Beyond equivalence: prisoners' right to health

Quality indicators and performance measures for prison healthcare: a scoping review

BACKGROUND

Internationally, people in prison should receive a standard of healthcare provision equivalent to people living in the community. Yet efforts to assess the quality of healthcare through the use of quality indicators or performance measures have been much more widely reported in the community than in the prison setting. This review aims to provide an overview of research undertaken to develop quality indicators suitable for prison healthcare.

METHODS

An international scoping review of articles published in English was conducted between 2004 and 2021. Searches of six electronic databases (MEDLINE, CINAHL, Scopus, Embase, PsycInfo and Criminal Justice Abstracts) were supplemented with journal searches, author searches and forwards and backwards citation tracking.

RESULTS

Twelve articles were included in the review, all of which were from the United States. Quality indicator selection processes varied in rigour, and there was no evidence of patient involvement in consultation activities. Selected indicators predominantly measured healthcare processes rather than health outcomes or healthcare structure. Difficulties identified in developing performance measures for the prison setting included resource constraints, data system functionality, and the comparability of the prison population to the non-incarcerated population.

CONCLUSIONS

Selecting performance measures for healthcare that are evidence-based, relevant to the population and feasible requires rigorous and transparent processes. Balanced sets of indicators for prison healthcare need to reflect prison population trends, be operable within data systems and be aligned with equivalence principles. More effort needs to be made to meaningfully engage people with lived experience in stakeholder consultations on prison healthcare quality. Monitoring healthcare structure, processes and outcomes in prison settings will provide evidence to improve care quality with the aim of reducing health inequalities experienced by people living in prison.

Incarcerated population in India: how many are dying? How are they dying?

Purpose

This study aims to examine sociodemographic characteristics, levels and patterns of mortality experiences amongst Indian prisoners over the past two decades (1998–2018).

Design/methodology/approach

This study used prison statistics in India to analyze occupancy rate, percentage distribution, annual/decadal change, male–to–female ratios, prison mortality rate and causes of natural/unnatural deaths.

Findings

During 1998–2018, prisons in India grew by 18% and prisoners by 69%, leading to overcrowded jails. Males outnumbered female prisoners. Seventy percent of prisoners had an educational attainment level lower than 10th grade. In 2018, over 14 per 1,000 prisoners suffered from a mental illness and 384 per 100,000 died. Unnatural deaths accounted for 8%–11% of all prisoner deaths; 84% were by suicide. Illness accounted for 95% of all natural deaths in 2018; one–quarter was due to heart diseases.

Research limitations/implications

The study did not establish an association between sociodemographic characteristics with mental illness and mortality due to the non-availability of data.

Social implications

The pattern of a deteriorating living environment, rise in mental illnesses and mortality among Indian prisoners calls for immediate action from the authorities to protect them. Almost all unnatural deaths were by suicide (mostly by hanging). This detailed study would help authorities to take corrective measures for prisoner safety and well-being. There is also a need to develop a scientific database for this population.

Originality/value

To the best of the authors’ knowledge, this is the first study to examine morbidity and mortality experiences of the prisoner population using national statistics.

How do policymakers interpret and implement the principle of equivalence with regard to prison health? A qualitative study among key policymakers in England

BACKGROUND

The principle of equivalence in prison health has been established for nearly four decades. It seeks to ensure that prisoners have access to the same level of healthcare as members of society at large, which is entrenched within the international legal framework and England's national health policies.

AIMS

This study examined how key policymakers interpret and implement the principle of equivalence in English prisons. It also identified opportunities and threats associated with the application of the principle.

METHODS

In total, 30 policymakers took part in this research. These participants engaged in policymaking activities and occupied positions of authority in the prison field.

RESULTS

Despite the policymakers' consensus on the importance of the equivalence principle, there was a varying degree of understanding regarding what constitutes 'equivalence'. Participants described how the security culture impedes prisoners' access to healthcare services. Additionally, the increasing size and complexity of the prison population, coupled with a diminishing level of resources, reduce the level of care being provided in prisons and thus compromise implementation of equivalence in English prisons.

CONCLUSIONS

Inconsistent interpretation of equivalence, the prevailing security drive, increasing numbers and health complexities of prisoners and fiscal austerity threaten the implementation of equivalence in English prisons. This research calls for new guidance on how to interpret and implement equivalence, along with measures to educate prison governors and staff on the prison rehabilitation value, ensure greater investment in prison health and consider alternatives to imprisonment to future-proof the principle of equivalence in the English prison system.

Mental illness and the provision of mental health services in prisons

INTRODUCTION

Around 11 million people are held in prisons internationally, and criminal justice systems are overburdened with a high prevalence of multiple psychiatric disorders. In England and Wales over 200 000 people enter prisons each year, and in many cases, this facilitates their first contact with mental health services.

SOURCES OF DATA

Research, evaluations, government reports and independent reviews.

AREAS OF AGREEMENT

Screening, Triage, Assessment, Intervention and Re-integration (STAIR) are necessary components of prison mental health provision, offering an opportunity to improve the wellbeing of a complex population.

AREAS OF CONTROVERSY

There are serious problems with service provision across many parts of the world, with human rights abuses occurring in some States. Screening and service delivery models still require substantial development. In England and Wales, self-harm, self-inflicted deaths and violence are increasing.

GROWING POINTS

Introducing comprehensive mental health models throughout prisons would offer a massive public health initiative, providing new services for the socially disadvantaged. A rights-based framework would be useful in ensuring systemic improvements, especially in low and middle-income countries.

AREAS TIMELY FOR DEVELOPING RESEARCH

Mechanisms for screening and triage, specific interventions across a broad range of conditions, and practical re-integration models, should be submitted to research across international sites.

Women's Health in Queensland Prisons

Internationally, best practice for prison health care recommends transferring health service provision from corrections to health authorities. Although it is expected that this change will result in improved health care, there is little evidence of evaluation. This article used qualitative interviews with health service providers to gain insight into the health needs of women's prisons in Queensland, Australia, both prior to and after the transition in health care service provision. We found that service providers identified that problems persisted regardless of service provider and that improvement required increased resources and more fundamental structural changes within prison environments.

Expert perspectives on Western European prison health services: do ageing prisoners receive equivalent care?

Health care in prison and particularly the health care of older prisoners are increasingly important topics due to the growth of the ageing prisoner population. The aim of this paper is to gain insight into the approaches used in the provision of equivalent health care to ageing prisoners and to confront the intuitive definition of equivalent care and the practical and ethical challenges that have been experienced by individuals working in this field. Forty interviews took place with experts working in the prison setting from three Western European countries to discover their views on prison health care. Experts indicated that the provision of equivalent care in prison is difficult mostly due to four factors: variability of care in different prisons, gatekeeper systems, lack of personnel, and delays in providing access. This lack of equivalence can be fixed by allocating adequate budgets and developing standards for health care in prison.

Variations in prison mental health services in England and Wales

In responding to high levels of psychiatric morbidity amongst prisoners and recognising earlier poor quality prison mental health care, prison mental health in-reach teams have been established in England and Wales over the last decade. They are mostly provided by the National Health Service (NHS), which provides the majority of UK healthcare services. Over the same period, the prison population has grown to record levels, such that prisons in England and Wales now contain almost 90,000 of the world's overall prison population of over 10 million people (roughly the size of Paris or Istanbul). This study provides an overview of mental health in-reach services in prisons in England and Wales, including variations between them, through a telephone survey of senior staff in all prisons and young offender institutions in England and Wales. 73% of prisons took part; of them 13% had no in-reach team at all (usually low security establishments) and the majority of services were run by NHS teams, usually according to a generic community mental health team (CMHT) model rather than other specialist models. Team size was unrelated to prison size. Each nurse covered around 500 prisoners, each doctor over 3700. Many provided few or no healthcare cells and 24-h psychiatric cover (including on-call cover) was uncommon. Despite developments in recent years, mental health in-reach services still fall short of community equivalence and there is wide variation in service arrangements that cannot be explained by prison size or function. The aim of community equivalence has not yet been reached in prison healthcare and a more sophisticated measure of service improvement and standardisation would now be useful to drive and monitor future development.