Health and Social care in the Adult prison estate– inquiry by the Health, Social Care and Sport Committee

A joint response by CAIS, Hafal, and WCADA

About us

Cais aims to empower positive changes in the lives of people affected by addiction, adverse mental health, unemployment, offending and other life challenges, through a range of services and support delivered by skilled and experienced staff and volunteers.

Hafal supports people with mental health problems - with a special emphasis on those with a serious mental illness - and their carers and families; we also support others with a range of disabilities and their carers and families.

WCADA provide a range of treatment intervention for those affected by substance misuse across Swansea, Neath Port Talbot and Bridgend. WCADA are also experienced in working across the Criminal Justice arena with Dyfodol workers in all of the Welsh public prisons and staff based within the Youth Offending Service in Neath Port Talbot and Bridgend, and Hillside Secure Unit, Neath.

The three organisations have drawn on their distinctive experience and perspectives to develop this response.

Comments on the inquiry’s areas of consideration

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

·  Parts 1, 2 and 3 of the Mental Health Measure are applicable in prisons and place statutory duties on all Local Health Boards (LHBs) and Local Authorities (LAs) in Wales. However, in our experience effective joint working has depended on local relationships and on local initiative and good will more than on national leadership. The result is great inconsistency and in many instances police and health staff still effectively work in isolation.

· For example, too often we see individuals leaving prison with no intention of linking with primary care service including local primary mental health support services or GP surgeries.

· Wales’ Mental Health Measure, alongside the distinctive Welsh Code of Practice for the Mental Health Act, prescribes holistic Care and Treatment Plans for people with a serious mental illness. This requirement forms a basis in law for care planning which is unique in the UK

· However, current practice falls short. In July 2018 the NHS Wales Delivery Unit published its National Report on The Quality of Care and Treatment Planning - Assurance Review of Adult Mental Health & Learning Disability Services. The report found that, although Care and Treatment Plans were widely now in place, “the quality of CTPs is generally poor. CTP outcomes are not routinely: specific, measurable, attainable, realistic and time-bound (SMART). As such CTPs outcomes are frequently not measurable…Importantly the Measure is not being used as the central document to coordinate and review treatment and care, nor are service users or carers being routinely engaged in the formulation of their CTP as the Measure intended. This is leading to frustration by staff and service users alike”

· Our own experience reflects this: we see some good examples of care planning but many people who have been detained do not have meaningful Plans and often receive minimal support

· We have observed particular problems with “revolving door” repeat detentions of individuals which requires special attention on a multi-agency basis

o We have seen this recently with a client released from prison, where treatment case with Mental health services were closed due to them going into custody as mental health staff were unaware that the person had been arrested and their case was closed as they missed an appointment. Their mental health was not followed up whilst in prison.   This has also been the case with his GP surgery and his medication was stopped due to him not picking up repeat prescription.  Due to lack of confidence and self-worth and the length of time it takes to get a GP appointment it has taken several weeks to get him to the GP.

o  We find very poor flow of information comes from prison when referring clients for services in the community on release.  A recent example; we had to send a referral back three times because they (prison health staff at Berwyn) were not fully disclosing risk details, they wrote on the referral ‘high risk of harm to others’ but did not give details.  We asked for more details and they sent the same form back still with no details about the high risk mentioned. This is typical of prison referrals in our experience it is not practical to arrange appointments in such a short time frame.

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

There is a high demand for H&SC services within Prisons across the UK, not just in Wales…

· In 2015, 32,000 incidents of self-harm incidents reported in England & Wales, this was a 25% increase from 2014.

· Between 2015/16 100 self-inflicted deaths, this was an increase of 27%

· 29% of 1,435 prisoners surveyed in England & Wales reported recent drug use and anxiety

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.

· 9 out of 10 prisoners in Wales have an either a diagnosable mental health or substance misuse problem and not infrequently these problems co‐occur. These are people that are often overlooked, seldom heard, and represent the most vulnerable in our society.  They are people who for many reasons tend not to access mainstream services and who often fall between gaps in existing services.

· In Swansea and Cardiff prisons around 35 – 50% of new receptions stay for less than one months and between 0-5% for over one year. The rapid turnover and short stays in the local prisons, i.e. HM Prisons Cardiff and Swansea, limit the scope of what can be offered to many prisoners by way of assessment and interventions.   All prisoners on reception are seen by Dyfodol staff, who provide harm minimisation information and advice and provide further interventions for those seeking support to address substance misuse issues.   Close partnership working with Dyfodol teams in the community ensure continuity of clinical and psychosocial care in the community on release.

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

· Following consultation with 300 service users, carers and interested professionals, our 2019 report Reducing Risk and Achieving Recovery found that individuals rated mental health and criminal justice agencies during the prison stage of the continuum as 2/5 (Very poor)

· Prisons were not geared up to help people with a serious illness. “I've been to prison many times and I have had no treatment for mental health. I can get the drugs to 'zonk' me out but not any counselling or treatment.”

· Welsh women are imprisoned in England because there are no prisons in Wales that are able to take female prisoners. Typically, evidence supports the view that Welsh women do not receive adequate support during their time in prison and, just as importantly, at the point of discharge. This perpetuates a ‘revolving door’ situation.

· After completing the prison sentence, getting back home to Wales can be complex, as many cannot be met at the gate by a familiar face and multi-agency liaison may be more difficult.

· The average distance from home amongst the total female prison population is said to be 60 miles

· There is a lack of suitable accommodation once someone leaves prison, the surroundings in which someone comes back to is often the reason for re-offending which in turn results in “the revolving door” syndrome.

· There is a lack of through the gate support for when someone leaves prison. If outside agencies were able to work with prisoners a good distance from release such as 3-6 months, then they would be better able to engage with prisoners which would assist with recovery on the outside. By introducing relevant services earlier into the process the prisoners have more chance of success on the outside. This in turn also alleviates the pressures on the staff working inside the prison.

The displacement of Welsh women to prisons outside of Wales results in a number of well documented problems. Increased geographical distance and cost of travel, clearly exacerbates the difficulties in keeping in touch and maintaining beneficial supportive relationships with loved ones, families and friends. Prohibitive costs of travel to England serve to hinder visits which become scarce, or sadly, non-existent

Other issues

· We have noted wide variation in consistency and quality across Wales in respect of both police and mental health services in relation to this issue.

· Given that 90% of the prison population have either a diagnosable mental health or substance misuse problem, the key issues affecting this client group are still prevalent and more likely amplified within a prison context.

o People with a serious mental illness such as schizophrenia or bipolar disorder have a life expectancy between 15 to 20 years lower than the general population.

o Cardiovascular disease is the single biggest and potentially preventable cause of premature mortality among people with a serious mental illness

o The prevalence of type 2 diabetes is two to three times higher for people who have a serious mental illness compared with the whole general population, and rates of undiagnosed diabetes are up to 70% in people with schizophrenia compared to around 25% in the general population.

o Weight gain is also a major issue for people with a serious mental illness, and is usually a major side effect

· We know that helping people with complex problems – especially co-occurring mental health and substance misuse problems – increases the challenge for effective joint working because this requires cooperation between professionals within health and social care as well as with the police. We are concerned that this client group may be disproportionately represented among those whose treatment falls short of best practice

· Improved staff training could also enhance safety and increase flexibility

· There should be recognition and a focus on the best practice which already exists: where agencies are cooperating effectively and resources are deployed efficiently clients are now receiving excellent support which keeps them safe, protects their dignity, and puts them on a pathway to recovery.   Examples of these are the joint Dyfodol/Healthcare meetings conducted weekly in the local remands to ensure the clinical safety of prisoners on release and also the information sharing system linking the community and prison Dyfodol.

Further information and resources

· Our web-sites: http://www.cais.co.uk/      http://www.wcada.org/ http://www.hafal.org/  

·  Reducing Risk - Achieving Recovery: An action plan for people with severe mental illness who come into contact with the Criminal Justice System  sets out  a broader range of short and long-term actions identified by service-users and carers with direct experience:  http://www.hafal.org/wp-content/uploads/2017/12/Reducing-Risk.pdf

· Jo’s Criminal Justice Survival Guide provides practical advice for service-users and carers: http://survivalguide.hafal.org/

Availability to provide further evidence

The three organisations are available to give further evidence including evidence in person; we also have service-users and carers with direct experience available to give evidence in person.