Linking probation clients with mainstream health services

Background

Hounslow is a borough in outer North West London, with an estimated resident population of approximately 263,799 persons (Greater London Authority, 2013) and a general practitioner (GP) registered population of 296,437 persons (at October 2013). In Hounslow, approximately 68 per cent of the population lives within the lower half of the national scale of deprivation (Hounslow Public Health Intelligence, 2012).

There were 224,823 persons on the probation caseload in England and Wales in December 2012 (Ministry of Justice 2012), in contrast with a standing prison population of 83,867 persons in April 2013 (Ministry of Justice, 2013). The system experiences a high level of churn, with people cycling between prison, community orders and suspended sentences.

In 2012, Hounslow probation supervised over 1500 offenders (London Probation Trust, 2013). Around two-thirds of people live in the community, the remainder in prison, with movement between the two settings. As of June 2013, there were 1086 offenders in the community under supervision from Hounslow probation. The majority (89%) of Hounslow probation clients are male, and 48 per cent are of non-white ethnicity. Probation clients are a ‘socially excluded group’, and are less likely to actively seek healthcare, even when distressed, often due to poor past experience or mistrust (Howerton et al., 2007). This article describes the initiatives to link probation clients with mainstream health services – GP registration, smoking cessation support, and health trainers.

Continuity of healthcare and GP registration for recently released prisoners

Improving Health, Supporting Justice (Department of Health, 2009) noted that people in the criminal justice system often experience significant problems in accessing health and social care services. A survey of 1213 probation clients demonstrated that long term illness and disability were more common amongst this group than the general population; for males aged 16−44 years, the contrast was ‘46% for probationers and 26% for the population as a whole’ (Mair and May, 1997). In July 2011, Hounslow probation noted that clients had difficulty in registering with a GP, usually because they lacked a proof of identity or address. Without registration, clients with chronic conditions often found themselves unable to renew their prescriptions.

Literature from America highlights the difficulties faced by recently released prisoners in accessing healthcare outside the prison setting. The Robert Wood Johnson Foundation (2008) noted that: ‘… after seeing a doctor in jail, they receive no case management and no medications for any chronic illnesses they may have when they leave jail.’

Although the American healthcare system is primarily private and insurance-based, and can be therefore difficult to generalize to the United Kingdom, available literature indicates congruence with Jarrett et al.’s (2006) stance that community re-entry is an opportunity to link former prisoners to health services. This is important as studies in Western Australia and the United Kingdom respectively have shown high rates of hospital admission amongst recently released prisoners compared to the general population, particularly for injury and poisoning (Hobbs et al., 2006), and higher mortality rates, particularly due to suicide (Pratt et al., 2010).

Continuity of healthcare for persons leaving prison is important. Prison Service Order (PSO) 3050 notes that ‘primary healthcare can often be a gateway to other services and so the failure to connect with a GP has wide-ranging consequences’ (HM Prison Service, 2006). For cases in which prisoners are released to another area from which they previously resided, ‘it may be possible to provide lists of primary care services for areas other than the host primary care trust’ (PCT, now Clinical Commissioning Group). The majority of homecoming Hounslow male prisoners are released from HMP Wormwood Scrubs, with the majority of women from HMP Bronzefield.

GP registration for Hounslow probation clients

Raising problems in GP registration needed careful handling, as this can be a sensitive area. For that reason, a pragmatic solution was reached, which involved approaching practices which were already used to seeing such clients rather than asking all practices to take part. In late 2011, on the advice of the NHS Hounslow Borough Director, public health approached two GP practice managers about the possibility of registering probation clients: one with a consortium of five GP practices, the other with a consortium of two practices, to cover a broad geographical area within the borough. We also had to be clear that there was no additional payment for the scheme; it was just normal patient registration.

Probation and public health created template letters, to be signed by the Assistant Chief Officer, for clients to bring with them to practices. In some cases, clients were taken to practices with their forensic mental health practitioner (from Together for Mental Wellbeing). For clients with no fixed abode (NFA; a common problem in the probation population, as approximately 11 per cent of Hounslow’s probation clients are NFA or living in transient accommodation, and therefore effectively NFA), the probation office was designated as the proxy address, with approval from North West London primary care services in the NHS. This is a concern for primary care because GPs need a safe place for patient letters to be sent to, in order to stay in touch with patients. Providing the proxy address at the probation office overcomes that issue for practices and ensures that clients have a safe place to receive their confidential mail.

The GP registration scheme started in May 2012, and is operating for newly released prisoners coming home under probation supervision (including the integrated offender management cohort), and for those seen in cells at court that may end up bailed and not known to probation. The scheme has now expanded to ten practices, enabling good geographical coverage − with clients registered from the probation office, and DIP clients registered by the drug and alcohol provider (iHear). This ensures that drug rehabilitation requirement, alcohol treatment requirement and other clients in contact with the substance misuse service are able to access primary care easily.

It is not possible to quantify how many clients were unregistered prior to the scheme, but an estimate was made that approximately 50 per cent of probation clients were unregistered. Since May 2012, approximately 20 probation clients have registered with a GP in Hounslow. For DIP clients, the scheme started later (in November 2012), and since that time approximately 30 clients have been registered (as of August 2013).

Smoking cessation

Bridgwood and Malbon’s (1994) survey of prisoners’ physical health needs demonstrated that approximately 80 per cent of prisoners smoke; over three times the prevalence in the general population (22%; Health and Social Care Information Centre, 2008), and that 10 per cent of prisoners reported respiratory conditions. Statistics from Nottinghamshire and Derbyshire indicate that 83 per cent of a sample of 183 probation clients smoked (Brooker et al, 2008); underscoring the need for targeted smoking cessation services.

From 2010 to 2011, the NHS in North West England piloted a regional stop smoking coordinator, covering 16 prisons, five probation trusts and 24 primary care trusts. These findings supported the role of such a regional coordinator ‘to employ a joined-up, strategic approach across criminal justice organisations and additional players such as primary care’ (MacAskill et al., 2012).

In-house stop smoking at Hounslow probation

In parallel with the work around GP registration, the community health provider was approached to deliver stop smoking sessions at the probation office for both officers and clients. Initially, a stop smoking advisor tried to generate referrals for clients through probation staff. This proved difficult, as probation staff had to prioritize clients’ other needs (such as housing), and the clients referred to smoking cessation were simply not engaged enough. The stop smoking advisor gained permission to use an existing weekly employment workshop led by probation − as this had the advantage of capturing several clients with motivation to change being in one place (a non-mandatory workshop), which they attended on a weekly basis. Using this forum, the stop smoking adviser carried out education sessions, and as a result, a number of clients decided to take up the six-week challenge to quit.

Since April 2012, the smoking cessation adviser has delivered weekly in-house sessions. In the following 12 months, 27 probation clients were seen, with 24 participating. Of the 24 clients that set a quit date, 10 of them were successful four-week quitters. Targeting a hard-to-reach group where smoking prevalence is higher than the average population has been a local breakthrough. As smoking is the primary reason for the gap in healthy life expectancy between rich and poor (Department of Health, 1998), this initiative is helping to reduce health inequalities locally.

Health trainer model

Literature on probation clients’ physical and mental well-being has focused on young people, with mixed results. In a systematic review of physical activity initiatives amongst young clients, Lubans et al. (2012) concluded that while the quality of existing studies was poor, ‘physical activity programmes to support social and emotional wellbeing amongst this at-risk group should be considered’.

Health trainers help people within their communities to develop healthier behaviours and lifestyles. Although recently released prisoners may not access health services, the requirement to visit probation offices on a regular basis means that there is a way to reach clients. Using a health trainer model to deliver a behaviour change and support service to probation clients not only improves access to health and well-being services, and − if peer-delivered − improves employability of the trainers themselves by gaining new skills and experience.

Health trainer models are known to have been successfully implemented in prisons nationally, including the Yorkshire and Humber area (Dart, 2010). Greater Manchester Probation developed a model in which 22 per cent of the probation caseload of 633 persons were seen by a peer health trainer during a 12-month period. Evaluation demonstrated positive results, including a decline in mean alcohol consumption, reductions in smoking, weight loss/gain, healthier eating, increased confidence, GP registration, and gym membership (Dooris et al., 2013).

Health trainers in Hounslow

In July 2012, a health trainer model was proposed for Hounslow probation clients. Following changes to the commissioning of the local health trainer service, the first probation officer was trained as a Level 2 health trainer in March 2013, and is now a ‘health ambassador’ in the probation service. The health trainer works with clients to identify health needs and to set and achieve health and well-being goals, and refers them to relevant community support services (e.g. weight loss, physical activity programmes, discounted gym membership, substance misuse). In addition to the trained ‘health ambassador’ probation officer, a Level 3 health trainer from the community health service is now attending the weekly employment workshop with the stop smoking adviser, to raise awareness and to provide further support.

Two Healthy Lifestyles Roadshows were delivered at the probation office in late 2013. Clients and officers received a general health check-up (e.g. blood pressure, weight, cholesterol) and were signposted to relevant healthy lifestyles initiatives. The community health service also clarified the referral pathways into the health trainer service. As healthy lifestyle roadshows are resource intensive, in future there will be quarterly health check sessions at the probation office instead. This will involve clients who are newly registered with a GP being invited to receive a general health check-up, and clients aged 40 to 74 years being invited to have an NHS health check, with information shared with their GPs. Plans also include probation clients being supported to gain a health trainer qualification – a skill they can use to drive health improvement in their peers, involve themselves in the health champions network, and improve their own employment chances. We see this as a valuable start to linking probation clients with mainstream services. These initiatives will be of relevance to many agencies’ agendas in health, social care, housing, and criminal justice. Directors of Public Health are now located in councils, and have a responsibility to reduce health inequalities in the population, so initiatives like this will improve access to healthcare and also meet targets for criminal justice and community safety.