Estimated reading time at 200 wpm: 15 minutes

A declared chimera — personal observation, clinical reflection, and structural critique. This piece makes no claim to objectivity. It is written by a single observer, through a lens shaped by decades of clinical practice. The question it raises is offered — not as a verdict – arrived at somewhere on a twenty-minute drive back to a hotel, at the end of a long and unsettling day. Not from theory. Not from grievance. From the accumulated weight of what had been witnessed. What follows is an attempt to examine that question honestly.

Has prison psychiatry become medical practice dressed in social care — with a dab of medication here and there, to keep the inmates calm?

I. The closed institution

The total institution

Erving Goffman in Asylums: Essays on the Social Situation of Mental Patients and Other Inmates (1991) described the total institution as a place that strips away individual identity and imposes a single overarching regime. He was not writing metaphor. He was writing about prisons.

The logic of the total institution is architectural as much as social. High walls, controlled movement, a single authority governing every dimension of daily life. The prisoner’s world is entirely contained within it. But so, in important ways, is the world of those who work there.

What Goffman understood — and what is rarely applied to the clinical environment inside prisons — is that total institutions do not merely contain people. They shape everyone within them. The norms of the institution gradually colonise the thinking of staff, not through coercion, but through immersion. What begins as compromise becomes habit. What begins as habit becomes standard.

This matters for clinical care in a way that has never been adequately confronted.

The accountability gap

The Care Quality Commission inspects healthcare provision in prisons. It arrives, examines documentation, and departs. It cannot monitor the culture between visits. The General Medical Council sets standards for doctors but has no inspectorate function of its own. It responds to complaints. In a closed institution, complaints from patients carry structural disadvantages — fear of disbelief, fear of reprisal, limited access to independent advocacy, and the basic power asymmetry of prisoner versus institution. No journalist roams the wing. No family member observes the consultation. The public eye does not penetrate those barbed-wire-decorated walls.

The result is a stable accountability gap. Not a conspiracy. Not deliberate concealment. Simply the natural consequence of placing a clinical service inside a closed institution and leaving the external scrutiny mechanisms incomplete.

How drift begins

In that gap, standards can drift — quietly, gradually, without anyone deciding they should.

II. What the standards require

GMC prescribing standards

Before turning to what has been observed in practice, it is worth being precise about what should be there.

The General Medical Council’s prescribing standards are not aspirational documents. They are the framework within which licensed medical practitioners in the United Kingdom are expected to operate. Paragraphs 97 to 109 set out what is required when initiating, continuing, or delegating prescribing decisions. They require documented assessment, evidence of capacity, and a record of consent. They are not optional in custodial settings.

Off-label prescribing and CR210

The Royal College of Psychiatrists’ CR210 — the guidance on the use of licensed medicines for unlicensed applications — exists because off-label prescribing is common in psychiatry and carries specific obligations. When a clinician prescribes an antipsychotic for sleep, or for emotional dysregulation, they are operating outside the licensed indication. That is not unlawful. But it requires explicit documentation of the clinical rationale, a record of the discussion with the patient, and evidence that capacity to consent was considered. The MHRA does not disappear at the prison gate.

The equivalence principle

The equivalence principle — the stated policy position that prisoners should receive healthcare equivalent in quality to that available in the community — has been NHS policy since 2003. It is not a vague aspiration. It is a commissioning standard.

Consent as a right

Consent to treatment with medication is not a bureaucratic formality. It is a legal and ethical requirement rooted in the Mental Capacity Act 2005, in common law, and in the foundational ethical principle of respect for autonomy. A patient in custody retains that right. The fact of imprisonment does not diminish it.

These standards are documentable, measurable, and publicly available. They are the baseline against which practice should be measured — not against what has quietly become locally normal.

III. What short placements revealed

A note on the observer

The risks in this section are worth naming at the outset. Memory is imperfect. Pattern recognition sharpened over decades can occasionally fire when the full pattern is not there. What follows is personal observation — specific and honest — offered without the claim that it constitutes proof of anything beyond what was directly witnessed over a brief period in corners of the prison estate.

That said, the observations did not emerge in isolation. A placement at a different establishment the previous year — also below Category A, also an NHS-commissioned mental health in-reach service — produced a broadly similar picture. The two settings were unconnected. The patterns that cohered across them were not sought. They simply recurred. That convergence does not constitute evidence in any formal sense. But it does make the observations harder to dismiss as the artefact of a single difficult placement.

The clinical record

With that declared: here is what a short placement in prison mental health in-reach produced.

Mental state examinations recorded at three to four lines. Risk assessments brief to the point of being nominal. These are not stylistic preferences — the mental state examination and the risk assessment are the core clinical documents of psychiatric practice. When they shrink to that extent, it is rarely because the patient is uncomplicated. It is usually because the thinking has compressed first, and the record is downstream of the consultation.

Prescribing practice

Prescribing not consistently adherent to GMC requirements. Antidepressants initiated for ‘low mood’ without documented assessment. Antipsychotics prescribed for sleep and emotional regulation — off-label use, not unlawful — but without documentation of capacity, consent, or clinical rationale. The frameworks that govern such decisions were largely absent from the records reviewed.

Consent to medication reduced, where it appeared at all, to a single phrase. ‘He agreed.’ No record of what was discussed. No record of what the patient understood. No record of capacity dialogue (required by the GMC).

The MDT in name only

A multidisciplinary team meeting covering 30 cases in a two hours in a stretch. That is not a multidisciplinary team in any clinically meaningful sense. It is a list review conducted at pace, in which the complexity of individual patients cannot be adequately held. But that sort of practice is something of a national norm. I’m the ‘odd person’ out to say anything about it. I’m therefore wrong. The attitudes – not the spoken word goes like this, “If you find somewhere better, go work there.“

The teamwork problem

And one further observation — less about standards, more about the nature of clinical teamwork itself.

A view appears to exist among some unqualified team members — at times reinforced by qualified colleagues — that those without clinical credentials need not concern themselves with patients’ diagnoses. This is treated, in some quarters, not as an oversight but as an accepted position.

Consider what that position actually means by way of analogy.

A Formula 1 car does not win races because its driver is talented in isolation. Consider what happens when an ERS Harvesting Mismatch is detected during a race — a fault in the way the Motor Generator Unit is recovering kinetic energy, serious enough to require a full Electronic Control Unit reboot during the pit stop. The engineers managing that reboot need precise technical mastery. The tyre crew do not. But they need to know that something significant is happening, roughly how long the car will be stationary, and that the clock is running differently from a normal stop. That contextual awareness — not deep technical knowledge, but sufficient shared understanding — is what allows the whole crew to function as a coordinated unit rather than a collection of specialists performing disconnected tasks.

If the tyre crew simply shrug and say ‘I don’t know, I’m not technical‘ — the pit stop fails. Not because they lacked expertise in energy recovery systems, but because they opted out of the shared awareness that teamwork requires.

In a high-functioning team everyone is unified – not just around the car. It’s about that but enabling the driver to be at his best and getting the best performance out of the car. If the driver says ‘I’m feeling a crazy vibration on the front end‘, the team listens and does something to investigate and fix. It’s not for the tyre crew to start arguing, ‘What are you talking about – we put on good tyres for you! You need to respect our work; you arrogant ungrateful sod!‘

Remove that graduated, role-appropriate knowledge from any member and the team does not merely become less efficient. It ceases to function as a team at all. It becomes a group of individuals working in proximity – along parallel lines with no clear focus.

A clinical mental team is no different in this respect. But teamwork is a massive topic that I’ve covered elsewhere.

When psychiatry became ‘mental health’

There is a cultural dimension to this that is rarely spoken aloud, perhaps because saying it plainly invites the charge of arrogance. But it is worth stating. In days of old we had ‘Departments of Psychiatry’ or similar words. In the last 20 years ‘Psychiatry’ as a word has been largely airbrushed out from service descriptions, and replaced by words such as mental health or psychological health or ‘well-being services’ etc. That’s like ‘Surgery’ being replaced by ‘Operational centre’ or something like that. Why? That’s a long story going back to around 1994 but I do not deviate here.

Psychiatry has, over recent decades, been progressively reframed — a shift driven by understandable impulses. Reducing stigma. Broadening access. Acknowledging that distress is not the exclusive territory of medicine. These are not ignoble aims. But the cumulative effect has been a flattening of clinical structure in settings where that structure exists for good reason. Diagnosis and its matched treatment — the medical core of what psychiatry is — have quietly slid down the list of priorities as the social and therapeutic dimensions of ‘mental health’ have expanded to fill the available space.

Raise the question of differential clinical knowledge in a mental health team and a certain kind of response is expected to follow — not always, but often enough to be recognisable. It rarely arrives as words. It arrives as a shift in the room. A cooling. A studied silence. A look that says, without requiring language: who do you think you are? This is a team. Everyone here has equal standing. That unspoken response deserves examination. Nobody in their right mind would direct such a response to a brain surgeon about to open a patient’s skull. Nobody tells the anaesthetist that the scrub nurse’s perspective on the procedure carries equal clinical weight. The hierarchy in the OR is not about status. It is about function, training, and the irreducible fact that some decisions require specific expertise that not everyone in the room possesses.

The HCA who feels no need to know a patient’s diagnosis is, in one sense, simply absorbing the ambient message of the culture they work within. That is a systemic failure — not a personal one. It is important to be clear on that point. HCAs are not the target of this argument. It is the culture that has made clinical disinterest feel acceptable. The truth is that a well-informed HCA or other non-qualified team member is one of the most valuable people in any mental health team. They are present on at ground zero for far longer than any psychiatrist, in far less formal circumstances, seeing the patient in moments that no clinical encounter captures. That observational vantage point is irreplaceable — but only if it is anchored in some basic shared clinical understanding.

With a working knowledge of a patient’s diagnosis and its core features, non-qualified staff can engage more purposefully, observe with orientation, and feed back in terms that carry clinical meaning. Take schizophrenia as an example. Any non-qualified member of the team who understands that delusions can drive behaviour — that behavioural activation may signal intensifying psychotic thinking — is in a position to notice things qualified staff may miss entirely. Whether a patient’s demeanour on the wing has shifted. Whether he is becoming more guarded, more agitated, more withdrawn. That observational thread, reliably reported, can sharpen the team’s focus on whether delusional thinking is translating into increased risk to the patient or to others.

That is not clinical assessment. It is informed observation. And in a closed institution where the psychiatrist’s contact with any one patient is brief and bounded, informed observation from someone closer to the ground is not a mere supplement to good clinical care. It is a vital part of its foundation.

A stable dysfunctional equilibrium

A team without shared clinical knowledge is not a team. It is a group. And groups, unlike teams, are not usually organised, coordinated, or directed toward any common goal. In a clinical setting, that distinction is not merely semantic.

None of this is offered as an indictment of individuals. Those observed were, in most cases, working hard within a system that has reached what can only be described as a stable dysfunctional equilibrium. Everyone is occupied. Nothing is visibly collapsing. The institutional pressure to change is therefore low.

That is precisely how drift becomes permanent. And it returns us, with some weight, to the question this piece began with.

IV. Interrogating the observer

The problem of the single witness

This piece would be easier to dismiss if its author did not share the same doubts as its sceptics.

The observations in Section III rest on a single pair of eyes over a limited period. There is no corroborating dataset, no independent audit, no peer-reviewed methodology. What is offered is the distillate of direct experience, filtered through memory — and memory, as any forensic psychologist will confirm, is neither neutral nor infallible. Repeated rehearsal of a narrative, even in private reflection, gradually smooths the rough edges of what actually happened. That risk has been present throughout the writing of this piece.

Thirty-five years and its double edge

Three and a half decades of clinical practice in forensic psychiatry is both an asset and a liability here. The asset is pattern recognition — the capacity to identify quickly what a functional clinical system looks like and to notice when something is missing. The liability is that the same experience can make an observer quicker to see patterns than the evidence strictly warrants. Familiarity with dysfunction does not guarantee that every apparent dysfunction is real.

That tension has no clean resolution. It can only be named and held.

Intellectual isolation

There is something else worth declaring. Working as a locum across multiple trusts, moving on before institutional roots form, means living without the peer challenge that ordinarily tests and refines clinical judgement. Grand rounds, case discussions, the uncomfortable question from a respected colleague — these are the mechanisms by which individual clinical thinking is stress-tested. Without them, the burden falls entirely on personal conscience and private reflection.

Over many years, two senior professionals have served as trusted sounding boards — neither a psychiatrist, both sharp and disinclined to simply agree. They provide something of that peer challenge function. But it remains a thin substitute for what a functioning peer network provides. That gap is acknowledged honestly, because it bears directly on the reliability of what is written here.

Why write it at all

The honest answer is that not writing it felt worse.

Psychiatry in prisons operates in the dark, in the sense that Goffman meant — beyond the reach of the scrutiny that disciplines standards elsewhere. A clinician who passes through, observes, and says nothing becomes, in some small way, part of the silence. That felt untenable.

This piece is not a formal complaint. It is not a referral to a regulator. It is a question, placed in a space where questions can be examined — by the writer, and by anyone who cares to read critically and push back. Sceptical readers are not merely tolerated here. They are needed.

V. The drive back

Seven in the evening

It did not arrive as a conclusion. It arrived as a question, somewhere on a twenty-minute drive back to a hotel, after an evening spent ‘rescripting‘ patients — reissuing medication under harm-reduction logic because the documentation required for proper clinical decision-making had not been produced by those who should have produced it. [‘Rescript‘ is the prison terminology – a term that is detached from prescribing, which is little to do with ‘scripting’ and far much more to do with duties of care.]

The day had been long. The placement had been unsettling in ways that were difficult to articulate cleanly. And somewhere in the car, not from theory, not from grievance, but from the accumulated weight of what had been witnessed over recent weeks, a question formed.

Has prison psychiatry become medical practice dressed in social care — with a dab of medication here and there to keep the inmates calm?

Leaving it open

It is not answered here. It cannot be — not honestly, not by a single observer writing from a declared position of partial knowledge.

What can be said is this. The question did not feel like cynicism in the moment it formed. It felt like recognition. Whether that recognition was accurate, whether it reflects something true about prison psychiatry more broadly or something specific to one small patch of the prison estate, is precisely what this piece cannot determine alone.

The question deserves a better answer than any one clinician can give it.

But it deserves an answer.