Health care for those in police custody can reach a vulnerable population

Detainees in police watch-houses have complex health needs in a difficult environment that nevertheless provides a unique chance to "intercept a vulnerable, complex and otherwise hard-to-reach population, and identify unmet health needs," according the authors of a Perspective published today by the Medical Journal of Australia.

Professor Julia Crilly, Professor of Emergency Care at Gold Coast Hospital and Health Service and Griffith University, and colleagues reflect on a recent report that indicates 43 (9%) of the 505 deaths in police custody between 1991 and 2016 occurred in a police station, police vehicle, police cell, or watch-house. Almost half of those were deaths due to a medical cause (49%).

"As a group, [police watch-house detainees] are largely disconnected from health services, so beyond their immediate, untreated health problems, comparatively little is known about underlying and unaddressed social determinants," Crilly and colleagues wrote.

"Access to health care in short term custody settings can be hampered by a range of underlying contexts, structures and processes of health care delivery."

Crilly and colleagues have been studying the key challenges for people and systems responsible for the health and safety of detainees in short-term custody.

Individual level challenges:

• detainees have significant health complexities with higher rates of mental illness, substance dependence and communicable diseases; they commonly present with acute exacerbations of chronic conditions such as diabetes mellitus, hypertension, asthma, substance dependence, and mental illness; they may also be acutely injured, intoxicated and/or distressed;
• detainees commonly have complex social needs, belonging to multiple categories of vulnerable populations;
• autonomous decision-making is limited for detainees and they rely on police assistance to access services; they may under-report or over-report health issues, either because they are mistrustful of those responsible for their health care access.

System level challenges:

• watch-houses are not health care settings and are not necessarily well equipped to manage health care delivery and health care settings are not custodial settings—"there are inherent risks when transferring detainees out of a secure setting and into a health care setting";
• watch-houses are not prisons, and may have both children and adults of different genders, all requiring segregation, which presents extra complications during a pandemic;
• police staff are not health care professionals but are expected to have a role in health screening of detainees and delivering some minor care—"many watch-house detainees have health problems which necessitate a rapid and effective response … Given the duty of care owed to detainees by police, a risk mitigation approach often guides decision making for transportation [but] there is limited evidence to guide health care management for detainees in police watch-houses."

Inter-agency challenges:

• a wide range of providers are involved in the health care of detainees, with "different communication preferences, organizational cultures, professional terminology, procedures, and sometimes different objectives";
• health care services need to plan care around criminal justice processes and outcomes that may not yet be determined leading to uncertainty regarding provision of ongoing or follow-up care;
• there are considerable costs of health care for watch-house detainees, such as health care personnel, medications, general medical supplies, police escort and guard costs for transfer to and treatment in external health care settings.

"Despite the myriad of challenges, watch-house detention provides a unique opportunity to intercept a vulnerable, complex and otherwise hard-to-reach population, and identify unmet health needs," Crilly and colleagues wrote.

They suggested increased access to health care providers in watch-houses, models of health care in watch-houses closely linked with public health services and administered by a health care agency rather than the police service, continuity of care, a shared electronic medical record, and "a broader governance framework that promotes integration between watch-house and community health care providers."

"These goals will require a sustained, coordinated investment in intersectoral collaboration. The overlap of health and law enforcement offers important opportunities to support health care delivery to detainees. It is time to capitalize on these opportunities," Crilly and colleagues concluded.