Case Study

THIS PROJECT WAS THE WINNER OF THE PENNA2019 INTEGRATION & CONTINUITY OF CARE CATEGORY AND THE USING INSIGHT FOR IMPROVEMENT (ACCESS) SUBCATEGORY

Hospital staff are often unaware of issues faced by prisoners in accessing secondary care. Once explained they typically consider changes to their practice and services to make them more inclusive. Educating staff and clinicians about the issues faced by prisoners is difficult because of work pressures and negative preconceptions.

In creating a tool to help others understand these issues, we conducted qualitative research with male and female prisoners in five prisons in the South-East including one that holds only adult male foreign nationals. The research sought to understand offender experiences of accessing secondary care while incarcerated and a thematic analysis of the data was undertaken to understand common themes and issues.

In partnership with an animation company, themes were turned into a five-minute animation exploring issues uncovered by the research and more effectively transferring this knowledge to secondary care staff and clinicians. The film is being used to support the transfer of this knowledge to trusts and a full evaluation is taking place in February and March 2020. The audio used in the animation is the real voices of prisoners collected as part of the research.

Link to Video – https://vimeo.com/460089474

NHS England recognises prisoners have poorer health and poorer access to health care services than the wider population. They experience a disproportionately higher burden of illness, poorer access to treatment and prevention programmes, and problems with substance misuse. Health concerns are often complicated by social issues, such as homelessness, unemployment and poor levels of education and there is a growing cohort of older prisoners with increasing health and social care needs.

The reasons behind this inequity are multifaceted. The closed prison environment restricts access to secondary care services and transfers to hospital are limited due to the lack of prison officers to escort patients. Additionally, prisoners often report they feel discriminated against by staff and patients when attending hospital which leads to self-exclusion from health services while imprisoned.

Hospitals that are informed about these issues can make immediate and simple changes to address inequalities. This research project aimed to influence community health professionals to design improved services by using an animation based on prisoner experiences of secondary care as the main knowledge dissemination mechanism.

We developed this arts-based approach to clinical engagement through collaboration with ex-prisoners, a prison charity, prison clinicians, and an animation company. This research received full ethical approvals from both NHS REC and HMPPS NRC and therefore followed very rigorous and repeatable qualitative research methodology.

At project outset we sought to understand misperceptions held by hospital staff in regards to patients from prison and informally interviewed a range of staff and clinicians in order to ascertain the antecedents for project success. We then collected focus group (n=5) and interview data (n=17) from prisoners across five prisons about their hospital health-care experiences, using the data collected from hospital staff to guide these conversations. We systematically analysed this data with input from the collaborative group and the rapid two-stage thematic analysis identified key themes to be included in the animation narrative.

Once we had the findings, we re-interviewed prisoners using the themes to guide conversation and collected broadcast quality audio about their experiences to narrate the film. Seven hours of high-quality audio was recorded for this purpose. The animation team led on the development of a five-minute soundtrack using this audio in line with qualitative themes and feedback from the collaborative group. Once finalised, an animation was developed to mirror the content in the audio.

The animation is being used to help secondary care clinicians and staff better understand the experience of prisoners so they can make simple adaptations to their day to day working practices to provide a service that better meets the needs of prisoners and reduces inequality in the provision of healthcare services in this setting. The project has provided a robust evidence base highlighting five major challenges identified to ‘equivalence of care’ for prisoners visiting hospitals including:

(1) Security overriding healthcare need or experience;

(2) Security creating public humiliation and fear;

(3) Difficulties relating to the prison officer’s role in medical consultations;

(4) Delayed access due to prison regime and transport requirements;

(5) Inability of patients to manage their own healthcare.

The animation helps secondary care staff and clinicians understand these issues. Prisoners describe in their own words some of the simple changes that can be made to help address these challenges. When the animation has been screened, staff have reported that the film dispels many misconceptions held about prisoners as patients and provides useful, actionable changes staff can make to their day to day practices. They have also reported a deeper awareness of the challenges experienced by prisoners in accessing secondary care as well as acquiring useful contextual information on the experiences of prisoners on the day of their appointment.

We will shortly deliver a large-scale evaluation in acute trust settings (n=3) and with medical students at UCL. This evaluation is currently undergoing HRA ethical approval through IRAS and will provide rigorous data to help understand:

• Whether this animated film can transform hospital clinicians’ and medical student’s knowledge and attitudes towards offenders
• How this film may influence hospital staff behaviour
• What aspects of the animation affect its ability to achieve these impacts

The animation is also being used to support the role out and engagement of local trusts in the development of telemedicine services. In Surrey we are developing a telemedicine service between prisons and hospitals. The animation will be used as a call to action for hospital staff, to encourage them to design telemedicine pathways for prisons. The animation is a really important tool in this process, if hospital staff don’t understand the problems faced by prisoners in accessing care, then they may be reluctant to design new services. Telemedicine in prison is important because it can significantly streamline health care for prisoners. Physicians who previously dealt with long travel times and extensive security in order to see patients onsite at the prison, can see their patients from the comfort of their office. Also, prisoners who would typically travel offsite for care only need to leave the prison for appointments that require in-person care from a specialist, like surgery. It enables them to receive specialist care much more quickly, and specialists are able to see a significantly higher number of patients.

We have also managed to secure a commitment from the Heads of HMPPS H&WB, RCGP SEG, NHSE H&J and PHE H&J to disseminate widely across the prison estate and associated trusts and have been approached by East Sussex to provide a seminar for junior doctors on prison patients where the animation will form the basis for a lecture on prisoners and secondary care. Our Senior Responsible Officer, Claire Fuller, will be supporting Royal Colleges to disseminate the film to their members.

Working with Royal Colleges, National Bodies and Medical Schools we aim to ensure this animation is embedded as a standard resource for training/induction of medical staff and students, surrounding the care of prisoners. To date, no resource exists that explains the challenges of providing hospital care at community-based hospital sites to patients from closed prison environments.

Many groups experience inequity in the healthcare they receive which can be related to their age, language, literacy, a physical or mental condition et al. During the evaluation and adoption of this animation we will also assess whether there is an appetite for further tools like this and if so, plan similar research projects focusing on the homeless, vulnerable migrants and those with profound learning disabilities. These projects will take any learnings and build upon the successes of this initial project.

This animation is highly relevant to prison officers escorting patients to hospital. Through connections at HMPPS Central team, this animation will be distributed to prisons in England. The animation is also relevant to those in training to provide hospital care. Colleagues at UCL Medical School are trialling the animation as a way to inform students of issues surrounding treatment for prisoners. Through Surrey Heartlands connections, we will approach other medical training bodies if this approach is successful.

We are also collaborating with The Slade Art School at UCL to design an interactive arts-based installation to screen the animation to public audiences (to be displayed in UCL campus and at hospital sites).

Given the secure and restricted nature of the prison environment it is difficult to undertake research with prisoners. We have successfully engaged with diverse voices from a traditionally underserved and marginalised population. In addition, ex-prisoners provided advice throughout and input on the analysis and animation. Prison engagement tends also to focus on healthcare services delivered within the prison. Very little research is undertaken at the interface of community and prison healthcare services, and has exposed significant issues that must be bought to the attention of all acute trusts serving prisons.

The use of animation to convey these issues is novel, as was the methodology designed to robustly report qualitative findings using animation as the medium rather than a written report. Finally, current prisoners were able to narrate the final audio in their own unscripted words, while ensuring that what they said was still closely related to the findings of the research. This lent their voice of experience to the findings.

• When engaging with a vulnerable population on a sensitive topic, more frank and honest data is likely to be gathered by using peer researchers
• Animators should be involved in all stages of the research so they are fully grounded in the data. Our animators visited prisons with us and spoke to current prisoners
• Pre-engage with the target audience to understand what knowledge gaps needs to be filled with the final tool so as to understand what a successful project will look like

Watch the Presentation Here!