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Tough times: supporting the health of prisoners on release

 

Time in prison can give some marginalised members of the community access to much- needed health services; but those gains are soon lost on release.

 

The health needs of Australia’s prison population are complex. Many people entering the system are acutely unwell, largely due to social and economic factors such as high levels of unemployment and drug and alcohol addiction, plus insecure housing, illiteracy and innumeracy. These can create a significant barrier to seeking appropriate diagnosis and care.

The Australian Medical Association (AMA) reported in 2012 that ‘as a group, prisoners and detainees have far greater health needs than the general population’. Many who enter the system live with mental illness, chronic and communicable disease, injury, poor dental health and disability. Indigenous Australians and prisoners with intellectual disability are over-represented in the prison population.

An Australian Institute of Health and Welfare (AIHW) report, The Health of Australian Prisoners 2015, indicated that one in two prison entrants was unemployed in the 30 days before entering prison, and two in three had not studied beyond Year 10. The same report found that one in four prisoners received medications for mental health related issues while in prison, and three in four entered prison as smokers.

Professor Stuart Kinner, head of Justice Health Unit at the Centre for Health Equity at the University of Melbourne, points out that incarceration is yet another symptom of an already marginalised population.

‘Incarceration, by definition, isn’t a choice,’ says Kinner. ‘It’s certainly not something that people, with rare exceptions, would choose. Yet from a public health perspective we tend to think of it as separate to all of the other health problems that can be responded to.’

 

From bad to better healthcare

 

Prisoners in Australia are excluded from the National Disability Insurance Scheme, Medicare and the Pharmaceutical Benefits Scheme, which Kinner says is in ‘direct contravention of our obligation to provide equivalent care to people in prison under the “Nelson Mandela Rules”.’
These are the recommended principles and practices for the treatment of prisoners, as set out by the United Nations.

The Public Health Association of Australia recommends that ‘standards of health-care service delivery in criminal justice settings should be comparable to those in community settings’.

Despite some reservations around policies, Kinner says the health and wellbeing of prisoners can actually improve when they are in the system.

‘This is partly because their health is so terrible when they come in,’ he says. ‘And partly because we do a few things to address their health needs and remove opportunities for poor health.’

Some of the provisions are quite simple, such as housing and food. Prisoners can also benefit when they quit smoking and drinking, and improve their nutrition and exercise.

The AIHW’s 2015 report notes that prisoners being discharged are more likely to rate their mental and physical health as generally good, than those entering prison.

The AIHW also states that health experiences of prisoners are largely positive: ‘Prison may provide an opportunity for people who don’t usually access health services to do so; indeed prisoners typically use health services much more extensively in prison than in the community.’

Ongoing care for ex-prisoners

 

The delivery of health services for prisoners in Victoria is the responsibility of Justice Health, part of the Department of Justice and Regulation. It contracts health service providers and reports to a committee of stakeholders from Corrections Victoria, the Department of Health and Human Services, and Victoria Police.

Dr Lyn Roberts, VicHealth Principal Adviser, is an independent committee member for Justice Health and agrees that health care in prison is well serviced. It becomes more challenging for prisoners to maintain their health and wellbeing when they leave the system.

‘Often people manage their drug issues, stabilise their diabetes and get chronic diseases identified properly in prison, for example,’ says Roberts. ‘But then how do you strengthen that and continue care once they leave? The systems don’t talk to each other particularly well around data.

‘That integrated approach is really important to give people the best possible chance for the future. It’s incredibly sad when you see some people go back on that cycle of re-offending again.’

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‘Often people manage their drug issues, stabilise their diabetes and get chronic diseases identified properly in prison.’ Dr Lyn Roberts, VicHealth Principal Adviser

Support problems after release 

One existing platform that could help with continuity of care is My Health Record, potentially providing an invaluable record of a person’s medical history – before, during and after their prison term.

‘My understanding is that prisoners, just like any of us, can opt out of My Health Record if they don’t want to be a part of it,’ says Roberts. ‘But it could give prisoners the opportunity to actually have a mobile health record they can control.’

Kinner revealed in 2015 the low level of information available on prisoners transitioning out of care, but says ‘we do know that they have a really rough time of it’.

He adds that a lack of support for people transitioning from prison increases health risks, even death, and 40 per cent of people return to incarceration within two years. ‘We really don’t invest meaningfully in supporting people’s health after they get out of prison and that’s a core problem,’ Kinner says. ‘We spend a lot of money picking up the pieces.’

The key, he says, lies in changing policy and improving post-release care – with support starting while people are still in prison.

‘Prisoners typically use health services much more extensively in prison than in the community.’ AIHW Report, 2015

A program that has resulted in correctional facilities going smoke-free exemplifies where support falls short beyond the walls of prison. The program is successful in helping prisoners quit while inside, but the benefits are not long lasting.

Maya Rivis, VicHealth Principal Program Officer for Alcohol and Tobacco, points to research that shows 94 per cent of prisoners resume smoking after release, with 72 per cent starting on the very day of their release.

‘You can understand why,’ says Rivis. ‘One of the biggest triggers for relapse in smoking is stress. They’ve left prison, which they’re probably happy about, but then they’re in this new stressful environment where they have no employment, nowhere to live, very little money, and very little, if any, support. You can imagine how difficult that is.’

 

For Kinner, the problem of maintaining healthcare beyond release is multi-layered and revolves largely around stigma and the need for cultural and policy change.

‘There is stigma associated with being in prison, with having an illness and with substance abuse, and these people are frequently characterised by complex co-occurring conditions,’ he says.

‘What is needed is cultural change and political leadership. Policy reform is important, but political leadership is a critical part of creating, enabling and supporting that change.’

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