Some material within this chapter has been reproduced with permission from Walton et al.1 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) licence, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.
Background
Prison population and increasing needs
Globally, the number of people being imprisoned has increased by 24% over the last 20 years.2 Across the world, it is estimated that currently over 11 million people (adults and children) are in prison.2,3 Worldwide, the majority of those in prison are men.2 However, the prevalence of imprisonment for certain groups has been increasing, including women,2 individuals from ethnic minorities2 and older adults.2,4–7
A key public health challenge is that those in prison experience significant health inequalities compared to individuals in the community.8 Some of these inequalities may have been exacerbated by conditions prior to prison, including economic deprivation, poor housing or homelessness, low levels of education and employment,8,9 or conditions experienced in prison (including overcrowding and having a lack of control over their diet, activity levels and sleep).8,9
Further inequalities have also been highlighted with regard to prisoners’ physical health, mental health and social care needs.2,8,10 Prisoners have been found to have higher prevalence of communicable diseases including tuberculosis, hepatitis C and human immunodeficiency virus (HIV).2,8,10 Additionally, those in prison have disproportionately higher levels of mental health conditions than those in the community;2,8,10 many of which may have been exacerbated by restrictions (inside and outside of prison) imposed due to the COVID-19 pandemic.2 Additionally, substance misuse, self-harm and suicide are more common within prison populations than general populations.2,8,9,11
A number of factors have also led to increased social care needs in prison. These include prison sentences getting longer12,13 and an ageing prison population.14 There has also been increased reporting of historic sexual offences following the sentencing of prominent public figures for historical sex offences (termed the ‘Yewtree effect’).15 This has resulted in increased prosecutions of older adults being sentenced to prison terms – sometimes when already in their 70s or 80s. As of 2022, reports estimated that 17% of the prison population were over 50.13 Additionally, many adults in prison also have a range of conditions which require social care support (such as dementia, autism, learning disabilities and frailty).4–6,16,17
Due to these health inequalities, it is necessary to ensure that prisoners are receiving appropriate support for their physical health, mental health and social care needs. However, prison settings face challenges relating to overcrowding, under-staffing, lack of funding, and security and operational constraints.2,9,13
Adult social care in prisons
Defining adult social care
Adult social care is often discussed in relation to older adults, but individuals of any age may require social care support.18,19 The definition of adult social care is:
The provision of personal and practical care and support that people may need because of their age, illness, cognition, disability or other circumstances. It also includes support for family members or other unpaid carers.20
Adult social care may be needed for a range of conditions and needs, including physical health disabilities, learning disabilities, autism, frailty, mental health conditions, sensory impairments, substance misuse, dementia and other long-term conditions.18,19 Social care support may be long term (e.g. to support with dementia or another long-term condition) or short term (e.g. following a hospital stay).18,19 Social care provision covers a wide range of support activities, including personal care tasks (such as washing, dressing, toileting, feeding and getting out of bed) but also non-personal care tasks (such as supporting someone to maintain independence and engage in domestic activities of daily living and communication).18,19,21 Improving social care in prisons is a current policy priority throughout the UK, and provisions in the Care Acts were introduced specifically to clarify the responsibilities of local councils to address the social care needs of people living in prisons in their areas.22–25
Provision of social care support in prisons in England and Wales
Prior to 2014, there was little clarity over which organisations (local authorities, prisons or healthcare providers) were responsible for the provision of social care in prisons. This changed when the Care Act was introduced in 2014 and clarified roles and responsibilities.22 The Care Act specified that the local authority where the prison is located is responsible for the assessment and provision of social care to prisons.22 Prisons also have responsibilities to support individuals with support that they would require in the community, including access to food, accommodation and a safe environment (see Chapter 7).
The prison service instruction (PSI) for adult social care (Probation Instruction 03/2016)26 highlights that, from April 2016, local authorities in England and Wales have a responsibility to assess and meet the social care needs of prisoners requiring social care support. It outlines that prisons must identify social care needs and work in partnership with the prisoners, local authorities, and prison healthcare services to put a care plan in place, and provide support to meet these needs. However, the PSI states that adult social care provision is not prescriptive and that it may vary across prisons. For example, who provides care may differ depending on each local authority, with some local authorities commissioning a bespoke care provider, other local authorities commissioning the healthcare provider in prison to provide social care, and some local authorities using community services to reach into prisons.26 PSIs are policy and guidance documents, produced and managed by His Majesty’s Prison and Probation Service (HMPPS), for prison professionals and probation professionals in England and Wales.27 PSIs outline guidelines and mandatory actions set out by HMPPS that must be adhered to in relation to each policy.
How social care is funded in England and Wales
Social care in prisons is funded by the Social Care in Prisons grant; a grant provided by the Department of Health and Social care to 60 + upper-tier councils that have prisons in their area.28 The amount allocated to each individual local authority differs depending on a cost formula based on factors, such as the prison function, category of the prison and each prison population’s perceived needs.29 Public records highlight that £10.95M was nationally allocated for the Social care in prisons grant in 2021–2,28 and that costs allocated to individual local authorities for social care in prisons in England and Wales between 2021 and 2022 ranged from £10,716 to £674,187.28 (Note: The amount paid to each local authority is subject to change each year and the calculation does not reflect social care assessments and support provided by each local authority.)
Gaps in social care provision
Policy documents indicate that social care in prisons should be broadly equitable to support that is provided in the community.26 Despite policy initiatives to improve social care, findings from previous research indicates that social care needs are often unmet,7,30–34 which has a large impact on individuals’ daily lives, for example on their personal hygiene, and on their ability to move around the prison and develop and maintain relationships.17 Additionally, findings have indicated that social care provision varies substantially in England and Wales.16,35 Previous research revealed a gap between the need for social care and the actual provision of social care across prisons.1 Challenges to social care provision in prisons have included difficulties identifying those with needs, difficulties sharing information, and difficulties co-ordinating care.36 Many recommendations to improve social care in prisons have been proposed, including the provision of social care by trained peer support workers (‘buddies’).16 While in the community a large proportion of social care may be provided by family and friends, this support is not available in a prison setting. Therefore, other innovative approaches have been developed to address this need in prison, one of which is peer support.
Peer support in prisons
Peer support workers are those who formally provide support to other prisoners.37 Peer support services have been used in a range of settings, including offender health38,39 and delivering non-personal social care to other prisoners in recent years.16 Previous research found that 6.5% of 482 prisoners reported receiving peer support.17 These initiatives may have many benefits for prisoners (such as increased confidence) and the wider prison (e.g. lower costs).6,40,41 However, evidence of these benefits is hard to find. Findings from a review of effectiveness and cost-effectiveness of peer support schemes to support offender health in prisons highlighted that the methodological quality of studies is poor, thus limiting effectiveness and cost-effectiveness evaluations.38,39
Peer support workers need to have clear roles and receive training and supervision when supporting other prisoners in peer support social care roles,5,16,37 but there is little consistency. This non-personal care may be equivalent to what is seen in the community in terms of family and friends providing non-personal care support to their loved ones (see Defining adult social care section for definitions of personal and non-personal social care).
A rapid prioritisation of adult social care innovations identified 158 innovations for adult social care that were being implemented throughout the UK.42,43 One of the top five priorities for evaluation was the scheme in Greenwich prison for peer-supported social care for adults in which prisoners were trained to provide non-personal social care support to other prisoners.42,43 This study builds on that report and the identified need to evaluate prison peer-supported social care.
Further, scoping work we have conducted has highlighted variation in the way that peer support social care services are organised. Some of the peer social care support models are led by a local authority, some are led in-house by prisons, and others have been supported and formalised by the charity sector (e.g. organisations such as Recoop, which have been involved in delivering training and/or supporting delivery of the scheme44).
Prison service instruction on peer-supported social care
Though peer support schemes for social care have not been mandated by the prison service, some guidance has been developed.45 For example, the prison service has developed a PSI for peer support: Prisoners assisting other prisoners (PSI 17/2015).45 This PSI was developed to provide guidance on peer support schemes in prisons. In relation to social care, the instruction states that local authorities have a responsibility for social care, and that care and support needs should be identified in a care and support plan. As part of this care plan, governors can mobilise adult prisoners to help other adult prisoners as needed. However, the PSI states that these peer support arrangements for social care should be governed by clear and consistent principles, and that there must be clear boundaries about the prisoner’s role so that the peer supporter and the person supported are safeguarded. The key requirements outlined for peer support are highlighted below in Table 1.45 The requirements outlined in the PSI relate to five key topics: (1) training and supervision; (2) boundaries; (3) clear employment processes; (4) collaborative working and (5) monitoring.
| Prison service instruction45 | General peer support or social care specific? | Topic PSI relates to |
|---|---|---|
| The benefits of peer support must be explained to peers (mandatory) | General | Training |
| Peers must not be relied on to provide care that is the responsibility of health and social care providers (mandatory) | General | Boundaries |
| Peers and recipients must be made aware of the limits of peer support (i.e. what they are and are not allowed to do), and that these boundaries must be explained in a care plan (or if not, recorded locally) (mandatory) | General | Training, boundaries and monitoring |
| Peers must be appropriately selected, risk assessed, trained, supported and supervised (mandatory) | General | Employment processes, training and supervision |
| Peer support schemes should be formal arrangements in which peers are paid for their work or aware that they are acting as unpaid volunteers (mandatory) | General | Employment processes |
| Peers and recipients must know of safeguarding policies and how to raise concerns should abuse or neglect arise (mandatory) | General | Training |
| Peer support schemes may be supported by partner organisations but remain the responsibility of the prison (mandatory) | General | Collaborative working |
| Peers must not provide intimate care (e.g. feeding, hygiene, toilet needs and dressing) for other prisoners or handle medication (mandatory), but are allowed to undertake personal care tasks (including transportation, transportation of food, cutting up food, helping to keep cell tidy, providing reminders about hygiene, reorganising cells, accessing work and recreational activities, helping prisoners raise concerns, moving and handling objects and furniture, helping prisoners to read) | Social care specific | Boundaries |
| Discussions with all parties need to be undertaken to ensure that everyone is happy with the proposed task allocation (and this should be sensitive to cultural differences) (mandatory). If the recipient lacks mental capacity, decisions should be taken on the basis of the recipients’ best interests by the prison lead for social care | Social care specific | Training |
| All peers and recipients must be aware of the types of activities that are and are not appropriate (mandatory) | Social care specific | Training |
| Prisoners must not provide assistance to other prisoners that they are in a relationship with (e.g. partner) (mandatory). | Social care specific | Boundaries |
| While informal arrangements whereby prisoners help other prisoners may occur, if it becomes regular support due to health and social care needs, this should be escalated to the social care lead who must refer the person to the local authority (mandatory) | Social care specific | Employment processes, monitoring |
| Peers and recipients must be protected from abuse and neglect (through selection, risk assessment, training, support and supervision arrangements) and must be made aware of definitions of abuse and neglect and how to report these (mandatory) | Social care specific | Training |
A further PSI that is relevant to peer support schemes for adult social care concerns adult safeguarding in prison (PSI 16/2015)46 which highlights prisons’ responsibility to protect adult prisoners from abuse (including physical abuse, emotional abuse, financial abuse, institutional abuse and sexual abuse) and neglect (failing to identify and meet needs of prisoners, e.g. ignoring care needs and failing to provide access to care).
Gap for this research
While previous research has explored the delivery of peer support initiatives in prisons, there has been little research evaluating the effectiveness, implementation and stakeholder experience of these initiatives. In addition to this, the lack of systematically collected cost-related data about peer support services does not allow their cost evaluation and, along with the limited research about effectiveness, explains the inadequate research about their cost-effectiveness. It is not clear which peer support initiatives are most feasible, effective or cost effective for supporting social care provision in prison and which approaches work best in different contexts.
Study aims
In this study, we aimed to evaluate peer support initiatives for adult social care in prisons in England and Wales.
Research questions
Research questions (RQs) for this study were developed through a series of scoping discussions with a range of stakeholders. Research questions for the empirical study were also informed by findings from the scoping process, the documentary analysis of social care, and the rapid systematic scoping review of peer support schemes.
Rapid systematic scoping review of peer support schemes (workstream 1):
- How have peer support schemes in prisons been implemented and experienced by staff and prisoners?
- What outcomes have been explored in previous research on peer support schemes (including for social care) in prisons, and what data were used?
- What evidence on costs exists on peer support schemes (including for social care) in prisons, and what data were used?
Documentary analysis of social care (workstream 2):
- What social care is currently provided in adult prisons in England and Wales?
- Who delivers social care?
- What peer support initiatives are used for social care?
- What social care indicators are relevant to adult prisons in England and Wales?
- Are there any differences between types of prisons in terms of the social care that is provided?
Implementation and experience study (workstream 3):
- What is the context for peer support services for social care in England and Wales at national and local levels, and what are stakeholders’ views of these services?
- How are peer support initiatives for social care implemented in adult prisons in England and Wales?
- What are the factors (including barriers and facilitators) influencing implementation?
- What are the experiences of those delivering and/or receiving peer support initiatives for social care in adult prisons in England and Wales? (Including risks and benefits.)
- Do these experiences differ between different models of peer support initiatives in adult prisons in England and Wales?
Measurement of outcomes (workstream 4):
- What are the important outcomes of peer support initiatives for social care in adult prisons in England and Wales? (Including for the person receiving social care, the person delivering social care, prison community, staff and health and social care.)
- How could these outcomes be measured?
Measurement of costs (workstream 5):
- What sources of data on costs of peer support programmes are available, what is the quality and completeness of these data, and who can provide this information?
- How could we use the available cost data in combination with the identified measurable outcomes in future cost-effectiveness analysis?
These research questions informed an understanding of whether peer support schemes for social care met the instructions set out in the PSI for peer support social care (see Table 1).
Structure of this report
- Chapter 1 (context) – Outlines the rationale for this evaluation.
- Chapter 2 (methods) – Presents the design and methods used in this evaluation.
- Chapters 3–10 (findings) – Present the findings:
- Chapter 3 – Rapid systematic scoping review of peer support services in prisons
- Chapter 4 – Documentary analysis of social care provision in prisons in England and Wales
- Chapter 5 – Implementation of peer support services for adult social care in prisons in England and Wales
- Chapter 6 – Experiences of peer support for adult social care
- Chapter 7 – Benefits and risks of peer-supported social care
- Chapter 8 – Measurement of effectiveness
- Chapter 9 – Measurement of cost
- Chapter 10 – Towards effective monitoring and evaluation of peer-supported social care.
- Chapter 11 (discussion and conclusion) – Key findings, strengths and limitations, implications/lessons learnt, and future research.
Working with stakeholders
Throughout this project, researchers from the National Institute for Health and Care Research (NIHR)-funded Rapid Service Evaluation Team (RSET) (Naomi J Fulop, Holly Walton, Pei Li Ng, Sonila M Tomini, Chris Sherlaw-Johnson, Efthalia Massou, Stephen Morris) worked in partnership with ‘Empowering People: Inspiring Change’ (EP:IC) consultants (Lucy Wainwright, Donna Gipson, Stephen Riley, Paula Harriott). EP:IC is an independent research, evaluation and consultancy collective with expertise in social and criminal justice. EP:IC consultants were closely involved in the design of the study, data collection, and analysis (together with the research team) and write-up. EP:IC consultants supported and co-ordinated the development of a study-specific service user involvement group.
Terminology
We acknowledge that different prisons refer to their peer supporters for social care using different names and terminology (including ‘buddies’, ‘care and support orderlies’, ‘peer workers’ and ‘carers’); however, in this report we will refer to those providing peer-supported social care as a ‘buddy’ or ‘buddies’ to ensure consistency.