Our findings demonstrate the significant challenges of managing LTCs in remand prisons, as highlighted by the fact that 75% of prisoners were no longer in the receiving study prison six months after entering prison. Of those still in prison, just 11% remained in the receiving study prison, with 14% transferred to another prison. The numbers were even higher for those with an LTC. Eighty-four percent of those with an LTC were no longer in the receiving study prison at six months. Regarding MH, 54% of those with a co-morbid MH condition were no longer in the receiving study prison at six months. Therefore, still being in the receiving study prison at six months was not associated with an increased likelihood of having either a co-morbid MH or physical LTC.
Regarding prevalence, 17% of the sample had at least one LTC, the most common condition being asthma, confirmed in 12% of the sample. Having an LTC was associated with female gender and increasing age. The confirmed prevalence rates for the other LTCs were hypertension 3%, CHD 2%, diabetes 2% and COPD 1%. The prevalence of epilepsy was 3%, but there was considerable variability between prisons. The likely reason for such variability is coding practice for patients with either pseudo-seizures or alcohol withdrawal seizures.
Our findings highlighted just 34% of the eligible sample had a QOF template completed. QOF completion rates varied between LTCs and was highest for asthma (40% completion rate), and lowest for diabetes (8% completion rate). Demographic variables were associated with QOF completion. Higher rates of completion were associated with younger age. There were also statistically significant inter-prison differences. This coupled with our finding of significant variation for time to completion triangulates with the findings in our linked paper reporting qualitative findings of differing clinical practice between prisons.
Strengths and Limitations
Our findings make a significant contribution to the evidence base regarding prevalence of LTCs in prisons, which constitutes an under researched area. As far as we are aware, this research is the first peer-reviewed study exploring existing processes regarding QOF monitoring in UK prisons. Whilst collated from four remand prisons, we are confident that our findings can be generalised across the remand prison estate, and also to training prisons, since all prisoners in such establishments have at some point been transferred from remand prisons.
Whilst extracting data from just four prisons could be perceived as a limitation, it remains the largest UK multi-centre research study to quantify LTC prevalence from clinical records and, the only UK study exploring prison based QOF monitoring processes.
Comparison with Existing Literature
Our prevalence statistics broadly concur with previous research conducted which highlights respiratory disease as the most prevalent LTC in UK prisons and prevalence statistics of lower than 5% for each of diabetes, CHD or hypertension.11 Our research highlighted that the level of agreement between self-report in the first night primary care consultation and subsequent supporting evidence was good for all the LTCs. This concurs with a UK data-linkage study in which self-report survey findings regarding LTC prevalence were cross checked with prisoner patient records and highlighted a good level of agreement regarding the prevalence of physical LTCs.3
The community prevalence rates for LTCs in the UK has been recorded as: asthma – 8% (+3.6% compared to global prevalence); COPD – 1.8% (-1.5%); CHD – 11.2% (+2.2%); diabetes – 7% (-1.8%), hypertension – 24.2% (+9.2%); epilepsy – 0.8% (-0.1%); opioid dependence - 0.4% (equal to global prevalence); depression - 3% (-0.9%); alcohol dependence – 0.9% (-0.5%) and schizophrenia – 0.95% (+0.67%). Within the UK, 1 in 4 people will experience a MH illness each year, the most common being General Anxiety Disorder (5.9%) and depression (3%). Differences can, therefore, be ascertained between the prison and community population.
Implications for Research and/or Practice
The key implication for future research is that for future prevalence studies of LTCs in prison settings, extraction and secondary data analysis of routinely collected clinical data will be as effective, but less costly than administering surveys to patients. We would recommend implementing research processes that fulfil the necessary requirements pertaining to robust information governance to facilitate extraction and anonymisation of routinely collected clinical data.
Regarding implications for practice, since LTC prevalence is associated with increasing age, yet our findings show an association between younger age and QOF completion, this presents a pressing training need to target QOF activity where the burden of disease is highest.