Health care in prison

All prisoners and young offenders are entitled to the same standard of health care as that available in the wider community.¹

This general principle is outlined in Prison Service Order 3200, which states:

“The Prison Service in partnership with the NHS has a responsibility to ensure that prisoners have access to health services that are broadly equivalent to those the general public receives from the NHS. This means that prisons already provide health education, patient education, prevention and other health promotion interventions in that general context.”¹

The healthcare services that each prison offers must be listed in a ‘clear and observed’ policy statement detailing what primary-care, dental and specialist clinical services are available to prisoners, along with who is responsible for providing them.²

A prisoner can ask to see the policy statement for his or her prison, to confirm what services are available there.

Moreover, the principle of prisoners being entitled to health service that are broadly equivalent to those provided to the general public was recently confirmed in the case of R (Brooks) v. Secretary of State for Justice (2008).

National guidance on commissioning sexual health and blood borne virus services in prisons, issued by the British Association for Sexual Health and HIV (BASHH) in 2011 states that all prisoners should have access to treatment for blood borne viruses, whether the infection is diagnosed in prison or not.³ Systems that ensure continuity of treatment should be in place, especially during transfer between prisons.

According to the standards that govern the prison service:

“Establishments must develop needs based health services in partnership with local Primary Care Trusts and other NHS agencies that deliver effective evidence based care to both individual prisoners and the prison population as a whole.”²

A prisoner living with HIV may have different or additional needs to the rest of the prison population. If these needs aren’t met, it can result in deterioration in their health, and may make their condition more difficult to bear.

A prisoner living with HIV needs to:

• Have access to antiretroviral medication – forced treatment interruptions are not uncommon in prison, due to problems with the delivery of health services.
• Adhere to their treatment – the drugs used to treat HIV need to be taken in the right combination at the right time each day.
• Manage side effects – treatment for HIV can cause side effects, such as diarrhoea, which are hard to manage in overcrowded or cramped conditions.
• Maintain wellbeing – everyday life in prison can make prisoners feel vulnerable, stressed out and depressed. Stress and depression can lead to a deterioration of general health.
• Maintain a healthy lifestyle – eating nutritious meals, getting enough sleep and regular exercise are all important ways to keep the immune system strong. Conditions in prison can make it difficult to practice these key elements of healthy living. 
• Stay private – prisoners have a right to keep their medical information private. However, confidentiality may be breached by prison staff (see the section on Confidentiality for further details).

Research suggests links between imprisonment, poor adherence and virological failure. There are particular risks of health care being interrupted when an individual enters prison or is released. On the other hand, longer periods of imprisonment can potentially allow for the continuous provision of health care.^{4, 5, 6, 7, 8}

The need for prison authorities to consider the HIV needs of inmates is widely recognised internationally. United Nations guidelines recommend that:

“Prison authorities should (also) provide prisoners (and prison staff, as appropriate) with access to HIV-related prevention information, education, voluntary testing and counselling, means of prevention (condoms, bleach and clean injection equipment), treatment, care and voluntary participation of HIV-related clinical trials, as well as ensure confidentiality and should prohibit mandatory testing, segregation and denial of access to prison facilities, privileges and release programmes for HIV-positive prisoners.”⁹

In theory, being in prison shouldn’t be a barrier to people living with HIV accessing the right treatment and support. However, in practice the quality of health care provided can vary between different parts of the prison estate. For example, some prisoners have reported difficulties gaining access to prompt medical treatment, as well as delays in being taken to external hospital appointments.

A 2005 report by the National AIDS Trust (NAT) and the Prison Reform Trust found that the prison service was failing to meet the needs of prisoners with HIV.¹⁰ In particular, the report highlighted how prisoners were finding it difficult to access condoms and clean needles to stop transmission of the disease.  

At the time of writing there is no comprehensive official policy on HIV in prisons. Because of this, individual prisons are left to interpret the various Prison Service Orders and form their own approach. While some prisons have been praised for forward-thinking initiatives on HIV, it’s generally acknowledged that there is room for improvement.

Responsibility for the health care of prisoners differs depending on where in the UK they are being held. However, the same principles apply to young offender institutions, immigration removal centres and women’s prisons.

In April 2013, NHS England became responsible for commissioning (planning and funding) health services in prisons and other secure institutions. It is hoped that this may lead to improvements in the quality of care, continuity of care when inmates transfer to a different institution, and greater consistency of care across the country. The relevant section of NHS England is known as Health in the Justice System.

In the past, prisons managed their own health services, with this responsibility being taken on by primary care trusts (local NHS organisations) from 2006 onwards. However, private prisons sometimes had different arrangements.

Now NHS England is responsible for care in all prisons, immigration removal centres and young offender institutions. It may nonetheless sometimes commission private companies (such as Care UK) to deliver services.

Moreover, arrangements with existing healthcare providers are likely to continue during a transition period.

Prisoners are treated as temporary residents of the local area in which the prison is located. The prison governor organises how health care is delivered within the prison and sits on the Prison Health Partnership Board, a joint structure between the prison and the NHS.

In Scotland and Wales, prison healthcare services are funded by the national government and commissioned by the local health boards in which the prisons are located.

In Northern Ireland, delivery of prison healthcare services is the responsibility of the South Eastern Health and Social Care Trust. But management, performance and discipline issues with healthcare staff remain the responsibility of Northern Ireland Prison Service.

There are currently eleven Immigration Removal Centres in the UK. They are prison-like structures, used for detaining asylum seekers, refused asylum seekers and undocumented migrants.

According to the Detention Services Operating Standards:¹¹

“All detainees must have available to them the same range and quality of services as the general public receives from the National Health Service.”

However, a 2003 All-Party Parliamentary Group on AIDS Enquiry reported that:

“All evidence received during the enquiry suggests that removal centres are unsuitable places for people living with HIV. Detention can undermine efforts to maintain good health.”¹²

Problems the group identified included:

• lack of expertise among medical staff about HIV and AIDS

• lack of continuity of care from healthcare providers

• disrupted or missed appointments with external healthcare providers

• people with weakened immunity to infection.

According to the report, people held in immigration removal centres living with HIV face similar problems to other HIV-positive prisoners. Though the situation is improving in immigration detention, these problems may be exacerbated by issues with language, cultural differences and the threat of repatriation.

NAT has a wealth of information on HIV and immigration removal centres. As a starting point see Detention, Removal and People Living with HIV, which is available to download from www.nat.org.uk.

For prisoners living with HIV the reception process is especially important, since it highlights their specific healthcare needs.

Under Prison Service Order 3050¹³ (PSO 3050), all prisoners must be given a healthcare assessment within 24 hours of their arrival in prison.

According to the order, this assessment must be designed to detect:

• immediate physical health problems

• immediate mental health problems

• significant drug or alcohol abuse

• risk of suicide and/or self harm.

A follow-up health assessment will also be completed in the prisoner’s first week.

Voluntary organisations working with prisoners living with HIV often find that they are reluctant to disclose their HIV status at reception. They are often worried about being abused by staff or other prisoners because of their status.

However, by failing to disclose their status they are putting their health at risk. To maintain uninterrupted access to HIV treatment, prisoners need to alert staff to their status as soon as possible.

PSO 3050 also states that:

“Efforts should be made to retrieve any information required from the prisoner's GP or other relevant service he/she has recently been in contact with. The prisoner's explicit consent should be obtained before doing this, although in exceptional circumstances information may be requested and disclosed without consent.”

During the reception process, prison staff will also assess a prisoner’s need for drug-misuse treatment, which could include a test for detecting illegal substances.  

Meeting the needs of drug misusers is important because intravenous drug use is one of the main ways HIV is transmitted, both inside prison and in the wider community. Clinical services for prisoners who abuse drugs or alcohol are provided by members of the healthcare staff. The staff work in conjunction with counselling, assessment, referral, advice and thoroughfare services (CARATs), plus drug workers and NHS specialist drug-misuse services.

The minimum standards prisoners who misuse drugs can expect include:

• that all prisoners are screened on arrival to prison by a healthcare worker who can identify the health needs of substance abusers
• that all prisoners have access to detoxification programmes
• that an NHS consultant in substance misuse has regular contact with prison healthcare staff.¹⁴

Because opiate substitution therapies may be sold to other prisoners, prisoners are not permitted to keep such medication in their cells ­– it is administered at set times by healthcare staff.

Whatever their HIV status, a prisoner’s experience of life inside will be affected by the staff with which he or she interacts. Although some voluntary organisations have praised the prison service’s attitude to those living with HIV, others have reported HIV-positive prisoners being bullied and harassed.

The prison service sends a clear message to staff that such behaviour is unacceptable in its code of conduct. This is outlined in Prison Service Order 8460.¹⁵ It states:

“Prison Service staff are expected to meet high standards of professional and personal conduct in order to deliver the Prison Service Vision. All staff are personally responsible for their conduct.  Misconduct will not be tolerated and failure to comply with these standards can lead to action which may result in dismissal from the service.”

The order goes on to explain that prison staff must:

• deal fairly, openly and humanely with prisoners and all others who come into contact with them

• promote equality of opportunity for all and combat discrimination wherever it occurs

• work constructively with criminal justice agencies and other organisations.

They must not:

• discriminate unlawfully against individuals or groups of individuals because of their sex, racial group, sexual orientation, disability (including HIV), religion, age or any other irrelevant factor

• harass others through behaviour, language and other unnecessary and uninvited actions

• victimise or bully others through their actions and behaviour.

In principle, these rules provide a framework which protects prisoners living with HIV from harassment and guarantees that they have access to the services that can support them. Prisoners who experience this kind of behaviour from prison staff have a right to complain, and can do so according to the prison’s standard complaints procedure.

In each prison the primary healthcare manager is in charge of delivering appropriate health care to prisoners. Although every prison is guided by the principle of health care broadly equivalent to the NHS, facilities differ from prison to prison.

Every prison will have an area put aside for health care, which may include a purpose-built hospital. The prison healthcare manager will be in charge of healthcare staff, including prison doctors, nurses and dentists.

The needs assessment carried out on reception to prison will form the basis of the healthcare services prisoners can expect once inside. If the prisoner has disclosed their HIV status, healthcare staff can organise medical appointments as necessary.

Ideally, this would be with a specialist HIV team which provides clinical sessions at the prison (sometimes called an ‘in-reach’ service), with both a doctor and multidisciplinary team member available.

Alternatively, the prisoner may be taken to an outside hospital to have their needs met. If a prisoner is taken to an outside hospital, they will remain in the custody of the Prison Service (see Escorts below).

An individual who does not speak sufficient English may need an interpreter (perhaps via a telephone interpretation service) in order to get the most out of their appointment.

However logistical problems and security concerns can often lead to medical appointments being missed or cancelled.¹⁶ There can sometimes be long delays before seeing a specialist and gaps between appointments. Regular prison healthcare staff may not always be aware of drug interactions and the importance of adherence in HIV therapy.

If a prisoner’s healthcare needs cannot be dealt with fully at the prison where the sentence is being served, a prisoner may be moved to another prison where different facilities are available. However, this may mean being taken to a prison farther away from friends, family and other support networks.

Sometimes a prisoner living with HIV will need to access healthcare services over and above their regular appointments. This might happen if they feel sick, or need access to condoms.

Prison staff must record a request to see healthcare staff, which must be passed on promptly to a member of the prison healthcare team.¹⁷

In practice, different prisons have different procedures for accessing health care. Some prisons have postal boxes through which prisoners can pass requests, while others rely on prison staff to communicate the need for health care.

Accessing health care in these ways can compromise a prisoner’s right to privacy about their HIV status. For instance, if prison staff are responsible for communicating requests there is a danger that confidential information may be passed on to other staff or prisoners (see Confidentiality).

Choosing a GP

Prisoners are not normally allowed to choose the GP they visit. Prisoners will only be entitled to see a doctor, or other specialist of their choice, if they are so far unconvicted and agree to pay any charge incurred, or when they need to see a doctor in connection with legal proceedings.¹⁷

Prisoners living with HIV may have to visit a hospital, clinic or outside counsellor to have their healthcare needs met. Depending on their security category, prisoners may be escorted to external appointments, or released with temporary license.¹⁷

In exceptional circumstances, remand prisoners can be temporarily released to remain in hospital if they are so seriously ill or incapacitated that they are incapable of escaping, and where they present no danger of assisted escape.¹⁸

Security concerns usually mean that prisoners are not informed of the date of their appointment before it occurs, making it harder for them to adequately prepare.

Before escorting a prisoner to hospital, prison staff must complete a risk assessment to establish the appropriate level of escort and restraint.

The standard escort arrangement for prisoners from closed prisons is that two officers accompany the prisoner. Handcuffs, or other restraints, will be used unless there are medical objections.¹⁹

The use of handcuffs in any circumstances must be necessary and proportionate to the assessed risk. Restraints are normally removed during medical consultations and reapplied once the consultation has finished.¹⁹ If handcuffs must be worn during the consultation, a long chain can be used, so that escorts remain outside the consulting room. Some prisoners living with HIV may have the kind of mobility issues which make the use of handcuffs unnecessary.

Having prison officers present hinders medical consultations and breaches confidentiality, with patients reluctant to disclose drug use for example. Many clinicians simply refuse to see a patient if an officer is present.²⁰

In cases where escorts are necessary, prisoners have experienced delays in attending hospital or outside appointments – especially when no staff are available. This can present specific problems for prisoners living with HIV, since the information or advice they need may be time sensitive. The need for escorts can also clash with a patient’s need for confidentiality concerning their condition, and may discourage prisoners from accessing care.

The prison population can be highly mobile and prisoners will often be transferred to other institutions during their sentence.

Prisoners are not necessarily given advance warning of a transfer. For example, a transfer may happen immediately after a court appearance.

Clinicians report that transfers frequently affect adherence and continuity of care.¹⁶

According to Prison Service Order 3050, when a prisoner is transferred from one prison to another healthcare staff have a duty to provide continuity of care. A new healthcare assessment is made every time a prisoner is transferred and medical records are passed on.²¹

In some circumstances, healthcare staff can place a prisoner on ‘clinical hold’, which prevents the prisoner being moved for health reasons. These cases arise when healthcare staff consider it vital for a prisoner to keep the same source of treatment.   

There are other ways healthcare staff can impose restrictions on a prisoner’s transfer. They can, for example, insist that prisoners are held in a prison with 24-hour healthcare facilities.²¹

NAT has set out a best-practice framework designed to tackle blood-borne viruses in prison, including HIV. Along with other useful information, the framework suggests four key questions healthcare staff should answer before a transfer takes place:

1. Is it in the prisoner’s best interests to suggest a ‘medical hold’ to preserve continuity of HIV treatment?
2. Are the prisoner’s medical records up to date regarding their needs/treatment?
3. How will any outstanding test results be communicated following the move?
4. If the prisoner is taking complex medication, have prior arrangements been made with the new prison to continue this without disruption?²²

Most English prisons use a system of electronic patient records, SystmOne, making it possible for medical records to be securely transferred from one prison to another when an inmate moves. This should facilitate prompt intervention with transferring prisoners who have healthcare needs, although it is not used by all HIV healthcare providers operating in prisons.¹⁶

Moreover, medical information recorded on SystmOne will be visible to a variety of prison healthcare staff and some individuals with HIV may be concerned about the implications for confidentiality.

If a prisoner becomes so ill they are not expected to get better, the governor of the prison may allow them to be released from prison on compassionate grounds to a hospice or to be looked after by friends and family.

A prisoner is prescribed medication by a doctor based on their healthcare needs. This includes any new or existing treatment for HIV.

The 2003 Department of Health publication A Pharmacy Service for Prisoners²³ recommends that:

• pharmacy services to prisoners should be patient focused, be based on identified patient needs, and support and promote self-care
• developments in medicines management in the NHS, including repeat dispensing and medication review, should be reflected in pharmacy services provided to prisoners
• all prisoners should have appropriate access to a pharmacist or pharmacy staff
• ‘in-possession’ medication should be the normal method of supplying medication in prisons.

‘In-possession’ medication means that, wherever possible, prisoners are responsible for storing and administering their own medication. The programme aims to put prisoners in charge of medication so that they will feel more in control of their lives and take more responsibility for their health.

Due to concerns about confidentiality, some prisoners may want to avoid having anti-HIV drugs ‘in possession’.

However, if a prisoner’s medication is considered to present a security risk (sedative drugs that could be sold on to other prisoners, for example) then it will be supervised by healthcare staff. Also, prisoners may not be able to store some HIV medication themselves, if it needs to be stored under special means – in a fridge, for instance.

Injections are normally always supervised by healthcare professionals since syringes could be used as weapons or sold to other prisoners.

Interruptions to the supply of medicines and forced treatment breaks have been reported by prisoners. There is a particular risk of this occurring following transfer to a different institution⁴ and following release into the community. 

A prisoner may need other medication in addition to antiretroviral treatment, and may see a different doctor for this. It’s important to check that the different medications do not interact with each other.

Healthcare staff and other prison staff have a duty of confidentiality towards prisoners.

Prison Service Order 0500 states that:

“Health information is normally collected from patients in confidence, and the common law duty of confidence prohibits the use and disclosure of such information without consent of the individual.”²⁴

Prison Service Order 8460²⁵ states that prison staff must not:

“Give prisoners or ex-prisoners personal or other information about staff, prisoners or their friends and relatives which is held in confidence.”

It also goes on to say that:

“Staff must protect any information which they have obtained through their work in the Service, for example procedures, security information and staff and prisoner details.”

Guidance from BASHH states that prisoners attending GUM clinics have the same entitlement to privacy and confidentiality as non-prisoners.²⁶

However, because of the close proximity of prisoners and staff, confidentiality can be hard to maintain in prison. For instance, if a prisoner with HIV is sharing a cell it can be difficult to store medicines they have been prescribed without their cellmate, or staff, discovering their status.

An audit of sexual health services in prisons identified problems with confidentiality in some prisons – lack of secure storage of medical records and prison officers present during medical consultations.²⁷

Sometimes a prisoner living with HIV finds that their confidentiality is breached because of poor practice by healthcare or prison staff. This can have devastating consequences.

People working with HIV-positive prisoners report that once a prisoner with HIV’s status is revealed they can be vulnerable to bullying and abuse by both prison staff and other prisoners.

If a prisoner is being bullied because of their HIV status, or feels that their right to confidentiality has been breached, they can make a complaint .

Prisoners living with HIV may find that prison life interferes with their treatment, or makes their condition worse. If this happens, prisoners can speak to healthcare staff about altering their routine. If they aren’t satisfied by the outcome they can make an official complaint.

The Equality Act 2010, which applies to people living with HIV, says that “reasonable adjustment” should be made for a disabled person, where it would significantly improve their quality of life. In prison this could mean changing treatment schedules, or adapting cells to ease mobility issues. The prisoner needs to have told the prison of their HIV status to rely on this act for adaptations.²⁸  

Resettlement is a process in which prisoners and their families receive support and assistance from the prison, probation services and voluntary agencies to help them get ready for life after prison.  

Prison Service Order 2300 states that the resettlement process is designed to:

• reduce reoffending by prisoners following release from custody, thereby protecting the public from harm
• help prisoners to participate effectively in society as law-abiding members of the community

It goes on to say that:

“The key processes (of resettlement) involve action by the Prison Service, the National Probation Service and others which is based on evidence of barriers to resettlement which are relevant for the individual prisoner and evidence of what is effective in tackling those barriers.”²⁹

For people living with HIV, these barriers can include: