Prison population: physical health care needs

Interviews with stakeholders, people with experience of prison, and family members

Overview

This chapter presents the findings of a thematic analysis of interviews conducted with stakeholders, people with recent experience of prison, and family members of people in prison on their views and insights into the physical health care needs of people in prison and physical health care services in prison.

Methods

The views and insights of stakeholders, people with experience of prison, and family members of people in prison were obtained through 22 one-to-one interviews. Seventeen of these interviews were conducted with a range of stakeholders from the Scottish Prison Service, NHS (prison- and community-based), Public Health Scotland, HM Inspectorate of Prison for Scotland, and third-sector organisations working with people in prison and/or on release from prison. Further, two people with experience of prison and three family members of people in prison were also interviewed. These individuals were recruited with the help of community-based organisations which provide support to people on release from prison and/or family members of people in prison.

The aims of the interviews were to engage with stakeholders and people with experience of prison (and their family members) to assess how health care in prisons meets people's physical health needs. The interviews were conducted with the support of topic guides which were tailored to the participant group. These topics guides covered the following: population needs and the extent to which they were being met; opportunities to maintain/improve physical health; impediments to maintain/improve physical health; the reception process; access to health care services/support, including secondary, end of life care, and other forms of extended health care; access to medication; resourcing of health care services; the impact of, and lessons learned from, COVID-19; transfer and liberation.

Interviews were conducted virtually via MS Teams or telephone and were audio-recorded and transcribed, before being coded and analysed thematically (as described by Braun & Clarke, 2006). The following provides a summary of the themes identified through this analysis.

Perspective of people with experience of prison and family members of people in prison

Opportunity for physical health improvement in prison?

Most participants felt that it was possible for people in prison to improve their physical health while in prison. Participants mentioned that people in prison have access to the gym for exercise; however, there were mixed opinions as to how appropriate the gym was for all individuals. One participant stated that he would be embarrassed to attend the gym due to the impact of his physical health condition on his ability to use the equipment, while a second participant outlined that some prisons hold separate gym sessions for individuals with particular health concerns, such as obesity. It would seem, however, that people in prison would welcome a range of exercise options for those who might not wish to, or are not able to, engage with the gym.

Participants commented on the food provided to residents in Scottish prisons. There were mixed opinions as to the nutritional value of the provided menus. Some participants commented that it was possible to eat a healthy diet while in prison, whilst others pointed to a lack of options to suit different needs and preferences. Another participant commented on the difficulty of storing fresh fruit and vegetables in cells; it was reported that some Scottish prisons, but not all, provide access to small refrigerators for this purpose. It was felt that appropriate storage options throughout the prison estate would encourage and enable healthy food choices.

One participant commented on how access to health provision in prison which they would not otherwise access in the community, meant that their family member had received screening and treatment to a blood borne virus which had contributed to an improvement in their health. Further, more than one participant disclosed that they were deterred from taking illicit substances when in prison. This was reported to be due to the availability of opiate substitution therapy, which they were able to manage more effectively in prison. As a consequence, they reported feeling healthier than when they first entered prison.

One participant did report, however, that their family member had not been able to work while living in one Scottish prison and had been told that this was because of prison rules relating to their physical health condition. It was reported that this individual felt that being prevented from working, and hence keeping active, had negatively impacted his physical (and mental) health.

Workforce and staffing

There was agreement between participants that prison-based physical health care was understaffed and that this situation had been exacerbated by the Covid-19 pandemic. It was reported by one participant that prison health care teams were diverted from providing primary care services to support testing and vaccination clinics:

"There was a massive impact. They just weren't being seen because the staff team were so busy dealing with COVID that there was no opportunity for the lads with other health conditions to see health care". [Lived Experience Participant]

Access to physical health care provision

There was a lack of consensus around the ease of access to primary care services for physical health. One participant stated that it was possible to gain access to a health care practitioner within two or three days; after making a self-referral on the halls, a nurse would visit the individual on the halls to assess their needs. Others, however, spoke of how health care provision was accessed through SPS staff on the halls and that their lack of compassion and understanding of physical health needs meant that such access was often blocked. One participant spoke of how their relative, who was not able to read or write and hence had difficulties with actioning a self-referral, reported being intimidated by SPS staff and hence reluctant to ask for their help, despite desperately wanting to seek health care support:

"he doesn't know how to, because he feels a bit anxious about asking anybody anything because they're not very pleasant people." [Family Member]

It was not clear whether these observations reflect differences between institutions in the pathways to access health care services (i.e. with some institutions requiring access to health care through direct self-referral and others through SPS staff) or a lack of understanding among people in prison of the designated pathway within their institution. What was clear, however, was that participants did not favour the notion of SPS staff acting as gatekeepers to health care services.

A family member described how their relative had experienced difficulty accessing the prison GP despite having complex health conditions and wishing to urgently discuss their prescriptions related to these. It was reported that the majority of this individual's prescriptions had been stopped without consultation or communication as to the reasoning for this decision. After lodging a complaint with the help of SPS staff, and making more than one self-referral to the GP, they reported that they had still not been seen by the GP. The family member reported that their relative was in ill-health but was concerned that making another complaint might exacerbate the situation further. Such accounts indicate how some people in prison feel a lack of agency over the management of their health and a lack of recourse to alternative provision.

"He's got to that stage where he's not even going to ask for help now because they're not helping. He's sitting there all day with pains in chest. I was like 'go and tell the nurse'. He said 'I did but she told me just to go into a cell to sit.'" [Family Member]

Access to medication for physical health conditions

Linked to the above, people with experience of prison and family members of people in prison described problems in accessing prescription medication in prison. Most participants reported delays in accessing medication on reception into prison due to inadequate information sharing systems between community-based GPs and prison-based health care teams. It was reported that prison-based health care teams would contact community-based GPs to determine the current prescriptions of those entering prison prior to issuing medication, but it could take up to three weeks to confirm and issue the prescription.

"Obviously there is an issue with medical records when they first go in. The doctors will say 'look we don't have your medical records, we don't know anything about you and we are not just taking your word for it'. So [NAME]^[28] said 'I have asthma, I need inhalers' 'well we'll have to wait until we get your medical record, we cannot prescribe inhalers until we see that in black and white that you have asthma'. So that's a huge issue." [Family Member]

One participant stated that his community-based surgery was only open one evening per week, and that this impacted the time it took for him to access medication on reception. Under the system described above, the prison health care team were required to wait until the community-based surgery was next open to receive confirmation of current prescriptions. Depending on when an individual entered prison, it could be up to a week before the surgery was open again and able to provide this information to the prison health care team.

Participants also spoke of how changes had been made to their prescribed medication that they felt were not appropriate. These accounts usually highlighted how these participants felt they had little agency in these decisions and that they happened to the participant rather than in consultation with the participant. For example, one participant spoke of how prescription medication for treating diabetes and angina had been stopped on entry to the prison without explanation. It is possible that there were sound medical reasons for these decisions, but these had not been explained to the participant who was reportedly suffering from increased ill health due to the withdrawal of these prescriptions. Despite placing further referrals to discuss the situation with the GP and also making a formal complaint, the prescriptions had not been reinstated.

One participant also reported that prescription medication, despite being given out in the early morning on weekdays, was not dispensed until much later in the day on the weekend due to health care staffing arrangements. The participant explained that this could lead to reduced effectiveness of the medication or withdrawal symptoms for the patient, depending on the prescribed medication.

Communication

As already outlined above, some participants felt that there was a lack of communication and consultation with people in prison around decisions related to changes in their prescription medication, around treatment decisions, and in the provision of the results of medical assessments and tests. Examples were given of changes to, or removal of prescriptions, with no discusssion as to the reasoning for these decisions. One participant reported that their family member was particularly anxious about unexplained changes to their prescription regime, despite having complex medical needs. This decision may have been made for legitimate clinical reasons, but the lack of explanation had resulted in clear anxiety for this individual. Another family member reported having legal guardianship over their imprisoned relative, which meant they should be consulted on all health care decisions. Despite this, their relative had received medical treatment within prison and in hospital during their time in prison, but the details had not been communicated to their guardian.

Physical health care management during transitions in the prison journey

Finally, people who had experience of prison spoke of their experiences of liberation and expressed the view that practical support at this time is critical to the outcomes of people being liberated from prison. Support in gaining access to a community-based GP was said to be especially critical for those with health conditions as they are likely to have increased vulnerabilities, as well as additional needs. Participants reported that navigating the systems required to register with a GP were particularly difficult, and stated that, if support for third sector organisations, such as the Simon Community Scotland^[29] and the Wise Group^[30], had not been available, they would have struggled to adapt to life outside of prison.

Perspectives of Stakeholders

Health Needs of the Scottish Prison Population

Participants identified the following as prominent physical health needs of people in prison: respiratory conditions, cardiovascular conditions, head injury, chronic pain, diabetes, blood borne viruses, oral health, and emergency health needs (discussed as a result of violence in prison). The increase in number and range (for example, non-communicable diseases, musculoskeletal and mobility issues) of physical health concerns due to the ageing prison population were also highlighted and the links here with increased need for social care support within the prison estate were discussed.

Most participants mentioned the mental health, trauma-, and substance use-related health needs of people in prison. The comorbidity of these needs with physical health needs was also recognised. Direct associations (for example, nerve damage due to intravenous drug use or respiratory conditions as a result of long term smoking behaviours) and indirect associations (for example, long term physical health conditions such as asthma or diabetes not being appropriately managed due "to the chaos, the addiction") with physical health care needs were outlined.

In addition to outlining these needs in general, participants were asked about the physical health care needs of different groups in the Scottish prison estate. Younger males were thought to require more trauma-related and mental health provision as opposed to physical health provision, and underlying health conditions due to substance misuse were also mentioned in respect of this group. Participants spoke of adult males requiring more acute care than younger males due to involvement in violent altercations within prison, and higher levels of respiratory problems, such as COPD and asthma, due to more smoking behaviours amongst this group.

Participants spoke of how poor physical health amongst women in prison was thought to be associated with involvement in prior abusive or controlling relationships, sexual victimisation, and/or through prioritising caring responsibilities over their own health needs, all of which were thought to decrease engagement with physical health care services in the community.

Opportunity for physical health improvement in prison?

The majority of participants spoke of how prison should be a place where pre-existing health issues were resolved. There were references to people in prison being a "captive audience" for health services and that with "everything in one place" health care services in prison should be "the opportunity to detect, to intervene and … to signpost on to treatment. It's just such a huge opportunity" [High Level Stakeholder].

More broadly, participants spoke of how, for some individuals, prison provides greater stability than life outside of prison - accommodation, food, warmth and a structure to the day, which includes access to outside spaces and the gym. From this more stable position, it was felt that those living in prison should be able to utilise the health services available to them to improve their physical health. Some participants did indeed speak of how individuals tend to engage more with health care services in prison than in the community. Examples given were increased engagement with diabetes clinics, sexual health screening and testing, and blood borne virus testing and treatment.

Conversely, however, participants spoke of the barriers to improving health in prison. Concerns were raised about the impact of the harms of prison on mental health and substance use in prison and the direct and indirect relationships between these and the occurrence of, and lack of management of, physical health issues. Further, the nutritional status of food in prison, the lack of access to daylight and to alternatives to the gym for exercise purposes were mentioned by participants as barriers to improving physical health in prison. Some participants also spoke of how the 'churn' of the prison population meant that individuals might engage with health services in prison, but would not complete treatment prior to liberation and hence progress may be lost on their return to the community.

Individuals held within prison on remand were reported to have their access to some primary care and oral health services restricted:

"it's just limited to a list of things that we can do in terms of urgent or sorting problems, it's not getting a check-up, a scale and polish and a whole course of treatment". [Health Care Professional]

This practice was thought by participants to be related to there being insufficient time to complete standard treatments prior to potential liberation: "they said there wasn't enough time".

Workforce and staffing

The majority of participants mentioned concerns around the resourcing and staffing of physical health care in Scottish prisons. The high number of vacant primary care nursing positions within the prison estate was mentioned by most participants as a limiting factor to service provision. It is important to consider these comments in the context of a national shortage of qualified nurses and to recognise that interviews took place during the Covid-19 pandemic which inevitably exacerbated staffing pressures. Despite this context, however, respondents reported that prison-based primary care nursing positions were particularly difficult to recruit to and subject to high rates of staff turnover. One participant commented:

"Honestly within nursing, prison nursing is seen as one of the lowest of the lows. You've got your ITU^[31] nurses here, your children's nurse there, and then … all the way at the bottom is prison nursing." [Health Care Professional]

Prison-based nursing was perceived by participants to be "high tariff work" - nurses often work independently without the level of supervision as similar positions within community-based NHS services. While some participants clearly relished this work, the prison environment and the nature of the population were said to add to the complexity of the role:

"I always felt we were at the heart of what it is to be a nurse…you leave all your fancy titles, your fancy equipment, you are very much on your own … And it's very basic nursing, isn't it? Like if you have your emergencies you have to use your skills, you have to use what you've got in the bag and you're relying on your colleagues" [Health Care Professional]

"There's security issues, there's access issues, they're a hard population, there's a lot of special needs." [High Level Stakeholder]

A good proportion of participants commented on how the remuneration of prison-based primary care nurses was not in step with the nature of the role and likely contributed to the high levels of turnover:

"I can understand why staff get weary and tired … they maybe need to look at it as some kind of speciality and increase the banding and increase the pay". [High Level Stakeholder]

It was also mentioned that prison-based physical health nurses were also banded lower (band 5) than nurses working in prison-based mental health and addictions (band 6), which was said to further demoralise those in physical health care roles. Further to this, some health care staff reported a perceived lack of understanding amongst non-prison NHS staff and SPS staff of the role and responsibilities of the prison-based nurse. This lack of awareness contributed to health care staff feeling undervalued and forgotten.

Participants reported that shortages of prison nurses impacts on the provision of staff training and development, and on the delivery of clinics for long term conditions, such as asthma and diabetes.

"…you need to see the admissions and make sure they're safe and you need to medicate. And that's the two things that'll happen. Everything else will go." [Health Care Professional]

"so much of their day is spent on giving out medication … it's really difficult for the health care team to function as a health care team". [Third Sector Stakeholder]

The views on whether the resourcing of GP positions in Scottish prisons is adequate were mixed. Some participants cited long waiting lists as evidence of under-resourcing, while others compared the number of people in prison per GP to patient-to-GP ratios in community practices and concluded that the "odds of accessing health care are much greater in a prison environment than they would be in the community". Such comparisons, however, perhaps fail to account for the more complex needs of the prison population which will undoubtedly require greater resource to achieve equivalence of outcomes with community populations.

A significant minority of participants reported how challenges around SPS staffing impacted on physical health care provision. It was reported that the primary care and, in particular, oral health clinics rely on SPS staff to escort patients from the halls to the clinic for their appointment and back again afterwards. Staff shortages or other priorities within the prison do, however, result in SPS staff being diverted elsewhere meaning patients were not attending clinics for their appointments. Within oral health clinics, it was estimated that 30-50% of the time that clinicians could spend assessing and treating patients was lost to the lack of escorts. One participant suggested the provision of dedicated NHS staff to perform this function could alleviate the problem.

Access to physical health care provision

Health care provision on reception:

Participants outlined that all new arrivals to prison, whether remand or sentenced, were given a health assessment within 72 hours of reception. It was reported that an initial assessment is completed by mental health or primary care nurses, depending on the prison, the aim being to determine any immediate health care needs or suicidal intent. Participants spoke of how this initial assessment is usually followed up by checks by either a nurse practitioner or GP (dependent on the establishment) to determine any prescription needs or ongoing treatment. One participant outlined that while information is collected by the prison health care team "it doesn't mean to say they'll get that treatment or access to that support. It just means they're aware of it". Others spoke of how the assessment of health care needs at the point of reception only was insufficient and that further assessment should follow once individuals are more settled. Reception is reportedly a highly stressful time for new arrivals to prison, and they may not fully disclose health care needs for a number of reasons:

"it's important to recognise that people might not immediately declare that they've got a problem [during reception] and that there should be opportunity to, as they settle down … to … know where to go for help". [High Level Stakeholder]

Participants lacked consensus in their views, however, regarding the ease of access to primary health care services in prison after reception. Some participants spoke of their confidence that individuals with legitimate and specific health care needs would be able to access the support they required, and others cited low numbers of complaints regarding NHS services within their prison establishments. Many outlined that access to physical health care services was available through the completion of an easily accessible referral form located on the halls. It was identified by some participants, however, that low levels of literacy may act as a barrier to this seemingly straightforward process for some people in prison. In recognition of this, some establishments had amended their referral forms to include pictures and single words in an attempt to improve access to health care for these individuals.

Participants commented on how oral health care is not discussed within the health assessment on reception to the prison. As such, all access relies on self-referral.

A reactive service:

A proportion of participants were critical of the reactive nature of prison health care services which requires individuals, many of whom do not prioritise their own health, to self-advocate for the health care provision they require:

"One thing that's true of the health care system generally is that it absolutely relies on the … patient to actually be in control and manage their own health. And many of the patients that end up in the prison estate haven't had the support or the skills development to be able to do that. And then when you add in to that, lots of challenges and complexity, you know it's way down their list of hierarchy of what they want to address." [Health Care Professional]

Participants spoke of how it should be the responsibility of prison health care teams to encourage the prioritisation of health amongst people in prison through the provision of health education, health promotion, regular check-ups and screening. It was clear from participant responses, however, that a wider approach is necessary to provide the space for individuals to prioritise their health. Experience of homelessness, physical and sexual abuse, caring responsibilities, mental ill-health, substance use issues, and learned helplessness around ill-health were all cited as reasons which may have contributed to why physical health concerns were not prioritised by some people in prison. Participants spoke of women avoiding cervical screening and other sexual health assessments and interventions due to trauma around previous sexual abuse and/or stigma around their past. One participant remarked:

"I did his cholesterol it was 9.7 … I said 'we need to look at that' and he said 'I'll be released in 2 weeks to live in cardboard box … my cholesterol is the least of my problems'." [Health Care Professional]

Given these complexities, some participants advocated a public health approach, focussed on the social determinants of physical health and built on multi-agency working, towards improving the physical health of people in prison.

Health literacy and education:

Improvements in education around health were identified by a number of participants as required for both people in prison and SPS staff. Participants felt it should be responsibility of prison health care teams to raise the health literacy of people residing in prison:

"There needs to be some literacy built in, to encourage people … to use this opportunity in a prison setting to get a health check". [Health Care Professional]

Oral health care services were reported to provide an oral health education programme for people in prison. 'Mouth Matters' provides information to individuals on reception to the prison around access to dental services, how to brush teeth effectively, and provides free toothpaste contingent on ongoing engagement with the programme.

Given their potential role in facilitating access to health care for, and supporting the needs of, people residing in prison, SPS staff were also identified as requiring further health education:

"it's also for the prison officers … to understand that you might need to speak a bit more slowly, not have too much noise going on". [High Level Stakeholder]

One area where participants identified the need for education of prison staff was in relation to palliative and end of life care:

"Having the education to support people and, if possible, to have more people dying in prison if that is their choice, would be better. But I think there's certainly … from the prison service staff and governors, 'we don't want them dying here, that's not dignified, they'd be far better dying elsewhere'. And in some situations that maybe appropriate, but I think if we could support people to die in the prison, if that's what they wish, then I think we should be able to do that." [Third Sector Stakeholder]

Participants outlined that are some misconceptions amongst people in prison and SPS staff around the service that the oral health care teams are able provide. Amongst people in prison it was reported that expectations around the extent of oral health provision can be too high, whilst SPS staff misconceptions centred around the extent of provision available for people on remand. Participants reported that there is a common misunderstanding amongst SPS staff that people on remand do not have any access to oral health services and hence residents are discouraged from putting in referrals. In reality, whilst routine check-ups and subsequent courses of treatment are not available to those held on remand, emergency dental care is available and people should be encouraged by SPS staff to make a self-referral to the oral health team.

Waiting times:

There was plenty of discussion amongst participants about waiting times for primary health care appointments within prison but no clear consensus emerged as to whether these were excessive, especially when considered in the context of waiting times for community primary care appointments. Some participants thought that waiting times to see a GP were too long, whereas others thought that people in prison were seen more quickly than in the community.

Some participants outlined a process that had been implemented to mitigate waits for appointments whereby nurses visit people who have made referrals on the halls to determine the nature of their health concern and to triage them appropriately. It seems, however, that these are locally instituted processes and are not utilised within all establishments. One member of prison-based health care staff commented that without such triage services…

"you don't always know if you're going to get somebody in who actually needs 'oh Jesus you are an emergency and actually we won't let you out of here' or the person whose been high for two years but decided that today is the day he wants to deal with it." [Health Care Professional]

Within prison-based oral health services, waiting lists were seen to be excessively long, especially given the changes to practice required since the onset of the Covid-19 pandemic. Within one establishment, it was reported that around 300 individuals were waiting on appointments for check-ups. In another establishment, the dental surgery on site was not operational and individuals were being transported by bus to another establishment once a week. Oral health care had been disrupted particularly badly by the Covid-19 pandemic. Due to enforced gaps between appointments due to poor ventilation and requirements around social distancing, throughput at each clinic had been substantially limited. This was compounded by the issue mentioned previously around the availability of SPS to escort patients to their appointments:

"Getting access to them is incredibly difficult … as a dental team we need a dental chair, we need our drills … We can't just go up to the hall and write a prescription and take blood pressure like the other teams can. So we need a bum on this seat." [Health Care Professional]

Access to secondary care:

Relationships between prison-based and hospital/community-based health care teams were stated to be good and hence arranging secondary care referrals and appointments was reportedly unproblematic. The majority of participants, however, did speak of their perceptions of the private service contracted to transport people in prison to their hospital or community-based secondary care appointments. Workforce issues, perhaps exacerbated by Covid-19, had meant that the company had struggled to fulfil their security transport role on a significant number of occasions, which meant that patients missed their appointments and rescheduling was necessary. Apart from the threat to the health of the patient that this might pose, given the security concerns in escorting people in prison to external appointments, it is generally not communicated to patients when their secondary care appointments are scheduled to be. Participants reported, hence, that individuals would miss appointments but would not be informed that they had missed their appointment. Some participants reflected on how this might impact on the individual's future treatment by, and access to, health care services.

Virtual hospital appointments utilising Near Me were reported to alleviate the issue of missed appointments due to transport failures. Participants also reported that utilising technology for such appointments has other benefits, such as avoiding the need for patients to be handcuffed within health care settings, but participants explained that not all establishments had access to this system and virtual appointments are not possible for all clinics or conditions.

Access to medication for physical health conditions

There was a general consensus amongst participants that if an individual living in prison required medication for a health care condition, they would be able to access it (or an equivalent) through contact with the prison health care teams (but note the discussions above around self-referral, self-advocacy and lack of prioritisation of health care needs by people living in prison).

Concerns were raised by a number of participants, however, about the availability of some medications for people in some establishments, particularly pain management medication (e.g. pregabalin and gabapentin). Security concerns related to the trading of prescription medications in prison has resulted in the restriction of these medications in some prisons:

"the biggest issue for us, is the people who come in from the community on long term prescriptions where they then meet up with a system … that potentially enforces the rules slightly more stringently than they might in the community." [Health Care Professional]

Participants outlined a number of concerns with this practice including inconsistencies between prisons in the prescribing pain mangement medication, the lack of effective alternatives for some restricted medications (e.g. mediations prescribed for the management of pain, such as pregabalin and gabapentin) and the subsequent impact on the wellbeing of individuals, and the lack of consultation with individuals around changing their medication:

"Just because they're in prison doesn't mean they're not genuine, they're not in pain. And we get a lot of prisoners that come in on a lot of painkillers, and the GP will stop them". [Health Care Professional]

A number of participants, however, did offer the alternate view that the prison environment results in more appropriate prescribing, as GPs feel more supported in the prison should an individual disagree with their refusal to prescribe the medications requested:

"When you're in here it's quite easy to say no because you know you've got a couple of guys behind the door to back you up … Whereas I think in GP clinics they don't have that, so sometimes they give them things that might not be the best course of treatment but it's the patients preferred." [Health Care Professional]

It was also mentioned that prison allows for the supervision of medicating practices, which encourages a level of compliance with medication regimes which may not be seen in the community:

"Because we do supervised medication for a lot of patients they're actually taking it at the right time whereas when they're taking it at home will they remember to take it? Definitely no, because of the drink and the drugs, you know." [Health Care Professional]

In relation to over-the-counter medication such as paracetamol and ibruprofen, participants reported that prison officers are able to provide access should any of the residents require it. One participant stated that they felt that such medication should be available for people in prison to buy as part of their canteen, but that this policy was not supported by SPS.

Physical health care management during transitions in the prison journey

Participants reported a lack of joined up working and continuity of care in relation to physical health care during transfers between prisons and liberation.

Participants indicated that individuals transferring between prisons were assessed by a health care professional on arrival at the new location, although it was unclear whether this was the practice at all establishments. Some participants reported that a record of an individual's medication would be sent to the new establishment, especially if they were on any uncommon or expensive medication, to alert the new establishment to these needs. It was reported, however, that differences in prescribing practices between establishments (and between health boards) meant that some people in prison had their medications changed on reception at their new establishment without consultation.

There were several issues identified in relation to the management of physical health care on liberation. The first of these relates to the practice of de-registering of individuals from their community GP practice once they enter prison. Participants appreciated the reasoning for this policy, but reported resulting delays in the provision of support to individuals on liberation, due to the need to re-register with a community GP practice. This could lead to an interruption in treatment or in the availability of prescription medication. It was also noted that the practice of de-registering people once they enter prison means that community-based GPs cannot access the individual's health record and hence are prevented from supporting the coordination of care in prison. Second, the support for individuals on liberation was reported to be insufficient. Participants stated that when liberation dates were known/planned, it was possible for SPS and prison-based NHS services to provide support to individuals in the lead up to liberation by pre-registering them with a GP and providing them with one week's supply of medication to cover their needs until they could see a community-based GP. It was reported, however, that the practice of pre-registration was not sufficiently widespread, and had indeed been negatively impacted by staff shortages during the Covid-19 pandemic, leaving many liberated individuals without support on release: "there's a lot of people who just literally fall off the wayside and don't contact anybody".

Further, unplanned liberations most often resulted in the liberated individual having to navigate the complex systems relating to social work, welfare, housing and access to a GP, without support and with no prescription medication supply:

"If it's not a planned liberation they wouldn't get any medication, so they would have to go to their GP and get an emergency prescription. So if they get out last minute … it is a bit of a nightmare … they wouldn't get a supply." [Health Care Professional]

Accessing GP services and ongoing treatment was further complicated by geographical issues. For example, access to ongoing treatment was reported to be disrupted when the prison and the new residence of the liberated individual fell under the responsibility of different health boards. One participant stated that

"it's not an automatic smooth transition for people … and that obviously then brings about delays". [Health Care Professional]

Some participants pointed to the work that third sector organisation undertake to support individuals on liberation and suggested that SPS and prison-based NHS services should work more closely with such organisations. Collaborative work with the aim of ensuring sufficient support in relation to housing, welfare, social work and health care needs not only in the days after liberation but throughout the whole of an individual's sentence, was suggested.

Finally, community GPs reported that they are provided with little information on how a liberated individual's physical health had been managed while they were in prison. Whilst details of prescribed medications are communicated by prison health care teams to the community GP, it was reported that details of any treatments individuals may have received in prison was lacking:

"We don't have a health summary, we don't know who they've seen or what they've seen. So that's really challenging." [Health Care Professional]

It was reported that, in the absence of any formal health record, GPs were required to rely on the liberated individual's reporting of any screening or treatment they received in prison. It was also reported that the lack of information sharing meant that the reasoning around prescribing or treatment was not clear:

"We don't always get good information about the decision making behind the routes to psychotropic meds in particular. We don't really ever get information about why someone's been started on an anti-psychotic medication or gone onto really complicated epilepsy meds. So I would say that's one of the other issues that we have." [Health Care Professional]

Potential unmet physical health care needs

Participants were asked whether there were any unmet physical health care needs in Scottish prisons. A number of needs were cited by more than one participant. Some of the older buildings which comprise the prison estate were thought not able to provide appropriate accommodation for those with physical disabilities or those that require palliative or end of life care. Accessible cells are not available in all locations, although some were reported to be in the process of being converted. Given the ageing prison population, there were concerns raised about how the prison estate will cope with increased demand for such facilities with more than one participant suggesting that SPS would benefit from dedicated care facilities for individuals with reduced mobility, physical disability, or palliative care needs. Further to this, one participant reported that some prisons do not have the resources - physical or staffing - to support people on return from hospital care:

"It's a very old building and very small cells, and quite challenging sometimes to get the hospital bed in there or if you're thinking about a hoist and a commode and all these sort of things. It can increasingly, to find the space and ability to do that, can be very difficult." [High Level Stakeholder]

Further to this, nursing shortages and the associated lack of opportunity for training in specific fields were reported to impact on the provision of clinics for cervical screening and the management of long term conditions, such as asthma, respiratory diseases and cardiovascular disease. Palliative and end of life care is another area where staffing shortages result in potentially unmet needs. Twenty-four hour care and medication is often required for these individuals but is not available within prisons without round the clock health care staffing. In such cases, it is reported that these individuals tend to get transferred out to hospital even when this would not be their choice. The lack of understanding of the needs of end of life patients within the prison service, it was stated, has resulted in the provision of reactive care for these individuals.

More broadly, more than one participant reported that there was an insufficient understanding of the physical health care needs of Scotland's prison population upon which to build a comprehensive service. One participant argued that in establishments that house individuals who do not prioritise, or advocate for, their own physical health, without knowledge of the population needs:

"you land up with an absolutely basic service … until we start anticipating the care [needed] and doing something to educate people and get them to take responsibility for their health, that's how we'll continue to be". [High Level Stakeholder]

Covid-19

The Covid-19 pandemic, it was reported, has exacerbated the prison health care workforce issues outlined above. Apart from Covid-19 related absences putting pressure on an already stretched service, prison-based NHS staff have also been required to undertake the testing and vaccination of people residing in prison:

"it's a lot of work … we have vaccinated this full prison three times over now with the boosters. Plus flu vaccines … it's really been a challenge". [Healh Care Professional]

Participants reported that the consequential lack of screenings and routine care has most likely resulted in missing a substantial amount of ill-health amongst residents. Furthermore, some participants stated that restrictions on prison regimes due to the pandemic had resulted in weight gain and reduced opportunities for exercise amongst people residing in prison, and they had concerns for the implications of this for physical health. Further to this, and as in the community, the length of time people in prison are required to wait for referrals to secondary care, was reported to have been negatively impacted by the Covid-19 pandemic.

Several participants discussed the impact of the pandemic on the experience of liberation. One outlined how information sharing around physical health between prison- and community-based health care services on liberation had been effected:

"Now it doesn't happen because of COVID … we're trying to get back to it, but for the last 2 years it's not happened. I've noticed a huge difference in the pooling together all of the information and having somebody walk out with a proper release plan and health care concerns noted, because that's just not happening now. So the quicker we can go back to that the better." [Third Sector Stakeholder]

Others spoke how the use of virtual courts, brought in to limit the spread of Covid-19, had resulted in people being less likely to be liberated with a supply of medication. Prior to the use of virtual courts, health care teams would utilise official transport lists to identify individuals travelling to court each day and would ensure a supply of medication would travel with them in case of liberation. Without the need for transport to court, however, transport lists were not available to health care teams for this purpose and hence medication was not prepared for those attending virtual courts. Participants explained that, should an individual be liberated, health care teams do not have sufficient time to provide a supply of medication prior to their liberation meaning that they would be liberated without it.

Participants spoke of how Covid-19 restrictions had impacted through-the-gate support provided to liberated individuals by third sector organisations. Face-to-face support was withdrawn during the height of the pandemic which meant that individuals were no longer met at the gate on liberation^[32]. There was concern about the impact of this on the outcomes of liberated individuals:

"when Shine are supporting a woman we would have done a gate pick-up in the past - take the woman straight to present as homeless, go to the GP, get a prescription sorted, get their methadone, whatever it is, get all that done. But now that [Shine] can't provide gate pick-ups, with the restrictions, you're kind of relying on the women ... and if she encounters one person on the way home who tries to encourage her to come and do whatever they want, that can all go to pot." [Third Sector Stakeholder]

When asked about the response of SPS to the Covid-19 pandemic, two participants outlined how the measures implemented had ensured a comparatively low number of cases and deaths. One participant also reflected on how the prison service had not witnessed high numbers of incidents of unrest among the prison population during the pandemic, despite the implementation of restrictions to the regime. Indeed, it was felt that the prison population supported the strategies implemented by the prison service to limit the spread of the virus within the estate:

"For the first time ever I saw, as a collective, they took responsibility for their health and the health of others". [High Level Stakeholder]

One participant commented that benefits of this collective responsibility included a reduction in the number of inappropriate self-referrals to primary care and more realistic expectations around time frames for appointments.