RCGP Secure Environments Group Working together'

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RCGP Secure Environments GroupWorking together.

• Dr. Mark Williamson
• Associate Director of Primary Care, DH
• Senior Medical Adviser Offender Health, DH
• NCL Prison Health IT, CFH
• Chair Secure Environment Group RCGP
• GP HMP Hull and the Quays, Hull

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The RCGP SEG

• Set up from the PHDT medical leads 9.04, linking
  to DH, RO, SHA regional networks, multi
  disciplinary
• Aims
• to improve the health and care for offenders
• To support the workforce and raise self esteem
• To raise the profile of offender health issues
• To contribute to strategy development
• By
• Acting as a voice for the workforce
• Raising issues, managing problems
• Delivering an educational course
• Working with other partners in the RCGP
• Maintaining a knowledge database
• Supporting research
• Support strategy development
• Managing the hub for regional networks
• Linking to regional DH presence

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1999 The Future Organisation of Prison
HealthcarePrison Service and the NHS formal
partnership to secure better healthcare for
prisoners.

• Healthcare in prisons should promote the health
  of prisoners identify prisoners with health
  problems assess their needs and deliver
  treatment or refer to other specialist services
  as appropriate. It should also continue any care
  started in the community contributing to a
  seamless service and facilitating throughcare on
  release. The majority of health care in prisons
  is therefore of a primary care nature. However,
  health care delivery in prisons faces a
  significant number of challenges not experienced
  by primary care in the wider community.

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Key values

• Equivalence
• Access
• Quality
• Reducing inequality
• Protecting vulnerability
• Safety

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A few vital statistics

• There are 138 Prisons in the UK (128 public, 10
  private) housing approximately 80 thousand
  prisoners (in 1992 the figure was 42 thousand)
  and the population is slowly rising.
• 5 are female and there are a small number of
  child prisoners, approximately 100 girls 3
  thousand boys, and approx 1000 lifers.
• There are about 135 thousand prisoners
  incarcerated per year, (and logically) a slightly
  smaller number released, and about 50 serve less
  than 6 months, average magistrates sentence of 3
  months.
• These figures mean that there are nearly a
  million relatives affected by imprisonment
  annually.
• England and Wales has the highest imprisonment
  rate in Western Europe, though some others are
  notably increasing their use of this sentence,
  e.g. Netherlands.
• 80 recidivism rate within 2 years of release.
• The ex-prisoner population and their families are
  a significant part of the socially excluded
  population and they share similar issues of
  health, health care needs and difficulties in
  respect of accessing health and social care
  services.

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Characteristics of prisoners

• Have been in local authority care 13 x
  (more likely than the non- prisoner
  population)
• 60 are unemployed 13 x
• Played regular truant 10 x
• Suffered school exclusion 20 x
• Have a family member convicted 2.5 x
• 42 of released prisoners have no fixed abode
• 50 on release have no GP
• 50 re-offend within 2yrs
• 50 of prisoners have reading skills lt 11year
  olds

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Women in prison

• Almost half are under the age of 30
• One in 10 has attempted suicide, and 50 have
  experienced physical, emotional or sexual abuse,
  and approximately 30 female prisoners
  self-injured each year

Are a young and vulnerable group
Majority are not violent, and serving short
sentences

• 68 are in prison for non-violent offences
  (compared with 47 for men) In 2003, 75 served
  under 12 months

• 55 women in prison have child under 16, 33 a
  child under 5.
• At least one third of mothers were lone parents
  before imprisonment

Majority have dependent family
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• 33 of the sentenced female population had been
  excluded from school
• 47 women offenders have no educational
  qualification

Have low educational attainment

• Around 70 of women coming into custody requiring
  clinical detoxification
• Over third (33) had committed drugs offence
  (2006)

Have high levels of substance misuse

• Up to 80 of female prisoners have diagnosable
  mental health problem.
• 40of women in prison have received care or
  treatment for mental health problem in previous
  year

Experience high rate of mental health disorders
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Characteristics of prisoners and the recently
released

• 1/3 of offenders debt problems worsen in custody
• 125,000 children have a family member in prison
• 38 drug users on admission to prison
• 24 injecting drug use of which
• 20 Hep B (N 3,600)
• 30 Hep C (N 5,400)
• high opiate rising crack dependency
• 50k prisoners per year access drug detoxification
  sessions
• 80 prisoners smoke ( 40 general population)
• there is a growing elderly population with
  chronic disease..

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And furthermore.

• People who have been in prison are up to 30x more
  likely than the general population to die from
  suicide in the first month after discharge from
  prison,
• 40 of prisoners declare no contact with primary
  care prior to detention,
• 90 of prisoners have substance misuse problems,
  mental health problems or both,
• Personality disorder is common in the socially
  excluded and in the prisoner population,
• PCTs are now required to commission and design
  health care services within and without prison,
• Multi disciplinary provision is effective for
  this population

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The bridges

• Built with.. values, principles, aims,
  objectives, actions
• Between.national structures, national policy,
  regional structures and policy, local structures
  and policy
• What we know about what is effective and
  commissioning and service delivery
• Health and social care and the criminal justice
  system, (police, courts, prisons, probation).
• The providers, the service users
• The workforce and their aspirations
• Clinicians
• Clinicians and management
• Focus on the individual and reducing inequality

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Engagement and Retention in the community
Assessment and lifestyle review
Problem management
Health promotion lifestyle support and
appropriate intervention
Social inclusion and Mainstream services
Information transfer
Community
Post detention/arrest Assessment and Support
settings, police custody, court, bail.
Information transfer
Care partnerships with community services
Release and resettlement planning
Problem Management, Acute, intermediate and long
term
Assessment of physical, psychological and social
needs
Managing prison transfers
Health promotion lifestyle support and
appropriate intervention
Appropriate information sharing within the prison
system
Prison
Resettlement and re-engagement with primary care,
community health and social care services
Information transfer
Social inclusion and Mainstream services
Problem management
Health promotion Lifestyle support and
retention in care
Primary care assessment
Care Continuity
Community
Offender health and social care pathway
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The model of care
Prison
C
I
Primary care vulnerable and socially excluded
GMS Primary care mental health service 2o Mental
health service Substance misuse service Sexual
health service Infectious diseases
service Dental, Optometry, Pharmacy
services Health promotion Chronic disease
management Learning disability services Social
care, Housing, Education, Leisure and Employment
O
N
N
T
T
E
I
G
N
R
A
U
I
T
T
I
Y
O
N
Community
Community
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My perspective

• Qualified in 1983 passionate about primary care
• Medical school to medical director
• Balint, Pickles, Berger, Tudor Hart, Neighbour,
• Primary care has allowed an Inverse Care Law to
  operate
• Primary care is designed around the interests of
  professionals, less so the needs of the
  population served
• Confident primary care is the foundation solution
  for this problem, requires some differentiation
• Pragmatic an argument to take this direction,
  not policy but developing a case
• Presenting a strategic vision
• Social exclusion is an inclusive term

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There are potential synergies to combined
services for several groups with access problems
These groups are likely to have similar problems
accessing primary care services as homeless
people. Each group is reasonably small so could
be manageable within a specialist service.
However, they are unlikely to have similar health
issues
Drug misuse services are in short supply, and a
sizeable proportion will also be homeless.
These may have mental health issues and substance
misuse and a sizeable proportion may be homeless
Ex-offenders may have chaotic lifestyles, have
challenging behaviour and/or be substance
misusers. A sizeable proportion will also be
homeless.
Hard to treat TB patients may have similar needs
for intermediate care beds.
A large proportion of homeless people have
alcohol misuse and/or mental health problems.
However, each of these groups are very large in
size and the majority will be otherwise
mainstream population with few similarities to
homeless people.
Although these groups have some access problems,
they do not have strong similarities or overlaps
to homeless people.
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Service designs
Most affluent and able
Open Market
Settled, discreet communities
Traditional
Mobile, able, urban
Integrate
Multiple problems, chaotic, vulnerable, less
able, addicted
Co-locate, provide solid floor of primary care,
social care and welfare support
Population need
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Aims

• To promote the interests of, and benefits for,
  the socially excluded and vulnerable in improving
  access to excellent primary and social care.
• To support the co-location and therefore improved
  effectiveness of primary care and support
  services of social care, housing, benefits and
  employment seeking support, and some secondary
  care.
• To change primary care and social care making it
  easier for vulnerable people to navigate
  effectively.
• To improve access for hard to reach groups.
• Improve the retention in care and treatment
• Improve customer satisfaction.
• To generate increased effectiveness and
  efficiency in urban primary care provision and by
  improving health inequalities to be potentially
  cost saving.
• To enhance the esteem of the workforce and
  promote the expertise in this field.
• To raise the expectations of the population to be
  served.
• To improve health and reduce health inequalities.
• To create a different and more effective model of
  primary and social care delivery where this is
  appropriate to do so.
• To ensure the right people are supported by the
  right team in the right place.

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Increased focus on social exclusion, health
inequality and deprivation
POLICY
Intensive Primary Care
More PCTs and LAs commission these services
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mark.williamson_at_dh.gsi.gov.uk