AMA Calls for Nationally Coordinated Approach to Health in the Criminal Justice System

Professor Dobb said there is a need for greater consistency of policies and practices across all the States and Territories and better integration of health and social support services.

“There is a strong association between imprisonment and poor health,” Professor Dobb said.

“As a group, prisoners have far greater health needs than the general population, with high levels of mental illness, chronic and communicable diseases, injury, poor dental health, and disability.

“Many prisoners come from disadvantaged backgrounds characterised by high levels of unemployment, low educational attainment, drug and alcohol addiction, insecure housing, and illiteracy and innumeracy.

“The growth in the Australian imprisonment rate in recent decades has disproportionately affected Aboriginal and Torres Strait Islander peoples, those with mental illnesses, and people experiencing socio-economic deprivation.

“Imprisonment can accentuate and further entrench the social and health disadvantages that contribute to incarceration in the first place.

“Access to quality health care for prisoners and detainees has important implications for the health of the wider community.

“With the constant interchange between prisons and the community, health problems and medical conditions experienced in custody become issues of public health for the community when people are released from prison or detention.

“The AMA is strongly promoting health care provision based on a principle of ‘throughcare’, which involves the continuous, coordinated and integrated treatment and management of offenders from their first point of contact with correctional services to their successful reintegration into the community.

“Throughcare is internationally recognised as a best practice approach to working with offenders to reduce recidivism, improve health outcomes, and assist community integration.”

Professor Dobb said that the AMA recommends that prisoners retain their entitlement to Medicare and the PBS, including their Medicare card, while in prison.

The AMA believes that health care in the criminal justice system should be provided according to the following guiding principles:

· prisoners and detainees have the same right to access, equity and quality of health care as the general population;

· health services in custodial settings should be resourced and designed to provide a level of care that is commensurate with the health needs of prisoners and detainees and should accommodate the diverse and complex needs of vulnerable and highly disadvantaged subgroups;

· an adequately resourced and nationally coordinated, whole-of-government approach is needed to health in the criminal justice system, which ensures greater consistency of policies and practices across jurisdictions and better integration of health and social support services;

· health service policy and provision in prisons and juvenile detention facilities must be provided independent of corrections authorities;

· the concept of throughcare should be central to the design and delivery of health services, ensuring coordinated and continuous health care from an offender’s first point of contact with the criminal justice system through to successful reintegration into the community;

· prisoners should retain their entitlement to Medicare and the PBS while in prison;

· a harm minimisation approach should be incorporated into health policy, services and standards of care in custodial settings;

· the high rates of incarceration of Aboriginal people and Torres Strait Islanders must be addressed as a priority by all levels of government;

· a commitment to addressing the factors that lead to imprisonment and the determinants of poor health amongst prisoners and detainees needs to be embedded in existing national strategies and intergovernmental agreements relating to public health, mental health, Indigenous health, disability, and homelessness and housing; and

· addressing the association between incarceration and poor health requires investment in upstream measures that address the social determinants of incarceration.

Key recommendations of the comprehensive AMA Position Statement include:

Responsibility for the provision of health care in prisons and juvenile detention facilities:

· responsibility for the provision and management of health care in state-run prisons should be allocated to state health authorities rather than corrective services or their equivalent;

In cases where private providers operate prisons or detention centres:

· prison health services should be independent of the prison operator. If both health and correctional staff are employed by a single private agency, there should be separation of management to ensure integrity of clinical records and professional responsibilities;

· the seeking of efficiencies and profit should not undermine the provision of health care to prisoners with high care needs, and who may require resource-intensive care and targeted programs;

Throughcare:

· prison and custodial health care services that provide a continuum of health services, supported by effective case management, and underpinned by the principle of throughcare;

· embedding the concept of throughcare in justice health policies and practices, from the level of systemic planning and the organisation of services, through to everyday operational practices;

· decisions to transfer prisoners or detainees give due consideration to the implications for the provision of health care, and that routine procedures are in place to facilitate the transfer of health information and continuity of care when transfers take place;

· prisoners should retain their entitlement to Medicare and the PBS (including their Medicare card) while in prison;

Assessment and screening:

· upon admission, all prisoners and detainees should receive screening from a medical practitioner for physical, addiction-related and psychiatric disorders, and potential suicide risk. Additional screenings should be undertaken periodically and as an individual is transferred between facilities or different stages of the justice system;

· health assessments should be promptly undertaken to define more fully the nature of health issues identified during screening, and to determine appropriate types of treatment. Health assessments must be undertaken by a medical practitioner or nurse, and mental health assessments should be administered by a trained mental health clinician;

· health assessments should include evaluation of substance use, hearing loss, acquired brain injury, intellectual disability and other cognitive disabilities given the significant implications these issues have for both health and recidivism outcomes;

Health promotion, early intervention and preventive care:

· prevention of illness, early identification and early intervention should be embedded within the operation of the justice system;

· health promotion strategies adopted at a national level should be inclusive of prisons and detention centres, and include input from the prison health care sector;

· immunisation against hepatitis B should be offered to all prisoners and uptake should be actively encouraged; and

· there should be standardised guidelines for the management of nicotine dependence, improved evaluation of smoking cessation programs, and free and equitable access to nicotine replacement therapy for all prisoners nationally;

Drug and alcohol services:

· prisoners with substance use disorders should have access to specialist treatment, in accordance with national guidelines, and at least equivalent to those provided in the community. Treatments should include opioid substitution therapy, detoxification programs, and therapeutic community programs;

· there should be mechanisms linking short-term prisoners and detainees with community-based services upon release, and continuity of treatment throughout admission, detention, transfer and discharge;

· accurate identification of disorders and health conditions that co-occur with substance abuse should underpin the development of appropriate treatment plans. Given the high incidence of co-morbid mental and substance use disorders, drug and alcohol services must be effectively integrated into, or coordinated with, mental health services;

· investing in court or prison alternatives are an effective way of reducing recidivism amongst offenders who have co-morbid substance and mental health disorders;

Harm minimisation:

· evidence-based harm minimisation is central to prison health care, and should be incorporated into health policy, services and standards of care in correctional services;

The AMA supports access within prisons to:

· needle and syringe exchange programs;

· sterilising equipment for tattooing and skin piercing;

· pharmacotherapy programs in accordance with national clinical guidelines (including methadone maintenance therapy);

· treatment and counselling services for alcohol and other drug problems;

· education about HIV, Hepatitis C and other blood-borne and sexually transmitted infections;

· and condoms and dental dams;

Primary care:

· primary care services in prisons have the capacity for clinical coordination, and include practitioners specialising in mental health and substance misuse;

· effective information management systems and other coordinating mechanisms are instituted to enable continuity of health care for prisoners who move between correctional facilities, and between correctional and community settings;

Specialist and acute care:

· where possible, medical specialist and allied health services should be provided on site. Where this is not possible, timely referral and transfer systems should be in place to facilitate access to external medical clinics or hospitals;

· where prisoners or detainees are transferred to hospital, an appropriate balance should be maintained between the demands of patient care and custody. Security measures should be commensurate with the assessed security risk of the patient, and should not compromise the quality of clinical care;

Mental health care:

· medical practitioners with suitable qualifications in psychiatry should be involved in the day-to-day management of prisoners with psychiatric disorders. These practitioners should also be represented at the policy and decision-making level in the administration of correctional health care services;

· persons must not be remanded in a correctional facility solely for psychiatric assessment;

· mental health services in prisons should be adequately resourced to provide appropriate screening, assessment and therapeutic procedures, including for co-occuring mental health and substance use disorders;

Suicide prevention:

· each correctional facility should have a suicide prevention strategy, including procedures to systematically screen inmates upon their arrival at the facility and throughout their stay in order to identify those who may be at high risk;

· corrections staff should be trained in suicide awareness and risk assessment, and appropriate systems should be in place to ensure prompt access to appropriate care and effective communication and notification of risk status within and between institutions and prison health staff;

· a prisoner or detainee who is identified as having a significant risk of suicide should be offered supportive human contact, access and communication with someone trusted, including family members and other appropriate people outside the correctional facility as appropriate. A prisoner or detainee should not be put into seclusion solely on account of their suicidal ideation;

Oral health care:

· routine dental health screening and follow-up care be an essential part of prison health services.

Correctional settings:

The AMA recommends that prison policies be instituted to support healthy settings, including:

· protections against harm caused by tobacco smoking (including passive smoking);

· support in adopting healthy behaviours, including appropriate levels of physical activity and a balanced diet;

· measures to promote mental health, including adequate time for association, meaningful occupation, and contact with people from outside the corrections environment;

Post-release support:

· develop formal linkages with community health services to facilitate transfer of essential information for the patient and the subsequent provider of care, and provision of medicines or a combination of medicines and written prescriptions;

· have ongoing arrangements with community agencies to ensure the continuation of psychiatric care and treatment for substance misuse after release from correctional facilities;

· arrange initial contact with community-based welfare and support organisations;

· train staff in the specific responsibilities of post-release planning and needs assessment.

Aboriginal and Torres Strait Islander peoples:

· Governments address the high rates of Indigenous incarceration as a priority;

· concerted efforts be made to establish suitable alternatives to imprisonment for Aboriginal people and Torres Strait Islanders, including the expansion of diversionary programs, non-custodial sentencing options, and justice reinvestment programs;

· Aboriginal and Torres Strait Islander peoples have full access in prison to culturally appropriate primary health care, including management of chronic illness, social and emotional wellbeing, mental health, and drug and alcohol problems;

· Aboriginal and Torres Strait Islander culture is respected in the design and provision of health and medical care in prisons and juvenile detention facilities; and

· access to Aboriginal health workers be expanded across Australia’s prison system,

· Aboriginal and Torres Strait Islander prisoners and detainees have access to community elders and to relevant representatives of their communities to address their cultural beliefs and needs;

People from non-English speaking backgrounds (NESB):

· routine access to accredited interpreters be made available for medical appointments, mental health services, and health screening for NESB prisoners or detainees, and for programs that support prisoner health and wellbeing; and

· people who are from NESB backgrounds and are in custodial settings have access to culturally appropriate health care and education programs, and are screened and assessed using culturally appropriate health screening protocols;

Young people:

· young offenders are fully screened and assessed when taken into custody, particularly for acquired brain injury, sexual health, hearing, foetal alcohol syndrome disorder, intellectual disability, and other conditions known to be prevalent amongst juvenile detainees;

· rehabilitation and education should be a primary focus of the health care provided to young people in custody;

· prisoners and detainees under the age of 18 should not be housed in an adult correctional facility;

Women:

· health services for female prisoners are resourced and designed commensurate to their levels of need, and recognise women’s gender-specific health care needs, including access to antenatal, obstetric and post-natal care and gynaecological health services;

· cervical screening and breast cancer checks are readily available, and all new female patients coming into prisons are maintained on existing pharmacotherapy treatment regimes unless clinically indicated;

· where practicable, arrangements are made for infants to be born in a hospital outside the correctional facility, and for the infant to remain with their mother at least until the age of two years, provided that the infant's welfare is not compromised by such arrangements;

· infants born in correctional facilities have adequate nutrition and access to paediatric care, and there should be sufficient facilities for the parent to properly care for the infant, including the provision of play areas,

· if an infant is born in a correctional facility, this must not be recorded on their birth certificate;

People with a disability:

· prisoners with an intellectual or physical disability are provided with relevant services and facilities, including for dual disabilities and/or multiple morbidities associated with disability;

· the heightened support available to people with disabilities in the broader community through the National Disability Insurance Scheme is available to people with disabilities in prisons.

Data collection, monitoring and evaluation:

· monitoring and accountability mechanisms should be comprehensive across the justice system and encompass private as well as publicly operated corrections facilities;

· data collected in different jurisdictions should feed into national reporting against standardised benchmarks, with the outcomes used as a basis for continuous improvement in terms of identifying gaps in service delivery, prioritising areas of need, and allocating resources; and

· the privatisation of prisons should not compromise the independence, accountability and quality of prison health care. Contractual arrangements should support rigorous monitoring and accountability mechanisms, including transparency in the allocation of costs, and reporting against benchmarks and standardised health indicators.

Professor Dobb said that many prisons and detention facilities currently provide a number of the services, practices and activities recommended by the AMA, but there is a lack of national consistency in quality and quantity of these services.

“Best practice must become the usual standard practice across the country,” Professor Dobb said.

The AMA Position Statement on Health and the Criminal Justice System 2012 is available at http://ama.com.au/position-statement/health-and-criminal-justice-system-2012