Prison health Contents

5Breaking the cycle of disadvantage: a whole system approach

101.Prisons are an opportunity to identify and treat the health and care needs of people who often live on the edge of society and who have faced a lifetime of disadvantage. In many instances, people who end up in prison have health and care needs that begin in early childhood, but remain unrecognised and/or underserved, and exacerbated by social problems. It is sometimes only when, as the Parliamentary Under-Secretary of State, Jackie Doyle-Price MP, told us, these people become a “nuisance to society and break the law” that these needs begin to be addressed.146

Whole systems approach

102.The challenge of providing a safer and healthier prison environment begins by managing the number of people going into prison. We agree with CQC that this requires “a whole system approach that has its roots in sentencing and release.”147

103.A more strategic, coordinated whole systems approach, we have heard during our inquiry, would provide a much more effective way of supporting the needs of people in contact with the criminal justice system and protecting the public. Such an approach, as CLINKs argued, could resemble some of the aspirations in the Government’s recent strategy for female offenders, with a particular focus on “pooling budgets and redesigning some of the systems and services around individuals.”148

104.Kate Davies from NHS England told us that there is a lot of work going on between Government departments, and their arms-length bodies, looking at how services outside of prisons can help manage the prison population, ensuring that there are the “right number of people in prisons for the right reasons” and that prisons are enabling environments that help people maintain their health and wellbeing and prepare for better life once they’re released.149

105.In the Female Offenders Strategy, the Government states it wants to see the “the spread of multi-agency, WSA models, which bring together local agencies (criminal justice, statutory and voluntary) to take a joined-up, gender-informed approach to providing the holistic, targeted support that female offenders need, with shared investment and outcomes.” The exact model is likely to vary to reflect the need and provision of services locally, but is likely to focus on an early identification and assessment of need (e.g. when offenders first come in contact with the police), a focus in court about the most effective means of addressing the offenders problem and targeted support from various agencies to address these problems, alongside a community sentence or on release from prison.”150

106.We recommend that the Government’s evaluation of the female offenders’ strategy should assess the merits of applying similar approaches to other parts of the prison population. In particular, we recommend that the evaluation should comment specifically on the extent to which a similar approach could be introduced for those with complex needs who would otherwise be given short custodial sentences.

Rehabilitative culture: narrative of care, health and wellbeing

107.Rehabilitation is one of the three core purposes of prison. Senior officials spoke of aspirations to bring about more positive rehabilitative and enabling environments inside prisons. Kate Davies from NHS England told us:

the right approach for a prison setting is to have an enabling environment where healthcare is at the core of the needs and responsibilities of the individuals from the moment they enter the gate throughout whatever length of sentence they are serving and in planning for their release.151

108.A rehabilitative culture and enabling environment would, in our view, and the view of many of the organisations we heard from, be synonymous with, and supported by, a greater emphasis on health, wellbeing, care and recovery within prison. The way the Government talks about the rehabilitative purpose of prisons should reflect the fact that people in prison, and in contact with the criminal justice system, are among the most vulnerable groups in society, whose lives are characterised by a poor state of physical and mental health, social problems and early adverse experiences. It is important that the minister responsible for prison health has an understanding of the particular challenges and complexities faced by the prison population.

109.Putting greater emphasis on health, care, wellbeing and recovery does not mean diluting the role of prisons in providing public protection and justice. On the contrary, it acknowledges that the health, care, wellbeing and recovery of people detained in prisons is integral to reducing risk.152 This includes current and future risks to people detained in prison, but also the safety of prisons and risks to the public when prisoners leave, including reoffending, but also health risks. The Royal College of General Practitioners told us:

We support the development of a rehabilitative culture within prisons including initiatives that seek to improve the safety of the environment in which healthcare and security staff work and in which prisoners live. We expect an emphasis on effective treatments and working with prison staff to address prisoner behaviour and that this will not only improve individual health outcomes, but which will be likely to reduce reoffending and ultimately benefit society as a whole.153

110.We are encouraged by the language used in the Government’s recently published strategy for female offenders. The underlying purpose of this strategy, and the language used, recognises that the vulnerabilities of female offenders, which are often a product of abuse and trauma, contribute to offending behaviour (chaotic lifestyles involving substance misuse, mental health problems and homelessness).154 The Government’s approach and narrative on prison reform should recognise the trauma experienced by large parts of the prison population and ensure that training and guidance given to all staff in prisons enables them to identify and respond to signs of trauma in prisoners.

111.We recommend that the Government’s programme of prison reform, and the way it talks about its plans for reform, should place greater emphasis on health, wellbeing, care and recovery. Improving the health, wellbeing, care and recovery of people detained in prison will help improve the safety of prisons and reduce reoffending.

Whole prison approach

112.Health in prisons, according to the World Health Organisation, “is too important to be left solely to the health team.” The WHO recommend prisons adopt a whole prison approach to promoting and improving health and wellbeing. A whole prison approach is:

a system-wide strategy aimed at creating healthy, supportive environments which engage at all levels of prison life and focus on promoting good health.155

113.The idea of a whole prison approach is not new. The WHO recommended its adoption in 1995 and Her Majesty’s Inspectorate of Prisons has used the idea to underpin its approach to inspections.156 However, the concept, while welcome and frequently used, still needs to be defined and developed so there is a clear, and shared, understanding of how such an approach should be applied in England. One of the National Prison Healthcare Board’s priorities between 2018–21 is to “develop and apply a whole prison approach to health and wellbeing that ensures that the regime, activities and staffing facilitate an environment that promotes good health and wellbeing and reduces violence for all prisoners, including those with protected characteristics.”157

114.We discussed the National Prison Healthcare Board’s priority with representatives from 18 stakeholders across the health and penal system, including royal colleges, providers of healthcare, charities and representatives of prison staff and private prison providers. They noted that the National Prison Healthcare Board’s priority is extremely complex to implement.158 To begin with, there is no shared understanding of what a whole prison approach means. Reaching a shared understanding is critical as prisons often have a broad range of services, often characterised by clear cultural divides, operating within them. Cultural barriers between prison and healthcare staff, stakeholders told us, are common and frequently have a detrimental impact on the delivery of care.159

115.No one establishment stood out as a model of a healthy prison that could be replicated across the estate. However, we have heard of pockets of good, and even excellent, care across the prison estate where services have found innovative ways to address some of the difficult challenges facing prisons. Some examples may be found in the box below. A whole prison approach is likely to vary between different types of establishments. At our stakeholder discussion, the view was that a whole prison approach would be easier to implement in establishments with a more stable prison population. In contrast, prisons with a high churn in their population frequently struggle with staffing, including problems with recruitment and morale, although these prisons are also ones which see a high prevalence of complex needs.160

116.A whole prison approach to health and wellbeing is one where a focus on health, care, wellbeing and recovery is exemplified through the environment, regime and provision of services, and where these aspects of prison life actively support people to maintain and improve their health and prepare for their release. A whole prison approach begins with identifying and acting on people’s health and care needs upon entry into prison, including needs that may have gone unrecognised and/or been underserved.

117.The Board’s intention to develop and implement a whole prison approach to health and well-being is the right one. We recommend this priority should be given much more prominence within its future plans.

118.In order to ensure that it is successful, much more work is needed to arrive at a shared understanding of what a whole prison approach looks like and how such an approach and best practice can be effectively implemented. The National Prison Healthcare Board, Her Majesty’s Inspectorate of Prisons, the Care Quality Commission and National Institute for Health and Care Excellence 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 prison governors and the appointed regional directors to develop more detailed plans for implementation at local level.

Box 3: Examples of best practice

Her Majesty’s Inspectorate of Prisons often find examples of good and excellent practice across the prison service, but they are rarely shared and adopted elsewhere. Below are some short examples of best practice that exist across the prison service.

Health promotion: Dovegate has a prison-wide approach to wellbeing. This includes health promotion days, healthy eating initiatives and 12 health champions who promote wellbeing through “physical health monitoring, peer information giving, and encouragement.” We also heard examples of a few prisons that had started park-run.

Maternity care and childcare support: Birth Companions identified good practice in maternity care in women’s prisons, including the appointment of a specialist midwife to design and deliver a pathway for perinatal women in prison (Low Newton); provision of counselling and support for women in crisis pregnancy and around the loss of a baby or child (HMP Bronzefield); 24-hour telephone access to the local labour ward, food packs, in addition to standard food, for pregnant women and breastfeeding mothers, and trained volunteers to support and advocate for women during birth (HMP Peterborough); a mother and baby unit providing parenting support, nursery provision and targeted intervention work (HMP Styal).

Family contact: From what we saw at Thameside, the social aspect of a prisoner’s life was well respected. Prisoners have 7 events a month, which they can use to book family visits. There is a monthly family day, a homework club and other opportunities for prisoners to see their partners, children and babies.

Tackling the supply and demand of illicit drugs: On the supply side, Belmarsh piloted technology to detect contraband, including a new body scanner which had achieved encouraging results, according to HMIP. Elsewhere, Northumberland has worked with prisoners to create and implement a drug supply strategy, in which peer mentors have been actively involved in “service delivery, service development and officer training,” and have “contributed to drug strategy meetings.” On the demand side, Preston, according to HMIP, provides an effective and supportive environment that encourages prisoners’ recovery from addiction, with excellent partnership working between prison, clinical and psychosocial teams. Dovegate prison has run a voluntary NPS awareness course for prisoners who “tested positive for using NPSs.”

Dentistry and oral health: Leeds provide a full range of dental services, equivalent to that provided on the NHS. These are provided at four sessions per week. There is also a dental hygienist clinic twice a month.

Long-term conditions management: Lindholme and Holme House have dedicated nurses, which ensure patients with chronic conditions or complex health needs are identified and reviewed promptly.

Mental health and learning disabilities: The National Audit Office’s report on mental health in prisons identified a variety of innovative approaches to improving mental health provision, such as well-being courses, specialist gym classes and family counselling. During our visits, we also heard about the benefits of peer mentoring schemes for people suffering from mental health problems in prisons. Written evidence from the Centre for Mental Health also praised such schemes, saying they lead to positive benefits, and called for such approaches to be used more extensively.

NHS England’s London Clinical Network on Health in Justice and Other Vulnerable Adults conducted an audit of support for people with learning disabilities in 8 London prisons and immigration removal centres. One of the main findings was the value of a learning disability practitioner or coordinator, as a source of expertise. In particular, the audit found “pathways for full assessment, reasonable adjustments and onward referral were most robust where there was a learning disability practitioner in post.”

Social care: Usk has an excellent approach to social care. Social care staff see prisoners on their induction. Prisoner buddies, who are well trained and supervised, are allocated to prisoners in need of social care. These buddies follow a care plan, which is reviewed monthly with the social care team, and keep daily records.

End of life care: Dartmoor was praised for its end of life care. The prison has links with the local hospice and the Macmillan Cancer Care. The prison had a monthly clinic run by Macmillan which provided expert advice to patients with cancer and life-limiting conditions as well as patients receiving palliative care.

Release from prison: Life after prison was also taken into account at Thameside. Senior leaders informed us about a self-funded scheme which has helped 263 prisoners into full-time work and education, with recent leavers taking up positions at Pret-a-Manger and other well-known companies. Another prisoner we spoke to was studying with the Open University. We have also heard about resettlement schemes, such as Landmark, which support prisoners, and people at risk of going into prison, away from crime and into the community. For example, Landmark is a training project in which prisoners, or those at risk of offending, learn practical skills such as woodwork, construction, landscaping, cooking, vegetable growing and arts and crafts through an intensive training placement that replicates a working day. The project has supported 60 people since it began in 2013, over 90% of whom are in employment.

Sources: HMI Prisons (PRH0039),DHSC, MoJ, HMPPS, NHS England and PHE (PRH0032),Royal College of Midwives/Birth Companions (PRH0018) and the visit to HMP Thameside (Annex 1), Landworks website (, National Audit Office, Mental health in prisons, HC 42 Session 2017–2019, 29 June 2017, Centre for Mental Health (PRH0021), London Clinical Network for Health in Justice & Other Vulnerable Adults NHSE (PRH0042)


119.A whole prison approach cannot work without a sufficient, well-trained, and stable supply of prison officers whose own safety and health is valued. The Care Quality Commission’s written evidence identifies problems arising from the lack of a stable and well-trained workforce, saying:

A well-recognised concern is prison staff turnover that has resulted in a reduction in welfare support and fragmented staff-prisoner relationships. In some prisons there is a low percentage of experienced staff who have the skills to identify risk and meet the complex needs of the population. Whilst there are some promising national initiatives to increase the staff-prisoner ratio, staffing is generally inadequate to effectively support risk management, relationship building, prisoner support and preparation for release.161

120.Prison officer numbers are now rising, but are still below 2010 levels and insufficient for the prison population.162 The prison service is also struggling with low rates of retention, including among new recruits, and the significant loss of experienced officers. Her Majesty’s Inspectorate of Prisons, the Care Quality Commission and the Prison Probation Ombudsman all identified significant gaps in the ability of prison staff to identify and respond appropriately to the health and care needs of people in prison, including their ability to respond effectively in emergencies.163

121.Healthcare services in prisons are expected to provide sufficient levels of suitably qualified staff, including an appropriate skill mix, to reflect the needs of prisoners. However, most prison healthcare providers struggle to recruit and retain health staff with the requisite qualities and skills.164 For example, Her Majesty’s Inspectorate of Prisons told us they “consistently observe acute staff shortages within prison health provision and this is often the primary reason for gaps in provision.”165

122.The security clearance process for those applying to work in prison can exacerbate recruitment challenges. The length of time in gaining clearance results in successful applicants withdrawing their interest before starting. The use of agency staff is widespread in prisons, which, according to CQC, can make it “difficult to ensure a consistently adequate skill-mix to deliver community-equivalent services”.166

123.Former prisoners have a lot of experience and insight that could be usefully deployed within prisons. However, we heard public sector prisons are often restricted from employing ex-offenders, whereas privately run prisons have more flexibility. A representative from G4S mentioned how ex-offenders have been employed in their prisons and are allowed to carry keys. Similarly, Craig Thomson, Director at HMP Thameside, run by Serco, told us that the company has employed 3 ex-offenders as apprentices across its wider business portfolio (e.g. supporting prisoners to find accommodation post-release). Mr Thomson believes there is an opportunity for ex-prisoners, once they are in a stable position, to be employed as peer mentors to support prisoners on release, as they have been through the process themselves.

124.Workforce is fundamental to addressing the problems in prisons. We recommend that the National Prison Health Board should develop a workforce plan to underpin a whole prison approach. The plan should set out how it will ensure there are sufficient and stable staffing levels and how it will fill key gaps in the skills and skill-mix of the prison workforce.

Oversight, commissioning and regulation

125.The prison service is poor at spreading best practice and learning lessons, both from serious incidents, including deaths, and from inspections. There are pockets of good practice across the prison estate, but such practice is not widely adopted. HMIP, CQC and the Prison and Probation Ombudsman stressed that the prison service frequently fails to implement recommendations following inspections and investigations, including ones which the MoJ, HMPPS and prisons agree with.167


126.Currently the model of provision in prisons varies considerably across the estate. Variation, in itself, is not a bad thing, but we heard that inconsistencies, particularly gaps in the provision in some places, has led to poor health outcomes.168 We were particularly concerned to hear that contracts do not always reflect the prison’s population need and that there are significant gaps in services such as dentistry, counselling and mental health services (particularly services for people with mild to moderate mental health needs), speech and language therapy and social care, including support for people with learning disabilities.

127.Health and care provision in prisons is delivered by a multitude of different providers specialising in different areas. This fragmentation of delivery can lead to a lack of continuity of care for prisoners. We are concerned to hear about the use of short-term contracts, in which providers frequently have to re-tender, since this can disrupt the continuity prisoners experience (e.g. as staff leave when contracts change hands) and acts as a disincentive for current providers to improve services. We are pleased to hear that longer-term contracts, informed by more robust data on needs, are beginning to address these problems. However, commissioners should remain vigilant and flexible to ensure contracts cater for changes in demand, which can be unpredictable. For example, Care UK told us that the contracts it has to provide care in prisons do not necessarily reflect the increase in demand its services have seen following the increasing use of novel psychoactive substances.169

128.Co-commissioning between NHS England and individual prisons is a welcome step, particularly in encouraging shared ownership of healthcare provision. The transfer of responsibility for commissioning healthcare to NHS England in 2013 has broadly been a very positive change. However, it has created some dissonance between the priorities of different organisations responsible for prisoners’ health and care, which co-commissioning can help address.

129.More broadly, the Care Quality Commission told us that the quality of strategic relationships between the prison service, commissioners and other services varies. These relationships are important as the governance arrangements covering prison services, including healthcare, creates barriers to making even small changes (see the note on our visit to HMP Thameside at Annex 1).

130.The commissioning of health and care in prisons, and for people in touch with the criminal justice system, should facilitate the whole prison and whole system approaches outlined above. It should do so first and foremost by reinforcing a shared ownership for the achievement of equitable standards and health outcomes among all services. An effective approach to commissioning would also ensure people in prisons have access to a broader range of health and care services that reflect their diverse and complex needs, and that they experience continuity in their care.

131.There must be strategic relationships locally in which leaders have shared ownership of making prisons safer and healthier, with better joined-up decision making, for example when commissioning services. In response to this report the National Prison Healthcare Board should set out its assessment of the effectiveness of co-commissioning and whether, and over what timeframe, this approach could be spread more widely. As part of its future work plans, we recommend the Board include a priority to strengthen the quality of local strategic relationships, beginning with increasing the engagement and joint working between key bodies. Prison Governors have a crucial role to play, particularly since they have a duty of care towards prisoners. However, they currently lack the financial and other levers to drive improvement. In response to this report, we recommend that the National Prison Healthcare Board set out how it will foster shared ownership among local bodies, and how it will empower governors to make their prisons safer and healthier.

132.We recommend the Secretary of State for Health use Section 48 of the Health and Social Care Act 2008 to instruct the CQC to conduct a special review of the commissioning of health and social care in a number of prisons and report next year.

Regulation and inspection

133.A whole prison approach and equivalency in standards and health outcomes for prisoners, as in the population as a whole, should be reinforced by a rigorous, respected inspection regime that supports the Government, prisons and providers of prison health and social care to improve. Such a regime needs to provide a robust picture of the state of health and care in prisons and drive up standards up ensuring best practice is shared, and, most importantly, lessons are learnt.

134.Unfortunately, the prison service frequently fails to learn lessons in response to concerns that are raised, including from inspections. HMIP, unlike CQC, does not have enforcement powers to take legal action against prisons. HMIP and CQC frequently find recommendations for improvements inside prisons are not achieved, or only partially achieved. HMIP note that effective implementation of its recommendations is an indicator of performance on subsequent inspections. However, when HMIP return to prisons in most cases they have either remained the same or deteriorated. Over the last two years the percentage of recommendations judged as ‘not achieved’ has exceeded the percentage that has been ‘achieved’.170

135.The Government has taken steps to ensure lessons are learnt following inspections. These include:

These are welcome steps forward, but we are sceptical about whether they are sufficient to ensure lessons are learnt effectively.

136.Currently CQC’s judgements inform the score HMIP awards to prisons under its ‘respect’ test. CQC told us significant breaches of fundamental standards may not receive sufficient attention as other aspects of a prison that come under HMIP’s respect test are “disproportionately positive” and outweigh CQC’s judgements.

137.In practice, while they claim to conduct unannounced inspections in prisons, CQC must notify the prison in advance, usually several days before. We accept there can be valid reasons for notice to be given in some circumstances (e.g. to ensure inspectors can visit the services and speak to the people they need to), but we believe it is in the interest of prisoners that an “unannounced inspection” is in fact unannounced.

138.The voice of Her Majesty’s Inspectorate of Prisons must be listened to and acted on. It is unacceptable that so many recommendations are not acted upon and that standards frequently decline between inspections. There must be greater accountability for these failures and in responding to this report the Government should set out who is accountable. We recommend that the Government should commission an independent evaluation of the new measures it has introduced to ensure the inspectorate’s recommendations are acted on. This evaluation should inform a dialogue with the sector, including user charities, professional bodies and academics, about what further proportionate regulatory measures and enforcement powers are needed to drive up standards.

139.To help drive equivalent standards and health outcomes, we recommend greater prominence should be given to CQC’s judgements in HMIP reports and that legal powers of entry into prisons should be granted to CQC inspectors.

140.We recommend that HMIP’s inspection reports, which CQC contribute to, should provide a clear rating about the extent to which prisons enable prisoners to live healthy lives. A rating should include not only the quality of health and social care provision in prison, but the extent to which all aspects of prison life enable prisoners to enjoy their fundamental right to health. A rating for each prison will support the implementation of a whole prison approach to health and care. We recommend, as part of the implementation of a whole prison approach, that CQC and HMIP work with stakeholders to develop a rating system.

141.We recommend CQC should assess the range of services provided in prisons, including mental health, physical health (older people, adolescents), substance misuse, dentistry as well as the prison environment, against their five criteria (safe, effective, caring, responsive and well-led).

142.Where a health and social care provider delivers services in prisons, the Care Quality Commission’s rating system should convey, as it does for other health and care services, the quality of care delivered to prisoners against each of CQC’s five key questions, namely whether the service is safe, effective, caring, responsive and well-led. We recommend where a provider delivers services in prisons that these services are classified as a core service under CQC’s rating scheme.

146 Q226 Jackie Doyle-Price

147 Care Quality Commission (PRH0004)

148 Q15 Hazel Alcraft

149 Q184 Kate Davies

150 Ministry of Justice, Female Offenders Strategy, June 2018

151 Q173 Kate Davies

152 Dr Emily Glorney (PRH0055)

153 Royal College of GPs (PRH0023)

154 Ministry of Justice, Female Offenders Strategy, June 2018

155 DHSC, MoJ, HMPPS, NHS England and PHE (PRH0032)

156 The Howard League (PRH0029)

157 National Partnership Agreement

158 Note on stakeholder discussion

159 Care Quality Commission (PRH0004), Annex 2 Prison Health Stakeholder Discussion, Q13 Sean Cox

160 Annex 2 Prison Health Stakeholder Discussion

161 Care Quality Commission (PRH0004)

163 Care Quality Commission (PRH0004), HMI Prisons (PRH0039)

164 HMI Prisons (PRH0039)

165 HMI Prisons (PRH0039)

166 Care Quality Commission (PRH0004)

167 Care Quality Commission (PRH0004), HMI Prisons (PRH0039), Prisons and Probation Ombudsman (PRH0017)

168 HMI Prisons (PRH0039)

169 Care UK (PRH0025)

170 HMIP annual report

171 Q100

Published: 1 November 2018