS and the prison service are hampered by a suspicion that prison healthcare is not exactly a priority, writes Ann McGauran

'There are only two important things in prison. Prisoners must not escape or die and nursing is just a necessary evil provided at the whim of the governor. ' Not a line from a Dickens novel - but the view of the nursing manager at HMP Holloway as expressed during a healthcare audit.

That manager is no longer with the prison, but those attitudes (see box below) may partially explain why health authorities and prisons are jointly drawing up prison health improvement plans for each of the 135 establishments in England and Wales - or PHImPs, as they are otherwise known.

But as the end of March deadline for the plans looms, progress appears to be patchy. Prisons minister Paul Boateng said in a parliamentary reply at the end of November that 'at least 38' prisons with their HAs had managed to complete needs assessments and were working towards a HImP.

Policy officer for the Howard League for Penal Reform Tim Colbourne believes many will be left unfinished. 'The impression Mr Boateng gave was that not much has happened, but that there are still a few months to go and they will catch up. This seems Tgrossly unlikely. '

He calls prison healthcare a 'real buck-passing culture'. It is nearly two years since the government accepted the recommendation for prison healthcare to become the joint 'partnership' responsibility of the prison service and the NHS.

The prison healthcare taskforce and the prison health policy unit were set up in late 1999 to help support and lead the reforms from the centre, and their job includes reporting back to ministers on progress with the plans.

Director of public health for Camden and Islington HA Dr Maggie Barker believes the taskforce can help by 'taking some of the burden' off the prison health plans. 'HAs do not always have the right skills to do work in prisons. I can fully understand why they might find it easier not to get on with it, ' she says.

Her HA completed one of the 12 early pilot needs assessments covering 23 establishments, including all the London prisons - thanks to 'really useful direct hands-on help' from the taskforce. 'We were being dragged kicking and screaming through the process. ' It may be much harder for the taskforce to spread itself around the remaining prisons and HAs.

There is a fear among some HAs, particularly those with many prisons on their patch, of drawing up added responsibilities without extra cash. 'There is a reluctance to dabble without extra resources, ' says Dr Barker.

Prison healthcare is not being highlighted as a priority by the Department of Health, she adds.

'It is a failure of the NHS to flag this up at a time when we are tripping over priorities - and prisons are remarkable for their absence from the list. '

Another NHS manager says lack of communication from the centre on crucial issues, such as the residence rules governing which HA pays for prisoners' secondary care, could be alienating health service staff.

Dr Hannah Patrick is public health consultant for Bexley and Greenwich HA and leads clinical governance at Belmarsh prison.

She says: 'What is so isolating is that the HA is not on board. There are no directives coming through to it. '

Her perception is that HAs started the needs assessments on the basis that more cash was going to become available, but that only 'some money' was getting through. 'There is enough for the HA to do, but It is not jumping. It needs to be supported. '

In her view, 'abysmal' health information systems in the prison service mean it is impossible even to work out how many prisoners have been prescribed a particular drug.

Dr Tom Marshall of the department of public health and epidemiology at Birmingham University was one of the team responsible for putting together a needs assessment tool-kit. He believes the 'long-term view' is that prison healthcare should be the responsibility of the health service.

But problems would remain, he says. Complete health service control of the money 'sounds great in theory', but 'you can't ringfence staff '. Many prison health workers are employed by the prison service, and security will always take precedence over healthcare.

He says that the perception of prison healthcare in the NHS tends to be, 'boy, I do not want this, because it seems like a lot of trouble'.

In Dr Marshall's view, complete NHS ownership might only work if something along the lines of a special HA was set up, holding a central pool of cash that did not impinge on any individual HAs.

But he admits it 'might be quite difficult to organise'.

Apart from a mention of better mental health services, prison healthcare was conspicuous by its absence from the NHS plan.

But Trent regional office lead on prison healthcare Ray McGowan points out that the 'deprived' prison population contains the 'very people' the NHS plan is trying to help outside the prison.

'It is ironic that the people We have got in prison as a captive audience are the very ones we do not get into contact with in the community, ' he says. 'It will take each HA working with prisons to make sure all benefit in the round. '