Locked out? Prisoners' use of hospital care

There were, on average, 83,000 people in prison in England and Wales at any one time last year, yet relatively little is known about prisoners’ physical health care needs; how and why they access hospital services; and whether their physical health needs are being adequately met.

Using a novel approach involving the linking of data on prisoners’ residences to their use of NHS hospital services, this research provides new insights into prisoners’ use of secondary health services. The work covers inpatient, outpatient, and accident and emergency care; the reasons for use; and how access to care compares to the general population. We also looked specifically at health care use by women  prisoners and people over the age of 50.

Key findings

Prisoners use hospital services far less and miss more hospital appointments than the general population

• Prisoners had 24% fewer inpatient admissions and outpatient attendances than the equivalent age and sex demographic in the wider population, and 45% fewer attendances at accident and emergency departments.
• 40% of outpatient appointments for prisoners were not attended (32,987 appointments) – double the proportion of non-attended appointments in the general population. Our research found that the value of non-attended appointments by prisoners in 2017/18 where no advanced warning was given equated to around £2 million for the NHS.
• Over three-quarters of missed appointments were cancelled in advance or recorded as people simply not turning up on the day.
• 2% of all outpatient consultations were carried out by telephone/video in 2017/18 – compared to around 3% for the general population.
• 22% of pregnant prisoners missed midwife appointments and 30% of pregnant prisoners missed obstetric appointments in 2017/18, compared to 14% of midwifery appointments and 17% of obstetric appointments missed in the general population.
• There is a noticeable drop in emergency admissions to hospital from the prison population in December. This is something that is not seen in the general population.

Prisoners have particular health needs related to violence, drug use and self-harm

• Injury and poisoning were the most common reason for prisoners being admitted to hospital, accounting for 18% of cases (2,169 admissions) compared to 6% of all admissions in the general population (aged 15+).
• There were 508 hospital admissions as a result of head injuries, including fracture of skull and facial bones, intracranial injuries and open scalp wounds.
• There were also 415 A&E attendances by prisoners in 2017/18 as a result of head injuries.
• Psychoactive substance use was recorded in more than 25% of all inpatient admissions by prisoners in 2017/18.

Hospital data reveals potential lapses of care within prisons for certain groups of prisoners

• Six prisoners gave birth either in prison or on their way to hospital, representing more than one in 10 of all women who gave birth during their prison stay.
• There were 51 hospital admissions by 39 prisoners with diabetes as a result of diabetic ketoacidosis (DKA), an avoidable and potentially life-threatening complication of diabetes caused by lack of insulin.

Recommendations

This analysis points to two key areas where more focused policy attention could result in improvements to prisoner health: improving prisoners’ access to hospital care and making better use of hospital data. We therefore make the following recommendations for the five public authorities involved in the National Partnership Agreement for Prison Healthcare – the Ministry of Justice, Her Majesty’s Prison and Probation Service, Public Health England, the Department of Health and Social Care, and NHS England – as well as prisons, health care providers, commissioners, and the research community.

Improving prisoners’ access to hospital care

1. Provide greater transparency over prison escort numbers and review the supply of prison escorts
2. Increase access to outpatient services via telemedicine consultations

Making better use of hospital data

1. Collect, collate and publish regular data on prisoners’ health care use and how it compares to the general population
2. Identify and monitor avoidable health outcomes for prisoners 
3. Collect and publish data on pregnant women in prisons

This analysis  raises important questions about access to health care services and whether prisoners’ needs are being met adequately. Furthermore, it highlights gaps in knowledge and understanding about the health care needs and service use of this population.

Reduced access to health care is not in the interest of prisoners – nor is it in the interest of the NHS, the criminal justice system or the taxpayer. With the prison population set to rise at the same time as the NHS faces unprecedented staffing and operational pressures, we hope this research will provide a useful basis on which to assess how we are meeting prisoners’ physical health care needs and what we might need to do to improve.