The implementation of healthcare equivalence in English prisons is threatened by a focus on security, tight budgets, an increasing — and aging — prison population, and an inconsistent interpretation of equivalence according to an article published in the Journal of Medical Ethics.

The idea of equivalence in prison healthcare has been around for nearly 4 decades. Equivalence dictates that individuals imprisoned should receive the same level of access to healthcare as the non-prison population, and recognizes the responsibility of the state to provide care for individuals it maintains in prison. However, implementation of this philosophy is less than perfect.

Nasrul Ismail, LLB, MSc, and Nick de Viggiani, PhD, MSc, both of the Centre for Public Health and Wellbeing, University of the West of England in Bristol, United Kingdom, interviewed 30 key decision makers in the English prison field to examine how they interpret and implement the principle of equivalence in English prisons.

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The researchers found that although all 30 participants agreed on the importance of the equivalence principle, their understanding of the term differed. There was a consensus among participants, however, that imprisonment is a temporary situation and that healthcare should be delivered continuously, before, during, and after time spent in prison. All participants agreed that prison should have a rehabilitative goal rather than a punitive one.

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Some participants commented on the failure of authorities to provide guidance on this issue and noted that it causes uncertainty and inconsistency in interpretation. For individuals involved in strategic positions, equivalence did not mean “the same” but was defined in terms of need — that is, prisoners often have a greater need for healthcare services. People in mid-level positions within the prison system were concerned about accessibility — that is, that prisoners should not have to wait weeks to see a healthcare specialist and should not be handcuffed during medical visits if possible. On the other end of the spectrum, individuals tasked with delivering prison healthcare felt that delivery of services should be essentially the same as it is within the general population. People working at the strategic level tended to feel that healthcare delivery was better than did people who were involved at a more operational level.

The investigators contend that instability within the English prison system caused by an increase in the prison population, the aging of that population, and a reduction in the resources allocated to prisons, threatens the implementation of healthcare equivalence. This is at odds with the Ottawa Charter, an international agreement that proposes a more supportive environment for healthcare within prisons.

The researchers suggest that prison gatekeepers must be persuaded to see that rehabilitation and security are not mutually exclusive. Furthermore, they argue that prison should be considered a last resort in order to reduce overcrowding and the pressure on resources so that prison healthcare systems can concentrate on individuals with the greatest need within the incarcerated population.


Ismail N, de Viggiani N. How do policymakers interpret and implement the principle of equivalence with regard to prison health? A qualitative study among key policymakers in England. J Med Ethics. 2018;0:1-5. doi:10.1136/medethics.2017.104692