Response to the Health, Social Care and Sport Committee Inquiry into the provision of health and social care in the adult prison estate.
http://senedd.assembly.wales/mgConsultationDisplay.aspx?id=344&RPID=1515455566&cp=yes
HMP Swansea Health Care
Section 1: The effectiveness of current arrangements for the planning of health services for prisoners in Wales and the governance of prison health and care services, including whether there is sufficient oversight.
1. Oversight for local delivery of prison health services is held by each individual Health Board. Welsh Government provides oversight through a Shared Priorities Working Group and through assurance arrangements, such as Health Care Standards and joint HIMP/HIW inspections.
2. Prison health service policies and pathways for issues such as prescribing, screening and substance misuse can vary across the prison sector. This means patients may receive a different service depending on where they are located. Reasons for this may be due to resources or differing care models dependent on health or Local Authority process. There also may be different health needs dependent on the prison population.
3. There is a great deal of movement between prisons, meaning that the variation in policies and pathways can have significant implications for stability of management for those imprisoned.
4. HMP Swansea Partnership Board is Joint chaired by the Prison Governor and Head of Nursing. The principle officer for the local authority attends. The Partnership Board has in recent years moved to a health and social care governance structure to strengthen service improvement.
5. Within Swansea Bay University Health Board (SBUHB), the HMP Swansea healthcare lead completes a quality and safety paper bi monthly. This is reported within the quality and safety meeting and reported back to the health board senior team in primary and community care directorate.
6. There is a Shared Priorities working group chaired by Welsh government and Public Health Wales and attended by representatives of all Welsh prisons. At these meetings reports on developments and national needs are highlighted. Liaison is then undertaken with Her Majesty’s prison and probation service to develop needs and work streams. The first work streams have included substance misuse and mental health. There has been discussion at the meeting in relation to health performance indicators and development of an overarching governance structure for prisons that will allow oversight of all partnership boards.
Section 2: 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
7. The evidence is clear about the increased complex health and social care needs of those residing in prisons, compared to the general community. Within the City of Swansea there are specialist health services for the homeless and those seeking asylum as examples, the prison will link with those services to help with care need. The prison has good links with the city and the services it offers.
8. However, it must be noted that not all the men at HMP Swansea will return to the city. The prison catchment area is a large one covering West Wales, Swansea, Neath and Port Talbot, but the prison will also have men from out of area -Cardiff and Newport as well as outside Wales. The healthcare centre will often be liaising with care services all over the country to try to establish continuity, often in areas where the services are unfamiliar to the referrer.
9. Local health and social care services can struggle to provide those residing in prisons with comparative services to those in the community partly because of restrictions prison life places on patients. This is exacerbated by the practicalities of how services are provided (with an increased emphasis on self referral/opting in, and access via internet, apps and phones which are not available within the prison environment).
10. The prison setting provides an opportunity to address complex health issues and contribute towards reducing inequalities. However, community services also have a key role in supporting the needs of vulnerable individuals before and after prison. Prison (or imprisonment) should not be solely relied upon to address multiple and complex needs which often stem from the community. There have been recent moves to deter sending those with less than 6 months sentence to prisons. This may have a positive effect as often those who are homeless and/or alcohol dependent or who have poor mental health will fall into a short sentence category (public disorder offenses etc). The care needs may be best assessed within the community using court diversion, housing and other wrap-around community care. Access is not always as quick once the person is sent to prison; despite services being available the sense of urgency is often changed with the prison often wrongly being seen as a place of safety.
11. The numbers of men held in prisons in Wales has increased over the last decade. Recent figures on prison overcrowding demonstrate that three Welsh prisons (HMP Swansea, HMP Usk/Prescoed and HMP Cardiff) are within the top twenty prisons in England and Wales in terms of prison population relative to certified normal accommodation[1]. This creates increased demand on prison health services.
12. Referrals to social work support are made through the Common Access Point by telephone. Healthcare prison staff and the patient can also self-refer. Referrals are very few. The Local Authority work closely with the prison and health care team. The access and provision of social care varies across the Welsh prison estate with different models being used in different prisons. Some have staff based within the prison.
Substance Misuse
13. Criminal Justice substance misuse services in prisons and in the community are commissioned by Her Majesty’s Prison and Probation Services and the South Wales Police and Crime Commissioner. In Swansea Bay the contract is delivered by the Dyfodol consortium, covering interventions, assessment and also liaison within the prison. (Across Wales there are other service providers, and in West Wales no service specifically providing Criminal Justice Substance misuse clinical care). There are no clinicians associated with the in-prison contract at HMP Swansea and so healthcare services work with Dyfodol to deliver treatments. In Wales there is no Integrated prison Drug Treatment Services for substance misuse.
14. At HMP Swansea a working group established to review Drug Treatment Services for substance misuse looked at HMP Swansea’s existing process and services. A revised service model commenced on 29th May 2018 and has been well received by those who have taken up the treatment option. Public Health Wales are evaluating the pilot and so far 289 men have benefited from this early treatment. This “early days opiate pathway” first morning medication is often supported by community drug teams and has led to stability and maintaining prescriptions for a large number of men aiding quicker recovery and improved mental health. It is noted that the significant additional work for prescribing, monitoring, dispensing and supervising has an impact on the nursing team, the establishment itself and on the workload of prescribers.
15. As noted above, within Swansea Neath Port Talbot the consortium Dyfodol provides the community Criminal Justice (CJ) drug services for people on release, as well as providing the psychosocial support within the prison. There is not usually access to the Community drug and alcohol team. Dyfodol supports the prescribing by the Health Care Team well and has been helpful during our pilot of treatment for those being released on medication.
West Wales no longer has a CJ service and the community Drug and Alcohol team provide the prescribing and clinical support for prison leavers in that area, although not set up to do so. This results in less seamless provision in West Wales with limited access to prescribers and very specific prescribing preferences. As a result the pilot has had a greater impact on resources in West Wales and there have been regular meetings with this team to plan care and allow the same opportunities for maintenance of Opiate Substitution prescribing on release that have been experienced by Swansea and Cardiff areas for example.
16. The ongoing monitoring of care for those in treatment has been a whole team approach within healthcare in HMP Swansea. Currently it is difficult to provide regular review by prescriber/specialist clinician for those on substitute prescribing, as would be recommended2 and appropriate to ensure safe on-going prescribing.
To improve this position, the Health Board has supported one of the nursing team to complete training as a Non Medical Prescriber. The Health Board is looking to create a senior nursing post within the team to help with the ongoing care, liaison and prescribing needs of those in treatment, and without this risk losing this experienced and valuable member of staff. Ensuring a strong educational framework and career progression for the nursing team is key to support retention.
17. Substances and alcohol dependence are reported as common conditions in new arrivals to HMP Swansea. The whole team are involved in assessment, treatment, medication administration and review. There are often other conditions alongside dependence which can impact as well such as depression, dual diagnosis of Significant Mental Illness, poor liver health from alcohol and other drugs as well as viral hepatitis. There is a need for improved Blood Bourne Virus testing in this high risk population, as well as other chronic disease management. Additional funding to help us continue to develop and do this work well within prison healthcare would be welcome.
18. Dual diagnosis services need further development to allow mental health needs and substance misuse problems to be managed in a seamless and effective manner providing the best support from both substance misuse and mental health services to deliver effective care.
Learning Disability
19.
The best evidence available suggests that around 7% of prisoners would be likely have IQs below 70 (a proxy for Learning Disability) and a further 25% who score between 70-79 (borderline requiring assessment)3. This compares to a national adult population rate of about 2% with Learning Disability[2].
We have sought to appoint a learning disability nurse at HMP Swansea. Such a nurse would support further development of systems. This would help us with care planning and nursing craft care for those with a learning disability. Such an appointment would need to be supported by a wider Learning Disabilities team.
Those who are already known to services that have social workers or nurses in the community healthcare services benefit from continuity of care and a visit from the care co coordinator.
20. Assessment for Learning Disability would often be appropriate and the recommended process would be through the mental health in-reach secondary care system and/or local authority and then onto the learning disability team. At Swansea we are looking to review this process to improve the pathway and the unmet need in the service to allow the opportunity of residing in a supported environment for assessment to be used and to link with services on discharge.
Mental Health
21. It is well recognised that levels of mental health disorder including severe and enduring mental illness are much higher in the prison population than outside. However, neither the UK nor Welsh government have definite data on numbers[3].
22. The Prison Mental Health In-Reach Team (MHIRT) is a multi-disciplinary team that provides Specialist Secondary Mental Health services to adult prisoners aged between 18- 65. The In- Reach team provide provision to both HMP Parc and HMP Swansea. The original service model recognised it was unrealistic to expect a comprehensive mental health in-reach service to meet all demands of the 18-65 age group, so it was agreed the MHIT provide assessment/treatment services for inmates with acute, or enduring serious mental Illness, but mainly relating to the mental health needs assessment at that time. The MHIT consists of: Consultant Psychiatrist (0.3wte), Band 6 Registered Nurses (3.0wte), Band 6 Occupational Therapist (1.0wte), Psychologist(0.2wte) and a Team Manager (1.0 wte).
23. The introduction of the Mental Health Measure 2010 placed additional responsibility on the In-Reach team as prisoners who had previously been seen can re-refer under Part 3 of the Measure. In addition the In-Reach team also provides care coordination to prisoners under secondary care which requires care and treatment planning and also planning for those prisoners already subject to 117 aftercare. In order to do this effectively, there needs to be liaison with other agencies involved in all surrounding resettlement needs.
24. There is very clear evidence that the prison population have a high incidence of mental disorder. Generally the evidence indicates that about 70% have a diagnosable mental disorder, however there are already clear issues relating to the capacity of the In-Reach team and risk management processes for the group of inmates of which they currently provide services for.
25. Traditionally, the prison core healthcare team has been referred to as primary mental healthcare. In HMP Swansea the services are run specially for prisons and there can be limited access to these much needed external services to allow those with mental health issues to have best treatment. The Health Board is exploring how treatment could be provided by the mental health directorate on a visiting basis or it could be developed to allow the team to expand and take over such intervention.
26. The prison service has a safer custody team with support of the ACCT (Assessment custody care team) document a care map is put in place to support those at risk of suicide and or self-harm. HMP Swansea is currently piloting the new document. There has been liaison with the prison service in reach and the prison healthcare team on how best to deliver the requirements. There is a bigger focus on mental health assessment and incorporation of health plans and interventions into the document. This has a resource implication. Within the community the equivalent would be mental crisis teams would undertake much of this support and assessment.
27. There are other requests that add to the strain on resources for mental health work within the core team. This may include MAPPA public protection requirements and possible reports for MAPPA or probation. This is becoming more frequent as is information for resettlement and housing to help with finding placement for the vulnerable or for those with health needs. Although welcomed in order to provide best care these much needed reports take time and resource.
Section 3: 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
28. The service within a prison is rather different from those elsewhere in health. There is a requirement for 24/7 nursing presence (including responding to emergencies) and for drug rounds like in hospital. But there is also a requirement for long term health care for example with chronic disease management like in primary care (assessment for asthma, COPD, IHD, hypertension etc) and wound management such as is usually provided by Community nurses. Because all of these services are provided by the same team of nurses, some elements which are less urgent can lose out to those which are time sensitive such as drug rounds.
29. Difficulties with retention of nursing staff in prisons in Wales is apparent. Most nurses at Swansea work at Band 5. As the service requires a range of specialities to be covered a nurse will often develop a skill in a key area such as sexual health, mental health, CBT for example. Support (in releasing time for training and in mentoring and allowing time within the prison) is offered to develop the skills. Often after a couple of years the nurse will leave for promotion in a job outside the prison utilising the skills gained. It is positive that nurses usually leave HMP Swansea with more skills than when they arrived. This does mean that training and development is constant and ongoing also it can leave a gap if a person with a similar skill set does not apply for the vacant post. In 2018 / 2019 there has seemed to be less mental health nurses applying for posts and this has left the team more weighted towards general trained nurses.
30. There are also difficulties in the retention of staff within the Mental Health Prison In-Reach Team. This is largely to do with the capacity of the team and the pressures of attempting to meet the service demand. The workforce are often working over and above their contracted hours to ensure they are addressing risk and safety issues, whilst working in a custodial environment where the prison regime is a priority. Staff retention can be an issue for health care provision in prison estate.
31. Supporting career progression for nurses and doctors working in custodial environments will help with retention. At Swansea most staff will leave to progress in experience of alternative area or for promotion. We have developed a post to be evaluated as a nurse prescriber for substance misuse within the prison. This area of work is vast due to substance misuse need. There are other health conditions where by external clinic could be set for visiting practitioners. For care of chronic conditions asthma epilepsy diabetes and some primary care clinics.
32. There are no healthcare assistants at HMP Swansea in order to provide the service additional resource would be needed as all staff available are needed to run the full range of duties needed to deliver care. This role has been discussed in relation to social care and self-care need. The role of the care assistant would help the local authority and healthcare in delivering personal care for example, Swansea does not have much need for personal care but this is often to its disadvantage as when the need does arise there can be difficulty in asserting who is best placed to deliver the care. In some other prisons some of the tasks which are done by nurses in Swansea are completed by other types of staff – for example pharmacy technicians in some prisons are used to administer medication freeing up time for nurses to complete other duties. If this were to be modelled at Swansea extra resources would be needed as the pharmacy team is small. Paramedics are being employed at some prisons and health settings consideration to this roll should be given at Swansea.
33. Nurses often work in high-pressured busy days being expected to administer 3 medication rounds daily and often delivering vaccinations or triage clinics in between as well as providing emergency response. This can leave little time for supervision and reflection, vital aspects of nursing that need to be developed at HMP Swansea. The nurse workforce at Swansea has been the primary provider as the team is small and so the nurse is probably more able to complete all care needs however expansion and addition to the team could help with retention and take away some of the pressure if other disciplines were added to the existing team.
34. The pharmacy team within HMP Swansea has benefited from a long-term and experienced senior pharmacist at the top but rather a high turnover of more junior team members. This impacts on the ability of the senior pharmacist to use all her skills and training to assess and prescribe and this is a loss to the service. Work needs to be done to support retention of pharmacy staff.
35. Access to external secondary care services for men in prison is reliant on the prison’s ability to provide staff to escort to appointments. At Swansea, we are allowed two appointments in one day. If an emergency presents on the day, core prison staff are expected to arrange this on top. If staff levels are low there are suggestions to look to cancel the routine appointment to allow the emergency to go. This can delay care and causes missed appointments in hospitals where consultant time and appointments are already stretched and involve long waits, causing additional costs to the NHS. This results in a delay to the patients care, a DNA for the secondary care service and an administrative resource to rearrange.
36. Where possible, many secondary care services will provide services within the prison to prevent the need for escorts, for instance consultant for sexual health services, the nurse specialist for Hepatitis C treatment, visiting psychiatrist clinics, visiting optician, and dentist all attend the prison for regular clinics. At Swansea we hope to attract physiotherapists to attend, podiatrists and specialists for pain clinics.
37. The medical provision for HMP Swansea has been reviewed and a contract placed out to tender in 2018.
Section 4: How well prisons in Wales are meeting the complex health and social care needs of a growing population of older people in prison, and what potential improvements could be made to current services
38. As highlighted, HMP Swansea has to develop the responsibilities and could improve its’ service in relation to personal care. There are few older people at Swansea despite the prison population getting older. HMP Swansea is a local remand centre. However when older people are in prison it must be noted that they may need help with social care the environment is also a tricky one as it’s an old Victorian prison making location an issue to ensure best safety. Local authority help with environment checks and providing OT assessments for equipment needed to enable those older persons.
39. In relation to dementia and assessment of early stages, this can be complex. If the person is already known to older person’s services, the social worker or CPN will visit and liaise for care need. In order to refer new people, this can be a different matter as the secondary care mental health in reach team does not work with older persons. However the older person’s mental health team again would usually expect a referral for assessment by the mental health in-reach team or social worker. There is a visiting psychiatrist who helps with mental health primary care need who often helps us with this process.
40. Help with self-care needs to be developed. A review should take place to establish if provision could be made by local authority or if this should be built into the existing team providing additional health support workers.
41. Both social care and mental health services in reach and community older persons services should look at referral pathways to ensure swift access to services are obtained. This would need to be a review of process inclusion criteria and responsibility.
42. The prison has responsibility for environment and will often use its works department to make physical adjustments to cells to fit need.
43. As highlighted above the Secondary Care Mental Health In-Reach team does not contain an element for the provision of specialist older person’s mental health services to older persons at HMP Parc or HMP Swansea. The Mental Health In-Reach team do not have the experience, skills or expertise in dealing with older adults with cognitive decline, including dementia type illnesses. There is developing work to meet the health needs of a growing population of older people at both HMP Parc and HMP Swansea.
44. There is no clear pathway for Older Adults Mental Health within HMP Swansea and HMP Parc, with the aging population that HMP Parc hosts referrals are likely to continue to rise, subsequently identifying further unmet needs within this specialist service of Mental Health within the prison estate. There are currently a number of older adults within prisons suffering from chronic, persistent disorders such as Dementia, with some prisoner’s progressive conditions deteriorating to a complex state. There are a group of older prisoners who require a full assessment of function and mental health and require Care and Treatment Planning under the Mental Health Measure that the MHIT are not resourced, or funded to deliver.
45. Those aged over 60 are the fastest-growing segment of the prison population, increasing 125% between 2004 and 2014 (2). The Ministry of Justice projects the population in prison aged over 60 to increase from 4,100 in 2015 to 5,500 in 2020. Dementia is a condition often associated with the ageing population. There have been relatively few investigations into deaths in custody which have highlighted issues relating to dementia, but this will be a growing issue as the prison population continues to age. The number of prisoners affected is unknown, although the Mental Health Foundation has estimated it at approximately 5% of prisoners over 55 years old. If this is the case, there are likely to be several hundred prisoners with dementia.
46. The inmate population within HMP Parc is 1600, 64 of whom are 65 and over. Statistics for the general population indicate that 7.1 % of this age group will develop a form of dementia (1). The needs of this population are not being met by the current configuration of prison in reach services. Prevalence among those age 85 and above, for example, is likely to be considerably higher than estimates based on those age 65 and above. In addition, prevalence data are often categorized more broadly or more narrowly than "dementia."
Over 42,000 of people under 65 have dementia in the UK, 5.2% of the total population (3), which would suggest up to a further 75 inmates may have a form of early on set dementia.
47. It is highly likely that the prison regimes mask the onset or early signs of dementia. The ratio of prison officers to prisoners make it very unlikely that they would recognise early symptoms and there are no screening opportunities or primary services for dementia in HMP Parc. This does not fit with the wider community’s expectation of early diagnosis and support or that of Welsh Government Dementia Action Plan 2018-22. Prison staff need the support of psychiatric services to be able to manage needs appropriately and reduce anxiety and emotional distress where possible.
Section 5: If there are sufficient resources available to fund and deliver care in the Welsh prison estate. Specifically whether the baseline budget for prison healthcare across Local Health Boards needs to be reviewed
48. The baseline budget for health services within the prison estate does need to be reviewed. Working through the services and needs of the population and having working knowledge of where we need to improve it is apparent that often these are the areas that need additional resource to achieve the best service for prison health.
Section 6: What the current barriers are to improving the prison healthcare system and the health outcomes of the prison population in Wales
49. Technology can help with some aspects of healthcare. However, there are practical limitations to this – no telephones in consulting rooms; cameras connected to the computers to enable telehealth or skype consultation which are not compatible with the computers currently in use. This will need support from the prison and engagement from secondary care providers, but could be an opportunity to meet care needs whilst in the prison and would be more effective for some external practitioners time to enable them to complete consultations without the need for travel. It is hoped the awaited IT upgrade will resolve this issue.
50. Consulting rooms are not designed to an agreed specification resulting in inadequate size and number, poorly laid out, with restrictive access and without telephone access. The level of equipment is limited. Computers are dated and do not run up to date versions of browsers, limiting access to online resources for clinicians.
51. There is a National Prison IT system, which makes continuity of clinical records easier to maintain.
52. A national structure would provide continuity of services across prisons, learning from different services, and the development of minimum standards of care. This would aid LHBs in understanding what is required in terms of healthcare provision in secure environments.
53. Prison health services are reliant on the support of the custodial services to deliver all aspects of care. Prison staff shortages, overcrowding and prison lock-downs will have repercussions for the provision of care beyond the control of prison health teams.
54. In relation to Secondary Care Mental Health In-Reach, the current barriers are aligned with capacity and the lack of investment and resource that would improve the health outcomes of those patients under our care within the prison estates at both HMP Parc and HMP Swansea.
55. The Secondary Care Mental Health Prison In-Reach Team have sought peer review from the Royal College of Psychiatry, Quality Network for Prison Mental Health, in order to obtain a benchmark of standards to work toward and compare performance and best practice from other secure estates as to date, there are no standards of care locally or nationally. This would be useful to improve practice and patient experience.
2 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/673978/clinical_guidelines_2017.pdf
3 https://www.choiceforum.org/docs/hmpliverpool.pdf
[2] https://www.mencap.org.uk/learning-disability-explained/research-and-statistics/how-common-learning-disability
[3] https://www.parliament.uk/business/committees/committees-a-z/commons-select/public-accounts-committee/inquiries/parliament-2017/mental-health-prisons-17-19/