The hypothesis was that the OHSCAP would significantly increase the proportion of met health and social care needs three months after prison entry, compared to TAU controls (Forsyth et al., 2017). However, there was no difference in the number of unmet health and social care needs between the TAU and OHSCAP group at the 3 months follow up. Additionally, no differences were found between the groups when depression or activities of daily living needs were examined. Specific health and social care need domains were examined separately. There were no differences between groups for how well specific health and social care needs were met, except for hearing instructions. Prisoners who received the OHSCAP were more likely to have their needs met for this domain, than those in the TAU group 9Forsyth et al., 2017).
The main explanation for the lack of difference between the TAU and OSCAP groups is that the OHSCAP was not implemented as intended (Forsyth et al., 2013; Forsyth et al., 2017). An audit of all accessible OHSCAPs was conducted (68%) to identify both the fidelity of implementation and the quality of the care planning. The OHSCAP manual stipulated that the assessments should be completed 7 to 14 days after prison entry. In spite of this, the audit found that the OHSCAPs were completed on average 20 days after arrival in prison (range 4 to 63). Equally, care plans should have been produced after each assessment. Nonetheless, care plans were documented for less than half of the OHSCAPs reviewed (43%). Moreover, no action was reportedly taken in 43% of cases where problems were identified (Forsyth et al., 2013; 2017).
The nested qualitative study generated a valuable understanding of why the OHSCAPs had not been adequately executed (Forsyth et al., 2017). Semi-structured interviews with 14 prisoners and 11 staff members detected fears about healthcare and prison ‘silos’ resulting in a lack of meaningful multi-agency and partnership working (Forsyth et al., 2017). Prisoners additionally stated that they considered it objectionable for prison officers to be facilitating the OHSCAP. Most strikingly, staff stipulated that they were working within a ‘broken prison system’, because of the recent considerable staff reductions. Staff stipulated that meeting basic needs such as enabling all prisoners to have showers and remain safe was more challenging since the staff reduction, thus facilitating the OHSCAPs was a low priority (Forsyth et al., 2017).
The findings of the nested qualitative study allude to the fact that, at the time of data collection, prisons were in crisis (Forsyth, 2017). The current study took place at a time when the government introduced policies with the intention of reducing staffing levels across the National Offender Management Service as a whole (House of Commons Justice Committee, 2015). Benchmarking encompassed an attempt to reduce costs across the prison system of England and Wales by reducing the number of prison officers (House of Commons Justice Committee, 2015). These reductions were enabled through changes to the prison regimes. Between March 2010 and September 2016, grade 3 to 5 operational prison officer numbers fell by 26.3% in public sector prisons, excluding structural changes (prison closures, movement between public/private operation) (Ministry of Justice, 2016). This affected the ability of staff to implement the OHSCAP as intended (Forsyth et al., 2017).
The damaging impacts of these staff shortages were widely described by participants, both professionals and residents, during the qualitative interviews (Forsyth et al., 2017). After data collection for this study was completed, the government White Paper ‘Prison Safety and Reform’ recognised grave problems with the prison system and the need for change (Ministry of Justice, 2016). The paper recommended several changes to the prison system, including increasing staff-to-prisoner ratios via the employment of an extra 2,500 prison officers. By December 2017, prison officer numbers were at the highest number they had been since September 2013, increasing by 161 percent between December 2016 and December 2017 (Ministry of Justice, 2019). Importantly, the newly recruited prison officers lacked the experience that previous staff held (Bullman, 2019).
Alternatives to increasing prison officer numbers to improve standards of care are also required. To better meet equivalency with the community and to enhance the quantity, scope and targeting of services additional research should explore and identify the role other prisoners and third sector organisations (such as older adult specialist services) may have in identifying and suitably meeting older prisoners’ health and social care needs (Forsyth et al., 2017). There have been recent efforts towards using prisoner peers to meet older prisoner health and social care needs, but the appropriateness and effectiveness of such interventions is largely unknown (Tucker et al., 2018).
The introduction of the Care Act (2014) also transpired during the data collection phase of this study (Forsyth et al., 2017). Essentially, this meant that local authorities became responsible for the provision of social care for prisoners (Tucker et al., 2018). The OHSCAP was designed to complement the Care Act by providing a system for meeting the social care needs of older prisoners who did not meet the high threshold for social care packages set by local authorities (Forsyth et al., 2017). Early research suggests that many different models of social care have been adopted by local authorities with varying degrees of success (Tucker et al., 2018). This marked change in social care provision may have further impeded the successful implementation of the OHSCAP at a time when there was confusion over the provision of social care in prisons and significant change (Forsyth et al., 2017)
Although the OHSCAP was not facilitated as planned, it is important to discuss the impact of potential limitations of the research. The possibility of contamination between the TAU and intervention arm was cautiously ruminated. An individual-level randomised design was adopted, and accordingly individuals within the same prison were receiving both TAU and OHSCAP, because it was predicted that there would be minimal contamination between the two groups. This was considered to be the situation because older prisoners were not systematically identified on entry into prison within the TAU arm and therefore the Older Prisoner Leads did not usually come into contact with these older prisoners (Forsyth et al., 2017; Senior et al., 2013).
The assessment tools used were the most suitable ones that were obtainable; however, they had some limitations (Forsyth et al., 2017). Several participants stipulated that many of the discrete domain items in the CANFOR-S were not relevant to their current situation in prison, or at all, given their age, (for example asking about needs in relation to childcare responsibilities). Furthermore,, the CANFOR-S considered needs to either be met or unmet, but it is unlikely that some health and social care needs are ever fully met as they are unending and variable in their nature and / or severity. Findings from our previous research suggest that older adults in prison are less likely to raise concerns than their younger counterparts (Senior et al., 2013); consequently participants in this research may not have always stipulated if they were experiencing unmet needs. In spite of the limitations of the CANFOR-S this tool was considered by the authors to be the best one available for measuring health and social care needs within the prison setting and has been successfully used with this population in previous studies (Hayes et al., 2012; Senior et al., 2013). It was decided that a three-month follow-up period should allow ample time for initial needs to be met. The CANFOR measures whether or not prisoners are receiving some beneficial assistance. The research team considered three months to be sufficient time for the prisoners to begin to get suitable assistance, and we also wished to minimise attrition (Forsyth et al., 2017).
Additionally, some limitations of the tools used to measure the secondary outcomes were present. The GDS-15 was not initially designed for use in prison. However, the scale has been used with older prisoners in a previous study (Murdoch et al., 2008). In that research, one question was adapted from ‘do you prefer to stay at home rather than go out and do new things?’ to ‘do you go ‘on association’?’ (Murdoch et al., 2008). ‘On association’ is the term used describe those residing in prison leaving their cell and socialising with other residents. We adopted the same approach. Additionally, very few activities of daily living needs were identified using the BADL (Table 3, appendix 1). This tool has been used in previous older prisoner research (Hayes et al., 2012). However, it is designed for use with dementia patients and is perhaps not sensitive enough to recognise activities of daily living needs among either older adults not experiencing dementia, and among those living in a limiting institutional setting (Forsyth et al., 2017).
We acknowledged at the planning stages that participants would inescapably became aware of which group they have been allocated to when they received the intervention. Additionally, the researchers knew which group some of the participants belonged to because 14 of the participants in the intervention group participated in qualitative semi-structured interviews (Forsyth et al., 2017).
The CANFOR-S was adopted because, it was the most suitable available tool for assessing unmet health and social care needs within the prison population (Forsyth et al, 2017; Senior et al., 2013). The research team were, however, aware that there were certain domains of the CANFOR-S that the OHSCAP specifically aimed to address and some domains of the CANFOR-S that the OHSCAP did not aim to address (Forsyth et al., 2017). The research team therefore felt it would be useful to analyse the data separately for the specific domains of the CANFOR-S that were considered most relevant to the OHSCAP. The aim of this analysis was to gain a more detailed understanding of the specific domains of the CANFOR-S that the OHSCAP seemed to assist more with and which domains the OHSCAP was less able to address (Forsyth et al., 2017).