Access to health services in custody

Report highlights

What the report is about

This audit assessed whether adults in custody have effective access to health services. The audit examined the activities of Justice Health and Corrective Services NSW.

What we found

The majority of custodial patients receive timely health care, but a small proportion of patients are not receiving care within target timeframes.

Eleven per cent of scheduled health appointments are not attended, and agencies can do more to understand the reasons for non-attendance.

Demand for mental health care exceeds service capacity and some patients are held in environments not appropriate for their needs.

Justice Health's information systems do not support the effective transfer of medical records as patients move around the prison network.

Not all patients are released from custody with a discharge plan.

Justice Health's system managers do not receive sufficiently detailed reports to understand strategic risks or opportunities to improve access to health services.

Public and private prison health operators do not report against consistent performance measures.

Justice Health is mandated to assess health services in private prisons. This conflicts with its role as a contracted provider of health services in the private prison system.

What we recommended

Enhanced reporting on patient access to health services, to identify risks and challenges across key service areas.

Identification and implementation of the improvements required for information to be shared across the custodial network and with external health providers.

Development of a framework to govern and monitor costs for patient health escorts and movements.

Development of a framework to govern responsibilities for mental health services.

Progression of infrastructure plans that address the lack of specialist accommodation for mental health patients and aged and frail patients.

Collaboration to align the performance measures to enable benchmarking between public and private prison health services.

Action to remediate the conflicting monitoring arrangements of public and private prison health operators.

Fast facts

  • 13,063 adults in the NSW prison population at 31 March 2021
  • 31,750 unique adult patients provided with medical care in 2020
  • 770,000 occasions of medical care provided by Justice Health in 2020
  • 50% of all health treatment in prisons is provided to patients who receive immediate medical attention
  • 60,000 appointments for health care in prisons were not attended in 2020
  • 94,810 occasions of psychology service provided by Corrective Services in 2020

Auditor-General's foreword

Access to health services in custody

This audit examined whether adults in the New South Wales public prison system have effective access to health services. In making this assessment, we considered whether Justice Health and Corrective Services NSW effectively cooperate and coordinate so that patients have timely access to health services, systems and practices support continuity of care, and access to health services is monitored and reviewed.

As part of this audit, we assessed actions undertaken by Justice Health and Corrective Services NSW in managing the first COVID-19 outbreak in 2020. However, due to the timing of this audit report, this audit does not report on the agencies’ response to managing the current outbreak of COVID-19 in September 2021.

Executive summary

Health services in New South Wales prisons are delivered by both public and private operators. The public prison system is made up of 33 correctional centres and the Long Bay Hospital. All health services in the public prison system are delivered by the Justice Health and Forensic Mental Health Network (Justice Health).

In the public prison system, Justice Health is responsible for the clinical care of patients with physical and mental illnesses. Clinicians provide health assessments, treatments, medication management, and some counselling services in prison health clinics. Patients are triaged by primary health nurses and if they require treatments or medication, they are referred to prison‑based doctors including specialists or other clinicians. Patients requiring complex or emergency care are transferred to hospitals or other specialty services outside the prison complex.

Private operators deliver health services in three private prisons through contract arrangements with Corrective Services NSW. Justice Health delivers health care at one correctional centre via a contract arrangement with Corrective Services NSW. In total, contracted health service operators deliver health care to approximately 25 per cent of the New South Wales prison population.

Justice Health is required by law to monitor the performance of contracted health service providers in New South Wales prisons, including services provided at the John Morony Correctional Centre. The Auditor‑General’s mandate does not permit a direct examination of information held by private sector entities, however this audit does assess the effectiveness of Justice Health's role in monitoring health services in private prisons.

Corrective Services NSW is responsible for security in public prisons, including the facilitation of patient access to health care at prison health clinics and the transfer of patients to hospitals and other health services outside of the prison environment. Corrective Services NSW also delivers behaviour‑based psychology services. Some are delivered as behaviour modification courses that aim to reduce criminal and offending activity amongst the prison population. These programs may be linked to parole or other custodial conditions. Other psychology services include counselling for people with self‑harming or suicidal behaviours.

Research from the Australian Institute of Health and Welfare indicates that people in custody are more likely than the general population to be affected by chronic and acute illnesses, including higher rates of mental illness and communicable diseases1. In March 2021, there were 13,063 adults in custody in New South Wales.

The objective of this performance audit was to assess whether adults in the public prison system have effective access to health services. In making this assessment, we considered whether Justice Health and Corrective Services NSW effectively cooperate and coordinate so that:

  • patients have timely access to health services
  • systems and practices support the continuity of health care
  • access to health services is monitored, reviewed, and reported across the network. 

1The Australian Institute of Health and Welfare, Adult Prisoners Snapshot, 11 September 2019. At: https://www.aihw.gov.au/reports/australias-welfare/adult-prisoners.
 

Conclusion

Justice Health delivers timely health care to adult custodial patients who need routine medications and treatment for minor medical conditions. Justice Health also delivers timely care to patients requiring urgent medical attention, including emergency transfers to hospitals. However, Justice Health does not always meet recommended timeframes to deliver health care to patients who are waitlisted for treatment from doctors and other medical specialists, or for those waiting for assessments and prescriptions.

In 2020, Justice Health provided over 770,000 instances of medical care to adults in the New South Wales prison network. Approximately half of this health care was delivered on the spot, by nurses who dispensed routine medications or treated the minor medical ailments of 'walk‑in' patients.

Doctors, specialists, and nurse clinicians delivered the other half of prison health care via scheduled health appointments. In most cases, this health care was timely, except for a proportion of patients who were waiting for time‑critical treatments, prescriptions, or assessments. In 2020, 40 per cent of patients identified as 'Priority 1' did not receive care within the recommended three‑day timeframe. Patients waiting for these appointments constitute a small proportion of all health care delivered in 2020, at about one per cent of all health care. Nevertheless, the needs of Priority 1 patients are significant, and Justice Health does not know whether the prolonged wait times led to deteriorations in health outcomes, or other adverse outcomes.

Close to 1,000 patients required emergency treatment in 2020, and were transferred to hospitals as soon as their medical condition was identified by prison health staff.

Justice Health uses multiple information management systems that are not sufficiently linked to transfer all patient medical records and appointment information when patients are moved across the prison system. Appointment schedules and patient medications are transferred through manual processes. There is also limited information sharing with community health providers when custodial patients enter or leave custody.

Justice Health has multiple and parallel information systems, including paper‑based medical records. These systems are not effective for information sharing across the prison system as patients are moved between prisons and facilities at frequent intervals. Clinical staff are not always alerted when a patient is moved from one prison to another, or released from custody after a court appearance. This impacts on the effective scheduling and management of prison health appointments, and the exchange of patient health records across the prison network.

Justice Health's information systems and protocols also do not support the effective exchange of information with external health providers. The transfer of health information is a manual process and there can be significant delays in providing or receiving information from community health providers when custodial patients enter prisons or are released.

Corrective Services NSW and Justice Health executives do not receive sufficiently detailed information or reports to understand the impediments to health service accessibility and to enable system improvements. There is also limited joint planning between the two agencies to improve patient access to health care. The governance and monitoring arrangements for public and private prison health services are flawed and create a conflict of interest for Justice Health as both a service provider and a system monitor.

Justice Health's data dashboard assists managers and clinicians to understand and manage the wait times for health appointments at the prison service level. However, reporting to senior executives on wait times for health services is insufficiently detailed to indicate risks or opportunities for strategic improvement. Corrective Services NSW does not produce sufficiently detailed reports on the costs of transferring custodial patients to health appointments outside the prison network to improve efficiencies or understand trends over time.

There is not enough system‑level planning between Corrective Services NSW and Justice Health to optimise patient attendance at health appointments. Greater collaboration is needed to improve appointment scheduling through notifications about patient movements across the prison network.

There are limitations in the performance monitoring of public and private prison health services. It is not possible to benchmark or compare public and private prison health services and outcomes because the two systems do not report against common Key Performance Indicators.

While Justice Health has taken steps to maintain independence and transparency in its legislated role as assessor of health services in private prisons, there is an inherent conflict of interest in this monitoring role, as Justice Health is also a contracted provider of health services in the private prison system.

1. Key findings

The majority of custodial patients receive timely health care, but a small proportion of patients with priority appointments are not receiving care within target timeframes

Approximately half of all health care provided by Justice Health is immediate. It is delivered to 'walk‑in' patients as soon as they present at prison health clinics. Most of these patients are receiving daily medications, while a small proportion require urgent or immediate care for injuries or illnesses. The other half of prison health care is delivered via scheduled appointments. Patients waiting for health appointments are given a priority rating according to the time within which they should be seen by a clinician.

Patients requiring the most time‑critical care are given a Priority 1 rating. These patients should receive treatment within one to three days. In December 2020, the average wait time for Priority 1 treatment was five and a half days, almost double the target. This is an improvement on wait times in June 2019, when the average wait time was just over 13 days. Justice Health does not assess or measure the impacts of delayed care on these patients.

According to Justice Health, the high numbers of ‘walk‑ins’ contribute to increased wait times for medical appointments. In addition, some specialty health clinics operate weekly, which means that patients cannot be seen by specialists within a one to three‑day timeline. Security events such as prison lockdowns can also contribute to increased wait times, as they limit the access that patients have to prison health clinics during out‑of‑cell hours.

If patients need emergency medical treatment, they are transferred to hospitals in line with Justice Health's policy. In 2020, just over 1,000 patients were transferred to hospital for emergency medical care.

A significant proportion of prison health appointments are not attended, and not enough is being done to understand the reasons, or to improve attendance rates

In 2020, 11 per cent of all scheduled health appointments in prison clinics were not attended. This amounts to approximately 60,000 appointments over the year. Non‑attended appointments have flow‑on impacts on wait times and backlogs for scheduled health appointments. Understanding why they occur is necessary to improve efficiencies in scheduling and patient access to health services.

In 2020, the most common reason for non‑attended health appointments was: 'patient unable to attend'. Justice Health clinicians use this when patients do not arrive at the prison health clinic at the scheduled time, and clinicians lack any other information to explain the non‑attendance.

The second most common recorded reason for non‑attended appointments was: 'cancelled by Corrective Services NSW'. These cancellations are due to operational or security reasons, including prison lockdowns. Data from Justice Health indicates that in 2020, there were an average of 12 lockdowns per week across New South Wales prisons.

A range of factors can impact on patient attendance at appointments, some of which are unavoidable. That said, more can be done to understand and reduce non‑attendance. For example, there is potential for Corrective Services NSW to implement tighter protocols to update information about patient availability on the daily movement lists. This might include checking whether patients are willing to attend appointments. Similarly, there is potential for Justice Health clinicians to implement tighter protocols to check patient lists ahead of scheduled appointments, and to re‑schedule appointments where patients are unavailable.

Demand for mental health care exceeds service capacity and some patients are held in environments that are not appropriate for their needs

There is a high demand for mental health services in New South Wales prisons. In March 2021, at least 143 mental health patients were waiting for access to an acute or sub‑acute mental health unit across the New South Wales prison system. The average wait time for a mental health facility was 43 days. Seventeen patients had wait times of over 100 days. Patients waiting for sub‑acute mental health services had longer wait times than those waiting for acute mental health services.

There are limited mental health beds for women across the New South Wales prison network. There are ten allocated beds for women at the Mental Health Screening Unit at Silverwater Correctional Complex, and no allocated beds for women at Long Bay Hospital.

A lack of bed availability in the Forensic Hospital means that, as of February 2021, 63 forensic patients were being held in mental health facilities in mainstream prisons, when they should have been accommodated in the Forensic Hospital. Some of these forensic patients have been held in mainstream prison facilities for decades.

Cross‑agency co‑operation and planning is required to identify and build infrastructure that will reduce wait times for mental health beds. Over several years, Justice Health has developed, reviewed, and worked to progress a strategic plan for NSW Forensic Mental Health that includes enhanced mental health bed capacity across the NSW system. The latest version of this strategic plan remains in draft and has yet to be approved by the NSW Ministry of Health.

In 2016, Corrective Services NSW commenced a Prison Bed Capacity Program. It was focussed on enhancing capacity across the prison system and did not include specialist health beds. More recently, Corrective Services NSW has been developing a business case to improve the provision of specialist health care facilities across the network, including mental health facilities.

Justice Health's clinical information systems do not support the effective transfer of health appointments or medication records as patients are moved to new prison locations

Justice Health's clinical information systems are multiple and complex. There are five health information systems that include a mix of electronic and paper‑based records. Information management systems contain clinical records, appointment information, medication records, dental records, and specialist health information. Corrective Services NSW maintain separate information systems relating to prison records and psychology treatment information.

The transfer of people across different correctional centres is a frequent occurrence. In 2020, there were over 41,000 movements between correctional centres. People are transferred for a range of reasons including for security purposes, or to be located closer to hospitals or specialist health services.

Justice Health receives a list of patient transfers one day prior to transfer. Nurses are required to prepare medications and clinical handovers for patients with complex health conditions. These handovers are verbal, however short timeframes mean that handover is not always possible.

While each patient's electronic health records are available across the network, transfer of appointment waitlists must be done manually. There is no automatic alert within the information systems to tell staff that a patient has been moved to another prison. There is a risk that if appointment records are not manually updated, or if staff at destination clinics are not contacted, then appointments will be overlooked.

Justice Health is working with eHealth NSW to develop an improved Electronic Medication Management (EMM) program with expected delivery in late 2021. The EMM has potential to improve the transfer of patient medication records, but it will not fully remediate all inefficiencies of the current systems.

Corrective Services NSW and Justice Health do not engage in sufficient joint planning to improve efficiencies in transports or escorts to health services

Corrective Services NSW and Justice Health do not engage in joint system‑level planning to mitigate the risks and the costs associated with transferring patients to health clinics in prisons, or non‑prison‑based health care. There are no protocols, and limited sharing of information to improve efficiencies in planning and coordinating patient transfers.

Corrective Services NSW does not collate or report on the costs of transporting patients to hospitals and specialist care. While there is data on the overall cost of medical escorts, estimated to be $19.9 million in 2020, Corrective Services NSW is not able to disaggregate this data to determine the reasons for transfers or the system‑level costs. For example, Corrective Services NSW does not know how many prison lockdowns occur when hospital transfers are required.

Medical escorts to specialist health services and hospitals increase the costs to the prison system and contribute to risks in prison management. Medical escorts contributed to 16 per cent of metropolitan prison lockdowns at the peak in 2018, though escort numbers have since been declining. Some Local Health Districts report significant concerns around safety incidents and assaults on staff during medical escorts to hospital.

Corrective Services NSW does not know if transport costs have increased since the 2016 Prison Bed Capacity Program which expanded prison beds in regional New South Wales. To date, there has been no assessment of the cost of taking patients to tertiary hospitals or specialist services. Corrective Services NSW has identified this as an area for improvement.

Justice Health's system managers do not receive sufficiently detailed reports on wait times for health care, to understand strategic risks or opportunities for system improvement

Justice Health's senior executives receive monthly reports on patient wait times for services in prison health clinics. These reports contain headline data about the numbers of days that patients wait for scheduled health appointments by their allocated priority level. Wait time data are averaged across all New South Wales prison health clinics. With some exceptions, almost all executive level reports describe system‑wide appointment wait times without offering further specific detail. For example, there is limited information which would allow managers to understand the performance of specialty health groups, or to make any comparative analysis of the performance of different prison facilities.

Executive reports are also not detailed enough to indicate whether prisons with particular security classifications offer greater or lesser access to health services. It is not possible to assess whether patients in metropolitan or regional prisons have different levels of health service access. This prevents managers from identifying strategic risks across the prison network, targeting resources to the areas of greatest risk, and making strategic improvements in system performance.

Trend data on wait times for the different health specialty areas is also required to enable senior managers to compare wait times across prison facilities, security classifications, and localities.

In response to the preliminary findings of this audit, Justice Health has made some improvements to its executive‑level wait time reports. This includes additional detail on health appointment wait times by prison facilities and wait times by health specialty areas.

It is not possible to compare or benchmark the performance of public and private prison health operators or to compare prison health against community health standards

It is not possible to compare or benchmark the performance of the public and private prison health operators in New South Wales using the current Key Performance Indicator (KPI) data. KPI data do not correlate across the public and private systems.

Justice Health reports to the Ministry of Health on 44 prison health KPIs. The 44 KPIs for the public prison system do not align with the seven KPIs the private health operators report against in their contracts with Corrective Services NSW. This means that public and private operators focus on different service areas. For example, private operators have a performance measure for ensuring that custodial patients are provided with release plans. Justice Health does not have a similar measure.

The KPI specifications for the private prison health system were developed by Corrective Services NSW with input from the Ministry of Health. The KPI specifications for the public prison health system were developed by the Ministry of Health in collaboration with Justice Health. There is no rationale for the difference in performance indicators across the public and private systems.

Private providers currently deliver prison services to 25 per cent of the prison population of New South Wales. This proportion has been increasing since 2016. Public and private health operators deliver comparable health services so there is scope to compare performance across the systems.

Justice Health aligns its standard for prison health services with a 'community’ standard of health care access. However, with existing health monitoring measures, it is not possible to assess how well Justice Health is tracking against community health standards with available data from most health specialties.

There is an inherent conflict of interest in Justice Health's monitoring role of health services in private prisons, as Justice Health is also a provider of health services in a private prison

There is a legislated requirement for Justice Health to monitor the performance of private health operators in New South Wales prisons. This monitoring role is described in the Crimes (Administration of Sentences) Act 1999.

Justice Health's monitoring role includes the collection and analysis of health performance data from private health operators, and periodic site visits to assess health service performance. Justice Health reports the findings of monitoring activities to Corrective Services NSW, the contract manager for private prisons.

Justice Health's monitoring role commenced in the late 1990s. In recent years, this role has expanded as the NSW Government has increased the number of privately managed prisons across the state. Justice Health now monitors health services in four private prisons, accounting for approximately one quarter of all custodial patients in the New South Wales prison system.

In 2018, Justice Health was awarded a contract to provide health services at the John Morony Correctional Centre. Justice Health also monitors the health services this Correctional Centre. The timing of the 1999 legislation did not anticipate that Justice Health would be a provider of the services it is required to monitor.

Justice Health has taken steps to maintain independence and transparency in its monitoring role by establishing a number of arms‑length governance arrangements. Justice Health set up a Commissioning Unit that operates independently from its service delivery operations. Justice Health also established an alternative reporting chain via a Board subcommittee to oversee the performance of health providers in private prisons.

Despite all actions to establish independence, the monitoring role confers dual responsibilities on the Chief Executive of Justice Health as both an operational manager of health services in a private prison and as a manager responsible for monitoring these same services. As a result, the Chief Executive of Justice Health has access to information about the overall performance of the private prison health system in New South Wales.

As a competitor for the provision of health services in privately operated prisons, Justice Health has access to information to which other private health providers do not. This potentially gives Justice Health a competitive advantage over other private health operators.

2. Recommendations

By December 2022, Justice Health should:

1. enhance reporting on patient access to health services to ensure that system managers can identify risks, challenges, and system improvements across key areas of its service profile

2. in collaboration with the NSW Ministry of Health, identify and implement the required improvements to its health information management systems that will enable effective transfers of patient clinical records and appointment information across the custodial network and with external health providers.

By December 2022, Justice Health and Corrective Services NSW should:

3. develop a joint framework to govern and monitor the costs of their common and connected responsibilities for patient health movements across the prison network and to external health services

4. develop a joint framework to govern their common and connected responsibilities for mental health services.

By December 2022, Justice Health and Corrective Services NSW, in collaboration with the NSW Ministry of Health, should:

5. progress infrastructure plans and projects that address the lack of specialist accommodation for mental health patients and aged and frail patients

6. standardise and align the key performance indicators that monitor the performance of health operators in public and private prisons so that system‑wide benchmarking is possible.

By December 2022, the NSW Ministry of Health should:

7. take action to remediate the conflicting monitoring arrangements of public and private prison health operators.

1. Introduction

1.1 Custodial health services in New South Wales

Custodial patient profile

People entering prison are more likely to have significant and complex health conditions than the general population. They have higher rates of chronic illnesses, communicable diseases, and acute mental illness. People in contact with the criminal justice system have poorer levels of contact with health care in general, and are less likely than the general population to be connected to medical services in the community.

As at 31 March 2021, there were 13,063 people in adult prisons across New South Wales (8,571 sentenced, 4,492 on remand). While the prison population decreased by about three per cent in 2020 to 2021, there has been an upward trend in population numbers over the past decade. From March 2013 to March 2021, the population increased by 31 per cent.

Health services delivered by Justice Health

Justice Health is responsible for health care in 33 public prisons and the Long Bay Hospital. In addition, Justice Health provides health services at the John Morony Correctional Centre under a contract arrangement with Corrective Services NSW.

Justice Health provides health care at some metropolitan police and court cells. This is the first point of contact with the custodial system. In these locations, nurses provide initial assessment, triage, or referral to hospital on a needs basis. Justice Health services are not available at all police intake cells or transit locations, and personnel are not available on‑site on a 24‑hour basis. While Justice Health doctors can be reached via a 24‑hour phone service, Corrective Services NSW generally calls ambulance services in instances where urgent medical assessment or treatment is required.

Under the public prison health model, Justice Health employs multidisciplinary teams of nurses and other health specialists. Primary health nurses deliver the majority of care in prison health clinics. They assess and triage custodial patients and, where necessary, make referrals to doctors and other health clinicians. Justice Health employs a range of clinicians to supplement the nurse workforce. They include general practitioners, psychiatrists, mental health specialists, drug and alcohol clinicians, dental health clinicians and radiologists. This workforce provides rostered services across the prison network.

While Justice Health provides a wide range of medical and psychiatric services in prison environments, some services are not available in prisons. For example, custodial patients can be transferred to hospitals for surgical procedures, for emergency medical treatment or other specialty care that cannot be provided in the prison clinic environment.

With a staffing profile of 1,335 FTE, in 2020, Justice Health clinicians delivered a total of 770,083 occasions of outpatient prison health care to adult patients in custody. While Justice Health provides services to a patient population of approximately 13,000, the movement of people in and out of prison significantly increases the number of unique patients. Justice Health records show that in 2020, health services were provided to over 31,000 patients with unique identifiers. The majority of these services (78 per cent) were primary health appointments.

Both public and private operators deliver health services in prisons in New South Wales. Three private operators deliver health services at the Junee, Clarence, and Parklea correctional centres. These health services are managed and monitored through contract arrangements with Corrective Services NSW.

Services delivered by Corrective Services NSW

Corrective Services NSW is responsible for custodial services in New South Wales prisons. Its core responsibilities include the management of prison security arrangements, the classification of adults when they enter prison, and the placement, accommodation and movement of people around the prison network. A significant component of this work is coordinating the flow of people in and out of prison and across the New South Wales prison network. As part of this mandate, Corrective Services NSW is responsible for transferring and accompanying custodial patients to health appointments in hospitals and other sites outside of correctional centres.

In addition to the custodial role, Corrective Services NSW is responsible for the delivery of psychology services in New South Wales prisons. These services include therapeutic and behaviour‑based treatments for custodial patients with mental illnesses or cognitive impairments. Some therapies and programs are focussed on reducing self‑harm or suicidal behaviours amongst individuals. Other services are delivered to groups and aim to modify behaviours and address criminogenic risks that may lead to reoffending. Some programs are linked to parole and sentencing conditions.

The psychology services provided by Corrective Services NSW sit alongside the psychiatric services provided by Justice Health. Justice Health's role is predominantly clinical, with a focus on psychiatric assessments and dispensing and monitoring psychotropic medications for the prison population.

In 2020, Corrective Services NSW delivered 94,810 occasions of psychology services. Over half were for mental health impairments, 13 per cent were for suicide or self‑harm, ten per cent were to reduce the risk of criminal behaviour or re‑offending, and the remainder were for behavioural or cognitive issues.

1.2 About this audit

The objective of this audit was to assess whether adults in custody in New South Wales have effective access to health services.

We addressed this objective by answering three questions:

  • Do patients have timely access to health services?
  • Do systems and practices support the continuity of health care?
  • Is the effectiveness of patient access to health services monitored, reviewed, and reported across the network?

The audit focussed on clinical health services provided to adult men and women in remand, reception, and post‑sentencing custodial environments. The audit did not assess Youth Justice NSW or health services for adolescents. It did not assess health promotion activities, non‑clinical programs or groups, or post‑release support provided to patients.

This audit was conducted under the provisions of the Government Sector Audit Act 1983. The legislation does not permit a direct examination of information held by private sector entities. However, the audit does assess the effectiveness of Justice Health's role in monitoring the health services in private prisons.

2. Timeliness of access to health services

2.1 Accessing custodial health services

Custodial patients have effective options to alert staff when they require health services

People in New South Wales prisons have a range of options to alert health staff to their medical needs. When the health issue is not urgent, patients can use a self‑referral notification form to schedule a health appointment. These forms are deposited in mailboxes that are checked by health staff each day. In some lower security prisons, patients can raise concerns with health personnel during the daily line up for medications.

When the need for medical attention is immediate, there is a buzzer or call out system, colloquially known as 'knock up'. Custodial patients and others can escalate their health concerns using this form of alert. If a patient needs to be treated immediately through the 'knock up' notification, they may be treated in the prison health clinic or transferred to hospital if it is a medical emergency.

In lower security prisons, custodial patients are able to go directly to the health clinic during their out‑of‑cell hours. These are unscheduled appointments, and they are also recorded as 'walk‑ins'. These 'walk‑ins' may be for immediate, time‑critical, or opportunistic health care.

Justice Health nurses and other medical staff make health appointments for patients as they enter prison. After an initial health assessment, patients are placed on waitlists to be seen by doctors, nurse practitioners, or other medical specialists on a needs basis. Appointments are also made as part of routine health care follow ups for physical or mental health conditions, including chronic disease management.

If families or carers have concerns about the health or mental health of someone in custody, they can call a 24‑hour mental health helpline or make a free call during office hours about other health concerns.

Patients requiring urgent medical attention are seen as soon as health staff are notified, but patients with scheduled appointments do not always receive care within target timeframes

Approximately 50 per cent of all health treatment in prisons is provided to patients immediately, upon presentation at prison health clinics. This includes those who require daily medications, patients who present for opportunistic care if staff are available, and patients experiencing medical emergencies. These patients do not have pre‑arranged appointments, and are usually treated as soon as they arrive. The vast majority of these patients are receiving daily medications.

A smaller proportion of patients presenting at prison health clinics are those with immediate and serious health conditions, and these patients are given priority over those with scheduled appointments. Justice Health records all of these patients as ‘walk‑ins'. If the patient requires emergency treatment, an ambulance is called, and these patients are escorted to hospital. Exhibit 1 shows health treatment types in 2020.

Exhibit 1: Justice Health treatment types in 2020
Appointment type Total Percentage of appointments
Walk‑in assessments and treatments 375,069 49%
Scheduled appointments 395,014 51%
Source: Audit Office analysis of data provided by Justice Health.

Patients with scheduled appointments are allocated a priority rating according to their health or treatment needs. In order to receive a priority rating, patients have an initial assessment by a nurse, and are waitlisted for an appointment with a treating clinician such as a GP, a prescribing nurse, or another medical specialist. Priority 1 patients require treatment for conditions such as changes to surgical dressings, medications, or minor infections. Even though the patient is not experiencing a medical emergency, access to the treating clinician is time‑critical to prevent deterioration of a medical condition or to ensure that a patient has a prescription for medication.

Justice Health data shows that Priority 1 patients are not receiving health treatments or assessments within recommended timeframes. Priority 1 patients should receive care within three days of their initial nurse assessment. In December 2020, the average wait time for Priority 1 patients was five and a half days ‑ almost double the target timeframe. This is an improvement from June 2019, when the average wait time for Priority 1 treatment was just over 13 days. Exhibit 2 shows the wait times for patients in December 2020.

Exhibit 2: Wait times for scheduled appointments in December 2020
Priority rating Recommended timeframe Number of waitlisted patients Average wait days Percentage seen within recommended timeframe
Priority 1* 1–3 days 480
5.5
58%
Priority 2** 3–14 days 1,418
14.1
70%
Priority 3 14 days–3 months 5,614
32.4
89%
Priority 4 3–12 months 6,534
29.6
100%
Priority 5        No designated timeframe 1,634   37.4   N/A

Meeting target.

Mostly meeting target.

Not meeting target.

 
* Ten per cent of Priority 1 appointments had a wait time of longer than 13 days.
** Ten per cent of Priority 2 appointments had a wait time of longer than 37 days.
Source: Audit Office analysis of data provided by Justice Health.

In general, Justice Health is performing better in meeting target timeframes for Priority 2, 3, and 4 appointments. However, some health specialties are not meeting these recommended timeframes.

For example, the recommended wait time for Priority 2 appointments is between three to 14 days. On average, most Priority 2 patients receive care within 14 days, but in December 2020, patients waiting for allied health care waited 34 days on average. The average wait time for optometry was 72 days, and for women's health it was 20 days.

The wait time data for Priority 3 appointments tell a similar story. In December 2020, the majority of Priority 3 patients had a wait time of 32 days for health appointments. This is within the recommended timeframe of 14 days to three months. However, in some specialty health areas, high proportions of patients did not receive timely care. Those specialties not always meeting targets include optometrist services where 67 per cent of appointments were not delivered within the three‑month timeframe, and allied health services, where 44 per cent of appointments did not occur within targets.

In December 2020, women typically had longer wait times for Priority 1 appointments, with an average wait time of 8.3 days, compared to men who waited 5.3 days. Men typically had longer wait times for scheduled appointments at the other priority levels, although these waiting periods were mostly within target timeframes.

According to Justice Health, high numbers of ‘walk‑ins’ contribute to increases in wait times for scheduled health appointments, and impact appointment backlogs across the prison network. In 2020, ‘walk‑ins’ accounted for 49 per cent of all patients seen, a reduction from 2018 when they accounted for 54 per cent. Justice Health does not have a policy guiding the prioritisation of walk‑ins as they relate to health service activity and scheduled appointments.

Wait times for psychology services have decreased, but when patients are moved between prisons, wait times increase considerably

Corrective Services NSW delivers therapeutic and behaviour‑based treatments for custodial patients with mental illnesses or cognitive impairments. In recent years, Corrective Services NSW data shows significant reductions in average wait times to access psychology services. In 2021, the average wait time for Corrective Services NSW psychology services was six days, compared to 27 days in 2018.

Corrective Services NSW managers advise that patient movements between prisons can impact on wait times for psychology services. The wait times for mental health assessments almost triple after prison transfers, and wait times for sub‑acute mental health services are five times as long for patients who are moved, compared with those who remain in the prison where the appointment is made.

Corrective Services NSW is responsible for making decisions about patient movements and managing patient transports. According to the business unit responsible for psychology services, reasons for increases in wait times include:

  • Patients can be moved to a variety of locations, and they are not available for appointments while in transit.
  • It is difficult for psychologists to manage their waitlists without a fixed patient location.

2.2 Cancellations and non-attendance at health appointments

Eleven per cent of health appointments are not attended and Corrective Services NSW does not collect sufficient data to indicate the impacts of security on prison health services

Timely access to health care in prison environments depends upon efficient and effective management of health appointment waitlists, and access to patients during their out‑of‑cell hours. Unavoidable factors can impact on patient attendance, including security arrangements and the associated logistics to manage prison populations. Corrective Services NSW has limited information about the nature and extent of security and operational factors, and their impact on a range of prison services, including health services.

In 2020, 11 per cent of scheduled health appointments in prisons were not attended. This amounts to approximately 60,000 appointments in the year; a significant volume that impacts on wait times and backlogs across all scheduled health appointments as shown in Exhibit 3.

Exhibit 3: Attended and non‑attended scheduled appointments in 2020
Appointment status Total Percentage of scheduled appointments
Patient attended 395,014 72%
Patient did not attend 60,761 11%
Appointment cancelled 59,026 11%
Not specified 31,772 6%
Source: Audit Office analysis of data provided by Justice Health.

There are many reasons why patients do not attend health appointments. They may have been transferred to another prison since the initial appointment was made, they may be on work leave, or they may not want to attend the appointment. According to Justice Health data, 15 per cent of non‑attended health appointments were cancelled by Corrective Services NSW for operational reasons in 2020. An additional seven per cent were attributed to prison lockdowns. Lockdowns can be scheduled, when correctional staff are participating in training or staff meetings, or unscheduled. One reason for unscheduled lockdowns is when there are insufficient correctional staff to escort patients to unscheduled hospital visits while maintaining prison security during out‑of‑cell hours.

According to available Corrective Services NSW data, the number of prison lockdowns peaked in 2018 in ten metropolitan prisons, and has since been declining. Justice Health data shows in 2020, an average of 12 lockdowns per week across the New South Wales prison network that resulted in missed health appointments.

A lockdown usually impacts on multiple appointments. For example, Metropolitan Remand and Reception Centre had a day where 46 appointments were not attended due to lockdowns. Corrective Services NSW operations had a higher impact on access to health services for men than women.

According to Corrective Services NSW managers, their information systems are also limited in accurately recording prison lockdowns. Their principal information system is a DOS‑based system and is described by senior managers as 'inefficient' and not built for recording prison lockdowns.

The available data on prison lockdowns indicates that in 2020, Goulburn prison had 64 days and Bathurst prison had 63 days of health service disruption due to lockdowns. Maximum and medium security prisons tend to have more lockdowns, although some minimum security prisons also experience high numbers, such as Kirkconnell prison (32 days) and Dawn de Laos (18 days). Several prisons had no days, or very few days where lockdowns affected health service access.

Improved communication and information management could enhance health appointment attendance rates

Corrective Services NSW and Justice Health share information about custodial patients in order to schedule prison health appointments. Both agencies need up‑to‑date information about the whereabouts of patients and the scheduled health appointments.

When information about patient whereabouts and availability are known ahead of time, Justice Health can effectively manage appointment schedules, and reschedule appointments to ensure maximum health attendance rates.

According to Justice Health records, the most common reason for non‑attendance at prison health appointments in 2020 was: 'patient unable to attend'. Justice Health records this reason when patients do not arrive at the prison health clinic at the scheduled time, and clinicians are unable to determine why the patient has not attended. This reason was recorded by Justice Health for 21 per cent of all non‑attended appointments in 2020.

Nine per cent of appointments were not attended because the patient was not in the facility at the time. These patients may have been transferred to another prison, released from custody, or attending court or work on the day of the appointment. Thirteen per cent of appointments were coded as not attended because the patient did not respond when called to an appointment.

Information about the movements of custodial patients is stored in systems that are operated by Corrective Services NSW. Justice Health does not have access to these systems. Communication between the agencies is therefore essential, so health clinicians are aware of patient movements ahead of time. More timely communication about patient movements will allow improved management of patient health appointment scheduling. This means that appointments can be cancelled if a patient is not in the facility, and potentially offered to others on the waitlist.

There is potential to improve the data and reporting on non‑attended health appointments in prisons. The drop‑down menu in the appointments database contains too many options for recording non‑attendance. Some are superfluous and some are repetitive. With so many codes, staff may be choosing the most convenient code, or those that appear higher on the menu list. Reducing and clarifying menu options is likely to improve the accuracy of information about non‑attended appointments.

Seven per cent of psychology services are cancelled or not attended

Corrective Services NSW provides the majority of prison psychology services. These services are both individual and program‑based. Individual services are focussed on assessments for active symptoms of mental illness, assessments for disruptive behaviours and risk for self‑harm or suicidality. Program‑based therapeutic interventions are for behaviours related to the person's offence or their risk of reoffending on release. They include Sex and Violent Offender Therapeutic Programs, Drug and Alcohol Treatment Programs and Countering Violent Extremism.

According to data provided by Corrective Services NSW, approximately seven to eight per cent of appointments were cancelled or not attended in the past three years. In a nine‑month period from July 2020 to April 2021, a total of 4,681 Corrective Services NSW psychology appointments were cancelled or not attended.

Thirty‑two per cent of cancellations were due to logistical or operational issues. A further 16 per cent were due to lockdowns of a wing or facility, and 13 per cent were due to lack of available custodial staff to escort the patient.

Other reasons for cancellation and non‑attendance include delays in patients arriving at appointments due to movements, patients not attending, no interview room available, or a psychologist was not available.

Our 2017 audit of Therapeutic programs in prisons found that in 2015−16, 75 per cent of prisoners who needed a prison‑based therapeutic program did not receive one before the earliest date they could be released. Timely access to prison‑based therapeutic programs can be a factor in parole refusal and can potentially exacerbate overcrowding in the prison system.

2.3 Access to specialist health services

Demand for mental health care exceeds service capacity and some patients are held in environments that are not appropriate for their needs

There is a high demand for mental health services in New South Wales prisons. The National Mental Health Commission has reported that people in custodial environments have much higher rates of mental illness than the general population, including higher rates of severe mental illnesses such as psychosis and mood disorders. Justice Health data shows that in March 2021, at least 143 mental health patients were waiting for access to an acute or sub‑acute mental health unit across the New South Wales custodial system. By the end of March, 40 patients had been admitted to a mental health unit and 69 were still waiting. An additional 11 people were released from custody before accessing a mental health unit. The remaining patients were either removed from the waitlist or transferred to other waitlists.

The average time that mental health patients waited to access a mental health facility in custody was 43 days. Seventeen patients had wait times of over 100 days. Patients waiting for sub‑acute mental health services had longer wait times than those waiting for acute mental health services.

There are limited mental health beds for women across the New South Wales prison network. There are a total of ten allocated beds at the Mental Health Screening Unit at the Silverwater complex. There are no allocated beds for women at Long Bay Hospital, but they can be accepted via a risk management and clinical review process.

Forensic patients are those who are found not criminally responsible, or not fit to be tried for an offence, due to reason of mental illness or cognitive impairment. They are not considered to be custodial inmates. These patients can be held indefinitely at the Forensic Hospital at Long Bay or another correctional or mental health facility. A lack of bed availability in the Forensic Hospital means that as of February 2021, 63 forensic patients were being held in mental health facilities within correctional centres. Some of these forensic patients have been held in mainstream prison facilities for decades.

When forensic patients are accommodated in mental health environments in mainstream prisons, this reduces the number of beds available to correctional patients requiring high levels of mental health care.

Sixty‑three per cent of people entering prison in 2019 had a mental illness diagnosis at some stage in their life, with 26 per cent presenting to custody with an active psychosis. Amongst the general population, the rates of people diagnosed with mental illness at some point in their life was 46 per cent, with rates of active psychosis at less than one per cent.

Cross‑agency co‑operation and planning is required to identify and build infrastructure that will reduce wait times for mental health beds. Over several years, Justice Health has developed, reviewed, and worked to progress a strategic plan for NSW Forensic Mental Health that includes enhanced mental health bed capacity across the NSW system. The latest version of this strategic plan remains in draft and has yet to be approved by the NSW Ministry of Health.

In 2016, the Prison Bed Capacity Program was commenced by Corrective Services NSW. It was focussed on enhancing capacity across the prison system generally and did not include specialist health beds. More recently, Corrective Services NSW has been developing a business case to improve the provision of specialist health care facilities across the network, including mental health facilities.

The prison population is ageing, and some specialist care is not currently available in prisons

The proportion of adults in custody aged 45 years and older increased from 22 per cent in 2016, to 25 per cent in 2020. People in this older age group accessed health care at greater rates than the rest of the custodial population. They accounted for 32 per cent of attended Justice Health appointments in 2020. Older patients had a higher need for specialist care than the younger population. They accounted for 44 per cent of external waitlisted appointments in December 2020. In future years, the population of older custodial patients is projected to significantly increase in New South Wales.

There are limited specialist units within the custodial setting for aged and frail custodial patients. Those that are available are at the Long Bay complex and the Metropolitan Remand and Reception Centre. Access to these beds is determined through assessments made at fortnightly meetings by Corrective Services NSW, Statewide Disability Services and Justice Health. Aged and frail specialist beds are at capacity, and there are long waitlists for access to these facilities.

According to managers from both Corrective Services NSW and Justice Health, aged and frail patients are being housed in accommodation that is not fit for their needs. Additional units and upgrades to existing spaces are planned to be delivered through a Prison Bed Capacity Adjustment Program under the Corrective Services NSW Infrastructure Strategy. Due to challenges with staffing in regional areas and access to hospitals and specialist health services, the new aged care units will be based in metropolitan areas.

Some hospitals are providing increasing levels of treatment that is not available in custodial environments

In recent years, patient transfers from prisons to metropolitan hospitals have been increasing. Of the 2,200 hospital transfers between July and December 2020, 57 per cent were for treatments or services not available in Justice Health, and 32 per cent were for medical emergencies.

Justice Health's model of health care is predominantly delivered by nurses. Visiting doctors and specialists arrive at pre‑arranged times to provide treatments not provided by nurses. Some services such as medication prescriptions or assessments can occur through audio visual links with medical practitioners. In 2020, nurses provided 77 per cent of all scheduled appointments and 98 per cent of walk‑in appointments.

When prison health personnel are unable to provide the care required, patients are transferred to specialist or hospital care outside the prison. Custodial patients accessing hospital services and specialist care outside the prison environment are affected by the same wait times and backlogs for surgery and other health services as the general population.

Hospitals receiving the highest volume of custodial transfers are shown in Exhibit 4. Justice Health policy specifies that The Prince of Wales Hospital should be the preferred destination for hospital treatments other than diagnostic imaging and emergency. From July to December 2020, the Prince of Wales Hospital received 15 per cent of total hospital transfers. Around 70 per cent of transfers to other hospitals were for non‑emergency reasons such as medical imaging or surgery.

Exhibit 4: Top hospital destinations for custodial patient transfer, July to December 2020
Hospital destination Volume of transfers (% of total transfers) Medical emergencies (% of total for that hospital)
Prince of Wales Hospital 335 (15.2%) 124 (37%)
Westmead Hospital 277 (12.6%) 105 (37.9%)
Kempsey Hospital 172 (7.8%) 62 (36%)
Nepean Hospital 168 (7.6%) 32 (19%)
Blacktown Hospital 152 (6.9%) 64 (42.1%)
Cessnock Hospital 142 (6.4%) 29 (20%)
Bathurst Hospital 120 (5.4%) 29 (24.5%)
Shoalhaven Hospital 102 (4.6%) 31 (30.4%)
Source: Audit Office analysis of Justice Health data 2020.

Justice Health has implemented programs to prevent and treat the spread of infectious diseases in prisons

In 2020, Justice Health and Corrective Services NSW implemented a collaborative program to respond to the COVID‑19 pandemic. People newly remanded to custody were tested for COVID‑19 on entry to prison. They then went into a 14‑day quarantine period. Screening and risk‑based quarantining was also required for custodial patients who were transferred across the prison network. Corrective Services NSW and Justice Health set aside 150 cells for these purposes. NSW Health screening, contract tracing and public health orders were applied in relation to prison staff. Temperature checks were required at the entry points of all prison facilities. Quarantine protocols were applied for staff who were identified as contacts of people with COVID‑19.

In 2020, Corrective Services NSW paused the prison visitor program to reduce the risk of community transmission of COVID‑19 into the prison system. Visits were replaced by video calls with the additional benefit of linking custodial patients with family members at significant distances from prisons, including those living interstate and overseas.

A 32‑bed field hospital was built within a six‑week timeframe at the Silverwater Correctional Complex. It was predominantly built by people in custody and was fully operational by April 2020. Justice Health partnered with Corrective Services NSW to fund and build the facility. It includes a disinfection station, an airlock entry, clinical areas for treatment and video consultation, and hospital bed tents that provide individual air supply and extraction.

The management and testing for COVID‑19 had a significant impact on prison resources. For example, in 2020, 18 per cent of Justice Health appointments were related to COVID‑19. In addition, Justice Health has delivered a prison information campaign to inform custodial patients about the benefits of vaccination.

Up until July 2021, Justice Health's management of COVID‑19 was successful in preventing transmissions amongst custodial patients within the public prison network. At the time of writing this report, New South Wales is experiencing a significant outbreak of COVID‑19, and positive cases of COVID‑19 have been identified in a number of prisons across New South Wales.

In addition to the COVID‑19 response, Justice Health has implemented programs such as the Hepatitis in Prisons Elimination (HIPE) program in order to address the spread of infectious disease both within prisons and in the community. This program has been effective in significantly reducing hepatitis prevalence and transmissions in New South Wales prisons.

Justice Health is not meeting recommended seven‑day wait times for dental patients requiring serious or urgent dental care

From January to April 2021, only 17 per cent of custodial patients who were recommended for dental care within seven days received care within this timeframe. The average wait time for these patients was 31 days. Wait times have improved since 2019 when only three per cent of dental patients received care within target timeframes, and the average wait time was 93 days.

Justice Health dental patients are waitlisted for more acute and more time‑critical dental care than those waitlisted for care in the New South Wales public dental system. According to dentists working in the prison system, custodial patients have a range of risk factors including smoking, poor oral hygiene, drug addictions and high sugar diet. For many, this has resulted in dental decay and gum disease.

Justice Health data shows that 25 per cent of custodial patients waited longer than the recommended maximum wait times for dental care during a sample month period in 2021. The data on community wait times for public dental care were slightly better, with 18 per cent of community members not receiving public dental care within recommended timeframes in 2021.

Delayed access to dental care has significant impacts on quality of life. For example, prison health staff and custodial patients told us that delayed access to care can impact on the ability to eat and sleep. Justice Health is currently examining dental health wait times through an oral health redesign project.

It is not possible to determine whether delays in dental care are leading to acute health conditions

Routine dental care in prisons is generally provided by dentists employed by Justice Health. Dental clinicians deliver dental care within the prison health clinics on scheduled days. Dental care wait times are recorded in a database specifically assigned for dental health care records. This database is mandated by NSW Health. Dental waiting lists are managed centrally by Justice Health, rather than at the prison health clinic.

The dental health care database is not linked to the main patient appointment system. This means that it is difficult for Justice Health clinicians to know if a minor dental issue becomes an infection that requires immediate treatment, for example. The databases will not link these events. An infection requiring antibiotics is likely to be recorded in the patient appointment system, not the dental health care record. The urgent care becomes a new entry record in a separate database, and it is not possible to know whether there has been an escalation in care through data records.

There are long wait times for dental care, and Justice Health is not able to fully assess the impact of poor dental health on the overall health and wellbeing of patients across the prison network.

A 24‑hour phone service is a key enabler of access to doctors and specialists in prisons

Justice Health maintains a 24/7 on‑call state‑wide phone service that acts as an enabler for health care when nursing staff or doctors are not available on site at a prison. The service provides access to an after‑hours nurse manager, doctors, and specialists in psychiatry and drug and alcohol services.

The service is available to staff from both Justice Health and Corrective Services NSW when they need clinical advice on patient management or responses. Policy states that the service is intended to provide clinical support to nursing staff who are managing urgent or non‑routine health concerns, including medication orders and decisions around emergency department transfers.

In practice, the service is used to enable a much wider range of activities, including supporting transfer of care between internal and external clinicians, review and follow up of any patients classed as 'urgent', and reviewing lists of patients scheduled for external appointments. It is also promoted as a contact line for external services to request information from Justice Health.

Access to doctors on the phone line is not always immediate, and nurses will often wait up to an hour for a doctor to return their call. Justice Health does not collect information on types of calls or correctional centres using the phone line.

Exhibit 5: Virtual health care in New South Wales prisons

Justice Health is using virtual care to overcome a range of security, operational and geographical barriers that limit access to custodial patients. Virtual care improves the access that Justice Health clinicians have to custodial patients. It improves access when patients are located in regional or rural locations, as clinicians do not have to travel to prisons that are remote from their usual locations.

Virtual health care is also being used to expand the number and range of health services that are delivered within the limited clinical space of prison environments. In many New South Wales prisons, only a few health specialty services can be delivered in a single day due to a lack of onsite space. Using virtual care, specialists can provide services on a flexible and needs‑basis and do not always take up a clinical room for an entire day. Doctors and specialists can offer their services to other prisons if patients are unable to access the prison health clinic due to lockdowns or limits on their movements.

Virtual health care was added to Justice Health's service agreement in 2020–21 as a new KPI with a performance target of ten per cent. Since 2018, Justice Health has been collecting data about virtual health care delivery, and has been enhancing its prison health capabilities through these technologies. In 2018–19 virtual health care constituted around three per cent of all prison health care. In 2021, virtual health care now accounts for five per cent of prison health care. Justice Health is currently delivering virtual care in the specialty areas of mental health, primary health, dermatology, dental care, and cardiology. Justice Health is continuing to identify opportunities for increasing this service profile.

Virtual care cannot replace all health services and, in many instances, physical assessments and in‑person treatments are necessary. However, virtual care has proven to be effective in some circumstances. For example, metropolitan‑based psychiatrists have been able to assess patients in prison health clinics across the state. Psychiatrists use video technologies to observe patients and conduct interactive sessions. According to Justice Health, patients receive timely care as they do not need to wait for visiting psychiatrists to conduct assessments or prescribe medications.

Increased virtual care also has the potential to reduce whole‑of‑government costs for patient transports and the associated operational expenditure. For example, the number of medical escorts may decrease, and this will potentially decrease transport costs, and the occurrence of lockdowns associated with staff being deployed from prison security to assist with secure medical escorts.

Source: Audit Office analysis of information provided by Justice Health and Corrective Services NSW.

3. Continuity of health care

3.1 Patient records management

Patients are transferred between correctional centres at short notice, and manual processes can compromise clinical handovers

The transfer of people across different correctional centres is a frequent occurrence. In 2020, there were over 41,000 movements between correctional centres. The protocol for managing these transfers requires Corrective Services NSW to provide Justice Health staff with a list of custodial transferees one day prior to the transfer. If any transferee has a medical condition, health staff must prepare transfer medications and clinical handover information at short notice.

Policy requires that a medical handover occurs prior to a patient being transferred but, in practice, this is inconsistent. For complex or severe patients, a verbal handover to the destination clinic is ideal but not always possible due to resource and time constraints.

While a patient's electronic health records are available across the network, the transfer of appointment waitlists must be done manually. There is no electronic transfer of this information, leading to a risk that appointments will be overlooked.

Patient medications are recorded on paper‑based charts. There are risks that records can be lost in transferring information across the prison network. Some paper‑based records accompany the patient. Others are scanned and sent to the new prison location. This is labour‑intensive and inefficient and adds to the administrative load on health personnel. Justice Health is developing an improved Electronic Medication Management (EMM) program with expected delivery in late 2021.

Justice Health policy states that a centre must provide one day of medication to accompany a patient being transferred to another centre. According to Justice Health personnel, some private prisons do not send medications when patients are transferred to the public prison system.

Communication between Justice Health, Corrective Services NSW, and private health providers is limited by legislative requirements and lack of access to information systems

The sharing of information between Justice Health and private providers is limited by legislative provisions that restrict Justice Health from providing clinical advice or opinion about patients under a private operator’s care.

Following the handover of a care plan for a patient transferred to a private prison, no further advice or input is provided about patient care until they return to a public centre, even if direct input is requested. Justice Health's monitoring role of private health providers limits information sharing across the prison health entities.

Justice Health staff have limited access to the Corrective Services NSW database for information about patient expected release dates and upcoming court appearances. Corrective Services NSW staff do not have access to any Justice Health records. Justice Health staff communicate information on a patient's health‑related needs to Corrective Services NSW officers via a paper‑based format. This contains health information relevant to a person's incarceration, but does not disclose specifics on diagnoses or conditions.

Clinical records of psychology services provided by Corrective Services NSW are maintained in hard copy by psychologists at each centre, and cannot be accessed by Justice Health mental health clinicians. Corrective Services NSW psychologists cannot access Justice Health's electronic medical records for psychiatry and acute mental health treatment.

Private prison health operators are able to access the Justice Health patient information management systems for clinical reporting and appointment management. This enables patient electronic records to be accessed from any centre within the network. However, some private prisons use alternative or parallel systems for medications and patient health records. When patients are moved between centres, records must be migrated between systems.

3.2 Continuity of care with external health services

New initiatives have been implemented to improve patient transfers to hospitals and external appointments, but more data and role clarity is needed to assess the full impact

In 2019, Corrective Services NSW established a trial to assist with the transport of patients from Long Bay, Silverwater and John Morony prisons to external medical appointments. A Medical Escort Unit was established to relieve the pressure on duty correctional staff for transferring patients to hospitals and other medical services. Staff were deployed and trained with the sole purpose of taking patients securely and safely to external medical appointments. Alongside the Medical Escort Unit, Justice Health established a Medical Appointments Unit to improve cross‑agency coordination and planning for external patient medical appointments. Staff from Justice Health and Corrective Services NSW were co‑located at a metropolitan prison to improve communication across agencies.

During a 12‑month period from June 2019 to May 2020, over 6,600 medical transports were completed from Long Bay and Silverwater prisons. Corrective Services NSW has not collected or assessed prison escort data against prison lockdown data, so it is not possible to make a conclusive link about efficiencies. Nevertheless, the Medical Escort Unit provides a service that would otherwise be the responsibility of duty correctional officers. According to Justice Health and Corrective Services NSW, on‑duty correctional staff are now less likely to be called away for medical escorts, and there is less reason to lock down prisons for security purposes.

Prior to 2021, it was not compulsory for Corrective Services NSW personnel to record data on prison lockdowns. Lockdown data prior to 2021 is unreliable and likely to be understated. As of 2021, correctional staff are now required to accurately record any restrictions of movements and lockdowns in New South Wales prisons.

Both Corrective Services NSW and Justice Health describe efficiencies since the establishment of the Medical Escort Unit and the Medical Appointments Unit. However, there are conflicting views about roles and responsibilities for managing patient appointments. Justice Health policy does not delineate the discrete responsibilities of Nurse Unit Managers with the responsibilities of personnel in the newly established Medical Appointments Unit.

Role clarity and more data analysis is required to assess the overall impact of both specialised units on the coordination and transfer of patients to external medical services. Corrective Services NSW is now considering whether to expand the operations of the Medical Escort Unit.

A recent agreement will give Justice Health access to Medicare numbers so they can use this unique identifier to link custodial patients with their community health records

Until recently, Justice Health had not been able to access the Medicare numbers of custodial patients to link them with their community medical records. This imposed a significant administrative burden on Justice Health clinicians as they could not access patient records using the unique Medicare identifier. If clinicians required medical information, they had to contact external health providers through a 'release of information' process. This was time consuming and inefficient. Information was only available when patients knew where they had received medical care in the community.

At the time of writing this report, an agreement was reached with the Australian Government (through Services Australia) that gives Justice Health permission to access the Medicare numbers of custodial patients. This agreement was achieved after ten years of negotiation. Until this point, Justice Health had not been able to link its clinical application systems with other electronic patient health record platforms such as HealtheNet (New South Wales health records) and My Health Record (Australian Government health records). It is anticipated that before the end of 2021, Justice Health will have access to these applications.

In the first stage of the project, Justice Health clinicians will have improved access to hospital discharge summaries, medication information, general practitioner (GP) medical records and pathology results. During this stage, information will move in one direction – allowing Justice Health to receive or access information from HealtheNet and My Health Record.

A second stage is anticipated whereby Justice Health will be able to upload information to HealtheNet and My Health Record, so that hospital clinicians, community health providers and GPs can see the health records of patients while they were in custody. No timeline has been set for the second stage.

To date, Justice Health has not monitored or recorded information about the numbers of patients who have access to their medical records as they enter or leave prison. Justice Health does not know how many custodial patients leave prison without medication records or other medical information. Justice Health does not know the impacts when there is a lack of continuity of care.

With the unique Medicare identifier, Justice Health will have greater access to patient information when they are received into custody. In time, it is proposed that Justice Health will be able to use the Medicare identifier to assist with the transfer of patient information as they leave custody. This is likely to improve the continuity of patient health care.

The separation of Medicare records from the custodial health system has impeded information sharing between prison health providers and community health providers, and continuity of health care as patients moved in or out of custody.

Justice Health has difficulty exchanging information with community health providers

When custodial patients enter prison, they are asked about existing medical conditions or medications. Justice Health then seeks verification from the community health provider to confirm any existing diagnoses and treatment plans. The process of requesting and receiving information from external services can take several days. Justice Health policy does not provide clear guidance or mandate timeframes for requesting and receiving information about a patient's medical history.

In 2020, almost 19,000 people entered custody. There are a range of assessment and management processes associated with patient transitions into custody. Justice Health nurses conduct the initial patient assessments. When there are high volumes of new entrants, nurses can be consumed with this task and this can impact on other health services and on wait times for scheduled appointments.

If new entrants to custody have been taking medications in the community, Justice Health clinicians must request information from prescribing doctors, a task generally done by phone. The inability to link patients with a Medicare number has historically made the task more labour intensive. The recent agreement with the Australian Government that gives Justice Health access to Medicare numbers is likely to streamline this process.

On release from prison, many custodial patients require medical services in the community. Medical practitioners have access to five different channels to request prison medical records. Some practitioners report that it is difficult to know the best means to request this information, and that numerous phone calls are required to request medical records. Patient consultations during GP sessions are time limited, and patients depart the clinic before practitioners are able to access medical records. Community health practitioners report that it is difficult to determine the most appropriate channel for requesting or accessing patient health records and that prison health records are not always readily available.

3.3 Planning for release from custody

Release planning is not occurring for all patients, though patients with complex health requirements receive priority

Justice Health policy mandates that patients be provided with health discharge summaries and seven days' supply of medication. More detailed health release planning is at the discretion of nursing staff.

Justice Health was not able to provide this audit with data on the numbers of patients released from custody with health discharge summaries or release medications. While policy mandates that Justice Health provide its patients with discharge summaries and seven days' supply of medication, there is no performance indicator requiring reporting on this issue or collection of data to demonstrate compliance.

Justice Health receives weekly and monthly reports from Corrective Services NSW on known upcoming patient release dates. In 2020, over 18,800 patients were released from custody around the state, and an additional 1,190 were released directly from court.

Justice Health managers and clinicians are not always aware when someone is due for release or has been released from custody. For example, people on remand can be released directly from court without notice. Justice Health does not automatically receive updates that a patient has been released, and is not always able to provide discharge summaries once a person is in the community. This is done on a case‑by‑case basis and there is no way of monitoring this activity.

If Justice Health is aware that a patient has a pending court date, nurses provide patients with a business card containing phone numbers to call for health information records. Justice Health policy does not provide clear guidance on how unexpected releases are to be managed or any follow‑up requirements that must be attempted.

The Integrated Care Service was established by Justice Health to manage release planning for particularly vulnerable patients with complex health needs. In 2020, the average number of patients enrolled in this service was 480, which is approximately ten per cent of all people in custody with a diagnosed chronic illness. During the last quarter of 2020, 96 per cent of patients enrolled with the Integrated Care Service received a detailed discharge plan and summary and the requisite medications on release. This constitutes a small proportion of the total prison population.

Exhibit 6: Continuous health care for Aboriginal patients as they enter and leave custody

As a population group, people entering custody are more likely to have chronic diseases than the rest of the population and are less likely to have sought treatment for these conditions. Of those in custody, Aboriginal people have the highest rates of chronic illness. Many have a history of early trauma and intergenerational trauma.

In the prison environment, patients have an opportunity to receive medical care for previously untreated conditions. They are screened on entry, and many commence treatments and medications. In recognition of the health disadvantages experienced by Aboriginal patients, Justice Health established the Aboriginal Chronic Care Program to assist in the management of chronic disease through treatment, education, and support.

On release from prison, patients require ongoing medical care. The discontinuation of treatment, in particular, the stopping of some medications, can pose health risks and increase risks of reoffending. For example, patients who discontinue anti-psychotic medications or opioid treatments, are at risk of behavioural changes that may lead to reoffending. As many as 26 per cent of people who enter custody in New South Wales have symptoms of active psychosis – a rate that is much higher than the general population. 2019 data on reoffending rates, show that within 12 months after release, 55 per cent of Aboriginal people and 34 per cent of non-Aboriginal people reoffended.

The risk of death due to drug overdose or suicide is high for Aboriginal and non-Aboriginal patients immediately following release from prison. Compared to the general population, the risk of suicide was 14 times higher for women recently released from prison, and five times higher for men. Effective connections with community medical care are therefore critical, in order to support and monitor patients as they transition to community living.

When custodial patients have a planned release date, Justice Health is usually able to provide them with a paper-based summary of their medical history, along with a week’s supply of medication. In most cases there is limited clinical handover to community health providers. When patients are bailed or released from court, in general, they do not receive release summaries or medications. Some Aboriginal patients are not certain of their destination on release and so it is difficult to identify a medical provider for handover of care. In addition, Local Health Districts require that patients have a fixed address within their boundaries before they will provide some forms of medical care. This creates significant barriers for patients who are released from prison into homelessness.

Justice Health has limited arrangements with Aboriginal Community Controlled Health Organisations. Some pathways exist, for example, the Waminda South Coast Women's Health and Welfare Aboriginal Corporation offers in-prison support and telehealth in some prisons. Without these arrangements, it is difficult for Justice Health to make referrals post incarceration.

Aboriginal people are imprisoned at over nine times the rate of non-Aboriginal people2. They make up 27 per cent of the prison population, while constituting around three per cent of the greater New South Wales population. Since 2014 there has been a 37 per cent increase in the numbers of Aboriginal people in prison.

Source: Audit Office analysis of information provided by Justice Health and Corrective Services NSW

4. Monitoring and reporting on access to health services

4.1 Reporting on health service access

Justice Health's reporting on access to health services in prisons is not sufficiently detailed to inform system managers about strategic risks or opportunities for system improvement

Justice Health's governance reports regarding health service access in New South Wales prisons are not sufficiently detailed to inform decision‑makers about areas of risk or areas where resources should be targeted to address underperformance.

Senior executives receive monthly reports on patient wait times for scheduled health services in prison health clinics. These reports provide high level, aggregate data about average wait times for scheduled health appointments across the entire prison health network.

Executive level reports do not compare wait time performance across different prison facilities or security classifications. They do not include detail about wait times for particular health specialty areas. There is insufficient detail for system managers to see strategic risks across the prison network or to identify opportunities to make system improvements.

Senior executives in Justice Health require more detailed reporting on patient access to health care to make informed decisions about resourcing the health network. Without trend data on access by health specialty, facility, and service type, decision‑makers are unable to target resources to areas of the system that are underperforming or to areas of emerging risk.

Justice Health has a fragmented approach to monitoring and reporting on patient access to urgent health care

Justice Health executives do not receive comprehensive reports on patients receiving immediate or time‑critical health care. Justice Health has three different systems for recording and reporting on the different types of time‑critical health care. Patients requiring time‑critical care can be:

  • Priority 1 patients who have scheduled appointments
  • 'walk‑in' patients requiring immediate assessment or health care without a pre‑arranged appointment
  • patients transferred to emergency departments via ambulance.

Data and reporting on these forms of care is not consolidated or viewed simultaneously by Justice Health managers. This limits the ability of senior managers to assess the nature and extent of urgent or immediate care across health facilities and trends over time.

Justice Health's wait time dashboard provides service directors with real‑time information about the wait times that patients experience in custodial environments. The dashboard is monitored by clinical staff at all levels of the Justice Health network. It provides oversight of health service accessibility at individual prisons across the New South Wales network.

The dashboard is designed to show managers whether the network is meeting its target timeframes against patient priority levels. For example, patients in Priority 1 category should be seen within three days, and those at Priority 2 level, within 14 days. Service directors use the dashboard to follow up on individuals who are waiting longer than the specified timeframes.

Monthly dashboard data reports to Justice Health executives are based on average waiting times for health services for patients who were triaged in the past month. Reports do not include data on patients added to waitlists in previous months. This distorts the wait times across the system. Average wait times are shorter in the executive level reports than the actual wait times experienced by patients across the network.

Justice Health is currently making improvements to its governance reports by enhancing detail about wait times for scheduled health appointments and comparing information about scheduled appointment wait times with data on the volumes of 'walk‑ins' in prison health clinics.

Justice Health managers do not receive routine reports on escalations and de‑escalations of patient priority levels

Patient health priority levels can be escalated or downgraded in the appointment system according to re‑assessments of patient acuity levels or requirements. However, increases in acuity are not flagged on the patient record and clinicians have to go to into individual appointment entries to find out the history of treatments. For example, a patient originally assessed as Priority 3 (should be seen within 90 days) may be escalated to Priority 2 (should be seen within 14 days). It is not obvious in the patient health record that an escalation of acuity has occurred while the patient was waiting for a scheduled appointment.

Justice Health managers do not receive routine reports on how often patient priority levels are escalated or downgraded, or any patterns in the frequency of changes by service type or priority of the care. While appointment systems can track where patient care priorities have been changed, either to a higher or lower priority, there is no system‑level reporting on these issues and there are inconsistencies in recording practices for changing patient priority levels.

When a patient's health needs are escalated, Justice Health staff may update the priority level of the original appointment, or they may create a new appointment for the patient. In some instances, the original health appointment record remains open, indicating that the patient is still waiting for a service when they have received treatment. Conversely, service managers frequently review and downgrade the priority levels of patients based on the clinical notes made by nursing staff. This is part of routine waitlist management practice.

Data on escalations and de‑escalations of care can be extracted from the back‑end of Justice Health’s data system, but this information is not available at the dashboard level or monitored by service managers. This means it is difficult to identify any emerging risks from data. Priority Level changes occurred most often at the Metropolitan Reception and Remand Centre, Cessnock Prison and Bathurst Prison.

In 2020, the adult ambulatory mental health services had the highest numbers of escalations, accounting for 34 per cent of all escalations during this period.

Justice Health has sufficient reporting mechanisms at the executive director level for monitoring patient safety incidents and risks

Justice Health has several mechanisms for monitoring serious health incidents and processes for implementing changes to improve health care across the prison network. Serious health incidents are a relatively uncommon occurrence across the prison network. For example, the month of January 2021 was fairly representative of incidents during the period from June 2020 and March 2021. In this month there were three incidents that were considered to cause a serious level of harm from over 69,000 episodes of care.

Between March 2019 and February 2021, there were 68 deaths in public prisons, of which 11 related to the medical deterioration of custodial patients and required an emergency response. Thirteen were related to the self‑harming behaviours or suicides of custodial patients and 17 related to drug overdose, violence, or other unexpected reasons. All other deaths were expected, and due to age or illness.

In 2019–20, Justice Health conducted 27 Root Cause Analyses to identify how its own systems and processes contributed to the clinical deterioration of custodial patients. These analyses assessed the causes of patient deterioration, and identified improvements aimed at preventing similar incidents.

Justice Health has a number of Board sub‑committees to monitor and review clinical quality and safety issues. Justice Health also reports to the Ministry of Health on a range of KPIs related to the safety performance of the prison health network.

Justice Health's ‘Close the Loop Committee’ oversees the implementation of recommendations arising from coronial inquests and root cause analyses. This Committee has mechanisms for ensuring recommendations are addressed within specified timeframes and allocating action officers. Of 36 open recommendations in March 2021, 16 have an allocated action officer.

Justice Health does not know how many patients leave custody with health release plans

Justice Health does not have obligations to report on the numbers of patients who exit prison with a health release plan. The Service Agreement between NSW Health and Justice Health does not contain a performance indicator on health release planning and Justice Health does not collect data on patients who leave custody with a plan. These plans assist custodial patients to maintain continuity of medical care in the community. Without this data, it is not possible to assess Justice Health's performance in maintaining patient continuity of care.

Private prison health operators are required to report on the numbers and percentages of remand and sentenced patients who leave prison with health release plans. Private operators have performance targets attached to these activities and financial abatements if targets are not met. Justice Health's performance on patient health release planning activity cannot be compared with the private operators.

Justice Health is reporting on the numbers and percentages of release plans that accompany a small cohort of patients with complex health needs. These patients are assessed as being particularly vulnerable and are enrolled in Justice Health's Integrated Care Service.

According to Justice Health policy, primary health nurses are responsible for providing basic discharge summaries, organising release medications, and release planning activities. Basic release summaries provide an overview of health services received during incarceration, pathology results, and current medications. These are provided in hard copy to patients ahead of their release date. There is some conflicting advice about who has responsibility for release planning for patients with complex health needs. There is some overlap in the release planning roles of primary health nurses, specialist clinicians, and the Integrated Care Service, and limited clarity around who should take lead responsibility.

There is no reporting on the volume or associated costs of patient transfers to metropolitan hospitals since the prison expansion program in regional New South Wales

In 2016, Corrective Services NSW commenced a major infrastructure project to expand its prison bed capacity in New South Wales by 7,000 beds. Most of the expansion occurred in regional areas. The core objective of the project was to meet accommodation needs for a growing prison population. Justice Health was not part of the planning for the 2016 prison infrastructure project.

The regional prison expansion program is likely to have increased the time it takes to transport patients to tertiary hospitals or specialist services and added to the overall costs of health transportation. To date, no assessment has been made of these costs and it is not known whether the regional expansions have placed a greater burden on regional hospital services.

Corrective Services NSW is now developing a business case to expand prison bed capacity in metropolitan areas to address a lack of specialist health care facilities across the network. The focus of the new project is metropolitan‑based purpose‑built facilities for patients with specialist health needs such as mental health care and services for the frail and elderly. Justice Health is now involved in the planning for the expansion of specialist health care facilities across the network.

Corrective Services NSW and Justice Health do not engage in sufficient joint planning to improve efficiencies in transports or escorts to health services

Corrective Services NSW and Justice Health do not engage in joint system‑level planning to mitigate the risks and the costs associated with transferring patients to health clinics in prisons, or non‑prison‑based health care. There are no protocols, and limited sharing of information to improve efficiencies in planning and coordinating patient transfers.

While some information is not able to be shared for privacy reasons according to Corrective Services NSW, greater transparency about the urgency of transfers, or the potential to postpone escorts until staff are available, could potentially avoid unnecessary lockdowns.

Corrective Services NSW does not collate or report on the costs of transporting patients to hospitals and specialist care. While there is data on the overall cost of medical escorts at $19.9 million in 2020, Corrective Services NSW is not able to disaggregate this data to determine the reasons for transfers or to assess system‑level costs as a result of transfers. For example, Corrective Services NSW does not know how many prison lockdowns occur when hospital transfers are required, or the costs of stationing staff with patients in hospitals. Corrective Services NSW has identified this as an area for improvement and acknowledges that more needs to be done to improve system‑wide understanding of this issue.

Medical escorts to specialist health services and hospitals increase the costs to the prison system and contribute to risks in prison management. Medical escorts contributed to 16 per cent of metropolitan prison lockdowns at the peak in 2018, though escort numbers have since been declining. Some Local Health Districts report significant concerns around safety incidents and assaults on staff during medical escorts to hospital.

Justice Health's systems for responding to serious incidents and adverse events show evidence of coordination with Corrective Services NSW at the prison level. Activity is focussed on process improvements, including the management of patients returning from hospital.

Justice Health and other organisations record patient satisfaction with prison health services, though some information sources are outdated

Justice Health's NSW Network Patient Health Survey Report provides a comprehensive overview of prisoner health in New South Wales, though the survey has not been conducted since 2015.

The 2015 Survey found that 23 per cent of patients reported their health as ‘fair’ or ‘poor’, and 53 per cent said they would access health care services if they had a health concern. Justice Health does not contribute to the National Prisoner Health Data Collection, arguing that its own survey provides more comprehensive longitudinal data. The national health data collections have been held in 2009, 2010, 2012, 2015 and 2018, so information at the national level is more current.

Justice Health has additional forums for patient feedback including the YES survey, patient experience focus groups, and the Patient Health Enquiry Line for patients to express concerns. Client Liaison Officers also act as a channel for complaints and concerns with health service access.

There are various avenues for people to make complaints about health services in New South Wales prisons. People in custody and their advocates can complain directly to Justice Health by phone, in writing, or in person. Justice Health received on average 44 complaints each month in 2020, of which 65 per cent related to quality of clinical care and 29 per cent related to delayed access to care.

Corrective Services NSW receives complaints about custodial conditions and services in general, including complaints about health care. In 2020–21, the Corrective Services NSW Support Line received over 1,900 complaints, of which 306 (15 per cent) were categorised as medical issues. The Executive Services Unit of Corrective Services NSW also received 1,700 complaints in 2020–21 of which 93 were categorised as medical issues.

Prison health complaints can also be made to external agencies such as the NSW Ombudsman and the Health Care Complaints Commission. In 2019–20, the NSW Ombudsman received 611 contacts from people in prison about Justice Health's services. Of these, 511 related to access to health care, and 36 related to dental care.

Access to health services in prisons is aligned with equivalent levels of health care in the community, though benchmarking is yet to occur

The Justice Health Strategic Plan 2018–2022 requires that health services and health outcomes in prisons align with standards of care in the community, and at the national and international levels. As part of its health service performance monitoring, Justice Health commits to benchmarking patient care against these standards.

Justice Health has not assessed the levels of access to health care in custody against the levels of access to health care in the community. According to Justice Health managers, this is a complex undertaking as the environments are different and the populations are not easily aligned. According to Justice Health managers, there is a plan to commence a benchmarking project to assess prison health care wait times with health care wait times in the community.

4.2 Monitoring and governance of public and private health providers in New South Wales prisons

Public and private prison health operators do not share consistent KPIs or reporting obligations and there is no performance benchmarking across systems

Justice Health reports to the Ministry of Health on 44 health care performance indicators. The performance indicators in the public prison system do not align with the performance indicators for the private prison health system. For example, private operators have a performance measure for ensuring that custodial patients are provided with release plans. Justice Health does not have a similar measure. The difference in the performance measures means that it is not possible to compare or benchmark performance across the public and private systems over time.

The KPI specifications for private prison health service delivery were developed by Corrective Services NSW with some input from the Ministry of Health. KPI specifications for performance monitoring in the public prison health system were developed by the Ministry of Health.

Some of the KPIs of the private system are linked with financial abatements if targets are not met. Justice Health is not subject to any penalties for not meeting targets for the public health system.

In the private prison health system, there are inconsistencies in the frequency of KPI data validations. Privately managed prisons report monthly on KPI data. Previously, this data was not validated by Justice Health at regular intervals. The Performance Monitoring Assurance Framework indicates that validation of KPI data will be conducted as resources permit. This has resulted in delayed validations, and delays in the issuing of abatements for underperformance in some instances. In July 2021, Justice Health committed to conducting regular KPI validations.

There are inherent flaws in the performance monitoring of public and private health services in prisons

There is a legislated requirement for Justice Health to monitor the performance of private health operators in New South Wales prisons. This monitoring role is described in the Crimes (Administration of Sentences) Act 1999. The timing of this legislation did not anticipate that Justice Health would be a provider of the services it monitors. In 2018, Justice Health was awarded a contract to provide health services at the John Morony Correctional Centre.

Justice Health's monitoring role includes the collection and analysis of health performance data from private health operators, and periodic site visits to assess health service performance. Justice Health reports the findings of monitoring activities to Corrective Services NSW, the contract manager for private prisons.

Justice Health's monitoring role commenced in the late 1990s. In recent years, this role has expanded as the New South Wales Government has increased the number of privately managed prisons across the state. Justice Health now monitors health services in four private prisons, accounting for approximately one quarter of all custodial patients in the New South Wales prison system.

Justice Health has taken steps to maintain independence and transparency in its monitoring role. Justice Health monitors private health providers through its Commissioning Unit. The Commissioning Unit operates independently from the service delivery operations of Justice Health. Justice Health also established an alternative reporting chain via a Board subcommittee overseeing the performance of health providers in private prisons.

However, the Justice Health Chief Executive remains in legislation the person responsible for monitoring performance of health entities operating in managed prisons. This confers dual responsibility on the Chief Executive as both an operational manager of health services in a managed prison and the manager responsible for the monitoring of these same services.

This creates a potential conflict of interest for Justice Health and indicates significant flaws in the governance structures for the monitoring of health services in private prisons.

The Justice Health executive has access to information about the overall performance of the private prison health system in New South Wales. As a competitor for the provision of health services in privately operated prisons, Justice Health has access to information to which other private health providers are not privy. This potentially gives Justice Health a competitive advantage over other private health operators.

The Ministry of Health's performance monitoring arrangements for the public prison health system do not always include alignments or comparisons with performance measures for other health entities. There are some alignments with mental health measures in Local Health Districts, though measures do not align with many other health service types. With the existing health monitoring measures, it is not possible to assess whether the wait times for health service types in prisons are in line with community health wait times.

Appendices

Appendix one – Response from agencies

Appendix two – About the audit

Appendix three – Performance auditing

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Parliamentary reference - Report number #356 - released (23 September 2021).