Healthcare is a major issue for people in custody in Australia. People in prison have substantially more complex physical and mental health care needs than the general population, and have significantly higher rates of both diagnosed and undiagnosed conditions. Despite their higher health needs, people in prison have significantly less access to healthcare in custody compared to the general Australian population.
There are no national standards for healthcare in Australian prisons. Prisoners in all jurisdictions, however, are prevented from accessing the Medicare universal health care system or the Pharmaceutical Benefits Scheme (PBS), which contributes to the lack of healthcare in custody as many prisons are unable to afford certain services and medications without Medicare or PBS rebates. Other issues inhibiting healthcare provision in custody include limited access to the National Disability Insurance Scheme, no access to needle and syringe programs, being reliant on prison officers to make medical appointments, and issues with record keeping.
Health services
There are no national standards for healthcare in Australian prisons. There are eight prison systems in Australia, one for each internal state and territory. No jurisdiction provides access to the Medicare universal health care system. In the absence of Medicare, each jurisdiction in Australia provides healthcare in custody differently through a variety of models, including services being provided by the public sector, outsourced to private providers, or through public-private partnerships. While prisoners do receive free healthcare, the range of services and medications are significantly lower than those available to the general community. Growth in prison populations around Australia are not matched with an equivalent growth in prison health resources or budgets. Medical issues in prisons were the most common category of complaint made to the Ombudsmen in New South Wales (NSW) during 2022–2023. Similarly, in Victoria in 2021–2022, the Ombudsmen received more complaints about Corrections Victoria than any other government department, with health services being the most frequent issue complained about within prisons.
Physical health
Prisoners on average are less healthy and have higher rates of chronic illnesses, infectious diseases, acquired brain injuries and drug use than the general community. People entering prison typically come from extremely disadvantaged backgrounds, and may have under-utilised health care prior to entering custody, as health was viewed as a lower priority than issues including housing, employment, caring obligations or drug addiction. For example, 43% of people entering prison were homeless, making prison entrants about 100 times more likely to be homeless than other Australians.
Despite their higher health needs, there is a lower level of health care available in prison than in the general community. However, for people in prison who underuse health services prior to their incarceration, prison can provide an opportunity to obtain treatment and improve health; 26% of people released from prison report being diagnosed with a previously unknown health condition while in custody. Among people being released from prison, approximately 53% reported their health improved in custody, 22% said it stayed the same and 25% said it deteriorated. While many surveyed people in prison rate the health care they receive as better than what they received in the community, these raw statistics do not take into consideration the lack of healthcare access many people had before entering prison.
Most chronic health conditions are more prevalent in prison entrants than the general community, though some conditions more associated with older people, such as arthritis and osteoporosis, are much less common in custody. This is attributed to the average age in prison being much lower than the general population. Communicable diseases are more prevalent, partly due to the higher levels of at-risk behaviours associated with people entering the prison system, such as drug use and unsafe sex. While only 18% of Australians have a disability, 39% of prisoners have one. Hearing loss affects approximately 90% of Indigenous Australians in custody.
Nine out of ten people incarcerated in Australia require dental treatment. Furthermore, 6% of the general Australian community between the age of 15 and 64 required dental extraction, whereas 28% of prison inmates between the age of 15 and 64 required an extraction. Some prisons do not offer dental services at all. While prisoners report positive interactions with some health professionals in prison, such as optometrists, reports about dental professionals are often negative, with complaints that dentists focus on extracting teeth, rather than doing fillings, and do not provide preventative services. Prisoners report that access to dental services is a significant concern, and that the typical treatments for toothache in prison, which is being given ibuprofen or paracetamol by nurses, are ineffective.
After their release, people wth poor health outcomes from their imprisonment place significant strain on themselves, the public health system, and the general community. Accordingly, improving the health of people in prison benefits the entire population.
Mental health
People with mental health conditions, particularly severe ones, are over-represented in Australian prisons. Rates of self-harm in prison occur at 3–8 times the rate of the general Australian community, and around 40% of people in custody report having been diagnosed with a mental health disorder, though it is estimated that 74% of people in prison have mental health disorders due to both undiagnosed conditions, and underreporting due to the consequences of disclosing such conditions. The typical response to reporting depression, self-harm or serious mental health issues in custody is to place the prisoner in solitary confinement under protective grounds. This practice exacerbates mental health conditions and rehabilitation prospects, and has been criticised for years, though remains common due to the absence of more appropriate supports. Mental health services offered in prison are widely considered to be inadequate, and prisoners typically have little to no access to ongoing counselling services in custody. Where psychological services do exist, they often focus on risk management services, rather than providing ongoing therapy.
As of 2023, there are no guidelines in Australia for the number of mental health staff who should be working in prisons. Accordingly, the guidelines in the United Kingdom, which recommend one full-time mental health worker for every 50 prisoners, are often cited in relation to Australian prisons. Only the Australian Capital Territory, the jurisdiction with the fewest prisoners in the country, meets this recommendation. In Western Australia, there are less than three full-time psychologists for the state's 17 prisons, giving a ratio of one psychologist per 2066 people, compared to a rate of one per 1031 people in the general population in that State.
Issues accessing healthcare
Many issues make health care access more difficult in prison than in the community. Prisoners have no choice of when they can access medical services in custody, face a restricted choice of healthcare providers, and experience longer wait times for services. Only 46% of surveyed prisoners in Australia reported they could easily see a doctor when required. Transport to medical appointments is significantly difficult, as consultations may require being transferred to another prison. If the location of that prison would prevent family members from visiting, has a higher security rating, or is perceived as more dangerous, people in custody might choose to forego a medical appointment. Prisoners may also decline medical appointments that need to take place in the general community to avoid the humiliation of being escorted in public while in shackles and prison clothing. Appointments that are booked may be cancelled due to staff shortages. In 2022, a Victorian prisoner killed himself after his appointment for cancer treatment was cancelled three times in a row due to staff shortages. The Coroners Court of Victoria found the appointment cancellations were a motivating factor in his suicide, and were "not consistent with the standard of medical care available in the community".
Paying for personal medical practitioners instead of relying on free services provided by the prison is not affordable for most people in custody. Officially, prisoners can apply for approval to be taken to an external medical practitioner, though they must pay the costs of their transport and escort by prison officers. The average cost of transport and escort to an external medical practitioner from a NSW prison is $1,060 per trip.
Accessing healthcare in custody requires a more advanced level of health literacy than is needed in the community, which may produce greater difficulties in both asking for and receiving healthcare. Prisoners on remand in Australia may not be eligible for certain healthcare treatments, such as drug and alcohol programs and psychological services, and may not be eligible for continuity of care programs if they are released without conviction. The timing surrounding release of prisoners from remand is often uncertain, leading to difficulties in preparing discharge reports. Women in custody do not receive the same level of reproductive care as those in the community, and may not have the option of seeing a female doctor.
Prison officers One of the main barriers to healthcare in custody is that prison officers with no medical background act as the gatekeepers for health requests and appointments. Access to health care in prison has been described as "wholly contingent" on an incarcerated person's ability to persuade staff that they need a medical appointment. Officers may not book appointments if they do not believe conditions are serious enough, and have the authority to over-ride recommendations from health professionals. A 2024 report into prison healthcare in Australia stated that this power is unique to prison environments, as prisoners are reliant for their healthcare from a person who is not necessarily obligated to act in their best interest. Needing to disclose confidential reasons for a medical appointment to a prison officer may discourage people from trying to make appointments in the first place. None of the mandatory components in the national qualification for prison officers address health care. Staff at the Alexander Maconochie Centre who work in the crisis unit, which is designed to house incarcerated people who are at a high risk of self-harm or suicide, do not receive additional training.
Medicare exclusion