Tag Archives: Substance Misuse

IMB Reports: Health Notes – June 2019

Published IMB reports during June 2019 were The Mount, Leyhill, Exeter, Lindholme, Grendon, Gartree, Northumberland, Lewes and Springhill.

Here are some of the more interesting points contained within those reports, pertaining to health:

IMB Report – HMP The Mount

Reporting period – 01 Mar 2018 to 28 Feb 2019.

  • A net gain of 83 officers in 12 months, going from 110 in Feb 2018 to 193 in Feb 2019. This increase has seen a positive reduction in prison cancellations of hospital appointments.
  • An operational Wellbeing wing is providing support to prisoners with both substance misuse and mental health needs. Prisoners with more serious mental health needs are often located in CSU in the interests of either Good Order or Discipline of Own Protection.
  • Peer supporters employed as Health and Wellbeing Champions (HAWCS) provide health and wellbeing advice, guidance, brief interventions and support to fellow prisoners.
  • Healthcare applications to the IMB decreased to 7 from 21 to 7 when compared to the previous reporting year.

Full IMB Report – The Mount


IMB Report – HMP Leyhill

Reporting period – 01 Feb 2018 to 31 Jan 2019.

  • As a Cat D prison, the Healthcare service is comparable to a well-run GP practice. Greater emphasis is placed on prisoners in accepting responsibility for improving their personal health, which is commendable.
  • Perhaps going to far in trying to replicate community equivalence, the GP Clinics have reduced by 1 day per week, leading to a waiting time of approx 3 weeks. The average waiting time for new dental referrals is reported as being 10 weeks.
  • Healthcare applications to the IMB increased to 5 from 2 when compared to the previous reporting year.

Full IMB Report – Leyhill


IMB Report – HMP Exeter

Reporting period – 01 Jan 2018 to 31 Dec 2018.

  • In May 2018, HMCIP invoked the Urgent Notification protocol, which provides its own challenging backdrop for the delivery of any healthcare services.
  • HMP Exeter boasts an 11-bed social care unit (F wing) which includes a palliative care suite and a constant supervision cell.
  • The telemedicine Video-link facility is proving to be effective in enabling prisoners to have specialist consultations without the need to attend hospital, although staff report delays in the receipt of those written reports.
  • Clinics receive the support of dedicated officers although attendances/DNA’s remain heavily reliant on motivated “runners” which is typical of many prisons. DNA rates fluctuate from less than 10 for the GP/Nurse clinics to as high as 60% for services such as the physio and the optician.
  • Healthcare applications to the IMB decreased to 25 from 39 when compared to the previous reporting year.

Full IMB Report – Exeter


IMB Report – HMP Lindholme

Reporting period – 01 Feb 2018 to 31 Jan 2019

  • The recruitment of extra prison staff is welcomed. However, the low age and limited life experience of a significant proportion of new recruits has been observed. The IMB pose the question to the Minister To consider raising the minimum age of application to the Prison Service to beyond the current 18 years.
  • The IMB ask the Prison Service to consider what measures are needed to ensure that the staffing levels of the Healthcare provider are maintained as per contract.
  • Incidents of self- harm decreased in comparison to the previous year, although the data still produced a worrying picture. The monthly average of incidents was 30.7 in this reporting year, with more or less consistency throughout the year. This compared to a monthly average of 44 incidents in the previous reporting year. The large majority of incidents were by cutting and were carried out on the wings in singular cell accommodation.
  • Cosistent with the above, the number of ACCTs opened in the reporting period saw a reduction with an average 15.5 per month compared to 36 per month in the previous year.
  • There were 7 Deaths in Custody during the reporting period.
  • Healthcare staffing levels revealed that at the end of the reporting year, 16 out of a total of 60 posts were either vacant, awaiting completion of the recruitment process or subject to a period of notice. Staffing recruitment problems have been identified on the risk register. Mental health has been the most affected, and Substance Misuse Services the least.
  • Waiting Times to see a GP varied significantly from month to month. At the end of the reporting year, this was 3 weeks 4 days. The vacant ANP post had an impact on this. Waiting times for physiotherapy were 41 weeks and podiatry 19 weeks.
  • The DNA rate for prison GP appointments has reduced towards the end of this reporting year to 7%.
  • A Telemedicine service has been provided but has proved to be not as useful as hoped. This was attributed to waiting times and the rejection of referrals, and therefore diverting referrals back into mainstream secondary care.
  • Cancellation of hospital appointments by the prison was high, and at the end of the reporting year it was 10.6%.
  • Work-fitness clinics: daily clinics (Monday to Friday) to assess prisoners who felt that they were not fit for work, in the context of a working prison, have been re-established with an 80% coverage of working days. This has been a welcome development.
  • Healthcare applications to the IMB decreased to 30 from 54 when compared to the previous reporting year.

Full IMB Report – Lindholme


IMB Report – HMP Grendon

Reporting period – 01 Jan 2018 to 31 Dec 2018.

  • Incidents of self-harm for the year were 26 compared with 43 for the previous year, which included two individuals who self-harmed on multiple occasions.
  • 52 ACCT’s were opened for the year compared with 62 in 2017. Reviews monitored by the Board, including some very challenged men, showed evidence of good care and support.
  • 8 assaults were recorded in 2018 compared with nine in 2017 and no use of force.
  • Grendon has been smoke free since 2017 and there is no current funding to support nicotine (cigarette) cessation, but some residents are now looking for support to come off vaping. Healthcare are exploring options.
  • Healthcare applications to the IMB increased to 7 from 4 when compared to the previous reporting year.

Full IMB Report – Grendon


IMB Report – HMP Gartree

Reporting period – 01 Dec 2017 to 30 Nov 2018.

  • The high number of men with complex mental health needs (i.e. those on ACCT documents, self- harming, on dirty protests in the SAPU puts considerable strain on staff, who despite doing everything they can in very difficult circumstances, may not be best placed to deal with some of these more complex prisoners.
  • The Board is aware of occasions throughout the year where men in the Segregation Unit have not received prescribed medication when it is due or needed.
  • For the majority of this reporting period, responsibility for provision of the integrated healthcare services at Gartree was provided through Mitie Care & Custody (Health) Limited. On 1 November 2018, Nottinghamshire Healthcare NHS Foundation Trust (NHFT) took over the responsibility for the delivery of healthcare at Gartree.
  • The IMB continued to hold the view, as expressed in their Annual Report 2016/17 that the prison regime and the health and wellbeing services at Gartree for this reporting period were not designed or resourced to improve health and wellbeing, or tackle health inequalities and the wider determinants of health.
  • The Board acknowledged that a change in provider was appropriate, and addressing the current inadequacies of the healthcare services is critical.
  • Healthcare applications to the IMB increased to 47 from 22 when compared to the previous reporting year. In many instances healthcare applications related to the lack of response to complaints by Healthcare.

Full IMB Report – Gartree


IMB Report – HMP Northumberland

Reporting period – 01 Jan 2018 to 31 Dec 2018.

  • 2018 saw one death in custody, compared with five in each of the two previous years.
  • The IMB have previously recorded their disappointment that the deterioration in routine waiting times for both GP and dental services has not been addressed more quickly. In this reporting year, the situation remains unchanged, with waiting times for both services continuing to fluctuate throughout 2018 despite the periodic provision of additional sessions.
  • Waiting times for the GP peaked at 36 days in July and August, and reduced at the end of the year. Waiting times for dental treatment stood at 29 weeks, with a hope that this would improve in 2019.
  • Healthcare applications to the IMB decreased to 38 from 46 when compared to the previous reporting year.

Full IMB Report – Northumberland


IMB Report – HMP Lewes

Reporting period – 01 Jan 2018 to 31 Dec 2018.

  • The Board is concerned about the safety of men in HMP Lewes. In the reporting year, recorded incidents of violence perpetrated by a prisoner on another prisoner rose from 165 to 278, an increase of 68%.
  • There have been five deaths in the reporting year. Over the last year 579 ACCT documents have been opened.
  • The Board has found that for much of the reporting year the delivery of healthcare services has suffered from staff shortages and poor process and communications which have significantly impacted on the care provided for prisoners.
  • The Board has found that waiting lists for routine GP and dentist appointments have been unacceptably long at various times: in the six months May-October the wait to see a GP was an average of 12 weeks, and in June and January, the waiting time for the dentist was 10–12 weeks. In addition, the integrated mental health team typically had in excess of 50 residents waiting for an assessment appointment, with some men waiting many months to be seen.
  • The Board considers that the complaint management process remains poor and provides little opportunity for an overarching view of healthcare delivery. Each service provider manages their own complaints, and the quality of responses and the integrity of the data is variable. There were typically 20–30 complaints a month to the two main providers and the consistent themes throughout the year were access and waiting times, and not getting the medication wanted.
  • The prison went smoke-free in April 2018, and a programme implemented by the pharmacy team supported by gym officers ensured that the transition went smoothly. The smoking cessation activity has continued, with 220–240 men supported each month. Feedback from participants of programmes run by Forward Trust (alcohol and substance misuse) was excellent.
  • Healthcare applications to the IMB increased to 72 from 50 when compared to the previous reporting year.

Full IMB Report – Lewes


IMB Report – HMP Springhill

Reporting period – 01 Jan 2018 to 31 Dec 2018.

  • HMP Springhill is jointly managed with HMP Grendon (located next door). A single Independent Monitoring Board monitors both prisons.
  • Opened ACCTs remain low at 5 for the year. It is a good indication that the prison has the confidence in care to be able to support men on ACCTs. There were no reported incidents of self harm for the entire reporting period.
  • Pregabalin appears to be the drug of choice over Spice/NPS (new psychoactive substances). Cannabis has also been more prevalent, which might account for the overall 46% increase in positive test results compared with 2017.
  • Healthcare staffing recruitment has proved challenging when striving for a full complement of staff during the year, and in particular to fill the post of pharmacy technician. Staff have been faxing scripts for validation to pharmacy staff at other prisons in the region, causing occasional delays in men getting their prescriptions at weekends.
  • There are currently no healthcare meetings with residents, but this is being addressed.
  • Dental services have made significant progress in ensuring that all new patients are seen within the prescribed time. Residents positively rate dental care.
  • Healthcare applications to the IMB decreased to 0 from 6 when compared to the previous reporting year.

Full IMB Report – Springhill


HMIP Report – Health Summary: HMP Berwyn, Mar 2019

This report was on an unannounced inspection of HMP Berwyn between 04–14 March 2019, and was published in July 2019.

General Points of Note.

This is the first inspection report for HMP Berwyn, having only opened in February 2017.

The full operational capacity of the prison will eventually be 2,106 prisoners. At the time of this inspection, the population was 1,273. The current operational capacity is 1300.

Predictably, 77% of officers had been in service for less than two years and about a third for less than a year.

All cells had a shower, telephone and laptop computer.

There had been no self-inflicted deaths since the prison opened.

Levels of self-harm were below those of other category C prisons. The strategic management of suicide and self-harm has been deemed to require improvement. Most of the at-risk prisoners on assessment, care in custody and teamwork (ACCT) case management did not feel sufficiently cared for. ACCT documents required improvement, and initial assessments and care plans were weak.

There had been 3,614 complaints in the previous six months, a much higher level than inspectors would usually see. Staff attributed this to the inexperience of many staff and ineffective operation of the applications process.

Healthy Prison Outcomes:

  • Safety = 2
  • Respect = 3
  • Purposeful Activity = 2
  • Rehabilitation and Release Planning = 2

Key:

  • 4 = Outcomes for prisoners are good.
  • 3 = Outcomes for prisoners are reasonably good.
  • 2 = Outcomes for prisoners are not sufficiently good.
  • 1 = Outcomes for prisoners are poor.

Key Points of Interest: Health, Well-Being and Social Care:

There had been no recent infection control audits, but they were planned as part of the developing audit cycle with the health board. All clinical areas were clean and well maintained, but there were no cleaning schedules evident.

During the inspection, there was a two-week pilot project with the Welsh Ambulance Service Trust, with a paramedic deployed for 12 hours a day in the prison, with the aim of reducing the need for unnecessary ambulance attendance. Early findings were that during the inspection alone, 11 emergency calls had been managed without the need for further ambulance input, which was impressive. A substantial proportion of emergencies were related to psychoactive substances.

There was no overarching health promotion strategy or action plan, Health promotion literature was available in the health care centre and some other key areas, but was limited elsewhere.

Smoking cessation support, vaccinations, immunisations and health screening initiatives were provided, but there was no bowel screening.

An impressive radiology suite, staffed by a full-time radiographer, ensured good access to X-rays and ultrasound services.

There was good access to nursing staff, and a new daily wing- based nurse-led ‘see and treat’ clinic was considered to be a promising initiative.

The electronic appointments system was well managed. Prisoners could use their in-cell laptops to make appointments, and a peer-run health and well-being telephone service enabled prisoners to cancel and rearrange their appointments. However, non-attendance rates were very high, at 17.2%, but it was not clear why. Work was under way by the health and well-being peer mentors, facilitated by health staff, to reduce it.

The prison facilitated four external hospital appointments a day, in addition to any emergency escorts. Appointments were rarely cancelled due to lack of escorting staff. Health staff did not see all prisoners returning from an external hospital appointment, and so could miss ongoing treatment plans.

Health staff saw all prisoners being discharged from the prison. Prisoners were given a summary of their care, medication where relevant, information on how to register with community dental and GP services, health promotion leaflets and condoms.

In our survey, 46% of prisoners said they had a mental health problem, of who 34% said they were receiving help. Support for prisoners with mild to moderate mental health problems was good, with the provision of a wide variety of evidence-based therapies in group and one-to-one settings. A selection of self-help material for prisoners was also available.

At the time of inspection, 171 patients were receiving opiate substitutes, mostly on a maintenance basis, and all with a well-supervised controlled drug administration. Treatment was individual, regularly reviewed and well integrated. There was very good joint working with the wider health care team, and a dual-diagnosis nurse (substance use and mental health) supported patients.

The substance use service was embedded in the wider prison and worked closely with offender managers, resettlement and the security team, and was involved in ACCT reviews. Custody staff had received substance use training during induction and knew how to refer prisoners. The service had good links with local community services, and worked jointly to ensure treatment continuation for prisoners after their discharge. On release and where indicated, prisoners were given naloxone to treat opiate overdose.

Pharmacy provision was well developed and well managed. The in-house pharmacy ensured that patients received medicines promptly. Pharmacy technicians administered medicines alongside nurses on weekdays. Pharmacists clinically screened prescriptions and monitored prescribing, but did not hold medicines use reviews with patients. Patients could also make an application to speak to a pharmacist. Pharmacy policies were in place and followed, although some staff had not signed training records for the pharmacy’s standard operating procedures.

Around 80% of patients received their medicines in possession, but there was no facility for administering medicines after 7pm. As a result, night time medicines were always supplied in possession. All prisoners could store their medicines in lockable cupboards.

The quality of dental care was good but waiting times for routine care were excessive, at 42 weeks during the time of the inspection. This was partially attributed to the dental practice not being fit for use initially, as well as difficulty in recruiting dental staff. Urgent dental care was managed well, but with 440 prisoners (a third of the population) waiting for a routine appointment, and often affecting dental outcomes.

Recommendations: Health, Well-Being and Social Care:

  • There should be a prison-wide strategy to support health promotion.
  • Health staff should always see prisoners returning from external hospital appointments to
    establish any treatment and support needs.
  • The prison should ensure that suitable occupational therapy equipment and adaptations are provided and installed promptly.
  • The substance use services should have the necessary rooms to deliver therapeutic treatment.
  • There should be a formal and robust procedure to follow up patients who miss medicine doses.
  • Pharmacists should carry out medicines use reviews with patients.
  • Prisoners should have access to dental treatment within community-equivalent waiting times.

Good Practice: Health, Well-Being and Social Care:

  • The presence of a member of the pharmacy team in reception enabled prompt medicines reconciliation and easy access to medicines information for new arrivals.

Links/Resources:

Full Report Here – HMP Berwyn

HMIP Report: HMP & YOI Foston Hall, Feb 2019 – Health Summary

This report was on an unannounced inspection of HMP/YOI Foston Hall between 04–15 February 2019, and was published 19 June 2019.

General Points of Note.

There had been two self-inflicted deaths since the previous inspection. Not all Prisons and Probation Ombudsman recommendations had been implemented in full.

Incidents of self-harm were very high and significantly higher than at similar prisons. A total of 900 self-harm incidents had occurred in the six months prior to the inspection, 52% of which were attributed to six individual prisoners with complex issues.

More than 300 assessment, care in custody and teamwork (ACCT) case management documents for prisoners at risk of suicide or self-harm were opened in the six months prior to the inspection, which was higher than at similar prisons. The ACCT documentation we examined showed some good practice and improvements, including regular case reviews and better attendance by health care staff. Care maps were limited – they were not updated regularly and were not always tailored to the prisoners’ individual needs, despite a PPO recommendation requiring these improvements.

A three-tier quality assurance process for ACCT documentation had been introduced. Although a positive initiative, it had not identified shortcomings in care maps or assessments of risk.

A new ACCT process was scheduled to be trialled for three months from mid-February 2019. The new process was more dynamic, prescriptive and holistic and included inviting family members to case reviews, which had been a previous PPO recommendation.

Healthy Prison Outcomes:

  • Safety = 3 (3)*
  • Respect = 3 (3)*
  • Purposeful Activity = 3 (2)*
  • Rehabilitation and Release Planning = 3 (3)*

Note: *(Previous inspection outcomes from June 2016 are stated in brackets)
Key:

  • 4 = Outcomes for prisoners are good.
  • 3 = Outcomes for prisoners are reasonably good.
  • 2 = Outcomes for prisoners are not sufficiently good.
  • 1 = Outcomes for prisoners are poor.

Key Points of Interest: Health, Well-Being and Social Care:

Not all clinical staff received clinical supervision, but some had received supervisor training and plans were in place to support the implementation of clinical supervision. Access to additional training was good and covered trafficking, sex working and domestic violence.

All prisoners had good access to health care services. Clinical space was limited, but the team used it effectively. All clinical areas were clean and well equipped, but there were no cleaning schedules.

Health care complaints were placed in boxes opened by PID workers, which meant they were not confidential. However, this practice stopped during the inspection. All concerns and complaints were dealt with face to face at a weekly clinic held by a senior manager. Issues that could not be addressed at this level were escalated. Responses to concerns and complaints were appropriate and timely. Analysis took place and trends were routinely discussed at regular governance meetings.

Health and well-being champions (peer workers) also saw prisoners in reception, asked health-related questions and made referrals to health and social care services. This breached prisoners’ confidentiality and the provider ended this practice during the inspection.

The introduction of telemedicine was a welcome development.

Medicines management had improved significantly since our previous inspection. Close links with the pharmacist at HMP Dovegate meant that advice and support was readily available in addition to the assistance provided by the medicine supplier.

The management of in-possession medication had improved. The senior pharmacy technician ran a weekly in-possession risk assessment clinic; 97% of prisoners had a completed risk assessment and 57% could keep their medication with them. At our previous inspection, the figure was less than 25%.

Prisoners requiring medication in the evening received a daily in-possession dose, or evening duty health care staff gave them their medication before they left the prison. A policy was now in place to ensure pain medication was available overnight if required.

In our survey, 74% of prisoners reported having a mental health problem and 54% of them said they had received help while at Foston Hall.

The integrated mental health team provided a service six days a week. The team was able to meet the needs of the population. With an average of 65 referrals a month, 37 patients were on the primary caseload, and 43 on the secondary caseload. This included 11 patients treated under the care programme approach (CPA).

Mental health practitioners held a daily meeting to discuss the allocation of all new referrals and consider any urgent patient issues.

Care UK provided the prison with a mental health worker to co-facilitate a mental health treatment programme Conquering Anxiety and Low Mood for prisoners with mental health needs.

The mental health team allocated a duty worker who attended all daily ACCT case management reviews for prisoners at risk of suicide or self-harm who were related to caseloads, or who were new in the prison, or in the segregation unit. All staff had clinical supervision and used multidisciplinary team meetings to discuss lessons learnt from ACCT reviews.

Care UK and Inclusion delivered the integrated substance use service. One third of the population was involved with Inclusion, which provided a good range of appropriate psychosocial interventions. Eighty-two prisoners were on opiate substitution treatment. Staff undertook 24-hour monitoring and regular observations.

Care UK and Inclusion provided specialist dual diagnosis treatment for prisoners with mental health issues, which was good. Prescribing was flexible, and there was a well-attended multidisciplinary approach towards clinical and psychological treatment, which demonstrated joint working.

The CQC found there were no breaches of the relevant regulations.

Recommendations: Health, Well-Being and Social Care:

  • Cleaning schedules should be in place and monitored regularly to ensure the cleaning has been done and infection prevention standards are met.
  • All clinical staff should receive regular clinical supervision.
  • A prison-wide strategy should be established to support health and well-being, and it should include easy access to barrier protection.
  • Health-related peer worker activities should not compromise patient confidentiality.
  • The environment in which medication is administered should ensure patient confidentiality.
  • In-possession medication should not be provided in transparent bags.

Good Practice: Health, Well-Being and Social Care:

  • The weekly in-possession risk assessment clinic ensured risk assessments were completed promptly and enabled patients to discuss their medication with pharmacy staff.
  • The safer prescribing meeting meant staff could focus on how they managed prisoners’ medication, which helped improve patient care.

CQC Requirement Notices Issued:

  • None.

Links/Resources:

News Release – HMP & YOI Foston Hall

Full Report Here – HMP & YOI Foston Hall

9 Steps To Prevent Drug Relapse And Deaths in Custody-Community Transition

In June 2019, the Advisory Council on the Misuse of Drugs (ACDM) published their report Custody-Community Transitions which contains details of the emerging evidence on the increasing drug-related harms in prisons and related to transitions through the criminal justice system. In particular, the increased risk of death, including by overdose, in the weeks immediately following release to the community.

This report from the Advisory Council on the Misuse of Drugs (ACMD) provides advice on how to reduce drug-related harms that occur when people move between custody and the community. It seeks to answer three questions.

  1. What are the drug-related harms and benefits associated with transitions between custody and the community?
  2. What are the most important existing recommendations in this area, and to what extent have they been implemented?
  3. Is there a need for new or adapted recommendations?

The report identifies substantial harms associated with transitions between custody and the community, especially for people who have problems with drugs, including the following:
• Homelessness. In 2017/18, 34.5% of adult prisoners under supervision from the National Probation Service (NPS) or Community Rehabilitation Companies were discharged to unsettled or unknown accommodation on their first night of release.
• Reoffending. Adults serving sentences of less than 12 months in England and Wales had a reoffending rate of 64.4% between April and June 2017, with rates likely to be even higher among those with a drug problem.
• Transmission of blood-borne viruses. Prison is a risk environment for the transmission of HIV and Hepatitis C, so entry to prison can be a risk for infection, and release may spread that risk to the community.
• Increased risk of death, including by overdose. Death rates among prisoners and, especially, those on post-release supervision are many times higher than in the general population. The few weeks immediately after release is a particularly high risk period for drug-related death.

There is a particular problem for people released from custody who use opioids (e.g. heroin). Restricted access to heroin while in custody can reduce physical tolerance to these substances. If these people then relapse to drug use on release, they face a heightened risk of dying by overdose. Such relapses and deaths are particularly likely when people are released without access to housing or drug treatment.

In the last ten years, a new challenge has emerged in the form of synthetic cannabinoid receptor agonists, which are often referred to as Novel Psychoactive Substances (also known by the acronym NPS but not to be confused with the National Probation Service), ‘Spice’ or ‘legal high’s’. These have exacerbated problems in prisons around safety, security and health. Prisoners reported that the main reasons for taking synthetic cannabinoids in prison were ease of access, avoidance of drug testing for other substances, and boredom. Action is already being taken by the Ministry of Justice in the 10 prisons project.

Issues around synthetic cannabinoids that are particularly related to custody-community transitions include the following.
• The frequent movement of people on short sentences or prison recall from the community into custody facilitates the supply of synthetic cannabinoids in prison.
• It is reported that many people begin or deepen a problem with the misuse of synthetic cannabinoids after entering prison, and may continue these problems on release.
• The additional problems caused by the use of synthetic cannabinoids in prison can inhibit effective rehabilitation and resettlement planning. This is because resources are often drawn away from rehabilitation-focused activities to deal with cannabinoid-related emergencies. It is also because the use of synthetic cannabinoids can inhibit individual prisoners’ engagement in pre-release planning.

Key Themes From Previous Recommendations

The biggest challenge, and the greatest missed opportunity for reducing reoffending and improving health, is the absence of continuity of care for people who enter and leave custody with complex needs.

  • That healthcare provided to people in the criminal justice system should be at least equivalent to that provided in the community.
  • Co-morbidity between mental health problems and drug misuse (‘dual diagnosis’) in prisons is prevalent. There needs to be more clearly defined mechanisms for managing patients with dual diagnosis, formal links between mental health and drug treatment provision, and greater awareness among staff.
  • The need for a cohesive, inter-departmental strategy on drug misuse in prison is often raised. Fragmentation between different services and conflict between different organisations’ targets was identified as a problem that leads to inconsistency in care and inefficiencies.
  • Services should be more integrated. The criminal justice system should coordinate with healthcare providers, mental health services, and community supports to ensure that people are given continuity of care in the vulnerable weeks following release. It is often noted that individuals should be involved in pre-release planning and should be put in contact with support and treatment options in the community quickly after leaving prisons.
  • Treatments that help people with drug problems to accrue recovery capital – which includes social relationships, health, skills and aspirations, as well as employment and housing – are identified as valuable to sustained recovery. It is often recommended that local housing and employment organisations are also integrated into the resettlement process.
  • The benefits of mutual aid to recovery are often highlighted. Support groups are linked to improved treatment outcomes, and it is suggested that actively guiding people towards these groups improved engagement.
  • Ensuring access to services and support is consistent across the country, as adapted to local needs. The difficulty of securing continuity of care for people who are imprisoned far from their homes is frequently mentioned.
  • Data collection should be developed, and different organisations should share information where possible to reduce inefficiency, identify areas for improvement and highlight gaps in service provision.
  • There should be a national framework for continual improvement of services by setting clear performance outcomes and analysing local needs and evidence of what works.

Despite the difficulty in assessing implementation of these previous recommendations, some concerning trends are visible in the data that are available.

  • Continuity of care. The Patel Report stated that the key issue to address was the continuity of care between prison and the community. However, the latest data from PHE (2017/18) suggest that only 32.1% of people who are assessed as needing treatment when they leave prison enter treatment in the community within 21 days.
  • Equivalence of care. The Bradley Review endorsed the principle of equivalence of health between custody and the community. The current guidelines on clinical management of people with substance misuse problems states that previously heroin-dependent prisoners should be provided with a supply of naloxone on release from prison and that commissioners should support the provision of naloxone and overdose training in the community. However, only 12% of prisoners who were previously heroin- dependent left English prison with naloxone in 2017/18. In Scotland, this figure is better at 35% but much more work is still to be done.
  • Reoffending. The aim of the Transforming Rehabilitation White Paper was to reduce reoffending rates. This was partly to be achieved by providing more support to prisoners released from sentences of less than 12 months, and an expansion of ‘through the gate’ services. However, the performance of CRCs in providing these services has been widely criticised, more recently by Her Majesty’s Inspectorate of Probation who commented on serious shortcomings in supervision of short-term prisoners on release, with no evidence that expanding post-release supervision to this group reduced their reoffending.

In English and Welsh prisons, the provision of screening and treatment was improved through the Counselling, Assessment, Referral, Advice and Throughcare (CARAT) teams and, in England, the Integrated Drug Treatment System (IDTS), which expanded the provision of opioid substitution therapy (OST) in prisons. Although CARAT teams and the IDTS are no longer centrally supported, the legacy of multi-agency working continues. NHS England’s service specifications from 2018 explicitly call for a joint, multi-disciplinary approach to the screening, assessment and provision of services for substance misuse, using a range of services that are equivalent to those used in the community. The provision of ‘opt-out’ testing for blood-borne viruses (BBVs) has increased uptake and the possibility to provide effective treatment in prison.

Systemic Recommendations

  1. That the Drug Strategy Board nominates one Minister who will have over-arching responsibility and accountability for the improvement of custody-community transitions for prisoners with complex health needs, including problems with drugs.
  2. That this Minister be given the following mandate: To assess and improve performance in delivering officially accepted recommendations on transitions between custody and community for people with substance misuse, mental health and homelessness problems. The indicators of progress in this area should include the following.
    a. Reducing the rate of reoffending (within six months and after two years) of people who leave prison and who have an assessed need for drug treatment.
    b. Reducing the numbers of people who die within four weeks of leaving custody (separated by police and prison custody) and while under the supervision of the probation services. These data should be collated separately for suicides and drug- related deaths, following the definitions that the Office for National Statistics uses for the general population.
    c. Reducing the proportion of people who leave prison with unsettled or unknown accommodation on the first night of release.
    d. Increasing the proportion of people who have an assessed need for drug treatment on release who enter treatment in the community within four weeks of release.
    e. Increasing the proportion of prisoners who are assessed as having a problem with opioids who leave prison with naloxone.
  3. That the Minister of Justice (England and Wales), the Cabinet Secretary for Justice (Scotland) and their counterpart in Northern Ireland take further steps to reduce the number of transitions into and out of prisons, especially as multiple short sentences are associated with increased risk of death. This should involve:
    a. reform sentencing to minimise the use of sentences of less than 12 months, with the aim of eliminating the use in sentencing of periods of less than 3 months in prison; and,
    b. reforms to the system of supervision on licence, so as to reduce the number of people who are recalled to prison.

When prisoners are released under licence to the supervision of the NPS or CRCs, they can be recalled to prison for breaching conditions of their licence. In the year 2017/18, there were 22,183 licence recalls to prisons in England and Wales. This is an increase of 27% since 2013/14. These recalls increase the number of transitions between custody and community. As noted above, these transitions increase the risk of health problems and often break continuity of care. They also create an opportunity to smuggle substances, including synthetic cannabinoids, into prison.

Practical Recommendations

In support of the systemic recommendations made above, this report makes the following practical recommendations.

  1. That the prison services of the UK take steps to minimise the release of prisoners with complex needs (including substance misuse) on Friday afternoons. As prisoners with release dates on Saturdays, Sundays or a bank holiday Monday are released on Fridays, more than a third of prisoners are released on Fridays. Friday releases makes it difficult to access stable housing, drug treatment, and connections with probations services and job centres. People often have to attend several appointments on their first day of release. If these appointments are missed on a Friday, then the person may be left for the weekend with no housing, no money and no drug treatment. These are circumstances in which relapse to drug use and offending are highly likely to occur.
  2. That the Department for Work and Pensions (DWP) should:
    a. accelerate the introduction of the measures listed in the 2018 Rough Sleeping
    Strategy (MHCLG, 2018) to enable prisoners to access employment or Universal Credit immediately on release;
    The Rough Sleeping Strategy committed the DWP to the following measures:
  • increasing the level of prisoner engagement with Prison Work Coaches;
  • supporting prisoners to begin the Universal Credit claim in prison;
  • continuing work to support prisoners to open bank accounts in prison; and,
  • supporting prisoners to verify their identity for Universal Credit purposes.
    b. work in partnership with Her Majesty’s Courts and Tribunal Services (HMCTS) and the NPS to ensure that people who are imprisoned are not overpaid the housing element of Universal Credit; and,
    c. Following the completion of the evaluation of the pilots, implement the effective elements identified through evaluation.
  1. That the prison and probation services of the UK should develop and extend services that provide face-to-face, individualised support to prisoners who have drug problems in the run up to release and through the transition to the community.
  2. That the Drug Strategy Board should make a clear statement that it is the responsibility of the national NHS bodies to ensure that all people who have an assessed problem with opioid use should be given the opportunity to take home naloxone when they leave prison or police custody. The Board should ensure that resources are made available to the national NHS bodies to support this responsibility.
  3. That relevant agencies (e.g. PHE) establish custody-community pathways into identified treatment for prisoners who have an assessed problem with alcohol, cannabis, cocaine, or other non-opioid drugs – as well as for users of opioids. Additionally, that a pathway should be developed that offers sufficient support to enable prisoners leaving abstinence-focused interventions to maintain such change following release.
    The experience of the drug recovery wing pilots suggests that existing services in England do not provide sufficient responses to the needs of people who have problems with substances other than opioids. It also suggests that the benefits of abstinence-focused interventions in prisons are often lost when people are released. The ACMD recommends that post-release pathways for people with non-opioid problems and for people who have achieved abstinence in prison be strengthened.
  4. That the Home Office should commission research specifically to identify and ameliorate problems and opportunities related to transitions into and out of police custody by people who have problems with drugs. This should include gathering information, across the UK, on:
    a. the levels of overdose and drug-related deaths in police custody and immediately afterwards; and,
    b. the coverage and effectiveness of Liaison and Diversion schemes in meeting the needs of arrestees with drug and alcohol misuse problems.

Conclusion

Transitions between custody and community are inherently risky. People with drug problems are particularly likely to experience such transitions, as they are frequently given short prison sentences for repeated acquisitive offences and are often recalled to prison from probation supervision in the community due to breaches of conditions. These transitions damage continuity of care, and so increase the potential for reoffending and relapse to problematic drug use. Short prison sentences are less effective than community penalties in reducing reoffending.

It is paramount that the government makes sure more is done to help prevent vulnerable people from relapsing after their release from prison.

Full Report Here

GOV.UK News Story

More ACDM Here

Photo by Jonathan Gonzalez on Unsplash

IMB Report: HMP Holme House 2018 – Health Summary

This report presents the findings of the Independent Monitoring Board at HMP Holme House for the period 01 Jan 2018 to 31 Dec 2018. IMB evidence comes from observations made on rota visits, scrutiny of records and data, attendance at various meetings, informal contact with staff and prisoners, prisoners’ applications and monitoring of areas of concern.

General Points:

In 2017 Holme House was chosen to pilot the concept of a Drug Recovery Prison (DRP) with an additional investment of £9 million provided by the Ministry of Justice (MOJ) and NHS England between 2017 and 2020. The objective is to test a whole prison approach to tackling both the supply and demand for drugs in prison, and to create an environment where opportunities for recovery can flourish.

The DRP Delivery Plan consists of four components: safety and security, care and well-being, community and environmental development, and continuity of care.

2018 saw significant and steady improvements in the stability and performance of the prison, characterised by a regular and consistent regime leading to a greater certainty for both men and officers alike.

Wing based community care is delivered by a dedicated healthcare team made up of DART nurses, recovery coordinators, mental health nurses, CRC and peer support.

The number of prisoners with a history of self-harm has been consistent throughout 2018 with approximately 250 prisoners in an average prison population of 1200. In 2018 there were 868 open ACCTs, a 6% increase over 2017, which remains an area of concern. The IMB has observed excellent examples of a caring and consistent approach to ACCT reviews.

There were 261 reported acts of violence in 2018, compared to 376 in 2017. Assaults on prisoners (including serious assaults) showed a downward trend in the second half of 2018. There were 98 reported prisoner-on-prisoner assaults in 2018 which is an ongoing cause for concern. Assaults on staff are an ongoing concern, with 16 reported incidents in the year. However, there is evidence of a downward trend in the last quarter of the year.

There were seven deaths in custody in 2018, five of which were due to natural causes. This compares to five deaths in 2017 when four were due to natural causes. Inquests into the other two deaths are currently ongoing.

Healthcare

Service Delivery Positives:

  • Screening for bowel cancer, retinal screening, diabetic screening and healthy heart checks continue to be part of the routine.
  • There have been some improvements in inpatient care, as a concerted effort has been made to remove prisoners with serious mental health problems to another provision, resulting in most of the beds being occupied by social or clinical need prisoners. A dedicated team of prison officers has also been established within the inpatient accommodation. A palliative care suite is available and there is close working with Teesside Hospice Care Foundation and Macmillan nurses.
  • There has been a significant reduction in the percentage of men not turning up to appointments from last year (18% in 2017 down to 6% in 2018). This improvement can be attributed to the improvement in the delivery of the regime in the prison this year.
  • The mental health team is fully staffed with nurses. psychiatrists, a speech and language therapist, a resettlement officer and counsellors from MIND. A range of group therapies are available to all men, including stress management, ’Hearing Voice’, team building and a well- being gym. Other therapies such as EMDR (eye movement desensitising reprocessing) are provided.
  • A speech and language therapist (SLT) is employed as part of DRP, working within the mental health team to work with men who want to improve their communication skills or have swallowing difficulties due to mental health or medical problems. Part of the work is about making information easier to understand and making Holme House a more positive place for effective communication.
  • The mental health team manager won the national Cavell Staff Nursing award during 2018, being the first mental health prison nurse ever to do so.

Service Improvement Opportunities:

  • The IMB does not consider that the services provided to prisoners by Healthcare are equivalent to those that prisoners would receive in the community, and in some instances they are considerably worse, with unacceptably long waiting lists.
  • Although this figure has improved, there are still unacceptable delays and at the end of the year men had to wait five to six weeks to have a GP appointment, with review appointments having an eight-week waiting list. There is some provision for urgent appointments with the GP.
  • Dental appointments are worse, with the end of year figure of 280 men on the waiting list for an initial appointment, which will take 21 weeks, with an ongoing treatment waiting time of eight weeks and dental therapy nine weeks.
  • A shortage of nurses has dominated the ability of Healthcare to deliver a fully effective service to the prison. There has been an average shortage of 10 nurses out of a total complement of 27.5. Bank and agency nurses cover the shortfall. This has impacted on attendance at GOOD and ACCT reviews as well as late delivery of medication and poor or late attendance in reception, causing disruption to the prison regime.
  • Medication is supposed to be delivered by pharmacy technicians. However, due to shortages of staff, nurses are deployed to this work, which adds to the shortages in other areas. Medications on two house blocks are combined due to the low number of men requiring not in-possession medication.
  • The IMB has observed problems with the health care complaint system, which is separate from the prison complaints system, is not well administered and does not appear to be monitored robustly, leading to long delays with responses. This is reflected in the high number of applications the IMB get relating to medical matters.

Conclusion

The IMB feels that Holme House has become a less volatile and dangerous place for both prisoners and staff in 2018. Staff training has been focused on violence and drug prevention, e.g. all safer custody staff are fully trained in engaging in Timewise, a violence reduction programme. A prison-wide focus on staff training on Five Minute Intervention [FMI] and key worker training under Offender Management in Custody [OMiC] have also contributed to this.

Holme House can present a very challenging and volatile environment. The IMB feels that due to the determination and effort of those who work there and with a more consistent application of assurance checking considerable progress has been made towards laying the foundations for improved performance indicators and a more safe and stable environment for all who live and work there.


Holme House IMB Report 2018

%d bloggers like this: