Prisons in crisis
Overcrowding and increasing violence in prisons means nurses are putting their own safety at risk to deliver healthcare.
Overcrowding and increasing violence in prisons means nurses are putting their own safety at risk to deliver healthcare
Prisons are overcrowded and understaffed, leading to nurses being subjected to increasing danger, the RCN says. There have been reports of nurses being held hostage, and a nurse manager was blinded in one eye last year after being punched by an inmate at a young offenders’ institution in Kent.
Recent violent unrest at prisons in Hertfordshire and Wiltshire led to prisoners and staff needing hospital treatment. In early August the RCN criticised prison safety and said that healthcare services are at ‘risk of collapse’ in a statement that adds to mounting evidence of a justice system in crisis.
The RCN says the number of nurses working in prisons is plummeting, partly due to the increasing danger that nurses find themselves in. RCN professional lead for criminal justice and learning disabilities Ann Norman said prisons have become ‘dangerous, overcrowded warehouses', and nursing staff are no longer willing to put their safety at risk.
The growing threat of violence has led to some nurses being provided with body cameras – a development that could make it hard for nurses to follow the requirements of confidentiality, respect and dignity set out in the Nursing and Midwifery Council’s code of conduct.
‘Nurses need some clear guidance in this contentious area,’ says Ms Norman. ‘We advise nurses not to wear cameras during clinical consultations and treatment. We would prefer cameras to be an area dealt with by prison officers, but cuts to their numbers and growing numbers of assaults mean their use has spread to nurses. We are discussing guidance with the prison service, the National Offender Management Service, and NHS England.’
Statistics from the Prison Reform Trust underline the picture of prisons as overcrowded, understaffed and increasingly dangerous places for staff and prisoners. Rates of suicide have reached near record levels, with 113 deaths last year.
There has been an 88% rise in assaults on prison staff in the past two years, with almost 7,000 incidents recoded. Self-harm is at a record level and sexual assaults have tripled since 2012.
Prison Governors Association president Andrea Albutt wrote to members in early August about the ‘current crisis’, describing a service in ‘complete decline’. Ms Albutt wrote that 40 prisons are causing concern, of which ten are causing serious concern.
‘This toxic mix does not have a quick fix and the future looks like more of the same’
Andrea Albutt, president, Prison Governors Association
She claimed that outbreaks of unrest have caused significant damage to accommodation, with the result that prisoners are being moved across the country 'de-stabilising the receiving prisons as they try to maintain order amongst disaffected displaced men. This toxic mix does not have a quick fix and the future looks like more of the same’.
Both the RCN and the Prison Governors Association have criticised the decision to separate the operational management of prisons from policy decisions, with Ann Norman calling the reforms 'catastrophic for both prisoners and staff'.
Ms Norman says there are many excellent nurses doing their best in challenging circumstances, and she tries to support as many of these as she can. ‘We need radical rethinking,’ she says. ‘We need more prison officers and more healthcare staff to go with an increasing prisoner population.’
A Ministry of Justice spokesperson said violence against staff 'will not be tolerated' and offenders who attack staff 'should feel the full force of the law'. The spokesperson pointed to plans to increase the number of prison officers by 2,500, as well as 'unprecedented action to stop the supply and use of drugs, which undermines security', including a new drug testing programme and the introduction of a specialist team to prevent drones bringing contraband in to prisons. The government is also investing in specialist mental health training for prison officers to reduce levels of self-harm and suicide in prisons.
The current difficulties follow more than two decades of overcrowding, according to the Prison Reform Trust. At the end of May this year 76 of the 117 prisons in England and Wales were overcrowded and holding almost 9,500 people more than intended. Almost 21,000 people were held in overcrowded accommodation in 2015-16, the majority doubling up in cells intended for one.
Overcrowding affects whether activities, staff and other resources are available to reduce risk of re-offending, as well as distance from families and other support networks, the trust says.
Peter Dawson, director of the trust, says inmates can struggle to access healthcare in overcrowded sites. ‘Prisoners are not spending much time out of their cells, and when they are out they’re not feeling safe. Both of these things are very distressing. Healthcare can’t be delivered through a closed door and it can’t be delivered if prisoners don’t feel confident moving about.’
‘Synthetic substances are an unknown quantity, and caring for someone under their influence is far more challenging’
Amanda Phillips, lead nurse, Isle of Man Prison
Nurses working in prisons say the demand for health services is growing. There is a greater proportion of older patients, and natural deaths are on the increase. The prison population has increased by more than 80% over the last three years and now stands at almost 85,000.
Isle of Man Prison lead nurse Amanda Phillips says her organisation does not struggle with the staffing and overcrowding issues of the UK, and assaults on staff are rare. But the prison is caring for a growing number of patients with serious mental health problems, such as personality disorders, which can be difficult to manage, and growing numbers of patients taking new psychoactive drugs such as Spice.
‘Synthetic substances are an unknown quantity, and caring for someone under their influence is far more challenging as we can’t predict how they will react physically or psychologically,’ Ms Phillips says.
‘There appears to be a very fine line between the user experiencing a relatively harmless high or becoming so deeply unconscious that airway support or resuscitation is necessary. The fact that the chemical composition of these drugs is constantly changing makes patients more susceptible to adverse effects and creates major problems for the prison healthcare staff caring for them.’
Nurses and other staff are often prevented from providing planned care because there is insufficient staff to let the prisoners out when they arrive. This is an issue frequently reported to Phil Garnham, nurse consultant for the forensic and prisoners directorate at Oxleas NHS Foundation Trust, which runs mental and physical health services in a number of prisons in Kent.
‘When nurses are planning therapeutic activities often, through no fault of the prison, there are not enough staff to unlock doors and take prisoners to the group,’ he says.
Despite the challenges of the environment and difficulties with recruitment and retention, there are many dedicated healthcare staff carrying out vital work, says Mr Garnham, who is a member of the RCN nursing in justice and forensic health care forum.
He says there are some good projects going on such as the programme at Swaleside prison on the Isle of Sheppey in Kent, in which prisoners have trained to act as mental health mentors to their peers. ‘This is the result of prison and healthcare staff working closely together to identify the mental health needs of their prisoners,’ he says.
‘This close working relationship has also resulted in educational and development opportunities for prison officers. I often see nurses using their resilience and skills to develop constructive relationships with prisoners and staff to enable doors to open.’
Prison crisis in figures
- 88% rise in assaults on staff
- 113 suicides last year
- 21,000 prisoners held in overcrowded accommodation
- 40,000 incidents of self-harm in 2016
- Prison population has risen 82% in the past 30 years
- England and Wales have the highest imprisonment rate in western Europe
Source: Prison Reform Trust
Erin Dean is a freelance health writer