The public health angle

There is evidence from studies in the UK and elsewhere that prisoners have higher prevalences of sexually transmitted infections (STI) and bloodborne viruses (BBV) than non-incarcerated populations.1–3 Prisoners are literally a captive audience and many use (and possibly abuse) opportunities for sex and relationship education, contraception, screening for STI and BBV, and hepatitis B vaccination during incarceration. Chlamydia screening programmes for prisoners under the age of 25 years have been successfully implemented, contributing to local targets in England and Wales.4 Partner notification schemes can be set up, and post-release STI care provided, accruing further health gains. In the UK the Genitourinary Medicine Clinic Activity Dataset STI surveillance system introduced in 2011includes a code for prisoners, and this will enhance the monitoring of STI and BBV in prisons on a national level.5 In the USA, the Corrections STI Prevalence Monitoring Project (formerly the Jail STD Monitoring Service) has been collecting such data for many years.6

Human rights and the prisoner

The practice of transporting prisoners to access health care outside prisons, shackled to one or more prison officers, is both demeaning and resource intensive. The British Medical Association has been against this practice for many years.7 Lack of provision of health care is an infringement of human rights for the prisoner. ‘Those who are imprisoned retain their fundamental right to enjoy good health, both physical and mental, and retain their entitlement to a standard of health care that is at least the equivalent of that provided in the wider community’.8 Prisons in the UK generally have in-house health care provided by doctors who are usually general practitioners (GPs), and a team of nurses managed by a healthcare manager appointed by the commissioners. The National Commission for Correctional Health Care in the USA aims to improve the quality of health care in correctional settings and sets out standards for service provision and provides guidance on management. The National Commission for Correctional Health Care recommends early detection and treatment of STI for all prisoners, and for youth in prisons this includes education and counselling on STI.

Key performance indicators

Prisons in the UK have over 30 health indicators, including hepatitis B vaccination and sexual health, with the latter containing five elements for compliance (table 1).

The responsibility for ensuring these are achieved rests with the governor of the prison concerned, who in turn works with the local health commissioners to agree on how services are delivered.

A national survey of STI services in prisons conducted in 2008 showed extreme variation in the quality of services and poor monitoring of standards.9 The ‘Standards for the management of STI 2010’10 have set best practice for all NHS-commissioned services and therefore include prison STI services. The 2008 survey shows that many services fall short of best practice as currently known, therefore it is urgent that peer review or health needs re-assessment is carried out.

Commissioning and contracting

There is currently no national guidance for commissioning and service delivery of sexual health services in prisons that prison partnership boards can refer to. Generally, commissioners want services that are broadly equivalent to those in the community, and the contract will be monitored for quality and cost effectiveness, while the governor has to ensure that services can be safely delivered in the prison setting. A good model document to use is a regional sexual health task force's ‘Guidance on commissioning sexual health and blood borne virus services in prisons in the South West of England’.11

The prison partnership board contracts one or more providers to deliver services; for example, the local STI service may be contracted to run sessions to diagnose and treat STI, while education may be delivered by a voluntary sector organisation. If your service is invited, or is successful in the tendering process, you may consider asking an expert in healthcare contracting to scrutinise the proposed contract, and decide on the length of the term. Typical measures in the contract or service level agreement include the number of sessions per year, numbers of prisoners seen, non-attendance figures (with reasons), STI diagnosed and treated. You should work with your host organisation and the commissioner to develop an appropriate contract, bearing in mind the considerations in this article and related references.

Commissioning should define core levels of service and areas for future development, appropriate to the type of prison and distribution of resources between services. Health commissioners do not have lead responsibility for sex and relationships education, condom provision and training for prison staff, but these greatly impact on the improvement of the sexual health of prisoners and it is essential to collaborate with other related providers (box 1).

Running the service

There are various models of care, from a traditional consultant-delivered service to a complete ‘patchwork’ involving prison nurses, specialist STI health advisors, specialist STI nurses, GPs and specialist doctors in STI management, each providing a component of the overall service. A few principles to bear in mind include:

• Referral/triage: agree a referral system, for example, application slips, or direct referral based on the secondary health screen questionnaire, with the prison healthcare team and link in with providers of sexual health education, ensuring the scope of your service is accurately portrayed.

• Booking: work out the capacity of the clinic, including extra slots and take into account non-attendance; record reasons for non-attendance; for example, refusal, security, in education.

• Accommodation: sound-attenuated consultation room; undisturbed intimate examination; adequate lighting; space for laying out specimen-taking equipment, keeping sharps out of prisoners' reach.

• Workforce: trained in sexual health and annually appraised; competencies appropriate for the level of service commissioned; communication with prison GP service; guidelines for syndromic management by GP on days between STI sessions; links with education service; chaperones; well-informed prison officers (especially important in high-security prisons, where prisoners are always seen in the presence of a prison officer).

• Records management: devise a case note system bearing in mind access, confidentiality, availability for clinical audit, recording of Key Performance Indicators; for example, HIV testing uptake; facilities for locked storage if kept in the prison.

• Treatment: check arrangements for prescribing, funding for the more expensive drugs (eg, imiquimod, podophyllotoxin), make arrangements for cryotherapy; check means of supply of antiretroviral drugs if relevant.

• Diagnostics: ensure specimens are delivered promptly to the pathology service and the transport time if using culture media, availability of microscopy and Gram staining.

• Results: agree a results notification system with prison staff; best practice is giving all results, be they positive or negative; alternative practice ‘no news is good news’ system, which must be enforced to avoid repeated enquiries from prisoners.

• Partner notification: decide who will advise and follow-up on partner notification; system for recording this in case records; agreement from prison staff on allowing telephone calls or emails or posted mail.

• Surveillance and monitoring: set up an information collection system to feed into clinical governance meetings and to provide data for annual reports, service reviews, etc. and ensure such data are collected regularly; data are available for contract monitoring by the commissioners; identify responsible staff in prison and also host service.

• Discharge planning: arrange continuing treatment; for example, antiretroviral drugs, wart treatment; condoms; location of nearest level 3 STI service; partner notification.

Much as the WHO checklist has transformed patient safety in surgery, a checklist for high quality STI services in prisons may help in the much needed reduction in variability and increase in standards (box 2).

Special considerations for prisons

Security may override running the clinic on some days, so make alternative plans for such eventualities. Personal security should always be borne in mind and, if available, having breakaway training is a good idea. Maintaining confidentiality—the proximity of prison staff to clinical rooms may compromise the process although personal security may be enhanced. Access to sexual health information in case notes by prison healthcare staff should be restricted by keeping separate records. These can be kept locked separately on prison premises or retained in the host genitourinary medicine service. If the latter, notes should be kept in secure container or bag during transportation. BBV screening nurses are useful allies; collaborate with them for blood tests and management of hepatitis B and C. Provide education and training for prison staff, aiming to inform of standards, raise awareness of the service and the needs of prisoners, improve cooperation with the running of clinics. Medicines that are allowed in cells (in possession medications)—no glass bottles are usually allowed for security reasons. Effectiveness of referral systems—secondary health screen question on STI could be supplemented by a referral slip to give multiple opportunities allowing for embarrassment and stress of initial incarceration. Risk of being moved—fights, court proceedings, age limit (in juvenile and young offender facilities) may make appointments difficult to arrange.