Health care needs assessment in prisons: a toolkit

Toolkit for healthcare needsassessment inprisons

Dr Tom Marshall, Dr Sue Simpson and

Professor Andrew Stevens

Department of Public Health & Epidemiology

University of Birmingham

February 2000

Contents

Health Care Needs Assessment – What is it? Why do it? 1

Aims 1

Objectives 1

Definitions 2

Methods of health care needs assessment 4

How to use this document 5

Preliminary Tasks 5

a) Putting together a team 5

b) Getting Started 6

THE HEALTH CARE NEEDS ASSESSMENT 7

Step 1. Description of the prison 7

a) What type of prison is this? 7

b) What type of prisoner do you have? 8

How to carry out this step in the needs assessment 8

Step 2. What major health and health care issues are already known? 9

a) Corporate needs assessment 9

How to carry out a corporate needs assessment 9

b) Comparative needs assessment 10

How to carry out a comparative needs assessment 10

Step 3. How many prisoners have each type of health problem in this prison? 11

a) Local Information 11

b) Health Care in Prisons: a health care needs assessment document 12

Other important information that can be collected at this stage 12

Thinking ahead 12

Step 4. What health services are currently available to this prison? 13

a) Services and Interventions 13

b) Human and physical resources 13

c) Pathways to care 14

Step 5. What health care (and other) interventions are worth doing? 15

How to identify effective interventions 15

Step 6. What services and procedures are required to ensure health care needs are met? 17

How to identify services and procedures which are needed and changes which are required 17

Step 7. Implementation plan for the provision of effective health services 18

Step 8. Monitoring progress 19

Conclusion: reviewing the needs assessment process 20

References 20

Appendices 21

Tom Marshall, Sue Simpson and Andrew Stevens, Department of Public Health & Epidemiology, University of Birmingham.

1

Health Care Needs Assessment – What is it? Why do it?

This document is aimed at those who are responsible for planning and commissioning healthcare within the prison service. This includes prison governors, prison health care staff andlocal NHS health care commissioners (Primary Care Groups and health authorities). Thesebodies will be responsible for assessing the health care needs of their prison populations.However, it should be noted that health care needs assessments can be and are carried out on amuch larger scale, for example, at national and regional level.

Prisoners present diverse health problems. When they seek formal health care, the prisonhealth care service is normally their first point of contact. Demand for health care oftenappears to outstrip the capacity of services. The Health Care Needs Assessment approachdeals with this problem by differentiating between needs and demands for health care services.This distinction is explained in more detail later. It builds up a picture of needs by taking intoaccount numbers of prisoners with problems and the effectiveness of services. Its methods areboth formal and informal. Adopting this approach is intended to help prison health servicesplan their health care provision and move towards a service which will tackle needssystematically rather than reacting to demand.

Aims

The aims of a health care needs assessment are:

To gather information to plan, negotiate and change services for the better and to improvehealth in other ways.To build a picture of current services, i.e. a baseline.

Why might services need changing for the better?

There are a number of reasons why services that are currently provided may need re-thinkingand changing for the better:

Historical patterns of services were not needs based.Shifts in pattern of disease and the emergence of “new” diseases e.g. HIV.Developments in medical technology such as new drugs, new procedures, or changes insettings where some health problems are addressed.Advances in medical knowledge, such as a better understanding of what does (and does not)work for specific illnesses and population groups.Changes in expectations.

Objectives

There are five objectives of a health care needs assessment:

1. Planning: This is the central objective of needs assessment; to help decide what servicesare required; for how many people; the effectiveness of these services; the benefits thatwill be expected; and at what cost.

2. Intelligence: Gathering information to get an overview and an increased understanding ofthe existing health care service, the population it serves and the population’s health needsi.e. what is the base-line?

3. Equity: Improving the spatial allocation of resources between and within different groups.

4. Target efficiency: Having assessed needs, measuring whether or not resources have beenappropriately directed i.e. Do those who need a service get it? Do those who get a serviceneed it? This is related to audit.

5. Involvement of stakeholders: Carrying out a health care needs assessment can stimulatethe involvement and ownership of the various players in the process.


2

Definitions

Need

In health care needs assessment, need is defined as “The individual or population’s ability tobenefit from health care”.1

This means that there is only a meaningful need for health care when an individual has ahealth problem (or runs a risk of developing a health problem) and there is an effective andacceptable intervention for that problem. Health care needs assessment therefore requiresknowledge of the numbers of people with the health problem (the incidence and prevalence).It also requires a knowledge of the services available to address the problem and theeffectiveness and quality of these services.

Health care interventions do not just mean treatment. They encompass prevention, diagnosis,continuing care, rehabilitation and palliative care. Similarly, benefit is not just a question ofclinical status, but can include reassurance and supportive care. In addition, the ability tobenefit does not mean that the outcome of the intervention is guaranteed to be favourable, butrather that it is on average effective.

“Neediness” versus “need for”

Those who are ill or in poor health can be said to need better health. A picture of this can begained by looking at patterns of disease. However, this need-for-health or “neediness” must bedistinguished from “need for” health care. Health problems only generate a need for healthservices to the extent that those services are effective at dealing with the problem. If there isno effective health service, there is no need for the service. The rationale for this is simple. If ahealth service is to do greatest good for the greatest number, it needs to focus its resources oninterventions which are effective.

Need, Supply and Demand

The commonest mistake in health care needs assessment is to equate demand for a servicewith need for the service. There are a number of reasons why this may be misleading. Demandfor health care is influenced by the supply of services available. Patients demand serviceswhen they believe that they are likely to benefit and that these benefits are likely to be greaterthan the inconvenience or costs. If a service is supplied (accessible and free) and patientsbelieve it is effective, there will be demand for it: even if the service is ineffective. Similarlythere may be little or no demand for a service simply because patients are unaware that it iseffective or because it is inaccessible or costly.

In judging whether or not a service is effective, patients generally defer to the expertise oftheir doctor (or other health care provider). This means that in practice, demand for any healthcare service is influenced by the attitude of the doctor and the incentives under which heworks. The doctor may induce demand for some services and decrease demand for others.

This leads to the conclusion that: measuring existing service provision as if it were anindication of need is likely to be misleading.

The relationship between need, demand and supply is illustrated in Figure 11. From thisapproach we can identify seven types of service.

1. Services where there is a need but no demand or supply.Inmates are not generally aware that they might benefit from speech and language therapy(no demand) and the service is unavailable in many adult prisons (no supply). Yet it mayoften be of benefit (need).

2. Services for which there is a demand but no need or supply.Patients may ask for (demand) antibiotics for viral infections such as the common cold.


3

However antibiotics are not effective in viral infections (no need) and the prison doctormay not prescribe them (no supply).

3. Services for which there is a supply but no need or demand.The provision of extra rations of full cream milk for diabetics. Diabetic prisoners do notrequest this (no demand), but in some prisons it is provided (supply). This has beendescribed as “dietetically unsound and economically wasteful” (no need).2

4. Services for which there is a need and demand but no supply.In surveys about a third of inmates identify smoking cessation as something with whichthey would like help.3,4 Nicotine replacement therapy (patches, sprays or gum) is known toincrease the chances of smokers giving up (need), but it is not always available (nosupply).

5. Services for which there is a demand and supply but no need.Prisoners may request (demand) and be prescribed (supply) long acting benzodiazepinesfor insomnia. In the long term this is not effective (no need).

6. Services for which there is a need and supply but no demand.Even when it is offered, not all inmates take up the opportunity of Hepatitis Bimmunisation (supply but no demand). Yet prisoners are at risk of Hepatitis B infectionand immunisation is effective at preventing it (need). This may also apply to PrisonOfficers, some of whom remain unprotected against Hepatitis B.

7. Services for which there is a need, demand and supply.Insulin dependent diabetic inmates know to ask for (demand) insulin, it is effective atmaintaining their health (need) and the prison health service provides it (supply).

Figure 1: The interaction between need supply and demand.

The aim of a health care needs assessment is to ensure that the services provided correspond topatients’ needs and that patients demand these needed services. This corresponds to area 7 inFigure 1.

Need Demand

Supply

1

4

2

3

7

56


4

Methods of health care needs assessment

There are three main methods of health care needs assessment. The first two give apreliminary idea of the areas of concern. The third can be used for a detailed assessment.

1. Corporate approach – where stakeholders or others with special knowledge (patients,purchasers, providers, politicians etc.) are canvassed to determine their views on what isneeded.

2. Comparative approach – where services are compared with the services of otherproviders and major discrepancies are investigated and addressed.

3. Epidemiological approach – This is the main approach used in this document. Healthcare needs are determined by considering three components as illustrated in Figure 2. Thisapproach can be usefully supplemented by the other approaches.

Figure 2: The triangulation of health care needs assessment

Source: Stevens A., Raftery J. Health care needs assessments: the epidemiologically based needsassessment reviews, 1994, Oxford: Radcliffe Medical press Ltd.

Effectiveness & costeffectiveness of servicesIncidence and/or

prevalence of problem

Services available todeal with the problem


5

How to use this document

Assessing the health care needs of a population is a complex task involving a number ofsequential steps. Some of these steps must be completed before the next steps can be started.The steps are illustrated in Appendix 1.

There are three key messages. Firstly it is often too large a task to be carried out by anyone individual and should therefore ideally be carried out by a team; this has theadvantage of widening the commitment to make the required service changes. Secondlyit is a process which can take several months. Thirdly it should be seen as an ongoinglong-term process.

The document Health Care in Prisons: a health care needs assessment should be used inconjunction with this toolkit. The document contains material that will help you to progressthrough the stages of the toolkit.

Preliminary Tasks

a) Putting together a team

Before a needs assessment is carried out it is advisable to put together a team which will beresponsible for completing the work. Different members of the team will contribute differenttypes of expertise. Prison health care staff, staff from the local hospitals (in particular the localNHS Trust responsible for mental health care) and the prison governor should all berepresented. The Chief Executive and the public health department of the local HealthAuthority should also be represented. Public health specialists can contribute expertise inassessing health care needs. Prisoners, as users of the service, can be directly or indirectlyrepresented (for example through the board of prison visitors). In addition, the team may needto liase with other individuals or departments to provide supplementary information. See Box1 for a summary of the participants you might want to include in a health care needsassessment team.

One person will need to lead the needs assessment process and ensure meetings and stages aremanaged efficiently. This role should ideally be allocated to a person with previous experienceof health care needs assessment: in practice this is most likely to be a public health physician.

Box 1: Suggested participants in a team carrying out a prison health care needsassessment.

People who might be members of the Health CareNeeds Assessment team:

People who the Health Care Needs Assessmentteam might refer to:

Governor (prison)Health care manager (prison)Doctor (prison)Nursing staff & health care officers (prison)Public health specialist/consultant (Health Authority)General practitioner (NHS)Psychiatrist (NHS Trust)Other health care staff (NHS Trust)Task Force member

Board of Prison VisitorsRepresentatives of prisonersNursing staff & health care officers (prison)Other health care staff (NHS Trust)Pharmacist (prison)

Genitourinary medicine services representative

Local health promotion unit

This list is not exhaustive. In some prisons it may be appropriate for other stakeholders to participate.


6

b) Getting Started

Once a team has been put together an initial meeting should be held. Team members may nothave met before and may be unfamiliar with each others roles and skills. Some of them willhave little or no prior experience of prisons, some will not be aware of the way HealthAuthorities and NHS Trusts operate. A useful first step might therefore be to invite possibleteam members to a preliminary workshop. This would give them an opportunity to meet, toexchange contact details and to give a brief presentation explaining their roles and skills. Itcould also provide an opportunity for team members unfamiliar with prisons to visit localinstitutions. A second meeting could set out a timetable for completion of the needsassessment, assign tasks to different individuals and establish the short-term aims i.e. the tasksto be completed by the next meeting (see Box 2).

Box 2: Suggested tasks for the first two meetings of the needs assessment team.

First meeting Second meeting

Meet other participants in needs assessmentteam.Exchange contact details.Brief presentations clarifying roles and skills.Arrange prison visits for those unfamiliar withprisons.Consider if membership of team is appropriate(too large or too small? Are all stakeholdersrepresented?)

Draw up a timetable for completion of the needsassessment with dates for completion ofcomponent steps.Assign tasks to team members.Establish short-term aims, e.g., completion ofStep 1 for the next meeting.


7

The Health Care Needs Assessment

Step 1. Description of the prison

b) What type of prison is this?

This section should include a description of the category of prison, its security status andcapacity. Do not describe the health care services in detail: a one-line description of the healthcare services can be included (i.e. is there a health care unit on site or a visiting service; ifthere is a unit on site does it have any in-patient beds?). Table 1 lists the types of informationthat should be collected to describe the prison.

Table 1: Basic description of the prison.

Category of prison

Status

Sex of prisoners

Capacity of prison

Type of health care services


8

b) What type of prisoner do you have?

Ultimately, the types of prisoner we are interested in are those with a health care need.Different kinds of prisoners have different health problems, so we first need a basicdescription of the prison’s population. This might be how many prisoners are women asopposed to men, the ages of prisoners and their ethnicity. In addition, because it has relevancefor mental health needs, it is helpful to divide prisoners into those on remand and those whohave been sentenced. Finally, because the turnover of prisoners is high, it is important to knowthe number of New Receptions to prison as well as the Average Daily Population (ADP). SeeTable 2 and Table 3.

Table 2: Average Daily Population of the prison.Age Remand (Average Daily Population) Sentenced (Average Daily Population)

Ethnicity White Black (Afro-Caribbean)

Asian & other White Black (Afro-Caribbean)

Asian & other

16-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

>54

Total

Table 3: New Receptions per year in this prison.Age Remand (New Receptions per year) Sentenced (New Receptions per year)

Ethnicity White Black (Afro-Caribbean)

Asian & other White Black (Afro-Caribbean)

Asian & other

16-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

>54

Total

How to carry out this step in the needs assessment

This task should be completed by the time the needs assessment team has met for the thirdtime.

Information on the ADP and the number of new receptions will be available from individualprions. It should also be available from the Task Force.

At this point do not describe the health services in the prison or health service activity. This isa step which takes place later in the course of a needs assessment and should be left until then.


9

Step 2. What major health and health care issues are already known?

There are two ways of answering this question quickly: corporate needs assessment andcomparative needs assessment.

b) Corporate needs assessment

Ask those who are familiar with the prison and with their health problems. This might includearticulate prisoners, prison officers, prison visitors and so on. It will also include those whoare familiar with the health problems of prisoners, such as the primary health care team (GP,nurses, health care officers) and visiting specialists from NHS Trusts.

Two caveats should be remembered. Firstly it is important not to feel bound by the views ofthe stakeholders. Individual stakeholders have their own agendas and are likely to be moreaware of demand than need. Secondly, because such information is anecdotal it should betreated with some caution.

How to carry out a corporate needs assessment

This is done by canvassing the views of key stakeholders in the prison health care system.Some (but not necessarily all) of these may be members of the needs assessment team (seeBox 3). It can either be done by convening a meeting of the stakeholders, chaired by amember of the needs assessment team or by asking stakeholders to make written submissionsor by some combination of the two. It is important to make some assessment of the views ofusers of the service. They are likely to provide the best information on the quality of theservice. This might be done by carrying out a survey, by convening a separate focus group ofselected prisoners and reporting on this or by delegating a prisoner to represent the views ofinmates.

When carrying out a corporate needs assessment it is helpful to ask the stakeholders todistinguish between what the health problem is perceived to be and what service is thought tobe likely to help with the problem. This is to avoid the situation where stakeholders simplyrequest more services without being clear what problems these services are intended toaddress.

Box 3: Suggested stakeholders who might usefully contribute to a corporate needsassessment.

Stakeholder

Prison health care staff:Prison health care managerPrison doctorPrison nursing staff & health care officersPharmacistExternal health professionals:General practitioner (NHS)Psychiatrist (NHS Trust)Staff from professions allied to medicine (e.g. dentist, occupational therapists, physiotherapists etc.)Task ForceRepresentatives of prisoners (service users):Board of Prison VisitorsRepresentatives of prisonersOthers:Voluntary organisationsGovernorPrison officersUniversity academics with an interest in the topic.

This list is not exhaustive. In some prisons it may be appropriate for other stakeholders to participate.


10

b) Comparative needs assessment

A comparative needs assessment is carried out by gathering information on how health careprovided in your prison differs from similar establishments elsewhere. This approach maypoint to areas where there is too much or too little provision.

Again this needs to be treated with caution. It is possible that some services are not providedin any prison even though there is a need. Other services may be provided by all prisons, butmay nevertheless be ineffective.

How to carry out a comparative needs assessment

There are a number of sources of information for a comparative needs assessment. Thesimplest approaches are to ask the Task Force for comparative data or to speak to your peersin similar prisons or to compare data between different prisons. Some of the moststraightforward data is prescribing data, health care activity data may also be useful and wherethey are available, measures of health itself (such as incidence of Hepatitis B) should be used.These data are available from the Prison Service. In addition to comparing data with otherprisons in your area it may be useful to compare data with general practices serving thecommunity in your area.

What you are looking for are variations in prescribing or activity between services as thesemay reveal important differences in health care practice. For example, effective clinicalpractice might be indicated by comparatively low numbers of prescriptions for sleepingtablets, tranquillisers or antibiotics and comparatively high numbers of prescriptions forantidepressants. For conditions such as asthma, good practice is thought to be reflected in arelatively high prescription rate of preventers (beclomethasone inhalers and similar) comparedto symptom relievers (salbutamol inhalers and similar).

Cost-effective practice tends to be indicated by the comparatively high use of generic drugs(equally effective but cheaper than branded products) or adherence to a limited list of drugs (adrug formulary).


11

Step 3. How many prisoners have each type of health problem in thisprison?

The aim of this section is to estimate the number of prisoners you can expect to have in yourprison at any one time with a particular health problem. This means that you should be able tofill in Appendix 2 and Appendix 3 (or Appendix 4 and Appendix 5 if it is a women’s prison)with the information relevant to your prison. This part of the needs assessment will take time.It is a task which may be more familiar to members of the public health department of thelocal Health Authority. Do not describe the prison health services at this point. This is done inthe next section.

Sources of information that will help to estimate the prevalence (or incidence) of healthproblems include:

b) Local Information

Prisons may have their own data on the prevalence of health care problems in their prison orin similar prisons. Some prisons have access to locally relevant information such as activityfigures and health surveys of prison inmates.

Routine Activity Data

Some activity data such as the data derived from HISP (Health Information Systems forPrisons) may be useful. It is important to remember that for long-term health problems(diabetes, asthma, epilepsy, psychosis, depression) we are trying to count the number ofprisoners with the illness not the number of consultations. For short-term health problems(such as infections or episodes of self-harm) we are also interested in the number of episodesof illness. This means that HISP data on the number of consultations may be confusingbecause each ill prisoner may be seen several times.

It may also be possible to estimate the number of prisoners with certain problems indirectlyfrom other routinely collected data. This may include data from the initial assessment atreception, data from inmate medical records (IMRs) and prescribing data (see Box 4).

Box 4: Suggested approaches to estimating the prevalence of illness in prison.

Health problem Indirect means of estimating numbers

AsthmaDiabetes requiring insulin or oral drugsEpilepsySevere mental illnessSelf-harm

Numbers receiving prescriptions for asthma medication.Numbers receiving prescriptions for diabetic medications.Numbers receiving prescriptions for anti-epileptic medication.Numbers reporting contact with psychiatric services at reception.Reported episodes of self-harm.

It should be noted that in some cases we can expect local data to underestimate the numberswith the illness. For example in Box 4 the numbers of prisoners receiving prescriptions fordiabetes medications may underestimate the total numbers of diabetics as some may bemanaged by diet alone. Mental health problems also tend to be underreported, as prisonersmay not disclose their previous medical history. Similarly, not all episodes of self-harm maycome to the attention of prison staff.


12

b) Health Care in Prisons: a health care needs assessment document

It is possible to estimate the number of prisoners with particular problems by looking at othersources of data and applying them to the prison population. This is useful because local datamay overestimate or underestimate the numbers with a particular problem. It is also usefulbecause in many cases local data will not be available.

Where local data are not available, the document Health Care in Prisons: a health care needsassessment provides estimates of the prevalence or incidence of many health problems. This issummarised in the tables at the end of this document (Appendix 2, Appendix 3, Appendix 4and Appendix 5). The tables give estimated prevalence figures for a range of physical andmental conditions which may be encountered in male and female prisoners. The list is notexhaustive. Some prisons may have prisoners with particular needs and some problems areonly found in particular groups (e.g. sickle-cell disease in people of African ancestry).Because of this it will be necessary to adapt the tables (Appendix 2, Appendix 3, Appendix 4and Appendix 5) to your prison.

If further information is needed the representative from the public health department of thelocal Health Authority may be able to provide this.

Other important information that can be collected at this stage

In addition there are requirements for health care interventions that are generated by the prisonitself. Table 4 lists these and includes medical examination at reception and dischargearrangements. Although they are not health problems as such, the information is important tocollect since there are resource implications.

Table 4: Health care interventions which are related to the the prison institution.

Nature of health careintervention

Indicator of incidence of thisproblem

Expected numbers per year inthis prison

Medical examination ofnew inmates at reception

Numbers of new receptions

Discharge planning forinmates

Numbers of discharges

Examination of inmates forlegal or forensic reasons

Numbers of court/disciplinaryhearings

Thinking ahead

It is also worth thinking ahead at this point to plan the collection of data which might be usefulin the future. This may involve changes in routinely collected data or carrying out locallybased surveys or research. It may be useful to draw on the public health representative’sexperience in data collection.


13

Step 4. What health services are currently available to this prison?

The aim of this section is to provide a picture of the services that are currently provided andthe health care interventions that are currently employed in the prison. It should also identifythe full range of human resources and physical facilities currently available to provide healthcare to inmates. Services/interventions can range from access to a visiting specialist orexternal health facility, to interventions which address minor health problems such as aheadache. If the care of minor illness often relies on informal networks, this is important tomention. The section should therefore also include information on inmates who have relevantskills as well as prison officers who have received training in aspects of health care.

b) Services and interventions

The services provided and the interventions employed to address the health problemsidentified in Step 3 should be described, for example:

Asthma

Patient education to promote self-care and appropriate use of health services.Support for asthmatic prisoners who wish to stop smoking.GP consultations.Respiratory care clinic.

• Appendix 6 should be completed. Again remember that the list in the table is notexhaustive and needs to be adapted to your prison.

b) Human and physical resources

The range of mainstream health care staff available to the prison population, whether these arecontracted in or employed by the prison, should also be estimated. In some cases, appropriatehealth care staff may have an input at a level other than individual patients e.g. occupationaltherapy advice on occupational regimes and the main prison regimes, dietetic advice oncatering. It should estimate the range of skills available to the prison. This differs from therange of staff. In many cases it is not important who provides a service, but it is important thatthey have recently received appropriate training. The cost of present provision should beestimated, so that it is clear what resources or staff might be available for redeployment. Thisinformation can be laid out in the manner suggested in Table 5 and in Appendix 7.

Table 5: Physical resources available to this prison.

Numbers Are facilities sufficientlyequipped?

Are facilities sufficientlymaintained?

Reception screening room(s)

Consulting room(s)- for individual consultations- for group consultations- treatment rooms

In patient beds

Pharmacy/dispensary

Other facilities

This list is not exhaustive: some prisons may have facilities which are not listed here.


14

c) Pathways to care

It is also useful to record any processes and protocols that are in place to ensure that referralruns smoothly at this stage.

What does a prisoner do when he first identifies an illness or health problem? To whom doeshe go?Is there easy and appropriate access to over the counter medication, information on the self-care of minor illnesses and on appropriate use of the health care services?What procedure does the first-contact health professional (health care officer, nurse or doctor)have to follow to get access to further interventions such as medicines or specialist advice?Quality standards: What quality standards are there? How do the services measure up to these?Is there any locally collected information on the quality of services provided.

This section is probably best addressed by representatives in the team from the prison service.

It may be helpful to illustrate the pathways to care in the form of a diagram.


15

Step 5. What health care (and other) interventions are worth doing?

This section aims to help you identify the health care services and interventions that areeffective. Information on effective services and interventions should be collected for eachhealth problem that you have identified in earlier steps (Appendix 8 should be completed). InStep 6 this will enable you to map the appropriate services against current service provisionand to identify gaps between current services, staff and skills and those which are needed. It isalso possible that some current services are of doubtful value and may be reduced in scope ordiscontinued. This task is likely to take some time.

How to identify effective interventions

The document Health Care in Prisons: a health care needs assessment contains a section onthe effectiveness of health care services and interventions. This section provides references onor identifies services and interventions which are of benefit in dealing with particular healthproblems. This is a useful first source of information on effectiveness.

Where information on effectiveness is not available from this document, there are a range ofother sources of information (see Box 5). The public health representative on your team maybe more familiar with this task.

Box 5: Sources of information on the effectiveness of health care interventions.

Quality of evidence Type of evidence Source of evidence

High quality evidence Systematic reviews of controlled trialsControlled trials

Fair quality evidence Comprehensive reviews of uncontrolled trialsUncontrolled trials

Cochrane library (and DARE database)NHS Centre for Reviews and Dissemination- Effective Health Care bulletinsBandolier.

Some agreementamong experts

Expert consensusGuidelines issued by professional body

Royal College of General Practitionersguidelines, Royal College of Psychiatristsguidelines, national guidelines, North ofEngland guidelines group, etc.

Weak evidence Accords with usual practice in UK Recommendation of health professional.

Listed below is an overview of some health care interventions that are effective and how theymight relate to the prison service.

Health care interventions which will improve health

Appropriate systems for the identification and management of chronic illnesses e.g. prisonerswith long-term mental health problems, asthma, diabetes, HIV or epilepsy.Appropriate systems for the identification and management of disabilities such as speech andlanguage difficulties and hearing problems.An environment and culture which fosters recognition and management of depression andanxiety5. Access to and training in cognitive therapy and cognitive behavioural therapy suchas problem-solving and relaxation.Advice on alcohol consumption delivered by a GP6; smoking cessation programmes (nicotinereplacement)7; Hepatitis B vaccination.

Health care interventions which will reduce the burden on prison health services

Initiatives to improve self-care by prisoners.At induction into the prison, provision of written materials on common health problemsexperienced by prisoners e.g., asthma, dermatological problems, coughs and colds, difficultiessleeping, anxiety and depression.


16

Good practice in primary care

Provision of written materials on how to access and make appropriate use of the prison healthservices.An appointments system for GPs. Operation of a limited formulary of pharmaceuticals.Initiatives to allow nurse dispensing where appropriate e.g. medications which are availableover the counter in the community.Staff training.

Good practice in liaison with NHS

Using staff who maintain links with NHS e.g. joint appointments between NHS Trusts or GPpractices.Arrangements for NHS and prison health care services to share information on reception andon discharge.For prisoners who may be released at short or no notice (remand prisoners), use of patient-held records of current medications and principal diagnoses.Assistance with registration with GP on discharge from prison.

Prison policies which may improve health

Improved access to a limited range of “over the counter” medications which have a lowpotential for misuse e.g. skin creams, anti-dandruff preparations, paracetamol containingmethionine (antidote to paracetamol overdose).Adopting a settings or whole institution approach to health promotion, in which policies andprocedures are regularly assessed for their impact on physical, mental and social well-being.Enforcement of smoke-free areas e.g. health care centres.Staff health initiatives to influence prison culture e.g. hepatitis B immunisation, stressmanagement, smoking cessation, smoke-free areas.Provision of dental health approved toothbrushes.Occupational therapy advice on main prison regime. This may help reduce boredom, improvemental health and reduce demands on health care services.Nutritional advice on prison catering.Development and implementation of infection control policies and local surveillance.


17

Step 6. What services and procedures are required to ensure health careneeds are met?

This section should identify and prioritise the services and procedures to be implemented toaddress the previously identified health care needs.

Services and procedures to address major health and health care issues in this institution.Services and procedures to address the prevalence or incidence of health problems.Changes that need to be made to the structure, process or quality of current services.

At this point the information collected in the previous steps is pulled together. It will enablethe team at a glance to identify what health problems are most prevalent; the services andinterventions that are currently employed to address these health problems; how effectivethese services and interventions are; and any services and interventions that are moreeffective. Staffing levels, skills available and future requirements will also be identified. Fromhere the changes that are required to ensure health care problems are addressed by effectiveservices can be identified and prioritised.

How to identify services and procedures which are needed and changes whichare required

The previous steps must have been completed before any attempt is made to identify whichservices are needed.

Go back to the previous steps. Using the information from here, it should be possible tocomplete the table in Appendix 9 for each health problem. It may be that only small changes(or no changes) are required. This is still important to record.

The information that you put into the table does not need to be very detailed. It is a means ofallowing the team to consider all the information you have collected previously. Byconsidering the information the team should be able to prioritise the health care problem thatshould be addressed. In general terms, the largest health needs which can be most easily metshould be the highest priorities.

This step will require the input of the whole team.


18

Step 7. Implementation plan for the provision of effective health services

Having established the health problems that are priorities and the services that are appropriateto address these, a plan should be drawn up to identify ways in which changes can beachieved.

It is advisable to tackle each health care problem separately (see Appendix 10). In this stepmore detail needs to be recorded including resource implications and timescale. The followingshould be considered:

equipment and facilitieshuman resources (internal and external)skill requirements and trainingcosts

In addition, political and/or cultural factors that may be relevant to the implementation planand prove barriers to change should be highlighted at this stage.

If numerous modifications are required to achieve a change, it is advisable to break theprocess down into manageable stages. For example, a series of steps could be outlined whichcan be used as benchmarks e.g. ensure all staff have been trained in the management ofdepression and establish a limited formulary.


19

Step 8. Monitoring progress

The process of implementation needs to be monitored with audit. Audit is an ongoing processwhich involves three basic steps:

Setting achievable targets- Increase Hepatitis B immunisation coverage to 50% of prison inmates.- Reduce the number of prison doctor consultations by 20% (this could be achieved byimproving access to information on self-care for minor illness, linked to the introduction ofprotocols on over the counter medication and triage by a health care worker).- Increase the proportion of health care consultations judged “appropriate”.- Train all health care staff in the recognition and management of depression.- Create a local health promotion strategy.Implementing changes so that the standards are met- Improved procedure for offering inmates Hepatitis B immunisation.- End morning “sick-parade”, implement an appointments system for the prison doctor, runclinics in the afternoon (to stop them being used to avoid work) and authorise nurses and otherhealth care workers to share clinical workloads.- Run a series of “Defeat Depression” workshops.- Appoint a health promotion co-ordinator with support from the senior management team;include health promotion as part of the business plan, incorporate in job description of seniorofficers.

Collecting data and comparing practice against these agreed standardsSome targets may be achieved or exceeded e.g.:- Data on Hepatitis B immunisation indicates 60% coverage.- Doctor consultations reduced by 25% following implementation of information, increasedaccess to over the counter medication and self-care strategy.-Following introduction of triage, a greater proportion of (a week’s sample of) health careconsultations judged “appropriate”.butOther targets may not have been achieved e.g.:- Only 6 out of 10 health care staff trained in recognition and management of depression.

The process is then repeated, setting new targets on the basis of the results of the first auditcycle. In this case, the target for Hepatitis B immunisation might be raised, a second series ofworkshops organised on depression and so on.


20

Conclusion: reviewing the needs assessment process

At the end of the health care needs assessment process the needs assessment team should havecompleted a number of tasks. It should have outlined the main characteristics of the prisonpopulation of interest and have clearly identified the key health problems of this population. Inrelation to each health problem it should have identified how many prisoners are affected andwhich prisoners these are.

The needs assessment team should also have described the informal and formal health servicescurrently available to address these health problems and then identified which services areknown to be effective in dealing with these health problems. The team should have prioritisedwhich changes should be made to these services and finally, have drawn up a plan outlininghow these changes will be implemented.

In carrying out the needs assessment the team will have gained valuable experience. It isworthwhile reviewing the strengths and weaknesses of the process and the lessons learnt. Thereview stage is an important way of passing on skills and experience. This could be done in afinal report, at a final meeting or even through an educational event.

References

1 Stevens A, Raftery J. Health care needs assessment : the epidemiologically based needs assessmentreviews, 1994, Volume 1, Oxford: Radcliffe Medical Press Ltd.2 MacFarlane I. The development of healthcare services for diabetic prisoners Postgraduate Medical Journal1996; 72:214-7.3 Smith C. Assessing health needs in women’s prisons. Prison Services Journal Issue 118:4 Cassidy J., Biswas S. et al. Assessing prisoners’ health needs. Prison Services Journal Issue 122:5 Standart SH, Drinkwater C, Scott J. Multidisciplinary training in the detection, assessment andmanagement of depression in primary care. Primary care Psychiatry 1997;3 (2): 89-93.6 University of York. NHS Centre for Reviews and Dissemination. 1993. Brief interventions and alcoholuse. Effective Health Care 1(7): p.13.7 Silagy C, Mant D, Fowler G, Lancaster T. Nicotine replacement therapy for smoking cessation (CochraneReview). In: The Cochrane Library, Issue 3, 1999. Oxford: Update Software.


21

Appendices

Appendix 1: The health care needs assessment process.

PRELIMINARY TASKS

STEP 1Description of

the prison

STEP 2Corporate and comparative

needs assessments

Form a Prison Health CareNeeds Assessment Team

Team meet to:-1. familiarise

2. plan the HCNA process

STEP 3How many prisoners have each type

of health problem in this prison?

STEP 4What health services are currently

available to this prison?

STEP 6What services are required to

ensure health care needs are met?

STEP 5What health care interventions are

worth doing?

STEP 8Monitoring and

evaluation

STEP 7Implementation plan for the provision

of effective health services

Tom Marshall, Sue Simpson and Andrew Stevens, Department of Public Health & Epidemiology, University of Birmingham.22

Appendix 2: The prevalence of physical health problems in male prisoners.

Physical conditions & health problems Prevalence (%) Overallprevalence

Expected no.in this prison

Local data if available

Epilepsy 16-24 25-34 35-44 45-64

1.1% 0.7% 0.6% 0.8%

Asthma 16-24 25-34 35-44 45+

Wheezing in the past year 20% 19% 18% 19% 19%

Diagnosed asthma 19% 12% 11% 8% 13%

Treated asthma 7% 5% 4% 4% 5%

Diabetes 16-24 25-34 35-44 45-54 55-64 64+ Total

Insulin dependent 0.3% 0.5% 0.6% 0.6% 0.9% 1.1% 0.5%

Non- insulin dependent 0.0% 0.1% 0.3% 1.0% 2.8% 4.2% 0.3%

IHD and cardiovascular risk factors 16-24 25-34 35-44 45-54 55-64

IHD 0.0% 0.3% 0.5% 3% 10%

30-39 40-49 50-59 60-69 70-74

>10% 5 year risk of IHD (whites) 1.5% 21% 58% 58% 64%

>10% 5 year risk of IHD (black) 6% 35% 53% 74% 67%

Smokers wanting help to give up (80% are smokers) 43%

Infectious diseases

Hepatitis B 8%

Hepatitis C 9%

HIV 0.3%

Sexually transmitted diseases

TB

Dental health

Special senses and disability

Disability (mobility, hearing and visual) Probably more prevalent in older inmates 0.6%

Speech and language problems Based on male young offenders 11%

The list of health problems is not intended to be exhaustive. The table should be used as a template and adapted for your prison.


23

Appendix 3: The prevalence of mental health problems in male prisoners.

Mental disorders Prevalence (%) Overallprevalence

Expectedno. in this

prison

Localdata if

available

Personality disorders Remand Sentenced

78 64

Functional psychoses Remand Sentenced

(In the past year) 10% 7%

Common neurotic symptoms Remand Sentenced

Sleep disorders 67% 54%

Somatic symptoms 24% 16%

Worry about physical health 22% 16%

Neurotic disorders (in the past week) Remand Sentenced

Post-traumatic stress disorder 5% 3%

Mixed anxiety & depression 26% 19%

Generalised Anxiety Disorder 11% 8%

Depressive episode 17% 8%

Phobias 10% 6%

Obsessive-Compulsive Disorder 10% 7%

Panic Disorder 6% 3%

Any neurotic disorder 59% 40%

Self-harm and suicide

Suicide attempts (past week) 2% 0%

Suicidal thoughts (past week) 12% 4%

Non-suicidal self-harm 5% 7%

Alcohol and drug misuse Remand Sentenced

Alcohol misuse

AUDIT score >32 (severe problem) 7% 4%

Drug dependence

Cannabis only 9% 8%

Stimulants only 17% 16%

Opiates and stimulants 15% 10%

Opiates only 11% 8%

Self-care & informal health care needs

Health promotion

Other special problems

The list of health problems is not intended to be exhaustive. The table should be used as a template and adapted foryour prison.

Tom Marshall, Sue Simpson and Andrew Stevens, Department of Public Health & Epidemiology, University of Birmingham.24

Appendix 4: The prevalence of physical health problems in female prisoners.

Physical conditions & health problems Prevalence (%) Overallprevalence

Expected no.in this prison

Local data if available

Epilepsy 16-24 25-34 35-44 45-64

1.1% 0.7% 0.6% 0.8%

Asthma 16-24 25-34 35-44 45+

Wheezing in the past year 23% 19% 17% 19% 20%

Diagnosed asthma 17% 14% 12% 11% 14%

Treated asthma 8% 6% 5% 6% 6%

Diabetes 16-24 25-34 35-44 45-54 55-64 64+ Total

Insulin dependent 0.3% 0.4% 0.5% 0.5% 0.8% 0.9% 0.4%

Non- insulin dependent 0.0% 0.1% 0.2% 0.7% 2.1% 3.1% 0.2%

IHD and cardiovascular risk factors 16-24 25-34 35-44 45-54 55-64

IHD 0.2% 0.1% 0.3% 2.3% 5.9%

30-39 40-49 50-59 60-69 70-74

>10% 5 year risk of IHD (whites) 0.5% 3% 18% 35% 64%

>10% 5 year risk of IHD (blacks) 3% 9% 70% 71% 72%

Smokers wanting help to give up (80% are smokers) 34%

Infectious diseases

Hepatitis B 12%

Hepatitis C 11%

HIV 1.2%

Sexually transmitted diseases

TB

Dental health


Disability (mobility, hearing and visual) Probably more prevalent in older inmates 0.6%

Speech and language problems Estimate based on male prisoners 11%

Pregnancy and maternity care

Prevalence of pregnancy 3%


Appendix 5: The prevalence of mental health problems in female prisoners.

Mental disorders Prevalence (%) Overallprevalence

Expected no. inthis prison

Local dataif available

Personality disorders Remand Sentenced

Probably more in remand prisoners 50%

Functional psychoses Remand Sentenced

(In the past year) Probably more in remand prisoners 14%

Common neurotic symptoms Remand Sentenced

Sleep disorders 81% 62%

Somatic symptoms 40% 30%

Worry about physical health 25% 23%

Neurotic disorders (in the past week) Remand Sentenced

Post-traumatic stress disorder 6% 5%

Mixed anxiety & depression 36% 31%

Generalised Anxiety Disorder 11% 11%

Depressive episode 21% 15%

Phobias 18% 11%

Obsessive-Compulsive Disorder 12% 7%

Panic Disorder 5% 4%

Any neurotic disorder 76% 63%

Self-harm and suicide Remand Sentenced

Suicide attempts (past week) 2% 1%

Suicidal thoughts (past week) 23% 8%

Non-suicidal self-harm 9% 10%

Alcohol and drug misuse

Alcohol misuse Remand Sentenced

AUDIT score >32 (severe problem) 8% 4%

Drug dependence Remand Sentenced

Cannabis only 2% 5%

Stimulants only 11% 12%

Opiates and stimulants 24% 13%

Opiates only 17% 10%


Health promotion


The list of health problems is not intended to be exhaustive. The table should be used as a template and adapted foryour prison.

Appendix 6: Current services and interventions employed to address health problems in the prison.

Health problem Current services and interventions employed

Physical health problems

Epilepsy

Asthma

Diabetes

IHD and cardiovascular risk factors

Infectious diseases

Dental health



Mental health problems

Personality disorders

Functional psychoses

Neurotic disorders (depression, anxiety)



Alcohol misuse

Drug misuse


Health promotion



Appendix 7: Human resources available to this prison for the provision of health care and health promotion.

Nature of human resources Numbers Total availablehours per week

Employed bywhom?

Specific skills Comments

Inmates

With access to basic health information (e.g., inmate drugcounsellors, peer educators

– –

Trained as “listeners” (counselling skills) – –

With other health related training – –

Prison Officers

With first aid training

With other health related training (eg: depression awareness)

Health care officers

Professions allied to medicine and others

Clinical psychologists

Occupational therapists

Speech and language therapists

Physiotherapists

Counsellors

Pharmacists

Health Care Professionals: nurses

Registered general nurse (RGN)

Community psychiatric nurse (CPN)

Midwives

Nurses with specialist training eg: asthma, diabetes, epilepsy

Health care professionals: doctors and dentists

Vocational trained general practitioners

General dental practitioners

Psychiatrists

Other medical specialists

Managerial and administrative staff involved in health care

Voluntary sector and self-help organisations e.g. Samaritans

The list of resources is not intended to be exhaustive. The table should be used as a template and adapted for your prison.

Appendix 8: Services and interventions that are proven to be effective in addressing health problems found in the prison.

Health problem Services and interventions that are proven to be effective


Epilepsy

Asthma

Diabetes


Infectious diseases

Dental health









Alcohol misuse

Drug misuse


Health promotion



Appendix 9: What services are needed?

Health problem Overallprevalence

Current services provided Effective interventions and servicesidentified

Changes required Priority


Epilepsy

Asthma

Diabetes


Infectious diseases

Dental health









Alcohol misuse

Drug misuse

Minor illness (for self-care etc.)

Psychological problems

Minor illness

Health promotion

Other health care needs


Appendix 10: Action plan for each health problem.

Priority No:

Health care problem: Target group:

What is being done now?

Services/interventions currently employed:

Staff and skills currently involved:

What is effective?

What changes are required?(Think about: equipment, facilities, staff, external agencies, skill requirements, training requirements, time-scale, costs)

A separate action plan will need to be completed for each health problem which has been identified.

ISBN no.

Department of Public Health and Epidemiology

Edgbaston, Birmingham B15 2TT, United Kingdom

Date post:	15-Nov-2023
Category:	Documents
Upload:	independent
View:	0 times
Download:	0 times

Health care needs assessment in prisons: a toolkit

Documents