From legal entitlement to administrative delivery: A comparative sociolegal analysis of external health care access in custody

External medical access in custody depends not only on legal entitlement or clinical need, but on whether penal institutions translate those obligations into specific administrative routines. This article examines how written custody-facing policies structure the “last mile” between referral and external care. Using a convergent mixed-methods legal and policy design, the study analyzes public statutes, correctional directives, facility procedures, inspection and ombuds materials, procurement documents, and judicial decisions across four comparative cases: the United States, Canada's federal correctional framework, England and Wales, and Australia. The article develops and applies a Policy Facilitation Index (PFI) to assess five domains: escort duty explicitness, escort authorization and prioritization, scheduling and rebooking, notification and confirmation, and documentation, oversight, and contractual clarity. Scores show substantial cross-jurisdictional variation. England and Wales and Canada score highest, with composite scores of 88 and 85, reflecting more explicit duty allocation, authorization pathways, rebooking expectations, notification practices, and documentation requirements. Australia scores 65, indicating moderate specificity with state and territory variation. The United States scores 47, reflecting fragmented authority across constitutional doctrine, accreditation, local policy, contract design, and litigation. The findings show that external health care access in custody is a problem of penal administrative governance: formal rights become meaningful only when converted into visible, assignable, and reviewable routines. The PFI provides an exploratory framework for comparing how written custody-facing policies specify the administrative pathway to external medical care.