In the latter part of the twentieth century, the health of prisoners posed major problems for the prison authorities, and was a subject to which prison reform campaigners repeatedly returned. This was partly related to the substantial overcrowding in the prison estate, with some establishments holding twice their optimum capacity in dilapidated Victorian buildings with antediluvian sanitary arrangements. The mental health of inmates was also a serious concern, as it had been since the modern prison system came into being in the 1840s. Medical writing from the 1970s and 1980s reveals that many prison medical officers struggled to deliver appropriate treatment to prisoners with various forms of mental disorder, and it was widely acknowledged that prison was not the most appropriate place for mentally-ill inmates to receive medical treatment. However, the prison authorities often had great difficulty in finding places for prisoners in psychiatric hospitals. This was partly attributed to post-war changes in the treatment of mental illness in general. From the 1960s onwards, a process of deinstitutionalisation took place, prompted both by concerns over the quality of treatment received in psychiatric hospitals, and by the increasing costs of health service provision. By the 1980s, many psychiatric hospitals had closed, as a greater emphasis was placed on care in the community.1 As noted by Richard Smith, an assistant editor of the BMJ who made a study of prison medicine in 1983/84, this meant that there were fewer beds available for prisoners who needed to be transferred. It was also suggested that hospitals were unwilling to accommodate patients transferred from prisons, either because they could be difficult or disruptive or, that there was little prospect of recovery.2 In 1977, RAH Washbrook, a doctor at HM Prison Winson Green, wrote that ‘at any one time about 15 men in Birmingham prison were there because they were not wanted by the psychiatric services’. Instead they remained in an unsuitable environment, cared for by staff ill-equipped to treat mental illness.3
While most doctors agreed that mentally-ill people should not be in prison at all, there were some dissenting voices. Peter Scott, a psychiatrist at the Maudsley Hospital and HM Prison Brixton, argued that it would never be possible to make a satisfactory distinction between all those prisoners who were ill and those who were not. Some who were ‘mentally abnormal’ would always remain in prison. Thus, there ought to be more suitable facilities for them there.4 Other prison doctors agreed that prison was an appropriate location for psychiatric treatment. Dr Mary Ellis, editor of the Prison Medical Journal, suggested in 1979 that, ‘it would be no bad thing if all those who committed offences should be seen to go through due process and like Dr Peter Scott I believe that they should be cared for with their neurosis or their mental illness in prison if that is the tariff for the offence that they committed’. Responding to criticisms of prison medicine by the Royal College of Psychiatrists, Ellis argued that doctors working in prisons possessed specialist expertise when dealing with prisoners whose behaviour posed particular challenges.5
During the 1970s and ’80s, the treatment received by mentally-ill prison inmates was a specific source of controversy. This was related to wider concerns about the impartiality of prison doctors, and whether they served the interests of their patients or those of the prison authorities. Their status as employees of the Prison Service, rather than the National Health Service, caused them to be seen as part of the prison’s management structure, whose actions aimed to reinforce prison order. Specifically, it was suggested that psychotropic drugs were being prescribed to inmates, not to alleviate their conditions and aid their recovery, but in order to control their behaviour, to facilitate the smoother running of the prison, and maintain discipline. Tony Whitehead, a psychiatrist who took a keen interest in prison conditions, wrote that while ‘prison medical officers have, over the years, done more for prisoners’ welfare than many would believe, or wish to believe’, the boundary between using drugs for legitimate treatment and unethical control could be blurred in the prison setting. Consent to treatment was particularly problematic inside prisons, due to the pressure brought to bear on prisoners to conform to the disciplinary system. Inmates might fear that refusing medication would mark them out as recalcitrant, thus making their choice illusory.6
Other commentators argued that the sensational coverage accorded to this issue in some quarters, including the medical press, was counter-productive. Stephen Shaw, director of the Prison Reform Trust, wrote in 1989 that ‘sensationalism’ contributed towards a ‘laager mentality’ among prison staff, which was not conducive to the improvement of prisoners’ welfare.7 In his 1984 examination of prison medicine, Richard Smith wrote, ‘My impression is that underprescribing may be as much a problem as overprescribing, and that prison doctors are often under great pressure to prescribe but usually resist.’ He likened the prescribing decisions made by prison doctors to those made by general practitioners in the health service.8
Concern about the welfare of prisoners continues, with a number of studies suggesting that inmates’ mental health needs are still unmet. The treatment of suicidal prisoners was identified as one such area. At a 1992 Physicians for Human Rights (UK) conference, it was noted that prisoners who appeared depressed were often secluded in the prison hospital. This was identified as a ‘destructive’ practice, and counter-productive.9 In the early 2000s, the Prison Reform Trust’s ‘Troubled Inside’ project, which examined the mental health needs of incarcerated men, women and children, demonstrated that there were still serious problems in relation to prisoners’ mental wellbeing and their access to treatment services was yet to be resolved.
1 Vicky Long, ‘Rethinking Post-war Mental Health Care: Industrial Therapy and the Chronic Mental Patient in Britain’, Social History of Medicine, 26 (2013), 738-58.
2 Richard Smith, Prison Health Care (1984).
3 RAH Washbrook, ‘The Psychiatrically Ill Prisoner’, Lancet, 18 June 1977, 1302-3.
4 Smith, Prison Health Care, 55.
5 The National Archives, HO 263/30, Letter, Mary Ellis to Royal College of Psychiatrists, cc. May Committee and Director, Prison Medical Services, 16 May 1979.
6 Tony Whitehead, ‘The Use of Psychotropic Drugs in Prison’, in Prison Reform Trust, Prison Medicine (1985), 71-82.
7 Stephen Shaw, ‘Prison Medicine’, Lancet, 14 January 1989, 104. The term ‘laager mentality’ is derived from the South African Dutch term ‘laager’, meaning an encirclement of wagons, and refers to an entrenched, defensive attitude towards criticism.
8 Smith, Prison Health Care, 53.
9 Physicians for Human Rights, Medicine within Prison: The Report of the Conference which took place on Saturday 27th June 1992 at the London School of Hygiene and Tropical Medicine (1992).