WLGA
AND ADSS CYMRU EVIDENCE TO
THE
HEALTH, SOCIAL CARE & SPORT COMMITTEE’S
INQUIRY INTO HEALTH AND SOCIAL CARE
PROVISION IN WELSH PRISONS.
May 2019
About Us
1. The Welsh Local Government Association (WLGA) represents the 22 local authorities in Wales, and the three national park authorities and the three fire and rescue authorities are associate members.
2. The WLGA is a politically led cross-party organisation, with the leaders from all local authorities determining policy through the Executive Board and the wider WLGA Council. The WLGA also appoints senior members as Spokespersons and Deputy Spokespersons to provide a national lead on policy matters on behalf of local government.
3. The WLGA works closely with and is often advised by professional advisors and professional associations from local government, however, the WLGA is the representative body for local government and provides the collective, political voice of local government in Wales.
4. The Association of Directors of Social Services (ADSS Cymru) is the professional and strategic leadership organisation for social services in Wales and is composed of statutory Directors of Social Services and the Heads of Service who support them in delivering social services responsibilities and accountabilities; a group of more than 80 social services leaders across the 22 local authorities in Wales.
5. As the national leadership organisation for social services in Wales, the role of ADSS Cymru is to represent the collective, authoritative voice of Directors of Social Services, Heads of Adult Services, Children’s Services and Business Services, together with professionals who support vulnerable children and adults, their families and communities, on a range of national and regional issues of social care policy, practice and resourcing. It is the only national body that can articulate the view of those professionals who lead our social care services.
Introduction
6. Under the Social Services and Wellbeing (Wales) Act 2014 (the Act), local councils have a range of duties to fulfil in respect of assessing and meeting the care and support needs of those individuals in the secure estate. They need to take a holistic approach when individuals are serving their sentence and when planning for their release.
7. Under the Act, local councils must engage with partner organisations to identify how existing resources can be best used. Local councils may commission or arrange for others to provide care and support services or, delegate the performance of the function to another party, but the responsibility for fulfilling the duty will remain that of the local council.
8. Local councils must support children and adults with care and support needs in the secure estate in Wales just as they would for someone in the community. However, the delivery of care and support arrangements operating in the community setting may need to be adjusted to meet the needs of the population and the regime of the secure estate.
9. This represents a major change, previously it was unclear who was responsible for assessing and meeting the social care needs of those in the secure estate, with the result that such needs have often gone unrecognised or have not been effectively met. Given this significant change and the additional duties and responsibilities placed on local authorities, the WLGA and ADSS Cymru welcome the opportunity to comment on the Committee’s inquiry into the provision of health and social care in the adult prison estate.
What these new responsibilities mean for local authorities
10. The change in legislation has meant new responsibilities being placed on local authorities and new ways of delivering services having to be considered. This includes:
· Information, advice and assistance must be provided to those in the secure estate while they are detained, in preparation for and on release;
· Preventative and wellbeing services must be provided to those in the secure estate as for those in the community;
· For those whose care and support needs cannot be met by signposting to preventive and wellbeing services, local authorities must find ways to undertake the assessment of those in the secure estate;
· Collaboration with partner organisations such as Health, Housing, Third Sector and Education is required to ensure a consistent and consolidated response;
· Local authorities needing to consider the value of developing an integrated approach with Health to respond to the health and social care needs;
· The approach to assessment is the same for people in the secure estate as it is for people in any other part of the community and liaison with carers and family is undertaken in the usual way. However, there are limitations on the rights of carers for people in the secure estate, for example there is no obligation to provide support plans for carers of people in the secure estate;
· The National Assessment and Eligibility Tool that has been developed for use across local authorities in Wales applies equally for those in the secure estate;
· Local Authorities needing to provide an appropriate staff resource that is appropriately
skilled and trained to meet the duties under the 2014 Act.
Demand and Pressures
11. The recent joint Thematic Report by HM Inspectorate of Prions (HMIP) and the Care Quality Commission (CQC) into social care in prisons in England and Wales highlights that recent years have seen prisons being reshaped in the face of an increasing prison population, coupled with longer sentences and sentences being given for historic offenses. As at December 2017, the number of people in prison aged 50 and over was 13,522, representing 16% of the total adult prison population (those aged over 18). Projections indicate that the number of people aged 50 and over held in custodial settings is likely to increase. As such, needs are changing, impacting provisions and raising questions about the suitability and training of staff to care for an increasingly older population.
12. Various studies have used different benchmarks to define old age in custodial settings, but it is widely accepted that what is considered old age in prisons differs from that in the community. According to several reports, prisoners experience a faster ageing process due to a wide range of factors which occur both during the prison sentence and prior to detention. Prison itself is considered to be an environment which can give rise to the development of physical and mental impairments. In addition, prisoners’ mental and physical health are widely recognised as poorer than the wider population.
13. An ageing population means that prisons are increasingly having to deal with frailty amongst prisoners. The British Geriatric Society defines frailty as a ‘distinctive health state related to the ageing process, in which multiple body systems gradually lose their inbuilt reserves’. Frailty reduces a person’s ability to thrive in the event of a deterioration in health or a challenge, such as entering a prison environment. In the general population, it estimates that around 10% of those aged over 65 years have frailty, rising to 25–50% of those over 85.
14. As also highlighted in the thematic report, the number of prisoners with dementia is a further concern. In the general population, dementia affects around 5% of those aged over 65 and 20% of those over 80. The prevalence of dementia in the prison setting is largely unknown and dementia may not be detected.
15. This aging population within prisons, coupled within increasing frailty and incidence of dementia, has accelerated the need for prisons to not only address social care needs but also the suitability of the physical environment within which prisoners are held. In addition, a significant proportion of prisoners also have learning disabilities, autism, mental health disorders or difficulties which may also inhibit their ability to cope with life in prison. It is estimated that across the UK[1]:
· 36% of prisoners have a disability;
· 11% have a physical disability;
· 18% have anxiety or depression; and
· 8% have a physical disability and anxiety or depression.
16. Significantly it has also been identified that 9 in 10 prisoners have a diagnosable mental health and/or substance misuse problem.
17. Previous health needs assessments for prisoners in Wales have also identified:
· significant levels of poor mental health and personality disorders;
· an increased risk of self-harm and suicide compared to the general population;
· significant levels of substance misuse, alcohol misuse and tobacco use;
· high levels of multiple chronic conditions in older prisoners;
· significant levels of premature, ‘accelerated’, ageing and significant levels of preventable illness and disability;
· high levels of blood-borne viruses;
· little evidence to suggest routine access to primary and secondary preventative services and interventions prior to prison; and
· low levels of literacy and numeracy.
18. Other key findings from previous research (May et al., 2008[2]; Stewart, 2008[3]) has also identified the following:
· Nearly half the sample had been unemployed in the year before custody and 13% had never had a job;
· Fifty-eight per cent had truanted from school regularly and 46% had no qualifications;
· Fifteen per cent were living in temporary accommodation or were homeless before custody; this was more common among short-term and adult prisoners;
· A quarter reported at least one long- standing illness or disability, musculoskeletal and respiratory complaints were the most commonly reported health conditions;
· Over four-fifths of the sample (82%) reported one or more mental health symptoms, and a third (36%) reported between six and ten symptoms;
· The majority of prisoners had used illegal drugs during the year before custody, use of heroin or cocaine was more likely to be reported by women, adult prisoners and those sentenced for less than one year;
· Heavy drinking was reported by 36% of the sample and was more prevalent among short-term prisoners and men;
· Prisoners tended to prioritise employment and skills deficits over health and family issues in terms of the help they wanted during the course of their sentence;
· Nearly half (48%) of the sample reported needing help finding employment. Help getting qualifications and improving work related skills were reported by 42% and 41% respectively. Around a third wanted help with housing and their offending behaviour.
19. There are also links between poor health and reoffending. For example, offenders with addiction or a mental health condition are more likely to need support with housing, education or employment to change their lives and prevent future criminal behaviour. However, at the same time research shows these offenders will find it more difficult to access mainstream help than the general population. Increased health inequalities are therefore compounded by greater barriers to accessing services to meet those need.
20. The reality is that many older jails are ill-equipped for prisoners in wheelchairs, or with mobility problems. Some prisoners struggle to wash and look after themselves and others who have fallen cannot get help during the night. For those who are imprisoned, but who need assistance with their social or personal care, it is especially challenging and daunting. Prisons were designed to accommodate physically fit and mentally stable individuals, with prison life being arranged to address the needs of the many. Prisoners with social care needs – unable to fully care for themselves, needing help in getting around the prison or in participating socially – are at a significant disadvantage.
How local authorities are meeting needs
21. In order to meet the duties and responsibilities required by the Act, some local authorities, such as Bridgend and Wrexham have established small dedicated teams that sit within the prison, comprised of a range of staff, including: senior social work practitioner; social worker; and occupational therapists who carry out assessments and develop managed care and support plans for people in the secure estate, as well as supporting the work of the existing health board’s mental health in-reach team. This includes the provision of information and advice services, and peer-mentoring and support.
22. For others, responsibility for these new duties sits within existing teams. For example, in Monmouthshire responsibility sits with the Monmouth Integrated Services Team who are forging new partnerships with National OMS and the Prison Health Service (ABUHB) and developing nurturing/initiating creative, preventative approaches (the ‘Buddy Scheme’, Yoga, Mindfulness, Day activities, Peer support sessions), which involve the prison population with care and support needs.
23. The recent HMIP and CQC thematic report highlighted concerns over the inconsistent care received by elderly prisoners, along with a lack of planning for an ageing population, however, it also recognised that there have been some improvements in care for older and disabled prisoners since the change in legislation.
24. The report identifies that in the main prisoners with a social care need were identified on arrival into establishments, either through generic prison screening tools or through specific health care screening tools. There was evidence that prisoners with social care needs were appropriately identified and promptly referred at most establishments included in the report. In addition, at HMPs Usk and Prescoed social care staff were highlighted for also attending the general induction to promote the service and identify any needs which may have been missed on reception.
25. Good practice was also found at HMPs Cardiff and Usk and Prescoed where the All Wales model had driven a target for initial screening and assessment by respective local authority social care teams within 24 hours of referral.
26. HMP Cardiff was also noted for its joint working between the health provider and prison to optimise the limited opportunities in the physical environment of the prison to make adaptations to meet needs. Here there were established systems for review, with service commissioners involved in the reviews and any required changes to care plans being put to commissioners for agreement.
27. At HMPs Usk and Prescoed the occupational therapist was in the process of assessing every cell to establish need. The main problems identified were the bunks and the low toilets. The therapist was exploring the use of plinths to raise the toilets as there was no other mechanism available. Prisoners had also been allocated four-wheeled walkers with built in seats. These allowed more comfortable resting as the seats were padded, and increased prisoners’ independence as a tray could be carried on the walker. This reduced the over-reliance on prisoner buddies.
28. However, what these examples demonstrate is that as oversight for local delivery of prison health and social care services is held by each individual Health Board and associated Local Authority, there is currently no national oversight. This lack of a national oversight means there is often no clear process for obtaining national agreement on prison health related matters. Each prison health service has different policies and pathways for issues such as prescribing, screening and substance misuse. This means patients will receive a different service depending on where they are located; this may be due to several reasons, including resources or differing care models dependent on health or local authority process. There also may be different health needs dependent on the local health needs. As there is a great deal of movement between prisons, this means that the variation in policies and pathways can have significant implications for stability of management for those imprisoned. National oversight could help to provide continuity of services across prisons, learning from different services and the development of minimum standards of care.
Areas for improvement
29. Whilst it is recognised that progress has been made in meeting the social care needs of prisoners, local authorities continue to highlight areas for action or improvement, these include needing to:
· improve access to, and continuity of, services including preventative services, between the secure estate and community. This includes services addressing substance misuse, mental health issues, and sexual health, in adults and young people;
· strengthen multi-agency preventative services, including providing family stability and support, for example through Families First and addressing Adverse Childhood Experiences (ACEs);
· continue to improve partnership working, e.g. networking, communication and joint working where appropriate;
· improve wider ‘community services’ (e.g. District Nurses) to enable additional resources to be deployed ‘inside the gate’ when the need arises (e.g. the management of palliative patients) and maintain the principle of ‘care closer to home’;
· develop treatment pathways for those using novel psychoactive substances; and
· make counselling more widely available for prisoners serving longer sentences.
30. Support relating to resettlement has also been identified as a priority, with effective resettlement being seen as key to reducing re-offending. Evidence has shown that:
· 45% of adults are reconvicted within one year of release;
· for those serving sentences of less than 12 months, this increases to 58%; and
· over two-thirds of under 18s are reconvicted within one year of release.
31. This means that there is a need to develop the vocational and employability skills in demand from employers in Wales due to the difficulties in developing links with employers and educational and training organisations. Along with a need to develop effective partnership working and good local resettlement arrangements.
32. Stable housing can act as a gateway to resettlement and there is a link between being homeless or living in temporary accommodation and reoffending. A lack of accommodation can reduce former prisoners’ chances of finding employment. People who have accommodation arranged on release are four times more likely to have employment, education and training arranged than those who do not.
33. Although there are many good resettlement programmes, there is still a need to improve the transition between prison and the community. There is a need to develop further provision of appropriate accommodation in the community on release from prison and develop housing support in prisons to prevent homelessness on release where possible, as well as improve access to mental health and substance misuse support post release.
Challenges
34. There are considerable challenges to providing the care services required by the Social Services and Wellbeing (Wales) Act 2014 in the Secure Estate; this is due to the nature of the prison environment being a locked secure premise. In order to access the prison, outside agency staff need to go through strict clearance processes in order to visit individuals requiring social care support. Clearance takes approximately eight weeks to complete for each carer employed to deliver care and support within the prison; it is therefore not possible to deliver services in the same way that would be provided in the community.
35. Local authorities have had to look at ways of overcoming these challenges. One approach taken by Bridgend, for example was to commission care from G4S medical services from within Parc Prison, which has supported the Authority to deliver on its duties and responsibilities. It is likely, had the prison not been privately run, that the Authority would have had to provide the care directly and because of the security rules within the prison, this would have meant staff would have had to deliver care in pairs which would have inflated the cost of care considerably. However, the original proposals have since proved unrealistic because of competing priorities for the medical services team and the impact of lock-downs within the prison. As a result, the care arrangements are now subject to review with a view to providing a more sustainable way forward; it is inevitable that the revised arrangements, whether they are provided by G4S or by the Authority, will incur additional costs.
36. Additional funding of £412,000 was originally provided as a specific grant to those Authorities with secure estates within their boundaries by Welsh Government to support the new responsibilities, however some authorities have identified that this falls short of the actual costs of delivering social care services in the secure estate environment. For example, the Prison Mental Health In-Reach Team (MHIRT) that provides provision to both HMP Parc and HMP Swansea, is a multi-disciplinary team that provides Specialist Secondary Mental Health services to adult prisoners aged between 18- 65. The original service model recognised it was unrealistic to expect a comprehensive mental health in-reach service to meet all demands of the 18-65 age group, so it was agreed the MHIT provide assessment/treatment services for inmates with acute, or enduring serious mental Illness, but mainly relating to the mental health needs assessment at that time. The MHIT consists of: Consultant Psychiatrist (0.3wte), Band 6 Registered Nurses (3.0wte), Band 6 Occupational Therapist (1.0wte), Psychologist(0.2wte) and a Team Manager (1.0 wte).
37. However, when this service was originally commissioned back in 2004 the agreed revenue allocation was based on a population of just 800 inmates at HMP Parc. The prison has undergone planned developments since involving the prison service and Welsh Government which has resulted in the prison population rising to over 1,700 inmates. In the period since the prison was originally established, there has been no increase in resource to the Mental Health In-Reach team. This sets the background for the challenge of Secondary Mental Health Services in offering a robust service to HMP Parc and HMP Swansea that the MHIT have been attempting to manage from the current funded resource. Given the significant existing financial pressures that local authorities continue to face we believe that it would be an opportune time to examine the funding levels that have been identified to meet these new responsibilities and whether they are adequate or not in order to meet prisoners social care needs, especially given the need to invest in additional areas in order to support and improve service provision.
38. Due to the challenging working environment, the recruitment and retention of qualified registered social workers and occupational therapists to be part of a prison-based workforce is difficult. Historically, social work and occupational therapy in prisons have not been established career choices for those professions and it has proved considerably challenging to find staff motivated to work in these settings. Having recruited, the vetting procedures are protracted and keeping appointed staff motivated through that process has also proved challenging.
39. The design and nature of our current prison estate provides an extremely challenging environment within which to deliver care. For men needing hospital beds, hoisting equipment, specialist chairs etc., the challenges are considerable. Whilst the men might not need an acute bed in a hospital ward, the alternative is an ordinary prison cell on a wing with the equipment in situ; this can prove to be a very restricted space in which to deliver care. Therefore, given the ageing prisoner demographic and the growing demand to have palliative care units on site, it’s going to be increasingly important to get the future design of our secure spaces right, so they are suitably fit for purpose.
40. The complex nature of prisoner health is also proving challenging, particularly when it comes to assessment for Continuing Health Care (CHC) because there are no clear protocols as to how this can be delivered within the Secure Estate. For example, Bridgend Council staff have recently supported the Healthcare team in HMP Parc to explore the eligibility for NHS Continuing Health Care in the prison with the University Health Board. Currently, there are no clear guidelines of who is responsible for carrying out Nursing Assessments for prisoners who appear to meet the eligibility for NHS CHC; and this is especially relevant if the prisoner is at the end of life and wants or has to remain in HMP Parc until death. It would be helpful therefore, if this area of guidance could be urgently reviewed.
41. With the ageing prisoner demographic, comes the rising cost of assessing, delivering and managing care on the Secure Estate. The cost of providing assessment and managed care and support within the prison will be considerably higher than the cost of providing equivalent care in the wider community; the impact is therefore disproportionately higher on authorities supporting prisons in their localities than authorities that just receive prisoners back into their populations on release. WLGA and ADSS Cymru believe that the resources for health and social care within the Secure Estate in Wales should be aligned to the providing local authorities and health boards to ensure they are not unintentionally adversely affected by the location and population of prisoners in the secure estate in their communities.