PRH0049
WRITTEN EVIDENCE FROM THE DISABILITIES TRUST
HEALTH AND SOCIAL CARE COMMITTEE INQUIRY INTO PRISON HEALTHCARE
The Disabilities Trust is a national charity and care provider for people with autism, physical disability and, through its Brain Injury Rehabilitation Trust, acquired brain injury. It also runs pilot schemes through its Foundation (innovation) arm to address unmet need and this includes specialist support for prisoners with a brain injury.
The Trust’s evidence is focused on the extent to which prisons and prison healthcare services effectively identify, treat and manage the health and social care needs of prisoners with brain injury.
- EXECUTIVE SUMMARY
1.1 Brain injury can be caused by an injury to the head through a traumatic event such as an accident, assault or fall, or by an illness such as encephalitis, haemorrhage, stroke or tumour. Repeated blows to the head or sustained misuse of alcohol or drugs can also result in brain injury.
1.2 Brain injury can significantly increase the risk of anti-social behaviour leading to law-breaking and incarceration. Research shows the prevalence of brain injury in prisoners may be as high as 60%[1] and due to the effects of these injuries on memory, cognition and behaviour, traditional means to reduce rates of recidivism may therefore be ineffective.
1.3 In response, the Trust has developed a specialist brain injury Linkworker service. This identifies prisoners with these injuries, trains prison staff, provides bespoke one-to-one support where appropriate to enable the prisoner to manage his/her deficits and ‘’links’ the person to the required services (eg GP, mental health, drugs and alcohol) both within the prison and on discharge.
1.4 Our free clinically validated tool, the 11-question Brain Injury Screening Index (BISI®), enables prison and healthcare staff to quickly and easily identify offenders with a history of brain injury either on admission (via the healthcare assessment process) or during their sentence. We recommend the use of the BISI or equivalent in all prison settings.
1.5 Our highly praised brain injury Linkworker scheme and associated prison staff training programme support the individual with brain injury and aim to reduce reoffending rates. Prisoners should be supported by staff appropriately trained in understanding and managing the behaviour of prisoners with brain injury. We recommend tailored support for prisoners with brain injury and a training programme for all staff in prison, probation and young offender settings, including appropriate healthcare staff. This screening and training should be accounted for in the relevant service level agreements/contracts between the MoJ/HMPPS and the NHS/private providers for the delivery of prison healthcare services.
1.6 Appropriate intervention has been shown to achieve positive outcomes and long-term cost savings to society. The long-term costs associated with brain injury in a young offender are at £345,000 more than double that of a non-offender[2]. In our experience specialist brain injury rehabilitation in a healthcare rather than custodial setting can save in excess of £80,000 per individual in the short-term[3]. We believe the effective identification and management of Traumatic Brain Injury to be a vital area requiring dedicated attention as part of the prison healthcare programme.
- LINK TO OFFENDING/VIOLENT OFFENDING
2.1 Research evidence demonstrates that 51 to 60% of adult male prisoners (and 50% of young prisoners) have a history of Traumatic Brain Injury (TBI)[4]. Our own research has found that 47% of adult male prisoners screened on admission to prison reported a history of TBI[5].
2.2 It should also be noted that in the same Trust study, of those with TBI, 70% reported their first TBI happened before their first offence and 60% reported having committed a violent offence, compared with 38% in the control group.
2.3 More widely, TBI is the leading cause of death and disability in people under the age of forty, and costs the UK economy around £15 billion a year. A&E departments in the UK see about 900,000 head injury presentations a year, including around 100,000 classified as severe, and it is estimated that there are up to 1.3 million people in the UK living with a TBI-related disability[6].
- IMPACT OF BRAIN INJURY ON INDIVIDUALS AND OFFENDING
3.1 Brain injury can result in impaired cognitive function and cause difficulties with impulsivity, aggression, poor judgement, problem solving, concentration, short- and long-term memory and understanding consequences. Traditional programmes to reduce rates of recidivism may therefore be ineffective with this population.
3.2 Though brain injury should not be considered a mental health issue, it can be a contributing factor to poor mental health. Our research has found that prisoners with a history of TBI are 3.4 times more likely to suffer from depression and anxiety than those without a history of TBI[7].
- ENABLING ENGAGEMENT WITH REHABILITATION
4.1 Prisoners with brain injury should be considered a vulnerable group, similar to those with mental health issues or learning disabilities, and staff and agencies working with the prisoner should be notified of their history of TBI. With tailored support from a Linkworker or brain injury trained staff, simple strategies such as memory prompts or anger management techniques can be taught and a network of support from probation, social care, health and education professionals put in place pre- and post-release.
- THE BRAIN INJURY SCREENING INDEX (BISI®)
5.1 There is no standard or statutory screening for brain injury at the point of entering the adult prison system in England and Wales, although the Comprehensive Healthcare Assessment Tool (CHAT) in young offender settings contains brain injury screening elements.
5.2 The Disabilities Trust has developed the Brain Injury Screening Index (BISI®), an 11-question screening tool to help identify people with a brain injury within prison, probation, community and rehabilitation settings. The BISI was developed for use by all levels of practitioner and is available free of charge through our website[8].
- OUR PRISON LINKWORKER PROJECTS
6.1 Comprehensive findings from our early Linkworker projects are available on our website[9], as well as an independent evaluation of the project with young prisoners aged 15-21[10]. The Linkworker service and associated training for prison staff has been successfully delivered within HMP Leeds, HMYOI Wetherby and HMYOI Hindley. A further Trust Linkworker service pilot has been completed and the results are currently being analysed, and we have also completed delivery of a similar service in a female prison in the Midlands which is undergoing external evaluation by Royal Holloway, University of London. The Linkworker service has also worked effectively in the community with homeless people and with offenders 4-8 weeks post-release, and (in Wales) directly with probation services.
6.2 In addition to the charitably funded pilots mentioned above, the Ministry of Justice has commissioned further Linkworker pilots from the Trust. The 12-month contract runs until later in 2018 and has enabled delivery of a Linkworker service across five prisons, two YOIs and one Probation Service, located at three sites across the UK. Prisons in South Wales, North East and Southern England all benefit from the service, which will also provide training for prison staff as well as clinical and healthcare teams.
6.4 As part of the admission process and healthcare assessment in the pilot schemes, prisoners who are identified as having a history of TBI are referred by prison staff to the Linkworker. The service is designed to sit within existing structures and to enhance, not duplicate, services already in place. There are wide-ranging benefits for both the prison and the individual in adopting a Linkworker or similar scheme tailored to the custodial setting.
6.5 Benefits for the prison and staff can include a prisoner population with fewer behavioural incidents and increased engagement in structured day-to-day activities, leading to increased wellbeing; staff trained in understanding brain injury, resulting in greater confidence to effectively manage the prisoners they support; increased job satisfaction and staff retention through the acquisition of new skills and knowledge.
6.6 Benefits for the individual can include an awareness (possibly for the first time) that they have sustained a brain injury; an understanding of the effect this may have had on their cognition, behaviour and emotions and introduction of coping strategies; establishment of links to health, social care, employment and housing professionals on release to promote increased access to these services when appropriate; maximisation of their chance of successful rehabilitation, and reduction of the chances of reoffending.
6.7 The Trust has also provided highly specialist and intensive brain injury training to forensic psychologists as well as providing a specialist service for high risk prisoners in Closed Supervision Centres which have a brain injury.
6.8 Whilst overall the Trust has built very close and positive working relationships with prison healthcare teams, the Trust has experienced problems in two settings where the healthcare provider refused to give the Linkworker access to the healthcare records system (SystemOne) because this fell outside the scope of their contract with the prison. Additional paper records and detailed risk assessments therefore have to be undertaken by the Trust to mitigate the situation, but this is a significant issue in terms of timely, accurate records and best practice. Brain injury screening and training should be accounted for in relevant service level agreements/contracts between the MoJ/HMPPS and the NHS/private providers for the delivery of prison healthcare services.
- COST SAVINGS ASSOCIATED WITH APPROPRIATE REHABILITATION
7.1 There are savings to be made in relation to tackling brain injury and offending. The Linkworker’s intervention and recommendations presented to court meant that Byron (see above case study under para 6.5) was diverted away from more time in custody. A prison sentence could have cost up to £209,000, over £80,000 more expensive than the route taken by Byron, and nearly £90,000 more expensive than an initial referral to rehabilitation at the point of the brain injury[11]. These calculations do not take into account the human and personal costs of an offence being committed. Full costings are available in the Appendix. A short video interview with Byron is available on our website[12] and his story has been featured on BBC Radio 4’s ‘You and Yours’ programme[13].
7.2 The Centre for Mental Health has estimated long-term costs of TBI for an injury incurred at age 15. In the general population, this is estimated at around £155,000, compared to £345,000 per case among young offenders[14].
- CONCLUSIONS
8.1 Introducing screening as part of the standard healthcare assessment process on admission to prison to identify the high numbers of adult prisoners with brain injury should be a priority. We recommend the use of the BISI in all adult prison settings.
8.2 Prisoners should be supported by staff appropriately trained in understanding and managing the behaviour of prisoners with brain injury. The Disabilities Trust has a proven record of providing brain injury training to prison staff and delivering Linkworker support in prisons and young offender settings. We recommend tailored support for prisoners with brain injury and a training programme for all prison and young offender settings staff.
8.3 Brain injury screening and training should form part of and/or be accounted for in the relevant service level agreements/contracts between the MoJ/HMPPS and the NHS/private providers for the delivery of prison healthcare services.
8.4 The Disabilities Trust can provide further evidence based on our experiences and research. We believe the effective identification and management of Traumatic Brain Injury to be a vital area requiring dedicated attention as part of the prison healthcare programme.
July 2018