Intended for healthcare professionals

Feature Healthcare and Justice

The prison service is still failing inmates’ healthcare needs

BMJ 2020; 368 doi: (Published 26 February 2020) Cite this as: BMJ 2020;368:m724

Linked Commentary

Incarceration is dehumanising, but good healthcare can restore dignity

Linked Opinion

Why we should worry about prisoners missing hospital appointments

  1. Stephen Armstrong, freelance journalist
  1. London
  1. stephen.armstrong{at}

UK prisoners face serious problems in accessing secondary care, the Nuffield Trust has found. Stephen Armstrong asks why

In September 2019 a newborn baby died after an inmate at HMP Bronzefield, Britain’s largest female prison, gave birth alone in her cell at night.1 An inspection by the Independent Monitoring Board, the prison welfare watchdog, had identified “severe shortages” of nurses at the privately run prison, as well as problems in accessing mental health support for inmates.2 Shortly afterwards the Ministry of Justice revealed the number of pregnant prisoners in the system, which in November 2019 was 47.3

This week the Nuffield Trust published an analysis of 2017-18 hospital data showing that prisoners—including pregnant women—faced severe problems in accessing secondary care.4 The research linked data on prisoners’ residences to their use of NHS hospital services—inpatient, outpatient, and emergency care, the reasons for use, and how access compared with the general population. Prisoners accounted for around 12 000 admissions, 18 000 emergency attendances, and 83 000 outpatient appointments.4

Pregnant prisoners

In one year, 56 prisoners gave birth during their prison stay. Of particular concern, says the Nuffield Trust, is that over one in 10 mothers gave birth either in prison or on the way to hospital. It also found that 22% of pregnant prisoners missed midwife appointments and that 30% missed obstetric appointments in 2017-18, compared with 14% and 17% in the general population.

These problems are not limited to pregnant prisoners. Prisoners had 24% fewer inpatient admissions and outpatient attendances than the same age and sex demographic in the wider population and 45% fewer emergency attendances. Some 40% of prisoners’ outpatient appointments (32 987) were not attended—more than double the figure in the general population. Over 75% of missed appointments were cancelled in advance or were recorded as people not turning up, the latter costing the NHS £2m (€2.4m; $2.6m).4

Miranda Davies, senior fellow at the trust, says, “One in 10 pregnant prisoners giving birth before reaching hospital suggests serious lapses of care within prisons. Prisoners have the same rights to healthcare as the rest of us, but these rights are not being upheld. This is particularly concerning, given their higher healthcare needs and greater likelihood to experience violence and injury.”

Kirsty Kitchen, head of policy at Birth Companions, a charity supporting mothers and babies in prison, is calling for an end to the imprisonment of pregnant women and new mothers, “in all but the most exceptional circumstances.”

She says, “One woman told us she was so worried about ‘not getting out in time’ that she lied about reduced fetal movements and then begged the midwives to help her stay in hospital.”

Poorer health

A 2018 report by the parliamentary Health and Social Care Committee5 found that physical health in the prison population was poorer than in the general population, even before incarceration. Most already had poor health linked to early childhood abuse, neglect, and trauma; problems with housing or employment; and higher rates of smoking, alcohol, or substance misuse. For example, tuberculosis cases per 100 000 were over five times higher in prison, and 13% of female prisoners and 7% of male prisoners had hepatitis C, compared with 0.4% of the general population.

Prisoners often have specific health needs related to violence, drug use, and self-harm: injury and poisoning account for 18% of admissions, compared with 6% in the general population. Psychoactive substance use was recorded in over 25% of inpatient admissions of prisoners.4 The average age of death of people detained in prison in England is 56.5

NHS England is responsible for commissioning all healthcare services for the country’s prisoners (excluding emergency and out-of-hours services).6 NHS England Health and Justice teams commission according to the “principle of equivalence,” meaning that prisoners should receive an equal level of service to the rest of the population.7

“This is just another symptom of a prison system in crisis,” Peter Dawson, director of the Prison Reform Trust, tells The BMJ. “Whatever else a sentence may mean, it surely shouldn’t include denial of access to essential hospital care. This report accurately diagnoses the problem—a chaotic prison system that routinely fails to get seriously unwell people to the appointments made for them.”

The report showed a huge rise in prisoners and a drop in prison staff. On average, 83 000 people were held in prison in England and Wales at any one time last year,8 up from just under 45 000 in 1990, while prison staff decreased by over a quarter during 2010-17.9

Health escorts

Hospital visits require two prison officers to accompany a prisoner. GPs working in prisons have told The BMJ that the number of healthcare escorts vary but are commonly two a day—one in the morning and one in the afternoon. Some prisoners suggest that relationships between individual prisoners and staff can influence how quickly their request for healthcare is passed on (see patient commentary).

“As GPs, we rely on our security colleagues, and we’re not in a position to send 100 prisoners to hospital in a day,” explains Anna Hiley, founder of the Leicester based Inclusion Healthcare, which runs primary healthcare practices for homeless people, asylum seekers, and prisoners. “There’s also the issue that patients can’t be told when an outpatient appointment is, to prevent escape plans—so prisoners can be left in the dark and suddenly get told they need to go to hospital when they may not be ready, or they may have a legal or family visit. We need to improve information for patients.”

Jake Hard, chair of the Royal College of General Practitioners’ Secure Environments Group, who has 14 years’ experience in prison based primary care, says, “Whilst the research draws attention to a number of weaknesses within the system, it is important to note the complexity of healthcare provision in the secure and detained setting, and, in my view, it further underlines the crucial need for stakeholders to work more closely in partnership and explore further these issues to find appropriate, cost effective solutions.”

Both Hiley and Hard say that reasons for the difference between the prisoner and general populations are multifactorial. Lower attendance at emergency departments could reflect prisoners’ primary healthcare preventing unnecessary admissions. They advise that all prisons should have visiting GPs and mental health teams, as well as in-house nurses, while other services vary between prisons. Prisoner health records are still being digitised, meaning that handwritten referrals to hospitals can delay appointments. Patients may move between prisons while waiting for an appointment.

Dawson concludes, “The problem is, we know very little about how prisoners’ physical health needs are being met. It is imperative that public bodies work together to publish data on prisoner health and the availability of health escorts in prison.”


  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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