RCGP Secure Environments Group Working together….

1. 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

2. 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

3. 1999 “The Future Organisation of Prison Healthcare”Prison 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.”

4. Key values • Equivalence • Access • Quality • Reducing inequality • Protecting vulnerability • Safety

5. 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.

6. 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 < 11year olds

7. 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 1

8. 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. • 40%of women in prison have received care or treatment for mental health problem in previous year Experience high rate of mental health disorders

9. 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…..

10. 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

11. 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

12. 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 Assessment of physical, psychological and social needs Problem Management, Acute, intermediate and long term Health promotion lifestyle support and appropriate intervention Care partnerships with community services Managing prison transfers Release and resettlement planning Appropriate information sharing within the prison system Prison Resettlement and re-engagement with primary care, community health and social care services Information transfer Primary care assessment Care Continuity Problem management Health promotion Lifestyle support and retention in care Social inclusion and Mainstream services Community Offender health and social care pathway

13. 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 E T G I R N A U T I I T Y O N Community Community

14. 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

15. 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.

16. 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

17. 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.

18. Increased focus on social exclusion, health inequality and deprivation POLICY Intensive Primary Care More PCTs and LAs commission these services

19. mark.williamson@dh.gsi.gov.uk