Download Balancing Act – Addressing Health Inequalities among

'UNDERSTANDING HEALTH NEEDS AND
INEQUALITY IN HEALTH AND JUSTICE'
By
Dr. Éamonn O’Moore,
Director for Health & Justice, Public Health England & Director WHO Collaborating
Centre for Health in Prisons Programme, (European Region).
and
Dr Autilia Newton
Deputy Director Health & Justice, PHE
Hampton Hospital, September 12th, 2014
PHE Mission Statement on Health & Justice
• Public Health England (PHE) will work in partnership with health &
social care commissioners , service providers, academic & third
sector organisations and international partners to identify and
meet the health & social care needs of people in prisons and
other prescribed detention settings, as well as those in contact
with the criminal justice system (CJS) in the community. .
• PHE will aim to reduce health inequalities, support people in
living healthier lives, and ensure the continuity of care in the
community.
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Rampton Hospital, September 12th, 2014
Health Inequalities & CJS
•
Health inequalities experienced by people in contact with the criminal justice
system (CJS) are well above the average experienced by the wider
community.
•
As well as those in a custodial setting, this includes offenders serving
community sentences, those who are in the community on licence and or
‘known to the police’.
•
Evidence that this group of people suffer from multiple and complex health
issues, including mental and physical health problems, learning difficulties,
substance misuse and increased risk of premature mortality.
•
These underlying health issues are often exacerbated by difficulties in
accessing the full range of health and social care services available in the
local community.
4.
Rampton Hospital, September 12th, 2014
‘Underserved’ NOT ‘hard to reach’
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•
People in PPDs often described as belonging to ‘hard-to-reach’ populations;
•
This is NOT true- more accurately described as ‘under-served’ both in
prisons and in the community;
•
‘Hard-to-reach’ implies some active withdrawal by population whereas
‘underserved’ describes situation where services fail to meet needs of
population in appropriate ways.
•
Need to stop blaming the patient for being ‘difficult’ and recognise instead
difficult circumstances (personal, social and cultural) in which patient often
lives as being a barrier to their accessing ‘conventionally delivered
services’.
. Rampton Hospital, September 12th, 2014
Role of PHE in Health & Justice:
• PHE will gather and provide evidence and intelligence to inform
and support the work of local and national commissioners and
service providers;
• PHE will provide expertise at local, national & international level
(in our role as UK CC for WHO HIPP) on a broad range of health
protection, health promotion and disease prevention activities
working in close partnership with local commissioners and service
providers.
• PHE will support partners, including commissioners and providers of
health and social care, in the development of care pathways which
account for the movement of people around the detention estate
and between prescribed detention settings and the community.
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Rampton Hospital, September 12th, 2014
PHE Resources for Health & Justice:
• PHE also has a dedicated resource to support work on
understanding and managing the health needs of people in contact
with the criminal justice system.
• The national team sits within the Health & Wellbeing Directorate;
• Ten Health & Justice Public Health Specialists are based in
Public Health England Centres, working in the Operations
Directorate, and ‘man-marking’ the ten NHS England AT Health &
Justice Lead Commissioners;
• These with the national team form the Health & Justice Network;
. Rampton Hospital, September 12th, 2014
PHE Resources for Health & Justice: cont’d
• A specialised Health Protection Prison Network composed of HP
staff from each PHE Centre and chaired by the H&J DD,
compliments the H&J Network and covers the specialised area of
HP
• The H&J DD works across 2 Directorates: Operations & Well Being,
co-ordinating with WB and leading the H&J agenda across Ops
• These resources within both NHSE and PHE at national and local
level allow for effective horizontal and vertical integration within
organisations and between organisations.
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PHE Regions & Centres
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Criminal Justice Estate- England & Wales
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Prison Population Rate per 100,00 globally
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Population Factors
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‘Community Dividend’ for public health
interventions in prison populations
•
Underserved populations passing
through prison estate ~160,000 per
year;
•
Often belong to wider social groups
and networks contributing significantly
to health inequalities generally;
•
Delivering health interventions in
prisons not only benefits prisoners‘community dividend’ in addressing
issues in underserved populations
generally.
1.77 million individuals annually
were dealt with by CJS;
~250K annually
~160K annually
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Some examples…
Hepatitis B vaccination programme in prison (started in 2003) has had a
significant impact on the incidence of the infection amongst IDUs in England
The opt-out BBVs policy has the potential to deliver the largest impact in the
reduction of BBVs pathology, especially Hepatitis C , in England
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Public Health Model for Health & Justice:
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Balancing Act
•
A briefing for Directors of
Public Health published Oct
2013 which suggests positive
actions and approaches DsPH
could use to tackle the health
inequalities of people in
contact with the criminal
justice system residing in their
local community;
Rampton Hospital, September 12th, 2014
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Higher Mortality Rates among people in
• Data on all cause mortality
contact with CJS
among current and or ex-prisoners
is difficult to identify and collect;
•
However, in jurisdictions where
such collections are possible,
dramatic differences are evident
between current or former
prisoners and general population in
relation to all cause mortality as
well as accidental death and
suicide.
• Data from the UK is shown as
example.
Rampton Hospital, September 12th, 2014
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Substance Misuse Among People in
Contact with CJS:
Rampton Hospital, September 12th, 2014
Mortality Rates: Drug Related Death Rates
Rampton Hospital, September 12th, 2014
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Mortality Rates: Suicide
•
Suicide rates are higher in prison
populations than among peers in
the community.
•
WHO data shows a suicide rate
which ranges from 0 (0.0%) to
almost 300 (0.3%) per 100,000
prisoners, with an average of about
60 (0.06%) per 100,000 in the 47
WHO European Member States
that belong to the Council of
Europe.
• Data from the UK is shown as
an example.
Rampton Hospital, September 12th, 2014
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High prevalence of diseases: Mental Health
Prisoners often have higher
prevalence of mental
health problems and
behaviours, including
personality disorder,
depression and psychosis.
Rampton Hospital, September 12th, 2014
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Learning Disabilities
Rampton Hospital, September 12th, 2014
Smoking Prevalence
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Rampton Hospital, September 12th, 2014
Physical Health Needs: cont’d
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Infectious Diseases: BBV/HIV infection
•
Many prison populations have
high prevalence of infection with
blood-borne viruses (BBVs)
(Hepatitis B & C) and HIV due to
large numbers of injecting drug
users (IDUs) among incarcerated
populations;
•
Some evidence of onward
transmission of infection in
some European states due to
injecting of drugs, tattooing and
unprotected sexual activityalthough definitive data is difficult
to find.
Rampton Hospital, September 12th, 2014
New commissioning context
• Section 15 of the Health and Social Care Act 2012 gives the
Secretary of State the power to require NHS England to commission
certain services instead of CCGs. These include ‘services or
facilities for persons who are detained in a prison or other
accommodation of a prescribed description.’
•
NHS England assumed these powers from April 1 2013.
• NHS England is responsible for ensuring that services are
commissioned to consistently high standards of quality across
the country, promote the NHS Constitution and deliver the
requirements of the Secretary of State’s Mandate and the
section 7a agreement with the NHS England.
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NHS Resources for Health & Justice
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•
NHS England is structured with a national team, 4 regions and 27 Area
Teams (ATs).
•
Nine ATs and a regional team for London have been designated to
support commissioning of preventive and public health services as set out
in the Section 7a agreement with SoS, in respect of persons detained in
prison, or in other secure accommodation.
•
The ATs and London regional team work with the NHS England national
team.
•
Commissioning intentions and structures were published by NHS in
‘Securing Excellence in Commissioning for Offender Health’ published
in February 2013.
Rampton Hospital, September 12th, 2014
Benefits of new system
• The rationalisation of a large number of local commissioners to one
single national commissioner provides the opportunity to
implement nationally consistent evidence-based commissioning
specifications and quality standards appropriate to the patient
population and integrated in community-based services.
• The is an opportunity to improve the continuity of care as
detainees move around the detention estate and / or back into
communities.
• There are significant opportunities to improve the health and wellbeing of people in detention and in turn, the wider community.
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Rampton Hospital, September 12th, 2014
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Public Health Outcome
Indicators
•
Indicators directly related to
offending behaviours:
Rampton Hospital, September 12th, 2014
•
Indicators relating to adult populations in
contact with CJS (in custody & in the
community)
Care inside and ‘through the gate’
• Primary care services are the major health services that individual’s
access in detention but specialist services including sexual health, drugs &
alcohol, and mental health services are also provided according to
need.
• Such services provide a prime opportunity to deliver therapeutic and
prevention services and to begin care which can be continued around
the detention estate and into the community.
• People in prison use primary care services at greater frequency and
intensity than their peers in the community, especially young men. This
is completely reversed on return to the community, where their use of
services is much lower than that of their peers.
• Challenge is to ensure care started inside continues ‘through the gate’.
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Transforming Rehabilitation
1. Reconfiguration of the Prison Estate to create network of
70 Resettlement Prisons (short sentences & last 3 months)
2. Creation of National Probation
Service
3. Tendering for rehabilitation
providers in package areas who
will operate ‘Through the Gate’
4. Supervision extended to
short sentences
6. New providers paid by their
results
5. Providers will provide, and
signpost to/work in partnership
with, wider services to reduce
reoffending
Conclusions:
• Public health challenges associated with detention settings are significant
and increasing;
• Prisons & other places of detention represent an opportunity to address
health inequalities in these settings specifically and society generally.
• Challenge to ensure that work commenced in prisons and other detention
settings is appropriately continued on return to the community- avoid ‘cliff
edge’;
• In England, opportunity in new public health system and NHS to address
these issues more effectively especially with advent of a single
commissioner (NHS England) for all prescribed detention settings in
England;
• Health and Justice organisations must work in ‘co-production’ mode to
ensure effective design & delivery of services in prisons and beyond the
prison walls.
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