Ruth Gray: “Understanding the system through the eyes of the people experiencing it is essential to improving services.”

As a dental surgeon working in prisons for over 15 years, I have witnessed the impact of incarceration on people’s well-being. A prison term can often end up deteriorating the health of those incarcerated, so they leave prison with poorer health than when they entered.

It does not have to be this way. Prisons can actually be an opportune setting for improving health – and the start of the prison stay is crucial to getting this right.

In Northern Ireland, the committal process – the review undertaken when people arrive into prison – is complex, and has been particularly criticized in inspection reports, by staff and by people in custody. Due to court schedules and transport logistics, it often happens late in the day, and is an intense period of risk assessment at a difficult time.

In 2017, I qualified as a quality improvement fellow for South Eastern Health and Social Care Trust (SEHSCT) and was given the responsibility of improving the committal process in HMP Maghaberry. We began by creating a multidisciplinary team with staff from both SEHSCT and the Northern Ireland Prison Service. Our main priority was to include the narratives of people in custody in the design and implementation of improvements. We wanted to provide a welcome as people enter custody.

The project began by interviewing over 100 people entering custody and hearing their stories, experiences and expectations of prison health care. Understanding the system through the eyes of the people experiencing it is essential to improving services. They decided our priorities – providing medication and communicating clearly about health care.

Before the project began, due to the complexity of the committal pathway, 89% of people were missing their first dose of medication. The delay in the administration of medication caused great concern for people entering prison, resulting in increased risk and frustration at the time of incarceration. Interviews also showed that people felt uninformed about how to access health-care services in prison. This meant people were not accessing the health care they needed once they were inside.

Using quality improvement methodology – reducing wastes in the system, introducing medicines reconciliation and establishing real-time measures – we significantly reduced the delay in the prescribing pathway. We also enhanced the skill mix of the committal team by introducing pharmacist independent prescribers.

To remedy the gap in communication, we also introduced a peer mentor programme. Now, a mentor welcomes all new people into prison and navigates them towards health-care services. These mentors are trained, supervised and connected to the Peer Mentor Support Hub, a collaboration between the Northern Ireland Prison Service, SEHSCT and Belfast Met, the education providers in the prison.

This process is still ongoing, but initial findings are promising. Evidence shows that omission of the first dose of medication has been reduced from 89% to 30%. The flow of medication has improved and, because of the prescribers, better medical information is transferred as people enter custody.

Our quality improvement project brought frontline staff and people in custody into the centre of innovation and decision-making. Listening to their voices means the committal process is rapidly transforming. This wouldn’t have been possible without the narratives of those who experience the system first-hand. We cannot ignore the fact that those closest to the problem are also closest to the solution.