Understanding and improving the quality of primary care for prisoners: a mixed methods study (Qual-P)

Description

Funded by NIHR HS&DR, Ref: 17/05/26

Background

The prison population experiences a disproportionately higher burden of illness and poorer access to treatment and prevention programmes compared to community populations. Prisoners consult general practitioners and other primary care professionals more frequently, and receive inpatient care at least 10 times as frequently. They have significant levels of long-term illness and disability, premature mortality, rates of communicable disease, mental health and drug and alcohol problems. There is a need to ensure that appropriate care and primary prevention is provided to prisoners both during and following their prison sentence. Relatively little research has examined the quality of primary care provided in prisons, however. While significant advances have been made in improving care for the population as a whole, disparities persist for patients with the most complex health needs or marginalised communities, such as prisoners. NHS England has set a key commissioning strategic goal to reduce the respective gaps in healthcare and health outcomes between those in criminal justice and the rest of the population.

Most research with prison populations has understandably prioritised drug misuse, mental health and communicable disease. Relatively little attention, however, has been given to common conditions that affect the quality and length of life and are amenable to evidence-based treatments such as hypertension or asthma. There has been little exploration of variations in the quality of care across prisons or between prisoner groups in the UK or how the provision of routine health care is disrupted by the prison environment.

We have previously developed and applied a set of ‘high impact’ quality indicators for primary care, based on criteria including: burden of illness (e.g. prevalence, severity), potential for significant patient benefit (e.g. longevity, quality of life), scope for improvement upon current levels of achievement, and the feasibility of measurement using routinely collected data. This study will build upon these to understand variations in prison primary care and initiate strategies to improve prisoner healthcare and outcomes. Currently, the detection and treatment gaps in the prison population are unknown, thereby undermining priority setting and planning reduce avoidable mortality and morbidity in this population.

Aim and objectives

The aim of this study is to explore gaps and variations in the quality of primary care for prisoners and identify quality improvement interventions to promote high quality prison care. We have four objectives:

1. To identify candidate quality indicators based on current national guidance which can be assessed using routinely collected data through astakeholder panel.

2. To explore perceptions of quality of care, including barriers to and enablers of recommended care and quality indicators, through qualitative interviews involving both ex-prisoners and prison health care providers.

3. To assess the quality of primary care provided to prisoners through quantitative analysis of anonymised and routinely held prison healthcare records.

4. To integrate the above findings within a stakeholder consensus process in order to prioritise and enhance quality improvement interventions which can be monitored by our set of quality indicators.

Methods

This is a mixed methods study, which comprises of four inter-linking work packages:

WP1: Identification of quality indicators

In this work package we will identify candidate quality indicators based on current national guidance which can be assessed using routinely collected data through a stakeholder panel. We will conduct a focused scoping review to identify any recent qualitative and quantitative research on quality of primary healthcare in prisons. We will then use a consensus development process to identify and select quality indicators for the prison population, which can be assessed using routinely collected data.;

WP2: Explore perceptions of quality of care

Work package 2 will explore perceptions of quality of care, including barriers to and enablers of recommended care and quality indicators. We will use qualitative interviews to explore ex-prisoners’ and prison health care providers’ attitudes, perceptions and experiences.

WP3: Assessing the quality of care

In work package 3 we will assess the quality of primary care provided to prisoners through statistical analysis of anonymised and routinely held healthcare records. Analysis will be based on the quality indicators identified in WP1. We will explore variations in the quality of care across prisons, prisoner groups and conditions. These data will be analysed to determine the quality of care that prisoners received across the years for each of the quality indicators, along with the use and uptake of preventive services.

WP4: Identification of interventions to improve prisoner health

Finally, we will integrate the findings from work packages one, two and three within a stakeholder consensus process in order to prioritise and enhance quality improvement interventions which can be monitored by our set of quality indicators. We will share our findings from WPs1-3 and seek consensus on key areas for intervention, and on what kinds of quality improvement interventions need to be enhanced or adopted to improve quality of care.

Impact

Our research will drive a new improvement agenda for the primary care of prisoners, aiming to address inappropriate variations between and within prisons and inform strategies to close the likely gaps in health care and outcomes between prison and community populations.