hmp swansea hna 121208 final

8/3/2019 Hmp Swansea Hna 121208 Final

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National Public Health Service for Wales HMP Swansea health needs assessment (2008).

HMP Swansea Health NeedsAssessment (2008)

Authors: Judith Tomlinson, Principal Public Health Specialist andChristian Heathcote-Elliott, Senior Health Promotion Specialist.

Date: 12/12/08 Version: 1.0

Status: Approved

Intended Audience: HMP Swansea Prison Partnership Board, NPHS (intranet andinternet)

Purpose and Summary of Document:

This health needs assessment (HNA) contains self-reported quantitative data about

the health status of prisoners entering HMP Swansea and qualitative data about staffand prisoners perceptions of health needs of prisoners and health service provisionwithin HMP Swansea.

It makes recommendations for building on the innovative progress made by thehealthcare unit of HMP Swansea in recent years and calls for further work refiningdata collection, examining the effectiveness of health interventions in a prisonenvironment and consideration of the wider determinants of prisoner health whenplanning future health care provision.

Publication/Distribution:HMPS Prison Partnership Board

Publication in NPHS Document Database (intranet and internet)

Link from NPHS e-Bulletin

Link from Stakeholder e-Newsletter

Authors: Judith Tomlinson,Christian Heathcote-Elliott

Date: 121208 Status: Approved

Version: 1.0 Page: 1 of 64 Intended Audience: Swansea LocalHealth Board, HMP Swansea / NPHS(Intranet) / Vulnerable Groups Team


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1 Contents

Chapter Page number

Executive summary 7

1 BackgroundHealth needs assessmentAims and objectives

111111

2 HMP SwanseaDescription of the prisonHealthcare services

131313

3 Health needs assessment methodology

Health needs assessment approachEthical approvalPrevalence of health conditions inprisonersCorporate needs assessmentComparative needs assessmentData analysis

20

202021

212121

4 Epidemiological needs assessmentPrisoner demographicsHealth issues amongst the prisoner

population

232325

5 Corporate needs assessmentPrison healthcare staff interviewsPrisoner focus group interviews

303035

6 Comparative needs assessment 37

7 DiscussionLimitation of health needs assessmentRecommendationsConclusion

39394041

8 References 42

9 Appendices 44





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Produced by Swansea Local Public HealthTeam

Judith Tomlinson Principal Public Health Specialist

Christian Heathcote-Elliott Senior Health Promotion Specialist

With acknowledgements to:

Sian Williams Head of Healthcare, HMP SwanseaGary Matthews Acting Primary Care Team Leader (Health

Promotion)Marie Philips Clinical Nurse SpecialistChris Davies Healthcare Officer Frank Feeney Healthcare Officer

Thanks also go to those members of staff and prisoners who participated in thecorporate needs assessment





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2 Executive summary

Methodology

A health needs assessment (HNA) was undertaken in Her Majestys Prison (HMP)Swansea during the summer of 2008 using a recognised toolkit. The HNA includesthree approaches to examining health needs and service provision:

An epidemiological approach: the health status of prisoners at the time of entry intothe prison was determined using self-reported data from the first reception healthscreen. Current health service provision in the prison was also examined.

A corporate approach: staff and prisoner perceptions of current service provision andhow services could be improved were obtained by undertaking semi-structured

interviews and focus group interviews.

A comparative approach: the provision of healthcare services in HMP Swansea wascompared with a similar size category B prison in England HMP Bedford.

Results

Epidemiological needs assessment

The most prevalent physical health condition at the point of reception was asthmawith one in six prisoners reporting this condition.

One in three prisoners reported that they had seen a psychiatrist at least once in theirlifetime and over one in four prisoners were receiving medication for mental healthproblems at the point of reception.

Consistent with other prison HNAs, the majority of prisoners were smoking cigarettes(79.5%) and nearly two-thirds reported using drugs in the month prior toimprisonment.

Corporate needs assessment

Seven members of staff and seven prisoners participated in the corporate needsassessment.

In terms of improving services a number of themes emerged from the interviews.These included: improving communication between prisoners, staff and prisonmanagement; improving throughcare; improving the detection and treatment ofalcohol problems; reviewing prescribing, timely and appropriate referral to psychiatricinpatient hospital services and the need for psychological input for prisoners withmental health needs.





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In both the prison staff and prisoner interviews a number of barriers to serviceimprovement were identified. It was clear that some barriers operated at theindividual and interpersonal level (e.g. staff and prisoner attitudes) whilst others weremore structural and in some cases more difficult to change (e.g. prison regime).

User involvement was felt to be important by prison staff, although it was recognisedthat prisoners sometimes were suspicious as to why they were being consulted. Withappropriate support it was felt that prisoners could be involved with the planning anddelivery of services.

Comparative needs assessment

The results from the comparative component of the needs assessment revealed thatthe provision of healthcare services in HMP Swansea is broadly similar to those inHMP Bedford. However, HMP Swansea uses a primary care model and HMPBedford still has a considerable number of inpatient beds. HMP Swansea would also

seem to have progressed more in terms of promoting health amongst prisoners andstaff.

Limitations of the health needs assessment

The first reception health screen was not designed as a HNA tool and uses self-reported data which are subject to response bias. Therefore it is a crude metric formeasuring the health status of prisoners.

For a significant number of prisoners the first reception health screen records wereincomplete and it was not possible to derive robust prevalence estimates for someconditions (e.g. actual levels of substance use and misuse).

It is recognised that the prisoners who participated in the corporate needsassessment may have had a distinct set of needs and therefore their views areunlikely to represent other prisoner groups.

The comparative needs assessment was limited to comparing HMP Swansea withone other category B prison in England.

An evaluation of the effectiveness and cost-effectiveness of healthcare interventionswas not included because of time and resource constraints.





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Recommendations

The initial identification, subsequent assessment, treatment and education ofprisoners with alcohol misuse problems needs to be improved.

HMP Swansea needs to develop clear referral criteria for prisoners requiring inpatienttreatment in a psychiatric hospital.

For future HNAs and health service provision planning, data-collection systems forhealth-related data should be refined and fit for purpose.

Appropriate training should be given to healthcare staff on the completion of the firstand second health reception screen forms to ensure accuracy and consistency. Thisshould be regularly audited.

The re-location of the health care unit into a more accessible building within the

prison should be prioritised.

The establishment of a prison NHS healthcare clinical network across the Welshprison estate would facilitate best practice and improve access to expertise.

The Prison Service needs to review its policy around prisoners who self-harm inorder to improve the health outcomes of repeat self-harmers.

Conclusion

HMP Swansea remains a challenging context in which to deliver healthcare serviceswhich are equivalent to those found in the community. However, since the transfer ofcommissioning responsibilities to Swansea LHB, HMP Swansea has madeconsiderable progress in developing healthcare services for prisoners. This directionof travel needs to be strengthened and sustained.

This HNA has shown that on entry to HMP Swansea some prisoners have a highlevel of need for health services, particularly in relation to substance misuse andmental health. Through refining data collection systems in HMP Swansea, futureHNAs will be able to provide a more detailed picture of the need for services and how

existing services can be improved. It is recognised that services which contribute totackling the wider determinants of health should also be considered in future healthservice provision planning.





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3 Background

The self reported physical and mental health of prisoners is poor (Bridgwood and

Malbon 1994; Fazel and Danesh 2002) coupled with a high prevalence of substancemisuse, poor educational attainment, learning difficulties and disabilities. Prisonersalso have poor emotional health and low social skills functioning.

Whilst in custody, prisoners can access a number of interventions which aim toimprove health, social skills and reduce the risk of recidivism. For example, throughthe education and skills department, prisoners can participate in a range of coursesdesigned to improve reading, numeracy, social skills, health literacy, self-awarenessand anger management.

Historically health care services in HMP Swansea were commissioned by the Prison

Service. However on 1

st

April 2006, the responsibility for commissioning prison healthcare services was transferred to Swansea Local Health Board (SLHB). SLHB isrequired to develop prison health care delivery plans and ensure that healthcareservices delivered in prison are broadly equivalent to those provided to the generalpopulation. As part of a continual programme of improvement health needsassessments (HNA) should be undertaken on a regular basis.

Since the last comprehensive HNA, undertaken in 2005 (Vidal-Alaball and Williams,2005), health care services in HMP Swansea has undergone a series of reformstowards a primary health care model. This HNA will update the 2005 HNA andprovide an insight into prisoners and healthcare staffs perceptions of current health

care service provision in HMP Swansea.

3.1 Health needs assessment

A methodology was devised after researching published needs assessmentsinvolving prison populations (Marshall, Simpson and Stevens, 2000; Harries, 2005;Vidal-Alaball and Williams, 2005; Huws, 2007 and Condon et al., 2007).

3.1.1 AimTo undertake a health needs assessment of HMP Swansea using a cross-sectionalapproach. It is outside the remit of this health needs assessment to look at the widerdeterminants of health and their impact of prisoner health and well being.

3.1.2 Objectives

To describe current health service provision in HMP Swansea,





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To collect quantitative data to provide a cross-sectional picture of thedemographics and health status of HMP Swanseas population.

To obtain prisoner and prison staff perceptions on current service provisionand how services can be improved, and

To make recommendations on future service developments.





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4 HMP Swansea

4.1 Description of the prison

HMP Swansea is a category B prison containing remand, convicted and sentencedadult male prisoners aged 21 years and over. The prison has an in-use CertifiedNormal Accommodation (CNA) of 240 prisoners and a maximum CertifiedOperational Capacity (COC) of 422 prisoners. The prison population in July 2008 was425 which represents 77% over the CNA. This makes the prison the third mostovercrowded in England and Wales1.

The prison is divided into five wings. Table 1 shows the capacity and designation ofeach wing.

Table 1: HMP Swansea prison wing capacity and utilisation

Wing Occupationalcapacity

Designation

A 171 Remand or Sentenced

B 49 Induction wing for new admissions

C 40 Sentenced

D 162 Remand or Sentenced

E 6 Segregation (deals with discipline issues as

they arise from other wings)Healthcareunit

2 Crisis beds for medical admissions awaitingtransfer to hospital

Source: HMP Swansea, 2008.

4.2 Healthcare services

4.2.1 Infrastructure

The current health care services are delivered from the health care unit which isseparate to the wings. The Type 3 unit has four consulting rooms, a day room, asmall meeting room, pharmacy and two crisis medical admissions cells.

There is also a treatment room on every wing which consists of an examination area,storage cupboards and equipment including oxygen and a defibrillator which is part ofthe First Responder initiative.

1 HM Prison Service monthly population bulletin (25/07/08)Authors: Judith Tomlinson,Christian Heathcote-Elliott




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The ring fenced service level agreement budget allocated to HMP Swansea for theyear 2008/9 is 1,150,000.

4.2.2 Model of care

HMP Swansea has developed a Primary Care health care service model whichmirrors that available in the community. This has resulted in the removal of inpatientbeds and released staff capacity to develop more meaningful therapeutic daytimeactivities and more healthcare activity on the wings. Table 2 lists the staffingprovision for the key healthcare services in the prison and a revised staffing structurecan be found in Appendix 9.1.

4.2.3 Access to services

Access to healthcare services is made available to prisoners when they enter HMP

Swansea during reception, throughout custody and at the point of release whereprisoners are referred to equivalent services in the community if appropriate.

Prisoners can self-refer to a number of services provided by the prison duringcustody including the stop smoking service and the Lighthouse primary care mentalhealth assessment and intervention clinic. Referrals can also be made to healthcarethrough other departments in the prison (e.g. learning and skills, the gym). If aprisoner wishes to see a GP or attend a specific health care clinic they are requiredto complete a Healthcare Application Form. These are available on every wing andcollected twice weekly, then the prisoners are placed on the triage list and referralsare made from the clinic if needed.

Attendance of some services, such as the Short Duration Treatment Programmeforms part of the prisoners Offender Management Plan. Medications are dispensedvia the pharmacy for a limited period in the morning, midday and early evening.Currently, all prisoners who take prescribed medication have been risk assessed and87% are given In Possession medication. This is a significant increase on the 20% ofprisoners receiving In Possession medication at the beginning of 2008.

4.2.4 Reception screening

The first reception health screen is undertaken by healthcare staff when an offenderfirst enters HMP Swansea. Its purpose is to identify any immediate healthcare needsso staff can refer to appropriate services where necessary. The process involvescompleting a standardised self-reported assessment form (form F2169) (Appendix9.2) which records information on health status including drug and alcohol use andprescribed medication. All prisoners are then subsequently seen by a GP within 24hours of entry into the prison to discuss their health needs and if necessary medicalscripts are issued.





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Table 2 Summary of health professional input to HMPSwansea.

SERVICE AREA NUMBER OF SESSIONS CURRENT PROVIDER

Primary Care NursingServices

Fulltime cover (see staffstructure above)

HMP Swansea

General Medical Services 24/7 Swansea Out of HoursService (SOS)

Dental Services 2 sessions per week A local General DentalPractitioner

Sexual Health Clinic 1 session per week Abertawe Bro MorgannwgUniversity Trust

Specialist Mental HealthServices

Mental Health In-ReachServices (consisting of 2Consultant Psychiatristsessions per week, 1 F/TCPN, 1 F/T OT and 1 F/TOT assistant, ConsultantClinical Psychologist 1session per week).

Forensic Psychiatry(Caswell Clinic) 1 sessionper week.

Abertawe Bro MorgannwgUniversity Trust

Pharmaceutical services 1 F/T Pharmacist and 1

F/T Pharmacy technician

HMP Swansea

Optician Ad-hoc sessions Specsavers Opticians

Counselling, Assessment,Referral, Advice andThroughcare (CARAT)service

3.5 workers West Glamorgan Councilon Alcohol and DrugAbuse Ltd (WGCADA)

Source: HMP Swansea, 2008.





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4.2.5 Nurse led clinics

There are a number of nurse led clinics. These include smoking cessation (onceweekly); hepatitis B vaccinations (once weekly), chronic disease management (onceweekly) and genito-urinary medicine (once weekly).

4.2.6 General Practitioner (GP) services

GP services are supplied by Swansea Out of Hours Services. Prisoners haveaccess to GP led clinics in the prison on Tuesday and Thursday between 8.00am and11.30am and on Saturday and Sunday between 10.00am and 11.30 am. There is outof hours GP service available between 11.30 and 6.00pm and an emergency on callprovision provided by SOS Services based in Singleton Hospital from 6.00pm until8.00am weekdays and on Saturday and Sunday from 11.30am to 10.00am.

4.2.7 General Dental Practitioner (GDP) services

A GDP and dental nurse currently provides dental care for one day a week withinHMP Swansea. A large proportion of the workload consists of emergency work andthere are many incomplete treatments due to the transfer or release of prisonersbefore the required treatment can be undertaken.

4.2.8 Management of communicable diseases

HMP Swansea is currently compiling a list of prisoners eligible for flu vaccination (i.e.those who are 65 years of age and over and those who have chronic illnesses).HMP Swansea hepatitis B vaccination rates are now amongst the best in the UK.One hundred and fifty four vaccinations were administered in July 2008. Fifty sevenprisoners refused to be vaccinated.

4.2.9 Disinfecting tablets and condom provision

In line with PSI 34/2007, disinfecting tablets are available on every wing landing at adispatch point at the side of the treatment hatches. Condoms are also available butprisoners have to ask healthcare staff for them. Anecdotal evidence would suggestprisoners are reluctant to ask for condoms because they fear being overheard byother prisoners. At the time of writing lubricants are not available.

4.2.10 Pharmacy and medicines management

The pharmacy is located within the healthcare unit and is staffed by one FTEpharmacist and one FTE pharmacy technician. The majority of prisoners are given InPossession medication following the induction period. Prisoners are initially assessedusing a risk assessment tool. As part of the risk management process, prisoners areinitially given a 7 day supply then re-assessed for risk. A 21 day supply of medication





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is then issued building up on the next issue to a 28 day supply. The process of riskassessment is continuous with prisoners being continually monitored. This is madeclear to prisoners on issue of medication. If the medication is being incorrectly takenthen the prisoner has an appointment made for him with the pharmacist. AMedication Usage Review is carried out and in some cases the supply of medication

is reduced to seven days supply. If deemed necessary the pharmacist will refer theprisoner to the pharmacy technician for further counselling on their medication. Theimportance of building up the supply of medication to 28 days is that the patient hasaccess to the manufacturers product information leaflets.

HMP Swanseas approach to managing medicines is innovative and in line withGovernment guidelines2. Other Welsh prisons (HMP Usk and Prescoed, Cardiff andParc) tend to limit the quantity of drugs prescribed to a maximum of 7 and 14 days. Inthe past 6 months since the In Possession medication has been expanded therehave been very few incidents of medication abuse. Anecdotal evidence fromprisoners has been very positive and they feel that they are being prepared for life

back in the community. Finally, as part of medication management the prisonershave to order their repeat medication at the appropriate time.

4.2.11 Mental health services

In 2006 the prison mental health pathway was launched which identifies goodpractice against which HMP Swansea is working towards. HMP Swansea has a dailyLighthouse Clinic which is run by a RMN Clinical Nurse Specialist and is anassessment and intervention clinic. A small number of prisoners are referred fromthis clinic to the mental health in-reach team. There is also a daily Intensive Prisoner

Support Group, which is run by a RMN and discipline staff and provides psychiatricsupport for self-referring prisoners. This too can act as a gateway to specialist mentalhealth services.

Specialist mental health services are provided in two ways. A mental health in reachteam provided by Abertawe Bro Morgannwg University NHS Trust (ABMU)comprising of two consultant Psychiatrist sessions per week, a full time communitypsychiatric nurse, a full time occupational therapist and a full time occupationaltherapy assistant. There is also one session per week provided by a forensicpsychiatrist from the Caswell Clinic which is medium secure forensic psychiatry unitrun by ABMU.

4.2.12 Substance misuse services

HMP Swansea provides a range of services for substance misusers including clinicalde-toxification, maintenance and re-induction procedures; psychosocial supportthrough the CARAT team; the Integrated Drug Treatment System, the Short DurationTreatment Programme, the Overdose Prevention programme and smoking cessation.

2 National Prescribing Centre (2005)Medication in-possession - A guide to improving practice insecure environments.Authors: Judith Tomlinson,Christian Heathcote-Elliott




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Since April 2008, CARAT workers have been relocated to the healthcare unit,resulting in improved communication and co-operation.

Detoxification, maintenance and re-induction procedures. Detoxification andmaintenance regimens are delivered in accordance with Prison Service Order 3550

(HM Prison Service, 2000) and the Drug Misuse and Dependence: UK guidelines onclinical management(Department of Health (England) and devolved administrations,2007). Limited one-to-one support is given during the period of detoxification. Wherepossible, remand prisoners who have been substituted in the community are kept ona maintenance regimen during custody. Prior to release, re-induction may be offeredto those prisoners who are opiate users with a long history of relapse and who areconsidered to be especially vulnerable in the early post-release period.

CARAT: Psychosocial support and drugs and alcohol education. Psychosocialsupport and education for prisoners with substance misuse problems is primarilyprovided by the CARAT team. Referral to a CARAT worker can occur at any stage

during a prisoners sentence or period on remand. For many prisoners referrals aremade at the stage of the initial reception screen or during the period3 on inductionwing. On initial contact with a CARAT worker basic information is given to theprisoner on drugs and alcohol. If the prisoner is considered to have a substancemisuse problem a full assessment of prior drug or alcohol use and treatment needs isundertaken. With the prisoners consent a care plan is drawn up which may includedetoxification or referral to a rehabilitation programme.

Integrated Drug Treatment System. Prisoners with substance misuse problems canattend the Integrated Drug Treatment System (IDTS). The IDTS is a 14 sessionmotivational intervention which aims to provide prisoners with information and skills

and encourage prisoners to increase their awareness of the effects of their substancemisuse. The sessions can be run on a 1:1 or group basis and are led by CARATworkers and one member of the healthcare team.

Throughcare. CARAT workers are primarily responsible for supporting prisoners whoare substance misusers through their transition from the prison to the community.This involves preparing a release plan and referring prisoners to external agencies,usually Drug Intervention Programme teams. Whilst still in custody prisoners can alsobe referred onto the Welsh Assembly Government funded Overdose Preventionprogramme.

Short Duration Treatment Programme. Whilst on induction wing prisoners can attenda short duration treatment programme (SDTP). The SDTP is a four week interventionbased on cognitive-behavioural theory and the harm minimisation approach (HMPSwansea, 2005). Referrals are made by CARAT workers and the programme isdelivered by the CARAT team. The programme is aimed at prisoners who are onremand or are serving a short sentence. Prisoners coming to the end of theirsentence can also attend. Over the course of 20 two-and-a-half-hour sessionsparticipants are taught a range of skills including goal setting, problem solving,

3 The length of time spent on induction wing varies but is usually between one and two weeks.Authors: Judith Tomlinson,Christian Heathcote-Elliott




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decision making and relaxation techniques. One-to-one counselling sessions are alsoavailable. In the financial year 2007/08 11 SDTP courses were run.

12-step programme. The Prison Partnership 12-Step Drug Rehabilitation Programmewas withdrawn in October 2007 and has been replaced by in-treatment drugs support

groups. Service provision will also be enhanced with the introduction of Cove Aid(Control Of Violence and Aggression in Impulsive Drinkers) courses. These are atpresent being piloted in other Welsh prisons.

4.2.13 Health promotion

In 2007, HMP Swansea appointed a Band 6 RGN Primary Care Team Leader with aremit specifically to develop health promotion within the prison. A prison healthpromotion steering group was also established in 2007 and currently hasrepresentatives from healthcare, learning and skills, gym, occupational health,catering and Swansea Public Health Team.

A major achievement of this group has been the development of a prison healthpromotion strategy and supporting action plan. The strategy aims to equip prisonersand staff with the knowledge and skills to enable them to make healthier choices andaddresses six key areas: drug use, eating well, immunisation, mental health and wellbeing, physical activity and sexual health. The strategy also looks at reducing someof the structural barriers to health improvement within the prison setting.





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5 Methodology

5.1 Health needs assessment approach

The HNA was undertaken over a period of 8-weeks starting in July 2008. The HNAfollowed a commonly adopted approach developed by Marshall, Simpson andStevens (2000, 2001). This approach involves three components:

i) Epidemiological needs assessment: This involves describing existing serviceprovision, obtaining incidence and prevalence data and examining the effectivenessof services. Due to time constraints it was not possible to undertake a detailed reviewof the effectiveness and cost-effectiveness of existing healthcare service provision inHMP Swansea.

ii) Corporate needs assessment: This involves gaining the perceptions of key

stakeholders on the provision of existing services and how they can be improved.

iii) Comparative needs assessment: This involves comparing the service provision inone institution with the provision of services in comparable institutions.

5.2 Ethical approval

Permission to undertake the healthcare needs assessment was given bythe Deputy Prison Governor. As the healthcare needs assessment was a

service evaluation it was not necessary to seek ethical approval fromNRES4.

5.3 Prevalence of health conditions amongst prisoners

The prevalence of specific health conditions and health behaviours were derived fromdata collected on the first reception health screen (revised form F2169) and secondreception health screen (Appendix 9.2)5. A cross-sectional survey was taken on the9th July 2008. To supplement this cross-sectional survey prescribing data wereobtained from the VISION database for each prisoner. This was undertaken as it wasfelt that the self-reported data on prescribed medications from the first reception

health screen were inaccurate.

Data were entered onto an Excel spreadsheet template by members of the prisonhealthcare team. To reduce the number of input errors where possible thespreadsheet contained drop-down menus and validation rules.

4 NRES is the National Research Ethics Service (this organisation was formerly COREC).

5 The first reception health screen collects data on self-reported health status at the point of receptioninto prison. It therefore does not reflect the health status of prisoners during custody.Authors: Judith Tomlinson,Christian Heathcote-Elliott




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5.4 Corporate needs assessment

In order to gain the views of key stakeholders involved with the delivery and receipt ofhealthcare services within HMP Swansea, two qualitative research methods wereemployed: focus group interviews and semi-structured interviews. For pragmatic

reasons a purposive sampling approach was adopted.

Focus group interviews were undertaken with two groups of prisoners i) prisonersfrom the Intensive Prisoner Support Group (N=3) and ii) prisoners participating in alearning and skills class (N=4). Prior to participating in the focus group interview,prisoners were given written and verbal information on the aim of the interview andasked to sign a consent form. All prisoners consented to the interview being audio-taped6. Prisoners were asked a series of questions using an interview schedule(Appendix 9.3) derived from Condon et al. (2007).

Focus group interviews work best when groups are relatively homogenous and there

are not clear social divisions amongst participants (Morgan, 1997). As the views of arange of staff involved with delivering healthcare services were being sought it wasfelt that a focus group approach would therefore be unsuitable. For this reason semi-structured interviews were undertaken. An interview schedule (Appendix 9.4) wasderived from a previous healthcare needs assessment undertaken in HMP Swansea(Heathcote-Elliott, 2007). Seven members of the staff participated in the interviews(Head of Healthcare, CARAT worker, Registered Primary Care nurse (band 5),Intensive Prisoner Support Team Leader (band 6), Substance Misuse Team Leader(band 6), GP and a mental health in-reach nurse (band 7)). Each participant wasgiven written information on the needs assessment and standard consentingprocedures were followed. All participants consented to the interviews being audio-

taped.

5.5 Comparative needs assessment

For the comparative needs assessment data on service provision were sought fromthree comparable category B local prisons in England: HMP Bedford, HMP Bristoland HMP Winchester. Telephone calls were made to the Head of Healthcare in eachprison requesting permission to send a postal questionnaire and to identify a namedrespondee. The questionnaire (Appendix 9.5) was sent to each identified respondee.No prison responded initially. Repeated telephone requests were made and the

questionnaires were re-sent. Only HMP Bedford returned the postal questionnaire.

5.6 Data analysis

At the time of the cross-sectional survey, 401 prisoners records were available foranalysis. However, 39 (9.7%) of prisoners were either at the point of release or werebeing transferred to other prisons. Little data were available on these prisoners and

6 It should be noted that one prisoner was required to attend an appointment at the start of theIntensive Prisoner Support Group focus group interview. In addition, one prisoner declined toparticipate in the learning and skills focus group interview.Authors: Judith Tomlinson,Christian Heathcote-Elliott




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they are therefore excluded from the analysis. The total number of prisoners recordsanalysed was therefore 362. Proportions are reported as valid percentages7 unlessspecified. Ninety five percent confidence intervals were calculated using a methoddescribed by Eayres (2008) are shown where appropriate. A 95% confidence intervalshows a range of values where the true population value is likely to lie. The wider the

confidence interval the less precise our estimate is of the true population value.

Data from the focus group interviews and semi-structured interviews were transcribedverbatim where possible8 by members of administration team at Swansea LocalPublic Health Team. A number of methods for analysing qualitative data aredescribed in the literature ranging from content analysis to phenomenologicalanalysis. For the purposes of this HNA thematic analysis was undertaken based onan approach described by Braun and Clarke (2006). This approach was undertakenfor pragmatic reasons. The five stages involved with this approach are show in Table3. A more detailed description of this approach is given in Appendix 9.6.

Table 3: Stages in thematic analysis

Stage Purpose

Familiarisation Researcher familiarises his or herself with the data byreading and re-reading transcripts. Ideas for initial codingare recorded.

Generating initial codes Data are organised into meaningful groups by applyinginitial codes

Searching for themes Initial codes are grouped into broader themes.

Reviewing themes Themes are reviewed and refinedDefining and namingthemes

Final themes are devised and quotations selected fromthe data to illustrate themes

Adapted from Braun and Clarke (2006).

7A valid percentage is a proportion where the denominator does not include those prisoner records

where the data were missing. Where the denominator excludes a large number of records, proportionsshould therefore be interpreted with caution.

8 It was not possible to transcribe two of the staff interviews (the GP and mental health in-reach nurse)and the two focus group interviews due to poor audio quality.Authors: Judith Tomlinson,Christian Heathcote-Elliott




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6 Epidemiological needs assessment

6.1 Prisoner demographics

HMP Swansea has a high throughput of prisoners and receives between 1700 and1900 new receptions each year. Figure 1 shows the breakdown of prisoners by legalstatus. At the time of the cross-sectional survey 77.1% of prisoners were convictedwith two-thirds of these being sentenced. The majority of prisoners surveyed hadbeen in prison before (77.3%, valid responses =348). The most common offences forimprisonment were burglary (12.5%, valid responses = 361), possession of drugswith intent (11.6%, valid responses = 361) and robbery (6.6%, valid responses =361).

Figure 1: Prisoner status (valid responses =362)

Source: HMP Swansea cross-sectional data collected on 09 July 2008.

Information about length of sentence is shown in Table 4. At the time of the cross-sectional survey 32 prisoners had an indeterminate sentence9. The proportion ofsentenced prisoners with a sentence over 2 years has increased compared with theprevious health needs assessment undertaken in 2005 (54.2% and 42.4%respectively).

9 An indeterminate sentence is defined as a sentence which prisoners have no automatic right to bereleased.Authors: Judith Tomlinson,Christian Heathcote-Elliott




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Table 4: Length of sentence

Length of sentence Number of prisoners % of prison population

Less than 3 months 5 1.4

3 6 months 21 5.8>6 months -


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Figure 2: District of residence (valid responses = 362)


6.2 Health issues amongst the prison population

6.2.1 GP registration and prescribed medications

At the time of the data collection 84.6% (95% CI 80.5%-88.0% valid responses =351)were registered with a GP. Nearly one in two prisoners reporting that they werereceiving prescribed medication at the time of entry into the prison (42.3%, 95% CI37.3%-47.4%, valid responses =362) with 28 prisoners stating that this medicationwas for mental health problems (8.1%, 95%CI 5.7%-11.5%, valid responses 344).

Using data derived from the VISION database, Table 6 shows the top five mostfrequently prescribed drugs at the time of the cross-sectional survey.





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Table 6: Most frequently prescribed medication (valid responses = 362)

Drug Number of prisoners % of prison population

Mirtazapine (anti-depressant) 22 6.1

Diazepam (sedative) 17 4.7

Diclofenac (NSAID) 14 3.9Methadone (opiate substitute) 14 3.9

Citalopram (anti-depressant) 13 3.6


6.2.2 Physical health conditions

The first reception health screen collects information on seven health conditions. The

estimated point prevalence of these conditions at the time of the cross-sectionalsurvey is shown in Table 7. The table shows that the most commonly reportedcondition is asthma with around one sixth of prisoners reporting this condition. This ishigher than would be expected in the general adult population where approximately 1in 20 people would be expected to have the condition. It is notable that the proportionof prisoners reporting epilepsy (5.4%) is also much higher than would be expected inthe general male adult population (0.6%).

Table 7 Estimated point prevalence of selected conditions in HMPSwansea (valid responses = 351).

Condition Number of prisoners a

Validpercentage

95% confidence interval Generaladult

populationestimate

(%)

Lower limit Upper limit

Allergies 46 13.1 10.0 17.0 NA

Asthma 58 16.5 13.0 20.8 5.8b

Chest pain 32 9.1 6.5 12.6 NA

Diabetes 6 1.7 0.8 3.7 6.0c

Epilepsy orfits

19 5.4 3.5 8.3 0.6d

Sickle celldisease

2 0.6 0.2 2.1 0.6e

Tuberculosis 3 0.9 0.3 2.5 NA

Sources:a

HMP Swansea cross-sectional data collected on 09 July 2008.

b. asthma and prescribed medication, England, all ages (2006/07), NCHOD Compendium of Clinicaland Health Indicators c. = currently being treated for diabetes, males 16+, Welsh Health Survey(2007). d. = male and females aged 18+ (2006/07), NCHOD Compendium of Clinical and HealthIndicators, e Sickle Cell Society, ONS mid-year population estimates 2007.





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6.2.3 Mental health conditions

The completeness of the mental health conditions data was poor and therefore it wasnot possible to derive point prevalence estimates.

However, given that nearly one in three prisoners (32.0%, 95%CI 27.3%-37.1%, validresponses 347) reported that they had been treated by a psychiatrist outside ofprison this would suggest that the mental health of many prisoners in HMP Swanseais likely to be poor. Just over one in ten prisoners (12.8%, 95%CI 9.7%-16.7%, validresponses 344) also stated that they had stayed in a psychiatric hospital at somepoint during there lives. Perhaps not surprisingly around a quarter of prisoners(27.5%, 95%CI 23.0%-32.4%, 346 valid responses) reported receiving medication formental health problems. Few prisoners reported being supported by a communitypsychiatric nurse or careworker in the community (4.1%, 95%CI 2.4%-6.7%, validresponses 343).

Figure 3 shows the percentage of prisoners who reported self-harming either in oroutside of prison. The lifetime prevalence of self-harm is 29.3% (95%CI 24.7%-34.3%, valid responses = 345). This is comparable with other recent prison basedestimates. For example, amongst sentenced Irish prisoners Duffy, Linehan andKennedy (2006) report a lifetime prevalence of 25.3%. Ten prisoners (2.9%, 95%CI1.6%-5.3%, 345 valid responses) reported current feelings of self-harm.

Figure 3: Self-harm status of prisoners in HMP Swansea(valid responses = 345)






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6.2.4 Lifestyle factors

In the general Welsh population, latest estimates would suggest 1 in 5 (25%) adultmales smoke cigarettes (Welsh Health Survey, 2007). The prevalence of smoking inHMP Swansea was found to be much higher with around three out of four prisoners

(79.5%, 95%CI 73.5%-84.5%, valid responses = 205) reporting that they currentlysmoked. This estimate is consistent with results from the Scottish Prison Survey2006 (cited in Graham, 2007) which found across the Scottish Prison estateprevalence estimates ranged from 63.4% - 88.2%.

The first reception health screen asks about drug use in the previous month and thetypes of drugs used (see Table 7). Nearly two-thirds (64.8%, 95%CI 59.6%-69.6%,valid responses = 349) of prisoners reported using drugs in the month prior toimprisonment. Figure 4 shows the main types of substances used by prisoners who

stated that they had used drugs in the month prior to imprisonment.

Figure 4: Types of drug use amongst prisoners who reported using in themonth prior to imprisonment (valid responses = 226)

90%

100%


Of those 64.3% of prisoners who had used drugs in the month prior to imprisonment31.4% (95% CI 25.7%-37.7%, valid responses = 226) had administered drugsintravenously.Authors: Judith Tomlinson,Christian Heathcote-Elliott




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A recent Scottish Prison Service health care needs assessment has shown thatnearly one in two male prisoners (41%) report problematic alcohol use (Graham,2007).In the current cross-sectional survey 61.7% (95%CI 56.5%-66.6%. validresponses = 347) of prisoners reported drinking alcohol. Due to the limitations of thefirst reception health screen form and poor completion of the question it was not

possible to determine the prevalence of harmful or hazardous drinking.

Height and weight data are recorded in the second reception health screen.However, of the 362 records available at the point of the cross-sectional survey, only56.2% had the height and weight fields completed. Due to the large amount ofincomplete records BMI data are not reported here.





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7 Corporate needs assessment

This section presents the results from the healthcare staff interviews and two prisoner

focus group interviews. Due to the poor audio quality of two of the prison staffinterviews and the two prisoner focus group interviews, it was not possible to provideverbatim transcriptions. A summary of the written notes is therefore provided at theend of this chapter.

7.1 Prison healthcare staff interviews

7.1.1 Improving services and priorities

Healthcare has seen many changes since the transfer of service commissioning from

the Prison Service to Swansea Local Health Board. A number of the staff interviewedexpressed the sentiment that the new way in which services were commissioned anddelivered was a significant improvement over the old model:

things have got a lot better since I first joined the service because at least now,and more so for the past couple of years since the LHB have basically taken over thereigns, theres a lot more coming through[Band 5, primary care RGN]

Closer working between discipline staff and healthcare staff would also appear tohave improved the level of service provided to prisoners. Issues related to prisonershealth are now dealt with outside of the healthcare unit. The RMN Intensive Prisoner

Support Team Leader felt that:

Healthcare is no longer the dumping ground for people that were unmanageable onthe wing. We work in conjunction with people to manage them on the wing.[Band 6, RMN Intensive Prisoner Support Team Leader]

In April 2008 the CARAT team moved into the healthcare unit and anecdotalevidence would suggest that this has been beneficial in caring for prisoners withsubstance misuse problems. The CARAT worker felt that the staff and healthcareservices provided at HMP Swansea were better than many of the otherestablishments he had worked at:

you know healthcare here is really good to us compared to other places Iveworked at.[CARAT worker]

Whilst overall, staff appeared positive about the services provided a number ofthemes in relation to service improvement emerged from the data. These themesrelated to improving communication, throughcare of prisoners, inadequate serviceprovision for alcohol misusers, revising prescribing regimens, psychological input inhealthcare services and improving audit processes.





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The theme of improving communication consisted of two sub-themes: communicationbetween staff and prisoners and communications between staff and management. Inrelation to communication between staff and prisoners, the Band 5 primary carenurse felt that staff could benefit from training to develop their skills around impartinginformation:

weve got knowledge but it is actually are we capable of passing that knowledgeon in a structured manner and in a coherent manner to our client base.[Band 5, primary care RGN]

The same respondent also felt that the lines of communication between healthcarestaff and senior management could be improved and that lower grade staff should begiven more opportunities to voice their opinions:

we dont often get opportunities to speak to people higher up in the echelon tosay well you know, have you thought of this, have you tried this?...communication is

a bit of an issue and has been an issue since I joined this job[Band 5, primary care RGN]

Linked to the communication theme was theme of throughcare. Effective throughcareservices are paramount to ensuring the smooth transition between custody andrelease. One aspect of throughcare which was felt to be lacking was the transfer ofprisoners health records to primary care services in the community:

Passing of information from us back to GPs, back to community mental healthteams, but particularly in the primary field back to GPs. I think its where we fall downgreatly.[Band 6, RMN Intensive Prisoner Support Team Leader]

A substance misuse needs assessment undertaken in 2007 (Heathcote-Elliott, 2007)suggested that at the point of receiving offenders into the prison, initial screening foralcohol related problems could be improved. It would appear that there are still issuesaround detecting prisoners with alcohol misuse problems. The substance misusenurse felt alcohol misuse problems were not always detected early enough:

I think it needs to be you know a standard question in reception. It isnt alwaysasked. I mean sometimes I only pick it up when I go over to reception wingor I seethem in the substance misuse clinic over here.[Band 6, Substance Misuse Team Leader]

Whilst there is a range of interventions for drug misusers in the prison, services foralcohol misusers are more limited, particularly as prisoners with alcohol only relatedproblems cannot access CARAT services:

weve got lots of services in place for you know opiate users etc but alcoholdependant clients, they were just coming in getting the Diazepam reduction and thatwas it[Band 6, Substance Misuse Team Leader]

However, the Substance Misuse Team Leader nurse did suggest she was working onimproving the services available to alcohol misusers.





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Its just making sure that they get the same kind of treatment as the drug users andlooking at their medication and maybe you know looking at a different way of detoxapart from Diazepam.[Band 6, Substance Misuse Team Leader]

Prescribing for substance misusers was also felt to be an area that could be

improved with the Substance Misuse Team Leader suggesting that prescribingregimens for substance misusers were not always comparable with those used in thecommunity.

The Head of Healthcare also pointed out that prescribing and detoxification regimesbetween prisons were often different despite clear government guidance which wasre-issued in 2007:

Another prison, you know like Cardiff, and Swansea, they are 50 miles apart yetweve got totally different detox regimes but were dealing with the same prisonersand it just seems absolutely bizarre to me that there isnt that level of communication

there.[Head of Healthcare]

It is notable that HMP Swansea only has limited input from a clinical psychologist. Inpart this would appear to be due to limited funding. A couple of respondents from thestaff interviews felt this was an important omission particularly given the mentalhealth needs of some prisoners:

I think we could certainly do with psychological input from a mental health point ofview. We deal with these people but we dont always give them the bestpsychological input that we probably, possibly could.[Band 6, RMN Intensive Prisoner Support Team Leader]

7.1.2 Barriers to service improvement

Three main themes emerged from the data in relation to the barriers to serviceimprovement: staff and prisoner attitudes, the prison regime and funding.

The attitudes and behaviour of prisoners and prison staff can impact on theeffectiveness of healthcare services. Whilst the interviews showed that staffrecognised that prisoners tended to have a high level of health needs, they alsoacknowledged that many knew how to manipulate the system in order to acquiremedication or alleviate boredom:

there are prisoners here that say theyre experiencing certain mental health issuesand theyre not displaying any of the signs that link them. I very much thinksometimes that maybe they get told to say this to get certain medication[Band 6, Substance Misuse Team Leader]

The RMN Intensive Prisoner Support Team Leader also voiced a sense of frustrationthat despite prisoners ostensibly good intentions to change their behaviour whilst inprison, they often reverted back to their old lifestyle once back in the community:





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They come in here and they seem to want to address their needs but then they goout and just revert the [their old] lifestyle. So sometimes you do feel like yourewhistling in the wind a bit.[Band 6, RMN Intensive Prisoner Support Team Leader]

Staff attitudes can also impact on the effectiveness of healthcare services. Whilst

closer relationships have been forged between healthcare and discipline staff onerespondent felt there was still a sense of them and us:

you know sometimes when you go over on the wings you do hear negativefeedback about healthcare and you just feel youre working really hard and theyveno idea of what we do you know. [Band 6, Substance Misuse Team Leader]

One of the biggest constraints on healthcare service delivery is the prison regimeitself and its inherent inflexibility:

our days are dictated by what the discipline staff are doing, what time they open

and lock[Band 5, primary care nurse]

In a Victorian prison like Swansea this is further exacerbated by the number of lockeddoors which prisoners must pass through in order to access the healthcare unit. Thisrequires considerable discipline staff resource and limits the amount of time prisonerscan for example spend using the day care facility. The location of the healthcare unitis also not ideal. The Head of Healthcare recognised that:

the location of healthcare needs to move physically to be more integrated with theprisoners[Head of Healthcare]

There have been discussions around moving the healthcare unit and the Head ofHealthcare felt positive that these discussions were taking place but that this wouldunlikely to be a priority area for another year. The Head of Healthcare also felt that abarrier to service improvement was the links between prisons and prison healthcaredepartments although she acknowledged that changes in the prison IT systems mayimprove this situation:

Prisons seem to be very insular and they deliberately isolate themselves from eachother. I mean again I think the IT system will go a long way to resolve thatbut I stillthink communication and practices, it still seems to be the choice of a single prisonhow they practice. [Head of Healthcare]

With the tightening of prison budgets, it is perhaps not surprising that the issue offunding was raised in a number of the staff interviews. In some cases this was felt todirectly affect quality of care available to prisoners. For example under the presentfunding agreement with the Home Office, it is not possible for prisoners who just havealcohol problems to access the CARATs service. Given the scale of alcohol-relatedcrime the CARAT worker viewed this as a major limitation in providing acomprehensive service:





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I think its crazy because you cant deal with somebody who is a chronic alcoholicand we cant do anything for them, CARAT service wise, because the prison servicessays oh no you cant do that, youre not funded for that[CARAT worker].

7.1.3 User involvement

All the staff interviewed acknowledged that prisoner involvement was an importantaspect of service improvement and that prisoners have a right to be heard:

I think their role is very important and its by asking them what they feel they need,would like [that] we can move forward[Band 6, RMN Intensive Prisoner Support Team Leader]

In particular it was recognised that with the move towards providing equivalence ofcare in prisons that prisoners have:

the same rights as we have when we go to access the GP or to access healthservices. [Band 6, RMN Intensive Prisoner Support Team Leader]

In recent years the prison has made attempts to involve prisoners more in theevaluation and provision of healthcare services through prisoner surveys and post-programme questionnaires. In 2007 a Prisoner Council was set-up although this isnot specific to healthcare services. The Head of Healthcare was positive about thePrisoner Council and felt that prison representatives on this group took their rolesseriously. However she felt that healthcare needs were not necessarily a priority forprisoners:

what it reminds me of time and time again is that most prisoners priorities [arent]healthcareIts not something that comes up in their mindsWhich I suppose in alot of ways reflects the general population.[Head of Healthcare]

The Head of Healthcare also expressed the view that prisoners were often wary ofwhy their views were being sought:

prisoners get quite suspicious why you want to involve them.[Head of Healthcare]

Prisoners can also be involved in the delivery of services and HMP Swansea was the

first prison in the UK to establish a Listening Scheme in 1991 in which prisonerstrained by the Samaritans provide one-to-one counselling support for other prisonerswho may be experiencing mental distress. Several of the staff interviewed recognisedthat prisoners experiences could be put to good effect in terms of mentoring otherprisoners or delivering specific educational sessions:

I think that with a little bit of education and little bit of guidance they [prisoners]could deliver you know drugs awareness sessions or mental health sessions[Band 6, Substance Misuse Team Leader]





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However, the Head of Healthcare felt that the prison system limited the degree towhich prisoners could be involved in the delivery of services:

its very sort of risk orientated it limits a lot of what prisoners can and cant do ona formal basis because of the litigation issues but certainly there is an opportunity to

develop accredited work that prisoners can do[Head of Healthcare]

7.1.4 Prison staff interviews supplementary information

Due to technical difficulties it was not possible to transcribe the audio-tapedinterviews with the GP and Band 7 Mental Health In-reach nurse. The key issuessummarised below are from written notes.

The GP felt that the strict prison regime often took precedence over healthcareissues. For example, clinicians often felt rushed because prisoners have to bereturned to their cells within a specific period of time. The GP expressed the view that

there tended to be a medicalisation of certain issues, for instance, a prisoner wouldhave to see the doctor to obtain a letter for new shoes. The GP also commented thatclinicians worked in isolation and that some prescribing practices within the prisonwere inefficient and could be improved.

The Mental Health In-reach nurse felt that clear referral criteria were needed tospecialist forensic services and for referral to low/medium secure mental healthservices. In addition, the lack of low secure mental health inpatient hospital bedsmeant that ill prisoners could not be referred to timely, appropriate care. The MentalHealth In-reach nurse also expressed the view that there was a need to developpsychology services within HMP Swansea.

7.2 Prisoner focus group interviews

The prisoners from the Intensive Prisoner Support Group expressed the view that theissue of self-harming was not well managed by healthcare staff and that there was aneed for staff to receive training around caring for prisoners who self harm. Incommon with the view expressed in two of the staff interviews, the prisoners also feltthere was a lack of psychology services available in the prison.

The issue of self-harm was also raised in the second focus group interview with the

prisoners from an education and skills class. These prisoners felt that discipline staffcould also benefit from training on how to handle prisoners who self-harm. Two otherkey issues emerged from this interview. Firstly the respondents felt healthcare staffwere not always sympathetic to their health needs and that often they would have towait long periods of time to see a dentist, optician or to access the stop smokinggroup. Secondly, the respondents thought it would be helpful if health information anddetails of courses being run by healthcare could be placed on information boards oneach wing as they were often unaware of what services were on offer unless theyvisited healthcare.





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8 Comparative needs assessment

The population of HMP Bedford is 19% higher than Swansea (506 compared with425 prisoners in HMP Swansea). The numbers of FTE nursing staff are very similarwith HMP Bedford having 17 FTE and HMP Swansea having 19 FTE nursing staff.Further analysis of the staffing structures reveals a variation in the type of nurseemployed with HMP Bedford employing 4 FTE RMNs and HMP Swansea employing6 FTE RMNs (one of which is a Band 7 clinical nurse specialist). There is alsovariation in the number of inpatient beds which suggests that the prisons areoperating different healthcare models as HMP Bedford has 14 inpatient beds andHMP Swansea has 2 crisis inpatient beds (HMP Swansea having adopted a primarycare model). There is variation in the number of commissioned GP, GDP, opticianand pharmacy sessions with HMP Bedford having the greatest number of sessions.

Both prisons operate detoxification services and neither has a dedicateddetoxification wing.

Table 7 contains a summary of the range of health care provision and staffingstructures of HMP Bedford and HMP Swansea.

Table 7: Comparative analysis of healthcare provision in HMP Swanseaand HMP Bedford

Area of health careprovision

Similarities and differences between HMP Swanseaand HMP Bedford

Staff structure HMP Bedford and HMP Swansea employ similar numbers of nurses but the type of nurse varies with HMPSwansea having a greater proportion of nurses from amental health background. HMP Bedford alsocommissions more GP, GDP, optician and pharmacysessions than HMP Swansea.

Models of care HMP Bedford has 14 in patient beds whereas Swanseahas 2 crisis beds for medical admissions. This suggeststhat HMP Bedford operates a different model ofhealthcare to HMP Swansea.

Substance misuse Both prisons operate similar substance misuse servicesalthough HMP Swansea co-locates CARAT workers aspart of the health care team.

Mental health services Both prisons operate in a similar manner. However HMPSwanseas mental health clinical nurse specialist runs adaily self referral clinic for mental health issues and triageto specialist mental health services. There is also a dailymental health prisoner support unit run within the healthcare centre.





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Area of health careprovision

Similarities and differences between HMP Swanseaand HMP Bedford

Health promotion Unlike HMP Swansea, HMP Bedford does not have awhole prison health promotion strategy and active multi-disciplinary steering Group to implement the strategy(with members from education and skills department,catering, gym, healthcare, pharmacy, smoking cessationand public health professionals). Both prisons operatesmoking cessation services and prison exercise referralprogrammes. HMP Swansea also operates an ExpertPatient Programme.

Communicable disease Both prisons have communicable disease policies anddiscrete access to condoms. However only HMP Bedford

issues lubricant.User involvement HMP Bedford has recently undertaken a population

questionnaire survey of prisoners views of health careservices. HMP Swansea has also conducted surveys toobtain prisoners views on shaping mental health servicesand the provision of condoms (undertaken in 2006 and2008 respectively). Feedback on healthcare services isalso obtained via the Prisoner Council.

Source: Head of Healthcare, HMP Bedford, 2008.





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9 Discussion

9.1 Limitations of the health needs assessment

9.1.1 Quantitative data available for health needs assessment

Whilst first reception health screen data gives a self-report measure of prisonershealth status at the point of entering prison, it does not inform service providers andcommissioners on changes in health status during custody, or how services impacton prisoners health over time. Further new information would be required to gain abetter understanding of the demand, supply and need for services in HMP Swansea.

As a tool for gaining information on health status at the point of receiving prisoners

into HMP Swansea, the first reception health screen is inadequate for a number ofreasons:

o A number of questions lack precision (e.g. there are no instructions for

recording alcohol consumption in a consistent manner),

o The responses to a number of the questions were poorly recorded and

subject to response bias, particularly those relating to measuringlifestyle factors (e.g. height and weight measures, smoking status,alcohol consumption), and

o

The data are initially recorded on a paper based form. This needs to beentered manually onto an electronic based spreadsheet and screenedfor data errors. This proved to be particularly time consuming in thepresent health needs assessment.

9.1.2 Representativeness of prisoner groups interviewed

It was difficult to gain access to a range of prisoners for the corporate needsassessment. It is recognised that the prisoners from the Intensive Prisoner SupportGroup have a distinct set of needs and therefore their views are unlikely to representother prisoner groups. Future health needs assessments need to examine the viewsof a wider spectrum of prisoners.

9.1.3 Lack of data for the comparative analysis

The comparative needs assessment was limited for the following reasons:

o There are no other similarly sized category B prisons in Wales,





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o The profile of prisoners and types of crimes committed in similarly sized

category B prisons in England is likely to be different and this will bereflected in the types of services available, and

o Only one of the three English prisons identified for the comparative

analysis completed the Comparative Needs Assessment Questionnaire.

9.1.4 Effectiveness and cost-effectiveness of services in HMPSwansea

It was not possible to review the evidence for the effectiveness of services in HMPSwansea because of time and resource constraints. A previous substance misusehealthcare needs assessment undertaken in 2007 indicated that not all servicesprovided are evidence based (e.g. auricular acupuncture for smoking cessation).

The HNA did not examine services provided by other departments, such aseducation and skills, which may contribute to tackling the wider determinants ofprisoners health.

9.2 Recommendations

The assessment of all prisoners for alcohol misuse and subsequent treatment ofprisoners with hazardous levels of alcohol use needs to be reviewed. In particular,the adoption of a validated screening tool should be incorporated into the initial health

screening of prisoners.

HMP Swansea needs to develop clear referral criteria for prisoners requiring inpatienttreatment in a psychiatric hospital. Without these there is a risk that some prisonersmay be inappropriately held in prison.

For future HNAs and health service provision planning data-collection systems forhealth-related data should be refined and fit for purpose. A lack of IT in systems inthe prison as a whole will thwart progress.

Appropriate training should be given to healthcare staff on the completion of the first

and second health reception screen forms to ensure accuracy and consistency. Thisshould be regularly audited.

The re-location of the health care unit into a more accessible building within theprison should be prioritised.

The establishment of a prison NHS healthcare clinical network across the Welshprison estate would facilitate best practice and improve access to expertise.

The Prison Service needs to review its policy around prisoners who self-harm.Although controversial, the development of safer self harming policies in prisons





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could lead to improved mental and physical health outcomes, and a reduction inadverse incidents, for the minority of prisoners who are repeat self-harmers.

9.3 Conclusion

HMP Swansea remains a challenging context in which to deliver healthcare serviceswhich are equivalent to those found in the community. However, since the transfer ofcommissioning responsibilities to the Swansea LHB HMP Swansea has madeconsiderable progress in developing healthcare services for prisoners. This directionof travel needs to be sustained.

This health needs assessment has shown that on entry to HMP Swansea someprisoners have a high level of need for services, particularly in relation to substancemisuse and mental health. Through refining data collection systems in HMP Swanseafuture health needs assessments will be able to provide a more detailed picture of theneed for services and how existing services can be improved. It is recognised thatservices which contribute to tackling the wider determinants of health should also beconsidered in future health service provision planning.





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10 References

Braun, V., and Clarke, V. (2006). Using thematic analysis in psychology. Qualitative

Research in Psychology; 3, 77-101.

Bridgwood, A. and Malbon, G. (1994). Survey of the physical health of prisoners.London: Office of population censuses and surveys.

Condon, L., Hek, G., Harris, F., Powell, J., Kemple, T and Price, S. (2007). Usersviews of prison health services: a qualitative study. Journal of Advanced Nursing58(3), 216-226.

Department of Health (England) and the devolved administrations (2007) DrugMisuse and Dependence: UK Guidelines on Clinical Management[online]. London,Department of Health (England), the Scottish Government, Welsh AssemblyGovernment Northern Ireland Executive. Available at:http://www.nta.nhs.uk/publications/documents/clinical_guidelines_2007.pdf[Accessed 11 August 2008].

Duffy, D., Linehan, S. & Kennedy, H.G. (2006) Psychiatric morbidity in the malesentenced Irish prisons population. Irish Journal of Psychological Medicine, 23, 2, 54-62.

Earyes, D. (2008) Technical Briefing 3: Commonly used public health statistics andtheir confidence intervals [online]. Association of Public Health Observatories.Available at: http://www.apho.org.uk/resource/item.aspx?RID=48457 [Accessed 08July 2008].

Fazel S, Danesh J. Serious mental disorder in 23,000 prisoners: a systematic reviewof 62 surveys. Lancet [serial online]. 2002 [cited 2007 April 27];359:545-550.Available from:http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T1B-4561RH6-5&_user=144092&_coverDate=02%2F16%2F2002&_rdoc=5&_fmt=full&_orig=browse&_srch=doc-info(%23toc%234886%232002%23996400693%23585489%23FLA%23display%23Volume)&_cdi=4886&_sort=d&_docanchor=&view=c&_ct=61&_acct=C00001197

8&_version=1&_urlVersion=0&_userid=144092&md5=9b4e878a028a610fe277989265676161

Graham, L. (2007) Prison Health in Scotland: A Health Care Needs Assessment.Scottish Prison Service.

Harries, J. (2005). Healthcare needs assessment for HMP Prescoed and Usk.(personal communication 20.06.08).



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