The finding came during a wider investigation exploring how prisons maintain continuity of care, both for internal (GP, dentist) and outpatient (hospital, specialist clinic) appointments.
The report states that often due to staff shortages, female prisoners are accompanied by male prison officers or a mix of male and female officers to appointments that are sensitive in nature or require intimate examinations (breast, gynaecological, obstetrics). One national organisation told HSSIB that they had heard reports of a woman being handcuffed to a male prison officer during a mammogram.
In addition to their concerns about privacy and visual dignity, patients and healthcare staff told the investigation that personal hygiene was not taken into consideration. This was particularly the case for women who were going to obstetrics and gynaecology appointments. The women stated that they wanted to shower before these appointments but were not given enough notice.
In the report, HSSIB says the HM Prison and Probation Service (HMPPS) policy ‘goes some way to detailing the expectation for sensitive female outpatient appointments, there is sufficient latitude that female patients may be escorted by escort crews containing male prison officers to any appointment.’
The privacy and dignity concerns described by national organisations, healthcare staff and patients were also complicated by the issue of medical confidentiality. Patients often had their clinic appointments with prison officers in the clinic room, removing patient medical confidentiality. The investigation was told some patients were put on a ‘long cuff’ which meant the officer could sit just outside the room while still attached to the patient; however, this was still within earshot of the conversation between the patient and the clinician.
Missed appointments
Concerns over dignity, privacy and confidentiality are a key reason for patients, especially female prisoners, not attending appointments. Data in the report showed overall ‘did not attend rates’ were high for outpatient appointments. However, when it came to appointments within the prison, the investigation was told female prisoners are very engaged and the attendance rate is good.
The investigation explored other reasons why prisoners miss appointments more than people in the community. HSSIB heard there were refusals based on prisoners prioritising social time or family visits, forgetting appointments or dismissing the health concern. Healthcare staff told HSSIB that often patients engagement and awareness in relation to risks to their health or making decisions could be low.
However, our report also points out that, due to privacy and security issues, patients are not always given the information they need to make informed decisions about their health. The report says ‘they may not be informed about timings, the nature of appointments or the health reasons for appointments.
The investigation also found there are times when missed appointments were out of their control due to prison rules, logistics and resource issues. For example, patients may be locked down in their cells, transport may not arrive or there may not be enough staff available to escort them to the appointment.
Remote technology
HSSIB identified that the use of video and phone appointments in prisons has declined since the end of the COVID-19 pandemic and is rarely used in comparison to face-to-face appointments.
Our report emphasises that using video and phone calls could help to solve some of the issues seen with missed outpatient appointments. It could increase the number of outpatient appointments available and reduce the number of appointments that patients refuse to go to. It could also potentially reduce the cost related to prison officer escort duties which costs around £48 to £50m per year.
Importantly, using remote technology could improve continuity of care for prisoners and reduce health inequalities. Whilst many female patients may have to be examined in person, digital appointments could create opportunity to share sensitive concerns or symptoms in a comfortable environment.
The safety recommendations in the report focus on ensuring dignity for prison patients, promoting the use of ‘telemedicine’ within the prison system and ensuring continuity of care on prisoner transfer or release.
Investigator’s view
Dave Fassam, Senior Safety Investigator at HSSIB, says: “We recognise that providing continuity of care to prisoners does create complexity – it is reliant on a number of processes aligning, not just inside the prison but with other healthcare providers and community services. There are security issues and also well-documented pressures on resources, specifically prison officer availability and numbers.
“However, our investigation highlighted that it can simply be the case that dignity and privacy of prisoners is not considered in the way it should be. This is concerning and we have emphasised it needs to be a priority when prisons are assessing the arrangements for outpatient appointments. It is even more important for female prisoners who may feel vulnerable and anxious about being escorted to their appointment by male prison officers. We know this is a huge factor in appointment refusals and could have a negative impact on female prisoner health, especially if they are having investigations relating to breast or gynaecological cancers.
“As well as improving standards around dignity and privacy, we have recommended that the prison system be enabled to make better use of technology. Video and telephone consultations would make it easier for patients to attend, improving continuity and equity of care and reducing the cost and time burden of missed appointments. Ultimately, our findings, recommendations and observations are aimed at ensuring patients in prison are not at a significant disadvantage when it comes to accessing safe and effective outpatient care."
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