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Howard League for Penal Reform response to the National Assembly for Wales Health, Social Care and Sport Committee’s inquiry into the provision of health and social care in the adult prison estate


Executive summary


·         Prisons are a public health issue

·         Prisons should be seen as communities which promote health

·         The culture and environment of prisons requires urgent change to ensure that prisoners and staff in Wales are able to live and work in a healthy community that promotes their physical, mental, intellectual, moral and social wellbeing

·         The Ministry of Justice must work in partnership with Welsh government to focus on prioritising and promoting the health and wellbeing of all prisoners and staff in order to prevent ill health

·         Prison health needs a whole prison approach. It is much more than providing medical treatment for individual prisoners

·         Systemic change is needed to ensure that the health and wellbeing of prisoners and staff is a primary consideration in all prison policy and practice

·         HMPPS has a responsibility to ensure all prisons promote health

·         Prisoners and staff will not be able to stay fit and healthy in a prison environment that is filthy, dehumanising and dangerous


1. About us

1.1 Founded in 1866, the Howard League is the oldest penal reform charity in the world. We have some 12,000 members, including lawyers, politicians, business leaders, practitioners, prisoners and their families and top academics. The Howard League has consultative status with both the United Nations and the Council of Europe. It is an independent charity and accepts no grant funding from the UK government. The Howard League works for less crime, safer communities and fewer people in prison. We aim to achieve these objectives through conducting and commissioning research and investigations aimed at revealing underlying problems and discovering new solutions to issues of public concern. The Howard League’s objectives and principles underlie and inform the charity’s work.


1.2 Since 2002 the Howard League has provided the only legal service dedicated to representing children and young people in custody. Our legal work began with a landmark case in 2002, brought by the charity in its own name, to successfully challenge the assumption that the protections of the Children Act 1989 did not apply to children in prison.


1.3 The Howard League for Penal Reform and Centre for Mental Health conducted a programme of work on preventing prison suicides. We looked at the impact of prisons on mental wellbeing and made recommendations for change. Frances Crook, CEO of the Howard League is a member of the ministerial board on deaths in custody.


1.4 Our submission, drawing on our lawyers’ experiences and our policy work, focuses on the impact of the prison environment on the physical, mental and social wellbeing of prisoners and prison staff. It addresses the final point of the inquiry; namely the current barriers to improving the health outcomes for prisoners in Wales.


2. Prisons are a public health issue

2.1 As a devolved responsibility, prison healthcare provides a special opportunity for the Welsh government to reduce health inequalities and improve the health and wellbeing of prisoners who face the greatest challenges to their health.


2.2 Prisons are an urgent public health issue. Prisons in England and Wales are currently in a state of crisis that is deleterious to the health and wellbeing of prisoners and staff. The Howard League and Centre for Mental Health (2016) found prisons were having a detrimental impact on the physical, mental, intellectual, moral and social wellbeing of prisoners and staff. Overcrowding, staff shortages, high levels of violence, poorly maintained buildings and infestations in prisons are damaging to health and wellbeing.


2.3 The high rates of violence, self-injury and suicide in prisons are an urgent public health issue which needs addressing. In evidence to the UN Committee Against Torture, the Howard League reported there were 49,565 incidents of self-injury in prisons in the 12 months to the end of June 2018 at a rate of one every ten and a half minutes. (Howard League, 2019). The Chief inspector of Prisons stated in his annual report (HMIP, 2018),


‘The increase in levels of violence that we have seen in recent years continued and self-harm and assaults reached new highs.’


2.4 Data from the Ministry of Justice (2019) showed that there were 1,498 recorded assaults in prisons in Wales in 2017 – an 18 per cent rise on the previous year. They included 39 assaults on prison staff. There were 942 recorded assault incidents in Parc prison alone. The only prison in England and Wales which had more recorded assaults that year was Birmingham. There were 2,363 incidents of self-injury in Welsh prisons. Incidents of assault and self-injury in prisons in England and Wales are at their highest levels since current recording practices began in 1978. On average, an incident of self-injury in prison was recorded every 12 minutes and an assault was recorded every 18 minutes.

2.5 325 people died in prison custody in 2018, including 92 people who lost their lives through suicide. In the same period, there were four homicides. In 2018, 13 prisoners died in Welsh prisons. This included two prisoners who died by suicide. Since 1990, 189 prisoners have died in Welsh prisons.

2.6 The Howard League gave evidence to the Health Committee on the physical conditions in prisons and reported that prisoners were being held in cramped, overcrowded and filthy conditions (Howard League 2018). In his annual report (HMIP, 2018) the Chief Inspector of Prisons found ‘living conditions were very poor for many prisoners, and in some cases squalid’. Living and working in such conditions is clearly detrimental to health and would not be tolerated in other communities.


2.7 Research conducted by the Howard League (2017) on the role of the prison officer found staffing levels and patterns of work were dangerous and prison officers, working in very challenging conditions, felt overstretched and neglected.


3. Prisons must be seen as communities that promote health

3.1 Prisons need to look at health in a holistic way and address the entire spectrum of health and wellbeing needs. This requires a shift in focus and scope. Prison health is not merely about providing medical treatment for individual prisoners who are unwell, important though that is. Prisons must provide conditions which enable people to thrive, to stay healthy, improve their health and wellbeing and prevent the deterioration of their health. Research by the Howard League and Centre for Mental Health (2016) found fundamental changes were needed to ensure prisons promote mental and physical health and mitigate the harmful effects of imprisonment.


3.2 Prisons must be designed and managed to ensure they promote health and prevent disease. Prisoners and staff must be able to maintain a good standard of health and be protected from threats to health. Prisons must ensure all who live and work there are able to make healthy choices to minimise the risk and impact of illness.

3.3 The introduction of smoke free prisons by the Prison Service is a good example of a public health approach that has improved outcomes of prisoners and staff. Alongside the ban on smoking, prisoners have been encouraged and supported to stop smoking. Smoke free prisons have improved the quality of life for those who live and work in prisons and undoubtedly prevented prisoners and staff from developing heart disease, lung cancer, strokes or other illnesses as a result of inhaling tobacco smoke.

4. The culture and environment of prisons requires urgent change

4.1 The culture of prisons in England and Wales does not encourage or promote a healthy lifestyle. The Howard League and Centre for Mental Health report on preventing prison suicides, published in 2016, stated that a prison regime should be built around a normal life. Prisoners should be able to get up, have a shower and breakfast, occupy themselves productively, socialise and exercise and go outdoors. Prisoners should be able to lead a good and useful life. The report found that prison life had become so divorced from this principle that ‘both prisoners and staff were incarcerated in a filthy and frightening world that, at its worst, was killing people’.


4.2 The limited prison regime prevents prisoners and staff from making healthy choices to maintain or improve their physical and mental wellbeing. Across the prison estate, prisoners are spending hours locked in their cells each day being physically and mentally inactive.


4.3 The Inspectorate found that time out of cell in Parc prison had reduced since the last inspection and up to 40% of the population were locked in their cells during the core day (HMIP, 2016). In Cardiff prison it found that some prisoners were locked up for over 27 hours, only being let out briefly to collect their meals (HMIP, 2016b). In Swansea prison half the prisoners were locked up during the working day and prisoners could only take exercise for half an hour each day (HMIP, 2018b).


4.4 Prisons restrict prisoners’ ability to lead a productive working life. Berwyn prison currently holds 1,293 men and is designed to hold over 2,000 men. According to the IMB report it will have workshop places for 520 men across 6 workshops. This is less than half of the current population. In November 2017 it had just two workshops open.

4.5 Prisons limit prisoners from making healthy choices. Prisoners have little choice over their diet and many prisoners eat their meals in their cells next to a toilet. Physical exercise is limited and access to the gym is restricted. Prisoners and staff spend little or no time outdoors. When prisoners do go outside, the surroundings are often bleak or for some prisoners in segregation, little more than an outside cage.

4.6 The punitive prison regime does not promote health and wellbeing. Instead, it places restrictions on factors such as physical activity, social interaction, visits and phone calls. Prison punishments deprive prisoners of healthy lifestyle choices. Exercise, showers, family contact and recreation time are all used as rewards for good behaviour or sanctions that can be taken away when behaviour is poor.

4.7 Prisons should promote and enable prisoners to make healthy lifestyle choices. They should not deprive prisoners of factors that enable people to thrive. Choices about health and wellbeing should not be luxuries that prisoners have to earn.

4.8 Research conducted by the Howard League (2016) found the physical environment in which prisoners and staff live and work is damaging people’s health. Prisoners are currently held in cramped, overcrowded and filthy conditions. Cardiff, Parc, Swansea and Usk/Prescoed prisons are all holding more prisoners than the certified normal accommodation (CNA) allows?. In February 2018 the Howard League gave evidence to the Welsh Affairs select committee on the sordid conditions at Berwyn prison (House of Commons, 2018). Berwyn, opened in 2017, is designed to force two prisoners to share each cell with a toilet in the cell at the head of the bed, contrary to the UN standard minimum rules for the treatment of prisoners that state ‘it is not desirable to have two prisoners in a cell or room.’ (OHCHR, 1957)


4.9 An inspection of Cardiff prison (HMIP, 2016b) found ‘showers were poorly ventilated and many had little or no screening. Cells lacked basic facilities, such as curtains, lockable cupboards and, in many cases, kettles. Most toilets were inadequately screened. There was poor availability of clean clothes and bedding and many prisoners had only one set of clothes, which was unacceptable.’


4.10 In Swansea prison ‘far too little attention was being paid to ensuring that prisoners could obtain the very basics for everyday living, such as clothing and bedding’ (HMIP, 2018b)


4.11 Newly built Berwyn prison faced ongoing problems and a complete failure of the heating and hot water system for five days, according to the IMB annual report (IMB, 2018).


4.12 In our experience of visiting almost every prison in the country over the past two decades, it is rare to find a whole prison environment that promotes health and wellbeing. Prisoners and staff should as a minimum have access to fresh air, natural light, a healthy diet, physical exercise, mental stimulation, peace and quiet and kindness.


4.13 Increasing the use of punishments for the challenging behaviour of prisoners does not address the underlying causes of that behaviour. In many cases, a punitive approach exacerbates levels of violence and is deleterious to prisoners’ mental and physical wellbeing.


4.14 Other jurisdictions have recognised the importance of promoting health and wellbeing in prison and making them integral to the prison environment. Prisons in Norway have been built to allow every prisoner to have their own cell with a clear view of trees, the outside world and natural light. Communal areas, access to fresh air and outside spaces are part of this prison design and as a consequence the prisons do not have the conflict and violence of our system.


5. The Welsh Assembly should ensure that the Ministry of Justice prioritises and promotes the health and wellbeing of prisoners and staff

5.1 Most prisoners come from deprived communities and many enter prison with poor health, drug and alcohol addictions, a history of mental ill-health and consequently are already likely to face premature mortality.


5.2 Discussion of prison healthcare has traditionally focussed on the need to provide improved individual treatment and whilst this is critically important, poor mental and physical health has been medicalised when better environmental conditions would obviate the need for medical interventions.


5.3 Secondly, it must be remembered that staff are incarcerated too. Their working conditions are cramped, fetid and unhealthy and would be vastly improved by a whole-institution approach to creating a healthy environment.


5.4 Much conflict could be prevented if prisoners and staff were existing in a healthy establishment that allowed for exercise, fresh air, decent food and better human interaction. Reduced violence would lessen the need for the repair of damaged bodies.


5.5 Prison Health Partnership Boards should ensure that prison health needs assessments take into account the impact of the prison environment on prisoners and staff.


6. Prison health needs a whole prison approach.

6.1 ‘Health in prisons is too important to be left solely to the health team’.


The World Health Organisation (2014)


6.2       NHS Wales has pledged to collaborate with others to understand and improve factors that impact on everyone's health’ and to ensure that ‘the people of Wales to have a more equal chance of living a fulfilling life, free from preventable ill health.’ The health and wellbeing of prisoners in Wales will not improve if health is not seen as a whole prison issue. As a devolved responsibility the Welsh Government and NHS Wales have an opportunity to show how, working together with the Ministry of Justice, governors, prison officers, healthcare staff and prisoners, they can promote health in prisons.


6.3 The concept of a healthy prison is not a new idea. It was first set out by the World Health organisation in 1995 and has been adopted by Her Majesty’s Inspectorate of Prisons as part of the criteria for inspection.


6.4 The whole regime in prisons must be geared promoting health and wellbeing. Prisons should as far as possible replicate the environment and services of the community but in a secure setting.


7. The health and wellbeing of prisoners and staff must be a primary consideration in policy and practice

7.1 Health outcomes for prisoners are below that in the wider community. The Howard League monitors the number of prisoners who die in prison and found that 22 prisoners who died of natural causes in 2018 were aged 49 or under. A report by the Prisons and Probation Ombudsman in 2012 found that the average age of male prisoners who had died from natural causes was 56, while for female prisoners the average was 47. In the UK, the average age of death is 79 years for men and 83 years for women. Given that many prisoners will enter custody in poor health (WHO, 2014) it is essential that the health and wellbeing of prisoners is prioritised.


7.2 Prison service policies should acknowledge and consider the potential impact on health. Policies which are likely to have a negative impact on health and wellbeing should be changed. As an example, the revised incentives and earned privileges (IEP) scheme which came into force in 2013 failed to take into account the known vulnerabilities of prisoners in the early days in custody, particularly the high risk of suicide (PPO, 2016). The revised IEP introduced Entry level for prisoners in the first two weeks following sentence, placing restrictions on prisoners’ access to coping mechanisms including family contact, physical activity and personal possessions. The policy is currently under review by the MoJ.


7.3 Prison policies and practices, such as control and restraint and segregation, have the potential to damage the health and wellbeing of all prisoners. The effects are known to be more harmful to prisoners who have poor mental and physical health. Howard League research on preventing prison suicide found that prisoners who were struggling to cope in prison and most at risk of suicide were more likely to be placed in solitary confinement. A study by the Prisons and Probation Ombudsman published in 2015 found that prisoners in segregation were at high risk of suicide. Of the eight prisoners who had killed themselves in prison segregation units, four had been assessed as at risk of suicide and self-harm.  The Committee on the Prevention of Torture (CPT) has referred to evidence that solitary confinement can have an extremely damaging effect on the mental, somatic and social health of those concerned’. Despite the known risks to health, the use of segregation in prison is widespread.


7.4 HMIP (2018c) reported that boys in Parc prison who were segregated were being placed in a unit in the adult prison.


7.5 In May 2018, the BMA published a statement, jointly with the Royal College of Psychiatrists and the Royal College of Paediatrics and Child Health, stating that solitary confinement should be banned for children who are locked up in the UK. The BMA statement refers to the unequivocal evidence of the profound impact solitary confinement can have on health and well-being’, such as ‘increased risk of suicide and self-harm’.


7.6 A healthy prison must recognise the damage prison policies and practices are inflicting on prisoners’ often fragile mental and physical health.


8. The Howard League legal advice service for children and young people in prison

8.1 Prison staff have a responsibility to ensure prisoners are able stay healthy, manage their own physical and mental wellbeing and stay fully informed about their health. It is our experience that in some prisons, barriers have been put in place that prevent prisoners from receiving the care they need.


8.2 In the 12 months leading up to March 2018 the Howard League legal advice line received over 180 calls raising concerns about their healthcare in respect of children and young adults in prison.


8.3 Young people have complained about lack of information about their own health treatment.  Howard League lawyers represented a young adult prisoner who did not have a working hearing aid for weeks.  Even after the Howard League took court action to ensure he would get a new hearing aid, he was still denied information about the date of his appointment was for this to be rectified. Another young person complained that she was denied access to letters from the hospital about follow up treatment for a serious and lifelong inherited health condition.


8.4 The Howard League has received a number of calls on behalf of children being denied their medication. For example, a 15 year old boy with ADHD on a restricted regime that meant he was locked in his cell for over 22 hours a day told us he had not received his medication.  The Howard League lawyers contacted the prison to ensure he received it.


8.5 Children, young adults and carers tell us they are not taken seriously when they raise concerns about health issues in prison. Many young people struggle to raise concerns about health, especially if they might consider the issues embarrassing.  It is essential that young people are actively encouraged to look after their health and wellbeing.


8.6 Prisoner/staff relationships are important in promoting health. Staff need to be able to build positive relationships with prisoners in order support their physical and emotional wellbeing.


8.9 Prisoner health and well-being is not a luxury; it is a legal entitlement.



The Howard League for Penal Reform

14 May 2019




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