CHE Economic evaluation seminar 16th February 2017 presented by Rachael Hunter, University College London

1. The economics of health care in prison – a
fiscal fugitive
Rachael Hunter
Research Department of Primary Care and
Population Health
York Economic Evaluation Seminar Series
15th February 2017

2. Why prisons?
• Personal area of interest

3. Why prisons?
• Personal area of interest
• Social and health inequalities in prison

4. Problems and needs of newly sentenced
prisoners – England and Wales
• Sample of 1,457 newly sentenced prisoners
2005/06
• 8% homeless prior to prison
• 7% in a hostel or other temporary accommodation
• 52% employed in the year before custody, 13%
never had a job
• 46% have no qualifications
• 62% claimed some kind of benefits year before

5. “You can do all of the work in prison only to be left
with nowhere to live leaving you to go to a hostel
which is full of drugs. We need more help in
resettlement.” (Service user forum)

6. “I mean for me I found it quite daunting because I
didn’t know when I was going. I was woken up at
five in the morning and told to get my stuff because I
was leaving and that was it and I was put on the
street with a bag.” (Service user forum)

7. Health needs of people in prison (1)
Substance misuse:
• UK (OASys data)
– 55% of prisoners have problematic drug use
– 60-70% of women in the UK prison system have drug
problems
• US ADAM study
– 65% of people arrested reported recent drug use.
– Drug offences were related with 59% federal inmates;
21% state inmates.
– 56.5% if state 44.8% of federal inmates reported using
drugs the month before arrest (McCollister 2004).

8. Health needs of people in prison (2)
Communicable diseases:
• 41% of injecting drug users in England and Wales
are Hepatitis C positive (HCV) and 30% are co
infected with HCV and Hepatitis B (HBV).
• 10% of prisoners HIV positive in low to middle
income countries. 1.5% in the US due to a range of
prevention initiatives.
• High tuberculosis (TB) risk in prisons due to
combined risk factors and environment
• Sexually transmitted infections like chlamydia,
gonorrhoea and syphilis all more prevalent in
prisons.

9. Health needs of people in prison – Mental
health world wide: Fazel and Baillargeon, 2011

10. SIZE OF THE PROBLEM

13. Fiscal concerns
• Health care cost in US cost 12% of total yearly
incarceration cost ($3350 per year in 2005)
• Cost of health care growing at a faster rate than
any other correctional cost in US and UK
• Aging prison population in both countries – over
55s representing a growing proportion of prison
population

14. PROBLEMS WITH PRISON
HEALTH CARE MARKETS

15. Jeremy Bentham
• Founding father of UCL
• Economist
• Utilitarianism: "fundamental axiom, it is the
greatest happiness of the greatest number that is
the measure of right and wrong“
• Wrote about the complex interplay of competing
interests of different stakeholders in achieving
objectives.
• Specifically addressed prison reform and
inefficiency of competing goals

16. Problems for health care markets in prison
• Aims of prison:
– Justice - retribution for crimes committed
– Protection of society and incarceration of those likely to
commit more crimes
– Deterrence of criminal activity
– Rehabilitation - preventing further crimes

17. Problems for health care markets in prison
• Aims of prison:
– Justice - retribution for crimes committed
– Protection of society and incarceration of those likely to
commit more crimes
– Deterrence of criminal activity
– Rehabilitation - preventing further crimes
• Aims of health care – improve the health and well
being of the population through the prevention
and treatment of disease

18. Problems for health care markets in prison
• Aims of prison:
– Justice - retribution for crimes committed
– Protection of society and incarceration of those likely to
commit more crimes
– Deterrence of criminal activity
– Rehabilitation - preventing further crimes
• Aims of health care – improve the health and well
being of the population through the prevention
and treatment of disease
• Problem – prison is bad for your health

19. Prison is bad for your health!
• Increases anxiety and depression;
• Increased risk of suicide;
• Risk of developing substance misuse problem in
the first place;
• Poor diet and reduced opportunity for exercise =
increased risk of obesity and cardiovascular
disease; and
• Close confines, high risk behaviour and less
access to harm reduction increase the risk of
contracting communicable diseases.

20. Incarceration; prevent
crime; public safety
Improve health and
well being; prevent
crime
Inefficiency

21. “It’s just that battle between CARAT workers and the
Screws. It’s like a faction you hear them when they
get out ‘oh them bloody CARAT workers are here
again...’ They see them as an interference.”

22. Health care market failure in prisons
• Externalities: If left untreated prisoners can go on to infect
and harm others, including those in the community when
released.
• The public can have strong positive and negative opinions
about prisoner rights to health care that differ to views
about other groups in society.
• Duty of care: prisoners are a vulnerable population where
a special duty of care exists.
• The nature of prison restricts access to health care and
market competition.
– Monopoly of power,
– single purchaser (the state) and provider
– Poor quality, access to and supply of care including access to
physicians. Prisoners’ unable to act as informed consumers.

23. Solution
• Improved health promotion/prevention
Overlaps:
• People in prison have higher rates of suicide in
prison and after release, with the first month being
the highest risk
• Current psychiatric diagnosis is associated with an
odds ratio of 5.9 (95% CI 2.3-15.4) of suicide in
prison. Only higher predictor is suicidal ideation or
previous attempted suicide.

24. National confidential inquiry – suicide in
prison 1999-2000 (Shaw et al 2003)
172 suicides

25. “I don't feel my mental health needs have been
addressed, I've now self harmed for 18 months
cutting my arms/wrists, hanging myself and taking
overdose. I still self harm and I feel nobody cares.
I've had no counselling at all and I got bullied and
the suicide liaison officer rewarded of the bullies.”
(Prison questionnaire respondent)

26. Fiscal responsibility
• Given mental health and substance misuse both
related to crime improve these = reduced the risk
of re-offending.
• Make health care responsible?

27. Fiscal responsibility
• Given mental health and substance misuse both
related to crime improve these = reduced the risk
of re-offending.
• Make health care responsible?
• NHS responsible for prison health care budget in
England since 2006
• Multiple funding bodies with different
responsibilities adds complexity

28. IDTS clinical
(excluding £2.7m central costs)
£16.5m allocated to PCTS through PTB.
MOJ via
NOMS
£83.3m
1. CARATs
2. Programmes
3. YPSMS
IDTS psychosocial
DCSF
£7m
YJB to
YOTs £8.5m
DH
DH
£411.094m
Drug Intervention
Programme (DIP)
Funds
held by
PCTs and
services
commissioned
through 149
local Drug
Partnerships
PTB Total £406m (including £24.7m
for YP)
A £20m contribution from NOMS.
is specifically to support
the treatment element of DRRs.
The £24.7m for YP is shown as a DH
Contribution below in to the
Young Persons
central funding programme.
Tier 4 capital investment
direct to PCTs / Trusts/ FTs
Young people central
programme funding is a
composite of 4 funding
streams. HO contributions
are in 2 parts, one is part
of the ABG in conjunction
with DCSF and one
contribution to YOTs via the
YJB.
DH PTB (please see above)
contribution via PCTs is for young
people drug treatment
15-18 year olds
Total £55.6m
National Funding Streams for Drug Intervention 2009/10
£11.195m
Grant
£22m
£7m
£15.4m
£8.5m
£24.7m
£142m
(excludes PPO
money)
£39.7m
Community Delivery Prison / YOI Drug Treatment Delivery
IDTS clinical
Funds
are held by
PCTs and
commissioning
for IDTS
is through
joint
arrangements
with
PCT, prison and
the local
Drug
Partnerships
£6m
£22.4m
HO
£180.3m
Highlights the relevance of mainstream
health & social care budgets
but not broken down and defined
for this chart; for example could include
Local authority social services
budgets for residential care (Tier 4)
and Supporting people finance
Total £217m
£217m
Various
Sources
Including
CLG via LAs
£217m
Shows funding levels for 2009/10, subject to (excluding
NOMS) confirmation by parent departments.
Figures quoted for NOMS are additional CSR allocations
and do not include pre CSR (1999) baselines.
ABG: Area Based Grant
CARATs: Counselling, Assessment, Referral, Advice
& Throughcare services
CLG: Communities & Local Government
DCSF: Department for Children Schools & Families
DH: Department of Health
DIP: Drug Interventions Programme
HO: Home Office
LAs: Local Authorities
IDTS: Integrated Drug Treatment System
MOJ: Ministry of Justice
NOMS: National Offender Management Service
PCTs: Primary Care Trusts
SHAs: Strategic Health Authorities
YJB: Youth Justice Board
YOTs: Youth Offending Teams
YPSMS: Young People’s Substance Misuse Service
£381.3m
APTB *
£28.2m
ViaNTA
Tier 4 capital
investment
£26.141m
DH Capital
Investment Branch
£4.7m
* Includes £20m
baselined
contribution from
NOMS to support
the treatment
element of DRRs
Positive Futures £6m
Drug Strategy Delivery £1.4m
Licensing
£0.7m

29. Solution: Efficiency
• Better use of limited resources: more evidence
based treatment
• Increased interest in economic evaluations in
prison.
• Started with cost-benefit analysis of substance
misuse interventions
• What is the evidence: amount and quality?
• Can we draw any clear conclusions?
• Are some interventions better suited to prison and
some to the community?

30. Systematic review – August 2013,
Updated April 2015.
• Comprehensive search of medical and social
science databases.
• General search using Google and Google
Scholar.
• Hand searching of references.
• Includes grey literature
• Search Terms
– prisons, criminality, offenders or incarceration;
– costs, economic evaluations or value for money; and
– health or drug treatment interventions.

31. Systematic review (2)
Inclusion Criteria
• At least one intervention group or the control group were
incarcerated.
• Included an economic evaluation or costing analysis of an
intervention, i.e. an assessment of the economic impact of
an intervention, policy or programme.
• The aim of the intervention was to address a health need
in an adult (over 18 years old) incarcerated population.
• The analysis could be a decision analytic model or an
analysis using data from an observational study or clinical
trial.
• The article is available in English

32. Flow diagram
Detected
Citations
n=2,115
Full text for
studies retrieved
n=188
Studies included
in the review
n=54
Studies excluded
on review of full
text
n=161
Studies excluded
by title and
abstract
n=1,926
Grey literature
and hand
searching
n=28

33. Results
• Papers were grouped into type of economic
evaluation e.g. cost-benefit analysis and clinical
area.
– Mental health; Addiction; communicable diseases;
telemedicine; and other
• Most common area: communicable diseases
(44%)
• Most common type of economic evaluation: cost-
effectiveness analysis and costing (34%).

34. CUA CEA CBA Costing CC Total
Mental Health 0 2 0 7 1 10
Addiction 0 5 5 2 0 12
Communicable
diseases
8 14 2 3 1 28
Telemedicine 1 1 1 5 0 8
Other 0 0 1 5 0 6
Total 9 22 9 22 2 64

35. Results (2)
• Effectiveness generally from observational
studies.
• Mechanisms for reducing bias were rarely
considered.
• Costs and consequences reported meant that
unless the intervention was clearly cost saving it is
hard to compare the cost-effectiveness or value
for money of different prison health care
programmes.

36. Address correlates with imprisonment prior
to prison
Prison
Substance misuse
Mental health
Education/employment
Previous incarceration

37. Prison
Substance misuse
Mental health
Education/employment
Previous incarceration
Treatment of
substance
misuse

38. Prison
Substance misuse
Mental health
Education/employment
Previous incarceration
Screening for
and treatment of
communicable
diseases

39. Prison
Substance misuse
Mental health
Education/employment
Previous incarceration

40. Penrose Effect
• 1939: English polymath Penrose investigated
relationship between mental health and crime.
• Established that as number of mental health beds
reduce number of people in prison increases.
• Effect seen across European, North American and
South American countries following
deinstitutionalisation of psychiatric hospitals.
• In South America – 5.8 more prisoners per bed
removed
• Does funding for mental health also play a role?

41. Relationship between mental health funding
and prison numbers
MentalHealthFunding
Prison Numbers

42. Costs and benefits of mental health services
versus prison
• Cost per year of mental health treatment versus
prison
• Probability of future criminality (impact on victim)
• Mortality
• Quality of life
• Employment
• Housing
• Impact on family

43. Costs and benefits of mental health services
versus prison
• Cost per year of mental health treatment versus
prison
• Probability of future criminality (impact on victim)
• Mortality
• Quality of life
• Employment
• Housing
• Impact on family
• Problem: how to evaluate? Randomised
control trial?

44. Improved mental health treatment and
reduced prison entry
• Evaluation of court diversion for mental health
• Observational data looking at costs and prison
numbers.

45. CHALLENGES FOR
ECONOMIC EVALUATIONS IN
PRISONS

46. Challenges for economic evaluations in
prisons
• Limited research in prisons
• Which outcomes: improved health; reduced re-
offending; other?
• Costs: Perspective – will depend on the research
question, but to what extent can you include CJS
costs?
• Other unexpected costs

47. ENGAGER II
• Trial in male prisons in England.
• Short sentence prisoners with a common mental
health problem to be released in the next 2
months.
• RCT of psychological therapy plus wrap around
service compared to current practice
• Current progress – intervention development and
pilot complete.

48. Analysis of pilot data - Aims
• To inform outcome measures for ENGAGER II
trial comparing three preference based tariffs:
– EQ-5D-5L
– CORE-6D
– ICECAP-A
• To inform a decision analytic model
• To provide information to other researchers on
which outcomes to use in a prison based mental
health trial economic evaluation.

49. Descriptive statistics – EQ-5D-5L
• 118 completed at baseline
• Average age 34; 25% < 25; 25%> 40
• Mean EQ-5D utility score = 0.815 SD=0.21
• Population norm England (18-45) = 0.915
• Significantly lower (about the same as a 55-64
year old)

50. 96
109
92
65
46
9
1
10
23
27
7
5
9
20 20
4
2
5
9
18
2 1 2 1
7
0
20
40
60
80
100
120
Mobility Self Care Usual Activities Pain Anxiety Depression
NumberofPatients
Response to EQ-5D domains at baseline
I have no problems I have slight problems I have moderate problems I have severe problems I am unable to

51. Descriptive statistics – ICECAP-A and CORE-
6D
• ICECAP-A
– 116/118 participants with complete questionnaires
– mean = 0.623
– SD= 0.19
• CORE-6D
– 58/60 participants with complete questionnaires
– Mean = 0.742
– SD= 0.16

52. Prison Research Challenges: On 3-month
follow-up
• EQ-5D
– 30 participants
– 0.84 (increase by 0.04)
• ICECAP-A
– 28 participants
– 0.64 (increase by 0.05)
• CORE-6D
– 9 participants
– 0.74 (0.014)

53. Conclusions
• CORE-6D was most effective in measuring
changes in the clinical outcome (PHQ-9D)
• ICECAP-A also effective tool.
• Question of which to use – CORE-6D if you are
interested in clinical outcome? ICECAP-A if you
are interested in rehabilitation?
• Follow-up and data collection challenging in this
patient group.

54. Questions
• Should the outcomes measures used in prison
health cost-effectiveness analyses be guided by
the aim of the intervention? Does the EQ-5D still
hold for comparability?
• Is/should the willingness to pay for a quality
adjusted life year (QALY) be the same in prisons?
• Are there potential challenges of using routine
data to look at mortality and morbidity of people in
prison?

55. References
Fazel & Baillargeon (2011) The health of prisoners.
Lancet, 377. pp. 956-965.
Shaw, Appleby & Baker (2003) Safer Prisons: A
National Study of Prison Suicides 1999–2000 by the
National Confidential Inquiry into Suicides and
Homicides by People with Mental Illness.
Patel, K., Bashford, J., Hasan, S. and Hunter, R.
(2009) Reducing Drug Related Crime and
Rehabilitating Offenders.
http://www.dh.gov.uk/en/Publicationsandstatistics/P
ublications/DH_119851

56. THANK YOU FOR LISTENING
Contact:
r.hunter@ucl.ac.uk