Introduction
The recent considerable increase in the number of older prisoners across many developed countries including the United States fo America (USA) (American Civil Liberties Union 2012), Japan (Ministry of Justice 2004), Canada (Uzoaba Reference Uzoaba1998), Australia (Grant Reference Grant1999), France (Gautier Reference Gautier2011) and England and Wales (Ministry of Justice 2013) has been well reported. The most significant increase has taken place in the USA where there were 246,600 prisoners aged 50 and over in 2010 (American Civil Liberties Union 2012). It is estimated that by 2030 one-third of all prisoners in the USA will be over 50, equating to a 4,400 per cent increase from 1980 (American Civil Liberties Union 2012). There has also been a sizeable increase in the number of older prisoners in England and Wales. At the end of 2012 there were 9,880 prisoners aged 50 and over in England and Wales; this figure incorporates 3,377 prisoners aged 60 and over and equates to 12 per cent of the total prison population. It also includes a small but important group of 413 older women (Ministry of Justice 2013). Those aged 50 and over are the fastest growing age group in the English and Welsh prison estate (Ministry of Justice 2013). This increase is fundamentally a consequence of an ageing population, enhanced forensic scientific evidence leading to increased convictions for historic offences and changes to sentencing practices (Ginn Reference Ginn2012).
It is widely reported that prisoners and ex-prisoners experience considerably worse levels of health and wellbeing than the general population in relation to suicide risk, mental illness, substance misuse and physical mobility (Dyer and Biddle Reference Dyer and Biddle2013; Fazel and Baillargeon Reference Fazel and Baillargeon2011). Similarly, older prisoners present with the highest rates of many disorders in comparison to the overall prison population (Fazel and Baillargeon Reference Fazel and Baillargeon2011) and have more complex health needs than their aged-matched counterparts in the community, with approximately 85 per cent of older prisoners having one or more major illnesses (Fazel et al. Reference Fazel, Hope, O'Donnell and Jacoby2001). The most common disorders experienced include cardiovascular disease (35%), arthritis and/or back problems (41%), respiratory disease (15%), endocrine disorders (21%) and sensory deficits (12%) (Loeb and AbuDagga Reference Loeb and AbuDagga2006). Furthermore, it is estimated that over half of older prisoners have a psychiatric illness, with depression being the most frequently diagnosed, but often untreated, mental health condition amongst older prisoners (Fazel et al. Reference Fazel, Hope, O'Donnell, Piper and Jacoby2001). Older prisoners also have increased social care needs, partly as a result of their complex health issues. These include mobility difficulties exacerbated by the physical environment of prisons (Snyder et al. Reference Snyder, Van Wormer, Chadha and Jaggers2009), incontinence (Williams Reference Williams2012) and difficulties with activities of daily living (Hayes et al. Reference Hayes, Burns, Turnbull and Shaw2012). Such health and social care needs often remain unmet (Ginn Reference Ginn2012; Her Majesty's Chief Inspector of Prisons (HMCIP) 2008).
The immediate post-release period poses particular risks for all prisoners, in terms of physical and mental health, and community tenure. Forty-two per cent of released prisoners are of no fixed abode, 50 per cent have no general practitioner (GP), 50 per cent reoffend within two years, a third experience debt problems that are worsened by custody and 60 per cent are unemployed (Williamson Reference Williamson2006). Similarly, recently released prisoners are also at a greater risk of suicide (Pratt et al. Reference Pratt, Appleby, Piper, Webb and Shaw2010) and drug overdose (Farrell and Marsden Reference Farrell and Marsden2008) than the general population, meaning that maintaining contact with care services on release from prison is vital (Binswanger et al. Reference Binswanger, Nowels, Corsi, Long, Booth, Kutner and Steiner2011; Lennox et al. Reference Lennox, Senior, King, Hassan, Clayton, Thornicroft and Shaw2012). Nacro, a charity that aims to reduce crime, recommends that the resettlement needs of every offender should be considered from the start of their prison sentence (Nacro 2005) and the UK Government has stipulated that the reduction of barriers to resettlement is a key priority (Ministry of Justice 2011). However, current discharge planning processes and a lack of effective multi-agency working have been cited as inhibiting the effective resettlement of prisoners into the community (Binswanger et al. Reference Binswanger, Nowels, Corsi, Long, Booth, Kutner and Steiner2011; Dyer and Biddle Reference Dyer and Biddle2013).
In 2011, 4,530 prisoners aged 50 and over were discharged from determinate sentences in England and Wales (National Offender Management Service, personal communication). HMCIP's review of older prisoner care identified grave concerns that older prisoners’ needs were not planned nor adequately provided for after release (HMCIP 2008). At that time, HMCIP only identified four prisons in England and Wales providing specific resettlement support for older prisoners, leading to them repeating the recommendation from their previous review of older prisoners (Her Majesty's Inspectorate of Prisons 2004) that the specific resettlement needs of older prisoners should be accurately assessed and provided for on release. The Department of Health's (2007) guidance entitled A Pathway to Care for Older Offenders. A Toolkit for Good Practice provided similar recommendations around preparing older prisoners for release and supporting them in their transition into the community. The Department of Health stipulated that release planning for older prisoners should involve the conduct of a pre-release health and welfare assessment, a face-to-face assessment by a social worker, collaboration with external organisations and the organisation of a care package (Department of Health 2007). The guidance further emphasised the importance of monitoring the progress of released prisoners to ensure they have access to the appropriate services (Department of Health 2007).
A limited number of studies have directly explored older prisoners’ concerns and issues about release prior to their discharge from prison (Crawley Reference Crawley2004; Crawley and Sparks Reference Crawley and Sparks2006; Davies Reference Davies2012). Findings suggest that older prisoners experience particular concerns due to reduced support networks and increased likelihood of suffering from health and mobility problems (Davies Reference Davies2012). Crawley (Reference Crawley2004), and Crawley and Sparks (Reference Crawley and Sparks2006), found that older prisoners experienced intense anxieties about release and inadequately understood the resettlement process. Key issues included where they were going to live and how they were going to get there, their physical safety on release (for those convicted of sexual offences in particular), loss of personal possessions and support networks, and access to health care for support with chronic illness. Concerns prior to discharge were so intense that many of them felt it would be better to stay in prison. Furthermore, research indicates that those aged 50 years and above show the greatest elevation in risk of suicide in comparison to younger ex-prisoners in the 12 months after release (Pratt et al. 2010). In spite of these increased needs, older prisoners’ resettlement requirements are often ignored, perhaps because they are generally considered less of a risk (Davies Reference Davies2012) and are less assertive than their younger peers (Crawley Reference Crawley2004). No research has been published to date that has followed up older prisoners after release to establish whether their pre-release fears about the resettlement process became reality. The current study aimed to address this gap in knowledge by exploring the health and social care needs of older male adults discharged from prison into the community, including their perspectives before and after release.
Method
Design
The National Research Ethics Service Committee West Midlands, Staffordshire reviewed and approved the project (09/H120347). Participants aged 60 and over were identified through each prison sites’ named research contact, via the prison computer system. Semi-structured qualitative interviews were carried out with prisoners in custody who had approximately four weeks left to serve, with follow-up interviews taking place in the community approximately four weeks after release. With consent, prisoners’ contact details (including those of family members, probation workers and any other appropriate professionals) were obtained to allow them to be contacted in the community; it was essential to obtain as many contact options as possible because participants were often unaware of where they would be living after release.
Setting and participants
A variety of prison types were included in the study to provide insight into the different approaches and experiences in prisons holding those who had served short, medium and long sentences. Interviews were conducted in six local prisons, where participants had served short sentences. and two training prisons and one open prison, where people were at the end of a longer period in custody. The individual prisons were selected for pragmatic reasons, due to their close proximity to the research base. During the data collection process, it became apparent that we were reaching data saturation for participants being released to probation-approved premises. We therefore ceased data collection for this group and attempted to recruit participants on short-term sentences who would not be going to such accommodation.
Sixty-two prisoners were interviewed in prison and 45 were followed up on release (73%). Interviews took place between May 2011 and June 2012. Six prisoners declined to participate in prison (10%), reportedly due to a desire not to be associated with prison after their release. The majority had a Probation Worker in the community, who was contacted upon release to assist with arranging the follow-up interview. Follow-up interviews took place in probation offices, probation-approved premises, over the telephone and one was conducted at the interviewee's home, due to their mobility difficulties. Two researchers attended this interview for safety reasons. Interview duration ranged from ten minutes to one and a half hours. The interviews were audio recorded and transcribed verbatim. The initial interview guide focused on prisoners’ preparation for release in terms of their health and social care needs; the perceived appropriateness of discharge accommodation; and their awareness of services that may be required for their continuing care. The follow-up interview covered how well release plans were put into action and what services prisoners subsequently accessed. During participants’ second interviews they were also asked about the key issues that they had expressed concern about during their initial interviews. Prisoners were also invited to discuss the contacts they had had with health and social services and any health and social care problems or suicidal thoughts they had experienced since discharge.
Analysis
The constant comparison method of data analysis was adopted (Glaser Reference Glaser1965). The method is based within the grounded theory approach (Glaser Reference Glaser1965) and aims to ensure that theory stays rooted in the data (Boeije Reference Boeije2002). Constant comparison methods involve both the fragmenting and subsequent connecting of data. Sections of data are coded and separated from their original transcript. There are four stages involved in the constant comparison method. The first stage involved identifying provisional themes and comparing incidents that applied to the themes. During the second stage, comparisons between interviews were made. The third stage included integrating concepts into themes. Overlapping or undefined concepts were re-examined until final versions emerged. Stage four involved clarifying ideas.
NVivo (version 8; QSR International 2008) was used to analyse data. One researcher conducted the analysis and another took the role of ‘peer debriefer’. Discussions were held between the researcher conducting the analysis and the peer debriefer regarding matters of methodology and analytical procedures. This provided an opportunity to test emerging themes and increases the credibility of the findings (Leech and Onwuegbuzie Reference Leech and Onwuegbuzie2011). Interview transcripts were linked in order to be able to identify participants’ initial and follow-up interview and track changes in perceptions.
Findings
Demographic information
Participants with a broad range of ages were included (mean=61.1; range=60–87). A higher number of participants were released to probation-approved premises (N=34, 55%) than other types of accommodation (N=27, 44%). Additionally, the follow-up rate was higher for participants discharged to probation-approved premises (82%) than those released to other forms of address (63%).
Three key themes emerged from the data relating to older prisoners’ health and social care needs on discharge from prison, namely release planning processes, communication and discontinuity of care.
Release planning processes
Older prisoners considered that planning for their release was fundamentally non-existent. This was summarised by one participant prior to their release who stated that ‘Nothing has been planned for my release, end of’ (Prisoner, participant 19). Another participant further described the experience of being released from prison without being appropriately prepared in advance, ‘It's a very, very strange feeling when you came out they just threw you out … gates open and that were it’ (Ex-prisoner, participant 9).
Only one of the nine prisons involved in the study reportedly offered pre-release courses to prisoners. However, prisoners at this establishment were frequently not aware of the course's existence and those who did attend felt it was not adequately tailored to meet older prisoners’ needs. For example, the course focused on employment and many of the older prisoners interviewed had reached retirement age and did not want, or feel able, to work, as one participant explained, ‘I mean, like getting jobs and what have you, that, that [part of the pre-release course] wasn't for me’ (Prisoner, participant 16).
Participants also felt unable to plan their release adequately themselves, due to restrictions placed on telephone use or limited ways of accessing community information. Participants discussed the practical challenges of making plans for release whilst incarcerated, namely the limited number of approved telephone numbers they could call, the lack of access to addresses for community services to allow them to write letters and their inability to attend appointments with services such as housing organisations.
The processes for managing health-care needs on release were discussed in detail. Medication on release was generally considered to be appropriately provided, as one participant explained, ‘They make sure you've got enough meds [medication] to come out with’ (Ex-prisoner, participant 27).
In the main, prisoners were seen a few days prior to their release and provided with a supply of medication (assuming this was deemed safe to be held ‘in possession’). However, prisoners were often only informed about this process by their peers, rather than through any formal channels, and consequently a number of prisoners were concerned about medication for release when interviewed four weeks prior to discharge. In addition to receiving medication on release, some prisoners were supplied with a letter to be given to their GP in the community which summarised their medical records whilst incarcerated. However, this was only standard practice in a minority of the participating prisons. In summary, there were some procedures in place to manage the physical health needs of older prisoners on release but these varied across establishments and often required improvement.
Communication
The issue of communication was a reoccurring theme throughout the interviews. Interviewees were frustrated by the lack of formal information received about their release. For many, this caused a great deal of distress. In particular, they lacked information about where they were going to be living, frequently only finding out a few days before release. Often this was because their licence conditions meant they had to live in probation-approved premises and/or would not be allowed to reside in the geographical location where their offences had been committed or where victims lived. This frequently meant they were excluded from living in what they regarded to be their home area. Lack of certainty about accommodation meant that prisoners were unable to plan adequately for any aspect of their release, as community services operate only within certain catchment areas. As one participant explained, ‘I think it's quite abysmal quite frankly … well you know the main thing is you don't even know where you are going to be going for a start … so you can't even start planning’ (Prisoner, participant 28).
Strikingly, one of the participants was wholly unaware of their impending release date. When the researcher went to speak to the person to inform them about the study and explained that they were being invited to participate because they were due to be released within four weeks, the participant was extremely shocked because they believed they still had a number of years left to serve in prison. The researcher verified the participants’ release date with prison officers who confirmed he would be released in four weeks. This example illustrated the lack of formal communication of the most fundamental information with prisoners regarding their release from prison.
The frustration over the lack of contact with Probation Workers in the community and Offender Managers inside prisons was described by participants. Prisoners often did not know the name of their assigned Probation Worker in the community, face-to-face meetings with probation services prior to discharge were held very rarely and many prisoners specified that they had only received one letter from their Probation Worker, very close to their release date. One prisoner described their frustration at the lack of communication from their Probation Worker, ‘I've got some questions I want … I've only seen her [Probation Worker] once while I've been in [prison]. I've been here two years. I saw her when I first came in and that's it, I've not seen her since’ (Prisoner, participant 12).
As a result of the lack of formal communication described, prisoners reported that they received the majority of information about what would happen on release from other prisoners. In particular, they relied on other prisoners for information about the conditions in probation-approved premises. As a result, participants were extremely anxious about the prospect of moving to approved premises as they believed they would be full of young people who misused substances. They were also concerned that other residents would not tolerate living with those convicted of sexual offences and would subject them to violence and/or intimidation. However, once participants had moved to approved premises, they found them to be acceptable and rarely reported serious problems with other residents, as illustrated in the quote below.
Yeah, you get information off the other inmates saying they're [probation-approved premises] rough and this, that and the other, and don't do this and don't do that. But when you get there it's totally different. It's totally different to what I expected. I expected it to be a right rough place and fighting and all coming in drunk and whatnot. (Ex-prisoner, participant 27)
Discontinuity of care
A lack of continuity of care was evident throughout the interviews. Participants perceived services to be disjointed on release and various examples were provided of discontinuity of care. Participants were generally supplied with medication on release, and some were provided with a summary of their medical notes to cover their period of incarceration. However, many participants were registered with GPs in areas that they were not returning to (usually as a result of their licence conditions). Therefore, often they were registered with a GP in the community but were not able to attend appointments there, as one participant described:
I have got a GP on the outside but the thing is I won't be living there, I don't know if I will be in that area. (Prisoner, participant 1)
Difficulties with continuity of care were also evident with regards to financial benefits and support. A number of participants received information about reinstating their benefits on release via letter, or face-to-face by a worker employed specially to assist prisoners with such issues. Participants reportedly followed the instructions provided; however, most still experienced delays of weeks and months in receiving benefit entitlements. Participants considered the length of these delays to be particularly frustrating, considering benefits were, without fail, stopped immediately on prison entry. There were also difficulties with individuals attempting to set up bank accounts for release. In the limited prisons where such services were available, problems were frequently encountered, as one participant stated:
There's nothing joined up, that's what I'm saying, the whole thing … Yes, I opened a bank account before I left prison … they sent me down to the bank … I phoned the bank they say they've sent all the stuff [relevant documents] to prison. The prison haven't forwarded it [relevant documents] to me, and I'm still stuck without a bank account. (Ex-prisoner, participant 19)
The lack of continuity of care was also apparent in relation to meeting participants’ housing needs. This was evidently different for those residing in probation-approved premises and those who were not required to reside in such accommodation as part of their licensing conditions, the details of which are discussed below.
Comparison of participants released to probation-approved premises with other types of accommodation
During data analysis, it became apparent that there was a distinct contrast in the findings from older prisoners who were discharged to probation-approved premises immediately upon release and those that were not. In general, participants released to approved premises were extremely anxious about the prospect of living in such accommodation, as one participant explained:
Well to be honest, I don't really know, because as I say, I'm going to a hostel [probation-approved premises]. I don't know what the hostel is. I'm apprehensive about the hostel. (Prisoner, participant 22)
These anxieties were so extreme that many participants reported that they would rather serve the term of their licence in prison than be released to approved premises. Fears were predominately based on reports from peers and included fears for physical safety, sharing accommodation with substance users and living with the prospect of being recalled to prison for seemingly minor irregularities, such as being late for appointments. However, when they were interviewed four weeks after release, participants residing in approved premises frequently reported that their immediate health and social care needs had been addressed. As one participant stated
My needs have been met very well so far I would say, I'd honestly say they have been met well. (Ex-prisoner, participant 4)
By the time follow-up interviews were conducted (approximately four weeks after discharge from prison), staff at approved premises had usually facilitated registration with a GP, located in close proximity. Those with mobility difficulties considered themselves to be fairly well catered for at approved premises, with large rooms and appropriate bathroom facilities usually provided. Demand for these rooms did not, however, always meet supply.
These findings were in contrast with the data generated from interviews with participants who did not reside in approved premises immediately on release. Whilst in prison, these participants were comparatively less anxious about the prospect of release and generally did not anticipate difficulties after discharge from prison, as one participant described, ‘It [release from prison] can't come soon enough (Prisoner, participant 32). However, once released, participants who did not move to approved premises were more likely to perceive their health and social care needs to be unmet. Unmet needs varied but included a lack of support with finance and employment, and being inappropriately housed. Examples included a participant in need of a hip replacement sleeping on a friend's sofa, reportedly causing pain; a wheelchair user being housed in accommodation with steps which he could not leave independently; and another wheelchair user with severe breathing difficulties being placed on the top floor flat. One participant described the difficulties of using a wheelchair in an ill-equipped house:
This house, it's not equipped for me. I have a struggle getting everywhere; I can't use the toilet because it's too close to the wall. If you sit on the toilet your knees are up against the wall, there's no safety rails round it. (Prisoner, participant 32)
Discussion
Summary of findings
This study is the first to examine older prisoners’ health and social care needs following release from prison. Older prisoners perceived release planning to be largely non-existent. Provision of medication on release was generally good, with a supply given to cover the immediate discharge period. However, summary letters were provided to GPs inconsistently and participants were often not registered with a GP that they could access on release. There was a paucity of pre-release courses to address wider social care needs and those in existence were not appropriately tailored to older prisoners’ needs. Furthermore, there was a lack of communication via formal channels in preparation for release and, as a consequence, prisoners were reliant on peers for information. Strikingly, there was a discontinuity of care once older prisoners were released and many with complex social care needs were housed inappropriately. Those due to be residing in approved premises were extremely anxious about their release, but subsequently found their needs well met immediately after discharge. Those not living in approved premises were less anxious about release but went on to experience greater difficulties, particularly those with complex social care needs. Overall, older prisoners’ release planning was deemed inadequate.
Comparisons to existing literature
The findings from the current study support previous research conclusions concerning inadequate release planning for older prisoners and their high levels of anxiety experienced prior to discharge (Crawley Reference Crawley2004; Crawley and Sparks Reference Crawley and Sparks2006; Davies Reference Davies2012; HMCIP 2008; Her Majesty's Inspectorate of Prisons 2004). This study went further than previous research by exploring older prisoners’ perceptions after release, to discover whether concerns expressed prior to release became reality. Crawley (Reference Crawley2004) described how older prisoners were concerned about their physical safety after release (particularly those convicted of sexual offences) but, within this study, no participants reported any major problems in relation to threats to their physical safety immediately after their release. The current study has added to prior knowledge and detailed how those residing in probation-approved premises have their immediate health and social care needs fairly well met whilst those in alternative placements struggle.
Limitations
It is possible that the participants who we were unable to follow up in the community had more complex health and social care needs than those who were successfully contacted. For example, they may have been more likely to be experiencing homelessness. Unfortunately, we were not able to overcome this challenge in spite of assiduously gathering information about all potential avenues of contacting participants on release from prison prior to their discharge.
A four-week follow-up period was selected for this study as this was considered to be a sufficient amount of time to allow immediate health and social care needs to be met. There is a need for future research to explore how well older prisoners’ health and social care needs are met in the longer term and when those initially located in approved premises move on to independent settings.
Implications for practice
The majority of prisoners serve short sentences, eventually returning to the community. Thus, timely release planning started whilst in prison and continued follow-up support in the community have the potential to improve health. This is particularly important for older prisoners who we know experience complex health concerns (Fazel et al. Reference Fazel, Hope, O'Donnell and Jacoby2001). Whilst in prison, older offenders are literally a ‘captive audience’ and we should maximise opportunities to provide appropriate health and social care services to this vulnerable group. The findings from this research suggest that this opportunity is not being fully exploited. More specifically, the findings suggest that the Department of Health's (2007) guidance regarding older prisoner release planning is rarely followed. We found no evidence of older prisoners partaking in specially designed pre-release health and social care and welfare assessments, receiving social worker assessments or the development of individual care packages. Consequently, a national policy for older prisoners is required, including mandatory release planning for older prisoners.
There were a number of examples of staff attempting to support older offenders in their release from prison; however, this frequently occurred too late when release was imminent. There is a need for staff to be supported to plan effectively for older prisoners’ reintegration into the community through the development of appropriate policies and mechanisms. The authors have worked alongside colleagues working in prisons and older prisoners themselves to develop the Older Prisoner Health and Social Care Assessment and Plan (OHSCAP) to identify and address systematically older prisoners’ needs throughout their time in custody. This includes considering issues related to release immediately upon entry into prison. The OHSCAP has been piloted and found to be feasible, acceptable, and of value to staff and older prisoners. Detailed accounts of the OHSCAP and its piloting are available elsewhere (Senior et al. Reference Senior, Forsyth, Walsh, O'Hara, Stevenson, Hayes and Short2013). The authors have recently commenced a randomised controlled trial to assess the effectiveness of the OHSCAP in improving outcomes for older prisoners.
Conclusion
Those residing in approved premises had their immediate health and social care better met than those who live in other accommodation types. However, release planning for older prisoners is generally inadequate, resulting in discontinuity of care. Existing guidance outlining the need to plan for older prisoners’ release from entry into prison is generally not adhered to. Older prisoners experience high levels of anxiety prior to release which could be ameliorated through appropriate communication from prison staff, health-care staff and Probation Workers, and systematic assessment and care planning procedures.
Acknowledgements
The authors are grateful for the support and assistance from all participants and prison staff. This paper presents independent research funded by the National Institute for Health Research (NIHR), Health Service and Delivery Research Programme. The views expressed are those of the author(s) and not necessarily those of the National Health Service, the NIHR or the Department of Health.
