Bridgend County Borough Council response to the NAfW Health Inquiry into Health and Social Services on the Welsh Prison Estate.
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.
We think it would be timely if there was a review of the current arrangements for the planning of health and governance services for prisoners in Wales; any such reviewed guidance should take account of the fact that the prison in the Bridgend County Borough, HMP Parc, is run by G4S prisons services and that health services are subcontracted to G4S health services which are two distinct organisations. Arrangements for prisons managed directly by the Ministry of Justice appear clear in terms of governance and inspection arrangements, these rest mainly with HM Chief Inspector of Prisons and the Prison and Probation Ombudsman; and in terms of the devolved matter of health services, Health Inspectorate Wales, the regulator in Wales has responsibility for the inspection of services; however this is not clear in respect of the privately commissioned services within HMP Parc.
Current guidance appears unintentionally to exclude HMP Parc, for example the Supplementary Guidance to support the Code of Practice Part 11 of the Social Services and Wellbeing Act, states:
HMP Parc in Bridgend is a private sector prison. The commissioning responsibility for primary healthcare in this prison rests with NOMS in Wales and is delivered via their contract with the main operator of the prison. (P24)
Unfortunately what is not clear in the guidance is how these health services are to be regulated and inspected in Wales to ensure that any service benchmarks is commensurate with the services in the public sector prisons and in community services generally. It would be helpful if this could be reviewed and addressed.
The NHS (Wales) Act 2006 imposed a duty of co-operation on the NHS and the Prison Service with a view to improving the way in which their respective functions were exercised (Supplementary Guidance to support the Code of Practice Part 11:24); it would be helpful if the guidance could be amended to explicitly apply equally to primary and secondary health services delivered within private sector prisons and clarification made on who is responsible for the inspection of health services in HMP Parc.
In respect of safeguarding arrangements, additional guidance would be helpful in respect of roles and responsibilities of health care teams within the secure estate including those provided by private contractors.
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.
From a social care perspective we have observed and can evidence that current health provision in HMP Parc is not always meeting the needs of the detained prisoners when compared to some services in the community. This particularly relates to the services for prisoners with a diagnosis of dementia and to those who have a cognitive impairment. The national strategic intent for early diagnosis of dementia does not appear to have transferred to the Secure Estate. Prisoners who have cognitive impairment or dementia also do not receive comparable after-care services from the health service as they would in the community. There are also inequalities in accessing Neurological and Psychological assessments, as well as services for prisoners who have Personality Disorders. From our work in the prison we have observed that there is a lack of services available to undertake assessments and formal diagnosis for prisoners who may have Learning difficulties or who appear to be on the autistic spectrum. Not only do these lack of assessments adversely affect prisoners whilst detained but also in release planning to onward Local Authorities to ensure that appropriate services are accessed on release.
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 terms of social care provision, it has proved very challenging to recruit qualified registered social workers and an occupational therapist to the workforce to enable Bridgend County Borough Council to provide a prison based social services team. HMP Parc is an unique, established private prison in Wales that accommodates approximately 1,750 men and provides primary healthcare via private contract. The prison is a category B and C prison, the majority of prisoners are not on remand, and therefore tend to have long stays within the secure estate and at the prison; environmental constraints of the prison and previous lifestyle choices often impact on the health and well-being of the prisoners, and this has resulted in a higher than anticipated demand for social care support services.
The most effective means of assessing and care planning has been to locate a separate social care team within the prison; this team is managed from core Adult Social Care services. Historically, social work and occupational therapy in prisons have not been established career choices for those professions, and it has proved considerably challenging to find staff motivated to work in these settings. Having recruited, the vetting procedures protracted and keeping appointed staff motivated through that process has also proved challenging.
In terms of employing and contracting a workforce to deliver managed care and support services, BCBC have been limited to contracting with the private healthcare contractor within HMP Parc to provide social care. This is an extraordinary response to a very challenging situation whereby BCBC was not able to meaningfully deliver care by usual arrangements either directly, or with the independent sector because of the restrictions of the prison regime. Examples of these would be the lengthy security checks for personnel arriving at the prison, and the restrictions on entry between 7 PM and 7 AM; the lockdowns of prison wings for security reasons; and the need to access prison cells in pairs. All of this to deliver a service to individuals that potentially is required up to 4 to 6 calls per day. The health care provider in the prison can access the prison wings in a more timely way and does not have to access prison cells in pairs.
Unlike the community, access to an individual can be dependent on a number of factors outside the control of the commissioning body or provider. It would be financially prohibitive to consider employing a team of Bridgend Council care workers in the prison, as this potentially would result in there being periods during a day where no services were needed but the staff could not easily leave the site and return in time to deliver the next call. The Council could not also ensure the safety of their care staff, unlike the prison health staff who are specifically trained in security procedures and have radios and backup protocols in place when they enter prison wings and cells.
There is limited social work intervention for prisoners who have mental health needs, substance dependence and/or learning disabilities within the prison. However there is considerable input from the Social Work team for prisoners with such needs on release planning, ensuring assessment and plans of managed care and support are completed. This is to ensure that the receiving local authority is aware of and able to meet the needs of individuals on release where possible. The Social Care Team undertakes support with life skills, but we recognise that potentially much more work could be carried out with prisoners in respect of supporting release planning and consolidating life skills, if there were more occupational therapy in particular.
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.
HMP Parc has a separate residential block (3 wings) accommodating prisoners who are considered to be vulnerable; their vulnerability can be from other prisoners. Within this block there is a high ratio of older prisoners some of whom either have a diagnosis of dementia or who would be referred for screening for such if living in the community. There is no Primary or Secondary Mental Health Service specialising in Dementia and we have observed that the likelihood of other prisoners and or staff noticing that a prisoner might be beginning to exhibit signs of dementia is slight. The prison regime can mask some symptoms and it is not until the prisoner is very unwell might he be seen by the Prison Mental Health in Reach team (Adults Secondary Mental Health Care service). However, even if the latter occurs, the In Reach team does not currently have the expertise or capacity to work within this arena.
Our experience has evidenced a dearth of alternative secure provision for prisoners who should no longer be detained in HMP Parc because of the extent of chronic ill-health; examples we have observed is people who have been affected by advanced dementia and complex stroke. Even when the Ministry of Justice has granted compassionate leave there is a paucity of options available to support people where the Index Offence history includes sexual assault, and care homes approved unlikely to offer placements.
In working with very poorly, physically frail men we have found the prison environment an extremely challenging place to deliver care and support. For men needing hospital beds, hoisting equipment, specialist chairs etc., the challenges are considerable. Whilst the men might not need an acute bed in a hospital ward, the alternative is an ordinary prison cell on a wing with the equipment in situ; this can prove to be a very restricted space in which to deliver care. There is no hospital wing in HMP Parc, other than one room allocated as a palliative suite. Therefore, nurses are not to hand for general monitoring but carry out specific tasks in the cells from their base in the Healthcare Department. Bridgend Council staff have recently supported the Healthcare team in HMP Parc to explore the eligibility for NHS Continuing Health Care in the prison with the University Health Board. Currently, there are no clear guidelines of who is responsible for carrying out Nursing Assessments for prisoners who appear to meet the eligibility for NHS CHC; and this is especially relevant of the prisoner is at the end of life and wants or has to remain in HMP Parc until death. It would be helpful if this area of guidance could be reviewed
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.
As members of The Prison Health and Social Care Partnership, we are aware as a local authority that health stakeholders and members of the prison services have frequently raised the capacity of health services within the prison to meet demands. For example we understand that the Mental Health In-Reach service was commissioned to meet the needs of 720 prisoners; the prison population of HMP Parc is closer to 1800 men, and is clearly not adequate to meet current demand.
The increasing and ageing population within the secure estate is a significant issue for both the health service and the local authority. Given the category of prisoners in HMP Parc it is likely that the population of ‘older older’ adults is going to increase and with this the associated prevalence in dementia and frailty. This potentially places a disproportionate responsibility for the managed care and support of people within HMP Parc on Bridgend County Borough Council. We have analysed the cost of providing assessment and managed care and support within the prison, and it is considerably higher than the cost of providing equivalent care in the wider community; the impact is therefore disproportionately higher on Bridgend than authorities that receive prisoners back into their populations on release. We believe that the resources for health and social care within the secure estate in Wales should be aligned to the providing local authorities and health boards to ensure they are not unintentionally adversely affected by the location and population of prisoners in the secure estate in their communities.
What the current barriers are to improving the prison healthcare system and the health outcomes of the prison population in Wales.
There are a number of health care issues that the social care team have observed whilst working within the prison. There is not adequate provision for the screening for and delivery of ‘Secondary Mental Health’ services for people living with dementia. Similarly there is a lack of primary mental health services within the prison, as well as timely assessments for people with Learning Disabilities and on the autistic spectrum from Neurological and Psychological services. There does not appear to be any services for prisoners with personality disorders and there is no specific hospital wing within the prison, and this means that there are not nurses with the specifics clinical skills for looking after people with complex needs.
Another challenge is access to the prison health records which are recorded on SystmOne; these are required for holistic assessments for care and support, MAPPA planning, and the planning of the release of prisoners. Within HMP Parc, access to this system is restricted by G4S health services, in a way that the local authority has not experienced with local health services. The local authority has a WASPI compliant information sharing protocol with G4S prison and health services, and we believe we are fully compliant with Caldicott guidance and GDPR requirements. There also appears to be no consistency about who can access this system, for example the health board employed occupational therapist in the In-Reach team can access the system fully, but the health board employed occupational therapist in the social care team cannot.
When Bridgend Council started working within the prison we had full access to SystmOne, however this has now been restricted to a limited access via the health care team. It is totally unclear who the data owner is, for example whether it is G4S health services, the Ministry of Justice, or HM Prison and Probation Service; however this change in access has caused significant impediments to the local authority social care team discharging its functions in terms of the Social Services and Wellbeing Act and has had a significantly adverse effect on multidisciplinary working and relationships with the health care team.
We have sought clarity from G4S health services about why the access of the team has been changed, and we have not been offered any clear reason for this change; for example we have not been made aware of any incident or concerns that would have precipitated this change of access. In trying to find a mutually acceptable way forward it is clear that the interpretation of the GDPR guidance by the Caldicott Guardian in G4S health services is different to that provided by the local authority’s senior legal adviser. The issue for the Council is that we need to deliver robust multidisciplinary working and holistic approaches to the planning of care and support of prisoners, and if there is not going to be full access of relevant health and social care information, then protocols will need to be developed on how this information is shared going forward.
Jackie Davies
Head of Adult Social Care
Directorate of Social Services and Well-Being
Bridgend County Borough Council
8th May 2019