Police perspectives on the economic considerations of providing healthcare in short-term custodial settings in Australia

Abstract

Providing appropriate healthcare to people in short-term police custody settings (i.e. watch-houses) is challenging due to the complexity of detainee health needs and the limitations of the custodial environment. However, little is known about how detainee healthcare is managed in Australia, including economic considerations. This study had two aims: (1) to understand police perspectives on the costs associated with the delivery of healthcare to watch-house detainees in Queensland, Australia and (2) to scope the applicability of the Prison Healthcare Expenditure Reporting Checklist (PHERC) tool for the Australian watch-house context. The study employed an exploratory qualitative descriptive approach. A purposive sample comprised 16 watch-house staff from six regions in Queensland, Australia, interviewed between April and November 2021. A key finding was that police viewed healthcare expenditure as a major, but largely unavoidable cost for Australian watch-houses. Participants reported that direct expenditure comprised mostly of in-house healthcare services (of which there were a variety of models), but also costs of medication and health-related consumables. Indirect costs included costs of escorting and guarding detainees requiring transfer to hospital for health assessment and treatment. Participants reported that the PHERC was not applicable to the Australian watch-house context. Future research should explore the cost-effectiveness of different watch-house healthcare delivery models and how best to measure this.

Keywords

Custody healthcare health economics forensic medical services Australia watch-house cost

Introduction

Healthcare in prisons and the prevention of morbidity and mortality in custody are prominent social issues that have been the focus of a significant amount of research and, increasingly, investment.^1–3 However, less focus has been given to healthcare provision in short-term police custody settings,⁴ known in different countries as watch-houses, jails, lockups, police cells or custody suites. Short-term custody typically varies from a few hours to a few weeks in countries including the United Kingdom, United States and Australia.^5,6 People in these facilities (detainees) include those who have been detained by police and are placed in the watch-house for public safety reasons or to await formal charge, court appearance or transfer to prison. Watch-houses also temporarily house prisoners who have been transferred from prison to attend court, before returning to prison.

The provision of healthcare in the watch-house setting is particularly challenging as detainees are often detained for brief periods of time, have complex health needs relative to the general population,^6,7 and are in a setting with multiple barriers to healthcare provision.^8–10 These factors challenge the ability to provide equitable and cost-effective healthcare. However, appropriate and timely health care also has significant potential for great social return relative to cost for this often hard-to-reach and vulnerable population.¹¹

Thoughtful policy response to providing healthcare in this difficult context requires identifying both the benefits and costs of alternative courses of action. This may include policy and intervention options that achieve equivalent health and social outcomes for this population at a lower cost, or improve outcomes at an acceptable additional cost. Although limited, evidence from single-site studies in the United States and Australia indicates the potential for cost savings associated with the implementation of new models of care.^12,13 However, from an implementation perspective, it is critical to comprehensively measure the cost-effectiveness of these models. Such measurement includes understanding who is responsible for these costs, especially where multiple agencies may be involved in the provision of healthcare, to provide decision-makers with a framework by which to compare models of care. Consequently, understanding the costs of providing healthcare to detainees is of fundamental importance in policy and decision-making.

In Australia, the economic costs of imprisonment are regularly reported, however, healthcare costs are not specified within this,¹⁴ and public data on watch-house expenditure is not available.¹⁵ The most recent estimate of the net operating expenditure on corrective services in Australia (which includes prisons and periodic detention centres, but not watch-houses) was AUD$3.88 billion in 2019–20.¹⁴ An international study estimated that healthcare makes up 9% of total prison expenditure, however also reported wide variation between countries and inconsistent expenditure reporting.¹⁶ Authors of that study developed a Prison Healthcare Expenditure Reporting Checklist (PHERC) in an attempt to provide a standardised approach to collecting healthcare expenditure data. However, as yet there is no equivalent costing tool available for watch-house healthcare. Adapting the PHERC to the watch-house setting would be useful, especially given the challenges associated with identifying costs faced by multiple organisations/services involved, and the difficulty obtaining these data from public records.

The limited information about the economic considerations of watch-house healthcare informed this exploratory study, which aimed to (i) understand police perspectives of the costs associated with the delivery of healthcare to detainees in watch-houses in Queensland, Australia, and (ii) scope the applicability of the PHERC tool to the Australian watch-house context.

Methods

Design, sample and setting

This study used a qualitative descriptive design, utilising semi-structured interviews to explore subjective information on economic considerations,¹⁷ as well as questions on how much the watch-houses expended on healthcare.

Using a pragmatic approach, a purposeful sample¹⁸ of police officers and watch-house officers (civilian officers who work within watch-houses and are temporarily conferred limited policing functions and powers¹⁹) working in six watch-houses in different regions in Queensland were invited to be interviewed. Sites included two metropolitan, three regional and one rural/remote watch-house. Inclusion criteria were: employed full-time/part-time; had worked in the watch-house during the past 12 months; had informed healthcare management decisions for at least one watch-house detainee in the past 12 months; and/or was responsible for healthcare expenditure for detainees in the watch-house.

Ethical approval was obtained from Gold Coast Hospital and Health Service (HREC/2020/QGC/63816) and Griffith University (2020/645) Human Research Ethics Committees, and approval was gained from the Queensland Police Service (QPS) Research Committee.

Data collection

Interviews took place between April and November 2021 and used a semi-structured approach based on an interview guide, of which a subset of questions related to economic considerations. Participants were also provided with the PHERC¹⁶ and asked to comment on its face validity for capturing healthcare costs for the watch-house context in Australia.

Data analysis

Data analysis was performed by a single researcher (CB) using content analysis with the conventional approach described by Hsieh and Shannon,²⁰ using QSR International's NVivo 10 qualitative analysis software. Findings were refined via a review of primary data (by JB and JC), and reflective meetings with the broader authorship team.

Results

Participants

Fourteen police officers and two watch-house officers (five female, 11 male) were interviewed. Their median age was 48 years (IQR: 43.75–50.25), their median years in the police service was 23.5 (IQR: 18.75–26.5), and their median years in the watch-house setting was four (IQR: 2.75–5.25).

Expenditure

Participants described the costs associated with the delivery of healthcare to detainees in terms of (1) general approaches to overall expenditure, (2) expenditure on watch-house nursing services (direct costs), (3) expenditure on medications and consumables (direct costs), (4) expenditure on guarding and transport (indirect costs) and (5) health-related services not paid by the watch-house.

General expenditure

Total healthcare costs were recognised by participants as a significant proportion of overall watch-house expenditure – one participant reported that direct healthcare costs accounted for just under a quarter of their total expenditure for the previous year. Participants reported healthcare expenditure by the six watch-houses ranged from AUD$8,500 to AUD$104,000 over a 12-month period. Expenditure did not seem to be linked to watch-house size (in terms of cell capacity), as the lowest expenditure was by a medium-sized watch-house, and the highest by the smallest watch-house.

Participants were generally risk-averse in their approach to healthcare in the watch-house, often erring on the side of caution, and this sentiment was reflected in their attitudes to economic considerations. In response to questions about the costs of delivering healthcare for detainees in the watch-house, participants framed this in the context of the importance of detainee healthcare irrespective of a pre-allocated budget: ‘whatever it costs is whatever it costs’ (QPS9). Due to the approach of spending what was necessary to keep detainees as safe as possible, participants indicated that they felt that most healthcare costs were unavoidable: ‘l don’t see where we could save money’ (QPS9). Despite an overall opinion that many healthcare costs were immutable, participants did feel that there were some options for improving the cost-efficiency of watch-house healthcare provision, as outlined below.

Expenditure on watch-house nursing services

Participants noted that one of the main areas of direct expenditure was in-house nursing services. The models for nursing services within the watch-house varied greatly between regions. Two used a private community nursing service, one used forensic nurses from the local public health service reportedly at no cost to the watch-house, one contracted nurses from the local public Emergency Department, one was in the process of changing from a private nursing service to an emergency nursing service, and one had ceased their private community nursing service and were scoping what their new service would comprise. Reported annual expenditure on in-house nursing services ranged from AUD$0 to AUD$104,000. For the watch-houses that engaged a private community nursing service, this was paid on an hourly, as needed basis, thus the costs were highly variable over time: ‘some months it might only be a couple of hundred [dollars]. And then the next month it might be two thousand [dollars]’ (QPS15). Despite the cost, participants rationalised that models of in-house nursing care were a more cost-effective option than hospital transfer: ‘If you cut down on certain amount of [hospital transfers], ambulance crews and [guarding] crews going up there too with that one patient by dealing with them back in house, surely that would have to go close to balancing each other out [cost-wise]’ (QPS2). QPS9 also highlighted the importance of preventative interventions as part of this in-house care: ‘we can save money in certain places like if we do the antibacterial [soap for scabies] we don’t have to go up the hospital [if the scabies worsens]’.

Expenditure on medication and consumables

Medications and consumables (e.g. dressings, medical equipment) were another main area of direct spending reported by participants. Reported annual expenditure on these aspects per watch-house ranged from AUD$3,000 to AUD$14,000. Watch-house staff spoke about efforts to reduce costs for this category, especially in medication provision. This may include efforts to use the detainees’ personal medication stock (e.g. encouraging the arresting crew to collect it from the detainee's house before coming to the watch-house), accessing existing scripts through other local services (e.g. Aboriginal and Torres Strait Islander health services) or ensuring prisons provided medications when transferring prisoners temporarily for a court appearance. ‘Where someone already had meds at home, already getting meds through this particular provider for free, well then we’ll try to hone in on that as a way of reducing the overall cost situation' (QPS10). Cooperating with prisons to ensure that they supplied medications for the length of transfer was noted to be a point of difficulty for some regions.

Some participants expressed irritation that the watch-house needed to pay full price for medications which could be very expensive, whereas if the detainee obtained them themselves in the community it would likely have been heavily subsidised by the Commonwealth Government under Australia's universal healthcare scheme, Medicare. ‘If [the detainee] paid for it and they’re on a pension that $700 box [if the watch-house purchased] will cost them $5.60’ (QPS7). Other participants also spoke about frustration with medication waste if scripts were not fully used and attempting to save costs: ‘Jails [prisons] basically don’t accept medication from anywhere including us … we’ve sometimes sent hundreds of dollars worth of brand new medications and they’ll just [gestures throw them out]’ (QPS10).

Expenditure on guarding and transport

Detainees require police guards at all times while outside the watch-house, including in the ambulance and while attending hospital. This is usually provided by general duties police officers (aka ‘on-road’ uniformed officers who respond initially to a call for police assistance), although may occasionally be provided by watch-house police officers. All participants considered guarding to be a major healthcare-related cost, and the impact on local policing resources could be quite significant in regional/remote areas, where it was frequently paid as overtime. The different regions had adopted different approaches regarding who paid for the costs of detainee guarding and transport. In some regions, transport and guarding costs were from the watch-house budget, in other regions it was from a general duties police budget, in others it was a combination of the two. Transport and guarding costs were considered a major, perhaps the largest, healthcare-related cost by participants. Exact costs were unable to be captured, as they were absorbed into overall staffing costs for the watch-house or general duties, however, participant estimates included AUD$2,400 per day, and AUD$120,000 per year for guarding costs. For remote areas, guarding costs could also include the cost of flying guard staff and the detainee to a regional hospital and back, which could be expensive.

Healthcare expenditure by other services

In addition to in-house nursing services and transport to the hospital, participants reported a range of other health-related services that were not paid for by the watch-house. A public health funded Forensic Medical Officer (aka Forensic Physician, Forensic Medical Examiner, or Police Surgeon; de Viggiani, 2013) service was available to all regions, either on-call or in person. Participants from different regions also described public health-funded indigenous, mental health court liaison and alcohol/other drugs services available in various forms but paid for by other agencies.

Reporting watch-house healthcare expenditure

Participants were also asked to comment on the applicability of the PHERC to their setting, and while discussing this, also commented more generally on their reporting needs, as outlined below.

Relevance of the prison healthcare expenditure reporting checklist to the watch-house context

Participants reported that most of the items on the PHERC were not relevant to the Australian watch-house context. A major point of difference was that many of the categories related to more long-term care, perhaps more appropriate to a prison setting, rather than the short-term focus of watch-house detention. As one participant noted: ‘this doesn’t really relate to watch-house; being a temporary hold. Like surgical procedures, dental, optical … we’re normally just trying to manage their health to the point of getting them transferred to prison’ (QPS12). Another issue identified with the PHERC was that some items were considered more suitable for other types of health systems, specifically the American health system. For example, some types of healthcare expenditure were not relevant as many of these were covered completely by the public health system and hence not paid for by the watch-house: ‘Generally if someone goes to hospital and requires surgery while they’re in our care, well it's under public spending … we [watch-house/QPS] don’t pay for it’ (QPS12). There was also the terminology used in the PHERC that needed further definition or adjustment for an Australian setting, for example around health insurance.

Most participants reported that only two of the items on the PHERC were relevant from the watch-house expenditure point of view, medical supplies and healthcare personnel, which were already captured by the current state-wide police finance system. As QPS12 said: ‘Essentially our only areas are paying for the nurse and paying for the meds that they use. We would not pay for any of these others’. Participants also noted that the checklist missed some of the important ‘hidden’ costs associated with detainee healthcare discussed earlier, especially prisoner guarding.

Requirements for a watch-house expenditure reporting tool

Participants did indicate that a tool which captured similar information to the PEHRC would be useful. Some interviewees noted that a full picture of detainee healthcare costs would require the collection of additional data from agencies outside the watch-house, like the watch-house nursing service, Forensic Medical Officer and mental health court liaison service. Participants were unclear if that information would be readily available on current systems. Participants made a distinction between expenditure information which may be useful to them in planning their own services, and that which may be more relevant to assisting multiple agencies in developing healthcare policy more broadly: ‘it may from this study point-of-view be relevant, but probably not so much to us in a day-to-day kind of thing’ (QPS3).

Discussion

This study aimed to explore police officers’ perspectives on costs associated with the delivery of healthcare to detainees in watch-houses in Queensland, Australia, and scope the applicability of the PHERC for capturing watch-house health expenditure. Findings indicated that healthcare costs in watch-house settings were considered a substantial portion of the overall budget, and were highly variable over time and between settings. Participants felt the majority of expenditure was unavoidable, due to the watch-houses adopting a generally risk-averse approach to healthcare decision making. However, we found that there was no systematic approach to quantifying these costs. In addition, we found that an evidence-based tool for estimating healthcare costs in prison settings, the PHERC, was unlikely to have utility in a watch-house setting.

Healthcare was a significant expense for watch-houses, in one case reportedly making up a quarter of overall watch-house expenditure. This outweighs the 9% expenditure estimated for prison healthcare expenditure.¹⁶ Expenditure in the six watch-houses sampled did not seem to be linked to watch-house size in terms of cell capacity. Participants indicated that they had little control over how much was spent on healthcare, as expenditure on in-house nursing services, medications/consumables and guarding costs was dependent on the health needs of detainees. This also meant that costs could vary substantially from day to day and between watch-houses, which served different populations. However, participants reported some specific areas where they were able to save costs, like medications, and also indicated that they felt that some models of care may be more cost-effective.

The cost-effectiveness of healthcare in short-term custody settings has received little attention in the literature to date. In the United Kingdom, different models of care using in-house custody nurses and/or Emergency Care Practitioners from local National Health Service Trusts have been implemented and evaluated.^6,21–23 However, beyond noting that these services come at a lower cost than the previous Forensic Medical Examiner-led model, these studies did not provide information on cost-effectiveness or even descriptive reporting of expenditure. One study did examine models of care and healthcare expenditure in 41 U.K. custody suites (similar to Australian watch-houses) and also found that models of healthcare and costs-per-patient were highly variable between regions.²⁴ However, there was no information on cost-effectiveness of these services (i.e. the detainees’ health outcomes relative to costs), which is lacking in the literature at large. It is possible that the variation in models of care internationally,²⁵ and within Queensland, may be due to lack of evidence including on their cost-effectiveness to aid decision making, but could also be due to the selection of models which best (or most pragmatically) fit the local context. In either case, the cost-effectiveness of different models of care should be a target for future research, to help inform service planning.

Our findings also shed light on the practice of cost-shifting and negotiations between agencies. As is common in public service organisations, the question of whose budget expenditure is drawn from predominates and hinders effective service planning and coordination.²⁶ Participants were highly aware of the ‘hidden’ costs of detainee healthcare for other agencies, namely general duties police, public health services and prison services. However, they felt ultimately bound to reduce costs for their own agency (the watch-house), sometimes at the expense of others. A key example of this was medication. In the Australian context, prisoners are excluded from Australia's notionally ‘universal’ health insurance scheme (Medicare), such that federal government subsidies for dispensing of (sometimes very expensive) medications are not applicable.^27,28 This legislation has also been interpreted to also apply to detainees, so watch-houses may rely on other agencies who use the subsidy to purchase medications more cheaply.

This propensity for ‘cost-shifting’ also affected other areas of health spending, as the risk-averse approach to health screening of detainees has the potential to put additional demand on public health services (e.g. ambulance callouts and Emergency Department presentations). Participants were acutely aware of these costs, and the resulting impact on policing and health services (e.g. fewer police on the road to deal with incidents), but considered it largely unavoidable within the options they had available to them. Given this, our findings underscore the critical importance of broad, interagency data on cost-effectiveness when evaluating current models of care or implementing new ones. This is important for ensuring that new models of care do not appear to be more cost-effective, whilst costs are simply being shifted to other agencies.

Our findings were clear that the PHERC was not suitable for collecting expenditure data from watch-houses in Australia, even with modification, largely due to the fact it was designed for the prison context. A different tool is required to capture total expenditure on detainee healthcare beyond direct costs to the watch-house, collecting data from multiple agencies including the watch-house, general duties police, and healthcare systems. This may involve developing a watch-house-specific tool, or adapting a tool like the Client Sociodemographic and Service Receipt Inventory,²⁹ a widely used research tool for capturing service utilisation across settings.³⁰ However, this may be a challenging undertaking, as healthcare systems would not necessarily identify whether or not a patient is a detainee, and the general duties police may not specifically capture how much staff time was spent on guarding.

Limitations

The findings of this study reflect the views and experiences of sixteen participants from six watch-house contexts in Queensland, Australia. However, the participants and sites were sampled to reflect the diversity, which supports the transferability of results to other settings. Another limitation is that this research was from the perspective of watch-house staff only, and does not include other stakeholders who would have valuable reflections on cost, such as general duties police and community healthcare providers. However, this exploratory descriptive study serves the purpose of scoping current practice, which will inform more extensive empirical research which should include other stakeholders.

Conclusion

This study provides a preliminary understanding of the economic considerations of healthcare provision in police watch-houses in the Australian context. While healthcare was reported to be a major cost, expenditure was considered both inevitable and largely immutable on a day-to-day basis. However, there was variability in models of in-house healthcare, and the cost-effectiveness of different models has yet to be explored. The collection of interagency data on costs, and a better understanding of the cost-effectiveness of different models, should be a target for future research. This information would support the best use of public funds and the provision of the best care for detainees.

Footnotes

Acknowledgments

We would like to thank the participants who generously contributed their time to this research.

Declaration of conflicting interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The views and findings presented are those of the investigators and do not represent those of the collaborating organisations.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Emergency Medicine Foundation (grant number EMLE-142R33-2020).

Data sharing statement

We are unable to share or make publicly available data used for this study due to ethical and data privacy requirements.

ORCID iD

Caitlin Brandenburg

References

Kinner

Young

. Understanding and improving the health of people who experience incarceration: an overview and synthesis. Epidemiol Rev 2018; 40: 4–11.

Watson

Stimpson

Hostick

. Prison health care: a review of the literature. Int J Nurs Stud 2004; 41: 119–128.

WHO. Health in prisons, https://www.euro.who.int/__data/assets/pdf_file/0004/463288/WHO-Health-in-Prisons-eng.pdf (2020, accessed 5 January 2023).

Wardrop

Ranse

Chaboyer

, et al. Structures, processes and outcomes of health care for people detained in short-term police custody settings: a scoping review. J Forensic Leg Med 2021; 81: 102198.

Queensland Police Service (QPS). Operational Procedures Manual: Chapter 16- Custody, https://www.police.qld.gov.au/qps-corporate-documents/operational-policies/operational-procedures-manual (2022, accessed 5 January 2023).

McKinnon

Thomas

Noga

, et al. Police custody health care: a review of health morbidity, models of care and innovations within police custody in the UK, with international comparisons. Risk Manag Healthc Policy 2016; 9: 213–226.

Rekrut-Lapa

Lapa

. Health needs of detainees in police custody in England and Wales. Literature review. J Forensic Leg Med 2014; 27: 69–75.

Van Dijk

Crofts

. Law enforcement and public health as an emerging field. Policing Soc 2017; 27: 261–275.

Crilly

Brandenburg

Kinner

, et al. Health care in police watch-houses: a challenge and an opportunity. Med J Aust 2022; 217: 287–289.

10.

Kennedy

Payne-James

, et al.

Provision of forensic healthcare services for police custodial settings in England, Wales and Northern Ireland: current practice and implications for other services?

Med Sci Law 2023; 63: 203–217.

11.

PEW Charitable Trusts. Jails: inadvertent health care providers: how county correctional facilities are playing a role in the safety net, https://www.pewtrusts.org/en/research-and-analysis/reports/2018/01/jails-inadvertent-health-care-providers (2018, accessed 5 January 2023).

12.

Crilly

Lincoln

Scuffham

, et al. Effect of a 24/7 nursing presence in a police watch house on police presentations to the emergency department. Aust Health Rev 2020; 44: 924–930.

13.

Eiting

Korn

Wilkes

, et al. Reduction in jail emergency department visits and closure after implementation of on-site urgent care. J Correct Health Care 2017; 23: 88–92.

14.

Steering Committee for the Review of Government Service Provision. Report on Government Services Volume C: Justice, https://www.pc.gov.au/ongoing/report-on-government-services/2021/justice (2021, accessed 5 January 2023).

15.

Queensland Police Service (QPS). Annual Report 2020–2021, https://www.police.qld.gov.au/sites/default/files/2021-10/QPS-annual-report-2020-21.pdf (2021, accessed 5 January 2023).

16.

Sridhar

Cornish

Fazel

. The costs of healthcare in prison and custody: systematic review of current estimates and proposed guidelines for future reporting. Front Psychiatry 2018; 9: 716.

17.

Bradshaw

Atkinson

Doody

. Employing a qualitative description approach in health care research. Glob Qual Nurs Res 2017; 4: 1–8.

18.

Cresswell

Plano Clark

. Designing and conducting mixed method research. 2nd ed. Thousand Oaks, CA: Sage, 2011.

19.

Police Powers and Responsibilities Act 2000 (QPS) s.21.1 (Austl.).

20.

Hsieh

Shannon

. Three approaches to qualitative content analysis. Qual Health Res 2005; 15: 1277–1288.

21.

Bond

Kingston

Nevill

. Operational efficiency of health care in police custody suites: comparison of nursing and medical provision. J Adv Nurs 2007; 60: 127–134.

22.

Brooker

Tocque

Mitchell

, et al. Police custody in the north of England: findings from a health needs assessment in Durham and Darlington. J Forensic Leg Med 2018; 57: 91–95.

23.

de Viggiani

. A clean bill of health? The efficacy of an NHS commissioned outsourced police custody healthcare service. J Forensic Leg Med 2013; 20: 610–617.

24.

Payne-James

Anderson

Green

, et al. Provision of forensic medical services to police custody suites in England and Wales: current practice. J Forensic Leg Med 2009; 16: 189–195.

25.

Heide

Chariot

Green

, et al. Healthcare and forensic medical aspects of police detainees, suspects and complainants in Europe. J Forensic Leg Med 2018; 57: 58–65.

26.

Richardson

. Priorities of health policy: cost shifting or population health. Aust N Z Health Policy 2005; 2: 1.

27.

Plueckhahn

Kinner

Sutherland

, et al. Are some more equal than others? Challenging the basis for prisoners’ exclusion from Medicare. Med J Aust 2015; 203: 359–361.

28.

Health Insurance Act 1973 (Cwlth) s.19.2 (Austl.).

29.

Personal Social Services Research Unit. Client Service Receipt Inventory (CSRI), https://www.pssru.ac.uk/csri/client-service-receipt-inventory/ (2023, accessed 5 January 2023).

30.

Chung

CCY

Fung

JLF

Lui

ACY

, et al. Client service receipt inventory as a standardised tool for measurement of socio-economic costs in the rare genetic disease population (CSRI-Ra). Sci Rep 2021; 11: 23837.