Telemedicine in prison?
This is a guest post by Chantal Edge (@ChantalEdge), Specialty Registrar in Public Health & NIHR Clinical Doctoral Research Fellow at the University of Central London. All names have been changed.
I first started working with local prison healthcare teams back in 2016 as part of my public health training. The world of health and justice was brand new to me and I was shocked when prison GPs started telling me about all the issues that had with trying to get patients out to hospital. As I came to understand these problems myself I began to realise I wasn’t the only one ‘in the dark’, and that in fact most hospitals had little understanding of the problems prisons have with getting patients out to their appointments.
Inevitably when I spoke to hospital doctors or managers I would hear about their frustration with the frequent appointment cancellations or treatment breaches for patients in prison. Junior doctors often reported feeling nervous around patients in handcuffs, presuming they were violent and sometimes even questioning whether they were entitled to the same level of healthcare as people in the community. Yet as soon as the prison GP and I started to engage with hospital staff and explain the difficulties prisons have with accessing hospital care, without fail attitudes started to change. Once hospitals understood why there were cancellations and treatment breaches they committed to working with the prison to improve service access through means such as the development of telemedicine services.
At this point we quickly realised that explaining the why to hospitals when asking them to do something different for prisons was really important. Prisoners form only a small part of a hospital’s patient population
This in turn led to a successful grant application from the Wellcome Trust to develop a short animated film, based on data collection in prisons and narrated by current prisoners, to understand what it’s like being a prisoner accessing hospital care. We collected data in five prisons in the South East and analysed this for common themes relating to hospital attendance as a prisoner. These themes were transformed into a 5 minute animation (which you can see below) aimed at hospital staff, to engage and inform them about the issues prisoners face.
The data included in this research study was collected through peer led prison models by User Voice charity. Research team members were based at UCL and Surrey Heartlands Health and Care Partnership. The research was funded by the Wellcome Trust and Surrey Heartlands Health and Care Partnership.
Animation by Tjoff Koong Studios at Passion Pictures
How do prisoners experience hospital care?
It was very clear from the data that the need to transport patients securely with an ‘escort’ i.e. prison officers, is a limiting factor for hospital based healthcare. Prison officer numbers are constrained by staffing pressures and most prisons only have capacity to escort a few prisoners to hospital every day. This means that people can wait a really long time for their turn to have an appointment and if someone sicker comes in to the prison or needs to go to hospital more urgently on the day, then they will take priority.
“Then, you get to the hospital […] an hour late […] From my perspective, I feel embarrassed and a pain to them as well, like I’m an inconvenience to them (the hospital), which it shouldn’t be. I’m here, I’ve done as much as I can. But unfortunately the circumstances we’re in and the logistics just don’t work. (Adam)
Leaving the prison walls to travel to hospital presents a security risk to HMPPS who have concerns that patients may plan to escape or collect illicit items if they know when they will be leaving the prison. For this reason patients aren’t allowed to know their appointment time and date in advance. It means people can wait for a very long time, with no knowledge of when they will be going to hospital, only to be told on the morning of their appointment with very little time to prepare.
“If they said, you’re going next week you can think the things you want to ask. Sometimes you forget, when you’re put on the spot, you don’t know what to ask. But if you were given notice, then you could think to yourself, I need to ask him, this, this and this. Note it all down, so when you go there you can say look, I want […] to ask about this, this and this” (Bobby)
At home we are free to choose a hospital, google our symptoms and plan lists of questions and take loved ones with us to appointments, none of which are options easily available to prisoners.
After they’ve been told they’re going for an appointment people are quickly whisked out of the prison and off to the hospital, for some people this might be their first time out of the prison for years. Although some people say they enjoy seeing the world outside, others say it reminds them all too much of the freedom they’ve lost. Entering the hospital tends to be a highly stigmatising experience. Being handcuffed and escorted by uniformed officers makes it clear to the public you’re a prisoner, many who stare and may even try to take photographs.
“As soon as you go out of this prison, the whole community, including doctors, public, officers, they are all one and you’re the other guy, that everybody looks down on” (Eric)
Quite often hospital staff seem unsure as to where prisoners should be asked to wait for their appointment, should they leave them to be stared at by the public in waiting areas? Or should they put them ‘out of the way’? Both of which can be equally distressing.
“In prison, you find yourself desensitised to certain things. […] You don’t make a situation out of certain things. You won’t highlight certain things because you’re used to a certain standard of care […] So, where I was put in a broom cupboard was wrong to me and my instincts. But because I understand where I am in prison and certain things don’t happen as I’d like them, I just decided I’d keep quiet” (Paul)
When the time for the consultation finally comes then the patient will most likely stay handcuffed to the prison officer who will enter the appointment room with them. The doctor may address the prison officer instead of the patient and prison officers may stay present even if intimate exams or discussions are taking place. Decisions for onward treatment can also be difficult. Many hospital staff are unaware of prescribing restrictions that exist in prisons and may prescribe something a patient cannot have, which inevitably causes upset and worry on return to the prison. All in all, if the experience is bad patients may not want to go back again.
“[…] and if it went bad, the first thing that you don’t want to do is ever go back, I don’t want to see that consultant ever again, so I’ll miss my appointment next time” (Gavin)
A brighter way forward
There are clearly many things that can be done to try and improve this experience for patients. Bringing care ‘on-site’ at the prison through delivery of in-reach clinics or telemedicine services can mitigate most of these issues, allowing patients to know their appointment date, removing the long wait associated with escorted transfers, ensure appropriate handover of clinical information and removing the need for prison officers to be privy to confidential medical information. For those patients that still have to attend hospital, staff empathy and understanding can go a long way. Hospital staff can take simple actions such as ensuring they direct questions to the patient not the prison officer, being tolerant of delays outside of patient control, prescribing appropriately and asking patients where they would feel most comfortable waiting. The task now is to get this information out to hospitals and encourage them to engage with their local prisons around improving patient experience and access to care.
You can read the full research article which covers all of these issues in more detail here.