Original Research | Published: 7 February 2024
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Comparing the rate of inpatient admissions of prison residents with COVID-19 to the general population in England in 2020/2021 using Hospital Episode Statistics data

https://doi.org/10.1136/bmjph-2023-000515

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Abstract

Objective To compare the rate of inpatient admissions of prison residents with COVID-19 to the general population and to consider differences in the use of inpatient and outpatient services by prison residents in England in the first year of the pandemic (2020/2021), to the 12 months prior to the pandemic (2019/2020).

Methods The pseudonymised records of patients who accessed admitted patient care and outpatient hospital services from a prison address in England between 1 April 2019 and the 31 March 2021 were extracted from Hospital Episode Statistics data. Descriptive statistics summarise the most common primary admitting diagnosis and the proportion of outpatient appointments attended and not attended. Indirectly standardised adjusted admission rate was calculated to compare the rate of inpatient admissions by prison residents with COVID-19 to the general population.

Results The standardised adjusted admission rate for COVID-19 was 2.2 times higher in prison than the general population. Hospital data highlight continuing challenges regarding high levels of violence and self-harm resulting in hospital admissions during a period when people were spending an increasing amount of time in their cells.

Conclusions Despite efforts to minimise the spread of COVID-19 in secure settings, prison residents in England were significantly more likely to be hospitalised with a COVID-19 diagnosis relative to the general population during the first year of the pandemic. This is in addition to the wider implications of the COVID-19 restrictions, particularly spending extended periods in isolation, on people’s mental health.

What is already known on this topic

  • During the COVID-19 pandemic, there were a significant number of COVID-19 outbreaks in prisons in England.

What this study adds

  • Prison residents in England were significantly more likely than people in the general population to be admitted to hospital with a diagnosis of COVID-19 in the first year of the pandemic.

How this study might affect research, practice or policy

  • This study highlights that joint working between the five national bodies that form the National Partnership Agreement for Health and Social Care for England is vital to address the complex healthcare challenges of secure settings.

Introduction

England and Wales had higher rates of COVID-19 infection among people in prisons than the general population throughout the early stages of the pandemic.1 There were over 10 354 confirmed positive COVID-19 cases among prison residents up to end of January 2021.2

Prisons are high-risk settings for outbreaks of communicable diseases. They are often characterised by overcrowding, poor ventilation, inadequate access to sanitation, and restricted access to, and quality of healthcare relative to the community.3 This paper investigates the likelihood of prison residents in England being taken to hospital relative to the general population in 2020/2021—a time when the average size of the prisoner population was approximately 80 000 people.4

Many people who enter the custodial system have established complex needs that have not previously been diagnosed or recognised. While prison can potentially offer an opportunity to identify health conditions and provide appropriate early intervention,5 prisons are unhealthy environments—for instance, the ability to exercise and eat healthily is severely restricted—and health outcomes for people in prison are poor. Prison residents have a higher standardised mortality rate than that of the general population and lower life expectancy.6

Within prison settings COVID-19 controls included physical distancing measures, use of personal protective equipment (PPE) and other infection prevention and control measures, and consequently restrictions to the normal regime were in place, meaning people had less time out of their cells.3 The restrictions affected services and activities important for well-being and mental health as well as rehabilitation, including access to education, training, employment and social visiting as well as health and counselling services.7

There were a significant number of COVID-19 outbreaks in prisons during the pandemic, and between March 2020 and April 2021, there were 3.3 times the rate of deaths of prison residents in England and Wales compared with people of the same age and sex in the general population.8 The aim of this study is to understand the rate of hospitalisation (admitted patient care) where an individual in prison tested positive for COVID-19 compared with the general population in 2020/2021, and how non-COVID-19 hospital admissions compared with the general population.

Methods

Data

The pseudonymised records of patients who accessed admitted patient care and outpatient hospital services from a prison address in England* (This work focuses purely on healthcare service use by prisoners in England, due to the division of healthcare organisation between England and Wales) between 1 April 2019 and 31 March 2020 (2019/2020) and 1 April 2020 and 31 March 2021 (2020/2021) were extracted from Hospital Episode Statistics (HES) data. The roll-out of the national Personal Demographic Service (PDS) database across prisons between October 2018 and May 2019 means that a prisoner’s address should be consistently registered as the prison where they are currently located, with addresses recorded in a standardised way.9 Comparative data for those not in prison (the general population) were also extracted from HES data.

The data were supplied by National Health Service (NHS) England who provided a prison status flag indicating which activity came from a prison address, alongside unique inpatient and outpatient record identifiers (EPIKEY and ATTENDKEY) for activity linked to those locations, in order to create a minimised datafile containing the relevant patient records.9

Participants

Participants included patients who were either admitted to hospital or received outpatient care while recorded as living at a prison address in England. On 30 June 2020, there were 74 218 people in prison in England, across 112 locations which were a mixture of prisons and young offender institutions. COVID-19 vaccination in England started in December 2020. Vaccinations were initiated in prison in the last week of January 2021 based on prioritisation criteria in the community, meaning that the majority of the population was unvaccinated in the data period under investigation.

Office for National Statistics (ONS) mid-year population estimates suggest that the general population of England (aged 15 plus) was an estimated 45 million people in June 2020.10 Hospital data for the general population included patients not recorded as living at a prison address in England who were either admitted to hospital or received outpatient care. Males under 15 of age and females under 18 years of age were excluded from the general population analysis to be comparable with the lower age boundary of the prison population.

Patient and public involvement

It was not possible to involve prison residents in the design, reporting or dissemination plans of this research.

Measures

COVID-19 status was identified in admitted patient care HES data using International Classification of Diseases 10th Revision (ICD-10)11 codes specified in primary, secondary or subsidiary diagnosis fields anywhere within hospital spell. This included where COVID-19 had been formally confirmed by laboratory testing (U07.1) as well as where it was suspected based on clinical symptoms, but testing was inconclusive or not available (U07.2).

Statistical analysis

Data analysis was conducted using SAS V.9.4. Groups smaller than n=10 are not reported due to disclosure control guidelines. Descriptive statistics for prison residents were calculated with discrete variables presented as proportions. The indirectly standardised adjusted admission rate12 was calculated to compare the rate of inpatient admissions by prison residents with COVID-19 to what we might expect to see based on admissions by people of the same age and sex in the general population.

Using this approach, the age-specific COVID-19 admission rates of the general population (the reference population) are applied to the prison resident population. The age-specific admission rate in the general population is multiplied by the number of people in each comparable age group in prison, based on mid-year population estimates, to establish the total number of expected admissions for prison residents. The prison population estimates were calculated for England only based on data from June 2020.13 Population estimates for the general population are drawn from 2020 ONS mid-year population estimates.10 The number of observed admissions by prison residents is then divided by the number of expected admissions (standardised admission rate). The adjusted admission rate is then calculated by multiplying the standardised admission rate by the crude admission rate.

Results

Sample characteristics

Summary descriptive characteristics of prison residents with a diagnosis of COVID-19 recorded at any time during their stay in hospital are presented in table 1.

Table 1
|
Prison residents in hospital with a diagnosis of COVID-19, in 2020/2021

A total of 606 prison residents were admitted to hospital in 2020/2021 with a diagnosis of COVID-19. COVID-19 was recorded as a diagnosis in 6.2% of all admissions by prison residents in 2020/2021 (n=675/10 864 admissions). The mean age of prison residents with COVID-19 admitted to hospital was 55.2 years (19–98), and 96.2% of admissions were by male prison residents. A total of 101 prison residents with COVID-19 died in hospital, which represents 56% of all in-hospital deaths (n=179) by prison residents in 2020/2021.

COVID-19 admissions

In the general population, 2.7% (n=3 33 425) of all inpatient admissions (12.4 million) recorded a diagnosis of COVID-19. The indirectly standardised adjusted admission rate for COVID-19 was 2.2 times higher in prison than in the general population, as shown in table 2.

Table 2
|
Indirectly standardised adjusted admission rate calculation

Non-COVID-19 admissions

Injury and poisoning

17% of all inpatient admissions by prison residents in 2020/2021 had a primary diagnosis of injury or poisoning, making it the most common primary diagnosis recorded on prison residents’ inpatient admissions (see table 3). Similar trends can be seen in previous years of data.7

Table 3
|
Prison residents primary admitting diagnosis on admission to hospital, 2019/2020 and 2020/2021 (top five-most common)

Outpatient appointments

Fewer appointments were cancelled on behalf of prison residents in 2020/2021, but there were far fewer appointments scheduled, as outpatient appointments fell between 2019/2020 and 2020/2021 from 100 933 to 72 317 (see table 4). The proportion of appointments cancelled on behalf of the prisoner fell from 13.7% to 10.6%, but the proportion of appointments cancelled by the healthcare provider increased sharply from 9.8% to 15.7%, meaning the overall attended proportion stayed consistent year to year, at 58%.

Table 4
|
Prison residents outpatient appointments in 2019/2020 and 2020/2021 (n and proportion attended and not attended, by reason) and general population, 2020/2021

Discussion

Despite efforts to minimise the spread of COVID-19 in secure settings, this paper demonstrates that prison residents in England were 2.2 times more likely to be hospitalised with a COVID-19 diagnosis relative to the general population during the first year of the pandemic. It also demonstrates that the challenges prison residents faced accessing hospital care prior to COVID-19 continued, and admissions driven by violence and self-harm remained high. This is in addition to wider concerns about the long-term implications of the COVID-19 restrictions in prison, particularly spending extended periods in isolation, on people’s mental health.14

Reasons for secondary care admissions

The total number of secondary care admissions by prison residents fell between 2019/2020 and 2020/2021. While there was a drop in the overall prison population during the pandemic, restrictions imposed to minimise the spread of COVID-19 across the prison estate included minimising movement of people in and out of prison,15 which will have impacted the ease of facilitating hospital attendances and appointments. Despite the drop in hospital admissions, during the pandemic, admission to hospital was primarily due to injury and poisoning, continuing a long-standing pattern driven by levels of violence and self-harm in the prison estate.9 There is a narrative that prisons were a safer place during the pandemic,14 but hospital data highlight continuing challenges in this space regardless of the increasing amount of time people were spending in their cells.

Poorer access to hospital care for prison residents is likely to mean that certain diseases like cancer may be more advanced by the time treatment is underway, leading to longer and more complex treatments, greater suffering, and higher costs.3

Access to services

In 2020/2021, prison residents missed 42% of their outpatient appointments. This continues a pattern observed prior to the pandemic of prison residents struggling to access secondary care services. Prison residents in England missed 42% of outpatient appointments in 2019/2020 and had fewer inpatient admissions than people of the same age and sex in the general population, despite high levels of healthcare needs.7 Prison residents reported that it was hard to access health services in prison and when they needed hospital care, there were not always staff available to escort them to appointments.14 One reason why prison residents’ hospital appointments can be missed is a limited supply and availability of escorts—the prison staff who take prison residents to and from hospital.7 This was a problem prior to the pandemic, but COVID-19 caused unique staffing challenges as absences occurred due to COVID-19 isolation requirements as well as sharing of staff across prison settings.

The proportion of outpatient appointments missed because the patient did not attend on the day, and no prior warning was given, was three times higher from prisons relative to the general population, both during and prior to the pandemic. This is an area to be addressed by service providers within prisons to ensure that equity of care is provided to those in their care. Non-attended appointments are a missed opportunity to allocate appointments to other people in need, both in and outside of prison.

Limitations of the study

This study identified hospital activity based on admissions or attendances linked to a prison address. While the implementation of PDS has improved the accuracy of address recording,9 there was no distinct identifier of whether someone was in prison (prison status).

This analysis explores prison residents’ use of secondary care services only and does not include information on the care prison residents receive from onsite prison healthcare. The prison healthcare team is often the first point of contact for prison residents and may make the decision as to whether secondary care is necessary as well as providing direct care. While prisons in England do not have hospitals, some have in-patient beds where people can receive care, and this study does not include information on prison residents being treated in in-patient units within prisons. Wider research suggests that there were changes in use of primary care in prison during COVID-19, most noticeably an increase in medication prescribing. A study suggests that infection control measures had meant an increase in the provision of paracetamol in place of a full medical appointment.16

Conclusions

Prison residents are a marginalised population with disproportionately high rates of mental illness, substance dependence, communicable and non-communicable disease and multimorbidity. Imprisonment can provide opportunity to address unmet healthcare needs but during the pandemic prison residents were at high risk of severe COVID-19 resulting in hospitalisation. The nature of regimen restrictions also meant prison residents spent extended periods of time in isolation. Concerns have been raised about the impact of this on mental health and hospital data provides evidence that violence and self-harm, endemic within the prison estate, still occurred at high levels. There is a need for rigorous rationalisation of all actions in prisons relating to healthcare screening, prevention and treatment. Joint working between the five national bodies that form the National Partnership for Health and Social Care for England17, Department of Health and Social Care, His Majesty’s Prison and Probation Service, the Ministry of Justice, NHS England and the UK Health Security Agency—is vital to address these complex healthcare challenges.