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BMJ. Jul 30, 2005; 331(7511): 248–249.
PMCID: PMC1181255

Making prison health care more efficient

Inmates need more organised and more preventive health care in emptier prisons
Niyi Awofeso, associate professor

The cost of providing prison health services has been debated since 1774, when the Health of Prisoners Act was passed by the British parliament.1 That debate continues now, although measuring how much taxpayers spend on prisoners is notoriously difficult. Nevertheless, the annual median cost of incarcerating a prisoner in secure custody in 2003-4 was about $28 000 (£15 800, €23 400) per state prisoner in the United States,2 $45 000 in Australia,3 and $53 000 in Britain.4 w1 US state prisoners' annual healthcare costs averaged 12% of total costs (around $3350). With rising rates of incarceration,w2 increasing public support for penal policies,w3 greater needs among inmates for health care,5 and limited budgets,w4 prison health care is becoming harder to fund adequately.

In September 2002, the British government announced that it would transfer budgetary responsibility for prison health from the Prison Service to the Department of Health. By April 2006 responsibility for commissioning prison health care will be devolved to NHS primary care trusts.w5 Elsewhere, many custodial authorities have implemented strategies such as managed care and copayment schemes to reduce pressure on prison health budgets. In the first three years of the introduction of managed care to Texan prisons, for example, the daily healthcare costs for each prisoner fell from $5.98 to $5.11.w6

Since prisoners are not generally paying customers, healthcare providers have little incentive to provide good quality care: indeed, they have a perverse incentive to minimise essential services that have high costs. Doctors and nurses generally have to seek approval from managed care organisations to request tests and surgical procedures, but such approval is sometimes so slow in prisons that it arrives after an inmate is released or transferred.w7 In the US, where managed care is fairly well established, allegations of poor quality health care and litigation by inmates because of poor care are not uncommon.6

All federal prisons and about 70% of state prisons in the US have copayment schemes for prisoners' health care, and part of the money raised is paid into the Victims of Crime fund.7 Although this has reduced healthcare costs in prisons,8 w8 it has adversely affected most poor prisoners, for whom a sick call fee of $5 typically represents two days' wages. Chronically ill and elderly prisoners—who generally have greater healthcare needs but are physically unable to work—have the least income and therefore suffer more as a result of such copayment policies. Evidence so far indicates that the cost of administering the programme is greater than its projected savings.w9

Most surveys in the US, Britain, and Australia indicate that prisoners' health is much worse than that of the general population.7 w10-12 This underlines the need for better initiatives for meeting prisoners' healthcare needs, particularly if it has to be done with the existing (substantial) resources for prisons.

One way to free up resources might be to reduce imprisonment rates, especially for minor crimes.9 In the UK, Australia, and the US, rates for most major categories of crime are lower than they were 10 years ago, yet prison numbers have risen by about half. In French philosopher Michel Foucault's words, imprisonment has become its own remedy.10 Greater use of other sentencing options, such as community service for minor offenders, and reserving imprisonment only for offences carrying a sentence of six or more months might reduce imprisonment rates by at least 20% in these countries, given the current average length of imprisonment.

Other ways to reduce the general costs of imprisonment include more mechanised custodial security and fewer staff, although such measures have not yet reduced the costs of staffing. Increased use of live communication via video conferencing between different departments involved with the criminal justice system, however, has allowed the New South Wales (Australia) Corrective Services Department to save $A2.3m (£1m, €1.4m, $1.7m).3 Inmates may now have their appeals heard by magistrates via such cross-justice videoconferencing, instead of being transported from prison to court.

Reform of prison health services might reduce costs if it brought greater focus on health promotion within the prison population and other preventive services, restructured staffing, obtained discounts through bulk purchases, and maximised resources through better cooperation with other government health agencies.11 w13 Finally, more effective use should be made of data from research, surveys, and clinical practice to reliably determine prisoners' core health needs, current healthcare practices, and cost effective ways to bridge identified gaps in services.12 w14

Supplementary Material

[extra: Additional references]


An external file that holds a picture, illustration, etc.
Object name is webplus.f1.gifAdditional references w1-w13 are on bmj.com

Competing interests: None declared.


1. Sim J. Medical power in prisons: the prison medical service in England, 1774-1989. Buckingham: Open University Press, 1990: 11-9.
2. US Department of Justice, Bureau of Justice Statistics. Prison Statistics, 2003/2004. Washington: US Department of Justice, 2004. www.ojp.usdoj.gov/bjs/prisons.htm (accessed 24 May 2005).
3. New South Wales Department of Corrective Services, Australia. Annual report 2003/2004. Sydney: DCS, 2004. www.dcs.nsw.gov.au/Documents/main.asp (accessed 24 May 2005).
4. British Home Office. Annual report of the HM chief inspector of prisons for England and Wales, 2003/2004. London: Home Office, January 26, 2005. www.homeoffice.gov.uk/justice/prisons/inspprisons/annual.html#annual (accessed 6 Apr 2005).
5. Treadwell HM, Ro M. Poverty, race, and the invisible men, Am J Public Health 2003;93: 705-7. [PMC free article] [PubMed]
6. Robbins IP. Managed Health Care in prison as cruel and unusual punishment. J Criminal Law Criminol 1999;90: 195-238. [PubMed]
7. United States 106th Congress, 2000. Federal prisoner health care co-payment Act of 2000. Washington, Public Law 106-294, 12 October 2000. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=106_cong_public_laws&docid=f:publ294.106 (accessed 22 Jun 2005).
8. Ormes WS. The impact of a co-payment policy on dental services in a correctional setting. Correct Compend 2004;29: 2-4.
9. Piehl AM, Useem B, Dilulio JJ. Right-sizing justice: a cost-benefit analysis of imprisonment in three states. Civic report No 8. Manhattan Institute of Policy Research, September 1999. www.manhattan-institute.org/html/cr_8.htm (accessed 6 Apr 2005)
10. Foucault M. Discipline and punish. Harmondsworth: Penguin, 1979.
11. United States General Accounting Office. 2000. Containing the health care costs for an increasing inmate population. Testimony by Richard Stana before the United States Senate subcommittee on criminal justice oversight. Washington DC, 6 April 2000. www.gao.gov/archive/2000/gg00112t.pdf (accessed 24 May 2005).
12. HM Prison Service. Clinical governance: quality in prison healthcare. London: Department of Health, 2003. (Prison service Order 3100.)

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