Prison population: social care needs

1. Introduction

The prevalence of physical and mental health conditions among the prison population is high, especially when compared to the non-prison population. According to Fitzpatrick and Bramley (2019), offending^[1] is likely to co-occur with at least one other severe and multiple disadvantage (SMD), including homelessness, substance dependency, mental health issues and domestic violence and abuse. In particular, over a year, 5,700 people in Scotland suffer simultaneously from 3 forms of SMD (offending, homelessness and substance misuse). 

People in custody often suffer from physical and mental health conditions that might be present before admission to prison, some of which may naturally deteriorate over time or due to imprisonment. Many of these conditions can also develop for the first time during their sentence as a consequence of prison-related factors, including overcrowding, social isolation, or inadequate support. A person in custody with physical and/or mental health conditions might develop social care support needs, meaning that they might require help with activities of daily living, as well as help in maintaining independence, managing personal relationships, taking part in prison life, and social interaction. To meet their social care support needs, people in prison usually need social care support, which is defined as helping people live independently, be active members of the community in which they are part of, and preserve their dignity and human rights.^[2] The social care support provided in prison should be comparable to the level provided in the community, although people in custody do not have access to family networks or community resources and support, which are often a source of social care support in the non-prison community.

The likelihood of people in prison having social care support needs, and consequently the need for social care support, is increasing. This upward change is partly explained by the changing demographics in the prison population in Scotland. In particular, the increase in the number of people convicted of historic sexual offences later in their lives has led to changes in prison demographics, causing an increase in the number and proportion of the prison population aged over 50 years old. According to the latest prison statistics published by The Scottish Government (2020), the number of people aged over 50 years old has been rising, and there has also been an increase in the number of people aged 30-39, especially after 2017. In contrast, the number of people aged under 25 has been reducing over the years, which is in-line with the Scottish Government's aim to reduce the size of the Scottish prison population.^[3]

Importantly, although it is the ageing of the prison population in Scotland that has been a key driver of focussing attention on the potential absence of comprehensive social care provision for people in prison, this issue may be equally relevant for all ages. Both older and young people in prison might have social care support needs that are not age-related and social care support in prison applies to everyone who needs it. This report estimates social care needs among all age groups in prison, rather than narrowly focusing on older people in prison.

Accelerated ageing among people in custody

There is reasonable debate about the threshold at which a person in custody is considered "older". Based on previous research (e.g. Aday, 2003; Loeb and Abudagga, 2006). The SPS has adopted the age of 50 years old as the threshold to classify someone in prison as "older". The threshold for the prison population is ten years younger than the one for the general population, due to the accelerated ageing observed among people in prison (SPS, 2017a). The faster ageing process is due to a number of health and lifestyle factors that occur either prior to conviction or during the sentence.

The Royal College of Psychiatrists (2018) highlight the relationship between age and substance misuse and the manifestation of complex needs in the general population. The report also highlights the significant correlations between substance misuse and mental health problems, as well as the impact of substance use on accelerated ageing (Beynon et al., 2010), which is further compounded by socio-economic deprivation and adverse psycho-social factors (Bachi et al., 2017). Substance misuse leads to biological ageing, exerting a compounding effect on chronological ageing, and it is exacerbated by low socio-economic status (e.g. as a consequence of limited use of health services, lack of sleep, insufficient exercise and poor nutrition, etc.). The Royal College of Psychiatrists (2018) observes that while clinical services in Europe define older people as being 65 and over 'for illicit drug [users], 40 years of age has been considered as more valid in defining older people'. 

Referencing research by Stojkovic (2007), which identified the difficulties faced by older people in custody, often as a result of inadequate resourcing by prison systems to care for their needs, Levy et al. (2018) note that imprisonment can hasten the biological ageing process. This is more prevalent among people in prison who experience some kind of disability. The authors found that people in custody felt that "their overall health and/or disability has deteriorated whilst in prison", mainly due to the impact of incarceration on their psychosocial health and the lack of professional support. While some people in prison had a disability prior to their imprisonment and had previously received social care support in the community, others in the study noted that they acquired some kind of disability, and/or health conditions necessitating social care support in prison and struggled to process changes in their support needs. Consequently, people coping with the same conditions may be differently affected, which may have implications for both the nature and extent of support required. 

Social care support needs

Against the background of changing demographic characteristics of the prison population and an increasing number of older people in custody, the social care support needs of the prison population in Scotland are increasing. This raises the question of what social care support need is. Although there is no universally agreed definition or conceptualisation of social care, the literature has previously narrowed social care support need to personal care, which risks under-estimating social care support needs, and calls into question issues surrounding rights. Such a definition, as Levy et al. (2018) note, ignores broader definitions of social care, that include a focus on wellbeing, the need to support the exercise of agency, citizenship, and opportunities for participation. There are, then, issues around defining social care too narrowly as personal care, which will impact on how need is perceived, self-reported, estimated, and provided. 

In this report, social care support needs are understood as those defined by the Commission on Funding of Care and Support (the "Dilnot Commission"). According to this Commission, people of all ages might need social care support due to "certain physical, cognitive or age-related conditions" that reduce their ability to perform "personal care or domestic routines", or because they need help to "sustain employment in paid or unpaid work, education, learning, leisure and other social support systems", to build social relationships and to participate in the community.^[4] This definition implies that social care support needs are not restricted to older people in prison. On this basis, young people in prison are also likely to need social care support, as social care support needs do not arise only from frailty related to age, but also from physical disability, mental health issues, substance use, learning disability and other hidden disabilities, which are more prevalent among young people in prison than those in the community (Youth Justice Improvement Board, 2017).

Challenges in providing social care support in prisons

The Scottish Prison Service (SPS) is currently responsible for personal care support in prisons. In 2017-18, the SPS spent around £542,000 on agency care workers who helped individuals carry out activities of daily living, such as bathing, using the toilet, getting dressed, eating (Bavidge, 2019). In 2019-2020, the SPS spent around £960,000, based on the Test of Change project, described in more detail below.

Although the SPS is currently commissioning personal care support, broader social care support needs in Scottish prisons are thought to be unmet. Prisons are not structurally designed to accommodate individuals who are unable to fully care for themselves. The architecture of the prison estate in Scotland, as in many countries, can represent physical challenges to people in prison with social care support needs that would not affect them in the community. It might also be suggested that the purpose and the restrictive nature of the prison regime presents challenges for the provision of social care in prisons. Prison can be a disabling space in this regard. 

People in prison receive social care support from other individuals in custody, prison staff, healthcare or social care workers. Other people in custody and prison staff are – in most cases – not trained to provide social care support, meaning that social care needs might not be adequately met, or the cared-for person or the carer could even be put at risk. Levy et al. (2018) highlight the need for providing appropriate training to prison staff and other people in custody, specifically in relation to social care support needs. Based on SPS guidance on personal care peer support policy, which sets out guiding principles for those in custody that provide support to others, peer support does not include intimate care (i.e. tasks related to personal hygiene), but it includes a broader definition of personal care support.

Other reasons that could lead to inadequate social care provision include the lack of tools to identify social care needs when people are admitted into prison, or throughout the duration of a person's sentence; the high-level support required; and the complexity of the needs, due to co-occurrence of causal factors. Indeed, Public Health England (2017) note that co-occurring conditions are common among people in custody, and many people affected have complex needs. These conclusions imply that there is a need to recognise and negotiate the inter-connectedness between conditions that can result in a range of health and social care support needs, which will be dynamic over the life course or even during a person's sentence. These needs require multiple, holistic, and integrated health and social care interventions.

Steps towards improving social care support in Scottish prisons 

As a response to the changing demographics in the prison population, and the increasing need for a health and social care model, which is in line with the provision in the community, the Scottish Government is taking steps towards integrating health and social care support in prisons. Responsibility for health services was transferred from the SPS to NHS Health Scotland in 2011 and, subsequently, became the responsibility of Integration Authorities when they were established in 2015. This transfer specifically excluded social care, which by default remains the responsibly of the SPS. The integration of health and social care in 2016 did not in practice extend to prisons, although the policy intention is that health and social care partnerships that deliver care in the community should do so in prisons.

Part of the work stream that supports the integration of health and social care in the prison community and aims to improve availability and quality of prison population's social care data is a Test of Change project conducted by Social Work Scotland. The purpose of this project was to explore different approaches to incorporating adult social work assessment and social care delivery practices within the existing services in prisons. Tests of Change were to be delivered within 4 Health and Social Care Partnerships, which covered 6 prisons. The Test of Change sites were also to identify the challenges in assessing and arranging services for people in prison in a way that was equitable with community-based assessment. All the test sites worked on the principle that people residing in prisons should be treated for social work and social care services in the same way they are for health services. The Test of Change initiative has already been delivered in HMP Castle Huntly and HMP Perth as part of a wider programme to deliver holistic health and social care packages within the prison settings.

The current study presented in this report will support the Scottish Government's objective of delivering integrated health and social care in prisons, through the assessment of social care support needs of people in custody for the duration of their sentences. The output of this study will serve as a key element of the evidence base for the integration of health and social care in prisons.