Title: Understanding and improving the quality of primary care for prisoners: a mixed-methods study
Funder: Department of Health and Social Care

Abstract: Prisoners often have poor health with higher levels of long term illness, disability and death especially compared with the health of people who are not in prison. There are lots of reasons why this might be the case and these inequalities in health can play an important part in the risk of prisoners reoffending in the future. Researchers know little about the healthcare that people receive when they are in prison and in particular the quality of this healthcare (how good it is)._x000D_ _x000D_ We are a group of experienced researchers from a range of backgrounds including prison health care, general practice, statistics and health research, which places us in a unique position to undertake this research. We also include a panel of men and women who have been prisoners who will provide their unique perspective on prison healthcare._x000D_ _x000D_ We have planned a large research study with five parts with the aim to improve the quality of healthcare that prisoners receive._x000D_ _x000D_ In the first part, we will talk to a panel of recent male and female ex-prisoners, prison based healthcare professionals (like GPs, nurses, pharmacists, physios and dentists), prison officers and managers. The panel will meet to talk about the health conditions which most affect prisoners and how they might be able to measure the quality of healthcare services for these conditions._x000D_ _x000D_ In the second part, we will talk to two groups: healthcare professionals and ex-prisoners. This will be done using interviews. We will ask the healthcare professionals what they think about the quality of healthcare (both good and bad aspects) and then ask them how it could be improved. We will ask both male and female ex-prisoners about their experience of healthcare in the prisons they have served time in and, again, how healthcare could be improved._x000D_ _x000D_ In the third part, we will measure the quality of healthcare services and we will try to understand whether healthcare is better for some prisoners over others and also some health conditions over others. We will do this by looking at patterns in the data across a large number of prisoners’ medical records. The medical records will be made anonymous so that we cannot ever find out who the prisoners are._x000D_ _x000D_ In the fourth part, we will take what we have learnt from the first three parts (above) and work together with healthcare professionals, ex-prisoners, prison officers and managers to work out ways to improve the quality of healthcare._x000D_ _x000D_ In the fifth part, we will go back to the interviews with healthcare professionals and ex-prisoners and look specifically at what people said about mental healthcare in prison to find out what they thought about the quality of it. We will also go back to the patterns of data based on a large number of medical records that we already collected for the third part. Here, we want to understand what the quality of physical care is like for people who have a mental health diagnosis and/or those people who take medication to make their mental health better. _x000D_ _x000D_ From this research we will find measures of quality; understand what is good and bad about current prison healthcare and how to make things better; both from talking to prisoners and those working in prisons and analysing prisoners’ medical records. This work will lead to a set of practical approaches to help improve the quality of care for prisoners.

Lay abstract: Compared to community populations, prisoners have significantly poorer health, with higher levels of long-term illness and disability, and mortality. Prisoners need and are entitled to appropriate health care. However, relatively little is known about their current quality of primary care. Our mixed-methods study will explore gaps and variations in the quality of primary care for prisoners and identify quality improvement interventions to promote high quality prison care._x000D_ _x000D_ Research objectives:_x000D_ 1. Identify candidate quality indicators based on current national guidance which can be assessed using routinely collected data through a stakeholder panel._x000D_ 2. Explore perceptions of quality of care, including barriers to and enablers of recommended care and quality indicators, through qualitative interviews involving ex-prisoners and prison health care providers._x000D_ 3. Assess the current quality of primary care provided to prisoners through a quantitative analysis of anonymised and routinely held prison healthcare records._x000D_ 4. Integrate the above findings within a stakeholder consensus process to prioritise and enhance quality improvement interventions which can be monitored by our set of quality indicators._x000D_ 5. To report on outcomes for prisoners with mental health problems by exploring perceptions of the quality of mental health care via a secondary thematic analysis of WP2 data and by conducting a secondary statistical analyses of WP3 data. _x000D_ _x000D_ Methods:_x000D_ The study comprises five inter-linking work packages (WP)._x000D_ In WP1, we will conduct a scoping review to identify recent research on quality of primary healthcare in prisons. Then, we will undertake a stakeholder consensus panel of 11 participants to select key quality indicators for the prison population. The Panel will select quality indicators based upon criteria including the feasibility of assessment using routinely collected data._x000D_ _x000D_ In WP2, we will use qualitative interviews to explore attitudes, perceptions and experiences about prison healthcare by talking to 15 ex-prisoners and 15 prison healthcare staff. Perceived barriers and enablers to optimising care delivery will be explored alongside the wider contextual factors that influence primary care delivery. All participants in WP2 will be interviewed in the community rather than in the prison estate._x000D_ _x000D_ In WP3, we will statistically analyse routinely collected data held in prison healthcare records for which Spectrum CIC is the healthcare provider. Analysis will be based on the quality indicators identified in WP1. We will explore variations in the quality of care according to prisons, particular prisoner groups and health conditions._x000D_ _x000D_ In WP4, we will integrate the findings from work packages one, two and three within another stakeholder consensus process. The purpose is to prioritise and enhance existing quality improvement interventions, or develop new interventions to improve quality, which can be monitored by our set of quality indicators._x000D_ _x000D_ In WP5, we will conduct secondary analyses on data already collected and extracted in WP2 and WP3 respectively in order to report on outcomes for prisoners with mental health problems. This will involve a thematic analysis to explore prisoners and healthcare staff perceptions of the quality of mental healthcare. We will conduct a statistical analysis to assess the quality of physical healthcare provided to people in three mental health subgroups. _x000D_ _x000D_ Outputs:_x000D_ Having identified appropriate quality indicators (WP1), gained insights into barriers to and enablers of change (WP2), and analysed inappropriate variations in practice within prison (WP3), we will identify a package of quality indicators and a suite of improvement interventions that can be sustainably embedded within available systems and resources (WP4). We anticipate that our recommended interventions will target individual, team, organisational and wider system levels. Findings will be directly communicated with relevant commissioners and providers alongside publication in the peer reviewed literature. We expect the focused mental health analyses (WP5) to be published and be of interest to key stakeholders.

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