Determining the availability and integration of health and social care services for older adults in prison

Mixed methods were adopted in this part of the study, comprising a national questionnaire and semistructured interviews with a range of professional respondents. The questionnaire was distributed to health care managers at all prisons housing adult men in England and Wales (n = 97) between October 2010 and June 2011. The questionnaire aimed to ascertain current levels and integration of health and social care services. Descriptive statistics were generated from these data and analyses by prison type were conducted. Data from the questionnaires were used to identify prisons that reported particular successes or challenges in integrating health and social care services. From these prisons a total of 32 staff members undertaking a wide range of professional roles were invited to participate in semistructured interviews between November 2011 and May 2012. The interviews explored facilitators and barriers to integrative working. Data from the interviews were transcribed verbatim and analysed using the constant comparison method.

Establishing the met compared with unmet needs of older people entering prison

This part of the study included structured and semistructured interviews with prisoners on entry into prison between March 2010 and November 2011. The overall sample was a consecutive sample of 100 prisoners aged ≥ 60 years. The following structured assessments were used: the Camberwell Assessment of Need – Short Forensic Version (CANFOR-S), the Geriatric Depression Scale short form (GDS-15), the Brief Psychiatric Rating Scale and the UK minimum data set (MDS) for home resident assessment and care screening background (adapted version). In addition, an audit of health care notes was undertaken. Descriptive statistics from these data were produced. Twenty-four of these 100 participants also took part in semistructured interviews. The semistructured interviews aimed to capture older prisoners' experiences of reception into custody. Data from the qualitative interviews were transcribed and analysed using the constant comparison method.

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

This part of the study involved mixed methods including action research, documentary analysis and semistructured interviews with action-learning group members and older prisoners. An action-learning group comprising older prisoners, health care staff and prison staff 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. Through a series of action-learning groups held monthly between November 2010 and September 2011, cycles of planning, action and evaluation took place to support the development of the Older prisoner Health and Social Care Assessment and Plan (OHSCAP) and its piloting in vivo.

During the life of the action-learning group, data were collected from a number of sources to capture the activity of the group alongside the development of the OHSCAP and its evaluation. This included analysing reflective notes from each action-learning group meeting, reflective diaries, email conversations and steering group meeting minutes. In addition, semistructured interviews were held with action-learning group members (n = 5) and older prisoners who received the OHSCAP (n = 24) between May and June 2012 to ascertain their opinions on the processes involved. These data were analysed using the constant comparison method.

Exploring the health and social care needs of older male adults discharged from prison into the community

Qualitative interviews were conducted with participants approximately 4 weeks before and 4 weeks after their release from prison, between June 2010 and November 2011. Sixty-two prisoners were interviewed in prison and 45 were followed up on release (73%). The majority of the prisoners had a probation worker in the community who was contacted on release to assist with follow-up. The initial qualitative interview covered their preparation for release in terms of their health and social care needs, including appropriateness of discharge accommodation and their awareness of health and social services that might be required for their continuing care. The follow-up interview focused on how well plans for release were put into action, and what services they accessed subsequent to release. Prisoners were also asked about contacts they had had with health and social services and about any health and social care problems or suicidal thoughts they had had since discharge. In line with the other parts of this study, qualitative analyses were conducted using the constant comparative method.

Determining the availability and integration of health and social care services for older adults in prison

In this cross-sectional national survey, an 80% response rate was achieved. Only 56% of the establishments had a written older prisoner policy while 80% of prisons had a designated lead for older prisoners; however, only a minority of these staff had received any specialist training to undertake their role. Furthermore, only 33% of health care managers believed that there was a co-ordinated approach between health care and social care services.

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. 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.

Establishing the met compared with unmet needs of older people entering prison

Results from the CANFOR-S showed that the highest proportions of unmet need 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 data found that 31% of this sample had a score indicative of mild depression and 23% a score indicating severe depression. Eight (17%) of those showing signs of depression were receiving antidepressant medication and five (12%) had contact with a mental health nurse during their initial 4 weeks of custody.

Semistructured interviews conducted during the initial period of prison custody highlighted that older prisoners entering prison for the first time often suffered from ‘entry shock’, which was made worse by a lack of information and an unfamiliarity with prison regimes and expectations. Delays in accessing health care and receiving medication were a particular cause of concern. In the main, personal care needs were reported as not having been met appropriately. Furthermore, older prisoners considered prison facilities to be largely inadequate for their physical and vocational needs.

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

Overall, the content of and the process of delivering the OHSCAP was perceived by both staff and prisoners to be appropriate, beneficial and feasible. 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 appeared 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 in order to facilitate action learning in prison. 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.

Exploring the health and social care needs of older male adults discharged from prison into the community

Before discharge from prison, older prisoners were often extremely anxious because of a lack of timely information about their future accommodation. Once they were released, their anxiety levels generally reduced substantially. However, those residing in Probation Service-approved premises considered themselves to still be in a transitional period, not yet fully integrated into the community.

Planning for release was perceived to be inadequate by older prisoners, causing high levels of anxiety. 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 general practitioner.

Implications for the management of policy and practice

The evidence from the current study suggests that:

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 role. Each prison should identify an OPL within their health care department to 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 recommendation 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 recommendation 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 care 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 recommendation for providing an older person-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 the National Association for the Care and Resettlement of Offenders' recommendation to start planning for prisoners' release from prison entry was being met. Furthermore, Her Majesty's Chief Inspectorate of Prisons' recommendations 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 recommendation 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.
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 through 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, where appropriate.
7. In-depth qualitative interviews with professionals involved in planning the release of older prisoners 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 these prisoners receive appropriate health and social care services when access to services may be reduced.