Numbers matter in prison

Looking at headlines from the last few years about prison conditions in England and Wales, it is clear there are major concerns. “Are prisons in England and Wales facing a meltdown?” “Violence and self-injury in prisons hit highest levels on record”, “What is going wrong with the system?”

The headlines address a number of the challenges facing the prison estate. At the Nuffield Trust we have started a new research project looking at prisoner health care. We want to consider how wider issues affecting the prison system, such as the sheer amount of prisoners alongside decreasing numbers of staff, may impact on health and care.

But first let’s consider some of the current challenges.

Numbers have dramatically increased and prisoners are getting older

Over the last quarter of a century, the numbers of prisoners have nearly doubled from 44,552 in 1993 to 85,348 in 2016, and overcrowding is a concern. In many instances, cells built for single occupancy are being shared by two people who have to eat, sleep and use the toilet very close to each other.

There is also a changing age profile. The numbers of older people, although comparatively small, represent a growing proportion of the prison population. This is partly due to a rise in older people jailed for historical sex offences. Older age in prison is also often described to happen 10 years earlier than in the community – meaning complex health needs present earlier than they might otherwise.

The physical nature of prisons is also challenging when it comes to dealing with specific health needs – older buildings are not equipped to easily deal with wheelchair accessibility, for example, or the provision of facilities on a single level.

Meeting the health needs of older people in prison, and on release, will be a growing issue as the demographics of the prison population continue to change. By the summer of 2020, it is predicted there will be around 14,500 over 50s in prison.

Our research will examine health care for prisoners of all ages, but hopefully will provide evidence of the needs of older people, as a national strategy to address those has already been identified as necessary.

Prison officer numbers have declined

While the numbers of prisoners have risen slightly over a comparable period, over the last seven years the numbers of frontline staff have fallen by around a quarter.

Staff can affect the health of prisoners on many levels – the most basic being facilitating access to the activities that can directly affect health, such as outdoor space and visits to the gym. Insufficient staff numbers can also mean prisoners have to spend longer in their cells without engaging in education or work programmes (where they exist).

If a prison is on a restricted regime, with people only allowed out of their cells for a limited period of time each day to maintain safe staffing levels, this is likely to affect mental health and decisions to engage in unhealthy behaviours such as drug taking.

Given these staff shortages to manage the everyday running of prisons, addressing the health care needs of prisoners presents extra challenges. Staff have to be available to take prisoners to hospital appointments, such as referrals for cancer diagnosis.

In our work, we will explore available evidence on the impact of missed escorts on health – that being the availability of staff to take prisoners to hospital in an emergency or for health care appointments, which is likely to have a significant impact on health outcomes. There is no clear evidence on how long prisoners have to wait if they request to see a doctor or need a referral and how waiting affects health, but early indications suggest they can cause health to decline or result in missed diagnosis.

What is our research?

Our work aims to better understand the health care needs of prisoners, their use of health services and how quality of care compares to those not in prison.

We will review existing research and inspection reports to identify what is known about prisoners’ health care needs, and identify gaps in knowledge. We will then use routine hospital data to describe their use of secondary health care services – drawing conclusions on quality by comparing key measures against those for people not in prison.  

The project is taking place over 18 months, and is due to be completed in June 2019 when a final report will be published. Before then, we will be publishing blogs and reporting on important developments from the research, so watch this space for more on this key piece of work.

*The project is funded by The Health Foundation, an independent charity committed to bringing about better health and health care for people in the UK.