HEALTHCARE IN

bmj.com ЖЖNews: Older miss out on health care, says charity (BMJ 2009;339:b3327) ЖЖAnalysis: environment and health (BMJ 2012;345:e5921) ЖЖViews and reviews: Can incarceration be thought of as disease? (BMJ 2012;344:e2851) ELDERLY PRISONERS Prisons were designed for fit young men. In the second of his series of articles on , Stephen Ginn looks at the problems among the rising number of older prisoners

lder prisoners are now the fastest No place for old men growing subgroup of prisoners A prison is a particularly difficult place in which in England and Wales.1 There are to be old. The needs of older prisoners are often about 8000 prisoners aged 50 and overlooked, as many pose no obvious behav- over, comprising 11% of the prison ioural problems for the prison authorities.12 Opopulation,1 and many have multiple health The physical frailty of older prisoners is a disad- and social needs. vantage when they are incarcerated alongside Some of the increase in older prisoners is younger prisoners, and bullying and victimisa- attributable to the overall growth of the prison tion can be a problem.7 In addition, because population,2 which has doubled in the past 20 older prisoners are over represented among years.3 The increase in older prisoners, how- sexual offenders, other prisoners may assume ever, outstrips that of other groups (fig 1).2 A that an older is a sexual offender purely key factor seems to be a greater inclination on on account of his age. This places many older the part of the authorities to secure convictions prisoners at the bottom of the prison social against sex offenders.4 Forty two per cent of hierarchy.7 men aged over 50 in prison Stuart Ware served 12 Special facilities for older prisoners are less common have convictions for sexual Although a 50 year old man months of a 21 month sen- in the UK than in the US. Above: the vulnerable offences (table 1).1 5 Sexual in the community would tence for theft and fraud in prisoners unit at Wandsworth prison, London; below: offenders are given long not usually be described Bedford Prison in the late Hocking Corrrection Facility, Ohio sentences, and advances as old, observers suggest 1990s, when he was in his in forensic science mean that typical prisoners are late 50s. He has since set up oners are cited as examples of good practice,15 it that it is possible to secure functionally older than their a support network for older is constrained by its buildings. Five storeys tall, 13 convictions for “historical” chronological age prisoners and is a consult- the prison was built in the early 1800s to house .4 When it comes to ant to the Department of French prisoners of war. “Prison cells are not sentencing, the age of an older offender rarely Health. While in prison Ware was shocked at how sufficiently large to allow disabled access,” says has any bearing.6 older prisoners were looked after. He tells me that Ware. “Prisoners leave their wheelchairs outside For researchers, “older” prisoners are aged the situation has since improved, especially with their door.” The Inspectorate of Prisons reports a 50-60 and above.7 Although a 50 year old regard to healthcare. Nevertheless, he points to lack of adaptation of cells and communal areas man in the community would not usually be examples of the problems that older prisoners in around half of prison inspections.14 described as old, observers suggest that typi- still face. Inspection reports also relate that most pris- cal prisoners are functionally older than their Certain problems have historical origins. “By ons have no separate activities for older prison- chronological age. This is as a result of their and large prisons are Victorian and designed for ers.12 14 Older prisoners may be excluded from previous lifestyle, lack of prior medical care, housing fit young men,” says Ware. “They are general activities because of their frailty and can and the experience of incarceration.7‑9 poorly placed to meet the needs of older prison- remain locked in their cells.14 Most prison research has focused on young ers, particularly if they are disabled.” The 2010 Although older prisoners’ health compares men, with older prisoners seldom included.10 Equality Act applies to prisons and requires them unfavourably with that of people of compara- There is a lack of knowledge concerning best to take reasonable steps to ensure that a disabled ble age living in the community, as well as with practice around the of older prisoner is not disadvantaged by his or her disa- that of younger prisoners,16 there is no require- people. Older prisoners’ health, social, and bility. For example, all areas of the prison should ment for regular health monitoring. A 2001 resettlement needs are not completely under- permit wheelchair access, allowing the use of study found that 85% of male prisoners over stood,11 and policy tends to be local and showers, educational facilities, and association 60 had at least one chronic illness recorded in responsive.11 There is no national strategy, with other prisoners. However, prisons struggle their medical notes, and 83% reported at least and only one national initiative: a unit at Nor- to meet these requirements.14 one long standing illness. The most common wich prison that holds elderly prisoners on life Ware gives the example of Dartmoor Prison. complaints were psychiatric, cardiovascular, sentences who have healthcare requirements. Although aspects of Dartmoor’s care of older pris- musculoskeletal, and respiratory disorders.16 A

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Distribution of offences among Fig 1 | Age distribution among sentenced men, Fig 2 | Numbers of women aged over 50 in prison 2 12 14 19 men aged over 50 years in prison England and Wales, 2000 and 2010 in England and Wales in England and Wales, 20115       Type of offence % of men   Violence against Ж 26 the person  

Sexual offences 42   Female prisoners over  Acquisitive 11  Male prison population (s)

Drug offences 12             -  - - - - ≥ Total Year Other offences 9 Age group SHEPARDSHERBELL/CORBIS ANDREWAITCHISON/ALAMY

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2004 inspectorate report concluded that “Man- are inevitable. Nigel Newcomen is the prisons Failing to provide social care agement of chronic diseases varied, and could be and probation ombudsman for England and Some prisoners have social care needs requir- undermined by prison moves.”12 Wales and is responsible for investigating all ing help with getting dressed, keeping their The prevalence of mental health problems deaths within the criminal justice system. cells clean, and personal hygiene. At present among older prisoners is five times that of a “Previously most deaths in prison were self it is unclear whose responsibility it is to fund similar community sample.17 Thirty per cent of inflicted,” he says, “but now we are investi- services to meet these requirements.9 The prisoners aged over 60 meet the criteria for major gating an increasing number of deaths from National Service Framework for Older People depression,17 18 most of which goes untreated.17 natural causes.” states that older prisoners should have access Prisons’ ability to provide end of life care is to the same quality of healthcare as people in Older women “still in its early stages, although it is improv- the community, but it does not suggest a similar The number of older women in prisons is also ing,” says Newcomen. Some prisons have links commitment for social care.9 Many older pris- increasing in absolute terms and as a propor- to local hospices,20 and others have dedicated oners’ social care needs are largely unmet.22 tion of the total female prisoner population facilities. Isle of Wight Prison, Current legislation makes (fig 2). As in male prisons, physical infirmity for example, has a large popu- Of the 113 prisoners local authorities responsible of female prisoners is poorly accommodated. lation of older prisoners and a receiving end of life care, for assessing prisoners’ needs “Older women receive little attention in prison,” King’s Fund financed bed for only 22 were released and providing community says Azrini Wahidin, reader in prisoners requiring end of life on temporary licence at care services.9 “However, and criminal justice at Queen’s University care. Nevertheless, the overall the time of their deaths local authorities are engaging B­elfast. “Younger women monopolise time provision is patchy. Between with very few prisoners,” says and resources.” There are no specialist units 2007 and 2010, 113 prisoners had end of life Ware. “They argue their only responsibility is for older women prisoners. care plans, but in almost a fifth of these cases towards prisoners who are ordinarily resident “Becoming ill is one of older women prison- the planned care was not equivalent to that in their area. Prisons routinely hold people ers’ greatest fears,” says Wahidin. “They know available in the community (Prisons and Pro- from all over the country, and many prisoners that they will become dependent on a system bation Ombudsman, unpublished data). Where are excluded.” that is overstretched and under resourced.” palliative care expertise is lacking, prisoners “Primary care trusts and prisons are provid- Wahidin has found that older women prisoners may die in either a hospital wing or a regular ing most social care” says Ware, “and prison report inconsistent access to breast and cervical cell rather than in a dedicated facility.21 officers or other prisoners are acting as carers.” screening, that medication fails to follow them Applications for compassionate release The drawbacks of this are obvious—this is not when they are transferred, and that special diets can be made when a prisoner is in the final their core role and individuals may lack suit- are rarely accommodated.8 The Inspectorate of stages of a terminal illness.21 In practice this able training. “It may be appropriate for one Prisons found provision of preventive care, such is allowed in only a fraction of cases. Of the prisoner to carry out some tasks for another as screening, to be “very mixed.”12 113 prisoners receiving end of life care, only less able prisoner. but more personal tasks are 22 were released on temporary licence at the also taken on,” says Ware. Terminal illness and dementia time of their deaths.20 One explanation is the The 2010-11 ombudsman’s report describes Given the age of some prisoners, and the length difficultly in predicting prognosis.21 Another is the experience of one prisoner who volunteered of their sentences, age related deaths in prison the need to reconcile security, , and to act as a carer for an elderly prisoner with compassion. complex medical needs.21 Although the volun- There is also a view that it is inappropriate teer had cared for his parents in ill health, he to release some prisoners to die. “Some of our had no formal experience or healthcare quali- prisoners have no family, and the prison is their fications. The report says, “He was expected home,” one governor told me. Guards escort to shower Mr J, and often had to clear up his prisoners if they are taken to a hospice but incontinence, among other difficult duties. He “primarily for emotional support rather than told the investigator that he felt isolated and security.” This approach makes some sense, unsupported by staff. Officers and healthcare although it is questionable whether it can jus- staff did not take responsibility for Mr J’s com- tify continued imprisonment. plex and demanding needs.” “The prison regime can easily hide signs and Release can also be a time of acute difficulty symptoms of dementia,” says Nick Le Mesurier, because older prisoners are often institutional- freelance researcher and honorary lecturer at ised and lack the skills for independent living.10 the Faculty of Health, Staffordshire University. Their release may be subject to conditions that “The rules in prison are constantly reinforced prevent them contacting their families, and and prisoners have to make few decisions for some will have lost all their possessions while themselves.” One study found dementia in in custody.10 Yet social services often have little 2/203 prisoners aged over 59,17 but otherwise involvement in plans for release,14 and anec- the subject has attracted little research atten- dotally local authorities have been known to tion. “Estimates for dementia are likely to be refuse social care funding for newly released on the low side,” says Le Mesurier. “Prison serv- prisoners. This issue can be particularly acute

SHEPARDSHERBELL/CORBIS ices are often poorly equipped to recognise and for older prisoners, who may need a greater A prisoner in Louisiana: all areas of a prison deal with something like dementia, which has level of support because of their age. should permit wheelchair access a slow developing, chronic nature.” Current social care reforms may change

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matters: the July 2012 white paper Caring for 1 . Bromley briefings prison fact BMJ BLOG Domhnall MacAuley file. 2012. www.prisonreformtrust.org.uk/Portals/0/ Our Future proposes that the government will Documents/FactfileJune2012.pdf. develop “a new framework for the provision of 2 Manns N. Doing harder time. Ashgate, 2012. Death and youth care and support in prisons, so it is clear where 3 Berman G. Prison population statistics. House of Doctors took a long time to recognise that people 23 Commons briefing paper. 2012. www.parliament.uk/ responsibility lies.” One solution is for social briefing-papers/SN04334.pdf. die. We are no longer afraid to talk about “end of care responsibility to be transferred to healthcare 4 Crawley E, Sparks R. Surviving the prison experience? life care.” And a large number turned up at an 8 am Imprisonment and elderly men. Prison Service Journal fringe meeting run by the end of life care subgroup providers. However, the current unsatisfactory 2005;160. www.pfi.org/cot/prison/offender/physical- and ad hoc arrangements will continue for some welfare/care-of-elderly-prisoners-crawley-2005. of the Royal College of General Practitioners time to come. 5 Ministry of Justice. Offender management caseload Scotland at the RCGP and Society for Academic statistics 2011. Ministry of Justice, 2012. 6 Relevant factors for sentencers dealing with sex Primary Care conference earlier this month (www. Lessons from the United States? offenders. Law report. Times 2003 Oct 29. rcgp.org.uk/annualconference). 7 Dochherty LJ. The healthcare challenges of older Lots of ideas are introduced with the British prisons have been slow to recognise and people in prisons—a briefing paper. www.ohrn.nhs.uk/ act on the needs of older prisoners. Special facili- resource/Research/OlderPrisonersReview.pdf. best intentions. Communication between ties for older prisoners are more established in 8 Wahidin A. Older women in the criminal justice system: professionals is essential, but there was now running out of time. Jessica Kingsley, 2004. excessive form filling to the point where a dying the United States, where people aged 55 and over 9 Williams J. Social care and older prisoners. J Soc Work account for 8% of the prison population.24 As 2012 Feb 21. [Epub ahead of print.] patient may have three sets of records. Asked to 10 Crawley E. Imprisonment in old age. In: Jewkes T, ed. ageing prisoners develop an increasing need for identify barriers to good care, the audience was Handbook on prisons. Willan Publishing, 2007:224-44. particularly frustrated by how process could get in medical care and assistance they are often placed 11 Philips J. Crime and older people: the research agenda. In: Wahidin A, Cain M, eds. Aging crime and society. the way of good care. in facilities where older and disabled prisoners Willan Publishing, 2006:53-70. 24 Palliative care teams seem like a good idea, predominate. Texas has special geriatric units 12 Her Majesty’s Chief Inspector of Prisons. No problems— but GPs found it difficult when, having cared for for prisoners aged 60 and above, where they old and quiet. 2004. www.justice.gov.uk/downloads/ publications/inspectorate-reports/hmipris/thematic- someone for a lifetime, they were expected to are given greater time to attend to the activities reports-and-research-publications/hmp-thematic- hand over to a palliative care team to manage the of daily living. The state also has a “higher level older-04-rps.pdf. 13 Restore 50plus. Information for statutory and voluntary patient’s death. The change of category grated: geriatric facility” that provides access to special- sector agencies. www.veteransinprison.org.uk/ the transition from good general practice to ist services such as physiotherapy and dialysis.24 restore50plus.html. 14 HM Chief Inspector of Prisons. Older prisoners in palliative care. Good care may not always mean a England and Wales: follow-up to the 2004 thematic change in care. Conclusion review. 2008. www.justice.gov.uk/downloads/ Making a decision to mark notes “Do not Britain is locking up increasing numbers of older publications/inspectorate-reports/hmipris/thematic- reports-and-research-publications/older_prisoners_ resuscitate” seems like a good idea. But the term people, but the British prison system is poorly thematic-rps.pdf. has negative implications, suggesting to patients equipped to deal with them. Prison buildings 15 Independent Monitoring Board. Annual report for that there was something that could be done are often unsuitable for elderly people. Com- HMP Dartmoor 2010-2011. www.justice.gov.uk/ downloads/publications/corporate-reports/imb/ that wouldn’t be done. It might be better that we prehensive data on older people as they move annual-reports-2011/dartmoor-2010-2011.pdf. talk about, and mark notes, to say, “Allow natural through the criminal justice system are not avail- 16 Fazel S, Hope T, O’Donnell I, Piper M, Jacoby R. Health death.” 25 of elderly male prisoners worse than the general able. Current evidence is that the health of population, worse than younger prisoners. Age Ageing Dying at home also seems like a good idea. Sue older prisoners is often poor, their social needs 2001;30: 403-7. Kinsey, a patient member of the panel, said that 17 Fazel S, Hope T, O’Donnell I, Jacoby R. Hidden are inadequately addressed, and end of life care psychiatric morbidity in elderly prisoners. Br J Psychiatry although many people worry about leaving their requires further attention. Given these problems, 2001;179:535-9. dog at home throughout the day when they are at a national strategy is long overdue. 18 Hayes AJ, Burns A, Turnbull P. Shaw JJ. The health work, there was little thought of older people living and social needs of older male prisoners. Int J Geriat There are arguments for and against treating Psychiatry 2012;27:1155-62. alone with a terminal illness who might have just older prisoners as a separate group.11 Some 19 Wahadin A. Older women in prison: issues and two 20 minute visits by a district nurse daily. There challenges. 2010. www.acjrd.ie/files/Women_in_the_ may wish to remain part of mainstream prison Criminal_Justice_System_%282010%29.pdf. are times when it may be better to die in hospital. life,10 and specialist units will mean that many 20 Prisons and Probation Ombudsman. Learning from The morning started with prisoners will be held further from home.11 But PPO investigations: natural deaths in prison custody death, and the afternoon 2007-10. http://iapdeathsincustody.independent. separate units prevent abuse by younger prison- gov.uk/news/ppo-report-on-natural-cause- ended with youth. It was ers and allow a greater focus on older prisoners’ deaths-2007-2010. lovely to be reminded of the 21 Prisons and Probation Ombudsman. Annual report great achievements of Ann needs. 2010-2011. www.ppo.gov.uk/docs/ppo-annual- In the absence of any fundamental change report_2010-11_web.pdf. McPherson in this inaugural in policy or shift in sentencing guidelines, the 22 Prison Reform Trust. Doing time: the experiences memorial lecture in her name. and needs of older people in prison. 2008. www. The lecture by Al Aynsley- phenomenon of older prisoners is here to stay. prisonreformtrust.org.uk/Portals/0/Documents/ Ann McPherson: Doing%20Time%20the%20experiences%20and%20 Green, the former children’s But questions concerning the appropriateness lecture in her name needs%20of%20older%20people%20in%20prison. commissioner for England, of imprisoning older people should also be cen- pdf. tral to the development of a coherent strategy 23 Secretary of State for Health. Caring for our future: encouraged us to think about children. But it for managing older prisoners and their needs reforming care and support. 2012 www.dh.gov.uk/ was Ann’s insights from her lifetime as a family health/files/2012/07/White-Paper-Caring-for-our- doctor that resonated so much with GPs, and her effectively. future-reforming-care-and-support-PDF-1580K.pdf. The first article in the series is BMJ 2012;345:e5921. 24 Human Rights Watch. Old behind bars—the brilliance was in articulating all our experiences Stephen Ginn Roger Robinson editorial registrar, BMJ, aging prison population in the United States. of caring for adolescent health problems. General 2012. www.hrw.org/sites/default/files/reports/ London WC1H 9JR, UKЖ usprisons0112webwcover_0.pdf. practice from youth to old age. It’s what we do. [email protected] 25 Wahidin A, Aday R. Later life and imprisonment. In: Domhnall MacAuley is the BMJ’s primary care editor Competing interests: None declared. Dannefer D, Phillipson C, eds. The Sage handbook in Provenance and peer review: Commissioned; not externally social gerontology. Sage, 2011:587-96. ̻̻Read this blog in full and other blogs at bmj.com. peer reviewed. Cite this as: BMJ 2012;345:e6263

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