Quality statement 4: Lead care coordinator

Quality statement

People in prison who have complex health and social care needs have a lead care coordinator.

Rationale

Having a lead care coordinator in place for people in prison who are receiving care from different teams means that they can receive joined-up care. The lead care coordinator can ensure good communication within the multidisciplinary team, which can include health, social care and custodial teams. By working with the multidisciplinary team the lead care coordinator can help to ensure that people in prison receive help and support to manage their health and social care needs. In addition, people in prison can receive help to reduce avoidable exacerbations of their physical and mental health conditions, reducing the risk of unplanned hospital admissions.

Quality measures

Structure

Evidence of local arrangements to ensure that a lead care coordinator is available for people in prison who are being cared for by different prison teams.

Data source: Local data collection including job descriptions.

Process

Proportion of people in prison who have complex health and social care needs who have a lead care coordinator.

Numerator – the number in the denominator who have a lead care coordinator.

Denominator – the number of people in prison with complex health and social care needs.

Data source: Local data collection and audits.

Outcome

a) Number of unplanned hospital admissions of people in prison.

Data source: Local data collection including healthcare records. The NHS England health and justice indicators of performance include data on escorts and bedwatches for urgent care.

b) Number of care plans jointly developed and shared on transfer between prisons or release from prison.

Data source: Local data collection including healthcare records.

What the quality statement means for different audiences

Service providers (providers of healthcare in prisons) ensure that systems are in place for people in prison with complex health and social care needs to have a lead care coordinator to manage their care. This will include liaison with the multidisciplinary team to coordinate care and ensure it is provided as needed while the person is in prison, during transfers and when the person is leaving prison.

Healthcare professionals (such as GPs and nurses in prisons) ensure that people in prison with complex health and social care needs have a lead care coordinator. The person should know who their lead care coordinator is and this should also be communicated to the prison staff. The lead care coordinator will liaise with the multidisciplinary team to ensure that care is coordinated and provided as needed while the person is in prison, during transfers and when the person is leaving prison.

Commissioners (NHS England) ensure that they commission prison healthcare services that identify lead care coordinators for people with complex health and social care needs.

People in prison who are cared for by different teams (for example a GP, social worker, mental health team or substance misuse team) have a lead care coordinatorwho is responsible for their care. They will know who their lead coordinator is. The lead care coordinator will work with everyone involved in their care to make sure they receive the care and support they need while they are in prison, being transferred or leaving prison.

Source guidance

Physical health of people in prison (2016) NICE guideline NG57, recommendation 1.2.3

Definitions of terms used in this quality statement

Complex health and social care needs

People in prison being cared for by multiple teams in and beyond the prison system (for example primary care, mental health, substance misuse or social care) on an ongoing basis. This could be for a number of reasons, for example a learning or physical disability with substance misuse, mental health or vulnerability issues.

[Expert opinion]

Lead care coordinator

This is a named professional who is responsible for managing a person's care when they are in prison, during transfers and when they are leaving prison. They liaise with other healthcare staff involved in the person's care (for example, ensuring follow-up on diagnostic tests) and ensure relevant information is shared between primary and secondary care teams, and other social care, probation and community service providers if necessary.

[NICE guideline on physical health of people in prison, full guideline and expert opinion]

Equality and diversity considerations

Barriers to communication can hinder people's understanding of how they can be involved in their care, particularly if they have complex health and social care needs. These barriers could include: mental health problems, learning or cognitive difficulties; physical, sight, speech or hearing difficulties; or difficulties with reading, understanding or speaking English. Adjustments should be made to ensure that all people in prison with complex health and social care needs can work with their lead care coordinator to plan their care, with access to an advocate if needed.