About Clinks
1. Clinks is the national infrastructure organisation supporting third sector organisations working in the criminal justice system (CJS) in England and Wales. Our aim is to ensure the sector, and those with whom it works, are informed and engaged in order to transform the lives of people in the criminal justice system and their communities. We do this by providing specialist information and support, with a particular focus on smaller third sector organisations, to inform them about changes in policy and commissioning, to help them build effective partnerships and provide innovative services that respond directly to the needs of their users.
2. We are a membership organisation with over 500 members, working in prisons and community settings, including the third sector’s largest providers as well as its smallest. Our wider network reaches 4,000 third sector contacts. Overall, through our weekly e-bulletin Light Lunch and our social media activity, we have a network of over 15,000 contacts. These include individuals and agencies with an interest in the CJS and the role of the third sector in rehabilitation and resettlement.
3. Third sector organisations in Wales make a vital and considerable contribution to community justice. It is estimated that of the 33,000 third sector organisations operating in Wales, just under 1% (around 300) work exclusively in the CJS. This includes work with people who have offended and are in contact with the prison and probation services, with their families, with victims, and in prevention and community safety activities. In addition to this, a larger number of other organisations will work with individuals who are in contact with the CJS in matters relating to housing, education and training, debt and finance, as well as health and social care.[i]
For more information see www.clinks.org
About this response
4. Clinks welcomes this inquiry into the provision of health and social care in the adult prison estate in Wales. Our response draws on evidence from our wide range of work supporting third sector organisations working with people in prison, including:
a. Clinks’ submission to the Westminster Health and Social Care Committee inquiry into prison healthcare[ii]
b. The good prison: why voluntary sector coordination is essential[iii]
c. Flexibility is Vital: the role of the voluntary sector in supporting older people in the criminal justice system[iv]
d. Whole prison, whole person: How a holistic approach can support good mental health in prison[v]
5. We have also drawn on evidence gathered from third sector organisations working in Welsh prisons, consulted with specifically for this submission and in our ongoing work to support the sector. Further evidence comes from our annual state of the sector survey[vi], which maps trends and feedback from third sector organisations across England and Wales; and a specialist survey of our members conducted in autumn 2017 on the health and care needs of those they work with.
The effectiveness of current arrangements for the planning of health services for prisoners held in Wales and the governance of prison health and care services, including whether there is sufficient oversight.
Engagement with third sector organisations
6. Third sector organisations working in prisons are a key partner in identifying and meeting the health and social care needs of people in prison. The third sector can bring professional expertise, energy, resource and creativity to bear. As well as delivering health and care services, such as treatment for substance misuse and mental health support, third sector organisations can advocate on behalf of those with health and care needs, support people to understand and manage their health, and adopt a flexible and holistic approach to support the health and wellbeing of people in prison.
7. Third sector staff and volunteers can develop relationships with and provide support to individuals which prison staff are not always able to do. Because they are seen as independent from the system, third sector organisations can develop greater trust with people in prison than prison staff and healthcare professionals, which is vital for identifying and managing health and care needs. For example, organisations such as Recoop run activity-based day centres for older prisoners in a number of prisons. These settings create a safe space, and trusting relationships with staff running the groups, enabling older people to feel confident in disclosing and discussing health concerns. In turn, the staff are able to advocate on their behalf when necessary.
8. However, third sector organisations have highlighted a lack of consistency across Wales in the way in which prison health services engage with and commission third sector organisations in the delivery of health services for prisoners.
9. This has an impact on the delivery of services, with prisoners missing out on services informed by the wealth of knowledge and experience the sector has to offer, and also on governance and scrutiny with the sector unable to play its full role as a critical friend to both private providers and statutory agencies.
10. To address this, prisons and prison healthcare services must view the third sector as an integral part of the prison system, and include it in strategic planning processes including Prison Health Partnership Boards.
11. All third sector staff and volunteers should also be included in training on safer custody and Assessment, Care in Custody and Teamwork (ACCT) processes. Local systems for reviewing safety in custody should include third sector organisations working in the prison. Clinks’ recent ‘Good prison’ project, which piloted the employment of part-time third sector co-ordinators in three prisons in the South West, demonstrated the positive impact of better engagement of the third sector in creating a safe prison environment and delivering more effective rehabilitation and resettlement.[vii]
Oversight
12. Effective monitoring and regulation of healthcare services in prison must include listening to the voices of those in the prison. People in prison and their families are a key source of intelligence on what is or is not working well, and how services can be improved. To ensure adequate oversight, it is vital that Prison Health Partnership Boards and regulatory agencies engage with service user voice.
13. Examples of this exist in England and include the User Voice councils[viii] for health and justice services in Kent, and the Patient Participation Project commissioned by NHS England Health and Justice in London. In the latter example, individuals with lived experience of the criminal justice system were trained to support improved service user participation across the region’s health and justice services. This provided user voice at strategic planning and contract review meetings, and advice to prison healthcare services to deliver improvements in patient participation.[ix]
The demand for health and social care services in Welsh prisons, and whether healthcare services are meeting the needs of prisoners and tackling the health inequalities of people detained in Welsh prisons.
Meeting the healthcare needs of prisoners
14. People in prison experience high levels of physical health, mental health and social care need. Many people in prison experience multiple and complex needs, with a high prevalence of co-morbid conditions including physical, mental health, substance misuse, and other vulnerabilities.[x]
15. Clinks’ members tell us that both the complexity and urgency of needs among their service users has increased in recent years. Over half the respondents to our health and care survey in 2017 felt the health and care needs of their service users had increased in the previous 3 years. While in our 2018 state of the sector survey, 80% of organisations agreed or strongly agreed that service user need had become more complex, and 73% said they had become more immediate.[xi]
16. Given this, and the challenges posed by the prison environment, it is unsurprising that prisons and prison healthcare services struggle to effectively meet this need and third sector organisations report that healthcare services in Welsh prisons are overstretched.
17. Healthcare in Welsh prisons was reported by third sector organisations to only be able to provide a basic standard of care, and not able to respond to the complex healthcare needs of a significant proportion of prisoners, in particular mental health and substance misuse needs. This view is further evidenced by recent Her Majesty’s Inspector of Prisons reports which, in regards to mental health, state:
· At HMP Swansea, 62% of prisoners reported mental health or wellbeing problems[xii]
· A third of prisoners said they felt depressed or suicidal or had mental health problems on arrival at HMP Swansea
· The number of self-harm incidents recorded at prisons in Wales (excluding HMP Berwyn) increased by 358% between 2010 and 2017[xiii]
· There were more self-harm incidents recorded at HMP Cardiff, HMP Swansea and HMP Usk/Prescoed in the first nine months of 2018 than in the whole of 2017
· There were 26 self-inflicted deaths at prisons in Wales between 2010 and 2018.
18. Recent inspections have shown challenges in meeting the needs of people with common mental health issues. At HMP Cardiff, care for people with mild to moderate mental health issues was deemed inadequate, with gaps in service provision and a lack of staff who had recent training in mental health awareness. At HMP Parc, there is a high demand for mental health support, but primary mental health provision has been deemed inadequate, in terms of both primary and secondary mental health support[xiv]. Prisoners with mild to moderate mental health needs were not always assessed promptly and did not get the regular ongoing support they needed.
19. Recent inspections have also shown inadequate care for those suffering from severe mental health issues. At HMP Swansea, the provision of mental health care for men who were vulnerable to suicide and self-harm was deemed inadequate, and recommendations from the Prisons and Probation Ombudsman (PPO) following self-inflicted deaths had not been implemented[xv]. Basic procedures designed to improve safety such as assessment, care in custody and teamwork (ACCT) documentation, were also deemed to be poor. At HMP Parc, some prisoners waiting to be transferred to hospital under the Mental Health Act had waited for excessive periods, including more than 20 weeks in one case. Similarly, organisations we spoke to reported long waiting lists at HMP Berwyn. The notable exception to these reports is HMP Cardiff, where care for those suffering from severe mental health issues was deemed good, despite a high demand on services[xvi].
20. In addition, concerning examples were highlighted by third sector organisations of staff (both prison and healthcare) interpreting underlying mental health issues as poor behaviour and of prisoners viewing self-harm as a quick way to access mental health services.
21. Similarly, the prevalence of drugs in prisons in Wales is high, with over 50% of people at HMP Parc saying that it was either easy or very easy to get hold of illegal drugs in the prison[xvii]. The prevalence of drugs, particularly new psychoactive substances (NPS), and the associated violence, debt and bullying, was a key factor in the low safety scores at both HMP Swansea and HMP Cardiff. Seventeen per cent of people said they had acquired a drug habit while being held in HMP Swansea[xviii].
22. There has been recent criticism of substance misuse services available in Welsh prisons. A 2015 review by HM Inspectorate of Prisons of substance misuse in adult prisons in England and Wales highlighted that a different approach in Wales had led to “poorer outcomes for some prisoners” and that it was responsible for “inconsistency in substance misuse treatment between prisons in England and Wales”[xix]. A follow up report last year reiterated such concerns. Neither HMP Cardiff nor HMP Swansea have been found by inspectors to have effective substance misuse strategies[xx]. Specific criticisms at HMP Swansea included inadequate clinical treatment for newly arrived prisoners withdrawing from opiates, which had contributed to a high demand for illicit drugs and a lack of understanding or mitigation of the impact of entering a smoke-free environment.
Continuity of care
23. Third sector organisations highlighted that inadequate standards of healthcare in prison were compounded by poor services in the community and a lack of continuity of care through the gate. This results in people entering and leaving prison without proper diagnosis and with significant levels of need, and then struggling to access appropriate care both in prison and after release in the community.
24. Organisations providing through the gate services for people leaving prison report that information sharing between healthcare services and the third sector is poor, presenting significant barriers to, for instance, securing suitable and appropriate accommodation for people on release. Good information sharing varies from prison to prison and is often reliant on individual contacts and relationships.
25. Prison healthcare services should establish consistent information sharing arrangements with third sector organisations working in prisons and through the gate to involve them in supporting continuity of care.
26. Third sector organisations also raised concern that there is a lack of access to both specialist services and social care services due to a lack of appropriately vetted and trained staff from those services and agencies. This was highlighted as a key barrier to ensuring that people receive correct diagnoses and needs assessments and to this information being appropriately shared to ensure continuity of care and appropriate resettlement support on release.
Tackling Health Inequalities
27. Many groups of people with protected characteristics are either overrepresented in the criminal justice system and/or experience differential access to, and outcomes from, health services, as identified, for instance, in the Lammy Review[xxi].
28. Clinks recently published Whole prison, whole person which explores how a holistic approach can support good mental health in prison and sets out three key principles and recommendations towards developing a whole prison approach to good mental health for people in contact with the criminal justice system, especially those protected under the Equality Act (2010).
29. It sets out three principles that are as applicable to physical health as they are to mental health:
· Respond to the individual needs of the whole prison population, including people from groups protected under the Equality Act (2010), many of whom are over represented in the criminal justice system and/or experience significantly poorer outcomes than the general population
· Ensure continuity of care throughout an individual’s sentence, recognising and meeting the needs of every person in prison at every stage of their journey through custody.
· Create a wellbeing culture for all, that is embedded in the structure and core business of all those working in the custodial estate.
30. The final principle in particular, is aimed at addressing discrimination and inequality by embedding a culture of culture of tolerance and respect from the top down throughout the prison, with prison governors held responsible for the treatment of people with protected characteristics in prison.
31. It is concerning, therefore, to see that HMP Cardiff received criticism from the inspectorate of a weak approach to equality and diversity, and a failure to address evidence showing disparities in treatment in most areas[xxii]. They were criticised for providing little support for prisoners with protected characteristics. In their survey, black and minority ethnic and disabled prisoners were particularly negative about their treatment. The strategic management of equality and diversity was also deemed weak at HMP Swansea[xxiii], while black and minority ethnic men were less positive about staff-prisoner relationships at HMP Usk[xxiv].
32. A key mechanism for ensuring the needs of prisoners who experience health inequalities are met is to involve third sector organisations who are based in and represent their communities and are therefore often able to build more trusting relationships with people who suffer inequalities and to advocate on their behalf.
What the current pressures on health and social care provision are in Welsh prisons, including workforce issues and services, such as mental health, substance misuse, learning disabilities, primary care out of hours, and issues relating to secondary, hospital-based care for inmates.
33. Many of the challenges facing prisons in Wales are shared by the rest of the prison estate across England, including overcrowding, staff shortages, increasing levels of violence, self-harm, drug use and poor physical environments. These broad challenges can both have a significantly detrimental impact to the physical health and mental welling of people in prison, and make it harder to deliver effective health and social care.
34. Third sector organisations particularly highlighted staff shortages as a key pressure on health and social care provision in Welsh prisons. This view is supported by the Chief Inspector of Prisons who has highlighted that at HMP Cardiff, staff shortages were seen to create significant challenges in delivering services to people in prison[xxv].
35. Staff shortages encroach on the ability for people in prison to access healthcare. Lockdowns, or simply having insufficient staff to escort prisoners to appointments, can lead to cancellations and drive up waiting times; as do shortages of doctors and other healthcare staff. Third sector organisations report being unable to access prisons and prisoners due to current challenges and pressures, which limits the impact they can have. We recommend all prisons employ a dedicated third sector co-ordinator to facilitate better engagement with the sector. This has been shown to deliver positive outcomes including improved awareness of and access to services, and contributing to improved prison safety.[xxvi]
36. Staff shortages can also impact the amount of time that people in prison spend out of their cells. At HMP Parc, up to 40% of people were locked in their cells during roll checks. At HMP Swansea, unemployed people in prison would spend 22 hours in their cell each day, partly as a result of a lack of purposeful activity places and jobs for the population to engage in. Such a lack of access to purposeful activity creates stifling boredom, with obvious impacts on an individual’s mental wellbeing.
37. Third sector organisations also raised that due to increased levels of self-harm and drug use, healthcare staff are required to spend a greater proportion of their time responding to critical emergency situations and individuals in crisis, which delays routine appointments and prevents the delivery of a high standard of everyday healthcare.
38. This observation is supported by Her Majesty’s Inspector of Prisons who have reported that, health and care services have struggled to keep pace with the increasing number of people entering prison, meaning needs are not being adequately addressed[xxvii]. Overcrowding at HMP Swansea, where 458 men were being held in cells designed to hold only 268 at the time of the inspection, has led to health services that are stretched and offer largely reactive provision only[xxviii].
39. Organisations also raised a lack of long standing and experienced staff as a significant challenge and that in some cases staff, both prison and healthcare, wrongly interpret healthcare needs as behavioural issues.
40. Prisons are high pressure environments in which to both live and work, so it is crucial to provide all staff and volunteers working in prisons with the right support. Prison officers, third sector staff and volunteers should be provided with training to equip them to identify and support people with health and care needs, which should include safeguarding, mental health awareness, trauma-informed approaches, and how to respond to people at risk of suicide and self-harm. In addition, prison staff should be provided with on-going supervision to support them in managing their own health and wellbeing, and in their role in caring for vulnerable people. This in turn will have a direct impact on service users within the prison.
41. Her Majesty’s Chief Inspector of Prisons has also criticised the poor physical conditions of some Welsh prisons. At HMP Cardiff, showers were poorly ventilated and many had little or no screening; cells lacked basic facilities such as curtains, lockable cupboards and kettles. Most cells in the segregation unit were in very poor condition[xxix]. At HMP Swansea, some cells were dirty and poorly ventilated, without enough furniture and with poorly screened toilets[xxx]. People in prison were also unable to access enough clean prison clothing and bedding. The lack of dignity and decency is likely to impact people’s wellbeing, while living in such a poor physical environment can also impact people’s physical health[xxxi].
How well prisons in Wales are meeting the complex health and social needs of a growing population of older people in prison, and what potential improvements could be made to current services.
42. The ageing prison population in England and Wales has led to concerns over the distinct health and social care needs of older people in custody. A report recently published following an inquiry into prison healthcare in England found that older prisoners are often held in establishments unable to meet their needs and many will be released into the community without any social care support in place[xxxii]. This is a growing problem that needs to be addressed given that:
· Older prisoners are the fastest growing demographic group in prison in England and Wales.
· 17.2% of all Welsh prisoners were aged 50 or above at the end of September 2018.
· The number of over 50s in prison in England and Wales is projected to increase by 11% by 2022, while the number of over 70s is projected to increase by 31%[xxxiii].
43. Clinks recently published report Flexible is Vital highlights that within prisons, an unintended combination of factors can create a climate of systemic ageism[xxxiv]. Older prisons are rarely wheelchair accessible, lack grab rails and have poor lighting. Hospital visits are delayed and put regimes under pressure because regulations require two officers to escort, despite the low risk of older prisoners absconding. Most of the education courses and work placements in prisons are limited to prisoners of working age. They are more likely than the general prison population to spend more time restricted to their cells, vulnerable to isolation and to bullying. For many older people their own offending history, and the challenges of resettlement in the community, lead to high levels of anxiety and depression[xxxv].
44. In a recent inspection, social care provision and support for the many disabled and older men at HMP Usk was deemed very good however[xxxvi]. Men who were in crisis mostly received very good care and support and recorded levels of self-harm were also very low. One in five people serving sentences at HMP Usk are aged 60 or above and 40% are over the age of 50[xxxvii]. Similar examples of good practice at HMP Berwyn were highlighted to us, with healthcare staff coming to collect older prisoners for appointments. However other concerns were raised about access to escape chairs in the event of emergency at HMP Berwyn, which is concerning given the modern facilities there.
45. Learning from the successes in meeting the health and care needs of older people at HMP Usk, and elsewhere, should be shared widely across the prison estate in Wales (and beyond), and consideration should be given to how this success could be applied in other establishments (recognising that HMP Usk is a small category C prison).
The third sector and flexible services
46. We also direct the committee the full findings and recommendations of Clinks’ report Flexibility is vital, which explores the role and the value of third sector organisations in meeting the needs of older people who have offended, and how this value might be maximised for the future to meet growing need[xxxviii].
47. The advantage of third sector provision for older people in the criminal justice system is found in its flexibility – approachable, people-centred, uncovering needs, acting as a gateway to statutory services, able to meet needs that fall outside statutory criteria, or that suddenly or gradually change. The distinctive, positive impacts of interventions delivered by third sector organisations must therefore be central to approaches that meet the complex health and social needs of a growing population of older people in prison.
48. The work of Recoop, a national charity that specialises in working with older people who have offended, highlights the impact flexible third sector services can have in prison. For example, Recoop deliver a Buddy management service in three Devon prisons, and have delivered formalised training on the Buddy model in seven other prisons across England and Wales, including HMP Usk.
49. The project involves training people in prison to act as buddies for older people in prison, providing flexible peer-support that might not otherwise be available, with the aim of empowering and supporting vulnerable individuals to control and maintain their independence, good health and well-being.
50. More than 200 Buddies have so far been trained across 10 prisons, and they offer wide-ranging support, including: setting up wing-based small social inclusion and well-being clubs to offer meaningful activities for those with mobility issues and memory problems; providing 1-2-1 support for those struggling with depression and learning difficulties; providing support to people with dementia; supporting people through to end of life. The impact on many older people in prison, and those trained as Buddies, has been transformative, while Devon County Council have said that the Buddy scheme is “critical to the implementation of new Care Act responsibilities for local government in a prison setting”. In Wales this activity could support statutory services to meet their responsibilities under the Social Services and Wellbeing Act.
51. Flexibility is vital, however, found that the flexible services that the third sector deliver are not always supported within the existing structures of commissioning and funding services. For example, it can be very difficult for third sector organisations to specify and measure outcomes of flexible services in the way funders favour. A third sector intervention could make an enormous difference to an individual’s health and wellbeing by signposting or referring to other services, or could contribute to a reduction in rate of decline of people with dementia or terminal illness. These kind of outcomes are hard to quantify, and evaluations involving observation and interviews may be the only option, though these may be prohibitively expensive. Philanthropic sources of funding are often not accessible to third sector organisations in this area, especially where older people are convicted of sexual offences.
52. Moreover, the holistic, cross-boundary scope of much third sector provision, and its relatively small scale and low cost, mean that it can be overlooked within joint commissioning arrangements. For example, a small local organisation might be able to make a significant difference across health, social care and criminal justice needs, but this would require three different commissioners to make collaborative arrangements for what would probably be a very modest amount of funding. Many such valuable opportunities are missed because commissioning structures are too tightly defined and inflexible. In Wales the devolved and non-devolved responsibility for different statutory services presents a further barrier to collaborative commissioning. At the operational level, there is a lack of knowledge about third sector provision among many public sector colleagues.
53. Governance, planning structures and commissioning strategies for healthcare in Welsh prisons should recognise the role and value of the third sector in meeting the needs of older people in the criminal justice system.
If there are sufficient resources available to fund and deliver care in the Welsh prison estate, specifically whether the baseline budget for prisoner healthcare across Local Health Board needs to be reviewed.
54. According to the Wales Governance Centre, in 2017/18 the UK Government transferred £2.544 million to the Welsh Government for prison healthcare in Wales, though this was significantly below the estimated cost of £3,879,794 of health services in Welsh public prisons. In addition, the information outlined in answer to previous questions, pointing to the overstretched nature of prison healthcare suggests that even greater resource is needed.
55. However, in addition to the level of resource, the nature of funding arrangements is also likely to have an impact on the quality of healthcare services. The inconsistencies highlighted above in the planning of healthcare for prisoners in Wales and in the engagement of the third sector in doing this is likely to be, in part, due to the inconsistent arrangements for funding of healthcare in Welsh prisons.
56. The UK government pays a block grant to the Welsh government for healthcare in the four Welsh prisons under public control. Parc Prison is a private prison and is therefore funded directly from the MoJ for health care. In Parc, primary health care is funded and commissioned via the MoJ under a private contract with G4S. HMP Berwyn, as a new prison, has a separate grant for health services paid directly from HMPPS to Betsi Cadwaladr University Health Board. In 2017/18 Betsi Cadwaladr University Health Board received £10,066,230 from HMPPS for the provision of health care in the prison. Berwyn receives significantly more healthcare funding per head of prisoner population than other prisons in Wales. In addition to the general allocations, the Welsh Government has made funding available for specific developments, e.g. mental health in-reach services to all of the prisons in Wales.
57. This inconsistency in funding models presents challenges for the third sector to engage and have its services funded or commissioned and in addition presents barriers for the sector to scrutinise the way in which healthcare services for prisoners are funded. A consistent funding arrangement for healthcare in all Welsh prisons should be established with transparency for how services will be commissioned from those funds.
What the current barriers are to improving the prison healthcare system and the health outcomes of the prison population in Wales.
58. Clinks is particularly concerned by the limited engagement between prison healthcare services in Wales and third sector organisations working in criminal justice. As a result, prisoners are unable to access the wide and diverse range of services provided by the third sector, in addition to, and support of statutory services. The sector is also unable to play its full role as a critical friend scrutinising the actions of statutory services and advocated on behalf of service users.
59. These challenges and barriers are compounded by the devolution of healthcare, while criminal justice remains the responsibility of the Westminster government, and the inconsistency in the arrangements between the two, in particular for healthcare funding.
[i] Clinks (2015) Justice, policing and the third sector in Wales Online: https://www.clinks.org/publication/justice-policing-and-third-sector-wales (last accessed 12.05.19)
[ii] Clinks (2018) https://www.clinks.org/publication/health-and-social-care-committee-inquiry-prison-healthcare
[iii] Clinks (2018) The Good Prison: Why voluntary sector coordination is essential Online: https://www.clinks.org/resources-reports/good-prison (last accessed 18.05.18)
[iv] Clinks (2019) Flexibility is vital Online: https://www.clinks.org/publication/flexibility-vital (last accessed 12.05.19)
[v] Clinks (2019) Whole prison, whole person Online: https://www.clinks.org/sites/default/files/2019-04/clinks_whole-prison-mh_V4.pdf
[vii] Clinks (2018) The Good Prison: Why voluntary sector coordination is essential Online: https://www.clinks.org/resources-reports/good-prison (last accessed 18.05.18)
[viii] See http://www.uservoice.org/about-us/our-services/ (last accessed 18.05.18)
[ix] See http://inspirit-training.org.uk/projects/ (last accessed 18.05.18)
[x] Revolving Doors Agency (2017) Rebalancing Act online: http://www.revolving-doors.org.uk/file/2049/download?token=4WZPsE8I (last accessed 18.05.18)
[xi] Clinks (2018) The State of the Sector 2018 Online: https://www.clinks.org/sites/default/files/2018-11/Clinks%20State%20of%20the%20sector%202018%20Website%20download.pdf (last accessed 12.05.19)
[xii] HM Chief Inspector of Prisons (2018). Report on an unannounced inspection of HMP Swansea. Online: https://www.justiceinspectorates.gov.uk/hmiprisons/wp-content/uploads/sites/4/2018/01/Swansea-Web-2017.pdf (last accessed 12/04/19).
[xiii] Jones, R., & Wales governance centre at Cardiff University (2019). The provision of health and social care in the adult prison estate. Online: https://www.cardiff.ac.uk/__data/assets/pdf_file/0009/1468512/WRITTEN-EVIDENCE-THE-PROVISION-OF-HEALTH-AND-SOCIAL-CARE-IN-THE-ADULT-PRISON-ESTATE.pdf (last accessed: 12/04/19).
[xiv] Her Majesty’s Chief Inspector of Prisons (2016). Report on an unannounced inspection of HMP/YOI Parc. Online: https://www.justiceinspectorates.gov.uk/hmiprisons/inspections/hmpyoi-parc/ (last accessed: 12/04/19).
[xv] Her Majesty’s Chief Inspector of Prisons (2018). Submission to the Commission on Justice in Wales. Online: https://gov.wales/sites/default/files/publications/2018-06/Submission-to-justice-commission-hmip.pdf (last accessed: 12/04/19).
[xvi] HM Chief Inspector of Prisons (2016). Report on an unannounced inspection of HMP & YOI Cardiff. Online: https://www.justiceinspectorates.gov.uk/hmiprisons/wp-content/uploads/sites/4/2016/12/HMP-YOI-Cardiff-Web-2016.pdf (last accessed 12/04/19).
[xvii] Her Majesty’s Chief Inspector of Prisons (2016). Report on an unannounced inspection of HMP/YOI Parc. Online: https://www.justiceinspectorates.gov.uk/hmiprisons/inspections/hmpyoi-parc/ (last accessed: 12/04/19).
[xviii] HM Chief Inspector of Prisons (2018). Report on an unannounced inspection of HMP Swansea. Online: https://www.justiceinspectorates.gov.uk/hmiprisons/wp-content/uploads/sites/4/2018/01/Swansea-Web-2017.pdf (last accessed 12/04/19).
[xix] HM Inspectorate of Prisons (2015). Changing patterns of substance misuse in adult prisons and service responses: A thematic review. Online: https://www.justiceinspectorates.gov.uk/hmiprisons/wpcontent/uploads/sites/4/2015/12/Substance-misuse-web-2015.pdf (last accessed 12/04/19).
[xx] Her Majesty’s Chief Inspector of Prisons (2018). Submission to the Commission on Justice in Wales. Online: https://gov.wales/sites/default/files/publications/2018-06/Submission-to-justice-commission-hmip.pdf (last accessed: 12/04/19).
[xxi] Lammy D (2017) The Lammy Review. An independent review into the treatment of, and outcomes for, Black, Asian and Minority Ethnic individuals in the Criminal Justice System.
[xxii] HM Chief Inspector of Prisons (2016). Report on an unannounced inspection of HMP & YOI Cardiff. Online: https://www.justiceinspectorates.gov.uk/hmiprisons/wp-content/uploads/sites/4/2016/12/HMP-YOI-Cardiff-Web-2016.pdf (last accessed 12/04/19).
[xxiii] HM Chief Inspector of Prisons (2018). Report on an unannounced inspection of HMP Swansea. Online: https://www.justiceinspectorates.gov.uk/hmiprisons/wp-content/uploads/sites/4/2018/01/Swansea-Web-2017.pdf (last accessed 12/04/19).
[xxiv] HM Chief Inspector of Prisons (2018). Report on an unannounced inspection of HMP Usk and HMP & YOI Prescoed. Online: https://www.justiceinspectorates.gov.uk/hmiprisons/wp-content/uploads/sites/4/2018/02/Usk-and-Prescoed-Web-2017.pdf (last accessed: 12/04/19).
[xxv] HM Chief Inspector of Prisons (2016). Report on an unannounced inspection of HMP & YOI Cardiff. Online: https://www.justiceinspectorates.gov.uk/hmiprisons/wp-content/uploads/sites/4/2016/12/HMP-YOI-Cardiff-Web-2016.pdf (last accessed 12/04/19).
[xxvi] Clinks (2018) The Good Prison: Why voluntary sector coordination is essential Online: https://www.clinks.org/resources-reports/good-prison (last accessed 18.05.18)
[xxvii] Her Majesty’s Chief Inspector of Prisons (2018). Submission to the Commission on Justice in Wales. Online: https://gov.wales/sites/default/files/publications/2018-06/Submission-to-justice-commission-hmip.pdf (last accessed: 12/04/19).
[xxviii] Her Majesty’s Chief Inspector of Prisons (2018). Submission to the Commission on Justice in Wales. Online: https://gov.wales/sites/default/files/publications/2018-06/Submission-to-justice-commission-hmip.pdf (last accessed: 12/04/19).
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