Publications on the internet
Defence Committee - Minutes of EvidenceHC 89
House of COMMONS
TAKEN BEFORE the
Tuesday 14 May 2013
Dr Seena Fazel, Dr Iain Brew and Professor Jennifer Shaw
Paul Grainge, Dr Stuart Ware and Gill Walker
Evidence heard in Public Questions 65 - 116
Taken before the Justice Committee
on Tuesday 14 May 2013
Sir Alan Beith (Chair)
Nick de Bois
Mr Elfyn Llwyd
Examination of Witnesses
Witnesses: Dr Seena Fazel, Royal College of Psychiatrists, Dr Iain Brew, Royal College of General Practitioners, and Professor Jennifer Shaw, Offender Health Research Network, gave evidence.
Chair: I apologise for the delay in starting this part of the session. We had some other business we had to complete. Can I warmly welcome Dr Seena Fazel from the Royal College of Psychiatrists, Dr Iain Brew from the Royal College of General Practitioners and Professor Jennifer Shaw of the Offender Health Research Network? We are really grateful to have your help in the work that we are doing on older prisoners, which has taken us to a number of prisons, so we have been looking for ourselves at the situation. We want to look particularly now at their healthcare needs, and I am going ask Steve Brine to open the questions.
Q65 Steve Brine: Thank you very much, Chair, and thank you very much for coming. Good morning. Starting with the RCGP, could I just ask you, in your view and your experiences, how do you think the healthcare needs of older prisoners differ from their counterparts in the community and from younger prisoners?
Dr Brew: It is well recognised that older prisoners are biologically older than their counterparts outside, often because of social exclusion that has been longstanding and poor engagement with healthcare services when they are in the open community.
Q66 Chair: That is measurable and measured, is it?
Dr Brew: It is certainly anecdotal. Whether it has been measured I would not like to say, but it is certainly observable. I have personal experience of seeing this in my practice, which goes back over 12 years. Comorbidity is a big problem. People will tend to have several health problems and these may well be compounded by poor self-care. They may well have had self-care issues outside as well. My practice is in Leeds. We have several older homeless chaps who come in on a regular basis, so they are not really able to access healthcare outside and their self-care is poor because of their homelessness. These things all compound each other.
Q67 Chair: Would anyone like to add to that?
Dr Fazel: Yes, if I may just add something. It has been measured, so people have done surveys where they have compared chronic illnesses-physical illnesses and also mental illnesses. But, if you take physical illnesses, people have compared the rates of physical illness reported by older prisoners and also documented in their medical records and compared them with people of similar age and similar gender who live in the community. It is a little bit difficult to make the comparison exactly like for like, but, as well as people can do, it is probably about double the rate of physical health problems. For instance, if you take any chronic illness, a survey done in the UK-it is a bit old now; it is about 10 years old-found that about 85% of men over the age of 60 in prison reported a chronic health problem. If you look at surveys of other people in the community of a similar age, you tend to find 20%, 30%, 40%; so you do find some disparity in physical health problems. The same thing has been found in the US, where there are two or three quite good and large surveys of physical health problems.
Professor Shaw: I don’t know if you wanted to go into the mental health as well.
Q68 Steve Brine: We will come on to that. I am mostly interested in what the prominent healthcare issues are conditions-wise, but if you have any thoughts on that, please chip in.
Professor Shaw: I have nothing else to add.
Q69 Steve Brine: Just going back to Dr Brew, you talked about comparables. We were on the Isle of Wight recently and the number of older prisoners is set to increase, partly because of advances in technology, which bring people to prison many years after the offence. There is quite a lot in the news at the moment about this. They could have been leading perfectly normal, healthy lifestyles on the outside, and then they come on to the inside. They don’t suddenly then develop chronic conditions, so does that challenge what you said at first?
Dr Brew: Yes, there are two populations. There is the prison population who have been in and out over many decades and have aged through the criminal justice system, as it were, and then, as you quite rightly say, there are people who have been living relatively normal lives and come in later. Both groups exist; there is no doubt about that, and I see them on a daily basis. Increasingly, over the last decade or so, you are absolutely right-there are people who are coming to justice many years after their offences, but they also bring in a number of health problems in the same way. It is important to bear in mind the two types of older prisoner.
Q70 Steve Brine: What do they bring in? Could you just give us some examples?
Dr Brew: You may well have patients who are type 2 diabetics, who have heart disease and lung disease from smoking and so on. The comorbidities all come together and make it a challenge to look after people. This is where social care gaps come in. People are not able to care for themselves because of their conditions.
Steve Brine: We will definitely come on to that. I think we will move on, Chair, because you have a lot to get through.
Q71 Jeremy Corbyn: Could we turn now to the issue of mental illness? Evidence seems to suggest that the rate of mental illness among older prisoners is much higher than the equivalent cohort in the community. I would be grateful if you have any information on that. Secondly, are you confident that there are enough people working in the Prison Service who have any knowledge or experience of issues such as dementia and psychological disorders among older people, and are there issues there that need to be addressed?
Dr Brew: There are probably people who are better able to comment than I, but I would say, yes, there does need to be more provision. We have had, for the last 12 years or so, mental health inreach teams, which are the secondary care provision, coming into prisons. Increasingly now we are getting primary care mental health nurses coming in, but their expertise may well be in substance misuse and learning difficulties. Getting someone who has extensive experience of dementia can be quite challenging. We diagnose dementia not infrequently, but I am sure there are cases that are going under our radar because we are not specialists in that field. I am sure that you are right that there could be more provision.
Dr Fazel: In terms of rates of mental illness, the particular mental illness that differs is depression. Rates of depression in older prisoners are probably about three times higher than the equivalent age and gender equivalent person in the community. Compared with younger prisoners, it is also higher. That would be the one illness that stands out. There have been a number of studies, including a recent study, that has confirmed that. In terms of other mental illnesses, the rates are not dissimilar to younger prisoners, apart from dementia, where it is not certain, but it may be around 1% of older people in prison who have dementia. That is not different from an aged-matched community group.
So it depends partly on your comparison. Compared with people in the general population of similar age, they seem to have higher rates of depression; compared with younger prisoners, you also have higher rates of depression and obviously higher rates of dementia.
Q72 Jeremy Corbyn: In your experience do older prisoners, when they come in, suffer from the same levels of mental illness conditions in the general sense and does it get progressively worse in prison, or are they already in a pretty difficult state before they arrive? Have you any way of assessing that?
Professor Shaw: We did a study not specifically on older prisoners looking at what happens to mental health as you go through prison. What we found, interestingly, was that all types of mental health problems improved in prison, but this was all ages and not just older prisoners. As far as I know, there has not been a similar study in older prisoners to see what happens to their mental health over time, but that was a general study that we did. There were significant improvements in people’s mental health in prison. We put that down to the fact that people often live quite chaotic lives in the community, but when they come into prison they have some stability and healthcare-perhaps for the first time-and, therefore, their mental health improved, but I cannot comment on the older people.
Q73 Jeremy Corbyn: The three of us went on a visit to Dartmoor two weeks ago and, clearly, some of the prisoners were totally traumatised at being brought in at all. They had been brought in for offences committed 30 years ago in some cases and they had recently arrived. What I observed-I don’t know if my colleagues would agree-was that there was a sense of community among the older prisoners that possibly would not have existed in their lives outside prison in the same way. I thought that there were interesting contradictions almost in their behaviour.
Professor Shaw: That is quite variable. Certain prisons have older prisoner wings. We have one in the area where I work in the NHS in Wymott prison and there, definitely, you get a sense of community. But in our recent study we did it in several prisons, some with few older prisoners. That was a very different picture.
Q74 Nick de Bois: Professor Shaw, I note that you were the chief investigator for a National Institute for Health Research-funded study that investigated the health and social care needs of other male adults in prisons. Were you able to give us an assessment or draw a conclusion as to what extent prisoners receive an equivalent level of healthcare to that which they would expect in the community? Are you able to do that?
Professor Shaw: Yes. The study that we did looked at various aspects. The aim of the study was to develop a screening instrument for health and social care needs for older prisoners, but, as part of the study, we did a national survey of health and social care provision in all prisons that had older prisoners. The most striking finding was that staff reported that there was a virtual nonexistent provision of social care and that was the main and significant problem, because, while most people had older prisoner leads, there was a problem with health and social care policy that only about half of the prisons had one, and they said the particular problem there was the social care bit of that. That was the most striking thing from the national survey. In terms of equivalence, we looked at needs and provision of care, and we found, similar to Dr Fazel’s study, that there were high rates of depression. What was striking with that was that only one in five of the people who had depression were on antidepressants and only one in six were in contact with the services.
Q75 Nick de Bois: How does that compare-presumably unfavourably-with what you would find in the community?
Professor Shaw: Yes; it is worse.
Dr Fazel: It is a little bit worse. The study that I found is that one in four people in the community who are older people in the community with depression are-
Chair: Could you speak up a little because the acoustics in this room are not very good?
Dr Fazel: Yes. We did a similar study where we looked at how many people with depression in prison were getting antidepressants, and it was one in five. At the time that we did it, we had a look at the equivalent study in the community and it was one in four. So it is a little bit worse in prison, but there still is a huge unmet need. Three out of four prisoners with depression are not getting adequate treatment.
Q76 Nick de Bois: In the study, did you look at how consistent older prisoners’ access to healthcare and prescriptions was, and did you examine or make any recommendations as to how this could be improved? Is that an area that you looked at?
Professor Shaw: Yes. We did not look at consistency between prisons. That was not something we looked at, but we did make recommendations. The tool that we developed, which is delivered by prison officers, was designed in conjunction with older prisoners, and we felt that would be useful to try and detect some of these mental health and social care problems.
Q77 Nick de Bois: That was a tool you used to make an analysis in a prison.
Professor Shaw: This is what we developed as part of the study, and we now have further funding to do a randomised control trial-
Nick de Bois: To roll it out.
Professor Shaw: To see if it works.
Q78 Nick de Bois: Dr Brew, we saw a quite extraordinary difference. We had an older persons unit at HMP Parc, which was basically saying it couldn’t be faulted; it was fantastic. Elsewhere, it was far from it. Have you drawn conclusions from your work in Leeds? Are you able to draw any comparisons as to how consistent across prisons older prisoners’ access to healthcare is-and prescriptions particularly?
Dr Brew: The variability around the country is not that surprising when you take into account the different types of prison. HMP Leeds, for instance, is a large category B local prison, so it is for short sentence and remand prisoners, with a churn of 6,000 people a year, with a roll of 1,200. In other words, each space is churned five times. We have a considerable number of older prisoners who are a bit stuck at Leeds, because some of the other training prisons that they would be going to are full with long-sentence people already. In a very busy category B local, you are going to have the primary health need being substance misuse and alcohol. Most of the energy is directed towards the treatment of those issues. We have developed a team of nurses who deal with longterm conditions-lifelong conditions. Probably the majority of our healthcare contact with older prisoners comes through that group, and they will involve me, as the GP, in directing the care of these people. That has been a big change in allowing us to deliver decent care that probably is equivalent. But you are right-there will be a huge variation around the country.
Q79 Nick de Bois: Can I just press you on one point because that sounds very encouraging? Do you, therefore, have more effective liaison between the prison healthcare staff that you have described working well, and the nursing staff particularly, and the healthcare staff in the community-you sound like you were very local-based, so they may have come from local practices if they had healthcare before-when they come out of prison? Do you think you are getting joined-up healthcare through their journey before, through and after prison?
Dr Brew: We are doing our best to achieve that, but when we ask for information from local GPs, because the two computer spines are not linked, we often get a single sheet of paper, which is the whole medical record, even for someone who has complex needs.
Q80 Nick de Bois: If you need to follow up, are you getting frustrated? Let’s face it-that happens now, sadly, whether you are in prison or not. Do you find that cooperation is less attentive because you are working in a prison with older prisoner self-care needs, or is it pretty much what you find everywhere?
Dr Brew: It is getting better and better since 2004, when prison healthcare commissioning was passed to the NHS. There is a lot more collaboration now than ever there used to be, and it is improving. This is not just a Leeds thing; this is national. The Secure Environments Group at the RCGP often discusses this and the push towards getting the NHS IT systems to merge. The resistance is from NOMS, primarily because of security and some very high-profile people. We wouldn’t want to know where they are.
Nick de Bois: That is interesting.
Professor Shaw: Also, can I just say a little about discharge? It is a massive problem. Again, we did a study, not in older prisoners but in all prisoners, and found that of people who had been under the care of mental health inreach in prison, which is the equivalent of secondary mental healthcare in the community, we had 100-odd of these people who are under inreach, and on discharge only four got plugged in to services in the community. These were people with severe mental health problems. So, out of 100, it was only four. I think it is a massive issue.
Q81 Mr Llwyd: Professor Shaw, the memorandum that you sent about unmet needs is very interesting. Are you aware of the evidence that we received from Leigh Day, a firm of lawyers that specialises in dealing with complaints made my prisoners? I will just very briefly refer to one or two points they picked up on. They are: failure to assess health problems on arrival at prison; failure to contact the community GP and get the notes; delays in seeing nurses or the GP while in prison; and, finally, transfers to other prisons when they then miss the connection with their consultant who is supposed to be dealing with them and thereby they fall down to the bottom of the list in another place. What do you think is the reason for this sort of disconnect? Is it because there is a stand-off between the prison authorities and the NHS, or is it a problem of thoughtlessness? What is the reason for this?
Professor Shaw: To answer that in this way, our study looked at needs of prisoners, and, again, it agrees with several of the points made by your previous expert. One of the main unmet needs-we use a standard measure of needs-was for information received by the prisoners. They felt there was a massive problem. They were not informed about what was going to happen to them about transfers, moves around and things like that. That, to them, was the biggest problem, which kind of agrees with what you said. The other ones were psychological issues and activities. In terms of what that is about, I don’t think there is a purposeful disconnect between prison staff and the NHS. The point of the prison is for security mainly and that is the overarching goal of the Prison Service. Therefore, at times it is very frustrating working in prisons, because you are treating somebody and they get moved. I don’t think it is a purposeful thing; it is just dealing with security issues or having to move people around for accommodation issues.
We do try to hold people. If we are treating them we can put on a medical hold, as it is called. That is quite often effective at getting the prison to keep somebody who is going through treatment-but not always so. It is a definite area that we need to work on because it causes enormous problems for prisoners. Particularly if they are quite troublesome prisoners, they tend to get moved all the time, which is probably the worst thing that could happen, because in a way you want them to have some stability, so you can get to the problem. We are constantly, on a local level, trying to work with our own prisons on this, to get them to keep hold of people, particularly if they are going through a period of treatment. Anecdotally, we are getting there a bit, but it needs much further attention.
Q82 Mr Llwyd: We visited Dartmoor a few weeks ago, as you have heard. I have to say that the staff there were very caring and committed to the work that they were doing, but, in general, would you say that there needs to be more raising of awareness among staff of this particular issue and perhaps some additional training?
Professor Shaw: Absolutely. That is what the problem is. It is raising awareness of how damaging it can be if somebody is undergoing treatment, has a relationship with a particular inreach team in my field of mental health, and then they get moved and they get moved again. It is very difficult to keep that engagement. We are always trying to raise awareness of that on a local level, but nationally it would be very useful.
Q83 Mr Llwyd: Do you find, in your experience, that staff are perhaps reluctant to prescribe medication or to take prisoners to hospital because of possible security issues and so on?
Professor Shaw: I suppose I can only speak anecdotally from the five prisons in my patch. Actually, I don’t think that is the case. We have been looking at this in our services recently. The numbers of people going out to outside services, both for outpatient appointments and emergencies, is actually quite high. There doesn’t seem to be any blockage in taking people out. It is very expensive and we are looking at more cost-efficient ways of doing that. I don’t think that seems to be a problem, but I can only speak for our five prisons on that one.
Q84 Gareth Johnson: I have a question for all of you about the lack of a national strategy when it comes to dealing with the healthcare of older prisoners. It seems at the moment that it is left very much to local prisons and equalities legislation to look after this. Do you think, taking into account the fact that we have new commissioning arrangements, that there should now be a national strategy dedicated to looking after the health needs of older prisoners? Who wants to go first?
Dr Brew: Yes.
Gareth Johnson: Yes; thank you. Why is that?
Dr Brew: It is unclear how the new commissioning arrangements are going to play out just at the moment being so early on, but there is an opportunity with a lower number of commissioners around the country to get more consistency around England in prison healthcare. We know that the older prisoner population is rising; it has doubled in the last decade. We project that it is going to go further, as far as I understand, and this is a very complex group. So, yes, some national guidance would be very much appreciated. Clare Gerada, the chair of the RCGP, commented yesterday-this isn’t just about prisons; this is about older people in general-that, if properly resourced, better joined-up working between GPs, secondary care and social care can deliver better health and wellbeing for our elderly patients. That definitely speaks to prison healthcare. So national guidance and a way of delivering reliable social care in the prison setting would be excellent, yes.
Dr Fazel: The Royal College of Psychiatrists would support a national strategy. Researchers have been calling for this for over 10 years now, so it is something that people have highlighted previously. Part of it also comes out of the fact that some prisons will inevitably have fewer older people in them and so they will not have the opportunity to develop expertise. Therefore, having a national strategy will enable minimum standards to be set; even things like thresholds for when you treat or admit someone or move them to a hospital could be quite helpful. We see that in the rest of medicine. If you have basic guidelines, that tends to generally improve the quality of treatment. But at the same time that needs to be audited. So, after a year or two of the new national strategy, there needs to be a cold, hard look at to what extent it has been implemented and whether it has actually improved outcomes.
Q85 Chair: Do we take it for granted that there would automatically be a national strategy because it is now the NHS Commissioning Board, not local primary care trusts and not the clinical commissioning groups who will be commissioning prisoner health services? Are you assuming that it just follows that they will have to have a policy because it is a national body anyway?
Professor Shaw: I don’t assume that. It should definitely follow, yes. It makes sense to; I agree.
Dr Brew: With NHS England, I know the commissioning board are going to be informed by clinical reference groups, and clinical reference groups will hopefully have this on their agenda. If they don’t, they should.
Q86 Steve Brine: Briefly picking up on the Chair’s point, everybody is aware, of course, that prisoner healthcare is commissioned through NHS England. Very interestingly, I was talking to NHS England Wessex yesterday, in the area that I represent. We have quite a lot of prisons in Hampshire, in the Wessex area, and prison healthcare services are being commissioned by the Thames Valley structure across the entire Thames Valley/Wessex region. It is quite a big regional reach. Therefore, does that not give you confidence that there is a more overarching picture instead of just local commissioner groups looking at this?
Dr Brew: I said earlier that we are reducing the number of commissioners from around 80 to more like 10.
Q87 Chair: Hang on a minute. Aren’t you reducing the commissioners from 80 to one in respect of prison healthcare?
Dr Brew: Yes. There is one overarching commissioner, which is NHS England, but my understanding is that that is then going to be devolved to local teams, and 10 local teams are going to be involved in commissioning prison healthcare. I would agree with you that reducing the number of commissioners can only improve consistency, but the clinical reference groups will have to have older prisoners’ health needs on the radar for that to work.
Q88 Steve Brine: To be clear, the Royal College of GPs did not support the Health and Social Care Act reforms, which this is now ushering in.
Dr Brew: I am here on behalf of the Secure Environments Group of the RCGP, which is the national hub for prison GPs. I am not well placed to comment on what the RCGP may or may not have said about healthcare reforms.
Q89 Chair: On a related point, we found it quite shocking that nobody seemed to be taking responsibility for the social care of prisoners who could not perform basic functions because of their medical condition. This was not something that prison officers were trained to do or allocated time to do. There was no consistency and very little actual positive experience, so far as we could see, of a system to make that provision. Is that impression mistaken or correct?
Professor Shaw: No, that is correct. From the national survey, it was the most striking finding. Local social services will not provide services for the prison in their area. There is all this argument about whether it should be provided by social services in the place where the person comes from or where the prison is, and nobody ends up doing it, which is very problematic.
Q90 Andy McDonald: Can I ask you about end-of-life care? We have evidence from the Prisons and Probations Ombudsman that he found in an investigation into end-of-life care that the majority of prisoners with foreseeable terminal illnesses-54% of them-died in hospital, a quarter died in prison and 15% died in a hospice. Of those that died in prison, 73% died in a healthcare centre or in their cell. There have been improvements, but it was also found that a third of prisoners didn’t have a palliative care plan in place. I just wondered, in your experience, what your view was as to whether it is possible to provide effective palliative care in prison.
Dr Brew: I was lucky enough to spend five years working in hospital as an oncologist-a cancer specialist-so I came into prison medicine with quite a good understanding of palliative care. I have been involved in the palliative care of probably 15 or 20 prisoners over my 12 years working in prisons. My experience is that we have been able to deliver very good care with the involvement of Macmillan and using their Gold Standards Framework previously.
In 2011, the National End of Life Care Pathway was introduced with a special prison version, and that is being rolled out increasingly around the country. But it is interesting that you speak about the Prisons and Probation Ombudsman. One of my other roles is to do clinical reviews of cases, and I have done several where palliative care has not been very well managed. It is to be hoped that the National End of Life Care Pathway prisons version is going to lead to improvement. People are much more aware of palliative care, but it is a specialist field and the expertise is not necessarily in place. You have to bear in mind that an awful lot of prison nurses have not come from primary care in the community; they have come from hospital jobs previously, and they may not be very familiar with caring for patients in the community setting. So that is a matter of training. As I say, I hope that the National End of Life Care Pathway will lead to improvements around the patch, but there is certainly space for improvement.
Q91 Andy McDonald: Moving on from that, do you support an increase in the use of early release on compassionate grounds, because we have heard from witnesses that that really ought to be expanded in the case of terminally ill patients? Does anyone support that in principle?
Dr Brew: Again, yes, absolutely. It is part of my care planning for anyone who has a terminal disease to look at the possibility of either compassionate release or release on temporary licence. Governors are understandably very risk-averse when making their decisions about releasing patients, and it has to be recognised that with some older prisoners, particularly those who have been guilty of sexual offences, the risk goes on until they are completely immobile. While, yes, I am in favour of making the application, it is understandable that quite often those are rejected.
Q92 Andy McDonald: Do you think the balance is right between the security and compassionate grounds? Do we have that about right?
Dr Brew: My personal experience would say that governors are a little too risk-averse.
Chair: Thank you very much. We are very grateful to the three of you for your very helpful evidence this morning. Now we have some further witnesses. Many thanks.
Examination of Witnesses
Witnesses: Paul Grainge, Lead Capacity Building Consultant, RECOOP, Dr Stuart Ware, Director, Restore Support Network, and Gill Walker, Chair of the Older People in Prison Forum, gave evidence.
Chair: Welcome, Ms Walker, Chair of the Older People in Prison Forum of Age UK, Mr Grainge, Lead Capacity Building Consultant for the charity RECOOP, and Mr Ware, Director of the Restore Support Network. We are very grateful to you for coming in today and giving evidence in this inquiry. You have been listening to the proceedings so far. I am going to ask Mr Brine to open the questions.
Q93 Steve Brine: Thank you very much, Chair, and welcome. This is for any of you to start; by all means fight it out among yourselves. In your experiences, what do you think are the main priorities we should have for supporting older prisoners, both inside prison and then on their release?
Gill Walker: The priority has already been alluded to, to some extent, with regard to the need for a policy or a national strategy, with policies and a framework that work, so that initially, when prisoners come into prison, there is a full assessment for both healthcare needs and social care needs and this is also reviewed. Once that is in place across the board-there isn’t really the consistency within the Prison Service-this would certainly help. The need for social care is evident, with a range of activities and social care generally, right through to resettlement and rehabilitation through the gate. So there is a whole range.
Q94 Steve Brine: That would be a very good moment to ask Dr Ware to come in, because through the gate is what you are partly all about, isn’t it?
Dr Ware: Yes. I support the concept of a national strategy, from our experience, especially being involved with the Isle of Wight project, because at the lower level you have the professions that are getting on with their job, but they work within their boxes. What we have found, and we have found in other places, is that, if senior management and commissioners are involved and there is a national strategy, there is a top down where it is led and there are instructions on how to deliver their boxed services that involve liaison between the other disciplines. One of the biggest failures I find is that some disciplines do not connect with another discipline. So you have healthcare and local social services, and you have the Prison Service even within a prison not communicating because they have their own remit. There is a need for a national strategy to drive it down from the top, from Government Departments. I like "Transforming Rehabilitation", where it mentions about Government Departments working together and then driving it down through the commissioners into the local services. If that is missing, then you are going to continue to have problems.
Q95 Steve Brine: That would be through NHS England and its regional directors.
Dr Ware: Yes, but making sure that the connections with the new police commissioners, crime and prevention commissioners, and local authorities all link up. If they don’t link up, they are going to be protecting their own budgets and their own services, and I am afraid that older offenders will end up falling between the gaps.
Paul Grainge: In addition to the healthcare and social care problems that have already been mentioned, the meaningful activity for the older cohort is very important, certainly for us. We are finding that in the majority of prisons the regimes are geared up around education and vocational training to get the younger majority into employment, but for the older cohort there seems to be very little meaningful activity for them to keep up the maintenance of their practical, social and personal skills. We have seen in a number of prisons, limitations in what is being delivered, and restricted to carpet bowls or dominoes, at the worst extent. In some prisons, there are some great services being provided, and I know you have seen some of the good work that is going in Dartmoor. Providing an environment where they can maintain some of those social skills and keep themselves mentally stimulated is an integral part before they get ready for that resettlement stage and preparation for release, so that they can carry that forward and ensure that they maintain that independence perhaps to live in the local community when they move out, successfully.
Q96 Steve Brine: You work in partnership with Dr Ware’s organisation, do you not?
Paul Grainge: Yes, we work very closely with it.
Q97 Steve Brine: Do you share Dr Ware’s enthusiasm or optimism for the "Transforming Rehabilitation" proposals that are winding their way through Government at the moment?
Paul Grainge: I do. What I have read and the fact that we are going to be picking up and supporting those who are serving less than 12 months is a great move. I am conscious that the older cohort has not been defined as a specific group, but I am also conscious that there are very small numbers of older prisoners being released. But the level of crisis they have is huge, so that would be an area of concern. The identification of the resettlement of prisoners three months before-
Q98 Steve Brine: Do we know the number of older prisoners, as in over 60 by our category, or over 70 by the category that some prisons define them as, which is slightly awkward, who are released inside 12-month sentences?
Paul Grainge: I don’t have that information, I am afraid.
Q99 Steve Brine: It would be interesting, if you did come across that information, to feed that into us.
Paul Grainge: It would be really helpful, particularly if we are looking at the new single rehabilitation activity and attendance centre orders, to look at increasing the work and specific services around the older cohort, because, if we could perhaps divert some of those at an earlier stage so that accommodation isn’t problematic and social isolation1, then that would be a huge step and an area of interest.
Gill Walker: Obviously, most of the initiatives look at older offenders from the age of 60, but there are quite a number from the age of 50-another 3,000 or so-and they may be approaching 60. I don’t know where they are within the ages of 50 to 59, but clearly, from what we have heard previously, many older offenders present themselves being much older than you would find in the community. The 3,000 who are there currently are a significant number in the 50 to 59 age group. I just mention it in passing.
Q100 Steve Brine: That is a very good point. Do you think we have it right with our 60 as the older-
Gill Walker: From an Age UK point of view, we would focus on 50-plus for those reasons-very much so.
Q101 Andy McDonald: It seems to me the consensus is that 50-plus is the age range. We did actually see an 83-year-old, who was a new arrival, who was very sprightly. Could I ask Dr Ware about the common assessment framework, because we visited the Isle of Wight as part of the inquiry? I am just interested to know from your research into the project what lessons you think might be learned to correct some of the failings in social care that some witnesses have told us about.
Dr Ware: When we commenced the evaluation, we found out that in the relatively local, small Isle of Wight Council there were over 100 separate assessments of needs carried out by different agencies. This led to a duplication of assessments. If someone had multiple care needs, the prison would call in a professional from a caring agency to carry out that assessment. There was a multiplication of care assessments with the agencies repeating similar care questions to the same older prisoner. We found there was marked failure of inter-agency communication and an unwillingness to share information. It was only when this was raised with the IOW steering group that involved senior managers that action was taken to ensure that services were integrated and delivered by local practitioners, such as prison healthcare and social services integrated care assessments. My guess would be that you could repeat this exercise in other prisons around the country and find a failure to produce a common care assessment.
We found there was a willingness by prison staff to support older prisoners. They had a caring remit. You always get the odd prison officer who might take the view, "My job is just control and security," but, overall, there was a good, caring ethos, especially when it came to older prisoners who were together in a wing or a unit where they were together.
When I went to Whatton prison, I found there was a very good older prisoners’ unit in which prison officers volunteer to work in that unit. There was a caring ethos for those with disabilities or care needs. One of the outcomes of this research is that where specific assessed care needs of older people with disabilities are assessed, their care plans may require them to receive specific services that their current prison placement cannot meet. You cannot expect a prison like Dartmoor, with very small entrances to their cells, to be able to provide wheelchair access throughout the prison. We found similar problems in the main Albany block in HMP Isle of Wight. Therefore, special units were created which enabled those with wheelchair disabilities to gain access to the facilities which also made it easier for thee staff to manage.
We also found that the Isle of Wight prison not only carried out healthcare assessments in Reception for new intakes, but when they identified an older person with care needs and was aged over 50, that a second needs assessment was made during the Induction stage. Then every six months, they were then given a Wellman care assessment. This followed the Department of Health guidance ‘Pathway to Care for Older Offenders: a toolkit for good practice’ (2007). Our evaluation report identified that where there was intervention as a result of the integrated care needs assessment within the prison, it reduced the costs to the NHS later on when they came to be released. It was very cost-effective.
Q102 Andy McDonald: That is very helpful, but we still have this dilemma as to where this provision is coming from-from the local authority or within prisons. If you get the local authorities to take responsibility, the prisons might step aside. Do you think that an obligation upon the local authority to provide care would improve the lot of older prisoners? Would we have better outcomes?
Dr Ware: Yes, it would improve it. I have no doubts about it. It would probably need legislation, as was recommended, but it depends on whether it is the local authority where the prison is based for a small council or a small local authority like the Isle of Wight, with the largest prison population in the country, or whether it would be the original local authority where the person was resident when they were sentenced, where they would most like to return unless there was a restriction on their licence.
Q103 Chair: Is there not a difference here between where you might think the costs should be dealt with and where you think the provision should be dealt with, because it seems inherently absurd to imagine Cumbria and Mid Wales and somewhere else all trying to organise social care in a prison in London?
Dr Ware: I agree. There is something to be said for almost the funding following the patient to meet the care needs, which was one of the original aims of CAF (Common Assessment Framework). The concept was that the funding might follow that individual with assessed care needs.
Q104 Chair: But the provision should surely be made by one authority per prison. It could be commissioned by a larger body. Should it fall into the national health commissioning structure that has now been created? We are looking around to see-because nobody seems to be effectively responsible at the moment-who should be.
Dr Ware: If you want my honest opinion, it should come within the national health service provision because it is the healthcare professions-the NHS professions-that pick it up more than the local authority, who lose track of the person who may have been a resident 20 to 30 years previously before they were sentenced. That is my own view.
Q105 Jeremy Corbyn: Can I move on to the question of staffing and staff training? As you may be aware, we visited a couple of prisons who had older prisoners. In the Isle of Wight they suggested that there ought to be specific training for caring for older prisoners rather than taking, as you simply describe it, volunteers to work in that section. In your experience, what kind of training does take place?
Dr Ware: There was an initiative funded by the Department of Health, where Nacro produced a workbook (A Resource Pack for Working with Older Prisoners, published in 2009) to help prison and even probation staff to raise awareness of older prisoners’ needs. I have been around asking, Where is it? It has disappeared. There was a little bit of follow up training when the pack was produced, but there is no training. Prison officers’ roles have changed so rapidly, and one that had done the training may well have moved on. It could have been a disability liaison officer, equality officer or whatever they were called. They change the officers and maybe the training manual has disappeared with the changes. It may be used to keep a door open or something like that, but to the best of my knowledge it is not used as a resource pack.
Q106 Jeremy Corbyn: It must be a big manual.
Dr Ware: It is two. One of my original concerns was that it was going to get lost. I said this to Nacro, "They’re going to lose it." There’s no provision for this training. If there was an external body, I thought Nacro or some other body might be doing the training. What is needed is some consistent training for prison officers who are changing roles. The same would apply to prison healthcare-and I would also say the new Probation Service.
Q107 Jeremy Corbyn: Is there any record kept of the training that officers have had so that, if officer X starts off in, say, Pentonville, moves on to somewhere else and ends up in Dartmoor, moving around the country as some do, they have a specific specialty in older people that the service would be aware of, or is it not as scientific as that?
Dr Ware: I would agree with you that it is not scientific. They don’t do it because their role is control and security. That is quite correct, and they have a caring role within that. But that can change from one to another, as they move from one prison to another. I would like to see a professional recognition that there are prison officers who are trained, just as some years ago there were prison officers who were trained as nurses. That was a plus. There is no consistent training for prison officers. With the growing need of older prisoners and the care need that is going to increase, I would say there is a need.
Q108 Jeremy Corbyn: Does it happen in any other specialty in the service?
Chair: Ms Walker wants to come in on this point.
Gill Walker: I just want to comment on the Nacro documents-the Nacro files- because they are extremely good. They were rolled out via Nacro on training for those who came from prisons. Sometimes, it was a governor who would come on this particular training. They got the packs. They then rolled them out to every prison in the country, as I understand it. They were extremely good because one was about the ageing process generally, so there was a general awareness and information about what it means to grow older, and all of us are. The other one was really about the sort of activities that would help enable wellbeing within a prison setting. They are extremely good documents. If these had been taken on board at the time in a very meaningful way, with the training and awareness raising for all prison officers, this would have done quite a lot at that stage. Those documents are available. They are not that old and they are still relevant.
Q109 Jeremy Corbyn: Just to come back on one point, do you have any knowledge of any other special training, apart from the former nurses in the Prison Service, where there is a kind of qualification recognition that goes through their careers?
Paul Grainge: I am not aware of any, but within the capacity building project that I am working on, which is funded by the Women and Equalities Group within NOMS, one of the objectives we have is to develop some training around the ageing process, health problems, linking behaviours to the underlying issues, and some resettlement needs. That is something that we are working on, and we are certainly developing a lot of resources around the signs and symptoms of those types of ailments that are likely to present for this group, which are going to be on a website that is accessible to all prisoners, and also I hope will go on to the Virtual Campus intranet system as well. That is work in progress, but it is still early stages at the moment.
Q110 Graham Stringer: What are the particular requirements for preparing older prisoners for resettlement while they are still in prison, and are these requirements being met?
Paul Grainge: Shall I start?
Graham Stringer: I didn’t think it was such a difficult question.
Paul Grainge: In our experience, the preparation for the older guys and women is limited, and we are finding that there is not a great deal at all and it is a real problem. We are certainly aware that there are older prisoners who are going out without photographic ID, bank accounts, accommodation, and not having registered with a doctor or a dentist. Certainly, if they have been incarcerated for long periods of time, I am aware that the electronic age and just the fast pace of living in the community is really difficult. My colleagues in the direct services that we are delivering are seeing that there are prisoners coming back in, and one of the aggravating factors of them selfsabotaging some of the licence conditions is that they have explained that they just can’t even buy food in a shop. They have gone into a shop where they have not had the confidence to speak to a cashier and they have not understood how the selfserve aisles have worked or how to use them. The fact that they have not even been able to buy food was almost the straw that broke the camel’s back. That was one of the reasons why they have selfsabotaged.
Resettlement for the older prisoners is a huge area. We are looking at the moment to try and develop a 16-week countdown where we can look at work with other older prisoners and train them in resources to help get a timeline in place, so that we can try and support those who are getting ready, and we can give them some photo ID-the basics really. We can help them get their national insurance number, if they do not have it, and find out where their doctor is, help them get registered, just so that the basics are there in place, because at the moment it is very sporadic between prisons as to what they are getting, I am afraid.
Dr Ware: I find, unfortunately, that a lot of resettlement officer roles have been changed because of cutbacks. Some of them are no longer resettlement officers. They are now on duty on the wings. I will give you an example. In the Isle of Wight prison, what was called a passport to care and resettlement was first developed by the prison orderly and resettlement officer in 2010. Now this ‘passport to care’ programme no longer exists. There is only one resettlement officer now responsible for the whole resettlement programme and I am she just cannot develop the resettlement programme on her own. The prison Orderly who helped to produce the ‘passport to care’ has been released for the past two years and I have kept in touch with him. He is now going to be working with me and with Restore in Devon. He is picking up that ‘passport to care’ and we are going to be working with RECOOP to develop this in the South West peninsula, as well as in Hampshire, with the Isle of Wight and the Hampshire Probation Service.
The problem, to answer your question, concerns through the gate resettlement is a very weak spot; there is no responsibility or very little responsibility for assisting an older prisoner prepare for their release while they are inside. It is expected that everything is done for them. Once they go through the gate, it is expected they have to do everything themselves. For example, they have to report to the probation officer that same day; they may have to travel by public transport from one end of the country to the next and be there on time, otherwise they have broken their licence. There is no through-the-gate resettlement. That is the biggest missing gap, and I am afraid unless we can fill this gap in resettlement there will be more recalls and reoffending. A possibility is that the private and voluntary sector can fill this gap, as identified in the Ministry of Justice ‘Transforming Rehabilitation: a strategy for reform’ (May 2013)
Q111 Graham Stringer: Is there any difference between the experience and the basic support between men and women in these situations?
Dr Ware: My own experience of working with a number of women exoffenders who are part of our support group is that I wonder how on earth some have ended up in prison. Some of them are very short-sentenced, and a number of these have come from abusive relationships or have drink problems and separated from their families. Many of them have families but they have lost their connections. In some ways, there is more difficulty getting them back into their local community because their family connections are broken, especially if they are expected to go back to abusive relationships.
Overall, I find there are a number of common factors between both sexes of the ageing prison population. They are - lack of accommodation, lack of knowledge of the local situation because some of them may have been in prison for a while, and no ID. Some are being released with no identification and no connection with GPs. I picked that up the last time. There is a very poor connection between the releasing prison and the local GP, unless they go to a probation hostel. There are some specific needs of women, but there are some common factors for men and women.
Q112 Mr Llwyd: One of the very big problems in this area is when prisoners are released with no fixed abode. I think I am right in saying that it is probably more acute in terms of the fallout for the individual if a person is of advancing years, because the statistics show that older prisoners, by and large, are sentenced to between four years and life, so they have spent a lot of time being institutionalised and it is an extra shock for them when they come out without anywhere to live. I was with the group in Dartmoor and I spoke with an elderly gentleman there, who said that he had eight days to go and he was at that stage NFA, so it is very worrying. The point that you make, Mr Grainge, about a countdown period is extremely important, to be honest. Those are general points. I don’t know if you are aware, but there is legislation in Wales to prevent the release to NFA. Should our friends on this side of the border adopt that, do you think?
Dr Ware: Yes. There are two women who were due for release from Eastwood Park, and return to south Wales, and they were in a group of older women I was recently visiting. The women who were due for release in England were rather envious of the support the other two were going to get when they were released. One of the women in England has been in touch with me, and she is homeless; she is still NFA. The two from south Wales have been housed.
Q113 Mr Llwyd: At least we get some things right. What are the most significant issues faced by older prisoners in general vis-à-vis resettlement?
Gill Walker: Perhaps reiterating what has been said, it is the preparation that is not there in advance and walking people through what it would mean, so that they have the information. Age UK, for example, has substantial information and advice for people generally and could be tailored for older prisoners in resettlement and moving towards release. If that was enabled within the prison, it would be helpful as one part-one very small part. There is also a need for volunteers perhaps, if they can be recruited, to be involved earlier and then to walk through the gate. Everything is very separate and compartmentalised, and it all needs to come together for the benefit of each and every prisoner.
Q114 Mr Llwyd: I remember, when I started off in practice as a lawyer, the rule was that a person being released from prison would be met by a probation officer on the way out. That is going back a few years, but we seem to have fallen into bad practice since then, and this no fixed abode is obviously asking for trouble. The other point I wanted to ask you about is this, and I understand the complexities of it. There are, of course, other problems with regard to resettling sex offenders in the community, are there not?
Dr Ware: Yes. There are restrictions on where they can go and there are exclusion zones. I suppose this applies to the majority are sex offenders that I am supporting at the moment. The one good thing-if I can say it is a good thing-is that, with some exceptions, they have to go to an approved probation hostel. That gives us time to work with the probation staff and negotiate with the offender manager about where they can be located and in helping them to find accommodation. In one sense, they get the support because, with some exceptions, they have to go to an approved hostel premises. That is something that works well with sex offenders and violent offenders. There is a problem with other older offenders, especially short-sentenced. As soon as they are released and walk through the prison gate they are on their own. My answer on sex offenders is that the system is working well.
Q115 Chair: That is very helpful; thank you very much. Does anyone have something to add on that particular point?
Paul Grainge: I was just going to add this about one of the problems that we experience. I have talked about the preparation, the 16-week countdown, but also, when they are coming out, where they are because of their age-they are old, frail and vulnerable-we are finding that sometimes there is no referral to the social services. They are going out to no fixed abode, but some of them are also going out having had their mobility support-their frames or their wheelchairs-taken away from them at the prison gates. Once they get off the bus, it is as far as they can manage to walk. They are stuck. It is so important that we make those links with social services and the prison and then help at least to put the basics in place. It is just the basic human needs, and then the support can be built around that.
Q116 Jeremy Corbyn: Thank you very much for coming today and giving us the evidence. Is there anything written or published on the idea of training prison officers, which I raised with you in questions, that we might consider for our report?
Paul Grainge: Not that I have seen, I am afraid. I am not sure at all what training there is for this at all.
Dr Ware: The thought I did have following our previous discussion on prison officer training. There could be a way forward in which the Prison Service College at Newbold Revel might include older prisoners in their officer training programme. Funding for this should be built into the programme.
Chair: Mr Ware, Mr Grainge, Ms Walker, thank you very much indeed. We are really grateful for your evidence. That concludes our proceedings this morning.
 Note by witness: Although I did say social isolation here the word I was actually trying to say was institutionalisation [...] . I was trying to describe some of the aggravating factors that could be removed if an older offender was managed using a community disposal. Social isolation was not the right phase at all.