Health and social care services for older male adults in prison: the identification of current service provision and piloting of an assessment and care planning model

Article history

The research reported in this issue of the journal was funded by the HS&DR programme or one of its proceeding programmes as project number 08/1809/230. The contractual start date was in February 2009. The final report began editorial review in August 2012 and was accepted for publication in December 2012. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors' report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

Copyright statement

© Queen's Printer and Controller of HMSO 2013. This work was produced by Senior et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

Background

Older prisoners are the fastest growing subgroup in the prison estate in England and Wales. 1–4 In spite of the rapid increase in numbers and the complex and costly health and social care needs of older prisoners,5 their service provision is currently often suboptimal. 6 Emerging evidence has suggested that there are particular service provision and integration deficits at key transition points for older prisoners, such as on entry to and discharge from prison. 7

This programme of research examined the health and social care needs and current service provision for older male adults entering and leaving prison, and evaluated a model for systematic needs assessment and care planning for these groups. Women have been excluded from the study because of the low number of older female prisoners. In June 2011 there were only 63 female prisoners aged ≥ 60 years in England and Wales compared with 2952 male prisoners in this age group [National Offender Management Service (NOMS), 2011, personal communication].

Objectives

The specific objectives of the current study were:

1. to explore the lived experiences and needs of older people entering and leaving prison

2. to describe current provision of services, including integration between health care and social care services

3. to pilot and evaluate an intervention for identifying health and social care needs on reception into prison and ensuring that these are systematically addressed during older people's time in custody.

Methods

The research programmes was a mixed-methods study divided into four parts:

1. a study of all prisons in England and Wales housing adult men, establishing the current availability and degree of integration of health and social care services for older adults

2. establishing the health and social care needs of older men entering prison, including their experiences of reception into custody

3. the development, implementation and evaluation of an intervention to identify and manage the health care, social care and custodial needs of older men entering prison

4. exploration of the health and social care needs of older men released from prison into the community.

Ethical considerations

Ethical approval to conduct the study was obtained from South Staffordshire Local Research Ethics Committee (09/H1203/47) and the University of Manchester's Research Ethics Committee. To access Her Majesty's Prison Service (HMPS) establishments, governance approval was obtained from the NOMS National Research Committee and from individual prison governors/directors. For each establishment, site-specific approval was obtained from the relevant NHS primary care and mental health trusts. Research staff had NHS research passports and letters of access.

To ensure informed consent, all participants were provided with a participant information sheet (see Appendix 11). The information detailed on the sheet was also verbally imparted to ensure comprehension and allow for any literacy difficulties. Participants were provided with the opportunity to ask questions and were given at least 24 hours to consider their participation. Participants were frequently reminded of their right to withdraw from the study at any time. All written consent was obtained by researchers rather than prison or health care staff.

All participants had issues of confidentiality explained to them and were aware that the informationthey provided would be treated in confidence unless we were concerned for their immediate safety, or the safety of others. In such circumstances the appropriate individuals at prison establishments were informed. In some instances this led to the opening of Assessment, Care in Custody and Teamwork (ACCT) documents to ensure that prisoners who were at risk of self-harm were appropriately supported by prison and health care staff.

The safety of researchers was also prioritised and appropriate strategies were in place for conducting interviews in prison and in the community. Interviews were conducted in public places when possible. When this was not plausible because of interviewees' mobility difficulties, two researchers were present.

The University of Manchester and NHS protocols for data protection were strictly adhered to.

The authors have no competing interests to report.

The growing number of older prisoners

It has been well documented that the number of older prisoners is increasing rapidly in England and Wales. 1 In December 2012 there were 85 women in prison aged ≥ 60 years in England and Wales, compared with 3292 male prisoners in this age group (NOMS, 2013, personal communication). The proportion of male prisoners aged ≥ 60 years has steadily increased from 2% in 2002 to 4% in 2011 (NOMS, 2011, personal communication). This trend is also evident in both Canada and the USA. 8,9

There are a number of factors contributing to this increase, including changes to sentencing practices, for example an augmentation in mandatory sentencing, the pursuit of convictions in later life for historical offences, the use of indeterminate imprisonment for public protection and an increased number of life sentences. 7 Furthermore, the general population are living longer, thus there are a greater number of older people in society to commit crimes. 10–12

The Ministry of Justice projections (2011) estimate that the overall prison population may increase to 94,800 by June 2017 (NOMS, 2013, personal communication). Such projections take into account a number of factors, including the age of defendants entering the system. NOMS figures show that prisoners aged ≥ 50 years were the only age category subgroup to increase year on year since 2006 (NOMS, personal communication). The projected increase of this subgroup of prisoners will undoubtedly affect many aspects of the system, including creating increased pressure on prison-based health care provision as services attempt to address the complex health needs of older prisoners. 13 It has been argued that prisoners aged ≥ 50 years acquire age-related health problems 10 to 15 times faster than their peers in the general population. 14–16 As a consequence, the cost of health care for older prisoners is significantly higher than that for younger prisoners, with costs estimated to be between three- and eightfold higher. 13,16–18

Defining older prisoners

In the general population the definition of an older person is wholly socially constructed, with different age-dependent events, for example pension and benefit entitlements, occurring at different age points. Similarly, the age at which a person in custody is regarded as an older prisoner is, to some degree, arbitrary. Throughout this study the minimum cut-off age of 60 years is used to define an older person. This is in line with the lower cut-off age generally used by social services.

Policy and legislation

Currently, there is no national strategy for the care of older prisoners, despite repeated recommendations for one to be developed. 7,19 The provision of services for older prisoners across the English and Welsh prison estate has been under formal review since 2004, at which time an independent inspection of 15 prisons housing adult men by Her Majesty's Inspectorate of Prisons (HMIP) found that the physical design of establishments often restricted older people from accessing many areas of the prison. 19 Older prisoners were observed to be excluded from taking part in a full range of activities as a result. Some older prisoners reported feeling unsafe within establishments, and specific staff training to deal with issues affecting older prisoners was found to be sparse. 19 A follow-up inspection of 29 establishments in 2008 found that only three prisons had a policy specifically addressing the needs of older prisoners. The later inspection did, however, find that older prisoners were less fearful than had been identified previously and that the majority were happy with the care they received. 7 Her Majesty's Chief Inspectorate of Prisons' (HMCIP) review of older prisoner care raised grave concerns that older prisoners' needs were not planned or provided for after release. 7 Only four prisons could be identified as providing specific resettlement help for older prisoners. The recommendation from the previous review that the specific resettlement needs of older prisoners should be accurately assessed and provided for on release was thus reiterated. 7

Stemming from findings of the reviews of 2004 and 2008, and updates to the Disability Discrimination Act (now replaced by the Equality Act 2010), HMPS published Prison Service Order (PSO) 285520 relating to prisoners with disabilities, including reference to older prisoners. The overall standard stated that, ‘The Prison Service ensures that all prisoners are able, with reasonable adjustment, to participate equally in all aspects of prison life without discrimination’. 20 The PSO outlined the requirement for prisons to ensure that offending behaviour courses, work and education were accessible to older prisoners, and that prisons should consider having a lead member of staff for older prisoners. It also emphasised the need to have continuity in managing chronic physical health problems through effective multidisciplinary working and information sharing, reflective of the care of older people in the community. It is a well-established principle that prison-based health care provision should be equivalent in quality and range to health care provided in the community and that all national standards for health care apply equally in prison and community settings. 21 Thus, the National Service Framework for Older People22 applies in prison. The framework focuses on providing person-centred care to older people, whether in their own home or in a residential setting. It aims to diminish age discrimination and promote independence among older people as well as ensuring that care provided is relevant to older people's needs. It focuses particularly on health conditions relevant to older people, such as stroke and specific mental health problems associated with ageing. 22

The Department of Health produced a toolkit for good practice for older prisoner care in 2007. 23 The toolkit made specific recommendations aimed at bringing prison-based care into line with national policy and community practice. The document stipulated that older prisoners should be assessed using a health and social care assessment specifically designed for their needs and that this should be repeated every 6 months, with care plans made and reviewed accordingly. The Department of Health’s A Pathway to Care for Older Offenders23 emphasised the importance of comprehensive and systematic identification of the needs of older prisoners on entry into custody.

Currently, the provision of health care services in prison relies heavily on information elicited at reception from a generic screening instrument. 24 There are specific versions of the instrument for men and women; however, there are no specific questions relevant to assessing age-related needs, for example relating to memory, cognition or level of independence with daily living skills. Previous studies have shown that, if health problems are not elicited at reception, they are unlikely to be detected later during a person's detention;25 thus, it is appears unlikely that, without tools specifically designed to identify age-related health needs, such deficits would be routinely detected later during the custody period.

As part of A Pathway to Care for Older Offenders,23 the Department of Health has also made recommendations around preparation for release and follow-on support in the community, which are particularly pertinent to this study. The Department of Health stipulates that release planning for older prisoners should involve the following:

• a health and social care needs assessment history being forwarded by the health care team to the offender manager

• the conduction of a pre-release health and welfare assessment

• an assessment by a social worker, conducted face-to-face

• collaboration with external organisations

• the organisation of a care package

• formal arrangements for loans of occupational therapy equipment

• a pre-release course specifically for older and retired prisoners. 23

In 2009, the National Association for the Care and Resettlement of Offenders (Nacro), in conjunction with the Department of Health, produced a training pack for prison staff working with older prisoners. 26 The purpose of this document was to raise awareness among staff of the common health difficulties experienced by older offenders. It intended to set out good practice guidelines and encourage the commencement of specialised activities for older prisoners such as older prisoner groups, in-cell work for those with mobility difficulties and appropriate exercise opportunities. Furthermore, it aimed to encourage staff working with older prisoners to contact community-based specialised agencies for older people to obtain information and support. 26 Throughout, the training pack attempted to pursue the principle of equivalent services for prisoners as for older people in the community.

The health and social care needs of older prisoners

Older prisoners have complex health needs. 27 The physical health needs of older prisoners are greater than those of both younger prisoners and those of a similar age living in the community. 14 Kingston et al.,3 in their UK sample of 121 prisoners aged ≥ 50 years in four prisons in and around Staffordshire, found that participants each had an average of 2.26 physical health problems. Approximately 85% of older prisoners have one or more major illness. The most frequently reported health conditions among older prisoners are cardiovascular diseases (35%), arthritis and/or back problems (41%), respiratory diseases (15%), endocrine disorders (21%) and sensory deficits (12%). 13,28

The mental health needs of older prisoners have been found to vary significantly from those of their younger counterparts in prison. 2 Older prisoners are at a greater risk of becoming isolated within the prison environment and are less likely to have social support, putting them at a greater risk of developing mental health difficulties. 29 In the aforementioned study by Kingston et al.,3 half of prisoners in the sample (n = 60) were identified as having a mental disorder, with depression being the most frequently diagnosed. Furthermore, 12% (n = 15) had symptoms of cognitive impairment. Strikingly, Fazel et al. 6 found that 86% of their sample showing signs of depression were not receiving antidepressant medication nor was depression documented in their medical records. In addition, alcohol is the most commonly misused substance among older prisoners. 30,31

There is a dearth of research regarding older prisoners' social care needs. Previous studies have shown that older prisoners have high levels of unmet need in the domains of accommodation release planning and daytime activities. 4 A comprehensive study carried out by Hayes et al. 32 in 2010 found that, of the sample of 262 prisoners aged ≥ 50 years, more than one-third had some level of functional need in activities of daily living and 14% had mobility difficulties. Nearly half were imprisoned far from their home area, which made contact with family and friends difficult; 15% had no contact at all with family or friends.

The provision of social care is an area often overlooked within the prison environment, largely because there is an apparent lack of understanding of what constitutes ‘social care need’ within a prison institutional setting. 33 The result is that the provision of social care becomes, by default and through a sense of necessity, the responsibility of health care services rather than being regarded as a wider, multi-agency responsibility. 7

There is currently very limited research focused on the specific issue of identifying and meeting the health and social care needs of older prisoners on entry into prison. It has been established that, within the general prison population, just over one-quarter of all self-inflicted deaths occur within 1 week of prison entry. 34 Furthermore, previous research conducted by Crawley35 suggested that older prisoners entering prison for the first time experience a number of distressing phenomena, labelled ‘entry shock’. Contributing factors included high levels of noise, lack of privacy, indigent facilities, claustrophobic conditions, perplexing rules and regulations and hostility from younger prisoners and uniformed staff. Within Crawley's study, many older prisoners reported that, in the absence of any support in prison, they were able to recall previous difficult experiences such as induction into the army or a childhood in care and that they used these as an, albeit imperfect, ‘blueprint’ for how to cope in the prison. 35

As well as the risks associated with reception into prison and the early weeks spent adapting to custody, some limited research has identified that the period post release is also risky in terms of prisoners' physical and mental health. 36 There have been a small number of studies that have explored, prior to discharge, older prisoners' concerns and issues about release,37–39 suggesting that older prisoners struggle disproportionately with community resettlement because of reduced support networks and the increased likelihood that they are suffering from health and mobility problems. 39 Crawley38 and Crawley and Sparks37 explored older prisoners' concerns regarding their release from prison, concluding that they often experienced intense anxieties about release and inadequately understood the resettlement process. Key concerns included where they were going to live and how they were going to get there; their physical safety on release (for those convicted of sexual offences in particular); loss of personal possessions and support networks; and access to health care for support with chronic illness. Their concerns prior to discharge were so intense that many of them felt that it would be better to stay in prison than be released into the community.

There is an increased risk of suicide among recently released prisoners in England and Wales, with the greatest elevation in risk identified in those aged ≥ 50 years. 40 Despite these increased needs, older prisoners' resettlement needs are often ignored; it has been suggested that, in spite of evidence to the contrary, this is because they are generally considered to be of lower risk than their younger peers,38 which is exacerbated by their being less assertive. 38 Crawley38 advocated the need for an emphasis on effective, proactive communication with older prisoners to reduce severe feelings of anxiety leading up to release. No studies have been published to date that have followed up older prisoners after their release to examine the barriers to and facilitators of successful community reintegration.

Assessing older prisoners' health and social care needs

There are challenges to effectively conducting health and social care assessments of older people in the community. 41 Problems have included the under-reporting of need, variations in assessments across disciplines and geographical areas and disagreement between different professionals. 41 The National Service Framework for Older People22 set out plans to improve the assessment of all older people's needs, including the introduction of the Single Assessment Process (SAP). The aims of the SAP were to standardise the assessment process across organisations and geographical areas, raise the standard of assessment, assist information sharing, prevent duplication of assessment processes and ensure holistic assessment of need. 22

Implementation of the SAP should result in an individual care plan that clearly describes the help to be provided and who should be contacted in case of emergency or should a person's needs change. 22 Additionally, the guidelines specify that care plans be agreed with the older person and that the older person should hold a copy of his or her own care plan. 22 Findings from an evaluation of the SAP suggested that its implementation had been uneven and that full implementation will be a long process. 42 Elsewhere, it has been suggested that statutory social services assessments have improved since the introduction of the SAP; however, the extent to which these improvements can be attributed to the SAP is unclear. 41

Health and social care services for older prisoners

The provision of services for older prisoners varies considerably between establishments. 7 HMCIP's 2008 review of 29 adult establishments7 found that few establishments had an older prisoner lead (OPL) responsible for co-ordinating the care of older prisoners. When in operation, the role was often given to the disability liaison officer (DLO), in addition to their already full workload. However, and more encouragingly, a further large-scale survey in 2010 of staff working in 92 establishments in England and Wales, conducted on behalf of the Prison Reform Trust,43 found that over one-third of prisons now had an older prisoner group/forum running at their establishment. It is also becoming evident that voluntary agencies are increasingly involved with older prisoners in some establishments, providing befriending services and help on release and running groups for older prisoners. 26 Specific older prisoner clinics were reportedly established in many prisons; however, the frequency of clinics varied considerably. Prison buddy schemes set up to help prisoners with tasks such as fetching meals or keeping cells tidy were also operational in some establishments. In certain prisons, older prisoners are housed together because of their differing psychosocial needs to those of their younger counterparts. 11 In summary, services available to older prisoners appear to be increasing, albeit in an ad hoc informal manner, lacking organisation or adherence to an overarching model of best practice but with some examples of apparent good practice. 44

Prisons are, for the most part, designed for younger, able-bodied prisoners. 7 Many prison establishments in England and Wales are of Victorian design and construction. Narrow staircases and cell doors and long corridors mean that those with mobility problems struggle to physically access many parts of prisons. 7 This frequently results in older prisoners with mobility problems being housed routinely in prison inpatient wards, simply because of a lack of appropriate facilities in other wing locations rather than because of a need for continuous nursing care. 7 It is noteworthy that, where adaptations have been made, such as the installation of chairlifts, equipment has often been found to be out of order. 7 Nacro and the Department of Health suggest that some simple adaptations should be made to care appropriately for older prisoners, for example doors and windows should be easily opened; less harsh lighting should be installed; radiators should be easily adjustable; special cutlery, plates, bowls and trays should be provided for older prisoners; and lower television shelves and appropriate seating should be made available in cells. 26

The commissioning of health and social care services

Historically, HMPS, through the existence of the Prison Medical Service, latterly renamed the Prison Health Service, was responsible for the provision of the majority of health care services for prisoners. Almost all services were provided ‘in house’, ranging from primary care for everyday physical complaints to inpatient care for those with severe mental health problems. HMPS directly employed doctors as prison medical officers, and part-time medical practitioners were also employed, usually local general practitioners (GPs). Other health care staff consisted largely of qualified nurses, usually with general or mental health qualifications, and prison health care officers, usually non-nurse-qualified personnel who undertook in-service training to assume duties traditionally associated with nursing staff.

Following sustained criticism of both standards of care provided to prisoners and the relative expense of such services, a clinical improvement partnership between the NHS and HMPS was established in 1999. 21 Initially, HMPS maintained control of the costs of health care services but, by 2006, budgetary control for health care provision in all public sector prisons was transferred to primary care trusts (PCTs).

The Health and Social Care Act 2012 heralded the transfer of the majority of NHS commissioning responsibilities across England from PCTs to clinical commissioning groups (CCGs), largely controlled by GPs. However, from April 2013, the responsibility for commissioning prison-based care will transfer from PCTs to the national NHS Commissioning Board, along with a number of other ‘specialist’ services. The national Commissioning Board will be supported across England by 27 local area teams (LATs) and it has been announced that 10 of the 27 LATs will develop specific expertise and lead on matters relating to the commissioning of offender health care including, but not limited to, prison-based services.

Although prison-based health care services within public sector prisons are now a fully integrated part of the wider NHS, the involvement of local authority social services with prisoners in need of social care remains underdeveloped. Anecdotally, particular issues seem to arise when requests are made to NHS services, and perhaps more markedly social services, to provide assessments or services for prisoner-patients not deemed to fall within the geographical boundaries of a particular area's service. For example, when a prisoner requires admission to secure mental health care, NHS commissioners for the prison where the person is housed may argue that they are not responsible for the care costs as the person's last known address outside custody is determined to be elsewhere in the country. Similarly, social services departments have frequently failed to accept that the populations of prisons within their geographical catchment area are ‘proper’ residents. Our study discusses these matters in detail throughout.

In future, again as part of the organisational changes contained within the Heath and Social Care Act 2012, a local health and well-being board (HWB) will be established in each of England's 152 upper-tier local or unitary authority areas, to co-ordinate commissioning across health, public health and social care. Each HWB will comprise representatives from the CCG, a director of public health, a director of children's services, a local Healthwatch England representative and other key stakeholders at the discretion of the local authority (Healthwatch England is the new independent ‘consumer champion’ for health and social care in England).

Each HWB is charged with co-ordinating a Joint Strategic Needs Assessment (JSNA) to identify the health and well-being needs of the local population, and producing an annual Joint Health and Wellbeing Strategy (JHWS) to outline how partners will address the needs of the local community through their commissioning of NHS, social care and public health provision. Most of the 152 local authorities in England have now formed shadow HWBs that are already developing the JSNAs and JHWSs for 2013–14. The need to undertake JSNAs for the whole of a local population may serve as a way of including prisoners' social care needs in a much more widespread and routine way than has previously been the case, although the success of this is currently unknown and will need to be reviewed when JSNAs and JHWSs are published and can be evaluated.

Integration between health care and social care services for older prisoners

The effective integration of health and social care services in the community has been a policy goal for over four decades. 45 The Department of Health's National Service Framework for Older People22 highlighted the importance of adequate integration between prison and community social care agencies to ensure that prisoners receive an adequate standard of care. 22 Successful integration between health care and social care services is challenging within prisons. 46 Accountability for the provision of social care services for older prisoners is a particular problem. 46 This is often because there is an overlap of service provision between prison, health and local authorities accompanied by high levels of uncertainty around which local authority is responsible for an older prisoner's care on release, particularly when older prisoners are discharged into different geographical areas from those of their prison establishment. 46 According to the Department of Health's recent publication entitled Caring for our Future; Reforming Care and Support,47 preparations are ongoing to address this dilemma. HMCIP's review in 20087 found little evidence of multidisciplinary working within prison environments, with particular deficits observed in the resettlement of older prisoners. In the main, prison staff considered the social care of older prisoners to be the responsibility of health care staff. In an overwhelming majority of cases, social care arrangements were found not to be in place for older prisoners. 7,44

Summary

The current study will identify whether or not any improvements have been made to service provision for older prisoners. It will also build on the existing literature to explore the barriers to and facilitators of integrative working between health care and social care services. Furthermore, it will aim to address the established deficit in systematically addressing the health and social care needs of older prisoners through the development, implementation and evaluation of a needs assessment and care-planning intervention for older prisoners.

Introduction

Previous research suggests that provision of health and social care services specifically for older prisoners is ad hoc7,19 and that successfully integrating services is challenging. 7 The first part of this study aimed to establish current levels of service provision for older men in prison across England and Wales. It also aimed to ascertain how well health and social care services were integrating currently and identify common facilitators of and barriers to more effective integrative working.

Methods

Mixed methods were adopted in this part of the study, comprising a national questionnaire and semistructured interviews with a range of professional respondents.

Results

First, the questionnaire response rates and the numbers of older prisoners at establishments are presented. Second, questionnaire findings are presented under two broad topic areas: service availability and the integration of health and social care services. Third, findings from the semistructured interviews are presented to augment the questionnaire findings with more detailed information about key points.

Summary

In this cross-sectional national survey an 80% response rate was achieved. Older prisoners represented 4% of the prison population within our sample; this is in line with national figures (4%; NOMS, 2012, personal communication).

Over half of the establishments had a written older prisoner policy and 80% of prisons had a designated OPL; however, only a minority of these staff had received any specialist training to undertake their role. An investigation of integration between health and social care services showed that 64% of establishments had contact with local social care services; however, only 33% believed that there was a co-ordinated approach between health care and social care services. Furthermore, only 16% of health care managers reported holding meetings with social services to discuss the care of older prisoners.

Qualitative interviews highlighted the nuanced institutional factors and working practices that facilitate the effective integration of health and social care services for older prisoners, and the barriers that staff face. Positive staff attitudes were highlighted as a prerequisite to effective working. Barriers to success included the lack of clarity felt by many staff regarding where responsibility and accountability for providing social care to prisoners actually lay. Locating people in prisons away from their home area impeded the ability, and indeed willingness, of social services to become involved in the very important tasks around resettling an older person in the community. Information sharing was felt to be successful only in terms of managing risks rather than in the equally important and, of course, very closely inter-related area of meeting individual need.

Introduction

Older prisoners' complex health and social care needs are often unmet. 4,6 The second part of this study aimed to establish the met and unmet needs of recently incarcerated older prisoners, as well as capture their experiences of being received into prison custody.

Methods

This part of the study employed mixed methods including structured and semistructured interviews with prisoners on entry into prison.

Results

Summary

The second part of this study aimed to assess the unmet needs of recently incarcerated older prisoners, as well as capture their experiences of being received into prison custody. Results from the CANFOR-S showed that the highest proportions of unmet needs were in the domains of information about condition and treatment (38%), psychological distress (34%), daytime activities (29%), benefits (28%) and physical health (21%). Analysis of GDS-15 data found that 31% of the sample had a score indicative of mild depression and 23% of the sample had a score indicative of severe depression. Eight (19%) of those showing signs of depression were receiving antidepressant medication and six (14%) had contact with a mental health nurse during their initial 4 weeks in custody.

Semistructured interviews conducted during the initial period of prison custody highlighted that older prisoners entering prison for the first time suffered from ‘entry shock’, which was made worse by a lack of information received. Delays in accessing health care and receiving medication were a particular cause of concern. In the main, social care needs were not appropriately met. Furthermore, older prisoners considered some prison officers to be inapproachable and prison facilities to be largely inadequate.

Introduction

The Department of Health has emphasised the importance of regularly assessing older prisoners' health and social care needs using specialised assessments and care planning. 23 The present study has identified that only 19% of establishments currently use a specialised older prisoner assessment on entry into prison. This part of the study aimed to develop, pilot and evaluate an intervention for identifying the health and social care needs of older prisoners on reception into prison and ensuring that these are systematically addressed during older people's time in custody.

Method

This part of the study involved mixed methods including action research, documentary analysis and semistructured interviews with action-learning group members and older prisoners.

Action-learning group meetings

Principles of action research were adopted to develop the Older prisoner Health and Social Care Assessment and Plan (OHSCAP) through the use of an action-learning group. An action-learning group comprising health care staff, prison staff and older prisoners was established at one adult male prison in England. The group was facilitated by an experienced action-learning group facilitator who was familiar with both prison culture and working practices. Action-learning group members were recruited following an initial open meeting at the prison when the aim of the project was explained and expressions of interest sought. At the first action-learning group meeting there were 14 members including two older prisoners, primary health care staff, a governor and prison officers from residential wings, the gym and the first-night centre. There was consistent representation from prison officers and prisoners throughout the life of the group; however, the involvement of health care staff reduced significantly as the project progressed.

Through a regular monthly action-learning group, cycles of planning, action and evaluation took place to support the development of the OHSCAP and its piloting in vivo. In developing the content of the OHSCAP, the action-learning group commenced by reflecting on current practice in their own prison, practice in other prisons using assessment tools currently being used elsewhere and provided to them by the wider project team, a HMCIP thematic review7 and a toolkit from the Department of Health. 23 Research publications pertaining to the needs assessments of older people in the community41,64,65 were also utilised to explore the nature of the SAP and other areas and types of assessment used in the wider community. Following reflection on the literature and existing practices, the action-learning group met monthly between November 2010 and September 2011 in a meeting room inside the prison where they developed the OHSCAP through iterative cycles of reflection and discussion, each of which underpinned the evolution of the tool.

The piloting of the OHSCAP by the prison's OPL took place between May 2011 and April 2012. This officer was deemed the most appropriate member of staff to undertake this work given his prison-wide lead responsibility for older offenders. During piloting the action-learning group met four times to receive feedback on the use of the tool and to agree amendments and changes in light of ongoing evaluation and reflection on practice. Feedback from the piloting phase centred on facilitated reflection by the OPL on a number of issues, including its ease of use, necessity, length of time to complete, referrals made, impact on role, influence on colleagues and prisoner response to assessment.

Figure 1 illustrates the action-learning group and piloting activity.

FIGURE 1.

Action-learning group and piloting activity.

Results

Demographic information for the 24 prisoners who participated in the semistructured interviews is presented in Table 29.

The findings are divided into two themes, namely the OHSCAP development and piloting and action learning in prison, as illustrated in Table 30.

Theme 1: the OHSCAP – development and piloting

Findings pertaining to the development and piloting of the OHSCAP are grouped into three themes: content, process and value.

The Older prisoner Health and Social Care Assessment and Plan content

Deciding the content of the OHSCAP was a key task for the action-learning group. Content was based on staff and prisoner experience (action-learning group members), information already collected elsewhere on the prisoner journey and literature/existing policies and practices in other prisons. The action-learning group designed the OHSACAP to include a series of open questions around relationships, activities, mobility, emotional well-being and physical well-being. In its initial stages the OHSCAP had two main sections, one relating to health care and the other to social care. Given the identified need for clear terminology that would resonate with prison officers, the action-learning group felt that the ‘health care’ section should be amended to refer to ‘well-being’. After the identification of issues among older prisoners pertaining to discharge from prison, a discharge planning section was also added. A care plan was also included that detailed any referrals and special arrangements to be made. A copy of the OHSCAP is included in Appendix 8.

In addition to the actual content, the way in which the OHSCAP was presented became very important to the group for a variety of reasons. It was decided that it needed to be clear, have a coloured cover to differentiate it from the ACCT assessment and include questions that promoted open discussion rather than requiring only a ‘yes/no’ response. Consequently, the OHSCAP had a format that aimed deliberately to facilitate discussion and exploration. This was considered imperative by the action-learning group to facilitate meaningful discussion between staff and prisoner, and to avoid the completion of the OHSCAP becoming a ‘tick box exercise’:

I don’t like tick box/questionnaires, they’re so impersonal, don’t always get the, I mean, when you’re just reeling off a question, yes, no, disagree, disagree strongly, tick boxes, yeah, I mean, that, to me, they’re a waste of time, statistically, but, yeah, the open questions that asks for some feedback were much better in my opinion, and we got quite a lot of information from doing that, rather than the tick boxes.

OPL, p3.26

The Older prisoner Health and Social Care Assessment and Plan process

The action-learning group considered the process of administering, formulating and reviewing the OHSCAP alongside the development of the tool's content. Although this dual focus could have been viewed as problematic, the nature of action learning lends itself well to the development of new initiatives in this way as group members can develop tools with a clear and simultaneous understanding of the current culture and practices. 58 It is suggested that this enables useful and effective tools to be developed that, from the outset, take account of local practices and are therefore less likely to fail.

In considering the overall aim of the OHSCAP, group members felt that developing an assessment tool that was based on the same operational principles as the ACCT process, which is well embedded and known in all prisons, would be useful. Figure 2 illustrates the OHSCAP process, which is explained further below.

FIGURE 2.

The OHSCAP process.

The OPL identified older prisoners entering the prison and conducted the assessments. Members of the action-learning group felt that he was the most appropriate person to conduct the assessments as his job description already included supporting older prisoners. The OPL stated that identifying older prisoners was a simple process and that they could be easily identified using the prison computer system C-NOMIS:

How we identified the older prisoners was, obviously, C-NOMIS, we ran a list of new admissions from the previous day, and any prisoner who showed up as an older prisoner by birth date we would highlight, and take some particular details off C-NOMIS to start his file.

OPL, p3.26

Prisoners considered the OPL to be helpful, professional and friendly and felt comfortable talking to him about their issues and concerns, as illustrated in the following quotes:

But the interview with [OPL], excellent, nice man, informed me of various things.

Prisoner, p3.8

I find him very understanding, he was very clear and concise when we went through the forms and the questions. You know, if everybody else was like [OPL], things would be alright.

Prisoner, p3.16

Older prisoners were very willing to discuss all issues with the OPL, including health care concerns:

No, I’ve had to speak to a lot of people about my health over the last, sort of 10 to 15 years so, quite used to it.

Prisoner, p3.16

The group decided initially that the health and social care nature of the assessment would necessitate a joint assessment by health care and discipline staff, with the latter taking the lead. Trialling this in practice identified some difficulties with health care staff availability; thus, it was decided that health care staff were not required at all assessments. Over time, it was decided by the group that it would be appropriate for the OPL to routinely conduct the assessment alone, with assistance from health care staff when deemed necessary:

Prisoners are happy to be assessed jointly [by a prison member of staff and healthcare member of staff], at the same time although there have been occasions when there has been no member of healthcare staff available. In those cases, the assessment has continued and healthcare been advised of any issues that were raised.

Facilitator notes, July 2011

It was decided that the OHSCAP would be best introduced between 7 and 10 days post reception into prison. This was based on discussion in the action-learning group around the wealth of information that is both asked for and provided to all prisoners, including older people, immediately after they arrive in prison. In particular, it was felt that older prisoners required a period to settle into the prison to be able to identify and articulate their needs effectively:

The prisoners in the group reported that their own experiences of reception had been ‘daunting’ and difficult, given that they did not know what questions to ask as they did not know what would be happening. They also said they had information overload during their first few hours in prison.

Facilitator notes, November 2010

Further evidence for the need to allow the older prisoners time to settle into prison before conducting the assessment was provided in the interviews with the older prisoners themselves, who often stated that they could not remember the details of what happened when they first came into prison because of ‘entry shock’, suggesting that it would therefore not be appropriate to conduct an assessment during the first few days after prison entry:

I did have an interview with someone [on entry into prison] . . . I can’t remember what it were for . . . I honestly couldn’t tell you.

Prisoner, p3.5

Prisoners were routinely offered a copy of their OHSCAP care plan but often declined it. The reasons for this are not clear. Further work is required to establish the advantages and disadvantages of the prisoner holding a copy of his care plan. For example, this may be advantageous when prisoners are discharged from prison, to avoid duplicating work and to allow professionals providing follow-on support to be able to easily identify what support has been provided to date. The care plan included space to detail any referrals made. As part of the OHSCAP, referrals were made to agencies such as Shelter, education, health care, solicitors and social services, illustrating the holistic nature of the assessment and planning undertaken. The OPL reported that such referrals were being made earlier as a result of the OHSCAP than would otherwise have happened. This has the potential to better prepare older prisoners for their release:

At least, we can get an early referral, then get details off the prisoner, and start making enquiries early, see what we can sort them out with, even if it’s just some temporary accommodation when they get out.

OPL, p3.26

The OHSCAP was designed by the action-learning group to be shared between appropriate agencies. Feedback during piloting indicated no perceived need to share the assessment itself. On reflection, during their interview the OPL felt that it would be useful to provide prisoners with a copy of their OHSCAP, write up a summary of the OHSCAP on the prison system C-NOMIS and also scan a copy of the OHSCAP onto SystmOne (the prison electronic primary health care records system). It was felt that this would save duplication of work when a prisoner moved on from the establishment and also allow other professionals in the establishment to be aware of the issues facing the older prisoner. It was, however, highlighted that prisoners would need to consent to health care information being shared.

The OPL conducted reviews of the care plans on an ad hoc basis. The action-learning group decided that it would be most appropriate for the OPL to decide when reviews were conducted, depending on the nature of an older prisoner's issues, rather than to have the process dictate fixed review periods. The OPL, however, stated that deciding when reviews should be timetabled was challenging. The OPL specified that a more structured time review period would be helpful. Training in case management may assist those conducting the OHSCAP to identify appropriate time periods for review, as this is a skill that is not currently routinely practised for other similar prison-based assessment processes:

Yeah, not having a set period, I mean, and it just being left open to doing a review was a bit difficult, I think if we had a set timescale for doing a review after doing the care plan, then it might have been more useful to me, because yeah, I did find it a little bit difficult when to revisit it.

OPL, p3.26

The Older prisoner Health and Social Care Assessment and Plan value

The OHSCAP allowed the OPL to identify older prisoners' health and social care issues. Key concerns identified were delays in receiving medication, problems using the telephone and homelessness/housing issues. A delay in receiving medication was a frequent concern of older prisoners, as it is in the wider prison population. 66 Prisoners discussed delays of up to 10 days for existing medication regimes to be re-established after prison entry. These delays caused them considerable distress. Some older prisoners even perceived these delays to be life-threatening:

To be without my medication for that length of time is not, it’s dangerous, it. I mean I’ve had a stroke, a slight stroke in past, but I’ve never gone to a full blown heart attack and doctor told me that any longer without this medication what I’ve got to have. It’s not a matter of just take it willy nilly, I’ve got to take it every day, which I’ve been doing since I got it like.

Prisoner, p3.1

Given an existing positive working relationship between the OPL and the health care team, effective liaison with health care staff appeared to speed up the prescription of medication:

Medication was something that I could probably resolve that day, or, certainly, get things moving, if they hadn’t already been resolved. I’d approach the wing nurse, and discuss the issue with her, and between us we’d come up with a plan as to what was the best way to approach, and sort out the problem, whether it was to book an appointment with the doctor straight away, or whether the nurse could contact the pharmacist, and sort it out that way.

OPL, p3.26

Use of the OHSCAP facilitated early resolution of day-to-day prison-based problems, as well as prompting early referral to other help agencies. Resolving such issues were considered to make life more tolerable for older prisoners who were deemed to be vulnerable by staff. Both staff and prisoners reported that older offenders tended not to complain about such issues but that the OHSCAP gave a structure through which to ‘legitimately’ discuss problems, even those of a sensitive nature:

I’ve only just come in [to prison], so I’m trying to keep a low profile. I don’t want to rock the boat.

Prisoner, p3.20

Because I think if I hadn’t asked them [older prisoners] outright about a particular issue they wouldn’t have mentioned it, that’s the impression I got.

OPL, p3.26

Prisoners appreciated the OPL's interest in their situation and enjoyed simply being listened to. The assessment therefore had additional therapeutic benefits for the older prisoners. There were also practical benefits of the OHSCAP for the OPL, who specified that the assessments created an easy record to refer back to when issues arose with specific prisoners. It also increased multi-agency working, with networking taking place as and when referrals were made.

Summary

Overall, the content of and the process of delivering the OHSCAP was perceived by both staff and prisoners to be appropriate and beneficial. There is a need to effectively share the information collected among prison officers, offender managers and health care staff and to further develop the assessment review process.

The OHSCAP is valuable for assisting prison officers to address older prisoners' health and social care needs using a format that older prisoners found acceptable and empowering. It provides an opportunity to support older prisoners who have complex health and social care needs and are unlikely to otherwise raise their concerns.

It is possible to conduct multi-agency action learning within prisons and to involve both prisoners and prison staff effectively. There are, however, a multitude of challenges to overcome to facilitate action learning in prison, namely maintaining focus, clarifying key concepts and maintaining attendance at groups. Communication across prison departments must be improved to increase attendance at action-learning groups.

Overall, the use of action learning to facilitate the development of the OHSCAP was successful as a completed tool was developed and piloted, with encouraging results. In addition to producing the OHSCAP, group members benefitted professionally and the awareness, and provision, of care and support needs of older prisoners improved because of the extra activity that the action-learning group engaged in, be it consciously or subconsciously, for example raising awareness of the needs of older prisoners, arranging for extra seating and producing an information sheet for new prisoners.

The OHSCAP is a wholly original tool and is inherently protected by copyright.

Introduction

We are aware that the post-release period is particularly risky for prisoners in terms of their physical and mental health. 40 Their anxieties about release prior to discharge from prison have also been documented;41 however, we are not aware of their issues and concerns after they have been released. This part of the study aimed to explore the health and social care needs of older male adults discharged from prison into the community.

Methodology

Qualitative interviews were conducted with participants approximately 4 weeks before and 4 weeks after their release from prison.

Results

Summary

In summary, planning for older prisoners' release was perceived to be inadequate by older prisoners. Indeed, the majority felt that their release had not been planned at all. A number of participants were unaware of where they were going to be living until a few days before their discharge from prison. This lack of information caused older prisoners high levels of anxiety prior to release and provided a key barrier for the older prisoner to plan his release. In particular, older prisoners were particularly anxious about the prospect of residing in Probation Service-approved premises. For those housed in Probation Service-approved premises, once they were released their anxiety levels were generally drastically reduced, largely as a result of having their key needs met. However, those residing in such locations considered themselves to be in a transitional period, not fully released into the community. Those who were not residing in Probation Service-approved premises had more unmet needs on release from prison.

The provision of pre-release courses was ad hoc and, when such courses were provided, information was not tailored to the needs of older prisoners. There was a perception that there had been minimal or no contact with probation workers and offender managers in preparation for release. Once released, older prisoners generally had appropriate access to a GP.

There appeared to be no real differences across types of prison in terms of release planning; it was perceived to be poor in all types of establishments. The majority of the participants who were not released into Probation Service-approved premises had been released from an open prison. Those who were not housed in Probation Service-approved premises were more likely to be concerned about financial matters. Those not released into Probation Service-approved premises who had social care needs were on occasion housed in inappropriate accommodation.

Current levels of service provision

The first part of this study aimed to establish current levels of service provision for older adults in prison across England and Wales. The Department of Health toolkit for good practice23 recommends that each prison should have an older prisoner policy, with a designated policy lead. This study found that only 56% of establishments had a written older prisoner policy. Previous research conducted by the Prison Reform Trust suggested that, when an older prisoner policy is in place, the needs of older prisoners have a higher profile within the prison system. 43 The lack of specific policies for older prisoners provides a possible explanation for why older prisoner service provision remains ad hoc across the prison estate. Consequently, findings from this study suggest that the development and effective implementation of an older prisoner policy at each establishment housing older males would be beneficial.

Since the last HMCIP report regarding older prisoners, there has been an increase in the number of designated leads for older prisoners within health care departments. 7 Within the current study, 88% of prisons had an OPL within their health care department compared with 38% in the latest HMCIP report in 2008. 7 However, only 36% of OPLs in the current study had received specific training to support them in this role, despite the Department of Health's recommendations that such training is essential. 23 Furthermore, although there was an increase in the number of assigned OPLs, there was a lack of evidence for the OPLs being active in their roles, despite this being a key theme of HMCIP's policy. 67 For example, only 35% of establishments had older prisoner/buddy schemes and only 53% had designated older adult clinics.

The integration of health and social care services

The first part of the current study also aimed to ascertain how well health and social care services were integrated and to identify facilitators of and barriers to effective integrative working. Only 33% of healthcare managers reported that there was a co-ordinated approach between their health care department and social services. This suggests that service provision for older prisoners is suboptimal and failing to meet the Department of Health's recommendation that there should be effective interagency co-operation between health care and social services. 26 Participants in the current study cited ambiguity concerning where responsibility for the social care of older prisoners lay as a key barrier to integrative working. This ambiguity, and the need for formal clarification of the responsibility of prisoners' social care needs, is well documented in the literature. 46,47 The current study has added to previous knowledge by illustrating that this ambiguity contributes to poor standards of social care for older prisoners.

Participants also referred to how the geographical organisation of social services accentuates the challenges of providing appropriate social care for older prisoners. This suggests that, where possible, it would be advantageous to locate older adults in prisons within the geographical area to which they will be released, to facilitate better co-ordination of their care. Furthermore, the development of local agreements between prisons and their local social services would assist in improving co-ordination of older prisoners' care. The findings of the current study further suggest that increased face-to-face networking between health and social care service staff would also improve co-ordinated care for this group.

The health and social care needs of older prisoners at prison entry

The second part of this study aimed to establish the unmet health and social care needs of older prisoners on entry to prison. We found that older prisoners have, on average, 2.74 unmet health and social care needs. A previous study conducted by Hayes et al. 4 on a cross-section of older prisoners found that they had, on average, two unmet needs. Our study focusing on reception only suggested that older prisoners have, on average, more unmet needs on entry to prison than at other stages of their sentence. Our findings further support the recommendation in the Department of Health toolkit23 that older prisoners' health and social care needs should be assessed appropriately on entry to prison. This is of particular importance because older prisoners have more complex health and social care needs than their younger counterparts and those of a similar age living in the community. 13

The current study found that 55% of participants had GDS-15 scores indicating symptoms of clinical depression on entry to prison, with 23% scoring in the range for severe depression. This was considerably higher than findings from a cross-sectional study by Hayes et al. 32 using the GDS, which found that 51% of older prisoners were showing symptoms of depression, with only 3% in the range for severe depression. Consequently, our findings suggest that symptoms of severe depression are more common on entry to prison than at other stages of the prison pathway. In addition, our findings illustrate that only 17% of participants showing symptoms of depression on prison entry were prescribed antidepressants within 4 weeks of entry into custody. These findings are similar to those of the cross-sectional study of Fazel et al. 6 conducted in 2004, which found that 14% of older prisoners presenting with depressive symptoms were prescribed antidepressants.

The development, implementation and evaluation of an intervention to identify and manage health, social and custodial needs of older people entering prison

The aim of the third part of the current study was to develop, pilot and evaluate an intervention for identifying the health and social care needs of older prisoners on reception into prison and ensuring that these are addressed systematically during older people's time in custody. This study successfully developed the OHSCAP through action learning with older prisoners, prison officers and health care staff. It was developed in line with the recommendations from the Department of Health's toolkit for good practice. 23 There is a dearth of research evaluating the use of older prisoner health and social care assessments. The OHSCAP was, however, perceived by both staff and prisoners to be acceptable, feasible and beneficial.

The Department of Health's toolkit emphasises the importance of regularly reviewing assessments and recommends that this should be conducted every 6 months. 23 During the piloting process the OHSCAP was reviewed as and when deemed appropriate by the prisoner and prison officer; however, making such decisions around flexible review intervals proved challenging. Consequently, training on case management may prove beneficial for prison officers administering and conducting the OHSCAP.

There is a need to effectively share the information collected from the OHSCAP among prison officers, offender managers and health care staff. This information was not adequately shared during the OHSCAP piloting process. The findings from this research suggest that it would be useful for the OPL to scan a copy of the OHSCAP onto SystmOne, write a summary of the key points from the OHSCAP onto C-NOMIS and provide a copy of the OHSCAP to the older prisoner. The Department of Health toolkit specifies that the older person should hold a copy of their own care plan. 23 However, older prisoners in the current study were reluctant to accept a copy of their OHSCAP. The reasons for this require further exploration.

Within the current study, both older prisoners and staff members stated that older prisoners normally avoid complaining. This finding is in line with the 2004 HMIP review,19 which found that older prisoners generally posed minimal problems for staff and, as a result, their own problems were often neglected. The OHSCAP proved a useful tool for supporting older prisoners who have complex health and social care needs and are unlikely to otherwise raise their concerns.

The action-learning approach taken to develop and implement the OHSCAP proved useful. To date, action learning has not been widely used in prison research; the involvement of prisoners in such an approach is particularly lacking. However, when it has been used, action learning has been proven to be an effective method for service and practice development in prisons, where there can be considerable resistance to change. 68,69

The health and social care needs of older prisoners discharged from prison into the community

The fourth part of the current study aimed to explore the health and social care needs of older male adults discharged from prison into the community. In the main, older prisoners perceived there to have been no planning for their release prior to their discharge from prison. This suggests that recommendations to assess the resettlement needs of prisoners on prison entry70 and to accurately assess and provide for older prisoners' needs on release7 are currently largely unmet. Those who are to be released to Probation Service-approved premises are often particularly anxious about this prior to their release; however, once they arrive there they generally have their health and social care needs fairly well met. Those who return home or who are housed in emergency accommodation were less likely to have their health and social care needs met on release.

In accordance with previous research conducted by Crawley,38 the current study found that the lack of information received by prisoners in preparation for their release caused high levels of anxiety. Many reported minimal or no contact from probation workers or offender managers. Crawley and Sparks37 had previously highlighted the need for more effective proactive communication with older prisoners to reduce severe feelings of anxiety leading up to their release; however, such improvements do not appear to have been made.

Pre-release courses are one means of providing information to older prisoners prior to discharge. Within the current study, a pre-release course was reportedly provided at only one of the nine establishments involved, and not all participants residing in that establishment were aware of the existence of the course. Additionally, the pre-release course identified was not designed with older prisoners' needs in mind. Consequently, it appears that establishments are currently largely failing to adhere to the Department of Health's23 recommendation to provide older prisoners with pre-release courses that are tailored to their needs.

Methodological strengths and limitations

Within this study, 60 years was used as the lower cut-off age for older prisoners. For a number of reasons, since this study began, there has been a shift towards using 50 years as the minimum age for defining older prisoners. Collins and Bird71 found similar rates of illness in male and female prisoners aged ≥ 50 years as in those in the community who were aged ≥ 60 years. Furthermore, Hayes et al.,4 investigating the physical, mental and social care needs of older male prisoners in England, found similarities in health needs in those aged 50–59 years and those aged ≥ 60 years. Much prison-based literature suggests that 50 years is an appropriate cut-off by which to delineate older prisoners, as lifestyle choices common among offenders, including substance misuse, risky sexual behaviour and a lack of preventative health care, have also been shown to accelerate ageing. 10,72 Prison-related factors, including the stress of prison life, increased anxiety, isolation and separation from family and friends, the threat of victimisation and the prospect of living one's life in detention, may also be associated with lower life expectancy and premature ageing. 72

Thus, current evidence suggests that adopting a cut-off age of 50 years is most appropriate when designing services for this group and this is reflected in the fact that, at the time of writing, both in the USA and the UK, the most frequently used cut-off age for defining ‘older’ prisoners is 50 or 55 years. 73 However, when the current study commenced in 2009 the age of 60 years was the most commonly applied minimum age used to define older prisoners in forensic mental health literature74 and this was reflected in our study. Fifty years should therefore be used as the minimum cut-off age for older prisoner studies in the future. This study did not include women because of the low number of female prisoners aged ≥ 60 years in England and Wales.

The questionnaire was a national survey distributed to all establishments housing adult males in England and Wales and achieved an 80% response rate. The main reason for this favourable response rate was the comprehensive follow-up strategy that was employed, involving telephone calls, letters and emails. Good response rates were received for all types of prisons. Furthermore, there was no difference in response rate between private and public prisons. Interviews were conducted with staff regarding the levels of integration between health and social care services. Staff from eight prisons undertaking various professional roles were interviewed. We selected prisons that reported particular successes or challenges in integrating health and social care services to ascertain a range of barriers and facilitators. We did, however, experience considerable difficulties in identifying social care workers to interview within the selected prisons, reflecting the relative shortage of this profession within establishments.

The research study involved interviewing 100 older prisoners on entry to prison. Local prisons were selected that were within reasonable geographical reach of the research base. The findings suggest that the sample was not dissimilar to national statistics in relation to offences. In total, 95% of the sample were White British; this is similar to the 92% of white British prisoners aged ≥ 60 years in England and Wales (NOMS, 2012, personal communication). Audits of health care records took place on entry into prison. This aspect of the study was reliant on accurate records being made by health care staff and the quality and availability of such information was found to vary across establishments.

It would have been beneficial to compare findings from those who received the OHSCAP with findings from those who had received treatment as usual. However, only a small number of older prisoners entered the prison where the OHSCAP was piloted and this proved not to be possible. The data obtained from participants who received the OHSCAP can, however, be used to inform and power a future randomised controlled trial to assess the effectiveness of the OHSCAP in reducing older prisoners' unmet health and social care needs. Furthermore, the qualitative data obtained have illustrated the feasibility of delivering the OHSCAP as part of the prison regime, and its acceptability to both prisoners and staff.

Action learning provided a successful means of developing and implementing the OHSCAP within the prison environment. There were, however, some challenges to overcome when adopting such an approach. The involvement of health care and senior staff reduced as time elapsed. This was not, however, detrimental to the development or implementation of the OHSCAP. It is possible that a lack of senior staff involvement in the groups actually allowed other members to speak freely. Furthermore, senior staff were very supportive of the implementation of the OHSCAP and were instrumental in establishing the action-learning groups. We do not have any evidence for the reasons behind the reduction in health care staff involvement and therefore speculation would be inappropriate.

Semistructured interviews were conducted with older prisoners released from prison into the community. We successfully followed up 73% of participants in the community. This was a far higher proportion than anticipated initially and was largely because the majority of older prisoners were assigned a probation worker in the community who could facilitate the follow-up interview. The interviews were conducted approximately 4 weeks after discharge, when the majority of participants were residing in Probation Service-approved premises. Additional follow-up interviews would provide an understanding of how well older prisoners' health and social care needs are met once they are residing in private premises, without the close links to services that are present in Probation Service-approved premises.

Implications for the management of policy and practice

The evidence from the current study suggests the following:

1. Fundamental adaptations to prison buildings are still required to allow older prisoners with mobility difficulties physical access to services and facilities fully in accordance with the Equality Act 2010.

2. There has been an increase in the number of assigned OPLs in health care departments; however, they are still not present in all establishments and a large proportion are not active in their roles. Each prison should identify an OPL within their health care department who should lead on the development of specialist services such as older prisoner/buddy schemes and designated older adult clinics.

3. A large proportion of establishments are failing to adhere to the Department of Health's recommendation23 that they should have an older prisoner policy in place. Each establishment should develop such a policy.

4. Establishments and their partners are, in the main, failing to meet the Department of Health's recommendation23 that there should be effective interagency co-operation between health care and social services. An identified social care lead may well assist with these difficulties and help to actively support and address older prisoners' social care needs.

5. The ambiguity regarding the responsibility of social care for older prisoners requires clarification to improve integrative working.

6. An increase in face-to-face networking opportunities would improve effective integrative working between health and social care staff.

7. It would be beneficial to house older prisoners in close proximity to their planned location on release from prison to improve the co-ordination of their care.

8. Comprehensive local agreements between prisons and social services should ensure that local social services effectively co-ordinate care for all prisoners.

9. The Department of Health's recommendation23 to provide an older person with a specific health and social care assessment on entry is largely unmet. Evidence suggests that such specialised assessments are required because older prisoners have more complex health and social care needs than their younger counterparts and those of a similar age living in the community.

10. The OHSCAP is feasible, acceptable and of value to older prisoners and staff. Furthermore, it has been developed with service user input through action learning.

11. It would be beneficial for OPLs to receive training in the use of the OHSCAP and case management.

12. Release planning for older prisoners requires improvement. There was no evidence to suggest that Nacro's recommendation26 to start planning for prisoners' release from prison entry was being met. Furthermore, HMCIP's recommendations7 around involving older prisoners and health care, social care and prison staff in the release planning process were generally not adhered to, causing high levels of anxiety for older prisoners.

13. The Department of Health's recommendation23 that prisons provide pre-release courses specifically designed for older prisoners was not adhered to. Each establishment should regularly provide such courses.

Recommendations for further research

1. The effectiveness of the OHSCAP in reducing older prisoners' unmet health and social care needs should be evaluated using a randomised controlled trial design. Studies should evaluate its effectiveness at prison entry, throughout custody and on release into the community and include investigation of the longer-term outcomes of the OHSCAP.

2. Future evaluations of the OHSCAP should include a review of assessments and care plans to ascertain the precise processes involved and the quality of care plans produced.

3. Methods of effectively sharing the information obtained using the OHSCAP should be explored.

4. Appropriate social care services for older prisoners should be modelled, commissioned and evaluated to ascertain their effectiveness in appropriately caring for older prisoners.

5. The delays that older prisoners experienced in receiving their medication on entry into prison should be further investigated.

6. Future prison health research should attempt to involve all relevant groups, including older prisoners, when appropriate.

7. In-depth qualitative interviews with professionals involved in planning older prisoners' release would help to ascertain the challengers to and enablers of effective release planning for older prisoners.

8. In-depth qualitative interviews with older prisoners after they leave Probation Service-approved premises were beyond the scope of this research. Such work would help to ascertain whether or not they receive appropriate health and social care services when access to services may be reduced.

Contribution of authors

Disclaimer

This report contains transcripts of interviews conducted in the course of the research and contains language that may offend some readers.

The views expressed in this publication are those of the authors and not necessarily those of the PHR programme or the Department of Health.

Aims/Objectives

This programme of research aims to establish the efficacy of services for older people entering and leaving prison, and to explore how a targeted intervention can improve pathways to care at key transitional times.

The specific objectives of the proposed project are:

• To explore the lived experience and needs of older people entering and leaving prison;

• To describe current provision of services, including integration between health and social services, and;

• To pilot and evaluate a mechanism for identifying heath and social care needs on reception into prison, ensuring these are systematically addressed during older people's time in custody.

Background

Methods

Contribution to existing research

This project will build on the existing continuity of care literature both in prison and community environment. This group of older adults has specific and complex needs not currently addressed by existing service provision. The proposed research will directly improve the care of older people entering prison, and provide useful data on which to base future interventions.

Plan of Investigation

The overall programme will examine health and social care needs and current health and social care provision for older adults entering and leaving prison, and evaluate a model for systematic needs assessment and care planning for these groups. The project is split into four parts, taking place in a variety of sites across the prison estate in England and Wales.

Project Management

Two research assistants will be employed for the duration of the project, one of which will act as project manager and the other will concentrate on data collection. The researchers will hold monthly meetings with the Chief Investigator and bi-annual meetings with the project steering committee.

Service users/public involvement

HMP Wymott houses the largest number of older offenders in the North West and runs a club for prisoners aged 60 or over. The team has accessed this group several times to introduce, discuss, and disseminate research relevant to older prisoners. The idea for this study came from comments made by this group during discussion of a previous project.

During the cross-sectional study of the health and social needs of older prisoners (Hayes, 2008), prison staff were asked about health and social services available to older prisoners. Their views demonstrated a specific interest in meeting the needs of older prisoners and meeting published guidelines from the DoH and HM Chief Inspector of Prisons.

Part 3 of the project incorporates service user involvement. The Action-learning group convened will include prisoners as well as staff from various prison departments. Their views will therefore be taken into account during the development of the assessment tool and care pathway for older prisoners.

References

SECTION 1: NUMBER AND PROPORTION OF PRISONERS AGED 60 YEARS AND OVER

1.1 What is the name of your establishment? (If you work at more than one establishment, please complete a separate questionnaire for each)

………………………………………………………………………………………………………………………

1.2 How many prisoners are currently located in your establishment? □

1.3 How many prisoners in your establishment are aged 60 years and over? □

1.4 Of those prisoners aged 60 years and over, how many are aged between:

60–69 years □

70–79 years □

80–89 years □

90 years and above □

1.5 Of those prisoners aged 60 years and over, how many are:

Sentenced prisoners □

Convicted, un-sentenced prisoners □

Remand prisoners □

SECTION 2: DETAILS OF STAFFING LEVELS IN HEALTHCARE DEPARTMENTS

2.1 How many staff are currently employed within your primary care and in-patient services (excluding specialist mental health/in-reach workers)? □

2.2 How many staff are currently employed within your specialist mental health/in-reach team (excluding primary care and in-patient services)? □

SECTION 3: NUMBER OF HEALTHCARE STAFF TRAINED IN THE CARE OF OLDER PEOPLE

3.1 Is any training (internal or external) in the assessment and care of older people offered to staff working within your establishment (if no, please go to question 3.12)?

No = 0 Yes = 1 □

3.2 If yes, who delivers this training (e.g. healthcare staff, in-reach staff, discipline staff, external agency – please specify)?

………………………………………………………………………………………………………………………

3.3 Please describe what training is offered to staff working within your establishment regarding the assessment and care of older people (i.e. title of course, how often is it held, how long does it last etc.).

………………………………………………………………………………………………………………………

3.4 What specific topic areas does this training cover?

………………………………………………………………………………………………………………………

3.5 How many staff within your primary care and in-patient services have received training in the assessment and care of older people during the last 12 months (excluding specialist mental health/in-reach team)? □

3.6 How many staff within your specialist mental health/in-reach team have received training in the assessment and care of older people in the last 12 months (excluding primary care and in-patient services)? □

3.7 Do all your healthcare staff have the opportunity to be trained in the assessment and care of older people (if yes, please go to question 3.9)?

No = 0 Yes = 1 □

3.8 If no, who is the training available to?

………………………………………………………………………………………………………………………

3.9 Is refresher training offered for those healthcare staff trained in the assessment and care of older people (if no, please go to question 3.11)?

No = 0 Yes = 1 □

3.10 If yes, how often is this refresher training offered to healthcare staff?

………………………………………………………………………………………………………………………

3.11 Do you consider training in the assessment and care of older people to be sufficient at your establishment?

No = 0 Yes = 1 □

3.12 Please explain why you consider training in the assessment and care of older people to be/not to be sufficient at your establishment?

………………………………………………………………………………………………………………………

SECTION 4: IDENTIFIED LEAD FOR OLDER PRISONERS

4.1 Do you have a written older prisoner care policy at your establishment? If so, please enclose a copy with your questionnaire.

No = 0 Yes = 1 □

4.2 Do you have an identified lead for older prisoners within your Healthcare Department (if no, please go to question 4.9)?

No = 0 Yes = 1 □

4.3 If yes, how long has there been an identified lead for older prisoners within your Healthcare Department?

□ years and □ months.

4.4 Please explain what duties the older person lead at your establishment is responsible for.

………………………………………………………………………………………………………………………

4.5 Has the older prisoners lead received training to support them in this role (if no, please go to question 4.12)?

No = 0 Yes = 1 □

4.6 If yes, please specify what training the older prisoners lead has received and which organisation/s provided the training?

………………………………………………………………………………………………………………………

4.7 Is the older prisoner lead offered refresher training (if no, please go to question 4.12)?

No = 0 Yes = 1 □

4.8 If yes, at what time intervals? (please now go to question 4.12)

□ years and □ months.

4.9 If your Healthcare Department does not have an identified lead for older prisoners, does your establishment have any existing plans to introduce one (if no, please go to question 4.11)?

No = 0 Yes = 1 □

4.10 If yes, when will a lead for older prisoners be established?

………………………………………………………………………………………………………………………

4.11 If your establishment does not have an identified lead for older prisoners, do you consider that one is required?

No = 0 Yes = 1 □

4.12 Please explain what you consider to be the benefits of having an older prisoner lead (Please answer this question whether or not your establishment has an older prisoner lead).

………………………………………………………………………………………………………………………

4.13 Do you have a prisoner helper/buddy scheme specifically for older prisoners?

No = 0 Yes = 1 □

SECTION 5: RECEPTION PROCEDURES FOR OLDER PRISONERS

5.1 Does your establishment currently use a reception screening assessment tool specifically designed for older prisoners?

at initial reception □

following transfer into the prison □

No = 0 Yes = 1 □

5.2 If you answered yes to either of the above, how long has this older prisoner specific reception screening assessment been used at your establishment?

□ years and □ months.

5.3 If an older prisoner is transferred from another prison into your establishment, do you receive their care plan from their previous prison?

Never = 0 Rarely = 1 Sometimes = 2 Always = 3 □

5.4 Does your establishment have any specific first night arrangements for older prisoners?

No = 0 Yes = 1 □

5.5 Do you have a written protocol regarding the forwarding of older prisoners' reception screening information to healthcare? If so, please enclose it with this questionnaire.

No = 0 Yes = 1 □

SECTION 6: ACCESS TO AND ENGAGEMENT WITH LOCAL SOCIAL SERVICES DEPARTMENTS

6.1 Which local social care services does your establishment have contact with?

………………………………………………………………………………………………………………………

6.2 Do you consider there to be a coordinated approach between your Healthcare Department and social services regarding older prisoners with social care needs?

No = 0 Yes = 1 □

6.3 Please explain your response to question 6.2.

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

6.4 Is there a written protocol between your Healthcare Department and social services regarding older prisoners with social care needs? If so, please enclose it with this questionnaire.

No = 0 Yes = 1 □

6.5 Do you hold meetings with staff from social services to discuss individual case management for older prisoners (if no, please go to question 6.7)?

No = 0 Yes = 1 □

6.6 If yes, on average, how often do these meetings occur?

Annually = 1 Bi-annually = 2 Quarterly = 3 Monthly = 4 Weekly = 5 Daily = 6 □

6.7 Does your establishment experience sufficient communication from social services?

No = 0 Yes = 1 □

6.8 Please explain your response to question 6.7.

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

SECTION 7: ACCESS TO AND ENGAGEMENT WITH SPECIALIST OLDER ADULT SERVICES

7.1 Does your establishment have contact with specialist older adult organisations/services (e.g. Age Concern/Help the Aged/Age UK) (if no, please go to question 7.7)?

No = 0 Yes = 1 □

7.2 If yes, please state which specialist older adult organisations/services are available to older people at your establishment?

………………………………………………………………………………………………………………………

7.3 Please state what services these organisations provide for older prisoners at your establishment?

………………………………………………………………………………………………………………………

7.4 Do you consider there to be a coordinated approach between your Healthcare Department and these specialist older adult organisations/services?

No = 0 Yes = 1 □

7.5 Please explain your response to question 7.4.

……………………………………………………………………………………..…………………………………

7.6 Do you have an Age Concern Coordinator working in your establishment?

No = 0 Yes = 1 □

7.7 If your establishment does not have contact with any specialist older adult organisations/services, do you consider that contact is needed (if no, please go to question 8.1)?

No = 0 Yes = 1 □

7.8 If yes, please state which specialist older adult services would be useful to older people at your establishment AND why.

………………………………………………………………………………………………………………………

SECTION 8: DETAILS OF CHRONIC DISEASE OR OLDER ADULT CLINICS

8.1 Does your establishment offer a chronic disease clinic (if no, please go to question 8.5)?

No = 0 Yes = 1 □

8.2 If yes, please specify what services the chronic disease clinic offers?

………………………………………………………………………………………………………………………

8.3 How often is the chronic disease clinic run at your establishment?

………………………………………………………………………………………………………………………

8.4 How long has the chronic disease clinic been running at your establishment?

………………………………………………………………………………………………………………………

8.5 If your establishment does not have a chronic disease clinic, do you think one is needed?

No = 0 Yes = 1 □

8.6 Does your establishment offer an older adult clinic (if no, please go to question 8.10)?

No = 0 Yes = 1 □

8.7 If yes, please specify what services the older adult clinic offers?

………………………………………………………………………………………………………………………

8.8 How often is the older adult clinic run at your establishment?

………………………………………………………………………………………………………………………

8.9 How long has the older adult clinic been running at your establishment?

………………………………………………………………………………………………………………………

8.10 If your establishment does not have an older adult clinic, do you think one is needed?

No = 0 Yes = 1 □

SECTION 9: DETAILS OF ACTIVITIES AVAILABLE FOR OLDER PRISONERS WITH MOBILITY PROBLEMS

9.1 Does your establishment provide any activities designed specifically for and accessed only by older prisoners (if no, please go to question 9.3)

No = 0 Yes = 1 □

9.2 If yes, please specify what activities are provided?

………………………………………………………………………………………………………………………

9.3 Does your establishment provide any activities specifically for older prisoners with mobility problems (if no, please go to question 9.5)?

No = 0 Yes = 1 □

9.4 If yes, please specify what activities are provided?

………………………………………………………………………………………………………………………

9.5 Can older prisoners with mobility problems access the following services/activities at your establishment (if your establishment does not provide a service/activity please mark N/A)?

No = 0 Yes = 1 Not applicable = N/A

Education □

Library □

Gym □

Workshops □

Healthcare □

Canteen □

Television room □

Association areas (inside) □

Association areas (outside) □

Visiting areas □

Chaplaincy □

Exercise areas (inside) □

Exercise (outside) □

Other service/activity (please state)…………………………………………………………………………………

Other service/activity (please state)…………………………………………………………………………………

9.6 In addition, please specify WHY they are unable to access some of the above activities/services (if applicable).

………………………………………………………………………………………………………………………

9.6.1 When activities are not accessible to older prisoners with mobility problems, does your establishment offer alternatives for this group (if no, please go to question 9.9)?

No = 0 Yes = 1 □

9.7 If yes, please specify what alternatives are provided for older prisoners with mobility problems?

………………………………………………………………………………………………………………………

9.8 Are there opportunities for older prisoners with mobility problems to work (If yes, please specify what types of work opportunities are available)?

No = 0 Yes = 1 □

Please specify:

………………………………………………………………………………………………………………………

9.9 Are the mobility problems of older prisoners taken into account when work is allocated to them?

No = 0 Yes = 1 □

9.10 Are walking frames routinely provided when needed?

No = 0 Yes = 1 □

9.11 Is age taken into account when cells are allocated to prisoners?

No = 0 Yes = 1 □

9.12 Is disability taken into account when cells are allocated to prisoners?

No = 0 Yes = 1 □

9.13 Are age-suitable arrangements made when allocating beds to prisoners?

No = 0 Yes = 1 □

9.14 Is disability taken into account when beds are allocated to prisoners?

No = 0 Yes = 1 □

9.15 Is seating in association areas suitable for older prisoners with mobility problems?

No = 0 Yes = 1 □

9.16 Is seating in cells suitable for older prisoners with mobility problems?

No = 0 Yes = 1 □

9.17 Are cells which have the necessary adaptations to accommodate less mobile and disabled prisoners routinely provided when needed?

No = 0 Yes = 1 □

9.18 Are washing facilities which have the necessary adaptations to accommodate less mobile and disabled prisoners routinely provided when needed?

No = 0 Yes = 1 □

9.19 Do toilet facilities have the necessary adaptations to accommodate less mobile and disabled prisoners?

No = 0 Yes = 1 □

SECTION 10: ADDITIONAL INFORMATION

10.1 Please use this space for comments and/or additional information you feel is not covered in this questionnaire, with specific reference to any difficulties your establishment faces in the care and management of older prisoners and/or suggestions for improvements.

10.2 Please use this space to provide any feedback about the questionnaire.

Many thanks for completing this questionnaire. Please enclose the following information if applicable:

• written policy regarding older prisoners

• written protocol regarding the forwarding of older prisoners' reception screening information to healthcare

• written protocol between your Healthcare Department and social services regarding older prisoners with social care needs

Introduction

1. 1.1 Could you tell me a little bit about your role?

2. 1.2 What specific duties/involvement do you have regarding/with older offenders?

3. 1.3 Are these official or unofficial duties?

Entry into prison

1. 2.1 Who gathers information regarding older offenders?

2. 2.2 When is this information collected?

3. 2.3 What information do you receive about older offenders?

4. 2.4 Do you get the information you need? Too much information? Irrelevant information?

5. 2.5 Are there problems with obtaining information?

6. 2.6 What happens to the information gathered at the assessment/induction phase?

Joined-up working within the prison

1. 3.1 Do you have a lead for older offenders within the establishment?

2. 3.2 Is this a prison or health care member of staff, or is there one in each department?

3. 3.3 Does the lead/leads link in with other departments in the prison and with outside agencies? If so, in what ways?

4. 3.4 What inhibits/facilitates this liaison function?

5. 3.5 Is there anything that could be improved concerning this role?

6. 3.6 If no older lead present, are you aware of such a role?

7. 3.7 Do you think there is a need to have such a role?

8. 3.8 In what ways do you and your colleagues work with other departments to support older offenders?

9. 3.9 What facilitates this joined-up working?

10. 3.10 What blocks such work?

11. 3.11 How could this be improved?

Communication/information sharing

1. 4.1 How do you share information between departments within the prison? Make referrals? Seek advice? Written means, informal meetings?

2. 4.2 How appropriate are these systems of communication? How could they be improved? Quantity of information received?

Internal staff working with external agencies

1. 5.1 What services do you link up with to support older offenders?

2. 5.2 What services do you think need to be involved with older offenders?

3. 5.3 What assists joined-up working?

4. 5.4 What are the barriers to joined-up working?

5. 5.5 What aspects of joined-up working could be improved?

6. 5.6 Are there any other services available that you think should be involved?

7. 5.7 How do you and your colleagues communicate with external agencies? To make referrals? In seeking advice?

8. 5.8 What are the problems you face working with external agencies?

9. 5.9 What would be a way of improving the communication/information gathering/referral process?

Discharge from prison/support in the community

1. 6.1 What is your role in the release of an ‘older’ offender?

2. 6.2 How far in advance does this take place?

3. 6.3 When is the offender notified about this process?

4. 6.4 How do you work with external agencies to support the release of ‘older’ offenders?

5. 6.5 What departments work with agencies to support the release of an older offender?

6. 6.6 What works well during this?

7. 6.7 How could this be improved?

8. 6.8 What communication takes place between you, your colleagues and external agencies involved in the release of ‘older’ offenders?

9. 6.9 What works well in this process?

10. 6.10 What doesn't work well in this process?

Summary

1. 7.1 What ways do you feel your establishment is successful in supporting ‘older’ offenders?

2. 7.2 How does your establishment support joined-up working between departments?

3. 7.3 How does your establishment support collaborative working with other agencies/services?

4. 7.4 What ways do you feel your establishment is successful at exchanging information?

5. 7.5 What are the barriers to appropriately supporting ‘older’ offenders?

6. 7.6 Is there anything else you would like to add about health and social care services for ‘older’ offenders at this establishment?

Before the implementation of the intervention

1. What was your role in supporting older prisoners before you became involved in this research?

2. How did you identify older prisoners before you became involved in this research?

3. What assessments were in place for older prisoners' health and social needs before this research started?

4. How were older prisoners supported before this research was started?

5. What worked well about the process for supporting older prisoners before the research started?

6. What required improvements to allow you and your colleagues to successfully support older prisoners before this research started?

After the implementation of the intervention

1. How did you identify older prisoners to participate in the assessment?

2. Can you describe how you conduct the assessments? (Where did you conduct them? Was a member of health care staff present?)

3. What were the common issues raised by older prisoners during the assessments?

4. What types of referrals were you making as a result of the intervention?

5. Is there anything you would change about the intervention?

6. How well did conducting the assessment and reviews fit into your job role?

7. How much of your time did you spend conducting the assessments and reviews?

8. How well equipped did you feel to conduct the assessment and reviews?

9. To what extent has the way you support older prisoners changed as a result of this research?

10. Is there anything else you would like to add about conducting the assessment and review process?

General information

• This assessment tool is divided into three areas: wellbeing, social care and discharge from prison. It revisits information that may already have been provided on initial reception, and identifies new information that has come to light following a few days in custody. It then explores any issues relevant to ensuring appropriate discharge from prison.

• It is to be completed 7–10 days after the prisoner has arrived in the prison.

• Ideally it will be completed by both health care and discipline staff together, jointly interviewing the prisoner. This is provided he is happy to discuss his health issues in front of the discipline officer. However, it may be more appropriate for the discipline officer to take the lead and refer to health care if necessary.

• The assessment will be reviewed at a time deemed appropriate by staff completing it, and the prisoner.

• A care plan must be completed by the staff conducting the assessment, and agreed with the prisoner. The prisoner may retain a copy of the care plan if they want to.

Social assessment

The aim of this part of the assessment is to discuss any issues with the prisoner that might be affecting his ability to settle into prison life and feel safe. The questions are divided into three sections: relationships, activities and mobility. There is space in the assessment to record discussion on any other areas that might be important to the prisoner.

Wellbeing assessment

This part of the assessment revisits the information gathered during medical reception a week earlier to see if there have been any changes, and to identify if the prisoner requires further health/wellbeing assessment following the first week of settling into custody.

Discharge from prison

This part of the assessment explores the issues that require addressing prior to the prisoner being discharged from prison.

SECTION 1: SOCIAL ASSESSMENT

SECTION 2: WELLBEING ASSESSMENT

SECTION 3: DISCHARGE FROM PRISON

Care plan

To be completed in conjunction with prisoner

Staff interview participant information sheet (see Chapter 3)

The University of Manchester

Health and Social Care Services for Older Male Adults in Prison

Staff Information Sheet

Older prisoner participant information sheet (see Chapter 4)

The University of Manchester

Health and Social Care Services for Older Male Adults in Prison

Participant Information Sheet

Older prisoner participant information sheet (see Chapter 5)

The University of Manchester

Health and Social Care Services for Older Male Adults in Prison

Participant Information Sheet

Action-learning group member (prisoner) participant information sheet (see Chapter 5)

The University of Manchester

Health and Social Care Services for Older Male Adults in Prison

Participant Information Sheet

Action-learning group member (staff) participant information sheet (see Chapter 5)

The University of Manchester

Health and Social Care Services for Older Male Adults in Prison

Staff Information Sheet

Older prisoner participant information sheet (see Chapter 6)

The University of Manchester

Health and Social Care Services for Older Male Adults in Prison

Participant Information Sheet

Staff interview consent form (see Chapter 3)

The University of Manchester

Health and Social Care Services for Older Male Adults in Prison

CONSENT FORM

Name _____________________________________________________________________________________

Research ID Number _________________ (please leave blank)

PLEASE INITIAL THE BOXES IF YOU AGREE WITH EACH SECTION:

Version 1, 14 October 2011. Part 1: staff consent form.

Older prisoner consent form (see Chapter 4)

The University of Manchester

Health and Social Care Services for Older Male Adults in Prison

CONSENT FORM

Name _____________________________________________________________________________________

Research ID Number _________________ (please leave blank)

Version 4, 2 December 2009. Part 2: older adults

Older prisoner consent form (see Chapter 5)

The University of Manchester

Health and Social Care Services for Older Male Adults in Prison

CONSENT FORM

Name _____________________________________________________________________________________

Research ID Number  _________________ (please leave blank)

Version 3, 8 June 2009. Part 3: older adults

Action-learning group member (prisoner) consent form (see Chapter 5)

The University of Manchester

Health and Social Care Services for Older Male Adults in Prison

CONSENT FORM

Name _____________________________________________________________________________________

Research ID Number _________________ (please leave blank)

Version 1, 29 September 2010. Part 3: prisoner action-learning group member

Action-learning group member (staff) consent form (see Chapter 5)

The University of Manchester

Health and Social Care Services for Older Male Adults in Prison

CONSENT FORM

Name _____________________________________________________________________________________

Research ID Number _________________ (please leave blank)

Version 1, 29 September 2010. Part 3: staff action-learning group member

Older prisoner consent form (see Chapter 6)

The University of Manchester

Health and Social Care Services for Older Male Adults in Prison

CONSENT FORM

Name _____________________________________________________________________________________

Research ID Number _________________ (please leave blank)

Version 3, 8 June 2009. Part 4: older adults