Ahead of a 2-day conference titled “Making prisons and places of detention resilient to infectious diseases” kicking off in London on 20–21 June, we spoke with 2 London-based leaders working at the health and justice interface – Sinéad Dervin, Deputy Director for NHS London’s Health and Justice Services, and Ian Bickers, Prison Group Director for London Prisons, His Majesty’s (HM) Prison and Probation Service. Here are some of their insights on innovative practices to support continuity of care and reflections on where attention should focus after the COVID-19 pandemic.
Prison patient profile
London has 8 prisons, all male, which represent around 10% of England’s overall prison population. Some of these are remand prisons for people awaiting trial and, therefore, have a high turnover of people.
“In the largest of our prisons, HM Prison Wormwood Scrubs, a high percentage of the population is on remand. Some are only in for a week, some for 6 months, some might be in for a year – it all varies. Trying to provide a rhythm of continuity of care is really challenging,” explains Sinéad.
“A lot of people come into prison in a very poor state. So many of the people I see as a volunteer magistrate had a poor start in life and led chaotic lives, with alcohol or substance abuse problems. They tend to have a long history of engagement with services, being in the care system, of homelessness – all significant entrenched problems. This is often the general profile. Mental health difficulties are quite prevalent.”
“You might just get them stabilized and then they’re gone. You have to work at such a pace as to be able to engage with that person. Our health-care providers need to work in tandem with the prison regime to ensure adequate access to the population. We have to quickly find out who they’re already seeing in the community, what their support networks and family connections are, and pull it all together in a very short time frame.”
Working at the intersection of the health and justice systems is challenging, as both are highly complex. Put them together and you will find that a person’s criminal justice pathway and their patient pathway rarely align.
“You aren’t always aware of forthcoming court appearances. That’s the bit that doesn’t line up often. Suddenly people are released. For example, if they go back to court and their bail decision is reviewed, they can be released immediately, even if they need care. This is the challenge for continuity. Of course, we should be releasing people if they don’t need to be in prison. But we also need to consider that they could be in the middle of treatment for a range of issues. In addition, unplanned releases bring about a greater risk of relapse and/or inadvertent overdose. If they have an established support system, it’s okay, but not all do,” says Sinéad.
People are often moved between prisons, which also has an impact on the care they receive.
“We see examples of people who are right on the verge of getting diagnosed in one prison but suddenly we have to move them because we need the spaces to serve the court. We then find that these people may have to start their diagnostic process again. Where’s the priority here?” asks Ian.
Assets for continuous care
All the solutions for aligning the health and justice systems are not yet clear. The electronic health record commissioned nationally by NHS England, however, is one of England’s major assets to ensure consistent, joined-up care for people who spend time in prison. Another key asset is the robust culture of partnership between the main agencies working in health and justice. NHS England, HM Prison and Probation Service, UK Health Security Agency, the Department of Health and Social Care, and the Ministry of Justice all work together under a partnership agreement to deliver health care for people in custody. Continuity in service delivery reflects the strong, enduring relationships and deep knowledge among the partners. This takes time, energy and a collaborative mindset. Ian, who works in HM Prison and Probation Service, says:
“I learned in my previous role as prison governor that you can’t do this stuff by yourself. I have to reach out into partnership. I suspect there are lots of people who manage health partnerships as part of their day job. I embrace working with Sinéad in the NHS and others, figuring out what we can do and how we can do it, in the face of all the urgent needs.”
This partnership approach was critical during the COVID-19 pandemic, not just between the agencies but at all levels.
“The relationships between staff and prisoners were probably the best that I’ve seen in my 20 years doing this work, because everybody was in it together,” says Ian.
“It drove innovation, it drove us to do things in a really different way, which is positive. COVID-19 also created a backlog in diagnosis and treatment, something that was always more difficult for the prison population to access. A lot of effort went into catching up on medical appointments. We worked closely with Sinéad and her team in particular to improve access to secondary care.”
Providing continuous care and ensuring that people can access the services they need is not just for post-release. Speaking about the juncture between prisons and the community more generally, Ian says:
“We need continuity of care from community to prison as well as from prison to community. Most people who end up in prison are there because they led chaotic lifestyles, and their access to mainstream health services before they come into prison was probably limited. How do we link from prison backwards into the community? Yes, the electronic system helps that process, but to make that electronic system work, the person needs to already be registered with a general practitioner. We have elements of the model that work, but we also have work to identify and address certain gaps.”
Ian provides a prison governance perspective and Sinéad – the perspective of a commissioner and magistrate. However, both have expansive views beyond their respective areas and they are passionate about what they do. Through their work, they see an opportunity to make a dramatic difference in someone’s life and help to break some destructive cycles. Sinéad says:
“Prison can be an opportunity because it provides containment that a lot of people need but don’t have in their lives, so it can be beneficial for them. But once they leave, that’s the critical bit about continuity of care. We can do everything we can to get people linked into services, ensure they have someone to meet them at the gate, ensure they’ve got their prescription, ensure they’re going to a team, but we can never replicate the experience of a managed and contained environment. When people leave, they are vulnerable to all the things in their lives again, including their triggers and stressors.”
Across the health and social care sector, there is a growing focus on the value of people’s lived experience. It recognizes that people who have spent time in prison or used substances have important insights that can inform policies and processes, particularly around rehabilitation. Ian says:
“How do you leverage the lived experience of people? For me, talking to people who have spent time in prison is hugely important. We know that people in prisons have probably endured quite traumatic events in their lives. We also know that people in prison will have suffered from adverse childhood experiences. I know that those two things are likely to come out as bad behaviour, which we might deal with in a certain way. Of course, if we knew and understood this better, we would be able to react better.”
People in prison are a vulnerable group with vast and complex health and social care needs. This is not a population that will easily access or engage with services. They need greater priority when it comes to allocation of health-care resources, to ensure some form of continuity of care and to break cycles of reoffending.
“When it comes to decision-making, policy-making, and prioritization, whether to invest, the narrative can get hijacked by media-driven messaging that people need to be punished and that those who are in prison are bad people,” says Sinéad.
“The punishment of imprisonment is administered before the person even reaches the prison gate because it involves loss of liberty. Prison should be a place of rehabilitation, where we can give people the opportunity to rebuild their lives, recover, grow and go back into communities as the best citizens they can be. The men I’m looking after right now are going to come out of prison and they’re going be our neighbours,” says Ian.
People working at the intersection of health and justice are managing levels of human suffering and complexity with which most of us will never contend, often against a backdrop of political instability. Society, and particularly the public health community, needs to understand what happens in prisons. This is a population with significant and varied health needs, in constant flux. The insights gleaned and practices being developed in this space could inform broader efforts around health-care system resilience – how to create agile, responsive systems that can provide continuous care in times of crisis.
Sinéad and Ian challenge us to consider how we view people in prisons, and how we think they fit in our idea of community.
“If we look through the lens of resilience and preparedness, then prisons must form part of any response, regional and national, for the very reason that this population and environment carries complications and risks. We need to think about this instead of focusing on who is in prison and for what reason. It’s also about remembering how vulnerable this population is,” says Sinéad.
Continuity of care is inherent to building resilient systems. Walls are hard physical interfaces, the opposite of continuity. They divide people into those on the inside and those on the outside. We may need to overcome both our mental and physical boundaries to see that we are essentially one community and one care system.
Snapshot: Prison patient pathway, London
Sinéad Dervin leads the commissioning of health-care services in London’s prisons. There are a range of NHS, independent and third-sector providers delivering health care in line with NHS England’s National Service Specifications. Services are commissioned and delivered to the principle of equivalence, in that the prison population receives the same standard of care as the general population. Prisoners can expect to receive a full range of primary care services, as well as secondary mental health care and treatment, substance misuse treatment, dentistry and other allied health services. In London, prisoners can also receive dialysis treatment within the establishment. For specialist care such as cancer care, patients leave the prison under escort to attend an external hospital for treatment.
In addition to the national prison electronic health record, in London, liaison and diversion teams, who work in police stations and courts to identify people with certain vulnerabilities, can input directly into the prison medical record system. This means that health and social care professionals can refer to a record of a person’s requirements and health-care interactions from their very first encounter with the criminal justice system.
When someone comes into prison, they are processed by the criminal justice system, and receive a health assessment within 24 hours of arrival and a comprehensive assessment within 7 days. On day one their health needs, including required medications, are identified. Following assessment, people are assigned a multidisciplinary care team based on their needs. In London, the models of care are structured around people’s first 14 days in custody, as it is common for people to arrive in prison with many complex problems. We know that early days in custody are some of the most vulnerable times for prisoners at increased risk of suicide. In addition, there are dedicated teams delivering a range of both planned and emergency care.
When a person leaves prison, efforts are made to engage them with services in the community to ensure a degree of continuity in their care. London has dedicated Transfer and Release teams who start working with people around 10 weeks before they are due for release, to get them linked into services in the community. This is part of RECONNECT, a national programme to ensure that people access care after custody and maintain health gains made whilst in prison.