A new approach to prison public health? Challenging and advancing the agenda for prison health

This paper explores recent developments in prison public health, recommending that future prison health policies and practices become more ‘upstream’ in their outlook and approach. It is argued that this will require much firmer acknowledgement of the significance of broad, systemic and structural determinants of prisoner health, particularly if the World Health organization's vision for a ‘healthy prison’ is to be realized. Epidemiological evidence plainly shows that prisoners have experienced—and continue to experience—worse health than the general population, despite the fact that prison settings across the European Union have been targeted for health promotion by the World Health Organization since 1994. In 2005, WHO launched a new 10-year prison public health plan, which it envisages will begin to address key prison health determinants. In the UK, New Labour has identified prison health as a key public health objective within Choosing Health, although health interventions within prisons continue to be predominantly geared towards efficient and effective primary and secondary healthcare, and much less towards public health goals. This paper strives to open up the debate on prison public health, advocating a progressive and more sustainable approach to developing and commissioning health services for prisoners.     

Deterioration,drift, distraction,and denial: How the politics of austerity challenges the resilience of prison health governance and delivery in England

Extant scholarship has demonstrated that macroeconomic austerity disproportionately harms marginalised end-users. Its impact on the governance and delivery of health provisions on such individuals, however, has received less attention. Drawing on interviews with 27 policy elites involved with England’s prison health policy, interviewees perceive that austerity policies have shaped and constrained the prison health system through the politics of deterioration, drift, distraction, and denial. The deterioration of the prison workforce size has been linked to diminished prisoner access to healthcare, attendant with an increased number of riots, assaults, acts of self-harm, and suicides. Concurrently, the microeconomic structure of organised crime is filling the void in prison governance, thus conducing to heightened abuse of psychoactive substances, as well as a surge in associated medical emergencies and violence. Successful prosecution of prior sexual offences, continued incarceration of those imprisoned for indeterminate sentences, and harsh sentencing practices have created policy drift, unremitting overcrowding, and reinforced excessive dependency on prison healthcare resources. The rapid turnover of justice ministers and intensified push for prison privatisation have enabled widespread distraction. Moreover, despite well-documented crises besetting English prisons, politicians seemingly remain in a state of denial. Preventive imprisonment, recurrent spending, and enhanced financial and political accountability measures are necessary to mitigate the effects of austerity and germane policies fomenting inimical impacts on England’s prison health system.     

Mental health. Sentence structure

Mental health issues are endemic in prisoner populations, with many trusts struggling to provide specialist intervention. Before the inreach team at Bullwood Hall prison was put in place, most of its work was left to non-specialist healthcare workers.     

Space,place and movement as aspects of health care in three women's prisons

This paper focuses on prison as a place in which the prisoner seeks health and health services. Drawing on the work of Henri LeFebvre, Edward Casey, Jeffrey Malpas, and Michel Foucault, a spatial analysis examines the constitutive roles of movement, social structure, and power in determining the prisoner's access to health care. The research methodology utilizes quantitative and qualitative analysis of women prisoners' attempts to get treatment for their health problems. The narratives of these often-failed attempts construct prison as a place where health care access is continually thwarted by rules, custodial priorities, poor health care management, incompetence, and indifference. Analysis of spatial practices, representations of space, and spaces of representation demonstrate the imposition of structural ordering, its naturalization, and the role of narrative in questioning the order, thereby creating possibilities for imaginary and real places where the prisoners' health needs can be met. Simultaneously, this analysis illuminates basic ethical questions about the limitations of human connection and medical caring in prison settings, regardless of the personal motivation of the caregiver.     

Criteria and procedures for determining benefit packages in health care. A comparative perspective

The legitimacy of procedures and criteria for determining benefit packages depends crucially on the representation of stakeholders in decision-making bodies, the transparency of procedures and the consistency of benefit decisions. Moreover, the assessment of the costs of healthcare services and its application as a decision criterion can be an important policy instrument in order to increase the overall efficiency of healthcare systems. Our analysis of procedures and criteria for determining benefit packages in England, Germany and Switzerland established potential for developing more legitimate procedures and criteria for benefits decisions. In Germany, representation of stakeholders and transparency of procedures can be improved. Consistency of decision-making is hindered by the veto positions of selected stakeholders. Moreover, benefit decisions are made for different healthcare sectors separately. In Switzerland, transparency of procedures is virtually non-existent at the moment. Thus, it is impossible to assess the consistency of decision-making. Only in England the costs of healthcare services influence the decision to include or exclude them.     

Access to Health Care in the Scandinavian Countries: Ethical Aspects

The health care systems are fairly similar in theScandinavian countries. The exact details vary, but inall three countries the system is almost exclusivelypublicly funded through taxation, and most (or all)hospitals are also publicly owned and managed. Thecountries also have a fairly strong primary caresector (even though it varies between the countries),with family physicians to various degrees acting asgatekeepers to specialist services. In Denmark most ofthe GP services are free. For the patient in Norwayand Sweden there are out-of-pocket co-payments for GPconsultations, with upper limits, but consultations forchildren are free. Hospital treatment is free inDenmark while the other countries use a system without-of-pocket co-payment. There is a very strongpublic commitment to access to high quality healthcare for all. Solidarity and equality form theideological basis for the Scandinavian welfare state.Means testing, for instance, has been widely rejectedin the Scandinavian countries on the grounds thatpublic services should not stigmatise any particulargroup. Solidarity also means devoting specialconsideration to the needs of those who have lesschance than others of making their voices heard orexercising their rights. Issues of limited access arenow, however, challenging the thinking about a healthcare system based on solidarity.     

Male prisoners and HIV prevention: a call for action ignored

US prison inmates are disproportionately indigent young men of color. These individuals are severely affected by HIV/AIDS, largely owing to the high-risk behavior that they engage in prior to incarceration. Researchers and practitioners have issued a call for the importance of offering HIV prevention services in prison settings. However, this call has largely been ignored. In this article, we outline reasons why these recommendations have been largely ignored, discuss innovative HIV prevention programs that are currently being implemented in prison settings, and offer recommendations for securing support for HIV prevention services in correctional settings.     

Future costs of stroke in the Netherlands: the impact of stroke services

OBJECTIVES: In the next decades, the number of stroke patients is expected to increase. Furthermore, organizational changes, such as stroke services, are expected to be implemented on a large scale. The purpose of this study is to estimate the future healthcare costs by taking into account the expected increase of stroke patients and a nationwide implementation of stroke services. METHODS: By means of a dynamic multistate life table, the total number of stroke patients can be projected. The model calculates the annual number of patients by age and gender. The total healthcare costs are calculated by multiplying the average healthcare costs specified by age, gender, and healthcare sector with the total number of stroke patients specified by age and gender. RESULTS: In the year 2000, the healthcare costs for stroke amounted to euro 1.62 billion. This amount is approximately 4.4 percent of the total national healthcare budget. Projections of the total costs of stroke based on current practice result in an increase of 28 percent (euro 2.08 billion) in the year 2020. A nationwide implementation of stroke services in 2020 would result in a substantial reduction of the costs of stroke (euro 1.81 billion: 13 percent cost reduction) compared with the regular care scenario. CONCLUSIONS: A nationwide implementation of stroke services is a strong policy tool for cost containment of health care in an aging population like that in the Netherlands. Policy makers should optimize the organization of stroke care.     

The need to prioritize research,policy, and practice to address the overdose epidemic in smaller settings in Canada

The majority of research and policy directives targeting opioid use and overdose prevention are based in larger urban settings and not easily adaptable to smaller Canadian settings (i.e., small- to mid-sized cities and rural areas). We identify a variety of research and policy gaps in smaller settings, including limited access to supervised consumption services, safer supply and novel opioid agonist therapy programs, as well as housing-based services and supports. Additionally, we identify the need for novel strategies to improve healthcare access and health outcomes in a more equitable way for people who use drugs, including virtual opioid agonist therapy clinics, episodic overdose prevention services, and housing-based harm reduction programs that are better suited for smaller settings. These programs should be coupled with rigorous evaluation, in order to understand the unique factors that shape overdose risk, opioid use, and service uptake in smaller Canadian settings.     

The impact of managed behavorial healthcare on the costs of psychiatric and chemical dependency treatment

As Congress debates the Health Security Act, a key issue centers on whether and how to include mental health and substance abuse benefits and how to contain costs if and when these benefits are paid at parity with general healthcare. Previous studies estimating the average annual cost of providing behavioral healthcare services have shown considerable divergence, depending on the nature of the defined population and the inclusion of various benefit categories, out-of-pocket expense and administrative costs. Experience from 14 members of the American Managed Behavioral Healthcare Association (AMBHA) is used to define the key features of managed behavioral healthcare, and to demonstrate that a properly managed behavioral healthcare benefit can be significantly less costly than the current reform debate would admit. AMBHA companies (which have many years of experience and presently manage the cost and quality of care for over 65 million people in the United States) [See Table 3, page 28], have shown that a specialty managed care approach can achieve not only significant savings to healthcare providers, payers and society, but also improve quality and access to care. Traditional attempts at reducing mental illness benefit coverage costs have entailed limitations on the availability or access to care. These approaches, however, ignored the larger implications to society of untreated mental illness and chemical dependency. When traditional coverages have offered more extensive benefits, they have primarily favored inpatient treatment, thus increasing costs by overemphasizing care of patients at expensive inpatient settings. AMBHA's proposed principles of healthcare reform and recommended benefit packages for behavioral healthcare can be found on page 80 of this magazine.     

Reducing smoking prevalence in Australian prisons: a review of policy options

Smoking of tobacco products is a major public health challenge in prison settings in most countries. Although tobacco use was tolerated by custodial authorities for many decades, the overwhelming evidence of the adverse public health effects of tobacco on both the smokers and those in the vicinity of exhaled or passive smoke, coupled with the risk of litigation by inmates involuntarily exposed to tobacco smoke, has recently prompted custodial authorities to implement tobacco control strategies to minimise both health and legal risks. The author examines the appropriateness of common policy initiatives put forward for reducing smoking prevalence in Australian prisons and suggests that, currently, apart from total prohibition and restriction on brands of tobacco, several policies and strategies may be utilised in combination to reduce smoking prevalence in prison settings, subject to their appraisal in terms of both effectiveness and cost-effectiveness, careful adaptation to prison conditions, and consistent implementation.     

Aging in Correctional Custody: Setting a Policy Agenda for Older Prisoner Health Care

An exponential rise in the number of older prisoners is creating new and costly challenges for the criminal justice system, state economies, and communities to which older former prisoners return. We convened a meeting of 29 national experts in correctional health care, academic medicine, nursing, and civil rights to identify knowledge gaps and to propose a policy agenda to improve the care of older prisoners. The group identified 9 priority areas to be addressed: definition of the older prisoner, correctional staff training, definition of functional impairment in prison, recognition and assessment of dementia, recognition of the special needs of older women prisoners, geriatric housing units, issues for older adults upon release, medical early release, and prison-based palliative medicine programs.Among Western nations, mass incarceration is a uniquely American experience.1 At the US prison population''s zenith in 2008, 1 in every 100 American adults was incarcerated, with an incarceration rate of 756 per 100 000 persons.2,3 This rate surpasses that of Russia, which has the next-highest rate at 629 per 100 000 persons.3 Perhaps more surprising than the sheer number of Americans who are incarcerated are the changing demographics of the prison population; the most rapidly growing prisoner age groups are middle aged (45–54 years) and older (≥ 55 years).4 Between 2000 and 2009, the overall US prison population increased 16.3%, and the number of older prisoners increased 79.0%.5,6Through the Eighth Amendment to the US Constitution (which protects against cruel and unusual punishment), prisoners have a right to timely access to an appropriate level of care for serious medical needs.7 Yet many health care and service providers in the criminal justice system are underprepared to provide cost-effective quality care for older adults. Older prisoners disproportionately account for escalating correctional health care costs and create new and costly challenges for the criminal justice system. Prison-based health care systems increasingly must provide care to older persons with multiple, costly chronic medical conditions, such as diabetes, heart failure, cognitive impairment, and end-stage liver disease.8–10 Older prisoners also have higher rates of disability than do younger prisoners, and their overall costs are approximately 3 times as high.9,11 In addition, older prisoners may generate high hidden costs. For example, prisons built to house younger persons may need to be renovated or rebuilt to accommodate an increasing number of older prisoners with disabilities.Beyond legal and moral arguments for attention to the health care needs of older prisoners, we should consider other benefits to society. More than 95% of prisoners are eventually released to the community.12 Many have chronic medical conditions and rely on expensive emergency services or are hospitalized after release.13 Earlier identification of and attention to age-related disabilities and chronic disease could foster independent function in the community through the use of community health care resources. Furthermore, prison programs that improve health and cognitive skills or that target substance abuse have been associated with decreased recidivism (and rearrest).14 Jails and prisons are also important sites for delivery of needed medical care to vulnerable populations with infectious diseases such as HIV, tuberculosis, and hepatitis C. In light of the increasing number and associated costs of older prisoners, our constitutional obligation to provide medical care to prisoners, and the potential benefits to society, it is critical that a policy agenda be set to improve older prisoner health care. This policy agenda can be advanced through the efforts of policymakers, correctional administrators, health professions organizations, and correctional health care organizations.We convened a roundtable meeting in 2011 at John Jay College of Criminal Justice in New York City to identify special considerations for the care of older prisoners and to propose a set of priority areas that need to be addressed in a new policy agenda. We also, when appropriate, identified important gaps in knowledge that should be addressed to better inform a policy agenda. This meeting was the third in a series of roundtable discussions that brought US private- and public-sector correctional health care leaders together with leaders in academic medicine, nursing, and civil rights to discuss topical issues in prison health care, where there are no existing standards. Discussion focused on the development of action items and standards through group consensus. The Jacob and Valeria Langeloth Foundation funded the public–private roundtables, with additional funding from private correctional health care vendors and in-kind contributions from John Jay College of Criminal Justice. The first15 and second16 roundtables addressed patient safety and challenges in contracting for correctional health care services, respectively.     

Cardiovascular risk assessment and management in developing countries

Causes of the burgeoning cardiovascular epidemic in developing countries (DC) are known. Whilst there are many prevention strategies and policies demonstrated to be effective in reducing the trends of cardiovascular disease in developed countries, applying them in DCs is challenging and complex. To utilize resources efficiently, two key decisions have to be made by policy makers in all DCs. The first is to decide on the appropriate mix of population and high-risk interventions. The second is to determine the threshold for implementing high-risk interventions. In making such decisions, due consideration needs to be given to scientific evidence, affordability, sustainability, opportunity costs, and social and political realities. High-risk approaches can be made cost-effective if individuals that are most likely to benefit from treatment can be identified through risk stratification systems. Although several such risk prediction systems are available, they have limited applicability to non-Western populations. Further, health systems in DCs do not have basic infrastructure facilities to support resource intensive risk prediction tools, particularly in primary healthcare. The World Health Organization has developed a flexible cardiovascular disease risk management package that is implemented in a range of less resourced settings. A risk prediction tool that enables more accurate prediction of cardiovascular risk in DCs is in development.     

Continuity of care and the control of costs: can case management assure both?

Case management is increasingly extolled as a mechanism to improve services in both health and mental health settings. However, in mental health service systems, case coordination of services is at the client level, while in health services it is applied mainly as a means to manage care and control costs. This paper discusses the background of case management, the policy and management conflict that is arising between the goals of cost control and continuity of care, and a number of steps to reduce the negative effects of these competing policies and goals.     

Reconsidering the public health failings of the criminal justice system: a reflection on the case of Scott Ortiz

Throughout most of the world, the primary response to the health and social impacts of illicit drug use has been to intensify the enforcement of drug laws. The consequences of this policy approach include an unprecedented growth in prison populations and increasing concerns regarding drug-related harms within prisons and without, including increased risk of HIV and hepatitis C (HCV) infection. This has led to calls from public health and prisoner advocacy groups to prison authorities to improve health services available in the community and those available to prisoners. While considerable progress has been made with respect to the growing implementation of HIV and HCV prevention measures within some nations' prisons, the case of Scott Ortiz illuminates a new set of challenges for prisoners and their advocates as judges often have a faulty understanding of public health arguments and data. In this case we see one such instance where a judge acts in ways not rooted in sound public health evidence or practice to produce a perverse outcome that violates both sound medical and judicial objectives.     

Health and human rights of women imprisoned in Zambia

Background

The healthcare needs and general experience of women in detention in sub-Saharan Africa are rarely studied and poorly understood.

Methods

A mixed-methods study was conducted including in-depth interviews with 38 adult female prisoners and 21 prison officers in four Zambian prisons to assess the health and human rights concerns of female detainees. Key informant interviews with 46 officials from government and non-governmental organizations and a legal and policy review were also conducted.

Results

Despite special protection under international and regional law, incarcerated women's health needs–including prenatal care, prevention of mother-to-child transmission of HIV, and nutritional support during pregnancy and breastfeeding–are not being adequately met in Zambian prisons. Women are underserved by general healthcare programs including those offering tuberculosis and HIV testing, and reported physical and sexual abuse conducted by police and prison officers that could amount to torture under international law.

Conclusions

There is an urgent need for women's healthcare services to be expanded, and for general prison health campaigns, including HIV and tuberculosis testing and treatment, to ensure the inclusion of female inmates. Abuses against women in Zambian police and prison custody, which violate their rights and compromise their health, must be halted immediately.     

Living with NHI

Our current healthcare delivery system is failing, and a number of health policy leaders have proposed some version of a national health insurance (NHI) program to reform it. Lawmakers, the nation's business community, unions, and the uninsured and underinsured are all pursuing ways to reduce the nation's healthcare expenditures. Most proposed NHI plans would be federally sponsored and state administered and funded by a combination of employer contributions and general revenues. If the government were the sole entity collecting premiums and making payments, the arrangement would reduce the nation's healthcare costs by an estimated 10 percent. NHI would eventually assign hospitals a "global budget," rather than reimburse them for specific services rendered. Although NHI as a whole will mean a loss of revenue for most hospitals, it may actually strengthen efficient and effective geographically linked healthcare systems (and thus could be an advantage to many healthcare systems). NHI would also allow hospitals to shift focus from the bottom line to patient care. Although NHI would mean less revenue for physicians, it would mean greater access to healthcare for members of communities.     

How to accomplish practice change in behavioral healthcare in less than one year

This is a challenging time in the field of public mental health. State and federal funding for public behavioral healthcare is declining in a time when the demand for services is increasing. Philosophical changes in mental healthcare service delivery, underscored by the tenets from the President's New Freedom Commission on Mental Health, are creating additional challenges for practitioners. The Adult Network of Pikes Peak Mental Health (PPMH) has developed a model for providing behavioral healthcare that meets these challenges while providing greater access to care, holistic care delivered in natural settings and, at the same time, maintaining the quality clinical outcomes at reduced costs.