Prisoners suffer from poorer health than the rest of the population. It is also more difficult for them to access healthcare, further exacerbating this inequality. A British nurse reveals how crucial this issue is if we want to prevent the “double punishment” of prisoners.

During the 1990s, I worked as a nurse delivering frontline care in an old Victorian prison in the south of England and under the management and leadership of Her Majesty’s (HM) Prison Service. In this relatively short period of time I saw phenomenal changes in both policy and practice in prison healthcare.

In 1996, HM Inspectorate of Prisons for England and Wales published a discussion paper entitled "Patient or prisoner" (HMIP 1996a). A response to many previous poor inspection reports, it posed the question of whether people in prison who have health problems are prisoners or patients first, and how their health needs can be met.

This seminal discussion paper, which still generates much debate, led to the decision that prisoner healthcare was to be provided by the National Health Service (NHS). Many staff were uncertain about what this change would mean for them in reality. Some were very positive and had a desire to "belong’" to the wider health service "family", whilst others viewed the change with suspicion and trepidation. How would funding and contracts change for the delivery of services? Would some staff lose their jobs? What would this mean for the day-to-day running of the prison? How would the NHS and HM Prison Service work together in a new "partnership"? These were just some of the questions raised.

I had been working as a prison nurse for almost twelve years when this partnership was finally established in spring 2000. A Prison Health Policy Unit and a Prison Health Task Force were set up to lead it. There was a clear need to focus on nursing services within prisons, and a working party report in October 2000 made a total of 34 recommendations which aimed to strengthen the nursing contribution to prison healthcare.

Increasing prisoner population

At that time the prisoner population in England and Wales stood at 65000 and was increasing. I personally felt that people in prison should have the same right to access mainstream health services in the NHS as any other citizen. I was therefore excited about these monumental changes and the potential to professionalise the services we worked in. Like me, many nurses were fed up with a sense of "not belonging".

I was appointed to work in the Prison Health Task Force at the Department of Health in London. I had learnt a great deal and developed an extensive clinical knowledge over my twelve years as a nurse working with prisoners. From very early on, I had a strong sense that if you treat people well, with professionalism, dignity and respect, you will be able to build a good relationship with those you are caring for. This principle was no different in a prison than in any other place I had worked. Addressing a person in prison by his/her name and not by their prison number, for example, was one significant way of acknowledging our common humanity. Not everyone took the same view, however, and this kind of principle could make you unpopular, but it was important for me to retain my moral beliefs. One of the first things I learnt from working in a prison was that it was crucial to challenge historical attitudes and practices. And, in fact, a consistent approach did deliver rewards, as I soon noticed other staff adopting the same approach.

I also learnt that respect has to be gained from both the staff and the people you care for. At the time, the Prison Service was adjusting to an increasing recruitment of registered nurses, to a point where today all prisons have registered nurses delivering care. Building trusting relationships with staff was a priority, particularly with discipline staff who had worked in the prison a very long time without benefitting from professional development and who had little or no experience of working with nurses. We had seemingly different objectives of custody or care, and this was a new way of working for us all. Over the years, however, division and mistrust have slowly given way to partnership and collaboration. This has been an essential evolution.

I am still a registered nurse but my current role as professional lead for criminal justice and forensic nursing at the Royal College of Nursing (RCN) also involves supporting other nurses in prisons. In my work, I strive to ensure that all decisions that have an impact on nursing care and practice are carefully considered. For example, should nurses wear body cameras or carry cell door keys? Whose role is this and what are the moral and professional implications? Developing policy, providing clinical guidance, and promoting the best and safest practices across services are the main priorities in my work.

In the prison nursing profession, we all need to look very carefully at what is happening in our prisons today and what impact it is having on prisoners’ wellbeing and the health and safety of our workforce. There is no doubt that prison services look very different today in 2019 than they did in 1999 when "Patient or prisoner" was published. Two decades on we have seen a great deal of good work but also the emergence of some new and very real challenges. In 2019 we have a prisoner population of around 96000 in England and Wales, an increase of more than 30 000 people since 1999, and across the whole UK the figure is nearer 100 000. Although there has been some government investment it has been insufficient to meet this increasing population and its complex needs.

This increase in the prison population has been largely influenced by political drivers, best epitomised by such statements as "tough on crime, tough on the causes of crime". Government policy to deliver lengthier sentences for certain crimes did not, however, prove to be effective and is now changing again, with the consideration of shorter sentences. Within prisons we are seeing rising rates of suicide, drug use, self-harm, violence and poor mental health, with prison healthcare staff stretched to the limits. We are also seeing a significant increase in the older prison population, bringing with it all the longterm health conditions that are common in this group. On a recent visit to a prison I was overwhelmed to see a whole wing with disability aids, wheelchairs and walking frames outside the cells. This indicates a huge unmet need for social care services in prisons, which will be the next big challenge.

Violence and psychoactive drugs

Prison inspectors citing dangerous conditions and overwhelming work environments have gained increasing attention from the media and consequently from the Health and Social Care Committee, which set up the Prison Healthcare Inquiry in 2018. In my current role at the RCN, I hear many reports of assaults and attacks on nursing staff. This, in part, is being driven by overcrowding and staffing shortages (in both healthcare and discipline). This was never such an acute problem when I was practising in the 1990s. In submitting written evidence to the Health and Social Care Committee in 2018, the RCN called for: comprehensive workforce planning; strategic action to attract, recruit and retain nursing staff; safer working environments in the light of increasing violence against prison staff; ringfenced funding to improve the pay of all prison nurses; the establishment of a new staff council, particularly for those not employed by the NHS; and a review of HM Prison Service guidance on psychoactive substances.

The explosion in the use of psychoactive drugs in the UK is another issue posing challenges that, in this case, did not exist even five years ago. A new breed of powerful synthetic drugs are being sold under a variety of names and are poorly understood by users and the clinicians treating them. The commonly named "Spice", for example, is a new compound that changes batch by batch and generates a wide variety of effects on the user. These substances are increasingly being used in the wider community but are also making their way into our prisons by various means, including visitors, drones and prisoners themselves, who see the huge potential for profit. Recent reports even cite evidence that some people are exploiting prison officer recruitment pathways to get into prisons for the purpose of selling drugs.

Most worrying is the rise in the number of prison deaths linked to these new psychoactive substances; the Prisons and Probation Ombudsman reported 79 deaths between June 2013 and September 2016. This is having a devastating impact on the government’s ambition to transform prisons into places of rehabilitation. Past cuts to prison officer numbers has been cited as one of the reasons for these developments. In recent times, the government has announced the recruitment of more officers, but many are merely replacing more experienced officers who have left the service.

All of these problems are having a direct impact on the nursing workforce in prisons. Our ability to retain excellent staff is being compromised in an already over-stretched NHS, while negative media coverage of riots and assaults in prisons is affecting their morale. These issues were raised and debated at the RCN Congress in May 2018 and as a result we are now seeing professional unions not only highlighting their own concerns but also working together in a bid to help find common solutions and influence government policy. I have had the opportunity to visit other prisons in Europe and further afield where many of the issues we face in the UK are also causing concern. We can certainly learn from each other and it has been good to see much greater international collaboration and sharing of ideas and solutions.

The road ahead for prison nursing is as challenging now as it has always been; indeed, more so. Yet despite these complexities, we have some of the most creative, dedicated and committed nursing staff working on the "frontline", delivering compassionate, quality care. One thing is certain: we cannot afford to lose such a valuable workforce. People in prison come from vulnerable communities and commonly have to endure poverty and poor health, education and life chances. It is important to realise that they need care, treatment and professional nursing support to improve their health and wellbeing in prison but also in preparation for their lives beyond, after they are released•.

Special report - Working behind bars

Table of contents

My experiences as a prison nurse