Promoting health in prisonBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2216 (Published 11 April 2013) Cite this as: BMJ 2013;346:f2216
In previous articles I have set out the challenges of providing healthcare in prisons and have examined the problems in British prisons of elderly prisoners, women prisoners, and prisoners with mental disorders.1 2 3 4 In this final article of the series I highlight how prison contributes to the treatment of people who are “hard to reach.”
Many British prisoners come from the most economically deprived and socially disadvantaged groups within society. They share with these groups the experience of being raised in care, low educational attainment, unemployment, and homelessness (table 1⇓).5 Some minority ethnic groups are substantially over-represented (table 2⇓). Many prisoners have chaotic lifestyles and complex health and social problems. They may also have limited health aspirations and low expectations of health services, which may not have the flexibility to respond effectively to their needs.7
Prison can provide an opportunity for the orderly assessment and treatment of those whose lifestyle has previously prevented engagement. Prisoners can be encouraged to adopt healthier behaviours, and prison can be viewed as an opportunity to address health inequalities.8 However, prisons are not principally in the business of promoting health and some people argue that there is an inherent contradiction between the aims of care and control.9 Prisons have values, rules, and rituals that enable prisoners to be observed, contained, and disempowered 10; these are at odds with any notion that prisoners can be encouraged to take charge of their health.9 In addition, any discussion about the health of prisoners cannot ignore the broader question of whether prison is the right place for many offenders.
Health promotion in prison
The first dedicated health promotion strategy for prisons in England and Wales was published in 2002.8 Because few resources have been invested in evaluating it, its impact is largely unknown.11 12 In 2008-09 Her Majesty’s Inspectorate of Prisons and the Care Quality Commission examined a sample of 21 primary care trusts and found that all undertook health promotion in prisons. Although there was evidence of good practice, the information on provision was not always sufficiently detailed to allow proper appraisal.13
Around 80% of prisoners in England and Wales smoke,14 four times the proportion of the general public.15 Reasons for prisoners smoking include relief from boredom and stress.16 Smoking in UK prisons has been restricted since 2007: prisoners may smoke in their cells but are not allowed to smoke in their workplace or during educational programmes or activities.17 The government’s 2010 tobacco control strategy for England mentions prisoners as one of the vulnerable and disadvantaged groups whose high rates of smoking should be tackled.18 An evaluation study of the use of nicotine replacement therapy in 16 prisons in north east England, found that quit rates similar to those in the community are possible.19
There are, however, no plans for British prisons to become smoke-free. This is in contrast to the United States, where 60% of surveyed prisons reported total tobacco bans, with 27% having an indoor ban on tobacco use.20 Non-smoking prisoners have successfully sued several states for exposing them to second hand smoke.21
Prisons are vulnerable to infectious disease as they are often overcrowded, with poor ventilation, shared facilities such as showers, and high turnover of prisoners, staff, and visitors.22 Outbreaks of seasonal influenza and gastrointestinal disease are common,23 although prisons in England and Wales did not experience significant outbreaks during the 2009 flu pandemic.24 Prisoners have higher rates of tuberculosis, hepatitis B, and HIV infection than a similar population outside prison.25 A 1997 survey in England and Wales found that 0.3% of male prisoners and 1% of female prisoners were positive for HIV, and that 8% of adult males and 12% of adult females had hepatitis B antibodies.26 Hepatitis C antibodies were found in 9% of men and 11% of women.26
Resources available to prevent spread of blood borne viruses in prisons include disinfectant tablets to decontaminate needles, syringes, and tattooing equipment. Condoms, dental dams, and water based lubricants are available on request. A hepatitis B vaccination programme is in place. As injecting drug use is the most common risk factor for hepatitis B in the community, and 61% of injecting drug users are imprisoned at some point, vaccination in prison helps to protect this group.27
Tuberculosis is associated with drug use, incarceration, and homelessness,28 and prison offers an opportunity for identifying people who are infected. A proposed national system in England and Wales to allow screening at reception is not yet in place, but eight prisons receiving prisoners from areas of high prevalence have x ray machines, and tuberculosis case finding in prisons has increased (46 cases in 2007 versus 91 cases in 2012).23 29 However, ensuring completion of treatment is difficult. Pentonville prison found that in 2005 62% of prisoners on directly observed therapy were homeless on release, with less than half completing a full course of treatment.30
Illegal drug use in prison is a substantial problem, with some prisons having very high levels.31 In one study 48% of male and 38% of female sentenced prisoners reported using drugs during their current prison term.14 Drugs may be posted into prisons, brought in by visitors or prison officers, or thrown over the perimeter.31 Investment in prison treatment in England and Wales has increased from £7m (€8m; $11m) in 1997-98 to £80m in 2007-08 (not adjusted for inflation).32
In 2009-10, 60 067 prisoners received clinical treatment for drug addiction in prison in England and Wales.33 Sixty per cent of these were entered on a detoxification programme and the remainder on a maintenance programme.33 Individual care is planned using the integrated drug treatment system,34 which aims to combine clinical and psychosocial approaches and to bridge prison and community care.
Standards of treatment vary greatly across the prison service.35 Particular problems are recognised in addressing the needs of those serving short sentences, for whom serious drug or alcohol problems are an “abiding feature.”36 Continued support on release is also a problem,31 and prisoners are at a substantially increased risk of death by drug overdose in the first month after release.37
Health on release
Release from prison can be a “health depleting experience.”38 For instance, one study of male probationers found the suicide rate to be nine times that of the local community population.39 The operational guidelines for prisoner resettlement in England and Wales include consideration of the need for follow-up healthcare in the community,40 but the quality of planning for post release care is variable, and continuity of care can be poor.41 Half of prisoners have no general practitioner when they are released.41
Former prisoners do not necessarily prioritise their health on release, instead focusing on basic needs such as accommodation.38 In a 2003 survey in England and Wales only two thirds of adult prisoners said they had accommodation arranged for their release.42 Broader determinants of health such as poor prospects for employment and lack of social support are also problems.38
Is this the only way?
Prison clearly has a part to play in meeting the health needs of a marginalised group of people. However, it is ultimately not the best place to tackle poor health. Some newspapers delight in caricaturing prisons as “holiday camps,”43 but even if prisons shared some of their characteristics, the harms of imprisonment would remain. Custody separates families, and former prisoners experience social disadvantages such as a high unemployment rate.5 Prison’s enforced passivity and conscious wasting of life also cause acute distress.44
The average yearly cost of a prison place in England and Wales is £39 573.45 In 2012 UK total prison spend was £4.1bn.46 Despite this expense, prison does little to deter offending and almost half of those sentenced to custody are reconvicted within a year.5 It is important to ask whether the resources allocated to imprisonment could be spent more wisely, whether custody is the best way of dealing with people who offend, and how prison numbers can be kept to a minimum.
People who commit crimes often come into contact with health and social services because of their problematic behaviour. Management revolves around sanctions such as custody47 rather than earlier assistance in the community that might prevent a prison sentence. Innovative thinking is required to allow resources currently allocated to prisons to be deployed more constructively and at all stages of the lives of people at risk of future imprisonment. Many of Britain’s most vulnerable citizens now pass at some point through the criminal justice system.48 People in the community with multiple needs and exclusions have not been a government priority, and there is no overarching strategy to tackle their health and social needs 48 with the explicit aim of avoiding custody.
Although recorded crime is falling,49 the number of British prisoners continues to climb. Arguably, many of them should not be there. This is because of the relative harmlessness of their offences, the vulnerability of the offenders, and the harmful consequences of imprisonment. This is not to say that people who break the law should not be punished, but that prison and punishment should not be synonymous. Alternatives to prison may offer better outcomes and save money. One economic analysis found that community sentences save £3437 to £88 469 per sentenced offender, rising to as much as £200 000 if longer term changes to offending patterns are also considered. Community based drug treatment was found to be particularly effective at saving costs as offenders receiving treatment were 43% less likely to re-offend after release.50 Court ordered community sentences are reported to be 8% more effective at reducing reoffending rates than custodial sentences.5
Continued and increasing reliance on imprisonment is a moral and political choice, a path that politicians choose and society implicitly condones. During 1997-2009 the British government introduced 1036 new offences punishable by imprisonment51 and the prison population in England and Wales has almost doubled since the early 1990s.1 Electorally, no major political party seems able to abandon a populist stance of being “tough on crime.” Yet everyone is affected by the increasing human and economic costs of an ever more punitive criminal justice system.52
Cite this as: BMJ 2013;346:f2216
This is the last in a series of articles examining the challenges of looking after prisoners’ health
I thank the following people for help with this series: Louis Appleby, national director for health and criminal justice; Annie Bartlett, clinical academic and clinical director; Michelle Baybutt, programme lead, Health, Inclusion & Citizenship, Lancashire University; Marcus Bicknell, chair, Royal College of General Practitioners secure environments group; Luke Birmingham, consultant forensic psychiatrist, Southern Health NHS Foundation Trust; Rex Bloomstein, documentary filmmaker; Richard Byng, senior clinical academic in primary care, Institute of Health Service Research, Peninsula College of Medicine and Dentistry; Clive Chatterton, former prison governor, HMP Styal; Angela Clay, chairman, Association of Members of Independent Monitoring Boards; Sally Cottrell, head of evaluation, Avon Primary Care Research; Andrew Coyle, former director, International Centre for Prison Studies; Graham Durcan, associate director, Criminal Justice Programme; Dawn Edge, research fellow, University of Manchester; Tim Exworthy, consultant forensic psychiatrist, St Andrew’s Hospital; Helen Fair, research associate, International Centre for Prison Studies; Michael Farrell, director, National Drug and Alcohol Research Centre; Seena Fazel, clinical senior lecturer, Department of Psychiatry, University of Oxford; Andrew Forrester, honorary senior lecturer in forensic psychiatry, South London and the Maudsley NHS Trust; Andrew Fraser, director of health and care, Scottish Prison Service; Claire Gauge, head of learning lessons, Prisons and Probation Ombudsman England and Wales; Paul Hayton, deputy director, WHO (Europe), Collaborating Centre for Health and Prisons; Alex Hewson, policy and programmes manager, Prison Reform Trust; Adarsh Kaul, clinical director, Offender Health, Nottinghamshire Healthcare NHS Trust; Annabel Kennedy, director, Birth Companions; Richard Knowles, head of prison healthcare, NHS Isle of Wight; Nick Le Mesurier, independent researcher and honorary lecturer, Staffordshire University; Jonathan Lloyd, GP, HMP Nottingham; Juliet Lyon, director, Prison Reform Trust; Eoin McLennan-Murray, president, Prison Governors; Natalie Mann, lecturer in criminology, Anglia Ruskin University; Ryan Mullally foundation year 2 trainee, Nottingham University Hospitals; Nigel Newcomen, prisons and probation ombudsman, England and Wales; Éamonn O’Moore, consultant in public health, Offender Health; Frankie Owens, former prisoner; Mary Piper, senior public health consultant, Offender Health; Emma Plugge, department of public health, Oxford University; John Podmore, former prison governor, HMP Brixton; Lord David Ramsbotham, former HM inspector of prisons; David Scott, senior lecturer in criminology and criminal justice, University of Central Lancashire; Toby Seddon, professor, School of Law, Manchester University; Joe Sim, professor, School of Humanities and Social Science, Liverpool John Moore University; Nicola Singleton, Director of Policy & Research UK Drug Policy Commission; Richard Smith, former editor, BMJ; Alastair Storey, clinical lead and manager Find&Treat; Elizabeth Tysoe, head of healthcare inspection, HM Inspectorate of Prisons; Azrini Wahidin, reader in criminology and criminal justice Queen’s University Belfast; Stuart Ware, founder of Restore Support Network; Susan Yates, research nurse, Royal Free Hospital; the staff and governor of HMP Nottingham; the staff and governor of HMP Isle of Wight.
Contributors and sources: SG is an ST5 trainee in general adult psychiatry and was the 2011-12 Roger Robinson BMJ editorial registrar. Information for this series was obtained from an unsystematic literature review, prison visits, and discussions with prison doctors, prison nurses, prison and forensic psychiatrists, prison governors, prison reformers, prison health managers, prisoners, criminologists, sociologists, and prison inspectors.
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed,