Results

PRIMARY CARE CONSULTATION RATES

Male prisoners consult doctors six times per prisoner year: three times more frequently than a demographically equivalent community population. They consult healthcare workers 23 times per prisoner year: 77 times more frequent than men in the community consult nurses (the nearest community equivalent to prison healthcare workers). Female prisoners consult doctors 14 times per prisoner year: three times more frequently than a demographically equivalent community population. They consult healthcare workers 59 times per prisoner year, 197 times more frequently than women in the community (table 1).

INPATIENT FACILITIES AND ADMISSION RATES

In 1997/98, there were 1792 inpatient beds within prisons; 29 health care beds per 1000 prisoner years. In comparison, in 1996, there were approximately 4.5 beds per 1000 population in the UK as a whole.5 Prisoner admissions to NHS beds are lower than would be expected in a demographically equivalent community population (table 1). However, admissions to prison health care centre beds are high. Male prisoners are admitted to health care centre beds 0.7 times per prisoner year. Total inpatient admissions among male prisoners are 10 times those of a demographically equivalent community population. Female prisoners are admitted to health care centre beds over three times per prisoner year. Total inpatient admissions among female prisoners are 17 times those of a demographically equivalent community population.

Discussion

Prison inmates are high users of primary care and of inpatient facilities compared with equivalent community populations. Possible explanations for this are an increased demand for health care—because of higher levels of morbidity and the institutional culture of prisons—and better access (supply) than is found in the community. Prisoners have a much higher incidence of mental health and substance misuse than the general population. However, increased morbidity alone is unlikely to explain the high service utilisation.6There are other additional explanations that may be more open to change in the long run. Firstly, the legalistic aspect of the institutional culture of prisons requires prisoners to have medical consultations before adjudication proceedings, again adding to demand. Secondly, the institutional culture of prisons restricts prisoners' ability to self care and almost eliminates their access to over the counter medication. This allows little opportunity to substitute informal and self care for primary health care services. Institutional culture may also affect the threshold at which prisoners are admitted to prison inpatient facilities. It is as easy to admit patients to inpatient facilities as to arrange for self management with frequent review. Thirdly, on the supply side, prisoners have easy access to primary care for even trivial complaints. The personal cost and inconvenience of seeking professional care is therefore low. Even simple health problems therefore become medicalised. Similarly, compared with the community, prisons are relatively well supplied with inpatient facilities. Access is clearly also a factor in the lower than expected NHS hospital admission rate.

It is unlikely that morbidity differences between prisoners and a population of equivalent age and sex in the community is sufficient to explain differences in service use. But to determine whether this is the case data need to be collected on the reasons for prisoner consultations and reasons for inpatient admissions: data that are not currently collected. Meanwhile it seems reasonable to suggest that some loosening of legalistic reasons for prison health service use and greater allowance for self care could be useful starting points for reducing demands on prison health care services.