Guidance

NHS population screening: improving access for people in secure and detained settings

Published 19 March 2021

Applies to England

People in secure and detained settings have a right to medical care and preventative measures. They are entitled to healthcare that is equivalent to that in the community.

Since 2006, NHS England has commissioned healthcare services in secure establishments. It commissions a primary care service, GPs, nurses, healthcare assistants, dental and optometry services.

This guidance primarily refers to screening people in prisons but also applies to people in other NHS Health and Justice secure and detained settings such as immigration removal centres, secure children’s homes, secure training centres and young offender institutions.

1. Health inequalities

Compared with the wider population, people in secure and detained settings often have higher rates ^{[footnote 1] [footnote 2]} of:

• physical ill health ^{[footnote 3]}
• some screen-detected conditions such as diabetic retinopathy ^{[footnote 4] [footnote 5]}
• social and emotional problems
• depression and serious mental illness
• self-harm and suicide risk
• learning disabilities
• smoking
• alcohol and substance misuse
• blood-borne viruses

People in secure and detained settings often come from under-served sections of society and may have issues with access to healthcare services within and outside secure settings ^{[footnote 6] [footnote 7]}.

Secure and detained settings offer an opportunity to address health inequalities and improve health outcomes for a number of long-term conditions ^{[footnote 8] [footnote 9]}.

There is a contractual requirement for national evidence-based healthcare practice and standards to be implemented in secure and detained settings.

All people in secure and detained settings are entitled to access NHS population screening programmes. The principle of equivalence of care applies but modifications may be required to screening pathways to take account of the circumstance of imprisonment.

A 2016 rapid review of the impact on health outcomes of NHS commissioned health services for people in prisons identified access to screening as an area in need of improvement.

For example, women in prison have higher rates of cervical cancer and are less likely to have had cervical screening ^{[footnote 10] [footnote 11]}.

2. Roles and responsibilities

Prison healthcare services have a duty to ensure safety and to address urgent health issues. They also have a duty to detect and manage long-term conditions and to provide screening programmes.

It is essential commissioners, screening providers, prison healthcare teams, primary and secondary care services, including specialist mental health services, work closely together to:

• plan and organise screening services in secure and detained settings based on findings of systematic health and social care needs assessments
• ensure consistent, effective delivery of screening services in secure and detained settings
• eliminate or reduce barriers to screening in secure and detained settings
• maintain continuity of the screening pathway when a person enters a secure setting, is transferred, or is released
• optimise coordination and communication between healthcare services in the community and secure and detained settings

2.1 Partners

The NHS England and Improvement (NHSEI) national and regional health and justice teams are responsible for the commissioning, tendering and performance management of healthcare services in secure and detained settings.

Public Health England’s (PHE’s) national health and justice team and 9 regional health and justice leads support the NHS by providing advice and evidence.

PHE’s screening and health and justice teams, health protection colleagues, screening and immunisation teams, local authority directors of public health, and criminal justice partners in prisons and the community all support the work of NHSEI in commissioning healthcare in secure and detained settings.

2.2 Requirements

The National Partnership Agreement for Prison Healthcare in England 2018-2021 sets out the agreement between the Ministry of Justice (MOJ), the Department of Health and Social Care, HM Prison and Probation Services (HMPPS), NHSEI and PHE.

The NHSEI Specification 29 Section 7A Public Health Services for Children and Adults in Secure and Detained Settings in England describes the scope of public health programmes commissioned by NHSEI for people in secure settings.

The specification states that:

• healthcare services provided to people in secure and detained settings should be equivalent to that available to people in the wider community
• all eligible people in secure and detained settings should have access to all cancer and non-cancer screening programmes for which they are eligible

The provision of healthcare should be consistent between secure and detained settings because services are commissioned against the same national service specifications.

The PHE Screening inequalities strategy states that providers and commissioners should aim to make sure people in secure and detained settings have equal access to screening as defined in the public sector equality duty.

National screening pathway requirement documents and contract schedules include an equality statement that states providers “will make sure systems are in place to address health inequalities and ensure equity of access to screening, subsequent diagnostic testing and any treatment or interventions for everyone invited for screening”.

Screening providers and commissioners should use the screening health equity audit guide to help identify screening inequalities in secure and detained settings and plan to reduce those inequalities.

3. Advice for commissioners

Commissioners of abdominal aortic aneurysm (AAA) screening, antenatal and newborn screening, bowel cancer screening, breast screening, cervical screening and diabetic eye screening need to be aware of prisons and other secure and detained settings in their area where eligible individuals might be detained.

Commissioners should highlight to service providers their responsibility as defined in the service specifications to enable people in secure and detained settings to access screening.

Commissioners should:

• ensure the screening needs of people in secure and detained settings are checked regularly through systematic health and social care needs assessments
• use local screening programme boards to raise the profile of people in secure and detained settings and their screening needs
• work to ensure prison healthcare providers understand all the NHS national screening programmes and their eligible cohorts
• work to ensure prison healthcare providers identify their eligible cohort to screening services on a regular basis
• make sure IT systems are in place to enable timely and secure transfer of information between prison healthcare providers and screening providers to identify and invite eligible screening cohorts
• support screening providers to develop and share appropriate information for prison healthcare providers so they are confident in discussing screening with people in secure and detained settings
• identify and close any gaps in knowledge and awareness among prison healthcare staff, screening providers and contracted services by sharing published evidence on the screening needs of people in secure and detained settings
• make sure prison healthcare providers have sufficient staffing and resources to provide preventive services
• ensure quality of screening services provided in secure and detained settings is measured against important indicators such as coverage

4. Advice for screening providers

All local providers of abdominal aortic aneurysm (AAA) screening, antenatal and newborn screening, bowel cancer screening, breast screening, cervical screening and diabetic eye screening need to be aware of secure settings in their area where eligible individuals might be detained.

Screening providers should work with commissioners and prison healthcare teams to deliver the relevant national screening pathways for people in secure and detained settings.

Local screening service providers should establish strong links with screening commissioners and prison healthcare teams. They should work towards gaining a shared commitment to the provision of screening services between all partners. Their primary points of contact should be named screening leads within each prison healthcare team. It is important for screening providers to establish good working relationships with clinical leads and advanced nurse practitioners (nurse prescribers) in prison healthcare teams.

Screening providers, facilitated by screening and immunisation teams, should engage effectively with prison healthcare teams to ensure all prison healthcare staff understand screening and can have confident screening discussions with people in secure and detained settings. Best practice can include the delivery of screening education and training events for prison healthcare staff and reciprocal fact-finding visits to each other’s settings.

This shared knowledge and resources should cover:

• an understanding of screening pathways, tests and target populations
• the possible benefits and harms of screening
• the importance of people in prisons being able to make an informed choice about screening
• the use of national screening information resources, including the printable screening timeline and easy guide resources for people with learning disabilities and low levels of literacy

In addition, screening providers should work with prison healthcare teams to:

• identify and regularly update the eligible screening cohort in the secure setting and the screening status and history of each individual
• develop processes for people to be screened safely within or outside the secure setting
• offer screening when it is due, and within the secure setting, whenever possible, even if during a short sentence
• ensure reasonable adjustments are put in place for individuals who require them (adjustments can include longer appointments or communication support such as easy read materials)
• make use of the reasonable adjustment flag record, if available, to identify individuals who require a change to the standard screening pathway in order to access screening
• establish a referral pathway for people in secure and detained settings who require follow-up tests or treatment following their screening result
• identify a suitable receiving hospital (known as a category A hospital) for referrals, and procedures to arrange safe transfer and admission of people requiring treatment
• make sure there are arrangements to continue and complete treatment if an individual is moved to another establishment or discharged

Procedures to arrange safe transfer and admission of people requiring screening and treatment should describe the:

• communication process between hospital and prison healthcare professionals
• roles of hospital security staff and prison staff during transfer
• areas in the hospital where individuals are allowed

Local screening service managers should be mindful that some staff might not feel comfortable or safe going into a prison environment to provide screening clinics.

5. Advice for prison healthcare teams

Each prison healthcare team should have named screening leads responsible for screening within that establishment. The screening leads should be the primary points of contact for local providers of abdominal aortic aneurysm (AAA) screening, antenatal and newborn screening, bowel cancer screening, breast screening, cervical screening and diabetic eye screening.

The prison healthcare team should work with local screening providers to support the provision of screening in the establishment.

To ensure continuity of care, the prison healthcare team should link with each individual’s community GP practice when they arrive and again on their release.

The prison healthcare team should work to make sure all individuals who are eligible for screening:

• are identified
• are invited for screening
• receive accessible and culturally appropriate information in a variety of formats and at different times so they can make an informed choice about screening
• receive all the screening pathway information relevant to them, including information about results and recommended follow-up tests
• receive answers to their individual questions
• are offered screening in a way that respects their dignity throughout the pathway, including being given time to prepare for screening tests and being screened in surroundings that protect their privacy
• can access screening, any follow-up tests and treatment if they wish to do so

It is the responsibility of the prison service to arrange the escorting and transport of any eligible individuals who need to travel outside the secure setting for screening tests or follow-up appointments.

Eligible individuals who remain registered with their community GP practice are automatically sent screening invitations to their registered address and may therefore not receive those invitations. Meanwhile, individuals registered with the prison GP practice may not be automatically identified by the national screening IT systems.

There must be a smooth transfer of information between the prison healthcare IT system, screening IT system and community primary care records. This helps to make sure eligible prisoners are identified correctly and can access the whole screening pathway.

Other best practice for prison healthcare teams includes:

• having a named point of contact who people in secure and detained settings can contact to get more information about screening if needed
• regular communication with local screening services, with secure transfer of data and information
• using a systematic approach to identify people eligible for all NHS population screening programmes
• making reasonable efforts to offer screening to eligible people in the secure setting
• helping people to understand their screening results when available
• linking with category A hospitals when required, including transferring the relevant patient information to healthcare professionals in charge of the patient and contributing to their understanding of the secure setting
• communicating with healthcare providers from other settings to make sure any relevant follow-up tests are offered when a screening test result comes back after a person has been transferred

Prison healthcare teams should work with local screening providers to organise screening clinics and plan the safe delivery and collection of appropriate screening equipment and test kits into secure and detained settings. This work can include, but is not restricted to:

• delivery and collection of bowel cancer screening test kits
• enabling AAA screening ultrasound machines, retinal screening cameras, equipment and laptops to be brought into secure and detained settings
• provision of suitable examination couches for supine AAA screening
• enabling women to have breast screening off site in a hospital setting if required
• supporting screening staff to feel more comfortable by providing guards outside screening clinic rooms
• identifying any security and safety risks associated with screening kits and equipment

6. Lived experience feedback

6.1 Health champions

Many people in secure settings are more open to discussing screening and other health issues with fellow prisoners. It is considered best practice for establishments to have identified health champions who can help spread information and act as screening advocates to other prisoners.

Health champions could be offered tailored training to help them answer non-medical questions about screening.

6.2 Communication

User feedback from ex-prisoners suggests people in secure settings prefer face-to-face communication with healthcare staff to electronic methods. Face-to-face communication can help to establish trust in screening and overcome prisoners’ fears.

It is important to have continuity of healthcare between community and secure settings and between secure settings, including the immediate and automatic sharing of NHS records. This helps to make sure prisoners do not have to repeat information about themselves many times. This is particularly important for people with anxiety.

7. Young person and adult screening

7.1 AAA screening

Local screening providers should refer to the AAA screening standard operating procedures. Annex C of this document includes a step-by-step process that providers can follow to make sure eligible men in secure settings can access AAA screening.

7.2 Bowel cancer screening

Prison healthcare teams should send a monthly list of people eligible for bowel cancer screening to the appropriate regional bowel cancer screening hub. Prison healthcare teams can email PHE.YPAScreening@nhs.net to check the contact details of their regional hub. The hub will then enable an invitation to be issued.

Screening centres and prison healthcare teams should collaborate and have standard operating procedures covering how to manage individuals who need further investigations following completion of a screening test kit.

Prison healthcare teams can email PHE.YPAScreening@nhs.net to check the contact details of their local screening centre.

7.3 Breast screening

Prison healthcare teams are responsible for identifying women who are eligible for breast screening and communicating this to the local breast screening provider. Best practice includes sending a monthly list of people eligible for breast screening to the local breast screening service.

Breast screening services that have a women’s prison within their catchment area should liaise with prison authorities on a regular basis.

Services should cross-check details with the women’s screening history on the BS-Select IT system to make sure they have not been screened within the past 36 months.

There are 2 models for the delivery of breast screening for people in secure and detained settings:

1. Screen eligible individuals at a mobile or static site in the community or in a hospital setting. Screening at a static site allows women to be screened more easily when their test is due. Eligible individuals may need escorting by the prison service. It is the responsibility of the prison service to arrange this. The local screening service may want to allocate appointments for people from the secure setting at the end of the screening clinic when they may be more comfortable attending with escorts.

2. Hold a screening clinic for all eligible individuals in a mobile screening unit in the grounds of the secure setting. An agreed frequency should be established for this approach. It is suggested this should be a minimum of once every 3 years, taking into consideration the transient nature of the population. The cost and associated downtime of transporting the mobile screening unit would need to be factored into the 3-year screening round plan.

Option 2 is more difficult to deliver and only accounts for eligible women who reside in the secure setting at the time of the mobile unit’s scheduled visit. The service delivery model should be agreed between the screening provider, commissioner and the secure setting.

7.4 Cervical screening

It is important to consider that a relatively high proportion of women in secure and detained settings may be victims of sexual violence, have had other traumatic experiences or mental health issues.

These women may find it difficult to attend cervical screening because they feel anxious.

It is important that prison healthcare teams try to provide the information and support these women need in order to attend screening if they wish to do so.

7.5 Diabetic eye screening

Diabetic eye screening (DES) is an essential part of care for everyone aged 12 and over with a diagnosis of diabetes (type 1 or type 2).

Diabetic retinopathy has been found to be higher in people with diabetes who are in secure and detained settings ^{[footnote 4]}.

Screening should be carried out at least annually but can be provided opportunistically if the local screening service is able to provide screening on site.

Prison healthcare teams should work with the local DES provider to make appropriate arrangements for screening to take place and for the identification of eligible individuals with diabetes.

8. Antenatal and newborn screening

Pregnant women in secure settings are offered antenatal and newborn screening as part of standard NHS care.

Babies born in secure and detained settings are not detainees but do reside in the secure setting.

Newborn hearing screening and the newborn and infant physical examination (NIPE) often take place in hospital before mother and baby return to the secure setting.

Newborn blood spot screening should be taken on day 5 by the community midwife visiting the secure setting.

The baby will have a GP outside the secure setting who is responsible for their care. The baby will not be the responsibility of the prison primary care service.

9. Acknowledgements

This guidance was developed in consultation with the national NHS screening programme teams in PHE, the national and regional NHS England and Improvement (NHSEI) health and justice (H&J) teams, the NHSEI national public health commissioning team, the PHE national H&J team, North West screening and immunisation teams, NHS Digital and the East Midlands Health and Justice Lived Experience Panel.

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