Julian Assange & the Crisis of British Public Service

By Helen Mercer
Special to Consortium News

When Julian Assange was forcibly removed from the Ecuadorian embassy in London in April 2019 and imprisoned in Belmarsh, a U.K. maximum-security prison, it was clear that this was part of a U.K., U.S. and Ecuadorian collusion to extradite him to the U.S.

Many hoped that in prison Assange might gain access to medical facilities, exercise and sunlight, which were not available in the embassy. Indeed the British home secretary at the time, Sajiv Javid,  assured the House of Commons that,

“While he remains in custody in the U.K., we are now in a position to ensure access to all necessary medical care and facilities.”

This was not to be and six months later Nils Melzer, the UN rapporteur on torture, echoing many others, stated:

“‘Unless the U.K. urgently changes course and alleviates his inhumane situation, Mr. Assange’s continued exposure to arbitrariness and abuse may soon end up costing his life.”

Three main factors have contributed to Assange’s deteriorating condition since April 2019:

• First, the extended judicial process with the continuing and prolonged threat of extradition and certain death in the U.S/ amounting to “punishment by process.”
• Secondly, he has endured that process while unjustifiably in Belmarsh prison, even after extradition had been refused, as well as effective solitary confinement in the prison health wing for part of that time.
• Finally, he endures along with all prisoners the effects of a mounting crisis in British public services.

Javid’s assurances were hollow, for just a few months earlier a major Parliamentary report into prison healthcare made trenchant criticisms:

“A prison sentence is a deprivation of someone’s liberty—not a sentence to poorer health or healthcare.”

A Prison System in Crisis

Since 2000, report after official report attests to a prison system in crisis. In 1900 there were 86 prisoners per 100,000 people in the general population. There followed a period of decarceration in the inter-war period, but a dramatic rise occurred in the 1990s and by 2018 there were 173 prisoners per 100,000.

Neither the prison estate nor staffing and resources have kept pace. Since 2010 the amount spent on each prison place has been reduced by 15 percent in real terms. Between 2010 and 2017 the number of frontline operational prison staff (bands 3–5) was cut by 26 percent. Additional funding from 2018 sought to reverse this trend, but in 2020 there were 12 percent fewer staff than 10 years earlier. Cumulative levels of staff experiencehave declined and nearly half of officers (48 percent) who left the service in the last year had stayed in the role for less than two years.

In 2019, 58 percent of prisons were classified as overcrowded. Reporting on conditions at Belmarsh, the 2018 report noted overcrowded cells often with unscreened toilets. There was insufficient space for out-of-cell activities, and insufficient staff to supervise it. For instance “the prison struggles to recruit workshop instructors due to low pay, noting that people would receive higher pay working in a warehouse down the road.”

In 2016 levels of staffing at Belmarsh were 9.3 percent below the benchmark target, compared with the national  level of 7 percent below target, hence: “Restrictions to the regime are mainly driven by staffing levels….A prison officer reported that it is ‘painful’ not to be able to do the basics of the job.”

Only 16 percent of prisoners report being unlocked for the recommended minimum of 10 hours per day. In Belmarsh:

“Prisoners, we were informed, are meant to be out of their cells for eight hours per day, but that the prison has had insufficient staff and a lack of space to manage this. Until recently, some prisoners were only coming out of their cell once every third day, when they might shower or use the phone, apart from time out to collect their meals or for a short period of exercise. A lack of time outside of their cells, we heard, limits prisoners’ access to fresh air and sunlight and their ability to remain physically active. If prisoners are unemployed, we were told, then they might spend 22–23 hours per day in their cell.”

Instead of time outside of cells being a human necessity, “exercise, showers, family contact and recreation time are all used as rewards for good behaviour or sanctions that can be taken away when behaviour is poor.”

One of the toothless prison “regulators” — the Independent Monitoring Board for Belmarsh — comments annually on the disgusting state of the showers:

“.. the condition of the communal showers in all house blocks has remained a disgrace and wholly unacceptable. The Board has reported adversely on this for a number of years, without the matter being resolved.”

Two Quid a Day for Food 

Low levels of staffing affect attendance at hospital for outpatient appointments as at least two officers are required to escort a prisoner to hospital. Cancelled outpatient appointments or “no-shows” were 13 percent of all appointments among the general population but 30.9 percent for prisoners. Staff shortages might also restrict prisoners’ access to pharmacy services and in-house doctor visits. Waiting times to see a health worker can be very long, even where there is pain, prompting some prisoners to abandon the attempt to secure appointments.

As well as staffing, funding cuts affect the amount spent on prison food. In 2018 the cost of feeding one prisoner per day was just £2.02, a fact which shocked the same Select Committee. As an HMIP report commented: “Various medical complications that arise from poor nutrition, including nutritional deficiencies, cardiovascular disease, diabetes and high cholesterol, add burden to prison health resources.” Poor food can be “a catalyst for aggression and dissent”: there is a strong link between poor mental health and poor diet.

The health, mental and physical, of people entering prison is predominantly below the average for the population as a whole. Inequality and poverty which prevails among the prison population creates complex social and economic problems, including poor nutrition and housing, which in turn have major health implications.

Mental-health provision absorbs about 37 percent of total National Health Service (NHS) spending on adult health care in prisons, yet the record of care is “appalling.” Over half of prisoners have common mental disorders, including depression, post-traumatic-stress disorder and anxiety, yet

“The deteriorating prison estate and long-standing understaffing have created an environment which exacerbates the mental health issues faced by prisoners.”

Failure to screen prisoners on arrival for mental health problems and risk of self-harm is common: the Prisons Ombudsman report for 2016 noted that no mental health referral was made when it should have been in 29 percent of self-inflicted deaths where mental health needs had already been identified. The significant decline in pre-sentence reports on prisoners’ health has reduced the opportunity for mental health records to be taken into account in sentencing.

It comes as no surprise therefore that incidents of self-harm are at record highs — over 60,000 cases affecting 12,740 individuals in the 12 months to September 2019. There were 83 self-inflicted deaths in 2019-20: rates among prisoners on remand (of which Assange is one) is especially high: one report estimates half of all suicides is among this group. Prisoners serving indeterminate sentences (which Assange also is effectively) are more vulnerable to self harm.

As an “older” prisoner Julian suffers from particular problems affecting the 50+ age group which now makes up 16 percent of the prison population. Ninety-three percent of those surveyed have health problems and on average older prisoners have 2.7 unmet health needs on entering prison. Oral health, pain and mobility are particular issues. Untreated dental decay is four-times higher in the custodial population than in people in the community.

Having done his worst as home secretary, Javid, a devotee of the works of Ayn Rand, is now secretary of state for health, a system in even deeper crisis.

The NHS

The NHS took over responsibility for prison healthcare from the Prison Medical Service in 2006. The change came at a time when the NHS was least capable of fulfilling the role for, like the NHS itself, prison healthcare suffers from all the effects of funding cuts, privatisation, fragmentation, bureaucratisation and politicisation.

Real term budget cuts have left hospitals struggling with huge debts. Cuts and other policies, such as withdrawing bursaries for nurse trainees have produced an acute staffing shortage. NHS hospitals, mental health services and community providers report a shortfall in 2020 of 84,000 FTE staff including 38,000 nursing vacancies, or 1 in 10 posts and 2,500 FTE GP vacancies.

In early 2020 there were 9,000 FTE job vacancies for doctors, a 17 percent shortfall of emergency medicine consultants and a 9 percent shortfall of respiratory medicine consultants. There was a 12 percent decline in the number of mental health nursing posts between 2009 and 2019 with psychiatrists and psychologists also being listed as shortage occupation in 2019.

The Royal College of Psychiatry estimates that an additional 1,000 mental health beds are needed to cope with Britain’s mental health crisis. Overall London is the worst hit in the U.K. with a 10.7 percent vacancy rate for all clinical posts

In addition to cuts in real terms to health budgets, an increasing proportion of NHS budgets is eaten up in the administration and transaction costs of privatization as well as covering the profit margins of privately provided services and consultancies, and the financiers involved in Britain’s program of health public private partnerships (the private finance initiative).

Marketization has cost the NHS anywhere between £4.5bn and £10bn per year in extra administrative costs alone, while the services provided have deteriorated. Hence administrative costs of the NHS have increased from 6 percent to 15 percent per year, between the 1990s and 2012-13.

The NHS has been systematically fragmented for over 30 years, a process designed to create easy, discrete pickings for private firms. Privatization now pervades the NHS, which has become, as the initiators of the smash and grab intended, a “kite mark” masking the extent of profiteering.

The private sector is winning 65 percent of the value of all contracts advertised and operates across a huge array of health services, including clinical services, ophthalmology, dermatology, muscular skeletal. They run GP practices, provide “ancillary services” such as cleaning, catering, laundry. The great Covid “procurement scandal” (a huge increase in the award of private contracts, done without public consultation and without the usual competitive procurement rules and at huge public expense) is a foretaste of the scale of profiteering and declining quality and access to services that the Health and Care Bill, currently on its way through Parliament, will bring.

Privatization has promoted a “business-oriented” outlook in health administration. Hospital trusts are now littered with board members with “business experience” and interests in private healthcare firms and advisory bodies. The retiring head of the NHS itself, Simon Stevens was a former boss of U.S. health insurance firm United Health. Prime Minister Boris Johnson’s special advisers on health is a former chief executive of Operose, a subsidiary of the U.S. firm Centene, which controls a string of private hospitals in the U.K.  Operose recently took over 54 GP practices.

Healthcare in Belmarsh

Fragmentation and privatisation have undermined and compromised prison healthcare. The 2018 report,drawing on damning evidence from the Care Quality Commission (CQC), noted:

“… health and care provision within prisons can be very fragmented, as different companies are contracted to look after different areas. For example, dentistry, general practice and mental health services in one prison may be delivered by different providers… This fragmentation of delivery can lead to a lack of continuity of care for prisoners.”

Healthcare at the Belmarsh ”cluster” of prisons is provided by Oxleas NHS Foundation Trust through a £12.6m contract with the NHS. As a foundation trust (FT), Oxleas has itself effectively been part privatized: it competes with other trusts and with private companies in providing services, and it may use NHS buildings to provide private healthcare.

In turn the Trust outsources prison health care. For instance, GP services, the first port of call for prisoners as for all U.K. citizens, is provided by South London Prison Service LLP. According to its company accounts on a turnover to March 2020 of £1.95m its two partners withdrew from the company £515,000. They have withdrawn a total of £1.3m since 2015 when the company was incorporated.

Other aspects of prison healthcare are also subject to privatization. Bidfood, owned by a South Africa based company BFS Group Ltd, is contracted to provide food to all the U.K.’s prisons.

BFS made an interim dividend payment of £23.6m on all its activities in the year to June 2020. The government is privatizing the storage and analysis of patient data and one firm which stands ready to pounce on contracts is Palantir, leading to a situation in which personal data on Assange’s health could be “mined” by a company dedicated to targeting and disrupting his activities.

At Assange’s extradition hearing, even the hard-faced judge Vanessa Baraitser accepted the damning evidence on the state of his mental health, yet in unjustly keeping him in Belmarsh she gave his care over to a trust which has had an uneven record.

In 2017 the CQC report on Belmarsh found that:

“Many patients requiring treatment for long-term health conditions and wound care did not have individualised care plans in place to inform their on-going care, and were not sufficiently monitored to ensure the care and treatment they received met their needs.”

By July 2019 the situation was, however, “improving.” In December 2020 the CQC issued a warning notice to Oxleas (a notice which has recently been withdrawn). The report in December 2020 described the care of elderly patients on mental health wards in the area served by Oxleas as “inadequate” and described poor “governance arrangements” after “serious incident investigations.”

Community-based mental health care for adults of working age is an area still requiring improvement. The CQC report criticized the high workload of many staff, long waiting times to start therapies, and multiple failures for instance in providing physical health checks, or addressing the comprehensive needs of patients.

The management of Julian’s mental health will also have suffered from another aspect of successive British governments’ obsession with the unproven strengths of the private sector in running public services.

The “New Public Management” which uses ideas and techniques which derive from business has been imposed on the NHS since the 1980s. That imposition involved the creation of a non-clinical manager class, whose emphasis was on managing performance through “controlling and reporting systems.” Frontline staff were required to shift their focus from caring to auditable outcomes. A paper in The Psychologist’ argues that the emphasis on procedure

“has led to psychological therapy with prisoners being deconstructed into a manual with set procedures…(with) no need to understand the individual to whom these procedures are applied.”

Together with a process of fragmentation and privatization, box-ticking and back-protecting  to prove the promotion of health, rather than actual actions to provide it, becomes the hallmark of “good governance.” As two recent authors on the theory of “governance” have put it in explaining the U.K.’s weak Covid response:

“The capacities of the post-war welfare state have been steadily hollowed out, with a shift to neoliberal, regulatory and networked governance. This system is better at creating the illusion of activity than actually delivering concrete public goods and services.”

This emphasis on governance now pervades all levels of health provision and allows extensive whitewashing of often defective services.

It is impossible to be precise about the part played in Julian Assange’s alarmingly deteriorating health by the matrix of problems in the British prison and healthcare systems. Every prisoner’s health may be expected to deteriorate, but add in the specific forms of cruelty inflicted on Assange over nearly 11 years and a perfect storm of threats to physical and mental health arise.

Securing Assange’s release from Belmarsh is an urgent imperative. He cannot be allowed to flounder while the U.S. presses its “threadbare” appeals in a seemingly unending process. Assange’s work as editor of WikiLeaks shed a piercing light on the world’s geopolitical landscape: his life in Belmarsh illuminates the parlous state of British public services which threatens all of us imprisoned in the ugly neoliberal world the profiteers have created.

Helen Mercer is a campaigner for the release of Julian Assange and has been a long- term health campaigner against the privatisation of the U.K. National Health Service.