In-reach Services Research Articles

P1161 PERI-TRANSPLANT TREATMENT WITH ANTI-HCV E2 HUMAN MONOCLONAL ANTIBODY MBL-HCV1 IN COMBINATION WITH A PROTEASE INHIBITOR RESULTS IN UNDETECTABLE HCVRNA IN THE EARLY POST-TRANSPLANT PERIOD

Background and Aims: 54% of prison Chronic Hepatitis C (HCV) services in England are local hospital in-reach (1). Can these services offer comparable outcomes compared with a District General Hospital (DGH) outpatients service? Aims of audit were to compare care and treatment outcomes, identify differences and implement change to ensure equitable care in the prison setting. (1) National survey of HCV services in prisons in England, DOH, 2012. Methods: Retrospective audit analysis of service databases for four year of treatment (anti-viral therapy) since prison in-reach service commencement in 2009 and care outcomes for 2012. Both services offered weekly clinics (covering 4 male prisons) and undertaken by one senior specialist nurse. Results: Care outcomes: Comparable patient groups, clinics held, numbers seen and genotype splits. Care outcomes comparable except that more prison patients were assessed but not treated, fewer prisoners received treatment with the majority being treatment naive. Treatment outcome: Comparable group, naive, treatment experienced and genotype splits. Fewer prisoners received treatment but sustained virological response rate (SVR) rates were comparable. The prison cohort was reduced due to loss to follow-up with lack of SVR data. Conclusions: Nurse led in-reach HCV prison services can deliver comparable outcomes including SVR’s compared to DGH services. More patients in the prison setting need to be treated. Since this audit we have implemented a one-stop pre treatment investigations hospital visit for prisoners and ensure results are forwarded to the next care provider when prisoners are transferred or released. These changes should increase the numbers treated in the future.

In-reach nursing services improve older patient outcomes and access to emergency care

To identify the impact of in-reach services providing specialist nursing care on outcomes for older people presenting to the emergency department from residential aged care. Retrospective cohort study compared clinical outcomes of 2278 presentations from 2009 with 2051 presentations from 2011 before and after the implementation of in-reach services. Median emergency department length of stay decreased by 24 minutes (7.0 vs 6.6 hours, P < 0.001) and admission rates decreased by 23% (68 vs 45%, P < 0.001). The proportion of people with repeat emergency department visits within six months decreased by 12% (27 vs 15%). The proportion of admitted patients who were discharged with an end of life palliative care plan increased by 13% (8 vs 21%, P = 0.007). There was a significant reduction in the median length of stay, fewer hospital admissions and fewer repeat visits for people from residential aged care following implementation of in-reach services.

Review of psychiatric services to mentally disordered offenders around the Pacific Rim

This article was commissioned to collate and review forensic psychiatric services provided in a number of key Pacific Rim locations in the hope that it will assist in future dialogue about service development. The Board of the Pacific Rim College of Psychiatrists identified experts in forensic psychiatry from Australia, Canada, China, Hong Kong, Japan, Russia, Singapore, Taiwan, and the US. Each contributor provided an account of issues in their jurisdiction, including mental health services to mentally disordered offenders in prison, competence or fitness to stand trial, legal insanity as a defense at trial, diminished responsibility, and special forensic services available, including forensic hospitals and community forensic mental health services. Responses have been collated and are presented topic by topic and country by country within the body of this review. The availability of mental health screening and psychiatric in-reach or forensic liaison services within prisons differed considerably between countries, as did provisioning of community forensic mental health and rehabilitation services. Diversion of mentally disordered offenders to forensic, state, or hybrid hospitals was common. Legal constructs of criminal responsibility (insanity defense) and fitness to stand trial ("disability") are almost universally recognized, although variably used. Disparities between unmet needs and resourcing available were common themes. The legislative differences between contributing countries with respect to the mental health law and criminal law relating to mentally disordered offenders are relatively subtle. The major differences lie in operationalizing and resourcing forensic services.

An audit of hepatitis C services in a representative sample of English prisons, May, 2013

BackgroundThis audit follows a survey of hepatitis C services in prisons in England published in 2012 by the Health Protection Agency (HPA) and the Department of Health (DoH). This survey revealed variation in the quality of hepatitis C services delivered in prisons, which required further examination. An audit instrument was developed in December, 2012, on the basis of the best practice guidance in the survey as well as existing national guidance to examine key areas of service provision. The aim of the audit was to identify best practice guidance that was being followed and provide evidence and intelligence for commissioners and service providers as a driver to improve the care received by patients. MethodsThe audit was done before April, 2013, by the DoH as well as the HPA (a predecessor organisation of Public Health England [PHE] that was formed in April, 2013). A sampling frame based on those adult prisons covered by the HPA's sentinel surveillance study for hepatitis C was used to select 21 prisons for audit. Prisons were then selected to ensure representation of the institutions identified in the whole estate by security category, population size, and geographical distribution in England. The sampling strategy was as follows: four category B (at least one of each size); seven category C or D (at least two of each size); one female (any size); one high security (any size); and eight local prisons (only large and medium in sample frame). A letter was sent by the National Offender Management Service, the HPA, and DoH to prison governors and health-care managers. Completion of the audit was not mandatory. FindingsOnly one prison did not respond (95% response rate) and we used another prison from the same region and of the same category to replace it. Six (29%) of 21 prisons had a steering group to oversee the testing, treatment, and care strategy in prisons. 13 (62%) had a written hepatitis C policy or equivalent document. 11 (52%) had blood-borne virus information available in the induction programme for new prisoners. Disinfectant tablets were available in 17 prisons (81%). 13 prisons (62%) stated that blood samples were automatically tested by PCR. 16 (76%) had documented guidelines requiring a pretest discussion and 15 (71%) a post-test discussion. The most common service delivery model was hospital outpatient (11 of 21 [52%]), followed by hospital in-reach (nine of 21 [43%]) and general practitioner led (one of 21 [5%]). 18 prisons (86%) reported that they always or sometimes place prisoners on medical hold. 17 prisons (81%) had training in blood-borne viruses for health-care staff; ten (48%) had training for prison officers; and 12 (57%) had training for drug workers. There are limitations to the audit because it is based on self-reporting from the prison. Also, the audit represents 17% of the total number of adult prisons in England. InterpretationThe audit highlighted areas of good practice as well as areas of concern; the findings are now being used to drive an improvement in the commissioning and service delivery of hepatitis C services nationally. The audit showed a scarcity of provision for in-reach hospital services. A set of 12 recommendations were made, which included the need for PHE and National Health Service England to coproduce a high-level service specification in relation to hepatitis C to ensure that all prisons and detention centres are consistently delivering good quality and accessible care in line with the good practice described in the audit. This recommendation has already started to be addressed nationally. FundingNone.

Variations in prison mental health services in England and Wales

In responding to high levels of psychiatric morbidity amongst prisoners and recognising earlier poor quality prison mental health care, prison mental health in-reach teams have been established in England and Wales over the last decade. They are mostly provided by the National Health Service (NHS), which provides the majority of UK healthcare services. Over the same period, the prison population has grown to record levels, such that prisons in England and Wales now contain almost 90,000 of the world's overall prison population of over 10million people (roughly the size of Paris or Istanbul). This study provides an overview of mental health in-reach services in prisons in England and Wales, including variations between them, through a telephone survey of senior staff in all prisons and young offender institutions in England and Wales. 73% of prisons took part; of them 13% had no in-reach team at all (usually low security establishments) and the majority of services were run by NHS teams, usually according to a generic community mental health team (CMHT) model rather than other specialist models. Team size was unrelated to prison size. Each nurse covered around 500 prisoners, each doctor over 3700. Many provided few or no healthcare cells and 24-h psychiatric cover (including on-call cover) was uncommon. Despite developments in recent years, mental health in-reach services still fall short of community equivalence and there is wide variation in service arrangements that cannot be explained by prison size or function. The aim of community equivalence has not yet been reached in prison healthcare and a more sophisticated measure of service improvement and standardisation would now be useful to drive and monitor future development.

2003 – Dual diagnosis in a local prison in UK

Aims The prevalence of mental disorder and addiction in any prison population is higher than for the general public. Mental health in-reach and addiction services were developed to treat this complex population. We identified the need to evaluate the service provided in a local prison, and make suggestions for improvement. Our main aim was to investigate the need for dual diagnosis services in a local male community prison. Methods Our data collection tool consisted of five parts; 1) Demographic Data, 2) Addiction problems and input received, 3) Psychiatric diagnosis and input received, 4) Physical health including medical problems related to substance use 5) Other comments including risks identified. The data were collected from the prison's patient record system. Results From the 134 inmates that were under the care of the addictions service in January 2012, 26 had a dual diagnosis (19%). From the dual diagnosis population, 24 inmates (92%) were mainly addicted to opiates. The main substitute prescribed was methadone (n=14). The most common psychiatric diagnoses was schizophrenia (35%) and anxiety disorders, with or without a personality disorder. Comments We found a big proportion of the addictions population with a psychiatric diagnosis (19%). As both illnesses can be interlinked and affecting prognosis it is important that we treat both simultaneously. The distinction between addictions and mental health services can bring difficulties in communication and care provided. A dual diagnosis service is therefore needed to assure quality and continuity of care in prison and to assist smooth transition after release.

Identification and management of prisoners with severe psychiatric illness by specialist mental health services

The prevalence of mental disorders among prisoners is considerably higher than in the general population. This is an important public health issue as the vast majority of prisoners stay in custody for less than 9 months and, when not in prison, offenders' lifestyles are frequently chaotic, characterized by social exclusion, instability and unemployment. Multi-disciplinary mental health inreach services were introduced to target care towards prisoners with severe mental illness (SMI) in a similar way to that provided by Community Mental Health Teams outside prison. The aim was to establish the proportion of prisoners with SMI who were assessed and managed by prison mental health inreach services. Method A two-phase prevalence survey in six prisons in England measured SMI upon reception into custody. Case-note review established the proportion of those with SMI subsequently assessed and treated by inreach services. Of 3492 prisoners screened, 23% had SMI. Inreach teams assessed only 25% of these unwell prisoners, and accepted just 13% onto their caseloads. Inreach teams identified and managed only a small proportion of prisoners with SMI. Prison-based services need to improve screening procedures and develop effective care pathways to ensure access to appropriate services. Improved identification of mental illness is needed in both the community and the Criminal Justice System to better engage with socially transient individuals who have chaotic lifestyles and complex needs.

Medical Patients' Experiences of Inreach Occupational Therapy: Continuity between Hospital and Home

Introduction: Reforms in the National Health Service have encouraged a whole system approach. However, coordinated care may be difficult at the interface between acute hospital and community services. Inreach services are community based and the same member of staff provides intervention in hospital and after discharge. This qualitative study aimed to understand medical patients' experiences of inreach occupational therapy. Method: Semi-structured interviews were conducted with a convenience sample of seven older people, following their discharge from a medical inreach occupational therapy service. Thematic analysis was used to explore findings. Findings: Uncertainty was expressed about the role of occupational therapy and about participants not feeling involved in their hospital discharge. There was an appreciation that inreach occupational therapy could aid continuity of care. Some participants considered regular contact with a known health professional to be reassuring on return home, whereas for other participants the principle of accurate information sharing between staff was particularly important at discharge. Conclusion: All participants valued a seamless service between occupational therapy in hospital and at home. The importance of services working across organisational boundaries is emphasised, tailoring the timing of interventions to meet individuals' needs.

Unmet needs of male prisoners under the care of prison Mental Health Inreach Services

Recent government policy has emphasised the importance of a patient centred approach, based on individual needs, in service design and planning. Mental Health Inreach Services (MHIS) have been developed in UK prisons, designed on the principle of providing equivalence of care to community mental health teams (CMHTs). To date no studies have systematically examined the needs of patients on MHIS caseloads, let alone obtained these prisoner–patient views of their needs. This study is the first to describe the self-reported ratings of needs of male prisoners (n = 151) under the care of prison MHIS in the UK, using the forensic version of the Camberwell Assessment of Need Forensic – Short Version (CANFOR-S). Inmate medical records were examined and prisoners were interviewed to obtain their ratings of their needs. The results showed that prisoners on MHIS caseload have six needs on average, of which almost half (2.6) are unmet. The most frequent unmet needs were for: daytime activities, psychotic symptoms, psychological distress and accommodation. The findings have implications for commissioning and resource allocation for this population.

The management of released prisoners with severe and enduring mental illness

Prisoners have higher rates of mental disorder than the general population. Imprisonment provides an opportunity to engage with mental health services. Release from prison is associated with a range of negative outcomes including increased mortality and suicide. This prospective, longitudinal cohort design study established the proportion of prisoners with severe and enduring mental illness in contact with prison mental health in-reach services who make contact with Community Mental Health Teams (CMHT) on discharge from prison. A total of 137 participants were recruited from prison mental health in-reach team caseloads and assessed as having severe and enduring mental illness. At a six-month follow-up, 53 (39%) had been released, but only four were in contact with the CMHT. There is a need for robust discharge planning and proactive through care for prisoners with mental health problems.

The DUNDRUM-1 structured professional judgment for triage to appropriate levels of therapeutic security: retrospective-cohort validation study.

BackgroundThe assessment of those presenting to prison in-reach and court diversion services and those referred for admission to mental health services is a triage decision, allocating the patient to the appropriate level of therapeutic security. This is a critical clinical decision. We set out to improve on unstructured clinical judgement. We collated qualitative information and devised an 11 item structured professional judgment instrument for this purpose then tested for validity.MethodsAll those assessed following screening over a three month period at a busy remand committals prison (n = 246) were rated in a retrospective cohort design blind to outcome. Similarly, all those admitted to a mental health service from the same prison in-reach service over an overlapping two year period were rated blind to outcome (n = 100).ResultsThe 11 item scale had good internal consistency (Cronbach's alpha = 0.95) and inter-rater reliability. The scale score did not correlate with the HCR-20 'historical' score. For the three month sample, the receiver operating characteristic area under the curve (AUC) for those admitted to hospital was 0.893 (95% confidence interval 0.843 to 0.943). For the two year sample, AUC distinguished at each level between those admitted to open wards, low secure units or a medium/high secure service. Open wards v low secure units AUC = 0.805 (95% CI 0.680 to 0.930); low secure v medium/high secure AUC = 0.866, (95% CI 0.784 to 0.949). Item to outcome correlations were significant for all 11 items.ConclusionsThe DUNDRUM-1 triage security scale and its items performed to criterion levels when tested against the real world outcome. This instrument can be used to ensure consistency in decision making when deciding who to admit to secure forensic hospitals. It can also be used to benchmark admission thresholds between services and jurisdictions. In this study we found some divergence between assessed need and actual placement. This provides fertile ground for future research as well as practical assistance in assessing unmet need, auditing case mix and planning care pathways.

Hospital transfers need proper assessment

Wilson et al [1][1] highlight the delays in transferring prisoners to hospital, including a suggestion that a ‘postcode lottery’ operates. Although we agree with much of the article, we would contest the statement that ‘Given the extensive development of mental health in-reach services, and

Survey reveals crisis in prison mental health in-reach services

Survey reveals crisis in prison mental health in-reach services

The second national survey of mental health in-reach services in prisons

The prevalence of mental disorder among prisoners is considerably higher than that in the general population. Historically, mental healthcare in prisons has been criticised for being under-funded and provided by the Prison Service. The 2001 policy Changing the Outlook envisaged multi-professional prison mental health teams funded by the local primary care trusts. Such teams are now in place, managing offenders with severe mental illness, but they have faced challenges. The second mental health in-reach team survey was conducted in 2007 and aimed to capture a variety of data, including: workforce features; connections with primary care services; the role of in-reach services, their caseload, the interventions provided, and barriers to successful operation; and the relationship with the wider NHS. It was found that the role and activities of in-reach teams had changed considerably since the first in-reach survey was undertaken in 2005.

Personality disorder, inreach services and day treatment services

Personality disorder, inreach services and day treatment services

Prison mental health inreach services

Prison mental health inreach teams have been established nationwide in England and Wales over the past 3 years to identify and treat mental disorders among prisoners. This paper summarises the policy content and what has been achieved thus far, and poses challenges that these teams face if they are to become a clear and effective component in the overall system of forensic mental healthcare.

Social‐cognitive determinants of help‐seeking for mental health problems among prison inmates

Prisoners experience high rates of mental health problems and suicidal behaviours. Failure to seek help may exacerbate these problems and limit opportunities to participate in offending-related programmes. To assess whether prisoners'; intentions to seek help for a personal-emotional problem, including suicidal feelings, can be predicted using variables from the Theory of Planned Behaviour (TPB). These TPB variables were supplemented by measures of emotional distress, prior contact with a psychologist and demographic variables. Male inmates from six New Zealand prisons were asked to participate, with approximately 50% (n = 527) of those who initially expressed an interest in the study completing the self-report questionnaire. Most participants completed the questionnaire in small-group meetings in the prison units and returned them to the researchers immediately after completion.Results On average, participants reported higher levels of current emotional distress than comparison student samples. TPB variables predicted help-seeking intentions for suicidality and personal-emotional problems. Those with prior contact with prison psychologists had lower intentions to seek help for suicidal feelings than prisoners without such contact. Older prisoners, those with more years of education, and those who had previous contact with a psychologist outside prison tended to have higher intentions to seek psychological help. Social-cognitive factors predicted intentions to seek help among New Zealand prisoners but prison-specific issues, such as relative reluctance to seek help when suicidal and reluctance to seek help from prison psychologists, were also identified. Implications for practice Prisoners'; access to services could be improved, for example, through directly working on attitudinal barriers. Strategies to ensure access to specialized forensic mental health in-reach services could also be an alternative or additional route to ensure that this disadvantaged group seeks appropriate help.

Policy into practice: The challenge of inreach mental health services for young people within a prison environment

Recent government policy has led a drive for the provision of inreach NHS mental health services to local prison populations. This is one account of a project to develop an inreach mental health service for young women (16–18 years old), piloted over a six-month period.

Characteristics of need and risk among women prisoners referred to inreach mental health services

High levels of need and complexity were identified in women referred to and accepted by the inreach team in HMP &amp; YOI Bullwood Hall during the first two years of operation. They included mental health problems, personality disorder, substance misuse and social factors. During the first and second years of operation, there were 124 and 194 referrals respectively. Prevalence of substance misuse was high, and a large proportion of women were involved in multi‐drug use. Low mood was the most common reason for referral. The prevalence of intentional self‐injury was high, and was significantly associated with previous suicide attempts, history of abuse and personality disorder traits. A number of factors were identified that compromised effective through‐care to the community, including lack of accommodation and primary care access on release, and that disrupted the connectivity of care. These factors contributed to the social exclusion of this vulnerable group.

Including the excluded: developing mental health in-reach in south west England

For many years, prisoners have not received a reasonable standard of mental health care, but now in-reach services could change the picture. Lynn Emslie and colleagues report on the work of the in-reach services operating in south west England