Measuring and improving health, and the quality of healthcare that people in contact with probation receive
As part of ensuring that people in contact with probation receive appropriate healthcare, we need to consider how their health and the quality of the healthcare that they receive could be measured, monitored and improved.
Healthcare quality can be defined in terms of the Darzi dimensions of quality, which are commonly used in evaluation of NHS services in the UK:
- Safety:prevention of harm caused by healthcare or lack of healthcare
- Effectiveness:improvements to or worsening of health status
- Patient experience:patients’ memory of what they received and which aspects of care they regard positively or negatively
When thinking about how such dimensions of quality can be measured, Donabedian (2005) divides information that can be used to measure the quality of care into three categories – information about:
- Structure:infrastructure and resources in the settings within which healthcare is provided e.g. staff training, equipment, buildings, staff to patient ratios, policies and procedures
- Process:what actually happens to deliver a desired outcome – includes technical and interpersonal aspects of care delivery e.g. giving vaccinations
- Outcomes:the impact on the service user in e.g. changes in health status, improvements in health literacy, or improved service user experience (Donabedian 2005)
Our recommendations here are based on:
- Findings from six national surveys that we conducted asking Clinical Commissioning Groups, Public Health Departments, Mental Health Trusts, the National Probation Service, Community Rehabilitation Companies and probation Approved Premises about what data they already routinely collect that could be used to measure and improve health and healthcare quality
- Data from interviews with key stakeholders in six areas of England,
- Reference to wider literature such as the NICE guidance for physical health of people in prison [NG57] and for mental health of adults in contact with the criminal justice system [NG66], and the National Probation Service Health and Social Care Strategy 2019-2022
Findings from our surveys told us a little about the outcomesthat some organisations routinely record, but did not tell us much about the processes or structures that lie behind those outcomes. Consequently, we have created a list of possible indicators that organisations could use for monitoring and improvement. These are shown in the table below.
| Darzi Dimension of Quality | Donabedian Definition | ||
| Structure
(Present/absent) |
Process
(Rates) |
Outcome
(Rates) |
|
| Safety | · Mortality review process in place
· Adverse event monitoring/review process in place |
· Mortality review process in place
· Adverse event monitoring/review process in place |
· Mortality rate
· Proportion of people attempting suicide · Proportion of people committing suicide · Proportion of people that self-harm |
| Effectiveness | · Probation involvement in commissioning
· Creation of pathways into services for different conditions · Systems for access to health professionals (e.g. GP, dentist) and services
· Registers of conditions e.g. mental illness (including personality disorder), learning disabilities, disability, substance misuse |
· Proportion of cases where GP registration (or lack of) is recorded
· Proportion of non-registered service users that go on to be registered with a GP
· Proportion of cases where dentist registration (or lack of) is recorded · Proportion of non-registered service users that go on to be registered with a dentist
· Proportion of service users screened for hazardous or dependent drinking [Prison reception screen Q13] · Proportion of hazardous or dependent drinkers a) offered and b) accepting referral to substance misuse services · Proportion of service users screened for drug misuse [Prison reception screen Q14 and 15] · Proportion of those misusing drugs a) offered and b) accepting referral to substance misuse services
· Proportion of cases screened for mental illness [Prison reception screen Q16-20] · Proportion of ‘likely’ or known cases of mental illness a) offered and b) accepting referral for diagnosis and/or treatment or c) continuing with existing treatment
· Proportion of cases where smoking status is recorded · Proportion of smokers a) offered and b) accepting referral to smoking cessation services
· Proportion of cases where physical health measures are recorded
· Proportion of cases where need or absence of need for vaccinations is recorded · Proportion of cases established as needing vaccinations that are a) offered onward referral for them and b) accept this referral · Proportion of cases screened for communicable diseases · Proportion of cases found to have a communicable disease a) offered and b) accepting referral for treatment or support · Proportion of people offered safe sex education |
· Proportion of NPS areas and CRCs reporting involvement in commissioning
· Proportion of staff that are aware of and understand these pathways · Proportion of people that are registered with a GP · Proportion of people that are registered with a dentist · Proportion of people drinking at hazardous or dependent levels
· Proportion of people misusing drugs · Proportion of people showing a reduction in misuse of drugs
· Proportion of people reporting well managed mental health
· Proportion of people smoking
· Proportion of people reporting well managed physical health
· Proportion of service users identified as in need of vaccinations that receive them
· Proportion of people with communicable diseases
· Proportion of people practicing safe sex |
| Experience | · Service user experience measure or survey | · Proportion of experience surveys returned
· Proportion of cases where service access is considered to be timely (number of days) |
· Proportion of service users reporting positive experience of services
· Proportion of service users reporting encountering barriers to service access |
Much of the above could be achieved through National Probation Service and Community Rehabilitation Company staff or a healthcare professional based with probation conducting a health assessment and making onward referrals to healthcare as appropriate for all new cases as set out in the NICE guidance on the physical health of people in prison. This covers aspects of both physical and mental health, and we have included key question numbers from this assessment in the table above.
Our suggestions fit well with the commitments set out in the National Probation Service Health and Social Care Strategy 2019-2022.
Our research showed that currently, very few Local Authorities include the health needs of people in contact with probation in their Joint Strategic Needs Assessments which inform local level healthcare commissioning. Data collected from the above process could be used to inform this type of assessment, providing data to enable comparison between the health needs of individuals in contact with probation, and members of the general population in a geographical area.
In addition, Her Majesty’s Prison and Probation Service are in the process of producing datasets from their routinely collected data, which could potentially be used to inform this and other commissioning processes.
Moreover, Public Health England has produced evidence-based guidance on undertaking Health Needs Assessments in prescribed places of detention which is available at:
Public Health England is also currently developing guidance on undertaking a Health and Social Care Needs Assessment for people in contact with the criminal justice system who are living in the community.
We would also suggest that it would be beneficial for all NPS and CRC areas to have a named Offender Health Lead with responsibility for sharing the above data at aggregate level with healthcare commissioners and providers and establishing inter-agency referral and information exchange procedures for staff to use and disseminating these to staff.