National Assembly for Wales

Thank you, Dai. Good morning. Local authorities should support adults with care and support needs in prisons in Wales, just as they would in the community. In the view of the WLGA, how effective are the current social care arrangements in meeting the needs of prisoners and ensuring that services are delivered as they would be in the community?

So, this is a very new requirement on local authorities in Wales. It's a requirement that we work hard to try and meet but there are obviously some inherent barriers that we have to overcome because much of the secure estate was not designed for people with disabilities or people with complex needs—it was designed for people who are fit and able. So, there are difficulties that we are working to overcome. And there are difficulties that all the health and social care sector faces around recruitment and retention. Again, that's something that is particularly challenging in the secure estate, because it's not a career choice for many in the health and social care sector. So, it's something we continue to work on, but there's more that we need to do in partnership with other agencies, particularly, obviously, the prison service and the health service.

Do you want to add to that?

I would say that there are some things that we do really well inside secure estates, and there are some things that we could do better. I think trying to compare providing social care within a secure estate is difficult because you haven't got the infrastructure of the whole health and care system that you have in the community—for instance, access to primary care, like district nurses, and those types of things. Some of the things that we find is prisoners being able to have diagnosis of dementia or learning disabilities—our access to some of those needs to be improved in terms of that. If people had the right diagnosis, you could then put in the right care and support plans around that. I think that the environment for delivering social care services within the prison presents us with challenges that we don't experience in the community, and I think that custodial staff and our social care staff, for instance, in HM Prison and Young Offenders' Institution Parc have worked really well together in terms of finding innovative ways of delivering things that you wouldn't have to do if you were in the community, really. So, I think we're trying very hard collectively to meet the needs of prisoners, but there are barriers in terms of the environment and the infrastructure around some of that.

Thank you. You mentioned there issues around diagnosis and, obviously, that's a particular problem when you've got a transient prison population that keep on moving. Whose responsibility is it to make sure that a prisoner, if they're presenting with something that suggests they might have, let's say, a learning disability—in this slightly confused governance picture, whose responsibility is it to that prisoner?

So, my experience is from within Parc prison. The health services in there are contracted via the Ministry of Justice, aren't they, Huw, and it's not a devolved responsibility? So, I think probably some of the governance around who should be doing that is blurred for us, really, in terms of that, really, so—.

Okay. You mentioned that there are particular issues around recruiting staff to work in that sort of setting. Are you aware of, or can you share with us, any work that's being done to address those particular needs in terms of getting the right staff into the right place?

We know that Social Care Wales have begun a campaign to recruit more into the social care sector. There are plans to ensure that there's specific targeted recruitment. So, we are looking to ensure that part of that targeted recruitment is identifying and encouraging more people to work in specialist settings like this.

Okay, thank you. And I think you, Ms Davies, might have touched on this a little bit: to what extent are local authorities across Wales, in your experience, developing integrated approaches with health services to respond to the health and social care needs of prisoners? I suppose it's a slightly different situation in Parc, because you've got the situation where they're using a private healthcare provider—and don't start me on what I think about that—but are you aware of anything that's happening perhaps elsewhere, because it must be more difficult to get those collaborations going, when you've just mentioned the governance? But is there any practice around health and care working together to meet prisoners' needs?

I think there are some good examples across Wales of integrated approaches—in Monmouthshire, for instance, and some of the work that they're doing there in terms of that.

In terms of Parc prison, we do work with G4S Health Services UK Ltd, and we have multidisciplinary meetings in terms of safeguarding on a very regular basis, and we develop care and support plans together in terms of that, really. So, I think it's evolving; it's very new for us, really, isn't it, in terms of that? And I think there are some examples where they've done some good work across primary care and health and social care.

And indeed, the recent Her Majesty's Inspectorate of Prisons and Care Quality Commission's thematic report identified some good practice in the prison in Cardiff, where health and social care and the prison service work very closely together, carrying out joint reviews et cetera, and where health provides some of those services for the local authority. So, there is some good practice that was recognised in that report—areas for improvement, but some good practice that exists across Wales.

That's useful. And just finally, if I may, Chair, you mentioned, Ms Davies, that in Parc prison the prison service and social care were working together with some innovative solutions to individual prisoners' needs. Could you perhaps share one or two examples of that with us, because I think those really practical things are really helpful for us to know about?

Yes. So, we had a situation—let me just find the part of it—where a gentleman went into prison. He was in his 80s when he went into prison. He'd been waiting a number of years for the sentence—to go through the process, really, in terms of that. When he lived in the community, he had a hospital bed, he had care and he had Lifeline-type technology within his own home. In the prison setting, we had to try and replicate that. He was at a high risk of falling at night, for instance. In the prison setting, people are in their cells, aren't they, at night, and we had to find ways of doing that. We managed to rearrange the cell in terms of being able to meet some of those needs and we had an extensive plan that we worked out with all of the custodial staff and the health staff in terms of trying to support him.

His anxiety levels were very high, as were his family's. So, we engaged a lot with his family in terms of—they needed to ensure, for instance—. He was very forgetful as well in terms of taking his medication. So, they've got buddy systems within the prison, and that works really well in terms of being able to prompt and those types of things. We, for instance, in terms of at night, the occupational therapist did some work within the cell and with the gentleman, and we had a doorbell, like you've got in the house, and she sourced that. So, they linked it up to the alarm system within the prison that they use. So, he could get somebody very quickly and people would respond in a way that was appropriate to meet his needs at night. So, those are some of the types of things that we've done. I could give you more examples, but—

That's a good practical one. Thank you.

I'd just like to expand on that a little bit further, actually, because you're talking about one specific prisoner. Are you able to give us an overview of how, throughout Welsh prisons, for example, older prisoners with dementia are even picked up—how they're diagnosed? And you talked of that one example, but I would be interested to know how prisoners with mild dementia, with moderate dementia and with severe dementia are handled within the prison system.

So, as I said, this is very new, isn't it? And I think that the prison population, in terms of the prevalence of dementia, is new to the prison population as well, and particularly now, as we've got historical offences. So, I think it's an evolving picture in terms of that. I think that getting access to the specialist dementia services that somebody would get in the community isn't robust enough for people that are within the secure estate at the moment.

I think that, as you go through the stages of dementia, sometimes, the prison environment actually is quite good because it's very routine and the layout of the prison actually supports somebody with dementia in the early stages. I think, as you get to the latter part of that in somebody, the environment—it's very difficult to maintain people safely within that.

And I think that people with very complex needs, so that could be physical frailty as well as dementia—. To give an example, for instance: somebody at night—that tends to be an issue sometimes for us in terms of trying to support somebody safely—and the person wasn't entitled, because they didn't have a terminal illness, to compassionate leave, but it was very clear that in the prison environment, we couldn't keep the person safe within that environment because of their needs. So, again, we work very closely with the prison in terms of, 'How do we keep this person safe?', and it is a challenge. It's a real challenge in terms of doing some of that, really. So, I think the support and the infrastructure for people with dementia needs to be strengthened across health and social care for people with dementia.

Are you able to comment on—? I'd just like to explore the safety angle a little bit. So, especially people with moderate to severe dementia, are they sequestered, are they in amongst the general prison population? How do you manage their social interactions with other prisoners, who may not have much understanding, or indeed, perhaps, compassion, as a lot of people don't towards people with dementia, or understanding of why this person might be displaying behaviours that they could find irritating or confusing?

Yes, I think there are a couple of things that we've been trying to do. So, in some prison settings, they have vulnerable prisoner wings, and those vulnerable prisoner wings are usually related to them being at threat from other prisoners, and they tend to be the older population. So, there is that. I know they are looking at creating other wings for the older population, but I can't comment on that, because that's how the infrastructure of the secure estate is—they're doing that.

I think that—. The prisons operate what they call buddy systems, which are from other prisoners, and I know our staff within Parc prison, for instance, have been doing a lot of sessions with those buddies in terms of raising awareness, almost providing them with tools to support people in terms of dementia or cognitive impairments, anyway, really. So, it's about that education and stuff, and our occupational therapist has done some great work with groups of prisoners, who I must say have embraced that, really, and there's been some great work done in terms of some of that.

In terms of your paper, where you talk about an ageing prisoner population, the older prisoner population presents as much older than the older people population outside of prison, if that makes sense. So, you recognise it, but is that matched by the provision of healthcare? Do the health services, in your experience—do the health boards understand that a 60-year-old in prison may actually present as much older than a 60-year-old would be outside of a prison? And do they reflect that in the provision of services?

They certainly recognise that. As you said, we know that prisoners are much, much more likely to have experienced significant health problems and, therefore, effectively, they are experiencing the signs of ageing and frailty at, on average, a much earlier time in their life, and they're much more likely to have quite significant health problems. There is provision, but, as with the general population, demand is rising quite rapidly, and we need to consider whether the health services for people in prison are increasing at the same pace as the level of demand is rising.

Certainly, for example, in terms of the mental health team that covered Swansea and Bridgend, when the prison population at Bridgend doubled, virtually—it did double in the early part of the century—we didn't see that team double in size. And we know that nine in 10 of our prisoners have mental health problems, but the specialist mental-health team for, as was then, the Western Bay region certainly didn't double in size.

Just to go back to your question, because I think it's an important question, about dementia, I know that in Monmouthshire, in Usk, they've done some work around training staff, because, obviously, we're not going to be able to carry out—there are just not the resources to have a specialist health worker checking whether anyone's got dementia. We would rely, as we would in the community, on somebody flagging up a concern about an individual, but what we need to do is raise awareness amongst the prison staff that these are the potential signs of dementia so that we can then carry out that potential assessment and diagnosis, if need be. So, that's something we're looking—authorities across Wales, with health services, are looking to develop more of that general training, which has been very effective in the general social care workforce and the general health workforce. 

Do you have any feel for how many prisoners there are in Welsh prisons who have a diminishment in their capacity, their mental capacity? 

Well, we know that about a third have a disability; we know that nine out of 10 identify or are identified as having mental health problems. I don't know whether we've got the—

I don't think we've got the exact number.

—exact number to hand, but we know it's much higher than the general population. That is recognised by every study and investigation that is carried out. We also know that, as you of course will all know, the rate of dementia within the general population is rising, and that's rising because we've got an ageing population. We also know that the prison population is ageing as well.

You—

Sorry, Angela—I've got a couple of supplementaries on these points before coming back to you. Okay, Lynne first, then David. 

Yes, and two supplementaries, really. I wanted to ask about the management of behaviour that could be described as challenging in a prison setting, because some people with dementia could be considered to have very challenging behaviour that care homes and the like struggle to manage, and have to be managed in very specialist settings. So, I was just wondering if you would comment on that. The other thing is that when we were at Parc we were told about a prisoner who'd been there a long time, had dementia, but was coming up to release, and they were really, really worried about how that process would work, really, and I wondered if you had any experience of managing that transition for people who are coming to the end, because there are big human rights issues there as well. 

Okay. So, in terms of managing behaviour within the setting, I gave you an example of somebody who was falling. We've had examples where—

Challenging behaviour in people with dementia can often be aggression, things like that, you know—

Sexually inappropriate acting out, all sorts of things.

—all sorts of things, yes. It's not so much your falls and things like that, it's—. 

So, what we've got within prisons is—we've got a social work team, for instance, in Parc, and an occupational therapist. So, if I give you an example, that might help to frame the answer, really. We had somebody that was demonstrating challenging behaviour and because of his behaviour was at risk from other prisoners, really. So, that's the sort of thing that you're talking about. What we did is we did some quite intensive work with that individual, like we would do in the community, really, for somebody, in terms of trying to understand where they were coming from, what was leading to their frustrations, which would then result in their behaviour, really. I must say that the custodial staff and the health staff, we all worked together in terms of trying to support that individual, but also about all the people that were around that individual, so for instance on the wing and in other parts of the prison where that individual would go. It wasn't without its challenge, it wasn't an easy process, really, but we did get to the point where other people understood what the triggers were for that individual, and that individual on some level understood that as well.

What we did do with that individual—. We're part of release planning for people with care and support needs; that's one of our key functions inside the prison. He was a gentleman from England, for instance, and we did a lot of work with the receiving authority, really, in terms of that. So, that individual, part of anxiety and that sort of stuff was around some of that, really. So, we did some work around that, but there's always more you can do; I recognise that, really, and I suppose what we are facing now are circumstances that none of us have come across before. So, we haven't come across having to provide care and support for these individuals in this environment before, and some of it we're learning with individuals. But I do know that Part 11 and our ability to do these things has resulted in some great results for individuals in terms of some of that, really, so—. 

Okay. David, a short supplementary. 

Just a short one. Huw mentioned in his earlier response about the 2009-10 mental health report, that Parc doubled in prison size but Western Bay didn't increase its staffing in one sense. I want to know the governance arrangements for that. What are the governance—? Because, obviously, Parc is slightly different, because it's a private prison, but what are the governance arrangements for that to ensure that if the needs are there—? Who makes the call in that? I know Western Bay is no longer Western Bay, but who made the call? What were the arrangements in place to say, 'Well, we won't increase the numbers', or 'We didn't have the funding to increase the numbers', or, if you didn't have the funding, who should have given the funding?

So, it would have been a decision, obviously, of the health board. 

The health board. 

The health board, yes. 

Reverting to Angela, with grateful thanks for your patience. 

Yes. Oh, sorry, I thought you were going to tell me to hurry up. [Laughter.] The examples that you've quoted have been absolutely—have been great. However, Huw, you've said that the prison population is escalating, and, as they're older, people are frailer, there are more and more cases of people with disabilities, with dementia, with mental health issues. I think you said 90 per cent of the prison population has some form of mental health issue, et cetera. So, although you've picked out instances where, obviously, there's been a great deal of thought and planning gone into that particular individual, my question is: how are you able to promulgate that good effort through an obviously older and more frail prison population with—you know, you've got limited staff, limited resources, et cetera? Because we can look at the beacons and walk away from this evidence session going, 'Wow, that's really great', but, for every couple of those, I just wonder how many prisoners are sitting in their cells incredibly confused, not sure what on earth is going on, and having to survive the rough and tumble of prison life with diminished capacity.

I suppose one of the advantages is that we haven't got too many prisons in Wales and, of course, those prisons are different. So, some of them are remand prisons where, thankfully, the prisoners don't spend too long in prison—they're remanded for a short period of time—and we've got two big prisons, I suppose we'd describe them, in Parc and Berwyn, that are much more likely to have a settled population. There is sharing of best practice, but we probably need to look to see how we can strengthen that. Resources are always an issue and, again, I think what we need to do is—thinking about the future and planning for the future, just as we're planning for a future of the general population where social and health care needs continue to rise, we need to think about that for our prison population as well, because there's no sign of the prison population declining in Wales. It's actually experienced a major increase because of the construction of and opening of Berwyn. As I said earlier, we anticipate that needs will increase. So, I think it may require some sort of—I don't normally say this, but some sort of national planning, where it's co-constructed with the relevant local agencies. 

Well, actually, as you've reached that point in the conversation, I'm going to ask you the question I wanted to ask you right at the end after two very factual questions about palliative care, and about who pays for what in terms of adaptations for disabilities. But the philosophical question is this: are you picking up, hearing, or part of any plan, movement, thought from the Ministry of Justice, from the Prison Service nationally—Wales's part in it—as to where we might go in the future with the management of prisoners with significant mental health capacity issues? Because you're talking about that the prison population is growing, you're talking about there being more and more older prisoners with dementia. There are more and more prisoners, in my view, who shouldn't be in prison because they have mental health issues. Are there any movements, have you picked up anything, any echoes, that there is actually a fundamental root-and-branch review of the penal system in terms of who we're putting in prison and, when they're there, how we're handling the people who really don't have that capacity to necessarily understand why they're there?

I've only got a couple of things to say about that. Just on a local level, we know that there are conversations that they're having at a Welsh level, but also at a national level, in terms of is the estate fit for purpose for the people that are there. So, as we are required to do a population needs assessment to develop our services, in a way, I think that they are doing that. And some of the examples that we've experienced in Parc prison, they are using in that environment to demonstrate why, for instance, things like the compassionate leave policy just isn't working for people with dementia. So, I think there is a move for that. The speed and pace of that I couldn't comment on, but I know that locally, they are raising that through the appropriate channels in terms of that, because they are equally concerned about it in terms of the governor and the deputy governor within the local things, really. So, that would be what I would say. 

In terms of some of the other comments that you made, what I'd like to see is a multiskilled integration team, like we've got in the community, operating within the prison service. The way that health is commissioned in Parc, for instance, that makes that slightly more difficult than we would experience in other areas. 

Okay. Do you want me to ask my two slightly more mundane questions?

Briefly, yes.

One is: who's got the financial responsibility for making adaptations in prisons? Does it fall on you or does it fall within the—? So, if somebody's got a wheelchair and you need to put in ramps, who has to pay for it?

It's tricky in terms of that. We've got responsibility to provide aids and adaptations to meet people's care and support needs, and we do that. So, we would put in handrails in the toilet and do those types of things. If there's anything that needs to be changed within the prison, then the prison do that. But, we do that together. So, I don't see that as a problem. I know in Monmouthshire, for instance, the OT is in the rounds of going into every cell to put those adaptations in. So, that's not an issue for us at the moment. 

And my last question, then, no matter who you are, I think the dying process can be a very difficult one for a lot of people, so how does the prison service handle the provision of palliative care to people who are in prison with terminal illnesses and who will probably spend their last moments there?

We've got examples of people who have expressed a wish to stay in prison for end of life, and we've been able to accommodate that and the health service within the prison has been able to accommodate that. We've got other examples where people have been discharged out of prison and they move into other care settings or other settings that are appropriate. So, we have got that. I think the issue of entitlement to continuing healthcare and how we do that and how we fast track people has some governance issues that just need to be worked through that aren't robust enough at the moment. 

Okay, thank you.

Just to emphasise there, it is about the individual circumstances of that person, their needs and their desires. Obviously, there are some choices that are outside that individual's sphere; the choices that are there if they were in the community. But that has to be the focus: what is it that that person wants at the end of their life? And we try and meet those needs as best we can. 

That's reassuring. I just wanted to check that there was a cultural acceptance that—I'm going to put this very badly, I know—no matter how 'bad' you might have been that you've had to be in prison for so long that you end up having to die there, despite that, we still recognise they're an individual and that they have the right to have as much choice as they possibly can around their end-of-life plan.

Thank you, Chair. Can you just clarify what the funding arrangements are for social care provision in prisons? And to what extent is funding aligned to local authorities with prisons in their communities?

We did have some additional funding that was provided as a specific grant to local authorities, which we welcomed. We certainly welcomed it in Bridgend because we're one of the local authorities that benefited from that, as did other local authorities that have prisons. But that's obviously been moved into the revenue support grant, therefore, it is shared out across Wales to all local authorities.

So, there's nothing ring-fenced specifically—any funding for prisoners.

No, it's within the pot. As I think you've all recognised, the need and demand are growing at quite a rapid pace, and obviously that would be a need and demand that has to be met by only a handful of authorities in Wales.

Okay. Did you want to say—?

I suppose all I would just comment there is that we have been able to demonstrate that, to deliver social care within the prison setting, it costs much more than it does in the community, because of the very nature of what we have to do.

In your written paper, you say that there's a need to invest in additional areas in order to support and improve social care provision in prisons. Do you think that's achievable within the current resources?

No, not within the current resources. Arguably, there is an invest-to-save case to be made here, because most of the prisoners will be discharged, and if, during their period in prison, their health deteriorates and deteriorates significantly, actually we're storing up problems for the health and social care sector for when these people are discharged. Some of what we could be doing—capacity building, awareness raising and training that, for example, identifies early signs of dementia—I think could deliver benefits to society, but it is a significant resource implication. Until the Act was put in place, we didn't deliver care or health needs in Parc prison. We now have a dedicated team with a team manager, OT assistants and social workers—a significant team—and they are very busy, aren't they, Jackie? We could probably double that team and that team would still be very busy.

Thanks, Chair. Your written evidence says that access to and continuity of services, including preventative services, between prison and the community is a key area for improvement, and that that includes services for substance misuse, mental health issues and sexual health. What specific changes would you like to see being made to strengthen those multi-agency links?

I suppose, if we were thinking about prisoners having equal access to services like they do in the community, I think it's about how we work through those barriers that stop that happening now, really, isn't it, in terms of that? That'll be a multitude of things, really. So, for instance, in substance misuse, we've got a working group in Bridgend now that is looking, from the area planning board, at the services that are delivered within Parc prison and how we can ensure that our responsibilities under APB are being delivered within the prison. So, some of this is just working through that, really, and trying to find solutions to get what we need in terms of support for individuals.

I suppose, just in terms of those general mental health problems that we've identified, from low-level to quite high-level mental health issues, as, again, with the general population and general communities, quite often it's about ensuring that people have value, worth and meaningful activities. So, I suppose we'd say that there needs to be a stronger focus on, for example, training and educational opportunities, but also some of the schemes that have been successful across prisons in Wales, for example, peer support, so that if we know that we've got people with dementia, if some other prisoners can provide support to the person with dementia, actually that can be a rewarding experience for that person as well, because they feel they're doing something meaningful, and that can help their mental health. What we do know is that the vast majority of prisoners have low self-esteem and if we want them to not reoffend when they leave prison, and unfortunately about half will, then we need to help them to change their lives. So I think some of the work that we're doing can really support that programme of rehabilitation.

Can I specifically ask about substance misuse? Because we know that those services are not there, really, for anyone, let alone somebody leaving prison, and we also heard that in Cardiff prison, they have a policy of maintaining prisoners on particular drugs in order to avoid the risk of them overdosing when they are released, which is a policy that they've introduced. But if there isn't support in the community, doesn't it just increase the risk of that kind of revolving door situation? Because someone is going to come out of prison and need to meet the needs of their habit, which is inevitably going to involve some sort of criminal activity.

Absolutely. So there does need to be that provision, both within the secure estate and within the community, otherwise—you are right. We know that a lot of prisoners will have serious substance misuse problems, and if those aren't addressed, then it is very likely that they will be returning to prison.

Diolch, Cadeirydd. You mentioned earlier, Councillor David, that there was some good practice across Wales, and I think the emphasis is on the word 'some', because you also, in your paper, mention inconsistencies across Wales, and that you would like to see a national oversight applied in Wales. What would you think would be the benefits of a national oversight, and how would it work, in your view, to make sure that you do get those benefits?

I think what we don't want to do is create an industry and an array of beautiful plans, obviously, that we have an army of people to develop. But I do think a light-touch national plan would actually ensure that the sharing of best practice that does happen now happens, I suppose, in a systematic way. Because as I said, we've only got six prisons in Wales, so we can work much more closely together and ensure that, where there are challenges, we identify ways of meeting those challenges. Although, as the Assembly Member for Torfaen has touched on, of course, one of the problems is that it does require a multi-agency solution, and we know that sometimes, it's not always easy to bring all the partners with us. I won't go into the details, but I think some of you can guess who those partners may or may not be. But it does require a real multi-agency approach, so, sometimes, you can have that national, local or regional partnership approach, but you need all the agencies to commit to that to make it work effectively.

I accept that, but obviously, we can't guess—it's not our job to guess, it's your job to tell us—who those partners are, who those agencies are. If you think there are some agencies not pulling their weight, let us know. I think that's important. But is there also a possibility, in your view, then, as a representative of the WLGA in that sense, that there's a failure in the Welsh Government in its recent partnership agreement between HM Prison and Probation Service and the Welsh Government in not including an oversight strategy in that partnership agreement, particularly for the older people? Because we've heard an awful lot this morning about the older people in prison and the issues and challenges they face.

So, in answer to your first question, then, health boards.

Thank you.

Though I think that's improved—we've got a new health board that we're working with locally, and, again, it's not every health board because not every health board has a prison in their area. In terms of that partnership agreement, I'd simply say that this is a relatively new development. It's not a brand-new area. And I think it does need to be considered. Even if it wasn't in that partnership agreement, then there are other ways of addressing this, and, like with everything, I don't think it's particularly about whether you have a piece of paper, because there's lots of pieces of paper floating around Wales—there's millions of pieces of paper—it's about the commitment and willingness to do something about it and making it a priority, and I think that that's the key thing. So, that's something that no doubt Welsh Government would want to do, particularly if this committee makes it a recommendation. I'm sure they'd consider it as a priority.

So, your one urge for us is to actually encourage Welsh Government to ensure that all partners in the delivery make it a commitment for them to have a priority of delivering those.

I think so, yes.

Thank you.

Thank you for allowing us to report in from here and not make the journey down. We very much appreciate it.

Diolch, Cadeirydd. We note that the governance arrangements should be by a local partnership board, the prison health and social care partnership. Before I come to Betsi, because, clearly, you've reported in your evidence that you meet four times a year, quarterly, I want to go to Cwm Taf, because, in your evidence, you've honestly opened up and indicated that you haven't yet met and haven't yet established a board. You cite other reasons, but you've taken over this since 1 April, we're now in November, you haven't yet met, I have some concerns, therefore, as to how you're going to oversee the governance arrangements of the healthcare services in Parc prison.

Shall I start?

Yes.

So, that was very honest in the evidence that we gave. The boundary change took place on 1 April, and there was a transfer of details and information in relation to the prison and how we operated with the prison as part of that exchange between the former Abertawe Bro Morgannwg university health board and Cwm Taf, which was very detailed. We have had a whole range of issues to deal with in terms of just how we manage our services and integrate our services across the piece, and I have to say it's unfortunate that establishing the partnership arrangements has taken some time to put in place. We're on with that now, and we will have our very first partnership meeting before Christmas. I'm being very honest about that; we probably let that ball slip against a range of other things that we were actually doing at that point in time.

That hasn't meant that there hasn't been a range of activity taking place with the prison service. Certainly, people have been—from a health perspective, we've been having familiarisation visits in the prison. There's been involvement from Public Health Wales with the prison; I've seen the documentation associated with that. And there was an effective arrangement in place, in addition to which, Carmel is linked in to the prisoners as well. So, the governance arrangement, absolutely, hasn't been in place, but it hasn't been that there hasn't been any relationship with the prison at all.

There's a difference between a relationship and the governance to ensure that that relationship is delivering for the care of the individuals within the prison, and I suppose my chief concern is what arrangements—take away the former board, the former partnership, what arrangements have you put into place to ensure that some form of governance is there so that you can satisfy yourselves that you are actually delivering the right type of care for those individuals?

I think we'll probably come on to that in due course, but the arrangements that exist in terms of delivery of healthcare into Parc prison are quite complex, and, actually, as a health board, we don't actually deliver any of the healthcare. I think there's an issue that I'm sure we'll pick up during the course of the next half an hour in relation to how that might maybe work more effectively.

It still hasn't answered the question. We all know the circumstances with Cwm Taf and maternity—let's take that to one side—but the consequences are reassurances that Cwm Taf is on top of this, and, from your answers, I've not been reassured that you're on top of this. So, how can you reassure me that you are on top of this and you are ensuring that your responsibilities are being met?

So, my—well, I go back to saying that it's something that we should have put in place earlier on in the year, we didn't, and that we're putting steps in place to ensure that we have that governance arrangement in place before Christmas.

Have we got a view from the north as regards how you deal with Berwyn?

Yes. I should say that if it looks like we're leaning in very close, it's not intended to frighten anybody, we're just trying to listen, because the sound's not great here, so bear with us if ask for something to be repeated. So, Rob, did you get that question?

Yes. We established quite early on our governance structure in order to have fluidity of what we were doing from a health board perspective from the project stage all the way through to what the prison were doing so that we met in the middle. It's been a real positive. Our governance meetings include external services, as well, like the Welsh ambulance service, the social services department, and this is where we develop and discuss new projects, and discuss existing ones.

And the governance structure is a very clear route into the health board, as is described in the submission. So, it's very much a part of our governance structure, reporting to the area health board that looks after health in Wrexham and Flintshire, and there's a report that comes into our formal governance meeting on a monthly basis to show all the performance indicators and a general management update into the area management group, and then on to the quality and safety executive within the board. So, that's an established mechanism that's been there since the prison was first established.

Okay. David.

Yes, can I move on, in a similar sense, then, to the House of Commons Welsh Affairs Select Committee, which has also done some work on the prison estate within Wales? One of the recommendations was that in effect there should be a central unit within NHS Wales established. Now, you have experience of, obviously, the governance arrangements. Do you think there should be a central unit within the national health service in Wales that could actually do some direction and set strategy for healthcare within the prison service?

Currently, the head of healthcare goes regularly down to Cardiff and is working with the Welsh Government looking at developing an oversight committee. But below that they're looking at developing a group that deals with the health priority-setting workshop, which it feeds into. So, it looks as though there is going to be, in the future, an oversight from Welsh Government with regard to healthcare within prisons.

Well, that sounds like good news, actually. Can I move on to funding, in that case? Clearly, there are different funding arrangements between yourselves, because Parc is a private prison and there's a different arrangement, and Berwyn is a new prison, shall we say, and when we visited it we were told quite categorically that they seem to get a lot of different funding arrangements compared to the south Wales prisons. How do you see, for Berwyn in particular, the funding arrangements? Are there going to be challenges ahead if this initial funding comes to an end and you go to the basic funding that everybody else is getting?

So, currently we are funded via the Ministry of Justice, because, like you've already alluded to, we're still quite in our infancy. So, with regard to—. We're not full to capacity for the men, so what the plan is is that we get to the full capacity of what we are going to be, have a period of stability, and then we're going to get another health needs assessment completed to inform what the funding should be when we've been at a stable state.

Because I read from your evidence again that there are, I think, 135 full-time equivalents employed at Berwyn, and that's not at full capacity. Do you expect to increase that when Berwyn is at full capacity?

Is that to increase the staffing levels?

Yes.

Berwyn was funded straight from the beginning to accommodate 2,106 men, and the staffing levels were agreed at the beginning, so we are fully funded for staffing.

You're fully funded, so I'm saying: are you fully staffed now, in that case?

Yes.

So, the staffing level you have now is what you would expect to have when the prison is full.

Apart from a few vacancies, yes. The established staffing level is based on the 2,106 men.

For Cwm Taf, clearly there is a different set of arrangements. How do you see the funding, particularly for you in the sense of the work and services you have to provide?

So, there's no direct funding for the prison that comes through the health board at all. The funding for the primary care element is funded by the Ministry of Justice. There is a service level agreement with Swansea Bay University Health Board in relation to provision of mental health services, but that's historical, and the rest of the money is money that—for other services that are provided, healthcare services provided in the prison—is from within the prison's budget. So, we don't get access, we haven't got money for that, and neither do we get access to any development funding. So, there was recently money that Welsh Government had available for improving healthcare in prisons, and Parc prison and therefore ourselves were excluded from being able to bid for that sort of money. So, there is an issue for us in relation to, as we start to get the governance arrangements in place, as we start to work through the health needs assessment, as we see the gaps in service there, how do we access funding, from where, to be able to put in place the sorts of services that are going to be needed for the prison population moving forward. So, I think that really is a key issue for us.

So, you get no additional funding from Welsh Government for the fact you've got a prison within your boundaries.

No.

Helen, you've got a supplementary. I'll come back to you.

Yes, just developing that a little bit, I understand that the primary care treatment in the prison is private, so that doesn't, in theory, impact on you at all, but presumably, there are also some cases of prisoners needing to be treated on the hospital estate, for example, and you don't get any additional resource to enable you to meet that cost.

I'm not aware of a specific allocation that we get from Welsh Government that specifically allows us to provide secondary care services within the Princess of Wales Hospital, for example. So, prisoners will require secondary care treatment within the Princess of Wales Hospital, and I'm not aware of a funding line that would allow us to do anything—

So, you don't get a funding line from Welsh Government and you also don't get any money from the company that runs the prison. 

No.

Okay. Are you done, David? 

Yes.

Okay. Moving on—Angela. 

Yes, thank you very much indeed, both health boards. Could I address my first question to you, Alan, perhaps? I was interested to read in your evidence paper that you felt that primary care delivery of services had not kept pace with the prison population and that you also raised it in your conclusions as an area that you believe needs to have a strong look at. So, are you telling us that G4S are not doing what they should be or what they have been contracted to do? I assume there's a service level agreement in place. 

There are a couple of points there, I suppose, aren't there? I might ask Carmel to leap in with some of the detail around that. The first thing is that, for the contract that exists for the provision of primary care services, we don't have sight of that contract, so—. 

So, who is it held between, then? G4S and—?

And the Ministry of Justice. 

Right. Directly. 

Right. Directly. Okay. 

So, we wouldn't know in precise detail what the contract was around that, and I think we would actually, in terms of moving forward with the governance arrangements, want to have clear sight of that contract to be able to provide—

Well, more than clear sight. If you've been tasked with the governance of it, as David said, you ought to have, in great detail, what the service level agreement is. 

Exactly. Yes. 

And the second point that runs from that is, if we look at the health services that are being provided into the prison—so, primary care services, mental health services, substance misuse services, blood-borne virus services and so on and so forth—they appear, from my perspective, having done some work on it, to be a series of silos in terms of you've got a private provider providing primary care, you've got Swansea Bay providing mental health services, you've got a private individual providing—. So, in terms of joined-up services in the way that we would provide joined-up services within the community, that doesn't feel as though we're providing joined-up services for the prison health-care population. So, it seems to me that there's a fundamental change required there in order for us to provide holistic care to prisoners, alongside colleagues from social work and others, in a joined-up way. 

The prison population has changed quite considerably over time. Therefore, again, without knowing the details of what's in the contract, has that kept pace with the number of prisoners that are now being catered for? We have some evidence that says that that's not the case for mental health services, so I would question whether or not—again, without seeing the contract—that is the case for the primary care services. 

Have you asked for the contract?

I haven't personally, but I know it has been asked for in the past. I don't think we've seen it.

Right. So, maybe that's a point for us, isn't it?

So, if you've identified all these different organisations that have responsibility for different bits of the delivery of healthcare services to the prison, who has responsibility for screening that prisoner when he walks in through the door? Who has responsibility for screening that individual in accordance with the National Institute for Health and Care Excellence guidelines?

My understanding is that, as part of G4S's contract, every prisoner has health screening when they're admitted to the prison, and there clearly are a number of checks that they undertake with each individual and there are good efforts by that organisation to ensure that there are plans around people for the areas that they focus on. I think the dissonance between the original contract, perhaps, and where we are in Wales now in terms of our ambition around, say, for example, people with dementia, is that the contract is not in keeping with that. So, for example, if you think about our ambitions in Wales around the screening of people for early diagnosis and assessment for things like that, that clearly isn't in their contract, whereas they are doing things like asthma, diabetes, healthy hearts, blood. So, they are doing lots of good work, but it hasn't, maybe, kept pace with some of the work and where we are in Wales in terms of our ambitions for seamless services. 

I think we understand that, for example, at Parc, it took 48 hours to see a nurse—it takes 48 hours to see a nurse, unless there's an emergency code initiated. So, I'll tell you why I'm a little bit concerned, because I appreciate that this is a new-ish contract for you, and I appreciate that it is down to G4S to provide these services, but I still would have expected a handle on how well they're doing and what they have to do, and I'm really concerned to hear that you don't have that information, because I would have thought that the previous responsible authority for the prison could have handed some of this over to you—I would have assumed they did. You used the word that you 'understand' that they're doing this and you're doing that, but it's the not knowing. What plans do you have to really understand quite quickly exactly what provision for secondary care and primary care the prisoners in Parc are having?

So, in relation to the primary care contract, absolutely to understand the detail of that, and I'll also have a conversation with the Ministry of Justice in relation to how we best work with them to manage that contract. The levers in relation to finances associated and key performance indicators that must be within that contract are held and commissioned by the Ministry of Justice. I think we need to have, as a minimum, a partnership with the Ministry of Justice in relation to that to be able to manage that in that way—that would be where I want to get to, or alternative arrangements in relation to why would it be that we have a private provider in terms of G4S, why would it not be that, in line with all the other prisons in Wales, we not look at primary healthcare services being provided by Cwm Taf Morgannwg? It appears across the rest of Wales that we have a much more joined-up system in terms of delivery of healthcare within prisons, because they are being provided by the health board, and we have a very effective arrangement in the health board and we have a very effective integration and alignment with Bridgend County Borough Council.

So, actually, a coterminous health and social care delivery into the prison feels like absolutely the way to go, as opposed to a series of individual silos that are commissioned and the levers for commissioning sitting in various different silos. That would be my ambition around that—to be able to deliver to the prison population that which we deliver to the population within the community. Do we deliver that perfectly all the time? We probably don't but, actually, we proactively could provide a service that is very joined up if we were able to do it in that sort of way. 

Thank you for that. Rob and Rob, I wonder if you could perhaps just tell us how it works in Berwyn. I understand it's out to a specialist provider, who I assume does everything for primary care services. 

Yes. The healthcare in the prison is one health board. So, it's—. Going on to the second part of your question, every man that comes into the prison is screened by a nurse on reception, and then, because we are an integrated healthcare provider, all the relevant referrals then are done at reception. So, if mental health needs to be involved, physiotherapy, all those are done within the reception screening. Also a part of the reception screening is a pharmacy team to look at meds optimisation. So, yes, we're quite fortunate that we have one provider for all. 

Can I just a comment from a previous question about the finances, just as an addendum? It's just to say that, as Rob was saying, we are funded for the number of staff that we've got for the current model, or the predicted model in terms of the case mix of men, but the needs assessment is then required because the case mix has significantly changed since the initial case was put together. So, that's the work that's going through at the moment in terms of that needs assessment. Sorry, back on to the—.

So, in terms of primary care, at project stage the big push was that we would have very limited impact on local services, so that's why we've got such a significant healthcare provision within the prison. So, predominantly, a lot of primary care is done within the prison. 

Thank you. That's me. 

Right. Moving on, Lynne Neagle's questions next. 

Oh, thank you, yes. I wanted to ask about delays and cancellations of escorts to external healthcare appointments. Are they being monitored against national waiting times targets for diagnostics and treatment by health services at both Parc and HMP Berwyn? 

Who wants to kick off? Alan, down here, then. 

The answer to that is I don't have the answer to that, I'm afraid. I can't answer that question. 

Okay. Maybe you could check and write to us.

I can check and find out, yes.

Okay, and from the north?

Yes, all medical appointments that are cancelled are reported via our dashboard, but they're also reported to the prison governor who is extremely keen on ensuring that men do go to their planned appointments. To date, compared to comparative prisons, we send very, very little work out to local hospitals, we tend to bring services in. So, we've got quite a lot of services that come and visit as well—audiology, optometry, et cetera. So, any cancellations of men's medical appointments are closely monitored and reported monthly via the local health delivery group and the partnership board.

And I should add that we've got, obviously, an advantage over Cwm Taf in terms of the fact that we've been involved in this with the prison for some time since it started. So, the links into local healthcare are well established and work well, I think, so when the service has been established in the prison, the managers and healthcare providers within the hospital and local services were involved in the set-up of that service in the prison. And that linkage and working relationship between the two areas of the service have continued to develop. It was kind of helpful that we were there at the beginning of the establishment of the service so that we set up those links.

How widespread are cancellations from Berwyn?

They're very minimal. It will be down to operational issues within the prison that would affect men's transfer out to hospital appointments. We have very little cancelled in terms of hospital appointments. The prison works quite closely with us with regard to whenever they reprofile their details. So, we're actively involved in anything that would affect us from a prison point of view of changing details and roles, so we're there at the beginning when they're thinking about changing stuff. So, it's minimal.

Okay, thank you. Just moving on to mental health, I wanted to ask Cwm Taf, in your written paper, you acknowledge the lack of primary mental health support at Parc prison. How confident are you that this is going to be addressed, either through the service level agreement with Swansea Bay University Health Board or through the direct provision of services, either from yourselves or from G4S healthcare?

For me, that's definitely one of the things we've got to get into. It's clear that the SLA we have with Swansea bay is historic and we want to review what is being delivered through that SLA with Swansea bay. If it can't be delivered by Swansea bay, then having integrated services across Cwm Taf Morgannwg in terms of local primary mental health services, we may have to look at how we deliver that directly as a health board. 

So, saying it's one of the things you want to get into isn't very reassuring, really, is it, for the committee? It doesn't sound as if that's been worked up very much.

For me, I think we have to take a view about how we want to look at delivering healthcare in totality for our prison. And to my mind, the way it's currently arranged in its silos is not the most effective way of delivering healthcare into Parc prison. So, I'm thinking about something that's a bit more radical than continuing to work on adding onto the bits of silos that we currently have operating. The fact we couldn't look at how we might invest with Swansea bay in terms of provision of additional local primary mental health services and any other bit, but I think that still leaves us in a position where we have not got a holistic approach to the delivery of healthcare into the prison.

So, I think what we've probably inherited is a set of arrangements that are in their silos, and they're probably delivering within their silos, but actually they're not delivering in a joined-up way. So, for me, actually coming out of—. A way forward for me and a way forward for the prison has got to be about how we deliver healthcare in a much more holistic way, alongside our colleagues from Bridgend County Borough Council. Now, in the community, we are delivering that in a very joined-up way, so I've got every confidence we can deliver that into the prison in a very joined-up way. So, we can clearly look at changing individual packages within those sets of silos, but I don't believe that's the right way forward.

Okay, thank you. And to both of you, Her Majesty's Inspectorate of Prisons has raised concerns about delays in transferring patients to hospital under the mental health Act. Are you both confident that you are meeting the guidelines in your areas?

Do we kick off in the north?

Yes. We have very good established links with our local medium secure unit, and the transfers that we've done to that unit, currently, they've been quick, they've been effective and there's been no kind of delay in transferring. They've taken the responsibility of the prison from that point of view. The difficulties that we sometimes experience is the second stage—transferring back the men to England—because we have both Welsh and English prisoners. So, from the prison into a hospital setting there is no delay, it's after that. 

Okay, thank you. How about Cwm Taf Morgannwg? 

In the same way I replied to the previous question, I'll have to find out the detail around that. 

Okay, thank you. And, finally, then, from me, the Welsh Government has a dementia action plan that sets out certain standards of expectation around early diagnosis for people living with dementia, are those efforts to improve early diagnosis being delivered in your respective areas for prisoners?   

As I alluded to, I don't think this is part of the contract for primary care in Parc, as it exists. Collaboration with the local authority, in terms of the new work under Part 11 of the Social Services and Well-being (Wales) Act 2014, has meant that our health and social care staff in that part of our team have been raising awareness within the prison around dementia. They have been doing dementia friends training and supporting some of the staff on where vulnerable prisoners are and where there are older adults within the prison. However, that said, that isn't necessarily being driven by the primary care part of the service. In fairness, that's just a by-product, if you like, of our integrated approach to our other services. 

Okay, and from the north? 

Yes, we are currently doing the same dementia friends training. We have an on-site consultant psychiatrist, but we also have funding for an older persons psychiatrist to deliver sessions within the prison. Currently, the population is quite young and we don't have very many older gentlemen with us, but we have got plans in place to develop an older people's input into the prison. 

Moving on, it's Helen Mary Jones next.

I'd like to ask you both about substance misuse services. Perhaps if we start with Berwyn, can you tell us about what substance misuse services are available to your prisoners? And, both, whether you've got any take on whether this is consistent across the Welsh prison estate, but also, particularly to Berwyn, issues about substance misuse and discharging prisoners and ensuring that, if somebody's part-way through some treatment or some support, whether they then can get that at home, because a very high percentage of your prisoners come from England, don't they? So, you're presumably discharging back into English areas. Sorry, that was a bit rambling. What services do they get in the prison? And how do you manage ensuring that they get some services when they're discharged, insofar as you can? 

Our substance misuse service is made up of two parts. So, the first part is we have a clinical substance misuse team that manage the men on active treatments. They're responsible for any kind of discharge planning back to their local communities, care plans around their treatment and 13-weekly reviews around their medication. The second part of our service is a psychosocial team that focus on harm reduction and education. They also do a lot of linking in with community teams ready for discharge. So, they take an active role in discharge planning of our men here, both in Wales and in England. So, we've got two. We've got the psychosocial team and then we've got the clinical team. 

Thank you, that's really helpful. What level of awareness have you got about the substance misuse services that are available in Parc? And have you got any take on how that works with regard to discharge, or is that something else that you're going to have to— 

Unless we've got men that are transferring to those prisons, I don't really know what their facilities are. 

Sorry, I should have said I was moving on to Cwm Taf colleagues, thank you. Sorry, I didn't make that clear.

Again, I think I've probably said it several times now, the arrangements for the provision of healthcare are very disjointed, and in relation to—. We are not directly providing substance misuse services. My understanding is that that's provided by a private provider. 

A different private provider from the ones who are doing the primary care.

Yes.

Dear oh dear, what a potch. If I can move on to medicines management within the prisons, and again, it's a question to both of you—perhaps I'll start with Cwm Taf this time. Prompt access to medicines and appropriate prescribing is obviously essential to manage health conditions and pain management. Do you know what access in Cwm Taf patients will have to medicines, say, for acute pain? Again, is that part of the contract that you're not clear, quite, about how that works at the moment?

It's part of the primary care contract. What we have had, through some complaints to local Assembly Members, are some concerns raised by prisoners around that. We picked that up and we picked that up back through the Ministry of Justice to say that, clearly, the contract wasn't working for a number of individuals. Two or three complaints came forward, so we were aware that there was an issue around that, which we did pass through to the contact points we've got in the Ministry of Justice around that. So, it's definitely an issue, and it's something that, if we were delivering the service, we would have it under our control.

Do you have any take about how the Ministry of Justice responded to that, or, again, because you don't have sight of the contract you don't really know what they did?

We weren't copied into that, no.

Okay, thank you. So, obviously, a very different situation for you up in Berwyn, where you've got direct control. Can you tell us what access to pharmacy services the prisoners who need medicines, let's say for acute pain, have, for example, is there out-of-hours access to pharmacy provision in the prison?

We have an on-site pharmacy facility. We have medications in Mediwell cabinets out of hours and we have 24-hour access to on-call general practitioners. As I've alluded to before, every man who comes into the establishment has a medication reconciliation by a pharmacist in reception, and then they are subsequently seen by the GP and prescribed appropriate medication. If a man is in pain throughout the daytime, they would get an emergency appointment with a GP to discuss any kind of issues with regard to the pain and appropriate prescribing.

Can I just add that although the pharmacy's on site, it's very much part of and integral to the medicines-management service that runs out of the hospital, in the Maelor? So, they work very closely together to make sure they've got consistent medicines-management policies.

Yes. So, if we haven't got access to the medication on site, we can use the 24-hour pharmacy service at the local hospital.

Thank you, that's helpful.

Can I just add in that G4S does have its on-site pharmacy? So, the sort of arrangements that are being talked about in terms of Berwyn, we do know that they have that on-site pharmacy in that way.

Thank you, Chair. Just starting off with Cwm Taf, really, regarding sexual health services, in your written evidence, you say that sexual health services are commissioned from an alternative provider. What impact does that arrangement have on the delivery of sexual health services?

I'm going to sound a bit like a stuck record, I think, aren't I? The arrangements for the delivery of healthcare are very fragmented. Therefore, I am sure that there will be arrangements between the provider of sexual health services and the primary care contractor to work those things through. But, we don't manage that and we haven't got details around it. If we were delivering the entirety of the service, it would be very joined up.

Okay. Just moving on, then, to prisoners with social care needs—and this is for both of you, I'll start with Cwm Taf, though—it's not entirely clear whether social services or prisons are responsible for the provision of equipment and adaptations that prisoners might need when they're being released. Can you just clarify that position?

Is that on release or within the prison?

Well, both, actually. 

Okay, so, my understanding—sorry to say that word, but my understanding is that, within the cell environment in the prison, if there's something that needs to be adjusted within the prison, G4S Custodial and Detention Services are responsible for that change. If it is for health reasons, then G4S Health Services are responsible for that change. In terms of aids for daily living, the local authority provides those pieces of equipment and adjustments, and are making recommendations to G4S custodial services and G4S healthcare, but I would agree with you that it's not clear, because, clearly, the prison is not set up to look after people with complex needs or changing needs in that way. The prisons are set up so that people can't harm themselves and that they are safe environments for prisoners to reside in. So, it is quite a challenge when we have people who have very high and complex needs and need care, to provide the right level of equipment. And I think there are about four cells in Parc that are adapted for that, but in a prison where there's 1,600 men at the moment I believe, clearly, that would not be adequate, I'm sure.

Okay. Thank you.

And from the north?

So, if those kinds of needs are identified through the reception process, we have an occupational therapy team based with us. They would do an assessment and we, health, provide any adaptations that need to be done. So, things like hospital beds, living aids, rails, anything like that, then we would do that. The more complex stuff would be a referral through to social services partners, and certainly, for anything to do with release, that would be referred through our social services department. But, the initial low-level stuff is done by our health team occupational therapists.

Okay, brilliant. Thank you. Just finally, on violence against healthcare staff, we know that the Royal College of Nursing raised concerns about violence in Welsh prisons and the number of assaults on healthcare staff. The recent inspection at Berwyn found that the assaults on prisoners were lower than in similar prisons, but the rate of assaults on staff was higher. What assurances can you give this committee that you're working swiftly with the prison service to address this issue, to ensure the safety of healthcare staff who work in prisons in Wales is upheld?

I'm only aware of one incident against healthcare staff. We do a lot of work with the security department around risk, so anybody that is identified as a risk is flagged to us. Our computer systems that we use—SystmOne—have alerts on them, so we're fully briefed to not see somebody alone and not a lone female, not a lone male. But with regard to assault against nurses, I'm only aware of one that has happened since I've been there in two and a half years.

Okay. Cwm Taf, would you like to say anything about that?

Again, it would be G4S Health Services reporting on that. I would have to get more information for you, I'm sorry.

Okay. It would be useful to have that, I think, though, Chair.

It would.

I just want to go back to Cwm Taf. Perhaps it's part of—[Inaudible.]—but it's also part of the question because I'm still concerned about this timescale, because I live where it was ABMU. Twelve months it took, and at the end of 12 months they confirmed all the transitions had been agreed and everything was in place, so, for 1 April, everything should have been handed over quite smoothly. So, we're now in a situation where we're still looking at setting up that partnership board. Has the health board identified a senior member of the board who has responsibility for this agenda?

Yes, that would be me.

You're a member of the board.

I'm a member of the board. I'm director of primary community mental health services, so it's my portfolio, and as part of the partnership arrangements that existed before, the director of primary community mental health services in ABMU had that responsibility, and therefore I've assumed that responsibility from a board perspective.

Okay. That's fine.

Thank you, Chair. Thank you for your written evidence. In all of your written evidence, you say that you're confident with the governance arrangements of prison healthcare locally, that they're robust and that health and social care partnership boards are working together effectively. The prison and probation service in Wales is calling for the role of health and social care partnership boards to be strengthened to include strategic planning. What are your views on that? Who would like to start?

I think our partnership working on the ground with individual prisons is very, very strong, as we've said. I think there's always opportunities to develop, and particularly within social care. So, in HMP Cardiff, for instance, we have a standing seat on our prison partnership board. That isn't always attended by social care, but I think there's an opportunity then for us to develop that further, and we know that brain injury particularly is very prevalent within our populations and that could be something that really could be strengthened around the social care element of the partnership.

I can reiterate that. We always have a member from our social care partnership group on our partnership board and we have regular meetings outside of that as well. On talking to them this week, they feel that maybe we should have a national strategy for the health and social care, which may help to forge those relationships and help us to work a bit better in partnership.

Good. We're always on the lookout for helpful recommendations for reports. Sorry. Jayne.

No, it's fine. Any other comments?

We have a principal officer who has a standing seat but doesn't always manage to get to those meetings.

Okay. And just another point: prison and probation services in Wales suggest that a Welsh prison health board should be established to address the inconsistencies across prisons and provide future direction for prison health services. Is this something you think is necessary, or would you support that?

Absolutely. I think that's essential. We see the situation in England where they have very robust structures and they have vast departments within Public Health England and NHS England that really drive forward the prisons agenda and I feel like we've missed that in Wales. I think if we had a dedicated department in Welsh Government looking at how to improve prisoner health, ultimately it would have a massive knock-on effect on our communities. These people go back to their communities, and it's remembering that prison health is public health, and if we deal with them when they're ready to access health when they're in prison, which is a key time on their health journey, when they often won't access health in the community, I think that's essential. So, it can't be done within existing structures, as is being tried now, in very much the right intention, but it's therefore a bit of an afterthought and the funding needs to follow because these people really do need to be prioritised, and I think it could really raise the governance agenda and the quality could be pushed up by monitoring lots of factors.

Excellent.

I think we would agree with that as well. I think the emphasis on inconsistencies, and I think that is something we want to avoid in healthcare throughout the whole patch, and variation is very dangerous in this particular vulnerable group of prisoners and patients. So, I think we need to be having a national approach; we need to have a very universal approach, and that's not necessarily the case. So, any support, any frameworks we can develop with a strong clinical voice, I think that is important because we are very close to the health needs of this cohort, and as long as that is valued and heard, I think there can be significant changes made, which will change outcomes.

And I think it also might give us a louder voice. It's good that HMPPS want this because I think that quite often, things are developed in the English context, and our voice isn't necessarily there, and so, then, we receive a new process for something and it doesn't fit.

Yes. I'd really echo that, actually. It's given us an equal voice around the table because often it's forgotten that health is devolved, and I think that would be a really valuable thing for our men.

Okay. That's great. Thank you, Chair.

Great. Angela next.

Yes. Thank you. I was going to talk about funding, and I was trying to find a particular bit that I'd spotted before, but—. But can I just ask the question, is the funding for the prisons ring-fenced?

I don't believe so. No.

Because I'm just trying to understand this little bit, and this must be the evidence from Aneurin Bevan, where it says

'Locally, the Health Board has contributed an additional £20,000 to the ringfenced prison budget to ensure core nursing'—.

Is it a different budget we're talking about?

So, the £20,000 comes out of the primary care nursing budget, and when the money was devolved to Aneurin Bevan, when they took over the prison nursing in 2012, they had that set amount. But it wasn't, obviously, enough, so they've backfilled it year on year with an extra £20,000.

Thank you. So, the funds that you have to put in place in order to provide the services for the prisons, none of that's ring-fenced, you just take it out of your day-to-day revenue spend. Do you feel that there should be a separate allocation made? And I'm going to say not necessarily on top of what you already have. Don't think, 'Oh, yippee, this is a way of getting extra money,' because we all know that that ain't going to work. But do you think that, actually, it would be helpful if there was a line of sight that this is the kind of money that the prison absorbs out of your budget?

I think with all primary care, it's changing on such a year-by-year basis, and our needs and requirements change, particularly now we've got a lot of older people. So, their needs are changing all the time and, yes, I think it would be good if we had our own pot of money, if you like, which is specific for prison.

I think it's difficult because the health boards are struggling generally for cash, aren't they? And they use their abilities to flex finances across services. I do think our population are particularly vulnerable, and by treating them, we would have large knock-on effects. But if you consider the fact that a lot of the people that we're treating in Cardiff and Vale prison are not Cardiff and Vale residents, we're having a massive impact on the health across Wales and England. And I get what you're saying about no increase in funding, but I would say the funding hasn't increased since 2012. And I do think that our health needs as a population have changed massively, and particularly within the prison, where you've had a situation where justice were delivering health, you've now got NHS delivering health. We're going to have a whole different concept of what we see as health, and it won't just be firefighting and ticking boxes. We're trying to now improve health, and we're struggling to do that, because we don't have the funding to support us in that.

Given that, for example, we know that a lot of prisoners have mental health needs, I'm interested, in terms of the funding: do you slice it out of—you say, 'Right, well, I'm going to take some of it out of the—'? Because, of course, mental health is ring-fenced, or funding for mental health is allegedly ring-fenced in health boards, and there's a lot of flex depending on what is happening with budgets elsewhere. So, would you say, 'Right, we're going to take some of it out of the mental health budget, and some of it comes out of the general revenue budget'?

I think you have to understand the way that mental health in the prison was historically commissioned, if you like. So, historically, the mental health service within prison was very much around secondary care, it was around enduring mental illness, and that's where the service sat. Now, as we've seen primary mental health become more of an issue across all our populations, or more recognised, I should say, then that has translated as issues within the prison, but no funding has ever followed that up till now. So, we saw our secondary care services, who deliver an exceptionally good service to secondary care, so our patients with schizophrenia, bipolar et cetera—we see them now trying to deal with primary mental health as well, and the revenues and resource were not adequate. But Welsh Government, through the healthcare reference group, have recognised that, and we've all bid on funding. An extra £1 million has come to Welsh prisons, and we're currently sorting out how we're going to spend that, but it's going to be with a priority for primary mental health.

So, if we were to make a recommendation based around funding, apart from the fact that you would obviously like to see more funding coming through, would you like it to be in a discrete pot?

I think the primary care needs to be discrete, as it is—

Because you've got things like chronic care building up, more dementia patients, I suppose, et cetera—

And the primary mental health as well, because that needs to be delivered and is quite general. But I think that there are all sorts of different parts of the mental health service, and you can't have—if you had it completely separate, the funding, then you might then get an argument that you can't access this other service that isn't—something unusual.

I think if you ring-fence the funding too much, you then stifle innovation, and you have to remember that our prisons are very different. So, Emily and I both share remand prisons, but Alison's is very different. She's working in a D category with sex offenders, and the challenges, then, across those groups are very different. I have very few older prisoners—

I have lots.

And Parc has lots. We can't be considered as 'prisons'—our individual functions have to be recognised, because we have very different needs.

I totally take your point. I'm not a great fan of ring-fencing this, that and the other. I think it's just because we've had a previous evidence session where, to be frank, a health board barely seemed to notice that they had a prison, so it was like, 'What can we do to make sure this very vulnerable group of people are recognised and treated appropriately?'

Could you perhaps just very quickly touch on what workforce issues might be barriers to providing good healthcare services in prison?

So, we've got lots of issues within HMP Cardiff in stabilising our nursing workforce, particularly. Our structure is very flat. I think our total workforce is around 46, and just under 30 of those are nurses. Now, what we find is that we recruit our band 5 nurses, and we train them to a very high level, because they work quite independently within prisons, and then they're highly sought-after within the environment to go on—they all stay within secure environments, whether they go on to hospitals et cetera—. But what we find, then, is our band 6 workforce stays stable, but our band 5 is constantly churning over, which then stifles us from delivering or developing any service, because it's nurse-led. So, we have loads and loads of ideas, but until we can stabilise our workforce, we'll struggle.

So, within HMP Cardiff, we are performing a full workforce review, where we're looking at the roles and looking at how we can be more prudent and innovative, where we can use pharmacy techs and healthcare assistants to dispense medication at the hatches, for instance, which at the moment is a core nursing role, which is pretty boring for them, and we want them out on the wings, nursing our men, and we feel that that may help. But we're also looking at whether we help them to get to band 6, because band 5 is no longer a career grade. People can't afford to stay there, and the pressure, and the post—. Because nurses are short everywhere, we lose them consistently to band 6. They want to stay in secure environments and as soon as we advertise band 6, they come back to us. So, that's our problem.

I was going to say, I think that's definitely—the professional progression—an issue, because it does stay very flat, and I've only got four nurses.

I can feel another recommendation coming here.

No, I've sorted it myself, it's fine. [Laughter.] We've actually offered an uplift for a band 7 because I don't have anybody between my 6 and then myself, so when I retire, I've got nobody to take over.

We've just done something similar.

But I think that is a problem—that there is no progression for them.

We've gone through that sort of workforce review, and particularly around the medical model we've had locums, GP locums, providing that service for many years, which is obviously not a great place to be because of accountability, about taking on lead roles, providing that continuity of care and really taking that responsibility for running a service. So we've changed the model now. We've just recruited into salaried GP roles. We've been successful to cover those sessions required, and we've built in some service development time, so we really want the GPs to step up and really take this as an opportunity to progress in their career as well, taking on lead roles for chronic disease, for medicine management, for substance misuse.

We've got clinical leadership in there now as well. That's only been over the last six to 10 months—Emily taking on the clinical leadership within the prison, which I think is absolutely crucial because we need that support. I think with the regular, permanent workforce and our GPs, we have a better link to the nurses, because they mentor them, they develop them, and they are going to be leading an MDT, in the multidisciplinary team approach now, where we work closer together. Our nursing staff has been quite regular and steady and we've managed to retain them, but a lot of work has been done to look at the training needs, because it's so important that we look after them and progress them. So, we've done a whole training review and identified our other training needs and have addressed that, but it is that approach that really changed things, and we are now on a trajectory with that, because I think it's been something that hasn't been taken seriously enough, but it has to be now. I think we feel quite confident that over the next six months we will have that steady workforce and a good multidisciplinary team within that.

The last, quick question was: Emily, do you have the same issues with allied healthcare professionals getting other people involved—the career progression and the attracting and keeping?

I think in Swansea we have a slightly lesser problem with turnover for the nurses, and I think that reflects where we are and the accessibility of other options. That's what our lead nurse says.

I think you always have a problem with prisons because of the stringent security checks to get people into that environment. It takes quite an amount of time, and there's a big perception within a lot of working populations. You've got to want to work in a prison. You have to be robust. You do face different challenges. I thought Anjula brought out a really important point about medical staff within the prison: we're lucky, we're at full complement, and it is really important to recognise the importance of GP leaders within this. We really shouldn't follow the NHS England model and really become all nurse-led. We're part of an MDT, a multidisciplinary team, and we all have our values, and the foresight of general practitioners mustn't be forgotten. However, in HMP Cardiff we're now struggling to deliver our innovation and our developments because our nursing workforce isn't stable, so it's about stabilising that whole workforce.

I think I'd probably add to that putting prison nursing more upfront, so they are more aware of it as a career. We've just started to take students now from one of the universities, so they go back quite excited and tell their colleagues. We've got a little bit of a waiting list now of them wanting to come and spend time with us. So, I think it's just taking away that stigma.

Absolutely, and we have nursing students, medical students, and that's really important. I'd like to see GP registrars actually having a GP registrar within the prison so it becomes a normal part of medicine and training—not a big deal.

Moving on—David Rees.

Good morning. You talked earlier about the ageing population within the prisons, but, of course, an ageing population also brings more challenges, in particular the need for equipment and adaptations, and there are also more disabled individuals going into the prison system now as well. How do you find the timeliness of getting those adaptations in place, to ensure that the prisoners are not left without something that meets their needs for too long?

We work very closely with our integrated team of OTs and social services. So, anything that they need—physical aids—we can get within 24 or 48 hours. So, they get the equipment that they need, like walkers or anything like that. From an environment aspect, that obviously can take a little bit longer. They're very Victorian prisons, the cells are very small. We've got a bigger wing that they're looking to adapt now to make it more for the elderly population, so all flat and flat beds. We've got two disabled cells at the moment, which are for more elderly people, but it is a challenge, because obviously HMPPS don't have that pot of money, either, to make these environmental changes. And we're Cadw-protected in our jail, so that makes it very difficult as well. So, you've got lots of hoops to jump through before we can actually get what we want in place. We've got stairlifts, we've got ramps, so they're able to get around, but obviously the size of the cells are a challenge.

In Cardiff, obviously, as you've mentioned, you don't have many older people, but surely you still have people who have conditions and who will have requirements.

We have to bear in mind that this age group gets morbidity at a much earlier age. So, we see a lot of younger men who are immobile. We've had people who don't have arms, who are in wheelchairs, who've had amputations. We have an advantage in HMP Cardiff, in some ways, because we have a healthcare unit that is a modern facility, as you remember, that has wide doors et cetera, but that facility is often full of people with chronic mental health issues awaiting transfer to hospital. Is that the right environment in which to put these people? And we need that for the acutely unwell, rather than accommodating people who have chronic issues. Our main issue, I would say, within HMP Cardiff, is the availability of flat location. So, if we try to put an elderly person up on the fourth floor, they can't get their medication, they can't get their food and that leads, then, to disparities. And men are very good at helping each other out, but we shouldn't have to rely on that.

And you don't need to be very disabled to struggle with all those stairs. They're not easy stairs and there are a lot of them, in Swansea as well. 

So, how is the system going to work for those individuals? If you see more coming in, you're going to get to a point where you haven't got the capacity. So, there's a huge problem coming up, now. 

It is a huge problem. How will it impact us? Because they don't stay with us, because we're remand, it's going to impact Usk Prescoed and Parc far more than us. But then, if they're coming through us, if Parc and Usk Prescoed don't have a reception function, it's also going to affect us if they're coming to us for reception. 

Okay.

I think there's definitely a lot more long-term planning, from the environment aspect as well as the social care aspect, that needs to be put in place. 

And on that point, then, clearly you have a good working relationship with the local authorities for the social services and the planning of that agenda. 

Yes. 

So, the integrated planning is there. 

It's starting to take effect, yes. 

Probably more for you. Certainly for us, because it's not that frequent, those connections are not so close.

We have social services and an OT in on most days, and in Usk and Prescoed, so we are very lucky. 

And with us, health tends to pick up the function that would probably be social care. We did have social workers based in the prison at one point, but their workload wasn't enough, apparently, to justify them being there, which I question, but that would be something useful to be reviewed and standardised across Wales, I would suggest.

And I think in Swansea there was a plan to have a team of social workers who could draw keys and could come into the prison easily, but that never quite happened, and people moved jobs and—.

So, there's still some work to be done on that side of things. 

Yes.

Okay. Moving on—Lynne Neagle. 

Thank you. I think some of the issues around funding have been covered, so if I can ask the Cardiff and Vale and Swansea Bay University health boards about the concerns that have been raised about the delay in transferring patients under the Mental Health Act 1983, which should take no more than 14 days, but inspections have found that transfers were delayed at Cardiff and Swansea, with an average waiting time of 3.5 weeks and four weeks respectively. What's your response to this and what are you going to do to make sure that those transfers occur in a more timely way? 

Okay. So, I will speak as much as I can about it, but primary care mental health will be a different team. There are lots of factors to this. The funding is a major issue, because funding comes from the original health board that they were resident in before coming into prison. If that's an English health board, that can cause issues because it's cross-border then. There are then often long waiting times. We don't have enough medium-secure beds in Wales, so it's presumed then that we will transfer out. We then have to wait for beds to become available, and then we have to wait for professionals to come and assess these people for suitability.  

My experience with a recent patient who we've been trying to get to a specialist autistic unit is that they accept them, and then they come and say, 'Well, we don't have capacity to take him anyway'. Because they're private units, the people on the phone just accept, accept. So, I think maybe we need to increase the capacity within Wales—I don't know; I'm not a specialist in that area—but it's very complex, and I think that would be useful, to get more information from mental health. 

My understanding is that there's been a little bit of an improvement in timing, but some of that may be a little bit of not counting it until going to court. I discussed this with our nurse lead. I'm not sure—. I don't really have any more information about that—that's what she said to me yesterday—but it seems to be moving reasonably quickly. Medium secure is the difficulty—other transfers are not so problematic—but, yes, it's mental health. 

Okay. And, in terms of suicide and self-harm, is there guidance in place to help ensure there's collaboration and partnership working between the Prison Service's safety custody teams and the health board's prison inreach mental health services in order to reduce risk and increase safety for prisoners? 

As we touched on mental health earlier, I think mental health starts at a much lower level than when we talk about inreach teams. Inreach teams really are the specialists, and we can't really rely on them to be as reactive and responsive as we need them to be. So, I think there is much more work to be done, as there is in primary care, around well-being and mental health prevention. Having now the additional funding, we are very committed to developing our own primary health mental health team in-house, where we're responding far more to those sort of concerns. I think we also absolutely recognise that we need to be working very much closer with the prison officers, because they are a valuable resource in terms of information and relationships with the prisoners. They can give us information we may not be able to elicit so quickly, because we don't have that regular contact as healthcare professionals. So, working closer with them, educating them about signs and symptoms of concerns, and having a very clear escalation policy for how they can get to us and flag those concerns is really, really important, I think.

So, we've got the new moneys coming in to devise our new mental health team, which I think will address a lot of those concerns, but we need to be absolutely identifying those high-risk patients very quickly and have a very close communication around all of the people within the prison, because there's a high incidence, a high prevalence, around mental health, and we absolutely recognise that.  

But what about the people who are in crisis? Have you got access then to mental health crisis teams for prisoners who are feeling suicidal or self-harming? 

No, but that is part of, I think, what we've bid for. Certainly, in Swansea, that's quite a big part of what we're planning to use our new money for, because I think inreach isn't probably the right place. Most of the men who are harming themselves and who are feeling suicidal don't have severe and enduring mental illness; they are in distress. It's very much like in the community. So, it's—. We assess people when they come in on their first night and in the morning, and we at the moment have little capacity, although the nursing team, in particular, do their best to support people, but that's the purpose of the new moneys in part, I think.  

I would echo that, partly. Partnership has to sit between primary care and primary care mental health and security, rather than inreach. We recognise that we don't have out-of-hours mental health and we don't have crisis mental health, because of this historic funding gap, and that was what our Welsh Government bid went in to address. We hope then we will have far more ability to assess quickly, be more reactive, and actually have some treatments available in that initial period.

We're also—. It was picked up in our inspection that we need to do more work with security on what happens with people with self-harming, and we have been looking at their audits and trying to tighten that up, and that's something we're going to more forward through our joint meetings and look at together. Because that's a really important thing, and the new Act process is probably going to be integral with that, but I would say that we've had little partnership working over that, so we need to review that. 

Okay. Thank you.

Diolch, Dai. Thank you. Can I ask you some questions about substance misuse provision? I guess that it'll be different for the long-term prisoners that you might have in Usk compared to the other two prisons. We've heard that the substance misuse provision in prisons isn't in line with what's provided in the community, that there are different substance misuse treatment pathways in prisons in England and Wales. Can each of you tell us a little bit about what the provision is like in your prisons, and, particularly thinking about prisoners who move on quickly, how that's sort of continued into their longer-term prison or whether they're released or whatever? So, I don't know who wants to start.

So, because we're not a receive and remand prison, we don't have anybody who's actually going through detox or in substance-misuse crisis when they come to us, because they'll have been in the system for quite some time before they get to Usk and Prescoed and have gone through that detox process. So, they work very closely with Dyfodol, who are our substance misuse team, and they work through programmes, they've got the CHASE programme that they do, a peer mentor run programme that they go through, and then they get put into touch with whoever their local—GDAS or Kaleidoscope or whoever it is on their release. They work very closely with third sector parties as well. 

Before I speak about Cardiff and Vale—and this is no reflection on Alison—I'd like to point out that Usk and Prescoed cannot take people maintained on opiate-substitution therapy. That would prevent them going D cat. So, men have to come off opiate-substitution therapy to gain their D cat status, which doesn't make sense to me. You're setting them up to fail. That's a security requirement and I think that should be addressed. We're not perfect; I'm not saying we are. So, in HMP Cardiff we have a massive turnover in our populations, so we will turn over 30 to 35 men per month—

Out of how many? Just remind us.

Up to 800.

That's quite a lot, isn't it?

Yes. So, a lot of those will have substance misuse issues, and the figures vary—around 40 per cent; it feels like a lot more. What we almost have in some respects is a better service than the community, because we get our men onto methadone very quickly, whereas they'll wait for four months in the community to start methadone. So, it becomes a perverse incentive, where men sometimes actually want to come in to us to get on a script. We aim to get our men started within 48 hours, but our substance misuse complement of staff is low. It works really well when everybody's in, but as soon as somebody goes on holiday or sick leave we then see it impacting our service. However, we have bid for money in our WAG bid and we've been successful in getting two extra substance misuse nurses, and we're also taking part in the Welsh Government task and finish group regarding a substance misuse—

Framework.

—framework—thank you—for Wales, which would standardise our procedures.

I think we have to be very, very careful. I know it's been picked up that we don't have the integrated drug treatment system in Wales as in England, but I would point out that England had IDTS when there was a surge and increase in violence and deaths and it did not prevent that. It isn't the be-all and end-all. I do think it's important we consider methadone-supported detox, but I'm really pleased that the Welsh Government aren't just blindly adopting it; they're looking at it cautiously.

And one final thing—HMPPS will quote how the figures remaining in treatment in Wales are up 80 plus per cent on leaving prison, whereas in England they're getting 30 per cent. So, our retention in treatment is really important to understand, but our service for drug users leaving is paid for by HMPPS—that comes out of their budget, not health.

Can I ask a question on that? 

Go on then, briefly. 

You mentioned a figure there. 

Sorry?

Is that service—? You said 80 per cent of people who are leaving—is that for Welsh prisoners or is it for all your prisoners? 

People leaving prisons in Wales, I believe. It's a HMPPS figure. 

Okay. 

So, in Swansea, I think like in Cardiff, things have changed quite a lot, probably, since some of the health needs assessments and so on that you will have seen, which may be why what we're saying sounds different from what was expected. In Swansea, we started an early days pilot last May, and we started commencing opiate substitution therapy, which previously hadn't happened. And I know we've had some criticisms similarly in previous HMIP inspections about the early days, the early time, that men are in, and quite a lot of that was to do with withdrawal it was felt. So, we do now commence methadone usually, mostly within 24 hours of admission, and we're able to continue that. We can be reasonably flexible about how long we continue it if, when they're going out—sorry, I'm slightly chaotic—they can be supported by service.

Unlike Cardiff, we have quite a lot of people who go out to further west in Wales, and there are some more difficulties sometimes for the services in west Wales just because of location and accessibility. So, sometimes, we need to check that they're going to be able to be continued so that they're not stopping, we're not making things worse for them. But we've had a public health review of the service and it's been very popular with men, with officers, with healthcare and largely with the services in the community as well, I think.  

Good. 

Can I make another point, I'm sorry? 

Of course. 

So, it's really important to consider the men coming in to us on opiate substitute therapy. Because we're remand we will take men on a Friday night, on a Saturday, and often those services then aren't open and we cannot confirm their methadone scripts. We use all different clinical systems. If they come from another prison, I can see what they've had. If they've come from the community, who uses Powerbase, I can't see—there are measures for making Powerbase talk to Methasure, which is the system we use to dispense, but there is no measure for SystmOne to start talking to that, but it means men who are doing well on a script they can potentially go without methadone then over a weekend while we're looking to confirm a dose. And we'll often give them 20ml just to try and hold them, because we think they're on a script but we can't prove it, and we can't make their risk worse by sticking them on a high dose when they're not. 

And if they miss three days then you have to start the titration again. 

A final point, just really on substance misuse. Obviously, it isn't just about one particular—. It's not just about medication, is it? It's much more about the holistic approach around, again, where the multidisciplinary team comes in. So, what we've now established—. Again, part of our new medical model is that there will be protected time for a substance misuse clinic, and also a multidisciplinary team working where we can look at patients individually, and not just looking at medication but also what else are we offering to address their dependency. So, I think that's just a new service, which probably will be part of the co-responsibilities of the GPs.

Yes, and that's another important thing. Health has no control over the behavioural support that goes with substance misuse. That's why we talk about prescribing. That service is funded via HMPPS, who commission Dyfodol. 

And because prescribing wasn't happening very much, so that's the new bit. Yes, the connections could be—. They're good on an individual basis, but they could be more straightforward. 

We have no control over the governance et cetera, whereas in England that's been recognised as a health function. But the funding is complex, because it goes into the police and crime commissioner's budget who partially fund with probation for that service. But I would say, before we stick it straight under health, it is seeming quite effective when you see the figures that they're retaining in Wales compared to England. So, I'd caution against just throwing it out; I think we just need to look at it. 

Don't worry, we're not taking everything you say as automatic recommendations. [Laughter.]

Most. 

It might come as a blow. 

Thinking—. We've touched on some of this already—the issues about providing any kind of support to a transient population when they're in and out, and we talked about it a bit when we visited Cardiff prison. Can you talk to us a little bit more about outside substance misuse treatment, and we have talked a little bit about it in the context of mental health as well, about what are the challenges around delivering healthcare to your transient populations and what sort of things you can do to minimise those negative impacts?

Okay. So, it's the timescales, isn't it? Seventy per cent of men in Cardiff are there for less than three months, so trying to get them clean, get them on a script, stabilised—I think that's the key thing. A massive, massive element that should not be underestimated, and it's beyond our direct control, is housing. If we release them homeless—47 per cent we picked up in our recent inspection go out homeless—you cannot expect these people to stay clean and value their health. If they're out looking for food and a home, they will prioritise that every time over their health. So, it might be difficult for us to understand that—'Why won't he go and sort out his diabetes?' All he needs is a roof over his head—not a tent—and food. He leaves an environment—. And some of our men don't want to go, because they leave an environment where they're respected, they have a bed, they have food, they have a job, and they're part of a valued, core-member team. And they go to the community and they're treated like nothing, and they have no status, and nobody cares, and it's very sad.

I think one of the biggest challenges is around IT and connectivity around having a transient population, because we need information quickly, and we don't get it quickly enough. I think, probably, Emily, you can—. Because that's what—. We've only got a small window of opportunity to deliver good quality healthcare, and, if we are struggling to actually have information around past medical history, what medication—what's already been tried and what didn't work—then we are losing time. And I think that's what I find is, probably, a massive—

I think that's true and also, when you think about prudence, I think we can sometimes end up repeating investigations, because we can't access them. We don't even know if they've happened. People often don't know what they've had. They'll tell you what they think that they've had and it's often not—

They tend to slip, don't they?

Yes. And so I think that is absolutely right, that we don't have access to—

I think Anjula's brought up a really important point here. The NHS Wales Informatics Service had lost all skills in SystmOne, which is the system that we use within the prison. That, I think, has been catastrophic for us within health, and I think we've now been left behind with England. England should be at the point, by the end of this year, where, when you go into prison, you register with the prison, your GP record follows. We are not even seeing that as a work stream right now. But I would say that NWIS has recognised that there is a lack of service for us, and they've really stepped up and we now have consultants coming in looking at our work streams trying to help us to build our skill and to build the services around the prison.

That is another recomendation.

Yes, that does sound like a recommendation. Are some of those issues that you've been talking about—are they exacerbated, particularly thinking about release, when you're releasing men back into home communities in England? And are there any particular challenges around that—particular things that need to be done to mitigate the challenges around that?

It's probably bigger for you, isn't it?

Yes, I was thinking that, because—

We struggle a lot. So, we have a lot of Englishmen, because we are closer to the border and as soon as a prison locks out or there's a riot—and our reception shuts a bit later—we will take Englishmen. That causes a lot of friction within the prison, between the men—that causes us lots of trouble. But when we're trying to release them on drug scripts, for instance, we often have to send them with a bridging script because we don't know the services as well, we don't have those relationships, and they don't see them as quickly. So, that is a major problem, I would say.

We have to do it for—. The other reason we have to do bridging scripts is because they're going out to west Wales and there may not be a prescriber available for a week, because they're smaller communities.

Right, that's helpful. A final question from me, but quite broad. We've heard that local health and local care services can struggle to provide men in Welsh prisons with comparative services to services that they would be receiving if they were in the community, and that this can be exacerbated by how services are provided. To what extent is a whole-prison approach needed to address these complex health and care needs, given the reliance of prison services on support clinics and health outside and inside the prison? And is there—? I think you've kind of already answered this as well, but do we need something to drive up the consistency around this across Wales?

I think there needs to be a set of indicators that we report up to Welsh Government and are held accountable to. It absolutely is essential that we have a symbiotic relationship—I cannot deliver health without security. We cannot expect men to have good health, if we were delivering perfect health with perfect access, unless they're getting good exercise, food, a bed that they're not hurting their back on every time and meaningful activity—men want to work and be educated. So, it is absolutely essential that we come together.

I would suggest that every health board should have a named—. Sorry, every social care board council should have a named person who's responsible for prisons and it's not lip service—there's something actually that they're held accountable for, some kind of indicator.

I can see a lot of support for that from the other two.

Yes, I completely echo what Mair's saying about the need for—. We have that in primary care—we have that autonomy to say, and that voice to say, what's needed from a health perspective. That needs to align with what those rules and regulations are around infrastructure and what is delivered through that—I think that's probably where we're struggling a little bit. We can do what we can in-house, internally, and have good relationships with our governor and have those discussions, but I think they are limited in terms of what they're governed by. I think that's where it can be very difficult.

For me—and we are all clinicians—I think that is a strong message. We do know what's needed, and I think, sometimes, it's quite frustrating and difficult and demoralising, I think, for a lot of health staff working in prisons that they cannot work to their best and they can't provide the quality they want to because of all of those barriers.

I think it's about recognising that Her Majesty's Prison and Probation Service have a very mature and very strong voice—they've been established throughout all of this. NHS England have developed a very strong voice in association with Public Health England, whereas I don't think we've had that in Wales. I think that's something we really lack and takes us back to this Welsh Government department with a remit for prisoner health.

You'd agree with that, in terms of—because you're dealing with a different population, but some of the challenges, I guess, are the same. 

Yes, particularly around palliative care for us, at the moment, in that we've got a gentleman who would like to stay where he is to die, but because we're not 24-hour healthcare and because of some of the boundaries around medication I'm having a little bit of a struggle with that at the moment. So, yes, definitely, we need a little bit more support. I think it's about the governor getting his team to understand that we can't do it all.

Right.

There has to be a little bit of give and take, sometimes.

And, with an older population, you're going to see more of that, potentially. 

A lot more, yes.

Thank you, that's really helpful.

A final point, just for the record: obviously, we've had a Prisons and Probation Ombudsman giving evidence to this committee before now, and also Her Majesty's Inspector of Prisons, you'll be aware. They make recommendations, occasionally, in the field of healthcare. Are you aware that health boards oversee the implementation of those recommendations?