_ RCGP Learning

July 2022 will see Integrated Care Systems (ICS) become statutory in England. Partnerships between NHS service providers, commissioners, local authorities, and other organisations will be responsible for planning, co-ordinating and commissioning health and care services that meet the needs of each geographically defined community. Included within each community will be a relatively small number of people who are in contact with the criminal justice system, some of whom will go in and out of prison more than once. It is recognised that this cohort, while heterogeneous, often has highly complex needs and frequently experiences poorer than average health access, experience, and outcomes.

Whilst in prison, men and women from this cohort will be temporarily ‘hidden’ from their community ICS commissioning landscape (commissioning of prison healthcare takes place separately, by NHS England and NHS Improvement health justice commissioners in England, Health Boards in Wales and Scotland and the South East Trust in Northern Ireland), and may be in secure settings distant from the locality to which they will return. It is essential that, as integrated care systems are launched, there will be representation and acknowledgement of the needs of these patients to avoid compounding the health inequalities gap. NHS England and NHS Improvement have introduced Core20PLUS5, an approach to address health inequalities at national and system levels. It identifies the most deprived 20% of the population, plus those not captured in the 20% who experience poorer than average health and recognises five ‘focus’ clinical areas requiring accelerated improvement. Those in touch with the criminal justice system are considered an ‘inclusion’ group in the PLUS cohort. This strategy aims to ensure that health and care needs are met in people in contact with the criminal justice system.

Once in prison, people are not able to choose where or from whom they receive their healthcare provision. Healthcare services in secure environments need to be configured to take account of the particular needs of the population they are serving, for example with regard to the increased prevalence of mental ill health, substance misuse and communicable diseases, whilst also acknowledging the distinctive settings in which the care needs to be delivered.

Healthcare practitioners have a duty of care to their patients, and in the secure setting this duty must be delivered in the context of the physical environment and lifestyle constraints prison brings, whilst utilising the assistance of the staff providing the security for the establishment. As a result, healthcare delivery in the secure setting requires continual collaboration and partnership working between prison and healthcare staff to deliver the most beneficial services.    

A healthcare worker in a prison has a unique opportunity to address the needs of some of society’s most vulnerable people and this must be done without prejudice. This means that the nature of someone’s offence, or the reason for their detention, should not alter how patients are cared for. 

Particular risks to patient safety, engagement and health equity occur at transition points, as people move into and out of prison, or are moved from one prison to another. NHS RECONNECT schemes have been set up to bridge the gap for patients being released from prison. They aim to facilitate continuity of care by ensuring that health information is shared, and connections are built with community health care practitioners before a patient leaves prison. The success of pre-release healthcare arrangements requires careful coordination with the probation service and the local authority to ensure that suitable housing is identified within the locality that community healthcare provision has been arranged.

In 1996, Her Majesty’s Chief Inspector of Prisons, Sir David Ramsbotham, published his paper “Patient or Prisoner?” in which his terms of reference were: ‘to consider health care arrangements in Prison Service establishments in England and Wales with a view to ensuring that prisoners are given access to the same quality and range of health care services as the general public receives from the National Health Service’. This paper introduced the concept of ‘equivalence’ of care and set the scene for what continues to be an evolving area of prison and secure environment medicine.

The principle of equivalence has been instrumental in helping to define and contrast the care being delivered in secure settings with that of the care in the wider community, with the aim of mirroring of provision. Since 2006 and the move towards the commissioning of health services in prisons by the National Health Service, there has been a significant transformation in the quality and consistency of services being delivered to people in prison. By aiming to deliver healthcare services that are ‘equivalent’, and achieving equitable health outcomes, we are not only striving to improve the health of our secure and detained patients, we are also benefitting society as a whole.

The RCGP has recently launched Secure Environments Hub that features information about healthcare in secure environments and eLearning for clinicians and multi-disciplinary team related to the prison system. You can access the Hub here: https://elearning.rcgp.org.uk/course/view.php?id=561