The legal foundation of Spanish prison healthcare (PH) is the General Prison Regulation Act of 1979 (LOGP)¹, which regulates, along with the General Healthcare Act (LGS)², the measures that protect the rights of the prison population to medical protection. The second and third final provisions of the LGS also provide the framework for the future of prison healthcare, stipulating that it needs to be integrated into the Spanish National Health System (SNS).

It should be remembered that the LOGP was the first organic law to be passed by the same parliament as the one that drew up the modern Spanish Constitution, which gives one an idea of the importance given to this issue by the representatives of the Spanish people, many of whom had been imprisoned in the years before the transition to democracy for their political activities. They wanted to make changes to the prison system, including the right of inmates to medical care.

This may well explain the subsequent marked increase in public employment announcements for prison medical and nursing professionals in an effort to develop the new prison healthcare system and adapt it to a democratic society. Years later, in 2003, the sixth additional provision of the National Health System Cohesion and Quality Act³, stated the need to integrate prison healthcare into the regional health systems, and established a maximum period of 18 months for this integration to take effect.

However, 37 years after the approval of the LGS and 20 years after the enactment of the National Health System Cohesion and Quality Act, only three autonomous communities (the Basque Country, Catalonia and Navarre) have integrated prison healthcare into their regional health systems^4-6. In other words, both the Spanish government and the administrations of the other 14 autonomous communities have flagrantly breached the law for over 18 years.

Evidently, the law should be complied with, and demands should be made to ensure that this happens. Compliance with the law is essential for any society to function, and should therefore be a common pattern of behaviour. According to one writer, a characteristic that distinguishes third world countries from first world ones is “a culture of respect for the rules”⁷.

If the Public Administration breaks the law, and does so repeatedly, then the situation is an extremely grave one, with serious legal and other consequences.

Non-compliance with the integration of prison healthcare into regional health systems has created (amongst other perverse effects) a situation in which prison healthcare units in many regions answer to the Ministry of the Interior. The raison d’être for this no doubt responds to legal needs, but it has little to do with healthcare. It leads to clashes and disputes between health professionals and prison management, which are often resolved under pressure, in situations where the medical staff are occupationally dependent, in an atmosphere that does not promote or guarantee professional decisions about the care of inmates made without any external interference.

The non-compliance with the law has also led to unequal working conditions and poor professional development in comparison to other medical professionals in the community, and to a distancing from and severe lack of coordination with the National Health System. The absence of any integration has in fact created the loss of three conditions that are basic to any truly effective health service: universality (equal healthcare for all); homogeneity (similar healthcare in all systems and centres); and equality (preventive and medical provisions comparable to those available outside prison).

The ongoing deterioration in recent years of a prison healthcare system that depends on the Ministry of the Interior is truly lamentable. The causes for this loss of quality include non-existent professional development and a lack of job attractions, which have led to extreme professional ageing due to the lack of generational replacement. In fact, less than 200 (out of 450) posts are currently filled by prison physicians, and more than 80% of the posts offered in the last civil service exams remain vacant⁸.

At present, more than half of the medical staff are civil servants of over 60 years of age. The lack of professionals is such that the Ombudsman has repeatedly denounced the shortage⁹.

The lack of human resources and the absence of any renewal of staff has been associated with a progressive and constant loss of quality in prison healthcare, which has brought the system, according to many professionals working in the field, to the edge of collapse¹⁰, and to a situation in which appropriate medical care and many of the public health programmes provided by Spanish prison healthcare have practically disappeared. And finally, in what is a truly absurd gesture, efforts are being made to take the prison health system out of public hands. There is now an increasingly common process of privatisation¹¹, which not only means a loss of opportunities in healthcare, but also, and much more seriously, it puts the health of the needy into the hands of private interests.

The integration of prison healthcare into regional health systems is a legal obligation, and in professional terms, an essential and urgent one, as our previous comments amply demonstrate. However, and as we stated above, only three autonomous communities have put this process into effect, although with some technical differences in the models that they applied.

The Basque model has structured prison healthcare into primary healthcare teams (PHT) that are basically similar to other PHTs that operate outside the prison system.

The Catalan model further defined such groups as prison primary healthcare teams, based on the understanding that staying in prison includes a number of special organisational and functional features. Therefore, the Catalan approach includes the integration of such teams into the PHTs of their geographical area, in the same functional network. At the same time they are assigned with specific healthcare objectives coordinated by the prison health programme of the Catalan Health Institute.

Finally, the integration of prison healthcare in Navarre has yet to be fully implemented, but it will probably be simpler, given that the region has just one prison and has little in the way of human and material resources.

Strictly speaking, the models of integration into the regional health systems are different, and perhaps this subject merits further analysis and debate, but that is not the purpose of this editorial. The objective here is a more prosaic one: to demand compliance with the law and prevent the further deterioration of prison healthcare in many parts of Spain. We hope then that it serves its purpose: as a savage criticism of the current situation and a cry for help when facing a grim future.