Social care in prisons: Urgent development required

Introduction

Almost a decade since the implementation of the Care Act 2014, ¹ there remain systemic failings in social care delivery throughout the UK criminal justice system.^2,3 There are high levels of unmet need ⁴ ; varied, often unsubstantial provision^2,5; and minimal active case finding, ⁶ despite the potentially heightened needs of people in prison. The recent review of health and social care in women's prisons again highlighted systematic failings and inconsistencies of social care provision. ⁷ However, promising routes of development have started to appear in the shape of legislation ⁸ and policy ⁹ aligning to known shortcomings in prison health and social care. We discuss the urgent need for development, and what this might look like.

Social care

The term social care describes a range of activities which help people who have difficulties with activities of daily living due to ageing, disability, or illness, to lead lives that are independent, safe, and comparable in quality to those of individuals without these difficulties. ¹⁰ Since the introduction of the Care Act 2014 ¹ in the UK, social care has become tied to the legalistic framework the act provides. To be eligible for formal social care, an individual is assessed through three key questions ¹¹ : (a) do an individual's needs arise from a physical or mental impairment or illness? (b) do these needs mean an individual is unable to achieve two or more specified outcomes? (Figure 1) and (c) is there a significant impact on the individual's wellbeing?

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Figure 1.

Care Act 2014 specified outcomes.

Depending on which outcomes the individual is unable to achieve, social care can include personal care, such as support for washing, dressing, and getting out of bed, as well as wider support to help people engage with their communities.^10,12 It can also take the form of reablement by providing aids and adaptations, information and advice, and support to those with caring duties.^10,12 The Care Act 2014 ¹ formalised local authorities’ legal obligation to assess individuals in prison against the above criteria. It also legally instantiated local authorities’ duty to perform social care planning and delivery for individuals who meet these criteria. ¹³ To understand the importance of this, we must consider the health characteristics of the prison population and how these characteristics interact with social care need.

The prison population and heightened social care need

Individuals in prison experience considerable health inequalities.^14,15 They typically show considerable levels of morbidity and mortality,^14,15 and present with a wide variety of overlapping risk factors for poor health, including: poverty; experience of violence; substance dependence; and trauma.^14,16–18 Importantly, poor health stimulates social care need, and unmet social care need stimulates poor health. This creates a vicious cycle of worsening health and increasing social care need. Given that prisoners present with a wide variety of overlapping risk factors for poor health, it follows that individuals living in prison are at heightened risk of developing social care needs.

Those who have arrived in prison have typically faced considerable barriers to accessing health and social care^19,20 including: substance dependence; chaotic lifestyles; and socioeconomic deprivation.^{14,16–18,21} Health and social care services often underserve these groups. As a result, these individuals commonly present to health and social care systems at the point of acute crisis.^16,22,23 They are thus deeper into the cycle of poor health and social care need than better served members of the community.

However, prisons are uniquely placed to remove these barriers to accessing health and social care. ²⁴ If well-functioning and resourced, prisons have the potential to address substance misuse, provide a non-chaotic living regime, and reduce some of the outcomes of socioeconomic deprivation by, for example, providing suitable accommodation and a well-balanced diet. In theory, prisons should facilitate interventions which are unhampered and effective and lessen the development or worsening of social care need. The link between poor health and unmet social care need therefore can theoretically be minimised, and as a result, crisis-driven health and social care access lessened.

Disappointingly however, this overwhelmingly remains an opportunity missed. Instead, evidence indicates health and social care in prison are in a state of perpetual disarray,^25–27 situated in a wider prison system which is itself in permacrisis.^27,28

Social care dysfunction

Social care provision in prisons is commonly and severely disordered. ² It is often ad-hoc and uncoordinated.^2,3 Despite the introduction of the Care Act 2014, ¹ local authority involvement in care remains limited, ⁶ processes to identify and meet social care needs vary significantly,^4,6 and there is a lack of active case finding, referral follow-up, and integration between services.^4,6 A combination of pressures on local authorities, ²⁹ and a lack of screening and active case finding, ³⁰ means few assessments and care packages are delivered, leaving many with unmet or poorly met care needs. ⁶ At current, untested and at times inadequately supported and supervised peer support schemes are increasingly utilised to plug this gap. ⁵

Though there is limited empirical evidence regarding the social care needs of those living in prison, a recent prevalence study of social care needs in men's prisons suggested that social care required serious attention. ⁴ It indicated that: 8% of men in prison reported health problems which impacted on daily living; approximately a tenth identified problems with making use of the prison safely, with most of these having difficulties mobilising; just over a tenth of younger people and a fifth of older people in prison reported problems maintaining their personal hygiene, dressing or undressing, toileting, and making use of the prison safely; approximately half reported a disturbance of their mood and emotional wellbeing, and approaching a quarter said that this had a noticeable impact on their behaviour, activities, or interaction most days or every day. ⁴

Data on the prevalence of social care needs in women's prisons, and the impact of the Care Act 2014, remains sparse. However, a recent review on health and social care in women's prisons recognised that women in prison have disproportionately higher levels of health and social care needs than their male counterparts in prison and women in the general population ⁷ ; 76% of women in prison reported mental health difficulty, compared to 51% of men, and nearly twice the proportion of women (40%) enter prison with a drug and/or alcohol problem compared to men (22%). The report also found that health and social care services across women's prisons in England are inconsistent, not always gender specific, and commonly insensitive to women with protected characteristics, such as particular religious beliefs, disabilities, or ethnicities. It concluded that the prison environment is unfit for purpose for many women and for health and social care providers. ⁷

Fixing a broken system

The findings from the women's report are cutting and clear. It makes eight strategic recommendations with women-specific considerations in mind, endorsing an appropriately tailored approach that is gender specific, gender compliant, considerate of protected characteristics, personalised, accessible, equitable, and consistent. ⁷ In the men's estate, the problems are perhaps even more clear, owing to the larger, though still limited, amount of evidence gathered. Social care provision in men's prisons suffers from major shortcomings, in particular, siloed working arrangements, ² patchy, widely varied social care provision,^2,5 and high levels of unmet care need. ⁴ As such, the case for universal, person-centred, integrated care systems (ICSs) in prisons is clear and pressing.^31,32 This is emphasised by recent UK legislation and policy highlighting the need for integrated care.^8,9

The 2022 Health and Care Act ⁸ provides a framework for ICSs. The purpose of this legislation overall is to bring providers and commissioners of NHS and Department of Health and Social Care (DHSC) services together with local authorities and other partners to collectively plan health and social care delivery. These ICSs hold great potential value to the criminal justice system, where interdepartmental and external agency collaboration is known to be particularly challenging.^2,5 Similarly, the National Partnership Agreement for Health and Social Care for England 2022–2025 ⁹ outlines a commitment to integrated care. Throughout this policy, collaboration, whole system, and multi-agency approaches are prominent. It provides an important opportunity to better integrate health and social care provision in prison and on probation, which has the potential to lead to more person-centred, effective care.

Importantly, the models of social care which arise from this vital policy and legislature must be supported by the appropriate evidence, which in some aspects remains lacking. The updated Medical Research Council and the National Institute for Health Research guidance for developing complex interventions emphasises the need to understand contextual and economic considerations. ³³ However, there are currently no empirical evaluations of implementing prison-based social care models, ²⁰ limited mechanistic exploration of prison social care design, ³¹ and minimal understanding regarding economic costs of care in prisons. ³⁴ There is a need to continue to gather evidence towards successful implementation and corresponding models of care, including the contextual factors effecting these complex interventions in prison and the economic costs.

Conclusion

Whilst social care in prison remains dysfunctional, imprisoned people will continue to suffer disadvantage, marginalisation, and vulnerability, on top of that which many have already endured,^{14,16–18,21} with prisons becoming mechanisms through which disadvantage propagates. This is not only an unacceptable situation for the individual, but wider society, with unmet social care need known to drive recidivism worldwide,^35,36 as well as increasing pressure on healthcare systems, including an already pressurised NHS. ³⁷ Empirical evidence on effective social care in prison, and how collaborative, integrated, trauma-informed social care can be achieved, is urgently required.