The provision of health and social care in the adult prison estate

Written evidence submitted by the Royal College of Speech and Language Therapists

 

1. Executive summary

·         The Royal College of Speech and Language Therapists is pleased to provide a submission to the Health, Social Care and Sport Committee inquiry into the provision of health and social care in the adult prison estate.  We would be pleased to provide further oral evidence to the Committee.

·         There is a high prevalence of speech, language and communication needs[i] and swallowing needs, amongst people in the prison estate.

·         As the prison population ages more people will experience communication and swallowing difficulties, partly as a natural part of ageing, but also due to other co-morbidities[ii].

·         Given the links between communication needs, a person’s ability to access and benefit from rehabilitation treatment programmes and to eat and drink safely, it is essential that prisons and the wider justice system is able to identify and support communication and swallowing needs.

·         Every Welsh prison should have access to a speech and language therapist

·         Current speech and language therapy provision for people across the criminal justice system in Wales is extremely patchy.  At HMP Berwyn there are two speech and language therapists. 

 

2. Speech, language and communication needs in the justice system

·         Research from an adult prisons found that up to 79% of adult prisoners had speech, language and communication needs and that the levels of communication difficulties are higher in the prison population than in the general population[iii] [iv].  Over 60% of young offenders have speech, language and communication needs and we know that communication problems persist into adulthood so it is expected that similar numbers of communication difficulties will be found across the youth and adult prison estates[v].

·         Those who entering prison often do so from settings where there is a heightened risk of people having communication needs which may not have been previously identified.  For adults, these include being unemployed, in touch with mental health services, being in care or having a special school history[vi]

·         People with communication needs can find it difficult to express their emotions and often communicate through behaviour.  This can lead to offending behaviour, behaviour leading to restraint and delays to their release from custodial settings.

·         Speech problems can also be found in people as a side effect of antipsychotic medication[vii]

 

 

 

 

3. Speech, language and communication needs associated with other conditions

·         A significant number of conditions prevalent across the prison estate have communication difficulties commonly associated with them.  These include autism, learning disabilities, mental health problems and neurodevelopmental conditions. 

·         20-30% of people in prison are estimated to have learning disabilities or difficulties that interfere with their ability to cope with the criminal justice system[viii].

·         80% of people in prison have learning disabilities or difficulties report having problems reading prison information – they also had difficulties expressing themselves and understanding certain words[ix].

·         With an ageing prison population[x] there are an increasing number of people with communication or swallowing needs as a result of long term conditions.  At HMP Berwyn the speech and language therapy team works with older people with dementia, stroke, dysphagia, long term substance misuse, head injury and cognitive decline associated with other neurological conditions.

 

4. Eating, drinking and swallowing needs in the justice system

·         Eating, drinking and swallowing difficulties (dysphagia) is a prevalent difficulty among ageing adults[xi]. Swallowing problems are associated with a range of conditions including learning disability, brain injury, stroke, cancer and progressive neurological conditions including dementia.  They can also be associated with the use of antipsychotic drugs. 

·         The prison population is ageing with people over 60 the fastest growing age group in custody[xii].  The swallow mechanism also decreases in efficiency with age[xiii], which is of relevance with an ageing prison population[xiv] [xv].

·         Evidence suggests that prisoners consult healthcare service more often than ‘standard’ populations: For example, three times more frequently asking to see a doctor, 80 times more frequently asking to see a primary care worker, 10 times more frequently accessing inpatient care[xvi]. This suggests the need for a robust healthcare system within prison settings.

 

5. The impact of unidentified and/or unmet speech, language and communication needs

·         Communication skills are fundamental and foundational.  They are not simply expressive skills (our ability to make ourselves understood), but also receptive (our ability to understand).

·         Speech, language and communication needs are often hidden so their importance can be overlooked.

·         If these difficulties remain unidentified or unmet, they can have negative consequences for both people’s ability to access and engage with the justice system; and for those working in the criminal justice system to be able to recognise and respond appropriately to people’s individual needs.

·         People with communication problems will have limited understanding of, and struggle to access treatment and rehabilitation programmes designed to reform and rehabilitate them which are verbally mediated.  Evidence suggests that around 40% of people are affected[xvii]

·         People with communication needs will struggle in group working due to poor attention, poor listening skills, poor social skills, poor auditory comprehension, lack of confidence in expressive language and inadequate vocabulary[xviii]

·         People with communication needs will struggle to participate in verbally mediated physical and medical assessments.

 

 

 

 

6. The impact of unidentified and/or unmet eating, drinking and swallowing needs

·         Eating, drinking and swallowing difficulties have potentially life-threatening consequences. Left unsupported they can result in choking, pneumonia, chest infections, dehydration and malnutrition.  They can also result in avoidable hospital admission and in some cases, death.

·         Swallowing difficulties can be caused by antipsychotics drugs[xix] [xx] with the possible consequences of choking and aspiration pneumonia.  There is an elevated rate of death due to choking due to the effects of medication[xxi].

·         There is an increased risk of aspiration pneumonia after a stroke or with dementia[xxii].  Identifying and attending to swallowing problems reduces the overall likelihood of getting pneumonia[xxiii] [xxiv]

·         They can also make taking medication more difficult.

·         People with swallowing needs may require access to texture modified food and drink, but access to equipment and blenders is not always available in prisons, compromising the safety of their eating.

 

7. Speech, language and communication needs and the impact on behaviour

·         People with difficulties understanding and using language are at risk of developing behavioural issues[xxv] [xxvi].  This can be due to frustration at being unable to understand the language they are exposed to and express themselves, particularly if their difficulties are unidentified.

·         People are often misdiagnosed as having a behaviour difficulty rather than an unidentified communication difficulty[xxvii]  [xxviii]  [xxix].  If behaviour issues are present, communication needs are often not considered[xxx]

·         As people’s communication difficulties increase, behaviours that are considered challenging also increase in frequency, intensity and duration[xxxi]

·         People with communication needs can find it difficult to express their emotions and may respond with challenging behaviour when they are confronted with situations they do not understand[xxxii].  People with communication problems, frustrated at their inability to express themselves, can display disruptive[xxxiii] or aggressive behaviour. 

 

8. The prison environment and physical intervention

·         People with communication needs can struggle to cope in a prison environment, with its complex rules, regimes and demands[xxxiv].  

·         Staff can misunderstand and misinterpret challenging or difficult behaviour and punish the offender rather than getting to the root of the problem.  In custodial settings, this can lead to physical interventions and restraint to reduce violence and disruptive behaviour. 

·         Consistent or disruptive behaviour can be an indication of an underlying problem and where there are concerns about behaviour there should be an assessment to determine if there are any casual factors such as communication problems[xxxv].

·         People with communication needs will often not understand the reasons for their discipline which can lead to frustration, anxiety, fear and depression.

·         This is a situation of compounding risks, where isolation has been shown to have a negative effect on mental health, yet people with communication needs are already at risk of mental health problems.

 

9. Seclusion

·         When someone has been in long-term seclusion, speech and language therapists work to support and maintain communication skills to support reintegration onto the prison wing.

 

 

 

10. De-escalation techniques

·         Where communication needs are not recognised, people are at risk of physical intervention which could have been avoided, if appropriate verbal differentiation and de-escalation had been used.

·         De-escalation techniques are also used in violence reduction, which rely on verbal and non-verbal communication skills[xxxvi].  Good communication skills, both expressive and receptive, underpin de-escalation techniques. 

·         People with communication difficulties will not have a significant understanding or necessary expressive language to follow these directions.  Without additional support these alternatives to physical intervention are unlikely to be successful.

 

11. How are communication and swallowing needs identified, supported and managed?

·         Speech, language and communication needs and swallowing difficulties are not routinely screened for and identified in prisons.  We recommend systematic assessment for all people due to the large numbers of people with communication needs and swallowing needs in prisons.

·         A model for this approach could be adapted from the screening tool the Youth Justice Board developed with The Royal College of Speech and Language Therapists as part of AssetPlus[xxxvii].   Every new entrant to the youth justice system is screened for speech, language and communication needs.  Furthermore, in the youth custodial estate the health needs of young person are assessed via the comprehensive healthcare assessment tool (CHAT)[xxxviii] but no equivalent exists in the adult estate.

 

12. Provision of Speech and Language therapy in youth offending teams and prisons in Wales

·         Despite the high prevalence of need, few speech and language therapists are commissioned to work in prisons. 

·         The National Assembly for Wales Communities and Culture Committee recommended that pilot work be undertaken on the potential benefits of speech and language therapy for juvenile offenders: both in custody and on release[xxxix].  Despite strong evidence from the pilots, currently only two youth offending teams (YOTs) in Wales (Western Bay and Gwent) employ speech and language therapists. 

·         HMP Berwyn opened in 2017 and currently employs two speech and language therapists.  There is currently no specialist speech and language therapy provision at Cardiff, Swansea, Usk or Prescoed prisons.

 

13. Learning from speech and language therapy provision at HMP Berwyn

·         HMP Berwyn currently employs two speech and language therapists. 

·         Clients are referred from a range of stakeholders to be supported for speech, language and communication and swallowing needs. 

·         The demand for SLT at HMP Berwyn remains stable at around 20% of the population. 

·         Around one third of the speech and language therapy work at HMP Berwyn is supporting clients with mental health needs and/or emotional regulation issues.  Speech and language therapy has taken the role of care coordinator under the mental health measures for some clients.

·         Staff training continues to be required to encourage appropriate and timely referrals but instability in the prison officer staff group impacts on this.

·         The speech and language therapy team provide training to a number of key staff groups such as the integrated healthcare team, the forensic psychology department and college tutors on language processing and strategies for communication.

·         Managing the dysphagia needs of clients at HMP Berwyn without them needing to leave the site has allowed for excellent client care and cost savings to the establishment.

Barriers

·         Speech, and language and communication and swallowing needs are not recognized uniformly across the estate so there is inconsistent provision for service users. 

·         A lack of speech and language therapy in other prisons affects the client care pathway.  This is problematic for clients with active goals who are transferred to another prison where there is no speech and language therapy service to pick up the work. 

·         A recent speech and language therapy client has been granted category D status but is conflicted about this as it means that he will be unable to access speech and language therapy services when he leaves HMP Berwyn.

·         A lack of clinical spaces and a shortage of treatment rooms impact upon clinical offerings

The way forward

·         Funds must be available to deliver speech and language therapy which is appropriate to the population.  At HMP Berwyn this is monitored and considered via health needs assessment as an ongoing review.

 

14. RCSLT recommendations

Given the high prevalence of communication and swallowing needs in people in the justice system and the consequences of not supporting them, the Royal College of Speech and Language Therapists recommend that staff working with in custodial settings, have access to speech and language therapy services. This would enable:

·         Identification - All people should be screened for speech, language and communication needs, as well as swallowing needs.  Those who have a problem should be referred to speech and language therapy for a specialist assessment

1.       Support – every prison should have access to speech and language therapy to support the people who need it, as well as providing ongoing advice and support to staff to enable them to meet the need of individual people.

2.       Training - All staff should be trained to recognise and respond appropriately to communication needs.  As part of training around violence and aggression, a section should be added on the impact of communication and the interaction of the staff- person on escalation and de-escalation of incidents.

 

15. Role of speech and language therapists

·         Speech and Language Therapists assess and support speech, language and communication and eating, drinking and swallowing problems in people of all ages.

·         Speech and Language Therapists work with staff to adapt their verbally delivered programmes to make them more accessible and support clients to access them

·         Speech and language therapists help to modify documents and signage to make them more accessible to ensure that individuals can understand the procedures in the prison. This is part of creating a communication friendly and accessible environment

·         Speech and language therapists link with catering to ensure texture modification is available to those who need it, due to their swallowing difficulties

·         Speech and Language Therapists train the wider prison and health workforce to develop strategies to improve the communication environment which has a positive impact on all everyone.

·         Speech and language therapists support staff to promote effective de-escalation strategies tailored to the communication needs of the individual.  This allow for more active strategies to manage behaviour that challenges and prevent the use of restraint

 

16. About RCSLT

15.1. The Royal College of Speech and Language Therapists (RCSLT) is the professional body for speech and language therapists (SLTs), SLT students and support workers working in the UK.  The RCSLT has over 17,000 members.  We promote excellence in practice and influence health, education, social care and justice policies. 

 

17. Further information

Submitted by xxxx, Policy Adviser, Royal College of Speech and Language Therapists

 

 



REFERENCES
[i]
Practice advice: speech, language and communication needs (SLCN) in the youth justice system, (2015),

Youth Justice Board and Royal College of Speech and Language Therapists,

https://www.gov.uk/government/publications/speech-language-and-communication-needs-in-the-youthjustice-

system/practice-advice-speech-language-and-communication-needs-slcn-in-the-youth-justice-system

[ii] Prison Reform Trust (2008). Doing Time: the Experiences of Older People in Prison. Prison Reform Trust: London.

[iii] Communication on Probation. / Pierpoint, Harriet; Iredale, Rachel; Parrow, Beth. In: Speech and Language Therapy in Practice, 31.05.2011, p. 14 - 16.

[iv] Nicola McNamara, (2012) "Speech and language therapy within a forensic support service", Journal of Learning Disabilities and Offending Behaviour, Vol. 3 Issue: 2, pp.111-117,  

[v] Bryan K, Freer J, Furlong C (2007) Language and communication difficulties in juvenile offenders. International Journal of Language and Communication Disorders, 42, 505-520.

[vi] Royal College of Speech and Language Therapists (2017). Supporting Social, Emotional, mental Health and Wellbeing, 2018 www.rcslt.org/speech_and_language_therapy/docs/factsheets/mental_health

[vii] Krämer et al. (2010)

[viii] Loucks,N (2007). No one knows: Offenders with Learning Difficulties and Learning Disabilities. Review of prevalence and associated needs. London; Prison Reform Trust.

[ix] Talbot, J (2008). Prisoners’ Voices: Experiences of the criminal justice system by prisoners with learning disabilities and difficulties.  London: Prison reform Trust

[x] Prison Reform Trust (2008). Doing Time: the Experiences of Older People in Prison. Prison Reform Trust: London.

[xi] Sura L, et al. Dysphagia in the elderly: management and nutritional considerations. Clinical Interventions in Aging, 2012, 7; 287-98 doi 10.2147/CIA.S23404

[xii] Prison Reform Trust (2008). Doing Time: the Experiences of Older People in Prison. Prison Reform Trust: London.

[xiii] Wakabayashi, 2014

[xiv] Robbins et al, 1999

[xv] Tracy et al, 1989

[xvi] Marshall T, et al (2001). Use of healthcare service by prison inmates: comparisons with the community. Journal of Epidemiology and Community Health. 55; 364-365

[xvii] Bryan, K (2004) Prevalence of speech and language difficulties in young offenders. International Journal of Language and Communication Disorders; 39, 391-400.

[xviii] Feedback from client case load at HMP Berwyn, May 2019

[xix] McCarthy and Terkelsen 1994

[xx] Varanese et al. 2011

[xxi] Chapter 17: Psychiatric Disorders and Communication, Bryan K, University of Surrey, UK

[xxii] Almirall et al 2103

[xxiii] Logemann 2008

[xxiv] Bray et al. 2016

[xxv]  Petersen et al., 2013

[xxvi] Humber and Snow, 2001

[xxvii] Humber & Snow, 2001, The oral language skills of young offenders: A pilot investigation Article in Psychiatry Psychology and Law 8(1):1-11 · January 2001

[xxviii] Cohen et al.,

[xxix] Lanz 2009

[xxx] Gregory & Bryan, 2011

[xxxi] Royal College of Speech and Language Therapists. Five good communication standards. London: RCSLT, 2013.

[xxxii] Reducing the Need for Restraint and Restrictive Intervention: Children and Young People with Learning Disabilities, Autistic Spectrum Disorder and Mental Health Difficulties, 2017

[xxxiii] Humber and Snow, 2001

[xxxiv] Bradley Report 2010

[xxxv] RCSLT response to the DH and DfE consultation on Reducing the need for restraint and restrictive intervention

[xxxvi] Craig, 1996

[xxxvii] AssetPlushttps://www.gov.uk/government/publications/assetplus-speech-language-communication-and-neuro-disability-screening-tool

[xxxviii] CHAT http://www.ohrn.nhs.uk/OHRNResearch/CHAT

[xxxix] National Assembly for Wales Communities and Culture Committee (2010).  Youth Justice: The experience of Welsh children in the Secure Estate. National Assembly for Wales;Cardiff.