The state of English prisons and the urgent need for reform
Authors: Nasrul Ismail, Andrew Forrester
Journal: The Lancet Public Health (2020)

People in prison are among the most marginalised in societies, often presenting with physical and mental illness.1Fazel S Baillargeon J The health of prisoners.Lancet. 2011; 377: 956-965Summary Full Text Full Text PDF PubMed Scopus (735) Google Scholar, 2Slade K Forrester A Baguley T Coexisting violence and self-harm: dual harm in an early-stage male prison population.Legal Criminol Psychol. 2020; (published online April 7.)DOI:10.1111/lcrp.12169Crossref Scopus (19) Google Scholar Their vulnerability is such that international treaties (eg, the UN Standard Minimum Rules for the Treatment of Prisoners known as the Nelson Mandela Rules, 2015) and organisations (eg, the Council of Europe's Committee for the Prevention of Torture [CPT]) are required to ensure that people in prison remain safe, that inhuman treatment is prohibited, and that their right to health is secured.3United NationsUnited Nations standard minimum rules for the treatment of prisoners (the Nelson Mandela rules).https://undocs.org/A/RES/70/175Date: 2016Date accessed: May 9, 2020Google Scholar These issues should be of particular concern in England and Wales, which have the highest imprisonment rate in western Europe (174 per 100 000 people, compared with the European average of 132 per 100 000 people).4House of Commons LibraryUK prison population statistics.http://researchbriefings.files.parliament.uk/documents/SN04334/SN04334.pdfDate: 2019Date accessed: May 9, 2020Google Scholar In April, 2020, the CPT reported on its previous ad hoc prison inspections in England in 2019. Earlier inspections, in 2016, had described restricted access to health-care resources and purposeful activities, along with increased violence and lengthy confinements within locked, overcrowded, and poorly maintained prison cells.5Council of EuropeCouncil of Europe anti-torture committee publishes report on the United Kingdom.https://www.coe.int/en/web/cpt/-/council-of-europe-anti-torture-committee-publishes-report-on-the-united-kingd-2Date: 2020Date accessed: May 9, 2020Google Scholar Following the 2019 visit, the CPT praised various prison reform programmes, including the recent addition of 3000 prison officers, improved violence monitoring, and better drug testing. However, the CPT also emphasised the crisis in English prison systems and issued 42 recommendations to address the unhealthy, unsafe, and unsustainable conditions registered in accordance with the 2016 inspections.5Council of EuropeCouncil of Europe anti-torture committee publishes report on the United Kingdom.https://www.coe.int/en/web/cpt/-/council-of-europe-anti-torture-committee-publishes-report-on-the-united-kingd-2Date: 2020Date accessed: May 9, 2020Google Scholar Specifically, the CPT noted, prisoners did not have access to purposeful activities. Unemployed prisoners spent up to 23 h a day in their cells, exceeding the daily recommended limit of 16 h.5Council of EuropeCouncil of Europe anti-torture committee publishes report on the United Kingdom.https://www.coe.int/en/web/cpt/-/council-of-europe-anti-torture-committee-publishes-report-on-the-united-kingd-2Date: 2020Date accessed: May 9, 2020Google Scholar Such surplus confinement is especially problematic in light of the recently published Ministry of Justice Safety in Custody statistics, which were released the same day as the CPT report, and documented 63 328 incidents of self-harm in 2019—a record number—and a total that amounts to an increase of 63% since 2012.6Ministry of JusticeSafety in custody: quarterly update to December 2019.https://www.gov.uk/government/statistics/safety-in-custody-quarterly-update-to-december-2019Date: 2020Date accessed: May 9, 2020Google Scholar Despite political acknowledgment by the UK government of the precarious conditions in English prisons, which was enshrined in their response to the CPT report,5Council of EuropeCouncil of Europe anti-torture committee publishes report on the United Kingdom.https://www.coe.int/en/web/cpt/-/council-of-europe-anti-torture-committee-publishes-report-on-the-united-kingd-2Date: 2020Date accessed: May 9, 2020Google Scholar the safety of those in custody has continued to deteriorate. Incidents of assault increased by 53% between December, 2012, and December, 2019,6Ministry of JusticeSafety in custody: quarterly update to December 2019.https://www.gov.uk/government/statistics/safety-in-custody-quarterly-update-to-december-2019Date: 2020Date accessed: May 9, 2020Google Scholar with increasing quantities of drugs entering prison establishments.5Council of EuropeCouncil of Europe anti-torture committee publishes report on the United Kingdom.https://www.coe.int/en/web/cpt/-/council-of-europe-anti-torture-committee-publishes-report-on-the-united-kingd-2Date: 2020Date accessed: May 9, 2020Google Scholar Episodes of prisoner on staff violence increased by 70% during the same period.6Ministry of JusticeSafety in custody: quarterly update to December 2019.https://www.gov.uk/government/statistics/safety-in-custody-quarterly-update-to-december-2019Date: 2020Date accessed: May 9, 2020Google Scholar Of great concern, the CPT also observed the use of physical violence or so-called preventive strikes by prison officers against otherwise compliant prisoners.5Council of EuropeCouncil of Europe anti-torture committee publishes report on the United Kingdom.https://www.coe.int/en/web/cpt/-/council-of-europe-anti-torture-committee-publishes-report-on-the-united-kingd-2Date: 2020Date accessed: May 9, 2020Google Scholar Because reporting and oversight mechanisms remain inadequate, most of these figures are probably underestimates.7Ismail N Rolling back the prison estate: the pervasive impact of macroeconomic austerity on prisoner health in England.J Public Health. 2019; (published online May 24.)DOI:10.1093/pubmed/fdz058Crossref Scopus (20) Google Scholar Serious overcrowding has not improved since the first UK visit by the CPT in 1990.5Council of EuropeCouncil of Europe anti-torture committee publishes report on the United Kingdom.https://www.coe.int/en/web/cpt/-/council-of-europe-anti-torture-committee-publishes-report-on-the-united-kingd-2Date: 2020Date accessed: May 9, 2020Google Scholar Exceeding certified capacity and doubling up of prisoners in single-occupancy cells has become the norm.5Council of EuropeCouncil of Europe anti-torture committee publishes report on the United Kingdom.https://www.coe.int/en/web/cpt/-/council-of-europe-anti-torture-committee-publishes-report-on-the-united-kingd-2Date: 2020Date accessed: May 9, 2020Google Scholar The CPT recommended investing in smaller prisons, but the UK government resisted, instead planning further space to accommodate an additional 20 000 prisoners.5Council of EuropeCouncil of Europe anti-torture committee publishes report on the United Kingdom.https://www.coe.int/en/web/cpt/-/council-of-europe-anti-torture-committee-publishes-report-on-the-united-kingd-2Date: 2020Date accessed: May 9, 2020Google Scholar Creating new space by building additional prisons will increase the prison population further, and such an approach is unlikely to improve prisoners' health and wellbeing.7Ismail N Rolling back the prison estate: the pervasive impact of macroeconomic austerity on prisoner health in England.J Public Health. 2019; (published online May 24.)DOI:10.1093/pubmed/fdz058Crossref Scopus (20) Google Scholar In light of the findings of this most recent report by the CPT, three matters warrant special emphasis. First, the global COVID-19 pandemic has underscored the poor living conditions within prisons by exposing the vulnerabilities of these institutions to an infectious disease outbreak. Cases and deaths linked to COVID-19 are emerging in English prisons8O'Moore E Briefing paper- interim assessment of impact of various population management strategies in prisons in response to COVID-19 pandemic in England.https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/882622/covid-19-population-management-strategy-prisons.pdfDate: 2020Date accessed: May 9, 2020Google Scholar and prisoners remain at considerable risk. Second, greater confinement and increased self-harm and violence have coincided with the government's austerity measures since 2012.7Ismail N Rolling back the prison estate: the pervasive impact of macroeconomic austerity on prisoner health in England.J Public Health. 2019; (published online May 24.)DOI:10.1093/pubmed/fdz058Crossref Scopus (20) Google Scholar Similarly to other countries that implemented austerity measures, prison staff were cut by 30%, despite persisting high rates of imprisonment.7Ismail N Rolling back the prison estate: the pervasive impact of macroeconomic austerity on prisoner health in England.J Public Health. 2019; (published online May 24.)DOI:10.1093/pubmed/fdz058Crossref Scopus (20) Google Scholar Although spending on UK prisons is consistent with the European average, amounting to 0·2% of gross domestic product, other European countries have comparatively smaller prison populations, meaning that their spend per prisoner is greater.9EurostatGovernment expenditure on public order and safety.https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Government_expenditure_on_public_order_and_safetyDate: 2020Date accessed: May 9, 2020Google Scholar A robust and recurrent spending budget is needed to improve the safety and decency of prisons. Third, the Conservative government, which won the UK 2019 general election, has pledged tougher and longer sentences, possibly further expanding the prison population. In the interests of a civilised society, a clear strategic national plan is required to implement the CPT recommendations, including the provision of adequate financing. Reducing the size of prison populations and improving the prison estate (eg, by creating safer and better quality cellular accommodation and ensuring better provision of education and employment) would immediately signify a commitment to addressing ongoing safety and decency concerns. Fyodor Dostoevsky wrote, "The degree of civilisation in a society can be judged by entering its prisons.".10Dostoevsky FM The house of the dead. Vremya, Saint Petersburg1862Google Scholar If the UK government is serious about attaining its vision of a world-renowned criminal justice system that transforms former offenders into future citizens, its reforms must now prioritise prisoners' health and safety. NI was supported by a UK Economic and Social Research Council Research Studentship Award (ES/P000630/1). AF declares no competing interests.