Delivering health care in prisons presents unique challenges. Nuffield Trust’s research project, funded by the Health Foundation, is using hospital data to gain a better picture of the health needs of prisoners and the use they make of secondary health care services. We have also been thinking about the impact of wider social and contextual factors on the health of the prisoner population. This blog examines one common and striking characteristic – the number of prisoners with experience of homelessness before and after their imprisonment.
Homelessness is hard to measure, but in 2017 it was estimated that over 250,000 people in England were homeless – around 1 in 200 people. At least 15% of people are homeless on arrival in prison, and an even larger proportion are likely to be homeless on release. Between January and March last year, more than 7,000 people left prison to either 'unsettled’ or unknown accommodation, which often translates into sleeping rough or temporary accommodation. When people describe prison as a revolving door, homelessness can be a contributory factor.
But what are the health issues that link prisoners and those who are homeless, and are there common approaches that might help both groups?
Health care issues in common
We know that historical experience of abuse, being taken into care and unemployment can affect prisoners’ health , and the same can be true for people who become homeless. Indeed, while less than 1% of children are in care, a quarter of the prison population and a similar proportion of people who are homeless have been in the care system. This can affect people’s attachments, relationships and mental wellbeing.
Head injuries are also more prevalent for people who have these experiences than they are for other parts of society. Some 4% of all hospital admissions by prisoners relate to injuries to the head, and research in Glasgow found that being homeless means you are five times more likely than the rest of the population to be admitted to hospital with a traumatic brain injury.
Such injuries are often the result of assaults. Since 2010, physical attacks against prisoners have doubled.
Reducing staffing and funding in prisons contribute to an environment where prisons become less safe with an increased risk of being an assault victim. Self-harm incidents in prison are also at record highs according to the Prison Reform Trust. Crisis argues that people who are homeless are 17 times more likely to be a victim of violence, with one in three reporting they had been hit or kicked over the previous year.
Beyond head injuries, health needs related to the use of drugs and alcohol are also a significant issue. Crisis reports that two-thirds of people interviewed said that drug or alcohol use was a reason for them becoming homeless, while in 2017/18 more than 55,000 over 18s in secure settings such as prisons were receiving alcohol or drug treatment.
How can things be improved?
At a time where rough sleeping has increased by 165% since 2010, it’s more vital than ever to ensure that leaving prison does not lead to people becoming homeless, and that becoming homeless doesn’t lead towards imprisonment. We need more options for safe and secure accommodation for all people at risk of homelessness, including those leaving prison.
The government has launched a pilot project to support prisoners to find accommodation on release, but housing is only part of the picture – the way that health care is managed in prisons and on release also has a role to play. Prison provides regular food and somewhere to sleep, and for those with a health condition such as diabetes, being in that environment and having access to health care may mean it is well controlled. Leaving a routine without the right support in place, particularly if homeless, can contribute to people ending up in A&E or back in the criminal justice system.
Pilot projects that address specific health needs (such as the Drug Recovery Prison pilot) are helpful, but we need to know what ‘works’ or shows promise before applying it more broadly. What can be effective is for health professionals such as nurses providing support in prison that can continue to impact on health when people leave prisons.
For instance, last year the Queen’s Nursing Institute funded a project to offer latent tuberculosis infection (LTBI) testing to prisoners at HMP Birmingham, aiming to improve people’s self-care on release. 10% of people tested positive for LTBI and were given vital treatment. The project offers an encouraging case for more people in prisons to have awareness about TB, as well as more testing in prisons to evaluate whether there is a public health case for a nationally applied prison screening programme. Having a community nurse able to come into prison to deliver care also helped to identify other issues and helped to join up care between prison health and the community health teams.
Breaking the cycle
Ultimately the health of people in prison is about more than what happens in prison. It reflects their wider experience such as homelessness, and it is important that these overlaps are acknowledged and underlying health problems addressed, to give prisoners the best possible chance of sustaining good health when they are released.
If some people arrive at prison having previously been homeless, and some leave prison with nowhere to go, it can be impossible to escape that cycle.
*The Nuffield Trust prison health project is funded by The Health Foundation, an independent charity committed to bringing about better health and health care for people in the UK.
*The Queen’s Nursing Institute’s Homeless Health Programme is funded by Oak Foundation, and is network for health professionals with resources, guidance, events and funded nurse-led innovation projects aimed at improving care for people who experience homelessness. Find out more.