Ahead of a 2-day convention 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 on the well being 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 a few of their insights on revolutionary practices to help continuity of care and reflections on the place consideration ought to focus after the COVID-19 pandemic. 

Prison affected person profile

London has 8 prisons, all male, which characterize round 10% of England’s general jail inhabitants. Some of those are remand prisons for individuals awaiting trial and, due to this fact, have a excessive turnover of individuals. 

“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.” 

Unpredictability

Working on the intersection of the well being and justice programs is difficult, as each are extremely complicated. Put them collectively and one can find that an individual’s prison justice pathway and their affected person pathway not often 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 sometimes moved between prisons, which additionally has an impression on the care they obtain.

“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 steady care

All the options for aligning the well being and justice programs aren’t but clear. The digital well being document commissioned nationally by NHS England, nonetheless, is one in every of England’s main belongings to make sure constant, joined-up look after individuals who spend time in jail. Another key asset is the strong tradition of partnership between the principle companies working in well being 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 collectively beneath a partnership settlement to ship well being look after individuals in custody. Continuity in service supply displays the robust, enduring relationships and deep data among the many companions. This takes time, vitality 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 strategy was essential in the course of the COVID-19 pandemic, not simply between the companies however in any respect ranges. 

“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 steady care and guaranteeing that folks can entry the providers they want isn’t just for post-release. Speaking concerning the juncture between prisons and the group extra usually, 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.”

Trauma-informed views

Ian supplies a jail governance perspective and Sinéad – the angle of a commissioner and Justice of the Peace. However, each have expansive views past their respective areas and they’re enthusiastic about what they do. Through their work, they see a chance to make a dramatic distinction in somebody’s life and assist to interrupt some harmful 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 well being and social care sector, there’s a rising deal with the worth of individuals’s lived expertise. It acknowledges that individuals who have frolicked in jail or used substances have essential insights that may inform insurance policies and processes, significantly round 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.”

Vulnerable populations

People in jail are a susceptible group with huge and complicated well being and social care wants. This shouldn’t be a inhabitants that may simply entry or interact with providers. They want larger precedence in terms of allocation of health-care assets, to make sure some type of continuity of care and to interrupt 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 on the intersection of well being and justice are managing ranges of human struggling and complexity with which most of us won’t ever contend, typically in opposition to a backdrop of political instability. Society, and significantly the general public well being group, wants to grasp what occurs in prisons. This is a inhabitants with important and diversified well being wants, in fixed flux. The insights gleaned and practices being developed on this area may inform broader efforts round health-care system resilience – find out how to create agile, responsive programs that may present steady care in instances of disaster. 

Sinéad and Ian problem us to contemplate how we view individuals in prisons, and the way we expect they slot in our concept of group.

“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 constructing resilient programs. Walls are arduous bodily interfaces, the alternative of continuity. They divide individuals into these on the within and people on the skin. We might have to beat each our psychological and bodily boundaries to see that we’re basically one group and one care system.

Snapshot: Prison affected person pathway, London

Sinéad Dervin leads the commissioning of health-care providers in London’s prisons. There are a spread of NHS, unbiased and third-sector suppliers delivering well being care consistent with NHS England’s National Service Specifications. Services are commissioned and delivered to the precept of equivalence, in that the jail inhabitants receives the identical normal of care as the overall inhabitants. Prisoners can anticipate to obtain a full vary of main care providers, in addition to secondary psychological well being care and remedy, substance misuse remedy, dentistry and different allied well being providers. In London, prisoners may also obtain dialysis remedy throughout the institution. For specialist care similar to most cancers care, sufferers go away the jail beneath escort to attend an exterior hospital for remedy. 

In addition to the nationwide jail digital well being document, in London, liaison and diversion groups, who work in police stations and courts to establish individuals with sure vulnerabilities, can enter straight into the jail medical document system. This implies that well being and social care professionals can check with a document of an individual’s necessities and health-care interactions from their very first encounter with the prison justice system.

When somebody comes into jail, they’re processed by the prison justice system, and obtain a well being evaluation inside 24 hours of arrival and a complete evaluation inside 7 days. On day one their well being wants, together with required medicines, are recognized. Following evaluation, individuals are assigned a multidisciplinary care group based mostly on their wants. In London, the fashions of care are structured round individuals’s first 14 days in custody, as it is not uncommon for individuals to reach in jail with many complicated issues. We know that early days in custody are among the most susceptible instances for prisoners at elevated danger of suicide. In addition, there are devoted groups delivering a spread of each deliberate and emergency care. 

When an individual leaves jail, efforts are made to have interaction them with providers locally to make sure a level of continuity of their care. London has devoted Transfer and Release groups who begin working with individuals round 10 weeks earlier than they’re due for launch, to get them linked into providers locally. This is a part of RECONNECT, a nationwide programme to make sure that individuals entry care after custody and preserve well being features made while in jail.