Views And Reviews Acute Perspective

David Oliver: Are hospitals heading the same way as prisons?

BMJ 2017; 356 doi: (Published 03 February 2017) Cite this as: BMJ 2017;356:j514
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}

In 2016 England’s jails faced riots,1 damning inspection reports on conditions,2 and tales of ready access to drugs.3 The latest and largest riot was at HMP Birmingham, where officers lost control for 48 hours.4

Widespread coverage has been given to prison overcrowding,56 superannuated buildings,78 and prison officers’ numbers, workload, and morale.9 Unions, campaigning charities, and the inspectorate have flagged concerns repeatedly.10

We in NHS hospitals can empathise. Overcrowding, short staffing, and low morale put patients and organisations at risk. Acute activity, overcrowding, and delayed transfers are at unprecedented levels: we’re full to bursting. These issues have been highlighted repeatedly but are played down and ducked by the government.

The UK prison population has increased steadily to a 2015 level of 84 000 inmates.11 This relentless upward trajectory looks much like NHS acute admissions—the response to which has been to cut beds and propose further cuts. Some of the prison overcrowding is a result of changes to sentencing policies. The UK now has one of the highest per capita prison populations in Europe (by contrast, the NHS has almost the lowest hospital bed base),1213 but it hasn’t matched capacity to demand.

The Prison Service remains short of its own targets for officer numbers. Poor staffing, loss of experience, and inadequate supervision have been cited as key safety factors behind recent troubles.14

The outsourcing obsession, familiar to the NHS, has led to serial scandals in facilities run by private contractors

Government policy around building new prison places has been stop-start and has failed to deliver on promised numbers—compounding overcrowding and risk. We’ve seen U-turns on proposed moves to giant “Titan” prisons and heard doctrinal debates on optimal institutional size, familiar to anyone studying NHS reconfiguration plans.15

Much rhetoric has focused on crime prevention, community solutions, and alternatives to prison. As with the NHS, the government hasn’t invested sufficiently in those approaches. The probation officer workforce has been cut, outsourced, and demoralised.16 The prevalence of mental illness, learning difficulty or disability, and addiction are far higher in prisons than in the general population.17 Inadequate funding for mental healthcare, drug and alcohol services, disability benefits, and public health are the antithesis of prevention.

The outsourcing obsession, familiar to the NHS, has led to serial scandals in facilities run by private contractors. Some, including HMP Birmingham, had to be rescued by public sector teams. Transient ministers have created uncertainty by taking prison policy in very different directions, hawkish or progressive.141517 The Treasury belatedly announced emergency funding only when reputational damage from crises forced its hand.1819 Political expediency trumps steady, long term leadership by expert career professionals. This is no way to run major, national, public services.

NHS hospitals may limp on through this winter. But, with prison-style crises looming, I predict a riot.



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