The research

People in prison attended A&E over 27,000 times in 2023/24. This is less than expected based on rates seen in the general population, probably because people in prison can’t choose to attend A&E in the same way as they might if they weren’t in prison, and because prison health care may be managing some of the health care needs which would otherwise have resulted in an A&E attendance.

At a time of renewed interest in the health of people in contact with the criminal justice system following the Chief Medical Officer’s report, this work highlights just how vital analysis of routinely collected hospital data can be to inform understanding of the needs of people in prison and how they can be best supported.

Key findings

• Paracetamol overdose rates were over six times higher for people in prison than the general population in 2023/24. Paracetamol overdose was the most recorded diagnosis for prisoners attending A&E in 2023/24, with far higher rates than we would expect based on the general population. In prison, there were 6.2 attendances per 1,000 with a diagnosis of paracetamol overdose, compared to 0.8 per 1,000 outside of prison. There have been significant efforts in the general population to reduce paracetamol overdoses, but high rates in prison suggest an opportunity for targeted action.
• The rate of A&E attendances from prison associated with seizures was three times higher than seen in the general population in 2023/24. While there are compounding risk factors for seizures in the prison population, such as drug and alcohol withdrawal and head injuries, the scale of emergency hospital attendances highlights potential points of intervention regarding seizure management.
• A&E attendances with an associated diagnosis of acute coronary syndrome (ACS) were twice as high for the prison population than seen in the general population, highlighting an opportunity for intervention to prevent cardiovascular disease in a population known to be at risk of poor heart health. ACS is an umbrella term for a range of disorders which can include heart attack and unstable angina as a result of reduced blood flow to the heart. Researchers found there were 8.2 attendances for ACS per 1,000 from the prison population aged 50+ compared to 4.1 per 1,000 for people in the general population of the same age.
• One in 10 prisoners who attend A&E leave without being seen or treated by hospital staff, which is around double the proportion who leave without being seen outside of prison. This raises questions about how and why A&E services are used by prisoners and the nature of health service organisation in prison. This is likely to reflect a range of factors, including challenges with delivering health care in prison settings, and the necessary role of prison staff in escorting prisoners to A&E for care, as well as difficulties with delivering care out of hours, with A&E being used as a safety net.
• Despite the challenges of attending hospital from prison, some people in prison attend A&E regularly. 30% of those who attend A&E (n=4,963) attended more than once and 719 people attended A&E five times or more, which would be considered high-intensity service use. Compared to those in prison who attend less frequently, this group were characterised by attendances linked to seizures and self-injurious behaviour. There are a range of risk factors in a prison context which increase the risk of A&E attendances linked to seizures, including an underlying diagnosis of epilepsy, use of certain medications, alcohol or drug withdrawal, as well as history of head injury. Epilepsy rates are believed to be higher in prison, and there are well-documented challenges of managing epilepsy in prison.
• A&E attendance while in prison is associated with high use of A&E services outside of prison. We looked at people who attended A&E in prison, and found that for this group, outside of prison, just under one in four people attended A&E five or more times over the course of the year, meeting the criteria for high-intensity service use. Attendances by the highest users of A&E outside of prison (those with 20 or more attendances) were most commonly linked to substance misuse, highlighting the importance of both how substance misuse is managed in prison, as well as continuity of care on release.

Conclusions

The researchers draw two main conclusions. Firstly, that more regular health checks for older prisoners as well effective preventative screening on reception could improve health outcomes for people in prison as well as reducing the number of A&E attendances.

Secondly, it appears that urgent care services are left to pick up the pieces when continuity of care for people in contact with the justice system isn’t managed effectively. This points to gaps in commissioning with the needs of dependent drug & alcohol users also highlighted.

Thanks to Andy Aitchison for kind permission to use the header image in this post. You can see Andy’s work here