Briefing paper: Health, Social Care and Sport Committee

Inquiry into health and social care provision in Welsh prisons

Healthcare Inspectorate Wales, September 2019

Our role in relation to Welsh prisons

Public Sector

Responsibility for prison health services in public sector prisons rests with the relevant health boards. This means the following health boards have responsibility for all healthcare services in these prisons:

HM Prisons Usk & Prescoed, Monmouthshire	Aneurin Bevan University Health Board
HMP Cardiff	Cardiff and Vale University Health Board
HMP Swansea	Swansea Bay University Health Board
HMP Berwyn	Betsi Cadwaladr University Heath Board

All relevant NHS standards in Wales apply to health care services for prisoners, with exceptions only where the constraints of the custodial environment are over-riding. NHS complaints regulations must be met by the public sector prisons; and serious patient safety incidents in all prisons are reported through usual NHS systems.

Private Sector

Healthcare in HMP Parc, a private prison operated by G4S, is more complicated. The responsibility for meeting the secondary and tertiary care health needs of all prisoners, whether held in the public or the private sector prison estate, rests with the NHS. Therefore Swansea Bay University Health Board currently (for 2019-20) has responsibility for the secondary and tertiary health care needs of prisoners at HMP Parc.

Primary care services at HMP Parc are delivered through a contract with G4S Medical and are therefore not the responsibility of the NHS. The Healthcare Centre at HMP Parc provides 24-hour primary care and has a unit dedicated for older prisoners with increased and complex healthcare needs. The unit also has emergency care beds for use as required for prisoners, to meet acute mental and physical healthcare needs. Healthcare is provided by doctors and nurses employed and contracted by G4S. There is also a dental suite within the Healthcare Centre and a dentist is on site 5 days per week. Primary care mental health services are supported by a Community Mental Health service commissioned by Swansea Bay University Health Board.

The NHS complaints regulations and standards do not apply to primary care provision within HMP Parc.

Our remit

HIW has the legal basis to inspect the majority of prison healthcare services. HIW has a remit to enter and inspect any premises where care is provided by or for Welsh NHS bodies under the Health and Social Care (Community Health and Standards) Act 2003. HIW would, therefore, have the legal basis to enter and inspect most prison healthcare premises in Wales, separate to the inspections and reviews of HMI Prisons and the PPO.

The exception is primary care services delivered to prisoners and Young People at HMP/YOI Parc. Prisons or custodial establishments are exempted from registration with HIW under regulations 3(3)c, 4(2)(i) and 5b of the Independent Health Care (Wales) Regulations 2011. HIW would not, therefore, have a remit to inspect primary care services in HMP Parc unless the service became registerable, or unless the service being provided was provided for or on behalf of the NHS.

In England, all providers of ‘regulated activities’ within prisons, Young Offenders Institutes and Immigration Remand Centres must register with the CQC. Although the CQC has the legal right to inspect registered health care providers, they generally enter secure settings under the powers granted to HMIP and undertake joint inspections. The CQC does not undertake its own separate inspections. This would appear to be an appropriate approach to utilise the knowledge and experience of HMIP inspectors and ensure that matters at the interface between prison healthcare and other aspects of prison life can be suitably addressed.

Governance arrangements for Welsh Prisons

There is a Partnership Agreement for Prison Health in Wales – which outlines agreed priorities between Her Majesty’s Prison and Probation Service (HMPPS), the Welsh Government, health boards and Public Health Wales. The Partnership Agreement is underpinned by a Prison Health Delivery Plan.

Offenders should have equitable access to health services both in the prison estate and community settings. The Prison Health Delivery Plan is a mechanism by which it is intended to ensure equitable healthcare is provided. The Delivery Plan focusses on four key priority areas:

1.  Ensuring prison environments in Wales promote health and well-being for all.

2.  Developing consistent mental health, mental well-being and learning disability services across all prisons that are tailored to need.

3.  Producing a standardised clinical pathway for the management of substance misuse in prisons in Wales.

4.  Developing standards for medicines management in prisons in Wales

We are aware that work in each of these areas is ongoing, and that progress against the priorities is monitored jointly by Welsh Government and the HMPPS. Each health board is expected to plan and deliver healthcare to prison establishments, including having necessary governance arrangements in place to assure the quality and safety of services. We are not part of these monitoring arrangements as we do not have a role in planning services.

The Prison Health Partnership Boards (PHPBs), jointly chaired by the Chief Executives of the LHBs and the Governors of the prisons (or their nominated deputies), have responsibility for the governance of prison health services, and should maintain a joint register of risks, both shared and to their respective organisations, which they are expected to agree and manage collaboratively. Again, we are not part of these arrangements however we are in the process of identifying with Welsh Government how we may be able strengthen our influence in relation to driving improvement in prison healthcare.

Our activity in Welsh Prisons

We currently discharge our role in relation to Welsh prisons by:

1. Contributing to death in custody investigations

The Prisons and Probation Ombudsman (PPO) is required to undertake an investigation of every death that occurs in a prison setting. HIW contributes to these investigations by undertaking a clinical review for all deaths within a Welsh Prison or Approved Premises. This arrangement is defined within a Memorandum of Understanding between the PPO and HIW.

These reviews critically examine the systems, processes and quality of healthcare services provided to prisoners during their time within prison or Approved Premises. We will also follow up on matters of concern arising from individual death in custody reviews with relevant health boards directly.

2. Contributing to inspections of prisons conducted by Her Majesty’s Inspectorate of Prisons (HMIP)

HMIP has a statutory duty to inspect healthcare and substance misuse within custodial settings in England and Wales. HMIP therefore leads inspections of prisons in Wales and aims to inspect each prison in Wales at least once every five years. HIW has a memorandum of understanding with HMIP and can accompany HMIP on their routine inspections of prisons in Wales. We also share intelligence with the HMIP regarding any concerns we receive about Welsh prisons.

Although the joint working arrangements between HIW and HMIP do not currently cover the private prison estate (unless an independent provider of healthcare registered with HIW provides the healthcare within the prison), the healthcare service provided by G4S is included in the scope of inspection when HMIP inspects HMP Parc, and the inspection report is shared with HIW.

As independent monitoring and inspecting bodies, HIW and HMIP both have responsibilities as members of the UK's National Preventive Mechanism (NPM) to prevent ill treatment of people in prison. The NPM is required under the international human rights treaty and the Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT).

What we find

The following table illustrates our death in custody investigations since 2014:

Setting	Type	2014/15	2015/16	2016/17	2017/18	2018/19	Total
HMP Berwyn	Natural causes	0	0	0	0	3	3	3
HMP Cardiff	Natural causes	0	0	5	1	4	10	15
	Suicide	1	1	1	1	0	4
	Homicide	1	0	0	0	0	1
HMP & YOI Parc	Natural causes	3	5	5	2	7	22	29
	Suicide	2	2	1	0	2	7
HMP Swansea	Suicide	0	1	3	1	0	5	5
HMP Usk & HMP / YOI Prescoed	Natural causes	4	1	1	1	2	9	9
	Total	11	10	16	6	18	Total	61

Key themes

The key high-level themes emerging from our death in custody reviews are:

· Concerns about the quality of healthcare documentation. This includes concerns about the standard of record keeping, and their lack of comprehensiveness

· Inadequate levels of mental health care support. We identified several instances where prisoners were not provided with the appropriate levels of mental health care and support, and identified concerns again regarding the quality of documentation and risk assessments

· Training. We have found issues specifically in relation to Cardio Pulmonary Resuscitation (CPR) training and when not to perform CPR

· Communication between health boards and prison settings. Poor communication between these organisations has been highlighted by our reports, in particular around missed appointments (either within prison settings, or hospital appointments).

Broader monitoring arrangements

We have relationship managers aligned to each NHS body, and part of this role is to observe the governance arrangements at that body. In relation to prison healthcare, our observations or quality and safety committees has painted a mixed picture in terms of understanding the adequacy of health board governance. For instance, in relation to HMP Berwyn and Betsi Cadwaladr University Health Board, we have seen evidence of prison healthcare featuring on the health board’s quality and safety agenda and monitoring of performance at the prison apparent. However we have less confidence in other health boards and how prominently prison healthcare features on their quality and safety agenda and whether appropriate governance is in place to assure themselves of both the quality and access to health services for men in the prison estate.

We have also been an attendee of the Prison Healthcare Improvement Network (PHIN). The network is chaired by Prison Heads of Healthcare and its purpose is to be a forum to share good practice and learn from issues of concern. Our experience of the network suggests that attendance is sometimes poor, that meetings are not frequently scheduled, and that the effectiveness of the network as a consequence is diminished.

Further work

The nature of detention is that it is largely out of sight of the public. This puts prisoners in a more vulnerable situation as they rely on authorities for their safety, care and wellbeing. This makes monitoring and inspection more important, ensuring the quality of care received by prisoners is at a level that is equivalent to the rest of the population.

There may, therefore, be occasions when HIW may wish to conduct an inspection or a review of prison healthcare. This could be because intelligence suggests that healthcare within a particular setting is a particular risk; or perhaps more likely for HIW’s standalone work might be a thematic review of prisoner healthcare, for example addressing themes arising from our death in custody reviews. Any decision to undertake further work in relation to prison healthcare would be considered in line with ensuring that we continue to discharge our broad range of responsibilities across healthcare in Wales.

Healthcare Inspectorate Wales

September 2019