A mixed picture
Donna Gipson, Dr Lucy Wainwright and the wider team from EP: IC Consultants explored issues around the physical health of people in prison during the COVID-19 pandemic, entirely from the point of view of patients. EP: IC used a variety of sources including direct responses from people in 19 different prisons which amounted to over 2,000 contributions. This allowed them to establish a broad and rich view of the challenges facing people in prison during the pandemic.
There was a mixed picture in terms of how individual establishments have adapted healthcare services to meet the needs of their population since prisons locked down in March 2020. There is no doubt this was a challenging time, and patients recognised this. Even within individual settings, healthcare provision has been changeable during the pandemic due to outbreaks, track and trace, and healthcare and officer staffing levels which impact on the ability to deliver already scaled back services. There was a clear sense from patients at the start of the pandemic that ‘we’re all in this together’ but this waned as time went on. Patients mostly felt healthcare were working hard, particularly nurses, but the restricted regime meant there was limited opportunity to meet the healthcare needs of communities. The main report summarises the key themes.
Despite changes to services, in a few prisons, individuals feel their overall needs are being met as much as they can be. Even where services are suspended and patients spoke about unmet needs, people felt cared for if communication was good, relationships between healthcare and patients were strong, medication was reliable and nurses were visible. These things alone go a long way towards positively impacting on a patient’s view of healthcare.
However, where communication is poorer, relationships are less positive and medication routines are changeable, EP: IC heard a contrasting view, resulting in patients feeling forgotten. In these cases, patients state their needs are not even assessed, let alone met. For example, in one prison over three quarters of patients felt healthcare services were unattainable, requests for appointments to see a GP (often viewed as the gateway to wider services) were unanswered, routine health checks were hit and miss, and medications were administered late, missing or incomplete, leaving patients worried for their health.
However, most prisons and patients sat somewhere in the middle, with around 60% of overall patients feeling their needs had been met, despite lockdown.
Those with existing and often complicated health conditions tend to report receiving poorer levels of care and achieving poorer health outcomes. Understandably, those with less need for healthcare appear to view them more favourably.
Despite this variability, there are some consistent themes:
- A significant proportion (around half) of patients feel their physical health has declined since the start of the pandemic.
- Younger prisoners (aged under 30) linked their poorer physical health with a lack of physical activity – rather than a specific healthcare need.
- Women and people from Black, Asian and Minority Ethnic communities were more likely to feel their physical health had declined.
Some of the key themes explored in the report include:
Confinement to their cells for the vast majority of every day played a monumental role in people’s views on their physical health.
“I’ve been confined to a cell for 23 hours 45 minutes [per day] for the past four months; of course it’s been affected! I’ve put bad weight on, and my muscles are not as strong as before. Can only imagine what my insides are like.”
Weight & fitness
Weight and fitness was a big concern in every prison. Some people lost weight and others gained weight during this time, and this appeared to be both celebratory and worrying for different reasons. Mostly, people reported weight gain and this was compounded by a poor diet, the distribution of unhealthy snacks, comfort eating and lack of exercise. In-cell packs with guidance for physical health were often well received, with some taking up exercise for the first time because they felt safe exercising alone in their cell without the scrutiny of others. However, some found working out difficult when sharing cell. The enthusiasm of some decreased over time as the workouts became repetitive, lacked challenge and simply because it had been so long.
Sleep disruption was common with people reporting the lack of regime adversely affected normal sleep routines and this was physically difficult to manage.
“My night-time meds are given to me at 3pm and I must take them at this time. They both have a sleeping effect. This is not what time they’re meant for and this has a negative impact.”
Access to healthcare
Access to healthcare was problematic for many people with the application “app” process proving ineffective in many establishments. Issues raised included: difficulty in explaining health concerns in writing, concern over confidentiality with access to healthcare sometimes mediated by officers and increased difficulty in accessing healthcare for those in “red zone” quarantine areas.
The importance of nurses
In all but one prison, nurses were seen to be the most accessible healthcare service. Visibility was key. For patients universally, nurses have become the ‘face’ of healthcare during the pandemic. Nurses were praised in all prisons for their availability, consistency, reliability and compassion. Patients said the increased visibility of nurses on wings led to opportunities for stronger relationships to form and consequently healthcare having a better and more immediate understanding of patients’ needs.
GP remote access
Remote appointments were, by far, considered the least effective way of treating patients during the pandemic; and as particularly problematic for those with low literacy levels or learning disabilities, or where English was not the first language.
In-cell telephone appointments, though an improvement on remote assessments, also created some anxiety. Where people shared cells, some patients found that the need to explain health conditions in front of others left them feeling embarrassed or vulnerable. Some patients felt this breached confidentiality. In a few cases, individuals chose to disengage with healthcare, resulting in unknown and unmet needs.
Health promotion & communication
Where health promotion materials were available patients welcomed these, although some were looking for more clear, consistent or appropriate messaging about COVID-19. This messaging was not always visible to patients if it was placed in healthcare, for example, which was barely visited, or placed on wing noticeboards which were rarely seen. Frequently, easy read material was said to be not available, health promotion in languages other than English was limited and verbal discussion was scarce due to isolation and social distancing measures.
Communication was important for people in prison. Some individuals were advised by healthcare they were ‘at risk’ but were offered no explanation for why this was.
“I’ve been asked to shield, but have no idea why.”
Some patients, particularly young adults or those from Black, Asian and Minority Ethnic groups, reported confusion as to whether they faced additional risks from COVID-19 and how they should manage any such risks in the prison setting.
“The news says I’m more at risk, but no one is talking about it here.”
It was evident that healthcare have been stretched to a point where some patients were not being seen or spoken to, which creates dissatisfaction and frustration in some, despite knowing the pressure on services.
“The nurses are amazing. They really care. I just wish there was more of them; they have no time.”
As most readers will know, people in prison suffered from a range of health inequalities before adding in the complications of the pandemic. COVID-19 has been anxiety provoking for all of us, therefore it is no surprise COVID-19 and prison, combined, create a harmful duo. A significant proportion of people in prison reported deterioration in their physical health; including those with no previous physical health conditions, but particularly among those with pre-existing health conditions. Younger individuals, those from Black, Asian and minority groups, and women appear to be disproportionately affected in a myriad of ways.
Limited access to healthcare due to scaled back or suspended services has compounded the issues. However, where services were visible and ‘within reach’ of patients, more positive views were reported alongside more positive health outcomes.
If you would like to read the full report click here and navigate to the bottom of the page.
Thanks to Andy Aitchison for kind permission to use the images in this post. You can see Andy’s work here.