Case study: Using telemedicine to help to improve access to healthcare for prisoners in Surrey

Study title

Using telemedicine to improve access, cost, and quality of secondary care for people in prison: feasibility study.

Background

Prisoners in England access secondary care services at local hospitals. Prisoners are escorted to hospitals by prison officers, at a cost to the NHS.

The use of video consultations (telemedicine) has been proven effective at improving the access, cost and quality of secondary care for prisoners in the USA and Australia. Telemedicine refers to the use of technology, including a video link, to allow remote consultation for patients without the need for direct physical contact with local health services. However, the use of telemedicine in English prisons has been limited.

Aims

The study sought to:

understand whether using telemedicine between English prisons and hospitals is feasible and acceptable to service providers, frontline staff and patients
find out what factors drive or hinder implementation
find out whether the model can improve healthcare outcomes.

Methods

prisoner/patient focus groups, interviews and questionnaires using peer researchers from the Prison Reform Trust.
Interviews and questionnaires with prison healthcare, hospital and wider prison staff
quality improvement and service evaluation data.

Researchers

Chief investigator: Andrew Hayward
Lead researcher: Dr Chantal Edge. The study was conducted as part of Dr Edge’s NIHR Clinical Doctoral Research Fellowship (CDRF).

Study participants

One hospital and Surrey-based prisons were involved. They were chosen based on their experience of using telemedicine and their readiness to use the technology.

How the topic of the research was decided

Dr Edge said: “In 2015 I was conducting some outreach work as part of my public health training with the Royal Surrey Hospital in Guilford. I worked with a hepatologist there who was interested in improving links with prisons to improve treatments for prisoners with Hepatitis C. There is a lot of Hepatitis-C in the prison population and there were hospital targets around outreach and treatment of high priority groups for this condition. I was asked to set up a project looking at whether the use of video consultations (telemedicine) would give more access to healthcare professionals for prisoners with Hepatitis C.

“I worked with one of the local male prisons in Surrey and there I realised that prisoners experience a high burden of disease, especially mental health and sexual health conditions. There are certain conditions that could be managed outside of hospital settings.

The problem

There are huge barriers to getting prisoners to hospital appointments because they are dependent on having a prison officer available as an escort. Therefore, prisoners may wait a long time for non-urgent care. If another prisoner needs emergency care, this will likely take precedence over the scheduled outpatient appointment which leads to the appointment being rescheduled and delayed treatment.

Due to concerns that prisoners may make plans to abscond, prisoners are not allowed to know the time and date of their hospital appointment, meaning they wait for an unknown period of time which could cause anxiety.

The NHS has to reimburse the costs of the prison officers' time so it's an expensive way to deliver appointments. Also, prisoners may be reluctant to attend off-site appointments due to being in handcuffs at the local hospital.

Dr Edge said: “It became clear to me quite quickly that any appointments that could potentially happen via video were better for the prisoner and better for the prison because it didn't take their prison officers away. It didn't pose an escape risk and was better for the NHS in terms of cost and timeliness and fewer cancellations.

“The commissioning for health and justice is complex and I didn't fully understand it to begin with. There are regional commissioners that are part of centralised NHS England commissioning. Then there are regional commissioners for NHS England who commission prison healthcare providers. The hospital has to work with the Commissioners who then work with the prison to see if we could set up these video consultations.

Gaps in the knowledge

“Telemedicine has successfully been used within prisons in the USA, but so far it has not been successfully implemented in the English prison system in the small number of pilots that have taken place. There is no current evidence of why it was not successful. This is where research can help fill in the gaps.”

Study design

“The study was designed as a feasibility study because it was hard to estimate how many video appointments prisoners would have. It's hard to assess the need in prisons because the need was reflected in appointments that had already happened. Many of these appointments may have been cancelled because they couldn't happen, so we weren't sure what the true need would be.

“We wanted to know about the prisoner's experience of using telemedicine and what would discourage them from using it. As well as focus groups with staff and prisoners we wanted to see whether there were some quantitative benefits to using telemedicine and to see if prisoners were more likely to be seen if using telemedicine.

“We also wanted to see the cost-effectiveness of delivering telemedicine as costs could be saved on the prison escort. However prisons could be paying the tariff for additional telemedicine appointments, so the overall health care spending could go up, but hopefully, the cost per appointment would come down.

Barriers to research

Undertaking research in prisons is complex due to the restrictive nature of the environment and access to health care and permissions for the introduction of digital technologies must be done within the constraints and security policies of Her Majesty's Prison and Probation Service (HMPPS). The prison service is strict on technology use due to the risk that cyber enabled criminals could misuse the technology to communicate with the outside.

Another barrier was that the prison Health Commissioning System is separate to the Community Health Commissioning system and this will still be the situation when the system is devolved. It will be important for Integrated Care Systems (ICSs) to work with the prison system.

Prisoners may have waited months for a video appointment and are then told they need to see the healthcare professional in person which then causes a further delay to treatment and may disengage them from using a video consultation again.

CRN support

“I approached CRN KSS for help with recruitment. We aimed to recruit participants to complete questionnaires after their appointment and also interview clinicians.

How the COVID-19 pandemic affected the delivery of the study

“In March 2020, we reached the point when the first video appointment took place and then the study stopped due to the pandemic. Prisons were locked down and they're only just starting to regain some level of normality because they've been outbreak-prone environments.

“We needed to ask for an amendment because volunteers from the Prison Reform Trust who were going to conduct the patient interviews were unable to go into the prisons. We worked with the Prison Reform Trust because it is better for peers with lived experience of being in prison to collect data than an academic with no experience of being in prison.”

The Prison Reform Trust work to collect patient interviews happened at the end of 2021. This interview data is being reviewed. Data came from a wider subset of five other prisons.

Application of study findings so far

From March to November 2020 Dr Edge worked for NHS England's National Health and Justice team on the applications of telemedicine, helping them procure software and rolling it out across the prison estate, providing guidance and liaison with the prison service around technology.

Dr Edge said: “I had the opportunity to put into practice some of the lessons we've learned from There were some technical issues about getting appointments to the right consultants calendar on the day.”
“My pandemic work of rolling out telemedicine is almost like an autoethnography of how the barriers changed within the pandemic context. I carried out some interviews with senior health and justice commissioners and practitioners and about what they felt changed.

Chief Investigator Professor Andrew Hayward said: “The experience gained from this Surrey prison telemedicine implementation study proved critical to the rapid national implementation of telemedicine across the prison network during the COVID-19 pandemic. This has helped to allow prisoners to access health care despite pandemic restrictions and will form a valuable base for improving access to care into the future.”

Next steps

There is a lot of potential to do more research around telemedicine which would be informed by the evidence base that could come from the community, looking at what video consultations work well for, and what they do not work so well for.

Publications

eClinical Medicine
Secondary care clinicians and staff have a key role in delivering equivalence of care for prisoners: A qualitative study of prisoners’ experiences
Published: 21 June, 2020

The Lancet Digital Health
COVID-19: digital equivalence of health care in English prisons
Published: 23 July, 2020

PubMed.Gov
Improving care quality with prison telemedicine: The effects of context and multiplicity on successful implementation and use
Published: 22 October 2019