Prison population: social care needs

2. Literature Review 

There is considerable evidence on the general themes of the drivers of social care needs in Scottish prisons, covering issues such as:

• Physical disability
• Increased social care needs due to ageing
• High prevalence of mental health issues in the prison community
• High levels of substance abuse
• High prevalence of hidden disabilities and head injuries

The prevalence of most of these conditions is higher among the prison population compared to the non-prison population. Many conditions are under-recognised in prison settings.

No specific precedents were found for statistical modelling of the type contained in this study. This prompts the development of a novel methodology (outlined in Section 4) that draws on traditional statistical techniques for modelling probabilities.

The literature review was undertaken to understand the characteristics of people in prison and to identify the relationship between health and demographic characteristics with associated social care support needs. Firstly, this review uses evidence from research on the prison population in Scotland and UK-specific evidence of the social care support needs of the prison population, as well as evidence on social care support needs and provision after imprisonment and in the community more generally. In particular, the literature review discusses the social care support needs of the prison population in Scotland, as well as in England and Wales. Secondly, the review explores evidence on social care support needs and provision outside prison. In particular, the second part of the review focuses on the social care support needs of people after their imprisonment and explores empirical methodologies used to model social care support needs of the non-prison population.  

Social care support needs of people in custody

i. Social care support needs in Scottish prisons 

The demographics of the prison population in Scotland are changing. There is a declining number of young people in custody and an increasing population of older people in prison, who the SPS have defined as individuals over 50 years old (SPS, 2017a). The main driver of demographic changes is the conviction of older people for historic sexual offences, leading to more people spending their end of life in custody. The number of older people in custody is expected to rise further in the coming years, causing an increase in the expected social care support needs of the prison population (Levy et al., 2018). 

However, social care support needs are not restricted to older people in prison. They can arise not only from frailty related to age, but also from physical disability, mental health issues, substance use, learning disability and other conditions such as autism, ADHD and brain injury. This means that young people and young adults in prison are likely to need social care support at greater levels than their non-incarcerated peers. 

Physical disability and social care support needs associated with ageing

The literature here has focused on the social care support needs of people in custody who have some physical disability or frailty related to ageing. People using a wheelchair, for example, find it difficult to move around prisons, which are not well designed for disabled people or those with mobility difficulties. According to a report from HM Inspectorate of Prisons for Scotland (2017), which explored the social care support needs of older people in Scottish prisons, people over 60 could face difficulties in eating, sleeping (if they have to sleep on the top bunk), walking around the prison or accessing the toilet. In the majority of cases, individuals were dependent on the help of prison staff or other people in custody. Perkins et al. (2014), using a sample from 10 Scottish prisons, found that older people in custody suffered from health issues associated with ageing, alcohol misuse, mental illnesses and learning difficulties. 

Mental health and wellbeing

The negative impacts and effects of imprisonment are multifarious. Among these effects is the deleterious impact of imprisonment on mental health and general wellbeing. The World Health Organisation (Regional Office for Europe)^[5] attribute this to the effects of 'overcrowding, various forms of violence, enforced solitude, lack of privacy, lack of meaningful activity, isolation from social networks, insecurity about future prospects… and inadequate health services, especially mental health' that people experience in prison.

A Health Needs Assessment conducted by NHS Greater Glasgow and Clyde (2012), based on published literature and reports, direct observations and engagement with prison staff and people in custody, shows that people in custody and prison staff in Scotland consider mental health to be the most important health issue. Other evidence from a now dated thematic inspection of Scottish prisons showed that 4.5% of people in prison in Scotland suffered from 'severe and enduring' mental health problems and the number of people with less acute mental health problems is likely to be much higher (HM Chief Inspector of Prisons for Scotland, 2008). These findings align with those from Davidson et al. (1995) which showed that there is high prevalence of mental health issues in the prison community: 2% suffered from a major psychiatric disorder, 40% reported symptoms of depression, 34% reported symptoms of anxiety and 40% disrupted sleep. 

People in custody are more likely to suffer from mental illnesses before their offence than the wider non-prison population. 14% of people in prison in Scotland have psychiatric records and 7.3% have records of self-harm incidents (Graham, 2007). Mental health issues can also arise due to imprisonment. Children and young people in custody can experience their sentence, however short, as traumatic, and they can suffer from symptoms of adjustment disorders in the weeks post-release (Youth Justice Improvement Board, 2017).

Tweed et al. (2019) also show that the mental wellbeing of prison community, which the authors defined as 'feeling good' and 'doing well', is lower than the non-prison population, even when they are matched to non-prison population in the most deprived areas. Additionally, the same research shows that people on remand have lower scores of mental wellbeing compared to sentenced people. 

Substance use

There is a long-established association between mental ill-health and substance misuse (The Royal College of Psychiatrists, 2018). Substance misuse is one of the risk factors of developing and/or contracting health-related problems, including bloodborne viruses, liver disease, Wernicke–Korsakoff syndrome, and dementia, which can increase health and social care support needs. Associated health and social care support needs are compounded by homelessness and mental health issues, which are more prevalent across the prison population compared to the general population. Thus, people with these kinds of conditions are likely to have distinct health and social care support needs, which may be amplified when co-occurring with incarceration.

Alcohol

Alcohol problems are under-recognised and under-recorded in Scottish prison settings, while evidence on the prevalence rate varies. According to a 2012 health needs assessment, 20% of the prison population in NHS Greater Glasgow and Clyde (NHSGGC) were alcohol dependent, and over half were drunk when committing their offence (NHS Greater Glasgow and Clyde, 2012). The prevalence of alcohol dependence is much higher than in the non-prison population, and this difference is more pronounced for women in prison. 

Parkes et al. (2010) compared the prevalence of alcohol problems of the Scottish Prison Population with the general population, using self-reported data, including the 2008 Scottish Prisoners Survey and the 2008 Scottish Health Survey. The results suggested that at all ages, 44% of men and 48% of women in custody had alcohol problems compared to 13% of men and 9% of women in the general population. Alcohol problems were also 2.5 times more prevalent among children and young men in custody aged 16-24 years old compared to the general population, and 3.5 times more prevalent for women aged 16-24 (NHS Greater Glasgow and Clyde, 2012). It should be noted that these results make no attempt to control for the characteristics of individuals, e.g. age and socioeconomic status.

Drugs 

People in prison are more likely than the general population to have a history of drug misuse, which might continue in prison. The 2017 SPS biennial survey of people in prison reported that 36% of the prison population said that they were drug users before their imprisonment, and 38% of them had used drugs when committing their offence. According to a health care needs assessment conducted in 2007 in Scottish prisons, which used data from the General Administration System for Scotland (G-PASS) register, the prevalence rate of illegal drug use on admission to prison was 67%, while the prevalence rate in the Scottish community was estimated at 8% (Graham, 2007). In 2010/11, results from drug testing in Scottish prisons showed that 86% of people in custody had used drugs at arrival in HMP Barlinnie prison, and 83% in HMP Greenock (NHS Greater Glasgow and Clyde, 2012). In 2018/19, 71% of people arriving into custody who were voluntarily tested at 12 Scottish prisons were found positive for illegal drugs (or misuse of prescribed medication).^[6]

People in custody might continue or start using drugs during their time in prison. In 2017, 39% of people in custody reported they had used illegal drugs in prison.^[7] During the same year, 18% of prison population reported that they had used new psychoactive substances (such as synthetic cannabis) while in prison (SPS, 2017b). In 2018/19, 26% of people voluntarily tested when leaving prison were found positive for illegal and/or illicit drugs at their release.^[8] This was lower than the previous year, when 31% tested positive, but the percentage of individuals who tested positive for illegal/illicit drugs when leaving prison had gradually increased over time from 17% in 2009/10.

Learning disability 

Staff and people in prison consider that the prevalence of learning disabilities is underestimated and under-recognised. Levy et al. (2018) state that 'people with diagnosed or borderline [….] learning disabilities (previously referred to as intellectual disability and/or brain injury) regularly end up in the prison system, but are not readily identifiable to themselves and prison staff'. Somewhat out of date, but included in the absence of a more recent source, in 2004, 17 people in Scottish prisons were either diagnosed or "were strongly believed" to have a learning disability, representing approximately 0.3% of the prison population, not statistically different from the 0.5% of the general population with learning disabilities (Myers et al., 2004). More recently, 10 people with learning disabilities were identified following a pilot study which screened new admissions over a 16-week screening in 3 Scottish prisons implying a low prevalence rate (National Prisoner Healthcare Network, 2016; NHS Greater Glasgow and Clyde, 2014). However, this prevalence rate excludes those already in those prisons. 

Although there is limited understanding of the prevalence of learning disabilities in Scottish prison settings, it is recognised that people with learning disabilities have "a distinctive set of needs" as they find it hard to settle in and adapt to the prison environment (NHS Greater Glasgow and Clyde, 2014). The first step towards helping people in prison overcome the challenges posed by their learning disabilities is to improve identification of cases. However, according to Equality and Human Rights Commission (2017), criminal justice agencies do not use a consistent procedure to identify them. 

NHS Greater Glasgow and Clyde (2012) highlighted the need for a screening tool of learning disabilities and difficulties that could be used at admission. In 2018, the Do-IT profiler was piloted in three Scottish prisons (HMO/YOI Polmont, HMP Glenochil and HMP/YOI Cornton Vale); 149 participants (21%) were identified with signs of learning disabilities or difficulties (Cameron, Downie & Carnie, 2018). The Do-IT profiler includes screening tools and assessments of learning difficulties and disabilities of people in prison. It provides tools to support people on their rehabilitative pathway, including continuous monitoring, and providing instant feedback and advice after screenings and assessments.^[9] The Do-IT profiler is expected to be used across all Scottish Prisons in the future and should improve the data on learning disability prevalence (Levy et al., 2018). 

Other hidden disabilities 

Hidden disabilities, including Autism Spectrum Disorders (ASDs), ADHD and other neurodevelopmental disorders, are conditions that are not obviously recognisable or visible. These impairments are more difficult to identify in prison settings, due to lack of awareness, resources and specific assessment systems in the criminal justice system (Ashworth, 2016). Conditions like ASDs (autism, Asperger syndrome, and pervasive development disorder) are over-represented among people in custody but underdiagnosed. This is despite there being standard measures to trace ASDs and efforts to develop screening tools for ASDs in prisons (Robinson et al., 2012).

The prevalence rate of ASDs in Scottish prisons is not known. Results from studies in Scottish prisons vary from no evidence that ASDs are common (Robinson et al., 2012), to a prevalence rate of 9% (Young et al., 2018a). Other studies explore the link between ASDs and offending behaviour – although some have speculated a potential correlation between them, more recent studies did not find any evidence that people with ASDs are more positive to offending behaviour, while others even found a negative correlation (Allely, 2015).

People with ASD are likely to suffer from another hidden disability, such as ADHD. Young et al. (2018) found that 22% of men in one Scottish prison had both ASD and ADHD, while 25% of them had at least ADHD. This estimate was consistent with results from an earlier study by Young et al. (2009), which used a sample of 198 men living in HMP Aberdeen, and found that 24% of them had childhood ADHD, of which 20% continued having symptoms during adulthood.

Head (brain) injury

Traumatic brain injury is more prevalent in the prison population than the general population. One in four people in Scottish prisons have experienced traumatic brain injury, while 10% have suffered from a severe head injury, or multiple head injuries (McMillan et al., 2019), that might require longer-term rehabilitative and social care. 

People in prison in Scotland are more likely to experience 3 or more hospitalised head injuries and suffer more severe ones than the non-prison population. Among the prison population, there is a higher risk of people in lower deprivation quintiles suffering from a hospitalised head injury (McMillan et al., 2019). Head injuries that can cause a brain injury are also common among young people in custody. According to the Youth Justice Improvement Board (2017), more than one third of the young people in custody in Scotland that participated in the study had a head injury, while 20% had experienced two or more head injuries. One out of four young people who had a head injury claimed that it happened during a fight. 

ii. Social care support needs of the prison population in England and Wales

Similar to Scotland, Wales and England have one of the highest imprisonment rates in Western Europe. The total prison population in English and Welsh prisons was 79,643 in July 2020, while the prison population rate was estimated to be around 133 people in custody per 100,000 of the national population.^[10] In Scotland, the imprisonment rate is calculated at 135 people in custody per 100,000 of the national population.^[11] The age structure of people in prisons in England and Wales is also changing, mirroring Scottish trends. The number/proportion of people over 50 in English and Welsh prisons has increased by more than 150% since 2002 (Sturge, 2020).

Although there are similarities between rates of imprisonment and the age profile of the prison populations in Scotland and England and Wales, the latter has legislation in place to support the prison population with social care support needs, while Scotland lacks "legislation that clearly defines responsibility and approaches to providing social care in prisons", impacting on peoples' lives during and after their imprisonment (Levy et al., 2018). 

Legislation in England and Wales

The social care needs of people in custody in England and Wales are not fully met (Care Quality Commission, 2018), although there have been improvements in delivering social care in prisons after the introduction of the Care Act 2014^[12] in England and the Social Services and Well-being (Wales) Act.^[13]

Both Acts state that local authorities are responsible for providing social care to people in prison who meet the eligibility criteria. People in custody are eligible under the same criteria used for people in the community (Tang and Kennelly, 2015).^[14] The eligibility criteria in England are: (i) needs for care and support arise due to mental health problems, physical ill-health, disability, learning and cognitive disabilities and substance (alcohol and/or drug) dependence; (ii) the person is incapable of doing at least 2 daily activities, such as going to the toilet, developing and keeping personal relationships etc.; (iii) not being able to carry out the aforementioned activities has an impact on personal wellbeing. In Wales, a person is eligible to receive social care support if needs arise from certain health problems that make them incapable of carrying out daily activities. Moreover, Welsh people are eligible for social care support if they do not have access to care support and they need help from the local authority to meet their needs.^[15]

Age, mental health issues, substance misuse and hidden disability

The needs of the prison population can be identified using a screening process at arrival. If the social care support needs of people in custody arise during their sentence, they have the right to ask for a social care assessment. However, needs are still unmet either due to failure of screening processes to identify potential needs, or people in custody not being aware that they can self-refer for a social care assessment (Care Quality Commission, 2018). 

During 2014-2016, 1,835 people in English prisons were identified as having social care support needs, including needing help with activities of daily living, or help related to health and wellbeing (2.3% of the total English prison population); 1,593 had an assessment (2.0% of the total prison population in England) and 790 (1.0% of England's prison population prison population) received social care (Tucker et al., 2018).^[16] Needs can arise due to age, mental health issues, drug and alcohol misuse, learning disabilities, and due to other health conditions, such as brain injury. 

According to the UK Department of Health (2014), 8.3% of people in custody aged 50 and over would need social care support. This estimate was based on prison data provided by prison governors from 5 prisons via a 2014 pilot questionnaire. When using self-reporting data of the prison population, the estimate of older people in custody needing social care is much larger. For example, in HMP Northumberland, 40% of older people self-reported that they were unable to carry out an activity of daily living, due to either a health condition or due to their age (Public Health England, 2017). There is a recurring theme of significant differences between levels of self-reporting of needs and official assessments that is noticeable in some of the results presented in Chapter 5.

According to the National Audit Office (2017), there were 120 self-inflicted deaths in English and Welsh prisons in 2016, while incidents of self-harm increased by 73% from 2012 to 2016. Without making any adjustments for the characteristics of individuals, self-inflicted deaths are 6.2 times more likely in prison settings than outside, while 70% of self-inflicted deaths in prison cases in 2019 had mental health needs (Prison Reform Trust, 2019). The prevalence of mental health problems can vary depending on age and gender. The younger prison population is more likely to suffer from neurotic disorders than the general population. Farrant (2001) states that 50% of young men on remand and 30% of sentenced young people suffer from a diagnosable mental health disorder. Depression is 5 times more prevalent among the older prison population than elderly people in the community (Fazel et al., 2001). Mental health problems are also 5 times more prevalent among women in prison, compared to women in the community; in 2012, 28% of the reported self-harm incidents in prison were committed by women (Prison Reform Trust, 2013).

Mental health issues are also prevalent among people with a neurodevelopmental disorder. People in custody have an increased risk of developing comorbid disorders, such as mood, anxiety or personality disorders alongside ADHD (Young and Cocallis, 2019). In the UK, around 25% of people in custody are identified to have ADHD, which is considered to be associated with increased recidivism (Young et al., 2018b). Other neurodevelopmental disorders, such as ASDs, can "slip through the gap between learning disabilities and mental health diagnoses", making it harder to be diagnosed in the criminal justice system (Ashworth, 2016). Indeed, Underwood et al. (2016), using a sample from a prison in London, identified around 16% people in custody with unrecognised ASD traits, while the estimate was not significantly higher than the rate found in a counterfactual group in the community. Regarding learning disabilities, the prevalence rate in the UK prisons ranges from 1-10% (Loucks, 2007).

Drug misuse is also prevalent among people in custody; this endangers their health and increases their respective needs. People in custody are more likely to have a history of drug dependence than the non-prison population, while drug abuse continues in prison. The extent and patterns of drug misuse in prison differ from in the community. For example, although the misuse of opiates in prison is declining, following the decreasing trend in the community, opiate misuse remains a significant issue in prisons. New psychoactive substances (particularly synthetic cannabis) are more widely used in prisons than the community (HM Inspectorate of Prisons, 2015). Additionally, there has been an increase in misuse of prescribed medication, such as Buprenorphine (Bi-Mohammed et al., 2017). 

Social care outside prison 

Social care support needs after prison

It is widely recognised that people leaving prison encounter difficulties accessing support and benefits – and this is more acute for those leaving prison on short sentences without statutory social work involvement.^[17] Needs tend to include accessing adequate housing, benefits and GP registration, and this is not only an issue for the continuance of social care, but it can also contribute to worsening socio-economic and health vulnerabilities. 

Levy et al. (2018) point to the impact of social sanctions and conditionality on social isolation and disengagement from support networks. The issue of social care post-release also needs to be situated in the context of the relative social isolation that prison leavers often face (Nugent and Schinkel, 2016). This is likely to be exacerbated for those with limited mobility, severe and enduring mental illness, and learning disability. Together, such impacts can increase vulnerability to and risk of homelessness; and by extension, exposure to violence and vulnerability to self-harm, escalating poverty, risk of reoffending – all of which are likely to underpin if not reinforce the cycle of re-imprisonment (Fernandes and Sharp, 2015).

Levy et al. (2018) highlight an urgent need to collaborate between social work and others 'to ensure the seamless provision of services to [people in prison] in the move from the community, into prison and back into the community'. Given the prevalence of short sentenced people in custody in the prison population in Scotland and taking into account the phenomenon of the 'revolving door', this is a particularly pertinent observation – more so when considering the absence of statutory social work support for individuals subject to short sentences who are not subject to post release licence and the withdrawal of SPS Throughcare Support Officers in 2019.^[18]

Modelling social care support needs of the non-prison population 

The literature here mostly focuses on the social care support needs of older people, since this group represents a growing population with significant social care support needs. The literature seeks to identify social care support needs through estimating people's care dependency, using different approaches, such as the 'interval' method of measuring needs or using assessment tools, including the Indicator of Relative Need (ioRN) and the CAPE tool. 

The 'interval' method of measuring needs

The 'interval' method of measuring needs classifies individuals into care groups based on social care support needs and the level of dependency on other people. Isaacs and Neville (1976) developed this method but it continues to be used in the literature to estimate care dependency of older people (e.g. Kingston et al. (2018)). 

Isaacs and Neville (1976) used the interval method to estimate the needs of older people for domiciliary services, using a sample from three areas in the west of Scotland. The authors classified the individuals into 12 care groups, based on potential need and solitude (i.e. social isolation). The social care support needs of the sample would equal to the sum of social care support needs estimated for the 12 groups. Potential need was defined as the measure of disability and its severity. The latter was categorised into 3 different levels based on how often the person needed help to cover activities of daily living (long, short and critical interval need). Solitude was also categorised into 4 groups, based on the frequency of the availability of social care support need provision (minimal, maximal, diurnal, nocturnal). The 12 groups were the combination of the above criteria. The model was based on the assumption that the social care support needs were approximately homogeneous among the 12 groups.

Potential need was linearly associated with age, but there was no significant relationship with sex, marital status, social class, living arrangements, family structure, and area of residence. Estimated social care support needs were similar to the estimate produced by a second method, according to which the social care support needs of older people were calculated as the sum of the actual help people received and the potential further help they should receive to fully cover their needs. Extrapolating the estimates for potential need to the Scottish population, it could be claimed that 250 people per 1,000 of population aged over 65 years old may have had potential social care support need.

Estimation of needs based on assessment tools

Another way to measure social care support needs is using assessment tools of needs and care dependency. An example of these assessment tools is the Indicator of Relative Need (ioRN), which was developed by and for health and social care professionals in Scotland to identify and measure people's functional needs and dependency.^[19] The ioRN includes a questionnaire that gathers information on people's physical and mental wellbeing, including activities of daily living, personal care, food and drink preparation, mental health and behavioural issues.^[20] Based on answers to the questionnaire, an algorithm categorises people into different groups of dependency. The assessment outcomes are essential to understand people's support needs and inform planning and delivery of future services (NHS Scotland, 2017). The tool can be used in the community, while there is another version which can be used in care homes and hospital settings. Although it was first designed for older people, there is no age barrier to its use.^[21]

Following a similar methodology but using a different tool to assess older people's care dependency, Wattis et al. (1992) estimated the needs of people with dementia and/or disability living in residential and nursing homes in Leeds. The authors used the Clifton Assessment Procedures for the Elderly (CAPE) to identify 5 care dependency grades (independent people, low, medium, high and maximum dependency) and classify the sample accordingly. CAPE is mostly used by professional workers involved in the care of the elderly to identify met and unmet needs of older people. It assesses people's quality of life as well as care dependency levels due to physical and cognitive impairments.^[22]