Exworthy et al ^{Reference Exworthy, Wilson and Forrester1} are to be commended for their attempt to go beyond the existing interpretation of the doctrine of equivalence of health service delivery in prison healthcare. This has driven improvements in prison healthcare for the past 10 years. However, they fail to identify the next challenge, that of achieving equal health status for prisoners and non-prisoners; this should be the doctrine that informs the strategy for service delivery for the next 10 years. Given the exceptionally high rates of mental and physical ill health in the prison population, not entirely explicable in terms of their sociodemographic profile, this will demand significantly greater investment than is currently the case. Per capita prison healthcare cost £2769 in 2007-2008, of which only £316 was for mental healthcare. ^{Reference Brooker, Duggan, Fox, Mills and Parsonage2} However, the advent of outcome-based payments for healthcare and for the management of offenders ³ allows for the relationship between health gain and criminological outcomes to be explored more rigorously.

The authors cite the UN International Covenant on Economic, Social and Cultural Rights as a guide to future prison health monitoring. This contains nothing to which anyone may object, but it is not specific to this very challenging area of healthcare. Exworthy et al largely neglect the advances in thinking by both the Department of Health ⁴ and Her Majesty’s Inspectorate of Prisons, ⁵ which have led to much improved, relevant markers of activity, performance and outcome in routine review of contract delivery by prison health providers, as well as the role of the Care Quality Commission in assessing prison healthcare. In truth, they look out of step with commissioners and providers of healthcare who are already engaged in the detailed determination of local standards based on a grasp of local needs, for example those of young offenders, older prisoners and women.

Exworthy et al have, as might seem reasonable, a focus on mental health and the important issue of prison transfers. Such problems are relatively rare, although they need quicker resolution than is currently the case. However, they say nothing about primary care, including primary mental healthcare, which is poorly modelled. Nor do they comment on the treatment of drug and alcohol problems, difficulties that compound the management of serious mental illness but where there have been huge improvements in the past 10 years. Most of the prison health budget is devoted to these two areas. Prisoners have often had poor access to primary care and are highly likely to have drug and alcohol problems. The de facto ‘polyclinic’ nature of the prison environment is different from the external community, but this may be an advantage rather than a disadvantage for rapid healthcare delivery. Within a short period of time a prisoner can have a health check and be stable enough to reflect and plan for the future. For this to work, practitioners, including senior psychiatrists, will be required to operate in an integrated and multifaceted system of holistic care delivery where acute mental illness, for all its headline grabbing potential, is not the main issue.