14.The prison population in England and Wales has remained historically high, but relatively stable, since 2010 and is projected to remain stable until 2022. The prison population is also high by international standards. England and Wales have the 8th highest prison population per 100,000 in the EU (as shown by the chart below), higher than Germany, Norway, Netherlands, Denmark and Sweden, which are all outside the top 20.
15.The prison population has shown a notable shift towards longer sentences. Only a third of the prison population had a determinate sentence over 4 years in 2010, compared to just under 50% in March 2018. Similarly, the percentage of the prison population on indeterminate sentences and shorter sentences, either 1–4 years or less than a year, has fallen since 2010.
16.The characteristics of the people detained in prisons fluctuates over time. However, the prison population is:
17.People in contact with the criminal justice system, including those in prison and on probation, tend to be in poorer health than the general population and have a greater need for health and care. For many people detained in prison, their poor health status arises from, and/or has been exacerbated by, early childhood experiences (abuse, neglect and trauma) social circumstances (problems with housing and employment) and higher rates of smoking, alcohol and substance misuse. The children of prisoners, we were told, are also three times more likely than their peers to engage in antisocial behaviour. Incarceration of a parent is traumatic for a child and can be classed as an Adverse Childhood Experience.
18.The physical health of the prison population, across a broad range of conditions, is much poorer than that of the general population, as shown by the chart below. Incidences of blood borne viruses are particularly more prevalent among the prison population. Cases of tuberculosis per 100,000 are over five times higher among the prison population. Hepatitis C is more prevalent among people in prison, especially women in prison, compared to the general population (13% of female prisoners and 7% of male prisoners have hepatitis C compared to 0.4% of the general population). The prevalence of HIV, although slightly higher among men in prison, is much higher among women in prison when compared to the general population (1% of women in prison have HIV compared to 0.3% of men in prison and 0.2% of the general population).
19.Mental health problems, including not only common mental health problems such as anxiety and depression, but also psychotic and personality disorders, are much higher among the prison population and people on probation. The prevalence of mental health problems, although high for men, is also greater among women in prison, with the exception of personality disorders.
20.Many people in prison have social care needs, with some of this need falling below the bar for publicly funded support. An ageing prison population is associated with increasing demand for social care, although social care needs are not limited to older prisoners. Evidence to our inquiry highlighted that learning disabilities, autism, ADHD and acquired brain inquiries are also common among the prison population. Many prisoners are also affected by Foetal Alcohol Spectrum Disorder. However, these problems may have gone undiagnosed prior to entering prison. Twenty-five per cent of the prison population, according to the Revolving Doors Agency, a charity specialising in the criminal justice system, have problems communicating or handling complex information, although they might not strictly meet diagnostic criteria for a learning disability and, consequently, are unlikely to be eligible for support.
21.The high prevalence of health and care needs among the prison population is reflective of the social circumstances these people experience before entering prison. Forty-one per cent of the people in prison have witnessed or experienced domestic abuse, either in childhood or adulthood. For example, over 50% of women in prison report having suffered domestic violence and experienced emotional, physical or sexual abuse during childhood.
22.Prior problems with housing and employment are common among the prison population. Research by the Ministry of Justice found only a third of the prison population were in paid employment 4 weeks before going into custody and 13% report never having had a job, with those in work being in typically low paid work. Almost a quarter of people in homelessness accommodation are former prisoners or ex-offenders and a third of people sleeping rough in London in 2015/16 had spent time in prison.
23.As already noted, the prison population is ageing, which, as the graph below shows, has been clear for over a decade. The ageing prison population reflects shifts towards longer custodial sentences and an increase in the use of imprisonment for sex offences, including historic sex offences, as well as an ageing of the general population. Her Majesty’s Inspectorate of Prisons and the Prison and Probation Ombudsman have both criticised the Government’s lack of strategic grip over the consequences of an ageing prison population.
24.During our inquiry, concerns raised about the treatment of older prisoners remain the same as those identified by the Justice Committee five years ago, namely that older prisoners:
25.Her Majesty’s Prison and Probation Service has produced a model of operation to advise governors on how to approach growing numbers of older prisoners. However, Peter Clarke, Chief Inspector of Prisons, told us:
The Ministry of Justice announced last year that they were going to create a strategy for older prisoners, and a steering group was set up. I was a member. It met once. A paper has now been produced, which, frankly, in my view, is not in any way strategic. It talks about more of the same. My view is that there needs to be a broader think about what needs to be done for a cohort of prisoners who, although they may need to remain in custody, do not necessarily need the same type of custody. There is good practice though, which needs to be picked up.
Box 1: Experiences of older prisoners
In response to our call for evidence in Inside Time, one older prisoner wrote to us describing some of challenges older prisoners on his wing experienced. He informed us that all the prisoners on his wing are elderly and that they receive very little support from staff. Healthcare, he said, “try their best, but are restricted by the regime.” He pointed out that “if we are unable to walk to healthcare we can be neglected”. With limited access to healthcare, “often, prisoners with serious medical needs have to rely on other inmates for things like diabetes injections.” He also described his living conditions, saying “this wing was built to house young offenders, not the elderly. Often, we have no hot water or heating. The sinks are tiny and we are not issued with plugs.” In his view, prison living conditions are, without doubt, “detrimental for the infirm and elderly.”
Source: Written response from Inside Time
26.The average age of death of people detained in prison in England is 56. The standardised mortality rate of prisoners is 50% higher than the general population. Dr O’Moore from Public Health England explained that this:
[ … ] represents the complex vulnerabilities that people have that they bring with them into prison, and then you are in an environment where maybe some of those needs are not well understood or well met. So, people presenting with particular signs and symptoms of disease or problems are not being managed in a particular way that one would expect.
The mortality rate of ex-prisoners and offenders on community sentences is even higher than that of the prison population, as shown by the chart below.
Revolving Doors Agency (PRH0046).
This also reflects some of the complex health needs of people in contact with the criminal justice system. For example, risk of death is highest immediately after release, often linked to substance misuse problems. Community offenders also show higher levels of accidental deaths, often relating to drugs and alcohol, as well as homicides.
27.Natural cause deaths are the leading cause of mortality in prisons, with the rate of natural cause deaths in 2017 equating to 2.15 deaths per 1000 prisoners. Of the 310 deaths in prisons in England and Wales from June 2017 to June 2018, 173 people died from natural causes. The high rate of natural cause deaths in a large part reflects the poor health, and prior social circumstances, of the prison population. However, INQUEST told us that many of these so-called natural cause deaths are far from natural, but are instead often premature and avoidable deaths stemming in part from lapses in care.
28.Investigations by the Prison and Probation Ombudsman, along with monitoring and casework carried out by INQUEST, reveal serious lapses in the delivery of, and access to, healthcare. These lapses include failures to make urgent referrals where it is suspected that prisoners might have cancer or a failure to “review and treat abnormal blood test results.” We have received similar complaints in response to our call in Inside Time. For example, one prisoner informed us of the death of his friend who complained repeatedly to healthcare services within the prison about pain he was experiencing. When healthcare services finally did help “it was too late, he had cancer and only had weeks to live.”
29.A prison sentence, we heard strongly, is a deprivation of someone’s liberty: it is not a sentence to poorer health or poorer health and care services. The idea that people detained in prison retain their right to health is woven into international law. The right to health includes:
… a right to the enjoyment of a variety of facilities, goods, services and conditions necessary for the realisation of the highest attainable standard of health.
30.The right to health underpins the idea of equivalence, in which prisoners’ access and quality of services should be the same as that of the general public. Equivalence is endorsed internationally and has (in theory) been a core part of the Government’s approach to the health of prisoners since the Joint Prison Service and National Health Service Executive Working Group in 1999 endorsed the following principle:
To give prisoners access to the same quality and range of health care services as the general public receives from the National Health Service.
31.Despite this endorsement and continued support, what equivalence means in practice has remained vague. For example, there is no resource describing how equivalence should be defined, measured and compared with health and care in the community. The National Audit Office criticised the then partnership between the National Offender Management Service, NHS England and Public Health England for not having defined measurable outcomes of equivalence and for not measuring progress, saying: “it is not clear how partners can assess whether healthcare in prisons is equivalent to healthcare in the community.” One prisoner told us:
It’s a joke. We are told we are treated the same in prison as we would be out of prison. If you believe that then you may as well believe in fairies at the bottom of the garden.
32.Ministers and senior officials told us the principle of equivalence remains the Government’s overriding aim. However, the National Prison Healthcare Board’s National Partnership Agreement for 2018–21, published in April 2018, does not include any reference to achieving equivalence. Instead, the agreement states that one of the Board’s objectives is to “improve health outcomes and reduce health inequalities” for people in prison compared to the general population. This may be a useful first step, but the Board has yet to specify the degree of improvement it intends to achieve over this period.
33.We heard strongly during our inquiry that the priority for prisons and prison health and care services, and the professionals within them, should be to achieve health outcomes for people in prison that are equivalent to those enjoyed by the wider population. Achieving equivalent outcomes is likely to require a different and, in many respects, enhanced level of provision than that which exists in the community.
34.Prison health is a public health issue, given the poor health of people detained in prison. Prisons are also an opportunity to break the cycle of poor health and disadvantage. Accordingly, a core purpose of prisons and prison health and care services should be to ensure the health outcomes of people detained in prison are equivalent to that of the wider population. Prisons and prison health and care services cannot and do not provide services and treatment that mirror exactly the type of provision available in the wider community. Services and treatments for people detained in prison should, however, reflect the complexity of their needs and be at least equivalent to the range and quality found within the wider community. Despite the clear evidence of health inequality and need, that is not the case.
35.We recommend that the National Prison Healthcare Board work with stakeholders over the next 12 months to agree a definition of “equivalent care” and indicators to measure the extent to which people detained in prison receive at least equivalent standards of care, and achieve equivalent health outcomes, as the population as a whole—in other words, to measure the health inequalities of people detained in prison.
36.In the meantime, in all future iterations of its strategy and plans, including its national partnership agreement, the National Prison Healthcare Board should explicitly state its commitment to achieve equivalent standards and health outcomes for people detained in prisons, compared to the population as a whole—that is, to reduce health inequality. Its plans should include an explanation of how its action to improve access to healthcare and enable prisoners to lead healthy lives will reduce health inequality.
17 , House of Commons Library Briefing Paper, Number CBP-04334, 23 July 2018
18 , House of Commons Library Briefing Paper, Number CBP-04334, 23 July 2018
19 , House of Commons Library Briefing Paper, Number CBP-04334, 23 July 2018
20 , House of Commons Library Briefing Paper, Number CBP-04334, 23 July 2018
21 Prison population figures 2018, Population bulletin: weekly 31 August, Available at:
22 , House of Commons Library Briefing Paper, Number CBP-04334, 23 July 2018
23 , House of Commons Library Briefing Paper, Number CBP-04334, 23 July 2018
24 Home Office, Public Health England and Revolving Doors Agency (2017), , January 2017.
25 Royal College of Midwives/Birth Companions ()
26 Revolving Doors Agency ()
27 Revolving Doors Agency ()
28 Revolving Doors Agency ()
29 Revolving Doors Agency ()
30 Revolving Doors Agency (), Association of Directors of Adult Social Services (ADASS) submission ()
31 Care Quality Commission ()CQC written evidence
32 National Organisation for Foetal Alcohol Syndrome, FASD Policy Focus Paper - No. 1: Overview of FASD Policy Debate in the Context of the Westminster Hall Debate on Alcohol Harm, 2 February 2017, 02/06/2017
33 Revolving Doors Agency ()
34 Revolving Doors Agency ()
35 Revolving Doors Agency ()
36 Revolving Doors Agency ()
37 Prisons and Probation Ombudsman ()
38 Prisons and Probation Ombudsman (), Peter Clarke
39 Justice Committee, Fifth report of Session 2013–14, , July 2013
40 Peter Clarke
41 Dr O’Moore
42 Revolving Doors Agency (), Revolving Doors Agency (supplementary evidence).
43 Ministry of Justice, , 26 July 2018
44 INQUEST ()
45 INQUEST ()
46 Royal College of General Practitioners, , July 2018
47 Article 12 of the International Covenant on Economic, Social and Cultural Rights (23).
48 Her Majesty’s Prison Service and NHS Executive, , March 1999
49 Royal College of General Practitioners, , July 2018
50 National Audit Office, , HC42 Session 2017–2019 29 June 2017
51 Written response from Inside Time
52 HM Government and NHS England, , April 2018
53 Note from stakeholder discussion
Published: 1 November 2018