And so to Bedlam

Observations on prisoners

It is official policy that medical care in prison should be no different from that in the NHS, which represents for the official mind some kind of gold standard. In fact, the NHS routinely lets prisoners down, and has been doing so for many years.

Prisoners with severe psychiatric conditions - usually paranoid schizophrenia - languish for weeks and often months in prison, prey to their hallucinations and delusions, because no NHS bed can be found, and the law does not allow doctors to treat them against their will inside prison. The result is predictable: a return to 18th-century Bedlam.

Psychotic prisoners flood their cells; smash furniture; assault staff and other inmates; bang their doors incessantly and shout at their unseen tormentors, sometimes all night, to the despair of other prisoners, who will then attack them if they get the chance; they deck themselves out in strange garb and put toothpaste in their hair; they render squalid a succession of clean rooms in no time at all; they cut their wrists; they stop eating and drinking. Doctors and prison staff watch them do this, until the prisoners deteriorate to the point at which their lives are endangered. Only then may doctors medicate them under the common-law doctrine of necessity.

It is not prison that has driven them mad: most are mad on arrival and their offences are the consequence of their madness.

Magistrates dealing with such cases are often aware that those they remand into custody are mad, but such is the chronic shortage of psychiatric beds, since the closure of psychiatric hospitals, that prison is the only place to send them. In modern Britain, to adapt very slightly Robert Frost's dictum about home, prison is the place where, when you have nowhere else to go, they have to take you in.

Sometimes (I speak from experience) there is not a single psychiatric bed to be had, however urgent the case. Prisoners come bottom of the list for admission, being by definition difficult or dangerous; and in any case, safely ensconced in prison, they are deemed to be looked after.

Recently, I had a patient who was quite clearly psychotic. He came into prison because of a mad assault. He had stopped eating and drinking because he thought that everything was poisoned. He became seriously dehydrated and I sent him out of the prison to hospital, where he was discovered to have a serious medical condition. Because he was mad, he refused treatment, believing the proposed treatment to be part of the plot against him.

You would think that, in these circumstances, a bed in a psychiatric hospital would be found, but you would be wrong. No such bed could be found and we shall have to treat him against his will (and risk being sued for assault) or passively wait until there are signs his life is in danger.

No matter how many times crises such as these arise, no one ever concludes that there is serious undercapacity in the system or admits that past policies were wrong, indeed plain stupid. And in public administration, stupidity swiftly translates into outright cruelty.