Edge, Chantal; (2021) Investigating the implementation of telemedicine in English prisons. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Background Prisoners experience significant health inequalities, tending to suffer poorer access to services and health outcomes than the general population. The delivery of secondary healthcare services by video consultation (telemedicine) offers an opportunity to improve the health outcomes for people in prison, by improving the access, quality and cost of healthcare services available. This PhD thesis investigated how prison telemedicine could improve access and quality of health services for patients in English prisons, and the issues that arise during implementation of prison telemedicine models. The study spanned the period both prior to and during the COVID-19 pandemic, and the research approach was adapted to these changing circumstances. Methods This PhD study employed mixed methods including systematic review, qualitative interviews and autoethnography. The PhD starts by considering how telemedicine could improve the patient experience of accessing secondary care in English prisons, through qualitative analysis of patient interview data collected by peer researchers (pre-pandemic). It then investigates the barriers and facilitators to prison telemedicine implementation, firstly via a systematic review of existing literature on prison telemedicine, secondly through qualitative analysis of a staff interview series relating to a local prison telemedicine implementation project (pre-pandemic). Finally the PhD sought to understand how the pandemic context affected the ability to implement prison telemedicine, through both an auto-ethnographic account from my perspective as a key agent in ensuring national implementation, and staff interviews with senior health and justice stakeholders. Findings Prison telemedicine could potentially improve the equivalence of care for people in prisons. Interviews with prisoners revealed that they experience numerous barriers to accessing secondary care services, and feel stigmatised and dehumanised at hospital sites. They have long delays for appointments, and poor treatment by both hospital and prison officer staff. A systematic review of prison telemedicine literature highlighted that many of these barriers could be overcome through delivery of remote appointments. Video consultations remove the need for prisoners to be chaperoned during appointments by prison security staff, and reduce delays associated with prison officer escorted transfer to the hospital. The systematic review revealed that implementation of prison telemedicine has flourished in countries with vast geographical distances to traverse, such as the USA and Australia, but prior to the pandemic had been limited in English settings. Despite successful overseas implementation, there are numerous operational and systems level barriers that need to be overcome during implementation efforts. These include: securing top-down and bottom-up support for implementation, framing the telemedicine intervention effectively, and considering the differing strategic and operational priorities of prison and hospital healthcare providers. Interviews with stakeholders in prison telemedicine described how a local telemedicine pilot in England struggled to find traction over a three year period, mainly as a result of provider resistance, commissioning barriers and incompatibility between health and justice systems. The COVID-19 pandemic represented a significant contextual shift which supported remote consultations and partnership working, resulting in telemedicine rollout across the entire English prison estate. The autoethnography described my role during the pandemic, working to overcome most barriers to implementation as part of centralised national leadership for the telemedicine agenda. This prompted the prison service to consider and assure innovative technology to improve care continuity by telemedicine. Issues still remained with the complexity of the prison commissioning landscape, existing prison infrastructure and the incompatibility of approved prison and community software solutions.

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