Prisoner health: a Q&A with Miranda Davies

1. What does the new report do and how does it differ from your previous prison health care report?

Our previous work was the first time that hospital data had been analysed to look at the realities of life in prison and what it means for people’s health. For this new report, we were able to look back at how things have changed (or not) over the last four years – with some very interesting discoveries.

We found that a lot of health care was needed to manage the impact of violence and self-harm, and that pressure on access to services leads to a lot of missed appointments. Prisons are often a contentious topic, but misconceptions about them being a ‘holiday camp’ hide the fact that in prison are a range of people whose health needs are not always being met. The tragic death of a newborn baby at HMP Bronzefield is an important example of this, as people don’t tend to think about pregnant women being in prison.

We also looked at new areas. Given the last 18 months, it was important to get an early sense of the impact of the Covid-19 pandemic on prisoners’ access to hospital care.

2. What did you find?

Prisoners continue to face challenges accessing hospital care. We found that they missed over 40% of outpatient appointments in 2019/20, and this has been a long-term issue. Our work also shows that when prisoners are accessing hospital services it’s often as a result of violence or self-harm, which points to wider challenges facing the prison system around poor living conditions, overcrowding and a loss of experienced staff.

Since 2016/17, injury and poisoning have consistently been the most common reason for inpatient hospital admission. Compared to people of the same age and sex in the general population, the latest data shows that admissions for injury and poisoning are twice as high for those in prison. 

We also looked at what happened to prisoners at the start of Covid-19. We only had data for the very start of the pandemic, but it showed a drop in hospital admissions among prisoners. In some ways we might have expected this as fewer people went to hospital at that time among the general population too, but for prisoners it’s a real worry as this came on top of what was already poor access to hospital care. Lockdowns in prison have also lasted much longer and many prisoners have been in their cells for 23 hours a day for over a year, which only adds to the concern.   

For the first time in this work we were also able to see how hospital data could help us learn more about people’s health care needs on arriving in prison. From a sample of 582 prisoners, just under 40% had been admitted to hospital before prison with a diagnosis related to drugs, and just under 30% had been admitted with mental health needs (specifically mood disorders such as bipolar disorder). Health care services in prisons need to be ready to meet this level of demand.

3. What surprised you most in your findings?

That the data surrounding prisoner ethnicity was so poor. In other Nuffield Trust research, we found in general population hospital records that just over 13% of ethnicity information is missing. But for prisoners this is as high as a third, either missing or coded as “not stated”. This really matters because we know that black and minority ethnic backgrounds are overrepresented within the prison system but we don’t know enough about what their health care is like.

4. What surprised you least? 

I wasn’t surprised that injury and poisoning are consistently the most common reason why people are admitted to hospital, as for me it points to the wider difficulties of the prison environment. Prisons are not an easy ride, and levels of self-harm, violence and drug-taking show the human cost of being in prison. In the 12 months to December 2020 there were more than 55,000 incidents of self-harm in prison in England and Wales. 

5. How worried should we be by what you found?

I was worried by this three years ago and I’m still worried now. In many ways nothing has changed. Violence and self-harm in prison are still rife, and prisoners continue to face challenges accessing health services that if anything will have been made worse by the pandemic.

Our work lays bare the systemic challenges facing the prison estate and this isn’t an easy fix. The health of prisoners and the health care they receive is a symptom of so many other things, but as an area it isn’t prioritised at a government level so the cycle continues. The rapid turnover of who holds ministerial posts linked to the justice system is a classic example of the lack of interest in criminal justice beyond narratives of being “tough on crime”. There is also a reported £900 million maintenance backlog in the prison estate, which means living conditions continue to get worse.

6. Talk us through how you carried out the analysis

We looked at inpatient and outpatient hospital data from 2016/17 to 2019/20, and used the prison’s postcode as a marker of hospital visits linked to a prison location. In the hospital data we can then look at the details of the visit, but we can’t see personal information about the patient such as their name, home address or NHS number. 

Alongside this data work we carried out a literature review to capture work going on in the prison estate in England and Wales around prisoners’ health care needs and experiences accessing health care services since 2018. We have also produced an explainer on the basics about how prison health care is commissioned and delivered, which we hope will be useful to people who might want to learn more about how health care is provided to prisoners.

7. What needs to happen next?

I hope in the future that it will be normal practice for hospital data to be used to inform health care provision for people in prison. This is an untapped resource that can be used to make care for prisoners more targeted to their needs. Looking at health care needs on entry to prison as an example, if we know that just under 40% of prisoners are likely to have specific needs related to drugs, this information should be used to shape service provision.

We also have plans for the future of our work. We have now started work looking in greater detail at the use of hospital services by women prisoners, older prisoners and younger prisoners. We will be working with a range of stakeholders, crucially including people with lived experience of prison, to decide which aspects of health to look at, as well as how this work can be used to inform policy and practice.