HMP Swansea Health Needs Assessment (2008)
Authors: Judith Tomlinson, Principal Public Health Specialist and Christian Heathcote-Elliott, Senior Health Promotion Specialist.
Date: 12/12/08 / Version: 1.0
Status: Approved
Intended Audience: HMP Swansea Prison Partnership Board, NPHS (intranet and internet)
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 staff and prisoners’ perceptions of health needs of prisoners and health service provision within HMP Swansea.
It makes recommendations for building on the innovative progress made by the healthcare unit of HMP Swansea in recent years and calls for further work refining data collection, examining the effectiveness of health interventions in a prison environment and consideration of the wider determinants of prisoner health when planning 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
Contents
Chapter / Page numberExecutive summary / 7
1 / Background
Health needs assessment
Aims and objectives / 11
11
11
2 / HMP Swansea
Description of the prison
Healthcare services / 13
13
13
3 / Health needs assessment methodology
Health needs assessment approach
Ethical approval
Prevalence of health conditions in prisoners
Corporate needs assessment
Comparative needs assessment
Data analysis / 20
20
20
21
21
21
21
4 / Epidemiological needs assessment
Prisoner demographics
Health issues amongst the prisoner population
/ 23
23
25
5 / Corporate needs assessment
Prison healthcare staff interviews
Prisoner focus group interviews / 30
30
35
6 / Comparative needs assessment / 37
7 / Discussion
Limitation of health needs assessment
Recommendations
Conclusion / 39
39
40
41
8 / References / 42
9 / Appendices / 44
Produced by Swansea Local Public Health Team
Judith Tomlinson Principal Public Health Specialist
Christian Heathcote-Elliott Senior Health Promotion Specialist
With acknowledgements to:
Sian Williams Head of Healthcare, HMP Swansea
Gary Matthews Acting Primary Care Team Leader (Health Promotion)
Marie Philips Clinical Nurse Specialist
Chris Davies Healthcare Officer
Frank Feeney Healthcare Officer
Thanks also go to those members of staff and prisoners who participated in the corporate needs assessment
Executive summary
Methodology
A health needs assessment (HNA) was undertaken in Her Majesty’s Prison (HMP) Swansea during the summer of 2008 using a recognised toolkit. The HNA includes three approaches to examining health needs and service provision:
An epidemiological approach: the health status of prisoners at the time of entry into the prison was determined using self-reported data from the first reception health screen. Current health service provision in the prison was also examined.
A corporate approach: staff and prisoner perceptions of current service provision and how 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 was compared 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 asthma with one in six prisoners reporting this condition.
One in three prisoners reported that they had seen a psychiatrist at least once in their lifetime and over one in four prisoners were receiving medication for mental health problems 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 to imprisonment.
Corporate needs assessment
Seven members of staff and seven prisoners participated in the corporate needs assessment.
In terms of improving services a number of themes emerged from the interviews. These included: improving communication between prisoners, staff and prison management; improving throughcare; improving the detection and treatment of alcohol problems; reviewing prescribing, timely and appropriate referral to psychiatric inpatient hospital services and the need for psychological input for prisoners with mental health needs.
In both the prison staff and prisoner interviews a number of barriers to service improvement were identified. It was clear that some barriers operated at the individual and interpersonal level (e.g. staff and prisoner attitudes) whilst others were more 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 recognised that prisoners sometimes were suspicious as to why they were being consulted. With appropriate support it was felt that prisoners could be involved with the planning and delivery of services.
Comparative needs assessment
The results from the comparative component of the needs assessment revealed that the provision of healthcare services in HMP Swansea is broadly similar to those in HMP Bedford. However, HMP Swansea uses a primary care model and HMP Bedford still has a considerable number of inpatient beds. HMP Swansea would also seem to have progressed more in terms of promoting health amongst prisoners and staff.
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 for measuring the health status of prisoners.
For a significant number of prisoners the first reception health screen records were incomplete and it was not possible to derive robust prevalence estimates for some conditions (e.g. actual levels of substance use and misuse).
It is recognised that the prisoners who participated in the corporate needs assessment may have had a distinct set of needs and therefore their views are unlikely to represent other prisoner groups.
The comparative needs assessment was limited to comparing HMP Swansea with one other category B prison in England.
An evaluation of the effectiveness and cost-effectiveness of healthcare interventions was not included because of time and resource constraints.
Recommendations
The initial identification, subsequent assessment, treatment and education of prisoners with alcohol misuse problems needs to be improved.
HMP Swansea needs to develop clear referral criteria for prisoners requiring inpatient treatment in a psychiatric hospital.
For future HNAs and health service provision planning, data-collection systems for health-related data should be refined and fit for purpose.
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. This should 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 Welsh prison estate would facilitate best practice and improve access to expertise.
The Prison Service needs to review its policy around prisoners who self-harm in order to improve the health outcomes of repeat self-harmers.
Conclusion
HMP Swansea remains a challenging context in which to deliver healthcare services which are equivalent to those found in the community. However, since the transfer of commissioning responsibilities to Swansea LHB, HMP Swansea has made considerable progress in developing healthcare services for prisoners. This direction of travel needs to be strengthened and sustained.
This HNA has shown that on entry to HMP Swansea some prisoners have a high level of need for health services, particularly in relation to substance misuse and mental health. Through refining data collection systems in HMP Swansea, future HNAs 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 to tackling the wider determinants of health should also be considered in future health service provision planning.
1 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 substance misuse, poor educational attainment, learning difficulties and disabilities. Prisoners also have poor emotional health and low social skills functioning.
Whilst in custody, prisoners can access a number of interventions which aim to improve health, social skills and reduce the risk of recidivism. For example, through the education and skills department, prisoners can participate in a range of courses designed to improve reading, numeracy, social skills, health literacy, self-awareness and anger management.
Historically health care services in HMP Swansea were commissioned by the Prison Service. However on 1st April 2006, the responsibility for commissioning prison health care services was transferred to Swansea Local Health Board (SLHB). SLHB is required to develop prison health care delivery plans and ensure that healthcare services delivered in prison are broadly equivalent to those provided to the general population. As part of a continual programme of improvement health needs assessments (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 reforms towards a primary health care model. This HNA will update the 2005 HNA and provide an insight into prisoners’ and healthcare staff’s perceptions of current health care service provision in HMP Swansea.
1.1 Health needs assessment
A methodology was devised after researching published needs assessments involving prison populations (Marshall, Simpson and Stevens, 2000; Harries, 2005; Vidal-Alaball and Williams, 2005; Huws, 2007 and Condon et al., 2007).
1.1.1 Aim
To undertake a health needs assessment of HMP Swansea using a cross-sectional approach. It is outside the remit of this health needs assessment to look at the wider determinants of health and their impact of prisoner health and well being.
1.1.2 Objectives
· To describe current health service provision in HMP Swansea,
· To collect quantitative data to provide a cross-sectional picture of the demographics and health status of HMP Swansea’s population.
· To obtain prisoner and prison staff perceptions on current service provision and how services can be improved, and
· To make recommendations on future service developments.
2 HMP Swansea
2.1 Description of the prison
HMP Swansea is a category B prison containing remand, convicted and sentenced adult male prisoners aged 21 years and over. The prison has an in-use Certified Normal Accommodation (CNA) of 240 prisoners and a maximum Certified Operational Capacity (COC) of 422 prisoners. The prison population in July 2008 was 425 which represents 77% over the CNA. This makes the prison the third most overcrowded in England and Wales[1].
The prison is divided into five wings. Table 1 shows the capacity and designation of each wing.
Table 1: HMP Swansea prison wing capacity and utilisation
Wing / Occupational capacity / DesignationA / 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)
Healthcare
unit / 2 / Crisis beds for medical admissions awaiting transfer to hospital
Source: HMP Swansea, 2008.
2.2 Healthcare services
2.2.1 Infrastructure
The current health care services are delivered from the health care unit which is separate to the wings. The Type 3 unit has four consulting rooms, a day room, a small 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 of the First Responder initiative.
The ring fenced service level agreement budget allocated to HMP Swansea for the year 2008/9 is £1,150,000.
2.2.2 Model of care
HMP Swansea has developed a Primary Care health care service model which mirrors that available in the community. This has resulted in the removal of inpatient beds and released staff capacity to develop more meaningful therapeutic daytime activities and more healthcare activity on the wings. Table 2 lists the staffing provision for the key healthcare services in the prison and a revised staffing structure can be found in Appendix 9.1.
2.2.3 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 where prisoners are referred to equivalent services in the community if appropriate.
Prisoners can self-refer to a number of services provided by the prison during custody including the stop smoking service and the Lighthouse primary care mental health assessment and intervention clinic. Referrals can also be made to healthcare through other departments in the prison (e.g. learning and skills, the gym). If a prisoner wishes to see a GP or attend a specific health care clinic they are required to complete a Healthcare Application Form. These are available on every wing and collected twice weekly, then the prisoners are placed on the triage list and referrals are made from the clinic if needed.
Attendance of some services, such as the Short Duration Treatment Programme forms part of the prisoner’s Offender Management Plan. Medications are dispensed via the pharmacy for a limited period in the morning, midday and early evening. Currently, all prisoners who take prescribed medication have been risk assessed and 87% are given In Possession medication. This is a significant increase on the 20% of prisoners receiving In Possession medication at the beginning of 2008.
2.2.4 Reception screening
The first reception health screen is undertaken by healthcare staff when an offender first enters HMP Swansea. Its purpose is to identify any immediate healthcare needs so staff can refer to appropriate services where necessary. The process involves completing a standardised self-reported assessment form (form F2169) (Appendix 9.2) which records information on health status including drug and alcohol use and prescribed medication. All prisoners are then subsequently seen by a GP within 24 hours of entry into the prison to discuss their health needs and if necessary medical scripts are issued.
Table 2 Summary of health professional input to HMP Swansea.
SERVICE AREA / NUMBER OF SESSIONS / CURRENT PROVIDERPrimary Care Nursing Services / Fulltime cover (see staff structure above) / HMP Swansea
General Medical Services / 24/7 / Swansea Out of Hours Service (SOS)
Dental Services / 2 sessions per week / A local General Dental Practitioner
Sexual Health Clinic / 1 session per week / Abertawe Bro Morgannwg University Trust
Specialist Mental Health Services / Mental Health In-Reach Services (consisting of 2 Consultant Psychiatrist sessions per week, 1 F/T CPN, 1 F/T OT and 1 F/T OT assistant, Consultant Clinical Psychologist 1 session per week).
Forensic Psychiatry (Caswell Clinic) 1 session per week. / Abertawe Bro Morgannwg University 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 and Throughcare (CARAT) service / 3.5 workers / West Glamorgan Council on Alcohol and Drug Abuse Ltd (WGCADA)
Source: HMP Swansea, 2008.