Towards a health-informed approach to penal reform? Evidence from ten countries to reducing reoffending risk (de Boer & Gerrits, 2007). The TBS can be imposed at the point of sentencing in any case where the prison term is at least four years and the court is satisfied there is a mental disorder. The Netherlands is known for its sparing use of custody and its legal requirement of proportionality in sentencing.31 By contrast, the TBS element of a sentence is open-ended and can be of long duration: 20 per cent of patients are deemed unlikely ever to be discharged after six years’ detention (Maden & Newman, 2017). Criticism of the system has centred on its unlimited nature and on the difficulty of challenging continued TBS detention. There is also an apparent contradiction in a sentence that punishes first and treats later, despite a need for treatment having been made out at the point of sentencing. 4.3 Improving conditions and health provision in custody Prisons are not easy places in which to provide healthcare, for a variety of reasons (Ginn, 2012), but when they are overcrowded, health provision will be severely compromised, as we have seen from the prisoner accounts featured in this report. Therefore, for most countries, reducing prisoner numbers overall is an essential first step in improving conditions of imprisonment and increasing access to healthcare and treatment. Healthcare services and treatments for people in prison should reflect their (often highly complex) needs and should be equivalent to the services and treatments provided in the wider community. Effective practice depends to some extent on how well different services and agencies in the health and justice sectors collaborate. It also requires clarity of responsibility for the health of people passing through the criminal justice system, including prisoners. The prison doctor comes only once a week. There are two clinical officers interchanging and if you say you’re feeling ill, they give you paracetamol at most. Usually, the doctor will assume you’re lying about your health and ignore you. A few times women went on hunger strike to help get a sick prisoner taken to hospital…. One time a woman couldn’t feed her baby daughter due to breast pain. The baby wouldn’t stop crying, the women would shout at her to feed the baby but she couldn’t. Eventually they discovered she had cancer. Female ex-prisoner 2, Kenya In countries where prisons are overseen by justice ministries, it is often unclear where responsibility for prisoner healthcare lies. This can lead to gaps in provision. In England and Wales, prison health is now the responsibility of the National Health Service. This arrangement should at least in theory make it easier to achieve equality of healthcare provision and help to maintain continuity of care for people who enter and leave custody. (In reality, staff shortages and an already stretched National Health Service can mean patchy or poor standards of provision (see House of Commons Health and Social Care Committee, 2018).) In the Netherlands, by contrast, healthcare in prisons is the responsibility of the Justice Ministry but prisons are legally required to provide healthcare equivalent to that which is provided outside prison. Below we discuss interventions and research capable of raising standards of mental healthcare provision in prison, before turning to those relevant to physical health. 4.3.1 Mental health Even if greater use is made of community-based interventions, it remains likely for the foreseeable future that prisons in much of the world will hold a high proportion of people with challenging mental health needs. It is important that the necessary care and treatment is provided for them, both while they are in prison and on their release. Treatment options in prison may be limited compared to services provided in the community; but in any prison, it should be possible to provide basic interventions. These may include psychological support through counselling (from a psychologist, a nurse, or a trained prison officer or prisoner) and treatment to stabilise addiction and 31 Netherlands Penitentiary Principles Act 1998 (Penitentiaire beginselenwet) 24