Ageing prison population Contents

5The health and social care of older prisoners

The healthcare needs of older prisoners

56.Older prisoners experience a heavy burden of physical and mental health conditions; among those over 60, rates of major illness have been found to be as high as 85%.135 Diseases responsible for the greatest morbidity and mortality in the general population are particularly prevalent in older prisoners. These include ischaemic heart disease, diabetes and chronic obstructive pulmonary disorder (COPD).136 Many older prisoners have co-morbidities,137 and may require multiple forms of treatment and specialist services.

Covid-19 and older prisoners

57.This inquiry was launched well before the Coronavirus pandemic but, following the outbreak of the virus, we took oral evidence on the impact it could have on the older prisoner population. NHS guidance states that all people over the age of 70, and those with underlying health conditions, such as diabetes, COPD, and heart disease are at greater risk from Covid-19.138 Studies of the virus have also indicated that morality risk is concentrated among older age groups.139 Taken together, these factors suggest that the older prisoner cohort, many of whom have underlying health conditions and whose health is generally poorer than for other inmates and people of the same age in the community, may be particularly vulnerable to Covid-19.140 Overcrowding on the prison estate, which predates the Covid-19 pandemic, potentially increases the risk to older prisoners; it makes social distancing more difficult. In oral evidence on 21 April, Peter Clarke, HM Chief Inspector of Prisons, said that 67% of older prisoners (defined as those aged 50 or over) were held in single-cell accommodation. Although this was a higher proportion compared to other age groups, it still meant, at the time, that just over 4,000 older prisoners were in shared accommodation.141

58.To reduce the spread of Coronavirus, HMPPS implemented social distancing on the prison estate. Prisons were instructed to restrict their regime, including ceasing all social visits, education, training, and employment activities (except for essential workers).142 Social distancing of 2 metres was mandated wherever possible.143 The intra-movement of prisoners has also been strongly discouraged. ‘Compartmentalisation’ and ‘cohorting’ approaches have been adopted in prisons, whereby groups of prisoners are housed together, to protect them from the virus or reduce the risk of their spreading it. Reverse cohorting units have been created to accommodate new prisoner receptions or transfers for 14 days to reduce the risk of the virus entering a prison.144 Protective isolation units have been established to house known or probable Covid-19 cases and shielding units have been established to protect the most vulnerable.145 Vulnerable prisoners have reportedly been identified in collaboration with NHS staff, though were informed of one incident where the number of vulnerable prisoners at an establishment was initially underestimated.146 These measures have prevented the explosive outbreaks of Covid-19 on the prison estate that were initially feared if mitigation measures were not taken. As at 10 July, 520 prisoners or children across the prison estate had tested positive for the Covid-19, while 23 prisoners are believed to have died from the virus.147 It is unclear how many of these were older prisoners.

59.Following the outbreak of Covid-19, some suggestions were made that the release of all elderly prisoners should be considered, given their potential vulnerability to the virus.148 It was noted, however, that the offences of many older prisoners would make them ineligible for early release: around 80% of those over 70 have convictions for sexual offences.149 The MoJ ruled out the early release of such prisoners due to potential risk to the community.150 Professor Jennifer Shaw, of the Offender Health Research Network, highlighted the resulting dilemma, and pointed to the additional consideration of needing to provide support for older inmates who are released early:

Compassionate release is a very difficult consideration. It is risk versus risk, almost. It is like the risk of release versus the risk of Covid. There is a third one, I think. We know that discharge into the community is not without its problems. The process of transition is difficult. That is a third factor that would need to be taken into account when considering this.151

60.In particular, it can be very difficult to find appropriate post-release accommodation for older prisoners, as Dame Anne Owers, National Chair of IMBs, pointed out:

[E]arly release is not as easy as it may sound because you have to release people to somewhere. The number of approved premises is quite small. It is even smaller because they, too, are trying to get down to single-room use, and for some of the people we are talking about there are not families to go back to.152

61.Away from the impact of the virus itself, concerns were raised about the longer-term effects of isolation on prisoners who are shielding. Isolation could greatly exacerbate the condition of those with cognitive problems or dementia.153 Jan Fooks-Bale of the CQC pointed out the need to ensure prisoners with existing medical conditions continue to be monitored and receive treatment during efforts to contain the virus:

We also need to think about who may slip through the net while everybody is focused on Covid-19 and ensure that the ongoing monitoring of people’s long-term health conditions is maintained so that they do not become worse and end up in hospital, where we know that there is an increased risk of contracting Covid-19 or, in the worst-case scenario, dying from non-Covid-related issues.154

62.We praise prison staff, HMPPS and MoJ officials for their work in responding to the Covid-19 pandemic. The virus has brought into sharp relief many of the issues affecting the prison system, including the particular health vulnerabilities of older cohorts. Amid the focus on protecting prisons from Coronavirus, HMPPS must continue to ensure that prisoners with existing health conditions are monitored and receive appropriate treatment and support.

Equivalence of care

63.An underlying principle of prison healthcare is that of equivalence of care: prisoners should be provided with, or have access to, appropriate services of treatment which are at least consistent with those available to the wider community.155 This reflects the view that prison is a deprivation of liberty, not a sentence to poorer health. In 2019, following a recommendation by the Health and Social Care Committee’s report into prison health, the National Prison Healthcare Board, which oversees coordination of prison health services, published a definition of equivalence of care for the first time:

‘Equivalence’ is the principle which informs the decisions of the National Prison Healthcare Board so that member agencies’ statutory and strategic objectives and responsibilities to arrange services are met, with the aim of ensuring that people detained in prisons in England are afforded provision of and access to appropriate services or treatment (based on assessed population need and in line with current national or evidence-based guidelines) and that this is considered to be at least consistent in range and quality (availability, accessibility and acceptability) with that available to the wider community, in order to achieve equitable health outcomes and to reduce health inequalities between people in prison and in the wider community.156

64.The Health and Social Care Committee’s report argued that, in practice, equivalence of care is often not delivered on the prison estate.157 The Committee identified several common problems in prison healthcare. These included:

a)Long delays in prisoners’ health concerns being acted on, including worrying symptoms not being responded to in a timely way, if at all.

b)Problems getting help to prisoners in an emergency, including those experiencing suspected stroke or heart attacks.

c)Prisoners experiencing delays in accessing required medicines, including prescription medication.

d)Difficulties in prisoners seeing a dentist, GP, speech and language therapist or an optician.

e)Poor complaints handling processes, with prisoners’ complaints or those made on their behalf about healthcare often going unanswered.158

65.In evidence for our inquiry, it was pointed out that problems with prison healthcare in general will have a disproportionate impact on the older prison population due to the higher prevalence of health conditions among the cohort.159

Health screening

66.Prisons are supposed to provide an initial health and social care screening to new inmates on reception, followed by a second screening within a few days.160 According to the CQC, overall compliance with the requirement for an initial screening has improved, though the provision of timely secondary screening and further monitoring thereafter is more variable in reception and remand prisons that have a high churn of prisoners.161 A lack of secondary screening is problematic, as it often provides a better opportunity to identify health conditions and care needs.162 Access to screening for age-related health conditions has also reportedly improved overall, with services brought in-house in some prisons, improving access.163 But provision of such screening across the estate remains inconsistent, with some older prisoners facing significant delays for assessments for conditions such as dementia.164


67.Some evidence suggested that while prison and healthcare staff are caring towards older prisoners, they do not always have a good understanding of how to assess and manage the specific needs of the cohort.165 The CQC reported that having a designated lead for older prisoners, who can coordinate their assessment, care, and onward referral generally produces better health outcomes. But prison healthcare teams do not always have such a lead and often lack other means to advocate for the needs of older prisoners.166 Clinks and RECOOP noted that as prison healthcare is designed to be reactive, older prisoners are expected to take the lead in applying to see health service providers. However, older prisoners may be reluctant to display vulnerability about age-related health issues.167 In addition, information about accessing health and care services is not always easily available, making self-referral difficult.168 More generally, prisons often face recruitment and retention issues among healthcare staff, which particularly affects the treatment of prisoners with long-term health conditions.169

Attendance at medical appointments

68.Issues around older prisoners attending external medical appointments were frequently cited in evidence. As the Health and Social Care Committee’s 2018 inquiry into prison healthcare highlighted, poor attendance at medical appointments is a problem affecting the whole prison population.170 But older prisoners are disproportionately affected as, due to the higher prevalence of health conditions in the cohort, they are more likely to need treatment at NHS hospitals or other external healthcare facilities.171 According to the Nuffield Trust, 35% (8,867) of outpatient appointments for prisoners aged over 50 were missed in 2017/18.172 Cancellations among older prisoners were more than double those of the general population aged over 50, raising serious questions about whether equivalence of care is being delivered.173

69.Prison regulations require two officers to escort prisoners to appointments outside the prison. This is despite the lower risk of older prisoners absconding.174 Each prison is allocated a certain number of health escorts per day, but it is not clear how this amount relates to the size or category of the prison or the medical needs of its inmates.175 Staff shortages or other demands within a prison can further limit escort availability.176 Given the fixed number of escorts, decisions often have to be made as to which prisoner’s healthcare needs should be prioritised through attendance of an external appointment.177 Both the Nuffield Trust and Royal College of General Practitioners raised concerns about how these decisions are made and pointed to the risks faced by prisoners whose health needs are deemed less urgent.178 The BMA suggested that, typically, routine appointments for long-term or chronic conditions are given a lower priority than those for acute cases, such as when a prisoner has a suspected broken bone.179 Older prisoners are disproportionately impacted by this prioritisation, and the cancellation of routine appointments can lead to increased deterioration of health and delays to the diagnosis and treatment of conditions.180

70.In their response to the Health and Social Care Committee’s concerns about missed medical appointments, the Government focused on their plans to recruit more prison officers and therefore increase the availability of staff to escort prisoners to appointments.181 While increased escort availability would help to reduce the number of missed appointments, several submissions called for more innovative solutions. These include making greater use of telephone medical appointments and tele-medicine, as suggested by Serco, the Nuffield Trust and Royal College of General Practitioners. Such initiatives would not only improve prisoners’ access to medical advice but would also reduce the demand for prison escorts.182

71.An ageing prison population will increase pressure on prison healthcare. To ensure an equivalent standard of care as in the community, it is important that prison healthcare services are appropriately resourced, and staff have awareness of age-related health conditions. We recommend that all prison healthcare teams have a designated older prisoner lead, and that training on age-related health-issues is available to all prison staff. The Government must also ensure that prison healthcare services are resourced in line with the needs of an older population.

72.Older prisoners are disproportionately affected by cancellations to external medical appointments, and their health can be seriously impacted by non-attendance. While increasing the number and availability of prison staff to escort prisoners to appointments is important, we also recommend that the Government review increasing the use of telemedicine and other innovative ways to give prisoners access to medical advice.

Mental healthcare provision

73.There is a high prevalence of mental health disorders among older prisoners. More than half have a mental health disorder and 30% a diagnosis of depression.183 Prisoners aged 50 to 59 have the highest risk of suicide at a rate of 13.4 self-inflicted deaths per 1,000 prisoners.184 In addition, particular concerns were raised in evidence about dementia. Its prevalence in prisons is largely unknown: Age UK reported that the diagnosis rate in the over-55 prison population was only 5%, compared to 68.7% in the general over-65 population, highlighting how the condition is overlooked in prisons.185 Limited research has been conducted on the issue, though a 2019 study indicated that up to 7% of the older prison population experience symptoms of dementia or mild cognitive impairment.186 Recognising the symptoms of dementia in prisoners is made more difficult in part because the repetitive nature of the prison routine and informal peer support can mask the signs of deterioration.187 Older prisoners can also be reluctant to disclose any symptoms due to stigma around the condition.188 But several submissions noted a lack of awareness among prison staff in how to identify and manage dementia.189 As a result, behavioural symptoms, such as forgetfulness, can be misinterpreted as the inevitable signs of ageing or as noncompliance.190 We were informed of cases where prisoners lost privileges earned under the Incentives and Earned Privileges Scheme because of the latter.191

74.According to the CQC, prisoners can face long delays accessing memory assessment services.192 Use of these can be challenging to facilitate as they rely on a prisoner attending a centre over a prolonged period, while application of the outcome can be difficult as the assessment environment may be very different to the prison setting.193 In addition, prison dementia services do not always reflect best practice or show consistency; for example, age thresholds for screening vary among different prisons.194 The MoJ’s submission cited good practice, reporting how some prisons have increased services for prisoners with dementia and provided training for staff:

HMP Stafford is also providing a dementia service, which includes screening all those over 50, a diagnostic clinic within the prison, behaviour management advice and training for officers. This service commenced in August 2019 and will be extended to HMP Oakwood later this year.195

75.However, the Prison Reform Trust highlighted that care for individuals with dementia is particularly difficult to manage in a prison setting, citing a consensus view from Independent Monitoring Boards “that dementia patients cannot be well cared for in a prison environment”.196 Some evidence questioned whether prisoners with severe dementia should remain on the prison estate. The Howard League suggested that if prisoners can no longer remember or understand why they are imprisoned, it is unlikely that they will be rehabilitated or deterred by their sentences. As such, the Howard League claims, continuing to incarcerate them does not fulfil penal aims.197 The BMA suggested that secure hospitals or similar institutions may be more appropriate for the management and care of prisoners with severe dementia.198 Accounts we received of the experience of such prisoners strengthened these arguments:

Mr X has severe dementia and every day he believes he has a taxi arriving to take him home to his wife. Consequently, he refuses to return to his cell until the staff tell him to get his coat because his taxi has arrived. He then enters the cell to get his coat upon which the door is slammed. He then spends many hours, including during the night, banging the door trying to get out to reach his taxi.199

76.The prevalence of dementia in prisons is poorly understood and prison staff can lack awareness of the condition. All older prisoners should have access to screening services for dementia, and prison officers who work with older prisoners should receive training on recognising and managing its symptoms.

77.Continuing to incarcerate prisoners with severe dementia, who may no longer remember or understand why they are imprisoned, raises practical and ethical considerations, especially as their condition is very difficult to manage on the prison estate. Equally, the Committee recognises that a significant element of this cohort are convicted for historic sexual offences. Particular attention must be given to the feelings of victims of such cases, both because of the nature of the offending itself and because of delays often experienced in bringing such perpetrators to justice. We recognise that some of those victims may consider that alternative custody arrangements and potential early release of some individuals risks adding to the suffering that they have already endured. This must be taken into consideration. The Government should review whether alternative arrangements for housing prisoners with advanced dementia would be more appropriate in some circumstances.

Social care for older prisoners

78.Though a need for support can arise at any age, older prisoners are more likely to be among those eligible for social care.200 Care needs can arise as a result of mobility or sensory problems, disability, and health conditions,201 which have a higher prevalence among the older prisoner population than other prison age groups. Under the Care Act 2014 and the equivalent Welsh legislation, the Social Services and Well-being (Wales) Act 2014, local authorities in whose area a prison is located are responsible for providing its social care.202 The threshold for eligibility for care and support service for prisoners are the same as in the wider community.203 Prisons, healthcare services and individual prisoners with needs can all request a social care referral assessment.204 Evidence indicated that the Acts have supported some improvements in the provision of social care in prisons by clarifying responsibilities for delivery of care and encouraging good practice towards the identification and referral of prisoners’ care needs.205

79.However, standards of social care are highly inconsistent among different prisons. HMIP and the CQC’s joint thematic report, Social Care in Prisons in England and Wales, published in 2018, described the quality of prison social care services being subject to a ‘postcode lottery’ across the prison estate, with the care needs of prisoners going unmet in a number of establishments.206

80.Not all prisons have effective procedures in place to identify prisoners with social care needs and to assess those needs.207 At some establishments, the identification of care requirements is the responsibility of healthcare staff as part of the secondary screening following a prisoner’s reception into the prison. However, as noted in the previous section, not all prisoners receive that secondary screening.208 In the joint thematic report, some prison authorities were also found to have poor awareness of social care. Consequently, self-referrals from prisoners were not assessed appropriately and were not passed on to local authorities for further assessment.209 In addition, the time taken by local authorities to carry out assessments varies widely, as HMIP described:

In our thematic report, we noted that we were pleased to see that the longest delay at Littlehey was 10 days. However, we also found delays of up to five months [at other prisons].210

81.The quality of social care provided varies across the prison estate, with good practice occurring where there are more older inmates in a prison.211 HMIP noted prisons with appropriate care planning and services that met individual need.212 At other prisons, however, care plans for individual prisoners are not always adequate or kept up-to-date and the delivery of social care packages is variable.213 There can be difficulties with external social care workers regularly visiting prisons to provide care.214 Gaps have also been noted in care provision for prisoners needing assistance with personal care but who do not meet the eligibility criteria for social care.215

82.Delivery of effective social care for prisoners also relies on appropriate accommodation and adjustments to the physical environment being provided to those with support needs. However, as set out in Chapter 3, the standard accommodation in many prison establishments is not suited to prisoners with reduced mobility, disabilities, or health problems that can result in care needs and appropriate reasonable adjustments are not always provided. In written evidence, the CQC also noted that prison inpatient units are increasingly being used to accommodate older prisoners requiring social care. This is because the location and availability of healthcare staff are considered to make such units most appropriate for providing care. However, this can lead to increased demands on inpatient staff time, potentially detracting from the clinical care of prisoners with acute medical need. It also means prisoners receiving social care are separated from the wider prison regime.216

Collaboration between prisons and local authorities

83.As noted above, under the Care Act 2014, local authorities are responsible for providing social care in prisons and are required to work with prison authorities and healthcare providers to coordinate the delivery of services.217 Each prison is expected to have a local delivery board, chaired by the governor and including local authorities and healthcare and social care providers.218 In practice, the effectiveness of joint working varies. According to ADASS, there is a common issue of responsibility for the care of individual prisoners being passed from organisation to another, rather than each recognising their shared responsibility:

Healthcare providers will complain of having to provide services to individuals who they consider require care and support from the local authority, who in turn, may assess the individual as not having eligible care and support needs or possibly may struggle to find a provider who can reliably meet the needs even if they are eligible to be supported.219

84.In HMIP and the CQC’s joint thematic report, good collaboration between prisons and local authorities in providing social care was found to occur mostly when a memorandum of understanding (MoU) had been established between the prison, local authority, and social care provider.220 These helped to clarify the responsibilities of each regarding social care.221 But several prisons did not have MoUs in place, while others were found to be out-of-date or lacking in detail.222 Prisons are required to sign MoUs with local authorities under HMPPS policy. In written evidence, the Government stated that as of July 2019, approximately 90% of prisons had MoUs either signed or in draft awaiting signature. They noted, however, that neither HMPPS nor the Department for Health and Social Care can mandate local authorities to sign these agreements with prisons.223

85.More broadly, evidence pointed to a lack of strategic planning for provision and coordination of social care services in prisons. Peter Clarke, HM Chief Inspector of Prisons, noted a disjoint between MoJ plans to reconfigure the prison estate and the role of local authorities as prison social care providers:

If the model for operational delivery for older prisoners says that resettlement prisons should in the future be configured to meet social care needs, because those are the prisons from which older prisoners are likely to be released, that is not joined up in any way, as far as I can see, with the responsibilities of local authorities to deliver social care in their particular geographic area. Of course, local authorities have no remit or ability at all to influence the physical conditions in prisons on which so much of the effective delivery of social care depends.224

86.The joint thematic report highlighted that, due to this lack of strategic planning, prison social care is focused on current needs without adequate consideration of what will be required in the near future as a result of the prison population ageing.225 Its main recommendation was that the Justice Secretary lead cross-governmental work to develop a strategy for prison social care and promote better coordination and consistency in its delivery. In its response to that report, HMPPS rejected this recommendation on the basis that delivery of social care in prisons is the responsibility of local authorities and beyond its or the MoJ’s remit.226 In their submission to us, the Government reported that ‘a number of actions have already been completed’ in response to the joint thematic report, with an update on progress to be provided ‘in due course’.227

87.An ageing prison population will increase demand for social care services in prisons. While the Care Act 2014 has brought some improvements, standards of provision are highly variable across the estate. A more strategic and coordinated approach is needed to improve consistency and ensure effective collaboration between prisons, local authorities and other organisation involved in delivering care. In its response to this report, the Government should update the Committee on the progress of the action plan for social care in prisons in England and Wales, published following HMIP and the CQC’s joint thematic report. The Government should also set out its plans for the future provision of social care in prisons.

Care from other prisoners

88.Older prisoners with social care needs can rely on the support of other, often younger, inmates. At several prisons these arrangements have been formalised into ‘buddy’ schemes and similar programmes, where trained prisoner carers provide for more routine support needs. RECOOP and Devon County Council have developed such an initiative for three prisons in the county:

This is a formalised programme where Buddies are required to undertake a two-week training package. Buddies provide non intimate support, promoting independence and empowering recipients to take control of their own well-being and health. RECOOP provides ongoing mentoring and management support to oversee the Buddies’ work.228

89.In evidence, schemes like this were generally viewed as an effective way to support older prisoners with independent living, and to build empathy between different generations of prisoners.229 However, concerns were raised that buddy systems have been set up in some prisons without adequate training and oversight for those prisoners giving care.230 This can affect the quality of the care delivered and enable buddies to exploit older prisoners they are assisting.231

90.Peer support or ‘buddy’ schemes can be an effective way to help meet the care needs of older prisoners. We commend the good work done by some prisons in partnership with third sector organisations to develop such initiatives. Prisons must ensure that prisoners providing care to other inmates are suitably trained and have appropriate oversight.

Palliative and end of life care

91.The average life expectancy of a prisoner is 56.232 In the UK as a whole, average life expectancy is around 81.233 Prisoners suffering from incurable or terminal health conditions can apply for early release. However, not all will be eligible and some prisoners, particularly those who have served long sentences or do not have social connections in the community, may wish to remain in prison.234 The increase in the older prison population has therefore led to a rise in the need for palliative and end-of-life care on the prison estate.

92.Evidence suggested that the standard of end-of-life care is inconsistent across the estate, though improving overall. In 2018, HMPPS launched the Dying Well in Custody Charter, which sets out standards and guidelines for palliative and end-of-life care in prisons.235 IMBs noted that this has been usefully applied by some prisons.236 Some establishments have developed specific end-of-life care facilities, often located within inpatient units.237 A prison’s relationship with local hospices can play an important role in the quality of end-of-life care, and we received examples of effective collaboration:238

At HMP Dartmoor (2018), health staff won a national nursing award for the provision of end of life care, in collaboration with a local hospice. This was in recognition of staff supporting patients to die with dignity within the prison, achieved with support from trained prisoner “buddies”, cell visits and regular palliative care clinics.239

93.However, care planning for terminally ill prisoners has not been consistently adequate at all prisons.240 There is no overall strategy for how prisons should manage inmates at the end of their lives, including as to which establishments should have palliative care facilities.241 Dame Anne Owers noted that one prison had established a palliative care unit which had never been used for providing palliative care.242

Release on compassionate grounds

94.It is possible for prisoners near the end of their lives, or those with conditions that are difficult to treat in prison, to apply for release before their sentence is complete.243 Release can either be on a temporary licence (ROTL) or early release on compassionate grounds.244 The risk a prisoner poses to the public has to be assessed as minimal for the application for early release to be granted; assessment are also made of the medical condition of the prisoner; their remaining life expectancy; the impact continuing incarceration will have on this; and the benefit early release will bring to a prisoner and their family.245

95.Evidence received for this inquiry indicated that early release application processes could be improved. Submissions from the Prisons and Probation Ombudsman (PPO), IMB and the Howard League pointed to the length of time applications can take to manage; the latter highlighted cases where terminally ill prisoners had died while waiting for theirs to be processed.246 The PPO also stated that compassionate release processes in some prisons are disorganised and poorly managed, with no single individual having overall responsibility for the progress on an application. They recommended that prisons designate a member of staff to be responsible for coordinating the progress of an application for compassionate release.247

96.The ageing prison population has and will continue to increase the need for end-of-life and palliative care in prisons. We welcome the publication of the Dying Well in Custody Charter and the good practice at some establishments. But standards are not consistent across the estate. In addition, as mentioned previously, we recognise that there has been delay in providing justice for the victims of some prisoners. Again, attention must be given to the needs of the victims of those crimes. The MoJ must ensure that provision of end-of-life and palliative care is properly resourced and coordinated to reflect the current and future needs of the prison population. The MoJ should also review whether, in certain circumstances, terminally ill prisoners nearing the end of their lives would be better cared for outside of the prison estate and how effectively current arrangements for compassionate release are operating in practice.

97.Prisoners applying for early release on compassionate grounds should have their applications processed in an efficient and timely manner. This is especially important for terminally ill prisoners near the end of their lives. We recommend prisons identify a single member of staff to have overall responsibility for progressing an application for compassionate release.

136 Public Health England, Health and Justice Annual Review 2017/18 (July 2018), p 14

137 Care Quality Commission (AGE0038)

138 National Health Service, “Who’s at higher risk from coronavirus”, accessed 24 June 2020

139 University of Oxford, “Covid-19 mortality highly influenced by age demographics”, accessed 24 June 2020

141 Q52 [Peter Clarke]

148 Prisoners’ Advice Service, “Coronavirus: PAS calls for the release of prisoners”, accessed 4 June 2020

149 Ministry of Justice, Department of Health and Social Care, Public Health England, NHS England and Improvement (AGE0036)

150 Ministry of Justice and HM Prison and Probation Service, End of Custody Temporary Release (April 2020) para 11

153 Q49 [Dame Anne Owers]

155 BMA (AGE0033)

157 Health and Social Care Committee, Twelfth Report of Session 2017–19, Prison Health, HC 963, 1 November 2018, p16

158 Health and Social Care Committee, Twelfth Report of Session 2017–19, Prison Health, HC 963, 1 November 2018, pp25−26.

159 Independent Monitoring Boards (AGE0034)

160 Health and Social Care Committee, Twelfth Report of Session 2017–19, Prison Health, HC 963, 1 November 2018, para 42

161 Care Quality Commission (AGE0038)

162 Care Quality Commission (AGE0038)

163 Care Quality Commission (AGE0038)

164 Care Quality Commission (AGE0038); HM Inspector of Prisons (AGE0039)

165 British Association for Counselling and Psychotherapy (AGE0011)

166 Care Quality Commission (AGE0038)

167 Clinks and RECOOP (AGE0018)

168 Care Quality Commission (AGE0038)

169 BMA (AGE0033)

170 Health and Social Care Committee, Twelfth Report of Session 2017–19, Prison Health, HC 963, 1 November 2018, para 29, para 71–76

171 Clinks and RECOOP (AGE0018)

172 Nuffield Trust (AGE0026)

173 Nuffield Trust (AGE0026)

174 Clinks and RECOOP (AGE0018)

175 Nuffield Trust (AGE0026)

176 BMA (AGE0033)

177 Nuffield Trust (AGE0026)

178 Nuffield Trust (AGE0026); Royal College of General Practitioners (AGE0015)

179 BMA (AGE0033)

180 Royal College of General Practitioners (AGE0015)

181 HM Government, Government Response to the Health and Social Care Committee’s Inquiry into Prison Health, CP 4, January 2019, para 7.2–7.5

182 Nuffield Trust (AGE0026); Care Quality Commission (AGE0038)

183 Criminal Justice Alliance (AGE0020)

184 British Association for Counselling and Psychotherapy (AGE0011)

185 Age UK (AGE0025)
Dementia diagnosis rates are calculated by dividing the number of people diagnoses with dementia (as reported in national health statistics) by the total estimated number of people living with dementia. See:

186 Offender Health Research Network, University of Manchester (AGE0030)

187 Care Quality Commission (AGE0038)

188 British Association for Counselling and Psychotherapy (AGE0011)

189 Care Quality Commission (AGE0038); British Association for Counselling and Psychotherapy (AGE0011); Offender Health Research Network, University of Manchester (AGE0030)

190 British Association for Counselling and Psychotherapy (AGE0011)

191 Clinks and RECOOP (AGE0018)

192 Care Quality Commission (AGE0038)

193 Care Quality Commission (AGE0038)

194 Care Quality Commission (AGE0038)

195 Ministry of Justice, Department of Health and Social Care, Public Health England, NHS England and Improvement (AGE0036)

196 Prison Reform Trust (AGE0021)

197 The Howard League for Penal Reform (AGE0013)

198 Ibid; BMA (AGE0033)

199 Dr Dennis Eady (AGE0008)

200 Ministry of Justice, Department of Health and Social Care, Public Health England, NHS England an (AGE0036)

201 Offender Health Research Network, University of Manchester (AGE0030)

202 Ministry of Justice, Department of Health and Social Care, Public Health England, NHS England and Improvement (AGE0036); Older People’s Commissioner for Wales (AGE0007)

203 Ministry of Justice, Department of Health and Social Care, Public Health England, NHS England and Improvement (AGE0036)

204 Ministry of Justice, Department of Health and Social Care, Public Health England, NHS England and Improvement (AGE0036)

205 Association of Directors of Adult Social Services (ADASS) (AGE0024); Older People’s Commissioner for Wales (AGE0007); Prison Reform Trust (AGE0021)

206 HM Inspectorate of Prisons and the Care Quality Commission, Social Care in Prisons in England and Wales: A thematic report, (October 2018), page 9−10

207 Care Quality Commission (AGE0038)

208 HM Inspector of Prisons (AGE0039)

209 HM Inspector of Prisons (AGE0039)

210 HM Inspector of Prisons (AGE0039)

212 HM Inspector of Prisons (AGE0039)

213 HM Inspector of Prisons (AGE0039); Care Quality Commission (AGE0038)

214 HM Inspector of Prisons (AGE0039); Independent Monitoring Boards (AGE0034)

215 HM Inspectorate of Prisons and the Care Quality Commission, Social Care in Prisons in England and Wales: A thematic report, (October 2018), p 7

216 Care Quality Commission (AGE0038)

217 Ministry of Justice, Department of Health and Social Care, Public Health England, NHS England and Improvement (AGE0036)

218 Ministry of Justice, Department of Health and Social Care, Public Health England, NHS England and Improvement (AGE0036)

219 Association of Directors of Adult Social Services (ADASS) (AGE0024)

220 Age UK (AGE0025)

221 HM Inspectorate of Prisons and the Care Quality Commission, Social Care in Prisons in England and Wales: A thematic report, (October 2018), p 25

222 HM Inspectorate of Prisons and the Care Quality Commission, Social Care in Prisons in England and Wales: A thematic report, (October 2018), p 26

223 Ministry of Justice, Department of Health and Social Care, Public Health England, NHS England and Improvement (AGE0036)

225 HM Inspectorate of Prisons and the Care Quality Commission, Social Care in Prisons in England and Wales: A thematic report, (October 2018), p 7

226 HM Prison and Probation Service, Action Plan: HMP Thematic − Social Care in Prisons in England and Wales (December 2018)

227 Ministry of Justice, Department of Health and Social Care, Public Health England, NHS England and Improvement (AGE0036)

228 Clinks and RECOOP (AGE0018)

229 Independent Monitoring Boards (AGE0034); Serco Ltd (AGE0028)

230 Criminal Justice Alliance (AGE0020); Offender Health Research Network, University of Manchester (AGE0030); Q58

231 Offender Health Research Network, University of Manchester (AGE0030)

232 BMA (AGE0033)

233 Office for National Statistics, ‘National life tables, UK: 2016 to 2018’, accessed 14 July 2020

234 Q67 [Peter Clarke]

235 Ministry of Justice, Department of Health and Social Care, Public Health England, NHS England and Improvement (AGE0036)

236 Independent Monitoring Boards (AGE0034)

237 HM Inspector of Prisons (AGE0039)

238 Q67 [Dame Anne Owers]

239 HM Inspector of Prisons (AGE0039); Care Quality Commission (AGE0038)

240 HM Inspector of Prisons (AGE0039); Prisons and Probation Ombudsman (AGE0042)

241 Independent Monitoring Boards (AGE0034)

242 Q67 (Dame Anne Owers)

243 Prisons and Probation Ombudsman, Learning from PPO investigations: Older Prisoners (June 2017), p 23

244 Prisons and Probation Ombudsman, Learning from PPO investigations: Older Prisoners (June 2017), p 23

245 Prisons and Probation Ombudsman, Learning from PPO investigations: Older Prisoners (June 2017), p 23

246 Independent Monitoring Boards (AGE0034); The Howard League for Penal Reform (AGE0013); Prisons and Probation Ombudsman

247 Prisons and Probation Ombudsman (AGE0042)

Published: 27 July 2020