Injustice? Towards a better understanding of health care access challenges for prisoners

Many prisoners still struggle to access hospital services despite their significant health care needs, and early data suggests the pandemic has worsened access further. In this report, we consider new evidence relating to pre-existing health conditions before prison, the use of remote consultation, different ethnic groups' use of health services and the early impact of the Covid-19 pandemic.

Since the start of the Covid-19 pandemic, the prison population has shrunk by approximately 6%, from just under 83,000 people in March 20201to around 78,000 people in March 20212 – the smallest it has been since 20063.

While people are in prison they are still entitled to receive health care, and the ambition of the National Prison Healthcare Board is that prison health care is equivalent to the health care received by the general population4. But prison is a unique environment in which to provide this, as delivering health care to prisoners is secondary to the primary function of the prison, and the custodial environment impacts on how care can be delivered day-to-day.

Poor working conditions and falling application rates mean the availability of prison escorts or escort slots continues to lead to access challenges. Meanwhile, many people are entering prison with specific health needs but it is not clear if prisons are equipped to meet these demands.

This research report follows our first report into prisoner health care and reviews the recommendations in light of new data and draws on admitted patient care and outpatient data as well as a review of recent policy literature. It also considers the new evidence in relation to: pre-existing health conditions, remote consultations, different ethnic groups' use of health services, the early impact of the Covid-19 pandemic and improving understanding of people's health care needs on entry to prison. 

  • 20/10/2021
  • Dr Miranda Davies
  • 20/10/2021
  • Rachel Hutchings | Dr Miranda Davies

Key findings

  • In 2019/20, prisoners missed 42% of outpatient appointments (compared to 23% of the general population) increasing the risk they will be more seriously ill by the time they are seen and making it more difficult to appropriately manage ongoing health conditions. Appointments missed without any warning were three times higher than for the general public.
  • Early data suggests that Covid-19 has worsened prisoners’ ability to access hospital services. Given that their access to services was already poor, this raises concern about unmet health care needs even further.
  • During the first month of the pandemic (March 2020), admissions to hospital by prisoners in England fell to 1,019. This was the lowest level seen in the last 12-months. Emergency admissions also fell by 16% with only the most urgent admissions going ahead for cancer and dialysis.
  • Over the four years up to 2019/20, one in five hospital admissions were related to injury or poisoning, highlighting the impact of poor living environments and the demand placed up health and care services as a result of violence and self-harm.
  • Hospital data needs to be used more effectively to plan services to meet the high level of health care need upon entry to prison. This information can inform our understanding of the level of health care needs relating to drug use, mental health and alcohol-related disorders.
  • Evidence shows that many prisoners are already arriving with health care needs that have required hospital care in the past, with 22% of prisoners having been previously admitted with a diagnosis of chronic obstructive pulmonary disease (COPD), and 11% with diabetes.
  • The data for understanding how a prisoner’s ethnicity might affect their access to health services is poor and needs to be improved. One-third of admitted patient care activity by prisoners has missing ethnicity data – compared with only 13% in the general population.
  • In the light of this new analysis, it is clear that many of the challenges identified in our 2020 report, such as prisoners’ poor access to services, are long-term problems that still need addressing. Further decline seems to have occurred over the last 18 months due to the pandemic, although the full impact of Covid-19 on prisoners’ health care needs is yet to be understood.

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

Suggested citation

Davies M, Keeble E and Hutchings R (2021) Injustice? Towards a better understanding of health care access challenges for prisoners Research report, Nuffield Trust

Official statistics: prison population figures: 2020: population bulletin: monthly March 2020’. prison-population-figures-2020. Accessed 27 April 2021.


Official statistics: prison population figures: 2021: population bulletin: monthly March 2021’. prison-population-figures-2021. Accessed 27 April 2021.


Annual prison population: 2020’. government/statistics/offender-management-statistics-quarterlyjanuary-to-march-2020--2. Accessed 9 September 2021.


National Prison Healthcare Board (2019) National Prison Healthcare Board Principle of Equivalence of Care for Prison Healthcare in England. GOV.UK. uploads/attachment_data/file/837882/NPHB_Equivalence_of_Care_ principle.pdf.