The Prison Administrations are under the obligation to watch over the life, integrity and health of all prisoners (Art. 3.4 OLGP). Health care is comprehensive and includes prevention, treatment and rehabilitation (Art. 207.1 PR). The equivalent care principle (equity) is guaranteed by law (Art. 208.1 PR); it comprises medical and health care as well as pharmaceutical services (Art. 208.1 and 209.3 PR), both of which are free of charge for prisoners. In the Central Prison Administration (we have no data for Catalonia), the procurement of certain pharmaceutical products is made by the General Secretariat of Prison Institutions (centralized procurement), although other drugs are purchased directly by the prisons. The expenditure for atypical antipsychotics in 2007 came to 6,849,002.48 Euros. The total expenditure for all pharmaceutical products in 2007 was 32,145,463.46 Euros. 69.1 % of the total budget for pharmaceutical products was for HIV/AIDS drugs, 20.1 % for atypical antipsychotics, 10.2 % for chronic Hepatitis C treatments, and 0.6 % for vaccinations.

Unless there are security reasons to the contrary, the prisoners may also, at their own expense, request medical services from professionals in the wider community who are not appointed by the Prison Administration (Art. 36.3 OLGP and 212.3 PR).

The health care system is divided into two levels of care: primary and specialized (Art. 209 PR). At the primary care level, all prison establishments must be equipped with an infirmary and rooms for psychiatric observation, with a certain number of beds per population in each prison (Art. 37 OLGP and 213.1 PR). There is a Primary Care Health Team in each prison, comprising at least one general practitioner, one qualified nurse and one health care assistant although in practice there are several health professionals of each category in every prison. Moreover, there are doctors and nurses on 24-h duty, all year round. Family practitioners are in charge of caring for the physical and mental health of inmates and therefore they are required to have basic knowledge of psychiatry (Art. 36.1 OLGP) although they may request the assistance of specialised doctors. The regulations also provide for regular psychiatric consultations (Art. 207.1 PR). The specialist doctors are contracted via agreements with other health administrations, private institutions or even on an individual basis (Art. 212.2 PR).

Specialised care is ensured via Spain’s National Health Service (the public health service that covers all of Spain) either through consultations or hospitalization. There are Prison Hospital Units for inmates in every province, equipped with the appropriate security measures. Art. 20.2 GHL provides that: Patients who require hospitalization to treat their conditions shall be admitted to the psychiatric units of general hospitals. These are general psychiatric units – not penitentiaries. Some hospitals provide ‘Units of Restricted Access’ which are secure units for medical or psychiatric patients with police presence for safety reasons, The ‘Study on Mental Health in Prison Contexts’ (DGIP 2007), which outlines a ‘Global Mental Health Policy’, was completed in December 2006. The most relevant policy outlined in this document was the approval of the ‘Framework programme for comprehensive care for psychiatric patients in prison centres (PAIEM)’, which is currently being implemented. According to this framework, the purpose of an intervention for prisoners with a serious or chronic illness is to: (1) Detect, diagnose and treat any inmates who suffer from a mental disorder and refer them to rehabilitation programmes; (2) Enhance patients’ quality of life, increase their personal independence and their adaptation to the environment; (3) Optimize reintegration into society and adequate referral to community social and health resources. Interventions include detection, diagnosis, treatment, rehabilitation and reintegration into society.

Under the PAIEM, important principles in the healthcare for prisoners with mental disorders include independence; quality and continuity; referral to external resources; multidisciplinary work; cooperation of health-related institutions, organizations and social resources; inter-prison coordination and coordination between prisons and the wider community; and educational training and research. Three programmes have been set up to achieve this: (1) medical care (detection of mental disorders, implementation of medical treatment and referral to rehabilitation programmes), (2) rehabilitation, and (3) reintegration into society. The PAIEM is designed to be adapted to the characteristics of each prison.

The care model in place in Spain has been criticised by some specialists who consider that prison institutions are not the ideal place for the mentally ill who have committed crimes. Instead, they suggest treating such patients in general hospital psychiatric units and in a community setting (Hernández and Herrera 2003). Some authors are of the opinion that, although this would be the ultimate goal, the immediate aim should be to ensure that current inmates of penal institutions receive truly equivalent care (which may currently not always be achieved owing to the lack of specialists) and enjoy the same rights, and that mental health professionals have an enhanced role in decision-making. An institution’s activities should reflect what is expected from its name; otherwise, a ‘label fraud’ might exist (Barrios 2007a).

All inmates (pre-trial prisoners and sentenced prisoners) are examined by a general practitioner within 24 h of entering prison (Art. 214.1 PR). The purpose of this examination is to detect any physical disease or mental illness and to proceed accordingly (Art. 288.1 PR 1981). If there is a suspicion of mental disorder the inmate is examined by a psychiatrist. The prison’s psychiatrist, if any, will examine the prisoner to detect potential mental disorders and prescribe adequate treatment (Art. 288.2 PR 1981).

If a mental disorder is detected at the time of admission or in the course of serving a sentence in prison, the patient is sent to the prison’s infirmary if the disorder is mild or to an external general hospital, if the disorder is serious and is acute.

In cases of psychiatric diagnoses that affect an inmate’s prison status (e.g. transfer to Psychiatric Penitentiary Hospital) a panel of experts is convened comprising a specialist in psychiatry, a forensic pathologist, and the prison’s primary care physician; a report by the Observation and Treatment Team (comprising the head of the team, a lawyer, a psychologist, and a social worker and a member of education staff) is also received (Art. 39 OLGP).

If an inmate shows signs of having a mental disorder after being sentenced to imprisonment, the prison governor provides for observation of the inmate and sends notice to the sentencing court. The court may then issue an order for the prisoner to be sent to an appropriate institution (Art. 991-994 LCP). In such cases, the enforcement of the sentence is suspended and a security measure of deprivation of liberty is issued (psychiatric institutionalization in prison or, occasionally, in a general psychiatric institution) (Art. 60 PC) (Vizueta 2007; Gómez-Escolar 2007).

If, in the course of legal proceedings, a court deems that when the criminal offence was committed, the accused was unable to understand that the act was unlawful or to act in consequence of such understanding owing to a psychiatric anomaly or disorder, the accused is declared to be immune from prosecution (Art. 20.1 PC) or the accused is declared of diminished responsibility, when not all the requirements are met for acquittal (Art. 21 PC). The court may then impose a custodial measure for medical treatment in a relevant establishment for the type of psychiatric anomaly or disorder concerned (Quintero 1996; García 1997; Santos 2001; Sanz 2003; Sierra 1997). This may be a prison (the most common option) or a different secure setting. The internment may not exceed the duration of the deprivation of liberty that would have been imposed if the accused had been declared mentally capable (Art. 101.1 PC). Security measures other than internment or deprivation of liberty may be imposed, e.g. deportation from Spain for foreign nationals, prohibition to reside in certain places, mandatory residence in a specific place, prohibition to go to certain places, events or establishments where alcoholic beverages are sold, family custody, withdrawal of a driving permit, withdrawal of a firearms licence, prohibition to approach a victim or a victim’s family members, prohibition to speak to the victim or the victim’s family members and treatment in the community.

Those who are admitted to Psychiatric Penitentiary Hospitals (forensic psychiatric hospitals) and Prison Psychiatric Units (the latter are pending implementation) are: (a) detainees and prisoners who have psychiatric disorder if the judge rules their admission for observation purposes and the issuing of a relevant report; (b) persons who are declared immune to prosecution by a court and who are sentenced to deprivation of liberty (psychiatric institutionalization) as a security measure, and (c) convicts whose mental illness is subsequent to their court case, when a Court decides they should be transferred to another institution (Art. 184 PR).

Care for inmates of Psychiatric Penitentiary Hospitals and Prison Psychiatric Units is entrusted to a multidisciplinary team comprising psychiatrists, psychologists, family practitioners, nurses and social workers. These health professionals and assistant staff are also required to implement rehabilitation programmes (Art. 185 PR). Hospitals and prisons are required to put in place a general programme of rehabilitation activities and individual rehabilitation programmes (Art. 189 PR).

Psychiatric institutionalization is always time limited. It may not exceed the sentence that would have been imposed if the accused had been liable to prosecution (Art. 101 PC). It can be for a briefer period. The Judge of Penitentiary Surveillance in charge of prison supervision is required to provide an annual report to the sentencing court in which he suggests whether to: (a) continue the deprivation of liberty, (b) rule that the deprivation shall cease, (c) suspend the measure for a period that does not exceed the time that remains to be served according to the sentence, (d) substitute the deprivation of liberty for a different measure (generally treatment in the community) (Art. 97 PC) (Fernández 2003; García 1997).

Before submitting recommendations, the judge in charge of prison supervision assesses the reports issued by the doctors and professionals involved in the care of the patient concerned (the multidisciplinary team).

Usually, if institutionalization ends before the sentence is served, it is replaced by a security measure called ‘external medical treatment’ (treatment in the community), which does not involve deprivation of liberty. After ratifying the measure, the Prison Administration requests the cooperation of the general Health Administration (Spain’s National Health Service) to ensure that psychiatric treatment continues after the patient is released (Art. 185.2 PR). Thus, after leaving the secure setting or Prison Psychiatric Unit, the released patient is referred to a local Mental Health Unit in his or her place of residence. The Court can also rule that the relevant social services shall assist and care for the released patient (Art. 106 PC).