Summary
The state of health and care in English prisons
The Government is failing in its duty of care towards people detained in England’s prisons.
Too many prisoners remain in unsafe, unsanitary and outdated establishments. Violence and self-harm are at record highs. Most prisons exceed their certified normal accommodation level and a quarter of prisoners over the last two years have lived in overcrowded cells. Staffing shortages have forced overstretched prisons to run restricted regimes, severely limiting not only opportunities for prisoners to engage in purposeful activity, but access to health and care services both in and outside prisons.
Too many prisoners die in custody or shortly after release. Whilst deaths, including by suicide, in prisons have fallen slightly since their peak in 2016, so-called natural cause deaths, the highest cause of mortality in prison, too often reflect serious lapses in care. We are also concerned about the increase in deaths during post-release supervision and reports of people being found unresponsive in their cells. Every suicide should be regarded as preventable and it is unacceptable that those known to be at risk face unacceptable delays awaiting transfer to more appropriate settings.
Prisons have also been grappling with the increasingly widespread use of novel psychoactive substances, which are a serious risk to the health and safety of users, fellow prisoners and staff alike. Evidence to our inquiry suggests the Government and the prison service are some way from having this under control.
Missed opportunities to break the cycle of disadvantage
The health of people in prison is a public health issue. Prisons could be an opportunity to address serious health inequalities which are part of the cycle of disadvantage faced by people in prison. No one is sentenced to worsened health but that, largely as a result of overstretched staff, overcrowding and poor facilities, is too often the outcome. Prison health and care services should be delivering standards of care, and health outcomes, for prisoners that are at least equivalent to that of the general population. Doing so involves identifying and addressing health and care needs, which may have gone unrecognised, and supporting prisoners to lead purposeful, healthier lives. We recommend that:
- the National Prison Healthcare Board work with stakeholders to agree a definition of equivalent care, and indicators to measure health inequalities between people in prison and the general population, which should then be reduced;
- the Board co-design with stakeholders a more comprehensive and robust approach to identifying the health and care needs of people in prison and those in contact with the criminal justice system;
- the Government name the date by which it expects to have enough prison officers in post to ensure the vast majority of prisoners can be unlocked for the recommended 10 hours per day;
- guidance on how prisons and prison staff use incentives should make clear that incentives should encourage prisoners to lead healthy lives and not deprive them of regular access to facilities and activities which promote a basic standard of wellbeing.
Prison reform
Supporting prisoners to lead healthy lives is consistent with the Government’s aim to use prisons to rehabilitate offenders. Health, wellbeing, care and recovery need to be a core part of the Government’s plans for prison reform.
A whole system approach
The challenge of providing a safer and healthier prison environment begins by managing the number of people going into prison. We agree with the Care Quality Commission that this requires “a whole system approach that has its roots in sentencing and release.” An example of a whole system approach may be found in the Government’s recent strategy on female offenders. We recommend that the Government’s evaluation of this strategy reports on whether, and if so how, similar approaches could be applied to other parts of the prison population.
A whole prison approach
For those in prison, we support the National Prison Healthcare Board’s intention to develop and implement a whole-prison approach to health, and recommend this priority is given much more prominence within the Board’s future plans. The National Prison Healthcare Board should work with a group of national stakeholders over the next 12 months to define the core principles of a whole prison approach, together with guidance and resources to support more detailed plans at a local level.
A shared understanding of what a whole prison approach looks like and how such an approach, and best practice, can be effectively implemented is critical for success. The key factors that underpin the successful delivery of a whole prison approach are:
- a sufficient, stable and well-trained workforce, both of prison staff and health and care professionals, whose own safety and health is valued;
- strong local strategic relationships, with a shared ownership for improving prison health and care;
- a collaborative approach to commissioning, which ensures service provision reflects the needs of the prison population and gives governors the financial and other levers necessary to make prisons safer and healthier;
- a rigorous, respected inspection regime that provides a robust picture of the state of health and care in prisons and drives improvement through reinforcing local whole prison approaches and equivalency in standards and health outcomes, ensuring best practice is effectively spread and lessons are learnt. Inspection reports need to be accompanied by real powers to drive implementation and consequences for failure to do so.
We recommend CQC should assess the range of services provided in prisons, including mental health, physical health (older people, adolescents), substance misuse and dentistry, as well as the prison environment, against their five criteria (safe, effective, caring, responsive and well-led).
We look forward to seeing a Government approach which brings all these factors together into a serious attempt to tackle the unacceptable health inequalities present in the current prison healthcare system.
Published: 1 November 2018