Transcript Prison Health: The Scottish Experience

Prison Health: The Scottish Experience
3rd Feb 2015
Wrexham
Dr Lesley Graham
Public Health Lead for Alcohol, Drugs and Health & Justice
Information Services Division
NHS National Services Scotland
Prison Population in Scotland
• 15 prisons in Scotland, 2 privately run under
contract to the Scottish Prison Service
• In 2014, imprisonment rate of 139/100,000
(E&W 149/100,000)
• Rise in prisoner numbers from turn of century
until fall over last 2 years
Prison population in Scotland
1997/8-2013/14
9,000
8,000
Average Daily Population
7,000
6,000
5,000
4,000
3,000
2,000
1,000
-
Year
Background and Policy Context:
Criminal Justice
• Criminal Justice and Licensing Act (Scotland) 2010
-Presumption against sentences <3 months
-More efficient community sentencing
• Commission on Women Offenders 2012
• Whole systems approach for young offenders 2011
• Reducing reoffending programme including funding for
mentoring services on release 2012
• Scottish Prison Service re-organisation (Unlocking
Potential, Transforming Lives) 2014
• Increasing recognition of health and healthcare in justice
policy e.g. Justice Strategy 2012
Background and Policy Context:
Health
‘it makes sense for NHSScotland to review its approach to the health
and healthcare of offenders and ex-offenders to consider what more
can be done in prisons and custody settings to ensure continuity of
care between prison and the community’
Better Health, Better Care Action Plan 2007
‘Offenders and ex-offenders should have access to the health and
other public services they need and benefit from the same quality of
service as the rest of the population’
Equally Well Scottish Government 2008
•Range of health policies e.g. Drug, alcohol , mental health, BBV
strategies
•Public sector reform (e.g. Christie Commission, Health and Social
Care Integration)
Principles for prisoner health
Transfer of prisoner health to NHS in Nov 2011
underpinned by:
• Prison health should be equivalent to that
delivered in the community
• Prison health is part of public health
• Prison health is an opportunity for health
improvement
• Opportunity to tackle health inequalities
• Potential to reduce (re) offending
Health of Prisoners in Scotland:
building the evidence base
•
•
•
•
•
•
Needs assessments (general/thematic)
Prisoner surveys
Audit
Inclusion in national reporting
Research
Other
Prison Health in Scotland 2007
Methods I
• Epidemiological
-SPS healthcare disease register
-prisoner self report survey
-prisoner record health care markers
-developed prescribing indicators
• Corporate
-discussions with key staff pre and post info gathering
• Comparative
-between prisons
-with other prisoner populations
-general population
• Triangulation
-data sources
Prison Health in Scotland 2007
Methods II
• Description of prison estate and population
• Prevalence of problems
• Service provision (including staff)
• Delivery against standards
• Gap analysis
But
• Not costed
• No wider health improvement scope
• No user consultation
Worked prevalence example: Epilepsy
•
•
•
•
SPS disease register (observed): 2.1%
General population: 0.5%
Standardised rate (expected): 1.2%
Sodium valproate: 26,245 DDD/1,000 (SPS) c.f.
903/1,000 (Scotland)
• No equivalent data in English prison population
• => prevalence of epilepsy in prison population at least
double that in general population
Key findings
• Higher prevalence of alcohol, drug and mental
health problems
• Poor dental health
• Higher prevalence of some Long Term
Conditions
• Likely under detection and recording
• Throughcare needing enhanced
• Limited user involvement
Health of prisoners in Scotland:
other evidence
• 73% prisoners had an AUD with 36% likely dependent
• 77% tested positive for illegal drugs on reception, 33% of
which were opiates
• 4.5% have a severe or enduring mental health problem
• 74% smoke
• 19% positive for Hepatitis C
• Severe dental decay three times that of the general
population (29% c.f.10%)
Relative risk of mortality for adults imprisoned
in Scotland for the first time 1996-2007, by
cause and deprivation
Underlying cause of death
Males
(n=68,315)
Observed deaths
Expected deaths
Adjusted rate ratio (95% CI)
All deaths (not deprivation adjusted)
3982
1222.6
3.3 (3.2, 3.4)
All deaths
3982
1734.9
2.3 (2.2, 2.4)
Suicide and Undetermined Intent
783
224.6
3.5 (3.2, 3.7)
Homicide
225
51.2
4.4 (3.8, 5.0)
1112
252.4
4.4 (4.2, 4.7)
All Alcohol Related
559
193.6
2.9 (2.7, 3.1)
All deaths (not deprivation adjusted)
432
57.8
7.5 (6.8, 8.2)
All deaths
432
77.2
5.6 (5.1, 6.1)
Suicide and Undetermined Intent
87
7.6
11.4 (9.1, 14.1)
Homicide
17
0.8
22.2 (12.9, 35.7)
163
8.6
19.0 (16.2, 22.1)
72
7.8
9.3 (7.2, 11.7)
All Drug Related
Females
(n=8,312)
All Drug Related
All Alcohol Related
Graham et al EJPH in press
Relative risk of mortality of adults imprisoned
in Scotland for the first time between 20032007 (n=25,797)
Males (n= 23 594)
Females (n=3 203)
Observed
deaths
Expected
deaths
Adjusted rate
ratio (95% CI)
Observed
deaths
Expected
deaths
Adjusted rate ratio
(95% CI)
In prison
11
19.29
0.6 (0.3, 1.0)
2
0.61
3.3 (0.3, 12.0)
Out of prison
471
76.35
6.2 (5.6, 6.8)
61
4.48
13.6 (10.4, 17.5)
Graham et al EJPH in press
The prison setting:
opportunities
• Population with a high prevalence of ill health
• Easier to reach the ‘hard to reach’
• Positive effect on others (many young offenders have
family members who have served a custodial sentence
and are also parents themselves)
• Potential to reduce re-offending
• Potential to reduce health inequalities
The prison setting:
challenges
•
•
•
•
•
Security and order constraints
Overcrowding and ‘churn’
Co-morbidities
Needs of differing groups
Absence (or limited supply) of alcohol but presence of
drugs
• Unwillingness to admit problems
• Risk of relapse on release
• Continuity of care
Effective Interventions
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•
•
•
•
•
Suicide prevention
Hepatitis B vaccination
Hepatitis C detection and treatment
Cervical Screening
OST
Take home naloxone
Suicides in Scottish Prisons
2001-2012
12
10
Number
8
6
4
2
0
2001
2002
2003
2004
2005
2006
Year
2007
2008
2009
2010
2011
2012
Effective Interventions
•
•
•
•
•
•
Suicide prevention
Hepatitis B vaccination
Hepatitis C detection and treatment
Cervical Screening
OST
Take home naloxone
Effective Interventions
•
•
•
•
•
•
Suicide: prevention
Hepatitis B: vaccination
Hepatitis C: detection and treatment
Cervical Screening
OST
Take home naloxone
Effective Interventions
•
•
•
•
•
•
Suicide: prevention
Hepatitis B: vaccination
Hepatitis C: detection and treatment
Cervical Screening
OST
Take home naloxone
Effective Interventions
•
•
•
•
•
•
Suicide: prevention
Hepatitis B: vaccination
Hepatitis C: detection and treatment
Cervical Screening
OST
Take home naloxone
Effective Interventions
•
•
•
•
•
•
Suicide: prevention
Hepatitis B: vaccination
Hepatitis C: detection and treatment
Cervical Screening
OST
Take home naloxone
Lessons Learnt
• Risk of lack of NHS leadership/prioritisation/coordination
• Need for strong and sustained policy support in both
health and justice
• Slow progress in some areas e.g. mental health
• Effective throughcare/community reintegration crucial
• Partnership working essential
Next Steps
• Continue to add to the evidence base
• Foster strong and effective national networks
• Continuing focus on
throughcare/reintegration/diversion
• Integration of care/service
delivery/commissioning
• Key role for public health:
-leadership
-advocacy
-intelligence
Prison health, swimming upstream….
Contact
Dr Lesley Graham
[email protected]