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Beyond equivalence: prisoners' right to health

  • Tim Exworthy (a1) (a2), Simon Wilson (a1) (a2) and Andrew Forrester (a2) (a3)
Summary

Prisons have high levels of psychiatric morbidity and function as mental illness recognition centres. Their healthcare wings are not hospitals and timely transfers to hospital are often unavailable. The United Nations' right to the highest attainable standard of health is assessed according to whether healthcare services are available, accessible, acceptable and of good quality (AAAQ). It is proposed that the AAAQ framework goes beyond the principle of equivalence of care and provides a more sophisticated measure for exploring prison healthcare.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Tim Exworthy (tim.exworthy@kcl.ac.uk)
Footnotes
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Declaration of interest

None.

Footnotes
References
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1 Lord Bradley. The Bradley Report. Lord Bradley's Review of People with Mental Health Problems or Learning Disabilities in the Criminal Justice System. Department of Health, 2009.
2 HM Prison Service, NHS Executive. The Future Organisation of Prison Health Care. Report by the Joint Prison Service and National Health Service Executive Working Group. Department of Health, 1999.
3 Wilson, S. The principle of equivalence and the future of mental health care in prisons. Br J Psychiatry 2004; 184: 57.
4 Fazel, S, Danesh, J. Serious mental disorder in 23,000 prisoners: a systematic review of 62 surveys. Lancet 2002; 359: 545–50.
5 Wilson, S, Forrester, A. Too little, too late? The treatment of mentally incapacitated prisoners. J Forens Psychiatry 2002; 13: 18.
6 Wilson, S, Dhar, R. Consent to treatment, the Mental Health Act, and the Mental Capacity Act. In Psychiatry in Prisons: A Comprehensive Handbook (eds Wilson, S, Cumming, I): 144–54. Jessica Kingsley Publishers,, 2009.
7 Forrester, A, Chiu, K, Dove, S, Parrott, J. Prison health-care wings: psychiatry's forgotten frontier? Crim Behaviour Ment Health 2010; 20: 5161.
8 Forrester, A, Henderson, C, Wilson, S, Cumming, I, Spyrou, M, Parrott, J. A suitable waiting room? Hospital transfer outcomes and delays from two London prisons. Psychiatr Bull 2009; 33: 409–12.
9 United Nations. International Covenant on Economic, Social and Cultural Rights (ICESCR), Article 12. United Nations, 1976 (http://www2.ohchr.org/english/law/pdf/cescr.pdf).
10 United Nations Committee on Economic, Social and Cultural Rights. The Right to the Highest Attainable Standard of Health: 2000-08-11. E/C.12/2000/4 (General Comments). Office of the United Nations High Commissioner for Human Rights, Geneva, Switzerland, 2000 (http://www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C.12.2000.4.En).
11 Her Majesty's Inspectorate of Prisons. Expectations: Criteria for Assessing the Conditions in Prisons and the Treatment of Prisoners. HMIP, 2009 (http://www.justice.gov.uk/inspectorates/hmi-prisons/docs/expectations_2009.pdf).
12 Brooker, C, Duggan, S, Fox, C, Mills, A, Parsonage, M. Short Changed: Spending On Prison Mental Health Care. Sainsbury Centre for Mental Health, 2008.
13 Riviere v. France (2006) European Court of Human Rights application number 33834/03. Judgment 11 July 2006.
14 Aerts v. Belgium (2000) 29 EHRR 50. European Court of Human Rights, application number 25357/94. Judgment 30 July 1998.
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BJPsych Bulletin
  • ISSN: 1758-3209
  • EISSN: 1758-3217
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Beyond equivalence: prisoners' right to health

  • Tim Exworthy (a1) (a2), Simon Wilson (a1) (a2) and Andrew Forrester (a2) (a3)
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eLetters

Health Status of Prisoners is the Real Challenge

Annie Bartlett, Reader in Forensic Psychiatry
03 August 2011

Exworthy et al (1) are to be commended for their attempt to go beyond the existing interpretation of the doctrine of equivalence of health service delivery in prison healthcare. This has driven improvements in prison healthcare for the past 10 years. However, they fail to identify the next challenge, that of achieving equal health status for prisoners and non-prisoners; this should be the doctrine that informs the strategy for service delivery for the next 10 years. Given the exceptionally high rates of mental and physical ill health in the prison population, not entirely explicable in terms of their sociodemographic profile, this will demand significantly greater investment than is currently the case. Per capita prison healthcare cost �2769 in 2007-2008, of which only �316 was for mental healthcare (2). However, the advent of outcome-based payments for healthcare and for the management of offenders (3) allows for the relationship between health gain and criminological outcomes to be explored more rigorously. The authors cite the UN International Covenant on Economic, Social and Cultural Rights as a guide to future prison health monitoring. This contains nothing to which anyone may object, but it is not specific to this very challenging area of healthcare. Exworthy et al largely neglect the advances in thinking by both the Department of Health (4) and Her Majesty's Inspectorate of Prisons (5), which have led to much improved, relevant markers of activity, performance and outcome in routine review of contract delivery by prison health providers, as well as the role of the Care Quality Commission in assessing prison healthcare. In truth , they look out of step with commissioners and providers of healthcare who are already engaged in the detailed determination of local standards based on a grasp of local needs, for example those of young offenders, older prisoner, women. Exworthy et al, as might seem reasonable, a focus on mental health and the important issue of prison transfers. Such problems are relatively rare, though they need quicker resolution than is currently the case. However, they say nothing about primary care, including primary mental healthcare, which is poorly modelled. Nor do they comment on the treatment of drug and alcohol problems, difficulties that compound the management of serious mental illness but where there have been huge improvements in the past 10 years. Most of the prison health budget is devoted to these two areas. Prisoners have often had poor access to primary care and are highly likely to have drug and alcohol problems. The de facto 'polyclinic' nature of the prison environment is different from the external community, but this may be an advantage rather than a disadvantage for rapid healthcare delivery. Within a short period of time a prisoner can have a health check and be stable enough to reflect and plan for the future. For this to work, practitioners, including senior psychiatrists, will be required to operate in an integrated and multifaceted system of holistic care delivery where acute mental illness, for all its headline grabbing potential, is not the main issue.Declaration of interest AB and FA are joint clinical directors in offender care, Central and North West London NHS Foundation Trust, and work clinically and have clinical director responsibility for a range of health services delivered to three London prisons.References 1. Exworthy T, Wilson S, Forrester A. Beyond equivalence: prisoners' right to health. Psychiatrist 2011; 35: 201�2. 2. Brooker C, Duggan S, Fox C, Mills A, Parsonage M. Short-Changed: Spending on Prison Mental Healthcare. Sainsbury Centre for Mental Health, 2008. 3. Ministry of Justice. Breaking the Cycle: Effective Punishment, Rehabilitation and Sentencing of Offenders. TSO (The Stationery Office), 2010. 4. Department of Health, National Offender Management Service, Her Majesty�s Prison Service. Guidance Notes: Prison Health Performance and Quality Indicators. Department of Health, 2008. 5. Her Majesty's Inspectorate of Prisons. Expectations: Criteria for Assessing the Conditions in Prison and the Treatment of Prisoners. HMIP, 2008. Annie Bartlett, Reader in forensic psychiatry, St George's, University of London.Farrukh Alam, Consultant Psychiatrist, Central and North West London NHS Foundation Trust. ... More

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