Challenges to the provision of dental care in prison

21 Nov 2019

Within the general population, it is widely known that patients are reluctant to attend the dental surgery. However there are some patients that are often eager to access dental care - namely inmates of prisons.

The type of dental care that they receive is often provided in conjunction with a multi-disciplinary team.

Furthermore, as in all aspects of healthcare, there is the requirement of equivalence of care compared with the general population. The Government’s Health and Social Care Committee in November 2018 recommended that the National Prison Healthcare Board, in conjunction with its stakeholders, provide an agreed definition of “equivalent care” as well as indicators to ensure such standards of health equality are reached[1] although it is accepted that this does not necessarily mean that equivalent means “the same” as provided in the community[2].

In providing care to the prisoners, dentists have additional barriers to overcome which include:

  1. The demanding nature of prisoners: prisoners are more likely to take legal action if they believe they have not received the level of care that they consider that they are entitled to. However, dental practitioners must be aware of patients exaggerating their symptoms or demanding urgent care[3], and must balance this awareness with the fact that often the pre-existing oral health was poor.
  2. Dentists often have to ensure that patient care is not compromised by  prison regimes which may conflict with safe clinical practice for example the standards of infection control. This means that  they might have to challenge the prison norms and adequate support is required to ensure clinically safe environments within the prison setting are retained.[4]
  3. Given the issues with arranging security arrangements during the prison dentist’s clinic session, there are restraints on the amount of time allowed for treatment. In 2005 an average session was three hours long with an average of 12 patients per session, therefore allowing around 16 minutes for the treatment of each patient[5] Given the often complex treatment required due to the poor state of the patient’s oral health, there are issues in relation to the efficient use of the clinic time.  
  4. Upon a survey of prison dentists, many stated that the resources such as equipment and facilities that they were provided needed replacing or upgrading, and in some cases needed to be done urgently[6].  Over 55% of dental surgeries in prisons have not undergone refurbishment and redecoration within the last 10 years[7]and 72% of prison dentists reported that at least one piece of equipment needed replacing or updating, with 31% of prison dentists reporting that items needed urgent replacement or updating[8].
  5. Record keeping can be difficult as 4% of sites are still not computerised, and of the computerised sites, only 45% have specific dental software. The main IT programme used in offender health is SystmOne which allows patient data to be shared securely across services however no software is available on that system specifically for dental use. This means either that the records will be paper records and radiographs which are not easily shared across the service or will not include pro formas for charting, making record keeping more difficult. A failure to transfer means that additional radiographs and investigations may be required, leading to  unnecessary exposure to radiation.
  6. Given the setting there are obvious safety and security concerns. In a recent survey, 89% of responding dentists stated that they considered the dental surgery to be a safe and secure environment[9]. However, issues raised in that survey include encouragement to see prisoners without a prison officer present, although 74% of responding dentists did feel that security staff were readily available[10], abuse/violence towards staff due to affected service provisions due to problems with dental equipment[11] and the lack of locks to drawers and cabinets containing instruments, including surgical equipment[12].

On top of the issue faced by the dentists themselves there are a number of additional problematic factors for prisoners and in addition to the obvious security measures not required in conventional dental settings, there are many additional barriers to overcome for such patients given the setting:

  1. The fact that prior to admission into the prison or young offenders institute, prisoners often have a history of poor access to dental services, often due to socio-economical restraints, resulting in poor oral health often masked and/or exacerbated due to substance abuse[13] or with a vast array of co-morbidities and chronic diseases[14]. These often lead to high incidences of dental caries and periodontal disease[15]. In 2003, in a joint report between the Department of Health and HM Prison Service, they noted the incidence of untreated dental diseases amongst all prisons was around four times greater than that of the general population with similar socio-economic background[16]. This can often mean that on admission into prison, their dental issues require emergency or urgent care[17].
  2. Logistical issues whilst in prison such as availability of prison guard chaperones, transfers between prisons, long waiting lists, clash of appointments with family or legal representative visits as well as lack of information regarding dental services[18].
  3. The existence of an ever ageing prison population in England and Wales; the 60 year old and over category is the fastest growing age group[19], and is anticipated to continue growing by June 2022[20] therefore bringing additional issues into play.
  4. Dental providers are often sub-contracted by a single provider commissioned by NHS England Health & Justice which is often under-commissioned[21] . This can lead to long waiting times.
  5. In circumstances where the prisoner is on remand, in for a short sentence, or due to be transferred to another facility, this can lead to some providers of dental care limiting the types of treatment that the prisoner can be receive e.g. dentures and crowns might only be provided for prisoners with sentences longer than six months[22]. In the case of prisoners who have been transferred, they are often unable to reach the top of the long waiting lists as, upon transfer, they would be placed at the bottom of the waiting list at the new establishment[23]. In a recent survey, 14% of prison dentists reported a wait time of over 18 weeks for a dental examination[24]. The Parliamentary Health and Social Care Committee have noted that prisoners have waited months for urgent treatments such as a tooth extraction and referred to User Voice who discovered that over 70% of prisoners found it difficult, or very difficult to see a dentist[25] In the case of emergency appointments 10% of prisoners wait in excess of four hours to see a dentist or appropriately trained staff.

The Parliamentary Health and Social Care Committee has stated that “Imprisonment represents an opportunity to identify, effectively diagnose and treat health and care needs, some of which may be drivers of behavioural problems, which may have gone unrecognised and/or unmet[26]”.

In light of the above, prison dentistry is an important resource in targeting oral health issues of a vulnerable group of society which constitutes a public health issue. The problems highlighted above present challenges in meeting the requirement for equality of care.

The commissioning and provision of healthcare services in prisons faces its challenges, alongside the challenges faced by other healthcare professionals. Now that the issues above have been recognised, steps need to be taken to address them and dental professionals given support to provide equivalent care for prisoners.

June Yam, Trainee Solicitor, BLM

Jane Lang, Partner, BLM

 


[1] Health and Social Care Committee’s Inquiry into Prison Health. Parliament of the United Kingdom of Great Britain and Northern Ireland, 1 November 2018

[2] Government response to the Health and Social Care Committee’s Inquiry into Prison Health. HM Government, January 2019

[3] Reforming prison dental services in England - a guide to good practice. Sarah Harvey, Beth Anderson, Stefan Cantore, Ewan King and Farooq Malik. PM, August 2005

[4] Oral healthcare in prisons and secure settings in England, BDA February 2012.

[5] Reforming prison dental services in England - a guide to good practice. Sarah Harvey, Beth Anderson, Stefan Cantore, Ewan King and Farooq Malik. PM, August 2005

[6] Survey of prison dental services England, Wales and Northern Ireland 2017 to 2018, Public Health England, March 2019

[7] Ibid

[8] Ibid

[9] Ibid

[10] Ibid

[11] Ibid

[12] Ibid

[13] Health in Prisons; a WHO guide to the essentials in prison health. Lars Møller, Heino Stöver, Ralf Jürgens, Alex Gatherer and Haik Nikogosian, WHO 2007

[14] Prisons and Health, Section 12. Ruth Gray, Sue Gregory, WHO Europe 2007

[15] Ibid

[16] Strategy for modernising dental services for prisoners in England, Department of Health, April 2003

[17] Reforming prison dental services in England - a guide to good practice. Sarah Harvey, Beth Anderson, Stefan Cantore, Ewan King and Farooq Malik. PM, August 2005

[18] Jones C et al. Dental health of prisoners in the north west of England in 2000: literature review and dental health survey results. Community Dental Health, 2005, 22:113–117

[19] Oral healthcare in prisons and secure settings in England, BDA February 2012

[20] Response to the Parliamentary Health and Social Care Committee Inquiry into prison healthcare from the British Dental Association and the National Association of Prison Dentistry (UK), May 2018

[21] Ibid

[22] Ibid

[23] Health in Prisons; a WHO guide to the essentials in prison health. Lars Møller, Heino Stöver, Ralf Jürgens, Alex Gatherer and Haik Nikogosian, 2007

[24] Survey of prison dental services England, Wales and Northern Ireland 2017 to 2018, Public Health England, March 2019

[25] Health and Social Care Committee’s Inquiry into Prison Health. Parliament of the United Kingdom of Great Britain and Northern Ireland, 1 November 2018

[26] Ibid

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Disclaimer: This document does not present a complete or comprehensive statement of the law, nor does it constitute legal advice. It is intended only to highlight issues that may be of interest to customers of BLM. Specialist legal advice should always be sought in any particular case.

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Jane Lang

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