The pitfalls of privatising prison healthcare

“Nowhere is the fragmentation of the corrections system more apparent than in the provision of health services.”

– Independent Investigation into the Management and Operation of Victoria’s Private Prisons (2000)

Four years ago, a renewed set of Guidelines for Corrections in Australia reaffirmed our nation’s commitment to the principle of healthcare equivalence. Being incarcerated was not to be a barrier – it was every prisoners’ right to receive healthcare equivalent to that which they would receive in the community. The guidelines stressed the importance of continuity of care in protecting this equivalence.

“[A guiding principle is that prisoners are] provided with access to healthcare, to the same standard as in the community, in response to need, with an appropriate range of preventative services, and promoting continuity with external health services upon release.”

Fast forward to the first weeks of 2017, and we straddle two possible futures for corrections healthcare. The first, maintaining the status quo; the majority of NSW prisons currently receive healthcare from the same public system that serves the communities prisoners come from and return to. This healthcare is comprehensive, accountable, and integrated both across prison sites and with the external community. The second, throwing the baby out with the bathwater; a move to privatise corrections healthcare along with the rest of the prison system, isolating prison health from the public health system that has been its foundation.

The privatisation of prison healthcare is believed by the NSW Government to represent a move of both innovation and inexpensive service delivery. As the past few years of health policy have demonstrated, healthcare is fast running out of such ‘efficiencies’ to deliver back to the Government’s bottom line. At some point – a point that many would argue we have already passed – savings in healthcare are provided at the expense of patient care.

Corrections health privatisation heralds countless blows to patient care: the absence of a whole-of-system healthcare advocate, as multiple private providers dilute responsibility for the prison population as a whole; the loss of healthcare provision independent of corrections management, which the WHO calls ‘a failsafe to detect and protect against prisoner mistreatment’; the risk of eroding patient-clinician relationships, based as they are on the goodwill and passion of public clinicians; the disintegration of medically skilled oversight, as private prison health providers are overseen by the Department of Corrective Services rather than the Department of Health.

Those employed by a private prison health provider face isolation from the public system, working in a single prison site in a professional silo. With this goes the benchmarking of prison health against wider health workforce strategies and the requirement to participate in state public health initiatives. Each of these issues are highlighted in AMA policy, alongside a recommendation that prison healthcare remain a domain of health – not Department of Corrections – authority.

In an earlier NSW inquiry into prison privatisation, the Department of Corrective Services stressed that privatisation does not represent the contracting out of responsibilities; rather, it should be seen as contracting in additional services. However, fulfillment of those responsibilities is far from assured.

Even the best efforts of private providers face significant barriers. In 2000, at the time of a review of entirely privatised Victorian prison healthcare, no less than eight separate health providers operated in the state. That is eight different note-taking forms and norms, eight different layers of management, eight opportunities for a prisoner, frequently transferred between facilities on short notice, to fall through the cracks.

This compromised continuity of care is particularly significant given the complex and chronic health needs of a patient base. Prisoners seek medical care three times more frequently than the general population, and require specialised care for issues of addiction, as well as higher requirements for psychiatric care. This is to say nothing of the disjoint between the multiple potential healthcare providers inside prisons and the patients’ eventual provider upon release – the state.

The present public management of prison health, independent of corrections management, is gold standard.

However, as the year of 2016 so clearly demonstrated, good policy is too often trumped by good politics. That which engages or enrages voters has come to have far more sway in government policy than a carefully considered, comprehensively developed, evidence-based plan. It seems that the future of prison health will hinge on how much medical practitioners and the general public alike make it known that they care.

It is not sufficiently recognised that the prison service is a public service… As with all public services, the extent and the quality of provision depend on a political decision.”- World Health Organisation