1. BDA Cymru Wales is pleased to provide a response to the consultation on the provision of health and social care in the adult prison estate by the Health, Social Care and Sport Committee.The British Dental Association (BDA) is the voice of dentists and dental students in the UK. We bring dentists together, support our members through advice, support and education, and represent their interests. As the trade union and professional body, we represent all fields of dentistry including general practice, community dental services, the armed forces, hospitals, academia, public health and research.
2. 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.
The current prison system, as well as the differences in commissioning of care, can present further barriers for a population that already has a high need. The prison population often present with high
needs, as emergency and urgent cases, and access or following through with care as a prisoner
Is not always easy. The high turnover of prisoners in some institutions - particularly in remand
or short-stay institutions with short sentences or frequent transfers between facilities - mean courses of treatment can go unfinished. There is a need for investment in a national IT system to transfer dental information between prisons similar to the information system already established for general medical records. If dental records were linked to a national IT system, dentists would be able to access patients’ notes. This would enable a level of continuity of care and prevent duplication of lab work and radiographs. This would also reduce the overall time taken to complete the patients’ treatment plan. In 2013, Public Health Wales carried out an Oral Health Needs Assessment of the Prison Population in Wales1. Findings showed that the varied use of computer systems and the lack of secure email hinder the sharing of patient information between prisons. There is also a need for clarity on wait times and oral health care plans in the various prisons. It is difficult to discuss the effectiveness of current arrangements when so little information is available.
3. 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.
The Oral Health Needs Assessment of the Prison Population in Wales survey found that only 26% of prisoners surveyed felt that their dental health was good1. This is in stark contrast to the 73% who participated in the Adult Dental Health Survey who felt their dental health was good2. Dental pain was also much higher, with 28% of those surveyed in Welsh prisons experiencing dental pain compared with 8% in the Adult Dental Health Survey2. Of those prisoners surveyed, 55% felt that the inability to access a dentist as often as they needed was a barrier to having a healthy mouth1, indicating that healthcare services are not meeting the needs of prisoners.
4. 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.
In 2010, the BDA embarked on a project across the UK to gather evidence from prison dentists regarding the challenges of working in the prison environment. This survey showed that 64 per cent of respondents said they would like to receive more training particularly around security or clinical training relating to patients with substance abuse problems3. The survey showed that the oral health needs of those in prison differ greatly to the needs of the general population. Proper training is necessary for all dental staff to gain an increased knowledge on treatment of patients who misuse substances. It is also important to recognise that smoking is far more prevalent in prisons than with the general population, reportedly as high as 80%4. Smoking was considered to be the greatest barrier to oral health, with 63% of prisoners feeling this way1.
5. 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.
The proportion of prisoners aged over 50 has increased from 7% in 2002 to 16% in March 20185. In 2014, the ministry of justice published the analytic summary of the needs and characteristics of older prisoners: Results from the Surveying Prisoner Crime Reduction. This summary report discussed the experience of older prisoners, including that “prisoners aged 50 and over typically suffer from ‘accelerated’ ageing: a typical prisoner in their fifties has the physical health status of someone at least ten years older, and this difference is due to health and/or lifestyle factors (e.g. prolonged drug use) which arise both before, and during, imprisonment”5. This means that older prisoners are facing more frequent, and possibly complex, health problems due to the accelerated aging they experience.
6. 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.
While approximately 50% of prisoners in Wales attend the prison dental service during their stay in prison, problems with obtaining appointments are frequently reported1. As previously stated, 55% of those surveyed felt that the inability to access a dentist as often as they needed was a barrier to their oral health. Of prisoners screened for dental treatment need at HMP Prescoed, 80% were in need of treatment, and 35% required at least one tooth to be extracted1.
7. What the current barriers are to improving the prison healthcare system and the health outcomes of the prison population in Wales.
The Oral Health Needs Assessment of the Prison Population in Wales survey found that 94% of prisoners reported having some natural teeth, and that this is comparable to the wider population1. Of prisoners surveyed, 70% reported brushing their teeth twice or more a day. Public Health Wales felt that very few lacked the knowledge to look after their mouth1. The two most common oral health problems dental caries (tooth decay) and peridontal disease (gum disease) are preventable. It is concerning that prisoners are reporting good oral health habits and knowledge when only 26% felt their dental health was good. As previously mentioned, smoking and a lack of access to dental appointments are clear barriers to good oral health in prisons in Wales. Public Health Wales also reported that approximately one third of prisoners felt that their diet was detrimental to their oral health1.
A further barrier to oral health is that Public Health Wales reported that a large portion of prisoners may be without basic toiletries, including a toothbrush, for a period of time when they first enter prison1. As well as ensuring that services are commissioned to treat patients in prison, it is also important that prisoners are able to maintain their own oral health and are provided with the tools and knowledge to do so.
Communication between the dental service and patients also seems to be an issue. The National survey of prison dental services 2017 to 2018 looked into why prisoners in England, Wales and Northern Ireland miss their dental appointments. Almost 40% of dentists reported that patients very frequently or frequently miss their dental appointment due to being unaware or not receiving notification of said appointment6. Sixty-five percent of dentists were unaware when patients were transferred6. This lack of communication creates a further barrier to the prison healthcare system. Furthermore, missing appointments wastes precious dental appointment time. The survey found most prisons have 1 dental surgery on site (93%), and that one third of dental services in prisons are delivered by a single dentist at a particular site (38%)6. A further 36% have just 2 dentists, with only 10% having 4 or more dentists delivering care. Dental teams are also small, with 40% of dental services have 1 dental nurse working with them in the prison and 48% of prisons did not have any of the wider team members6. Dental resources in prisons are limited, so it is vital that barriers are addressed to provide the best dental care possible.
References
1) Wilson M (2014) Health and Needs Assessment of the Prison Population in Wales: Executive Summary and Recommendations Available: http://www2.nphs.wales.nhs.uk:8080/DentalPublicHTDocs.nsf/($All)/26F88A56A05D4ACE80257CBC0033A3DC/$File/Oral%20Health%20Needs%20Assessment-%20Prison%20Population%20of%20Wales%202013%20Executive%20Summary%20and%20Recommendations%2016.04.14.pdf?OpenElement
2) Chenery V, Treasure E (2011), Adult Dental Health Survey 2009- Wales Key Findings. NHS Health and Social Care Information Centre
3) BDA (2010) Prison dentist survey Available: http://www.bda.org/Images/prison_dentist_survey_report_sept_2010.pdf
4) Tomlinson J, Heathcote-Elliott C (2008), HMP Swansea Health Needs Assessment, Public Health Wales
5) Omalade S (2014) The needs and characteristics of older prisoners: Results from the Surveying Prisoner Crime Reduction (SPCR) survey. Analytic Summary. Available: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/368177/needs-older-prisoners-spcr-survey.pdf
6) White S et al (2019) Survey of prison dental services England, Wales and Northern Ireland 2017 to 2018, Public Health England. Available:
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/786782/Survey_prison_dental_services_2018.pdf