HMP Swansea Hna 121208 Final

National Public Health Service for Wales
HMP Swansea health needs assessment (2008).
HMP Swansea Health Needs Assessment (2008)

Authors: Judith Tomlinson, Principal Public Health Specialist and Christian Heathcote-Elliott, Senior Health Promotion Specialist. Date: 12/12/08 Status: Approved Intended Audience: HMP Swansea Prison Partnership Board, NPHS (intranet and internet) Purpose and Summary of Document: This health needs assessment (HNA) contains self-reported quantitative data about the health status of prisoners entering HMP Swansea and qualitative data about staff and prisoners perceptions of health needs of prisoners and health service provision within HMP Swansea. It makes recommendations for building on the innovative progress made by the healthcare unit of HMP Swansea in recent years and calls for further work refining data collection, examining the effectiveness of health interventions in a prison environment and consideration of the wider determinants of prisoner health when planning future health care provision. Publication/Distribution: HMPS Prison Partnership Board Publication in NPHS Document Database (intranet and internet) Link from NPHS e-Bulletin Link from Stakeholder e-Newsletter Version: 1.0
Authors: Judith Tomlinson, Christian Heathcote-Elliott Version: 1.0
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Status: Approved Intended Audience: Swansea Local Health Board, HMP Swansea / NPHS (Intranet) / Vulnerable Groups Team
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1
Chapter
Contents
Executive summary 1 Background Health needs assessment Aims and objectives HMP Swansea Description of the prison Healthcare services Health needs assessment methodology Health needs assessment approach Ethical approval Prevalence of health conditions in prisoners Corporate needs assessment Comparative needs assessment Data analysis Epidemiological needs assessment Prisoner demographics Health issues amongst the prisoner population Corporate needs assessment Prison healthcare staff interviews Prisoner focus group interviews Comparative needs assessment Discussion Limitation of health needs assessment Recommendations Conclusion References Appendices Page number 7 11 11 11 13 13 13 20 20 20 21 21 21 21 23 23 25 30 30 35 37 39 39 40 41 42 44
6 7
8 9
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Produced by Swansea Local Public Health Team

Judith Tomlinson Christian Heathcote-Elliott Principal Public Health Specialist Senior Health Promotion Specialist
With acknowledgements to: Sian Williams Gary Matthews Marie Philips Chris Davies Frank Feeney Head of Healthcare, HMP Swansea Acting Primary Care Team Leader (Health Promotion) Clinical Nurse Specialist Healthcare Officer Healthcare Officer
Thanks also go to those members of staff and prisoners who participated in the corporate needs assessment
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Executive summary
Methodology
A health needs assessment (HNA) was undertaken in Her Majestys Prison (HMP) Swansea during the summer of 2008 using a recognised toolkit. The HNA includes three approaches to examining health needs and service provision: An epidemiological approach: the health status of prisoners at the time of entry into the prison was determined using self-reported data from the first reception health screen. Current health service provision in the prison was also examined. A corporate approach: staff and prisoner perceptions of current service provision and how services could be improved were obtained by undertaking semi-structured interviews and focus group interviews. A comparative approach: the provision of healthcare services in HMP Swansea was compared with a similar size category B prison in England HMP Bedford.
Results
Epidemiological needs assessment The most prevalent physical health condition at the point of reception was asthma with one in six prisoners reporting this condition. One in three prisoners reported that they had seen a psychiatrist at least once in their lifetime and over one in four prisoners were receiving medication for mental health problems at the point of reception. Consistent with other prison HNAs, the majority of prisoners were smoking cigarettes (79.5%) and nearly two-thirds reported using drugs in the month prior to imprisonment. Corporate needs assessment Seven members of staff and seven prisoners participated in the corporate needs assessment. In terms of improving services a number of themes emerged from the interviews. These included: improving communication between prisoners, staff and prison management; improving throughcare; improving the detection and treatment of alcohol problems; reviewing prescribing, timely and appropriate referral to psychiatric inpatient hospital services and the need for psychological input for prisoners with mental health needs.
Authors: Judith Tomlinson, Christian Heathcote-Elliott Version: 1.0 Date: 121208 Page: 7 of 64 Status: Approved Intended Audience: Swansea Local Health Board, HMP Swansea / NPHS (Intranet) / Vulnerable Groups Team
In both the prison staff and prisoner interviews a number of barriers to service improvement were identified. It was clear that some barriers operated at the individual and interpersonal level (e.g. staff and prisoner attitudes) whilst others were more structural and in some cases more difficult to change (e.g. prison regime). User involvement was felt to be important by prison staff, although it was recognised that prisoners sometimes were suspicious as to why they were being consulted. With appropriate support it was felt that prisoners could be involved with the planning and delivery of services. Comparative needs assessment The results from the comparative component of the needs assessment revealed that the provision of healthcare services in HMP Swansea is broadly similar to those in HMP Bedford. However, HMP Swansea uses a primary care model and HMP Bedford still has a considerable number of inpatient beds. HMP Swansea would also seem to have progressed more in terms of promoting health amongst prisoners and staff.
Limitations of the health needs assessment

The first reception health screen was not designed as a HNA tool and uses selfreported data which are subject to response bias. Therefore it is a crude metric for measuring the health status of prisoners. For a significant number of prisoners the first reception health screen records were incomplete and it was not possible to derive robust prevalence estimates for some conditions (e.g. actual levels of substance use and misuse). It is recognised that the prisoners who participated in the corporate needs assessment may have had a distinct set of needs and therefore their views are unlikely to represent other prisoner groups. The comparative needs assessment was limited to comparing HMP Swansea with one other category B prison in England. An evaluation of the effectiveness and cost-effectiveness of healthcare interventions was not included because of time and resource constraints.
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Recommendations
The initial identification, subsequent assessment, treatment and education of prisoners with alcohol misuse problems needs to be improved. HMP Swansea needs to develop clear referral criteria for prisoners requiring inpatient treatment in a psychiatric hospital. For future HNAs and health service provision planning, data-collection systems for health-related data should be refined and fit for purpose. Appropriate training should be given to healthcare staff on the completion of the first and second health reception screen forms to ensure accuracy and consistency. This should be regularly audited. The re-location of the health care unit into a more accessible building within the prison should be prioritised. The establishment of a prison NHS healthcare clinical network across the Welsh prison estate would facilitate best practice and improve access to expertise. The Prison Service needs to review its policy around prisoners who self-harm in order to improve the health outcomes of repeat self-harmers.
Conclusion
HMP Swansea remains a challenging context in which to deliver healthcare services which are equivalent to those found in the community. However, since the transfer of commissioning responsibilities to Swansea LHB, HMP Swansea has made considerable progress in developing healthcare services for prisoners. This direction of travel needs to be strengthened and sustained. This HNA has shown that on entry to HMP Swansea some prisoners have a high level of need for health services, particularly in relation to substance misuse and mental health. Through refining data collection systems in HMP Swansea, future HNAs will be able to provide a more detailed picture of the need for services and how existing services can be improved. It is recognised that services which contribute to tackling the wider determinants of health should also be considered in future health service provision planning.
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Background
The self reported physical and mental health of prisoners is poor (Bridgwood and Malbon 1994; Fazel and Danesh 2002) coupled with a high prevalence of substance misuse, poor educational attainment, learning difficulties and disabilities. Prisoners also have poor emotional health and low social skills functioning. Whilst in custody, prisoners can access a number of interventions which aim to improve health, social skills and reduce the risk of recidivism. For example, through the education and skills department, prisoners can participate in a range of courses designed to improve reading, numeracy, social skills, health literacy, self-awareness and anger management. Historically health care services in HMP Swansea were commissioned by the Prison Service. However on 1st April 2006, the responsibility for commissioning prison health care services was transferred to Swansea Local Health Board (SLHB). SLHB is required to develop prison health care delivery plans and ensure that healthcare services delivered in prison are broadly equivalent to those provided to the general population. As part of a continual programme of improvement health needs assessments (HNA) should be undertaken on a regular basis. Since the last comprehensive HNA, undertaken in 2005 (Vidal-Alaball and Williams, 2005), health care services in HMP Swansea has undergone a series of reforms towards a primary health care model. This HNA will update the 2005 HNA and provide an insight into prisoners and healthcare staffs perceptions of current health care service provision in HMP Swansea.
3.1
Health needs assessment
A methodology was devised after researching published needs assessments involving prison populations (Marshall, Simpson and Stevens, 2000; Harries, 2005; Vidal-Alaball and Williams, 2005; Huws, 2007 and Condon et al., 2007).
3.1.1
Aim
To undertake a health needs assessment of HMP Swansea using a cross-sectional approach. It is outside the remit of this health needs assessment to look at the wider determinants of health and their impact of prisoner health and well being.
3.1.2
Objectives
To describe current health service provision in HMP Swansea,
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To collect quantitative data to provide a cross-sectional picture of the demographics and health status of HMP Swanseas population. To obtain prisoner and prison staff perceptions on current service provision and how services can be improved, and To make recommendations on future service developments.
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4.1
HMP Swansea
Description of the prison
HMP Swansea is a category B prison containing remand, convicted and sentenced adult male prisoners aged 21 years and over. The prison has an in-use Certified Normal Accommodation (CNA) of 240 prisoners and a maximum Certified Operational Capacity (COC) of 422 prisoners. The prison population in July 2008 was 425 which represents 77% over the CNA. This makes the prison the third most overcrowded in England and Wales1. The prison is divided into five wings. Table 1 shows the capacity and designation of each wing. Table 1: Wing A B C D E Healthcare unit HMP Swansea prison wing capacity and utilisation Designation Remand or Sentenced Induction wing for new admissions Sentenced Remand or Sentenced Segregation (deals with discipline issues as they arise from other wings) Crisis beds for medical admissions awaiting transfer to hospital
Occupational capacity 171 49 40 162 6 2
Source: HMP Swansea, 2008.
4.2 4.2.1
Healthcare services Infrastructure
The current health care services are delivered from the health care unit which is separate to the wings. The Type 3 unit has four consulting rooms, a day room, a small meeting room, pharmacy and two crisis medical admissions cells. There is also a treatment room on every wing which consists of an examination area, storage cupboards and equipment including oxygen and a defibrillator which is part of the First Responder initiative.
HM Prison Service monthly population bulletin (25/07/08)

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The ring fenced service level agreement budget allocated to HMP Swansea for the year 2008/9 is 1,150,000.
4.2.2
Model of care
HMP Swansea has developed a Primary Care health care service model which mirrors that available in the community. This has resulted in the removal of inpatient beds and released staff capacity to develop more meaningful therapeutic daytime activities and more healthcare activity on the wings. Table 2 lists the staffing provision for the key healthcare services in the prison and a revised staffing structure can be found in Appendix 9.1.
4.2.3
Access to services
Access to healthcare services is made available to prisoners when they enter HMP Swansea during reception, throughout custody and at the point of release where prisoners are referred to equivalent services in the community if appropriate. Prisoners can self-refer to a number of services provided by the prison during custody including the stop smoking service and the Lighthouse primary care mental health assessment and intervention clinic. Referrals can also be made to healthcare through other departments in the prison (e.g. learning and skills, the gym). If a prisoner wishes to see a GP or attend a specific health care clinic they are required to complete a Healthcare Application Form. These are available on every wing and collected twice weekly, then the prisoners are placed on the triage list and referrals are made from the clinic if needed. Attendance of some services, such as the Short Duration Treatment Programme forms part of the prisoners Offender Management Plan. Medications are dispensed via the pharmacy for a limited period in the morning, midday and early evening. Currently, all prisoners who take prescribed medication have been risk assessed and 87% are given In Possession medication. This is a significant increase on the 20% of prisoners receiving In Possession medication at the beginning of 2008.
4.2.4
Reception screening
The first reception health screen is undertaken by healthcare staff when an offender first enters HMP Swansea. Its purpose is to identify any immediate healthcare needs so staff can refer to appropriate services where necessary. The process involves completing a standardised self-reported assessment form (form F2169) (Appendix 9.2) which records information on health status including drug and alcohol use and prescribed medication. All prisoners are then subsequently seen by a GP within 24 hours of entry into the prison to discuss their health needs and if necessary medical scripts are issued.
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Table 2 Summary of health professional input to HMP Swansea.
SERVICE AREA Primary Care Nursing Services General Medical Services Dental Services
NUMBER OF SESSIONS Fulltime cover (see staff structure above) 24/7 2 sessions per week
CURRENT PROVIDER HMP Swansea Swansea Out of Hours Service (SOS) A local General Dental Practitioner Abertawe Bro Morgannwg University Trust Abertawe Bro Morgannwg University Trust
Sexual Health Clinic Specialist Mental Health Services
1 session per week Mental Health In-Reach Services (consisting of 2 Consultant Psychiatrist sessions per week, 1 F/T CPN, 1 F/T OT and 1 F/T OT assistant, Consultant Clinical Psychologist 1 session per week). Forensic Psychiatry (Caswell Clinic) 1 session per week.
Pharmaceutical services Optician Counselling, Assessment, Referral, Advice and Throughcare (CARAT) service
Source: HMP Swansea, 2008.
1 F/T Pharmacist and 1 F/T Pharmacy technician Ad-hoc sessions 3.5 workers
HMP Swansea Specsavers Opticians West Glamorgan Council on Alcohol and Drug Abuse Ltd (WGCADA)
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4.2.5
Nurse led clinics
There are a number of nurse led clinics. These include smoking cessation (once weekly); hepatitis B vaccinations (once weekly), chronic disease management (once weekly) and genito-urinary medicine (once weekly).
4.2.6
General Practitioner (GP) services
GP services are supplied by Swansea Out of Hours Services. Prisoners have access to GP led clinics in the prison on Tuesday and Thursday between 8.00am and 11.30am and on Saturday and Sunday between 10.00am and 11.30 am. There is out of hours GP service available between 11.30 and 6.00pm and an emergency on call provision provided by SOS Services based in Singleton Hospital from 6.00pm until 8.00am weekdays and on Saturday and Sunday from 11.30am to 10.00am.
4.2.7
General Dental Practitioner (GDP) services
A GDP and dental nurse currently provides dental care for one day a week within HMP Swansea. A large proportion of the workload consists of emergency work and there are many incomplete treatments due to the transfer or release of prisoners before the required treatment can be undertaken.
4.2.8
Management of communicable diseases
HMP Swansea is currently compiling a list of prisoners eligible for flu vaccination (i.e. those who are 65 years of age and over and those who have chronic illnesses). HMP Swansea hepatitis B vaccination rates are now amongst the best in the UK. One hundred and fifty four vaccinations were administered in July 2008. Fifty seven prisoners refused to be vaccinated.
4.2.9
Disinfecting tablets and condom provision
In line with PSI 34/2007, disinfecting tablets are available on every wing landing at a dispatch point at the side of the treatment hatches. Condoms are also available but prisoners have to ask healthcare staff for them. Anecdotal evidence would suggest prisoners are reluctant to ask for condoms because they fear being overheard by other prisoners. At the time of writing lubricants are not available.
4.2.10 Pharmacy and medicines management

The pharmacy is located within the healthcare unit and is staffed by one FTE pharmacist and one FTE pharmacy technician. The majority of prisoners are given In Possession medication following the induction period. Prisoners are initially assessed using a risk assessment tool. As part of the risk management process, prisoners are initially given a 7 day supply then re-assessed for risk. A 21 day supply of medication
is then issued building up on the next issue to a 28 day supply. The process of risk assessment is continuous with prisoners being continually monitored. This is made clear to prisoners on issue of medication. If the medication is being incorrectly taken then the prisoner has an appointment made for him with the pharmacist. A Medication Usage Review is carried out and in some cases the supply of medication is reduced to seven days supply. If deemed necessary the pharmacist will refer the prisoner to the pharmacy technician for further counselling on their medication. The importance of building up the supply of medication to 28 days is that the patient has access to the manufacturers product information leaflets. HMP Swanseas approach to managing medicines is innovative and in line with Government guidelines2. Other Welsh prisons (HMP Usk and Prescoed, Cardiff and Parc) tend to limit the quantity of drugs prescribed to a maximum of 7 and 14 days. In the past 6 months since the In Possession medication has been expanded there have been very few incidents of medication abuse. Anecdotal evidence from prisoners has been very positive and they feel that they are being prepared for life back in the community. Finally, as part of medication management the prisoners have to order their repeat medication at the appropriate time.
4.2.11 Mental health services

In 2006 the prison mental health pathway was launched which identifies good practice against which HMP Swansea is working towards. HMP Swansea has a daily Lighthouse Clinic which is run by a RMN Clinical Nurse Specialist and is an assessment and intervention clinic. A small number of prisoners are referred from this clinic to the mental health in-reach team. There is also a daily Intensive Prisoner Support Group, which is run by a RMN and discipline staff and provides psychiatric support for self-referring prisoners. This too can act as a gateway to specialist mental health services. Specialist mental health services are provided in two ways. A mental health in reach team provided by Abertawe Bro Morgannwg University NHS Trust (ABMU) comprising of two consultant Psychiatrist sessions per week, a full time community psychiatric nurse, a full time occupational therapist and a full time occupational therapy assistant. There is also one session per week provided by a forensic psychiatrist from the Caswell Clinic which is medium secure forensic psychiatry unit run by ABMU.
4.2.12 Substance misuse services

HMP Swansea provides a range of services for substance misusers including clinical de-toxification, maintenance and re-induction procedures; psychosocial support through the CARAT team; the Integrated Drug Treatment System, the Short Duration Treatment Programme, the Overdose Prevention programme and smoking cessation.
National Prescribing Centre (2005) Medication in-possession - A guide to improving practice in secure environments.
Since April 2008, CARAT workers have been relocated to the healthcare unit, resulting in improved communication and co-operation. Detoxification, maintenance and re-induction procedures. Detoxification and maintenance regimens are delivered in accordance with Prison Service Order 3550 (HM Prison Service, 2000) and the Drug Misuse and Dependence: UK guidelines on clinical management (Department of Health (England) and devolved administrations, 2007). Limited one-to-one support is given during the period of detoxification. Where possible, remand prisoners who have been substituted in the community are kept on a maintenance regimen during custody. Prior to release, re-induction may be offered to those prisoners who are opiate users with a long history of relapse and who are considered to be especially vulnerable in the early post-release period. CARAT: Psychosocial support and drugs and alcohol education. Psychosocial support and education for prisoners with substance misuse problems is primarily provided by the CARAT team. Referral to a CARAT worker can occur at any stage during a prisoners sentence or period on remand. For many prisoners referrals are made at the stage of the initial reception screen or during the period3 on induction wing. On initial contact with a CARAT worker basic information is given to the prisoner on drugs and alcohol. If the prisoner is considered to have a substance misuse problem a full assessment of prior drug or alcohol use and treatment needs is undertaken. With the prisoners consent a care plan is drawn up which may include detoxification or referral to a rehabilitation programme. Integrated Drug Treatment System. Prisoners with substance misuse problems can attend the Integrated Drug Treatment System (IDTS). The IDTS is a 14 session motivational intervention which aims to provide prisoners with information and skills and encourage prisoners to increase their awareness of the effects of their substance misuse. The sessions can be run on a 1:1 or group basis and are led by CARAT workers and one member of the healthcare team. Throughcare. CARAT workers are primarily responsible for supporting prisoners who are substance misusers through their transition from the prison to the community. This involves preparing a release plan and referring prisoners to external agencies, usually Drug Intervention Programme teams. Whilst still in custody prisoners can also be referred onto the Welsh Assembly Government funded Overdose Prevention programme. Short Duration Treatment Programme. Whilst on induction wing prisoners can attend a short duration treatment programme (SDTP). The SDTP is a four week intervention based on cognitive-behavioural theory and the harm minimisation approach (HMP Swansea, 2005). Referrals are made by CARAT workers and the programme is delivered by the CARAT team. The programme is aimed at prisoners who are on remand or are serving a short sentence. Prisoners coming to the end of their sentence can also attend. Over the course of 20 two-and-a-half-hour sessions participants are taught a range of skills including goal setting, problem solving,
The length of time spent on induction wing varies but is usually between one and two weeks.
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decision making and relaxation techniques. One-to-one counselling sessions are also available. In the financial year 2007/08 11 SDTP courses were run. 12-step programme. The Prison Partnership 12-Step Drug Rehabilitation Programme was withdrawn in October 2007 and has been replaced by in-treatment drugs support groups. Service provision will also be enhanced with the introduction of Cove Aid (Control Of Violence and Aggression in Impulsive Drinkers) courses. These are at present being piloted in other Welsh prisons.
4.2.13 Health promotion

In 2007, HMP Swansea appointed a Band 6 RGN Primary Care Team Leader with a remit specifically to develop health promotion within the prison. A prison health promotion steering group was also established in 2007 and currently has representatives from healthcare, learning and skills, gym, occupational health, catering and Swansea Public Health Team. A major achievement of this group has been the development of a prison health promotion strategy and supporting action plan. The strategy aims to equip prisoners and staff with the knowledge and skills to enable them to make healthier choices and addresses six key areas: drug use, eating well, immunisation, mental health and well being, physical activity and sexual health. The strategy also looks at reducing some of the structural barriers to health improvement within the prison setting.
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5
5.1
Methodology
Health needs assessment approach
The HNA was undertaken over a period of 8-weeks starting in July 2008. The HNA followed a commonly adopted approach developed by Marshall, Simpson and Stevens (2000, 2001). This approach involves three components: i) Epidemiological needs assessment: This involves describing existing service provision, obtaining incidence and prevalence data and examining the effectiveness of services. Due to time constraints it was not possible to undertake a detailed review of the effectiveness and cost-effectiveness of existing healthcare service provision in HMP Swansea. ii) Corporate needs assessment: This involves gaining the perceptions of key stakeholders on the provision of existing services and how they can be improved. iii) Comparative needs assessment: This involves comparing the service provision in one institution with the provision of services in comparable institutions.
5.2
Ethical approval
Permission to undertake the healthcare needs assessment was given by the Deputy Prison Governor. As the healthcare needs assessment was a service evaluation it was not necessary to seek ethical approval from NRES4.
5.3
Prevalence of health conditions amongst prisoners
The prevalence of specific health conditions and health behaviours were derived from data collected on the first reception health screen (revised form F2169) and second reception health screen (Appendix 9.2)5. A cross-sectional survey was taken on the 9th July 2008. To supplement this cross-sectional survey prescribing data were obtained from the VISION database for each prisoner. This was undertaken as it was felt that the self-reported data on prescribed medications from the first reception health screen were inaccurate. Data were entered onto an Excel spreadsheet template by members of the prison healthcare team. To reduce the number of input errors where possible the spreadsheet contained drop-down menus and validation rules.
NRES is the National Research Ethics Service (this organisation was formerly COREC).
The first reception health screen collects data on self-reported health status at the point of reception into prison. It therefore does not reflect the health status of prisoners during custody.
5.4
Corporate needs assessment
In order to gain the views of key stakeholders involved with the delivery and receipt of healthcare services within HMP Swansea, two qualitative research methods were employed: focus group interviews and semi-structured interviews. For pragmatic reasons a purposive sampling approach was adopted. Focus group interviews were undertaken with two groups of prisoners i) prisoners from the Intensive Prisoner Support Group (N=3) and ii) prisoners participating in a learning and skills class (N=4). Prior to participating in the focus group interview, prisoners were given written and verbal information on the aim of the interview and asked to sign a consent form. All prisoners consented to the interview being audiotaped6. Prisoners were asked a series of questions using an interview schedule (Appendix 9.3) derived from Condon et al. (2007). Focus group interviews work best when groups are relatively homogenous and there are not clear social divisions amongst participants (Morgan, 1997). As the views of a range of staff involved with delivering healthcare services were being sought it was felt that a focus group approach would therefore be unsuitable. For this reason semistructured interviews were undertaken. An interview schedule (Appendix 9.4) was derived from a previous healthcare needs assessment undertaken in HMP Swansea (Heathcote-Elliott, 2007). Seven members of the staff participated in the interviews (Head of Healthcare, CARAT worker, Registered Primary Care nurse (band 5), Intensive Prisoner Support Team Leader (band 6), Substance Misuse Team Leader (band 6), GP and a mental health in-reach nurse (band 7)). Each participant was given written information on the needs assessment and standard consenting procedures were followed. All participants consented to the interviews being audiotaped.
5.5
Comparative needs assessment
For the comparative needs assessment data on service provision were sought from three comparable category B local prisons in England: HMP Bedford, HMP Bristol and HMP Winchester. Telephone calls were made to the Head of Healthcare in each prison requesting permission to send a postal questionnaire and to identify a named respondee. The questionnaire (Appendix 9.5) was sent to each identified respondee. No prison responded initially. Repeated telephone requests were made and the questionnaires were re-sent. Only HMP Bedford returned the postal questionnaire.
5.6
Data analysis
At the time of the cross-sectional survey, 401 prisoners records were available for analysis. However, 39 (9.7%) of prisoners were either at the point of release or were being transferred to other prisons. Little data were available on these prisoners and
6
It should be noted that one prisoner was required to attend an appointment at the start of the Intensive Prisoner Support Group focus group interview. In addition, one prisoner declined to participate in the learning and skills focus group interview.
they are therefore excluded from the analysis. The total number of prisoners records analysed was therefore 362. Proportions are reported as valid percentages7 unless specified. Ninety five percent confidence intervals were calculated using a method described by Eayres (2008) are shown where appropriate. A 95% confidence interval shows a range of values where the true population value is likely to lie. The wider the confidence interval the less precise our estimate is of the true population value. Data from the focus group interviews and semi-structured interviews were transcribed verbatim where possible8 by members of administration team at Swansea Local Public Health Team. A number of methods for analysing qualitative data are described in the literature ranging from content analysis to phenomenological analysis. For the purposes of this HNA thematic analysis was undertaken based on an approach described by Braun and Clarke (2006). This approach was undertaken for pragmatic reasons. The five stages involved with this approach are show in Table 3. A more detailed description of this approach is given in Appendix 9.6.
Table 3:
Stages in thematic analysis Purpose Researcher familiarises his or herself with the data by reading and re-reading transcripts. Ideas for initial coding are recorded. Data are organised into meaningful groups by applying initial codes Initial codes are grouped into broader themes. Themes are reviewed and refined Final themes are devised and quotations selected from the data to illustrate themes
Stage Familiarisation Generating initial codes Searching for themes Reviewing themes Defining and naming themes
Adapted from Braun and Clarke (2006).
A valid percentage is a proportion where the denominator does not include those prisoner records where the data were missing. Where the denominator excludes a large number of records, proportions should therefore be interpreted with caution.
8
It was not possible to transcribe two of the staff interviews (the GP and mental health in-reach nurse) and the two focus group interviews due to poor audio quality.
6
6.1
Epidemiological needs assessment

Prisoner demographics
HMP Swansea has a high throughput of prisoners and receives between 1700 and 1900 new receptions each year. Figure 1 shows the breakdown of prisoners by legal status. At the time of the cross-sectional survey 77.1% of prisoners were convicted with two-thirds of these being sentenced. The majority of prisoners surveyed had been in prison before (77.3%, valid responses =348). The most common offences for imprisonment were burglary (12.5%, valid responses = 361), possession of drugs with intent (11.6%, valid responses = 361) and robbery (6.6%, valid responses = 361). Figure 1: Prisoner status (valid responses =362)
Source: HMP Swansea cross-sectional data collected on 09 July 2008.
Information about length of sentence is shown in Table 4. At the time of the crosssectional survey 32 prisoners had an indeterminate sentence9. The proportion of sentenced prisoners with a sentence over 2 years has increased compared with the previous health needs assessment undertaken in 2005 (54.2% and 42.4% respectively).
An indeterminate sentence is defined as a sentence which prisoners have no automatic right to be released.
Table 4:
Length of sentence Number of prisoners 5 21 25 70 143 98 362 % of prison population 1.4 5.8 6.9 19.3 39.5 27.1 100.0
Length of sentence Less than 3 months 3 6 months >6 months - <12 months 1 2 years More than 2 years Not sentenced / on remand Total
Table 5 shows the age structure of the prisoners and indicates that nearly half of prisoners (45.9%) are aged under 30 years. It is notable that the age structure of the prisoner has remained almost identical between 2005 and 2008.
Table 5: Age 21-24 years 25-29 years 30-34 years 35-39 years 40-44 years 45-49 years 50-54 years 55+ years Total
Age structure of HMP Swansea prisoners 2005 Number of prisoners 100 100 65 64 40 17 12 11 409 % of prison population 24.4 24.4 15.9 15.6 9.8 4.2 3.0 2.7 100.0 Number of prisoners 80 86 61 59 37 21 9 9 362 2008 % of prison population 22.1 23.8 16.9 16.3 10.2 5.8 2.5 2.5 100.0
Source: HMP Swansea cross-sectional data collected on 23rd July 2005 and 09 July 2008.
The majority of prisoners were normally resident in Wales (85.6%) with one third of prisoners living in Swansea (see Figure 2). It is worthy of note that at the time of the cross-sectional survey 28 prisoners (7.7%) did not have a permanent address. Nearly one-third of prisoners (31.2%, valid responses = 346) reported being homeless in the previous year. This is much higher than the 13.9% estimated lifetime prevalence of homelessness in the UK general population reported by Toro, Tompsett, Lombardo et al. (2007).
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Figure 2: District of residence (valid responses = 362)
6.2 6.2.1
Health issues amongst the prison population GP registration and prescribed medications
At the time of the data collection 84.6% (95% CI 80.5%-88.0% valid responses =351) were registered with a GP. Nearly one in two prisoners reporting that they were receiving prescribed medication at the time of entry into the prison (42.3%, 95% CI 37.3%-47.4%, valid responses =362) with 28 prisoners stating that this medication was for mental health problems (8.1%, 95%CI 5.7%-11.5%, valid responses 344). Using data derived from the VISION database, Table 6 shows the top five most frequently prescribed drugs at the time of the cross-sectional survey.
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Table 6:
Most frequently prescribed medication (valid responses = 362) Number of prisoners 22 17 14 14 13 % of prison population 6.1 4.7 3.9 3.9 3.6
Drug Mirtazapine (anti-depressant) Diazepam (sedative) Diclofenac (NSAID) Methadone (opiate substitute) Citalopram (anti-depressant)
6.2.2
Physical health conditions
The first reception health screen collects information on seven health conditions. The estimated point prevalence of these conditions at the time of the cross-sectional survey is shown in Table 7. The table shows that the most commonly reported condition is asthma with around one sixth of prisoners reporting this condition. This is higher than would be expected in the general adult population where approximately 1 in 20 people would be expected to have the condition. It is notable that the proportion of prisoners reporting epilepsy (5.4%) is also much higher than would be expected in the general male adult population (0.6%). Table 7 Condition Estimated point prevalence of selected conditions in HMP Swansea (valid responses = 351). Number of prisoners a Valid percentage 95% confidence interval Lower limit Upper limit General adult population estimate (%) NA 5.8b NA 6.0c 0.6d 0.6e NA
Allergies Asthma Chest pain Diabetes Epilepsy or fits Sickle cell disease Tuberculosis
46 58 32 6 19 2 3
13.1 16.5 9.1 1.7 5.4 0.6 0.9
10.0 13.0 6.5 0.8 3.5 0.2 0.3
17.0 20.8 12.6 3.7 8.3 2.1 2.5
Sources: a HMP Swansea cross-sectional data collected on 09 July 2008. b. asthma and prescribed medication, England, all ages (2006/07), NCHOD Compendium of Clinical and Health Indicators c. = currently being treated for diabetes, males 16+, Welsh Health Survey (2007). d. = male and females aged 18+ (2006/07), NCHOD Compendium of Clinical and Health Indicators, e Sickle Cell Society, ONS mid-year population estimates 2007.
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6.2.3
Mental health conditions
The completeness of the mental health conditions data was poor and therefore it was not possible to derive point prevalence estimates. However, given that nearly one in three prisoners (32.0%, 95%CI 27.3%-37.1%, valid responses 347) reported that they had been treated by a psychiatrist outside of prison this would suggest that the mental health of many prisoners in HMP Swansea is likely to be poor. Just over one in ten prisoners (12.8%, 95%CI 9.7%-16.7%, valid responses 344) also stated that they had stayed in a psychiatric hospital at some point during there lives. Perhaps not surprisingly around a quarter of prisoners (27.5%, 95%CI 23.0%-32.4%, 346 valid responses) reported receiving medication for mental health problems. Few prisoners reported being supported by a community psychiatric nurse or careworker in the community (4.1%, 95%CI 2.4%-6.7%, valid responses 343). Figure 3 shows the percentage of prisoners who reported self-harming either in or outside of prison. The lifetime prevalence of self-harm is 29.3% (95%CI 24.7%34.3%, valid responses = 345). This is comparable with other recent prison based estimates. For example, amongst sentenced Irish prisoners Duffy, Linehan and Kennedy (2006) report a lifetime prevalence of 25.3%. Ten prisoners (2.9%, 95%CI 1.6%-5.3%, 345 valid responses) reported current feelings of self-harm. Figure 3: Self-harm status of prisoners in HMP Swansea (valid responses = 345)
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6.2.4
Lifestyle factors
In the general Welsh population, latest estimates would suggest 1 in 5 (25%) adult males smoke cigarettes (Welsh Health Survey, 2007). The prevalence of smoking in HMP Swansea was found to be much higher with around three out of four prisoners (79.5%, 95%CI 73.5%-84.5%, valid responses = 205) reporting that they currently smoked. This estimate is consistent with results from the Scottish Prison Survey 2006 (cited in Graham, 2007) which found across the Scottish Prison estate prevalence estimates ranged from 63.4% - 88.2%.
The first reception health screen asks about drug use in the previous month and the types of drugs used (see Table 7). Nearly two-thirds (64.8%, 95%CI 59.6%-69.6%, valid responses = 349) of prisoners reported using drugs in the month prior to imprisonment. Figure 4 shows the main types of substances used by prisoners who stated that they had used drugs in the month prior to imprisonment.
Figure 4:
Types of drug use amongst prisoners who reported using in the month prior to imprisonment (valid responses = 226)
100% 90%
Of those 64.3% of prisoners who had used drugs in the month prior to imprisonment 31.4% (95% CI 25.7%-37.7%, valid responses = 226) had administered drugs intravenously.
80%
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A recent Scottish Prison Service health care needs assessment has shown that nearly one in two male prisoners (41%) report problematic alcohol use (Graham, 2007). In the current cross-sectional survey 61.7% (95%CI 56.5%-66.6%. valid responses = 347) of prisoners reported drinking alcohol. Due to the limitations of the first reception health screen form and poor completion of the question it was not possible to determine the prevalence of harmful or hazardous drinking. Height and weight data are recorded in the second reception health screen. However, of the 362 records available at the point of the cross-sectional survey, only 56.2% had the height and weight fields completed. Due to the large amount of incomplete records BMI data are not reported here.
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Corporate needs assessment
This section presents the results from the healthcare staff interviews and two prisoner focus group interviews. Due to the poor audio quality of two of the prison staff interviews and the two prisoner focus group interviews, it was not possible to provide verbatim transcriptions. A summary of the written notes is therefore provided at the end of this chapter.
7.1 7.1.1
Prison healthcare staff interviews Improving services and priorities
Healthcare has seen many changes since the transfer of service commissioning from the Prison Service to Swansea Local Health Board. A number of the staff interviewed expressed the sentiment that the new way in which services were commissioned and delivered was a significant improvement over the old model: things have got a lot better since I first joined the service because at least now, and more so for the past couple of years since the LHB have basically taken over the reigns, theres a lot more coming through [Band 5, primary care RGN] Closer working between discipline staff and healthcare staff would also appear to have improved the level of service provided to prisoners. Issues related to prisoners health are now dealt with outside of the healthcare unit. The RMN Intensive Prisoner Support Team Leader felt that: Healthcare is no longer the dumping ground for people that were unmanageable on the wing. We work in conjunction with people to manage them on the wing. [Band 6, RMN Intensive Prisoner Support Team Leader] In April 2008 the CARAT team moved into the healthcare unit and anecdotal evidence would suggest that this has been beneficial in caring for prisoners with substance misuse problems. The CARAT worker felt that the staff and healthcare services provided at HMP Swansea were better than many of the other establishments he had worked at: you know healthcare here is really good to us compared to other places Ive worked at. [CARAT worker] Whilst overall, staff appeared positive about the services provided a number of themes in relation to service improvement emerged from the data. These themes related to improving communication, throughcare of prisoners, inadequate service provision for alcohol misusers, revising prescribing regimens, psychological input in healthcare services and improving audit processes.
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The theme of improving communication consisted of two sub-themes: communication between staff and prisoners and communications between staff and management. In relation to communication between staff and prisoners, the Band 5 primary care nurse felt that staff could benefit from training to develop their skills around imparting information: weve got knowledge but it is actually are we capable of passing that knowledge on in a structured manner and in a coherent manner to our client base. [Band 5, primary care RGN] The same respondent also felt that the lines of communication between healthcare staff and senior management could be improved and that lower grade staff should be given more opportunities to voice their opinions: we dont often get opportunities to speak to people higher up in the echelon to say well you know, have you thought of this, have you tried this?...communication is a bit of an issue and has been an issue since I joined this job [Band 5, primary care RGN] Linked to the communication theme was theme of throughcare. Effective throughcare services are paramount to ensuring the smooth transition between custody and release. One aspect of throughcare which was felt to be lacking was the transfer of prisoners health records to primary care services in the community: Passing of information from us back to GPs, back to community mental health teams, but particularly in the primary field back to GPs. I think its where we fall down greatly. [Band 6, RMN Intensive Prisoner Support Team Leader] A substance misuse needs assessment undertaken in 2007 (Heathcote-Elliott, 2007) suggested that at the point of receiving offenders into the prison, initial screening for alcohol related problems could be improved. It would appear that there are still issues around detecting prisoners with alcohol misuse problems. The substance misuse nurse felt alcohol misuse problems were not always detected early enough: I think it needs to be you know a standard question in reception. It isnt always asked. I mean sometimes I only pick it up when I go over to reception wingor I see them in the substance misuse clinic over here. [Band 6, Substance Misuse Team Leader] Whilst there is a range of interventions for drug misusers in the prison, services for alcohol misusers are more limited, particularly as prisoners with alcohol only related problems cannot access CARAT services: weve got lots of services in place for you know opiate users etc but alcohol dependant clients, they were just coming in getting the Diazepam reduction and that was it [Band 6, Substance Misuse Team Leader] However, the Substance Misuse Team Leader nurse did suggest she was working on improving the services available to alcohol misusers.
Its just making sure that they get the same kind of treatment as the drug users and looking at their medication and maybe you know looking at a different way of detox apart from Diazepam. [Band 6, Substance Misuse Team Leader] Prescribing for substance misusers was also felt to be an area that could be improved with the Substance Misuse Team Leader suggesting that prescribing regimens for substance misusers were not always comparable with those used in the community. The Head of Healthcare also pointed out that prescribing and detoxification regimes between prisons were often different despite clear government guidance which was re-issued in 2007: Another prison, you know like Cardiff, and Swansea, they are 50 miles apart yet weve got totally different detox regimes but were dealing with the same prisoners and it just seems absolutely bizarre to me that there isnt that level of communication there. [Head of Healthcare] It is notable that HMP Swansea only has limited input from a clinical psychologist. In part this would appear to be due to limited funding. A couple of respondents from the staff interviews felt this was an important omission particularly given the mental health needs of some prisoners: I think we could certainly do with psychological input from a mental health point of view. We deal with these people but we dont always give them the best psychological input that we probably, possibly could. [Band 6, RMN Intensive Prisoner Support Team Leader]
7.1.2
Barriers to service improvement
Three main themes emerged from the data in relation to the barriers to service improvement: staff and prisoner attitudes, the prison regime and funding. The attitudes and behaviour of prisoners and prison staff can impact on the effectiveness of healthcare services. Whilst the interviews showed that staff recognised that prisoners tended to have a high level of health needs, they also acknowledged that many knew how to manipulate the system in order to acquire medication or alleviate boredom: there are prisoners here that say theyre experiencing certain mental health issues and theyre not displaying any of the signs that link them. I very much think sometimes that maybe they get told to say this to get certain medication [Band 6, Substance Misuse Team Leader] The RMN Intensive Prisoner Support Team Leader also voiced a sense of frustration that despite prisoners ostensibly good intentions to change their behaviour whilst in prison, they often reverted back to their old lifestyle once back in the community:
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They come in here and they seem to want to address their needs but then they go out and just revert the [their old] lifestyle. So sometimes you do feel like youre whistling in the wind a bit. [Band 6, RMN Intensive Prisoner Support Team Leader] Staff attitudes can also impact on the effectiveness of healthcare services. Whilst closer relationships have been forged between healthcare and discipline staff one respondent felt there was still a sense of them and us: you know sometimes when you go over on the wings you do hear negative feedback about healthcare and you just feel youre working really hard and theyve no idea of what we do you know. [Band 6, Substance Misuse Team Leader] One of the biggest constraints on healthcare service delivery is the prison regime itself and its inherent inflexibility: our days are dictated by what the discipline staff are doing, what time they open and lock [Band 5, primary care nurse] In a Victorian prison like Swansea this is further exacerbated by the number of locked doors which prisoners must pass through in order to access the healthcare unit. This requires considerable discipline staff resource and limits the amount of time prisoners can for example spend using the day care facility. The location of the healthcare unit is also not ideal. The Head of Healthcare recognised that: the location of healthcare needs to move physically to be more integrated with the prisoners [Head of Healthcare] There have been discussions around moving the healthcare unit and the Head of Healthcare felt positive that these discussions were taking place but that this would unlikely to be a priority area for another year. The Head of Healthcare also felt that a barrier to service improvement was the links between prisons and prison healthcare departments although she acknowledged that changes in the prison IT systems may improve this situation: Prisons seem to be very insular and they deliberately isolate themselves from each other. I mean again I think the IT system will go a long way to resolve thatbut I still think communication and practices, it still seems to be the choice of a single prison how they practice. [Head of Healthcare] With the tightening of prison budgets, it is perhaps not surprising that the issue of funding was raised in a number of the staff interviews. In some cases this was felt to directly affect quality of care available to prisoners. For example under the present funding agreement with the Home Office, it is not possible for prisoners who just have alcohol problems to access the CARATs service. Given the scale of alcohol-related crime the CARAT worker viewed this as a major limitation in providing a comprehensive service:
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I think its crazy because you cant deal with somebody who is a chronic alcoholic and we cant do anything for them, CARAT service wise, because the prison services says oh no you cant do that, youre not funded for that [CARAT worker].
7.1.3
User involvement
All the staff interviewed acknowledged that prisoner involvement was an important aspect of service improvement and that prisoners have a right to be heard: I think their role is very important and its by asking them what they feel they need, would like [that] we can move forward [Band 6, RMN Intensive Prisoner Support Team Leader] In particular it was recognised that with the move towards providing equivalence of care in prisons that prisoners have: the same rights as we have when we go to access the GP or to access health services. [Band 6, RMN Intensive Prisoner Support Team Leader] In recent years the prison has made attempts to involve prisoners more in the evaluation and provision of healthcare services through prisoner surveys and postprogramme questionnaires. In 2007 a Prisoner Council was set-up although this is not specific to healthcare services. The Head of Healthcare was positive about the Prisoner Council and felt that prison representatives on this group took their roles seriously. However she felt that healthcare needs were not necessarily a priority for prisoners: what it reminds me of time and time again is that most prisoners priorities [arent] healthcareIts not something that comes up in their mindsWhich I suppose in a lot of ways reflects the general population. [Head of Healthcare] The Head of Healthcare also expressed the view that prisoners were often wary of why their views were being sought: prisoners get quite suspicious why you want to involve them. [Head of Healthcare] Prisoners can also be involved in the delivery of services and HMP Swansea was the first prison in the UK to establish a Listening Scheme in 1991 in which prisoners trained by the Samaritans provide one-to-one counselling support for other prisoners who may be experiencing mental distress. Several of the staff interviewed recognised that prisoners experiences could be put to good effect in terms of mentoring other prisoners or delivering specific educational sessions: I think that with a little bit of education and little bit of guidance they [prisoners] could deliver you know drugs awareness sessions or mental health sessions [Band 6, Substance Misuse Team Leader]
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However, the Head of Healthcare felt that the prison system limited the degree to which prisoners could be involved in the delivery of services: its very sort of risk orientated it limits a lot of what prisoners can and cant do on a formal basis because of the litigation issues but certainly there is an opportunity to develop accredited work that prisoners can do [Head of Healthcare]
7.1.4
Prison staff interviews supplementary information
Due to technical difficulties it was not possible to transcribe the audio-taped interviews with the GP and Band 7 Mental Health In-reach nurse. The key issues summarised below are from written notes. The GP felt that the strict prison regime often took precedence over healthcare issues. For example, clinicians often felt rushed because prisoners have to be returned to their cells within a specific period of time. The GP expressed the view that there tended to be a medicalisation of certain issues, for instance, a prisoner would have to see the doctor to obtain a letter for new shoes. The GP also commented that clinicians worked in isolation and that some prescribing practices within the prison were inefficient and could be improved. The Mental Health In-reach nurse felt that clear referral criteria were needed to specialist forensic services and for referral to low/medium secure mental health services. In addition, the lack of low secure mental health inpatient hospital beds meant that ill prisoners could not be referred to timely, appropriate care. The Mental Health In-reach nurse also expressed the view that there was a need to develop psychology services within HMP Swansea.
7.2
Prisoner focus group interviews
The prisoners from the Intensive Prisoner Support Group expressed the view that the issue of self-harming was not well managed by healthcare staff and that there was a need for staff to receive training around caring for prisoners who self harm. In common with the view expressed in two of the staff interviews, the prisoners also felt there was a lack of psychology services available in the prison. The issue of self-harm was also raised in the second focus group interview with the prisoners from an education and skills class. These prisoners felt that discipline staff could also benefit from training on how to handle prisoners who self-harm. Two other key issues emerged from this interview. Firstly the respondents felt healthcare staff were not always sympathetic to their health needs and that often they would have to wait long periods of time to see a dentist, optician or to access the stop smoking group. Secondly, the respondents thought it would be helpful if health information and details of courses being run by healthcare could be placed on information boards on each wing as they were often unaware of what services were on offer unless they visited healthcare.
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Comparative needs assessment
The population of HMP Bedford is 19% higher than Swansea (506 compared with 425 prisoners in HMP Swansea). The numbers of FTE nursing staff are very similar with HMP Bedford having 17 FTE and HMP Swansea having 19 FTE nursing staff. Further analysis of the staffing structures reveals a variation in the type of nurse employed with HMP Bedford employing 4 FTE RMNs and HMP Swansea employing 6 FTE RMNs (one of which is a Band 7 clinical nurse specialist). There is also variation in the number of inpatient beds which suggests that the prisons are operating different healthcare models as HMP Bedford has 14 inpatient beds and HMP Swansea has 2 crisis inpatient beds (HMP Swansea having adopted a primary care model). There is variation in the number of commissioned GP, GDP, optician and pharmacy sessions with HMP Bedford having the greatest number of sessions. Both prisons operate detoxification services and neither has a dedicated detoxification wing. Table 7 contains a summary of the range of health care provision and staffing structures of HMP Bedford and HMP Swansea. Table 7: Comparative analysis of healthcare provision in HMP Swansea and HMP Bedford Similarities and differences between HMP Swansea and HMP Bedford HMP Bedford and HMP Swansea employ similar numbers of nurses but the type of nurse varies with HMP Swansea having a greater proportion of nurses from a mental health background. HMP Bedford also commissions more GP, GDP, optician and pharmacy sessions than HMP Swansea. HMP Bedford has 14 in patient beds whereas Swansea has 2 crisis beds for medical admissions. This suggests that HMP Bedford operates a different model of healthcare to HMP Swansea. Both prisons operate similar substance misuse services although HMP Swansea co-locates CARAT workers as part of the health care team. Both prisons operate in a similar manner. However HMP Swanseas mental health clinical nurse specialist runs a daily self referral clinic for mental health issues and triage to specialist mental health services. There is also a daily mental health prisoner support unit run within the health care centre.
Area of health care provision Staff structure
Models of care
Substance misuse Mental health services
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Area of health care provision Health promotion
Communicable disease User involvement
Similarities and differences between HMP Swansea and HMP Bedford Unlike HMP Swansea, HMP Bedford does not have a whole prison health promotion strategy and active multidisciplinary steering Group to implement the strategy (with members from education and skills department, catering, gym, healthcare, pharmacy, smoking cessation and public health professionals). Both prisons operate smoking cessation services and prison exercise referral programmes. HMP Swansea also operates an Expert Patient Programme. Both prisons have communicable disease policies and discrete access to condoms. However only HMP Bedford issues lubricant. HMP Bedford has recently undertaken a population questionnaire survey of prisoners views of health care services. HMP Swansea has also conducted surveys to obtain prisoners views on shaping mental health services and the provision of condoms (undertaken in 2006 and 2008 respectively). Feedback on healthcare services is also obtained via the Prisoner Council.
Source: Head of Healthcare, HMP Bedford, 2008.
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9
9.1 9.1.1
Discussion
Limitations of the health needs assessment Quantitative data available for health needs assessment
Whilst first reception health screen data gives a self-report measure of prisoners health status at the point of entering prison, it does not inform service providers and commissioners on changes in health status during custody, or how services impact on prisoners health over time. Further new information would be required to gain a better understanding of the demand, supply and need for services in HMP Swansea. As a tool for gaining information on health status at the point of receiving prisoners into HMP Swansea, the first reception health screen is inadequate for a number of reasons: o A number of questions lack precision (e.g. there are no instructions for recording alcohol consumption in a consistent manner), o The responses to a number of the questions were poorly recorded and subject to response bias, particularly those relating to measuring lifestyle factors (e.g. height and weight measures, smoking status, alcohol consumption), and o The data are initially recorded on a paper based form. This needs to be entered manually onto an electronic based spreadsheet and screened for data errors. This proved to be particularly time consuming in the present health needs assessment.
9.1.2
Representativeness of prisoner groups interviewed
It was difficult to gain access to a range of prisoners for the corporate needs assessment. It is recognised that the prisoners from the Intensive Prisoner Support Group have a distinct set of needs and therefore their views are unlikely to represent other prisoner groups. Future health needs assessments need to examine the views of a wider spectrum of prisoners.
9.1.3
Lack of data for the comparative analysis
The comparative needs assessment was limited for the following reasons: o There are no other similarly sized category B prisons in Wales,
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o The profile of prisoners and types of crimes committed in similarly sized category B prisons in England is likely to be different and this will be reflected in the types of services available, and o Only one of the three English prisons identified for the comparative analysis completed the Comparative Needs Assessment Questionnaire.
9.1.4
Effectiveness and cost-effectiveness of services in HMP Swansea
It was not possible to review the evidence for the effectiveness of services in HMP Swansea because of time and resource constraints. A previous substance misuse healthcare needs assessment undertaken in 2007 indicated that not all services provided are evidence based (e.g. auricular acupuncture for smoking cessation). The HNA did not examine services provided by other departments, such as education and skills, which may contribute to tackling the wider determinants of prisoners health.
9.2
Recommendations
The assessment of all prisoners for alcohol misuse and subsequent treatment of prisoners with hazardous levels of alcohol use needs to be reviewed. In particular, the adoption of a validated screening tool should be incorporated into the initial health screening of prisoners. HMP Swansea needs to develop clear referral criteria for prisoners requiring inpatient treatment in a psychiatric hospital. Without these there is a risk that some prisoners may be inappropriately held in prison. For future HNAs and health service provision planning data-collection systems for health-related data should be refined and fit for purpose. A lack of IT in systems in the prison as a whole will thwart progress. Appropriate training should be given to healthcare staff on the completion of the first and second health reception screen forms to ensure accuracy and consistency. This should be regularly audited. The re-location of the health care unit into a more accessible building within the prison should be prioritised. The establishment of a prison NHS healthcare clinical network across the Welsh prison estate would facilitate best practice and improve access to expertise. The Prison Service needs to review its policy around prisoners who self-harm. Although controversial, the development of safer self harming policies in prisons
could lead to improved mental and physical health outcomes, and a reduction in adverse incidents, for the minority of prisoners who are repeat self-harmers.
9.3
Conclusion
HMP Swansea remains a challenging context in which to deliver healthcare services which are equivalent to those found in the community. However, since the transfer of commissioning responsibilities to the Swansea LHB HMP Swansea has made considerable progress in developing healthcare services for prisoners. This direction of travel needs to be sustained. This health needs assessment has shown that on entry to HMP Swansea some prisoners have a high level of need for services, particularly in relation to substance misuse and mental health. Through refining data collection systems in HMP Swansea future health needs assessments will be able to provide a more detailed picture of the need for services and how existing services can be improved. It is recognised that services which contribute to tackling the wider determinants of health should also be considered in future health service provision planning.
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10
References
Braun, V., and Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology; 3, 77-101. Bridgwood, A. and Malbon, G. (1994). Survey of the physical health of prisoners. London: Office of population censuses and surveys. Condon, L., Hek, G., Harris, F., Powell, J., Kemple, T and Price, S. (2007). Users views of prison health services: a qualitative study. Journal of Advanced Nursing 58(3), 216-226. Department of Health (England) and the devolved administrations (2007) Drug Misuse and Dependence: UK Guidelines on Clinical Management [online]. London, Department of Health (England), the Scottish Government, Welsh Assembly Government Northern Ireland Executive. Available at: http://www.nta.nhs.uk/publications/documents/clinical_guidelines_2007.pdf [Accessed 11 August 2008]. Duffy, D., Linehan, S. & Kennedy, H.G. (2006) Psychiatric morbidity in the male sentenced Irish prisons population. Irish Journal of Psychological Medicine, 23, 2, 5462. Earyes, D. (2008) Technical Briefing 3: Commonly used public health statistics and their confidence intervals [online]. Association of Public Health Observatories. Available at: http://www.apho.org.uk/resource/item.aspx?RID=48457 [Accessed 08 July 2008]. Fazel S, Danesh J. Serious mental disorder in 23,000 prisoners: a systematic review of 62 surveys. Lancet [serial online]. 2002 [cited 2007 April 27];359:545-550. Available from:http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T1B4561RH65&_user=144092&_coverDate=02%2F16%2F2002&_rdoc=5&_fmt=full&_orig=brows e&_srch=doc-info(%23toc%234886%232002%23996400693%23585489%23FLA %23display %23Volume)&_cdi=4886&_sort=d&_docanchor=&view=c&_ct=61&_acct=C00001197 8&_version=1&_urlVersion=0&_userid=144092&md5=9b4e878a028a610fe27798926 5676161 Graham, L. (2007) Prison Health in Scotland: A Health Care Needs Assessment. Scottish Prison Service. Harries, J. (2005). Healthcare needs assessment for HMP Prescoed and Usk. (personal communication 20.06.08).
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Heathcote-Elliott, C. (2007) A substance misuse healthcare needs assessment: A report to HMP Swansea. National Public Health Service for Wales [unpublished MPH dissertation]. Her Majestys Prison Service (2005). Drug and Alcohol Strategy 2005: Operational Instruction No. 20. London: The Stationary Office. Huws, D.W. and Williams, A. (2007). Health needs of prisoners at HMP Cardiff. [unpublished]. Huws, D.W. (2005). The health and health care needs of prisoners in HMP and YOI Parc (Bridgend). [unpublished]. Marshall, T., Simpson, S., Stevens, A. (2000). Toolkit for health care needs assessment in prisons. Birmingham: University of Birmingham. Morgan, D.L. (1997). Focus groups as qualitative research (2edn). London: Sage Publications NPHS (2008). Stop Smoking Wales Annual Report 1April 2007 to 31 March 2008. Cardiff: National Public Health Service for Wales. Toro, P.A., Tompsett, C.J., Lombardo, S., Philippot, P., Nachtergael, H., Galand, B., Schlienz, N., Stammel, N., Yabar, Y., Blume, M., Mackay, L. & Harvey, K. (2007) Homelessness in Europe and the United States: A Comparison of Prevalence and the Public Opinion. Journal of Social Issues, 63, 3, 505-524. Vidal-Alaball, J., Williams, N. (2005). HMP Swansea health care needs assessment. Swansea: NPHS and Swansea LHB. Viggiani, N., Orme, J., Salmon, D., Powell, J., Brindle, C. and Murphy, S. (2004). Healthcare needs analysis: an exploratory study of healthcare professionals perceptions of healthcare services at HMP Eastwood Park, South Gloucestershire. Bristol: South Gloucestershire NHS Primary Care Trust and Faculty of Health and Social Care Bristol University.
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Appendix 9.1
Healthcare staffing structure
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Appendix 9.2
Reception screen forms
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Appendix 9.3
Preamble
Focus group interview schedule
I want to talk to you about the healthcare services in Swansea prison. I am interested in the healthcare services in Swansea prison and I want to hear about any ideas you have which would make the services better for prisoners. What I would like to get is a picture of how easy it is for you to use these services and why some of you may have not used services, and how they may be made better. Warm-up question As I have no idea what it is like to be in prison can you tell me a little bit about what things are like here? (Prompts: daily regime, activities to reduce boredom, prison food, staff) Main questions 1. Thinking about your health, what is your experience of healthcare in this prison? (focus is in HMP Swansea) PROMPTS i. When you first arrived in prison ii. Health problems you already had, new problems e.g. injuring yourself in the gym, feeling low iii. Receiving meds iv. How did the staff react to you? v. Appointments vi. Health information given 2. What types of healthcare services are you aware of in HMP Swansea? PROMPTS i. ii. iii. iv. v. vi. vii. viii. Minor health problems (primary care) Immunisation Dentists, opticians Counselling, occupational therapy Health education, advice, sexual health, Substance misuse services Listener schemes Wider services e.g. diet and health course run by the Learning and Skills Department
3. What are the good things about healthcare in HMP Swansea?

i. Compared to healthcare you have received outside of prison 4. What are the bad things about healthcare in HMP Swansea? PROMPTS i. Compared to healthcare you have received outside of prison ii. Barriers communication, access 5. How have you looked after your own health since you have been in HMP Swansea? PROMPTS In relation to: i. Physical activity ii. Smoking iii. Substance use iv. Talking with other prisoners / staff v. Avoiding confrontation with others vi. Seeking help and information 6. How do think healthcare services in HMP Swansea can be improved? PROMPTS In relation to: i. More prisoner improvement ii. Improved access iii. Wider range of services
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Appendix 9.4
Preamble
Semi-structured interview schedule
The aim of this interview is to look at your role in providing healthcare services for prisoners and how you feel services might be changed to better meet the needs of prisoners. Please give as much information as you can. Background 1. How long have you been working for the prison service? 2. How long have you been working for Swansea prison? Participants role in Swansea prison 3. What is your role in providing healthcare in Swansea prison? (PROMPTS. If not generated by participant ask them to consider: reception screening, care in custody, throughcare; in relation to assessment, prevention, treatment, evaluation) Need for healthcare 4. What do you feel are the main healthcare needs of prisoners in Swansea Prison? (PROMPTS. If not generated by participant ask them to consider: physical health, psychological wellbeing, lifestyle behaviours) Service improvement 5. In what ways do you think healthcare services could be improved in Swansea prison? (PROMPTS. If not generated by participant ask them to consider: continuity of care on release, work related to prevention, peer support schemes, greater involvement of discipline staff, greater capacity, more funding) 6. What do you see as the barriers to improving healthcare services in Swansea prison? (PROMPTS. If not generated by participant ask them to consider: prison regime, prison environment, staff attitudes, training, capacity issues, funding)
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7. What do you see as the opportunities for making realistic changes to improve healthcare services in Swansea prison? (PROMPTS. If not generated by participant ask them to consider: new working practices, new staff, changes in prison environment, staff training) 8. What would you say are the priorities for improving healthcare services in Swansea prison over the next year? 9. How is the service you and your colleagues provide audited? (PROMPTS. If not generated by participant ask them to consider: how do you know what you do is effective?) 10. What do you think is the role of prisoners in shaping healthcare services in Swansea prison? (PROBES: how could prisoners be involved? What are the barriers to increasing prisoner involvement?) 11. What do you think is the role of prisoners in delivering healthcare services in Swansea prison?
Date: 121208 Page: 58 of 64
Appendix 9.5
1. Name of prison:
Comparative needs assessment questionnaire
2. Do you have a dedicated healthcare unit? 3. How many inpatient beds do you have?
Yes
No
________________________
4. Do you have a dedicated detoxification unit/wing?
Yes
No
5. Please indicate how many of the following staff work in healthcare: Role RGN(s) (excluding substance misuse or detoxification workers) RMN(s) (excluding substance misuse or detoxification workers) GP(s) Psychiatrist Forensic psychiatrist Clinical psychologist Forensic psychologist Substance misuse worker(s) Detoxification worker(s) CARAT workers
Are CARAT workers fully integrated into healthcare (i.e. as part of a multi-disciplinary team)?
No. of staff (FTE)
Please add further detail if appropriate:
Yes
Dentist Optician Occupational therapist Other workers (please list) 1. 2.
Authors: Judith Tomlinson, Christian Heathcote-Elliott Version: 1.0 Date: 121208 Page: 59 of 64 Status: Approved
No
Intended Audience: Swansea Local Health Board, HMP Swansea / NPHS (Intranet) / Vulnerable Groups Team
6. Which of the following services does the prison offer (please tick all boxes that are appropriate): Substance misuse services Detoxification Service provided YES NO Please give details of the service (e.g. type of service, length of intervention(s), who delivers intervention(s))
Re-induction
Cognitive-behavioural interventions (e.g. relapse prevention)
In the last year on average how frequently have these been run?
12-step programme (e.g. AA, NA, RAPt)
Other (please describe):
Date: 121208 Page: 60 of 64
Mental health services
Service provided YES NO
Please give details of the service (e.g. type of service, length of intervention(s), who delivers intervention(s))
Anger management groups
Anxiety or stress management groups
Depression management groups
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Health promotion and others Stop smoking group
Service provided YES NO
Please give details of the service (e.g. type of service, length of intervention(s), who delivers the intervention(s))
Healthy living groups These could include those related to:

Healthy eating Physical activity Sexual health
Prison exercise referral programme
Expert patient programme
Life and social skills group (e.g. parenting skills, relationship skills):
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7. Do you have a whole prison health promotion strategy (i.e. a strategy that covers prisoners and staff)?
Yes
8. Do prisoners have discrete access to condoms? No If yes, are condoms supplied with lubricant? 9. Do you have a communicable disease policy?
No
Yes Yes Yes No No
10. Are prisoners involved with improving healthcare services?
Yes
If yes, how are they involved?
No
____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 11. If you wish to add any other comments about the services you offer please write them in the box below.
THANK YOU FOR COMPLETING THIS QUESTIONNAIRE.
Date: 121208 Page: 63 of 64
Appendix 9.6
Stage Familiarisation
Thematic analysis
Purpose Both authors read and re-read through the interview transcripts and noted ideas for initial codes on the transcripts. Data were organised into meaningful groups by applying initial codes to the transcripts. Initial themes were identified from the transcripts and recorded on sheets of A3 paper. Authors refined and discussed initial themes and subthemes. A consensus on the final overarching themes was reached. Final titles for the themes were agreed and quotations were selected from the transcripts by Christian HeathcoteElliott.
Generating initial codes Searching for themes Reviewing themes
Defining and naming themes
Source: The analysis method was adapted from Braun and Clarke (2006).
Date: 121208 Page: 64 of 64

HMP Swansea Hna 121208 Final

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National Public Health Service for Wales

HMP Swansea health needs assessment (2008).

HMP Swansea Health Needs Assessment (2008)

Authors: Judith Tomlinson, Christian Heathcote-Elliott Version: 1.0

Date: 121208 Page: 1 of 64

National Public Health Service for Wales

HMP Swansea health needs assessment (2008).

Authors: Judith Tomlinson, Christian Heathcote-Elliott Version: 1.0

Date: 121208 Page: 2 of 64

National Public Health Service for Wales

HMP Swansea health needs assessment (2008).

Authors: Judith Tomlinson, Christian Heathcote-Elliott Version: 1.0

Date: 121208 Page: 3 of 64

National Public Health Service for Wales

HMP Swansea health needs assessment (2008).

Authors: Judith Tomlinson, Christian Heathcote-Elliott Version: 1.0

Date: 121208 Page: 4 of 64

National Public Health Service for Wales

HMP Swansea health needs assessment (2008).

Produced by Swansea Local Public Health Team

Authors: Judith Tomlinson, Christian Heathcote-Elliott Version: 1.0

Date: 121208 Page: 5 of 64

National Public Health Service for Wales

HMP Swansea health needs assessment (2008).

Authors: Judith Tomlinson, Christian Heathcote-Elliott Version: 1.0

Date: 121208 Page: 6 of 64

National Public Health Service for Wales

HMP Swansea health needs assessment (2008).

National Public Health Service for Wales

HMP Swansea health needs assessment (2008).

Limitations of the health needs assessment

Authors: Judith Tomlinson, Christian Heathcote-Elliott Version: 1.0

Date: 121208 Page: 8 of 64

National Public Health Service for Wales

HMP Swansea health needs assessment (2008).

Authors: Judith Tomlinson, Christian Heathcote-Elliott Version: 1.0

Date: 121208 Page: 9 of 64

National Public Health Service for Wales

HMP Swansea health needs assessment (2008).

Authors: Judith Tomlinson, Christian Heathcote-Elliott Version: 1.0

Date: 121208 Page: 10 of 64

National Public Health Service for Wales

HMP Swansea health needs assessment (2008).

Health needs assessment

Authors: Judith Tomlinson, Christian Heathcote-Elliott Version: 1.0

Date: 121208 Page: 11 of 64

National Public Health Service for Wales

HMP Swansea health needs assessment (2008).

Authors: Judith Tomlinson, Christian Heathcote-Elliott Version: 1.0

Date: 121208 Page: 12 of 64

National Public Health Service for Wales

HMP Swansea health needs assessment (2008).

Occupational capacity 171 49 40 162 6 2

Source: HMP Swansea, 2008.

Healthcare services Infrastructure

HM Prison Service monthly population bulletin (25/07/08)

Authors: Judith Tomlinson, Christian Heathcote-Elliott Version: 1.0

National Public Health Service for Wales

HMP Swansea health needs assessment (2008).

Authors: Judith Tomlinson, Christian Heathcote-Elliott Version: 1.0

Date: 121208 Page: 14 of 64

National Public Health Service for Wales