This paper has been commissioned in order to support the Sainsbury Centre for Mental Health in better understanding the health and social care and the physical and mental health needs of offenders upon release from prison.
In addition the following questions were addressed; what development work is currently being undertaken or being planned in this area, what are the national policy drivers covering wider health care which may significantly relate to and affect prisoners, how are they enabled to access primary care services and what organisational issues affect this access? And what are the gaps which require research, training or service development?
• This review of the current primary care research about prisoner and offender health, shows that more is required, particularly looking at what works, in reducing mortality, morbidity and health related re-offending behaviour in the post release period.
• This work observes that prisoners are marginalised in society and tend to fall easily between care systems and structures as they attempt to have their multiplicity of ‘never serious enough’ needs met. Care should be taken to overcome this tendency.
• The provision of health care in prisons and for offenders upon release faces many uniquely difficult challenges e.g. high consulting rates, prisoner reliability as historians, poor prisoner concordance with treatment planning, prisoner personal health neglect and health damaging behaviours, poor clinical information and support systems, staff shortages, poor planning of service integration. This must therefore be considered when designing services.
• This paper shows that despite the relative lack of evidence much good work, appropriately designed and planned to deliver the objectives of improving offender health, can be effective in each unique prison and community setting. There is a move to multi-disciplinary and multi-agency models of care and such new modes of delivery require further evaluation.
• Imprisonment, the evidence repeatedly confirms, can be good for physical health and improving health intervention opportunities but is usually not good for mental health. The post release period is extremely dangerous in physical and mental health terms and for recidivism. Prisons, delivering good health and social care, can be seen as another, ‘community based healthcare station’.
• Imprisonment rates are increasing especially amongst women and the elderly and alternatives, whenever possible, should be used to avoid the deleterious health effects of incarceration. • Health and social care services need to be designed to be acceptable to and accepting of young people. Women and young prisoners have special needs. Other sections of the population, e.g. older men, should also be considered and their special needs identified.
• Researchers state that it is imperative that screenings for infectious diseases be conducted in prisons and/or treatment administered before detainees are released back into the general population.
• A number of studies have shown that for the clinical management of prisoner health problems, unless proven otherwise, the assumption should be that a normal approach will achieve normal outcomes. There is also no evidence that imprisonment per se prevents the successful application of any particular healthcare interventions however technological.
• The quality of post release planning is reported as variable and to be effective must be strengthened, particularly for prisoners with mental health problems who will require assertive outreach, and should become a key quality indicator to be performance managed.
• There are negative implications from the cumulative effects of engagement with the criminal justice system, and the process through which persons with mental illness and a criminal history, cycle through institutions. The multiple and diverse aetiologies driving behavioural disturbance in mentally ill offenders need to be better understood for individuals at sentencing and for populations in respect of service planning.
• There is an important role to be developed for therapeutic communities and group support methodologies as aids to personal future planning for prisoners.
• Investment in, monitoring, reporting and evaluation of, prison-based and community interventions is needed to help reduce substantially drugs-related, suicides and all cause deaths in recently released offenders.
• Services which aim to meet the needs of substance misusing prisoners will, because of the high prevalence of dual diagnosis, have to be effectively delivered in partnership with mental health providers.
• Integrated Inclusive Care Programme approaches work, but must be focussed, provide continuity from within the prison into the community, be multi-disciplinary and multi agency, well resourced and well integrated with mainstream services.
• Reduction in structured support and reduced autonomy both contribute to the risk of poor management of chronic conditions, or adherence to recovery programmes for more acute conditions, following release from prison.
• The key challenge for prison healthcare is to enable continuity of care, within, between, on admission and upon release. Using the prisoner journey from pre-arrest to post release as a template it will be possible for local health and social care, and criminal justice communities to better plan continuity of health and social care, alternatives to imprisonment and long term support services.
• Maintaining therapeutic relationships initiated with in the prison, into the post- release period are likely to reduce recidivism and improve health outcomes. Because it can be shown that prisons can be a place of relative safety and health promotion for some prisoners, we should endeavour to make them more so for all.
• The direction of national strategy on prisoner and offender health is aligned with the evidence provided in this paper. Prisoner and offender health is to be provided by services commissioned by the NHS, and developed under guidance from regionalised development centres, with an aim to deliver better continuity and through care with improved integration between health, social care and criminal justice services. In taking forward this important agenda it will be necessary to ensure effectiveness and develop the evidence base.
Dr. Mark Williamson
Registration no.328239 