Does living in prison lead to worse health? And how could prisons be an opportunity to address serious health inequalities? Anna Charles explores the health and wellbeing of people living in prison, their access to health and care services, and what happens on release. She’s joined by Dr Jake Hard, Chair of the RCGP Secure Environments Group, Christina Marriott, CEO of Revolving Doors, Chantal Edge, Public Health registrar and NIHR research fellow, and Kate Morrissey, National Implementation Lead for RECONNECT at NHS England and NHS Improvement.
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AC: Anna Charles
CM: Christina Marriott
KM: Kate Morrissey
CE: Chantal Edge
JH: Jake Hard
AC: Hello and welcome to The King’s Fund podcast where we talk about the big issues and ideas in health and care. I'm Anna Charles, I'm the Senior Policy Advisor to the Chief Executive here at The King’s Fund and I'm going to be your guest host for this episode. Today we're going to be exploring health and health care for people in prisons. Now in their recent enquiry into prison health, the health and social care select committee said that prisons could be an opportunity to address serious health inequalities which are part of the cycle of the disadvantaged faced by people in prison, but they also said that while no one is sentenced to worse health that is too often the outcome. So to help us navigate those issues and opportunities I'm joined by four fantastic guests. I'm going to ask each of them to introduce themselves. So Christina, let's start with you.
CM: So I'm Christina Marriott, I'm the Chief Exec of Revolving Doors Agency and we're a small charity who work around policy, particularly bringing lived experience into policy debates around those in the Revolving Doors group, those who are in and out of the criminal justice system and in terms of prison very often serving very, very short ineffective sentences. AC: Thanks Christina. Kate, what about yourself?
KM: My name is Kate Morrissey, I work for NHS England and NHS Improvement in part of the health and justice team and I'm responsible for mental health of people who live in prisons and also care after custody the new Reconnect service.
AC: And Chantal, what about your background?
CE: So I'm a public health registrar and now I'm an NIHR PhD fellow at UCL researching around the areas of prisons and hospital care specifically around the use of video consultations and prisoners' experience of accessing hospital care.
AC: Thanks, and last but not least Jake.
JH: My name is Dr Jake Hard. I'm a part time prison GP and I've been working in prisons for about fourteen years. I'm currently the chair of the Royal College of GP Secure Environments Group and have been doing that role for about the last four years.
AC: Well thanks all. I wanted to start by setting the scene really, so I wanted to think a bit about the context of the prison population. Christina, I wonder if you could give us a bit of an overview. So how many people are we talking about? What are the sorts of health issues that people living in prison might face?
CM: So in terms of the people in contact with the criminal justice system we know the police deal with 1.7 million people each year, a bit over one and a quarter million will be sentenced most of whom will go into community sentences. Those in immediate custody is about 88,000 and at any one point we have just under 90,000 people at the moment in prison. It's worth pointing out that's doubled in the last 20 years and the government is now talking about another 10,000 prison places. We have internationally very, very high rates of imprisonment. So we have the highest rate in Western Europe and there are very few countries who imprison more people than we do. Of course there are many more people serving community sentences and on probation and in and out of prison and one of the things to understand is the churn in and out of prison. So 70% of women who are sentenced to a prison sentence go for less than six months. For men it's about 50% who go for less than six months. In terms of their health, and I think that churn is important when we think about health because we have to think about the pathway in and out and reconnecting with services, services being disruptive, people being taken into prison and not being able to get back into mental health services or physical health services when they come back out; when we think about the health challenges if we think about the health and equality social gradient very often prisoners are people who fall off the end of that gradient. So the challenges are really profound. So we see blood born virus rates off the scale. So 13% of women will have Hep C for example, HIV is very common, musculoskeletal problems are very common. When we think about mental ill health, two thirds of male prisoners have a diagnosable personality disorder, half of women. Half of women in prison are depressed, a third of men are depressed. So really, really profound inequalities expressed through smoking rates, through substance misuse or whether it's through mental ill health and very often very low engagement with services. This is the end of the health gradient where people literally fall off the edge.
AC: And Jake, you spend some of your time still working as a GP in prisons, does that tie in with your experience?
JH: Yes, most of my clinical work at the moment in HMP Eastwood Park which is a lady's prison, a high proportion of the people that come in in evening reception will be coming in on very short sentences, often I'll have known them historically because of their revolving door nature. For them I see that coming back to prison is a chance at a break for the cycle of what's going on outside, but equally it's a pretty desperate place going back into prison again knowing that they are only there for actually a very short space of time and we as health care providers know there's only so much we can do. For those that aren't used to the system you're talking about another set of people who are being essentially torn away from their families and their other support networks. It's pretty desperate to be so powerless over the system and feel that you've got no real connection other than this very closed environment that you're now in. So you can see how people will resort to adverse behaviours to try and get their feelings across and it's pretty distressing to watch and I find it … from a personal point of view, as much as I love going in there to help people, I find it very sad myself to see women in that state.
AC: And Kate, from your experiences.
KM: So I think from NHS England and NHS Improvement our services are providing for these patients within a really, really difficult environment. So prisons are difficult, we've heard high levels of depression, strict regimens, very limited access to wellbeing activities in some cases and so we're seeing this as a pathway of care and an opportunity to improve people's health and then to complete that pathway we need to ensure that these people are reconnecting back into community health services when they leave the establishments, and I think that to me is key, that something … that these are people. People in prison are absolutely part of the communities. They may be in prison for a while but they will be back in the community and we need to make sure that we safeguard the health gains and then embed them and improve them as they move forward out of … and become prison leavers.
CM: And if I could just comment that I think it's even more than just safeguarding those health gains, it's also about thinking about how risky that moment of release is. So we know the mortality rate on release from prison is horrific. If you think about the suicide rate for women just released from prison it is 40 times the general population. For men though it's still ten times the general population rate and we see huge amounts of substance misuse death in literally the day or two after release from prison. So we also have to acknowledge that actually going into prison brings a risk and that very real risk is death on release. So there's a lot to be said about doing good gains but we also have to acknowledge that there is something fundamentally very, very risky about putting people in prison.
AC: Some really shocking statistics there and we're going to talk a bit later on about specifically what can be done around that period of release and return into the community. I've also heard people talk about this idea of the community dividend, this idea that what you do in terms of people's health and wellbeing in prison reaches far beyond those individuals and the walls of the prison. Christina, can you say a little bit more about what that means, what it involves?
CM: And I think certainly Public Health England have been really clear about the positive things around community dividend. So if you can start positive health work in prison and that carries on through the gate back into the community, actually you're reaching into those communities that are on the whole away from health interventions and I think there are some really good examples around things like blood born viruses, vaccination rates, smoking cessation where you can see the benefit to the wider community of those who have been in prison. Of course the reverse can also happen. So we have some anecdotal evidence from lived experience that, for example, spice was first part of the drug scene in Birmingham because people were coming out of prison and had discovered it as their drug of choice in prison and were then essentially driving the market because their demand was we want spice over anything else. So that dividend can be negative or positive, but I think there are some really good examples of how good work in prison can take that health dividend out into the community. So there is an opportunity there but we shouldn't run away with an idea of healthy prisons that help communities, there are healthier ways you can do it which is supporting people in the community.
AC: Yes, and I think I've heard a lovely or read a lovely phrase in some of the documents your organisation has produced that this sort of sums up why looking after the health and wellbeing of people in prison isn't just the right thing to do it's the wise thing to do as well from a public health perspective.
CM: It's entirely sensible. AC: Yes. So I want to move on to talk a bit about the kind of health and care services that people can access while they're living in prison. Jake, can you talk us through what kind of support might be on offer within the prison walls?
JH: So since 2006 the provision of health care services in prisons has been commissioned in England by NHS England essentially as a primary care service and really it's primary care plus because you have dental services, optometry services, as well as general practitioners and nurses, health care assistants. So it's a really big team of people in there and they will deliver everything from the immediate first night reception through to chronic disease management, long term condition management and substance misuse services. So it's a real diverse range of skills that you need inside the prison within your health care team.
AC: From the point of view of somebody who's living in prison, what is it like for them to interact with that sort of primary care plus service that you described with the professionals? Can they book themselves an appointment? Do they go on their own? How does it look and feel from the user's point of view?
JH: It varies from prison to prison. Some places you have to put in an application which is a piece of paper saying I want an appointment. If you say I need a pair of glasses obviously you'll be channelled over to an optometrist rather than a GP, if it's a discussion about medicines or a painful knee then of course you're going to be put in with a nurse or a GP to discuss that. I believe in some prisons they're using telephones to allow prisoners to make appointments.
KM: Yes, we have some pod systems and some online systems within some establishments and also telephone lines with access to things like Samaritans, mental health support as well.
AC: Because I imagine things like privacy must be really difficult to offer, things that are quite straightforward for other services or are there ways round that?
JH: Privacy actually is something largely very well catered for. So you will have … in our prison for example you have a consulting room, it's the prisoner that comes into the room with me, it's just me and them and we have a chat and it's confidential. There's no need for anybody else to be listening to the conversation and largely I mean I think when you talk to other people who don't work in prisons they think, oh aren't you scared? Isn't it dangerous in there? I've never been attacked or anything like that inside a prison. I've never felt that unsafe. So I don't have any concern about giving that availability to that person so that they can have that confidential conversation with me. The challenges to that are when we talk to prisoners in segregation because of course they will often … you will often be speaking to them through a door in the presence of officers, but I think confidentiality for any health care provider is such an important part of your job that you would do everything you can to ensure that you provide that to your patient group.
AC: So we've started touching on there a bit, Chantal, about the experience that people might have when they need to go outside prisons for treatment because obviously there's a limit to what can be offered within a prison itself. I think a lot of your work has focused on this area, can you tell us a bit about how it works if somebody needs to go outside for specialist medical treatment or mental health services or whatever it might be?
CE: So obviously they'll see the GP and they'll make a referral to secondary care, but the problem is is that when someone goes out from prison to secondary care they've got to go with prison officers and so because there aren't hundreds of prison officers around to escort hundreds of patients out every day, essentially these appointments or what they call escorts everyday are limited. So the prison system advocate for four transfers to be available to hospital every day, but realistically I found in the prisons I work with it's around two or three per day that they can spare.
AC: And is that because there's not enough -
AC: - officers to go round?
CE: There's not enough prison officers to take any more patients out. So effectively what it means is that appointments are rationed in such that people will be prioritised for who's most urgent to go out. So prioritised alongside their peers, if emergencies come up on the day they may have to go out. If you're not that serious you could wait months and months and months for your turn to come up. So there's first this issue with not enough appointment escorts, but not only that they're not allowed to know when they're going off site for security reasons. So actually they're waiting a very long time in complete limbo having no idea when they'll be taken. Then they'll often find that on the morning someone may come along, "You're going now," or you're going in half an hour's time, no time to shower, you might have come just from work, no time to mentally prepare, think of all those questions you wanted to ask nine months ago, off you go, you're strip searched, handcuffed, put in a taxi with prison officers and whisked out to the hospital. Then of course when you get to the hospital you're in handcuffs and people notice that. So people stare at you, people take photos, staff don't know where to put you. We've had people talking about being put in broom cupboards with old crutches and bits of medical equipment. Finally when you get in to see the doctor the doctor sees the handcuffs they might be a bit unsure who to speak to. We get lots of reports that the doctors speak to the prison officers not to the patient. The prison officers they can go on a long chain to get out of the room, more often they either don’t offer it, the doctor doesn't know they can ask or perhaps the prison officer refuses, meaning that they stay in the consultation room with the patient. So actually in the hospital setting there is very little privacy if that happens. They will be privy to the conversation and to any examinations that take place. I mean we had one woman for instance talking about an examination for past female genital mutilation with a male and a female prison officer in the room who could see all the examinations. It's horrendously distressing. Then after that because there are prison officers there may not be any sort of clinical handover to the prison health care staff team. So you might find that something is prescribed at the hospital that actually you're not allowed within the prison rules. So people go back and then find out that they can't have the medication they're prescribed and in fact the whole process adds up to being so stressful that you find a lot of people say, "I wouldn't go through that again."
AC: I know as part of your research you've done lots of work both understanding the perspectives of people in prison and what sort of experiences they've had, and also the experiences I think of staff, medical staff, who have had contact with people, can you say a little bit more about the themes, stories, experiences that you've heard from people and what that feels like?
CE: So when you talk to people who are actually the patients who have come out the prison, like I said, you'll find generally reporting relatively negative feelings about the hospital process, not necessarily about the staff but people often describe their experience as being like animals, being dragged like a dog on a lead, like a bull with a ring in its nose, how embarrassed they feel, how infantilised by having the prison officer speaking over them. So they tend to have pretty poor feelings about the hospital experience, but when they have had a good experience the way they remember it is in a golden light, "Oh my goodness, someone offered me a cup of tea I couldn't believe it. They spoke to me like a normal person and said hello to me first," and that shouldn't be such a big deal, that should be expected. In terms of the staff, so we did quite a lot of pre-engagement work with staff around what they felt about prisoners when they came into their care. When it comes to the younger staff I think there's definitely a training gap. So I spoke to several junior doctors and I asked them some questions such as, "Do you think people in prison are entitled to equivalent care as community patients?" and one of them looked at me and he thought and he said, "Well, I know they're not allowed to vote so I'm going to say no," which was a bit of a shock. We had others who I said, "Do you know why … who comes in handcuffs, why people come in handcuffs?" and the fact is that everyone goes in handcuffs because they don’t want people to escape, and they said, "Oh, I presume the ones in handcuffs are the really violent ones and I shouldn't be left alone with them." So there's a lot of misperceptions to counter amongst people.
AC: Yes, and that's really quite shocking that perception from the staff member because actually it's widely I think agreed that people in prison should have access to equivalent health care and also that a prison sentence is about deprivation of liberty not deprivation of your health. So quite a lot of misperceptions there.
CE: Yes. CM: And I think there's a … I think that reflects a more general misconception actually, people think we only send to prison people who are violent and a threat to the public. They don't know that huge numbers are sent to prison for shoplifting, for evasion of your TV licence fine, for not paying your council tax and very often for low level acquisitive crime and I'm not supporting … obviously I'm not supporting criminal activity, but a lot of this is very low level stuff that is committed driven by addiction or mental ill health or sometimes the vulnerability of actually wanting to get back into prison. So I think there's a fundamental misconception that people assume that every prisoner is somehow really violent, really threatening, really risky, really high … a high risk person and actually the vast majority of people we send to prison aren't, they've done low level crimes.
AC: Christina, I think you have got quite a bit of experience in your organisation about working with people with lived experience to understand their perspectives. I said this because I think what you're saying Chantal there is about the importance of stories and understanding why this matters, I can also imagine that people would often say, "Oh it's just too difficult, it's just too difficult to work with people in the criminal justice system, to involve them." So what experiences do you have of how that can be done? So really bringing people with lived experience to improve the services so they work better for them.
CM: So I would completely reject the idea that it's too difficult.
CM: It might be complicated but it's not too difficult, and more than that it's absolutely vital actually. So most of us who have worked in the NHS, in commissioning, as a clinician, we come from very different life chances to this population and for us to imagine that we can design services for this population without their input I just think is the height of arrogance because we just don't understand those lives. So we do lots of work taking people with lived experience into NHS commissioning, into thinking about improving services, we also do work with other bits of the criminal justice system. I think what's always really striking is how positive are groups who all have lived experience, they've all been in and out of prison and the criminal justice system. What's always really striking is how positive they are about wanting to make good change and how pragmatic they are about wanting to make good change. So to give a couple of examples, over some years a group of lived experience worked at the national strategic level of designing the liaison and diversion services that are in police custody and in courts and they are there to screen for vulnerability and address and divert people into health services, and for about four years our lived experience group kept saying, "You really need peer support in this because we know it works, it works in substance misuse, we know you can't get people to your first health care appointment because they don’t trust the NHS. The way to overcome that trust issue is to have peer support to help people in," and the NHS was very willing to listen but I think really struggles with the idea of commissioning peer support as opposed to commissioning clinical, but they were really open hearted and listened to it and lo and behold four years later it was piloted, it evaluated, it gave really good engagement rates, it gave really good access to health care and it's now being rolled out nationally. So I think our lived experience can work at the national level really well but they can also work and have done some brilliant work actually at quite a detailed level in prison. So we were talking earlier about privacy. One of the bits that comes up through our lived experience team is privacy in the medicine queue in prisons. So one of the things we hear and a lived experience team worked with one of the NHS England regions around this, they heard that as everybody from all the different wings came together in the medicine queue actually it was such a place of violence and bullying that some of the patients were refusing to get their medicine. It was just too risky for them to go down there, they didn't feel safe enough. There were particular issues around some prisoners with learning disabilities picking the meds up and then just getting bullied into handing them over to other people. There were issues around mobility, so people not being able to stand up long enough in that queue. NHS England's commissioners responded really well with that. They and the lived experience team went in and spoke to the health care team and spoke to the prison regime and within half an hour they said, "Right, okay, so everybody we know who is vulnerable, will take their medicines at the hatch so they don't have to go back through the queue and be bullied into handing their medicines over to somebody else. We'll put some chairs out so people with mobility can sit down whilst they wait," and that queue was transformed really quickly but it was never known until people actually listened to the lived experience just how bad the queue was.
AC: One of the things that is striking me, as all of you are speaking actually, is how much a lot of this rests on lots of different services and agencies being able to work together, something that we know people generally tend to find quite difficult working outside their organisational boundaries, but all the good examples you're talking about seem to be coming about when people are managing not to do that. Kate, some of the examples you've given about the work NHS England and Improvement are doing seems to be a lot of work with Revolving Doors, with Public Health England and others too.
KM: Absolutely and I think we have to remember that when we're talking about a prison environment we are delivering our health care services in someone else's house. So we have to abide by their rules but work in partnership with them to ensure that we can absolutely deliver the right care and we work in cross government to make sure that we are delivering outcomes that are equal for all and that we're not siloed in our thinking and we absolutely do work in partnership to try and improve things. We don't always get things right first time, but we are working really hard to try and embed good practice, share that and then build upon that.
AC: And Chantal, your work then that looks at when people are requiring services outside of prison, do those partnerships … can they work effectively across that boundary? I'm wondering if I were a medical professional and one of my patients coming to see me in my outpatient clinic was a prisoner, would I feel able to work as part of the … with Jake and his colleagues to address their needs?
CE: So I think there's a lot of willing but it's very hard. So I've been working with one particular system for three years now, one area of England, and sort of acting almost as the liaison initially between the hospital, so the community system, and the prison system and I've been doing some interviews recently and I think some of the comments there encapsulate the feeling that were there definitely at the start and I say to the clinical commissioning groups and I say to the hospital managers, "Are prisons on your health care radar?" To be honest, no, they weren't. They are a tiny part of our patient group, we don't see that many, we're focusing on our own strategy, and then you speak to prison health care teams, "Where does hospital care for your patients sit on your radar?" "Well it's sort of once they've gone out of the hospital they're not really our problem, we've got too much to deal with here," and then because there's quite a high turnover in … or not necessarily, but providers are on five year contracts within the prisons and so by the time they get in and they embed as the health care team they're not going to spend all their time trying to build a relationship with the local hospital. So there generally weren't any forums for people to meet and discuss their commission separately. We did try to set up some steering groups which worked quite well. There were forums where prisons and hospitals came together to discuss local innovations which are being done in the community that could be offered to prisons, but ultimately there even became issues there of is this a prison group that hospitals are going to? Is it a hospital group that prisons are going to? Who should be running it? It just became very political. So I think there's a lot of willing but the system is difficult where the commissioning is separated and there's a need to kind of increase visibility and the need to help the patients in the prison, to suggest to a lot of the community services that they're likely to move back into the community, they're likely to be a patient you're going to see in a few months' time, they're not just in another world because they're in prison and try and facilitate those relationships, but it's not easy.
AC: And I imagine even things like sharing of notes and information might be not quite there yet.
KM: So obviously this is a national issue and NHS England and Improvement is absolutely dedicated to resolving this and we've invested a significant amount of money into our health and justice information system which is rolling out new capabilities all the time, including the functionality to allow GP to GP transfer of notes so that we can absolutely have that information at the GP or the nurses' fingertips. We're also … we were successful in including within the new primary care contract for community GPs around preregistration and rolling out the capacity to preregister people who do not have a GP within the community before they leave prison so that we absolutely know where they're going and we can make sure that any notes, any follow up appointments are directed to the correct place.
AC: And so previously would it have been the case that someone would come out of prison and only then would they be able to register with a GP? KM: Some people were in for such short lengths of time that they're not registered with a GP … they don’t deregister with a GP.
AC: I see, they're still registered.
KM: So they already have a GP, they know where they're going. Some people have been in for so long that they're inactive on the GP records and … but in the past people would be given a discharge summary and the Spine would be updated as far as it could be but this is a real innovation and it's going to make a real marked change in the improvement of health care for prisoners.
CM: Can I just say how important that is in terms of the pathway of care. So we know one in four people who have come out of prison after a sentence of less than six months come out with nowhere to live and of course it's really hard to access a GP if you don't have anywhere to live. It's one in seven of the general population in prison come out homeless. So this is not an significant number of people and obviously it's not your first priority. If you've got nowhere to live then registering with your GP is probably quite a long way down. That busy day when you're released, when you have to go to probation on that day, you've got to find somewhere to sleep that night, thinking about how you access your health care, how you get registered with a GP, even how you get your script ends up a long way down the list and that's one of the reasons why we see the spike in substance misuse deaths in the first 48 hours after release.
AC: So what happens if someone is released from prison and they are having active treatment, for example for substance misuse, what's available to them when they come out?
JH: So normally when somebody is having treatment with either methadone or buprenorphine inside the prison on an ongoing basis while they're in prison normally you would only continue that treatment when you know that there's an outside provider who's willing to pick up that treatment on release and there are different services that will pick up those patients when they're released. So Rapid Access Prescribing will normally facilitate those immediate Friday release prisoners for example and then carry on their prescribing in the community. So there's a pretty good system that's been in place for a number of years around that. The difficulties, as Christina is pointing out, is around those patients that perhaps are not allowed to go back to the area that they came from for licence conditions or for a number of other reasons and then it becomes a bit more of a challenge, but we often have sight of that and try and deal with that ahead of the curve, but of course you do get people released from video link or from court and we're none the wiser.
CM: There's real variability.
JH: Yes. CH: So we took some people with lived experience of prisons to speak to a minister last year and one of the things that came up was actually real disruptions in prescription of antipsychotics both on the way in and on the way out. Not being able to access antipsychotic medicine as they came out obviously led to really significant difficulties. I know Public Health England estimated that probably about a third of the people coming out of prison who have been on substance misuse treatment then get picked up in the community, now that data is a bit old, and I'm hoping that it's been improving recently. What was really frightening was that they said that they thought that was the best pick up rate. So mental health services would be worse. Now if we're only picking up a third there are real issues and certainly from the lived experience point of view we do hear of lots of issues about being released at five o'clock on a Friday and having no access and I think we still see it in the substance misuse deaths, we still see it in the fact that people don't have methadone and there's also really those pragmatic issues. So I was talking to somebody a few months ago who said he was released with a script and he had a pharmacy to go to except he had to go every day in order to get daily prescribing and the pharmacy was down in the centre of town and the centre of town was two bus rides away from him and he didn't have enough money to get to that pharmacy everyday and so he literally did withdrawal on his own because he couldn't afford to get daily down to get his methadone script. So I think there's those kind of really pragmatic issues that people have.
KM: I think also we need to highlight that women very often have a very difficult pathway because they are often so far away from home and so if they have been in prison for a period of time and they may be having secondary care somewhere local to the prison and then when they're going back home to their … which would be a large distance away, we have to negotiate the local health landscapes to get that care continued and it is something that we're working on to improve, but that is generally the difficulty of keeping people so far away from home which is why we do have specialist women's pathways throughout our services.
AC: And that being further way that's because there's fewer women's prisons so people tend to have to be further away for those -
AC: - sentences, is that right?
JH: And just take a moment to think about female prisoners from Wales because of course there are no female prison places in Wales at all, they all go over the bridge to England. So …
AC: So connecting back into communities is even more challenging.
AC: So we're nearly out of time, but I do want to ask you all just one final question. So looking to the future and summing up your answer in just a single sentence because we really are nearly out of time, where would you like to see prison health in five years' time? Let's start with you Jake.
JH: I think my key thing is getting prison research, proper research, undertaken on a systematic basis in the prison so we can really start to understand what the health needs are and start working towards delivering to meet those needs and indeed improve the health care of people who are in provision.
KM: For myself I think it would be that we were viewing prisoners as part of the community and treating the health care services and the access to health care as people would within the community and not seeing prisoners as separate and offenders as separate because in no other health care setting would you know that someone had committed a criminal offence and so we need to … just because where they live does not need to impact on their care.
CE: I think in the era of the integrated care systems I would like to say that I would like to see prison health care further integrated into the community. I'd also reiterate what Jake says about research. Doing research in prisons is tricky, it's hard, so a lot of people don't try but actually we need a bit more.
AC: Christina, what about you?
CM: So in five years' time I would like to see prison health care treating far fewer people because I would like to see fewer people in prison particularly those who are driven there by mental ill health and substance misuse, but those who are there I would like to see in an integrated system that treats them from the community into prison and back out and I think good strides are happening in that direction but that still remains the challenge.
AC: Well thank you all so much. That's it from us, you can find the show notes for this episode and all our previous episodes at www.kingsfund.org.uk/kfpodcast. Thanks as always to our podcast team, our researcher Emily Cooper and our producers Ian Ford and Sarah Murphy and thank you to you for listening. If you enjoyed this episode then please do subscribe, rate and review us on iTunes or wherever you get your podcasts because it helps others find us and it helps us improve the show and of course we hope you can join us next time.