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The health of prisoners in the UK

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There remains a gap between the notion of health There remains a gap between the notion of health promotion in prison and the reality of promoting health in prisons

Those people who find themselves in our prisons are part of our community. They have come from our community and most of them will return to it. The care and safeguarding of those people in our prisons provides protection for our communities.

The Government is failing in its duty of care towards those people who are detained in England’s prisons.1There are too many prisoners who are in unsafe, unclean and archaic institutions with violence and self-harm at record highs. Most of our prisons are overcrowded, exceeding their certified normal accommodation level. Staffing shortages have resulted in lack of opportunity for prisoners to engage with and access health and care services inside and outside of prisons.

Standards and decrees

It is over a quarter of a century since the World Health Organization (WHO) published a report on health promotion in prisons, this was the catalyst for further debate on the concept of the health of prison populations.2 The United Nations published the Standard Minimum Rules for the Treatment of Prisoners (known as the Nelson Mandela Rules) in 2015.3 The rules set out what is generally accepted as being good principles and practice in the treatment of prisoners and prison management, and this includes the provision of health care for prisoners.

Prisoners should enjoy the same standards of health care that are available in the community, and should have access to necessary health-care services that are free of charge and without discrimination on the grounds of their legal status. The Council of Europe revised the European Prison Rules in 2006, stating that the health profile of prisoners compared to the community as a whole is very poor with deficiencies in the provision of health care. There remains a gap between the notion of health promotion in prison and the reality of promoting health in prisons, with a suggestion that there has been a weakening of commitment over time. This results in negative experiences for those who require healthcare in the prison setting who are among the most vulnerable and excluded in our society.

Prisoners are entitled to receive the same healthcare and treatment as anyone outside of prison. In England NHS England Health and Justice are responsible for commissioning services working with clinical commissioning groups and local authorities to provide support for the delivery of social care within secure settings and the continuity of care as individuals transfer in and out of them. They adopt the ‘principle of equivalence’ maxim, this means that the health needs of a population that are constrained by their circumstances are not compromised and that they will receive an equal level of service as that offered to the rest of the population.

Treatment in prison has to be approved by a prison doctor or a member of the healthcare team. Prisons do not have hospitals, many of them have in-patient beds. The majority of health care problems are dealt with by the healthcare team. If they cannot be managed by the health care team, the prison may request an expert to visit the prison or they will arrange for treatment in an outside hospital.

It is the responsibility of the Care Quality Commission (CQC) to monitor, inspect and regulate health and social care in the criminal justice and immigration detention systems with the aim of ensuring that those people who use services in secure settings will receive the same quality of care as the rest of the population

In secure settings in England, most healthcare services have to register with the CQC (there are some exemptions) as is the case with other care services. The CQC inspects a range of health services, those that form part of youth offending teams to prison healthcare, working in partnership with other inspectorates, using different frameworks to inspect different types of service, these include:

  • Adult prisons
  • Immigration removal centres
  • Police custody facilities
  • Secure children’s homes
  • Secure training centres
  • Sexual assault referral centres
  • Young offender institutions
  • Youth offending teams

Her Majesty’s Inspectorate (HMI) of Prisons (an independent inspectorate in England and Wales) reports on conditions and treatment. The CQC has responsibility for monitoring, inspecting and regulating health and social care providers.

Prison populations

There are over 11 million people held in penal institutions globally.4

Between 1900 and 2018 the prison population of England and Wales quadrupled in size with around half of this increase taking place since 1990. Scottish prison population almost doubled since 1900, with a 60% increase since 1990. Between 2000 and 2018/19 the prison population of Northern Ireland increased by 36% (data for Northern Ireland commenced in 2000), however, the prison population here is currently lower than at its peak of around 1,800 in 2014/15.

Since the end of February 2020, the UK prison population has shrunk by around 5,500 people, or 6%, following lockdown measures that were introduced in response to the COVID-19 pandemic.5

The prison population is ageing: in 2002, 16% of the prison population were under the age of 21 years compared with 6% in 2020. The number over the age of 50 years increased from 7% in 2002 to 17% in 2020. People of minority ethnicities made up 27% of the prison population which is compared with 13% of the general population. 49% of prisons in England and Wales in May 2020 were said to be overcrowded (overcrowding occurs if the number of prisoners held exceeds the establishment’s Certified Normal Accommodation threshold).6

Health in prisons

Health is a human right which everyone is entitled to regardless of who they are. Society should aim to respond to the needs of the underserved, marginalsed and most vulnerable populations. We have a moral obligation to make health fully inclusive and non-discriminatory in all contexts; this is key to an understanding of universal health coverage.7

Many people who are in contact with the criminal justice system experience numerous and complex needs. Coexisting health and social problems, for example, substance misuse, mental ill health and housing problems co-exist with offending behaviour. These problems can be made worse by poor physical health and social factors that can include unemployment, unrelenting poverty and debt.

The physical health of the prison population, when considering a wide range of conditions, is much poorer than that of the general population.1 Incidences of blood borne viruses are especially more prevalent among the prison population and the prevalence of HIV and hepatitis C is substantially higher among the prison population, there is a greater prevalence among female prisoners, tuberculosis is higher among the prison population.

Mental ill health and personality disorders are higher among the probation caseload than in the general population. Those women in contact with the criminal justice system have higher rates of mental ill health. Men who leave prison are around 10 times more likely to commit suicide compared to the general male population; women leaving prison are nearly 45 times more likely to commit suicide than the general female population.1

Substance use among sentenced prisoners and those on remand is considerably higher than among the wider population. 60% of people sentenced to less than 6 months in custody have reported upon their arrival to prison a substance misuse problem. A substantial proportion of new entrants to community substance misuse treatment arrive via a criminal justice system route. The criminal justice system was the second most common referral source for opiate clients, accounting for 26% of referrals in 2017.8

The possibility of an ex- prisoner dying as a result of drug misuse is significantly increased immediately after they have been released.9 Providing access to drug treatment can have a protective effect, reducing the likelihood of drug related death.

People in prison may have complex and varied health and care needs and these can be exacerbated as a result of incarceration. If people are not provided with access to good care and if the criminal justice setting does not make the necessary adjustments that are required to support prisoners, this will only become more of a challenge to address.

The prison population is ageing, and those older prisoners are more likely to develop new conditions whilst they are in prison. It is important that services are appropriately prepared and managed insuch a way that they offer high-quality care to this ageing population.

The average age of death of people who are detained in prison in England is 56 years.8This may be as a result of the complex vulnerabilities that those in prison bring with them as well as being in an environment where it could be that some of those needs are not understood nor being met.The mortality rate of ex-prisoners and offenders on community sentences is even higher than that of the prison population. Risk of death is highest immediately after release and this is frequently linked to substance misuse problems. Community offenders also show higher levels of accidental deaths, often relating to drugs and alcohol, as well as homicides.

A whole prison, whole person approach

A holistic approach can support good mental and physical health for those people in contact with the criminal justice system, particularly those who are protected under the 2010 Equality Act, many of whom are overrepresented in the criminal justice system and/or experience significantly poorer outcomes than the general population. Continuity of care throughout an individual’s sentence is essential, enabling the recognition and meeting of the needs of each person at all stages of their journey through custody. Clinks10 also suggest the creation of a wellbeing culture for all, embedding it in the structure and core business of all those who are working in the custodial service.

The successful delivery of
a whole prison approach requires a well-trained and stable workforce comprising prison staff and health and care professionals.1 Robust local strategic relationships, that engender a shared ownership for improving prison health and care is essential. There has to be a collaborative approach to commissioning services, ensuring that service provision is reflective of the needs of the prison population, and enabling governors and others with the authority that is required to make prisons safer and healthier.

An independent, rigorous and respected inspection regime that can provide a robust picture of the state of health and care in prisons and has the influence to drive through improvements is a key requirement.

The community dividend

Improving prisoner health is key for public health.11 Prisons are an important setting to address health inequalities and to improve the health of a population who are underserved.2

For most people, prison is a transitional venue in the course of their lives, most will return to the wider community. Addressing the health needs of people in prison offers an opportunity to improve outcomes for an underserved population group in the community. Prisons are not healthy environments, and as such policies that aim to reduce overcrowding and provide alternatives to incarceration must form part of a conversation on a whole-of-government approach
to prison health and what it could be.

As those in prison move in and out of prison and the community, addressing health in prisons can have an impact on wider community health outcomes, for example, the prevention and control of infectious diseases such as tuberculosis. Many drivers of criminal behaviour, including substance use disorders and mental health, are related to health, action taken on these health-related conditions has the potential to reduce reoffending. In addressing health needs early, there is a real possibility to reduce later costs in health care and community safety.

The community dividend model suggests that when the health needs of those in contact with the criminal justice system are addressed there can be positive outcomes for the wider population. Those in prison or those in their friendship, family and social networks also experience undue wider societal health and social inequalities. Wright and Khan12 note that children of offenders are three times more likely to have mental health problems or to engage in anti-social behaviour than their peers. When there is a reduction in reoffending and a reduction in the number of those parents experiencing incarceration, this could also reduce their children’s chances of future offending and coming into contact with the criminal justice system.

Under-served populations return to their communities when their involvement in the criminal justice system has concluded, therefore meeting the health needs of people in contact with the criminal justice system may help to accomplish cuts in crime, reduce offending and enhance the health of individuals.12

Developing and delivering health interventions that are specifically meant for people in contact with the criminal justice system can deliver a ‘community dividend’ offering a positive effect on wider health, including health inequalities and offending behaviour. Both PHE and WHO13 proclaim that delivering effective healthcare to those who are in prison or those who are in contact with other parts of the criminal justice system is not only the right thing to do, it is also the wiser thing to do.

Conclusion

Those who are incarcerated are among the most vulnerable and excluded in society. There is an urgent need for policy makers to address prison physical and mental health and this should be given greater priority. Providing prisoners with the opportunity to lead healthy lives aligns Government’s aspirations to use prisons so as to rehabilitate offenders. Health, wellbeing, care and recovery have to become a central aspect of the Government’s plans for reform.

People in contact with the criminal justice system very often come from those communities that are seriously affected by health inequalities. They present with higher levels of need with regards to mental health, substance misuse and blood-borne viruses. The mortality rates among this group are up to four times higher for those who serve community sentences. Addressing inequalities, including health inequalities and directly focussing on offending behaviour has real potential to improve public safety, prevent offending and reoffending and reduce crime.

Meeting the health and social care needs and reducing inequalities can also help to enhance outcomes for other people, including those people who are not in contact with the criminal justice system – the community dividend.

Ian Peate OBE, Head of School, School Of Health Studies, Gibraltar

Acknowledgement

I would like to thank Mrs Frances Cohen for her help and support

References

1. House of Commons Health and Social Care Committee. Prison Health. 2018

https://publications.parliament.uk/pa/cm201719/cms...

Last accessed September 2020

2. World Health Organization. Health in Prisons. Health Promotion in the Prison Setting. Summary Report on a WHO Meeting, London, 15–17 October 1995. WHO. Copenhagen

World Health Organization. Health in Prisons. 2020.

https://www.euro.who.int/__data/assets/pdf_file/00...

Last accessed September 2020

3. United Nations Office on Drugs and Crime. Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules). 2015.

https://www.unodc.org/documents/justice-and-prison...

Last accessed September 2020

4. Institute for Criminal Policy Research. World Prison Population List. 2018. 12th Ed https://www.prisonstudies.org/sites/default/files/...

Last accessed September 2020

5. House of Commons Library. UK Prison Population Statistics. 2020

https://commonslibrary.parliament.uk/research-brie...

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6. Ministry of Justice. 2020. Population Bulletin May 2020

https://www.gov.uk/government/statistics/prison-po...

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7. Klug, H.P. (2020) Health in Prisons.

https://www.euro.who.int/__data/assets/pdf_file/00...

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8. Public Health England and Department of Health. Adult Substance Misuse Statistics from the National Drug Treatment Monitoring System (NDTMS) 1 April 2016 to 31 March 2017

https://assets.publishing.service.gov.uk/governmen...

Last accessed September 2020

9. Farrell M, and Marsden J. Acute Risk of Drug-related Death Among Newly Released Prisoners in England and Wales. Addiction. 2007. Vol 103 pp 251-255

10. Clinks. Whole Prison, Whole Person. How a Holistic Approach can Support Good Mental Health in Prison. 2019.

https://www.clinks.org/sites/default/files/2019-04...

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11. Public Health England. Public Health Matters. 2015.

https://publichealthmatters.blog.gov.uk/2015/07/06...

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12. Wright S and Khan S. The Support Needs of Offenders and Familie. 2010

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13. Home Office and Public Health England (DATE) Rebalancing Act. A resource for Directors of Public Health, Police and Crime Commissioners, the Police Service and Other Health and Justice Commissioners, Service Providers and Users.

http://www.revolving-doors.org.uk/file/2049/downlo...

Last accessed September 2020

14. Public Health England and World Health Organization. Public Health England Health and Justice Report 2014

https://assets.publishing.service.gov.uk/governmen...

Last accessed September 2020

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