Subcontracting long-term care (LTC), whereby facilities contracted with third party agencies to provide care to residents, became widespread in British Columbia after 2002. This qualitative study aimed to understand the impact of subcontracting from the perspective of care workers. We interviewed 11 care workers employed in subcontracted facilities to explore their perceptions of caring and working under these conditions. Our overarching finding was one of loss. Care workers lost wages, benefits, security, and voice. Their working conditions worsened, with workload and turnover increasing, resulting in a loss of experienced staff and a loss of time to provide care. These findings call into question the promises of quality and flexibility that legitimated policies permitting subcontracting, while adding to the mounting evidence that subcontracting LTC harms both workers and residents.

BACKGROUND: In France, on the first of January 2018, 772 underage persons were in jail or about 1.1 % of the incarcerated population. The prevalence of psychiatric disorders among those inmates is high. As a result psychiatric care (and particularly full-time hospitalization) is essential for this population. The unités hospitalières spécialement aménagées (UHSA) are full-time inpatient hospitalization units for inmates in France. Adults but also underage inmates can be admitted to UHSA for voluntary or involuntary hospitalization. However, no study about the characteristics of young patients admitted to UHSA is currently available. The aim of this study is to describe the population of children and adolescent patients hospitalized in these facilities and to evaluate the care provided.
METHODS: We conducted a retrospective study, including all the patients under 18 years of age, who have been hospitalized in UHSA since its creation in 2010 until 31 December 2016. Anonymized data concerning socio-demographic profile, clinical symptoms and care provided have been collected from the medical records of each patient.
RESULTS: Overall 80 underage patients were included, for 120 hospitalisations in UHSA. Those patients are mainly male (80%) with a mean age of 16.7 years. They are mostly hospitalized with their consent (59%) for stays of about 50 days and frequently after self-harm behaviours. The main diagnoses are anxiety disorders (26%) and psychotic disorders (25%). At the end, 86% of the patients are prescribed a psychotropic drug treatment and 40% of those medical drugs are prescribed outside the guidelines. Finally, several specific problems were identified. Especially, contact with families and educators or access to education programs are very challenging.
CONCLUSIONS: This study highlights the current difficulties encountered in the management of inmate underage patients in full-time psychiatric hospitalization. In this paper, we propose areas for improvement through (1) specific arrangements to receive young patients (specific service\'s management in order to reinforce the observation of those young people, to facilitate contact with their families, to improve the access to education programs, etc.); (2) specific arrangements in the treatment offered to young patients in UHSA (specific training course for nurses, specific therapeutic programs, etc.); (3) the development of networks working with psychiatric services inside and outside the prison, educators, families and prison services, in order to promote the continuity of cares.