BRITISH MEDICAL JOURNAL VOLUmE 288 14 JANUARY 1984 129 to be expanded to help keep more old people in their own houses, but the Dutch to whom I spoke did not believe that enough money would be found for the expansion needed. As in Britain and Denmark, the government has mounted a public relations campaign to convince the population that old people are best cared for in their own homes with the support of their neighbours and family, with help from volunteers and from home nursing and home help services. Certainly there has been some increase in the numbers of home nurses, but other support services (such as helps) have been frozen or actually declined a little. Administrators of nursing homes can produce objective evidence of a recent decline in the quality of care provided for the elderly. Projections based on demographic change have shown that 5000 additional beds will be needed by the end of the decade. No one now believes that these new nursing homes will be built. Waiting lists are lengthening substantially: in Eindhoven (population 200 000) the number waiting for admission to psychogeriatric beds has doubled (from 90 to 180) in the past 12 months. Patients in hospital beds (who make up about 25% of all admissions to long term psychogeriatric care) are now having to wait for between six and 12 mouths for transfer to a nursing home-only two years ago the average delay was only one month. Those doctors, nurses, and administrators to whom I talked saw the future as depressing. Until very recently the system had functioned efficiently and compassionately, with few old people having to wait more than a few weeks between assess- ment and admission to a nursing home. Now the admini- strators have been told to cut their budgets by 3% in the coming year; new building has come to a virtual end; and-remarkably quickly-free movement of the elderly from their own houses to residential units or nursing homes has slowed down and in some cases stopped. The presence of demented old persons in units meant for the physically disabled is lowering the quality of life for the non-demented-a problem all too familiar in Britain but new to the Netherlands. Resignedly, however, the health professionals accept that the economy is in a poor state, and they believe that the care of the elderly will have to worsen substantially further before there is any real public protest. The State of the Prisons The physical health of prisoners RICHARD SMITH The uninitiated might imagine that dreadful diseases are to be found in our thoroughly unpleasant prisons and that prison doctors are specialists in dealing with these conditions. It was true at the end of the eighteenth century that prisons had their own disease-gaol fever, a form of typhus-but now the diseases to be found in prisons are the same as those in the community, only some are much commoner behind prison walls. The special skills required of a prison doctor are less to do with knowledge of disease and much more to do with being able to practise medicine within difficult conditions. Conditions of prisoners on entering prison Any doctor who has ever worked in the casualty department of a large hospital in an inner city would recognise the chaos that prevails in the prisons that take prisoners directly from the street. At Brixton, for instance, which is London's main remand prison for men, about 200 new prisoners come in each day, and many of them are in a desperate state. Many have spent some time in police cells, but few have been "sorted out." The mad, the bad, the sad, the homeless, the filthy, the infested, the drunk, the high, the dangerous, the grief stricken, and the suicidal pour into Brixton every day and have to be quickly sorted out into those needing close medical attention, those who need to be watched, and those who will be safe in the main body of the prison. British Medical Journal, London WC1H 9JR RICHARD SMITH, MB, cHB, assistant editor All of them are searched, bathed, and examined, usually by part time doctors who are also local general practitioners but sometimes by full time prison doctors, but the examination is necessarily brief. This is triage, as in a wartime casualty station, and any diabetic or epileptic or prisoner with a heart problem, no matter how stable his condition, is likely to end up in the hospital for a while at least, and anybody showing the least sign of mental instability will be sent to the euphemistically named "psychiatric wing." I know of no detailed study of the medical state of prisoners entering British prisons, but a study was done on 1420 prisoners entering the New York City correctional facilities over two weeks in June 1975.1 Thirteen hundred of the prisoners were men, and 120 women; three quarters were under 30; and 57% were black, 24% Hispanic, and 17% white. Forty one per cent of the prisoners gave a history of illicit drug use, and a previous study reported in the same paper had found that urine samples from 36% of 485 adult male prisoners taken on admission contained either opiates, methadone, barbiturates, or amphetamines. In addition 18% of the men and 14% of the women had a history of alcohol abuse. More than a quarter of the prisoners reported an illness at the time of admission, and 60% received at least one diagnosis. Four per cent gave a history of epilepsy, 8% of asthma, and 8% of hepatitis. On examination new trauma was seen in 10% of the men and 17% of the women. An abnormality of the mouth and teeth was noticed in 18%, and a detailed examination of the 257 with dental findings showed that two fifths had missing teeth and a third multiple caries. Seven per cent had eye abnormalities, and 46% skin abnormalities-mostly scarring secondary to drug use, tattoos, non-specific dermatitis, and fungal infections. When it came to making an examination of the prisoners' mental state, 13% of the total and 10% of the women were judged to be