Many PCTs struggle to provide for the specialist needs of prisoners. But a different way ahead is emerging. Alison Moore reports

Many PCTs struggle to provide for the specialist needs of prisoners. But a different way ahead is emerging. Alison Moore reports

For many prisoners, difficulty in accessing healthcare and having control over their own health is an additional punishment.

Secure Healthcare, a social enterprise organisation, hopes to change that. On 1 June it took on the contract to provide healthcare in Wandsworth prison, where it sees itself as working in partnership with prisoners and 'putting the prisoner at the heart of healthcare'.

Chief executive Peter Mason has a simple philosophy: 'All prisoners should get the best quality care - no exceptions, no excuses. We have to be seen as advocates for prison healthcare. People are in prison for a reason but that does not mean they should not have good healthcare.'

The south London prison was ripe for change. Wandsworth primary care trust, responsible for commissioning at the prison, says it was looking for more integrated and higher-quality services to replace the present provision a combination of PCT and prison employees, with input from local NHS trusts and independent providers.

Prison governor Ian Mulholland says the delivery of health services has improved since the PCT took over commissioning in 2005, but a vision for further improvement was needed. While other areas of the prison have made strides in dealing with prisoners with care and respect, healthcare has lagged behind.

Prison inmates and staff ill be able to sit on the organisation's board. This engagement process has already started with discussions on prison wings and is progressing to healthcare.

It is a big cultural shift for staff as much as prisoners. Mr Mason is particularly keen that healthcare staff are not co-opted into a discipline role in prisons, while acknowledging that there are issues of control as well as care.

He aims to 'normalise' healthcare for prisoners while making it more accessible. Part of this will involve developing better facilities at the prison, such as improved diagnostics and telemedicine links. This will reduce the need for prisoners to be taken to hospital under escort and frequently handcuffed, which many find humiliating.

Existing staff

Care will be nurse led but with strong GP input and the support of NHS specialists.

Partners in the venture include a local practice, South West London and St George's Mental Health trust and sexual health services. 'We are the lead organisation, with total responsibility for healthcare in the prison. We're subcontracting other organisations to provide the healthcare services we cannot,' says Mr Mason.

He is keen to use the skills of the existing healthcare staff - who will transfer under transfer of undertakings (TUPE) arrangements and retain NHS pension rights. He points out they have great expertise and experience in dealing with these patients. But he also has a word of caution for newcomers to the field: 'I don't think healthcare people on the outside realise the day-to-day dilemmas met by prison healthcare staff,' he says.

Secure Healthcare can offer staff opportunities for 'upskilling' - he sees a bigger role for nurses trained as nurse practitioners, for example, and staff will need to acquire the skills to use telemedical equipment.

But the vision Secure Healthcare espouses is about more than just prison healthcare: it could be extended to cover prisoners in the difficult first weeks after release.

This is when they are vulnerable to a swift descent back into drug or alcohol abuse, or failure to complete courses of medication or control chronic conditions. 'When you come out the drug dealers are waiting, they know where the hostels are and that's where you are,' says Bobby Cummines, chief executive of .ex-offenders' organisation Unlock, which is supporting the new venture. 'It's a bad business but with proper healthcare you can be halfway there.'

The newly released prisoner can find it hard to access appropriate care - especially if preoccupied with finding a job or somewhere to live. 'They are not people who find accessing mainstream services easy,' says Unlock chair and .former North East London strategic health authority chief executive Julie Dent.

Secure Healthcare plans to support prisoners through this difficult time, helping them find a GP and sorting out appointments. Mr Mason has already had discussions with people at the Big Issue about the needs of some of its vendors who live on the streets after coming out of prison.

'If you can connect prisoners with healthcare you can get them to start taking responsibility for their own lives÷ that could be a useful tool in reducing offending.'

Expert help

Mr Mason is interested in models such as expert patients, which could also be applied inside prisons.

'Healthcare workers can provide a different role for offenders than prison officers,' says Ms Dent. She believes letting offenders take more control over their own care could trigger other changes and ultimately contribute to their rehabilitation.

And in the long run fewer repeat offenders would benefit the public purse.

Mr Mason foresees plenty of challenges. First, there is the danger that both Wandsworth PCT and the prison system see the new organisation as a foreign body. 'We want to be part of the NHS family and part of the prison,' he says.

He is frank about the day-to-day niggles which need sorting out and the fact that the dual roles of care and control need reconciling. He is expecting plenty of negotiations as these issues are encountered.

Mr Cummines says prisoners have traditionally been mistrustful of the prison healthcare system and have seen it as another form of discipline, where they are viewed as problematic or malingerers. These attitudes among prisoners will need to be overcome, but expectations will also need to be kept realistic. Mr Mason is hoping for some 'early wins' to consolidate support and trust.

Meanwhile Mr Mulholland points out that existing healthcare staff are feeling apprehensive, but they are willing to be won over.

Secure Healthcare hopes it will fill a gap, ultimately winning contracts to provide prison healthcare across the country. 'We want to talk to other PCTs who are, bluntly, trying to get out of providing prison healthcare,' says Ms Dent.

This chimes with the thrust of government policy, with PCTs concentrating on good commissioning rather than provision; prison healthcare is often a marginal service for them.

Mr Mason argues organisations such as Secure Healthcare should be 'an irritant' as well, pointing out when people are placed in prison inappropriately. 'We have prisoners who should be in mental health facilities or could be more appropriately treated for substance abuse in the community.'