Oral evidence: Prison reform, HC 548
Tuesday 21 February 2017
Ordered by the House of Commons to be published on 21 February 2017
Members present: Robert Neill (Chair); Alex Chalk; Philip Davies; Kate Green; Mr David Hanson; John Howell; Victoria Prentis.
Questions 372 - 448
Witnesses
I: Amy Rice, Deputy Director, Prison Safety and Reform Lead on Empowerment and Accountable Governors, Ministry of Justice; Nina Champion, Head of Policy, Prisoners’ Education Trust, Prisoner Learning Alliance; and Nathan Dick, Head of Policy and Communications, Clinks.
II: Kate Davies, Director of Public Health, Armed Forces and their Families and Health & Justice, NHS England; Dr Rachael Pickering, Co-chair, BMA Forensic Medicine Committee; and Dr Eamonn O'Moore, Public Health England and Director of the UK Collaborating Centre to the WHO Health in Prisons Programme.
Written evidence from witnesses:
- Clinks
Witnesses: Amy Rice, Nina Champion and Nathan Dick.
Chair: Welcome everyone to our evidence session on the prison reform inquiry. We are very grateful to all of you for coming to give evidence. Before we start, both for this and the next panel of witnesses, can I check if any members have any interests to declare? I am a non-practising barrister and consultant to a law firm.
Alex Chalk: I am a practising barrister.
Victoria Prentis: I am a non-practising barrister.
Chair: Can I ask our witnesses to identify themselves and their organisation?
Nina Champion: I am Nina Champion. I am head of policy at the charity Prisoners’ Education Trust, and I founded and provide the secretariat for the Prisoner Learning Alliance, which is a coalition of 23 different organisations with expertise in prison education.
Nathan Dick: I am Nathan Dick, head of policy and communications at Clinks. We are the umbrella organisation that supports the voluntary sector working in criminal justice.
Amy Rice: I am Amy Rice. I am a deputy director on loan from HMPPS to the MOJ. I am working on prison reform and leading on empowered and accountable governors. I was previously head of commissioning for NOMS, and before that operational.
Q372 Chair: Great. Thank you very much all of you. We want to start by talking about the proposed changes to the way education and related matters are commissioned under the Government’s new proposals. Looking at what the Government are setting out, the changes that they are seeking to achieve, can you identify what you think the main potential obstacles are in providing education and other services in prisons at the moment? Do you think that the proposed changes for the reforms that the Government are making will address those, or is there something else that ought to be done?
Nina Champion: Sally Coates in her review of prison education, “Unlocking Potential,” clearly identified what all the barriers were in education. It was a fantastic report that dealt thoroughly with a whole range of issues. The fact that all the recommendations were accepted by the Government is very welcome. The White Paper should be judged on how far those recommendations are implemented in full in practice. Putting learning at the heart of the prison, which is what Sally Coates is trying to do, will be crucial. The Prisoner Learning Alliance was very clear, as the review started, that governors had a central role in providing learning, culture, environment and opportunities, and had to have the accountability, freedom and flexibility to meet the needs of their population. The main problem previously was that there was very much a centralised one-size-fits-all approach to prison education that was very output driven—numbers of hours in classrooms, numbers of qualifications—and did not address the needs of individual populations. The freedom and flexibility that will be coming in some areas is very welcome. We are excited about all the opportunities that it could provide for partnership working and innovative work, and to build on what we know works as well.
Q373 Chair: That is helpful. Nathan, you seem to be broadly agreeing with that.
Nathan Dick: Absolutely. We broadly agree. The Coates review was a really good assessment of what needs to change to improve education in the prison setting. It could generate new ideas. It will have to be based on good evidence as to what works. There might be areas we can touch on as to how evidence can contribute to commissioning of services, and that will be important. We value the comments around arts, creative practices and different types of educational practices outside what would be normally traditional classroom-based education. That is really important.
Some of the previous contracts let to prisons have not given the flexibility to bring in those kinds of services. Our hope is that executive governors with a bit more autonomy, based on good practice and evidence, could find ways to commission them. The OLASS contracts have already been given a bit of flexibility to do some of that, which is really good news, and I would like to see it increased. If we could broaden the number of providers we are bringing into our prisons, to broaden the offer, that would be helpful as well, but I am not sure whether right now prisons have some of the skills or maybe some of the support they need to bring in a range of other organisations, especially at local level.
Q374 Chair: That is helpful. Amy, do you have any thoughts?
Amy Rice: I would not disagree with that. The whole thrust of the White Paper was around putting the governor at the centre of the design of the vision for their entire prison. Education is no different in that regard. The huge opportunity is to see education in context, which was referred to. There is an opportunity to tailor the offer for prisoners in a specific place for their particular needs. The emphasis on local partnership work with the community will give a different dynamic. The ability of some of the reform governors to be more outward facing—you have probably heard quite a lot of that discussed—and to have the time and headspace to do that suggests to me that the energy put into that sort of work will bring a different feel to education in prisons. As Nathan mentioned, we have already released some of the shackles around subcontracting and made some technical changes, but the cultural and partnership change is going to be the biggest driver.
Q375 Chair: For the broadening of providers that Nathan was talking about— getting a broader spread of providers—what do you think we need to do to achieve that?
Amy Rice: Some of it starts with how we think about education and what education is. The OLASS contracts have evolved historically, but they started from a traditional educational point of view. Education for prisoners is different for the individual and different for the cohort in prisons, and there is a different set of needs. The role of education can be a bit broader than a traditional academic perspective. Then you start to look at who the people are who bring a different skillset and a different way into education, and who do preparation for the academic side of education and link through to employment. You get a more tailored service, which opens the door to lots of different providers who might not have thought of themselves as purely educational.
Nathan Dick: When Clinks was founded as a charity, we were a project supporting prisons to engage with their communities before we were properly registered as a charity. We did a lot of work to embed voluntary sector co-ordinators in prisons across the country. This is something that has fallen by the wayside over recent years, with benchmarking and cuts to budgets. They were an easy post to cut from the system, but they were incredibly valuable where they worked well and someone had a dedicated role for engaging with charities locally—it could be broader than that—to bring organisations into the prison, to reach beyond the prison wall and find out how they could come in. We recognised the decline and we started a project with funding from the Monument Trust, which is one of the Sainsbury family trusts, to pilot that model again in three prisons. We are working in Dartmoor, Exeter and Guys Marsh in the south-west. The early findings are that it has been incredibly positive. The governor from Dartmoor was interested in how we could continue the post, and the others are looking at how they might be able to come together to do something similar.
In Ranby, separate from the education side, we were lucky to get one of the innovative grants put out by NOMS to work with executive governors. There, we are focusing on how we bring in family-specific organisations to influence the family services they want and commission them locally. They are asking us to go out to the sector and find out who they are, but a lot of that is not about Clinks doing that work as an organisation, because we are a small national body; we are engaging with local infrastructure organisations that know the area, know the organisations and can engage with them. We think that is one way of reaching out and increasing the diversity of providers.
Nina Champion: I agree with what Amy was saying about the broader vision for education. It is something that the Prisoner Learning Alliance has been working quite closely on, looking at developing a theory of change for prison education, really unpicking what it is about education that learners value and that teachers see in their classrooms, beyond just the qualifications. It is around personal social development, health and wellbeing and resilience as well as life skills. It is having that broad view, and, as Amy said, thinking about who can mix that and thinking quite innovatively about local partnerships. Something exciting that is happening at the moment is developing prison-university partnerships. NOMS in London were looking at trying to have every prison in London linked with a university. That can take a whole number of shapes, such as organisations like Inside Out and Learning Together, as well as other types of partnerships. Whether it is FE colleges, the voluntary sector or universities, it is looking at partners in the community we can reach out to, because many of them want to get involved. The more you can involve the community in the provision of education, the better the links through the gate. Also it changes perceptions of the community and sees prisons as part of that community.
Q376 Chair: Is the fact that it is proposed to make rehabilitation a statutory purpose likely to make any change to commissioning decisions? Does it underpin it?
Amy Rice: It certainly brings a different focus to commissioning decisions. Of course, once you have the statutory purpose, your eyes are on the purpose of the services that are being commissioned. That is not to say that services are not already geared towards resettlement and preparation for release. With a statutory purpose, the point is that they will have to be. In balancing where we target scarce resources in the future and value for money in terms of public money, there is a key driver to say that one of the purposes of imprisonment is to focus on rehabilitation.
Q377 Chair: I get the sense that you all welcome the fact that it is a statutory purpose.
Nathan Dick: Absolutely. It is one of the things that has been missing for a long time and is incredibly welcome. It needs to come alongside some real careful thinking about what we mean by rehabilitation and, to use that phrase again, theory of change. It is easy to say that the statutory purpose of prison should be rehabilitation, but what do we mean by that? That might not be for the purposes of legislation to set out, but it is absolutely necessary to have a good and robust understanding of the sorts of activities you would like to see that you think will lead to rehabilitation, not just a simple measure: “Rehabilitation is a reduction of reoffending.” Someone with multiple and complex needs, who is very far from the labour market, with mental health issues or drug and alcohol addiction, will need a particular kind of rehabilitation that may well be different for someone who is able and engaging with education, looking for work on the out and on release on temporary licence doing well. It is very welcome, but we need to think carefully about what we mean by rehabilitation. We have thought quite carefully about what we mean by incarceration, so we should probably do the same on the other side of the fence.
Nina Champion: Moving on from that, it is very much about culture. For a while there has been talk of a rehabilitative culture. It is crucial to define what that is and help governors and others to measure and define it. You heard in a previous session from Alison Liebling, who works on the MQPL, looking at the dimensions and values that you can measure a prison on. We have been working with her team to look at defining a learning culture and looking at dimensions such as empowerment, aspiration, how engaging the learning is and how relevant someone sees it to their life. It is a matter of using cultural and value-based measures and dimensions to judge a prison in terms of how rehabilitative it is. Is the environment conducive to that kind of transformation and change? There is a lot of theory and evidence available around desistance theory and transformational learning theory. We should be drawing on those disciplines about the culture and ethos. Governors need to lead on those values. At Berwyn, the new prison in Wrexham, Russ Trent, the new governor, has recruited his staff using a values-based approach rather than a competencies-based approach. That is because the rehabilitative culture there is so key. In everything they do and the language they use, they have thought very clearly about how to get an ethos and a culture. It does not just have to be in a new prison. It can be in a prison that is already up and running. It is just about driving that. We have seen that in the reform prisons and at Wandsworth and other places. It is very much about setting that vision.
Q378 Alex Chalk: I would like to focus on two aspects of governor commissioning of services. First of all, we have received some evidence questioning whether governors themselves have the skills and the wherewithal to capably commission these services. It is a technical area. This is no criticism of them. What skills, knowledge and information do you think they need, and are you confident that the Ministry’s capability strategy will provide that expertise?
Amy Rice: It is absolutely acknowledged that what we are asking of governors is for some new territory, for some a development of their existing skills and for some who have not worked in that environment, we just do not know. Part of the capability strategy is to look at the skillsets we think governors will need but also to do a bit of diagnosis with them and involve them in that conversation. At an individual level, they are best placed to know that. We are not seeking to make governors experts in everything, because we are looking at commissioning activities, but they will cover a broad range and they cannot be experts in procurement, data analysis and all the things that sit behind effective commissioning. Work is in progress to say, “What kind of skill level would they need?” and, as importantly, “What is the central support that will be available to them?” That is a piece of design work that is under way right now.
Q379 Alex Chalk: How well progressed is that? How far down the track are we to having a structure, so that we can feel confident that governors will have the skills they need?
Amy Rice: Skills are not my specific area, but it is progressing fairly well. There is already some planning about what the particular interventions will be. I would not want to go into too much detail because I do not know it intimately. In terms of central support, the infrastructure is already in place. The question is around capacity and response. One of the things that executive governors talked about, I think, was that in their new role there was a change in the dynamic of how their requests were received. As much as skillset, it is about culture change and governors feeling empowered.
Q380 Alex Chalk: They are the customer now.
Amy Rice: Exactly.
Q381 Alex Chalk: Does anyone else want to comment on the provision of training for governors, before I move to the next point?
Nathan Dick: It was an interesting experience with police and crime commissioners. Police authorities did not have a commissioning function, and when they transferred to being a commissioner there was a lot of querying from the voluntary sector about where they would get their skills. There probably was not enough done in that process robustly to ensure that the offices of the police and crime commissioner had people in them with good experience and knowledge of what a proper commissioning process is. That is necessary, and the training programme, rightly, focused on executive governors knowing what they should be leading, but there should be an acknowledgment that potentially there will need to be new skillsets in the senior management team of a prison. I wonder what that role should be, where it should sit and what its link is with the Ministry of Justice once, from 1 April, they take back responsibility for commissioning, and what the responsibility is then with the new HMPPS. That is something that needs to work itself out.
We need really good guidance on who is setting the commissioning processes. We have noticed, from a voluntary sector perspective, that a lot of commissioning processes, not just the MOJ’s, but the MOJ’s as well, can be incredibly bureaucratic. They can often be quite large scale so they do not sit very well with a local commissioning process. To what extent will governors be able to break from a very red-tape, bureaucratic commissioning process? Will they be able to grant-fund? Will they be able to approach local specialist organisations with opportunities outside the commissioning process if they are identified?
Q382 Alex Chalk: Can we leave that to one side? What I want to focus on for these purposes is the extent to which they will be given the skills and resources they need to do their part of it, however large or small that part is. The point you are making is that there needs to be training not only for them, but for the people around them in the prison.
Nathan Dick: I would say so. There is the National Council for Voluntary Organisations and the Commissioning Academy, and there might be other Government initiatives that are improving the quality of commissioning practice cross-departmentally that the MOJ might want to look at accessing to support governors or members of their team in going through the process of training. It might not just be MOJ specific. It might be a bit more cross-departmental.
Nina Champion: One of the crucial things for governors is a thorough needs analysis of what the needs are of their prison population, and that requires data and evidence. That is lacking at the moment. What are the needs? Governors should be looking creatively about not just buying in or commissioning services but commissioning mechanisms by which they can, on a regular basis, test the water of that needs analysis, whether that is initial assessment data or feedback from learners, prisoners and staff about their experiences. There should be a very involved consultative approach with a robust self-assessment process, so that they really understand their population and have the data that back it up.
Q383 Alex Chalk: Thank you. In this brave new world, governors are going to have these powers and they are going to go out into the marketplace with their skills, hopefully, but of course education provision will remain with the various providers. Are the potential future providers prepared for this brave new world? Are they being given enough information and support to enable them to adjust?
Nina Champion: A lot more information is required, particularly around the different needs analysis of the prisons, mapping what is currently there and what added value they can offer. There is a huge amount of potential and opportunity. The current providers know that they need to work in partnership with a whole variety of local organisations. They want to collaborate with others.
Q384 Alex Chalk: Yes, but in terms of how they interface with governors, when the governors are going out saying, “It’s pick and mix. I want that, that and that,” are the people providing those services geared up for this new culture? That is the question.
Nina Champion: There needs to be much more dialogue between governors and what governors want. We have been running some round tables with providers and other voluntary sector organisations. There is a lot of information that they need and want. We have been gathering what they want.
Q385 Alex Chalk: I want to try to drill down. What are they missing? What still needs to happen for them to be able to operate in this new environment?
Nina Champion: They need to understand what the governor’s vision and strategy for the prison is. As with any leader, what are they trying to achieve? What are the needs of the individual population and how can they best meet those needs? What is already going on? If there are things that are already working, that is great. How prepared are they to take risks? Some of this innovative work is going to rely on some risk taking, but the benefits could be great. One of the areas, in particular, which has not been picked up and was missing from the White Paper, is around technology and the role that technology needs to play in order to drive improvements in education, resettlement, family contact and prisoners being able to self-service and take responsibly for different aspects. It is a matter of thinking about risks and what risks they are prepared to take, and mitigating them.
Q386 Alex Chalk: Have the providers got what they need to prepare?
Nathan Dick: It is an interesting question taken in the round. Some probably have and some might not. It depends on how you go out to the market and get the services you want. If you want to cluster a bunch of prisons together and do a big commissioning exercise with governors who say, “We want to work together on this,” and you put something out through a very heavy bureaucratic process, the smaller organisations might not be well geared up to respond to those kinds of requests for invitations to tender and the procurement that surrounds them. We need to understand when we ask, “Are providers ready for it?” that there are some multi-million pound charities that work across a large-scale area that do what they do well and have access to the big contracts, but the majority of the sector that we represent at Clinks are very small organisations. They tend to be organisations with even less money—
Q387 Alex Chalk: In the interests of time, are they up to speed? Are they getting ready for this or is there just going to be a big problem when we find ourselves in April and they just don’t know what has hit them?
Nathan Dick: Information is key, as Nina said. If we can get the information out to the organisations transparently, which means understanding what the processes will be, what kind of services are needed and what the profile of the population is, so that they can say, “I have a service,” or, “I don’t have the service that will be useful to you,” then those organisations can prepare. They will be able to understand the commissioning processes, but they need to be flexible and mindful that there will be different size providers out there. It is a bit of a two-way process. If the way providers are engaged with is flexible and transparent enough and they know what is happening, yes, they will be ready, but there probably needs to be a bit of work before that happens.
Nina Champion: It also needs to be as diverse as having a single person; for example, at Wandsworth they have a former prisoner who used to reside in Wandsworth now delivering induction programmes and getting people involved and inspired. It is about the use of role models—who delivers and how—and making the most of people who have gone through prison education that has transformed their lives and who are now setting up social enterprises. We come across many people at the Prisoners’ Education Trust who have made that journey. It is how we can support them. The most powerful way to persuade someone to take up opportunities for learning and education is someone who has been there themselves. We need to support, as at Wandsworth, people who have had direct experience to come and be part of the provider matrix.
Chair: People have the picture. In the interests of time, we need a little brevity in some of the answers, if people don’t mind, as well as for my colleagues when asking questions.
Q388 Mr Hanson: Amy, we have in place already six reform governors who have been operating since 1 July last year. What kind of changes have they made in the commissioning of education provision in that period, so that we can get some flavour of how it is going to work in the future?
Amy Rice: I have a slight correction. There are four executive governors and six reform prisons. In terms of actual education commissioning, I cannot point to anything from personal knowledge that they have done differently. The process to change a commissioning offer takes a period of time. What they have done, for the most part, is to concentrate on stabilising their prisons so that the environment is right to deliver a whole range of services, but there is nothing to report back at the minute to say that there is a radically different approach to commissioning education.
Q389 Mr Hanson: If these new freedoms—all three of you have touched on this—are going to enable you to commission a wider variety of services and the governors, if they get things stabilised, are able to focus on that commissioning, what specifically do you think will be the first year or two years’ worth of change that you would visibly be able to show us whenever we look to the future and say, “That’s the timescale we looked at”?
Amy Rice: It will be different across the piece, because the whole emphasis is that it should be based on what is necessary locally. For example, in the open estate, I would expect to see a different type of arrangement and different things happening through ROTL—whether there is a commissionable service through that, as there may well be. There might be mentoring-type services for people going out on release. In the closed part of the estate, you might get different types of family services, or education that is more heavily learning-disability based.
Q390 Mr Hanson: Why does it need governor freedom to do that?
Amy Rice: The two things go hand in hand. At the moment, we have something that is fairly heavily centralised, that models what a prison looks like based on a number of factors, but there is never a perfect system that gets all the local nuances. Things change much faster than you can change a central system. In terms of driving the strategy and the vision for the prison, governors are best placed to do that. The freedoms that we are going to give them are not just around commissioning. For example, they will be able to look at their staffing model, and say, “Where do I want to put the emphasis? Where do I want to change what is centrally prescribed, to get the right types of staff and the right mix of staff to do the services that I think are most important for my prison? What do I want the day to look like in this prison? How am I going to carve up the work and look at what skills I am providing in my prison? Who am I talking to outside? Where can we connect those things to make real jobs for people leaving prison?” In the long-term estate, there will be a completely different emphasis, so it will be bespoke.
Q391 Mr Hanson: I suppose some people might say that that would lead to complete fragmentation of services and lack of oversight from the centre, and the points Mr Chalk mentioned about governor capability for dealing with all those things. What would you say to those who say, “This is going to be dependent on the quality of the governor, more so than even now, and will lead to fragmentation of services, so we will have a postcode lottery for prisoner education” and possibly health, which we will talk about later?
Amy Rice: It is where you are on the spectrum, and we are at neither end of that, so we are not completely centrally prescribed at the minute. We are not heading for a free-for-all. There absolutely will be a level of central oversight; commissioning at MOJ will set policy frameworks that set out for every governor the minimum standards. There are minimum legal standards, for sure, but there may be other things that we mandate to make the system work together effectively. The central role will be, “Does this thing hang together? What is the impact of local decision making and have they got the framework right?” Within that, governors will have the freedom to buy the best things for their places.
Q392 Mr Hanson: What about things like offending behaviour courses and family services and the lack of ability to do that? We have had a lot of discussion in the Committee about IPP prisoners, for example. Give me a flavour of how a reform governor, either currently or in the future, would have the ability to influence, potentially, offending behaviour courses, IPP prisoner courses or family courses in the future, different from what is done now, and without the fragmentation and lack of control and lack of understanding of what is happening from the centre.
Amy Rice: We do not have the final design yet for accredited offending behaviour programmes, but I can lead you through the thinking, if that is helpful. What you want is some sort of rigour around any intervention that is focused on high-risk cases. What we have at the minute is a suite of programmes that are mandated, so a small number are centrally held. Governors, through their SLAs, as were, would agree to deliver a number. The freedom we will get to is that if in the round—in discussions with other organisations through better use of data analysis, through what prisoners are saying, through feedback from the Parole Board: a whole plethora of evidence—a governor believes that the interventions running in a prison are either not the best possible configuration, sequencing or type or are more expensive than something else that would be effective, we will design a way to manage that. The governor can come forward and say, “I want to change something. I’ve got a better idea and I have an evidence base. What’s the evidence base for believing that this will work?”
Those are not the sort of things that you just switch off at no risk. It would have to be a managed process. As I said, it is not fully designed yet, but the complete shift is that it will be open to governors to say that they want to do something different, and potentially design that or do it in partnership with somebody else. That is not currently available to them.
Q393 Mr Hanson: You said that it is open to governors to do that. What does that mean in accountability terms for the governors? If some of them have decided to commission externally and some of them have not, it is back to that fragmentation point. Who judges what is happening to the individual prisoner ultimately?
Amy Rice: To the individual prisoner?
Mr Hanson: Yes.
Amy Rice: It depends. In terms of parole outcomes, it would be feedback from the Parole Board. There would need to be rigour behind anything like that. It is an expensive use of public money to wrap an intervention around an individual. In terms of accountability, the bit that we have not yet designed is how we add up the governor’s view of the evidence base, the cost of any such intervention and its effectiveness. At the minute, we have an evaluation process, which is very clear because it is centrally driven, and there would have to be something that was equivalent, but, as I said, it is not yet designed.
Q394 Victoria Prentis: This question is probably for Nathan, from what you said to Mr Chalk earlier. Do you think that providers have got their heads around providing different levels of services in different prisons? They may have to meet very different expectation levels in different prisons. Do you think that is something for which preparatory work has been done?
Nathan Dick: I don’t know if preparatory work has been done for it. Most of the organisations in the membership of Clinks—I imagine it is fairly similar for the Prisoner Learning Alliance—are smaller organisations that tend to work within an establishment or a couple of establishments in a local area. Those organisations are geared up to dealing with the difference of the one establishment that they work with. For other organisations, which might work across larger areas, we need to get better at specifying how the service should differ from place to place. We have all mentioned a few times the quality and availability of evidence and data. Taking those two things separately, the data are on who is in the prison, what the need is, what you are trying to address and how that is different from prisons A to B to C? Then there are other bits of evidence around interventions that might work better for women, men or young adults.
Q395 Victoria Prentis: Different prisons will have different focuses now. That is the thing we have to change for.
Nathan Dick: Yes. There is a question. We would normally advocate commissioning to a high standard specification based on evidence, and that you can do that locally as long as you have transparently available evidence and data backing up that you are doing it. The danger of fragmentation is if you do not have that evidence and you start to commission services on a more black-box approach: “You tell us what you think will be the best approach.” There is a risk that organisations could bid across a number of prisons but not understand the nuance of what they need to provide for individual client groups.
Q396 Victoria Prentis: I have one question, finally, for all of you. Do you think the localisation of provision will push up the cost of education services generally?
Nina Champion: Economies of scale have to be looked at in terms of provision, but the local link is absolutely vital in getting the outcomes that we need. There need to be good connections to learning that can happen through the gate, seeing it as a journey not just in custody but in transition into the community in keeping that learning going, whether it is formal or informal learning, and brokering that relationship and having local links is absolutely vital.
Q397 Victoria Prentis: Do you think it will be more expensive?
Nina Champion: There are ways around looking at economies of scale. Technology can be looked at in terms of providing some of the content to supplement and complement local teaching, and then have time in cells or on the wings to complement and practise skills as well as accessing high-level courses. Distance learning, which is something that we provide through the Prisoners’ Education Trust, is a low-cost way of delivering higher-level qualifications. There are various different ways and means. The new freedoms give the ability to look more creatively and to reduce waste. There is a lot of waste at the moment, in the sense that prisoners repeat the same courses in different prisons, or they do courses that are not relevant for them or they are not progressing. It is about using the budget better. The freedoms and flexibilities will enable less wastage and will be driven more on outcomes than on output measures. That is why these performance measures are absolutely vital to get right, and cannot be just reduced to numbers of qualifications.
Kate Green: Do you really believe that fragmented commissioning is going to be cost-effective, particularly for small providers? To what degree do you think there is a danger that what we will actually end up having is large-scale providers with a lot of subcontracting? What would be your view on that?
Q398 Mr Hanson: Can I back that up? Are you telling me that 36 or 37 contracts are going to be more cost-effective than one contract?
Amy Rice: There is a choice and a balance between cost and quality, as in all these things. I cannot answer the question as to whether a specific service would cost more, but there are options in the way you allow local commissioning. For example, I would not expect governors right across the country to do a full commissioning process for every service. They will want to put a focus on different things in different places. It is interesting to look across at the privately managed prisons, because they often use a central contract. It is quite possible that, if we do effective central contracting, governors can buy off the framework, therefore you maintain cost-effectiveness, but the tailoring of services is more bespoke locally.
Q399 Mr Hanson: When the Minister put forward the proposals to have reform governors given commissioning powers at local level, were any costings supplied to the Minister as to the options that might cost more or cost less at that time?
Amy Rice: I really don’t know.
Q400 Chair: Who would know? There must be some costings, surely.
Amy Rice: I guess the programme director would know.
Q401 Chair: You seem very vague, forgive me, Ms Rice.
Amy Rice: I am just not aware of that.
Q402 Chair: It has not been discussed.
Amy Rice: Not with me.
Q403 Mr Hanson: Chair, would it be possible for Amy to contact whoever it is in the MOJ to see whether advice was given to the Minister with regard to costings? It is not a negative or a positive. It might be a saving or it might be more expensive. I just want to get to the bottom of whether it was considered as part of the reform management programme.
Amy Rice: Absolutely. I will come back with that.
Q404 Chair: That would be very helpful. On a final point, you said that the accountability framework had not been designed yet, but it was being thought through. When are we likely to have that in place? When is it going to be designed?
Amy Rice: A draft is in progress at the minute, so we are aiming to have that in by April when the performance agreements go live.
Chair: That is very helpful. Thank you very much.
Q405 John Howell: I want to pick up a point that you mentioned earlier. It also relates to the issues you have just been questioned on. Surely, when you have more devolved contracting, you have the power to involve prisoners and staff in particular contracts. To what extent do you think that is really possible?
Nina Champion: It is very possible and absolutely vital in order to get it right. I would expect to see that at every level. What has happened in the past is that involvement of prisoners or consultation with prisoners can be quite tokenistic. What I would like to see, and what is happening in the reform prisons, is much more meaningful involvement in the different layers of process, bringing in different organisations, such as User Voice, to help to gather the views of prisoners and find out what their needs and aspirations are.
Q406 John Howell: Can you give an example of a successful contract that has involved prisoners in helping to change things?
Nina Champion: There are prisons councils that User Voice runs, for example, where they use prisoners themselves to look at various aspects of prison life. That is ongoing. It is not a one-off. It is over a long period of time. What has happened, unfortunately, particularly around education, is that, because the contracts lacked flexibility, the ideas and the needs that were being voiced by prisoners about things they felt would be useful to them were met with, “No, we can’t do that within the contracts.” The greater flexibility will give an opportunity to listen and take on board ideas and suggestions, and then put them into practice.
Nathan Dick: It needs to be built into the commissioning process. That is what we have lacked. Most of us who have worked in the criminal justice system for a long time would say that we have really not grasped the nettle of involving people in the system—staff, prisoners and their families, as well as people who have been through the system—and treating them as customers or John Lewis partners or something to that effect. We have not got them around the table at the pre-purchasing stage to say, “We are designing our specification. Have we gone out and spoken to people who have a vested interest in this from a family perspective or people who are having the service delivered to them? What are they telling us about what they want and need?”
At the more local level, you might be able to get that with a bit more nuance, with a bit more interest, but I don’t know if it can be done necessarily by prison staff. You might want an external organisation that has neutrality, that can bring out the key issues, so that it is done away from the power dynamic between the prison institution and the people or the families who are interacting with it. You absolutely can do it. You need to do it earlier in the commissioning process, so we have an opportunity within that to do something a bit more radical than we have done in the past, but you need also to design a process so that, once a service such as the prison council is up and running, you can do a bit of check and balancing, to see if it is working; maybe the prison has been re-roled and the people in it have changed, and the service that you bought two years ago is the wrong service and you want to change it again.
Nina Champion: This is a great opportunity for co-production, for involving staff, the voluntary sector and all the other partners together. We ran a pilot project with eight prisons, funded by NOMS, looking at the co-production approach. It involved taking prisoners and staff from all the different departments and giving them one problem: “How do you engage more prisoners in learning and providing some facilitation?” It was about getting their ideas and buy-in, and they came up with some fantastic initiatives. It is empowering them to come up with the ideas and then having the flexibility to take those ideas and turn them into practice.
Q407 John Howell: The prison reform programme is supposed to allow governors to bring innovation into the system. How much innovation can you see governors being able to bring in?
Nina Champion: We are certainly seeing that in the reform prisons. The example I mentioned of a former prisoner coming in to run some services is very new. You also have to look at what is currently working, and keeping what is currently working. There has been great progress, for example, with the Shannon Trust, on peer mentoring and other initiatives. It is ensuring that what is working is kept and built on, but, yes, being creative and incrementally creative.
Q408 John Howell: What does creativity mean in a prison context?
Nina Champion: One of the things I mentioned earlier was technology, which has to be one of the key ways in which we innovate to ensure that prisoners have access and engage. A prison teacher described herself as a naked teacher, because she said, “I don’t have any of the normal technology that you would use in an FE college, in a school or a university to engage learners.” We could use flipped classrooms, having classroom time and then using technology in the cell to build on that learning, to be able to do high-level courses. Potentially, there is a huge amount. Technology is definitely one area of creativity. Using former prisoners as delivering partners is another strong area for growth.
Nathan Dick: Commissioning does not often lead to innovation from our experience in the criminal justice system. You might want to look at a different funding mechanism. Grants might be an interesting way of encouraging innovation and testing things. In every area of public service everyone is always looking to innovate, and sometimes that can lead to us not testing rigorously already well-established ideas or trying them in different settings. We need to be careful when we push innovation that we are also pushing something alongside it around evidence. We need to be quite flexible on the sort of outcomes that we are willing to achieve if we want to enable innovation. If the assessment criteria for what a prison has to achieve are quite rigorous, it might design services that just lead it down the path of ticking the box—
Q409 John Howell: I am sorry to interrupt you. I take your point on that, but I cannot see how it relates to the performance agreements that will be negotiated with individual governors. Surely, that is not going to encourage them to go down an innovative route.
Nathan Dick: I think that is the point I was trying to make. To take, for instance, basic literacy and numeracy, if one of the key targets that people have to meet is to achieve basic numeracy and literacy, that might lead you down the path of just getting a basic numeracy and literacy programme that you think works, getting people to go through it and saying, “We have given people basic numeracy and basic literacy classes,” and that is how you achieve your target. We need to be very careful about what the drivers are for prisons, to help them to think more creatively about what sort of services they want. We are quite keen to see a bit more nuance around the targets that prisons are set, which might enable more innovation.
Nina Champion: Having a values-based measurement as well as output- based measurements will drive that. If you are trying to achieve a prison that has greater empowerment, greater aspiration or greater inclusion, that is going to enable you to be creative, because that is the outcome you are looking for. Those are the types of dimensions that we know work and are conducive to transformation.
Q410 John Howell: I have a last question to all three of you. If you are looking at the power of governors to commission, what are the top three principles that they should look out for?
Nina Champion: It needs to be based on individual need and a really strong set of data so that they know what is happening. If it is working, don’t fix it; build on it. Put the learner at the centre, not just in terms of seeing them as an end user but in shaping and influencing the decision in a really meaningful way, because they will have the best ideas, and they will be the most powerful advocates to others, if it works, to get the ripple effect.
Nathan Dick: I am loth to add to those, but I will anyway.
Chair: You don’t have to.
Nathan Dick: I would say this because I am from Clinks, but involving the voluntary sector has to be a key part of it. They are key providers. There should be a good partnership approach to whatever you do, and we should really understand the diversity of prisoners. The White Paper said lots of great things, but it did not say a lot about people with learning disabilities or difficulties. It did not say a lot about people from black, Asian and minority ethnic communities. It mentioned the launch of a women’s strategy. We have to understand diversity, and commissioning on that basis as well.
John Howell: Amy, I am conscious that I have not asked you.
Amy Rice: I would add to it rather than change. Fundamentally, it is keeping the outcome in mind, to keep a constant check on whether what you commissioned is delivering what you wanted from it. There is something about commissioning services in silos, so we need to maintain a holistic view of the whole system, whether a prison or whatever it is, to make sure that services are complementary and add value to each other. A slightly longer term one for me would be commissioning in context. There are a number of other commissioners dealing with prisoners post-release. There are opportunities to do different things by commissioning in partnership.
Q411 Victoria Prentis: We all know that there has been a big shake-up with NOMS, and HMPPS has to start tripping off the tongue. We understand that many national policies will now go and be replaced with different instructions, presumably, or locally based instructions. Have you been consulted on possible education changes?
Nina Champion: No, not at the Prisoner Learning Alliance formally.
Nathan Dick: No, not formally from Clinks.
Q412 Victoria Prentis: If you were consulted, what do you think we ought to keep from the education instructions?
Nina Champion: There are several things. I would look at things around individual learning plans, which should definitely be kept. Coates mentioned the data collected at assessment. There are things around being able to access high-level learning and distance learning, education across prisons when prisoners are transferred to different prisons. It is not just moving from one to the other. Support for learning disabilities is something that should be kept. There is a certain amount of consistency that needs to be applied across the board. Coates also recommends consistency with basic skills-type qualifications, so if a prisoner is transferred midway they can continue with those. There should be a certain level of consistency. Broader than that, it needs to be open to governors to interpret. Things around technology, in particular, need governors to take autonomy and look at their prisons.
Q413 Victoria Prentis: You would need something central for that. Nathan, what about you?
Nathan Dick: I agree with that. I do not know that I have a great deal to add. At the moment, we are at a stage where externally we are not entirely sure where things sit, so it is very difficult to comment, to say whether we think it is good or bad.
Q414 Victoria Prentis: Amy, I have a question for you. NOMS had a lot of commissioning experience. Has any thought been given to how that will not be lost?
Amy Rice: Yes. An exercise is under way at the minute to look at what happens with the staff from NOMS who were in commissioning. A number of them will move into the MOJ, so that expertise will be imported.
Q415 Victoria Prentis: Does that mean that there will be real change or do you think the commissioning body will effectively move from one place to the other?
Amy Rice: No. There will be real change, because we will redesign how we do commissioning from the MOJ. With commissioning sat in the MOJ, there is a slightly different relationship as well. There are probably better opportunities to look right across the piece. We should, if we get it right, get the best blend of people who are very used to commissioning in that world and have the skillset and experience, with the opportunities of a new design and, potentially, a new infrastructure.
Q416 Victoria Prentis: What role do you think the new HMPPS should have in monitoring the quality of services?
Nathan Dick: There has to be some level of contract management, whatever that looks like. There might be quite a lot of learning from what has happened through the transforming rehabilitation programme, how contracts were designed and how easy or difficult it was to contract-manage the performance of both the community rehabilitation companies and the National Probation Service.
Q417 Victoria Prentis: Is that something that is happening—learning from the transforming rehabilitation programme contract letting?
Amy Rice: Yes. Quite a lot of work is ongoing. Again, it is not my area.
Q418 Victoria Prentis: We know work is being done on that and that there have been quite a lot of difficulties with those contracts. Are you learning from the way that was done?
Amy Rice: Yes. There is a feedback loop into the rest of the organisation.
Nina Champion: It is important to think how this marries up with the role of the inspectorates, in terms of getting that kind of robust inspection of different elements. The new expectations framework that has been put out for consultation makes some progress in that area, and I would like to see it even more strengthened in terms of the teeth that it has, particularly around its purposeful activity elements. There is definitely a role for that to play.
An interesting approach that the probation inspectorate looks at is case-by-case analysis. When they were looking at transforming rehabilitation, they looked at 86 random case studies. They looked at those individual journeys from the perspective of the individual, and said, “Was this a sensible thing to happen? How was it progressed against your milestones?” What was shocking and very disappointing, to say the least, was that none of the 86 had had any support into education, training and employment. That is what it revealed, even though some had been engaged in education in prison and had been on a pathway, but that disconnect had happened. There needs to be very much a monitoring of the quality of what is going on in custody, and through the gate, and that brokerage—
Q419 Victoria Prentis: And you see that as a role for the centre.
Nina Champion: Yes. It needs to be about the journey for the individual. Looking at those cases was a really powerful way of indicating it; not just looking at learners, but looking at who has not been engaged in learning, why they have not been engaged and what efforts have been made to engage somebody, because that is how we are going to understand what the barriers are for somebody to engage, and how you get a really inclusive learning-centred learning culture in the prisons.
Nathan Dick: We recently did a big exercise in the voluntary sector with the inspectorate to talk about their expectations. We see them as absolutely central, as the independent body to help highlight where things are going well and where things can be improved.
Chair: That is very helpful. Are there any other questions from colleagues?
Q420 Philip Davies: I would like to ask a quick question about how prisons should be judged, how prison governors should be judged and what performance measures they should have. RAND Europe said that we should avoid governors cherry-picking offenders. Surely, we want governors to cherry-pick offenders, because it strikes me that some offenders are in a position where they want to turn their lives around and some are determined at that particular stage not to turn their lives around. Surely, we should be encouraging governors to cherry-pick offenders who want to turn their lives around and throw resources at them rather than spread them evenly on people who do not want to turn their lives around. What would you say to that?
Nina Champion: It is about distance travelled. You only have to look at what has happened in schools with value added—looking at where someone starts off and weighting that, and if someone is further away, giving weight to their progression. It is important that we look at how people are engaged and the processes, rather than looking at “How many times did you go back and try to change your provision to make it fit the needs of the individuals who were furthest away?” That might look different for different people. Nathan said that someone who has mental health problems, drug addiction problems or other problems might look different. It might be about informal learning. It is about progress on their individual measures.
Under education, the White Paper talks about that: “In future we will improve how we measure education and training by developing measures that assess a prisoner’s progress against milestones on their individual learning plan.” That is in the future. In the meantime, they are looking at numbers of qualifications. I really worry that unless we get that right at the beginning, so that it has to be about how an individual moves from wherever their starting point was, they will try to cherry-pick. If people are moving from wherever they are in a positive direction, that has to be rewarded, and you can only do that if you look at how progress was made individually.
Nathan Dick: From our members in the voluntary sector, a lot of organisations are set up to help people who are in very difficult situations with quite multiple and complex needs. One of the concerns about contracting and setting easy targets is that you park a lot of people who have dire needs and are in dire situations but you decide not to do anything with them because you may have even a small proportion of the prison population for whom you think you can reduce the amount of input but you will nevertheless get a good result. There is quite a lot of evidence that people who are going to do well, will do well and they need minimal contact to do well in those systems, as long as the services are good. But there is a real danger that, if we do not work with people who have multiple and complex needs, they will be the people coming in and out of prison, costing the Prison Service a lot of money. They are going to be in and out of A&E costing the NHS a lot of money, and they are going to create more victims in our communities when they get released because they do not have the right level of support. There is an argument to go both ways.
Q421 Philip Davies: I am not talking about people who have complex needs. I am talking about people who want to turn their lives around and people who do not want to turn their lives around. There is a complete difference. There might be somebody who wants to turn their life around who has complex needs that need dealing with, whereas there might be somebody who does not want to turn their life around who does not have the same complex needs. There are not unlimited resources and there has to be a limit placed somewhere, so surely we should be focusing resources on people who are in a position where they want to turn their lives around, rather than wasting them on people who could not care less.
Nina Champion: But we need to help people get to that point. It is only by having hope, inspiration and having services and a culture in which that naturally happens, and learning is taking place everywhere in the prison. It is not a matter of, “Why aren’t you coming to us?” but, “What are we doing to go to you?”
Q422 Philip Davies: This is all airy-fairy stuff, isn’t it? At the end of the day we are trying to measure the success or otherwise of what the governors are doing. Your premise is, basically, for governors to have a get-out-of-jail card and say, “Yes, of course, nothing has really changed, but I have taken someone from being a million miles away from turning their life around and he is now only half a million miles away. It is an absolute triumph and isn’t it wonderful?” Surely, we need some proper measures. The only real measure should be whether people released from prison reoffend or not. All these things that you are suggesting, we are always told, will reduce reoffending. Surely, the only measure that is worth while is, when people leave prison, did they reoffend or did they not reoffend? If they carried on reoffending, it doesn’t matter how much airy-fairy stuff you did—it failed, didn’t it? Surely, the only measure at the end of the day for the governor should be, “How many people, when they leave prison, reoffend?”
Amy Rice: The only real measure of success in the system, I would argue, is that. That is what we are set up to do, to stop people reoffending. The difficulty, if you put it at a prison level, is that prisons in the round have a different function in different parts of the estate. If you solely measured the reoffending of people in a prison, governors would start from a very different place and, therefore, their personal performance and the performance of the prison could not be fairly measured by that single metric, which is why we have to have a suite of measures that fit the prison. What is important in the design of those measures is what they drive.
In terms of cherry-picking, absolutely, you want to focus resources where you are going to get some success, but you do not want to incentivise people to put money into somebody who is going to succeed anyway and then be profligate with the rest of the money. That is taking it to an extreme, but that would be a disgraceful use of public money. I cannot imagine that anybody would set out to do that but you could incentivise bad behaviour. What you want is to try to get a balance, I would argue, between focusing on people who are change-ready, and giving them a push and helping them, and a whole load of other people who, quite frankly, could become more dangerous if we did not spend some of the resources on them. As Nina says, we have to move them towards that. For some people, that will take several times, but, for me, we owe it to the public to make sure that we move people towards that goal. On a purely prison-by-prison basis, because it is a function of the prison, it would not be a fair measure for governors personally.
Nathan Dick: There is some really good research looking into desistance theory, which has been changing a lot of our thinking around how people themselves, as you say, make that conscious decision and how we can drive people to owning their own rehabilitation and resettlement and taking some agency in that, and designing the right kind of support around an individual to get them to take some of that responsibility. There are some good services designed around the principle of helping people to the point where they want to make the change themselves, and then identifying other people who want to make that change and giving them the right level of support to move forward. Those are aspects of working with people to get them to that point, and for others, giving them the right services to move on, not come back to prison and not reoffend. There are lots of other intermediate measures around reoffending that are really important for us to capture and tell us how well or badly we are doing as a society or as a public service in helping individuals.
Chair: I understand the point, but we are pushed for time. I think, as a conclusion, ultimately, all the other interventions are a means to the end of preventing reoffending, aren’t they? I think that was the point Mr Davies was making. I do not think there is any dispute about that. Thank you very much for your time and evidence. It is very much appreciated. We will move on to our second panel.
Examination of witnesses
Witnesses: Kate Davies, Dr Rachael Pickering and Dr Eamonn O’Moore.
Q423 Chair: Thank you very much for your patience and for coming to help us with your evidence. Without more ado, I will ask each of you to introduce yourself and your organisation. Then we will move straight into the questions.
Kate Davies: I am Kate Davies, a director in NHS England. I have responsibility for health and justice, the armed forces and sexual assault referral centres.
Dr O’Moore: I am Dr Eamonn O’Moore, the national lead for health and justice with Public Health England, and director of the UK Collaborating Centre for the World Health Organisation health in prisons programme.
Dr Pickering: I am Dr Rachael Pickering, the chair of the British Medical Association’s forensic medicine committee. I am a GP with experience of working for the police and most types of prisons, including the high-secure estate. I also direct a small NGO that looks at torture and ill treatment, and delivers humanitarian healthcare in prisons in less developed countries.
Q424 Chair: Thank you. It is pretty clear, from the conversations you heard earlier, that everybody recognises that there are real challenges around both physical health and mental health with many of the inmates in the prison system, and delivering the services they need to deal with that. As a starting point, looking at where we are now and then the reforms, what would you say are the main issues faced in delivering health and mental health provision in the system at the moment? Do you think that the reforms are going to help to address those, and how?
Kate Davies: Certainly. We have been working very hard with our partners in NHS England, in the MOJ, the Department of Health, NOMS and now HMPPS on the prison reforms and the White Paper. One of the things about the prison reform is that it is a great opportunity to heighten how healthcare and the provision of healthcare, both physical and mental healthcare and health and wellbeing, is absolutely key, not only for the vulnerability and health inequalities but also for rehabilitation and the reduction of offending behaviour. To answer your question, yes, healthcare is important, particularly understanding the needs assessment of different individuals and of an establishment, because there are very many different prisons. What those prisons need as part of a good healthcare service is absolutely crucial.
Q425 Chair: Are those needs adequately understood at the moment?
Kate Davies: What is important for the inquiry and in the information today, following the questions to the other panel, is that NHS England has been the commissioner of healthcare within our detained and secure estate since the beginning of NHS England. Prior to that there was legislative change. That is the bit that is really important. When patients are going through the criminal justice system, sometimes they are there for many years, but the majority are only there for months. That is the position we are in, so we take the opportunity both pre and post custody to access healthcare but also to continue with the healthcare package.
Chair: I understand that. Dr O’Moore.
Dr O'Moore: I would start from the premise that people who come into prison have often experienced significant levels of need prior to incarceration, and often experience lack of access to services appropriate to their need. In prison, NHS England has been transforming the way services are commissioned and provided. That includes a rigorous assessment of need at or near reception, and then delivering services according to that need. That is at individual level and at prison level through a formal process of health needs assessment. They have also been very supportive and proactive with a broad range of agencies in thinking about what happens after incarceration. As Kate said, the vast majority of people in prison spend the least amount of their life in prison and the most amount of their life in the community, so we have to think about a whole-system approach.
Where the White Paper gets us in helping some of that thinking is putting at the heart of reform a whole-prison approach. That means exactly what it says. We have to think about every element of the way the regime is delivered, as well as the way healthcare is delivered in order to understand and meet needs across the broadest range of those needs. That will help with some of the challenges. It is important to start from the point that people coming into prison are multiply challenged; they have complex needs and it will require a complex response to those needs if we are to get them to where we hope to take them.
Dr Pickering: Speaking as a jobbing prison GP, there are seven or eight issues affecting healthcare in prisons. Would it help if I just whip through them?
Chair: Yes.
Dr Pickering: The first is lack of funding for many things, but especially clinical hours. A colleague of mine, who is the lead GP for a large cluster of prisons, had his GP provision slashed almost in half with very little notice, despite the powers that be operating above him being warned that it would have fairly catastrophic consequences.
Q426 Victoria Prentis: I am sorry to interrupt, but how does that compare with the position outside prison?
Dr Pickering: I am not a community GP, so I cannot speak as a community GP partner. The decision to employ so many salaried doctors or an extra partner is down to each individual GP practice, but you would not get a practice manager in a GP practice telling the senior partner, “You’ve got to sack half your doctors in a couple of months’ time.” That is a big problem, as is lack of funding and availability of locums.
The second thing is clinical time. As Eamonn said, prisoners often come in with a lot of need. They are not only less likely to engage before they come to prison in preventive healthcare measures—not smoking, doing screening and so on—but they are also more likely to adhere to health-damaging practices while they are in prison. They often have mental health problems that makes for personality traits, and makes consulting very challenging. Therefore, you need quite a lot of appointment time compared with, say, visiting your GP, in order to get to grips with the same problem. Often we are expected to do things on a very tight timescale, and there is often no consideration given to the amount of clinical administration time and other service development time that a doctor running a unit needs.
The third thing is equivalence of care—the principle that prisoners should receive the same scope and standard of clinical care as you would in your community healthcare. If the Government are serious about promoting equivalence of care for prisoners, we need to take significant action because, on the ground, clinicians report that daily they have to triage and re-triage patients, deciding who gets to go out to a hospital today, because we have, say, seven patients who need to go out, but we do not have enough prison staff. Therefore, we need to decide whether a two-week skin cancer referral is more urgent than, say, a patient who is having severe angina and needs their treadmill test. That has resulted in lots of complications and daily stress for doctors. It is also a problem that prisoners who, say, cut up or have a fit because they have taken too much synthetic cannabis—spice—would then trump that escort from prison-to-hospital slot because they have suddenly got a medical emergency. That disrupts continuity of care for people.
The fourth thing is mental health. It is said that about 90% of prisoners have at least one of the five main psychiatric problems. We often find that the sheer weight of psychiatric morbidity impacts everything you do day-to-day as a prison doctor or nurse.
Chair: You will have to speed up a little, I am afraid, because we are pressed for time and the House sits at 11.30.
Dr Pickering: Sure. Substance abuse and violence are intrinsically linked. I have been assaulted several times as a prison GP. Substance abuse goes hand in hand with violence. The ageing population is a huge challenge, and it often gets neglected when we are looking at whether we need to increase sessions. The last thing I want to say on this question is about morale. It is very difficult to have recruitment and retention of good quality clinical staff—I would say, the best-quality staff—when morale is at rock bottom.
Q427 Alex Chalk: Perhaps the key to all of this is to what extent the governor reforms change any of that. Does it make any difference if you do not have enough staff or you do not have enough resources when making those tough decisions? Is this shuffling deck chairs on the Titanic? Will it make any difference?
Dr Pickering: It may make things better. In principle, the BMA certainly supports the idea of giving governors more commissioning power.
Q428 Alex Chalk: Why does it make any difference?
Dr Pickering: It could make things a lot better. For example, I was talking about the day-to-day struggle to get enough prisoners out to hospital. If a governor said, “I am looking at the need in my prison. I am going to commission more inreach,” where the hospital comes into the prison, that would make a direct difference, or, as has happened in some of the prisons I have worked in, “I am going to recruit X number of specific healthcare officers whose job it is to take people to hospital. How many do you need, doctor/nurse?” That would be good. On the other hand, it could make things a lot worse if you get a governor who is not responsive and just adds extra layers of bureaucracy but does not listen to the front-line staff in his or her particular prison.
Chair: That is about the governor’s skills.
Q429 Alex Chalk: Yes. Kate, if I may call you Kate, in your initial biog you said that your national role is to assure quality, consistent and sustained services across the country. Is this a recipe for consistency or inconsistency?
Kate Davies: The importance of NHS England’s role in this is consistency, because what we want is what we want for our own sons or daughters, whether they are in prison or out of prison—the same level of quality of national standards of clinical governance and care. That consistency must be there as part of all the healthcare services we commission and provide, and in how we listen and learn from our patients and our service users in and out of prisons.
There is an opportunity around quality. You asked whether this was going to happen and whether it is a good opportunity. Many thanks to Dr Pickering and to the many people who work very hard in prisons as providers of our services at the moment, because prison is a very difficult place to work in. In many of our prisons it is very difficult to see the patient group at a consistent level, at availability. That might be to do with staff shortages or different regimes. The prison reforms and the reconfiguration of the prison and the estate absolutely will put a spotlight on how healthcare, which was mentioned by the previous panel, can be at the core of any good prison. That element needs to be consistent, but at the same time it needs to ensure that we look at the flexibility of the needs of the prison and the patient group. That is the difference.
Q430 Chair: You would agree with that, would you, Dr O’Moore?
Dr O'Moore: Yes. To answer your question about how reform will make a difference, I mentioned the whole-prisoner approach, and we have done work in PHE, looking at the way that the commissioning of health services by NHS England has had an impact on public health outcomes, which reported a concern that, in the past, governors would have been closer to health issues. There was criticism that they had become quite distant from understanding them.
Dr Pickering made a point about the impact of things such as how many people you have to escort urgent cases out to A&E or whatever. These are things that have bubbled up over the last few years, particularly in the last few months, as important issues. We believe that there is now a better place for us to talk together as partners in delivering high-quality healthcare to people in prison, because the issues around how the regime, staffing and custodial staffing impact on the delivery of high-quality healthcare are now front and centre of those discussions. It has created a new space for those conversations to happen. It will take time, it is reasonable to say, because those issues are not going to be fixed tomorrow, but I think everyone agrees that the direction of travel is the right one. Taking account of the total regime—custodial staffing and healthcare staffing—as part of the whole system of delivery of healthcare, is inherent in the new approach, which is to be welcomed.
Q431 Mr Hanson: The reforms are scheduled to take place from April 2017. I want to get a sense of where you think all those governors are, given that they are going to be co-commissioning, and what level of skills and upgrades they will need to make sure they are up to speed on how to deal with the new landscape.
Kate Davies: We have local teams for all our health and justice commissioners. NHS England is working with every individual prison and every individual governor at the moment to look at the co-commissioning framework. We have been doing that for many years, but you are quite right: it is about saying what is different and new. There is an awful lot of change in the system at the moment, whether that is consideration of the reconfiguration of a prison or prison disturbances. We have been working, and will continue to work, with every single governor in every prison, and with the provider, the commissioner and the client group, to see how we can support current services—what is good, what needs changing and what needs developing—and what the opportunities are in the future. On that point, it is important to examine what we need to change. One of the things that has been crucial is looking at safety and patient safety within prisons with individual governors, and what the different individual risks are within their establishments and prisons, whether that is about suicides, self-harm and deaths in custody, which is one of our biggest concerns; it is also about a whole-prison approach, as Eamonn outlined.
Q432 Mr Hanson: Are governors ready for April 2017?
Kate Davies: One of the things we are doing at the moment with our partners and Public Health England is a new co-commissioning framework from 1 April. We are looking at a number of prisons at the moment as pathfinders to see how ready they are and whether, under a number of criteria, they are now in a position to have more influence to support the needs of their prisons. We are getting mixed findings. Many prisons are engaging and supporting change and innovation, and that includes quite a lot of estate changes as well, but in some prisons we still have to risk-manage some of the needs and some of the healthcare provision in those establishments. It is important as a partnership that before 1 April we have a clear position—we are doing that currently—on where the risks lie and where the changes need to occur.
Q433 Mr Hanson: I know you are NHS England, but the biggest prison in the system is going to be in Wales very shortly.
Kate Davies: Yes, HMP Berwyn.
Q434 Mr Hanson: We also have Cardiff, Swansea and Parc in Bridgend. What is your assessment, if you can give one, of what is happening in Wales?
Kate Davies: I will let Eamonn answer that. There are a number of feeder prisons in England that will ensure that men are coming into HMP Berwyn from next Monday. We are aware that two thirds of the inmates are likely to be from England. Travel between English prisons and Welsh prisons is key. We have been working for a number of years with our colleagues in HMP Berwyn, sharing good practice, looking at models of care and looking at the commissioning framework. An important lesson to learn is to have a more flexible, open-flowing system, I hope, within HMP Berwyn, and movement within that prison will be key to observe.
Dr O'Moore: I sit on the HMP Berwyn shadow partnership board, and have been supporting some work with colleagues from Public Health Wales and health partners as well as NOMS and commissioners from the Prison Service, thinking through the challenges and questions. My understanding is that Berwyn is ready to receive prisoners from early next month, and that that is being delivered in a way that assures people that the services are capable of receiving them. There is a challenge around dentistry currently, I understand, which people are looking at. Some resolution is required, but it is an interesting way of putting a spotlight on some of the ways that services in the community affect the services available to people in prison and vice versa. One of the contingencies that we are looking at is the provision of dental services from the community to the prison population, but those services are also challenged, so it shines a light on that.
Berwyn will be one of the largest new prisons in Europe. It will have some very innovative ways to approach everything from healthcare to the delivery of the regime. That is my understanding. The specific challenge that we as partners in England face is the care pathway from England to Wales, which has a devolved health system, and then from Wales back to England. These are the active challenges that we are thinking and talking about together with our partners to ensure that people do not simply fall between two stools.
Q435 Mr Hanson: My general question is linked to what Mr Chalk was asking earlier. With all these balls being shaken up, we are not quite sure where the governors are yet. The co-commissioning is new, but how is this going to impact upon the healthcare providers, and are they ready for the changes? How do the local trusts and boards in different parts of the country deal with this? Ultimately, will it lead to even more private sector involvement in prison health? I do not know. I am just asking.
Kate Davies: We have a very mixed economy of healthcare providers across England. That includes mental health trusts, collaboration with smaller GP practices and primary care, and independent and private sector and third sector providers as well. That has been the case in prisons for healthcare for many decades. What is important, whoever those providers are, is that we have the quality and number of clinicians and a range of providers. It is a very difficult time for providers at the moment. There is a lot of change. One of the important things is continuity of staff, and ensuring that our healthcare providers can have continuity with their patients as well. While we are delivering under a partnership agreement with the MOJ and with the new HMPPS, what is important for us as part of healthcare and our providers is supporting continuity of care and provision. Too much change will have a negative impact. It is important that we carefully manage that as part of the co-commissioning and the White Paper reforms.
Q436 Mr Hanson: Do you expect at the end of this process that a greater proportion of healthcare services to prisons will be provided by the voluntary and private sectors than now?
Kate Davies: I do not. We will continue as the commissioner of healthcare to support a commissioning and procurement process that looks more at a local governance arrangement. One of the new co-commissioning agreement requirements is looking at local governance and supporting it, and ensuring that you get providers and commissioners that have continuity of care with the community, with the new cluster approach. I am hopeful that, as well as the independent and private sector, which will remain—I am absolutely sure of that—we will also have the opportunity to increase local NHS and third sector providers in the prison system.
Q437 Chair: Dr Pickering, what is your thought?
Dr Pickering: I am speaking as somebody who works at the coalface. If you want to make continuity of care and continuity of staff staying on when a provider changes, two things are important. First, there needs to be, on the ground, clinical representation in the local governance arrangements to which governors are held accountable. An example is the senior nurse on the shop floor and the senior GP on the shop floor being invited to feed into the governor and say, “It looks right on paper, but it’s not working. What are you going to do about it, Mr Governor or Mrs Governor?”
The second thing we need is to ensure that governors really understand what they are co-commissioning. I changed from one high-secure prison to another a few years ago, and the governor there was very good, but shortly after that he left. A new gentleman came and in his very first week he said, “How is your job working for you? What can I do to make it better?” He was not working under the co-commissioning agreement, because it had not come in yet, but he was very humble, approachable and energetic. He even asked if he could come and see me in my room. I suggest that you say to governors, “How about going and shadowing some of these staff?”—obviously if the patients give consent. They need to see what it is like, in the same way as MPs are invited into community GP practices to see the stress and strain for community healthcare staff. I am sure any of my colleagues in prisons would welcome the opportunity to give governors that chance.
Chair: Mr. Howell has to get away, and I will bring in Ms Green after that.
Q438 John Howell: I want to ask about the role of governors in the commissioning of healthcare services. The governors are going to be involved in all stages of the commissioning process, but the governors are not medical experts. How will their involvement occur and how will that improve the needs assessments?
Kate Davies: The point about governors not being medical experts is why the Government and the Department made the decision that NHS England will continue to be the healthcare commissioner, in order to support clinical standards. However, as Dr Pickering said, what is really important as part of the needs assessment in looking at how healthcare services are working and what is needed as part of the changes—there will be a lot of changes coming forward as part of the White Paper—is that we work together with the governor and with the broader management structure in different prisons, and we sit down, plan and support what that means. In the same way as the healthcare providers are there to provide good quality standards of primary care, secondary care, mental health services, dental and sexual health, it is also important that we know how that will work best in different prisons. I was recently in HMP Durham, which is a really good example where providers, the governor and commissioners all sit down to look, plan and support what that means as part of the provision, but also—
Q439 John Howell: I am sorry to interrupt you. What happens if there is a disagreement between the governor and the commissioner?
Kate Davies: Those happen. There are sometimes differences of opinion. What is important is that we establish a governance process where we can iron them out, to put it bluntly. That always has been achieved. I have been a commissioner within a prison setting, and what needs to be done is understanding what the differences are. In the high-secure estate at the moment, there are quite a lot of pressures. There may be some good ideas coming from the governor, and some of the resistance—I use that word advisedly—may be from the commissioners of the providers not knowing whether they can give an extra service or a change in regime.
As part of the new co-commissioning framework, we are making quite sure that we can have those changes as well, so that we do not do what we have always done, and we can make sure that the changes happen. I hope that will ensure that when there are disagreements or changes we can work through them. Of course, if there are ultimate disagreements, that is where our partners in HMPPS and the MOJ, the Department of Health or even the clinical bodies come in. We would certainly use the RCGP and the BMA, and the forensic faculty is very supportive in additional negotiation or on tricky issues.
Dr O'Moore: The way of working that Kate outlined, and our experience based on many years of partnership work with governors, does not start on 1 April. It is a continuum of many years of effective work. We have NHS England, NOMS currently and PHE in national partnership agreements. We have had several iterations of that. We are redrafting the new national partnership agreement for the next period. It also describes a formal governance structure—a way of working together that is binding on all levels of the organisation nationally, regionally and locally. It has an associated prison healthcare board for England. The ways of working, therefore, are clearly understood. Often when disputes arise, it is because people are coming from different perspectives. Sometimes it is about understanding; I completely support Dr Pickering’s point that sometimes the best way to understand is to experience the level of service.
Many governors are very proactive in that. I had the pleasure of sitting in a room full of governors managing the women’s estate, who were thinking collectively with health partners about how to address issues of mental health, including self-harm and suicide. In that room, I met very energised, innovative and collaborative partners, who had a very good understanding of the health approaches, but who brought something in addition, which was really helpful. That is the model we work to and will continue to develop together.
Dr Pickering: If I could just add quickly—I realise we are pressed for time —that from an on-the-ground clinician’s point of view, performance measures need to be concrete and absolute. A colleague arguing with a clinical manager said, “Patients are not getting off the wings to our appointments. Our DNA”—do not attend—“is through the roof. We cannot tell whether it is because they do not want to come or because the discipline staff are not letting them off the wing.” The answer they got back was, “Oh no, DNAs are going down.” No, they are not. Clearly, that is not our experience. When you are told a fact by management, because the performance indicators say that, it is very hard to argue with. We would like clinically transparent and realistic performance measures. Perhaps the staff who deliver the healthcare, rather than just the commissioners and the governors, could be involved at local level in saying, “What’s the most important measurement in this particular prison?” never mind nationally or in a particular prison. That would be very helpful.
Q440 Kate Green: To what degree do you think that the changes to commissioning and the co-commissioning with governors will enable improvements in the continuation of healthcare on release? Can they also look at pre-incarceration, so that all the knowledge about a prisoner’s healthcare and health condition is fully utilised immediately on admission? I have constituency cases where that clearly is not happening. I am interested to know if the new arrangements will make any difference and, if so, whether it will be for the better.
Kate Davies: That is a key question. One of the things that NHS England has been doing, as part of commissioning under the health and justice requirement, is the new liaison and diversion service, which is absolutely crucial to supporting and identifying early intervention at both the police custody and court stage, and often, we hope, earlier upstream as well. Looking at sentencing, one of the things that is part of the justice reforms is alternatives to custody, which I support, such as the models of healthcare in community sentences for men and women as part of their journey through the criminal justice system.
Considerable work has been done on through the gate, on how we link up services way before someone is released. We clearly say, as healthcare providers, that they should be planning for someone’s release on their entry to an establishment, not the day, the week or even the month before they leave. One of our biggest challenges is getting continuity of care with services in the community. Sometimes establishments cover a vast range geographically in a community area. I was in HMP Woodhill the other day, and that prison covers a large area of the midlands. Women’s prisons, in particular, cover an even bigger range geographically.
We have done a lot of work with service users, which has been absolutely key for us, on getting this right, because it is not as good as we would like it to be. Part of our work and part of our lived experience is how to ensure we get continuity. Peer support seems to be a great opportunity with the prison reform agenda. One of the things that has been very effective is commissioning a peer-support model through the gate, but also as part of the interventions at court and in custody. That is something we would like to see more of.
Q441 Kate Green: Are the incentives that would be needed to encourage that behaviour being built into the new model?
Kate Davies: The NHS does not have any incentives, payments or otherwise.
Q442 Kate Green: I did not mean that so much as the new governor appraisal and governor performance incentives.
Kate Davies: The league tables are part of looking, for the first time, at how healthcare will be part of continuity in the whole-person approach. We welcome that. We have had to push it quite hard. That is important. I welcome employment and education as part of the core of the White Paper reforms. In this panel today, I welcome the questions on health, because that element in how you support the two-way improvement of healthcare provision and reduction of reoffending is important for governors and for the criminal justice system as a whole.
Dr O'Moore: Supporting people with continuity of care requires a number of approaches. First and foremost is an understanding by the patient of how to use the health service. That may seem an obvious thing to say, but we know that many people who come into prison are either not registered with GPs or, if they are, they have not seen them in a decade. Literally, we have to educate people about entitlement to care, and support people with GP registration while they are in prison, and enable that when they leave prison and measure it in a meaningful way.
Secondly, we have to enable the infrastructure to support that. NHS England has been extremely foresighted in commissioning a new health and justice information service, which will enable continuity of care between prison and community-based health services. We are working with them to think about how we could use the opportunities of the new system, using a unique identifier, like an NHS number, to monitor over time the engagement that people have with services post release.
Thirdly, we need to remember that the partners around the table include community-based partners like local government. As commissioners of drug and alcohol services, sexual health services, and commissioners and providers of a range of other services that our population require, they are a key part of the agenda. Working with health and wellbeing boards, making sure that joint strategic needs assessments take account of people coming from prison and take account of offender journeys back into communities is really important.
There are a number of approaches. Kate mentioned peer support in enabling them to happen. If you do not do all of those, you will probably not succeed, but doing them in concert will enable them to happen better. We certainly have huge challenges, but we also have a road map of where we might get to, and we have the infrastructure commissioned by NHS England through the information services, and a way of working that is enabling partners to come together around a shared problem. We are speaking with the Local Government Association in a few weeks’ time, thinking about the challenges of working across the local public health system and the local system in continuity of care. There is lots of work in the system on that.
Dr Pickering: From my point of view, it is very important that we start to think a little more laterally, and that governors start to think more laterally about blurring the boundaries between prison, the detained estate, and communities. We have an ageing prison population and they are becoming less risky, but not no risk. Increasingly, healthcare staff use up a lot of time caring for them, when they do not need to be in prison. We should be encouraging governors to look at models in other countries where they have an ageing population, such as America. We should be looking at ways of housing these, mainly, gentlemen, but not entirely, in community secure settings. That is really hard to do. My colleague spent ages looking for a nursing home that would take a prisoner who had been given a release on temporary licence for healthcare reasons. Finding somewhere to take him was nigh on impossible and he was dying, so he was not able to harm anyone. We need to look in the community for new types of establishments, and I encourage governors and NOMS to take that search seriously.
Dr O'Moore: They are. We are working collaboratively on that shared problem.
Chair: That is helpful.
Q443 Victoria Prentis: I know we are here to talk about commissioning, but while we have you, could you tell us, very quickly, how much spice is affecting healthcare in prisons? I mean both the thing you mentioned, Dr Pickering, which is having to transfer people who have had a bad reaction to spice as an emergency to hospital, and the mental health issues that are coming back from hospital.
Dr Pickering: I am happy to speak to that. It is a major problem because it is not just spice but prescribed drugs, such as pregabalin, which is the current “Please give me a prescription for this, doctor” drug of choice, and a range of tradeable illicit drugs. It is not so much people coming back from hospital—we can cope with that—but the underlying temper of the prisoners affected by it. The amount of violence between prisoners, the clashing of doctor-patient, patient-nurse, that kind of dynamic, is huge on the ground. You cannot overemphasise how much illicit drugs are causing problems in prisons.
Kate Davies: Illicit drug use has been a factor in offending behaviour for many years and decades. I have sat around similar tables and committees talking about what that meant for heroin and crack cocaine use 20 years ago. I welcome the fact that we are having that conversation around NPS. What is important about NPS is that it is the changing face of drug use within the prison. We need to modify, change and support our drug and alcohol services, which are part of the healthcare commissioning requirement, as part of their response to NPS and the misuse of prescribed and other medications.
We are doing a lot of work with our clinicians and our clinical management at NHS England to look at guidance for prescribers around pregabalin and other drugs that are used and misused. They may be overprescribed in the community as well, with all that means for our clinicians when they have an onslaught of different demands, needs and requirements. We commissioned User Voice just over two years ago to do a piece of work in over 10 prisons with service users—currently serving and who had left prison—to say, “What does it feel like? What is the reality? How is that affecting your rehabilitation, your regime and your motivation?” That was stark. I am pleased to say that it had some impact in highlighting the needs within prisons. We are currently under a formal review of our substance misuse service specification across all detained and secure establishments, including the through-the-gate element of that, to support and modify that going forward. Our clinicians, our service users and our providers are telling us that the impact of NPS is key to that piece of work at the moment.
Dr O'Moore: Public Health England is going to publish next week a statement of concern about novel psychoactive substances that we have worked on collaboratively with partners from across the United Kingdom and the Republic of Ireland. We have also been working closely with NHS England and NOMS colleagues in delivering training to people at the frontline to support them in the management of this problem. There is no doubt, however, that it is a very impactful problem, and we all recognise that. It is adding to an already stressed situation in a most unhelpful way.
Dr Pickering: I do not think there is enough on-the-ground training for prison healthcare professionals to deal with it. It is not filtering through yet.
Chair: That is very useful. Mr Davies, do you have any questions?
Philip Davies: No.
Q444 Kate Green: I have one quick question. What is your view of the Government’s proposal for testing for drug misuse on entry and on release? Is it the right approach?
Kate Davies: One of the things that we are doing with the Government’s proposals is looking at the supply element—the supply demand—and the reduction in the element of demand because of the input. There is an issue about the amount of substance misuse that can enter an establishment. I am not quite sure whether testing on entry is necessarily going to support all elements of the needs and concerns, but what is important, regardless of that process in the Government’s policy, is that all our healthcare services will be working with all our patients to support what their current drug use is without or without testing.
Dr O'Moore: As a doctor, I would say that the value of the test is not only in doing it but in understanding what it tells you, and the meaning and the context in which it is delivered. There is value in testing, but how one interprets the meaning will depend on a number of variables, I am sure.
Dr Pickering: Personally, I do not think it is a good move. I do not think it is going to show very much, other than a lot of statistics. It is more important to designate more funding for clinical time for clinicians to get in and work with patients.
Q445 Chair: It is what you do with the test afterwards—that sort of thing.
Dr Pickering: Yes.
Dr O'Moore: Although people acquiring drug habits in prison is an interest.
Q446 Chair: That is an area that gives rise to some concern, doesn’t it?
Dr Pickering: It is a statistical input and a research interest. I do not think it really helps individual prisoners.
Q447 Chair: Is it a problem—people acquiring drug habits?
Dr Pickering: It is massive.
Dr O'Moore: We certainly have evidence that people will acquire different behaviours and different experiences of substance use during their incarceration. It is a concern, and this may at least shine a light on some of those aspects, but I totally understand and agree with the point that clinical services are required, and treating people according to defined clinical care pathways is what is really needed.
Kate Davies: Part of that is positive use of time. When you are in a prison, whether for weeks, months or years, the last thing you want is to be bored and locked up. Whether that motivation is about a reduction in your offending behaviour, the bit that is really important about prisons is that positive use of time will not only create a safer environment but will give less opportunity to get involved with elements like current drug use.
Chair: Purposeful activity.
Dr Pickering: I agree with that. Drugs are a massive thing. In most of the drug consultations I have, when you really challenge the patient and say, “Look, I know why you want pregabalin,” they say, “Yeah, doc, but you don’t understand how boring and long my day is.” If I was in their shoes, I might be tempted to ask for the same.
Q448 Chair: Is that your experience, too, Dr O’Moore?
Dr O'Moore: Yes. If you wanted to have one thing that you would measure in a prison estate to demonstrate a healthy system—health in the broadest concept of what we mean by that—time out of cell and purposeful activity might be the single most important measure. If you define what that means, if you measure it in a way that is meaningful, and people understand that it is about education, training, employment and so on, we believe it is analogous to some of the metrics on improvement wellbeing in mental health in the community, such as social engagement, employment, training and so on. It may be the most important thing that we need to focus on over the next few years.
Chair: That is extremely helpful. Thank you all very much for your evidence. It has been very useful to us. Thank you for your time and trouble in coming.