1. Prison Health: The Scottish Experience 3 rd Feb 2015 Wrexham Dr Lesley Graham Public Health Lead for Alcohol, Drugs and Health & Justice Information Services Division NHS National Services Scotland

2. Prison Population in Scotland 15 prisons in Scotland, 2 privately run under contract to the Scottish Prison Service In 2014, imprisonment rate of 139/100,000 (E&W 149/100,000) Rise in prisoner numbers from turn of century until fall over last 2 years

3. Prison population in Scotland 1997/8-2013/14

4. Background and Policy Context: Criminal Justice Criminal Justice and Licensing Act (Scotland) 2010 -Presumption against sentences <3 months -More efficient community sentencing Commission on Women Offenders 2012 Whole systems approach for young offenders 2011 Reducing reoffending programme including funding for mentoring services on release 2012 Scottish Prison Service re-organisation (Unlocking Potential, Transforming Lives) 2014 Increasing recognition of health and healthcare in justice policy e.g. Justice Strategy 2012

5. Background and Policy Context: Health ‘it makes sense for NHSScotland to review its approach to the health and healthcare of offenders and ex-offenders to consider what more can be done in prisons and custody settings to ensure continuity of care between prison and the community’ Better Health, Better Care Action Plan 2007 ‘Offenders and ex-offenders should have access to the health and other public services they need and benefit from the same quality of service as the rest of the population’ Equally Well Scottish Government 2008 Range of health policies e.g. Drug, alcohol, mental health, BBV strategies Public sector reform (e.g. Christie Commission, Health and Social Care Integration)

6. Principles for prisoner health Transfer of prisoner health to NHS in Nov 2011 underpinned by: Prison health should be equivalent to that delivered in the community Prison health is part of public health Prison health is an opportunity for health improvement Opportunity to tackle health inequalities Potential to reduce (re) offending

7. Health of Prisoners in Scotland: building the evidence base Needs assessments (general/thematic) Prisoner surveys Audit Inclusion in national reporting Research Other

8. Prison Health in Scotland 2007 Methods I Epidemiological -SPS healthcare disease register -prisoner self report survey -prisoner record health care markers -developed prescribing indicators Corporate -discussions with key staff pre and post info gathering Comparative -between prisons -with other prisoner populations -general population Triangulation -data sources

9. Prison Health in Scotland 2007 Methods II Description of prison estate and population Prevalence of problems Service provision (including staff) Delivery against standards Gap analysis But Not costed No wider health improvement scope No user consultation

10. Worked prevalence example: Epilepsy SPS disease register (observed): 2.1% General population: 0.5% Standardised rate (expected): 1.2% Sodium valproate: 26,245 DDD/1,000 (SPS) c.f. 903/1,000 (Scotland) No equivalent data in English prison population => prevalence of epilepsy in prison population at least double that in general population

11. Key findings Higher prevalence of alcohol, drug and mental health problems Poor dental health Higher prevalence of some Long Term Conditions Likely under detection and recording Throughcare needing enhanced Limited user involvement

12. Health of prisoners in Scotland: other evidence 73% prisoners had an AUD with 36% likely dependent 77% tested positive for illegal drugs on reception, 33% of which were opiates 4.5% have a severe or enduring mental health problem 74% smoke 19% positive for Hepatitis C Severe dental decay three times that of the general population (29% c.f.10%)

13. Relative risk of mortality for adults imprisoned in Scotland for the first time 1996-2007, by cause and deprivation Underlying cause of deathObserved deathsExpected deathsAdjusted rate ratio (95% CI) Males (n=68,315) All deaths (not deprivation adjusted)39821222.63.3 (3.2, 3.4) All deaths39821734.92.3 (2.2, 2.4) Suicide and Undetermined Intent783224.63.5 (3.2, 3.7) Homicide22551.24.4 (3.8, 5.0) All Drug Related1112252.44.4 (4.2, 4.7) All Alcohol Related559193.62.9 (2.7, 3.1) Females (n=8,312) All deaths (not deprivation adjusted)43257.87.5 (6.8, 8.2) All deaths43277.25.6 (5.1, 6.1) Suicide and Undetermined Intent877.611.4 (9.1, 14.1) Homicide170.822.2 (12.9, 35.7) All Drug Related1638.619.0 (16.2, 22.1) All Alcohol Related727.89.3 (7.2, 11.7) Graham et al EJPH in press

14. Relative risk of mortality of adults imprisoned in Scotland for the first time between 2003- 2007 (n=25,797) Males (n= 23 594)Females (n=3 203) Observed deaths Expected deaths Adjusted rate ratio (95% CI) Observed deaths Expected deaths Adjusted rate ratio (95% CI) In prison 1119.290.6 (0.3, 1.0)20.613.3 (0.3, 12.0) Out of prison 47176.356.2 (5.6, 6.8)614.4813.6 (10.4, 17.5) Graham et al EJPH in press

15. The prison setting: opportunities Population with a high prevalence of ill health Easier to reach the ‘hard to reach’ Positive effect on others (many young offenders have family members who have served a custodial sentence and are also parents themselves) Potential to reduce re-offending Potential to reduce health inequalities

16. The prison setting: challenges Security and order constraints Overcrowding and ‘churn’ Co-morbidities Needs of differing groups Absence (or limited supply) of alcohol but presence of drugs Unwillingness to admit problems Risk of relapse on release Continuity of care

17. Effective Interventions Suicide prevention Hepatitis B vaccination Hepatitis C detection and treatment Cervical Screening OST Take home naloxone

18. Suicides in Scottish Prisons 2001-2012

19. Effective Interventions Suicide prevention Hepatitis B vaccination Hepatitis C detection and treatment Cervical Screening OST Take home naloxone

20. Effective Interventions Suicide: prevention Hepatitis B: vaccination Hepatitis C: detection and treatment Cervical Screening OST Take home naloxone

21. Effective Interventions Suicide: prevention Hepatitis B: vaccination Hepatitis C: detection and treatment Cervical Screening OST Take home naloxone

22. Effective Interventions Suicide: prevention Hepatitis B: vaccination Hepatitis C: detection and treatment Cervical Screening OST Take home naloxone

23. Effective Interventions Suicide: prevention Hepatitis B: vaccination Hepatitis C: detection and treatment Cervical Screening OST Take home naloxone

24. Lessons Learnt Risk of lack of NHS leadership/prioritisation/co- ordination Need for strong and sustained policy support in both health and justice Slow progress in some areas e.g. mental health Effective throughcare/community reintegration crucial Partnership working essential

25. Next Steps Continue to add to the evidence base Foster strong and effective national networks Continuing focus on throughcare/reintegration/diversion Integration of care/service delivery/commissioning Key role for public health: -leadership -advocacy -intelligence

26. Prison health, swimming upstream….

27. Contact Dr Lesley Graham lesley.graham@nhs.net