How are health services in prison delivered?

In Australia, there are several differences in the delivery of health services to people in prison compared with the general community, including funding arrangements and models of service delivery.

In the community, health services are provided by both the Australian Government and the relevant state or territory government department. Health services for people in prison are the sole responsibility of state and territory governments, and the way in which these services are delivered varies among jurisdictions.

In some jurisdictions, the state or territory health department provides prison health services; in others, the provision of health services is the responsibility of the justice or corrections department.

Most jurisdictions use a mix of directly provided services, community health services and contracted health services. Providing mental health services and alcohol and other drug services can be particularly complex, both in terms of the services delivered and the method of delivery.

In prisons, nurses usually provide primary health care (or the first level of contact with the health-care system). In the general community, general practitioners provide most of the primary health care.

Specialist medical care can be provided to people in the prison system, or through services that are not prison based – such as general hospital inpatient and emergency care services – depending on the prison, jurisdiction and service required. For example, some prison clinics deliver dental services and perform x-rays, whereas other smaller prison clinics are staffed by a single nurse only.

The Medicare Benefits Schedule (Medicare) gives residents of Australia access to no-cost or subsidised health care, including no-cost or low-cost treatment and accommodation in public hospitals. Medicare is funded by the Australian Government and does not apply to services provided directly by state and territory governments. This means that prison health services are not provided under the Medicare system (Cumming et al. 2018). The Pharmaceutical Benefits Scheme (PBS), which provides access to medicines at lower cost for Australian residents, is also funded by the Australian Government. Medications dispensed to people in prison are not covered, except for medications that fall under Schedule 100 of the PBS, known as the Highly Specialised Drugs Program.

For people who underuse health services in the general community, prison can provide an opportunity to access treatment to improve their health. Many types of health care are accessed less often in the community than in prison (see Health services) for various reasons, including cost, work or family commitments, and alcohol or other drug issues (see Health risk behaviours). The stability of the prison environment may provide opportunities for people to reflect on, and seek treatment for, their health concerns.

The Royal Commission into Aboriginal Deaths In Custody included recommendations for Aboriginal health services to be included in providing mental and physical health care for First Nations people in custody (Johnson 1991). A small number of prisons currently have Aboriginal Community Controlled Health Organisations (ACCHOs) visiting to assist with the delivery of health care. However, ACCHOs can be subject to funding shortages and are often over‑stretched to deliver services to people in their communities (Moran et al. 2014; NACCHO n.d; Pettit et al. 2019) which can limit their capacity to reach people in prisons. There is no nationally coordinated approach or body whose role is to assess the specific health needs of First Nations people in prison (Pettit et al. 2019) – and funding for ACCHOs to visit prisons is the responsibility of state and territory governments.

Objective 3.2 of the National Aboriginal and Torres Strait Islander Health Plan 2021–31 outlines that health-care providers must have cultural safety values, behaviours and standards embedded in the workplace culture (Department of Health 2021). 

Providing and operating health services in a prison environment is not always straightforward. Delivery of services to people in prison can be affected by:

  • regimes and processes in the prison environment that make continuity of care between the community and prison difficult
  • delays in establishing communication with the community-based doctor of a person in prison, or to confirm existing prescriptions, leading to disruptions to regular medications or to self-medication practices, and leaving prison entrants at increased risk of mental health instability during a particularly difficult time (Bowen et al. 2009)
  • uncertainty about exact discharge dates, often affected by bail and parole applications, which makes continuity of care from prison to the community difficult.

The prison population in Australia is increasing, both in overall numbers and in the rate of imprisonment. As a result, prisons in some states and territories exceed 100% prison design capacity. Prison design capacity utilisation is reported in the Report on Government Services (Productivity Commission 2023). If prisons are operating above capacity, overcrowding can create issues for maintaining a safe and healthy environment; one strategy used to manage this is to move people between prisons. This can, however, make it difficult for health-care providers in prison to maintain continuity of health care (Grace et al. 2013).