Prison population: social care needs

3. Stakeholder interviews

Qualitative interviews were conducted with a range of stakeholders in the SPS, NHS and with social care representative bodies outside of prisons.

The majority of stakeholders view there to be unmet social care support needs in Scottish prisons, although some respondents thought provision is reasonably comprehensive. Among those who view there to be unmet needs, respondents raised the problem of addressing invisible disabilities and suggested there is too much focus on a narrow definition of physical care needs.

To maximise the chance of successful delivery of social care in Scottish prisons, there was a relatively high consensus around improving the following areas: governance, partnering and information sharing; capability and skills; stigma levels associated with receiving support; accommodation; and taking a holistic approach.

The key challenges to successful delivery were flagged as: identifying invisible disabilities; security; and fluctuations in social care support needs in prisons.

To assist with understanding the social care support needs in Scottish prisons, 10 stakeholder interviews were conducted, consisting of 4 interviews with SPS personnel (including 2 Prison Governors), 1 with an NHS prison healthcare team leader, and 5 with social care representatives external to the process of delivering care in prisons.^[23] Fieldwork was affected by potential interviewees having very high workloads due to the COVID-19 pandemic and being unable to participate, resulting in engagement with fewer stakeholders than would have been the case otherwise, particularly among potential NHS respondents.

The purpose of stakeholder interviews was to inform the process of estimating the number of individuals in custody in Scotland with social care support needs. Interviews covered: the importance and understanding of social care needs in prisons; the possibility of unmet needs; the main challenges for delivering social care in prisons; current provision; and options for maximising the chances of successful delivery.

The write-up below presents the range of views expressed by stakeholders without providing a critique, and the responses go well beyond those needed for the scope of this study. The difference in views between stakeholders who have a relatively narrow view of social care support needs (primarily relating to visible disabilities) and those with wider views of social care support needs (including invisible disabilities and a more holistic approach to care) has been key to determining the conclusions of this study. Commenting on the wider themes raised by respondents, there were many similarities to points raised in Levy et al. (2018), including issues with facilities and physical barriers to social care in prisons. Similar issues were found in relation to governance, i.e. whose responsibility it is to provide social care.

The current level of social care in Scottish prisons

The extent of care needs currently addressed

A number of respondents noted that while the NHS provides healthcare services in prisons in Scotland, local authorities do not provide social care in prisons (in line with the more detailed discussion of the policy context in sections 1 and 2). A number of respondents noted that access for people in custody to social care, assessment, equipment and support, is currently neither integrated with community services nor fully equitable with services and support available in the community.

There is a high level of consensus that there are significant and growing needs for social care in prisons in Scotland, particularly due to the ageing prison population, but also due to a growing need for throughcare (covered further below). A number of respondents noted that people are "older earlier" in prison, so people in prisons often have health and care conditions more typical of those who are 10-20 years older in the general population.

There was also a high level of consensus that provision of social care in Scottish prisons has become a high strategic priority for the SPS. As one respondent puts it, "everyone has needs and you have to meet them". The total level of social care support needs varies considerably by prison and particularly affects prisons with a large number of people in custody on long-term sentences. Social care support needs can also vary significantly with turnover in people in custody, particularly in prisons with higher numbers of admissions and releases, due to having a large number of people in custody on remand or short-term sentences.

One respondent emphasised the vulnerability of the prison population, particularly for individuals regularly in and out of prison. Among this group, homelessness (when out of prison), substance misuse, and mental health problems are common.

Current provision

The SPS does not directly employ carers, qualified care managers, occupational therapists or adult care social workers, but instead procures social care (primarily personal care) from external care providers as required. The provision of social care, estate adjustments, and equipment for people in custody who have social care support needs is handled on a case by case basis, dependent on individual needs and establishment capability. 

One SPS respondent described how they have a comprehensive understanding of social care support needs in the prison they work in, but that this has only become the case recently. They noted that services and facilities (covered below) are of equal importance, and stressed that drug use and poor mental health are significant drivers of social care support needs. Another SPS respondent raised the issue of increasing spend on social care, which had risen 10-fold in the last 5 years. This increase was mainly represented by higher spend on social care support per recipient, rather than a greater number of individuals with social care support needs, i.e. it primarily represents increased quality of care per individual with support needs. 

The process of going from first identifying a social care support need to implementing a care plan was discussed. One SPS respondent noted that in the first instance, people in custody normally self-refer either to prison officers or to the NHS team, but in some cases, staff (either SPS or NHS staff) make the first approach. At this point, there is typically triage, a case conference, and then a care plan is agreed between the SPS and NHS staff. A number of prisons also operate a Peer Carer scheme, which tends to provide social support but with no delivery of personal care. 

Where there are contracts for external care services, it is typical for carers to come into the prison several times per day to engage in support activities such as washing, helping people eat, helping the bed-bound move around in bed, changing dressings, and helping with changing clothes, etc; although in some cases a 24-hour support can be required. It should be noted that these activities generally represent personal care related to physical health rather than wider social care and support. One respondent emphasised that 100% of care is provided by external carers or the NHS, and prison officers do not provide care.

Potential unmet needs

Some SPS respondents thought that there aren't currently unmet needs in the prisons in which they work. One respondent noted that although the SPS would not be able to fully assess needs if working alone, they were able to do so via close working with the NHS and the private company that provided care. In contrast, another SPS respondent noted that the 2017 SPS Prisoner Survey (covered elsewhere in this report in more detail) suggests the likelihood of significant unmet needs. This respondent noted that the number of this survey's respondents self-reporting difficulties with daily living was much higher than the number of prisoners currently receiving care.^[24]

A number of respondents (both SPS and non-SPS) noted that the focus of social care provision is very much on providing packages of support for physical needs. Physical needs are perceived to be well understood, but there are likely to be unmet needs for invisible disabilities, including mental health problems. Respondents noted particular gaps around talking therapy, with under-provision of counselling and cognitive behavioural therapy (CBT) relative to the number of individuals who could benefit from this treatment. One particular area of concern was around whether social care support needs due to autism were being fully addressed, and it was suggested that a higher level of autism awareness among SPS staff would be beneficial. One respondent noted a gap around therapeutic support and suggested there would be significant benefits from providing structured activities to encourage social interaction.

More than one respondent raised the point that there are some unmet needs due to people in custody not wanting support, citing pride and the potential stigma of receiving support as motivations for this. One respondent gave the example of recipients of COVID-19 "shielding" letters. Where individuals were recommended to shield and had full discretion over whether they did or not, the majority chose not to, and this was in large part to avoid creating a negative impression among peers. It was also noted that some individuals do not make their needs known due to having low expectations about the level of care they are entitled to.

One respondent noted that there are some challenges around the speed of accessing social care services, suggesting that even if needs might end up being met, there can be time lags before that happens. Another respondent raised the difficulty of assessment in prisons, noting that someone may need to be seen several times over a period of time to assess care needs, and that a single assessment might lead to unmet needs. 

A number of respondents (both SPS and non-SPS) noted that social care needs will continue to grow over the medium-term, due to the continued ageing of the prison population and increasing numbers of complex cases. This creates the potential for an increase in unmet needs.

Facilities

The majority of respondents raised the issue of prison accommodation and facilities as a significant problem for addressing social care support needs. It was noted that most prisons have been designed for a young able-bodied prison population, with security as the primary concern. This makes prisons typically badly suited to older people in custody, causing difficulties getting around the prison for many. Relatively few cells have been adapted for people in custody with significant disabilities, with respondents mentioning that they had "a few" disabled-friendly cells but noting that they would ideally have more. One respondent provided the figure of around £8,000 just to widen a cell door.

One respondent gave the opinion that accommodation and facilities are as important as services for fully delivering social care and support in prisons.

Improving social care in Scottish prisons

Options for maximising successful delivery

Governance, partnering and information sharing

One of the most frequently mentioned areas for improvement was around governance and the role of social care delivery through Health and Social Care Partnerships. On governance, it was felt that it is not always fully clear whose responsibility it is to deliver care and this can have a negative impact on levels of accountability. Clarity of responsibility was seen as vital for successful delivery.

Most respondents mentioned the need for social care to be delivered as a partnership working in collaboration with the SPS and NHS. A number of respondents recommended having some co-location of social care and NHS staff or management within prisons to facilitate collaboration. A number of respondents also made the point that Health and Social Care Partnerships should have an important role to play in providing social care in prisons, noting that this is not currently the case.

A related point, raised by a number of respondents, is that at present, information sharing between statutory services is not working well, tending to be slow or to not happen at all. This is particularly a problem for providing throughcare as individuals transition between prisons and the community. One respondent noted that to maximise chances of success there needs to be connectivity for the journey of people through the justice system.

Capability and skills

Most respondents mentioned the issue of needing to make sure that people with the right skills are involved with providing comprehensive social care in prisons, with assessment noted as one particular area where this is particularly important. Respondents noted that the right skills were needed for thorough assessment, effective commissioning and subsequent monitoring. It was also noted that skills were needed for working with both younger and older people in custody, and that these skills were different for the two groups.

One respondent particularly highlighted the need for skills relating to end of life and dementia care, and that this should include training for prison workers as well as care workers.

Destigmatising social care

Multiple respondents raised the issue that there are some unmet social care support needs in prisons due to unwillingness by people in custody to receive support because of the perception that it would show weakness to their peers and could lead to bullying. One respondent noted that there is no gender difference in this perception of stigma, with women in custody just as likely to be reluctant to receive support as men.

Respondents noted that attempting to destigmatise social care via communication exercises could be part of the solution to addressing this. One respondent noted that privacy could be part of the solution via the provision of private places for delivering care, given that prisons are currently characterised by very low levels of privacy.

Adapting accommodation

A number of respondents noted that to fully address social care support needs in Scottish prisons, there will need to be improvements and adaptations made to accommodation. This is true also for relatively modern prisons with one respondent commenting that they wished they had known in the 1990s about the future increases in social care support needs when making plans to develop their estate.

A number of respondents commented on the cost implications of adapting and improving accommodation, which are relatively large. One respondent noted that it would be ideal to have a facility that is more like a secure care home than a traditional prison but noted that this would represent a significant change to how custodial sentences are delivered. 

Taking a holistic approach and providing throughcare

A number of respondents highlighted the need for a holistic approach to social care in prisons, with comprehensive assessment and recognising the high number of complex cases, defined as having multiple types of social care support need. For example, mental health issues often lead to alcohol and substance misuse and vice versa. One respondent noted that social care in prisons needs to involve social workers, particularly for assessment.

As part of this, a number of respondents made the point that people in custody need to be at the centre of determining person-centred care. This approach would base care on the individual aspirations of people in custody and give them a voice on issues that affect them, which is in line with current Scottish legislation, so it should be happening at present. Related to taking a holistic approach that considers the breadth of needs of people in custody is the issue of delivering a programme of care for an individual over a period of time to consider the throughcare journey with transitions into and out of prison. A number of respondents commented on this as a current shortcoming that could be addressed, particularly to support the transition from prison back into the community. It was noted that the throughcare journey should be planned and would ideally involve replication of provision, including continuity of care staff where feasible.

The role of prison officers

A number of respondents discussed the current and potential future roles of prison officers, which was an area where views differed. It was generally noted that prison officers have limited training in issues relating to social care. Some viewed prison officers as rightly having a limited role, whereas others thought they could have their roles changed to get more involved. One respondent suggested it would be worth considering the possibility of a hybrid role that combined being a prison officer with assisting with social care. One point that was particularly flagged as an area for improvement was more training about autism awareness and understanding.

Peer caring

Voluntary peer caring (or buddying) schemes can play a helpful auxiliary role in providing social support in prisons, which is an activity that happens at present with the SPS having existing guidance on peer caring and support. Respondents were clear that peer caring should not be for personal care, but instead peer carers could provide other forms of social support such as providing social interaction or company.

Alcohol misuse, substance misuse and non-severe mental illness

One area where views differed slightly was on the responsibilities around providing care to support issues relating to alcohol misuse, substance misuse and non-severe mental illness.^[25] Whilst it was a common theme that these issues were prevalent in Scottish prisons, there were different views regarding the role for social care in addressing them. Most respondents (both SPS and non-SPS) highlighted the role for social care in this area, but a small number of respondents highlighted the role of the NHS in addressing these issues, with some suggesting the NHS could provide a comprehensive solution for most issues in this category. Where respondents saw significant responsibility for social care in this area, this was seen as a key area to address in order to successfully provide comprehensive social care in Scottish prisons.

Challenges

One respondent put it very succinctly by noting that some of the challenges of providing social care in prisons are fundamental to how prisons are traditionally operated. Firstly, prisons typically rely on relatively strict routines with everyone doing the same activity at the same time, and this can be a poor fit with providing social care and support where individuals need to be able to go about tasks at their own pace. Secondly, the facilities in prisons have been built to provide secure accommodation for an able-bodied prison population, which causes significant problems for providing social care. This emphasis on facilities was a common theme, with a number of SPS respondents noting how expensive it is to adapt accommodation.

These comments provide a helpful summary of the overall level of challenge. The sections that follow outline some of the more specific challenges raised by respondents.

Identifying invisible disabilities

A number of respondents, particularly non-SPS respondents, noted that one of the biggest challenges to delivering comprehensive social care in prisons is fully addressing invisible disabilities, particularly relating to mental health. Where individuals in custody do not self-refer with invisible disabilities, these can be hard to detect. One respondent noted that this presents a strong case for wider screening processes in order to assess the social care support needs of more people who choose not to self-refer.

One respondent noted that in some cases, it is hard to detect invisible disabilities because individuals receiving help to follow routines by others in custody and by prison officers can appear more capable than is truly the case. In these cases, support suppresses indications that someone is struggling. Invisible disabilities are particularly likely to cause individuals to withdraw into their cells, reducing participation with prison life. One respondent gave the example of an individual in custody unable to participate in work in prison due to having severe Obsessive Compulsive Disorder, which was exacerbated by the available environment for work in prison.

Security

A number of respondents noted security issues as a challenge. One respondent made the point that prisons are a secure custodial environment, which is likely to be perceived to be a challenging and unattractive environment for many care providers. At present, this results in a limited number of agencies that are able to offer services. Another respondent noted that all actions taken to improve the health and wellbeing of people who live and work in prisons need to be balanced with security and order considerations.

Another respondent noted that having additional external service providers creates additional security risks, including for controlling what is going into and out of prisons. This non-SPS respondent suggested that this presents a case for SPS having its own social care staff. 

Fluctuations in social care support needs in prisons

One respondent raised the issue that social care support needs in prisons can fluctuate quickly with little warning, which is particularly an issue for prisons with a large number of people on remand or short-term sentences. This respondent noted that this can be particularly the case with Friday admissions, which can lead to increases in social care support needs for a prison without advance warning.