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Our team’s experiences have found that justice-involved people who are older are at risk of inadequate care and falling through service gaps, writes Jane Hwang.
The relationship between justice system involvement and higher health needs is well established (here). A lesser known phenomenon, however, is the rapid rise people who find themselves in contact with the justice system at an older age in Australia, making “prisoner health as public health” a more pressing issue.
Prisoner populations in Australia are ageing at a pace that far exceeds the general population (here). A report by the Australian Institute of Health and Welfare (AIHW) confirms that prisoners over 45 years “are a growing proportion of Australia’s prison population; [and] the population of older prisoners is growing at a faster rate than the population of younger prisoners” (here). This means an unprecedented number of people are being released from prison at an “older” age. In this article, “older” is defined as someone aged 50 years or older, or 45 years for Aboriginal or Torres Strait Islander peoples. This is in line with international literature and the AIHW.
The increasing volume of marginalised adults who experience intersecting needs due to their age, justice system involvement and social determinants of health poses new challenges for primary care providers (here). The societal, systemic and individual-level disadvantages in accessing equitable care after release from prison mean this population are at serious risk of inadequate care and rapid health decline (here and here). General practitioners, among others, will need to increase their awareness of this high needs population, as they are often their first point of contact for care in the community.
So far, there is a clear resounding message in Australia and the international literature: efforts to improve primary care and care continuity for this growing population are urgently needed and will be of benefit to individuals, communities and the wider society.
A unique population
Typically, older people in prison have multiple physical, mental and cognitive health comorbidities (here and here). These comorbidities are higher in number and present at a younger age compared with similar aged-peers in the community (here and here).
Older people in prison also have unique and pronounced health care needs compared with their younger counterparts. They tend to take a higher number of medications while imprisoned (average 3.5), and require more management for chronic, age-related conditions such as cardiovascular disease or diabetes compared with younger adults whose most common health needs relate to mental health and substance misuse (here).
Release from prison creates a risk of significant disruption to care during an already volatile period. Medicare is not available in prison; rather, prison health care services are run separately by each state and territory government (here). This makes the transfer of care from prison to the community more important to ensure care continuity for this high needs group.
Unfortunately, prison release processes have no formal provisions for care transfer. The priority for release planning is on reducing a person’s risk of reoffence (here). In terms of health, this goes as far as support for any identified substance misuse or mental health issues. Consequently, our team’s recent research (which is still being analysed) has found people are commonly released without their medical records, medications or medical equipment.
Visiting a GP or other primary care professionals within a reasonable period following release is crucial to prevent deterioration and ensure care continuity. However, research suggests people released from prison most likely lack the crucial social support, self-efficacy, and financial or physical resources to do so (here and here).
There are some specific considerations for providing care to this population. Additional efforts involving contact with different organisations and individuals may be required to fully assess a person’s needs and history. The likelihood of underdetected conditions, especially cognitive impairment, should not be ignored (here).
Importantly, understanding the individual’s complex life history and social determinants is crucial. An “institutionalising” effect of prison may be pronounced in this population, who have often experienced lengthy, repeated imprisonment (here). This means additional support should be provided for tasks that require organisation and independence, such as making and keeping appointments, following written instructions, seeking further referrals or follow-up actions. Individuals will likely be hyperaware of the multiple stigmas attached to their being older and justice-involved (here and here). Moreover, levels of literacy, especially written, health and technology literacy, cannot be assumed. Appropriate sensitivities will thus be important for building care relationships that are trusting and productive.
A call for change
Care continuity and person-centred, inclusive care have risen on the agenda for health service provision in Australia. Despite being a priority group for such care, our team’s on-the-ground experiences have found that justice-involved people who are older are at risk of inadequate care and falling through service gaps.
There are compelling human rights, public health, economic and criminal justice grounds on which to argue for better health care for ex-prisoners (here). To do so, multiple levels of change and concerted efforts between stakeholders across prisons, health and social services will be required. I call for improved systems for medical information sharing between justice and health sectors, the introduction of Medicare to prisons, and improved awareness for community-based aged and health care providers regarding this group.
Research and practice in Australia are still in their infancy but important first steps have been taken. Our team at the Justice Health Research Program in the School of Population Health at the University of New South Wales have set out to understand and respond to the phenomenon. So far, we have received $4.5 million funding from the National Health and Medical Research Council for several projects, such as the first longitudinal cohort study of frailty and age-related health progression in Australian prisoners. Moving forward, much more collaborative efforts will be needed across government, research and industry to tackle the entirety of this phenomenon.
Jane Hwang is a Postdoctoral Research Fellow in the Justice Health Research Program at the School of Population Health, University of New South Wales, Sydney.
Her research focuses on improving health equity for underserved groups in contact with the justice system.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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