Written evidence from the National Women’s Prisons Health and Social Care Review
The National Women’s Prisons Health and Social Care Review (Women’s Review) is a partnership between NHS England and NHS Improvement (NHSE/I), and Her Majesty’s Prison and Probation Service (HMPPS) and has been jointly commissioned by them. The Women’s Review began in January 2021 and will report in March 2022.
The purpose of the Women’s Review is to improve health and social care outcomes for women in prison and upon their release, to reduce inequalities and ensure equity of access to the full range of health and social care services for all women across the Women’s Estate.
Membership of the Women’s Review comprises senior representatives from across health, justice, and social care, third sector organisations and women with lived experience. Through their own organisations, many members of the Women’s Review will be responding to this important inquiry (including HMPPS and NHSE/I). At this stage of the Women’s Review, we are unable to provide a comprehensive, evidence-based response to questions posed by this inquiry. We have, however, commented where we are able – our primary focus being health and social care for women in custody. Comments made do not provide a single view from the membership of the Women’s Review or definitive conclusions.
We look forward to the report from the Justice Committee’s Inquiry into Women in Prison and feel certain that the Women’s Review will both learn and benefit from it.
About the Women’s Review
The Women’s Review is taking a Key Lines of Enquiry standardised approach across the 12 women’s prisons. Where relevant, it will draw on existing work to avoid duplication of effort. Gender and trauma informed responses to women’s needs will be a common thread throughout the Women’s Review, as will the involvement of women with lived experience. Priority areas for the Women’s Review include:
A literature review and commissioned research to hear from women in prison will further inform our work.
Findings from the Women’s Review, and recommendations made, will inform NHSE/I as commissioners of prison healthcare for women, local authorities as commissioners of social care, and HMPPS as enabling commissioners for the Women’s Estate, and help to develop a shared understanding of what actions are needed to improve outcomes for women in prison and upon their release.
The Women’s Review Group reports into NHSE/I and HMPPS; specifically, the Specialist Commissioning/Health and Justice Delivery group, which is the national leadership forum for NHSE/I, and the HMPPS Board and National Safer Custody Group.
The Independent Chair of the Women’s Review is Jenny Talbot OBE; she was appointed in January 2021.
For further information about the Women’s Review and this submission, contact the programme manager, email@example.com
Submitted: Monday, 7 June 2021
Reducing the number of women in custody
We would highlight the importance and potential of the Community Sentence Treatment Requirement (CSTR) in reducing the number of women in custody. CSTRs seek to reduce reoffending by providing effective, treatment-based alternatives to short custodial sentences (women mainly serve short sentences of less than 12 months). CSTRs include a Mental Health Treatment Requirement (MHTR), an Alcohol Treatment Requirement (ATR) and a Drug Rehabilitation Requirement (DRR), and treatment orders may be combined. In 2017, to encourage take-up, a CSTR programme was developed and tested in five areas. Over an 18-month period, the number of MHTRs across the five areas increased from 55 to 456. The Luton and Bedfordshire CSTR began operating in 2018, providing an alternative to custody for around 80 people, most of them women, and has seen some notable examples of mothers and carers receiving treatment for undiagnosed mental health conditions through the CSTR. During the pandemic CSTR programmes continued to operate, providing much needed treatment and support for offenders in the community.
A three-year national independent evaluation is being undertaken by the Institute for Public Safety, Crime and Justice at the University of Northampton. This multi-site evaluation began in August 2020, with new sites coming on board, and six-monthly reporting to participating sites. A policy paper based on the first round of analysis will be published towards the end of summer 2021, which will showcase the health benefits of completing the mental health intervention. Preliminary analysis shows statistically significant reductions in global distress, anxiety and depression between the start and end of the mental health intervention as part of the Treatment Requirement.
What more can be done?
Do community sentences currently offer a credible alternative to custody? (If no, why not?)
Yes, especially where women can access support via a Women’s Centre. As part of their sentence, many women can access the care, treatment and support they need, often for the first time and for undiagnosed conditions, and are incentivised to comply. They are further obliged to accept some form of routine and order into their lives, which is helpful in orienting them to rehabilitation. Liaison and diversion services are uniquely placed to make referrals to Women’s Centres at an early stage and to identify when a CSTR might be appropriate.
Community sentences allow for women who are care givers to continue to support their families, which in turn has a less detrimental effect on the family, especially children who can be vulnerable when their mother is in prison. For example, they are twice as likely as their peers to have poor mental health and are more at risk of poverty, poor health, and insecure housing and finances. Parental imprisonment can treble the risk of antisocial behaviour in children, with the cost to the state of imprisoning mothers for non-violent offences estimated at more than £17million over ten years, primarily due to the increased likelihood of their children not being in education, employment, or training.
What more could be done?
See response to 1a: nationwide roll out of the CSTR programme should be expedited; see response to 1b: Women’s Centres should be routinely available and properly funded. This would help prevent women’s initial contact with the criminal justice system, promote greater use of and confidence in community sentences, and support for women on release from prison.
Women in Custody
The National Women’s Prisons Health and Social Care Review (Women’s Review) was established to improve health and social care outcomes for women in prison and upon their release, to reduce inequalities and ensure equity of access to the full range of health and social care services for all women across the Women’s Estate.
The review and analysis of Health Needs Assessments (HNAs) undertaken by the Women’s Review will consider the intersection between women and protected characteristics; specifically, it will seek to address the range of health and social care needs of women of all ages in a way that is sensitive to the unique characteristics of individual women, their prior experiences, and aspirations for the future.
Main findings and recommendations from the Women’s Review will be reported in March 2022.
An early observation by some members of the Women’s Review is that improvements in custody are frequently made at the local prison level, often in response to immediate risk or other situations that demand an immediate response.
6. Does the female prison estate take a Whole System Approach (that considers all of the offenders’ needs) to those in their care? What does this look like in practice? Are there any barriers in achieving a Whole System Approach to female offending?
Health and custodial services are interdependent and cannot achieve their respective and shared objectives in isolation.
In March 2018, Public Health England (PHE) published Gender Specific Standards to Improve health and Wellbeing for Women in Prison in England. Implementation of these evidence-based standards is a shared objective for HMPPS, NHS England and PHE to improve the quality of health services, reduce health inequalities and improve the health and wellbeing of women in prison. The overarching principles reflect the need for a whole prison approach to promoting and improving the health and well-being of women in prison. The standards recognise that women in prison face distinct challenges and have complex needs. They set out evidence-based good practice in addressing the health and wellbeing needs of women in prison and complement existing national and international health standards and guidance, such as HMIP Expectations and relevant Prison Service Orders/Prison Service Instructions. Women’s prisons have been assessed by PHE to establish a baseline assessment against which future progress can be judged, and to identify key areas to prioritise for improvement as well as areas of good practice. Recommendations were made regarding areas that require multi-agency work and coordination with external agencies. Embedding the Gender Specific Standards to Improve health and Wellbeing for Women in Prison in England into prison systems needs to be a priority for all organisations working with women in prison.
Capturing progress to date and assessing and reviewing progress against the relevant PHE Standards for Women’s Prisons/national service specifications is a focus of the Women’s Review, following which main findings will be reported and recommendations made.
7. How are women supported to maintain family ties in prison? What progress has been made on improving family ties since the Farmer Review? What effect has Covid-19 had on maintaining family ties for women in custody? What support is available for mothers to maintain contact with dependent children?
If a woman is pregnant and likely to have her baby in prison, or has recently given birth to a baby, they may apply for a place in a Mother and Baby Unit (MBU); there are six such units across the Women’s Estate. The low number and geographic location of MBUs mean that most new mothers and pregnant women are imprisoned at a significant distance from their family and support networks, at a time when they need them most.
Women as parents and carers of children is being considered by the Women’s Review; main findings will be reported and recommendations made.
8. What factors contribute to the high levels of self-harm in the female estate?
High numbers of women in prison have complex histories of trauma, which are often left undiagnosed and untreated. Self-harm is a highly complex issue, which occurs for a range of different reasons. Some self-harm is strongly associated with specific conditions, and some is a coping behaviour for people who have experienced trauma. Some self-harm is behaviour that has been adopted by women for many years and therefore the response within a prison needs to be comprehensive and long term and, when women leave prison, join up with services in the community so that progress made is sustained (leaving prison can itself be distressing, despite being a cessation of the challenges of being in prison). A range of responses to reducing self-harm is needed. For example, the living and working environment of prison is distressing for most women – one response to self-harm should be to focus on making the prison environment less traumatic and listening more to what women have to say; adequate screening/assessment and information sharing to identify women in need of support; and the commissioning and provision of Dialectic Behavioural Therapy and other forms of talking therapies.
Self-harm trends differ considerably by gender. The number of incidents in male establishments decreased by 16% from 51,691 in the 12 months to December 2019 to 43,554 in the 12 months to December 2020. The number of incidents in the Women’s Estate increased 0.5% from 11,931 in the previous 12 months to 11,988.
In the Women’s Estate there are number of women who self-harm multiple times. The number of incidents per individual who self-harmed in female establishments was more than twice that in male establishments and increased in the latest year. In the 12 months to December 2020, there were 9.9 incidents of self-harm per self-harming female compared with 9.3 the previous 12 months, while for males it decreased to 4.1 incidents per self-harming individual from 4.4 the previous 12 months.
Self-harm and other mental health needs can be linked back to previous adverse childhood events and so it is important women are able to access services which address the root cause of self-harm. Linked to this is the need for a trauma informed environment for women in prison, which is supportive and caring.
Women mainly serve short sentences of less than 12 months and can be held over 100 miles from home, which means that providing continuity of care on entry into prison and on release can be challenging. Further, it can be hard for women on short sentences to effectively engage with and benefit from available health and social care services, and for services to develop the most appropriate package of care. Short prison sentences fracture relationships with local services – for example, the most recent HNA for HMP Styal noted that some women ‘lost’ their Community Psychiatric Nurse, which can lead to referral procedures needing to be reinstated, repeated screenings and the need for a full mental health assessment. Short prison sentences disrupt lives – they are too short for any benefit to be gained but long enough for women to lose their home, their job and potentially, their children.
Short prison sentences are damaging for women and should cease in favour of community penalties and support to address health and social care needs. Liaison and diversion services identify women’s needs at an early stage in the justice process (police custody). Greater investment in Women’s Centres and women’s pathways would help ensure timely access to women specific care, treatment and support, and a reduction in reoffending.
The use of prison for a woman’s ‘own protection’ or as a ‘place of safety’ should cease. Prisons are ill-equipped for women in need of such levels of care and protection, and the environment unsuitable.
Despite numerous initiatives and investment to address self-harm, there is no evidence of a reduction in incidents across the Women’s Estate.
What is being done to address the high levels of self-harm in the female estate?
9. Does the custodial estate offer a trauma-informed environment for females? (a trauma informed environment, being that which is about putting experience, behaviours and needs first, and creating a safer, healing environment that aims to reduce and prevent trauma and retraumatising an individual).
A trauma-informed environment as part of a custodial estate is a contradiction in terms. The most we can aim for is an environment that does not traumatise women or exacerbate existing trauma.
The prison estate is the legacy of 200 years of prison expansion to meet the demand for places. Facilities and conditions within and between the Men’s and Women’s Estate vary. Whilst there are purpose-built prisons for women, such as HMP & YOI Bronzefield, women are, in the main, living in prisons built for men. Women are living in Victorian prisons and prisons repurposed from military bases; many are old, poorly designed, and often overcrowded. The geographical location of a prison and the amount of space, equipment, and technology each impact on access to and the type and range of health and social care services that can be delivered. For some women, being in prison may provide greater opportunity to access services they were unable to access in the community; however, the prison regime, staffing levels and security concerns can reduce women’s ability to access prison health and social care services. The culture and environment of prison is also important, with outcomes often dependent on how well health, social care and well-being are promoted and delivered, and the relationships between front-line health and justice personnel.
Members of the Women’s Review attended a workshop that considered the building design requirements for new accommodation for women as part of the prison capacity expansion programme. This provided the opportunity to highlight the need to consider women specific, trauma-informed accommodation for a population with a high prevalence of neurodiverse traits.
Could more be done? If so, what?
Yes. Reduce the number of women in prison, invest in the fabric of prison buildings, match health and social care provision to the needs of individual women, and empower women in prison to take control of their own lives, within the confines of prison and on release.
10. What support is available to ensure that women are successfully resettled into the community upon release and reduce reoffending?
Reconnect services, which are being commissioned from 2021 onwards, are important in supporting women on their release from prison to identify and to engage with health and social care services in the community. For example, at HMP Peterborough, NHS England has commissioned a service operated by peer support workers (people with lived experience), to work with women in the three months leading to their release. During this period women are encouraged to identify the services that would help them when they return to the community and provided with information and contact details so they can more readily access the care they need on release. Access to mental health care, substance misuse services and other services are recognised as important in improving health outcomes and reducing re offending.
Are there any barriers to effective resettlement, and reduced reoffending?
The Women’s Estate constitutes 12 prisons throughout England. This means that women are generally held long distances from home, which can make it hard to maintain contact with family members, especially children, and significant others. The ability for women to maintain relationships, supported through prison visits plays a powerful role in supporting women’s rehabilitation.
Homelessness is one of many factors that continues to negatively impacts women’s health and wellbeing and is strongly correlated with poor outcomes on release from prison. Nearly six in ten women leave prison homeless, while data analysed to inform the 2020 HNA for HMP & YOI Foston Hall indicated that 43% of women were homeless during the year prior to imprisonment.
Women who have experienced domestic abuse often return to the same situation. There is a lack of support for women who wish to relocate after their release from prison. A home that is decent, safe, and stable is vital for women on release from prison to support continuity of care, prevent a return to poor health and reduce reoffending.
Resettlement pathways will be considered by the Women’s Review; main findings will be reported and recommendations made.
11.What support does the female adult estate offer to girls transitioning from the youth custodial estate?
This will be considered by the Women’s Review; main findings will be reported and recommendations made.
In addition to questions posed by this Inquiry, we would make the following comments:
 Including social care.
 Community Sentence Treatment Requirements Protocol – Process Evaluation Summary Report, DHSC, 2019:12
 For more information, see:
Supporting CSTR Programme Development and Practice — University of Northampton's Research Explorer Callender_Matthew_Lugli_Valentina_ONPFCC_2019_Client_Perspectives_of_the_CSTR_Pilot_in_Northamptonshire.pdf
 Murray, J., Farrington, D. P., Sekol, I., and Olsen, R. F. (2009) Effects of parental imprisonment on child antisocial behaviour and mental health: a systematic review. The Campbell Collaboration, University of Cambridge
Smith, R., Grimshaw, R., Romeo, R., Knapp, M. (2007) Poverty and disadvantage among prisoners’
families. London: Joseph Rowntree Foundation
 New Economics Foundation (2008) Unlocking value: How we all benefit from investing in alternatives to prison for women offenders London: New Economics Foundation
 HMPPS (2021) Use of Prison as a “Place of Safety” and Outcomes for People in Local Prisons in England and Wales. A study by Gabrielle Lee OBE BSc. (Ms Lee is a member of the First night and early days in custody Task and Finish group for the Women’s Review.)