A qualitative exploration of the older prisoner health and social care assessment and plan (OHSCAP) in a “dangerous” prison system

ABSTRACT

Older prisoners are the fasted growing sub group in prisons across developed countries. They have high levels of health and social care needs in relation to their younger counterpart and those of the same age living in the community. There are a lack of interventions to ensure their needs are met. The older prisoner health and social care assessment and plan (OHSCAP) provided a structured process for addressing need and it’s effectiveness was evaluated in a randomised controlled trial (RCT). This paper presents findings from the nested qualitative study relating to this RCT. The aim of this study was to explore the facilitators and barriers to delivering the OHSCAP. Semi-structured interviews were conducted with twelve staff members delivering the OHSCAP and 14 service users who had received the intervention. The framework method was used to analyse the data produced. Participants described a ‘broken’ prison system. They discussed a staffing crisis resulting in individuals’ human rights being violated, which led to dangerous conditions in the prison. These conditions further impeding the staffing crisis, as recruitment was difficult and staff sickness was high. This ‘broken’ prison cycle significantly contributed to a lack of adequate attention being paid to OHSCAP processes. The delivery of health and social care interventions in prison is challenging when basic systems relating to staffing and safety are not adequate. Future research needs to consider how these circumstances can be mitigated.

KEYWORDS:

• Older prisoners
• assessment
• prison system
• danger

Introduction

A variety of conditions, particularly mental illness and infectious diseases are more common in incarcerated individuals than in the general population (Fazel & Baillargeon, 2011). Those aged 50 and over are particularly vulnerable; they have more complex health needs than their peers in the community and younger prisoners (Fazel, Hope, O’Donnell, et al., 2001). Around fifty percent of older prisoners have a diagnosable mental disorder, with depression being most common (Kingston et al., 2011). A 2001 study found that 85% of male prisoners over 60 had at least one chronic illness recorded in their medical notes. The most common illnesses were psychiatric, cardiovascular, musculoskeletal, and respiratory disorders (Fazel, Hope, O Donnell, et al., 2001).

The number of older prisoners in developed countries has risen in the last decade and is likely to continue to increase (Ministry of Justice. Prison Population Projections, 2018). There is no national strategy for the care of older prisoners, despite repeated recommendations for one to be developed (A. Hayes et al., 2013, 2013; A. J. Hayes et al., 2010, 2012; Crawley & Sparks, 2005, 2006; Her Majesty’s Chief Inspector of Prisons, 2008). Service provision is consequently generally ad hoc and uncoordinated with targets set out in the National Standards Framework for older people largely unmet in prisons (Prison HMI of, Commision QC, 2018). In addition, older prisoners often have complex social care needs there is ambiguity concerning what constitutes social care for this group and who is responsible for providing it (O’Hara et al., 2015; Tucker et al., 2018). It is argued that ‘Institutionalised thoughtlessness’ can lead to older prisoners being ‘doubly punished’ in prison. Firstly in relation their offence and secondly as a result of their complex health and social care needs that frequently remain unmet (Crawley, 2005). Older prisoners experience intense anxieties about release and they perceive their release planning to be non-existent (Forsyth et al., 2014).

Department of Health guidance recommends that older prisoners’ health and social care needs should be assessed, using a specialised assessment on entry into prison (Department of Health, 2007). However, in 2013 only 19% of prisons in England and Wales had introduced such an assessment and these assessments have not been formally (Senior et al., 2013). A more recent survey, conducted after the introduction of the Care Act (2014) detailing local authorities’ responsibility for identifying and addressing social care needs in prison, found that 65% of local authorities had introduced a social care assessment on prison entry (Tucker et al., 2018).

The data in this paper was collected as part of a larger study (Forsyth et al., 2017) which aimed to evaluate the effectiveness and acceptability of the Older prisoner Health and Social Care Assessment and Plan (OHSCAP) in a randomised controlled trial (RCT). The OHSCAP is a structured approach to identify and manage older prisoners health and social care needs (Forsyth et al., 2021). It includes an assessment, care plan and review of these (please refer to Forsyth et al., 2021 for full description), This paper explores the experiences of older prisoners and staff of facilitating and receiving the OHSCAP.

Methods

We have adhered to the American Psychological Association’s Journal Article Reporting Standards for qualitative research (JAR-Qual) (Levitt et al., 2018). Ethical approval for the study was granted by the Research Ethics Committee (REC) for Wales in May 2013 (reference number 13/WA/0108). National Offender Management Service (NOMS) research approval was provided in July 2013 (reference number 2013–115). The trial was registered with the ISRCTN (reference number ISRCTN 11,841,493). Additionally, all required site-specific permissions and research governance approvals (R&D) were obtained from the relevant NHS trusts, prison governors and healthcare managers.

Written informed consent was sought from all potential participants prior to their taking part. Researchers explained the project, provided an information sheet and described the relevant ethical rights as part of the consent process. Sensitivity was shown to the high levels of learning difficulties and vulnerability in this population, with researchers reading and explaining the information sheet where required and remaining aware of the potential for any coercion.

For context, this paper presents the findings of a nested qualitative study. The overall study consisted of a parallel two group RCT with 1:1 individual participant allocation to either the OHSCAP intervention plus Treatment as Usual (TAU) (intervention group) or TAU alone (control group).

Semi-structured interviews were held with staff delivering the intervention. A purposive sampling approach was adopted ensuring prison and healthcare staff were included. Prisoners from all of the 10 sites were also interviewed. The sample was also purposive, and attempts were made to included prisoners with a range of ages, and health and social care needs.

The interview guide format followed the OHSCAP process itself (identifying older adults, health, social and wellbeing issues, care planning and reviews) to ensure that all relevant issues were covered. Prisoners were interviewed between one and four times (mode = 2). They were interviewed as soon as possible after they entered the prison, then immediately after they had received the initial OHSCAP and, if they remained in prison, we went back to interview them after 2–3 months. All interviews with staff were audio recorded and lasted for approximately 1 hour.

All interviews were analysed thematically. This approach is the most commonly used form of qualitative data analysis and was used to identify, analyse and report patterns (themes) within the data (Boyatzis, 1998). Thematic analysis was adopted because it is simple, flexible and has the ability to generate findings that are accessible to practitioners and policy makers (Braun & Clarke, 2006). The framework method, a specific form of thematic analysis (Gale et al., 2013), was used to produce a matrix of summarised data, providing a structure to analyse and reduce the data. It also allowed systematic constant comparisons across cases to refine themes. This method has also been successfully adopted in other prison based studies (Lennox et al., 2020; Tompkins et al., 2007).

Gale et al (2013) proposed a seven-stage approach for applying the framework method that was followed within this study. Stage one involved transcription of the data. Transcriptions were produced by professional transcribers for pragmatic reasons. Transcriptions were produced in vivo, however the focus was on verbatim content rather than pauses and tone. During the second stage, the researchers conducting the analysis familiarised themselves with the whole interview. Coding commenced at the third stage of the process to classify the data so that it could be systematically compared. The first few transcriptions were coded by two researchers who both coded the same transcripts to aid rigor. This involved applying a label that described the aspects of the transcripts that were considered to be important. Codes were developed throughout the process and included behaviours, incidents, structures, values and emotions. The coding was conducted using the computer software NVivo (version 10) to assist with the organisation of the data. Stage four encompassed developing a working analytical framework. After the initial few transcripts were coded, codes were discussed, and a final set of codes were developed that were applied to the analysis of all subsequent transcripts. The constant comparison method was used to achieve this (Gale et al., 2013). Constant comparison methods involve both the fragmenting and the subsequent connecting of data. Pieces of data are coded and separated from their original interview transcript. Extracts are then compared and combined with other fragments until connections are made to help the researcher understand the overall picture of what the interviewee has said. Numerous adaptations were made to the analytical framework throughout the analysis process until no new themes emerged. An ‘other’ category was developed to include data that did not fit the analytic framework that was revisited a number of times. During stage six, a framework matrix was developed in NVivo and data was charted into the matrices. This involved summarising the data by category for each transcript. It was important to try to achieve a balance between reducing the data and maintaining the meaning of the data. The chart will include references to illustrative quotations. The final stage seven involved interpreting the data. Impressions, ideas, and early interpretations of the data were noted throughout the data generation and analysis process. Analytical memos were written and discussed with the wider research team throughout the data collection and data analysis process.

A key benefit of this approach, in comparison to other forms of thematic analysis, is that the context of participants’ data was not lost because it could be connected to other sections of their transcript across the matrix. The framework approach is not limited to a particular epistemological, philosophical or theoretical approach but is a flexible tool that can be utilised within many different types of qualitative studies. It was useful for this study because it allowed the inclusion of some key predefined themes and allowed others to be developed through the data. The research team wanted to ensure they learnt about the OHSCAP process and therefore included the pre-defined themes of facilitators and prisoner involvement. Facilitators was included as a pre-defined theme because the use of prison officers delivering health and social care initiatives was novel and it was important that we captured the acceptability of this. ‘Prisoner involvement’ was included because within our previous work, this was an important aspect of the intervention.

Findings

Semi-structured interviews were held with staff delivering the OHSCAP, including prison officers (n = 5) and health-care staff (n = 7). All five prison officers worked in safer custody or diversity and equality teams. Three had the specific title of Disability Liaison Officer. The health-care workers interviewed included health-care assistants (n = 3), general nurses (n = 2) and a mental health nurse (n = 1).

Additionally, semi-structured interviews were held with 14 prisoner participants who had received the OHSCAP. The prisoner participants ranged in age from 50 to 69 years (mean = 58 years). The most common index offences were sexual (n = 5) and drugs offences (n = 5). The majority had been imprisoned between one and eight times previously (n = 11). Two of the prisoners had not been incarcerated previously and one had been imprisoned on > 10 previous occasions.

Themes

Participants described a ‘broken’ prison system. They discussed a staffing crisis resulting in individuals’ human rights being violated, which led to dangerous conditions in the prison which further impeded the staffing predicament as recruitment was difficult and staff sickness was high. This ‘broken’ prison cycle significantly contributed to a lack of adequate attention being paid to OHSCAP processes. This cycle is presented in Figure 1 and the details are discussed below. Prison staff and healthcare staff, as well as prisoners themselves, described consistent themes, with minimal difference across roles. This was because the issues highlighted were prison wide affecting all staff and prisoners. Data saturation was therefore reached.

Figure 1. ‘Broken’ prison key themes.

Staffing crisis

Prison and healthcare staff, as well as those residing in prison, described a staffing crisis. This consisted of staff shortages, low morale, high stress levels, and difficulties with tendering and privatising health care services.

Staff shortages

Participants explained that the staff reductions had occurred because of the ‘benchmarking’ programme. This initiative involved changing the prison regime to reduce staffing and associated costs. This was deemed, by both prison and health-care staff, to have had a negative impact on the care of prisoners of all ages but the impact was more striking for vulnerable individuals, such as those aged 50 and over, because of their higher level of health, social; and custodial need.

All the prison officers delivering the OHSCAP were based within wider safer custody and diversity teams. These teams conducted a variety of tasks to support prisoners. This included monitoring prisoners who were at risk of suicide and self-harm, resolving bullying issues and assessing the needs of prisoners with disabilities. The prison officers employed within these specialised roles, described how they were frequently redeployed to general wing security duties, resulting in them being unable to appropriately support vulnerable prisoners, including older adults. Furthermore, this redeployment occurred with minimal notice, as one participant described below:

I’ve had probably 10 hours in my job this month in 23 days. Ten hours and you’re just playing catch-up all the time and that’s when you start missing things. I like … I love this job, or like/love. If I could do it properly but I don’t feel I can do my job properly. It’s redeployment, it just, it messes you up.

Prison officer 7

So how much notice would you get if you’re going to be redeployed?

Interviewer

About a minute

Prison officer 7

The Disability Liaison Officer was a role that was lost in many establishments, as part of the benchmarking process. It was initially intended that it would be the individual in this role that would lead the OHSCAP. Where the role did still exist, often staff members were being redeployed to standard prison officer duties for the majority of their working week, as one DLO described below. This had a major impact on the ability for them to complete the OHSCAPs, even though they were willing to do so and perceived there to be value in the process.

So, at the minute it’s probably half to 75 per cent of my time I’m getting redeployed to other wings.

Prison officer 4

In addition to the loss of prison officers, there were staff shortages in healthcare, largely as a result of being unable to fill vacant positions. This placed further strain on staffing across the prison estate and impacted upon the general mood of the prison staff and prisoners. One individual described the challenge of attracting suitable candidates for vacant healthcare positions.

They’ve shortlisted about three or four [potential healthcare staff members] each time, there have been three sessions and not one’s turned up.

Healthcare Worker 3

Low morale

Six out of the 11 staff participants interviewed were in the process of leaving their job role, three of whom were leaving the prison service altogether. They referred to the current staffing crisis as the main explanation for their departure. Staff members stated that there was extreme low morale among the workforce due to the recent drastic reductions in staff numbers and the added pressures this placed on them. As one health-care assistant surmised:

I’m totally disillusioned by it all

Health-care worker 5

A further member of healthcare staff described how the staffing difficulties amongst custodial staff had created substantial changes to the workforce resulting in low morale amongst healthcare staff too:

And the prison staff aren’t happy, I think as well, ‘cause they’ve had a lot of changes so they’re feeling very negative about things, and it has a knock-on effect really doesn’t it?

Health-care worker 4

Stress

Staff members stipulated that staff shortages were having a negative impact on their own physical and mental health. Prison officers and health-care staff described how staff shortages were causing high levels of stress among their colleagues, because individuals were having to complete the workload of more than one individual resulting in high levels of staff absence:

Staff are stressed, sickness has gone up massively. Plus you’re doing three people’s jobs instead of one person’s job and you can’t, it’s a lot to deal with, it’s a lot to deal with.

Prison officer 3

The older adults who were interviewed, had also noticed the marked increase in the stress levels of staff members. Prisoners described the high levels of stress among prison officers, and how this led them to be less likely to request support or approach prison officers for advice. As one older adult stated:

They [prison staff] don’t come in to ask how I am, they don’t care. If you ask too much, the officers go angry because they had too many people come asking, all complaining.

Prisoner 7

Tendering of healthcare services

Challenges in relation to prison health care services, being regularly tendered with subsequent changing providers with the associated disruption to services, was discussed by both prison and healthcare staff. Such disruption, leads to interventions such as the OHSCAP which are not seen as essential, not continuing as intended as healthcare services struggle to maintain vital services. Healthcare Worker 4 below describes one example of the challenges they faced when their prison pharmaceutical services changed to a private provider.

Now they [management] come along with some bright idea to give it [pharmacy] out to tender and … what happens now is the doctors give us the prescription, we give it to the pharmacist, she scans it, faxes it off to [name of pharmacy] … Anyway nine times out of ten, the medication doesn’t arrive, so you’re left then with prisoners spitting in your face, almost, like with anger that their medication hasn’t arrived, which is no fault of ours … If it’s lotions and potions, you can get round that kind of thing, but if it’s anti-convulsion medication or anything like that, you’re struggling.

Healthcare worker 4

The impact of having a prison pharmaceutical service that is failing to provide medication in a timely manner is vast. The person quoted above eludes to how older adults with serious medical conditions can be affected by this system without any power to fix it, resulting, in some cases to violent behaviour. Thus, tendering ill managed prison services, particularly one so crucial as a pharmacy, can have a detrimental impact on the whole prison population and consequently on low staff morale. Such changes and problematic services impact the way in which staff are able to address issues that arise during the OHSCAP process.

Violation of human rights

Participants stated that individuals living in prison were having their human rights infringed largely due to staff shortages, in relation to a lack of socialisation opportunities, education, employment and even an inability to regularly access adequate washing facilities. When such basic needs are not being met, it was difficult for OHSCAP facilitators to prioritise conducing OHSCAP assessments and care planning. Therefore, completion of the OHSCAP was frequently not undertaken.

Lack of socialisation

Both prisoners and staff described how current staff shortages were resulting in prisoners’ basic needs frequently not being met. For example, individuals were having limited or no ‘association time’ (i.e. time to socialise on the wing playing pool and mixing with other residents.) They were also having less time to call family members which was an important, and frequently only, way of staying in touch with the outside community.

Well, … we’ve heard the prisoners saying that it’s going to ‘go off’ [going to be a riot] soon because they’re always locked behind their doors, because they’re getting back from work, they’re getting locked up, they’re not even able to, make a phone call, it’s all those little things that mean a lot to people.

Prison officer 3

The implications of the reduced socialisation time for those living in prison, has detrimental consequences to the safe running of the prison. Consequently, the completion of the OHSCAP was not seen as important and could not be prioritised at this time.

Unable to meet hygiene needs

Limited time outside of their cell caused by changes to the routine to facilitate staff reductions meant that prisoners had minimal time to shower. Prison staff were consequently unable to meet very basic hygiene needs.

I’m using wet wipes to shower still. There is a wet room on A wing and they [prison officers] say they’ll give me access but it’s when they’ve got time on their hands.

Prisoner 8

Therefore completing OHSCAP assessments were considered a ‘luxury’. This perception meant facilitators’ motivation for completing OHSCAP assessments was often limited. For vulnerable prisoners, such as those that are older with mobility difficulties, this meant further challenges to ensuring their basic hygiene needs are met. One prisoner, who suffered from mobility difficulties, described how a lack of available prison officers to take prisoners to a suitable, safe shower facility meant that they were unable to have their basic hygiene needs met:

Dangerous conditions

Staff and prisoners discussed the perceived dangers of prison in relation to physical violence and with the introduction and increased use of the synthetic cannabinoid substance which was frequently referred to as ‘Spice’. Coping with these dangerous situations, which were more prominent in prisons that housed those received straight from court, were a daily struggle and surpassed the need to complete OHSCAP assessments which were viewed, by prison and healthcare staff, as a ‘[luxury’.

Violence

Individuals were being locked up in their cells for longer periods of time and were becoming more violent, particularly with prison staff. This reduction in time out of cells, accompanied by reduced staffing was creating an environment where violence could prevail. This was considered to have had an impact on day-to-day prison practices, as illustrated by this prison officer’s quotation:

The staffing levels are just ridiculous, to be honest, every day there’s a wing shut down because there’s no staff, prisoners are noticing it, prison officers are stressed, it’s dangerous at the minute, to be honest, the staffing levels.

Prison officer 3

The example provided by prison officer 3 above helps to explain the vicious cycle of reduced staffing levels in prisons, creating reduced association times for prisoners, which increases violence in the long term. This then increases staff illness and reducing morale, resulting in less individuals wanting to become prison officers or remain in the profession. This has consequences for all types of interventions in prison.

Some prison officers expressed concerns that the current prison environment was a dangerous place to work. Consequently, staff would prioritise remaining safe over meeting prisoners’ health and social care needs and the completion of the OHSCAP. Therefore, although they were willing to conduct the OHSCAP assessments, such action was a low priority and therefore often remained incomplete, or completed to a limited extent

I think some people [prison officers] kind of come in and just think, as long as I go home at the end of the day safe then it’s alright.

Prison officer 8

‘Spice’

Spice is a synthetic cannabinoid which was thought to be having a serious detrimental impact on the management of prisoners, more than any other substance had previously. Staff and prisoners talked of the dangers of ‘Spice’. It was thought to increase violence on the prison wings and drastically increase the number of prisoners being sent to hospital via ambulance. This added to general disruption and prevented the prison regime from being run as ‘normal’. For example, the regular use of Spice amongst prisoners had resulted in them being held in their cells for longer periods of time. This created further frustration amongst the prisoner population and led to more aggressive and violent behaviour. The use of Spice therefore impacted on the morale of staff and prisoners and the day-to-day running of establishments. This impeded the ability and willingness of staff to complete tasks that were seen as non-vital, such as the OHSCAP. Some older adults could be victimised because of their vulnerability. One older adult discussed an incident when they are deceived into smoking Spice.

Cause some people were giving me spice and I didn’t know what it was. People just gave me, like, a rollie and I smoked them and I went under. I nearly died. And then tried to kill myself … .

Prisoner 6

Participants discussed how older prisoners were particularly vulnerable to victimisation in the way described by prisoner 6 above. Therefore, older adults were being effected by the use of synthetic cannabinoids in two ways. Firstly, there were victims of unknowingly ‘testing’ it and secondly, the chaos it caused in the prison was preventing their health and social care needs being prioritised.

Discussion

Summary of findings

This nested qualitative study was conducted alongside a randomised controlled trial (RCT) to assess the effectiveness of the OHSCAP. The RCT found no significant differences between the OHSCAP and TAU group (Forsyth et al., 2021). However, an audit of the assessments produced as part of the OHSCAP found that the OHSCAP was not delivered as intended (Forsyth, Swinson, et al., 2020). The nested qualitative study encompassed semi-structured interviews with staff delivering the OHSCAP and those receiving the intervention. The key theme arising from the transcripts was the ‘broken’ prison system that impeded the successful implementation of the OHSCAP. Key sub-themes included staffing issues, violation of human rights; and dangerous conditions. These themes relating to the broken system were cyclical and inter-related.

The reduction in prison officers due to benchmarking process and the difficulties in recruiting healthcare staff impacting on running the prison. This in turn had implications for the whole prison regime and meant residents spent more time in their cells. Furthermore, residents’ human rights were infringed as they had limited access to washing facilities and socialising opportunities. The anger and frustration this created, accompanied by a reduction in prison officers resulted in dangerous conditions with physical violence and the increased use of cannabinoid substances. This higher risk situation further impeded staff shortages with low morale and staff opting to leave the prison service. These cyclical challenges facing staff meant OHSCAP completion was a low priority and, in some instances, deemed impossible to fully complete.

Comparisons to the literature

Staffing

Low morale amongst prison staff has previously been recognised (Hayton & Boyington, 2006). Prison officers deem their occupation to be undervalued and underappreciated (Crawley & Crawley, 2013). The current study was conceived and in process at a time when the then coalition government introduced policies with the intention of reducing the full-time equivalents of staff across Her Majesty’s Prison and Probation Service (HMPPS), with alterations to the prison regime, to reduce costs. This likely impacted in a negative way on morale.

Data collection itself was undertaken when the benchmarking process came into operation. Findings from this study suggest, this bench marking process led to reduced morale amongst prison staff, which impacted upon willingness and ability to deliver on multi-discipline health and social care interventions, such as the OHSCAP.

A further change to the prison landscape during the study time period was the introduction of the Care Act (2014). The Care Act placed a number of new duties upon local authorities in England, including a historic change in their responsibility for adults in prison, a previously little-accessed group (Department of Health, 2012). Since April 2015 local authorities with prisons in their catchment area have been responsible for identifying, assessing and meeting the eligible social care needs of people in custody (Department of Health, 2012). The Care Act came into force in April 2015, during the data collection period for this study. Little is known about the different models of social care adopted in prison (Tucker et al., 2018). Research suggests there is a lack of active case finding to ascertain levels of social care need in prison (Forsyth, Heathcote, et al., 2020). The OHSCAP provides one was of establishing active case finding, if it is implemented as intended.

Human rights

Concerns about the human rights of older adults residing in prison are well documented (Crawley & Sparks, 2005; Human Rights Watch. Old Behind Bars, 2012; Maschi et al., 2012, 2014). Previous research has emphasised the way in which the system prevents older prisoners from accessing equivalent services to their age-matched counterparts living in the community (Maschi et al., 2014). It also highlights how the lack of adaptations, to the regime and environment, means that older adults’ human rights are effected (Crawley & Sparks, 2005). This research, however, has shown how even the most basic needs of all prisoners, such as access to washing facilities and time out of cells, often goes unmet. The impact of this, is that interventions, such as the OHSCAP, are often seen as ‘luxury’ services, when in reality it is a simple means of ensuring older adults health and social care needs are met.

Dangerous conditions

Over the last seven years, safety in prison has deteriorated rapidly, with both staff and prisoners feeling less safe than at any time since records began (Prison Reform Trust, 2019). Rates of self-harm are the highest on record, more than doubling between 2012 and 2018 (267/1000 to 667/1000) (Prison Reform Turst, 2008). Equally, assaults on staff have more than tripled between 2013 and 2018 (3266 to 10,213). HMCIP has stipulated that prisons in England and Wales, are currently ‘unacceptably violent and dangerous’ (HM Inspectorate of Prisons Annual Report 2015–16, 2016). The House of Commons Justice Select Committee has stipulated that ‘The key explanatory factor for the obvious deterioration in standards over the last year is that a significant number of prisons have been operating at staffing levels below what is necessary to maintain reasonable, safe and rehabilitative regimes’ (HMPPS, 2018). Furthermore, the evidence reports these research findings that Spice was entrenched in the prison system from 2014 and that the problem is growing (Ralphs et al., 2017). The catastrophic outcomes of Spice engulfing the prison population include increased violence, self-harm, suicide and mental health difficulties (Adrienne, 2015; Ralphs et al., 2017). This data on safety supports the findings of this study that the prison system in England and Wales was undergoing a significant crisis during the data collection phase of this study and beyond, which was likely to have impacted upon the effective delivery of the OHSCAP as well as other health and social care interventions.

In 2004, Her Majesty’s Chief Inspector of Prisons entitled their report ‘no problem – old and quiet’ after an entry that was found in an older prisoner wing history sheet (HM Inspectorate of Prisons, 2004). The authors of that report felt it aptly summarised how older adults’ needs were often neglected because they cause no control issues for staff. Our findings go further to suggest that those tasked with supporting older adults are frequently prevented from doing so, due to the conditions they are working under.

Implications

Health and social care initiatives in prison are reliant on previously established mechanisms and staffing within a secure and limited environment.

1. Prisons should be adequately funded to provide equivalence of care to those residing in the community.

2. To maximise the impact of interventions in prison, future health and social care services should attempt to minimise reliance on previously established services and staffing where possible.

3. Further research should explore and identify the role that other prisoners and third-sector organisations (such as older adult specialist services) could play in identifying and appropriately addressing older prisoners’ health and social care needs.

4. A national strategy for older individuals residing in prison is required to ensure the meeting of older adults health and social care needs is mandatory.

Future research

Research in prison and, perhaps most acutely, the conduct of RCTs in prison, is challenging. Sometimes changes to the landscape may occur as a result of positive policy initiatives. For example, a RCT conducted by Abel et al. among women who repeatedly self-harm was affected by the publication of the Corston Report on women’s imprisonment, which made numerous recommendations for a holistic person-centred approach in supporting female prisoners (Abel et al., 2015). Consequently, general improvements were made to support women in prison at risk of suicide and self-harm across England and Wales, and the added benefit of the introduction of the Women Offenders’ Repeated Self-Harm Intervention Pilot was not established. However, other RCTs conducted by our research group have been affected in more negative ways. For example, the current study was affected by the loss of the dedicated time given to prison officers and others as older prisoner leads and/or DLOs, meaning that the individual role identified in the pilot study as core to the OHSCAP process simply no longer existed in many establishments. Where it did still exist, individuals within the role were often redeployed to other largely security related duties. Other trials into through-the-gate support to promote engagement with mental health services for people with serious and/or common mental health problems have been similarly negatively affected by reduced staff time and availability.

The quite dramatic shift in the prison landscape throughout this study illustrates the challenges of conducting an RCT in a real-life setting. It may have been possible to fund a designated role to deliver the OHSCAP for the duration of the trial, which may have reduced some of the problems with staffing shortages, but wider staff shortages would still have had an impact on the ability of the OHSCAP facilitator to make referrals to other services, etc. Furthermore, it is likely that such funding would not have been made available after the study ended, so the effectiveness of the OHSCAP would not have been evaluated within a real-life setting.

The conduct of this research highlights fundamental issues relevant to future research in particular, and to service improvement initiatives more generally in prisons and, by logical extension, the NHS, during times of public service cuts and austerity. This research was commissioned by NIHR at a time when the problems faced within prisons regarding the care of older people had clearly had an impact on regimes, gained recognition from managers, commissioners, civil servants and politicians, and become a routine consideration during inspections by Her Majesty’s Inspectorate of Prisons. We have discussed the day-to-day negative impact that staff cuts and reduction of specialist officer roles had on our ability to trial the OHSCAP intervention, which maintained fidelity to the research protocol. This may, of course, be only a partial explanation for the failure of this intervention, but it is undoubtedly an important part of the overall problem. It became clear that, as a result of staff cuts and a number of other changes, frontline staff struggled to be mentally receptive or physically resourced to work with the research team.

Conclusion

The RCT found no significant differences in the meeting of older adults’ health and social care needs between the OHSCAP and TAU group. The fidelity of implementation audit identified that the OHSCAP was however, fundamentally not delivered as intended. The nested qualitative study reported in this paper found that a fundamental reason for this was the ‘broken’ prison system. The system was experiencing significant strain because of reductions in staffing levels, as part of austerity measures. Participants perceived this to be impacting upon low morale, violating human rights and resulting in dangerous conditions. Considering this context, it is not surprising that the OHSCAP was not delivered as intended. Future health and social care interventions should consider the appropriate use of the third sector and peers/buddy schemes to reduce the impact of austerity measures on vulnerable populations, including older adults. However, without significant funding and an increase in prison officers, health and social interventions in prison will be negatively impacted upon. The findings of this paper are largely applicable to public health settings in general. Interventions will be of limited benefit when basic systems relating to staffing and safety are not adequate.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The work was supported by the Health Services and Delivery Research Programme [12/5001/21]; National Institute for Health and Care Research [12/5001/21]; HS&DR Programme NIHR [12/5001/21]; NIHR [12/5001/21].