Prison population: physical health care needs

Literature

Overview

This chapter presents the findings from a literature search conducted to explore the physical health needs of people in prison and the use of health care services in prison. It focuses on the literature relating to 17 areas of physical health need, selected in consultation with the Scottish Government and relevant stakeholders, that present the greatest health burden to people in prison and to health care services.

Methods

A literature review was conducted to explore the physical health needs of people in prison and the use of health care services in prison. To do this, two separate search strategies were used: (1) physical health needs of people in prison and (2) the use of health care services in prison. The databases searched were APA PsychInfo, MedLine, Web of Science, JTSOR and Science Direct. Searches were limited to studies written in English, relating to the UK prison population between 2011 and January 2022. This time period was chosen to follow on from a previous literature review conducted as part of a prison health needs assessment in NHS Greater Glasgow and Clyde (Gillies et al., 2012), which reviewed literature up to 2011. The titles and abstracts of documents were screened, after which the full text of articles was read to identify the final sample of documents to include in the review. The search terms for both reviews can be found in Annex 1.

Physical health care needs of people in prison

In the 17^th Scottish Prison Survey, conducted in 2019 (Scottish Prison Service, 2020), 41% of people in prison reported having a long term illness, a figure that has increased from 35% in the 2017 survey. Of these, 63% stated that staff were aware of it. Over one third reported having a disability (38%), an increase from 34% in the 2017 survey (Scottish Prison Service, 2018). When asked about use of health care services, almost 60% of respondents reported having seen a doctor (57%) or nurse (59%) in prison, figures which were lower than those in the 2017 survey (73% doctor and 77% nurse) (Prisoner Survey, 2017). Just over a quarter of people in prison (29%) had seen a dentist in prison, down from 41% in 2017. Around half of respondents reported having to wait over 10 days to see a member of health care staff (dentist 55%, doctor 41% and optician 41%).

Cardiovascular disease

Cardiovascular disease (CVD) includes a range of health conditions affecting the heart/blood vessels, including coronary heart disease, angina, heart attacks, hypertension, stroke and vascular dementia, as well as congenital heart disease. As such, it can sometimes be difficult to distinguish between these conditions in research, with many sources using the general terminology of 'cardiovascular disease'. In England, Packham et al. (2020) conducted an observational survey looking at the uptake of the NHS Health Check programme to identify cardiovascular risk for 35-74 year olds in six male prisons. Of those who were eligible, 76.4% took up the opportunity and 12.1% had new significant CVD risk factors, such as Type 2 diabetes, hypertension, or chronic kidney disease. While CVD risk was similar overall to the general population, it was noticeable that the prison sample screened was 10 years younger, suggesting an age-accelerated risk. Gray et al. (2021) also reported from a study in one male prison that the majority of people residing there (81%) were either overweight or obese – a risk factor for CVD. This is considerably higher than in the general population, with figures from 2019 showing that 68% of adult men in England are either overweight or obese (NHS, 2020) with a simlar figure in Scotland (69%) (Scottish Government, 2020). The Prison and Probations Ombudsmen (2012) examined the natural cause of 402 deaths in prison in England and Wales over the period of 2007-2010 and found that the leading cause of death were cardiovascular diseases (including coronary artery disease and strokes, which were the cause of death for 43% of the sample). In Scotland, Arora et al. (2020) found 15% of people in prison reported suffering from hypertension, and 2% each for myocardial infarction and angina. International research shows prevalence of stroke-related diseases as 1.8% in US state and federal prisons and 2.3% in US jails^[2] (Maruschak et al., 2016) and 2.3% in people in Australian prisons (Field et al., 2020).

Musculoskeletal disorders

There is little research on musculoskeletal disorders among people in prison. However, prevalence figures for arthritis/rheumatism in people in prison in the US and Australia suggest a prevalence of around 15% (Field et al., 2020; Maruschak et al., 2016). Rocha et al. (2020) examined muscuoloskeletal trauma injuries in a US prison, finding that the most common fractures were metacarpal fracture (22%), interphalangeal dislocation (10%), and phalangeal shaft fracture (10%). The most injured region was the hand and wrist, with 65% of all injuries, followed by foot and ankle with 20%.

Diabetes

A health needs assessment conducted across prisons in the West Midlands reported prevalence rates for diabetes from 1.9% - 7.5% in adult male prisons, 0.5% for the two young adult male prisons, and 0.63% in the female prison (PHE, 2015), compared to a national UK prevalence of around 6%. A prevalence rate of 4.8% was reported by Mills (2015) in one English prison, of which 37% were type 1 diabetes and 63% were type 2 diabetes. Recent research by Gray et al. (2021) used data from diabetes risk assessments in one male prison, estimating that 6.4% of prison residents had risk scores indicating an increased likelihood of developing diabetes in the next 10 years, rising to 16.4% among those over 50 years. A systematic review on health needs with older people in prison (defined as those older than 50 years) reported a pooled prevalence of diabetes of 14% across all studies for this age group (Munday et al., 2019). It should also be noted that characteristics of offender populations in general (as well as those in prison) will likely contribute to a higher prevalence, particularly for type 2 diabetes (e.g. higher levels of smoking, drug and alcohol use, and increased dietary risk factors for diabetes) as well as an increase in the number of older people in prison.

Epilepsy

A PHE (2015) health needs assessment of prisons in the West Midlands reported prevalence rates for epilepsy ranging from 1.55% to 3.8% for adult male prisons and 3.18% for the female prison, all of which are higher than the national average for the UK (0.9%). In contrast, rates were much lower at the two YOIs included (0.50% - 0.85%). In a study across 10 Scottish prisons (including male and female adult and young male offender institutions), Arora et al. (2020) reported a prevalence rate of 3%.

Asthma and Chronic obstructive pulmonary disease

Prevalence of asthma reported by PHE (2015) across West Midlands prisons was higher than the UK national average of 5.9%, with rates in the prisons ranging from 7.2% - 12.6%. These were comparable to the two YOIs, with rates of 8.04% - 10.9%, with a higher prevalence of 16.24% in the female prison. Across 10 prisons in Scotland, Arora et al. (2020) reported prevalence of respiratory diseases including asthma at 16%. Prevalence rates of 6% for COPD have been reported in US and Greek prison populations (Bania et al., 2016; Trotter et al., 2018).

Blood borne viruses and sexually transmitted infections

Blood borne viruses include HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV). Given that not all people will be tested during their time in prison, overall prevalence rates can be difficult to determine. However, based on a systematic review of research on the global prevalence of HIV, HBV and HCV in prisons, it is clear that the prevalence of all of these is higher than the general population both internationally and within the UK (Dolan et al., 2016). The authors comment that this is likely to be linked to the criminalisation of drug use and high levels of drug use amongst people in prison, particularly for HBV and HCV.

Across all 14 closed prisons in Scotland, Taylor et al. (2013) reported an overall prevalence rate of 19% for hepatitis C. Among those who reported a history of injecting drugs, this rose to 53% (in contrast to 3% amongst those without a history of injecting drugs). This is similar to reports from the rest of the UK. As part of a study examining the impact of an opt-out testing policy for hepatitis C in Welsh prisons, Perrett et al. (2020) reported that between September 2015 and December 2017, 6,949 HCV tests were conducted, which was 29% of admissions to prisons, with a percentage positivity of 11%. Furthermore, short-stay residents had higher rates of HCV positivity than those residents serving longer sentences. In an audit of ~ 1260 receptions into HMP Northumberland in England during 2013-14, 102 were tested for hepatitis C, with a positivity rate of 29% (Darke et al., 2016). Furthermore, a systematic review by Falla et al. (2018) reported a pooled prevalence of 17.4% in prisons from four UK studies.

Analysis of data from the WHO's Health in Prisons European Database and the European Centre for Disease Prevention and Control's hepatitis C database by Nakitanda et al. (2020) found that the prevalence as measured by anti-HCV ranged from 2.3% in an English high secure forensic hospital to 82.6% in two prisons in Germany. Of the six studies from the UK, the prevalence across all prisons in Scotland (including young offenders institutions) in 2011 was 19.2%, as compared to 18% for all English prisons in 2016, 6% in all prison in Wales in 2015) and 12% in prisons in Northern Ireland in 2016. Nakitanda et al. (2021) repeated this analysis for hepatitis B reporting a seroprevalence^[3] ranging from 0% in a UK high secure forensic hospital to 25.2% in two Bulgarian juvenile detention facilities, with prevalence of 2.0% for a general prison in London. Prevalence rates for HIV and HCV appear to differ by age, with a systematic review by Kinner et al. (2018) finding lower prevalence rates among adolescent and young adult residents (under 25 years) compared to adult residents, although there was no difference for HBV.

A health needs assessment in two YOIs in West Midlands reported that the most common Sexually Transmitted Infection (STI) was chlamydia, with approximately 6.26% of all new referrals across both establishments testing positive on reception, and genital warts being the second most common (PHE, 2015). A US study reported an estimated prevelance of STIs among people in prisons as being 6% in state and federal prisons, and 6.1% in jails (Maruschak et al., 2016). However, beyond this, there appears to be little recent research on STIs in prison populations.

Oral health

Looking at older research, a systematic review of 21 papers on dental health in prisons found a range of prevalence for number of decayed, missing and filled teeth (DMFT), ranging from 9.8 – 16.8 teeth (Walsh et al., 2008). Flanigan (2020) compared this to prevalence rates in Scottish prisons in 2011 from the Scottish Oral Health Improvement Prison Programme (SOHIPP), which reported the average number of DMFT as 12.37 (CI 11.39 – 13.34) (Freeman et al., 2013 cited in Arora et al., 2020). More recently the 3^rd Scottish Report on Oral Health in Prisons collected data (including an oral examination) from 353 people in prison (of which 348 had an oral examination), finding that the mean number of DMFT was 13.70 (95% CI 12.75-14.64) (Arora et al., 2020). There were also differences between prison population groups, with women having greater levels of dental decay compared to male adults and male young people in prison. People with more prison experience (based on remand, sentences and sentence length) had more dental decay, and those on prescribed medication and a history of using drugs had higher levels of dental decay. In an English female prison, Rouxel et al. (2013) reported a high prevalence of oral diseases, with three quarters of their sample having decayed teeth. They also had more decayed and missing teeth and fewer fillings (average DMFT = 12.3) than the general female population (average DFMT = 11.4), and 96% reported gingival bleeding (bleeding gums), with 73% reporting that their dental health had an impact on their daily life as result. Poor oral health amongst prison residents is likely to be caused, and exacerbated, by poor diet (specifically high sugar intake), smoking and drug use. However, while dental health is an important issue, Rouxel et al.'s study reported that nearly half of their sample had been on the dentist waiting list for between 1 and 3 months.

Cancer

In 2017/18, there were more than 1,000 hospital admissions from prisons in England for cancer, covering 567 people (Davies et al., 2020). The most common cancer diagnoses were benign neoplasm of colon, rectum, anus and anal canal; other and unspecificed malignant neoplasm of skin; malignant neoplasm of bronchus and lung; and malignant neoplasm of bladder (Davies et al., 2020). In terms of prevalence, Maruschak et al. (2016) reported a prevalence of 3.5% for cancer in US state and federal prisons and 3.6% in US jails, with a corresponding figure of 6.6% in Australian prisons (Field et al., 2020). Puglisi et al. (2020), using data from the US, reported that people with criminal justice invovlement had higher age-adjusted prevalence of lung cancer, cervical cancer, and alcohol-related cancer compared with those without criminal justice involvement, although these figures included anyone who had ever been arrested, rather than only people in prison.

Chronic liver disease

There appears to be little research on chronic liver disease among people in prison. However, figures from the US estimate a prevalence of 1.8% for cirrhosis of the liver in US state and federal prisons and 1.7% for cirrhosis of the liver in US jails (Maruschak et al., 2016). In Australia, Field et al., (2020) found a self-reported prevalence of 4.10% for liver disease among people in prison.

Lower respiratory tract infection

Little research is available on lower respiratory tract infections, although a study with a Ghanaian prison population estimated a prevalence of 4.43% for respiratory viruses (Sylverken et al., 2019).

Covid-19

Covid-19 led to massive changes in prison regimes across all of the UK, with lockdown restrictions introduced limiting time out of cells – and in many cases people were locked in their cells for up to 23 hours a day. Prisons also implemented mitigation strategies such as compartmentalisation (separating out vulnerable individuals), isolation for new arrivals and measures to reduce the prison population such as the early release scheme. Within a setting characterised by overcrowding and living in close proximity to others, and a population that tends to have elevated rates of a number of risk factors (e.g. CVD, diabetes, obesity) this was seen as vital to reduce the spread of Covid-19 and associated mortality. There is little published research on Covid-19 in prisons, with official reports and figures the main sources. These show that between May 2020 and September 2021, 1,520 people in Scottish prisons tested positive for Covid-19, with 56 needing to be admitted to hospital and 6 who died within 28 days of a positive test (WHO, 2022). In England and Wales, 18,576 people in prison tested positive for Covid-19 during the same time period, with 116 who have died from Covid-19 (WHO, 2022).

Pregnancy, maternal health and post-natal care

Many women in prison around the world, including Scotland, are of a child-bearing age and each year there are a small number of women who are in prison during pregnancy. In Scotland, between 2013 and 2017, there were 104 pregnant women in prison, with 31 babies born (Prison Reform Trust, 2019). However, there is a paucity of research looking at this group and their health. Bard et al. (2016) conducted a systematic review of 18 studies looking at the health of pregnant women in prison. Of these, fifteen were in the US, two in the UK and one in Germany. There was some evidence that women in prisons receiving enhanced health care were less likely to have inadequate prenatal care (15.4 % vs 30.7 %), preterm delivery (6.4 % vs 19.0 %) or caesarean delivery (12.9 % vs 26.5 %) compared to women in prisons receiving "usual care". A qualitative study by Abbott et al. (2020) in a prison in England highlighted pregnant women's negative experiences in prison and the stress and anxiety this produces, which in turn may impact on the baby.

Past brain injury

Traumatic brain injury (TBI) is more prevalent in prison populations than the general population and TBI and offending share many risk factors, such as alcohol and drug use, lower socioeconomic status, and being young and male. A recent systematic review of brain injury in prison populations reported a range of prevalence (25% - 86%), although the variety of assessments and different definitions used are likely to be a factor (Moynan & McMillan, 2018). Where a validated tool was used, the variation remained high (36% - 78%). Focusing on Scotland, McMillan et al. (2019) reported that 25% of people in prison in Scotland had experienced a head injury requiring hospitalisation, compared to 18% in a matched general population sample. Furthermore, there was a higher number of people in prison (compared to the general population) reporting three or more head injuries requiring hospitalisations, and almost twice as many with intracranial injuries. A similar picture exists amongst young people in prisons in Scotland, with over a third reporting at least one head injury and 20% two or more, with a quarter of young people in prison receiving the injury whilst fighting. Another study in Scotland sampled 390 adult males from HMP Inverness (Young et al. 2018). Self-reports of at least one head injury were made by 72% of respondents, with 70% of these occurring before that age of 16 years. Furthermore, 70% self-reported losing consciousness as a result of a head injury. In a study of women in four Scottish prisons McMillan et al. (2021) found that 78% had a self-reported significant head injury.

Older People in Prison

Although there is no set definition for older age among prison populations, research often uses a cut-off of 50 years and older, and there is an increasing number of ageing people in prison in Scotland, in common with the rest of the UK. A Her Majesty's Inspectorate of Prisons for Scotland (HMIPS) report in 2017 reported that the majority of older people in Scottish prisons were in their 60s, with almost half serving sentences of 4 years or longer and 18% serving life sentences. The vast majority (85%) reported taking medication. With research suggesting that the health of people in prison is similar to that of non-offenders up to 10 years older, there is likely to be an increasing health need and care burden in coming years. The prevalence of many physical health conditions increases with age, as does co-morbidity – and this can be exacerbated by the lifestyles of people in prison. In England, a study conducted in prisons in North West England by the Offender Health Research Network reported that older people in prison have high rates of chronic physical health problem, with 80% aged 60-64 years reporting at least one moderate or severe illness, increasing to 92% of those over 70 years (Hayes et al., 2012). Medication is taken by 70% of older people in prison, compared to 44% of the whole prison population (Omolade, 2014). A systematic review of health conditions in older people in prison by Munday et al. (2019) reported that the prevalence of non-communicable disease in those over 50 years old was higher than younger people in prison and higher than age-matched cohorts. They found that the most prevalent non-communicable diseases were hypertension 39% (95% CI 32–47%), cardiovascular disease 38% (95% CI 33–42%), diabetes 14% (95% CI 12–16%), cancer 8% (95% CI 6–10%), and chronic obstructive pulmonary disease (COPD) 4% to 18%.

Dementia

In many countries (including the UK), older people are the fastest growing group in the prison population, and with an accelerated ageing process they are at a high risk of developing dementia. A systematic review of ten studies by Brooke et al. (2020) reported the prevalence of dementia in prison populations ranged from 0.8 to 18.8%, with the two studies in prisons in England and Wales showing prevalence rates of around 2% (Fazel et al., 2001; Kingston et al., 2011). More recently, using a sample of 869 men from adult male prisons in England and Wales, Forsyth et al. (2020) reported that 8% screened positively for possible dementia or mild cognitive impairment. However, only 3% of these men had an official diagnosis of dementia in their prison health care records. It is also worth noting that the variation in how dementia has been assessed in different studies makes it difficult to know the full prevalence within prisons.

Physical health care services delivery: Literature review

Equivalence of health care services

National Institute for Clinical Excellence (NICE) guidelines for England, Wales and Northern Ireland state that people in prison are entitled to access all appropriate cancer and non-cancer screening programmes relevant to their age, gender and other risk factors (NICE, 2016). Although these guidelines have no formal status in Scotland, the same principle of equivalent access to screening is followed. In Scotland this includes the NHS Well man/Well woman check for people between 40 and 64 years living in high deprivation areas (known as the NHS Health Check in England) that assesses risk of developing heart disease, stroke, diabetes and kidney disease, along with the national screening programmes for abdominal aortic aneurysms (AAA) for men aged 65 and over, diabetic retinopathy, bowel cancer, breast cancer and cervical cancer, as well as pregnancy screening and new born screening where relevant. In Scottish prisons, it is also expected that all people entering prison should see a health care professional within their first 24 hours in custody.

Uptake of screening programmes tends to be lower in prisons than in the community (Public Health England, 2021) and this is similarly seen in Scottish prisons. For example, between May 2015 and April 2017, the uptake of bowel screening among men in prison was 39%, compared to 53% nationally (National Prison Health Network, 2018). Similarly cervical cancer screening uptake was lower among people in prison (68%) compared to the national figure of 75%, and the AAA screen had a 73% uptake among men in prison vs. 84% in the community, although the report acknowledged that as there is only a small number of eligible men in prison, this percentage can vary by year.

NICE guidelines also recommend that prisons who receive people from high TB incidence areas should offer a Interferon-Gamma Release Assay (IGRA) blood test for TB to all new entrants who are younger than 65 and are in regular contact with substance misuse services (NICE, 2016). This screening should ideally be carried out within 48 hours of entering a prison. NICE further recommends that people in prisons are screened for hepatitis B and C and HIV.

Barriers to engaging with health care services

Research has found a number of barriers to engaging people in prison with health care services.

Staffing

Having sufficient health care staff in prisons is vital to ensure that screening programmes are implemented and that health care can be delivered to a good standard. However, recruiting to prison health care positions (and retaining staff) is challenging (HMIP, 2020). Shortages in prison staffing more generally can also impact on access to health care in terms of being able to take people to health care units or escort to services outside of the prison (e.g. to hospital appointments) (Jack et al., 2020; Williams et al., 2020). The impact of staff shortages is also perceived as reducing ability to manage complex/chronic health conditions and reducing opportunities to promote preventative health care (Woodall, 2013). While preventative care is likely to be cost-effective in the long term, lack of staff can mean that acute health needs are prioritised.

Lack of understanding and knowledge about physical health conditions and health care

A lack of understanding and knowledge by people living in prison and prison staff about physical health conditions, as well as about screening and treatment, can also impact on engagement with health care. This is illustrated by a study with prison officers in England that reported that some prison officers thought that hepatitis C was airborne, with 44% of prison officers surveyed believing that it could be transmitted by sneezing (Jack et al., 2020). In another study in an English prison, Williams et al. (2020) reported that a lack of awareness and understanding about NHS Health Check^[4] among both people in prison and staff impacted on uptake. Related to this, other studies have found that fear, anxiety and stigma among people in prison can be a barrier to engaging with health care services (Blagden et al., 2020). Fear and stigma about receiving a positive hepatitis C diagnosis was seen as a key barrier to uptake of testing in a study in an English prison (Jack et al., 2020).

Prison environment

A number of studies have noted the tension between the secure prison environment and health care culture. A systematic review of perceptions of nurses working in prisons found that the tensions between the ethos of prison and health care was something that many struggle with (Dhaliwal & Hirst, 2016). This is supported by Choudhry et al. (2017) who found that nurses felt security was often prioritised over health care, with a perception that this compromised their feelings of professional autonomy. Nurses also reported a tension between the role of custody and care, with some commenting that they could be manipulated by requests for medication and self-harm which was at odds with their professional obligations to provide care and address symptoms. A similar point was made by Felton et al. (2018), whereby perceptions of limited professional autonomy was felt to impact on their ability to build relationships with patients.

Williams et al. (2020) found that problems accessing health care due to restrictions posed by the prison environment were perceived to be the main barrier to uptake of the NHS Health Check in an English prison. Security constraints also impact on access to secondary health care, with Edge et al. (2020) reporting that the need for escorts, lack of confidentiality and stigma associated with being in handcuffs during outpatient consultations impacting negatively on people in prison. Linked to the issue of confidentiality, while there may be concerns about the confidentiality of health conditions among people in prison, for example, if prison staff are required to be present during health care appointments, this can work two ways. Jack et al. (2017) reported that prison officers raised concerns about how the need to maintain patient confidentiality with regards to blood borne viruses could put the safety of other people in prison and staff at risk.

Short sentences

The fact that many people in prison are serving short sentences^[5] along with waiting times to see health care and delays between diagnosis and referrals to specialist services, can make it difficult to get good engagement with health care services. This is exacerbated by the challenges relating to staff shortages and the logistics of moving people around the prison to see health care, which only serve to lengthen delays. Release from prison can also cut short the process of working with health care, for example Bhandari et al. (2020) found that the main reason that people in prison didn't start treatment for hepatitis C was due to being released from prison after receiving a positive diagnosis but before they had started treatment. Similar points apply to people on remand who may reside in prison for a relatively short period of time^[6].

Facilitators to engaging with health care services

Despite these barriers, there is now growing evidence of some ways in which engagement with health care services by people in prison can be improved.

Consistent staffing

The importance of consistent staffing of health care services can be seen from a service evaluation of a bowel screening programme in an English prison, in which having a dedicated staff lead for the programme was seen to facilitate uptake (Blagden et al., 2020). This study also found that clear communication of the benefits of the screening to people in prison enhanced uptake, with staff taking time to verbally discuss the service and its benefits before providing a written follow-up. This was seen a particularly beneficial given the low literacy rates among people in prison.

Location of health care services

Bringing health care services/screening onto prison wings can help to reduce the logistical issues of moving people in prison around the prison or out to secondary care. Willliams et al. (2020) found that conducting the NHS Health Check on wings maximised uptake as it considerably reduced the challenges associated with delivering this service.

Education of people in prison and prison staff

Education for people residing in prison and staff to increase awareness of physical health problems and health care services (assessment/treatment) that are available is important. Education can also go some way to reducing the fear/anxiety and stigma that can prevent some people from engaging in testing and with health care services. In their systematic review of correctional nursing, Dhaliwal & Hirst (2016) recommend that joint training/education for prison and health care staff can bring about improvements in staff understanding. One example of prison staff having positive perceptions relating to screening and testing is shown by Jack et al. (2017) who reported that prison officers in England thought hepatitis C testing was a positive thing. Furthermore, many also expressed the opinion that it should be mandatory to safeguard the wider prison population and staff (e.g. if staff were exposed to blood as a result of self-harming behaviour by people in prison).

Use of innovative methods to provide health care

Mohammed et al. (2020) found that implementing a 'fast track' service for hepatitis C in a prison in London, resulted in much higher rates of screening, assessment and treatment compared to the standard NHS recommended pathway of testing at the primary and secondary screen followed by discussion at a bi-monthly multi-disciplinary team (MDT) meeting. The fast track service entailed a rapid 'screen and treat' pathway in which a health care assistance conducted a 20 minute hepatitis C antibody test, with positive patients immediately offered treatment approved by a fast-track MDT. Similarly Connoley et al. (2020) found that developing a streamlined assessment process for hepatitis C reduced the delay between diagnosis and referral for treatment – again by bringing in a sexual health nurse at assessment to facilitate referrals.

Covid-19 has led to changes in the delivery of health care in the community with an increased use of remote consultations, e.g. by phone or video. While the digital infrastructure in prisons was poor before Covid-19 (Edge et al., 2020), prison services have now recognised the importance of this in a number of arenas (e.g. video visits) and there is a growing recognition that this could extend to health care. However, while this would reduce the constraints related to the logistics of moving people around the prison, there remain questions about privacy and confidentiality of patients.

Prison as an opportunity

It is also worth noting that people living in prison sometimes see it as a good opportunity for engaging with health care for the first time and to improve their physical health (Blagden et al., 2020; Williams et al., 2020). Quinn et al. (2018) also reported that people in prison viewed prison health care as easier to access than health care in the community. As a result, some people in prison may actually engage with health care services more than in the community. However, it has also been noted that this can be disrupted after release, for example, due to issues related to (re)registering with a GP.

Conclusions

Given the higher prevalence of many physical health conditions among prison populations and that people in prison often had poor access to and/or uptake of health care prior to this, it is clearly important that screening and treatment are offered, and that these are taken up. The question has also been posed as to whether the key issue is equivalence of access or equivalence of outcomes (Charles & Draper, 2012; Jotterand & Wangmo, 2014). With prison populations typically having higher levels of physical health problems than community populations, this would mean a higher level of health care services may be required in prisons to ensure or work towards equivalent outcomes.