Social Care in Prison: Emerging Practice Arrangements Consequent upon the Introduction of the 2014 Care Act

Social Care in Prison: Emerging Practice Arrangements Consequent upon the Introduction of the... Abstract Despite an obvious and growing need, there has historically been scant provision of social care and social work in prisons. Thus, although the 2014 Care Act gave local authorities in England responsibility for identifying, assessing and meeting adult prisoners’ social care needs, little was known about the number of prisoners eligible for support, the extent of their needs or how best to meet them. Against this background, this paper reports the findings of two national surveys of local authority managers undertaken in 2016 which found that upwards of 1,800 prisoners with social care needs were identified in the first year, of whom almost 1,600 received an assessment and approaching 800 were deemed eligible for the provision of care and support. Whilst specialist social care staff (primarily social workers) were widely engaged in prisoner assessments, many local authorities had delegated their responsibility for identifying prisoners with social care needs to prison health care staff, and there was considerable variation in the way that social care and support were delivered. A number of implications for social work practice and research were identified, including a need for greater active case finding and further evaluation of the impact of the emerging arrangements on prisoners’ outcomes. Prisons, prisoners and families, adult offenders, local authorities, social care services, social care, social care staff Introduction Following the introduction of the Care Act in April 2015, local authorities in England have a newly defined responsibility for the social care of prisoners, both whilst in custody and on release. In particular, those local authorities that have prisons within their boundaries are responsible for identifying and assessing inmates with social care needs and, where these meet the new national eligibility criteria, for providing appropriate support. Older prisoners are expected to make up the majority of eligible inmates. However, the number of prisoners eligible for support is currently uncertain, and little is known about the range of their needs or how best to meet them. Against this background, this paper presents the findings from two national surveys of local authorities which were designed to identify the extent of demand experienced by local authorities and the early care arrangements that have been put in place to deliver the reforms. Background In light of growth in the total prison population, the rising number of older prisoners and longer prison sentences, the level of social care needs in prisons is increasing (Parker et al., 2007). Mirroring global trends, the total prison population in England and Wales has risen considerably in recent decades, with a 92 per cent increase since 1993, representing more than 41,000 people. Indeed, England and Wales have the highest imprisonment rate in Western Europe, locking up 146 people per 100,000 of the population (Berman and Dar, 2013; MoJ, 2015; Walmsley, 2015; MoJ et al., 2016; International Centre for Prison Studies, 2017). Older prisoners (commonly defined as fifty and over) are the fastest growing subgroup. Between 2004 and 2015, the number of sentenced older prisoners more than doubled to nearly 12,000, whilst the number over sixty rose still faster (Omolade, 2014; MoJ, 2016). Demographic ageing accounts for some of this increase (Omolade, 2014). However, tougher sentencing policy has also played a part, as have improvements in forensic science techniques, leading to a surge in retrospective prosecutions for serious crimes (Moll, 2013; Omolade, 2014). Prisoners serving determinate sentences of four or more years now account for more than a third of the prison population, and inmates serving indeterminate or life sentences make up about a sixth (Berman and Dar, 2013; MoJ, 2013; Omolade, 2014). Research indicates that, in association with a poor history of engagement with/access to health care services, a combination of poverty, diet, smoking and substance misuse accelerates the ageing process in the prisoner population (Anno et al., 2004) and it is often suggested that older prisoners possess a physiological age ten years in excess of their chronological age (NACRO, 2009; Omolade, 2014). A number of chronic conditions, including arthritis, hypertension and diabetes (as well as mental illness and substance misuse disorders), are therefore overrepresented in this population (HoC Justice Committee, 2013; Senior et al., 2013; Charles, 2015). Moreover, not only are older prisoners disproportionately likely to suffer from these problems when they enter prison; prisons themselves are high-risk environments for their development (Møller et al., 2007), whilst the psychological stress of prison life can also accelerate the ageing process and have detrimental effects on well-being (Anno et al., 2004; Sterns et al., 2008). Older prisoners are thus a particularly vulnerable group. Studies suggest that around one in eight has difficulty mobilising, over a third have a functional need with activities of daily living (ADLs) and more than half have a diagnosable psychiatric condition (Hayes et al., 2010, 2013; HoC Justice Committee, 2013). Despite this picture of complex needs, a series of reports in recent years have found the quality of social care in prisons to be, at best, variable and, at worst, non-existent (HMiP, 2004, 2008, 2009; Parker et al., 2007; Cooney and Braggins, 2010; Anderson and Cairns, 2011; Senior et al., 2013). In one 2011 survey of prison governors, for example, more than a third of respondents described the provision of social care as below average or poor (Pitt, 2011) and the literature contains many examples of a marked lack of support, including a deplorable absence of basic personal social care. Historically, this situation has been in part attributed to considerable confusion as to whether or which local authorities were responsible for assessing and meeting prisoners’ social care needs, with consequent low levels of engagement (Department of Health, 2014a). A 2004 report found local authorities were extremely reluctant to carry out assessments of older prisoners, still less to offer support (HMiP, 2004), whilst, as recently as 2014, local authority social work staff were engaged in assessing/meeting prisoners’ needs in just a quarter of establishments, and fewer than 7 per cent had dedicated social care workers (Local Government Association (LGA) and NOMS, 2014). In their absence, prison health care staff were the most common providers of personal care, whilst, despite long-standing concerns about their levels of competence and training, the majority of hours of personal care were delivered by other prisoners (LGA and NOMS, 2014). It is hence perhaps unsurprising that as many as half of older prisoners with personal care needs considered these unmet (Hayes et al., 2010). Indeed, it is generally recognised that very few prisoners were being properly assessed or effectively assisted, and that the provision of social care in prison fell well short of that available in the community, with potential negative consequences for prisoners’ day-to-day functioning, health, well-being, rehabilitation and risk of re-offence (Parker et al., 2007; Department of Health, 2014b). The introduction of the 2014 Care Act was thus widely welcomed. This legislation was designed to reform how social care services were delivered in England and placed a number of new duties upon local authorities, including a historic change in their responsibility for adult prisoners. From 1 April 2015, the local authority in whose area a prison is located has been responsible for identifying and assessing prisoners with social care needs, regardless of the geographical area they come from or where they will live on release. This includes inmates’ need for help with ADLs, and care that supports health and well-being (e.g. access to work or training). In addition, where prisoners’ needs meet the new national eligibility criteria for publicly funded care (SCiE, 2015), the authority must commission appropriate support and, where their needs do not meet the eligibility criteria, they should look at how their general well-being could be improved with a view to preventing, delaying or reducing deterioration. Whilst all local authorities are responsible for the social care provision of offenders who come into their area on release, this new legislation thus has particularly significant implications for the fifty-nine local authorities in England with prisons within their boundaries. A national audit of local authorities in January 2015 found most were fairly or very confident of delivering the wider Care Act reforms (LGA and Association of Directors of Adult Social Services (ADASS), 2015). Nevertheless, the extent of likely demand from prisoners was unclear, and service planning was difficult. Estimates suggested authorities would receive an average of seventy-nine referrals for assessment in the first year. However, concern was expressed about the accuracy of these data. Whilst older prisoners were expected to make up the majority of eligible inmates, it was recognised that a number of younger prisoners with mental health problems, physical or learning disabilities, autistic spectrum disorders or long-term health conditions may also be eligible for support (LGA and NOMS, 2014; LGA and ADASS, 2015; Skills for Care et al., 2015). Moreover, little was known about how best to meet prisoners’ social care needs and, although the Care Act and associated guidance set out the minimum expectation of service from local authorities, the way in which this should be delivered was left to individual authorities’ discretion. This included the nature and extent of any social work involvement. Against this background, this paper reports the findings of two national surveys which sought to capture local authorities’ early experience of providing social care and support for prisoners. In particular, it explores the initial arrangements local authorities had in place to: identify prisoners in custody who may be in need of care and support; assess these prisoners’ needs; and deliver care and support to prisoners with eligible needs.In so doing, it seeks to provide evidence that will assist local authorities implement the reforms in an efficient manner, facilitating the development of better social care services for prisoners in custody. A separate paper will address the arrangements for prisoners upon release. Methods This paper employs data from two national surveys of local authorities in England. The sixth Care Act stocktake (Stocktake 6) In order to monitor local authorities’ readiness for, and implementation of, the Care Act, the LGA and the ADASS undertook a series of ‘stocktakes’ between June 2014 and June 2016. The sixth and final online survey was emailed to the Directors of Adult Social Services in all local authorities in England. Reminders were sent to non-responding councils, and data collection closed in July 2016. The survey covered all aspects of the Care Act. Quantitative items relating to prison activity included the number of: new requests for support; prisoners assessed; and prisoners assessed who were eligible for care and support. The Social Care in Prison Survey (SCiP) A short bespoke survey of the early arrangements local authorities had put in place to meet their new responsibilities to prisoners was undertaken as part of a wider research study of social care in prisons (the SCiP study). An introductory letter was emailed to the Directors of Adult Social Services in each authority in England in December 2015 requesting that they forward this to the person in their organisation with the most local knowledge about the provision of social care for prisoners. The invite contained a link to the questionnaire on the university’s website and an attached Word version. Follow-up reminders were sent to non-respondents, and data collection closed in July 2016. The survey tool was designed to complement and build on the Care Act stocktakes and was piloted with and revised in accordance with the comments of a small number of authorities in north-west England prior to final dissemination. It contained a majority of open-ended questions, organised into three sections. The data in this paper are taken from the first section which explored how local authorities were meeting their responsibilities for prisoners in custody, including arrangements to: identify prisoners with social care needs (case finding); deliver assessments; develop care and support plans; and procure/provide services. Data analysis Responses from both surveys were analysed by PSSRU staff with input from ADASS colleagues. The presented analysis relates only to those local authorities that had prisons within their boundaries. Numerical and pre-coded data were analysed using SPSS for Windows version 19.0. Analysis comprised a descriptive account of the data, plus measures of variability (coefficients of variation) within comparator groups of prisons identified by the Ministry of Justice (2014). An inductive approach was used to summarise the free text data. This was an iterative process whereby the research team identified commonalities and differences in the responses through the process of coding, recoding and categorising the data into analytically meaningful categories (Bradley et al., 2007). Exemplar quotes were identified to illustrate each category. Ethics Ethical permission was not required for the Care Act stocktakes, which constituted a form of audit. Ethical permission for the wider SCiP study was received from a National Research Ethics Committee (ref. 14/NW/1425) and additional research governance procedures required by some individual authorities were complied with. The study was approved by ADASS (ref. RG15-019) and supported by the ADASS Care and Justice Network. Findings Sample characteristics The Stocktake 6 and SCiP surveys were completed by 100 per cent and 81 per cent of the fifty-nine local authorities containing prisons, respectively. Comparison of respondents and non-respondents to the SCiP survey identified no significant response bias with respect to geographical spread or the number and type of prisons authorities contained. Identifying prisoners with social care needs Data from Stocktake 6 indicated that, across all local authorities, there were 1,835 requests for support for prisoners in the first year (see the second column of Table 1). Eleven authorities had received five or fewer referrals, whilst twelve authorities received fifty or more, with four exceeding 100 and the highest receiving 218. In comparing activity across authorities, much will depend on the number, size and function of the individual prisons within local authority catchment areas. For example, prisons with a high proportion of younger prisoners might be expected to generate a lower level of demand for social care than those with a high proportion of older/vulnerable prisoners. Nevertheless, comparison of referral rates within comparator groups of prisons found high levels of variation in over 40 per cent of these. Table 1. Social care for prisoners in custody: local authorities’ activity levels in the financial year 2015/16   Number of new requests for support  Number of prisoners who were assessed for care and support in 2015/16  Number of prisoners who were assessed for care and support who met the eligibility threshold  Total  1,835  1,593  790  Range  0–218  0–195  0–141  Mean  33  29  15    Number of new requests for support  Number of prisoners who were assessed for care and support in 2015/16  Number of prisoners who were assessed for care and support who met the eligibility threshold  Total  1,835  1,593  790  Range  0–218  0–195  0–141  Mean  33  29  15  Table 1. Social care for prisoners in custody: local authorities’ activity levels in the financial year 2015/16   Number of new requests for support  Number of prisoners who were assessed for care and support in 2015/16  Number of prisoners who were assessed for care and support who met the eligibility threshold  Total  1,835  1,593  790  Range  0–218  0–195  0–141  Mean  33  29  15    Number of new requests for support  Number of prisoners who were assessed for care and support in 2015/16  Number of prisoners who were assessed for care and support who met the eligibility threshold  Total  1,835  1,593  790  Range  0–218  0–195  0–141  Mean  33  29  15  Of the forty-eight authorities that responded to the SCiP survey, thirty-one reported the use of a screening tool to identify prisoners who may be in need of social care and support upon reception to custody, whilst two others said that they were planning to develop one. Not all respondents provided further detail. However, it appeared that most authorities had added extra questions to existing health care screens: Prisoners are identified on admission to the prison when they are seen by reception nurse. We added four social care questions to the admission assessment (Authority 33). The prison healthcare staff conduct an initial health screening tool and this has been adapted to include information from the Care Act eligibility criteria to encourage staff completing the screening tool to make a referral for a social care assessment i.e. questions include; do you have a care plan, do you need help with personal care etc. (Authority 52).Indeed, prison health care providers appeared to play the leading role in identifying prisoners with social care needs on prison entry, and there were a number of instances where authorities had formally commissioned the local health care provider to fulfil this responsibility under the Care Act. Over and above this, approaching half of respondents described attempts to identify existing prisoners with social care needs through routine interactions with prison or health care staff: Existing prisoners are identified by … the mental health team at assessment, health staff via health appointments, prison wing officers through observation, and other agencies (Authority 43). Following on from the first night screen we have a referral process … that allows any member of staff … to refer [a] prisoner … if they feel they need assistance. This can be done at any time during their sentence (Authority 110).However, a small number of authorities also identified multidisciplinary team meetings and reviews as a fruitful means of eliciting potential referrals, whilst one reported a systematic attempt (by the prison health care provider) to screen all existing prisoners, and another had employed a dedicated health care assistant whose remit included identifying current prisoners with a change in need. In addition to the above, several authorities (n = 19) described prisoner self-referral schemes, whilst six detailed arrangements for prisoner buddies or mentors to make referrals, and another had plans to train prisoners on the Prisoners Information Desk so that they could raise awareness of social care needs amongst prisoners. Indeed, it was clear that authorities had undertaken a lot of activity to raise the awareness of social care needs: In order to identify prisoners who may have eligible care and support needs, social care staff have provided training for the prison officers, healthcare staff and the prison mentors. Advocacy training has also been provided for the mentors and health care staff. Promotional material has been provided to the prison to advise of possible social care services (Authority 114). The responsibility to identify prisoners in X is multi-agency. To raise awareness of this responsibility … all key agencies were consulted on the design of the new process and services that have subsequently been developed. Formal training was provided to Prison Officers, healthcare staff, chaplaincy, Probation staff, Advocacy worker, domiciliary care provider and targeted staff in Adult Social Care. An e-learning module has been produced for new staff and refresher training to meet ongoing training needs (Authority 146). Assessing prisoners with social care needs Data from Stocktake 6 indicated that, across all local authorities, 1,593 prisoners had had their care and support needs assessed in the first year (see the third column of Table 1). This represented 86.8 per cent of prisoners referred. Whilst some referrals were not considered in need of a full assessment, other reasons for not completing an assessment included the transfer of prisoners to other authorities before assessments could be arranged, prisoners declining assessment and death. As with the referral numbers, both the absolute number of assessments and the proportion of referrals that translated into assessments varied between authorities: seventeen authorities undertook five or fewer assessments and ten undertook fifty or more, with three exceeding 100 and the highest 195, whilst the proportion of referrals that translated into assessment ranged from zero to 100 per cent. Again, this diversity could not fully be explained by the size and function of their respective prisons, with high levels of variation found in almost half the aforementioned prison subgroups. Whereas the identification of prisoners with social care needs was largely undertaken by health care staff, the SCiP survey suggested that the assessment of prisoners was almost always undertaken by specialist social care staff, most commonly social workers, who were reported to be engaged in this activity in all bar four authorities. That said, occupational therapists were also reported to undertake (specialist functional and/or full overview) assessments in many authorities (n = 25), and three respondents said that occupational therapists undertook most or all assessments. Seven authorities referred to the participation of sensory impairment team staff. Just a handful of authorities appeared to have delegated their assessment responsibilities to other agencies. In one authority, prison-based health care employees undertook the assessments, which were then ‘sent on to the social work team manager at the LA for consideration and eligibility determination’ (Authority 23), whilst, in another, assessments were completed by dedicated (prison-based) staff employed by a third-sector agency. Still another noted that, although they had commissioned the health care provider to undertake assessments on their behalf, ‘to date we have not asked them to do this because they do not have the confidence or skills to do so’. Social care staff were thus ‘working alongside them to support their learning’ (Authority 48). In the vast majority of cases, assessments were undertaken in response to specific referrals and utilised the same assessment schedules as were used in the community. However, staff from at least one authority ran regular prison clinics, whilst another had adapted their standard FACE assessment to meet the specific needs of prisoners. The total number of staff undertaking assessments in any individual authority appeared small, with one to four personnel typical, and a range of organisational arrangements were emerging. As noted, not all assessors were employed by local authorities. Furthermore, although most assessors were based in community locality and (less frequently) contact teams, in a few instances, they were based in prisons. Similarly, whilst some staff worked exclusively with prisoners, many combined this role with other responsibilities: We have a virtual prisons team drawn from a number of social work teams (Authority 72). We have 4 social workers and 1 OT who have been cleared to enter prisons to carry out the assessments. The staff are from our contact front door and locality social work teams (Authority 54). The assessment of prisoners with social care needs is carried out by social work staff employed by [private prison provider] using the Council’s care and support assessment. A point of contact at the Council’s Social Care Direct has been established for [private prison provider] social work staff to obtain advice and support. Specialist assessments in relation to occupational therapy or sensory support are carried out by the Council’s own staff (Authority 36). The assessments are mostly carried out by an Occupational Therapist based within the Prison Healthcare team (funded by X council). If a prisoner requires a funded social care package to meet their eligible needs then there would be further assessment by a social worker in our community team to look at the personal budget required to meet eligible needs (Authority 146). Providing care and support to prisoners with eligible care and support needs Data from Stocktake 6 indicated that, of the 1,593 prisoners who had their care and support needs assessed in the first year, 790 (49.6 per cent) had eligible care and support needs (see the fourth column of Table 1). However, once more, there was considerable variation between authorities. For example, thirty-two authorities had assessed five or fewer prisoners as eligible for care and support, and eight had not assessed any as eligible. In contrast, three authorities had assessed fifty or more prisoners as eligible, with the highest being 141. Further, considerable differences were again seen in the proportion of assessed prisoners deemed eligible for care and support, ranging from zero to 100 per cent. In terms of the delivery of social care and support, care plans were typically being formulated in conjunction with prisoners and other key players (albeit scant reference was made to the involvement of family): Where a prisoner meets the eligibility criteria for adult social care and support a plan will be developed as it would be in a community setting. Key personnel will be involved in the development and management of the care and support plan—this will involve the prisoner (Authority 14). The support plan is a collaboration between the social worker, Occupational Therapist, prisoner and people involved with the prisoner’s wellbeing inside the prison such as a mental health nurse and the wing Governor. Prison staff and healthcare staff are always involved but the role of the person changes according to individual service user needs. As in the community the prisoner is fully involved in the support plan, they have multiple opportunities to input into how they would like to be supported (Authority 55).However, it was stressed that the presence of eligible needs did not necessarily mean a prisoner would be offered commissioned services. Several authorities noted that prisoners’ needs were often already being met by the prison regime, or could be met by other services, and sixteen authorities described arrangements for prisoner buddies/orderlies to meet prisoners’ non-intimate personal care needs, with the increased flexibility such schemes offered seen as a particular strength: Many social care eligible needs are already met within the prison regime (e.g. managing nutrition, access to prison facilities). To date we have had limited unmet needs for which we have needed to provide services (Authority 23). To date prisoners’ eligible needs have been met through the provision of information and advice and specialist equipment or professional support only (Authority 146). The regime of the establishment means that choices are limited but through the help of the prison buddy system more flexibility can be offered than they previously had. For example, the buddies assist with carrying meals and this means service users have more choice over when and where they eat (Authority 55).With regard to the delivery of commissioned care and support (which, as expected, focused on prisoners’ personal care and safety), twenty-eight authorities identified prison health care staff (usually health care assistants) as the main providers. This included three authorities where an independent agency had been contracted to deliver both health and social care. The benefits of health care staff undertaking this role were said to include their on-site presence 24/7, their ability to respond to changing levels of demand, and the potential for integrating health and social care: Council X have procured a service which is delivered through our current health provider … We fund the equivalent to 1 FTE HCA, this is used flexible [sic] to accommodate the transient population within the prison (Authority 43). The care provider is the same provider as the health provider ensuring continuity of care/treatment (Authority 24). Prison healthcare provide services for prisoners who have eligible social care needs—this is done by prison healthcare assistants … . External providers are not used mainly due to the ‘lock down’ process for the prison in that there is no access to anyone from the community during the night (Authority 49).However, a few authorities indicated that there were sometimes issues around the capacity of health care staff to undertake this work, and several authorities (n = 15) had rather (or also) made arrangements for local domiciliary care providers to deliver social care in prisons, through a mixture of spot and block contracts. In addition to this, one authority had contracted a social enterprise to deliver social care, another had contracted a third-sector provider and two had seconded local authority-employed support staff into prisons. There were, however, some indications this early picture might change, as a significant minority of authorities were reviewing their initial arrangements: Our current model is to deliver any dom care style services via the HCA within the prison health team. However this post is to become vacant and the prison health team wish to pass the function on. We are therefore in the process of considering our options and possibly looking at our locally commissioned dom care provider to act as the main service for delivery (Authority 46). We have a spot contract with a Local Provider to provide services for prisoners … . In addition to this provider we are also in the process of finalising a Social Care delivery contract with [independent health care provider] who are currently providing Health Care Services in X Prison (Authority 47). Eligible need met by a range of in house and X council employed Support, Time and Recovery Workers (STRs) for personal care. Explored a number of options initially including spot contract agreements (not supported by prison health commissioners or private prison) and agencies which did not work (Authority 134). Discussion This article explores the early arrangements that local authorities in England have put in place to meet their obligations to prisoners in custody under the Care Act, and reveals the extent to which specialist social care practitioners are starting to work with this very vulnerable group, drawing on a mix of quantitative and qualitative information. Whilst the former permitted direct comparison of different authorities’ activity levels, the latter befitted the investigation of the emerging practice arrangements, and the surveys’ high response rates give confidence in the findings’ representativeness. The data suggest that, in the first year alone, upwards of 1,800 prisoners were identified as having social care needs, of whom almost 1,600 received an assessment and approaching 800 were deemed eligible for care and support. However, considerable variation was found between similar prisons, which may be due to the prison, the local authority or both. The remainder of the discussion considers some of the potential implications of the findings in relation to authorities’ new responsibilities which it is envisaged will be of interest to service planners and providers across the UK. Indeed, Wales introduced a series of similar reforms in the 2014 Social Services and Well-being (Wales) Act; there are ongoing concerns about local authority social workers in Scotland’s focus on a minority of serious offenders and the lack of a national strategy (Social Work Inspection Agency, 2011; Scottish Prison Service, 2016); and the Independent Monitoring Board for Northern Ireland have recently warned that social care for prisoners in Northern Ireland is currently being ‘batted’ between the prisons and the responsible health and social care Trust amid reduced staffing levels (McHugh, 2017). Identifying prisoners with social care needs This study suggests that the majority of authorities had a process in place to identify people on entry to custody who had, or may develop, social care and support needs. Reception interviews and health assessments are clearly key opportunities to establish whether individuals have been receiving, or need, social care and support, enabling appropriate help to be offered at the earliest opportunity. However, past reports suggest that similar entry screens can fail to detect a wide range of needs, including physical disabilities, mental health problems and alcoholism (HMiP, 2009, 2010; Edgar and Rickford, 2009), and the same may well be true of social care needs. Certainly, not all prisoners will feel comfortable disclosing a need for help at this time, and others will lack insight into their condition. There is thus a need for further research on the specific tools employed, and their sensitivity. Further, whilst it may be time-efficient for health and prison care staff to take the lead in identifying prisoners with social care needs, it is also important to identify what training such staff require in order to do this effectively. One study, for example, suggested that health care problems not elicited at reception were rarely detected later (Birmingham et al., 1997), whilst another found little evidence that prison staff knew when to seek a specialist social care assessment (Parker et al., 2007). The very limited extent of active case finding identified in this research is therefore a major concern, for, although it may appear sufficient to screen on admission, prisoners may develop social care needs at any point during their imprisonment, whilst their willingness to acknowledge a need for help may also change. This in turn highlights the potential utility of self-referral processes, and it was clear that a number of authorities had these in place. However, further information is needed on the extent to which they are being used and the best way to promote them. Assessing prisoners with social care needs In contrast to the situation before the Care Act, this study found that specialist social care staff, particularly social workers, were engaged in assessing prisoners in the vast majority of authorities. Given that assessment is a core function of social work practice and the relevance of social work skills for people with complex needs (College of Social Work, 2010), this seems entirely appropriate. However, whilst assessment skills are generally considered to be transferable between practice contexts, assessing prisoners might be expected to require some additional training, and it is not clear how well practitioners had been prepared to work with this client group. Several studies of social work practitioners have found that many feel ill-equipped to assess or respond effectively to people with substance abuse problems (Galvani et al., 2014) and, although most social work training in the last century included some coverage of crime and social work in criminal justice, this has been less prevalent since 2003 (Raynor and Vanstone, 2015). It will also be important to determine whether, in terms of prisoners’ outcomes, these new roles are best incorporated into community teams’ wider casework or undertaken by specialist practitioners. Arguments for the former might include the opportunity for greater numbers of staff to develop experience with this client group, as well as the potential for continuity upon release (if within the same authority) and the promotion of equitable care with people in the community. In contrast, arguments for the latter include the development of increased knowledge of the prison and legal system, and closer working relationships with prison staff. Providing care and support to prisoners with eligible care and support needs A 2015 briefing on the social care of prisoners (Skills for Care et al., 2015) anticipated that, whilst many local authorities would commission existing prison health care providers to deliver services for prisoners with eligible care and support needs, some local authorities may choose to provide services through separate care providers or in-house resources, and it is clear this is what happened. It is likely that there are a number of different factors at play here. Although research suggests that, prior to the Care Act, prison officers often provided social care, it was generally acknowledged that they did not have the necessary training, support or capacity to undertake such activities (Lee et al., 2016). Further, it has been argued that the very culture of prison officers militated against their developing the required skills, there being a clear conflict between the objectives of care and custody (Charles, 2015). In this situation, extending the role of the health care provider may appear a straightforward option, particularly given the perception that some inmates’ social care needs were already being met in prison health care units (Lee et al., 2016), and the presence of a pool of staff in place 24/7. However, it is possible that, when resources are stretched, health care staff may prioritise their health care role over the provision of social care, whilst it could be difficult to ensure that monies for social care are always used for this purpose. That said, there are also potential problems with the employment of external domiciliary care providers, including the time taken to obtain security vetting, and the reduced flexibility (there sometimes being no or limited access to prisons in the evenings and at night), and further research is required to assess the relative advantages and disadvantages of the different options, and the extent to which the prison mix influences the choice of model. Finally, the increasing engagement of prisoners to provide social care for peers described in our study and the arrangements in place to select, risk assess, train, support and supervise them are also worthy of future examination. Although prisoners have always helped other prisoners, not least as ‘Listeners’ and tutors, the 2015 Prison Service Instructions on prisoners assisting other prisoners states that all governors must now ‘have the ability to mobilise assistance from other prisoners for a prisoner who has a care and support plan or written information from the local authority, or is awaiting a care and support needs assessment, should it be needed’ (NOMS, 2015, p. 4). Although prisoners are explicitly not permitted to provide other prisoners with ‘intimate care’, they can assist with a wide range of activities, including dressing and undressing that does not involve body areas that are usually clothed for reasons of privacy and decency (e.g. putting on socks); providing reminders to take medication/go to the toilet; and keeping cells tidy. There is, however, a potential concern that prisoners might feel they have no other option but to accept such help from other prisoners—a situation that would not be permissible in any analogous community-based institution, such as a care home. Conclusions In light of serious and ongoing concern about the provision of social care for prisoners, the Care Act clarified local authorities’ responsibilities for this previously neglected client group, and was intended to ensure that prisoners received equivalent care to people in the community, to support their rehabilitation and (it was hoped) to impact on the likelihood of their reoffending (Department of Health, 2014b). Against this background, this paper provides a unique and important insight into the initial arrangements that local authorities in England have put in place to meet their new responsibilities to prisoners in custody, and suggests that there has been a substantial step forward in the provision of social care and support for this population. Perhaps not surprisingly, given the preliminary nature of this investigation, no overarching model of best practice was identified. Rather, the data serve to highlight the extent of variation in practice, and identify some of the advantages and disadvantages of the different arrangements, providing a valuable resource for authorities seeking to support service planning and commissioning in both England and elsewhere. They also suggest a number of areas on which further research might concentrate. Acknowledgements We are grateful to all the local authority staff who took the time to complete these surveys, and in particular those that assisted in the testing and development of the SCiP questionnaire. We are also grateful to the Association of Directors of Adult Social Services Care & Justice Network for their support of this research. This article presents independent research commissioned by the National Institute for Health Research (NIHR) School for Social Care Research. The views expressed in this publication are those of the authors and not necessarily those of the NIHR School for Social Care Research or the Department of Health, NIHR or NHS. References Anderson S., Cairns C. ( 2011) The Social Care Needs of Short-Sentence Prisoners , London, Revolving Doors Agency. Anno B. J., Graham C., Lawrence J. E., Shansky R. ( 2004) Correctional Health Care: Addressing the Needs of Elderly, Chronically Ill, and Terminally Ill Inmates , Washington, DC, National Institute of Corrections. Berman G., Dar A. ( 2013) Prison Population Statistics , London, House of Commons Library. Birmingham L., Mason D., Grubin D. ( 1997) ‘ Health screening at first reception into prison’, Journal of Forensic Psychiatry , 8( 2), pp. 435– 9. Google Scholar CrossRef Search ADS   Bradley E. H., Curry L. A., Devers K. J. ( 2007) ‘ Qualitative data analysis for health services research: Developing taxonomy, themes, and theory’, Health Services Research , 42( 4), pp. 1758– 72. Google Scholar CrossRef Search ADS PubMed  Charles A. ( 2015) ‘ Current issues in prison health care’, International Anesthesiology Clinics , 53( 3), pp. 39– 52. Google Scholar CrossRef Search ADS PubMed  College of Social Work ( 2010) Roles and Functions of Social Workers in England , London, College of Social Work. PubMed PubMed  Cooney F., Braggins J. ( 2010) Doing Time: Good Practice with Older People in Prison—The Views of Prison Staff , London, Prison Reform Trust. Department of Health ( 2014a) Care and Support Statutory Guidance , London, Department of Health. Department of Health ( 2014b) Factsheet 12: The Care Act—Prisoners and People in Resident in Approved Premises , London, Department of Health. Edgar K., Rickford D. ( 2009) Too Little Too Late: An Independent Review of Unmet Mental Health Need in Prison , London, Prison Reform Trust. Galvani S., Hutchinson A., Dance C. ( 2014) ‘ Identifying and assessing substance use: Findings from a national survey of social work and social care professionals’, British Journal of Social Work , 44( 7), pp. 1895– 913. Google Scholar CrossRef Search ADS   Hayes A. J., Burns A., Shaw J. ( 2010) Health, Social and Custodial Needs of Older Men in Prison , Manchester, University of Manchester. Hayes A., Burns A., Turnbull P., Shaw J. J. ( 2013) ‘ Social and custodial needs of older adults in prison’, Age and Ageing , 42( 5), pp. 589– 93. Google Scholar CrossRef Search ADS PubMed  HM Inspectorate of Prisons (HMiP) ( 2004) No Problems—Old and Quiet: Older Prisoners in England and Wales , London, HM Inspectorate of Prisons. HM Inspectorate of Prisons (HMiP) ( 2008) Older Prisoners in England and Wales: A Follow-Up to the 2004 Thematic Review by HM Chief Inspectorate of Prisons , London, HM Inspectorate of Prisons. HM Inspectorate of Prisons (HMiP) ( 2009) Disabled Prisoners: A Short Thematic Review on the Care and Support of Prisoners with a Disability , London, HM Inspectorate of Prisons. HM Inspectorate of Prisons (HMiP) ( 2010) Alcohol Services in Prison: An Unmet Need , London, HM Inspectorate of Prisons. House of Commons (HoC) Justice Committee ( 2013) Older Prisoners: Fifth Report of Sessions 2013–14 , London, The Stationery Office Limited. International Centre for Prison Studies ( 2017) World Prison Brief Data Highest to Lowest, available online at http://www.prisonstudies.org/highest-to-lowest/prison_population_ rate?field_region_taxonomy_tid=14 (accessed 3 October 2017). Lee C., Haggith A., Mann N., Kuhn I., Cater F., Eden B., Van Bortel T. ( 2016) ‘Older prisoners and the Care Act 2014: An examination of policy, practice and models of social care delivery’, Prison Service Journal , 224, pp. 35– 41. Local Government Association (LGA) and Association of Directors of Adult Social Services (ADASS) ( 2015) Care Act Stocktake: Stocktake 3 (January 2015), available online at https://www.local.gov.uk/our-support/our-improvement-offer/care-and-health-improvement/care-and-support-reform/stocktake (accessed 11 October 2017). Local Government Association (LGA) and National Offender Management Service (NOMS) ( 2014) Social Care Needs in Prisons, available online at https://www.local.gov.uk/our-support/our-improvement-offer/care-and-health-improvement/care-and-support-reform/implementation/integration/prisons (accessed 11 October 2017). McHugh M. ( 2017) ‘Prisoners “acting as untrained carers for elderly inmates”’, The Irish Times, available online at http://www.irishnews.com/news/northernirelandnews/2017/02/07/news/prisoners-acting-as-untrained-carers-for-elderly-inmates--923358/ (accessed 11 October 2017). Ministry of Justice (MoJ) ( 2013) Story of the Prison Population: 1993–2012 England and Wales , London, Ministry of Justice. Ministry of Justice (MoJ) ( 2014) FOI Request 91109: Annex B: Guidance to the Comparator Groups Used in the Prison Rating System , London, Ministry of Justice. Ministry of Justice (MoJ) ( 2015) Offender Management Statistics Prison Population 2015 , London, Ministry of Justice. Ministry of Justice (MoJ) ( 2016) Offender Management Statistics Quarterly: October to December 2015 , London, Ministry of Justice. Ministry of Justice (MoJ), National Offender Management Service and HM Prison Service ( 2016) Prison Population Figures: 2016, available online at https://www.gov.uk/government/statistics/prison-population-figures-2016 (accessed 3 October 2017). Moll A. ( 2013) Losing Track of Time: Dementia and the Ageing Prison Population: Treatment Challenges and Examples of Good Practice , London, Mental Health Foundation. Møller L., Stöver H., Jürgens R., Gatherer A., Nikogosian H. ( 2007) Health in Prisons: A WHO Guide to the Essentials in Prison Health , Copenhagen, WHO. NACRO ( 2009) A Resource Pack for Working with Older Prisoners , London, NACRO. National Offender Management Service (NOMS) ( 2015) Prisoners Assisting Other Prisoners , London, NOMS. Omolade S. ( 2014) Analytical Summary: The Needs and Characteristics of Older Prisoners: Results From the Surveying Prisoner Crime Reduction (SPCR) Survey , London, Ministry of Justice. Parker H., McArthur M., Poxton R. ( 2007) Adult Social Care in Prisons: A Strategic Framework, Birmingham , University of Birmingham. Pitt V. ( 2011) Why Social Care in Prison Falls Short, available online at http://www.communitycare.co.uk/2011/07/29/why-social-care-in-prisons-falls-short/ (accessed 3 October 2017). Raynor P., Vanstone M. ( 2015) ‘Moving away from social work and half way back again: New research on skill in probation’, British Journal of Social Work , 46( 4), pp. 1131– 47. Google Scholar CrossRef Search ADS PubMed  Scottish Prison Service ( 2016) Annual Report and Accounts 2015–2016 , Edinburgh, Scottish Prison Service. PubMed PubMed  Senior J., Forsyth K., Walsh E., O’Hara K., Stevenson C., Hayes A., Short V., Webb R., Challis D., Fazel S., Burns A., Shaw J. ( 2013) ‘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’, Health Services and Delivery Research , 1( 5), pp. Skills for Care, National Skills Academy for Social Care and College of Occupational Therapists ( 2015) Briefing: Care and Support for People in Prisons and Approved Premises , Leeds, Skills for Care. Social Care Institute for Excellence (SCIE) ( 2015) Eligibility Determination for the Care Act 2014 , London, SCIE. Social Work Inspection Agency ( 2011) Social Work Services in Scotland’s Prisons: A National Inspection , Edinburgh, Social Work Inspection Agency. Sterns A. A., Lax G., Sed C., Keohane P., Sterns R. S. ( 2008) ‘The growing wave of older prisoners: A national survey of older prisoner health, mental health and programming’, Corrections Today , 70( 4), pp. 70– 6. Walmsley R. ( 2015) World Prison Population List , 11th edn, London, Institute for Criminal Policy Research. © The Author 2017. Published by Oxford University Press on behalf of The British Association of Social Workers. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The British Journal of Social Work Oxford University Press

Social Care in Prison: Emerging Practice Arrangements Consequent upon the Introduction of the 2014 Care Act

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Abstract

Abstract Despite an obvious and growing need, there has historically been scant provision of social care and social work in prisons. Thus, although the 2014 Care Act gave local authorities in England responsibility for identifying, assessing and meeting adult prisoners’ social care needs, little was known about the number of prisoners eligible for support, the extent of their needs or how best to meet them. Against this background, this paper reports the findings of two national surveys of local authority managers undertaken in 2016 which found that upwards of 1,800 prisoners with social care needs were identified in the first year, of whom almost 1,600 received an assessment and approaching 800 were deemed eligible for the provision of care and support. Whilst specialist social care staff (primarily social workers) were widely engaged in prisoner assessments, many local authorities had delegated their responsibility for identifying prisoners with social care needs to prison health care staff, and there was considerable variation in the way that social care and support were delivered. A number of implications for social work practice and research were identified, including a need for greater active case finding and further evaluation of the impact of the emerging arrangements on prisoners’ outcomes. Prisons, prisoners and families, adult offenders, local authorities, social care services, social care, social care staff Introduction Following the introduction of the Care Act in April 2015, local authorities in England have a newly defined responsibility for the social care of prisoners, both whilst in custody and on release. In particular, those local authorities that have prisons within their boundaries are responsible for identifying and assessing inmates with social care needs and, where these meet the new national eligibility criteria, for providing appropriate support. Older prisoners are expected to make up the majority of eligible inmates. However, the number of prisoners eligible for support is currently uncertain, and little is known about the range of their needs or how best to meet them. Against this background, this paper presents the findings from two national surveys of local authorities which were designed to identify the extent of demand experienced by local authorities and the early care arrangements that have been put in place to deliver the reforms. Background In light of growth in the total prison population, the rising number of older prisoners and longer prison sentences, the level of social care needs in prisons is increasing (Parker et al., 2007). Mirroring global trends, the total prison population in England and Wales has risen considerably in recent decades, with a 92 per cent increase since 1993, representing more than 41,000 people. Indeed, England and Wales have the highest imprisonment rate in Western Europe, locking up 146 people per 100,000 of the population (Berman and Dar, 2013; MoJ, 2015; Walmsley, 2015; MoJ et al., 2016; International Centre for Prison Studies, 2017). Older prisoners (commonly defined as fifty and over) are the fastest growing subgroup. Between 2004 and 2015, the number of sentenced older prisoners more than doubled to nearly 12,000, whilst the number over sixty rose still faster (Omolade, 2014; MoJ, 2016). Demographic ageing accounts for some of this increase (Omolade, 2014). However, tougher sentencing policy has also played a part, as have improvements in forensic science techniques, leading to a surge in retrospective prosecutions for serious crimes (Moll, 2013; Omolade, 2014). Prisoners serving determinate sentences of four or more years now account for more than a third of the prison population, and inmates serving indeterminate or life sentences make up about a sixth (Berman and Dar, 2013; MoJ, 2013; Omolade, 2014). Research indicates that, in association with a poor history of engagement with/access to health care services, a combination of poverty, diet, smoking and substance misuse accelerates the ageing process in the prisoner population (Anno et al., 2004) and it is often suggested that older prisoners possess a physiological age ten years in excess of their chronological age (NACRO, 2009; Omolade, 2014). A number of chronic conditions, including arthritis, hypertension and diabetes (as well as mental illness and substance misuse disorders), are therefore overrepresented in this population (HoC Justice Committee, 2013; Senior et al., 2013; Charles, 2015). Moreover, not only are older prisoners disproportionately likely to suffer from these problems when they enter prison; prisons themselves are high-risk environments for their development (Møller et al., 2007), whilst the psychological stress of prison life can also accelerate the ageing process and have detrimental effects on well-being (Anno et al., 2004; Sterns et al., 2008). Older prisoners are thus a particularly vulnerable group. Studies suggest that around one in eight has difficulty mobilising, over a third have a functional need with activities of daily living (ADLs) and more than half have a diagnosable psychiatric condition (Hayes et al., 2010, 2013; HoC Justice Committee, 2013). Despite this picture of complex needs, a series of reports in recent years have found the quality of social care in prisons to be, at best, variable and, at worst, non-existent (HMiP, 2004, 2008, 2009; Parker et al., 2007; Cooney and Braggins, 2010; Anderson and Cairns, 2011; Senior et al., 2013). In one 2011 survey of prison governors, for example, more than a third of respondents described the provision of social care as below average or poor (Pitt, 2011) and the literature contains many examples of a marked lack of support, including a deplorable absence of basic personal social care. Historically, this situation has been in part attributed to considerable confusion as to whether or which local authorities were responsible for assessing and meeting prisoners’ social care needs, with consequent low levels of engagement (Department of Health, 2014a). A 2004 report found local authorities were extremely reluctant to carry out assessments of older prisoners, still less to offer support (HMiP, 2004), whilst, as recently as 2014, local authority social work staff were engaged in assessing/meeting prisoners’ needs in just a quarter of establishments, and fewer than 7 per cent had dedicated social care workers (Local Government Association (LGA) and NOMS, 2014). In their absence, prison health care staff were the most common providers of personal care, whilst, despite long-standing concerns about their levels of competence and training, the majority of hours of personal care were delivered by other prisoners (LGA and NOMS, 2014). It is hence perhaps unsurprising that as many as half of older prisoners with personal care needs considered these unmet (Hayes et al., 2010). Indeed, it is generally recognised that very few prisoners were being properly assessed or effectively assisted, and that the provision of social care in prison fell well short of that available in the community, with potential negative consequences for prisoners’ day-to-day functioning, health, well-being, rehabilitation and risk of re-offence (Parker et al., 2007; Department of Health, 2014b). The introduction of the 2014 Care Act was thus widely welcomed. This legislation was designed to reform how social care services were delivered in England and placed a number of new duties upon local authorities, including a historic change in their responsibility for adult prisoners. From 1 April 2015, the local authority in whose area a prison is located has been responsible for identifying and assessing prisoners with social care needs, regardless of the geographical area they come from or where they will live on release. This includes inmates’ need for help with ADLs, and care that supports health and well-being (e.g. access to work or training). In addition, where prisoners’ needs meet the new national eligibility criteria for publicly funded care (SCiE, 2015), the authority must commission appropriate support and, where their needs do not meet the eligibility criteria, they should look at how their general well-being could be improved with a view to preventing, delaying or reducing deterioration. Whilst all local authorities are responsible for the social care provision of offenders who come into their area on release, this new legislation thus has particularly significant implications for the fifty-nine local authorities in England with prisons within their boundaries. A national audit of local authorities in January 2015 found most were fairly or very confident of delivering the wider Care Act reforms (LGA and Association of Directors of Adult Social Services (ADASS), 2015). Nevertheless, the extent of likely demand from prisoners was unclear, and service planning was difficult. Estimates suggested authorities would receive an average of seventy-nine referrals for assessment in the first year. However, concern was expressed about the accuracy of these data. Whilst older prisoners were expected to make up the majority of eligible inmates, it was recognised that a number of younger prisoners with mental health problems, physical or learning disabilities, autistic spectrum disorders or long-term health conditions may also be eligible for support (LGA and NOMS, 2014; LGA and ADASS, 2015; Skills for Care et al., 2015). Moreover, little was known about how best to meet prisoners’ social care needs and, although the Care Act and associated guidance set out the minimum expectation of service from local authorities, the way in which this should be delivered was left to individual authorities’ discretion. This included the nature and extent of any social work involvement. Against this background, this paper reports the findings of two national surveys which sought to capture local authorities’ early experience of providing social care and support for prisoners. In particular, it explores the initial arrangements local authorities had in place to: identify prisoners in custody who may be in need of care and support; assess these prisoners’ needs; and deliver care and support to prisoners with eligible needs.In so doing, it seeks to provide evidence that will assist local authorities implement the reforms in an efficient manner, facilitating the development of better social care services for prisoners in custody. A separate paper will address the arrangements for prisoners upon release. Methods This paper employs data from two national surveys of local authorities in England. The sixth Care Act stocktake (Stocktake 6) In order to monitor local authorities’ readiness for, and implementation of, the Care Act, the LGA and the ADASS undertook a series of ‘stocktakes’ between June 2014 and June 2016. The sixth and final online survey was emailed to the Directors of Adult Social Services in all local authorities in England. Reminders were sent to non-responding councils, and data collection closed in July 2016. The survey covered all aspects of the Care Act. Quantitative items relating to prison activity included the number of: new requests for support; prisoners assessed; and prisoners assessed who were eligible for care and support. The Social Care in Prison Survey (SCiP) A short bespoke survey of the early arrangements local authorities had put in place to meet their new responsibilities to prisoners was undertaken as part of a wider research study of social care in prisons (the SCiP study). An introductory letter was emailed to the Directors of Adult Social Services in each authority in England in December 2015 requesting that they forward this to the person in their organisation with the most local knowledge about the provision of social care for prisoners. The invite contained a link to the questionnaire on the university’s website and an attached Word version. Follow-up reminders were sent to non-respondents, and data collection closed in July 2016. The survey tool was designed to complement and build on the Care Act stocktakes and was piloted with and revised in accordance with the comments of a small number of authorities in north-west England prior to final dissemination. It contained a majority of open-ended questions, organised into three sections. The data in this paper are taken from the first section which explored how local authorities were meeting their responsibilities for prisoners in custody, including arrangements to: identify prisoners with social care needs (case finding); deliver assessments; develop care and support plans; and procure/provide services. Data analysis Responses from both surveys were analysed by PSSRU staff with input from ADASS colleagues. The presented analysis relates only to those local authorities that had prisons within their boundaries. Numerical and pre-coded data were analysed using SPSS for Windows version 19.0. Analysis comprised a descriptive account of the data, plus measures of variability (coefficients of variation) within comparator groups of prisons identified by the Ministry of Justice (2014). An inductive approach was used to summarise the free text data. This was an iterative process whereby the research team identified commonalities and differences in the responses through the process of coding, recoding and categorising the data into analytically meaningful categories (Bradley et al., 2007). Exemplar quotes were identified to illustrate each category. Ethics Ethical permission was not required for the Care Act stocktakes, which constituted a form of audit. Ethical permission for the wider SCiP study was received from a National Research Ethics Committee (ref. 14/NW/1425) and additional research governance procedures required by some individual authorities were complied with. The study was approved by ADASS (ref. RG15-019) and supported by the ADASS Care and Justice Network. Findings Sample characteristics The Stocktake 6 and SCiP surveys were completed by 100 per cent and 81 per cent of the fifty-nine local authorities containing prisons, respectively. Comparison of respondents and non-respondents to the SCiP survey identified no significant response bias with respect to geographical spread or the number and type of prisons authorities contained. Identifying prisoners with social care needs Data from Stocktake 6 indicated that, across all local authorities, there were 1,835 requests for support for prisoners in the first year (see the second column of Table 1). Eleven authorities had received five or fewer referrals, whilst twelve authorities received fifty or more, with four exceeding 100 and the highest receiving 218. In comparing activity across authorities, much will depend on the number, size and function of the individual prisons within local authority catchment areas. For example, prisons with a high proportion of younger prisoners might be expected to generate a lower level of demand for social care than those with a high proportion of older/vulnerable prisoners. Nevertheless, comparison of referral rates within comparator groups of prisons found high levels of variation in over 40 per cent of these. Table 1. Social care for prisoners in custody: local authorities’ activity levels in the financial year 2015/16   Number of new requests for support  Number of prisoners who were assessed for care and support in 2015/16  Number of prisoners who were assessed for care and support who met the eligibility threshold  Total  1,835  1,593  790  Range  0–218  0–195  0–141  Mean  33  29  15    Number of new requests for support  Number of prisoners who were assessed for care and support in 2015/16  Number of prisoners who were assessed for care and support who met the eligibility threshold  Total  1,835  1,593  790  Range  0–218  0–195  0–141  Mean  33  29  15  Table 1. Social care for prisoners in custody: local authorities’ activity levels in the financial year 2015/16   Number of new requests for support  Number of prisoners who were assessed for care and support in 2015/16  Number of prisoners who were assessed for care and support who met the eligibility threshold  Total  1,835  1,593  790  Range  0–218  0–195  0–141  Mean  33  29  15    Number of new requests for support  Number of prisoners who were assessed for care and support in 2015/16  Number of prisoners who were assessed for care and support who met the eligibility threshold  Total  1,835  1,593  790  Range  0–218  0–195  0–141  Mean  33  29  15  Of the forty-eight authorities that responded to the SCiP survey, thirty-one reported the use of a screening tool to identify prisoners who may be in need of social care and support upon reception to custody, whilst two others said that they were planning to develop one. Not all respondents provided further detail. However, it appeared that most authorities had added extra questions to existing health care screens: Prisoners are identified on admission to the prison when they are seen by reception nurse. We added four social care questions to the admission assessment (Authority 33). The prison healthcare staff conduct an initial health screening tool and this has been adapted to include information from the Care Act eligibility criteria to encourage staff completing the screening tool to make a referral for a social care assessment i.e. questions include; do you have a care plan, do you need help with personal care etc. (Authority 52).Indeed, prison health care providers appeared to play the leading role in identifying prisoners with social care needs on prison entry, and there were a number of instances where authorities had formally commissioned the local health care provider to fulfil this responsibility under the Care Act. Over and above this, approaching half of respondents described attempts to identify existing prisoners with social care needs through routine interactions with prison or health care staff: Existing prisoners are identified by … the mental health team at assessment, health staff via health appointments, prison wing officers through observation, and other agencies (Authority 43). Following on from the first night screen we have a referral process … that allows any member of staff … to refer [a] prisoner … if they feel they need assistance. This can be done at any time during their sentence (Authority 110).However, a small number of authorities also identified multidisciplinary team meetings and reviews as a fruitful means of eliciting potential referrals, whilst one reported a systematic attempt (by the prison health care provider) to screen all existing prisoners, and another had employed a dedicated health care assistant whose remit included identifying current prisoners with a change in need. In addition to the above, several authorities (n = 19) described prisoner self-referral schemes, whilst six detailed arrangements for prisoner buddies or mentors to make referrals, and another had plans to train prisoners on the Prisoners Information Desk so that they could raise awareness of social care needs amongst prisoners. Indeed, it was clear that authorities had undertaken a lot of activity to raise the awareness of social care needs: In order to identify prisoners who may have eligible care and support needs, social care staff have provided training for the prison officers, healthcare staff and the prison mentors. Advocacy training has also been provided for the mentors and health care staff. Promotional material has been provided to the prison to advise of possible social care services (Authority 114). The responsibility to identify prisoners in X is multi-agency. To raise awareness of this responsibility … all key agencies were consulted on the design of the new process and services that have subsequently been developed. Formal training was provided to Prison Officers, healthcare staff, chaplaincy, Probation staff, Advocacy worker, domiciliary care provider and targeted staff in Adult Social Care. An e-learning module has been produced for new staff and refresher training to meet ongoing training needs (Authority 146). Assessing prisoners with social care needs Data from Stocktake 6 indicated that, across all local authorities, 1,593 prisoners had had their care and support needs assessed in the first year (see the third column of Table 1). This represented 86.8 per cent of prisoners referred. Whilst some referrals were not considered in need of a full assessment, other reasons for not completing an assessment included the transfer of prisoners to other authorities before assessments could be arranged, prisoners declining assessment and death. As with the referral numbers, both the absolute number of assessments and the proportion of referrals that translated into assessments varied between authorities: seventeen authorities undertook five or fewer assessments and ten undertook fifty or more, with three exceeding 100 and the highest 195, whilst the proportion of referrals that translated into assessment ranged from zero to 100 per cent. Again, this diversity could not fully be explained by the size and function of their respective prisons, with high levels of variation found in almost half the aforementioned prison subgroups. Whereas the identification of prisoners with social care needs was largely undertaken by health care staff, the SCiP survey suggested that the assessment of prisoners was almost always undertaken by specialist social care staff, most commonly social workers, who were reported to be engaged in this activity in all bar four authorities. That said, occupational therapists were also reported to undertake (specialist functional and/or full overview) assessments in many authorities (n = 25), and three respondents said that occupational therapists undertook most or all assessments. Seven authorities referred to the participation of sensory impairment team staff. Just a handful of authorities appeared to have delegated their assessment responsibilities to other agencies. In one authority, prison-based health care employees undertook the assessments, which were then ‘sent on to the social work team manager at the LA for consideration and eligibility determination’ (Authority 23), whilst, in another, assessments were completed by dedicated (prison-based) staff employed by a third-sector agency. Still another noted that, although they had commissioned the health care provider to undertake assessments on their behalf, ‘to date we have not asked them to do this because they do not have the confidence or skills to do so’. Social care staff were thus ‘working alongside them to support their learning’ (Authority 48). In the vast majority of cases, assessments were undertaken in response to specific referrals and utilised the same assessment schedules as were used in the community. However, staff from at least one authority ran regular prison clinics, whilst another had adapted their standard FACE assessment to meet the specific needs of prisoners. The total number of staff undertaking assessments in any individual authority appeared small, with one to four personnel typical, and a range of organisational arrangements were emerging. As noted, not all assessors were employed by local authorities. Furthermore, although most assessors were based in community locality and (less frequently) contact teams, in a few instances, they were based in prisons. Similarly, whilst some staff worked exclusively with prisoners, many combined this role with other responsibilities: We have a virtual prisons team drawn from a number of social work teams (Authority 72). We have 4 social workers and 1 OT who have been cleared to enter prisons to carry out the assessments. The staff are from our contact front door and locality social work teams (Authority 54). The assessment of prisoners with social care needs is carried out by social work staff employed by [private prison provider] using the Council’s care and support assessment. A point of contact at the Council’s Social Care Direct has been established for [private prison provider] social work staff to obtain advice and support. Specialist assessments in relation to occupational therapy or sensory support are carried out by the Council’s own staff (Authority 36). The assessments are mostly carried out by an Occupational Therapist based within the Prison Healthcare team (funded by X council). If a prisoner requires a funded social care package to meet their eligible needs then there would be further assessment by a social worker in our community team to look at the personal budget required to meet eligible needs (Authority 146). Providing care and support to prisoners with eligible care and support needs Data from Stocktake 6 indicated that, of the 1,593 prisoners who had their care and support needs assessed in the first year, 790 (49.6 per cent) had eligible care and support needs (see the fourth column of Table 1). However, once more, there was considerable variation between authorities. For example, thirty-two authorities had assessed five or fewer prisoners as eligible for care and support, and eight had not assessed any as eligible. In contrast, three authorities had assessed fifty or more prisoners as eligible, with the highest being 141. Further, considerable differences were again seen in the proportion of assessed prisoners deemed eligible for care and support, ranging from zero to 100 per cent. In terms of the delivery of social care and support, care plans were typically being formulated in conjunction with prisoners and other key players (albeit scant reference was made to the involvement of family): Where a prisoner meets the eligibility criteria for adult social care and support a plan will be developed as it would be in a community setting. Key personnel will be involved in the development and management of the care and support plan—this will involve the prisoner (Authority 14). The support plan is a collaboration between the social worker, Occupational Therapist, prisoner and people involved with the prisoner’s wellbeing inside the prison such as a mental health nurse and the wing Governor. Prison staff and healthcare staff are always involved but the role of the person changes according to individual service user needs. As in the community the prisoner is fully involved in the support plan, they have multiple opportunities to input into how they would like to be supported (Authority 55).However, it was stressed that the presence of eligible needs did not necessarily mean a prisoner would be offered commissioned services. Several authorities noted that prisoners’ needs were often already being met by the prison regime, or could be met by other services, and sixteen authorities described arrangements for prisoner buddies/orderlies to meet prisoners’ non-intimate personal care needs, with the increased flexibility such schemes offered seen as a particular strength: Many social care eligible needs are already met within the prison regime (e.g. managing nutrition, access to prison facilities). To date we have had limited unmet needs for which we have needed to provide services (Authority 23). To date prisoners’ eligible needs have been met through the provision of information and advice and specialist equipment or professional support only (Authority 146). The regime of the establishment means that choices are limited but through the help of the prison buddy system more flexibility can be offered than they previously had. For example, the buddies assist with carrying meals and this means service users have more choice over when and where they eat (Authority 55).With regard to the delivery of commissioned care and support (which, as expected, focused on prisoners’ personal care and safety), twenty-eight authorities identified prison health care staff (usually health care assistants) as the main providers. This included three authorities where an independent agency had been contracted to deliver both health and social care. The benefits of health care staff undertaking this role were said to include their on-site presence 24/7, their ability to respond to changing levels of demand, and the potential for integrating health and social care: Council X have procured a service which is delivered through our current health provider … We fund the equivalent to 1 FTE HCA, this is used flexible [sic] to accommodate the transient population within the prison (Authority 43). The care provider is the same provider as the health provider ensuring continuity of care/treatment (Authority 24). Prison healthcare provide services for prisoners who have eligible social care needs—this is done by prison healthcare assistants … . External providers are not used mainly due to the ‘lock down’ process for the prison in that there is no access to anyone from the community during the night (Authority 49).However, a few authorities indicated that there were sometimes issues around the capacity of health care staff to undertake this work, and several authorities (n = 15) had rather (or also) made arrangements for local domiciliary care providers to deliver social care in prisons, through a mixture of spot and block contracts. In addition to this, one authority had contracted a social enterprise to deliver social care, another had contracted a third-sector provider and two had seconded local authority-employed support staff into prisons. There were, however, some indications this early picture might change, as a significant minority of authorities were reviewing their initial arrangements: Our current model is to deliver any dom care style services via the HCA within the prison health team. However this post is to become vacant and the prison health team wish to pass the function on. We are therefore in the process of considering our options and possibly looking at our locally commissioned dom care provider to act as the main service for delivery (Authority 46). We have a spot contract with a Local Provider to provide services for prisoners … . In addition to this provider we are also in the process of finalising a Social Care delivery contract with [independent health care provider] who are currently providing Health Care Services in X Prison (Authority 47). Eligible need met by a range of in house and X council employed Support, Time and Recovery Workers (STRs) for personal care. Explored a number of options initially including spot contract agreements (not supported by prison health commissioners or private prison) and agencies which did not work (Authority 134). Discussion This article explores the early arrangements that local authorities in England have put in place to meet their obligations to prisoners in custody under the Care Act, and reveals the extent to which specialist social care practitioners are starting to work with this very vulnerable group, drawing on a mix of quantitative and qualitative information. Whilst the former permitted direct comparison of different authorities’ activity levels, the latter befitted the investigation of the emerging practice arrangements, and the surveys’ high response rates give confidence in the findings’ representativeness. The data suggest that, in the first year alone, upwards of 1,800 prisoners were identified as having social care needs, of whom almost 1,600 received an assessment and approaching 800 were deemed eligible for care and support. However, considerable variation was found between similar prisons, which may be due to the prison, the local authority or both. The remainder of the discussion considers some of the potential implications of the findings in relation to authorities’ new responsibilities which it is envisaged will be of interest to service planners and providers across the UK. Indeed, Wales introduced a series of similar reforms in the 2014 Social Services and Well-being (Wales) Act; there are ongoing concerns about local authority social workers in Scotland’s focus on a minority of serious offenders and the lack of a national strategy (Social Work Inspection Agency, 2011; Scottish Prison Service, 2016); and the Independent Monitoring Board for Northern Ireland have recently warned that social care for prisoners in Northern Ireland is currently being ‘batted’ between the prisons and the responsible health and social care Trust amid reduced staffing levels (McHugh, 2017). Identifying prisoners with social care needs This study suggests that the majority of authorities had a process in place to identify people on entry to custody who had, or may develop, social care and support needs. Reception interviews and health assessments are clearly key opportunities to establish whether individuals have been receiving, or need, social care and support, enabling appropriate help to be offered at the earliest opportunity. However, past reports suggest that similar entry screens can fail to detect a wide range of needs, including physical disabilities, mental health problems and alcoholism (HMiP, 2009, 2010; Edgar and Rickford, 2009), and the same may well be true of social care needs. Certainly, not all prisoners will feel comfortable disclosing a need for help at this time, and others will lack insight into their condition. There is thus a need for further research on the specific tools employed, and their sensitivity. Further, whilst it may be time-efficient for health and prison care staff to take the lead in identifying prisoners with social care needs, it is also important to identify what training such staff require in order to do this effectively. One study, for example, suggested that health care problems not elicited at reception were rarely detected later (Birmingham et al., 1997), whilst another found little evidence that prison staff knew when to seek a specialist social care assessment (Parker et al., 2007). The very limited extent of active case finding identified in this research is therefore a major concern, for, although it may appear sufficient to screen on admission, prisoners may develop social care needs at any point during their imprisonment, whilst their willingness to acknowledge a need for help may also change. This in turn highlights the potential utility of self-referral processes, and it was clear that a number of authorities had these in place. However, further information is needed on the extent to which they are being used and the best way to promote them. Assessing prisoners with social care needs In contrast to the situation before the Care Act, this study found that specialist social care staff, particularly social workers, were engaged in assessing prisoners in the vast majority of authorities. Given that assessment is a core function of social work practice and the relevance of social work skills for people with complex needs (College of Social Work, 2010), this seems entirely appropriate. However, whilst assessment skills are generally considered to be transferable between practice contexts, assessing prisoners might be expected to require some additional training, and it is not clear how well practitioners had been prepared to work with this client group. Several studies of social work practitioners have found that many feel ill-equipped to assess or respond effectively to people with substance abuse problems (Galvani et al., 2014) and, although most social work training in the last century included some coverage of crime and social work in criminal justice, this has been less prevalent since 2003 (Raynor and Vanstone, 2015). It will also be important to determine whether, in terms of prisoners’ outcomes, these new roles are best incorporated into community teams’ wider casework or undertaken by specialist practitioners. Arguments for the former might include the opportunity for greater numbers of staff to develop experience with this client group, as well as the potential for continuity upon release (if within the same authority) and the promotion of equitable care with people in the community. In contrast, arguments for the latter include the development of increased knowledge of the prison and legal system, and closer working relationships with prison staff. Providing care and support to prisoners with eligible care and support needs A 2015 briefing on the social care of prisoners (Skills for Care et al., 2015) anticipated that, whilst many local authorities would commission existing prison health care providers to deliver services for prisoners with eligible care and support needs, some local authorities may choose to provide services through separate care providers or in-house resources, and it is clear this is what happened. It is likely that there are a number of different factors at play here. Although research suggests that, prior to the Care Act, prison officers often provided social care, it was generally acknowledged that they did not have the necessary training, support or capacity to undertake such activities (Lee et al., 2016). Further, it has been argued that the very culture of prison officers militated against their developing the required skills, there being a clear conflict between the objectives of care and custody (Charles, 2015). In this situation, extending the role of the health care provider may appear a straightforward option, particularly given the perception that some inmates’ social care needs were already being met in prison health care units (Lee et al., 2016), and the presence of a pool of staff in place 24/7. However, it is possible that, when resources are stretched, health care staff may prioritise their health care role over the provision of social care, whilst it could be difficult to ensure that monies for social care are always used for this purpose. That said, there are also potential problems with the employment of external domiciliary care providers, including the time taken to obtain security vetting, and the reduced flexibility (there sometimes being no or limited access to prisons in the evenings and at night), and further research is required to assess the relative advantages and disadvantages of the different options, and the extent to which the prison mix influences the choice of model. Finally, the increasing engagement of prisoners to provide social care for peers described in our study and the arrangements in place to select, risk assess, train, support and supervise them are also worthy of future examination. Although prisoners have always helped other prisoners, not least as ‘Listeners’ and tutors, the 2015 Prison Service Instructions on prisoners assisting other prisoners states that all governors must now ‘have the ability to mobilise assistance from other prisoners for a prisoner who has a care and support plan or written information from the local authority, or is awaiting a care and support needs assessment, should it be needed’ (NOMS, 2015, p. 4). Although prisoners are explicitly not permitted to provide other prisoners with ‘intimate care’, they can assist with a wide range of activities, including dressing and undressing that does not involve body areas that are usually clothed for reasons of privacy and decency (e.g. putting on socks); providing reminders to take medication/go to the toilet; and keeping cells tidy. There is, however, a potential concern that prisoners might feel they have no other option but to accept such help from other prisoners—a situation that would not be permissible in any analogous community-based institution, such as a care home. Conclusions In light of serious and ongoing concern about the provision of social care for prisoners, the Care Act clarified local authorities’ responsibilities for this previously neglected client group, and was intended to ensure that prisoners received equivalent care to people in the community, to support their rehabilitation and (it was hoped) to impact on the likelihood of their reoffending (Department of Health, 2014b). Against this background, this paper provides a unique and important insight into the initial arrangements that local authorities in England have put in place to meet their new responsibilities to prisoners in custody, and suggests that there has been a substantial step forward in the provision of social care and support for this population. Perhaps not surprisingly, given the preliminary nature of this investigation, no overarching model of best practice was identified. Rather, the data serve to highlight the extent of variation in practice, and identify some of the advantages and disadvantages of the different arrangements, providing a valuable resource for authorities seeking to support service planning and commissioning in both England and elsewhere. They also suggest a number of areas on which further research might concentrate. 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The British Journal of Social WorkOxford University Press

Published: Oct 27, 2017

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