The Welsh NHS Confederation response to the Health, Social Care and Sport Committee’s inquiry into the provision of health and social care services in the adult prison estate.
Contact:	xxxx Policy and Research Officer
Date created:	May 2019

Introduction

1. The Welsh NHS Confederation welcomes the opportunity to respond to the Health, Social Care and Sport Committee’s inquiry into the provision of health and social care services in the adult prison estate. The Welsh NHS Confederation represents the seven Local Health Boards, three NHS Trusts and Health Education and Improvement Wales. We support our members to improve health and wellbeing by working with them to deliver high standards of care for patients and best value for taxpayers’ money. We act as a driving force for positive change through strong representation and our policy, influencing and engagement work.

2. This response will address to each of the inquiry’s Terms of Reference in turn.

Terms of Reference

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.

3. Health Boards work closely with prisons within their areas to provide a range of health and care services. Some Health Boards provide 24/7 access to primary care at prison sites, while others provide them for a period of 8.5 hours from Monday to Friday, with GP Out of Hours Services in operation outside of these times. In these cases, a GP is available either in-person or over the phone. On-site mental health services are also provided in some prisons during daytime hours. These teams consist of a range of nursing, medical and allied health professional staff.

4. NHS organisations also provide a range of additional services at prisons across Wales, including dental services, physiotherapy services, optometry services and sexual health services. Health Board nurses have undergone additional training programmes to meet the changing physical and mental health needs of the prison populations in some areas. These programmes include training in Blood Bourne Virus (BBV) screening, dementia, spirometry, diabetic foot checks/foot care, and skills for healthy nutrition. Some prisons also have a dedicated pharmacist who is also an independent prescriber of medications on-site for complex medication reviews.

5. In terms of governance and oversight, some Health Boards have established dedicated Partnership Boards to oversee the delivery of relevant Health Needs Assessments and inspections. In most cases, representation on these Boards includes Health Board Directors of Primary and Community Care, prison officers, Public Health Wales and the Independent Monitoring Board (IMB) among others. Particularly over the past two years, these Boards have supported a range of operational groups (some Health Board-led, some prison-led, some jointly-led) to develop relationships between Health Boards and prisons and deliver co-produced objectives. These groups report to their respective organisations’ governance structures.

6. With the duty under the Social Services and Well-being (Wales) Act 2014 to provide social services to prisoners, the effectiveness of current arrangements for the planning of social care is largely sufficient across Wales. However, Health Boards recognise that some flexibility is required on the part of local integrated teams and social services to respond to a changing profile of prisoners. For example, the anticipated ageing of the prison population means that Health Boards, Local Authorities and prison staff will need to work in partnership to assess the suitability of prison environments, individual care and support needs and the offer of meaningful activities for a changing population. Health Boards are confident that their existing governance arrangements are robust but recognise that the key challenge lies in the long-term planning of health and care services and ensuring that they are sustainable in the long-term, given the dynamic and frequently-shifting nature of the prison population in Wales.  

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 demand for health and care services in Welsh prisons is largely dependent on the length of sentence that prisoners in individual prisons are serving. For example, HMP Cardiff is a remand facility, and as a result, the majority of prisoners there are serving short-term sentences. Meeting all the health and social care needs of a population with such a high rate of turnover therefore can be challenging. In these cases, robust arrangements have been put in place to meet the day to day health and care requirements of prisoners, but Health Boards recognise that greater focus is needed on the long-term population projections of Welsh prisoners to ensure future sustainability.

8. Some Health Boards have undertaken quantitative and qualitative research in recent years to assess the extent to which the demand for health and care services in prisons is being met. In most cases, the findings of these projects have shown that the health needs of prisoners across Wales are largely being met. Despite this, Health Boards have noted that further work is needed around access to dental services and optometry. Access to these services has greatly improved since Health Boards provided additional resources in high demand areas.

9. Demand for social care services in Welsh prisons has been limited. Some Health Boards have been carrying out preventative work in this area, which has included the provision of training in activities and techniques deliberately offered to enhance physical and mental wellbeing e.g. mindfulness, yoga, supervised individual fitness programmes and social group activities.

10. Overall, there are no restrictions to the provision of health and care services in Welsh prisons. That said, some Health Boards are looking to deliver more interactive sessions to prisoners through patient education groups, health promotion days etc. Health Boards recognise that additional resource would be needed to deliver sessions of this nature but consider these initiatives a necessary step towards improving prisoners’ physical and mental wellbeing as a means of supporting their rehabilitative programme.

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.

11. The physical and mental health needs of Welsh prisoners is generally being met by existing services, with some resource also coming from in-reach services and hospital-based care. As mentioned, the prison population in Wales, like the wider Welsh population, is ageing and this brings with it a number of key considerations for the long-term planning of health services in prisons. For example, services to support prisoners living with dementia, chronic long-term conditions and pain management issues will increase in specific prisons with a higher number of prisoners serving medium to long-term sentences.

12. While health and care services are sufficiently staffed in Wales, some Health Boards have been required to support the core funding of prison nurses through additional investment around securing appropriate staffing levels. Prison nursing is not perceived as a ‘job for life’ and the average time between a prison nurse starting his/her role and leaving that role is three years. Furthermore, there is an ageing workforce within prison nursing. With a ‘flat’ structure, there is little career development, which is specifically cited as one of the key reasons for nurses leaving the service. Health Boards are investing in local workforce planning initiatives to ensure that team leaders are available to deputise for senior nurses when necessary, to allow for the senior nurse to become more involved in more strategic work. Health Boards recognise that part of the solution to this challenge is to make prison nursing a more rewarding career opportunity with clear lines of career progression.

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.

13. As mentioned, the prison population in Wales is ageing and this brings with it a number of key considerations for the long-term planning of health and care services in prisons. More generally, Health Boards experience specific challenges in relation to substance misuse, which is recognised as a growing pressure.

14. It is suggested that all prisons in Wales ensure that their infrastructure, policies and services are age-friendly and dementia-friendly. From a health perspective, this means adopting primary and secondary falls prevention strategies among other measures that can be delivered locally though multi-disciplinary teams.

15. In some areas, Health Boards and prisons have established closer relationships with the voluntary sector to develop an older people’s ‘hub’ for activities. Health Boards have welcomed these developments as timely expansions of resources, energy and ideas which provide a useful framework for developing similarly-targeted interventions for other vulnerable prisoner groups.

16. Greater focus needs to be placed on ageing well plans in prisons, particularly in relation to engaging prisoners with complex conditions in Advanced Care Planning. This needs to be done alongside palliative care pathways and in-reach palliative care services.

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.

17. The existing models of joined-up working between Health Boards, prisons and Local Authorities has meant that partners have achieved good value for money with existing resources. Health Boards and partners are committed to reviewing the provision of services as part of their long-term planning and sustainability work.

18. Despite this, Health Boards continue to operate in an extremely challenging financial environment, which has meant that additional funding to ring-fenced prison budgets has been utilised to secure appropriate nurse staffing levels and the employment of Healthcare Support Workers in a small number of cases.

19. In terms of developing projections of future costs, Health Boards are currently undertaking work to assess funding requirements of closer working with prisons and Local Authority partners. It would be useful if there were additional staff resource to provide health promotion training for the residents of prisons to support resilience training, coping strategies and self-care options for physical and mental health issues, where appropriate. It is also likely that social care budgets will need to be revisited as a result of the recently delegated resettlement functions, which may confer the need for additional social work resources in some Health Board areas.

What the current barriers are to improve the prison healthcare system and the health outcomes of the prison population in Wales.

20. While the existing models of integrated working between Health Boards, prisons and Local Authority partners are well-established, the main barrier to improving the physical and mental wellbeing of prisoners in Wales is linking the prison nursing workforce to wider ‘community services’, particularly District Nurses. Improved links between these groups would enable additional resources to be employed ‘inside the gate’ when the need arises (e.g. the management of palliative patients) and support care closer to home. Although this happens as the need arises, there needs to be further consideration of the total community resource over a 24-hour period.

21. Health Boards recognise that despite these challenges, there are also emerging opportunities to be realised that could be used to improve patient outcomes. These include increased use of telehealth/telemedicine (which could be used as an effective mechanism for reducing the number of outpatient appointments); improved communication channels between prisons, particularly for the purposes of medicines management when a prisoner is transferred from one prison to another; and a standardised IT system to support more targeted patient interventions. It is recognised that these challenges are consistent with the challenges that NHS Wales as a whole faces, which underlines the requirement that a whole-system approach be adopted to improving outcomes for prisoners in Wales.

Conclusion

22. Meeting the demand for health and care services for the prison population in Wales is a unique challenge that NHS organisations are working towards. Despite these challenges, Health Boards are working on a range of initiatives with prisons and Local Authority partners to deliver multi-disciplinary care on-site. The prison population often present with disproportionately high cases of substance misuse, drug addiction and mental health conditions, which Health Boards and prisons are working collaboratively to address as part of the rehabilitative programme. Health Boards recognise that challenges persist around the prison nursing workforce and are undertaking strategic planning work to assess the funding requirements of this workforce in future.