Discussion and conclusions

Overview

This study was a rapid mixed-methods evaluation of the implementation of peer-supported social care in prisons in England and Wales.

The rapid systematic scoping review aimed to analyse the current international evidence base on peer support services in prisons, including how effective and cost-effective they are, how they have been implemented and experienced, what outcomes have been measured, what evidence on costs exists, and what data were used (see Chapter 3).

With documentary analysis, we aimed to explore how social care is provided in adult prisons in England and Wales and whether peer support schemes are used for social care (see Chapter 4).

In the empirical study we aimed to explore the implementation of peer support schemes for social care in adult prisons in England and Wales (see Chapter 5); staff, peer and recipient experiences of peer support schemes for social care (including risks and benefits) (see Chapters 6 and 7); what data are available to measure effectiveness and cost of peer-supported social care and how outcomes and cost can be measured for peer-supported social care (see Chapters 8 and 9). In Chapter 10 we provide a guide on data collection and measurement to inform future monitoring of services and their evaluation.

This chapter outlines summary findings, how findings relate to previous research, implications and lessons learnt, strengths and limitations, future research and conclusions.

Summary of key findings

Key findings are outlined below from each aspect of the evaluation (Figure 6).

FIGURE 6 Summary of key findings. (Figure not reproduced here; see the original article.)

Rapid systematic scoping review of peer-supported services in prisons internationally (Chapter 3)

Findings relating to peer-supported services in prisons generally indicated that:

• A variety of peer support programmes are used in prisons internationally to support a range of health, social care and educational needs.
• No studies measured cost or cost-effectiveness.
• Only 8 of the 70 studies (that we reviewed) focused on peer-supported social care and none measured effectiveness of these schemes.
• There are some positive effects of peer support (e.g. in relation to disease detection, mental health, pre- and post-release behaviour, improved knowledge and skills), but limitations in the quality of data was evident.
• The implementation of peer support schemes is influenced by the individuals receiving and providing peer support services, peer-support-service-level factors and organisational factors.
• There are a range of benefits (e.g. improving community atmosphere, reducing workload, safeguarding and self-development) and a range of risks (e.g. burden and confidentiality) associated with peer support.
• Different methods are used to measure effectiveness (e.g. surveys and cohort studies), implementation and experience (e.g. interviews, surveys and observation).

Documentary analysis of His Majesty’s Inspectorate of Prisons reports to analyse social care provision in England and Wales (Chapter 4)

Findings relating to social care more generally highlighted that:

• Social care provision varies between prisons in England and Wales.
• Some aspects of social care are more frequently reported (e.g. assessments and referrals) and others less frequently reported (e.g. care plans and reviews).
• There are unmet social care needs in prisons.
• There is a lack of consistency of reporting of social care provision across HMIP reports.

Findings relating to peer-supported social care highlighted that:

• Peer support services for social care are frequently used (40% of 102 reports).
• Peer support schemes outlined in HMIP reports ranged from formal (training and supervision) to informal unsupervised schemes.

Implementation of peer-supported social care in prisons in England and Wales (Chapter 5)

Findings relating to social care in prisons more generally highlighted that:

• There are no nationally collected data on the number of people with social care needs in prisons in England and Wales but reported numbers varied across different types of prisons (e.g. long-term vs. remand prisons).
• Individuals with a wide range of needs require social care support.
• Different models of social care were used but most involved a partnership between a local authority and a prison.
• Different people are involved at different stages of the social care pathway (e.g. prison staff, local authority staff and commissioned social care providers).
• A range of factors influence the delivery of social care in prisons in England and Wales, including: (1) prison staff having an understanding of social care and ensuring dedicated social care roles; (2) collaboration between prisons and local authorities; and (3) having clear processes and procedures for social care, and availability of resources.

Findings relating to peer-supported social care outlined that:

• Peer support services for social care have been developed and implemented in prisons in England and Wales to formalise support provided by prisoners and in response to the Care Act of 201422 and perceived rising social care needs.
• Most prisons implemented formal peer support schemes for social care. Some prisons only have informal peer support.
• Findings indicate that peer-supported social care plays an important and valuable role in providing social care in prisons, filling a gap regarding the provision of non-personal social care.
• Implementation of peer support schemes for social care varies across prisons in England and Wales, demonstrating different leadership models and governance processes.
• Some examples of good practice were identified (e.g. collaborations between prisons, local authorities and external organisations, formalised training modules, and security vetting), but none of the prisons had clear processes in place for all aspects of employment (buddies) and training (buddies and staff).
• Some prisons had no formal training for buddies, and buddies do not always receive the training on offer.
• Implementing peer-supported social care is influenced by a range of factors relating to the service (e.g. resources and collaboration between organisations), the prison (e.g. prison regime and turnover of buddies), staff (e.g. attitudes and awareness) and prisoner (e.g. role desirability, need and attitudes).

Experience delivering and receiving peer-supported social care (Chapter 6)

• Staff, buddies and care recipients reported positive views of peer support schemes, demonstrating their potential value in prisons in England and Wales. For example, the buddy role was perceived to be necessary for helping recipients maintain independence, participate in the prison regime, and receive the social care support that they needed.
• Buddies and recipients generally reported feeling safe, but did highlight some potential risks (see Chapter 7).
• In the site without formal peer support, recipients still highlighted social care needs which were supported by informal buddies.
• Many factors help and get in the way of delivering and receiving peer-supported social care, including respect, reward and recognition, skills, training and awareness for staff and buddies, access and regime, time and capacity for staff and buddies, attitudes of staff and prisoners, and processes and procedures.
• Key attributes of buddies were identified.

Risks and benefits of peer-supported social care (Chapter 7)

• Findings highlighted a wide range of benefits for the wider society (outside of prison), prison (e.g. improving prison atmosphere), staff (e.g. saving time and safeguarding), buddies (e.g. fulfilment, pride and skill development) and recipients (e.g. enabling recipients to receive necessary non-personal social care support, and promoting independence and integration in the prison community).
• Potential risks were identified. The most frequently reported risks included risks to recipients (e.g. risk of bullying and buddies overstepping boundaries to undertake tasks/provide care that they are not meant to provide), risks to buddies (e.g. burden) and exploitation of the role by staff, buddies, and recipients (e.g. buddies being asked to do things not part of role).
• Governance processes together with monitoring must be in place to mitigate against risks and ensure the safety of buddies and recipients.

Measuring impact of peer-supported social care (Chapter 8)

• No routine national data are collected on peer-supported social care in prisons. However, there is a need for better data and for there to be national standards for what that data should be.
• Some local data are collected (e.g. by local authorities), but this is not widespread and is often operational.
• There are particular data gaps that affect any ability to measure the impact on prisoners themselves, including safety concerns, the experiences of prison and other professional support staff, how well social care needs of prisoners are being met, and for monitoring outcomes on prisoners after release or prison transfer.
• To evaluate peer-supported social care in the future, we recommend the development of national standards for the delivery of peer-supported social care. These should include guidance on the data needed to collect to enable monitoring of these national standards and evaluation of effectiveness, cost-effectiveness, implementation, and experience.
• It may be feasible in research studies to use some of the existing routine data collections to infer possible impacts of these schemes, such as on hospital attendance, self-harm and recidivism after release.

Measuring cost of peer-supported social care (Chapter 9)

• Cost data collected locally by prisons are limited and frequently not collected.
• Therefore, calculating the cost per prisoner receiving peer support and cost-effectiveness of the service more generally is currently not possible or feasible due to the availability and quality of the data.

Monitoring and evaluation guide (Chapter 10)

• To monitor and evaluate peer support schemes for social care, we have proposed a monitoring and evaluation guide which outlines the types of data needed to routinely monitor and for the evaluation of peer support schemes for social care, while also recognising the resource pressures facing the prison estate at the current time.
• We acknowledge that the routine monitoring of these services would require funding (e.g. for dedicated roles and training) and co-ordination between different organisations.
• We propose that monitoring may be best placed with HMIP, with some local operational data recorded in each prison.
• Evaluation of experience, implementation, effectiveness and cost-effectiveness would be best carried out by research teams.

How findings relate to previous research

In this section we discuss findings in relation to previous research.

The use of peer support services in prisons

Findings from the study support previous findings indicating the widespread use of peer support services for a range of support needs in prisons both internationally and in England and Wales.17,38,39

Social care provision more generally

The Care Act in 201422 clarified that local authorities have a responsibility to assess and meet the social care needs of prisoners requiring social care support, but that the provision of social care may differ in terms of type or extent of care needed (e.g. personal social care, such as support with showering or dressing, being provided by commissioned care providers, healthcare providers in prisons, or community services).26 Additionally, prisons have a responsibility to provide equivalent support to that in the community (e.g. access to food, accommodation and a safe environment).26 While the study did not focus on all aspects of social care in general, findings from the documentary analysis (see Chapter 41) and empirical study (see Chapters 5–9) provide an insight into what social care provision currently looks like in prisons in England and Wales. Findings highlighted large variations in how social care is delivered in prisons in England and Wales but that most prisons had some sort of partnership between the prison and local authority in place (though links were stronger in some places than others). However, findings indicated that there may be some unmet social care needs, supporting previous research.7,30–34

Findings outlined that for general social care support to be provided in prisons, there needs to be an understanding about social care and resources for dedicated roles, a collaboration between prisons and local authorities, clear processes and procedures to help prisons ensure provision of social care support, and availability of resources. While there were some examples of good practice in terms of social care provision, these factors may not be in place in many prisons in England and Wales (see Chapter 4), limiting prisons’ ability to ensure that everyone who requires social care receives social care. These factors are also important if prisons are going to use peer-supported social care, as they underpin the prison systems’ ability to implement peer support services (e.g. services with pre-existing collaborations in place between local authorities and prisons may be better placed to collaborate, develop and run peer-supported social care).

The use of peer support services for social care

Evidence from this evaluation demonstrated that peer-supported social care is implemented in many prisons in England and Wales. This is likely to be due to the policy focus on improving social care in prisons, implementation of Care Acts6,22,23,25,26 and the rise in social care needs experienced in prison.4–6,16,17 However, the use of buddies in a prison context seems to provide an option for some aspects of social care to be provided to prisoners effectively at a potentially lower cost than external provision.

While care providers should provide personal social care support to eligible prisoners,22 findings suggest that peer-supported social care fills a gap in the provision of everyday non-personal social care tasks for adult prisoners (e.g. collecting meals, cleaning cells and transportation), roles which are typically undertaken by family members or friends in the community. Findings highlighted some gaps in the provision of external social care, and that many recipients of care may not receive support from external providers but rely on buddy support alone, perhaps due to not meeting the threshold for external social care support on assessment. Risks relating to unmet needs and quality of care were identified (e.g. risks in the quality of care received or gaps in external social care provision and unmet need). Unmet need may offer an explanation as to why buddies may overstep boundaries in some situations, out of a duty of care and wanting to help (see Chapter 7), and why informal peer-supported social care takes place in some prison establishments. Based on the findings, it is recommended that receipt of peer-supported social care could be documented on health records or care plans and regular assessments of social care needs could be undertaken to ensure that recipients receive the social care package that they require to meet their needs, if and when health declines and needs progress (e.g. external social care support and buddy support). Furthermore, consideration must be given to those who may not be appropriate to receive (e.g. due to risk level) or want to receive peer-supported social care. In these cases, it is necessary to determine where responsibility would sit to ensure that prisoners receive non-personal social care support in the absence of buddies.

Implementation of peer support services for social care

To our knowledge, this study is one of the first to evaluate peer-supported social care in a range of prisons in England and Wales. The study provides critical insight into how these schemes have been implemented. Findings highlight large variation of the implementation of peer-supported social care and demonstrate that peer support services are not standardised nationally. While variation may be appropriate in some situations (e.g. some prisons may have more of a need for social care peer support than others), substantial variation in governance processes such as training and monitoring may be problematic. For example, the PSI for peer support in prisons highlights mandatory guidance relating to training and supervision, employment processes, boundaries, collaborative working, and monitoring and evaluation45 (see Chapter 1). Findings from the study indicated that these guidelines are not consistently being implemented for social care across prisons in England and Wales (see Appendix 6, Table 35). To address this, we recommend building on these findings together with the existing PSIs26,45,46 to develop national standards of peer-supported social care, including recommendations on the data that should be collected for regulatory bodies (e.g. HMIP) to routinely monitor these services against national guidelines and for researchers to conduct future evaluations of the effectiveness and cost-effectiveness of these services.

Experience with peer-supported social care

While previous research outlined benefits of peer support schemes for prisoners and prisons,6,40,41 findings extend knowledge by providing insight into staff, peer, and recipient experiences, an area where there is a limited evidence base (see Chapter 3). Findings demonstrate that staff, buddies, and care recipients reported positive views of peer support schemes demonstrating their potential value in prisons in England and Wales. The buddy role was perceived to be necessary for helping recipients maintain independence, participate in the prison regime, and receive the social care support that they needed. Findings also offered insight into key barriers and facilitators of peer-supported social care. These included the payment and recognition given to buddies, training for both buddies and staff, time spent unlocked to do the job, attitudes of staff and recipients, and clarity of processes. As peer support schemes for social care may still be in their infancy or not yet developed for peer support, key learnings from this study could help to inform the development of services that work for prisons, staff, buddies, and recipients.

Risks and benefits of peer-supported social care

Findings supported previous research6,40,41 by highlighting a wide range of benefits for society (outside of prison), prison, staff, buddies and recipients. Findings support and extend evidence by categorising the benefits and risks of peer support and triangulating these with potential data needed to be collected to measure these impacts.

The three most prominent and frequently reported categories of risks were potential risks to recipients, buddies and potential for exploitation by staff, buddies, and recipients. For example, boundary issues associated with peer-supported social care schemes are complex (see Appendix 6, Table 35). Peer-supported social care requires buddies to stick to boundaries that may go against their human nature (e.g. wanting to help someone if they fall or wanting to help someone with their personal social care if these needs are not met by external social care providers). Examples of buddies feeling that they needed to cross these boundaries were identified in the study (by staff) and buddies and recipients spoke about frustrations with the boundaries due to not being able to help where they would want to (e.g. if someone is left needing support for hours). This boundary may also be blurred by staff asking buddies to do roles that are not explicitly specified in their job description and this contradiction may also contribute to the burden on buddies.130 Findings indicate that complexities surrounding boundaries is an inherent risk of peer-supported social care schemes (and more so with informal peer support). This risk needs to be carefully considered and monitored within the wider context of social care provision by ensuring that recipients of peer-supported social care have regular assessments and appropriate external social care provision in place (where appropriate), and that there are plans in place for the prison or local authority to support buddies and recipients, should situations arise where unmet needs occur.

These findings highlight that while peer support services for social care, and peer support services more generally, have the potential to provide benefits at many different levels (prison, staff, buddies and recipients), these services are not implemented without potential risk. Therefore, governance processes together with monitoring and evaluation must be in place to mitigate against risks and ensure the safety of buddies and recipients. Additionally, findings indicate that with appropriate mitigations and monitoring in place to protect against potential risks of buddy support, these schemes may also have the potential to support safeguarding of recipients from wider safeguarding issues more generally.

Monitoring peer-supported social care

There are some recommendations relating to peer support services (see Appendix 6, Table 3545), adult social care26 and safeguarding.46 However, it is currently difficult to monitor peer-supported social care against the PSIs due to the lack of data collected (see Chapters 8–10). For example, policy documents highlight the importance of prison social care being equivalent to that received in the community.26 It is difficult to tell whether this is the case from the study due to gaps in reporting of social care provision in HMIP inspection reports (see Chapter 4), and gaps in monitoring of social care provision in prisons (see Chapters 8 and 9), which would need to be improved in order to make robust comparisons between social care in prisons and in communities in future (see Chapter 10).

To monitor the success of peer-supported social care against recommendations, there is an argument on one hand to increase regulation and monitoring of these schemes (e.g. through national data collection). Monitoring and regulation of these schemes would therefore be equivalent to the need for monitoring of such services in the community (e.g. non-personal support provided by volunteers through third-sector organisations). On the other hand, increased monitoring and regulation has potential downsides in that it would lead to additional work for overstretched prisons and local authorities and may put prisons off implementing peer-supported social care, thus, potentially negatively impacting on prisoners in need of this support. However, without peer-supported social care, resources would then need to be found for staff members (from prisons, local authorities, or commissioned providers) to provide equivalent non-personal social care support. Alternatively, this would perhaps lead to an increased likelihood of prisoners receiving informal peer support, or not receiving any support and therefore potentially declining. Therefore, it is necessary for stakeholders (e.g. HMPPS, HMIP, local authorities and prisons) to consider how best to ensure that monitoring of peer-supported social care could be done in the most resource-friendly and feasible way.

Evaluating impact and cost of peer-supported social care

Findings concur with a previous review on offender health which highlighted that the methodological quality of studies looking at peer support needs to be more robust in order to carry out effectiveness and cost-effectiveness studies.38,39

Factors influencing implementation and variation

Findings highlighted many factors that influence peer support generally and peer-supported social care, thus offering explanations as to why peer-supported social care may vary in different prison establishments. As outlined, there are many positive views associated with peer-supported social care schemes, but also some contested views that they are used to save money in lieu of professional social care support. However, we do not yet have evidence to show whether peer-supported social care is effective or cost-effective. If services are to be implemented and used, then findings indicate that to improve the implementation of peer support schemes for social care, and peer support more generally, individual-level, peer-support-service-level, and organisational-level factors must be considered. Findings highlight that peer support schemes need to be sufficiently resourced, and that collaborations are in place between local authorities, prisons and other necessary organisations to ensure peer-supported social care can be implemented effectively. Additionally, it is important to consider how the type of prison and the prison regime affects peer support, for example making sure that buddies can deliver their role despite the prison regime and access issues. Furthermore, while some staff see the value in peer support schemes and are passionate about supporting peer-supported social care, there is a need to increase staff awareness and improve some staff attitudes across the prison estate to enable their effective implementation. Finally, peer-supported social care roles need to be perceived to be valuable and desirable to buddies and recipients. If peer-supported social care services are found to be beneficial, further work is needed to ensure that all prisons see the value of implementing them, even when they may not have obvious social care needs (e.g. in places where support is being provided outside of a formal scheme).

Strengths and limitations

Strengths

A key strength of this study was that it was a rapid, large-scale mixed-methods study that included a wide range of prison sites and a wide range of different stakeholders. Therefore, the findings from this study should be informative in improving peer support services for social care in England and Wales.

The composition of the evaluation team [including academics, researchers from Nuffield Trust and researchers from EP:IC consultants (an independent research, evaluation and consultancy collective with expertise in social and criminal justice)] was a key strength as it enabled us to successfully complete this study rapidly by working with the key strengths provided by different members of the team (e.g. EP:IC consultants were able to quickly navigate access to conduct interviews with the five case study sites). Additionally, while rapid, we have held four meetings with the PPIE group and four meetings with the evaluation advisory group to draw on their expertise throughout all stages of the project (e.g. ensuring we were asking the right questions, identifying further analysis themes to explore and reach relevant stakeholders).

Throughout the study, researchers have worked together to discuss and triangulate findings from different parts of the study to ensure that we were able to draw out key findings from across different data sources. This has culminated in the development of an evaluation guide drawing on all aspects of the study.

Limitations

While the study included a large sample of prisons in England and Wales, we acknowledge that we were unable to include all prisons, therefore findings may not be representative of all prisons in England and Wales. Similarly, we were only able to interview a sample of staff, buddies, and recipients from each prison, therefore there may be views that we were unable to capture. For example (as acknowledged in Chapter 6), the buddy interview participants were mostly White British and the recipient interview participants were solely White British, despite the strategies to try and include a range of different participants. Additionally, the sample included more older adults than younger adults with social care needs. The representativeness of the sample was perhaps limited by the sampling being led by individual prison’s guidance on who would be appropriate to interview. This could potentially result in individuals selecting potential participants that may be more likely to provide positive responses.

Due to COVID-19, the empirical study was paused and conducted later than originally planned. In the meantime, we conducted desk-based work (e.g. the documentary analysis reported in Chapter 4), and conducted scoping work to help us to undertake the study once resumed.

In terms of practicalities of conducting this research, one challenge we experienced was difficulties identifying the most appropriate person to speak to in each of the prisons and the job roles for those we interviewed varied substantially across prisons. In some establishments there may have been other individuals who could have been more appropriate to speak to. Similarly, in certain case study sites, we faced some challenges in terms of our time in some of the prisons being cut short, thus limiting how many participants we were able to interview.

There is a lack of data collected on impact and cost of peer-supported social care schemes; therefore we had to design this study to develop an evaluation guide rather than to measure effectiveness and cost.

We sometimes received different responses from different data sources when triangulating findings (e.g. differences in number of buddies reported in implementation and cost findings). Ability to triangulate data was therefore difficult due to differing time frames and limited cost data.

Implications

The study is an implementation study that does not measure outcomes of peer support social care services and therefore does not provide evidence on the effectiveness and cost-effectiveness of peer-supported social care. However, the study indicated that peer-supported social care services were valued by all groups of stakeholders that participated in this study, providing necessary support that bridges a gap in care provision between local authority care services and independent daily living. These peer support services are perceived to have many benefits for prisons, staff, buddies and recipients but also challenges and potential risks.

Below we present recommendations to consider where peer-supported social care services are used, or considered for use in future.

1. Relevant stakeholders (e.g. HMPPS, HMIP, local authorities and prisons) could consider the production of national standards for peer-supported social care which builds on the existing guidance and resources (e.g. toolkit) provided in PSI dealing with prisoners assisting other prisoners45 on how to implement peer-supported social care in prisons. Standards could include information on how to mitigate potential risks (implications 2 and 3), what data need to be collected on a national and/or local scale to ensure services can be monitored and evaluated against PSI guidance and other relevant criteria, who should monitor these services, and how they should be monitored. We recommend that standards allow for adaptation to account for the circumstances of individual prisons (see Chapter 5, Figure 5 for key factors that could be taken into account, e.g. the type of prison and amount of social care need). While this would require resources to implement, it is important to be able to monitor care provision for quality consistency, as would be the case with any community-based service. In instances where informal peer-supported social care is happening regularly and there is a clear need for non-personal social care support, it seems important for these prisons to have formalised peer-supported social care schemes to provide safeguarding for both buddies and recipients.
2. When planning, developing and providing peer-supported social care, prisons and/or local authorities should consider how to mitigate potential risks. Potential risks to be aware of include risks to recipients (e.g. bullying, safeguarding and boundary issues), buddies (e.g. burden of care) and risks of exploitation by staff, buddies and recipients. Risks to prisoners may be overcome by putting robust systems in place to prevent and monitor peer-supported social care (processes described in some of the prisons studied in this evaluation).
3. Relevant stakeholders (e.g. HMPPS, HMIP, local authorities, and prisons) could consider how wider risks relating to social care provision will be monitored (e.g. potential risks relating to the quality of care received, delays in care provision or prisoners not receiving formal social care support in addition to peer support and risks of continuity of care on release). For example, provision of peer support could be noted on individuals’ prison healthcare record, and regular assessments of social care needs could be undertaken by relevant bodies (depending on locality) to ensure that recipients receive the social care package that they require to meet their needs, if and when health declines and needs progress (e.g. external social care support and buddy support). Each prison could also have plans in place for the prison or local authority to support buddies and recipients should situations arise where unmet social care needs occur.
4. We suggest that the responsibility for routine monitoring of prison peer support services for social care against national guidelines belongs to HMIP in its role as inspector (in partnership with other inspection partners such as CQC if appropriate) and that data are collected for this purpose. In inspection reports, HMIP reports could include more details on how social care (formal and peer supported) is implemented in prison settings, whether prisons are meeting personal and non-personal social care needs and whether social care in prisons is consistent with community provision. The data collected will also facilitate research evaluations of the effectiveness, cost and implementation of peer support schemes for social care in future (see Chapter 10 for evaluation guide).
5. For implementation of peer-supported social care, we recommend:
   1. Dedicated roles in prisons and/or local authorities to drive, manage and support the peer support social care scheme, including protected time for these staff members. These positions need to have clear roles and responsibilities and a proportion of their time ring-fenced to ensure that social care and peer-supported social care is not overlooked. Policy indicates that prisons should have an allocated social care lead who is responsible for the peer-supported social care support;26,45 however, it is necessary for social care leads to understand that their role includes responsibility for peer-supported social care and these individuals must be given ring-fenced time to dedicate to this task.
   2. Appropriate levels of funding for prisons to ensure that they are able to manage and lead peer support services for social care.
   3. Collaborations between organisations (e.g. prisons, local authorities and external organisations) to manage and deliver peer-supported social care schemes.
   4. Formalisation of peer support procedures, including:
      1. Clear standardised employment processes (e.g. consistent application processes, security vetting, interviews and job descriptions).
      2. Formalised, standardised, module-based training for buddies (as used by some sites in the study) that is delivered to all buddies undertaking this role. Training could cover material relevant to the role, for example why the role is needed (benefits), relevant background information such as the Care Act, safeguarding, and how to report issues, boundaries of the role and how to do the role (including practical training for items such as pushing wheelchairs, cleaning and dementia). This training may also include some shadowing of buddies already in post.
      3. Training for staff (on social care needs and peer-supported social care, to include role and boundaries).
      4. Formal regular supervision processes for buddies by staff (e.g. group meetings, one-to-one meetings, and a way of contacting staff members if needed). Within this, it would be helpful for there to be ongoing feedback mechanisms between trained officers, buddies, and recipients to ensure that buddies are able to appropriately provide support within restrictions imposed by the prison regime.
      5. Standardised and fair payment for buddies and recognition for good practice.
      6. Succession planning to ensure that a team of buddies are always in place and that additional buddies are trained to guard against gaps when high turnover of buddies occurs.
      7. Local monitoring of peer support roles for social care by relevant prison staff and/or local authority staff (e.g. number of buddies, number of recipients, how many hours they undertake their role for, whether or not they have been trained, and recording of the support provided).

Future research

The development of national standards for peer support services for social care, which builds on the existing PSIs26,45,46 and provides details on how to implement services and what data to collect, would enable regular monitoring of these services within the wider context of external social care provision in prisons. It would also enable future research to conduct a robust evaluation of effectiveness and cost-effectiveness of peer-supported social care. This would enable further analyses regarding optimal service design and impact on inequalities.

In the first instance, it may be appropriate to conduct future research to pilot any national standard and routine monitoring plan in a proportion of prisons, to further explore and determine feasibility of data collection and implementation recommendations.

Further mixed-methods research could be conducted in other areas of England and Wales to determine whether findings concur or differ from those raised in this study.

Conclusions

Peer support services for social care are widely used in prisons in England and Wales. However, the implementation of these schemes varies due to a range of factors relating to the service, the prison, staff, and the prisoners. Some issues were identified, for example not all prisons have clear employment or training processes. Staff, buddies and recipients generally valued peer-supported social care and these were well received by recipients. However, there were some challenges that need to be overcome in order to facilitate the delivery and receipt of social care peer support, for example a need to ensure that buddies are recognised for their role and that buddies and staff are adequately trained. Peer-supported social care may have wide-reaching benefits (e.g. helping to meet social care needs, supporting independence, developing buddy skills and saving staff time), yet there are several potential risks that must be mitigated. It is currently not possible to evaluate impact and cost of peer-supported social care due to limited data. To monitor peer-supported social care in future, we recommend national standards developed against which different peer support services can be monitored. These national standards could build on existing PSIs26,45,46 and also include guidance on the data needed to collect in order to monitor them. This in turn would enable the evaluation of effectiveness, cost-effectiveness, implementation, and experience in future. To facilitate monitoring and evaluation of peer support schemes for social care, we have proposed an evaluation guide.

Patient and public involvement

In this study, we worked closely with EP:IC consultants to develop a service user involvement group with lived experience. Over the duration of the study, the group consisted of six individuals, all with personal experience of imprisonment.

The group were involved throughout the project and provided feedback on the protocol, study methods, aims, early findings from data analysis, and dissemination. We held four meetings throughout the study with the service user involvement group to discuss each topic as findings emerged. In terms of future dissemination plans, we are involving the service user group in the development of materials to reach different audiences, for example a lay summary that can be shared with prisoners, radio and podcast outputs, and potential blogs for the general public.

Throughout the study we have also met with the evaluation advisory group three times. The members of the evaluation advisory group were recruited to provide critical feedback and support on this study throughout all stages (including planning and analysis). Members of the evaluation advisory group provided feedback on specific chapters of this report. We will be working closely with this group to ensure that dissemination outputs are appropriate for a wide range of audiences (e.g. HMPPS and ADASS Care and Justice network).

Additionally, we sought input from the RSET public and patient involvement group throughout the study (e.g. when developing the protocol).

Equality, diversity and inclusion

Participant representation

In the study, we aimed to ensure that prisons and participants were representative of different locations in England and Wales.

Site characteristics

We recruited 20 prisons for the study. However, we were able to interview participants from only 18 of these prisons. As shown in Report Supplementary Material 8, the prisons were selected to be representative of different areas of England and Wales and different types of prison (e.g. public/private, male/women and different categories).

Strategies to improve representation

In the study we tried to ensure representation of a range of groups (national stakeholders, prison leads, staff and prisoners), and that the study was inclusive. For example, we asked prisons to help purposively identify potential interviewees from prisons with different characteristics and models of peer-supported social care and a wide range of individual demographic characteristics. However, we acknowledge the challenge with relying on prisons to select participants and in an effort to raise awareness with all prisoners, we developed a bright, easy-to-read poster that could be displayed in the prisons. It was hoped this would encourage people who had something to say to come forward and to prompt discussion about the study between peers (including those who may not be able to read). We offered different modes of consent (written or audio recorded) to remove barriers to participation, and offered different modes of interview (e.g. face to face, telephone or online). We also planned to offer translation services and/or the translation of materials as required for those who did not speak English or who had communication difficulties; however, this was not needed by any participants in the study. Finally, the interviews undertaken with buddies and recipients were conducted by researchers from EP:IC consultants, who are researchers with experience conducting prison research, some of whom have lived experience of prison settings.

We are planning to disseminate the findings from the study in many different formats (e.g. lay summaries, podcast/radio outputs, slide sets, animation and infographic) to ensure that findings are accessible to as many people as possible.

Participant characteristics

The staff, prison leads, and national leads were representative of a range of different organisations, job role, and length of time in their roles. The interviews with buddies and recipients included both men and women, and a range of different ages (20–80 +). It is important to note that the sample included more male prisons than women prisons and more public prisons than private prisons which represents the overall prison landscape. However (as acknowledged in Chapter 6), the buddy interview participants were mostly White British and the recipient interview participants were solely White British, despite the strategies to try to include a range of different participants. Additionally, the sample included more older adults than younger adults with social care needs. The representativeness of the sample was perhaps limited by the sampling being led by individual prison’s guidance on who would be appropriate to interview.

Research topics relating to equality, diversity and inclusion

Prison populations are understudied in the academic literature and many inequalities have been identified in relation to prison populations. Therefore, this study provides an important perspective on the views of different stakeholders on social care support received in prisons in England and Wales and the role of peer-supported social care.

Reflections on research team and wider involvement

Research team

The research team consisted of researchers from one rapid evaluation team (NIHR RSET), spanning three organisations (University College London, University of Cambridge, and Nuffield Trust). Additionally, the research team comprised of researchers from EP:IC consultants. The team was multidisciplinary in nature and team members differed in seniority. The research team comprised a mix of backgrounds in relation to gender and ethnicity.

The team held fortnightly meetings throughout the project to ensure that all members of the team were well supported. All members of the team have been involved in all aspects of the project (from project planning through to data analysis and dissemination).

Service user involvement group

The service user involvement group was made up of six individuals over the course of the study. Three of these were consistent throughout the whole project, while two left the group (one due to other commitments and one due to ill-health). Two of these individuals had received social care support in prison, while the other four had supported prisoners with social care needs. The group was made up of three women and three men, aged between 62 and 32. Three were white, one was Asian and two were mixed race.

The group was co-ordinated and facilitated by a member of the EP:IC collective, who had personal lived experience of imprisonment and had witnessed social care provision in prison. This meant she was able to directly contribute to the conversation where appropriate. We identified the most appropriate method of involvement was to present the material to the group in advance of the meeting and to provide PPIE members with the opportunity to digest and ask questions to the coordinator prior to the full research team being present.

Impact and learning

While findings are unable to demonstrate whether peer-supported social care is effective or cost-effective, this study shows that peer support schemes for social care are perceived by staff, buddies and recipients to be an important and valuable service that helps to meet social care needs, promote independence, and enable recipients to live life meaningfully. These schemes also supported stretched staff and enabled buddies to develop skills and fulfilment.

The findings from this study provide important lessons on what peer-supported social care in prisons in England and Wales should look like, if they are to be used and implemented in practice, for example in terms of governance, training, supervision and monitoring. Additionally, findings highlight a wide range of barriers that must be overcome to optimise peer support services for social care in future. Findings highlight the need to produce national standards for implementing peer-supported social care.

Findings outline gaps in data for measuring impact and cost. Additional data need to be collected on a national scale to ensure that services can be monitored (e.g. against PSIs) and evaluated. We provide an evaluation guide (see Chapter 10) from which future researchers in the long term can use to evaluate the impact and cost of peer-supported social care in prisons in England and Wales.

Throughout the project we have shared early interim findings with stakeholders from a range of organisations (e.g. HMPPS, local authorities, and the ADASS Care and Justice network) through the evaluation advisory group (in the form of presentations and sharing early drafts of chapters). We have plans to formally share the final findings with a range of stakeholders, including individual prisons, HMPPS, the ADASS Care and Justice network, prisoners and relevant charities. Therefore, it is expected that findings may help prison services to further develop peer-supported social care services that are offered in future.

Implications for decision-makers

Findings highlight the need to produce national standards for peer-supported social care, which specifically outlines how peer support services for social care should be implemented in prisons in England and Wales. In addition, these standards would specify what data would need to be collected on a national and local scale to ensure that services can be monitored and evaluated. While this will require resources to implement, it is important to be able to monitor and evaluate care provision, as would be the case with any community-based service.

We provide lessons for individual local authorities and prisons on how to implement peer support schemes for social care and the governance processes that need to be in place.

The findings provide lessons for HMIP on what information should be reported in the inspection reports in future.

Research recommendations

Further research should focus on the following areas:

• Exploring the impact of peer-supported social care on inequalities.
• Developing and piloting national standards and monitoring processes in a number of prisons to determine feasibility.
• Conducting a robust evaluation of effectiveness and cost-effectiveness of peer-supported social care.
• Exploring the relationship between different models of implementation and effectiveness and cost-effectiveness.