1. Why did you decide to research prisoners’ hospital use?
When I started researching prisoner health it quickly became clear there was a lack of publicly available data at a national level on the physical health of prisoners. The main focus of existing literature was on mental health, substance abuse and communicable diseases, underpinned by the impact of social inequality on the unmet needs of people entering prison. Physical health content tended to be drawn from international research.
These are all important areas, but we felt that using hospital data in England we could add something new by looking at how often and why prisoners use secondary care – and what in particular that tells us about their physical health care needs.
2. What did you find?
• In 2017/18, prisoners had 24% fewer inpatient admissions and outpatient attendances than the same 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. Over three-quarters of missed appointments were cancelled in advance or recorded as people simply not turning up on the day. The value of the latter equated to around £2 million for the NHS.
• Prisoners have particular health needs related to violence, drug use and self-harm, with injury and poisoning accounting for 18% of admissions, compared to 6% in the general population. Psychoactive substance use was recorded in more than 25% of all inpatient admissions by prisoners.
• 56 prisoners gave birth during their prison stay, and over one in 10 of these (six prisoners) gave birth either in prison or on their way to hospital.
3. What surprised you most about these findings?
The sheer volume of outpatient appointments missed by prisoners. 40% of outpatient appointments for prisoners were not attended, which is double the rate of missed appointments we see in the general population. When you then start to think about the reasons why appointments are missed, it’s a really powerful illustration of some of the practical difficulties prisoners face getting access to hospital care. Whether that be staff availability to escort them on the day, or whether their appointment is cancelled at the last minute as someone else has to be rushed to hospital in an emergency.
4. What surprised you least?
That injury and poisoning were the most common reasons for prisoners being admitted to hospital. The conditions in prison, as well as the overwhelming impact of violence, self-harm and use of psychoactive substances, are clear from safety in custody statistics, inspection reports on conditions in prisons and what is reported in the media – that’s clear before you even speak to those living and working in prisons.
Hospital data, however, shows the practical reality of what this means for people in prison – the number of head injuries is particularly shocking. There were over 500 hospital admissions as a result of head injuries, including 39 intracranial injuries.
5. Talk us through how you carried out the analysis
We looked at over 110,000 patient hospital records for prisoners at 112 prisons in 2017/18. Prisoners’ use of hospital services was identified using postcode information in routinely collected hospital data (Hospital Episode Statistics). By knowing the postcode of prison estate locations, and with permission from NHS Digital, we can look at anonymised hospital records linked to when people in those locations go to hospital for whatever reason. The data doesn’t give us details like anyone’s name or NHS number, so specific individuals in prison cannot be identified.
6. Did you talk to prisoners and prison staff?
Yes, I visited a number of prisons, and spoke to prisoners as well as people and organisations that work with prisoners on a day-to-day basis. The main focus of the work was hospital data and what it tells us about prisoners’ use of hospital services as that hasn’t been looked at before, but the visits and wider conversations were vital to make sense of the data.
There are other organisations better placed to do justice to people’s lived experiences of prison, but hopefully the data is important context to sit alongside the experiences of people living and working in prison, as well as their family and friends (all of whom are affected by conditions).
7. Have you engaged government and parliament with the findings?
Throughout the project we have engaged with representatives from a number of public organisations involved in the National Partnership Agreement for Prison Healthcare, as well as other organisations and individuals who work directly with prisoners – many of whom sat on the expert panel supporting our work and provided invaluable advice and guidance.
On a practical level it has been hard to engage with ministers over the course of the project as there have been many changes in personnel. Since starting this work in 2018, there have been three changes to the Lord Chancellor and Secretary of State for Justice and four new Parliamentary Under Secretary of State for Prisons and Probation.
We have engaged MPs in the work, through responding to recent inquiries from the Justice and Health Select Committees and by sending copies of the report to parliamentarians. We hope they take on board the key message that there needs to be more transparency around prisoners access to health care.
8. How worried should we be by these findings?
The biggest worry for me is the lack of publicly available information about the health of people in prison and all the gaps in knowledge our report highlights – such as uncertainty surrounding how many prisoners can be escorted to hospital on any given day and how this relates to underlying health care need. The ongoing political rhetoric is of being ‘tough on crime’, but reoffending rates remain high so something obviously isn’t working.
9. What do you hope will change as a result of this research?
Prisons, and people in prison, are easy to ignore, so one thing I hope this research does is raise awareness of things about prison that people might not know. I was surprised by how many people I spoke to while out and about who had no idea about the death of the new born baby at HMP Bronzefield and hopefully our research will help to give such circumstances the attention they deserve.
The Nuffield Trust’s report, Locked out? Prisoners’ use of hospital care, is published today. The research, funded by the Health Foundation, points to a number of key recommendations for the public authorities involved in prisoner health. Further research by the Nuffield Trust will explore prisoners’ use of hospital services over time.
Davies M (2020) “Prisoner health: Dr Miranda Davies Q&A”, Nuffield Trust comment.