Improving genitourinary medicine services in prison

Prisoners have a fundamental human right to expect their health needs to be met by services that are broadly equivalent to services available to the community at large. Current genitourinary (GU) medicine service provision in prisons is, however, patchy and inconsistent in the range of clinical services offered, staff skill mix and training as well as the frequency of clinics. Addressing these challenges as well as achieving 48-hour access targets will require a better understanding of what constitute the core components of sexual health service in prisons to develop new models of delivery and commissioning that will aid in the creation of a national minimum standard.

There are sound reasons why prisoners should be offered GU medicine services to a comparable level as the rest of the community. Prisoners are generally drawn from marginalized communities that have poor access to primary health care and are at a high risk of blood-borne virus (BBV) and sexually transmitted infections (STI). A multicentre European survey reported that 27% of inmates had ever injected drugs and of these, nearly half (49%) reported they had injected while in prison. ¹ As a consequence, the prevalence of BBV, such as hepatitis C virus (HCV) infection, especially among incarcerated injected drug users, is high. A seroprevalence survey in eight of 135 prisons in England and Wales detected anti-HCV antibodies in 7% (293/3930) overall, and 31% (240/775) among IDUs. ² Rates of some STIs are also high: Chlamydia screening by urine nucleic acid amplification test testing among an intake of young male offenders in West London was reported as 13%, comparable with the estimates from national UK screening programmes for young women. ³ High rates of some STIs in prison may partly be explained by behavioural differences from the norm. In a study of 1009 adult male prison inmates across England and Wales, subjects reported engaging in more sexual (casual) relationships, sex with IDUs and commercial sex workers and using condoms infrequently, compared with the general population. ⁴

Understanding the true scale of sexual health needs is hampered by difficulties in estimating the prevalence of STIs in prison. Quarterly KC60 returns for England and Wales yield anonymized aggregated data that do not specifically identify prisoners from other client groups. This applies equally to the bi-annual UK survey of prevalent HIV infections diagnosed (SOPHID), where prisoners or prisons are not specifically identified.

Delivery of GU medicine services in prison are also affected by a number of operational factors, such as prisoner transfers, social and legal visits and court attendances clashing with outpatient appointments. There can be misunderstandings about the services on offer and prisoners are sometimes inappropriately referred, thinking that the ‘GUM clinic’ is the dentist. ⁵ In addition, in-reach clinical services are conducted in holding areas with limited capacity, or use consultation or examination rooms that are not purpose-designed.

Service delivery should also be considered against the backdrop of an increasing and changing prison population. By September 2007, the population of prisoners in England and Wales reached a record of 81,135. The prison population has grown by 12% per annum since 1993, when it was approximately 28,000. ⁶ Some of the increase can be accounted by successive Home Secretaries introducing tougher legislation that has changed sentencing behaviour. Courts are now allowed to take into account previous convictions when determining sentences, making repeat offenders more likely to face longer sentences. Another significant factor has been the introduction of shorter sentences rather than electronic tagging or community orders, principally for anti-social crimes such as burglary and theft. ⁷ This has had a dramatic impact on changing the demographic of the prison population, with the largest increase in numbers seen among young (largely male) offenders aged between 15 and 20 involved in drugs-related crime. Rapid turnover of these prisoners and frequent transfers between prisons (because of over-crowding) can make medical management of chronic conditions such as HIV and hepatitis C particularly challenging.

There has also been an increase in the number of foreign nationals imprisoned, rising from 5587 in 2000 to over 11,000 in 2007. Foreign nationals currently account for 14% of the prison population as a whole. ⁸ Many of these prisoners are from areas of the world where HIV and other BBV infections and tuberculosis are common. Access to health care in this group is frequently complicated by language and cultural barriers as well as concerns about how their medical care might be sustained when they are eventually repatriated or deported.

Providing GU medicine in-reach prison services that are comparable with the wider community will not be easily resolved without a better understanding of the problems faced by providers and users. Later this year, the British Co-operative Clinical Group will be conducting the most comprehensive survey on sexual health services in prisons ever undertaken. The survey will look at existing services, service funding, waiting lists, job plans, staffing, tests offered, record-keeping, service reviews and training to define national standards for delivering sexual health for prisoners (Dr Alan Tang, personal communication). This work runs in parallel to a wider consultation process that started in November 2007, Improving health, supporting justice: a consultation, ⁹ run jointly between the Department of Health, Department of Children, Schools and Families, Ministry of Justice, Youth Justice Board and the Home Office.

Central to these consultations is how initiatives such as condom provision, hepatitis B vaccination, needle exchange programmes and examples of good service delivery are measured. The absence of processes that systematically measure sexual health outcomes for inmates make it difficult to determine the effectiveness of interventions. Better clinical governance, based on a solid foundation of health informatics for prisoners that allow the separation of prevalent STI and HIV statistics in prisons from other settings, is vital. Systems are also required that enable longitudinal measurement of health outcomes for a range of chronic conditions, including BBVs. A prisoner register that links an inmate's medical record to other health-care systems within the National Health Service should significantly improve the quality and availability of data to monitor the impact of health interventions in prisons and beyond.

Imprisonment is seen as punishment. It should, however, also be seen as an opportunity to address the sexual health needs of the most disadvantaged members of society to ensure that the health needs of the wider public are met.