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Nurses at Ashworth Special Hospital are not trained to work with patients with forensic personality disorders, according to evidence which the hospital submitted to the police enquiry into activities at the hospital. Nurses are frightened of the patients and unable to be assertive with them. The issue raises questions about whether a treatment regime is the best option for these patients. Expert opinion is divided on whether or not personality disorders are treatable, but the work of two therapeutic communities indicates that therapy can be successful.

There is a recognised need for the provision of mental health services to prisoners, but despite official recommendations there has been little progress towards providing services comparable to those available in the community. Forensic nurses, currently used in medium secure units, have the skills and expertise to provide high quality mental care in the prison service and could work with prisoners to ensure that their mental health needs are recognised.

There have been radical changes in the approach to nursing in the UK's three high-security hospitals since 1990 as a result of changes introduced by the Special Hospitals Service Authority (SHSA). Previously, the public and even nurses tended to view special hospitals as essentially a sort of prison. Now however, the approach is based more on offering therapeutic care within a secure environment. For example, the three hospitals now offer 24-hour care, instead of patients being locked in wards or rooms between 9pm and 7am, and try to avoid secluding potentially violent patients if at all possible.

The record-breaking overcrowding of prisons has had a major impact on the prison healthcare services with the result that unnecessary delays occur in assessing and treating patients, with mental health and substance abuse problems.

The potential for practice development in prison health care services is described by providing two examples of ongoing developments undertaken as part of a program of research and development in mental health. Prison health care service has moved into mainstream health services, thereby creating an opportunity for innovative modes of delivering training and education and for highlighting practice development that is locally relevant, based on sound evidence and that meets patients' needs.

Lisa Holler, an A&E nurse in Guildford, took up a job of a custody suite nurse for Metropolitan Police to look after the detainees in Charing Cross, a central London station. Although a challenging job with the patients being suspected offenders, she finds that custody suite environment is actually safer than A&E.

The use of handcuffs on prisoners in hospital frequently creates public debate. Nurses have a duty to promote the interests of patients but prison officers also have a duty to ensure that prisoners do not escape. Rules concerning the use of restraints apply to prisoners according to their security risk category, but there are routes to overriding these rules for individual cases. These rules would benefit from review but, in the meantime, nurses must try to liaise with prison staff in a non-confrontational manner to effect any policy changes concerning individuals.

A nurse describes her personal experience of health care in UK prisons. Her Majesty's Inspectorate of Prisons states that prisoners should have the same level of health care as any member of society, but this does not occur in practice. Prisoners do not have recourse to any complaints procedure concerning their health care, and prison doctors have no audit or peer review. Prison officers frequently cancel the short periods of exercise in the fresh air, which, in any case, is limited to walking, the nutrition is poor, and the conditions are detrimental to mental health.

Prisoners at Wormwood Scrubs jail in London, England, receive a high standard of health care and immediate access to medical personnel if required, despite the low number of staff employed in comparison with conventional National Health Service operations. Around one-third of prisoners have a mental disorder but remain at the prison for long periods prior to transfer. Qualified nurses work in conjunction with prison officers who have undertaken health care training. The medical staff must use their intuition to identify potential suicide risks among new admissions.

People with diabetes who are sent to prison generally lose their ability to manage their own health care, while health care workers' care of diabetic prisoners may be influenced by security considerations. A survey of 26 prisons in England and Wales revealed considerable variations in the service provided to prisoners with diabetes. Some prisons are attempting to provide an adequate service but few have followed the recommended practice of setting up channels of referral to specialist diabetic care or buying in such care from the National Health Service.

The number of suicides in prisons in England and Wales has grown by 107% from 29 in 1985 to 60 in 1994, while the prison population has risen by only 14% during that period. Pressure group Prison Watch believes that a major factor behind the number of suicides is the poor level of health care offered to prisoners. Prison Watch coordinator Tim Taggett says that many health-care officers have had only basic first-aid training. Prison Watch is calling for a full-time doctor in all prisons, backed by fully trained nursing staff, and for the full-time doctor to be a psychiatrist.

A scheme at Blakenhurst prison Worcestershire aims to offer nursing care within the prison health centre. The prison is commercially run and is the second prison to be operated by the private sector under contract to the prison service. The 12 nurses and clinical manager are employed permanently by Worcester Royal Infirmary NHS Trust. Nursing care in prisons had been traditionally given by health care officers many of which held a discipline role meaning that they could be called on to help restore order, for instance, during a riot. New practices will be introduced which may offer bluprints for other ventures to follow.

Secure accommodation nursing is one of the most difficult types of nursing to undertake, as the people under medical treatment are being held against their will. UK nurse training bodies need to ensure mental health service nurses avoid falling into the trap of racism and sexism so often associated with nursing mental patients in secure accommodation units. Care should be provided on medical grounds, not on race or gender.

Saughton Prison, Edinburgh, has been piloting a drug withdrawal scheme which may now be implemented by other prisons. The scheme involves a 28-day programme during which time the drug user is given steadily reduced quantities of methadone or sedatives, along with counselling and education. A report on the initiative has revealed a successful reduction in drug use. Similar programmes have already been launched at Glenochil and Perth prisons.

Health and nursing experts say that prison hospital wings must be modernised in the face of alarming evidence of suicide rates in prison hospitals. A Howard League report says that in 1991 24% of all prison suicides occurred in hospital areas. According to some experts, the risk of suicide may be increased by concentrating vulnerable people in hospital wings. Experts want ward accommodation to be improved, and professionally qualified staff brought in to help spot potential suicides. This early detection is vital, and this can be helped by measures such as improving the prison reception process.

In April 1992 psychiatric nurse Derrick Walker introduced a support scheme at Ranby Prison, Nottingham, England for potential suicide victims. Fourteen inmates have been trained as care supporters for those at risk. Two supporters provide 24 hour care during a depressive's crisis period. The scheme has prevented three suicides since its inception. Responsibility has also improved the self-esteem of the supporters. However, some believe that mentally-ill criminals should not be imprisoned.

Health authority managers must offer in-patient care to mentally disordered offenders, according to the new Reed Committee report reviewing the services delivered to these offenders by local and health authorities. Employees and agencies must collaborate to overcome geographical, operational and professional boundaries. Capital funding for regional secure units (RSUs) will increase to 18 million pounds sterling in the coming financial year from 3 million pounds sterling. Many psychiatric nurses are unaware of the direct effects of the Committee's proposals, says Psychiatric Nurses' Association general secretary, Granville Daniels. Mentally disordered offenders may have to be cared for in inappropriate places by inadequately trained mental health specialists, he claims.