Elderly prisonersBMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e6263 (Published 15 October 2012) Cite this as: BMJ 2012;345:e6263
Older prisoners are now the fastest growing subgroup of prisoners in England and Wales.1 There are about 8000 prisoners aged 50 and over, comprising 11% of the prison population,1 and many have multiple health and social needs.
Some of the rise in older prisoners is attributable to the overall growth of the prison population,2 which has doubled in the past 20 years.3 The increase in older prisoners, however, outstrips that of other groups (fig 1⇓).2 A key factor seems to be a greater inclination on the part of the authorities to secure convictions against sex offenders.4 Forty two per cent of men aged over 50 in prison have convictions for sexual offences (table 1⇓).1 5 Sexual offenders are given long sentences, and advances in forensic science mean that it is possible to secure convictions for “historical” crimes.4 When it comes to sentencing, the age of an older offender rarely has any bearing.6
For researchers, “older” prisoners are aged 50-60 and above.7 Although a 50 year old man in the community would not usually be described as old, observers suggest that typical prisoners are functionally older than their chronological age. This is as a result of their previous lifestyle, lack of prior medical care, and the experience of incarceration.7 8 9
Most prison research has focused on young men, with older prisoners seldom included.10 There is a lack of knowledge concerning best practice around the imprisonment of older people. Older prisoners’ health, social, and resettlement needs are not completely understood,11 and policy tends to be local and responsive.11 There is no national strategy, and only one national initiative: a unit at Norwich prison that holds elderly prisoners on life sentences who have healthcare requirements.
No place for old men
A prison is a particularly difficult place in which to be old. The needs of older prisoners are often overlooked, as many pose no obvious behavioural problems for the prison authorities 12. The physical frailty of older prisoners is a disadvantage when they are incarcerated alongside younger prisoners, and bullying and victimisation can be a problem.7 In addition, because older prisoners are over represented among sexual offenders, other prisoners may assume that an older prisoner is a sexual offender purely on account of his age. This places many older prisoners at the bottom of the prison social hierarchy.7
Stuart Ware served 12 months of a 21 month sentence for theft and fraud in Bedford Prison in the late 1990s, when he was in his late 50s. He has since set up a support network for older prisoners13 and is a consultant to the Department of Health. While in prison Ware was shocked at how older prisoners were looked after. He tells me that the situation has since improved, especially with regard to healthcare. Nevertheless, he points to examples of the problems that older prisoners still face.
Certain problems have historical origins. “By and large prisons are Victorian and designed for housing fit young men,” says Ware. “They are poorly placed to meet the needs of older prisoners, particularly if they are disabled.” The 2010 Equality Act applies to prisons and requires them to take reasonable steps to ensure that a disabled prisoner is not disadvantaged by his or her disability. For example, all areas of the prison should permit wheelchair access, allowing the use of showers, educational facilities, and association with other prisoners. However, prisons struggle to meet these requirements.14
Ware gives the example of Dartmoor Prison. Although aspects of Dartmoor’s care of older prisoners are cited as examples of good practice,15 it is constrained by its buildings. Five storeys tall, the prison was built in the early 1800s to house French prisoners of war. “Prison cells are not sufficiently large to allow disabled access,” says Ware. “Prisoners leave their wheelchairs outside their door.” The Inspectorate of Prisons reports a lack of adaptation of cells and communal areas in around half of prison inspections.14
Inspection reports also relate that most prisons have no separate activities for older prisoners.12 14 Older prisoners may be excluded from general activities because of their frailty and can remain locked in their cells.14
Although older prisoners’ health compares unfavourably with that of people of comparable age living in the community, as well as with that of younger prisoners,16 there is no requirement for regular health monitoring. A 2001 study found that 85% of male prisoners over 60 had at least one chronic illness recorded in their medical notes, and 83% reported at least one long standing illness. The most common complaints were psychiatric, cardiovascular, musculoskeletal, and respiratory disorders.16 A 2004 inspectorate report concluded that “Management of chronic diseases varied, and could be undermined by prison moves.”12
The prevalence of mental health problems among older prisoners is five times that of a similar community sample.17 Thirty per cent of prisoners aged over 60 meet the criteria for major depression,17 18 most of which goes untreated.17
The number of older women in prisons is also increasing in absolute terms and as a proportion of the total female prisoner population (fig 2⇓). As in male prisons, physical infirmity of female prisoners is poorly accommodated. “Older women receive little attention in prison,” says Azrini Wahidin, reader in criminology and criminal justice at Queen’s University Belfast. “Younger women monopolise time and resources.” There are no specialist units for older women prisoners.
“Becoming ill is one of older women prisoners’ greatest fears,” says Wahidin. “They know that they will become dependent on a system that is overstretched and under resourced.” Wahidin has found that older women prisoners report inconsistent access to breast and cervical screening, that medication fails to follow them when they are transferred, and that special diets are rarely accommodated.8 The Inspectorate of Prisons found provision of preventive care, such as screening, to be “very mixed.”12
Terminal illness and dementia
Given the age of some prisoners, and the length of their sentences, age related deaths in prison are inevitable. Nigel Newcomen is the prisons and probation ombudsman for England and Wales and is responsible for investigating all deaths within the criminal justice system. “Previously most deaths in prison were self inflicted,” he says, “but now we are investigating an increasing number of deaths from natural causes.”
Prisons’ ability to provide end of life care is “still in its early stages, although it is improving,” says Newcomen. Some prisons have links to local hospices,20 and others have dedicated facilities. Isle of Wight Prison, for example, has a large population of older prisoners and a King’s Fund financed bed for prisoners requiring end of life care. Nevertheless, the overall provision is patchy. Between 2007 and 2010, 113 prisoners had end of life care plans, but in almost a fifth of these cases the planned care was not equivalent to that available in the community (Prisons and Probation Ombudsman, unpublished data). Where palliative care expertise is lacking, prisoners may die in either a hospital wing or a regular cell rather than in a dedicated facility.21
Applications for compassionate release can be made when a prisoner is in the final stages of a terminal illness.21 In practice this is allowed in only a fraction of cases. Of the 113 prisoners receiving end of life care, only 22 were released on temporary licence at the time of their deaths.20 One explanation is the difficultly in predicting prognosis.21 Another is the need to reconcile security, punishment, and compassion.
There is also a view that it is inappropriate to release some prisoners to die. “Some of our prisoners have no family, and the prison is their home,” one governor told me. Guards escort prisoners if they are taken to a hospice but “primarily for emotional support rather than security.” This approach makes some sense, although it is questionable whether it can justify continued imprisonment.
“The prison regime can easily hide signs and symptoms of dementia,” says Nick Le Mesurier, freelance researcher and honorary lecturer at the Faculty of Health, Staffordshire University. “The rules in prison are constantly reinforced and prisoners have to make few decisions for themselves.” One study found dementia in 2/203 prisoners aged over 59,17 but otherwise the subject has attracted little research attention. “Estimates for dementia are likely to be on the low side,” says Le Mesurier. “Prison services are often poorly equipped to recognise and deal with something like dementia, which has a slow developing, chronic nature.”
Failing to provide social care
Some prisoners have social care needs requiring help with getting dressed, keeping their cells clean, and personal hygiene. At present it is unclear whose responsibility it is to fund services to meet these requirements.9 The National Service Framework for Older People states that older prisoners should have access to the same quality of healthcare as people in the community, but it does not suggest a similar commitment for social care.9 Many older prisoners’ social care needs are largely unmet.22
Current legislation makes local authorities responsible for assessing prisoners’ needs and providing community care services.9 “However, local authorities are engaging with very few prisoners,” says Ware. “They argue their only responsibility is towards prisoners who are ordinarily resident in their area. Prisons routinely hold people from all over the country, and many prisoners are excluded.”
“Primary care trusts and prisons are providing most social care” says Ware, “and prison officers or other prisoners are acting as carers.” The drawbacks of this are obvious—this is not their core role and individuals may lack suitable training. “It may be appropriate for one prisoner to carry out some tasks for another less able prisoner. but more personal tasks are also taken on,” says Ware.
The 2010-11 ombudsman’s report describes the experience of one prisoner who volunteered to act as a carer for an elderly prisoner with complex medical needs.21 Although the volunteer had cared for his parents in ill health, he had no formal experience or healthcare qualifications. The report says, “He was expected to shower Mr J, and often had to clear up his incontinence, among other difficult duties. He told the investigator that he felt isolated and unsupported by staff. Officers and healthcare staff did not take responsibility for Mr J’s complex and demanding needs.”
Release can also be a time of acute difficulty because older prisoners are often institutionalised and lack the skills for independent living.10 Their release may be subject to conditions that prevent them contacting their families, and some will have lost all their possessions while in custody.10 Yet social services often have little involvement in plans for release,14 and anecdotally local authorities have been known to refuse social care funding for newly released prisoners. This issue can be particularly acute for older prisoners, who may need a greater level of support because of their age.
Current social care reforms may change matters: the July 2012 white paper Caring for Our Future proposes that the government will develop “a new framework for the provision of care and support in prisons, so it is clear where responsibility lies.”23 One solution is for social care responsibility to be transferred to healthcare providers. However, the current unsatisfactory and ad-hoc arrangements will continue for some time to come.
Lessons from the United States?
British prisons have been slow to recognise and act on the needs of older prisoners. Special facilities for older prisoners are more established in the United States, where people aged 55 and over account for 8% of the prison population.24 As ageing prisoners develop an increasing need for medical care and assistance they are often placed in facilities where older and disabled prisoners predominate.24 Texas has special geriatric units for prisoners aged 60 and above, where they are given greater time to attend to the activities of daily living. The state also has a “higher level geriatric facility” that provides access to specialist services such as physiotherapy and dialysis.24
Britain is locking up increasing numbers of older people, but the British prison system is poorly equipped to deal with them. Prison buildings are often unsuitable for elderly people. Comprehensive data on older people as they move through the criminal justice system are not available.25 Current evidence is that the health of older prisoners is often poor, their social needs are inadequately addressed, and end of life care requires further attention. Given these problems, a national strategy is long overdue.
There are arguments for and against treating older prisoners as a separate group.11 Some may wish to remain part of mainstream prison life,10 and specialist units will mean that many prisoners will be held further from home.11 But separate units prevent abuse by younger prisoners and allow a greater focus on older prisoners’ needs.
In the absence of any fundamental change in policy or shift in sentencing guidelines, the phenomenon of older prisoners is here to stay. But questions concerning the appropriateness of imprisoning older people should also be central to the development of a coherent strategy for managing older prisoners and their needs effectively.
Cite this as: BMJ 2012;345:e6263
This is the second in a series of articles examining the challenges of looking after prisoners’ health
I thank the following people for help with this series: Louis Appleby, national director for health and criminal justice; Annie Bartlett, clinical academic and clinical director; Michelle Baybutt, programme lead, Health, Inclusion & Citizenship, Lancashire University; Marcus Bicknell, chair, Royal College of General Practitioners secure environments group; Luke Birmingham, consultant forensic psychiatrist, Southern Health NHS Foundation Trust; Rex Bloomstein, documentary filmmaker; Richard Byng, senior clinical academic in primary care, Institute of Health Service Research, Peninsula College of Medicine and Dentistry; Clive Chatterton, former prison governor, HMP Styal; Angela Clay, chairman, Association of Members of Independent Monitoring Boards; Sally Cottrell, head of evaluation, Avon Primary Care Research; Andrew Coyle, former director, International Centre for Prison Studies; Graham Durcan, associate director, Criminal Justice Programme; Dawn Edge, research fellow, University of Manchester; Tim Exworthy, consultant forensic psychiatrist, St Andrew’s Hospital; Helen Fair, research associate, International Centre for Prison Studies; Michael Farrell, director, National Drug and Alcohol Research Centre; Seena Fazel, clinical senior lecturer, Department of Psychiatry, University of Oxford; Andrew Forrester, honorary senior lecturer in forensic psychiatry, South London and the Maudsley NHS Trust; Andrew Fraser, director of health and care, Scottish Prison Service; Claire Gauge, head of learning lessons, Prisons and Probation Ombudsman England and Wales; Paul Hayton, deputy director, WHO (Europe), Collaborating Centre for Health and Prisons; Alex Hewson, policy and programmes manager, Prison Reform Trust; Adarsh Kaul, clinical director, Offender Health, Nottinghamshire Healthcare NHS Trust; Annabel Kennedy, director, Birth Companions; Richard Knowles, head of prison healthcare, NHS Isle of Wight; Nick Le Mesurier, independent researcher and honorary lecturer, Staffordshire University; Jonathan Lloyd, GP, HMP Nottingham; Juliet Lyon, director, Prison Reform Trust; Eoin McLennan-Murray, president, Prison Governors; Natalie Mann, lecturer in criminology, Anglia Ruskin University; Ryan Mullally foundation year 2 trainee, Nottingham University Hospitals; Nigel Newcomen, prisons and probation ombudsman, England and Wales; Éamonn O’Moore, consultant in public health, Offender Health; Frankie Owens, former prisoner; Mary Piper, senior public health consultant, Offender Health; Emma Plugge, department of public health, Oxford University; John Podmore, former prison governor, HMP Brixton; Lord David Ramsbotham, former HM inspector of prisons; David Scott, senior lecturer in criminology and criminal justice, University of Central Lancashire; Toby Seddon, professor, School of Law, Manchester University; Joe Sim, professor, School of Humanities and Social Science, Liverpool John Moore University; Nicola Singleton, Director of Policy & Research UK Drug Policy Commission; Richard Smith, former editor, BMJ; Alastair Storey, clinical lead and manager Find&Treat; Elizabeth Tysoe, head of healthcare inspection, HM Inspectorate of prisons; Azrini Wahidin, reader in criminology and criminal justice Queen’s University Belfast; Stuart Ware, founder of Restore Support Network; Susan Yates, research nurse, Royal Free Hospital; the staff and governor of HMP Nottingham; the staff and governor of HMP Isle of Wight.
Contributors and sources: SG is an ST5 trainee in general adult psychiatry and was the 2011-12 Roger Robinson BMJ editorial registrar. Information for this series was obtained from an unsystematic literature review, prison visits, and discussions with prison doctors, prison nurses, prison and forensic psychiatrists, prison governors, prison reformers, prison health managers, prisoners, criminologists, sociologists, and prison inspectors.
Competing interests: The author has completed the ICMJE unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.