Progress in the
Penal System (PIPS)

12: Access to healthcare services

Standard 12:

The healthcare needs of individual prisoners are met. Every prisoner has access to healthcare that goes beyond the ‘equivalence of care’ principle, with a full range of preventative services and continuity of healthcare into the community.

Rationale:

The right to healthcare in prison is equal to that enjoyed by the general population is laid out in the Mandela Rules, the Bangkok Rules and the European Prison Rules.[248] The healthcare needs of the prison population are in fact higher than those of the general population. These needs must be met, particularly because of the lack of autonomy prisoners face in terms of their access, choice and responsiveness to healthcare.

Current context:

According to the World Health Organization (WHO, 2019), there is evidence that people who are imprisoned disproportionately experience complex, co-occurring health problems, including mental illness, cognitive disability, substance dependence, non-communicable diseases, HIV, tuberculosis, hepatitis C and other infectious diseases.[249] The poor health experienced by this population typically occurs in the context of deeply embedded socioeconomic disadvantage.[250] While many people have health problems when entering prison, the prison setting can worsen existing mental health or physical health conditions.[251]

In 2019, the Minister for Health published Sláintecare Action Plan 2019.[252] It is a ten-year plan with a vision for reformed health and social care services in Ireland. One of its overall aims is to improve population health. It is important that the healthcare needs of the prison population are considered within this context.

Currently, the IPS manages healthcare in Irish prisons, despite an increasing trend internationally whereby Ministries of Health are responsible for prison healthcare (see progressive practice section below).

A number of healthcare issues have been raised in the OiP reports on deaths in custody, with causes of death in prison including suspected suicide, overdoses, serious medical conditions and natural causes.[253] The OiP has made a number of important recommendations related to healthcare in these reports. For example, the Inspector recommended that centralised policy and standard operating procedures be developed to ensure that the nurse in change within each prison is notified immediately when a new committal has medication in his/her possession. In the same report, the Inspector recommended that no medical items should be placed in an area to which nurses do not have access to 24 hours a day, seven days a week.[254]

The 2017 Prison Visiting Committee reports also document issues of access to healthcare.[255] For example, there was no doctor available in Arbour Hill at weekends, despite the high volume of elderly prisoners in need of constant medical attention there. In Cloverhill, prisoners raised the issue of delays in accessing the medical doctor there, as well as access to medical visits outside the prison.[256] The Cloverhill Visiting Committee recommended improvements be made to healthcare services.[257]

In 2016, there was a total of 153 prison healthcare staff in Ireland.[258] The healthcare staff–prisoner ratio was 42 per 1,000. Comparatively, the ratio in other European countries was: 46.3 per 1,000 in Belgium; 49.9 per 1,000 in France; 61 per 1,000 in Finland; and 89.1 per 1,000 in Switzerland.[259]

The WHO’s database shows that there were 101 healthcare complaints made by prisoners in Ireland in 2016.[260]

A number of recommendations have been made by external bodies related to improving prison healthcare in Ireland.

Following its last visit to Ireland, the CPT (2015) described healthcare in some Irish prisons as being ‘in a state of crisis’.[261] They recommended:

… that the Irish authorities identify an appropriate independent body to undertake a fundamental review of health-care services in Irish prisons. Further, it would appreciate the observations of the Irish authorities on the question of bringing prison health-care services under the responsibility of the Ministry of Health.[262]

It also highlighted the deterioration of healthcare services in Midlands prison. The CPT recommended that that there be at least one full-time GP in Castlerea Prison, and that psychiatric visits take place there. It also recommended that there be two full-time GPs in Mountjoy Prison and that improvements be made in terms of increasing the time of attendance of GPs in Mountjoy, Midlands and Castlerea prisons.

In a 2016 thematic review of healthcare in prisons by the OiP recommended that a health needs assessment of prisoners in all prisons should be “undertaken immediately”.[263] The OiP recommended that the lead in undertaking the healthcare assessment must be a clinician.

In July 2018, an executive clinical lead was appointed to prison healthcare.[264] Since this appointment, the Minister for Justice and Equality has confirmed that the terms of reference for the review of prison healthcare were agreed between the Department of Justice and Equality, the Department of Health and the IPS in August 2018.[265] In June 2019, the Minister stated:

This assessment will determine the health status of prisoners, the need and demand for healthcare services, while also establishing the current level of healthcare service provision in prisons. It is proposed that this assessment will outline current and future health needs and make recommendations, based on best international practice, to the Steering Group on the future development of health and personal social services. [266]

In a 2019 report examining a health-informed approach to penal reform, two urgent questions were highlighted for every government to consider:[267]

“whether all available routes are being pursued to prevent overcrowding in prisons and thereby minimise the associated risks to public health; and

how the work of criminal justice and community health agencies can be reconfigured to prevent the imprisonment of people whose health needs could be better met in the community.”

These questions should be considered as part of the assessment in Ireland, given the current issue of overcrowding, and in order to ensure that Ireland delivers upon the principles of continuity and equivalence of care in prisons.

Outlined below are two groups with a particular set of healthcare needs: women and older people.

Women

Women have a distinct set of healthcare needs and should therefore have access to gender-specific healthcare services. Basic healthcare needs, including women’s lack of access to sanitary products, were reported in 2019 as not being met.[268] These needs are further outlined under the United Nations Rules for the treatment of Women Prisoners and Noncustodial Measures for Women Offenders (the Bangkok Rules).[269] In England, there are a number of gender-specific standards to improve the health and well-being for women in prison.[270]

Older people

There is a growing number of older people in our prison population. The healthcare needs of this cohort require specific attention.[271] For example, while reporting on the death of an elderly prisoner in Midlands, the OiP stated that as prisons do not have hospital wings, prisoners with significant medical problems should not remain in prison.

Furthermore, in relation to end-of-life care, the Inspector recommended that “when it is apparent that a prisoner is reaching the end of his/her life, a case conference involving a palliative care team should be convened to formulate a care plan”.[272] The Inspector recommended:

Decisions to release prisoners on grounds of severe ill-health, severe pain and/or where such prisoners are nearing death, such as in this instant case, should be made by the Director General having regard to advice from all appropriate professionals such as Doctors, Healthcare Staff and Senior Management of the prison.[273]

It may be necessary to amend legislation to give effect to this recommendation. If so, it should be prioritised in the interest of the human rights of terminally ill prisoners.

As highlighted by the CoE (2019):

“The normal prison environment is harmful and amounts to inhuman and degrading treatment for some prisoners: those with terminal illness, those with serious mental disorders, those with chronic infectious diseases”.[274]

Some key ethical cornerstones to providing prison healthcare have been highlighted by the CoE.[275] These include: access to healthcare; equivalence of care; patient consent and confidentiality; preventative healthcare; humanitarian assistance; professional independence; and professional competence.

Indicators for Standard:

Indicators for Standard 12

Indicator S12.1: Responsibility for prisoner healthcare is held by the Health Service Executive (HSE), with independent inspections by the Health Information and Quality Authority (HIQA).

This has not happened yet, although a healthcare assessment of the needs of the prison population is underway with agreed terms of reference between the Department of Justice and Equality, the IPS and the Department of Health.

Indicator S12.2: Publication of an annual report on prison medical services as recommended by the CPT.

Thus far, there has been no annual report published on prison medical services in 2018–2019.

Indicator S12.3: Ratio of medical staff to prisoners, including GPs and nurses (new).

The IPS directly employs four permanent prison doctors. Locum doctors are also employed. A panel of 30 qualified GPs are available. According to the Minister for Justice, “[t]his equates to approximately 12 whole-time equivalent (WTE) locum doctors delivering general practitioner sessions across the prison estate”.[276]

A total of 127.5 WTE nurses are currently employed by the IPS.[277].

The table below shows the average number of prisoners within each prison and the numbers of nurses assigned to each prison.

Nurse–prisoner ratio by prison, 2019

Prison (WTE) Average number of prisoners in custody, 2018 Nurses Nurse to prisoner ratio
Arbour Hill 135 5 1:27
Castlerea 300 10 1:30
Cloverhill 402 14.5 1:27.7
Cork 288 10 1:28.8
Dóchas Centre 132 7 1:18.9
Limerick 247 (33 female, 214 male) 11 1:22.5
Loughan House 110 2 1:55
Midlands 823 20 1:41.2
Mountjoy 679 21.5 1:31.6
Portlaoise 227 8 1:28.4
Shelton Abbey 97 2 1:48.5
Wheatfield Place of Detention 452 16.5 1:27.4
Total 3,892 127.5 1:30.5

Analysis

There has been some progress in the area of prison healthcare, with agreed terms of reference and tender advertised for a health needs assessment in 2019.[278] However, this is long overdue, given past recommendations made by the CPT (2015) and by the OiP (2016); the Inspector at that time recommended that a health needs assessment be carried out ‘immediately’.[279]

Poor prison conditions can exacerbate poor health – for example, the major outbreak of tuberculosis in Cloverhill prison at the start of the decade and the impact it had on health and safety in that prison.[280] Poor health conditions in prison can also lead to poor health conditions in the community, a current concern given the increasing number of prisoners serving short sentences.

In order to adhere to the principles of continuity and equivalence of healthcare in prisons, the Department of Health and the Department of Justice and Equality should consider the transfer of healthcare governance to the Department of Health. The Department of Health should also ensure that the healthcare needs of the prison population are taken into account when considering its goal of improving the overall health of the general population.

Status of Standard 12: Mixed

Progressive Practice:

Transfer of prison healthcare to ministries of health

A number of European countries now have their ministry of health governing prison healthcare services. These include Finland, France, Italy, Norway and the United Kingdom.[281]

A number of lessons were identified from the Finnish experience including: the importance of detailed planning and cooperation between organisations; ensuring that roles and responsibilities of organisations are formally defined and agreed; and that staff in all agencies are listened to and have support to adjust to the change.[282] After the transfer to the Ministry of Health, the strategy focused on: assessment of health needs within 24 hours of admission to prison; a health and wellness plan during imprisonment; and ensuring continuity of care upon release from prison.[283]

A 2018 report focusing on prison healthcare governance highlights that the longer-term impact of healthcare governance transfers to ministries of health is not yet known.[284] However, evidence suggests that countries that have made this change report increased professional independence for healthcare professionals.[285] The same report highlights the importance of national reporting and the establishment of solid indicators to assess the quality of in-prison healthcare.[286]

Actions required:

Action 12.1: The Department of Justice and Equality and the Department of Health must ensure that the prison healthcare assessment is completed and published by July 2020.
Action 12.2: The Department of Justice and Equality and the Department of Health should consider the transfer of prison healthcare to the Department of Health as part of the assessment.
Action 12.3: A national reporting framework and the development of indicators should be established in order to continually assess the quality of prison healthcare by the IPS.
Action 12.4: The IPS should take steps to ensure that terminally-ill prisoners can be released into appropriate care and have their rights respected.
Action 12.5: The IPS should develop gender-specific healthcare standards for women.

References:

Irish Penal Reform Trust

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