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Introduction
Betsi Cadwaladr University Health Board (BCUHB) welcomes the opportunity to contribute to the Health, Social Care and Sport Committee’s inquiry into the provision of Health and Social Care in prisons in Wales. This paper provides the Health Board’s written response to the areas highlighted by the Committee as part of their inquiry.
Overview of HMP Berwyn
HMP Berwyn is a Category C training and resettlement prison located on the outskirts of Wrexham, North Wales. HMP Berwyn opened in February 2017 and is the only prison provision in North Wales. The Health and Wellbeing services are provided directly by BCUHB and Adult Social Care provision is provided by Wrexham County Borough Council (WCBC).
HMP Berwyn will become a remand facility from 2nd December 2019 serving the North Wales courts. The remand provision is for approximately 100 men who have previously been remanded in the North West prisons, primarily HMP Altcourse in Liverpool.
The planned full occupancy of 2,106 has not been reached to date, current capacity at month end October 2019 was 1,584. However, the prison is planning to reach capacity in early 2020. Due to the nature of the ramp up there are a high number of men arriving at HMP Berwyn which creates an average of 154 receptions per month.
The age profile of the current population has been consistent since the prison opened with the majority of men within the 30-49 age range. The following provides a breakdown of the current population in terms of age demographics; there are 2 men over the age of 80 within HMP Berwyn at present.
BCUHB provides an extensive range of services on site to men within HMP Berwyn. These include:
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GP |
In and out of hours provision |
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Primary Care |
Service includes nurses, health care support workers and phlebotomist |
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Mental Health & Learning Disabilities |
Service includes psychiatrist, nurses, health care support workers, clinical psychologists, psychology assistants and practitioners |
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Integrated Substance Misuse |
Service includes both clinical and psychosocial with nurses, health care support workers, psychosocial practitioners, community practitioners and programme facilitators |
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Therapies |
Service includes full time physiotherapists, speech and language therapists, occupational therapists, radiographer and sessional dietician, audiologist and podiatrist. There is a contracted Optometry service which provides 2 sessions per week |
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Dental |
Service includes dentist, dental hygienist, nurses and support worker |
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Pharmacy |
Full pharmacy service including pharmacists, pharmacy technicians and pharmacy assistants |
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Additional sessional |
Sexual health service visit for 2 sessions per week |
There are approximately 135 FTE BCUHB staff within the Health and Wellbeing Service at HMP Berwyn representing a range of grades and professions, as detailed above. However, all posts are not filled at present due to a number of vacancies.
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A prospective Health and Social Care Needs Assessment was undertaken by Public Health Wales in May 2015 ahead of HMP Berwyn opening in February 2017. This was used by BCUHB to develop the service specification and delivery model of the Health and Wellbeing Services.
A full Health and Social Care Needs Assessment was conducted by Tamlyn Cairns Partnership in March 2019 commissioned by BCUHB to better understand the needs of the men at HMP Berwyn, two years since opening. The service specification is being reviewed in light of the recent Health and Social Needs Assessment to ensure that service provision meets the needs of the current and predicted population.
HMP Berwyn received its first Her Majesty’s Inspectorate of Prisons (HMIP) Inspection in March 2019 which reported that ‘the health provision was integrated and well led, and its quality and governance were very good overall’. The following shows the governance arrangements in place for the Health and Wellbeing Services within HMP Berwyn which provides good oversight by BCUHB.
The Health, Wellbeing and Social Care Partnership Board meets on a quarterly basis and is attended by all key partners including BCUHB, Her Majesty’s Prison Probation Service (HMPPS), Public Health Wales, Wrexham County Borough Council, Welsh Ambulance Service Trust and Welsh Government. The meeting is jointly chaired by the Prison Governor and the BCUHB Area Nurse Director.
Working relationships between key partners are robust and BCUHB and HMPPS work effectively to resolve day to day operational issues to ensure Health and Wellbeing services are delivered to the men at HMP Berwyn.
A monthly comprehensive Quality, Safety and Performance Report is completed in relation to the Health and Wellbeing Service at HMP Berwyn. This is discussed within the monthly Quality, Safety and Performance Group and shared with the HMP Berwyn HMPPS Senior Management Team and BCUHB Senior Managers with an aim of providing an update on the delivery of health and well being services at HMP Berwyn, identifying current performance, and highlighting any areas for improvement alongside any area of good practice.
Robust action planning is in place to inform service improvements following inspections, death in custody’s and serious incidents with reviews built into the governance arrangements.
The Health and Wellbeing Service review risks throughout the governance processes detailed and manage risks in line with the BCUHB risk management process.
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All men who arrive at HMP Berwyn receive a comprehensive, robust health screening which includes physical and mental health, alongside substance misuse history. All men within HMP Berwyn have been received from another prison but this is due to change with the introduction of remand men from December 2019.
Access to services is good, with men able to obtain an urgent appointment with the GP the same day and an effective out of hour’s service in place from the same provider which provides consistency. The therapies service consistently meets the Welsh Government Referral to Treatment Times (RTT) target of 14 weeks. The Dental team is currently the only service experiencing high demand and long waiting times due to the service not being in place when the prison opened due to issues with the build. This is resulted in extensive waiting times for a routine appointment, all parties are cited and working in partnership to resolve, the longest waiting time at end of October 2019 is 35 weeks since request for appointment.
The Mental Health and Learning Disabilities team utilise the Mental Health Measure and are monitored against their adherence to Welsh Government targets under Part 1 with all referrals received during October being assessed within the 28 day target. Compliance of men under Part 2 receiving care and treatment plans is not in line with targets due to significant vacancies within the Mental Health and Learning Disabilities team.
There is a current demand for therapeutic groups which are unable to be delivered at present due to vacancies for clinical psychologists. The recent Health Needs Assessment also identified access to counselling services as a need within HMP Berwyn.
All men within HMP Berwyn have access to national screening programmes in line with guidelines.
The delivery model and range of services provided within HMP Berwyn support men accessing health and wellbeing services in line with community equivalence as there is a reduction in the reliance on HMPPS to support escorting officers to external appointments.
There is an effective Peer Engagement Service in place within HMP Berwyn, supported by a Service User Engagement Officer, which is made up of four trained Peer Mentors. Their role involves conducting the Health and Wellbeing induction for all men arriving at HMP Berwyn, carrying out welfare checks on all men during their induction period and being able to answer any queries or resolve any concerns in relation to Health and Wellbeing services. This is either in person whilst on communities or via the Health and Wellbeing Helpline which is manned from 7.45am-3.30pm Monday to Friday by Peer Mentors. This service has been in place for one year and has been a well used resource by the men in HMP Berwyn with over 5,000 contacts made.
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Health and Wellbeing services within a prison are highly complex. Services within HMP Berwyn are 24/7 and although there are a range of services on offer, planned clinics are required to be cancelled due to staff responding to emergencies or alternative pressures from ‘core duties’ such as medication administration.
In line with all services within BCUHB, and nationally, recruitment and retention of registered nurses is an issue which has impacted on the provision of services at HMP Berwyn. HMP Berwyn have reviewed their staffing structure with a view to recruiting allied health professionals (AHP’s) and pharmacy technicians to compliment the nursing roles and ensure that the health and wellbeing services are delivered to the men, this has included utilising occupational therapists within the mental health and learning disability team and pharmacy technicians to support long term condition reviews.
Training and development opportunities have been plentiful for staff employed within HMP Berwyn which has aided retention to date, however as the service has been in place for 3 years with many staff in place since the opening of the prison, retention is now a challenge, particularly within the Mental Health and Learning Disability team.
Men accessing health and wellbeing services within a prison environment has added complexity due to the reliance on HMPPS to facilitate their attendance; this does impact on the number of men not attending their appointments. Within HMP Berwyn, the Peer Mentors are utilised to ascertain whether non attendance was due to prison operational issues or men choosing to not attend their appointments. Did not attend (DNA) rates are reviewed monthly within the Quality, Safety and Performance report and discussed at monthly partnership meetings with HMPPS colleagues.
Access to external secondary care services is good, although reliant on the prison operational team to facilitate access, either planned or unplanned. There are four planned appointments allocated escorting prison staff per day with emergency attendance in addition. Good working relationships have been formed to support additional emergency attendance when required, however there are instances where men do not attend their appointments due to prison operational issues. All non-attendances at planned hospital appointments are reported within the monthly Quality, Safety and Performance reports and to the monthly Local Health Delivery Group partnership meeting and quarterly Partnership Board.
Discussions are ongoing with the Emergency Department at the local acute hospital for key staff to access SystmOne, which is the prison clinical system and patient record. This development will support continuity of care and improved discharge information.
There are good working relationships with the BCUHB Palliative Care service and a secondment is being progressed in partnership for a specialist palliative care nurse to join the HMP Berwyn Health and Wellbeing team to lead on the implementation of the Dying Well in Custody Charter.
The physiotherapy service within HMP Berwyn have strong links with the community and acute BCUHB teams to avoid external appointments were possible, this includes triaging all orthopaedic referrals in house and working with the cardiac rehabilitation service to oversee all men following an assessment, reviewing and monitoring to avoid routine follow up appointments off site.
There are robust arrangements in place at HMP Berwyn in relation to release planning with all men released from HMP Berwyn receiving contact from a discharge co-ordinator 12 weeks in advance of planned release, organisation of referrals where relevant resulting in a personalised discharge summary and health promotion advice on day of release along with any required medication. There are challenges in relation to release and transfer, in that accurate and timely information is required from the prison to ensure that this process is completed.
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There are low numbers of older men at HMP Berwyn as detailed in the introduction.
Facilities within the prison environment as not conducive to caring for men with complex health and social care needs. There are a limited number of rooms which are classed as low mobility at HMP Berwyn, however following an assessment by the Occupational Therapist there are a number of changes required to ensure the room meets the needs of older men with complex needs. The inadequate facilities are included on the health and wellbeing risk register.
The lead physiotherapist within HMP Berwyn has developed a falls pathway based on the model in place within the community, to ensure that any men at risk of falls are identified and supported appropriately. The physiotherapy team work in partnership with the prison gym staff to support older men with walking groups and increased mobility exercises.
Adult Social Care services are provided by Wrexham County Borough Council and there is a process in place for BCUHB Health and Wellbeing staff to complete referrals for an adult social care assessment.
As detailed in section 2, any men that attend the BCUHB Cardiac Rehabilitation Service for assessment, are then monitored and reviewed by the in house physiotherapy team to avoid multiple follow up appointment externally.
Dementia friends training is available to all staff as two members of staff have completed the train the trainer course to facilitate delivery in house.
There are two audiology sessions provided on site per week, this supports men who require appointments in relation to hearing aids. There is an established process in place for hearing aid battery replacements which does not require an audiology input so is available at all times.
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All associated costs are fully funded by HMPS on a monthly basis as outlined in a Memorandum of Understanding (MOU). This agreement has been in place since the prison became operational. As part of the MOU, quarterly reviews are carried out in relation to funding to ensure all costs are captured and invoiced accordingly. As a result the allocated budget is under constant review. The MOU outlines a financial envelope of £9.5M for costs associated with healthcare at HMP Berwyn.
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Sufficient space for delivery of the Health and Wellbeing service is a barrier to improving provision at HMP Berwyn, there is currently a shortfall of office accommodation, clinic space and group rooms. Increased accommodation would enable the Health and wellbeing service to deliver a wider range of services to the men at HMP Berwyn.
Recruitment and retention of staff, particularly registered nurses as documented above is a significant barrier to improvement of services at present.
The delivery of health and wellbeing services within a prison setting are reliant on HMPPS colleagues, resulting in health and wellbeing services being impacted by issues beyond BCUHB’s control such as by prison staff shortages and regime issues such as lock downs and restricted movement.
Continuity of care is a challenge within HMP Berwyn but is echoed across the prison estate due to the unpredictable movement of men between establishments. This affects a number of men who have engaged with services for treatment which may not continue if the receiving prison cannot provide the same offer.
The Health Needs Assessment which was completed in March of this year has identified areas where provision could be developed further and is available on request.