Prison health care

“The doors in here don’t have handles,” said my guide as he led me in through the prison entrance, “my keys are like a portable door handle.” And indeed you can’t get anywhere inside Dorchester prison without a set of keys—every door was locked behind me before the next was opened as I walked around. My visit to three of Dorset’s men’s prisons was an eye opening introduction to the constraints of prison health care. But at least I could go home at the end of the day.

Complete loss of freedom is the punishment intended when an offender is given a custodial sentence, but should inadequate health care also be part of the sentence? Absolutely not. According to the United Nations, prisoners should have access to equivalent health services available in the rest of a country without discrimination based on their legal situation.¹ If properly used, the prison system can provide a unique public health opportunity to target the most deprived sections of society, a group often invisible to the wider healthcare system. Evidence shows that improving the health of prisoners by tackling problems such as mental health and drug use can reduce reoffending and should therefore be of interest to those aiming to reduce crime and improve public health.²

The opportunity

Prison health care isn’t only a humanitarian concern; it constitutes a major public health issue. Nearly all of the prisoners currently behind bars in the United Kingdom will be released back into the community at some point, carrying any health problems with them. The unmet needs of prisoners can threaten the wellbeing of their families and communities. For example, an outbreak of a multidrug resistant strain of tuberculosis in New York in 1989 was later linked to prisons that had given inadequate treatment.³

Many prisoners have had little or no regular contact with health services before coming into prison. They tend to come from sections of society with high levels of social exclusion and have poorer physical and mental health than the general population. Common problems include mental illness (table 1), substance misuse (table 2), and communicable diseases associated with intravenous drug use and poor sexual health.⁴ Entering prison, away from their previous chaotic lifestyles, prisoners have an opportunity to consider health needs and concerns that they may not have been able to deal with on the outside. At their best, therefore, prisons can provide a unique opportunity to reduce inequalities in health as they reach disadvantaged, usually hard to access populations with health promotion, health education, and disease prevention measures, and they engage prisoners in primary care, mental health, and drug services.

Furthermore, it is not only the prisoners themselves who can be targeted by health initiatives. Visits by relatives and friends to people in prison present opportunities for healthcare programmes to reach an even wider section of the disadvantaged population with health and lifestyle education and promotion campaigns. Families can benefit too; one particularly insightful project that I learnt about provided parenting classes for prisoners in an attempt to help imprisoned parents give their children a better home environment and upbringing when they are released.

The response

With opportunities abounding, how well is prison health care stepping up to the plate? I was amazed to discover that it was only in 2003 that the National Health Service became responsible for health care in UK prisons.⁵ Before then, prisoners had limited access to NHS services. The prison healthcare system was run by the Home Office and was not subject to NHS standards; the quality of health care in prisons was patchy around the country and did not meet the needs and opportunities that were presented.

Since the integration of NHS and prison healthcare systems was initiated, much has improved. A general practitioner service provides primary care for each prison and is available to every prisoner—this allows prisoners to seek help for issues, from an acute skin rash to chronic lung disease or diabetes. In many prisons, however, prisoners must apply in writing for an appointment—a problem when a large proportion of the prison population is illiterate.

There are many similarities between primary health care in prison and in the community but there are also unavoidable differences and obstacles that go along with loss of freedom. The prison environment itself poses a threat to mental wellbeing; prisoners cannot choose their healthcare team, and healthcare staff cannot determine the beginning or end of a course of treatment because prisoners are liable to be moved or released with little notice. Other difficulties of prison life include bullying, loneliness, boredom, and lack of privacy, exercise, fresh air, and opportunities for working and learning—all of which can affect prisoners’ health despite the quality of health care available.⁴ Such problems must be addressed if the general wellbeing of prisoners is to be improved further; a culture of health promotion should be incorporated into the wider work of the prison.

Mental health is a particular problem for many prisoners. The reasons for this are twofold; firstly, people with mental disorders may be at risk of behaviours leading to arrest and imprisonment, resulting in more people with mental health problems coming into the prisons, and secondly, some factors associated with imprisonment, such as depressing environments, lack of purposeful activity, and lack of contact with family and friends are themselves linked with poor mental health, exacerbating existing problems.⁴ Not all prisoners with mental disorders need specialist psychiatric referral, however, and for most, adequate mental health promotion and treatment are offered by primary care teams.

Treatment of drug dependency is an area where great advances have been made. Sixty to seventy per cent of prisoners entering UK prisons have a history of illicit drug use.⁶ With high turnovers in many local prisons, this equates to a huge number of drug users passing through the prison health service each year. I discovered that most prisons do not succeed in making themselves drug-free environments, however, and imprisonment per se does not seem to motivate prisoners to stop their drug use. In some cases prisoners may even start using drugs for the first time or relapse from withdrawal on the outside.⁷ Imprisonment has also been shown to be associated with an increased risk of drug related harmful behaviour such as syringe sharing.⁸

Many drug users in prison have had no previous contact with services, so time spent inside can represent an opportunity for a wide range of drug services and support projects to target users with drug treatment services, counselling, and pre-release and post-release programmes. Alongside these services are also opportunities to address risky behaviours accompanying injecting drug use, for example educating users about the dangers of needle sharing, which can lead to a high risk of acquiring infectious diseases such as hepatitis C and HIV.

In the past, prisoners were given little support other than services promoting abstinence, and minimal support for detox. A high proportion of prisoners were consequently at risk of overdose within 24 hours of their release, with associated high mortality rates as they had lost tolerance to the quantity of drugs they had used previously.⁹ This system also increased risk taking behaviour by increasing the demand for drugs to be smuggled into the prison and encouraging covert needle sharing. A number of initiatives have been introduced improving the quantity and quality of drug services, culminating in a programme known as “integrated drug treatment system,” which is now being introduced into selected prisons.¹⁰ This service encompasses the planning and delivery of clinical interventions such as detoxification and substitute prescribing, and psychosocial interventions, and aims to ensure uninterrupted continuity with community treatment programmes after release. The system allows prisoners on short custodial sentences to be maintained on a substitute such as methadone, significantly reducing their risk of overdosing on release.

The challenge

Despite the advances that have been made, there is still some way to go. Remnants of a traditional prison attitude to doctors remain; prisoners sometimes approach doctors as allies against the prison authorities, and prison staff may see doctors as giving the inmates excuses or treating them too gently. For example, one general practitioner consultation that I observed involved a prisoner who wanted a letter for permission to wear flip-flops in the wing as his feet had severe blisters—he was anxious that without such evidence, a prison officer might confiscate the flip-flops.

Another particularly frustrating difficulty for prison healthcare staff concerns referrals to secondary care outside the prison. Prison staffing is generally tight, and because each prisoner must be accompanied by two officers, capacity to take prisoners to specialist outpatient clinics is limited. This can lead to problems with prisoners missing essential appointments.

The challenge also remains that the health of prisoners tends to be worse than that of the community, so that even if equivalence in healthcare provision in prisons is achieved, it may not guarantee equivalence in health status.

Valuable experience

A prison sentence should signify a loss of freedom, not a loss of health. In the prisons that I visited, health care is striving to meet the glut of opportunities presented. The staff I met were proud of the considerable progress that has been made in recent years, especially with the quality and availability of primary care and the introduction of drugs services, yet prison health care still poses a fascinating challenge to doctors on both a personal and a national public health level. As a personal challenge doctors face working with a diverse, interesting, and needy patient group that necessitates the development of exceptional personal skills, and on a public health scale prisons present a unique opportunity to address the distinctive health needs of a disadvantaged and hard to reach population.

Prison health services are keen to expand opportunities for student placements and to engage young doctors. Involvement in prison health care can be a valuable experience, giving students a unique educational opportunity to observe and understand complex healthcare needs and demands not often encountered in our medical training. Why not consider organising a special study module at your local jail?

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

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