Conclusions and recommendations
The state of health and care in English prisons
1.Governments, according to the World Health Organisation, have “a special duty of care for those in places of detention which should cover safety, basic needs and recognition of human rights, including the right to health.” The Government is failing in this duty of care towards people detained in prisons in England. Too many prisoners remain in unsafe, unsanitary conditions that fall far short of the standards we should expect. The Government must urgently fulfil its special duty of care for prisoners. (Paragraph 9)
People detained in prison
2.We recommend that the National Prison Healthcare Board work with stakeholders over the next 12 months to agree a definition of “equivalent care” and indicators to measure the extent to which people detained in prison receive at least equivalent standards of care, and achieve equivalent health outcomes, as the population as a whole—in other words, to measure the health inequalities of people detained in prison. (Paragraph 35)
3.In the meantime, in all future iterations of its strategy and plans, including its national partnership agreement, the National Prison Healthcare Board should explicitly state its commitment to achieve equivalent standards and health outcomes for people detained in prisons, compared to the population as a whole—that is, to reduce health inequality. Its plans should include an explanation of how its action to improve access to healthcare and enable prisoners to lead healthy lives will reduce health inequality. (Paragraph 36)
People’s journey through prison
4.We are disappointed that nearly a decade on from the Bradley report in 2009, liaison and diversion services do not yet exist in nearly 20% of the country. In the response to this report, the National Prison Healthcare Board should set out the remaining areas where it needs to roll out these services, the reasons for the delay and how the roll-out of these services to the rest of the country will be achieved. (Paragraph 40)
5.We are also disappointed by the decline in the use of hospital orders, despite liaison and diversion services identifying more people with vulnerabilities who may be more appropriately directed to other services besides prisons. The Board should set out the reasons for the decline in hospital orders, what action it is taking to reverse that decline, and by when that action will be completed. There must also be sufficient resourcing of community mental health services so that people are not sent to prison because of a lack of appropriate community mental health care. (Paragraph 41)
6.Imprisonment represents an opportunity to identify, effectively diagnose and treat health and care needs, some of which may be drivers of behavioural problems, which may have gone unrecognised and/or unmet. We recommend that over the next 12 months the National Prison Healthcare Board, in collaboration with stakeholders, particularly those representative of health and care professions, develop a more comprehensive and robust approach to health screening in prisons, capable of testing for a broader range of health and care needs. Once a new approach is designed its implementation must be supported by a training programme for staff carrying out assessments. (Paragraph 47)
7.In its next annual report, we recommend that Her Majesty’s Inspectorate of Prisons comment specifically on the quality of health screenings, including the extent to which prisons are conducting a second health screening within 7 days. (Paragraph 48)
8.In response to this report, the Government should set out what its plan is to ensure that all prisons are clean and sanitary all of the time and by when and how they expect to stop overcrowding. (Paragraph 53)
9.In response to this report, we request that the Government set out its future plans for the recruitment of prison officers, including a date by when it expects to have enough prison officers in post to ensure the overwhelming majority of prisoners can be unlocked for the recommended 10 hours per day. (Paragraph 57)
10.The Government’s approach to prison reform emphasises the importance of harnessing incentives. Incentives should encourage prisoners to lead healthy lives. In addition, incentives should not deny prisoners regular access to facilities and activities that enable them to maintain basic standards of health and wellbeing. This point should be made clear in guidance on how prisons and prison staff use incentives. People in prison should not in effect be sentenced to a reduction in life expectancy or worsening health. (Paragraph 58)
11.The Government must urgently ensure that all prisoners have access to a reasonable quantity and quality of food which supports health and wellbeing rather than adversely affecting it. Public Health England should carry out an assessment to determine whether the daily food budget of £2 per person can realistically deliver this objective and review the national food standards in prison, which should be consistently implemented across the prison estate. (Paragraph 60)
12.The Government in its response should set out how it intends to drastically reduce the number of missed appointments both in and outside prison across the prison estate to ensure that clinical need is always met. (Paragraph 75)
13.We agree with the Independent Advisory Panel on Deaths in Custody that drug-related deaths in prison should be clearly recorded. We recommend that in the Government’s official response to this report the Ministry of Justice set out the steps it intends to take to ensure that happens. (Paragraph 80)
14.We recommend the approach to health screening is modified to enable prisons to get a much more comprehensive understanding of people within their prison who have a pre-existing substance misuse problem. The approach to screening should also enable prison healthcare providers to identify, and assist, those who develop such a problem during their sentence. (Paragraph 81)
15.The National Prison Healthcare Board’s Partnership Agreement states that it will “continue work at all levels to reduce the impact of substance misuse (including from the use of psychoactive substances), to address the risks of misuse and resultant harms, and to ensure the right help is available at the right time.” This statement of intent is very vague. In its place we recommend the National Prison Healthcare Board commit to reducing substance misuse in prison, as well as its impact, and set clear and ambitious targets for:
(a) reducing the supply of, and demand for, illicit drugs in prisons; and
(b) improving the recovery, and associated health outcomes, of people in prison with a substance misuse problem. (Paragraph 82)
16.There are well known risks relating to suicide and self-harm for people in prison. While rates of self-inflicted deaths in prisons have fallen since reaching a peak in 2016, there is no room for complacency as incidences of self-harm remain at a record high. We expect to see a concerted effort from Government to reduce suicide and self-harm in prison, supported by ambitious targets and a clear and credible plan for achieving them. The newly identified role of a minister with responsibility for suicide prevention is welcome, but we expect the Government within its response to report on how this role will extend to suicides and self-harm within prisons and on release. (Paragraph 88)
17.The National Prison Healthcare Board’s agreement states that between 2018–21 it plans to “continue to work collaboratively to improve practice to reduce incidents of self-harm and self-inflicted deaths in the adult secure estate, by strengthening multi-agency approaches to managing prisoners at serious risk of harm and further embedding shared learning.” Like the reference to substance misuse described above, this is too vague. The Board should set clear reduction targets and measures of success for this period, including improving access to psychological therapies, especially for those with mild to moderate mental health needs. (Paragraph 89)
18.In response to this report, we recommend that the Board set out the level of reduction in waiting times for transfers to secure mental health facilities it plans to achieve in each of the remaining years of the its partnership agreement (2018/19, 2019/20 and 2020/21). We also recommend that the Board set out its plans for expanding the number of secure hospital beds, including dates by which extra capacity will be operational and the contribution this extra capacity will make to reducing waiting times. (Paragraph 90)
19.We recommend a target should be introduced for all of the 50 local authority areas with prisons to have a memorandum of understanding on the provision of social care in place with each prison in their area in the next year. (Paragraph 95)
20.We recommend that the Government undertake a thorough investigation of deaths during post-release supervision in the community, including the reasons for the rise in death rate that has been described. We further recommend that the Government clarify where responsibility for oversight of such deaths should lie and set out a plan to reduce this death rate. (Paragraph 100)
Breaking the cycle of disadvantage: a whole system approach
21.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. (Paragraph 106)
22.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. (Paragraph 111)
23.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. (Paragraph 117)
24.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. (Paragraph 118)
25.Workforce is fundamental to addressing the problems in prisons. We recommend that the National Prison Healthcare 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. (Paragraph 124)
26.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. (Paragraph 131)
27.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. (Paragraph 132)
28.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. (Paragraph 138)
29.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. (Paragraph 139)
30.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. (Paragraph 140)
31.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). (Paragraph 141)
32.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. (Paragraph 142)
Published: 1 November 2018