3Commissioning services in prisons
93.The role of the governor has changed since 2016, particularly with regard to commissioning and governance arrangements across healthcare and education sectors. There is now an increasing need for cooperation and collaboration. Many prisons have multiple organisations providing different types of services across the healthcare and education sectors.
Healthcare in prisons
94.Since 2003, healthcare for prisons in England has sat within the remit of the Department of Health and Social Care and its delivery agencies, NHS England and Public Health England. NHS England is responsible for commissioning healthcare for people in prisons in England. HMPPS is responsible for providing a safe and decent custody environment, including aligning the delivery of health and non-health-related services within establishments. The National Prison Healthcare Board for England was established by the Ministry in 2013 and has responsibility for the oversight and ongoing management of the National Partnership Agreement and the delivery of the partnership’s shared objectives. More information on this can be found in box 9.
Box 9: National Partnership Agreement for healthcare in prisons
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There are five signatories to the National Partnership Agreement, each with defined roles and responsibilities:
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Source: HM Government, National Partnership Agreement for Prison Healthcare in England 2018–2021, April 2018
The role of the governor in the provision of healthcare
95.The 2016 White Paper proposed that a joint approach to commissioning health services across England be introduced, where governors would take a joint responsibility at each stage of the commissioning cycle. This joint approach would involve governors in co-designing service specifications, appointing health providers and a key role in performance and quality management of services.170 The National Partnership Agreement refers to HMPPS as “Healthcare Co-Commissioners”.171
96.A number of our witnesses disagreed with the description of HMPPS as co-commissioner and challenged the extent to which governors are involved and have influence in commissioning. The Royal College of Psychiatrists felt that governors’ involvement in healthcare had become more limited over time and that the degree of involvement of governors in healthcare management “varies considerably from prison to prison.”172 Dr Ian Cumming, Consultant Forensic Psychiatrist, echoed this, saying that “the governor moving away from being more centrally involved has been a bit of a loss. Governors had more flexibility in the past to develop things.”173 Andrea Albutt said that it was “wholly untrue” to describe governors as core commissioners of health services, saying that they remained ‘influencers’.174 Digby Griffiths, Executive Director, Safety and Rehabilitation, HMPPS, also described governors as influencers.175
97.The National Partnership Agreement refers to HMPPS as co-commissioners, but governors expressed frustration that they felt they were held accountable for healthcare when it was not technically their responsibility. One governor estimated that they had only 2% influence over which healthcare provider was commissioned in their prison.176 Others provided examples of where it was unclear which organisation was accountable; we heard of instances where there had been disputes between the prison and healthcare provider over who was responsible for providing constant supervision for prisoners with mental health needs. Digby Griffith explained that “Accountability for the quality of the healthcare resides with the provider and the commissioner of that healthcare. The accountability for the environment in which that healthcare is delivered is held by the governor.”177 He said that where disputes existed, they could be escalated up to the National Partnership Board; he emphasised they were trying to take a position of shared ownership.178
98.The need for partnership working and teamwork was emphasised by many as a key driver in successfully delivering healthcare in prisons. Dr Sarah Bromley, National Medical Director, Health in Justice, Care UK, described the governance structure for healthcare as a partnership arrangement, emphasising that “It is only when that partnership is working well that we can start to deliver. When the partnership does not work well, it starts to fall over.”179 Michelle Jarman-Howe, Executive Director, Public Sector Prisons South, HMPPS, said that “One of the core roles of the governor is to orchestrate a wide range of providers, partners and stakeholders who operate in prisons, which are very complex environments.”180 She emphasised that it was a governor’s responsibility to bring services together.
99.NHS England told us that they had produced a comprehensive paper in 2018 to help governors understand the commissioning process, enabling them to support the process from an informed point of view. The Ministry are responsible for circulating this, but NHS England said that “there has been no further information as to the status of this document or intentions to disseminate.”181 When asked what training, support and guidance HMPPS gives governors on the management of healthcare in their prison, Digby Griffith said “probably not enough”.182 It is clear that governors are not in reality “co-commissioners” of healthcare. For governors to play an effective and influential role in the provision of healthcare, they must work effectively in partnership with healthcare colleagues. There is a risk of inconsistency in the quality of provision across the estate, depending on the quality of those partnerships. We recommend that the Ministry work with NHS England to ensure that effective guidance and training is in place to support governors develop high-quality partnerships with healthcare providers and commissioners.
Healthcare and the wider regime
100.The need for strong partnership working is exemplified by the symbiotic relationship between healthcare and the wider prison regime. Digby Griffith emphasised that “one of the issues that will make healthcare very difficult to provide is a badly run prison where there are difficulties, where there are not enough staff and where there are drugs coming into the prison. The governor has a responsibility to tackle those issues, and to provide an enabling environment where good-quality healthcare can be provided.”183 Effective information-sharing was also emphasised by several witnesses as an important part of delivering good healthcare. Dr Bromley told us that she was not confident that governors had access to healthcare data that was shared between healthcare providers and NHS England.184 Digby Griffith said he expected “governors to ensure that information is being shared at proper strategic and tactical levels within the prison, and that there is a coming together of information about any individual prisoner.”185 In response to this Report, the Ministry and NHS England should set out the steps they are taking to improve information sharing between Prison Service staff, healthcare providers and health commissioners.
101.Dr Bromley also emphasised the problem of inexperienced staff and the impact this can have on patients reaching healthcare appointments. She said that staff working for Care UK saw about 50,000 patients a month, but a further three or four thousand appointments were made but not attended.186 Dr Bromley noted that “There was a loss of the healthcare officer role, as healthcare professionals took over healthcare in prisons. There was a good argument for that in some ways, but the loss was in having experienced prison officers who understood how healthcare operated and what the priorities and their roles were.”187 She called for improved training on responsibilities in relation to healthcare. Dr Cumming emphasised “that it may seem fundamentally wrong to have prison officers doing the job of healthcare, but they certainly have a role to play.”188 The Health and Social Care Committee, in its report Prison Health, also expressed concern about the number of missed healthcare appointments.189 We agree that governors and prison officers play a vital in facilitating healthcare. We recommend that HMPPS reviews the training available to ensure that prison staff fully understand what their role is in relation to healthcare and how they can support its provision.
102.We are concerned about the impact that missed appointments might be having on prisoner health, but we are unclear of the impact because HMPPS does not publish performance data on missed appointments. This is something that was originally envisaged in the 2016 White Paper and we recommend that such a measure is included in the Prison Performance Tool. It should also set out the steps it is taking to reduce the number of missed appointments.
Drugs in prisons
103.The issue of drugs in prisons is a good example of where collaboration between HMPPS and health professionals is required to make progress on a key strategic issue. In the 12 months ending in March 2019, 10.4% of Random Mandatory Drug Tests (RMDTs) were positive, a decrease of 0.5 percentage points since the 12 months ending in March 2015, but still the second highest annual rate since 2005–06 when 10.3% of tests were positive.190 Dr Bromley said that the influx of new psychoactive substances (NPS) into prisons had been a “game changer”, adding “One of our prisons had up to about 35 alarm calls last month, largely around NPS usage. Of course, if our nursing staff are resuscitating people or going to see people who are acutely under the influence of drugs, they are not able to deliver the routine clinics. That has a big knock-on effect.”191
104.The Ministry published its prisons drugs strategy in April 2019, more information on which can be found in Box 5. In July 2018, the Ministry announced a joint HMPPS, DHSC and NHS England £9 million Drug Recovery Prison pilot at HMP Holme House to tackle drugs in prison and help prisoners to build their recovery. NHS England told us that results yielded so far were largely positive, for example ambulance attendance has fallen from approximately 40 per week to zero since the introduction of an on-site paramedic. They noted that they had identified ongoing funding for the Drug Recovery Prison and for sustaining the programme through shared learning, but noted that the Ministry “are not currently able to commit to this pending the outcome of any future spending review.”192 Now that the Spending Review has been announced, the Ministry should set out what funding will be available to the support the drug recovery pilot, as well as the sharing of good practice at other establishments.
105.The Chief Inspector of Prisons, Peter Clarke, noted that the Inspectorate was still finding prisons without a “coherent or comprehensive drug supply reduction strategy.”193 The Ministry’s Drugs Strategy says that “all prisons will have implemented their own Drugs Strategy, tailored to their specific needs and challenges, by September 2019.”194 We are concerned to hear that the Inspectorate is continuing to find prisons without any proper drug strategy, which was a clear commitment in the Ministry’s own overarching strategy. The Ministry should set out the steps it is taking to ensure all prisons have a drugs strategy in place, as well as how it measures the quality and effectiveness of individual strategies.
106.A number of our witnesses emphasised the need for more body scanners across the estate to prevent the entry of drugs into prisons. The Prison Governors Association said that body scanners remain elusive across the estate;195 Sir Richard Heaton told us that of the 118 prisons in the estate, 25 have body scanners.196 The Secretary of State told us that in the closed estate “there is a clear crossover between the need to check at the gate and scan at the gate, staff as well as prisoners, sadly, in order to make prison a safer place. We are seeing some good results in the use of scanning equipment.”197 He said that there was evidence to suggest they were a worthwhile investment, noting that it was not a significant outlay compared to other technologies.198 Phil Copple, Director General for Prisons, said that a “number of millions in single figures would enable us to put them across all the category B local prison estate”. The Government announced in August 2019 that it was making £100 million investment in security in prisons, including putting x-ray scanners into prisons across the estate.199 We welcome the Government’s announcement that funding will be available to install x-ray scanners across the prison estate. Given the Secretary of State’s comments that such scanners will be more effective in some parts of the estate than others, we would welcome further information about how many and which types of prisons will have scanners installed in them, as well as when the Ministry expects these to be installed by.
Education in prisons
107.Responsibility for prison education in England transferred from the Department for Education to the Ministry in 2016. Since then there has been a series of significant pieces of work into prisoner education, beginning with Dame Sally Coates’ independent review into prison education, Unlocking Potential.200 This advocated a greater role for governors, including “new autonomy in the provision of education, and to be held to account for the educational progress of all prisoners in their jails.” The Ministry published its Education and Employment Strategy in 2018, which made the commitment that governors would be fully in charge of education. The Strategy said that governors would “commission the providers and manage its delivery.”201
108.In April 2019, existing arrangements were replaced by two primary vehicles: The Prison Education Framework (PEF), covering core education provision, including provision of a core curriculum and the Dynamic Purchasing System (DPS), covering more niche and localised provisions. Our witnesses broadly welcomed the changes, although the Prisoner Learning Alliance noted that while the “new arrangements have the potential to deliver improvements, there are many areas where progress is too slow.”202
The Prison Education Framework
109.Under the PEF, prisons are grouped into lots of 17 geographical areas.203 All contracts are let centrally and managed locally by governors. All 17 lots have been awarded to four providers: the same four as under the previous system.204 The Ministry says that the Framework is designed to “enable governors to commission bespoke education in their own establishments quickly and with minimal bureaucracy.”205
110.Our witnesses told us about the extent to which governors would be able to influence the new education contracts. The Prisoner Learning Alliance said that “the new contracts, in theory, have built-in flexibility as if a governor finds that a service is not being delivered through the PEF, they will be able to take action easily, holding the provider to account and asking for an improvement plan. Ultimately, if the provider fails to take action to improve the service, they could lose 5% of their budget for the next quarter.”206 However, Serco noted that where its prisons were included in the PEF, it has limited ability to influence the provider.207 Francesca Cooney, Head of Policy at the Prisoners’ Education Trust, said that “It is a bit more complicated because the education contracts are run at lot level, which is between four and 10 prisons. A group of prisons is part of that contract, and it is a contract that is being monitored across the lot.”208
111.We discussed how education providers would in practice be held to account; Chris Emmett, Director of Strategy, Prison Education, Weston College, said that this was the role of both the governor and the contracts team in the Ministry.209 Francesca Cooney added that “It should be possible for a contract to be breached prison by prison, so it should be possible to penalise a provider because of their service provision in one prison rather than the rest of the prisons in that lot. All those decisions, even if they are initiated by a governor, will be signed off by MOJ contracts team.”210 One governor we met emphasised that the new system has resulted in collective autonomy, as prisons are grouped into lots under one contract.211 The Ministry says that the contracts will be managed through a hybrid contract management model, where the contracts are managed at prison and lot level with the support of a central team. The national contract management team manages the relationship with the provider at a national level.212
112.There was also a lack of clarity as to how governors would be held accountable for education in their prisons. Francesca Cooney said that there will be assessment data in core areas, such as maths, but in “terms of outcomes that are more connected to progression and more detailed achievement, we are waiting to see how that is going to be implemented.” She noted that governor responsibility for these areas was unclear, as accountability measures had not been finalised, but thought they might be implemented by the end of 2019.213 The Ministry says that it is currently developing an education performance measure.214 We are concerned to hear that the new arrangements for education provision have been launched without clarity about what governors are responsible for, nor clear measures to hold governors and service providers to account. The Ministry should set out the performance measures that will be used to hold service providers and governors to account. We also seek further detail about how prisoner progression is going to be measured.
113.A number of our witnesses raised concerns about the lack of training and support for governors to help them in their new role. Francesca Cooney said governors were not yet equipped to be responsible for education. She said “The training on managing the contracts happened far too close to the start of the contracts. There was a push to get the contracts into place without the infrastructure being there. The HMPPS team to support the process was also put in place too late, and its roles and responsibilities are still being developed and ironed out. The regional structures are still being finalised in terms of supporting prisons with the legal and technical support that they need to do the commissioning.”215 Chris Emmett added that the extent to which governors and heads of learning were versed in education varied.216 The Ministry says that significant support has been put in place for governors, including contract management support at both a local and national level.217
114.The Prisoner Learning Alliance told us that it had “recently carried out a survey of prison governors and senior managers in the run up to the new education contracts. We received 60 responses. Overall too few respondents (five) felt prepared enough for the start of the new education contracts on April 1st 2019. Only ten respondents felt their staff team had the skills and knowledge needed to manage the contracts and ten staff felt they were getting good support from their region or the centre.”218 We welcome the changes to education provision and believe they represent an opportunity to deliver positive change to support the rehabilitation of prisoners. However, we are concerned to hear that some governors do not feel they have the skills or support to manage the new education contracts and this represents a real risk to the long-term success of the new arrangements. We recommend that the Ministry urgently review the training and support available to governors and their teams and the extent to which this training has been received.
Dynamic Purchasing System
115.The second part of the new education arrangements is the DPS. The DPS is designed to enable governors to commission bespoke education directly from suppliers registered to the system to meet specialised learning needs. This is in addition to the core service provided through the PEF. As at 19 July 2019, the total value of contracts awarded under the DPS is £7.65 million.219 Francesca Cooney said that the Prisoner Learning Alliance had received overwhelmingly negative feedback from governors, prison staff and service providers about the DPS.220
116.DPS contracts are awarded for only one year and several witnesses said that this was too short. The Prisoner Learning Alliance explained that this can act as a disincentive to both prison staff and service providers because of long lead-in times and security vetting, which can take a few months.221 The NPC said that one-year contracts leave charities that provide services vulnerable and can undermine quality of service.222 There is clear evidence to suggest that small providers need longer-term contracts to offer them security. The Ministry should review the arrangements for awarding contracts under the DPS to enable contracts of longer than one year to be offered.
117.Witnesses also emphasised the complexity of submitting and reviewing bids under the system, as well as the length of time it takes for both prison staff and service providers to review and submit bids. Clinks said that the system is too complex and requires too much resource to be valuable to small organisations, when contracts are worth relatively small amounts of money.223 Francesca Cooney told us that prison staff wanted more training, noting that “It takes far too much time for them to be able to get on to the system and process the information. They are getting conflicting advice from different specialists about how they can use the tenders, and what they are allowed to tender for.”224 The Ministry says that it held training and information events leading up to and since the launch of the DPS, as well as hands on training for staff using it.225
118.As part of its proposed reforms to the probation system, the Ministry has proposed a dynamic framework for resettlement and rehabilitative interventions so that it can access the full range of specialist services and interventions available. It cited the DPS for prison education as an example of a similar system.226
119.The DPS was intended by the Ministry to give prisons access to suppliers that are able to meet the bespoke educational needs of their establishment and offers a flexible route to services that add real value. However, we are concerned that the roll-out of the system has had the opposite effect, acting as a disincentive to governors to tender for services and to service providers to apply for them. The Ministry should urgently review how it can make the DPS more accessible and less time consuming for service providers and prison staff. We note that a similar system is being considered for the probation system; the Ministry should ensure it undertakes a full evaluation of the roll out of the DPS before it introduces a similar initiative as part of its probation reforms.
Education within the prison setting
120.Witnesses emphasised to us the importance of education being properly integrated into the rest of the prison regime. Paul Cottrell, Acting General Secretary, University and College Union, told us that “The prison regime always comes first and controls the education. The need to integrate education provision with the regime is the really big challenge that we have never got right, and I think it is probably getting worse, rather than better.”227
121.Chris Emmett emphasised the need for a whole prison culture to develop.228 She noted the important role that prison staff play in supporting prisoners access to education, explaining that “If a wing officer does not understand why it is important for a prisoner to do English and maths, or learn to do brickwork, he goes to the cell and goes, “Education? No, not this morning,” and just shuts the door again. Everyone has a part to play, and if it is valued, it helps to get the prisoners there.”229 Paul Cottrell agreed, saying that “If prisoners are engaged in purposeful and satisfying activity, their social and communication skills improve. Their self-respect improves, and that will affect the whole culture of the institution and behaviour in the institution more broadly. It is actually in the interests of prison officers to understand and support education. That needs to be built into their training, just as it does into the governor’s training.”230 He expressed concern that the success of the new arrangements would depend on governors’ interest in and commitment to education.231 Chris Emmet emphasised that it was easier for governors to focus on education if areas, such as safety and decency in the prison, were stable.232
122.Education in prisons is an important part of the regime and the Ministry needs to ensure that it retains a focus on this, and other purposeful activity, as well as safety and decency in prisons. We recommend the Ministry reviews the training available to prison officers and governors to ensure they are best able to support prisoner’s access to education.
Healthcare and education in Welsh prisons
123.HMPPS in Wales works in partnership with the Welsh Government to deliver offender management services. While the UK Government has responsibility for prisons in England and Wales, the Welsh Government has responsibility for devolved matters that intersect with criminal justice, such as prison healthcare and education.233 The Welsh Government is responsible for the overall delivery of health services in public sector prisons in Wales. Healthcare is provided by NHS Wales and delivered by Local Health Boards, who are responsible for commissioning mainstream healthcare services.234 In their report, Prison provision in Wales, the Welsh Affairs Committee raised concerns that difficulties in the coordination between HMPPS and NHS Wales meant that healthcare needs were not being addressed.235
124.In 2009, the UK Government transferred further powers and functions to the Welsh Government in the area of prison education. As a devolved matter, it requires cooperation between UK and Welsh Governments, but in his review, Reforming Outcomes: A Review of Offender Education in Wales, rt hon David Hanson MP, a member of this Committee, concluded that “the Welsh Government has a tremendous amount of power in bringing people together and they should utilise it more to reduce barriers between prisons, individuals and organisations.”236 The review made 22 recommendations. The Welsh Government responded on 21 March 2019 and have produced a full response. They are currently implementing the recommendations.
170 Ministry of Justice, Prison Safety and Reform, November 2016, page 31.
171 Ministry of Justice, National Partnership Agreement for Prison Healthcare in England 2018–2021, April 2018, page 4.
176 See Annex 1.
189 Health and Social Care Committee, Twelfth Report of Session 2017–19, Prison Health, HC 963, 1 November 2018
190 Ministry of Justice, HMPPS Annual Digest 2018–19, 25 July 2019, page 22. These figures exclude new psychoactive substances. Including the rate of positive results for new psychoactive substances brings the total percentage of positive results from random drug tests to 17.7% in the 12 months ending in March 2019, a decrease of 3.6 percentage points on the 12 months ending in March 2018.
194 HM Prison and Probation Service, Prison Drugs Strategy, April 2019
196 Letter from Sir Richard Heaton, Permanent Secretary, Ministry of Justice to Bob Neill, Chair, Justice Committee, Ministry of Justice Main Estimate 2019–20, 2 July 2019
199 Ministry of Justice, £100 million crackdown on crime in prison, 13 August 2019 [Accessed 30/09/2019]
200 Dame Sally Coates, Unlocking Potential: A review of education in prison, May 2016
203 Prison Education Trust, New prison education contracts create challenges and opportunities, 20 January 2019 [accessed 30 September 2019]
204 The four providers are: Weston College of Further and Higher Education, People Plus Group Ltd, Novus (LTE Group trading as Novus) and Milton Keynes College.
211 See Annex 1.
226 Ministry of Justice, Strengthening Probation, Building Confidence: Response to consultation, CP 93, May 2019, page 25
233 Welsh Affairs Committee, Prison provision in Wales, Fourth Report of Session 2017–19, HC 742, 17 May 2019
234 NHS Wales, Governance e-manual: Responsibilities for prisoner healthcare
235 Welsh Affairs Committee, Prison provision in Wales, Fourth Report of Session 2017–19, HC 742, 17 May 2019
236 Rt hon David Hanson MP, Reforming Outcomes: A Review of Offender Education in Wales, March 2019
Published: 31 October 2019