Prison healthcare in England and Wales is in perpetual crisis
BMJ 2024; 384 doi: https://doi.org/10.1136/bmj.q562 (Published 11 March 2024) Cite this as: BMJ 2024;384:q562
- 1Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
- 2Department of Health Sciences, University of York, York, UK
- Correspondence to: K McLintock k.l.mclintock{at}leeds.ac.uk
The global prison population totals around 11.5 million people,1 and over 30 million people move between communities and prisons each year.2 Prisoners experience a disproportionate burden of ill health, including high levels of long term physical and mental illness, bloodborne virus infections, and substance misuse.3 Healthcare delivery is difficult in overcrowded, often outdated prison estates facing security, staffing, and funding challenges.4 Prisoners experience variable healthcare quality,5 delays to assessment and treatment,6 stigma and discrimination,7 and poorer health outcomes, including excess mortality.8 People in contact with the justice system often experience health inequalities, including social exclusion, whether they are living in custody or the community.9 The principle of equivalence—that prison healthcare “should be of the same scope and quality” as services in the community—is well established2 but remains aspirational.
Two organisations that review standards of care recently published hard hitting reports on healthcare in prisons in England and Wales. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) review of “natural” and “non-natural” deaths (cause unintentional or unknown) identified that 22% of the 247 deaths in 2019-20 were avoidable and many were premature; the median age for natural death in prisoners was 67.5 years compared with 86.7 years in the general population.10 Natural deaths could have been prevented by earlier identification of clinical deterioration, and non-natural deaths by reducing availability of illicit drugs in prisons. The report recommends six priorities for improvement: healthcare assessment and monitoring, recognition of deterioration, transfer to hospital, cardiopulmonary resuscitation training, end-of-life care, and learning from independent clinical reviews of deaths.
A second report, from prison independent monitoring boards (IMBs), described inhumane conditions and treatment delays for men with mental illness.1 Many are placed in segregation units because of a lack of capacity in prison healthcare units and secure hospitals. Inappropriate, prolonged segregation—over 800 days in one instance—resulted in deteriorating health and behaviour. The report calls for increased numbers of secure hospital beds, reinstatement of the proposed mental health bill to accelerate transfers to hospital, and improved community mental health provision. Core to both reports is staffing: NCEPOD’s primary recommendation is to provide enough, skilled prison healthcare staff,10 and the IMBs describe how low staffing undermines care quality.11
Inadequate staffing
Poorer health outcomes are associated with deficiencies in how prison healthcare is organised, resourced, and staffed.12 Although the expertise, commitment, and teamwork between prison officers and healthcare staff is recognised,13 enduring problems with recruitment, retention, and attrition of the combined workforce since 2010, partly through austerity, has led to destabilisation of prison regimes and healthcare.14 Vacancies across prison healthcare are at an all-time high.15 Chronic understaffing was a dominant organisational influence on quality of and access to healthcare in prisons in the north of England.12 Combined with dependence on locum staff, this can lead to reactive, crisis led healthcare.12 A lack of prison officers directly affects healthcare as staff are unable to escort prisoners to appointments, both within prisons and for emergency or routine hospital attendance. In 2017-18, 40% of hospital outpatient appointments for prisoners in England and Wales were missed.16
Prison healthcare careers are often considered unappealing because of negative preconceptions,17 a demanding, sometimes discriminatory environment,18 and an atypical career structure. There is no mandated training for prison healthcare. NHS prison healthcare in England and Wales varies by site and is delivered by competing NHS, private, and third sector providers. The terms offered by some providers (including pension provision, sick pay, and holiday pay) compare unfavourably with clinical careers in the wider NHS. Internationally, published evidence on the effect of prison healthcare governance on health outcomes is limited.19 Improving conditions for prison healthcare staff could improve prison healthcare. For example, promoting recruitment and retention through parity of terms across the NHS, enhancing patient and staff safety by increasing prison officer staffing, providing consistent training and development opportunities for healthcare staff, and developing a diverse, representative workforce through changes to NHS and prison culture.20
Both reports highlight serious shortcomings in a closed prison healthcare system where people largely depend on a depleted body of healthcare professionals and prison staff to ensure their safety. The findings are of national and international importance, augmenting existing reports and guidance1521 and amplifying longstanding concerns that the UK government is in breach of duty of care towards prisoners.22 Prison healthcare is continually in crisis, and the much needed change will require coordinated, evidence informed action across multiple sectors. For example, improving information sharing and tackling health inequalities through “population health management,”23 and reducing the prison population through changes to sentencing so that resources can be diverted from building more prisons to investing in prison healthcare.24 Obstacles to change include political and societal indifference to prison healthcare and lack of understanding of the relation between unmet health needs and reoffending.25 High quality contact with prison healthcare services provides a crucial opportunity to confront these needs and improve outcomes. A combined focus on the inextricably linked issues of staffing and quality of prison healthcare is now required.
Footnotes
Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: KMcL was a case reviewer who undertook peer review for The National Confidential Enquiry into Patient Outcome and Death. Inside Prison Healthcare. London; 2024. Further details of The BMJ policy on financial interests are here: https://www.bmj.com/sites/default/files/attachments/resources/2016/03/16-current-bmj-education-coi-form.pdf.
Provenance and peer review: Commissioned; not externally peer reviewed.