Documentary analysis is a research approach that systematically analyses organisational and institutional reports . Prison researchers working toward a greater understanding of health promotion in prison have largely neglected documentary methods, opting instead to pursue empirical approaches [25-27]. While these studies have substantially advanced critical debate and dialogue and added rich insight, they often focus on a single, or small number of settings which makes transferability of findings challenging given the heterogeneity of most prisons.
The analysis of prison inspection reports is becoming a useful way of understanding how health and wellbeing is understood and delivered in prison contexts [8, 28] and used to effect in assessing mental health provision . Prison inspection reports are publicly available documents and can offer unique and independent insight into the strategy and operation of prison establishments and moreover give understanding of the “cross-section of strengths and needs” in the estate [29, p.3]. Despite this, prison inspection reports have been criticised for being very narrow in their conceptualisation of health and wellbeing – focusing predominantly on disease prevention and screening activities which arguably supports the safe running of the institutions as a primary outcome, with genuine prisoner health and wellbeing as a secondary .
The HMIPS reports were accessed from the website hosting the public repository. As this repository contained the full archive of inspection reports undertaken by the Inspectorate the sample was limited to the full inspection reports conducted in prisons using the 2018 revised Standards to ensure comparability between reports. Eight unique inspection reports meeting this criterion were downloaded between January and October 2020 each covering a single prison, with no prison being inspected more than once during this period and, as a result of the coronavirus pandemic, the suspension of the ongoing independent prison monitoring and inspection in March 2020 
To ensure the data most relevant to the aims of the analysis were collected the following Quality Indicators underpinning Standard 9 were focused upon :
9.1 An assessment of the individual’s immediate health and wellbeing is undertaken as part of the admission process to inform care planning.
9.2 The individual’s healthcare needs are assed and addressed throughout the individual’s stay in prison.
9.3 Health improvement, health prevention and health promotion information and activities are available for everyone.
9.4 All stakeholders demonstrate commitment to addressing the health inequalities of prisoners.
Analysis of the data were undertaken on NVivo 12. Initially the data were coded inductively and this identified 18 open codes. To organise the codes into more coherent thematic categories, the values and principles outlined in the SPS’ own framework for promoting health  were used as a structure to organise the data. The codes were each aligned to the values (fairness and justice) and principles of the framework (empowerment; equity; partnership; sustainability).
This section reports analysis from eight male prison inspection reports. It is organised under themes which were informed by the principles and values of the SPS’ framework for promoting health. The prisons have not been identified in the reporting.
Fairness and justice
All the institutions contained evidence of fairness and justice in their prison inspection reports. For most of the institutions this was reflected in the healthcare staff demonstrating respect for the prisoners when undertaking routine interactions. Within the data prisoners reported that they were fully involved in aspects of their health care and several inspection reports detailed how confidentiality was prioritised by healthcare staff with screening carried out in a room that maintained the prisoner's dignity:
“Staff explained the health screening process to prisoners, made sure that they understood its purpose; actively encouraged and supported prisoners to be fully involved in their screening.”
The understanding of health inequalities by health care staff, and the challenges and barriers prisoners faced as a result of them, was described in all the inspection reports along with the high levels of professionalism and human rights-based approach to the provision of care. Several inspection reports described how equality, diversity and human rights training was part of mandatory and ongoing training for all staff working in the health centre. In practice this meant that staff demonstrated a human rights-based approach both inside and outside the health centre with a positive and non-judgemental approach:
“Inspectors observed patient consultations at which inequalities, sensitive practices, and the principles of a human rights approach were clearly embedded. Inspectors also observed a number of nurse-patient interactions outside of clinics where these qualities were also witnessed.“
The majority of inspection reports described how staff were observed to adapt their approach to their patients as a result of their understanding of health inequalities, for example, providing information about the range of services available in different languages and formats as required. This included the use of easy formats using pictures and images, using Language Line and interpreters for those whose first language was not English, and Braille:
“Translation services were available for patients when English was not their first language.”
Several reports described how the relationship with healthcare staff was described as a positive one by the prisoners who felt that they were encouraged to make informed choices about their health care.
Several inspection reports described adverse environmental conditions. This included the high population numbers in the prison and resultant demand for services, particularly in relation to drug use, and the state of disrepair of some buildings:
“The general state of repair of the health centre and medical rooms in the halls was poor. The environment used for the delivery of healthcare in the prison was not fit-for-purpose. There were multiple areas of damage to the walls, flooring and paintwork. Similarly, the health promotion building had damaged ceiling tiles with exposed insulation.”
In some prisons, the lack of staff in post made it difficult to provide the full range of activities, including the provision of clinics:
“the increase. In addition, several nursing posts were sitting vacant and recruiting to them was proving challenging. This reflects the national picture, with many prisons having difficulties recruiting to key clinical posts. As a result, the demand on existing staff to deliver a comprehensive range of services was almost at its ceiling.”
There were concerns in one report that the reliance on agency staff as a result of vacant posts may mean that the healthcare team was unable to provide the full skill mix to deliver safe care.
Assessment screening tools were used on admission to prisons to identify immediate health and wellbeing needs of people arriving in prison. Plans were also put in place to manage ongoing, long term health issues:
“The healthcare needs of all prisoners were assessed on admission to [Institution] using a validated standard tool, and then managed and reviewed in line with national and local policy and guidelines throughout their stay in prison. Individuals with pre-existing long-term conditions, considered to be at risk of self-harm or suicide were asked to consent to information about their health being shared with relevant others.”
However, one report described how the standardised health screening only occurred for those prisoners arriving during the day and those arriving at night would not be assessed until the next day. There were other examples of institutions where health needs were identified at reception but then information was not shared or follow up:
“Not all individuals with a long-term physical health condition were identified on arrival at the prison, and those that had been were not always followed up in line with current best practice, or, had appropriate care plans and accurate and detailed assessment documentation.”
The majority of inspection reports also acknowledged inequity in the provision of information to all prisoners. Despite the recognition of the impact of health inequalities and the adoption of a human rights approach, many of the institutions did not provide printed information in languages other than English or in a format suitable for those with literacy issues:
“Different versions of referral forms were available and although the forms used simple language and some had pictures, they were not available in different languages or suitable for patients with literacy issues.”
Though the forms used by the health care team had simple language and pictures, inspectors felt they were not suitable and, in several institutions, individuals were not asked if they had any issues with literacy. As a result, some individuals may not fully understand the information given about access to healthcare.
Similarly those who may have had issues reading or writing in English were not always able to maintain confidentiality around their health needs. Some reports gave examples of prisoners needing other people to translate information or complete referral forms:
“The referral forms were not suitable for those with literacy difficulties or difficulty reading and writing in English. In these instances inspectors were told that other prisoners could be asked to complete the form for the prisoner. These processes breach patient confidentiality.”
In regards to equity, individuals with physical disabilities were not always placed in accessible cells, and several reports described the impact of institutions which were not designed to house people with disabilities such as the lack of wheelchair accessibility to cells and accessible toilets and showers:
“There was only one accessible cell available within the prison. On discussion with [Institution] senior management and healthcare staff, inspectors were told that this cell had been identified as not fit-for-purpose as it did not have appropriate adaptations.”
Within section 9 of the inspection reports, there was no mention of empowerment in its fullest sense. Instead referring to attributes more closely associated with psychological (or individual) empowerment, such as increased self-esteem or knowledge (i.e. access to information). All the inspection reports contained reference to health promotion within the prison. In the majority of reports, however, this reflected the provision of information about services available to prisoners:
“Prisoners were encouraged and supported to take up the wide range of health promotion activities and opportunities available to them including; harm reduction, smoking cessation, sexual health, alcohol services and smart recovery groups.”
Some reports described how staff actively ‘encouraged and supported’ prisoners to take up the health promoting opportunities either through giving advice or through health promotion events for prisoners to both attend and raise awareness about. One example described the campaigns calendar used to focus on a different health issue each month.
Even where a prison was reported as having health promotion activities in place these were focused on a narrow range of individual risk factors such as smoking cessation or substance misuse. There was also an emphasis on transmissible disease through screening programmes such as those performing blood borne virus testing:
“A range of national screening and immunisation programmes were available to prisoners including blood borne viruses (BBV), bowel screening and flu vaccinations. An opt-out model had been adopted for both the sexual health screening and the smoking cessation programmes. Staff told inspectors they would follow up with prisoners who had initially opted out of these at their admission, to check whether they wished to participate.”
There were examples of other areas where access to information and support was not widely available. Several institutions did not provide information about access to condoms for sexually active prisoners.
Evidence of collaborative partnerships were found in some prison inspection reports. These included individual institutions working in partnership with third sector and community organisations to deliver health promotion activities or services for prisoners:
“...had established strong links with a wide range of community and voluntary agencies where prisoners could be referred.”
One inspection report also described how the healthcare team had built relationships with community and third sector groups to help support prisoners both prior to and after their liberation.
Peer support was described in some reports, often focusing on overcoming drug and alcohol problems. There were also examples of patient forums and focus groups in some institutions where issues relating to healthcare provision could be raised, though the levels of engagement were variable:
“Despite efforts, prisoners in [Institution] refused to engage in the patient forums.”
All the prisons inspected showed evidence of their person-centred approach to the provision of care. Individuals could self-refer to the healthcare service where staff would discuss their concerns and signpost or refer to appropriate services. Those with complex needs often had anticipatory holistic care plans in place which were discussed and ‘owned’ by the patient and there was an emphasis on directly involving prisoners in their care:
“Inspectors saw evidence that patients were being encouraged to be responsible for their own care, which was good practice.”
However, several reports demonstrated a lack of person-centred care within the institution:
“Patients with a long-term condition were given limited support to self-manage their condition. Although care plans were in place, they were not person-centred or outcome-focussed and had not been developed in conjunction with the patient.”
In some institutions there was no evidence of a collaborative approach or reviews of ongoing care. One institution lacked a robust process for identifying those with long term conditions and ’relied on conditions being identified ‘‘opportunistically’ at other appointments’.
Health promotion leadership was described in some inspection reports, which manifested in highly motivated teams who were continually aiming to meet the needs of the prisoners in their care despite poor or challenging conditions. One report described the health promotion strategy for the prison:
“The health promotion strategic lead had developed a health promotion strategy specifically for [Institution]. The strategy focuses on issues specific to both staff and prisoners and covers issues such as violence reduction, supporting the journey of recovery, smoke free prisons and staff health and wellbeing.”
There were good working relationships between healthcare and Scottish Prison Service staff as a result of close working between the senior management and an understanding and respect for each other’s critical roles in the wellbeing of prisoners. These positive working relationships led to good team dynamics and communication as well as an understanding of professional and ethical boundaries. This in turn led to positive impact on the health care of prisoners:
“NHS and SPS staff within the health centre had a good understanding of each other’s roles and responsibilities and were seen to have a supportive working relationship. Effective two-way communication meant prisoners were supported to attend appointments within the health centre and within the community.”
However, in other institutions there was a lack of strong leadership with the health care staff feeling unsupported:
“...many of the staff spoken with expressed feelings of vulnerability and of feeling unsupported in their roles by the healthcare leadership team.”
There were also reports of a lack of collaborative working with the wider prison staff team, including some reports of officers being abusive towards nursing staff, and the lack of resolution of longstanding operational issues such as the facilitation of attendance by prisoners at their healthcare appointments:
“Inspectors were concerned that [Institution] staff did not work together to solve problems which negatively impacted on the delivery of healthcare within the prison.”
One report described that processes to discuss operational issues were not in place amongst senior management.