Prisoners in England miss 40% of their scheduled outpatient appointments—double the rate for the general population. This is one of the most striking findings of a new Nuffield Trust study on prisoner health. It raises a number of serious concerns: the cost and waste of appointments that go unused; the adverse consequences for prisoners when their immediate health needs go untreated; the additional costs and suffering of delayed diagnosis and treatment; and for specific groups of prisoners such as pregnant women, the impact of missed obstetric and midwife appointments.

The opportunity cost of these unmissed appointments can be placed at around £2 million per year, but more significantly, the sheer scale of missed appointments is a clear sign of a system under immense strain. Unpicking some of the reasons highlights the range of challenges surrounding the provision of healthcare for prisoners.

Why are prisoners missing outpatient appointments? 

There are a number of practical and possibly unavoidable challenges in managing hospital appointments for prisoners. They may be moved to a new prison without notice, have a court appearance or even be released, requiring hospital appointments to be cancelled or rescheduled. However, there are other causative factors that are perhaps more amenable to change. 

Limited slots for hospital appointments

In prison only a certain number of people can be escorted to hospital per day. It is therefore a logistical challenge to prioritise the disparate needs of the prisoner population given the number of slots available. Hospital appointments can be missed on any given day if someone else is in more urgent need. 

There is also a wider concern about the level of unmet healthcare need in the prisoner population, resulting from the fixed quota of escorts and the impact this has on how patient care is prioritised. 

Not enough prison staff

A lack of staff available to escort prisoners to hospital is an acknowledged reason for missed appointments. Although the number of prison officers is now starting to rise, between 2010 and 2017 there was a 26% drop in the number of prison officers, set against a prison population that has increased from just under 45,000 in 1990 to around 83,000 today. The loss of staff, and in particular experienced staff, has exacerbated the challenges of keeping prisons operational. As a result, appointments may be cancelled as staff are needed to maintain the basic day-to-day running of the prison and are simply not available to escort prisoners. 

Greater transparency on escort numbers, including the proportion achieved, would be a useful marker of the pressure on the prison system. It might also shed light on other pressures such as the capacity to oversee exercise and other activities vital for health. 

Prisoners refusing to attend appointments  

In some instances appointments are missed because prisoners “refuse” to attend, but this is not necessarily clear cut. For security reasons, prisoners are not told when their external hospital appointment will take place. If, for instance, the prisoner is expecting a visit from a family member on the day the appointment comes round, they may choose to prioritise the visit over going to hospital. This is another area where experienced staff are vital to help build relationships and navigate the concerns of prisoners over the uncertainty of when appointments will take place.  

What are the gaps in our knowledge about prisoner healthcare?

High levels of missed appointments are a visible sign of the challenges facing healthcare delivery for prisoners. The NHS took over the majority of commissioning of prison healthcare in 2006, yet there remain many gaps in our knowledge and limited quantitative evidence of service improvement. We need a better understanding of unmet need in the prisoner population—who should be getting to hospital, but isn’t, and how delays in care affect long term health outcomes. Perhaps then we might start to get answers to some of the concerns that we’ve uncovered.

 

Miranda Davies, senior fellow at the Nuffield Trust.

Competing interests: None declared.