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House of CommonsHealth and Social CareCommitteePrison healthTwelfth Report of Session 2017–19Report, together with formal minutes relatingto the reportOrdered by the House of Commonsto be printed 22 October 2018HC 963Published on 1 November 2018by authority of the House of Commons

Health and Social Care CommitteeThe Health and Social Care Committee is appointed by the House of Commons toexamine the expenditure, administration, and policy of the Department of Health& Social Care.Current membershipDr Sarah Wollaston MP (Conservative, Totnes) (Chair)Luciana Berger MP (Labour (Co-op), Liverpool, Wavertree)Mr Ben Bradshaw MP (Labour, Exeter)Dr Lisa Cameron MP (Scottish National Party, East Kilbride, Strathaven and Lesmahagow)Rosie Cooper MP (Labour, West Lancashire)Diana Johnson MP (Labour, Kingston upon Hull North)Johnny Mercer MP (Conservative, Plymouth, Moor View)Andrew Selous MP (Conservative, South West Bedfordshire)Derek Thomas MP (Conservative, St Ives)Martin Vickers MP (Conservative, Cleethorpes)Dr Paul Williams MP (Labour, Stockton South)The following Members were members of the Committee during the SessionDr Caroline Johnson MP (Conservative, Sleaford and North Hykeham)Maggie Throup MP (Conservative, Erewash)PowersThe Committee is one of the departmental select committees, the powers of whichare set out in House of Commons Standing Orders, principally in SO No 152. Theseare available on the internet via reports are published on the Committee’s website and in print by Order of the House.Evidence relating to this report is published on the inquiry publications page of theCommittee’s website.Committee staffThe current staff of the Committee are Huw Yardley (Clerk), Masrur Ahmed(Second Clerk), Laura Daniels (Senior Committee Specialist), Lewis Pickett(Committee Specialist), Dr Joe Freer (Clinical Fellow), Cecilia Santi O Desanti (SeniorCommittee Assistant), Ed Hamill (Committee Assistant), and Alex Paterson (MediaOfficer).ContactsAll correspondence should be addressed to the Clerk of the Health and SocialCare Committee, House of Commons, London SW1A 0AA. The telephonenumber for general enquiries is 020 7219 6182; the Committee’s email address

Prison health1ContentsSummary 31The state of health and care in English prisons 62Our inquiry 83People detained in prison 9Older prisoners 12Life expectancy 13Natural cause deaths 14Equivalent care 15Conclusion 164People’s journey through prison 17Entry into prison 17Liaison and diversion 17Screening 18Prison environment 19Prison regime 21Diet 22Experiences of safety 23Experience of health and social care 23Medical appointments 26Drugs 275Mental health in prisons 28Social care in prisons 30Release from prison 31Breaking the cycle of disadvantage: a whole system approach 33Whole systems approach 33Rehabilitative culture: narrative of care, health and wellbeing 34Whole prison approach 35Workforce 38Oversight, commissioning and regulation 39Commissioning 39Regulation and inspection 40

Conclusions and recommendations 43Annex 1: Visit to the Greenwich cluster 48HMP Thameside 48Overview of the prison 48Prison officers at Thameside 49Health and healthcare at Thameside 49The health and care needs of people inside Thameside 50Prison environment and regime 51Commissioning 51HMP Belmarsh Overview of HMP Belmarsh 5252Healthcare 52Prison environment and regime 53Deaths and serious incidents 54HMP/ YOI Isis 55Overview 55Healthcare at HMP/YOI Isis 56Prison environment and regime 58Healthcare across the cluster Annex 2: Prison health stakeholder discussion 5860Key problems 60The National Prison Healthcare Board’s Agreement 2018–21 61Priorities 63Formal minutes 67Witnesses 68Published written evidence 69List of Reports from the Committee during the current Parliament 71

Prison healthSummaryThe state of health and care in English prisonsThe Government is failing in its duty of care towards people detained in England’sprisons.Too many prisoners remain in unsafe, unsanitary and outdated establishments.Violence and self-harm are at record highs. Most prisons exceed their certified normalaccommodation level and a quarter of prisoners over the last two years have lived inovercrowded cells. Staffing shortages have forced overstretched prisons to run restrictedregimes, severely limiting not only opportunities for prisoners to engage in purposefulactivity, but access to health and care services both in and outside prisons.Too many prisoners die in custody or shortly after release. Whilst deaths, including bysuicide, in prisons have fallen slightly since their peak in 2016, so-called natural causedeaths, the highest cause of mortality in prison, too often reflect serious lapses in care.We are also concerned about the increase in deaths during post-release supervisionand reports of people being found unresponsive in their cells. Every suicide shouldbe regarded as preventable and it is unacceptable that those known to be at risk faceunacceptable delays awaiting transfer to more appropriate settings.Prisons have also been grappling with the increasingly widespread use of novelpsychoactive substances, which are a serious risk to the health and safety of users, fellowprisoners and staff alike. Evidence to our inquiry suggests the Government and theprison service are some way from having this under control.Missed opportunities to break the cycle of disadvantageThe health of people in prison is a public health issue. Prisons could be an opportunityto address serious health inequalities which are part of the cycle of disadvantage facedby people in prison. No one is sentenced to worsened health but that, largely as a resultof overstretched staff, overcrowding and poor facilities, is too often the outcome. Prisonhealth and care services should be delivering standards of care, and health outcomes, forprisoners that are at least equivalent to that of the general population. Doing so involvesidentifying and addressing health and care needs, which may have gone unrecognised,and supporting prisoners to lead purposeful, healthier lives. We recommend that: the National Prison Healthcare Board work with stakeholders to agree adefinition of equivalent care, and indicators to measure health inequalitiesbetween people in prison and the general population, which should then bereduced; the Board co-design with stakeholders a more comprehensive and robustapproach to identifying the health and care needs of people in prison andthose in contact with the criminal justice system;3

4Prison health the Government name the date by which it expects to have enough prisonofficers in post to ensure the vast majority of prisoners can be unlocked for therecommended 10 hours per day; guidance on how prisons and prison staff use incentives should make clearthat incentives should encourage prisoners to lead healthy lives and notdeprive them of regular access to facilities and activities which promote abasic standard of wellbeing.Prison reformSupporting prisoners to lead healthy lives is consistent with the Government’s aim touse prisons to rehabilitate offenders. Health, wellbeing, care and recovery need to be acore part of the Government’s plans for prison reform.A whole system approachThe challenge of providing a safer and healthier prison environment begins by managingthe number of people going into prison. We agree with the Care Quality Commissionthat this requires “a whole system approach that has its roots in sentencing and release.”An example of a whole system approach may be found in the Government’s recentstrategy on female offenders. We recommend that the Government’s evaluation of thisstrategy reports on whether, and if so how, similar approaches could be applied to otherparts of the prison population.A whole prison approachFor those in prison, we support the National Prison Healthcare Board’s intention todevelop and implement a whole-prison approach to health, and recommend this priorityis given much more prominence within the Board’s future plans. The National PrisonHealthcare Board should work with a group of national stakeholders over the next 12months to define the core principles of a whole prison approach, together with guidanceand resources to support more detailed plans at a local level.A shared understanding of what a whole prison approach looks like and how such anapproach, and best practice, can be effectively implemented is critical for success. Thekey factors that underpin the successful delivery of a whole prison approach are: a sufficient, stable and well-trained workforce, both of prison staff and healthand care professionals, whose own safety and health is valued; strong local strategic relationships, with a shared ownership for improvingprison health and care; a collaborative approach to commissioning, which ensures service provisionreflects the needs of the prison population and gives governors the financialand other levers necessary to make prisons safer and healthier; a rigorous, respected inspection regime that provides a robust picture ofthe state of health and care in prisons and drives improvement through

Prison healthreinforcing local whole prison approaches and equivalency in standards andhealth outcomes, ensuring best practice is effectively spread and lessons arelearnt. Inspection reports need to be accompanied by real powers to driveimplementation and consequences for failure to do so.We recommend CQC should assess the range of services provided in prisons, includingmental health, physical health (older people, adolescents), substance misuse anddentistry, as well as the prison environment, against their five criteria (safe, effective,caring, responsive and well-led).We look forward to seeing a Government approach which brings all these factorstogether into a serious attempt to tackle the unacceptable health inequalities present inthe current prison healthcare system.5

6Prison health1 The state of health and care in Englishprisons1. Persistent concerns have been raised over a number of years about the overcrowded,unsafe and unsanitary conditions inside some of England’s prisons. Evidence collected andpresented by Her Majesty’s Inspectorate of Prisons (HMIP), the Care Quality Commission(CQC) and others has shown a system struggling to cope with budget reductions, staffingshortages and outdated establishments. There are signs that the Government is beginningto address some of these problems, but also that it needs to go further. During the courseof the inquiry which has led to this report, we have heard examples of good practice acrossthe prison estate, but the scale of the challenge is immense.2. The Justice Committee in 2015, and again in 2016, warned that available indicatorspointed to a rapid deterioration in safety.1 Rates of deaths, suicides, incidents of self-harmand violence inside prisons have risen considerably, reaching record highs over recentyears.2 There have also been reports of prisoners living in unacceptably poor conditions(e.g. at HMP Liverpool).3. Deteriorating standards within English prisons followed significant reductions inpublic spending, which resulted in staffing levels falling substantially (from almost 25,000in 2010 to just over 18,000 in 2014). These numbers remained low for a sustained period oftime (the number of prison officers in post remained below 19,000 until September 2017).During this period thousands of experienced prison officers left the prison service, whichfurther diminished the quality of staffing provision.34. During this time the prison population, which the Government had projected wouldfall, remained historically high.4 The prison service has simultaneously been grapplingwith the rising use and impact of new psychoactive substances. These drugs, in particularspice,5 are harmful not only to users, but to staff, who have to deal with the consequences.Widespread access to spice and other drugs has increased violence within prisons andcontributed to the deterioration in safety.65. Our main concerns about the current state of health and care in English prisons areset out below.6. Many prisons remain unsafe. Whilst deaths in prison have fallen slightly includingself-inflicted deaths, since reaching a peak in 2016,7 incidences of self-harm continuedto rise during 2017 and 2018 and, according to the latest safety indicators, remain at a1234567Justice Committee, Sixth report of Session 2015–16, Prison Safety, HC 625UK Prison Population Statistics, House of Commons Library Briefing Paper,Number CBP-04334, 23 July 2018 p15–16;Institute for Government and the Chartered Institute of Public Finance and Accountancy, Performance tracker: Adata driven analysis of the performance of government, Autumn 2017 p54–55Q200 Digby GriffithsSpice is a brand name for synthetic cannabinoids. These synthetic drugs aim to mimic the main active ingredientfound in cannabis. They are sold in herbal smoking mixtures which means it can be difficult to know whichsubstances are being consumed. The Psychoactive Substances Act, which passed in May 2016, made it illegalto produce, supply and import of synthetic cannabinoids for human consumption. For more information annabinoids).Royal College of GPs (PRH0023)UK Prison Population Statistics, House of Commons Library Briefing Paper,Number CBP-04334, 23 July 2018 p16

Prison health7record high.8,9 Levels of violence are of great concern too. The number of assaults andserious assaults in prison, including prisoner on prisoner assaults and assaults on staff,are also at record highs.10 Her Majesty’s Inspectorate of Prisons consistently finds safetylevels declining between inspections, and has reported that many institutions are failingto address safety concerns relating to violence, suicide and self-harm and the supply ofillicit drugs.117. Even the most basic needs of people detained, such a

health and care services should be delivering standards of care, and health outcomes, for prisoners that are at least equivalent to that of the general population. Doing so involves identifying and addressing health and care needs, which may have gone unrecognised, and supporting prisoners to lead purposeful, healthier lives. We recommend that: the National Prison Healthcare Board work .

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prison. By 2004, people convicted on federal drug offenses were expected to serve almost three times that length: 62 months in prison. At the federal level, people incarcerated on a drug conviction make up nearly half the prison population. At the state level, the number of people in prison for drug offenses has increased nine-

Prison level performance is monitored and measured using the Prison Performance Tool. The PPT uses a data-driven assessment of performance in each prison to derive overall prison performance ratings. As in previous years, data-driven ratings were ratified and subject to in depth scrutiny at the moderation process which took place in June 2020.

information was available for women in prison with mental health problems and what more could be made available.4 The findings from this report will help Mind compile information specifically for women in prison. We used mainly focus groups on the basis that they are a lot easier for prison staff to facilitate and far less time-consuming:

Security and safety first Lack of resources and overcrowding Employment by prison admin. Pathogenicity of the prison Lack of public support Confidentiality, privacy, consent Equivalence of medical care Free access to medical care Professional independence Disease prevention Prison health is public health

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