Title: Using telemedicine to improve access, cost, and quality of secondary care for people in prison: feasibility study
Funder: Health Education England

Abstract: BackgroundPeople in prison tend to experience poorer health, poorer access to health care services and poorer health outcomes than general society. The period of incarceration represents a key opportunity for these patients to access relevant health care treatment, given that primary needs such as shelter and food are addressed by the prison environment. However, there are significant barriers associated with prisoners accessing hospital health services and there is an urgent need for research to identify strategies to improve the quality of healthcare for prisoners. This Fellowship concentrates on patient access to secondary care, defined as health care services and treatment provided by acute hospital sites, using telemedicine, defined as remote video consultations between prison patients and secondary healthcare staff. AimsTo determine whether Prison-hospital telemedicine is useable and acceptable, and can mitigate system blockers to secondary care for people in prison, thereby improving access, cost and quality of careTo determine the feasibility of collecting appropriate quantitative, qualitative, clinical and economic outcome data to allow further formal assessment of prison-hospital telemedicine effectiveness Investigation planThis study includes four objectives incorporating qualitative, quantitative and health economics work, which will be combined in a final report to provide feasibility evidence. OBJECTIVE1. To review existing published literature to understand how telemedicine has been used in prison settings previouslyI will undertake a systematic review of literature describing the use of telemedicine in prisons, to develop an understanding of existing or trialled telemedicine models and model effectiveness. OBJECTIVE2. To review local prison health care data to describe admission/outpatient attendance patterns, and to understand which hospital departments are most utilised/hardest to access by people in prison I will seek to describe local prison priority areas for telemedicine using a combination of: epidemiological data, whereby local prison health care records and published national data are described in terms of external attendances at secondary care sites; corporate data, whereby I will conduct semi structured interviews with 10 staff involved in facilitating/prioritising secondary care appointments to understand barriers to commencement/completion of secondary care treatment for PIP and how healthcare issues are prioritised for limited hospital transfers; comparative data, from the systematic review. Current costs of secondary care treatment from priority departments will also be recorded. Epidemiological data and current costs will be used as baseline data for the feasibility study (OBJ4).OBJECTIVE3. Develop telemedicine hospital-prison care pathways with the hospital departments identified by needs assessment, including prison healthcare staff training elementsI will engage secondary care multi-disciplinary teams identified by OBJ2 (2 departments total) in the co-design of telemedicine appropriate care pathways and associated training packages. OBJECTIVE4. To test telemedicine and associated care pathways in prisons (feasibility study) Quantitative data (prison health care records), qualitative data (12 patient, 12 healthcare key informant interviews) and economic data will be collected to assess outcomes, cost benefit and perceived acceptability of the model, to increase access to healthcare, reduce the number of off-site visits to hospital required by people in prison,improve care quality, and to expedite commencement of appropriate care. Outputs from each objective will be incorporated into a report, providing feasibility evidence for a further formal study of effectiveness of local prison-telemedicine models. Potential Benefits to Patients and NHS This Fellowship will draw together evidence of needs, barriers, and data collection feasibility, to enable further development and evaluation of prison-hospital telemedicine models. By providing evidence and tools, I hope to improve access to secondary care for people in prison, contributing to a reduction in inequalities in healthcare access. Reduced need for patient transfer to hospital appointments will also lower overall NHS costs.

Lay abstract: Background Prisoner's health, access to healthcare services and health outcomes are typically poorer than for other people. Providing funding to improve healthcare for prisoners, and developing policies to improve prisoner's health, has historically been a low priority on the political agenda. Therefore, raising the profile of prison health, and ensuring prisoners receive good healthcare services even though they are in prison, has become very important in recent years.There are many problems faced by prisoners who need hospital treatment including the stigma experienced by patients, limited transfers between prison and hospital, and last-minute cancellation of trips to hospital. These often mean that people in prison have less access to hospital services than non-prisoners. For security reasons, patients in prison never know when appointments at hospitals will take place, or if they have even been scheduled, leaving them stressed and anxious. AimI plan to develop a telemedicine hospital-prison treatment model in Surrey and test whether it can improve access and quality of hospital care for prisoners. Telemedicine means speaking to doctors and nurses over the internet using a computer and a webcam. It will mean that patients in prison can see and hear the doctor, but they do not have to leave the prison healthcare department, and doctors can remain on-site at the hospital. This could potentially improve healthcare treatment for prisoners as they will not have to wait so long to start treatment. It could also save money by reducing the numbers of cancelled appointments, and reducing the costs of transferring patients to hospitals. Methods This proposal will have four steps;1.Assessment of what good' telemedicine might look likeI will find published evidence on other prison-telemedicine models. I will combine information from these reports to identify successful and unsuccessful models, barriers and supporting factors.2.Deciding which local hospital departments are a high priority to provide telemedicine appointmentsData from prisons can show us which hospital departments prisoners use the most, and whether these appointments could be done via telemedicine. Talking to prison doctors who organise appointments can also help us understand whether some conditions that are not typically scheduled for hospital appointments, could be treated effectively over telemedicine. I will combine this information to choose hospital departments to develop telemedicine models.3.Development of standard models for telemedicine treatment in prisons, drawing on patient experience and expertiseTeams of hospital staff, patients and prison healthcare staff representatives will design the pathway patients follow for treatment in prison, using telemedicine where possible.4.Use of and evaluation of telemedicineI will test the telemedicine model in local prisons for nine months. I will collect data to understand whether more appointments happen, whether treatment starts quicker after referral, whether patients find telemedicine acceptable, and whether it represents value for money. Patient and Public InvolvementPrisoners (current and ex) and prison healthcare staff will be involved at all stages of this proposal, through one-to-one interviews, as research advisors, and through working groups.DisseminationI will combine information from all four steps into a report for wider distribution. This will show whether telemedicine use is possible, and whether it can improve prisoner's care. This will help other hospitals and prisons to setup their own telemedicine models,and allow us to perform a bigger study in the future to evaluate success.Surrey prisons include a wide range of prisoners including men and women, young offenders, life sentences, remand prisoners and those in mother and baby units. Therefore, these results will apply to a wide range of people.I will hold an end of project meeting to bring together the people who have contributed to this project, people with experience of prison, and key people who make decisions. This meeting will discuss and decide how results might be shared and used to change the way that services are delivered for people in prison. Results will be shared widely by organisations involved in prison healthcare such as Public Health England Health and Justice, NHS England Health and Justice, and the National Offender Management Service.Prison charities, e.g.Women in Prisons, will also be asked to promote the results of my research on their websites. Social media, will also be used to share the advice and overall results. Finally, results will be shared through publication of scientific papers and at national and international scientific meetings.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE