Housing some of the UK’s most infamous serial killers and gangsters, including the Yorkshire Ripper and the Krays, Broadmoor hospital has lodged a collection of criminals and law-breakers like no other.

The stories surrounding the high-security walls housing the red-brick fortress are colourful and horrendous. But it is tales like these, boosted by sensational news reports and public fears, that have built up dangerous misconceptions of hospitals behind bars.

Prison healthcare in the UK today has moved on from the picture of hospitals housing the most dangerous criminals and lunatics, bonding over drawings for their next felony.

Under the leadership of the National Health Service (NHS), clinics in prisons have developed to high-quality health centres where patients receive the same healthcare as every other member of the public.

Unlike treating every other member of the public, convicted felons require far closer scrutiny. Safety and security for both medical staff and other patients is naturally paramount, especially in the case of violent inmates.

Drug misuse is also rife and medication has to be carefully controlled. Perhaps most staggering is the ‘normality’ of dealing with mental disorders. Figures show almost two thirds of prisoners in the UK have been diagnosed with some form of mental illness, forcing doctors to treat it as the norm and often as an antecedent cause of behaviour.

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Quality healthcare in prisons

Around 85,000 people are currently in prison in England and Wales. Just like the general public, they are entitled to primary healthcare, provided by general practitioner (GP) surgeries, emergency departments and hospital outpatient clinics.

Since 2006, prison health services have been in the hands of NHS primary care trusts, employing a range of doctors, pharmacists, clinical managers, administrators and nurses working to keep prisoners healthy.

"Healthcare you receive in a prison should be as a minimum equivalent to healthcare you receive as a normal member of the public."

One of the main commitments of the Department of Health (DH) and the NHS is to ensure prison health services are ‘broadly equivalent in range and quality to the wider NHS.’ In 2008, the governmental body Offender Health (OH) issued a first set of voluntary prison health performance indicators. Under these rules, prisons collect evidence on the quality of healthcare to monitor and improve existing prison services. NHS West Midlands performance manager David Williams, who is responsible for the performance brief for prison health, explains: "Everything we’re trying to do is to get the provision of healthcare in prisons to be as good as the NHS care for people in the community. Healthcare you receive in a prison should be as a minimum equivalent to healthcare you receive as a normal member of the public."

"It’s the same as working with any other patient: it’s about getting them the right care that they need and to help them address their health requirements," he says.

"Obviously there are just a few more doors, gates and walls but in the end it’s all about getting the right care to the right people at the right place."

That offenders have generally poorer health than the population at large is strong evidence of health inequalities, unhealthy lifestyles and social exclusion.

With quality care in prisons, the NHS attempts to reverse these inequities. When the inmates first arrive in prison, they receive a primary health check, and throughout their stay medical staff provide them with basic treatment for light injuries and for long-term conditions such as asthma and diabetes, working the same way as drop-in centres.

"This isn’t a place where a prisoner would get an operation," explains Williams. "It is simple clinical treatment facilities. There are some centres with inpatient beds but the majority are healthcare centres that are like a member of the public would access for primary care."

Should one of the prisoners need to be hospitalised, they would be checking in as normal patients into one of the local hospitals – under supervision of at least two guards.

Healthcare in an ‘abnormal’ setting

David Williams emphasises the ‘normality’ of how doctors and nurses work in prisons, but also admits medical staff have to face a number of challenges. Offenders are more likely to have learning disabilities and often have problems with drugs and alcohol. Perhaps the biggest challenge however is dealing with mentally ill patients – a staggering 72% of male and 70% of female inmates. 

"The main pressure for medical staff and prison officers is dealing with prisoners who have mental health problems," also says Prison Officer Association (POA) vice chairman Tom Robson, who is responsible for security and custody, operations, as well as high security and health care in UK prisons. "Mental health issues are dealt with day in and day out on normal basis."

"We can’t give patients responsibility for their medication as drugs may have a value as a commodity in prisons."

Among other training programmes for new employees, mental health awareness training is an important part to ensure that medical staff achieve adequate knowledge of mental health issues among patients.

"You don’t just turn up at a prison on Monday and end up just being given a set of keys and wandering around and doing what you want," explains David Williams.

"The training programmes have been implemented to make sure that staff is aware, knows the right way of behaviour and understands what they can and cannot do."

Another major problem within prison healthcare settings is substance misuse.

"Obviously we can’t give patients responsibility for their medication as drugs may have a value as a commodity in prisons," says Williams.

As a result, one of the initiatives to improve the health of offenders features an integrated drug treatment system (IDTS), which includes measures such as supervised and limited medication, improved clinical management with greater use of maintenance presenting and intensive psychological support. 

The biggest concern: safety

According to Robson, the number one priority of prison services is to protect the public from dangerous people and keep the prison establishment safe for staff and other inmates. This also applies to healthcare centres in prisons, where medical staff are assisted by a number of medically untrained prison officers.

For healthcare professionals this approach can be hard to understand. "I found it difficult to get used to the fact that the main priority in prison healthcare is not so much patient care but security," wrote GP Olivia Bush, after a placement in a UK prison, in the Nucleus spring 2007 edition, a magazine published by the Christian Medical Fellowship.

"There is no doubt that the type of patient also poses significant problems to healthcare staff. Most are very needy, some are violent and others are malingering since they are frightened of going onto the main prison accommodation blocks."

Robson highlights the resulting safety gap between medical staff and prison officers: "People who come from the NHS to work inside prison establishments don’t understand the necessity for security to be the number one priority sometimes," he says. "They will have to have an amount of prison officers also working in there, to return to the security aspect of the job, to make sure that the prisoners are compliant, to make sure that the premises are secure and all of those types of issues."

David Williams understands the fact that the general public, the prisoners and the prison staff have to be kept safe. "But at the same time we have to try and give the best healthcare we possibly can give. There are times security may be more important than other aspects but I think the biggest challenge is to do the best for the people we can."

Prison doctor – a rewarding position

"I found it difficult to get used to the fact that the main priority in prison healthcare is not so much patient care but security."

Despite the challenges and the pressured environment, working in a prison environment would be one of the most rewarding experiences a medical professional can have, Williams claims.

"I suppose the general rule is that people aren’t very positive about prisoners and therefore healthcare isn’t seen necessarily as a rewarding career," he says.

"We’re able to support people who try to rehabilitate and to take an active part in society, having good health is one of those things that will impact on their ability to contribute to society or not."

And as prison and high-security hospitals overhaul their daunting public image, more and more healthcare professionals could be drawn to the challenge of providing healthcare for people living behind bars.