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.
Questionnaire
Development of the questionnaire
A questionnaire was designed to ascertain what health and social care services were available for older male prisoners in England and Wales and how well these services were currently integrated. A copy of the questionnaire is included in Appendix 2. The topics included in the questionnaire were drawn from the recommendations for good practice made in the Department of Health's older offender toolkit23 and HMCIP's review,7 supplemented by examination of additional key themes identified across the wider published literature base. The final version of the questionnaire examined the following areas:
details of staffing levels and training on issues related to ageing
absence/presence of an identified lead for older men
services available to older men
details of chronic disease and/or older adult clinics
details of work/activities and environmental adaptations for older men
access to, and engagement with, local social services departments and other specialist older adult services.
As part of the development process the questionnaire was piloted at 13 prisons. Findings from the pilot resulted in some minor alterations to the wording and structure of the questionnaire.
Distribution of the questionnaire
It was decided that, in the likely absence of an identified OPL in each prison, the health care manager at each establishment would be the most appropriate member of staff to complete the questionnaire, providing a consistent approach. An up-to-date list of names and contact details of all health care managers was obtained from the Offender Health Division at the Department of Health and cross-checked against records held by regional offender health leads.
A complete list of all prisons in England and Wales housing adult men (n = 97) at the time of the questionnaire distribution (October 2010) was created through HMPS sources, and questionnaires were distributed by post and email to the health care managers of all of these establishments. Sites were followed up by email 2 weeks after the initial distribution of questionnaires; by telephone after a further 2 weeks; and by letter after an additional 2 weeks for those still outstanding. If they wished, health care managers were given the option of completing the questionnaire by telephone interview with a member of research staff.
Questionnaire data analysis
Questionnaire data were entered into the Statistical Package for the Social Sciences (SPSS) version 19 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were generated from these data and analyses by prison type were conducted. Data were examined to identify whether or not there were any differences between geographical regions; none was observed and thus the data are presented here without any regional stratification.
Semistructured interviews
Semistructured interview sampling
Data from the questionnaire were used to identify prisons that reported particular successes or challenges in integrating health and social care services. A coding system was devised and responses to key questions about the integration of health and social care services were tallied. These questions identified whether or not contact with social care services occurred, by what means and how successful this contact was. Prisons that scored the highest and those that scored the lowest were identified and then approached for inclusion in the semistructured interview process.
In total, 32 staff members from the four highest-scoring and four lowest-scoring prisons, holding the following roles, were invited to participate in the semistructured interviews: health care manager, OPL, general nurse, health care assistant, offender manager, DLO, education employment and training officer, equalities/diversity officer, prison officer, social worker, social care worker, probation officer, specialist older adult worker, specialist older prisoner worker and housing worker.
Semistructured interview procedure
Staff members were approached in the first instance by the health care manager at each establishment to introduce the study and ask permission to pass their professional contact details on to the research team. A research assistant then contacted the prospective interviewees by telephone to discuss the study further. Information sheets and consent forms were sent electronically to all participants (see Appendix 11). Consent forms were signed by each participant and returned to the research assistant before interviews were conducted. All interviews were conducted between October 2011 and May 2012. Interviews were conducted over the telephone by a research assistant and recorded digitally. Interviews lasted approximately 30 minutes. Questions enquired about joined-up working, communication and information-sharing practices. At the end of the interview participants were thanked for their time and co-operation and informed of the next stages of the research and the timetable, outputs and methods of dissemination. The interview schedule is provided in Appendix 3.
Semistructured interview data analysis
Data from the interviews were transcribed verbatim and analysed using the constant comparison method.48 Constant comparison analysis is one of the most widely used qualitative methods of analysis.49 The method is rooted within the grounded theory approach developed by Glaser48 during the 1960s. Constant comparison ensures that theory stays rooted in the data,50 resulting in emerging theories developing from the data rather than already existent literature.51 It is most appropriate for studies in which little is known about the topic or a new perspective is required and was therefore highly relevant to all aspects of this study.
Constant comparison methods involve both the fragmenting and the subsequent connecting of data. Pieces of data are coded and separated from their original interview transcript. Extracts are then compared and combined with other fragments until connections are made to help the researcher understand the overall picture of what the interviewee has said.50 According to Glaser,48 there are four stages involved in the constant comparison method of analysis. For the purpose of our research these stages were followed in the context of our research questions. The first stage involved identifying provisional themes and comparing incidents that apply to such themes. The second stage involved comparisons between interviews. The third stage involved delimiting and integrating categories/concepts into themes. Overlapping categories/concepts or undefined categories/concepts were re-examined until final versions emerged. Stage four involved clarifying ideas, which leads to the formulation of a theory or multiple theories.
NVivo (version 8; QSR International, Southport, UK), a qualitative software package, was used to analyse transcripts. Such programs aid the researcher to store, sort and code qualitative data and increase the rigour of a qualitative study.49 Two researchers conducted qualitative analysis for this study and there was therefore the opportunity for one researcher to take the role of a ‘peer debriefer’. This involved periodical discussions between the researcher conducting the analysis and the peer debriefer regarding matters of methodology and analytical procedures. This provided an opportunity to test emerging themes and increases the credibility of the findings.49
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.
Questionnaire response rates
The questionnaire was distributed to the health care managers of the 97 establishments housing adult males in England and Wales. Following rigorous follow-up processes, 78 health care managers returned a questionnaire, resulting in an overall response rate of 80%. Response rate by prison type ranged between 73% and 92% (). There was no difference in response rate between public sector prisons and private finance initiative prisons.
Questionnaire response rate by prison type
Numbers of older prisoners
shows the total numbers of older prisoners across the 78 prisons and the proportion of the overall population that they constitute. Overall, older prisoners aged ≥ 60 years accounted for 4% of the population in the 78 establishments. These 78 establishments held 77% of the male prison population in June 2011. Prisons holding only sentenced prisoners had a higher proportion (5%) of older prisoners than local (3%) and open (3%) prisons. The private and public prisons had similar proportions of older prisoners.
Numbers and proportions of prisoners aged ≥ 60 years held in the 78 prisons that returned a questionnaire
A breakdown of older prisoners by specific age group and conviction status is shown in . Almost three-quarters (71%) were aged between 60 and 69 years. One-fifth (20%) of older prisoners were aged between 70 and 79 years and three (< 1%) prisoners were aged ≥ 90 years. Examination of the conviction status of older prisoners showed that the majority had been sentenced (84%) with fewer convicted but unsentenced (2%) or on remand (6%).
Age group and conviction status of older prisoners
Service availability for older prisoners
Questionnaire findings
Details of health care department staffing levels and training
The percentage of health care staff trained in the care and assessment of older prisoners within particular staff groups is shown in . Specific training in the care and assessment of older people was provided to health care staff in less than half of prisons in this sample (41%, 32).
Staff training in the care and assessment of older people
In primary care and inpatient services, 8% (135) of health care staff had received training in the care and assessment of older people. A similar proportion of staff in mental health and in-reach services (7%, 28) had received training in this area.
Comparatively, training prisons contained a higher percentage of trained staff, both in primary care and inpatient services (14%, 78) as well as in mental health and in-reach teams (15%, 22). The proportion of staff trained in open prisons was lower (2% and 0% respectively). There was a significant difference in the number of staff trained in primary care and inpatient services between private and public prisons [χ2 (1, n = 135) = 8.34, p = 0.004].
Older prisoner strategy and specific services for older prisoners
outlines the specific services available to older prisoners across prison types. Overall, of the 78 establishments, 44 (56%) had a written older prisoner care policy. Only two of the seven open prisons (29%) had such a policy compared with 19/33 local prisons (58%). The majority of prisons (81%, 63/78) had an identified OPL in their health care department. The percentage of prisons with an identified OPL was higher within local prisons (88%, 29/33) than in open prisons (71%, 5/7). However, of the 63 designated OPLs, only 28/78 (36%) had received any specific training to support them in their role. In establishments where there was no identified OPL, 64% (n = 9) of health care managers stated that there was an intention to introduce one.
Older prisoner strategy and services available for older prisoners
A prisoner helper/buddy/peer support scheme was most commonly found in training prisons, although they were not available in the majority of such establishments (45%, 17/38). None of the private prisons had an older prisoner helper/buddy scheme. The majority of prisons had a chronic disease clinic (89%, 69/78) but just over half operated a specific older adult clinic (53%, 41/78).
Specific activities for older prisoners
Just over half of the establishments (55%, 43/78) provided one or more activities specifically for, and accessed only by, older prisoners. Within these 43 establishments such services included social groups (26%, 11/43), gym and exercise sessions (42%, 18/43) and in-cell work (2%, 1/43). Activities specifically for older prisoners with mobility problems were provided by 33% (26/78) of prisons. Health care managers were asked what type of factors affected access to certain activities/areas for prisoners with mobility problems. Of those who responded, 64% (14/22) reported that there was a lack of lifts/ramps available where access to activities required prisoners to use stairs and 14% (3/22) stated that door dimensions were not large enough for wheelchairs. Where this was the case, two-thirds of respondents noted that no alternative activities were provided for those negatively affected.
The integration of health and social care services for older prisoners
Questionnaire findings
Over half of establishments (64%, 50/78) reported having some form of contact with external social care services. However, only 31% (24/78) of health care managers stated that there was a co-ordinated approach between their health care department and local social services, with only 15% (12/78) holding meetings to discuss older prisoner cases. Only 51% (40/78) had contact with other types of specialist older adult organisations ().
Integration between health, social care services and specialist older adult services
Semistructured interview findings
Thirty-two interviews were conducted to investigate levels of integration between prison, prison health care and social care services staff. The overall aim of the interviews was to provide supplementary in-depth information to add context to the questionnaire findings, in particular to identify specific barriers to and facilitators of the integration of prison and community-based health and social care services.
Three overarching themes were identified and explored during the analysis. Themes and subthemes are shown in .
Main themes and subthemes regarding integration between health and social care services
Theme 1: responsibility and accountability
Ambiguity
A prominent theme that emerged during interviews was the ambiguity that staff felt around who, or which disciplines/agencies, was properly responsible for providing social care to prisoners.
Problems around the integration of prison and community-based services was a recurring theme and integration was felt, in the majority of cases, to be non-existent. Even when they existed, relationships between prisons and social services were generally considered to be strained. One interviewee described how prison staff often considered the social care of older prisoners to be the responsibility of other prisoners rather than staff and therefore other prisoners would be left to assist older prisoners with their social care needs without adequate training to undertake such tasks:
‘Oh you [social care worker] shouldn’t have to do that [change incontinence pads]. Just leave . . . we’ll get the prisoners to do that.’ But it was giving our knowledge and expertise over to the prisoners to deal with the situations that they were dealing with in a safe manner, because they [other prisoners] were dealing with incontinence, and not dealing with it properly. So the spread of infection could have been quite high. So passing that knowledge over to them [other prisoners] from our point of view, we thought was quite . . . you know, it needed to be beneficial for them, because they [prisoners] were very much left by the prison officers [to care for older prisoners].
Social care worker, p1:32
Ambiguity over responsibility for social care was also evident among staff working within the prisons:
Because there is a social care aspect to some of it [care of older prisoners] there’s ambiguity over where that falls and who is responsible for delivering that. There is the belief by, I think a cultural belief, that older people, if they have a social care need or maybe need help with getting dressed or washed, that that should fall to health care because prison staff aren’t here to do that.
Health care manager, p1.9
Budget constraints
Funding restrictions, in particular depleted local authority and social care service budgets, reportedly led to services not taking accountability for older prisoners' health and social care. This was reported by many interviewees as a major issue facing the sector as a whole:
Unfortunately, social services won’t get involved in prisons, because they say they don’t have the budget for it. And we’ve tried, even in cases where we’ve had people terminally ill, it’s been very difficult to get social services involved. We’ve had a chap who’s got quite . . . he’s quite disabled, mobility wise, and we had to pay for the assessment of that patient ourselves, whereas in the community he wouldn’t have to do that.
Health care manager, p1.23
Geographical limitations
Geographical limitations were highlighted as a significant barrier to effective integrative working. Many prisoners, particularly those serving long sentences, do not reside in prisons in their home area. Additionally, people are often routinely transferred between a number of establishments during their sentence and ongoing care from outside or prison-based agencies is often not considered to be a sufficient priority to keep an older person in one particular establishment. This can create tension between the prison and local social care services. A social worker in the mental health in-reach team illustrated this by detailing an experience of contacting a local authority on behalf of a prisoner, outside of the area in which his current prison was situated. He described a laborious process of trying to get staff in the person's home local authority area to accept that the prisoner was originally from their area. The local authority instead stated that the prisoner should be released to the area in which the prison was located, an area in which the prisoner had no home or family ties to help with successful community reintegration:
But certainly the local authority weren’t fully accepting of that individual and say, ‘yes this man’s from [our area] and therefore he can come back to us’.
Social worker, p1.31
One interviewee described a perverse situation whereby only by seemingly creating or allowing social care needs to arise through deliberate inaction could a prisoner be helped by social services:
[What the local authority says] He’s not a resident in our area – even though he may have been, it doesn’t matter. The usual thing – I’ve come across this several times when I visit [prison name]. The [local] authorities tend to say, okay, well, he’s in a residence already, he’s in prison. When he’s released and he’s homeless then we have a responsibility to pick him up. So they have to make themselves homeless before the local authority will respond.
Older prisoner organisation worker, p1.22
Theme 2: information sharing
Confidentiality of health care information
Within the prison environment, as in the community, health care records are maintained in confidence; thus, information contained therein is not routinely shared with non-health care staff. With regard to meeting the social care needs of older men, this situation can have many repercussions, given that prisoners routinely live on residential wings under the day-to-day care of prison officers. Health care records can contain a wealth of information that would make the day-to-day support of older prisoners easier for prison discipline staff to manage, for example issues around incontinence management, mobility difficulties and maintaining personal and environmental cleanliness. Such information was generally not imparted to prison staff, and discipline staff in particular noted this as problematic:
Yes, giving information about people’s particular social needs, a lot of nursing staff will not give that information out because of medical confidence.
DLO, p1.4
A lack of adequate information sharing and effective integration was attributed to assessment and IT systems not being linked:
It’s integrating the assessment process but, at the moment, the IT systems just don’t talk.
Older prisoner organisation worker, p1.22
Focus on risk
According to staff, information sharing was primarily focused on risk and public protection rather than the health and social care information needed to support individuals. Interviewees explained that appropriate links and communications were made when liaising with agencies involved in managing risk, for example the police and probation services; however, sharing around care issued was not considered to be of the same importance or as valuable an activity. It was evident that information-sharing practices were possible to develop and operate; however, to make progress integrating health and social care services to improve the meeting of individuals' needs, a greater importance needed to be placed on routine practices rather than on only higher-level risk-based information-sharing practices:
It’s not the health they look at, they look at the risks, it’s risk focused.
Older prisoner organisation worker, p1.22
We’re well aware, particularly in my department, of the need to protect the public. So we will always information share and contact the appropriate people.
Offender manager, p1.20
Theme 3: working practices
Staff were fully aware that the professional styles and attributes of individual staff directly affected how well staff worked together across professional and prison/community boundaries. Staff who adopted positive attitudes and proactively nurtured working relationships created an environment in which different agencies operated effectively together. Conversely, negative staff attitudes severely impeded the effective integration of health and social care services. A further barrier to integration and the meeting of individual needs was noted to be the time-bound and institutional fixed routines of all prisons, which frequently curtailed imaginative work and hampered new initiatives as they became caught up in, and were rendered inoperable by, overly burdensome security procedures.
Staff attitudes and relationships
A number of staff noted that forming positive working relationships improved integrative working. It resulted in staff having the ability to approach each other in an appropriate manner when seeking assistance:
But what oils the wheels if you like is the relationships, getting to know people, getting to know who you can ask about what and, if I say knowing how to approach them that’s perhaps not quite right, but if you know somebody and you’re able to just have a chat to them and they can put a face to the name and whatever, then it does make life a lot easier if you’re just talking to folk and trying to get what you want from them.
Probation officer, p1.30
The approach that a staff member takes when meeting the needs of older prisoners was seen to be an integral part of working. One interviewee emphasised that some prison staff had a very negative attitude towards the needs of less able prisoners:
Prison officers don’t really care about things like that [social care needs]. Prison officers felt that we [social care workers] shouldn’t have been in there [the prison] caring for the person that we were caring for.
Social care worker, p1.32
Restrictive prison regime
The prison regime was described as ‘time bound’. This caused problems as staff were continuously under pressure to maintain the strict prison regime. A social worker highlighted that it remains difficult for external agencies to gain access to prison establishments because of the limited time available to access prisoners. This inhibits effective integrative working, possibly leading to inequality of care provided to those in prison in comparison with older people in the community:
As a social worker, I have to work within the constraints of the prison regime, it’s difficult for outside agencies to gain access [to prisoners].
Social worker, p1.31
A lack of face-to-face contact between prison staff and staff working for external agencies was identified as a barrier to integrative working. There were limited opportunities for staff from outside agencies to meet with prison staff as a result of the strict prison regime. Face-to-face meetings were considered an essential part of multi-agency working but were held infrequently because of the practical difficulties faced:
I guess, the difficulty, again, that I’ve found is, you can make good links, with people, on the phone, but, ideally, it’s so much more effective, if you can go out and introduce yourself, to people, and they get to know a face and, you know, they put a face to a name, and vice versa.
Housing officer, p1.14
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.
