Deterioration, drift, distraction, and denial: How the politics of austerity challenges the resilience of prison health governance and delivery in England

Highlights • The impact of austerity on English prison health system remains under-theorised.• Austerity decreases the resilience of prison health governance and broader enabling environment.• Policy drift contributes towards sentencing proliferation and increased imprisonment of vulnerable populations.• High turnover of justice ministers and privatisation impact coherent offender management.• Preventive imprisonment and recurrent spending will restore English prison health system.


Introduction
Austerity measures, instituted in response to the 2008 financial crisis, have profoundly affected English prisons adversely, thus raising serious concerns about prisoners' human rights. In May 2010, the UK's coalition government frontloaded large spending cuts for public programmes in the interest of deficit reduction, despite serious and sustained protests [1]. Even more, the government preemptively implemented a deflation strategy by instituting severe policy reforms. That the government would take such action, akin to steps taken by Greece, Ireland, and Portugal during the same period-even though the UK is not part of the eurozone-may well infer that austerity was intended to and has functioned primarily as a political tool to appease the financial markets, hence allowing E-mail address: Nasrul.Ismail@uwe.ac.uk the government to continue borrowing at reasonable interest rates [1,2].
Further, austerity has reified neoliberalism through state restructuring processes prioritising economic efficiency, minimal state intervention, and individual (rather than collective) rights [3]. Its objectives mutually reinforce the aims of neoliberalism, particularly regarding the state's role and redistribution of wealth and power [4]-dynamics explored within this article.
Austerity's impact is especially salient in the UK because England and Wales imprison 174 individuals per 100,000, compared to the European average of 132 [5]. With a greater number of prisoners to manage, problems associated with prisons and prison life are amplified. For example, seven in 10 prisoners suffer from two or more mental disorders [6], often owing to the adverse childhood experiences that are typically associated with offending behaviour [7].
England is unique in that its National Health Service (NHS) provides healthcare services in communities and secured settings according to the notion of equivalence [8]. The UK government has created five national health and justice organisations that comprise the National Partnership Agreement for Prison Healthcare in England 2018-2021 [8]. NHS Prison healthcare funding has been relatively ring-fenced at £400 million since 2013 [9]. Although overall NHS support is protected from the cuts associated with austerity, its growth shrank from 3.8 % in 1979 to 1.1 % in 2010; a rate that, due to funding constraints, remained steady between 2009/10 and 2014/15 [10,11]. With increased demands of a large prison population, the diminished level of outlays has become questionable.
Although NHS funding has decreased in real terms, so too has the rate of staff retention in the health sector [12]. In 2019, England faced a shortfall of 39,520 nurses and registered vacancies for 9000 doctors [13]. Though official statistics did not disaggregate these rates among prison providers, nearly one-half of prison nurses (45 %) have indicated that their care was compromised owing to staff shortages [14]. Furthermore, the most recent European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) inspections of English prisons documented numerous unfilled general practitioners and healthcare staff posts [15]. These observations likely reflect serious inadequacies in prison healthcare, a trend that might conceivably worsen.
Extant research indicates that the poor have borne the brunt of austerity measures [16]. Indeed, this finding is compatible with the observations of Philip Alston-the former Special Rapporteur on extreme poverty and human rights-following his visit to the United Kingdom [17]. Scholars have shown that high-risk groups, such as migrants and the homeless, are particularly vulnerable to infectious diseases [18]. In addition, they have underscored that young people attended to by local authorities experience poor access to mental health services [19]. Moreover, empiricism has revealed an increase in the mortality rate among pensioners age 85 and older, an effect linked to unprecedented reductions in income support [20]. Collectively, the preceding is redolent of the chasm between economic efficiency and health equity.
Prisoners tend to come from areas with high levels of deprivation [21]. Studies have demonstrated that the impacts of austerity are most severe in such locales [22,23]. A one-third reduction in local authority budgets between 2010 and 2015 and another 56 % decrease in central grant funding to local authorities between 2015 and 2020 [24] further reinforced inequalities in these deprived areas. Diminishing social determinants of health in the community-such as housing, education, and income-contribute to the broader unfulfilled promise to protect the well-being, welfare, and social care needs of these communities [25]. Diminution or loss of social and welfare services in the community conceivably could catch up with prisons.
Over  [5]. Indeed, this ratio of 3.7 prisoners for every one frontline staff member was nearly double that of any other European country [29]. The anticipated increase of 20,000 prison spaces by 2025 could worsen this ratio [15]. Government statistics demonstrate that reducing prison staff directly hinders access to healthcare and purposeful activities for prisoners-resources that are key to prisoner rehabilitation. For example, two-thirds of prisoners waited more than 14 days to be seen by an acute mental health professional, with some waiting longer than 12 months to be transferred to a secure mental hospital [9]. Moreover, only one in 10 were allowed to move freely for at least 10 h a day [30]. The lack of resources has also been linked to a threefold increase in the number of self-inflicted deaths, a rate that has now reached 86 per 1000 prisoners [31,32]. Furthermore, decreasing staff numbers and attendant supervision likely influenced the unprecedented 57 % increase in both self-harm and assaults among prisoners between March 2010 and March 2019 [32].
New psychoactive substances, such as Spice and Black Mamba, have been increasingly linked to prisoner medical emergencies and violence. By the end of 2019, these substances were seized in 6699 instances, an increase from the 15 recorded seizures in 2010 [33]. Prison staff reductions have likely prevented effective stanching of the flow of such substances.
Relatedly, these drugs have been linked to increases in the prevalence of organised crime and prison gangs within and beyond the prison walls. Transnational studies reveal that criminal groups create and administer the governance of institutions [34]. Although Maitra [35] suggested these groups are less entrenched in English prisons, recent research indicates otherwise. Sophisticated financial trading and a wider availability of these psychoactive substances [36] have enabled organised crime and prison gangs and have been linked to coercion, violence, debt, and overdoses [37].
Consistent with neoliberal ideology, increased privatisation of prisons and prison healthcare has diminished governance in both domains. Custodial contracts represented 16 % (£6.8 billion) of HMPPS's overall expenditures in 2018/2019 [38], an increase of £6.6 billion compared to total outlays in 2009 [39]. Additionally, although the government's official data on financial support did not aggregate Department of Health and Social Care (DHSC) spending for private providers according to setting-which would include prisons-DHSC spent £9.2 billion on private providers in 2018/2019 [40], a rise of 29 % over the 2013/2014 total [41]. These statistics suggest that private contractors have played a larger and more pronounced role since the advent of austerity measures.
Under the foregoing conditions, prisoners in private institutions might indeed feel that they are merely tools for profit-making rather individuals undergoing community-conveyed sanctions [42]. Although research has found no significant difference in key performance between public and private contractors [43], the rise in prison privatisation in England has increased the government's monitoring costs, thereby contradicting austerity's putative costsaving rationale [37].
The government has responded to crises in English prisons through investments, but only when spending coheres with its neoliberal vision. In 2016, it allocated £291 million to recruit 2500 extra prison officers [44], while also dispensing £10 million to reduce violence and restrict drugs in ten underperforming prisons [45]. For 2020/2021, the government recommended a 4.9 % realterms increase in the budget for the Ministry of Justice, alongside a commitment of £2.5 billion to build an additional 10,000 prison spaces and provide an extra £100 million to introduce body scanners in prisons [46]. While partially seeking to address concerns pertaining to drugs and violence, these foregoing efforts took the focus off the existing issues of chronic overcrowding and degrading living conditions in English prisons.
The planned cash injection of £20.5 billion for the NHS by 2023/2024, to be funded through a combination of tax increases and a Brexit dividend [47]-in conjunction with a 2019 Conservative pledge to provide 50,000 more nurses and 50 million more general practitioner surgery appointments per year [48]-might provide some benefits. However, sceptics doubt that the government can meet such commitments, as certain factors militate against success. For example, the Brexit "divorce bill" and negative fiscal implications of Brexit-the UK's exiting of the European Union, following a national referendum in June 2016 [49]-will lead to lower tax receipts and higher welfare spending. Moreover, forecasts point to an expected reduction in trade flows, as well as stalled economic growth following Brexit [50][51][52]. These financial phenomena would likely make such plans infeasible [53].
The present interdisciplinary study critically examines the impact of macroeconomic austerity on England's prison health governance and delivery. Using the perceptions of national experts on prison health, the actual costs of austerity will be evaluated through an assessment of how they compromise the resiliency of prisons and their health services, as well as the ability of actors delivering and mobilising prison health agendas. In the end, this study reveals that austerity-attendant with shortcomings of germane extant government policies-adversely affects prisoners and the workforce supporting them.

The constructivist grounded theory approach
This study employed constructivist grounded theory to examine the various dimensions of austerity affecting England's prison health system. This inductive approach relies on qualitative research and is characterised by a juxtaposition of systematic and flexible guidelines for collecting and analysing data during the construction of theory [54].

Participant access and recruitment
Compatible with prior research [31,37,55], this study drew on the expertise of 27 of an invited 73 (38 %) national health experts with experience devising and implementing prison health policies across England, whether through the government or for non-governmental organisations. As such, they reflected a broad composition of England's prison health terrain, political and policy elites in an ideal position to understand the impact of austerity measures.
Executed in three stages, purposive, theoretical, and snowball sampling techniques facilitated participant recruitment [56]. Individuals able to provide information on the research topic were sought, based on examination of official documents pertaining to prison health, as well as assistance provided by several research collaborators on this project. The following criteria were used for participant selection: interviewee perspectives, richness of experiences, and decision-making capacity within the organisational hierarchy. Theoretical sampling was subsequently deployed, and new participants possibly with perspectives either supporting or challenging provisional findings were contacted [57]. Finally, snowball sampling was used to ascertain whether participants knew other interested elites willing to participate [58].

Data collection
Most data were collected during face-to-face meetings that took place between February and May 2019. Written informed consent was obtained from all participants. Because austerity is a politically contentious topic, participants were guaranteed confidentiality to promote candour. Congruent with constructivist grounded theory, a semi-structured interview format was used [54].
The average duration of the interviews was 53 min (with a range from 34−110 min). Interview length helped establish rapport and trust with interviewees, which in turn elicited enhanced in-depth responses [59]. Probing techniques were used to encourage further elaboration and clarification of initial responses [60]. All interviews were audiotaped and transcribed verbatim. Overall, over 398 pages and 174,452 words were generated for analysis.

Data analysis
Analysis of the data occurred iteratively, in that, having been analysed, the data also shaped future data collection [61]. All transcripts were imported into NVivo 12 software that was used to manage the complex data created from multiple interviews. Those efforts revealed patterns and connections to different parts of the analysis.
Consistent with the grounded theory approach, coding took place in three stages. Initially, open coding was undertaken, in which each line of text was labelled using gerunds to capture participants' opinions [54]. Next, focused coding was performed, in which differences in codes were reconciled and emerging theories were reviewed. Finally, during axial coding, the data were reassembled to provide coherence to the developing theory [54]. As such, a continuous comparative method was employed to identify patterns and to compare meanings among the codes.
Transcripts were analysed to the point of data saturation-that is, until no new themes emerged across the 27 interview transcripts [54]. This was accomplished by culling the remainder of the data set, returning to what seemed to be the most divergent stories within the sample, and seeking deviant cases where the theory did not fit [54].

Ensuring the trustworthiness of the study
Trustworthiness is a key hallmark that demonstrates both credibility and plausibility in a qualitative research study [62]. Rich and varied findings from different participants with diverse backgrounds are detailed in the Findings section below. Identifying similarities or dissimilarities between the viewpoints and experiences of the participants enabled triangulation of data sources [62]. To provide further analytical insight into the developing theory and an alternative interpretation of some of these data, external peer debriefing during conference presentations occurred at the Fifth International Conference on Law Enforcement and Public Health (Edinburgh, United Kingdom, 22 October 2019) and at the 12th European Public Health Conference (Marseille, France, 23 November 2019).
Self-reflexivity was preserved through self-awareness of the researcher's own background in prison health commissioning, policy, and the law [54]. To this end, a journal and general field notes were maintained before and after the interviews. They documented the researcher's views and various decision points concerning changes to methods throughout the study, while affording opportunity to reflect on austerity and its impact on prison health and enhancing the trustworthiness of the study [54].
Ethical approval from the National Research Committee of the Ministry of Justice was obtained in January 2019 (reference: 2018−381). Following this authorisation, the Faculty Research Ethics Committee at the University of the West of England, United Kingdom, granted ethical approval in February 2019 (reference: HAS.19.01.115).

Findings
The results reveal that austerity has shaped and constrained the prison health governance and delivery via the politics of deterioration, drift, distraction, and denial. Indeed, the four data categories outlined below emerged from interviews with the 27 national prison policymakers. Table 1 Deterioration.

Theme
Illustrative Quotes

1a) By-product of the lack of access to healthcare
The seriousness of the complaints seems to have increased. Heart medication had not [been] provided, and diabetes medications were not available. People could die-it was that serious. It is not happening every week, but it is happening-things that really should not be happening. Massive delays to operations, or even things like cancer treatment. They are just cancelling appointments. Broken bones are not being taken to the hospital. A prisoner actually has lost his sight in one eye recently because he was not taken promptly to hospital. (Participant 21, Head of Legal of a national penal reform organisation) Looking at 33 custodial deaths between 2014 and 2018, there were failures in communication regarding medical records, information about mental health, and prescriptions not being transferred from prisons and from courts into prisons, and, therefore, there is quite a high risk for people. We are concerned about emergency responses, poor training for staff, and inadequate CPR training. There were attempts at resuscitating people, but they have clearly been dead for a long time. (Participant 23, Head of policy of a national penal reform organisation)

1b) Normalisation of risk-taking activities in English prisons
If you think about a person having a series of Spice attacks, that will take three or four nurses and staff away from core duties to deal with that individual if they go to hospital. That means all the people who are waiting to see those nurses or doctors can no longer do so. Healthcare is hugely affected by the levels of drug use because they are the first to respond. (Participant 1, Commissioning Lead at a justice ministry) The use of the Tornado Team (an elite militarised squad that is tasked with bringing prison riots under control) has risen enormously. This team moves between prisons. We sometimes need to alert our healthcare providers. Going into prisons like we do, we hear the general alarm bell. The number of these incidents has gone through the roof. You just hear it more. You hear: "General alarm, general alarm, general alarm." It is staggering. (Participant 24, Regional Prison Health Lead of a national health organisation)

1c) Lack of experience exhibited by the newly-recruited prison officers
We have successfully recruited 2500 prison officers. The government did invest in new officers, and we are now reaping the benefits of them coming online. It is heart-warming to see the number of new officers on the landings. (Participant 1, Commissioning Lead at a justice ministry) [A senior manager] of the Prison Service said to me: "Well, now we have recruited 2000 people." What he failed spectacularly to tell me was that 45 % of those people had left after the first week. Most people do not expect to get knifed with a sharpened toothbrush every time they go to work. Let's face it; we are not talking about pink, fluffy bunnies here. There are some nasty [expletive deleted] in our prisons. What these prison officers do need to be is risk-aware and not be puppies, thinking they are going to save the world. And they have had just six weeks of training, which amounts to nothing because they have not got the life skills to be able to manage somebody. (Participant 7, Prison Health Lead of a national health organisation) 1d) Disruption created by the continual procurement cycle If the NHS organisation loses the contract to another organisation and the staff transfer to an independent organisation, then those staff members remain within that prison healthcare centre. This is because they transferred over with the same employment terms and conditions under the Transfer of Undertakings (Protection of Employment) Regulations 2006. It is still the same staff. But it is unsettling. I remember one nurse saying: "One week, I am wearing this uniform with this badge, and the next week it is a different colour uniform and a different colour badge. These are not your policies and procedures now; this is our strategic plan, and you have to follow this now." That is really confusing for people who are trying to just get on and do a good job. (Participant 16, Lead Officer of a nursing trade union) 1e) Lack of systematic workforce planning More people are leaving the system. A significant number of GPs have left the medical profession. Others plan to leave. We have retirement figures for the next five to ten years, and we are going to be left significantly short of prescribing doctors. Those are the people we employ in prisons. We also do not have enough nurses. That is national, not just prison healthcare-that is every healthcare department. There are 40,000 nurse vacancies. Yet, the government removed the training bursary.. . . We have never been more desperate for more nurses and GPs. (Participant 26, Commissioning Lead of a national health organisation) 1f) Transactional nature of interactions between prisoners and prison staff Of course, we are completely reliant on the resources of HMPPS to facilitate our access to prisoners, outpatients, and for the environment in which we work. It is different than a hospital, where we have ultimate control over our clinic facilities and everything else. In a prison, we do not. We will set standards. We will expect the healthcare facilities that we are provided with to be appropriate and to be up to the NHS standard. But that is not entirely within our control because it is prison service property. (Participant 26, Commissioning Lead of a national health organisation) We have lost the ability for people to have that one-to-one officer relationship. Most of our rehabilitative approaches are about relationships. They are all relational. If you do not have that, there is nothing there for you to identify with and no reason to feel that it is worth the effort. (Participant 7, Prison Health Lead of a national health organisation)

g) Growing prison gangs and organised crime groups in English prisons
The influence of serious organised crime is making sure that those substances are available within the prison estate. Some small local-level dealers will get them in, but the scale of the supply into the prison system indicates the problem of serious organised crime nationally. It is not just small-scale individual dealers or small groups of dealers. (Participant 26, Commissioning Lead of a national health organisation) I do not think it is all negative. I think some of it has been extremely challenging-things like the arrival of psychoactive substances. It has probably been as impactful on health as a range of other things. We do not have a clear evidential [base] that says the financial reduction causes instability. [. . .] It is very difficult to attribute certain effects that you might see to a particular cause because there are so many other contextual factors going on that you cannot be sure. (Participant 2, Prison Services Lead at a justice ministry)

Deterioration
As interviewees explained, downsizing of the prison workforce destabilised prison health governance and delivery. Owing to a reduction in the number of prison employees, some participants suggested that prisoners filed more health complaints when they could not adequately access healthcare services, thus increasing the burden on staff and even leading to prisoner death (Table 1a). Additionally, given the declension of officers available to supervise prisoners, increased time within cells fostered more prisoner self-harm, suicides, riots, drug use, and assaults among prisoners (Table 1b).
Most participants directly involved in delivering a nationwide recruitment campaign for prison officers in 2017 deemed the effort successful in restoring institutional stability (Table 1c). However, this positive assessment was not shared by all; those sceptics argued that new recruits lacked appropriate training and experience in the prison environment, meaning replacement workers did not match the skills of those who had departed (Table 1c). Apart from enabling access to healthcare, prison staff was also expected to provide pastoral and emotional support for prisoners, while concurrently admonishing poor behaviour among prisoners-a challenge that has become increasingly difficult. New recruits have tended to resign, owing especially to unsatisfactory working conditions and diminished workplace safety.
Several participants illustrated a parallel pattern among prison healthcare staff subsequent to intensification of privatisation since 2010. Pay packages for NHS Trust staff were diluted, and private providers eliminated employee pension and sick pay, thus allowing such providers to enjoy a competitive edge throughout the procurement cycle for government services that occurs every five to seven years (Table 1d). This had the effect of dichotomising organisational survival and professionalism, emphasising the diminished systematic workforce planning necessary to stabilise the number of prison healthcare staff and thereby compromising the care afforded prisoners (Table 1e).
Study participants universally agreed that staffing numbers had been reduced to an unsafe level. In particular, those directly delivering prison health services felt as if they lacked autonomy because providing prison health services requires a stable prison regime (Table 1f). Participants also emphasised that prisoners' increased time in their cells reinforced the transactional relationship between prisoners and staff, while discounting care and attention that might support rehabilitation (Table 1f).
Given the shortage of custodians enforcing requisite institutional order, participants in this study observed that prison institutions had become fertile ground for organised crime operations and prison gangs (Table 1g). Informal governance structures of this sort are supported by the burgeoning availability of drugs, particularly new psychoactive substances that have sparked waves of violence across English prisons (Table 1g) and that impair both prison governance and the delivery of healthcare that depends on it. One policymaker, though, rejected any connection between austerity and the current instability in prisons (Table 1g). Nonetheless, the overwhelming sentiment of the other interviewees was that such a dismissive viewpoint amounted to "living in denial," was simply "a lazy way out," or sounded "outrageous."

Drift
Whereas policymakers would typically have exercised oversight powers to contain the rate of imprisonment, findings revealed that their recent attention has too often been focused on resolving crises. In fact, many participants involved in policymaking reasoned that criminal activities committed after 2010 were construed in light of the riots of August 2011 [5], thus eliciting lengthy sentences that run counter to state intention of reducing the prison footprint under austerity (Table 2a). Similarly, several interviewees believed historical statutory commitments, especially the Criminal Justice Act of 2003 and indeterminate sentences for public protection, increased sentences for certain serious crimes, attendant with Operation Yewtree's prosecutions of sexual offences also lengthening terms (Table 2a).
Despite reduced crime overall, as well as diminished police resources, mandatory minimum sentences and an increased number of maximum sentences maintained the high rate of imprisonment. Although certain statutory obligations pre-dated austerity, they have nonetheless exacerbated longstanding issues of overcrowding and scarce prison and prison healthcare resources. Moreover, despite their efforts to avoid carceral sentences, members of the judiciary are constricted by sentencing guidelines, (Table 2b), thus reinforcing the drift observed in this study.
Finally, though this theme was not as resonant as the other three, certain participants explained in detail how the loss of community resources under austerity indirectly raised imprisonment rates. Put simply, when vulnerable individuals can no longer access such resources, penal institutions must bridge the gap (Table 2c), even as they struggle to address the complex health and social needs of an at-risk population. Participants concluded that prisons have become a cul-de-sac social service without being equipped to do so, especially as the efficacy of prison healthcare services is declining.

Distraction
Most interviewees articulated that, given the high turnover of politicians in charge of justice portfolios-which include prisons-political distraction has destabilised the prison system. Participants compared the high turnover of justice ministers-seven since 2010-to other ministerial portfolios, such as the health department, which had only three Ministers depart during the same period [63,64]. Ministers have "mark[ed] their territories" by instituting sectoral reforms, which was described as reactive (Table 3a). Several policymaking participants doubted the reactivity of these reforms and averred that its absence only served to destabilise further the system and caused a policy overdrive, even while ignoring the impact of austerity-the "elephant in the room"-in terms of prison and prison healthcare issues (Table 3b).
Calls for prison and its healthcare privatisation have intensified amid increasing constraints on the prison health system, further distracting policy elites from coherent penal policy. Participants in health commissioning positions felt compelled by law to find the best provider to deliver penal services based on the balance of costs and quality (Table 3c). Several, however, described risks in terms of governance accountability when private organisations are allowed to avoid external scrutiny by hiding behind a veil of commercial confidentiality (Table 3c). Even those directly involved in commissioning emphasised that punishment should be administered by the state rather than by a private entity (Table 3d), especially amid a conflicting agenda between rehabilitation and profit making that could undercut rehabilitation. Finally, the bankruptcy of Carillion, a private-sector provider of prison maintenance responsible for 50 prisons across southern England in 2018 [65], induced most policy informants to be fraught about future arrangements for contracting out prison and prison healthcare services (Table 3e), particularly because Carillion's financial ills could cause ripple effects.

Denial
Findings revealed that, although there exist internal and external inquiry mechanisms holding the government accountable, these mechanisms have not ameliorated the effects of austerity on prison health governance and delivery. The majority of participants averred that intergovernmental and regulatory inspection channels-as well as parliamentary lobbying-have not yielded meaningful action nor systemic change in prisons (Table 4a). Such diminished impact underscores the dangers of denying austerity's effects, with those in power framing cost-saving exercises as a way to provide enhanced efficient public services (Table 4b). This approach fails to concede the ways austerity has directly mediated the aspirations of the prison health governance and delivery agenda.
Nearly all participants expressed some degree of doubt regarding the Treasury's announcement that austerity would be ending. Given that the spending trajectory has yet to improve (Table 4c), these interviewees' responses were telling, with various individuals describing the announcement as a "soundbite," as "rhetoric," or as "a political sell." At the same time, several emphasised that the increase in NHS funding was for all parts of the organisation. Considering the "Cinderella status" of prison health, prioritisation could

2c) Prisons as the first resort for vulnerable individuals
Prisons cannot turn people away or say, "We have not got enough room tonight. We have not got enough beds." They have to take what the court sends them, so they have not really got that choice. They just have to take them. Police have mopped up as many people with mental health problems as they can. There is nowhere else for them to go. It actually costs more money because they are mopping up things that the other services should deal with. (Participant 9, Policy Lead at a health and social care organisation) If you think about the criminal justice system, the number of people who have got mental health problems, who live in poverty, and their childhood experiences, austerity is going to affect all the services that they would have gone to for support. People who slipped through the net will end up going to prison now, whereas before, there might have been a bit more support around to help them. Once that gets cut back or taken away, it leads to more problems. You only have to look at the homeless people in the street to realise there is an issue. A lot of those homeless people have already been in and out in custody. (Participant 3, Regional Prison Health Lead of a health organisation) Table 3 Distraction.

Theme
Illustrative Quotes

3a) High throughput of justice ministers
The rate at which we have cycled through Secretaries of State for Justice compared to Secretaries of State for Health has been significant. The short-term application of political leadership is reflected in the loss of focus. The planning is necessarily somewhat more reactive and short term than perhaps it needs to be. As officials, we work on that, and we try to hold on to the big and long-term positive gains so that we can continue to drive through, but then sometimes these changes are not very helpful. (Participant 2, Prison Services Lead at a justice ministry)

3b) Lack of acknowledgement of austerity
The policy function and the headquarters' function spend their time dealing with dreadful inspection reports and ministers coming in and saying, reasonably enough: "This is a calamity. What are we doing about it?" Then, in the middle of it, there are bits of complete insanity, like utterly reorganising the National Probation Service at the worst possible moment to do so and incentivising an exercise to save money. So austerity drives the extreme organisational solutions because there is a need to save a lot of money and not admit to a reduction in services. (Participant 11, Head of a national penal reform organisation) 3c) Tendency of private sector organisations to avoid scrutiny We do not have a [preference] in commissioning services to the public, voluntary, or private sector. When we commission a service, it goes out to open tender. It goes into the Official Journal of the European Union (OJEU) as a tender opportunity. It is made nationally available. People bid against the specification. We then have a process of reviewing all of these bids against the specification, in detail. The most qualified provider within the cost envelope is awarded the contract. If they are the best organisation to provide it, great. They can come in, show their worth, and provide it. (Participant 26, Commissioning Lead of a national health organisation) The Ministry of Justice will say: "Well, that prison is not run by us. That is run by G4S or Sodexo." These providers, in turn, will say: "We are just following government policy. This is what we have agreed in our contracts regarding how we will deliver services." So, they just push the responsibility backwards and forwards, so who do you hold to account? We have also seen this specifically around healthcare providers. There is a real gap there in terms of accountability because Sodexo Justice Services have Sodexo Healthcare providing their services. mean that prison spending would be sacrificed to more politically popular measures (Table 4c).
In fact, investments in 10 underperforming prisons [45] indicates that funding from other establishments was being siphoned away, a clear sign that austerity was still in place (Table 4d). Finally, forecasting the long-term financing of the prison service, several participants viewed Brexit might further exacerbating austerity, at least initially, especially given the nation's overborrowing and the increasing demand trajectory for healthcare (Table 4e).

Alternatives to austerity
To end the current crisis, interviewees unanimously recommended reducing rates of imprisonment (see Table 5, online appendices). Measures such as abolishing short sentences, using alternative community sanctions for lower-risk prisoners, and utilising suspended sentences could address overcrowding while permitting staff members time to focus on a reduced cohort of users. Participants also emphasised that cost-saving measures under the guise of operational efficiency should be halted, stress- Table 4 Denial.

Theme
Illustrative Quotes

4a) No meaningful actions following adverse publicity regarding prisons
We see recommendations being made all the time, from the Chief Inspector, from the prison, and Probation Ombudsman, from Independent Monitoring Boards. Recommendations are made, and then they are not implemented. There is no national oversight mechanism, and there is no independent organisation that is (a) tracking what the recommendations are, and (b) tracking whether they have been appropriately implemented, enforced, or if anyone is held to account. (Participant 23, Head of policy of a national penal reform organisation) 4b) Framing cost-saving measures as increasing service efficiency In reality, we have seen a reduction in staffing for services such as drug treatment, and many uses of words such as "efficiency" and "economy." In reality, we have not got the staff on the ground. It means that our services are not going to be as robust as they were before in terms of those interventions for health. (Participant 3, Regional Prison Health Lead of a health organisation) 4c) Unconvincing assurance that austerity is ending To genuinely end austerity, either to freeze the real-term budgets or better still to at least increase them in line with population growth, actually requires the Treasury to allocate more money to departmental spending. . .Even if more money goes into it, to end austerity on average, there is still a choice about where that money goes. (Participant 13, Chief Economist of a national think tank organisation) The NHS has received more money year-on-year, but it has never received as much money as we need year-on-year, so they have always played with the numbers and the way they presented them, and have passed the problem back down to NHS England, saying: "You have got to manage this." There are things, high-profile political things, that you have got to deliver, such as responding to people in Accident and Emergency and making sure people are not detained in hospitals longer than they need to be. . .Because prison healthcare is a bit of a Cinderella-it has not got the attention that it should have had because other things have been of a much higher physical profile. . .[They are] not going to invest in prison healthcare; they will just pass the problem down, and it will be quietly ignored. If we leave the European Union, then austerity is not only not coming to an end, it is about to get a whole lot worse. We are still wildly over-borrowed as a nation and demand is growing in all sorts of areas, especially health. You have got an ageing population. The number of people who pay taxes is reducing. The number of people who consume services paid for by taxes is increasing. The circle has not got any more square. (Participant 11, Head of a national penal reform organisation) ing, that, rather than further expanding the carceral state, recurrent investment should be made within affected communities.
Some participants suggested raising taxes on profitable corporations and wealthy individuals. To these interviewees, the public's expectation of high-quality public services could only be realised by increased tax revenues. After all, prisons require investment as any other critical service.
To encourage greater transparency in England's penal policy, some participants recommended integrating prison spending data into public discussions. They presuppose that with such openness, the public would be better informed about how money is spent within prisons. A small number of interviewees proposed that spending data should include a projected return on investment (i.e., outcomes on prison health), rather than have the government merely reveal spending totals. In addition, they advocated for a thorough impact assessment to forecast the effects of prisoners on the public. Moreover, several called for ameliorated accountability of politicians' spending on governmental programmes, as well as an increasing proactive capitalisation of media reporting to highlight prison instability.

Discussion
This is the first in-depth, interdisciplinary qualitative study exploring the impact of England's macroeconomic austerity on prison health governance and delivery from the perspective of national prison experts. As the data demonstrate, interviewees believe that austerity has shaped and constrained the prison health system through the politics of deterioration, drift, distraction, and denial.
First, interviewees promulgated that the diminished prison workforce and loss of expertise flowing from the government's austerity programme has destabilised the current system [27]. Prison healthcare delivery cannot achieve its goals if prisoners cannot access these health services. Participants in this research argued that prisoners suffered from long waiting times and insufficient consultation time with medical professionals, further compro-mising the quality of their healthcare. They also described how inadequate access to acute and urgent healthcare services, such as operations and cancer treatment, caused prisoner death and disability. Although healthcare in penal institutions has proverbially been inadequate, the concerted effort in addressing this issue has been impeded by draconian measures, per study participants. These examples underscore the fact that prison healthcare services are highly dependent upon the stability of prison governance, which appears to be deteriorating.
Interviewees noted that a nationwide recruitment campaign sought to reverse the resulting precarity, yet new prison officers lack the training and experience of their predecessors. The high rate of attrition for these new recruits, especially those with under one year of experience [28], is symptomatic of the adverse working conditions they face. A severe staffing deficiency continues, indicating that prison reform programmes appear to have failed to ameliorate existing penal institution instability [15].
Similarly, participants declaimed that the decrease of NHS funding in real terms, combined with population demand [10,11], has created a ripple effect: the constant cycle of prison commissioning and procurement have had an inauspicious impact on prison employees. Predictions suggest a continuing trend [12]. Overall, safe staffing levels within English prisons, as well as healthcare services in those institutions, cannot be maintained without enhanced systematic attention to workplace recruitment, which, in turn, could affect availability, accessibility, acceptability, and quality of prisoners' healthcare.
Consistent with prior work [30][31][32], this study's participants identified a rapid deterioration of the existing poor standards of health and decency under austerity. Given the longstanding overcrowding problem within prisons, reducing the number of officers within institutions diminishes interactions between prisoners and staff. In addition, augmented in-cell time increases the number of riots, assaults, acts of self-harm, and suicides.
Interviewees also stated that the deterioration of formal prison governance indirectly fuelled the rise of prison gangs and organised crime within England's prisons. The growth of these informal governance structures paralleled the escalation in drug use within penal institutions, especially the use of new psychoactive substances [33]. Staff reductions create difficulty in stemming the flow of psychoactive substances. This has caused a surge in medical emergencies that has overconsumed scarce medical resources-within and beyond the prison walls-which has further strained NHS England budget and delivery of prison healthcare and precipitated increased frequent acts of prisoner violence [30,33].
Drawing on and advancing previous research [34][35][36][37], this study demonstrates the sophistication of the microeconomic structure of organised crime, showing how gangs thrive in England's prisons and manifesting how criminal groups sustain a monopolistic market through coercion and violence. Beyond this informal economy, the lack of detection and enforcement owing to having a reduced number of prison custodians signifies a broader crisis of legitimacy in prison governance [66]. The denouement is a loss of control of the prison institution, which undermines leadership and coordinated action for prison health care delivery, per interviewees.
Further, this study reveals an imprisonment drift owing to prison instability. Participants implied that offender planning by the government has been hurt, with several statutory commitments on sentencing that predated austerity running in the background. The consequence is a continued high rate of imprisonment over the last ten years. Following England's riots of 2011, the plan to scale back imprisonment was abandoned. But as statutory commitments have thwarted austerity's intentions, the length of prison sentences for several serious crimes have increased. Successful prosecutions for sexual offences-as well as the continuing incarceration of those 2223 individuals imprisoned under indeterminate sentences-despite that option being abolished in 2012 [67]-have perpetuated this trend. Given a lack of scrutiny, sentencing guidelines tend to encourage longer-than-necessary prison terms, exacerbate longstanding issues of overcrowding, and reinforce excessive dependency on scarce prison and prison healthcare resources, as interviewees noted.
Austerity also affects the health of vulnerable populations within the community, forcing penal institutions to become, in a sense, first responders. Fourteen million people in the UK live in poverty, experiencing record levels of hunger and homelessness [17]. The majority of British prisoners come from areas with high levels of deprivation that have thus far been blighted by austerity [21][22][23][24]. Therefore, they arrive at penal institutions with especially complex health and social needs that have gone unmet owing to austerity's reduction in community services. Interviewee comments support the conclusion that the poor health of prisoners is partly a by-product of their experiences prior to entering incarceration [21] and affirm that the poor bear the brunt of austerity [16].
A citizen's need for healthcare can remain so underserved in the community that, ironically, imprisonment offers an improvement. But, concurrently, the efficacy of prison healthcare services is declining, per study participants. As such, the quality of the provision and the overall prison regime are compromised. Liaison and Diversion services have shifted people with mental health issues away from the criminal justice system [68], but future studies must gauge the success of these efforts.
With respect to the politics of distraction, interviewees mentioned a high turnover of justice ministers since 2010. This flux has contributed to system reactivity and further instability that affects prison healthcare governance and delivery. Additionally, they objected to the increasing wholesale prison and healthcare privatisation for three primary reasons. First, privatisation lacks accountability; private actors have often avoided scrutiny in ensuring that prisoner care is properly delivered [43]. Second, participants emphasised that the state, not private businesses, should administer official punishment [42]. This finding speaks to how private businesses could thwart the prison rehabilitation agenda through prioritising profit over health. Third, health is a common good, and thus interviewees regard it as incompatible with marketbased strategies for its distribution.
Finally, the Carillion bankruptcy gave participants cause for concern. As one recent study [37] indicated, the race to the bottom increases monitoring costs, thereby contradicting ostensibly costsaving measures, particularly during the time of austerity, and making it untenable to justify privatisation on the grounds of quality and efficiency. Despite this, private contractors are forecast to occupy a dramatically increasing role in the penal landscape following an outsourcing plan of two new prisons, HMPs Glen Parva and Wellingborough [69]. This plan is counterintuitive and unlikely to have much substantive impact on prison governance.
Amidst continual feedback from policymakers regarding instability and precarious conditions in England's prisons, the government's lack of meaningful action amounts to a denial of the effects of austerity. As many interviewees averred, building additional penal institutions-with room for an extra 20,000 spaces anticipated by 2025 [15]-merely increases the incarceration rate [70]. Such denial may well be regnant of agnotology, or the promotion of ignorance and indifference-a status strategically manufactured through gaslighting, whereby those in power manipulate the public by fragmenting the reality of austerity [71]. Without sufficient agency or viable alternatives, policymakers have tended to adopt the narrative that austerity streamlines prison service, an outcome that has depoliticised austerity through economic logic, disguised the use of it as a political apparatus, and disconnected political accountability.
Moreover, financial reorganisation of the prison service budget saw funding taken from other areas, especially in terms of how investment was provided for 10 underperforming prisons. Participants' trust in the announcements of the former and current Chancellors of the Exchequer [72,73]-signalling the end of austerity-was diluted by increasing demands for public services in the face of government debt that ballooned from 74.9%-84.1% (as a percentage of GDP) between 2010/2011 and 2018/2019 [74]. Despite austerity's purported goal of reducing debt, spending has ballooned, underscoring the perhaps doctrinaire assumptions of such an ideological commitment.
Although the NHS has been promised a funding increase [47], prison health could be compromised owing to its "Cinderella status," meaning more politically popular measures might take priority. Informants' optimism regarding the recent assurance of a cash injection was tentative, at best, because Brexit, which was to fund this injection, is expected to reduce trade flows and stall economic growth [50][51][52]. All of this is transpiring amid the global COVID-19 pandemic predictions of the worst recession in the UK in over 300 years [75].
Considering the hefty price tag of imprisonment, interviewees declaimed that reducing England's current prison population would allow prison staff to concentrate on prisoners needs, including healthcare, of a smaller population cohort. A preventive sentencing policy-abolishing short sentences and prioritising community sanctions-would mandate imprisonment only on the grounds of security and public protection, while allowing a reduced workforce to deliver improved prison governance.
Apart from ending cost-saving measures, recurrent stimulus that meets the demand is also vital. This comports with the recent House of Commons Justice Committee's [76] recommendation that the Ministry of Justice should work with HM Treasury to affirm long-term funding plans that might facilitate prison reforms. Participants in this study proposed a tax increase on profitable corporations and wealthy individuals. They also explained how additional funding could support critical services and address underlying social issues in the community rather than further entrenching carceral spending.
Integrating sufficient data on return on prison investments into media discussions, conducting a thorough impact assessment to forecast the fiscal impact on prisoners, linking spending on government programmes to the appropriate ministers, and continuing media exposure on extant prison conditions could encourage enhanced transparency in penal policy, per the interviewees. As with austerity [1,2], imprisonment is a political choice. To enable effective responses to existing prison instability, advocates and researchers must scrutinise the leadership of the current government and hold decision makers accountable for their actions.

Strengths and limitations
This research contextualises the impact of austerity on the prison health system in England, yet its findings are somewhat qualified by the fact that the sample comprised only 27 national prison experts. This exclusivity assumes a homogeneous effect of austerity across all prison establishments in England. As such, the specificity of the impact of austerity on the diverse penal institution types and populations should be addressed in future research. Additionally, conducting studies with those who work on the frontline-prison governors, officers, and those who deliver prison healthcare services in England's prisons-could facilitate much-needed theorising regarding how prison health governance and delivery have been managed under austerity.
Considering the qualitative nature of this study, the findings of the instability of the prison health system and the broader regime of prisons cannot be precisely attributed solely to austerity. There are longstanding prison issues that are connected to government policy decisions and are broader than austerity, notably inadequate funding and delivery of prison healthcare services, poor health of prisoners, and statutory commitment on sentencing-which have been discussed within this article. However, given the qualitative focus of this study, asserting with quantitative certainty that austerity is responsible for worsening prison health governance and delivery in England is beyond its remit. Nonetheless, austerity might plausibly reinforce longstanding prison issues that mitigate system resilience in absorbing their effects and affect how their interplay thwarts the concerted effort to address poor health of prisoners and improvement in the prison health system.
Nevertheless, the significance of the study's findings pertains to countries beyond England, particularly those where austerity has shaped prison policy following the 2008 global economic recession. Considering the fluidity of health governance and delivery, the prison environment presents an opportunity to reflect on the impact of austerity measures in other domains where health could be compromised by policy choices. Given austerity's putative deleterious health effects on governance, the workforce, and policy end users, such exploration might well indicate that austerity cannot be justified empirically or ethically.

Conclusion
This study demonstrated-through the lens of prison healthcare experts-how the politics of deterioration, drift, distraction, and denial have shaped and constrained the prison health governance and delivery in England. Austerity negatively affects the resilience of prison health governance and its enabling environment, wherein prisoners and the prison workforce are immediately impacted. Informal governance-in the form of organised crime organisations and gangs-now plays a dominant role in England's penal institutions. They are sustained by the microeconomic framework of a monopolistic illicit drug market within and outside prisons, which is regularly reinforced by bullying, coercion, and violence.
The high turnover of justice ministers and the increasing rate of privatisation have jeopardised long-term commitments to coherent offender management. The government's apparent failure to respond to prison crises-despite having had them documented by various official reports and academic studies-seemingly demonstrates political officials' refusal to acknowledge the damage inflicted by austerity. Instead, they appear to adopt a posture of denial, even as harsh sentencing policies and diminished community resources have disproportionately affected vulnerable populations and rendered prisons a first-yet woefully underequipped-resort.
Admittedly, some issues highlighted by study participants existed prior to austerity. Nonetheless, these problems have continued and worsened, thus demonstrating the fragility of prison health governance and delivery. Preventive imprisonment, recurrent spending, increased transparency in spending and political accountability, and activation of external scrutiny measures to ensure that reform programmes are adequately financed and politically supported are pragmatic options for rebuilding prison service.
Austerity is an expensive political choice, and imprisonment can constitute a violation of human rights. The social contract undergirding Britain's government demands that politicians take increased care to protect the welfare of all, including those whose behaviour warrants censure. Questions of health should never be answered solely by consulting an institution's bottom line.