Suicide, self-harm and social care– solving healthcare problems in prison and the equivalence of care

There is growing concern over the rise of violence, drugs, suicide and self-harm in our prisons, which is supported by figures from the Ministry of Justice published in July 2018:

• 310 deaths in prison custody during the 12 months to June 2018;
• The number of self-harm incidents reaching a new record high. There were 46,859 incidents of self-harm in the 12 months to March 2018 (an increase of 16%);
• Numbers of assaults reaching record levels. There were 31,025 assault incidents in the 12 months to March 2018 (an increase of 16%). Prisoner-on-prisoner assaults also reached a record high of 22,374, while the 9,003 assaults on staff was an increase of 26% from the previous year.

The actual scale of the problem may be even greater, as audits of prison data quality have revealed some under-reporting in assaults and self-harm incidents. Research also indicates that the risk of violence within prisons is integrated with self-harm and suicidal behaviour.

At the beginning of September, prison staff took part in widespread protests over “unprecedented violence”. The protests followed an unannounced inspection by HM Inspectorate of Prisons, which reported a dangerous lack of control in many parts of the prison.

Following these protests, the head of the prison service, Michael Spurr, was asked to step down by the Ministry of Justice to allow for a “change in direction.” The director of the Prison Reform Trust, Peter Dawson, has been critical of the move, saying that whoever took over would face the same fundamental problems of overcrowded and under-resourced prisons. He highlighted that these were problems which ministers alone could address and had failed to do so to date. He concluded “anyone who thinks the problems in our prisons can be solved by a change of leader is deluding themselves.”

Prison health and equivalence of care

There is general agreement that prisoners should receive an equivalent standard of healthcare as the rest of the population. However, reports by Her Majesty’s Inspectorate of Prisons, the Care Quality Commission, the National Audit Office, the Public Accounts Committee and the Justice Committee have raised various concerns, about:

• The mental and physical health of the prison population, including high incidences of suicide and self-harm;
• Health risks arising from the prison environment and prisoners’ access to healthcare;
• The recruitment and training of the healthcare workforce in prisons; and
• The inadequate consideration of the obvious needs of the older prison population.

What is meant by an “equivalent” standard has been the subject of wide debate. One of the main concerns raised by doctors working within the secure estate is that the principle of equivalence of care is not respected. For example, doctors are routinely required to cancel inpatient and out-patient treatment in NHS hospitals due to a lack of transportation.

In July, the Royal College of General Practitioners published a position statement setting out how the “equivalence of care” between secure and non-secure settings should be defined. It explains that “equivalence of care” does not mean that care provision in secure environments should be the same as that provided in the community. Instead, prisoners should be offered healthcare that is “at least consistent in range and quality with that available to the wider community.” Equivalent care requires partnership working between healthcare providers, security authorities and community services. This definition should enable commissioners, healthcare providers and inspectors to better assess the care provided in secure environments.

Social Care in Prisons

This month a joint report entitled "Social Care in prisons in England and Wales. A thematic report" from HM Inspectorate of Prisons and the Care Quality Commission highlighted that the disparity in services between prisons is disadvantaging prisoners in their ability to be rehabilitated and that there is inadequate consideration of what will be required in the near future as a result of the projected growth in the older prisoner population.

The recommendations from the report are as follows:-

1. The Secretary of State should lead coordination of cross-governmental work to develop a strategy for delivering social care in prisons.
2. All prisons and local authorities should develop a memorandum of understanding to ensure that the social care needs of prisoners are met.
3. Prompt ongoing systems should be implemented to identify the social care needs of prisoners. This should begin at reception and include the ability of prisoners to self refer.
4. Social care needs should be met as soon as they are identified and any prisoner providing social care support to another prisoner should be appropriately trained and supervised.
5. Prisons should make reasonable physical adaptations to meet social care needs and if this is not possible arrangements should be in place to transfer prisoners to appropriate establishments.
6. Prisons and local authorities should ensure that processes are in place for a smooth transfer of prisoners with social care packages to other establishments and on release into the community. This should include effective information sharing.

Health and Social Care Committee Inquiry

Recent research has found that prisoners are more likely to suffer from physical health, mental health and substance misuse problems than those in the community. Imprisonment can exacerbate these challenges and will impact on reoffending rates if they are not addressed in prison.

According to the New Economics Foundation, Britain’s prisons will face severe funding shortfalls of up to £70m per annum by 2025. Funding shortfalls put the prison system under significant staffing pressures such that governors may be forced to run restricted regimes where prisoners spend more of the day in their cells. This makes it more difficult for prisoners to access mental health services, and makes it less likely that prison officers will detect changes in the mental health of prisoners. Funding pressures may also mean that officers do not receive regular training on understanding mental health issues.

The Health and Social Care Committee is exploring the effectiveness of prisons and prison healthcare services in meeting the physical and mental health and social care needs of prisoners. Oral and written evidence has been received by the committee and the committee expects to publish their report this autumn.

Bevan Brittan has a dedicated prison health team who can provide practical advice in this complex area. Please contact Claire Bentley, Associate for more information.