Prison population: substance use and wider support needs

Chapter 3: Perspectives of professional stakeholders

• Stakeholders feel that prison is simply the wrong place to try and meet the multiple and complex needs that most of those who are in prison currently have. This is true of both the convicted population and the excessive remand population. In particular this is the case for those with substance use needs as to them substance use is generally a coping strategy and logical response to imprisonment.
• This needs assessment is taking place during a period of optimism for stakeholders, inspired by the implementation of the MAT Standards and the policy directions of the Scottish Government. However, this optimism is tempered by the view that further progress is needed.
• There remain a significant number of challenges for those using substances in prison including mental heath, lack of treatment and healthcare options and a culture of punishment for substance use disclosure.
• Moving away from a punishment-focused approach is key to supporting those using substances in prison and reducing the number of associated deaths.

Introduction

To address the corporate element of the health needs assessment, through representation of the views of a range of stakeholders and interested parties, 20 qualitative interviews were conducted with a range of executive and senior level stakeholders. Representatives from SPS with strategic, health, justice and governance remits were interviewed alongside representatives from the Third Sector, and bodies providing legislative and welfare oversight. A further 16 interviews were conducted among NHS, SPS, Local Authority and Third Sector staff with operational and/or support responsibilities.

A short-life working group was also formed with a diverse range of professional stakeholders from key partners in SPS, NHS, and the Third Sector. [4 meetings involving different combinations of 10 professional stakeholders: SPS (n=4), NHS (n=1), and Third Sector (n=5)].

A selection of illustrative qualitative examples are included under each sub-heading, with a fuller sample of examples provided in Appendix C.

The wrong starting place

'How do we keep people [who use substances] out of prison in the first place? Because if we can do that then we're not having these conversations.' [Key Stakeholder interviewee #13]

'Is there a more holistic way that we can assess an individual, rather than what we see them to be, and that's a pain in the ass because they've committed an offence and they're taking drugs.' [Key Stakeholder interviewee #12]

We heard many comments from stakeholders suggesting that the easiest and most obvious way of meeting the needs of individuals who experience problems with substance use was by not criminalising or imprisoning them. All stakeholders who participated in the study believe that prison is the wrong place to try and meet the range of intensely complex environmental, emotional, physical, psychological, and social needs that are present amongst those individuals living in Scottish prisons who experience problems with substances. This is true not just of the convicted population but also of the remand population, which has been increasing in numbers over recent years.

Further, there was consensus that viewing substance use as a 'problem', which the current system appears to do, is the wrong underlying assumption. For most, substance use is considered by them to be a coping strategy and often a logical response, both outside and inside prison to medicate the traumas of past and present experiences.

Implementation of MAT Standards

'In the prisons you'll be lucky if [MAT Standards are] implemented by April 2023. They're so far behind. There's no way they're going to meet that deadline, or they will skewwhiff their KPIs and their figures to meet it, but in reality, that's not going to be the experience of the prisoner on the ground.' [Key Stakeholder interviewee #02]

Respondents spoke at length, and in detail, about the opportunity that will come with the full implementation of the MAT Standards across Scotland's prisons. The strongly-held perception is that the MAT Standards, if fully implemented, will be a game-changer that address many of the issues highlighted within this report (particularly in respect to improving speed of access to treatment, continuity of treatment, and choice of treatment options).

However, from the current starting point, the implementation of MAT Standards within Scotland's prisons is viewed as a much harder challenge than community implementation. This was particularly reflected in terms of: issues of fragmentation and continuity in respect of OST delivery; a lack of clarity over responsibilities with regard to the implementation of the MAT Standards; and the need to ensure all prison-based staff have confidence in the ability to fully implement the MAT Standards.

Policy perspectives

'When you … look specifically at the impact of the Misuse of Drugs Act … it has a huge negative impact on people who are experiencing drug problems. It's antiquated, it's out of date, it's seriously not helpful, and it undermines a public health approach.' [Key Stakeholder interviewee #22]

We heard significant praise for the Scottish Government in relation to policy development and the perceived direction of travel, with particular mentions of:

• The implementation of MAT Standards.
• The importance of having a dedicated Drugs Minister.
• Welcoming additional Scottish Government investment into drug treatment over the next five years.
• Moves towards depenalisation and a public health approach to justice.

However, despite these positive developments, there was also a consensus that there is still a long way to go if Scotland is to view the issues relating to substance use not as a problem and from a basis of any better starting place (i.e. for meeting needs without the reliance on custodial sentences). Particular references were made to keeping those with complex needs, and who are not necessarily a threat to public/society, embedded in continuous community networks of treatment and support.

This consensus has implications for Scottish Government substance use work programme and policy responses, many of which are currently under intense public and policy review (Scottish Parliament, 2022). We heard multiple references to the notion that policy, notably crime and justice, should be calibrated towards prevention first and punishment/protection second, as this might promote early interventions that prevent or negate the need for more intrusive or harsher responses later on. However, for many, it feels the other way round at present. Respondents discussed the need for greater use of combinations of decriminalisation, depenalisation, community sentences and alternatives to imprisonment.

Scotland has high rates of incarceration compared to the rest of Europe and slightly higher rates than in England and Wales (ScotPHO, 2021). Within the Scottish prison population there are also comparatively high levels of substance use (Toomey et al., 2022). These are seen as symbols of existing approaches and systems that are struggling if not failing. The discourses on alcohol, through minimum unit pricing, and drugs, through conversations about deaths and drug consumption rooms, have become high-profile media and political topics in recent years. While there are limits to what the Scottish Government can do (i.e. due to devolution), many still feel that there are opportunities to do things differently in Scotland to the rest of the UK (for example, the lawful establishment of Drug Consumption Rooms – see Foster, 2021).

High drug death rates has brought a priority focus to co-ordinated policy work at governmental level. Considerable reflection was given in the majority of discussions about how policy needs to be more overt in keeping people who experience problems with substances out of prison, and how the role of courts and Sheriffs in meeting this need is critical.

Systemic complexities

'You perhaps use the justice system to help the public health agenda as opposed to the justice system competing with the public health agenda.' [Key Stakeholder interviewee #04]

Planning structures – where do prisons fit?

Significant attention in professional stakeholder interviews was paid to the complexities of existing systems and structures when trying to understand where prisons fit into a broader policy landscape. Recognition was afforded to how prisons do not fit neatly into local health and community planning structures. Nor do they sit comfortably within regional or national structures, given that individual prisons have different populations and catchment areas (e.g. some are local, whereas others take in people from across Scotland).^[13] It was regularly noted that individual Governors in Charge [GiCs] have significant levels of autonomy and decision-making on how their prison is run.

There was recognition of the significant challenge and complexity for SPS to engage in local partnerships when prisons generally service populations from a wide range of geographical areas and not just the local community population. Moreover, the extent of this varies for different prisons, adding a further layer of complexity and making the task of achieving consistency across the country, in respect of engagement with local partnerships, more difficult. Some prisons, for example, are faced with having to negotiate and establish relationships with multiple Health Boards and Local Authorities to enable the delivery of in-prison and throughcare support services. This can create a de facto postcode lottery, where services available to people in different prisons are inconsistent and shaped by local partnerships and services which vary across the country (and where a person resides ordinarily). This complexity was noted as being more significant for the bigger urban prisons.

Respondents questioned who is ultimately responsible for substance use treatment in Scottish prisons and concluded that it appears to be a confused picture with uncertainty between respondents over the exact role of Alcohol and Drug Partnerships [ADPs]^[14] and Integration Authorities [IAs].

ADPs – where do prisons fit?

These systemic complexities are particularly felt when consideration is given to the place of prisons in the planning landscape of Scotland's ADPs. Given that ADPs have a local agenda focus, whereas prisons a have regional, national and local focus, fitting prisons into this model can be difficult. The result has been mixed engagement experiences between prisons and ADPs as well as a lack of focus on prisons within ADP agendas and work plans.^[15]

ADPs are often seen as a new cultural landscape for prisons to operate within, a contrast between doing by committee (the usual ADP approach), rather than a task-orientated approach (the usual prison approach). ADPs are also often seen as having, and focusing on, a wide range of community health related needs and do not, in the main, give due consideration to the needs of those involved in the criminal justice system and (in particular) prison populations.

Financial considerations

Thoughtful reflection was often provided in discussions regarding the importance of understanding funding structures and the challenges these provide for prisons. Mention was made of how 'following the funding' helps to establish the behaviour and/or responses of different partners or partnerships (whether ADPs, IAs, Community Justice Partnerships [CJPs], Health Boards, or prisons).

In particular, it was noted that the current funding structures tend to prevent ADPs from taking responsibility and leadership where prisons are concerned. For example, there are fears that if ADPs start investing in prison-based services then counterparts in IAs or Health Boards or Community Justice partners might start withdrawing from their funding responsibilities.

It was noted by several stakeholders that 'investment' (i.e. time, commitment, energy), often only comes with the investment of money (funding). There was also some fear expressed about how SPS/GiCs will sometimes view outside funding as meaning that 'outsiders' will have a say in what goes on in prisons.

Fusing organisational cultures

Consideration was also given by a number of respondents to the complexity of relationships and the challenges of fusing significantly different organisational cultures between key partners (SPS, NHS, Local Authorities, and Third Sector). Particular mention was given to the difficulties of merging the different cultural traditions of healthcare and addictions work, from the previous SPS and Third Sector led arrangements to NHS working practices. Although this change took place over a decade ago, the differences in culture resonate today and are seen to take multiple forms (such as communication, information sharing, and medical-led decision making).

Non-substance use specific needs

'But that's the group. Multi-complex, often long-term needs that are really hard to get into.' [Key Stakeholder interviewee #04]

Respondents placed greater emphasis on many non-substance use specific needs (highlighted below) rather than people's health needs directly concerned with or connected to substance use.

Housing

The biggest and most consistent need we heard expressed was housing upon liberation. The importance and benefits of having secure non-hostel/homeless residential status upon release was consistently emphasised, whether maintained or a new tenancy, through family, or via residential rehab.

Despite the existence of the Sustainable Housing on Release for Everyone [SHORE] Standards^[16], it would seem that people leaving prison often have to take what is available on the day of their release. It was also noted that there is a need for greater sign-up and national consistency in how SHORE Standards are implemented.

Greatest concern was expressed over those individuals who are released onto the streets, into a hostel, or into a House in Multiple Occupancy [HMO], where they are faced with the prospect of going straight back into a substance using community.

The increased use of Housing First schemes^[17] was viewed as a significant positive development in Scotland, particularly for those individuals who leave custody and have a history of substance use.

Mental health

Housing was very closely followed by concerns about the mental health needs of those who experience problems with substances^[18]. These concerns are compounded by regular reports of significant capacity issues for mental health service provision within Scottish prisons^[19].

Connectivity and finance

The extent to which some of the practical aspects of being released from prison, such as securing benefits or housing, had to be done online (and was therefore contingent on people having access to, and the literacy to use, a mobile device, mobile data, broadband etc.) was noted as a significant challenge for people leaving prison. Included in this was the necessity to have a bank account or an address, both of which are often lost through time spent in prison. These challenges are also often compounded by transport issues including the distance people have to travel home from prison or if they were released from prison on a Friday or ahead of a public holiday. The latter means that people are often forced to go without accessing key services (e.g. OST prescriptions) at a time when they are vulnerable to relapse into the risky behaviours that led to their imprisonment or leads to them self-medicating, putting them at risk of overdose or even death.

Loneliness and lack of connections

A further unmet need that respondents talked about was a desire to feel human, loved, valued, connected, and to have a sense of hope. In a sense, none of these were viewed as being about the substance use itself, but rather about the social isolation that characterises people's experiences of imprisonment.

Dentistry

The importance of dentistry in helping and supporting individuals through and beyond custody was stressed across a number of conversations. Dental issues are noted as often being more acute for those with a significant history of substance use. It was also reflected that those individuals who use substances in Scotland's prisons are disproportionately locked down in their cells, when compared to other individuals, and therefore unavailable to attend all their dental appointments.

Poor dental health is common among people with a history of substance use problems. The pain caused by this is often a motivation for self-medicating and, combined with the self-consciousness caused by dental issues, can lead to mental health problems.

Life skills and basic needs

The opportunity available within prison to support people to develop life skills as well as basic literacy and numeracy skills was frequently commented upon.

There were numerous references to how prison provides people with basic needs such as shelter and food, which are important as the first building blocks required for rehabilitation and recovery. However, all too often these basic needs were reported as not being in place upon release, which could lead to the progress people have made in prison being undone.

Substance use in Scotland's prisons

'If I was in [a cell] 23 hours a day and I was in that situation, I'd probably want to medicate against it as well… unless you are a much better person than me.' [Key Stakeholder interviewee #21]

We heard consistent views that people were using substances to help them cope with living in prison and could be understood as a logical response to life in prison. Examples given for why this was the case included, 'getting yer heid down', dealing with peer pressure, and/or dealing with emotional, physical, and/or psychological pain.

Current patterns of drug use in Scottish prisons

It is evident from the extensive discussions we had around drugs that the type and nature of drugs being used in Scottish prisons has: (1) changed over time; (2) is rapidly changing at the moment; and (3) will likely continue changing in the future. For example, in years past, rates of smoking and of heroin use in Scotland's prisons were likely far higher than today, with heroin and tobacco now increasingly scarce commodities.

Working group members offered an overview of the drugs they believe are currently being used in Scottish prisons. These include: gabapentinoids, prescribed and street benzodiazepines (predominantly etizolam), and synthetic cannabinoids (predominantly spice). Key stakeholders also noted that there has been an increase in paper that has been soaked in illicit substances being sent into prison, mostly through the mail. There were reports that heroin is still available but the extent of this appears to vary and was debated by respondents. However, there was general agreement that it is much less available in Scottish prisons than previously. There were also some reports of low levels of cocaine availability. Whilst this might not provide a complete or indeed accurate picture of current drug use in Scotland's prisons, it gives a sense of what substances may be most prominent. These views were echoed across all interview groups.

Particular concerns were expressed about not knowing or being unable to distinguish between what substances were being soaked on the paper being sent to people in prison. It appears to be extremely difficult for the individuals taking these substances and prison staff to establish the exact nature and strength of these substances. Laboratory testing can establish retrospective patterns of use, but often the substances used do not show up on the more immediate random testing. Individuals and staff are reliant upon being informed of substance use patterns by the observations of recent users.

Respondents reported that the drug market in Scotland's prisons is based on availability rather than choice. The dominant illegal and illicit drugs available in Scottish prisons are reported to be:

• Novel Psychoactive Substances [NPS] / Cannabinoids (with the largest and most structurally diverse class of NPS being Synthetic Cannabinoid Receptor Agonists [SCRAs]); and
• 'Street Benzos' (most commonly Etizolam).

It was a prevailing view that 'Street Benzos' are causing widespread concerns and are the cause of serious incidents across the prison estate due to the unpredictability of what is being consumed. Questions were raised about whether this points to potentially more reckless patterns of substance use within Scotland's prison population and people are not put off by the risks of not knowing what they are consuming. No hard conclusions can be drawn from our study data in regard to this, but it is noted as an area that is worthy of further exploration. Reports were also provided indicating that both NPS and Street Benzos are currently entering Scotland's prisons as liquids, either soaked in paper or clothes. Specifically, the use of blotters^[20] was reported as being more common. Respondents expressed serious concern about the increase in blotters, particularly because they appear to be used to hold increasingly more potent substances.

Alcohol

Alcohol consumption appears not to be viewed as a problem within Scotland's prisons as it is less prevalent than other substances – and this is reflected in a significantly lower level of study data relating to alcohol compared to drugs. Having said this, we heard mixed reports about the extent to which alcohol, usually made illicitly by people in prison (commonly referred to as 'Hooch'), was available. The tradition of a 'Christmas brew' in prisons still seems to be in place.

Hooch in itself does not appear to be a significant issue within Scotland's prisons due to it being difficult to produce in large volumes. However, the health concerns from illicit alcohol are two-fold: (1) people not knowing what it is made of, and/or (2) people combining hooch with other substances, which in many instances the individual is also unlikely to know what they contain.

We heard some concerns about 'powdered alcohol' being consumed in Scotland's prisons and the potential for it to be distributed as a soaked liquid. Whilst this wasn't something that was thought widespread, it might become a trend in the future.

Prison policy is mostly concerned about confiscating and shutting down alcohol production, with less attention being paid to the impact that harmful alcohol use has on people's lives. The focus for those who enter prisons with a history of harmful or hazardous alcohol use is on physical dependency and medical management (i.e. medical support for either detox upon arrival or relapse prevention upon liberation). What appears to be less well covered is the help and support required for psychological dependency caused by dependent alcohol use, which is often related to underlying trauma.

This commentary highlights how time in prison provides a period of enforced abstinence for people with a problem with alcohol. However, it appears that there is currently insufficient help and support relating to how people will manage after they are released, when they have easier access to alcohol than in prison.

Tobacco

We heard many reports about the experiences of individuals (both staff and those living in prison) following the implementation of the smoking ban across Scotland's prisons in 2018.

Many respondents talked about their concerns when the initial policy had been introduced, but we heard that it had been surprisingly easy to implement, well met by those who are currently living in prison and generally resulted in health improvements ^[21]. Respondents felt that the lessons of good partnership working that enabled the implementation of the smoke-free policy to happen should be applied to other aspects of the prison system, such as the implementation of MAT Standards.

However, there has been a significant unintended consequence of the smoking ban, with people in prison using vape machines to smoke paper-soaked drugs. It was noted that one form of punishment used within prisons is the confiscation of vapes, which in the main is viewed as an unproductive and unnecessary approach.

Substance use specific needs – in prison

'The idea that you can punish someone out of taking an illegal drug, meanwhile holding them in arcane conditions where one of the few ways out and the way to cope with trauma and distress is to take drugs … then I just find it just unbelievable.' [Key Stakeholder interviewee #18]

We heard very strong views about the need to focus attention on the support and information provided to individuals as soon as they arrive in prison, and that this needs to set the tone for the rest of their time in prison. This was often framed around the need to make greater use of those with lived experience as well as Third Sector agencies to help individuals navigate their way through their time in custody. Current arrangements appear inconsistent and mainly centred on the role of prison officers and prison healthcare staff. It was felt that initial assessments are too brief and insufficient to connect individuals with support options within the prison.

We repeatedly heard that there is no incentive for individuals to be honest with prison staff about their substance use. For example, it was described to us that no additional support or interventions were offered to people if they disclosed using substances and instead this was met with (futile) punishment. A punishment first approach to people disclosing substance use in prison was considered by all respondents to perpetuate stigma about those individuals who experience problems with substances. There was a palpable sense in discussions of how impossible it would feel to sustain abstinence in the current prison culture and environment. There was no acknowledgement or sense that either the punishment first approach or the ability to maintain abstinence needs to or will change any time soon.

One of the greatest concerns of all stakeholders was the lack of continuity of prescribing, both upon entry into prison and upon prison transfer. For example, it was common for people to experience delays in accessing existing prescriptions following prison entry or transfer.

Respondents discussed four further areas of needs that were substance use specific.

1. Pain relief medication (for physical and psychological conditions) is often removed from those individuals who have a history of experiencing problems with substances as they are viewed negatively as 'drug-seeking'.

2. A lack of continuity and consistency of prescribing across prisons and Health Boards, and between prisons and the community.

3. Varying choice around prescribing options in some prisons (for example, sporadic availability of Buvidal across different prisons) and in particular treatment options beyond OST (such as the sporadic availability of recovery café's and a lack of alcohol-specific psychological interventions).

4. Variations in harm reduction approaches and expertise across Scotland's prisons.

Throughcare and liberation

'I felt when our [SPS] throughcare support service was suspended in 2019 that my right arm had been cut off because they were my eyes and ears for what was actually happening beyond the prison gate.' [Key Stakeholder Working Group member #03]

One of the most consistent messages heard throughout the study was the need for a diversity of 'through the gate' support for people during the transition from custody to community, and to ensure that release plans happen 'as intended'. This included the perceived need for expanded provision and improved coordination between the plethora of available statutory and third sector agencies. Comprehensive 'planned liberations' are viewed as current best-practice whereas in reality they are often reduced to date and diary management of release rather than supported liberation. For respondents, a lack of support planning often equated to increased vulnerability and subsequently an elevated risk of overdose or death for people leaving prison. Particular references were made to failures of prescribing continuity due to unplanned release.

We heard numerous references to the negative impact of ending the SPS Throughcare Support Officer [TSO] role, specifically that it had been a significant loss and denied prison leavers access to supportive staff who provided a beneficial service. We also heard how the TSO role had been symbolically important as they were the first extended venture into the community by SPS. To many this represented a breakdown of silos and establishing bridges and personal connections between prisons and communities. The TSO scheme was viewed as part of a widely held aspiration to make prisons more permeable, a common plea from respondents for future priority attention. Respondents were not all advocating for the TSO scheme to be reinstated as it was, but rather recognising that its removal had left a significant gap in provision and support. By contrast, we heard very little about the wide range of Third Sector and Criminal Justice Social Work services that are currently available across Scotland to support individuals upon release, possibly indicating a lack of visibility of such services and an inconsistency of connectivity with in-prison-based services.

Views were strongly expressed regarding the need to establish a more comprehensive system of throughcare. We heard regular discussions of the need to redefine 'throughcare' as a whole pathway (that begins before, during and after time spent in prison), and a pathway that should equally involve all relevant in-prison and community/community justice partners, rather than just the final few weeks in preparation for liberation, where prison staff are historically viewed as having the substantive role. This was epitomised by the sense that throughcare planning needs to start prior to an individual entering prison, with a consistent focus thereafter. In this regard, there was considerable support for the principle that prisons should be more permeable and responsibility for shared throughcare, i.e. prison staff working with services in the community; more community providers, families and peer led provision coming into prisons. It was felt that these kind of steps would create a less stark division between custody and community for people in prison. It could also create opportunities for people living in, and leaving, Scotland's prisons to access more employment and college activities in the community.

The implementation of the new 'Prison to Rehab Pathway'^[22] has been welcomed, with one residential rehabilitation provider noting a significant increase in admissions (of prison leavers) as a percentage of their total population. However, many respondents suggested there was limited consistency and effectiveness of the pathway to date and were more cautious about how long it might take to fully implement.

One of the greatest challenges identified by interviewees for individuals moving from prison to rehab was an acknowledgement that the prison culture of rules and punishments often travels with the individual into the rehab placement. This leads to an expectation of punishment in a rehab setting and a wariness of being honest with staff and peers, which both work against the fundamental principles of the opportunities provided by rehabilitation programmes.

Distinct Populations

Various sub-populations of interest and concern were noted consistently through our evidence gathering. The most commonly mentioned groups were: (1) people on remand; (2) women; (3) young people; and (4) people who have diagnosable mental health conditions. These are discussed in more detail below. Other sub-groups that received some mentions were individuals from Eastern Europe who have very little or no grasp of English (indicating a need for translation support), as well as those who transition from being a young person to adulthood whilst in prison or across several prison sentences.

Remand

'I don't think it's the right place for them to actually address their substance use, because people that are going on remand might not get any contact with the NHS services because they're in for too short of a period, so they're not getting the right support or help for their substance misuse.' [Key Stakeholder interviewee #08]

All professional stakeholders noted the seemingly ever-increasing remand population in Scotland's prisons ^[23]. To a great extent, people on remand were the sub-population that caused respondents the greatest concern, due to their high levels of risk and vulnerability. In part this was due to the emotional uncertainty and difficulty in accessing services that came with the unknown length of incarceration, and rapid returns to unstable community settings. There was general agreement that prison is not a conducive place for those on remand to address substance use issues. In particular, it was noted that SPS does not exercise the same responsibilities towards people on remand who experience problems with substances. It also has reduced ability to do meaningful work with those on remand when compared to the convicted population.

Respondents frequently described how people on remand have little access to the structured programmes and provision associated with continuity of case management approaches whilst in prison^[24], which tends to lead to an operational culture of crisis and short-term management towards the remand population.

We also heard regular reports that invariably those on remand are more often involved in unplanned release/liberation, with less planned support available for a range of critical considerations, such as benefits, housing, networks, treatment, etc.

Women

'The female population … generally manifests itself in self-violence, self-harm, and … in my experience, underpinned by horrendous trauma that's been over an extended period of time, and in prison itself retraumatised again because of the separation from family and community and support networks.' [Key Stakeholder interviewee #25]

Women who live in Scotland's prisons were regarded by respondents to be highly vulnerable with significant levels of trauma experiences and victimisation across the population. It was noted that women in prison tend to use substances more collectively than men (i.e. use with others rather than in isolation).

There was consensus amongst all respondents that good progress has been made following the Angiolini report (2012)^[25] in terms of decentralising provision for women and the development of smaller Community Custody Units.

Young People

'Sentencing policy and the changing to sentencing policy means that the ones who shouldn't be here are not here … So, they are locking up the right [young] people, but now the needs of those people are significantly greater than what it was 10 years ago … We have a lot of children that have come from a care background who don't have a lot of support … working with young people is probably about five to 10 years behind working with women.' [Key Stakeholder interviewee #26]

There has been a significant shift in Scotland in recent years to divert young people away from prison, through changes in sentencing policy. However, having diverted more young people out of the criminal justice system, has left a smaller set of young people living in Scotland's prisons who have multiple and complex needs beyond substance use.

The needs of these young people has provided a different challenge to SPS and its partners, which has not been strategically prioritised in the way that progress has been made with the female population following the Angiolini report.

Multiple respondents noted that substance use issues among young people living in Scotland's prisons do not present themselves or come to the fore in similar ways to the adult population. For example, it was felt that young people often did not take substance use and overdoses as seriously as they should. Young peoples' seemingly different attitudes towards substance use provides a complex challenge of how to support them when compared with the adult population. There is also further difficulty added by the significant challenge of recruiting young person focused specialists to work with this population.

People with co-occurring and diagnosable mental health conditions

Various respondents noted that mental health needs were common amongst individuals living in prison who experience problems with substances. However, a distinct sub-group that have diagnosable (acute) mental health issues were identified as being inappropriately placed in prison. We heard reports that some individuals are inappropriately remanded to prison if there are no secure hospital beds available or that some people were being placed in prison as a result of a lack of appropriate community and/or psychiatric provision. This is considered as leading to significant levels of vulnerability for these individuals. Respondents were clear in their view that prisons should not be a place someone is sent for their own protection and that Sheriffs are sometimes considered as believing this to be appropriate.