Improving health in prisons – from evidence to policy to implementation – experiences from the UK

• Date: 11 September 2017
• DOI: https://doi.org/10.1108/IJPH-09-2016-0056
• Pages: 139-167
• Published date: 11 September 2017
• Author: Jane Leaman,Anna Amelia Richards,Lynn Emslie,Eamonn Joseph O’Moore
• Subject Matter: Health & social care,Criminology & forensic psychology,Prisoner health,Sociology,Sociology of crime & law,Public policy & environmental management,Policing,Criminal justice

Improving health in prisons –from

evidence to policy to implementation –

experiences from the UK

Jane Leaman, Anna Amelia Richards, Lynn Emslie and Eamonn Joseph O’Moore

Abstract

Purpose –The purpose of this paper is to understand the components of a high-quality prison healthcare

system and the impact, ten-years on, of the transfer of accountability in England, from a justice ministry to a

health ministry.

Design/methodology/approach –A rapid evidence review was undertaken, which included a review of

82 papers and qualitative interviews with key informants. The concepts and themes identified were

summarised and analysed through a framework analysis, designed to improve population outcomes and

address health inequalities. The use of a rapid evidence assessment, rather than a systematic review

methodology, the use of abstracts (rather than full-text articles) to extract the data, and limiting the search

strategy to articles published in the English language only might mean that some relevant research papers

and themes were not identified. The need for the evidence to be produced within a limited time frame and

with limited resources determined these pragmatic approaches.

Findings –The review found that English prison healthcare has undergone “transformation”during this

period, leading to increased quality of care through organisational engagement, professionalisation of the

healthcare workforce, transparency, use of evidence-based guidance and responsiveness of services.

The review also highlighted that there is still room for improvement, for example, relating to the prison regime

and the lack of focus on early/preventive interventions, as well as specific challenges from limited resources.

Research limitations/implications –Time and resource constraints meant a rapid evidence review of

papers in the English language was undertaken, rather than a systematic review. This might mean relevant

papers have been missed. The review also only covered a small number of countries, which may limit the

transferability of findings. The lack of quantitative data necessitated the use of qualitative data gathered from

key informants. However, this enabled a good understanding of current practice.

Practical implications –The review findings support the World Health Organisation position on the value of

integrated prison and public health systems in improving quality of healthcare. It also recommends future

policy needs to take account of the “whole prison approach”recognising that healthcare in prisons cannot

operate in isolation from the prison regime or the community.

Originality/value –This is unique research which has great value in supporting prison reform in England.

It will also be of interest internationally due to the paucity of data in the published peer-reviewed literature on

the impact of commissioning models on healthcare or health outcomes.

Keywords Health, England, Prisons, Prison healthcare, Prison healthcare commissioning, Prisoner

Paper type Research paper

Background

The World Health Organisation (WHO) advocates that health ministries, not justice ministries,

should provide, and be accountable for, healthcare services in prisons (WHO, 2013). Currently

this model applies only in a small number of Western European states of which the UK has the

longest experience (since 2006, the National Health Service (NHS) has commissioned healthcare

in prisons in England and Wales) (Public Health England, 2016). An early assessment of the

transfer of control of prison health services to the Department of Health in England concluded

that benefits included greater transparency, evidence-based assessment of health needs,

Received 9 September 2016

Revised 13 December 2016

13 April 2017

Accepted 17 May 2017

Jane Leaman is a Consultant in

Public Health at Health and

Justice Team, Public Health

England, Reading, UK.

Anna Amelia Richards is a

Consultant in Public Health at

Public Health Devon, Devon

County Council, Exeter, UK.

Lynn Emslie and

Eamonn Joseph O’Moore are

both based at Health and

Justice Team, Public Health

England, Reading, UK.

DOI 10.1108/IJPH-09-2016-0056 VOL. 13 NO. 3/4 2017, pp. 139-167, © Emerald Publishing Limited, ISSN 1744-9200

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tackling professional isolation, improving the quality of care and integration of prison populations

into wider public health programmes (Hayton and Boyington, 2006).

This paper reviews the evidence of the impact of ten years of direct prison health commissioning

by the NHS (currently undertaken by NHS England). It provides evidence from both literature

reviews and key informants of the components of a high-quality healthcare system in prisons,

identifies where current practice meets these components, and recommends areas of focus for

future policy. This evidence supports the WHO position on the value of integrated prison and

public health systems in improving quality of healthcare.

Methods

Rapid evidence review

A rapid review of evidence was commissioned by the Department of Health in England from

Public Health England (PHE) (Department of Health, 2015). Search terms relating to prisoners,

healthcare commissioning and health issues known to be more common among prison

populations were used across six databases: CINAHL, Embase, Medline, PsychINFO, Social

Policy and Practice and NHS Evidence (see Table AII). All search terms were looked for in the

title and abstract fields. The Boolean operators “AND”and “OR”were used alongside truncation,

phrase searches and proximity operators. Only papers published between 1995 and 2015

and in the English language were included in the study; research papers from all countries

were included.

Grey literature searches were undertaken on NHS Evidence using a condensed version of the

search strategy.

Papers which were set in the wider criminal justice system (e.g. secure hospitals, probation,

courts) were included.

A researcher read ea ch relevant paper (or, due to time cons traints, the abstract if the full a rticle

was not easily available), extracted information on country, setting, study design and

participants and i dentified releva nt themes. These the mes were recorded a gainst an existing

framework –the Health Inequal ities National Su pport Team (HINST ) diagnostic fram ework

(Department of Health, 2008) –any themes not covered by this framework were recorded

separately and classified as “additional themes”. The theme s informed the lines o f enquiry for

the qualitative int erviews.

Key informants

Interviews were undertaken with 29 key informants and an expert stakeholder group, between

January and February 2016. Table I gives more details of the participants. Purposive sampling

was used to identify experts who collectively had a comprehensive understanding of current

practice and what is (and is not) effective with respect to commissioning and provision of

healthcare in English prisons. They were drawn from both the health and justice systems.

The HINST framework informed by the rapid evidence review shaped the lines of enquiry,

designed to facilitate discussion between the researchers and delegates. The topic guide is

outlined in Table II. This approach offered an opportunity to consider different points of view and

to come to a reasoned decision (Abelson et al., 2003). Using an appreciative enquiry approach

(Khangura et al., 2012) enabled discussions and built on identified areas of strength, to develop

possible solutions for areas of improvement and to help identify future commissioning priorities.

Contemporaneous notes were taken to record the concepts and themes identified in the

interviews and the findings were analysed using the HINST framework (Figure 1) (Department of

Health, 2008).

Ethical approval

The study methodology was reviewed by the PHE Research Ethics and Governance Group.

Ethics approval was not needed, as people in detained settings were not being interviewed.

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