Urgent reforms are needed for prison healthcare services after a decade of austerity

The UK government’s 2012 Benchmarking Programme, which implemented austerity measures on prison spending, has led to a reduction in the prison workforce without a corresponding reduction in the prison population. This policy has negatively affected healthcare in English prisons.

Access to healthcare services for prisoners has been limited, resulting in delayed treatments that pose serious health implications for the prison population and have a knock-on effect on healthcare provision for the general public. This research supports the findings of previous studies: over 75% of prisoners’ missed appointments were partly due to the lack of prison staff and engendered a cost to the National Health Service of £2 million.

The reduction in staffing also contributes to reduced rehabilitative activities and to the growing availability and misuse of drugs in prisons, leading to increases in medical emergencies and violence as well as the growth of organised crime groups. These circumstances could lead to further dysfunction and a loss of control in prisons, as seen in the Strangeways Riot in 1990. Because most prisoners eventually return to their communities, the continued impact of austerity places the health and safety of the broader population at risk. Nearly half of prisoners (45%) reoffend after being released, a finding that is linked to the reduction in prisoner access to purposeful activities while incarcerated.

After a decade, austerity has neither reduced the burgeoning national debt nor improved healthcare for prisoners in England. Rather, it has led to an increased the rate of imprisonment and a deterioration of services—and there is no political will to change or reject these policies. In the context of Brexit, the COVID-19 pandemic, and the Bank of England’s prediction of a recession between October 2022 and December 2023, these failures will intensify economic uncertainty for years to come. Politicians, policymakers, non-governmental organisations, and academics must act now to address the impact of austerity on prison healthcare and prisons.

Funded by the Economic and Social Research Council (ESRC), this three-year interdisciplinary study uses data gathered via semi-structured interviews with 87 research participants. They included policymakers from key organisations relevant to international prison work, such as the United Nations, the World Health Organization, and Amnesty International, as well as national policymakers and prison reform advocates, prison governors and officers across high-, medium-, and low-security prisons and resettlement prisons, and representatives from the voluntary and private sector organisations who were commissioned to deliver the prison health agenda across English prisons.
This data is supplemented by existing longitudinal and economic analyses to ensure a rounded view of the investigation. While it mainly focused on prison healthcare in England, this study can shed light on other forms of detention and community settings, and indeed beyond England, particularly for countries that have adopted a policy of austerity.

• 30% reduction in prison staff between 2009 and 2017 hampered the ability of prisoners to attend healthcare appointments outside prisons, because all prisoners need to be accompanied by two prison officers. This policy led to frequent postponement or cancellation of appointments, with 75% of missed appointments being partially attributed to a lack of prison staff. The loss of clinical time created a ripple effect on the wider performance of the NHS.

• Prolonged and inadequate access to acute and urgent healthcare services, such as operations and cancer treatment, increased the rate of death and disability among the prison population.

• Stagnant prison health funding since 2006 forced prison healthcare providers to reduce services, pay less for permanent staff, and increase the use of volunteers. Given the high attrition rate of healthcare workers, prison healthcare services also had to use agency staff, which were more expensive, thus hindering cost-saving measures. This trend is predicted to worsen in the absence of a coherent government approach to staff recruitment and Brexit migration policies.

• Silence and a lack of meaningful actions to challenge austerity have sustained its acceptance and implementation, as well as violating prisoners’ rights to access healthcare and decent living conditions in prisons, and compromising the working conditions of the prison workforce. Research participants observed how prison oversight organisations such as the HM Inspectorate of Prisons (HMIP), the Prisons and Probation Ombudsman (PPO), and the Independent Monitoring Boards (IMBs) refrained from commenting on the direct impact of austerity on prisons and prisoners. These participants were also sceptical about the efficacy of parliamentary committees in regulating prison healthcare and prison conditions. The Lobbying Act of 2014 has prevented third-sector organisations from opposing austerity due to contractual clauses and statutory requirements.

• Research participants observed how being locked up in cells for 23 hours a day in unhygienic and overcrowded cells left prisoners isolated and restless and contributed to unprecedented spikes in self-harm, assault, and suicide. These incidents, which foster a negative psychological climate in prisons, show no sign of abating, leading experts to predict higher rates of prison violence as well as a rise in recidivism and radicalisation.

• Staff reductions made curbing the flow of psychoactive substances into prisons even harder. The growth of prison gangs and serious organised crime has coincided with rising drug use in prisons, a dynamic that can also be attributed to staff reductions, reflecting a weakening of institutional governance. These circumstances could lead to further dysfunction and a loss of control in prisons, as seen in the Strangeways Riot in 1990.

• Data from 2019 shows that there has been a dramatic increase in seizures of psychoactive substances, such as ‘Spice’ and ‘Black Mamba’, part of a wave of new psychoactive substances, from 15 seizures in 2010 to 6699 in 2019 (Ministry of Justice, 2019). The availability of these substances in prisons, as noted by research participants, increased medical emergency cases, created a fearful environment for staff and vulnerable prisoners, undermined health interventions, and drew upon already limited external healthcare resources (e.g., ambulances).

Austerity/deficit reduction

From 2010 to 2019 the UK government, first under the Conservative–Liberal Democrat coalition (2010–2015) and then under Theresa May’s Conservative government (2015–2019), focused on reducing the UK deficit by cutting spending on public services. Despite these policies, the UK debt-to-GDP ratio reached its highest point in 2019, higher than in the pre-austerity era in 2010. The government of Boris Johnson abandoned the term ‘austerity’ but did little to improve the funding of public services, including prisons. Indeed, the Treasury announced in 2020 that more than £10 billion per year would be cut from departmental spending plans in 2023 and in subsequent years (HM Treasury, 2020).

Given the rejection of Liz Truss’ ‘mini-budget’ in September, the new Prime Minister Rishi Sunak and his Chancellor, Jeremy Hunt, have made it clear that all government departments will be expected to make large savings in an attempt to balance the books. This, then, will deepen the impact of austerity across public services, prisons included.

Policy recommendations

• The UK Government should work towards a reduction in the prison population—for example, by supporting alternative community sanctions for those who do not pose public threats and by diverting individuals with acute mental health and substance use problems to hospitals or community-based treatment. These alternatives are less costly, more proportionate to criminal harm, more responsive to prisoners’ needs (especially for those with mental health issues), and less disruptive to prisoners’ families and social networks.

• Judges and magistrates should avoid short-term sentences and be encouraged to use suspended sentences, as much as is permitted by the Sentencing Guidelines. These options are more financially sustainable and safer than current efforts, especially for reducing COVID-19 transmissions (and other potential pandemics) among prisoners and staff.

• Government should increase resources for prison healthcare services to improve prisoners’ access to healthcare and an improved quality of life, rather than build new prisons that will only increase the number of prisoners without addressing prisoners’ health needs.

• Government should increase spending on healthcare and preventative services across the community to reduce pressures on prison healthcare services and prisons.

• Government and nongovernmental organisations (NGOs) should improve data collection and publication of the true social and economic costs of imprisonment. Apart from monitoring per capita spending on prisons and prison healthcare services, this can be used to highlight the negative impact of austerity measures on the NHS.

• NGOs and advocates should link the government’s commitment to providing sufficient financial resources for prison health to existing government obligations on prison healthcare provisions, such as the principle of equivalence of healthcare in prisons under the Mandela Rules as well as the Sustainable Development Goals 2030.

• Advocates and academics should continue to remind politicians and the public that prison healthcare affects the health of the public. From the multidrug resistant tuberculosis epidemic in Russia in the late 1990s that caused 20,000 deaths in the general public to the prison-based spread of COVID-19 in the United States exacerbated by cycles of release and re-imprisonment, improving prison healthcare is essential to safeguarding the health of the public.

Strangeways prison
Image credit: Strangeways prison (Keith Williamson / Her Majesty’s Prison, Manchester (formerly Strangeways Prison) CC BY-SA 2.0

Further information

Further information about this research can be found in Ismail, N. (2022) The English Prison Health System After a Decade of Austerity, 2010-2020: The Failed Political Experiment

The dissemination of findings of this project, ‘Sharing the lessons learned to improve prison healthcare in the UK’, is funded the ESRC Impact Accelerator Account.


Nasrul Ismail (University of Bristol)

Contact the researchers

Feedback, ideas for collaborations, and requests for presentations can be directed to:

Dr Nasrul Ismail
Lecturer in Criminology
School of Policy Studies
Edit this page