Elderly prisoners
BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e6263 (Published 15 October 2012) Cite this as: BMJ 2012;345:e6263All rapid responses
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Stephen Ginn has provided a timely and thought-provoking article on the difficulties of providing good health and social care to elderly prisoners in the UK. As a psychiatrist working in a prison in the South West of England I am confronted with the practical difficulties of delivering such care to the increasing proportion of elderly prisoners in the prison population, particularly those with cognitive decline and those requiring social care. A Prisoner's deprivation of liberty should not be accompanied by lower quality health and social care (1).
There are provisions to move prisoners to hospital when they require healthcare not available within the prison, including the Mental Health Act 1983 as amended 2007 (MHA) but no such provision exists for social care. Additionally, the boundaries between health care and social care, particularly with prisoners who have mental disorder, can be hard to agree amongst commissioners and providers.
Elderly prisoners with cognitive decline or dementia are a case in point. Admission to a psychiatric hospital is possible under Part III of the MHA in England and Wales but the bar is set high (requiring a need for urgent treatment) and this leaves many who don’t require such hospital-based treatment in prison. If in the community many would often be receiving significant social care within their own homes or be in residential care or nursing homes, but in prison it is often prison officers or other prisoners who are left to provide the care without adequate training or supervision.
Whilst there are some prisons which are better equipped to provide health and social care for elderly prisoners, they are few in number and arranging a transfer can be a very lengthy process. The reality is, therefore, that many elderly prisoners struggle to access the level of social care that is available to the general population.
Addressing commissioning difficulties is an important part of improving the situation for elderly prisoners. With regards to social care commissioning it would seem sensible to require the local commissioners for the area in which the Prison sits to take responsibility for commissioning appropriate social care within the prison in a matter consistent with health commissioning (2).
(1) Prison Service & NHS Executive Working Group (1999) The Future Organisation of Prison Health Care. London: Department of Health.
(2) Department of Health (2007) Who Pays? Establishing the Responsible Commissioner. London. Department of Health.
Competing interests: No competing interests
Re: Elderly prisoners
We welcome Stephen Ginn’s (1) recent paper on elderly prisoners with its helpful focus on their health care needs but cannot agree with some of its conclusions.
First, we worry that the prison service continues to use a cut off of 50 years for elderly prisoners. Both the age and the terminology are stigmatising. The terminology of the external health service is more usually “older adults”. This is more appropriate to individuals who should have an expectation of life beyond 80 and anticipate largely good health in old age. We suggest that prisons inadvertently reduce expectations by taking the pessimistic view that 50 is old. In contrast, the Prison Reform Trust suggests that "older" starts at 60 (2). Prisoners may be functionally older as Ginn points out but imprisonment can actually reduce some of the risks associated with an unhealthy, external lifestyle. Excess alcohol, illicit drug use, poor diet and exercise and poor medication compliance for long term conditions all contribute to premature ageing and are common in offenders. NACRO (3), promoting "good practice" in prisons, suggests that the structure and discipline of prison could alter such a decline. Ironically, older prisoners may fare better in prison than they would have, had they remained free.
Second, Ginn also argues that "older prisoners" are specifically vulnerable. He suggests they may be victimised by younger prisoners. Age may be a factor but this can be more to do with the nature of the offences i.e. child sex offences, for which older men are more likely to be detained, as age. He claims the frail elderly may suffer from outdated building design. In fact, the design of many prison buildings is difficult for anyone with limited mobility. The Equality Act 2010 (4) applies to prisons and therefore requires prisons to make reasonable adjustments for disability, regardless of the age of the person.
Third, sentenced prisoners dispersed around the country can be far away from their catchment area mental health services. This is not true for physical health care which is truly local. Access to mental health care for the timely assessment and diagnosis of dementia is important. This is being stepped up everywhere thanks to the National Dementia Strategy (5); it is important that prisoners do not lose out. In our experience, commissioners are keen to establish care pathways for this group. Prisons are definitely not appropriate places for people with moderate to severe dementia.
Fourth, the paper does not take sufficient account of the impact of commissioning changes in 2005/6. The NHS local commissioners have had 6 years to introduce health care based on the principle of equivalence (6). Several of Ginn’s key references (4,8,17,18) relate to the earlier period where it is widely acknowledged health care delivery was poor. Since then the wholesale adoption of electronic records has done much to improve the efficient transfer of information with prisoners as they move around the prison estate. Primary Care Trusts have taken commissioning seriously. Prison contracts can be closely scrutinised through Partnership Boards and the use of extensive reporting frameworks, to ensure key health targets are attained. This is not to be complacent. Rather, it is to suggest that up to date service evaluations and national needs assessments would be timely. This would enable the assessment of the current state of health care delivery to this growing group of older adults and cease reliance on piecemeal and sometimes dated research.
References:
1. Ginn, S. 2012. Healthcare in Prisons: Elderly Prisoners British medical Journal 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e6263 (Published 15 October 2012)
2. Prison Reform Trust 2008 Doing Time: Older People in Prison 2008 www.prisonreformtrust.org.uk/projectsresearch/olderpeopelinprison (accessed 31/10/12)
3. NACRO/DH 2009 Resource Pack for Working with Older Prisoners. www.dh.gov/en/publicationsandstatistics/pub (accessed 01/11/12)
4. Equality Act 2010 http://www.legislation.gov.uk/ukpga/2010/15/contents
5. DH (Department of Health) Living Well with Dementia: A National Dementia Strategy 2009
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPoli... (accessed 03/11/12)
6. DH/HMPS (Department of Health and Her Majesty’s Prison Service) 1999 The Future Organisation of Prison Health Care. Report by the Joint Prison Service and National Health Service Executive Working Group. London: Department of Health
Annie Bartlett Reader in Forensic Psychiatry, SGUL
Sandra Evans Consultant in General and Old Age Psychiatry East London Foundation NHS Trust.
Competing interests: Annie Bartlett in Clinical Director (Jt)of Offender Care, CNWL Foundation Trust which provides health care in a number of prisons in London and the South East.