Enhancing life opportunities should be a priority for those working in prison settings. A project reveals how the health needs of young offenders were addressed
Sarah Goodwin, MA, BA, RHV, RGN, is modern matron, Oxfordshire Primary Care Trust; Helen Carter, MA, PGCE (FE), BSc, RGN, is independent healthcare adviser, Carter Consulting, Oxford.
Goodwin S, Carter H (2010) Implementing a health promotion model in a young offender institution.Nursing Times; 106: 29, early online publication.
Young people in young offender institutions experience more physical and mental health problems compared with the general population. This article explores how the primary nursing service at HM Young Offenders Institution Huntercombe used national policy as a framework for managing change.
In outlining the challenges and opportunities that influence practice development, we hope to demystify nursing in a prison setting, which is a hidden and often misunderstood aspect of healthcare.
Keywords Offender health, Health promotion, Young offender institutions, YOIs
- This article has been double-blind peer reviewed
- Implementing change requires a bottom up, rather than a top down, target led approach to practice.
- Practice focused workshops allow staff to take ownership of changes to healthcare.
- Creating a learning and development plan helps support the implementation of clinical supervision and boosts attendance at training events.
- Health promotion activities in young offender institutions should reflect national and local programmes.
The government’s health strategy for offenders recognised that being in custody presents a vital opportunity to address health needs (Department of Health, 2002). Young offender institutions (YOIs) engage in partnership working, and have responsibilities for delivering a healthy environment shared between healthcare and prison staff. This article examines the challenges of meeting such aspirations.
Issues relating to crime and social disorder cross the government’s departmental boundaries. As a result, several national drivers have an impact on children and young people and inform healthcare service development. These include:
- Every Child Matters: Change for Children in the Criminal Justice System(Department for Children, Schools and Families, 2004);
- The National Service Framework for Children, Young People and Maternity Services (DH and Department for Education and Skills, 2004);
- The Children’s Plan: Building Brighter Futures (DCSF, 2007);
- Promoting Mental Health for Children Held in Secure Settings (DH, 2007).
Healthcare and prison services must work to Prison Service Instructions (PSIs) and Prison Service Orders (PSOs), the operational frameworks to maintain safety and security within the institutions. There is also a requirement to safeguard children and young people and build a team around the child. This aspect of work is addressed in such documents as:
- Common Assessment Framework for Children and Young People (DCSF, 2005a);
- Her Majesty’s Prison Service (2003) PSO 3200 Health Promotion.
In 2005, responsibility for the commissioning of healthcare in prisons and YOIs transferred from the prison service to the NHS. This shift was recommended by the World Health Organization (2002), to ensure that people in prisons have access to the same range and quality of healthcare as they would receive in the community - their punishment being loss of freedom, not loss of healthcare.
HM Young Offenders Institution Huntercombe is a juvenile institution, which takes young men aged 15-18 years who have been sentenced to a term of imprisonment. Before entering HMYOI Huntercombe, many of the young men have led lifestyles that have put their health at risk.
Lewis and Heer (2008) said there was considerable evidence that young men in secure settings experience health inequalities, and have a higher incidence of physical and mental health problems including self harm, communicable diseases and substance use compared with the general population.
Health services at HMYOI Huntercombe
Situated near Henley-on-Thames in Oxfordshire, this YOI can hold up to 350 offenders and has an annual turnover of 1,200-1,500 young men, most of whom stay for 6-8 weeks. The institution accommodates young people mainly from the South East. It comprises six units including an induction unit and those that can accommodate young people with mid to long term sentences. It also has an education department, gym facilities, and substance misuse, chaplaincy and resettlement teams.
Due to the reduction in numbers of children and young people being given custodial sentences, Huntercombe will close at the end of July 2010. National Offender Management Services has proposed using it as an adult prison. However, the issues explored within this article remain relevant to all nurses working with vulnerable children and young people.
All primary healthcare services are provided from the on-site healthcare centre. The range of services at Huntercombe includes a 24-hour nurse-led service, GP services and children’s and adolescent mental health services (CAMHS). There are no inpatient facilities, but young people may be transferred to local NHS services for specialist care.
Identifying health needs
The system for audit and inspection cuts across the Ministry of Justice and the DH. PCTs and prisons are accountable for implementing recommendations made by Her Majesty’s Inspectorate of Prisons, the Care Quality Commission, local committees and performance monitoring arrangements that are linked into the prison health delivery plan (DH, 2002).
In 2007, an audit based on the National Healthy Schools Programme (DCSF, 2005b) - which promotes a “whole school” approach to health, which addresses the needs of pupils, staff and the wider community – was commissioned by Oxfordshire PCT’s public health department. It found Huntercombe provided a range of education and training activities to support the development of young people. The audit positively benchmarked the YOI services against the Healthy Schools Programme audit criteria, which includes personal, social and health education (PSHE), healthy eating and physical activity.
The following year, a health needs assessment was conducted on behalf of the PCT by a specialist registrar at Huntercombe. This assessed the range of met and unmet needs, identifying that staff shortages and frequent staff turnover contributed to poor morale and problems in delivering such elements of healthcare as in depth health screening. This unpublished assessment also highlighted concerns around medicines management, lack of continuity of care and basic health promotion.
Developing practice in a prison setting
To coordinate many of the competing priorities for the healthcare department, Oxfordshire PCT’s commissioner and service provider wanted to include staff in implementing change, using a bottom up, rather than a top down, target led approach to practice. Following a period of transition - where there was high staff turnover and agency staff were frequently used – the PCT commissioned two external advisers to conduct a clinical audit, facilitate workshops and support the redesign of services in the healthcare department. Their aim was to build team cohesion and work with staff to develop a robust service model. This involved a process of practice development to integrate local and national directives in a systematic way.
The advisers found a number of action plans had been cascaded to staff to implement with no clear direction or leadership to take the work forward. Nursing staff were not aware of the national and local context for driving their development, and had not been sufficiently involved in the change process.
Within Huntercombe it became obvious that nothing could happen without the development of staff skills and that change would need to be implemented with clear goals and evaluation mechanisms. This required support from leaders with the ability to consider the needs of children and young people.
Within six months of the external advisers’ appointment, the commissioning manager changed, a new service manager was appointed and staffing levels were reduced due to sickness or people leaving. By August 2008, it was clear that several areas needed to be addressed at Huntercombe. These included integration with the mental health in-reach team, improving medicines management, and understanding the responsibilities of nurses towards safeguarding children.
Prison nursing comes with specific difficulties. The YOI regime follows a strict timetable, and offering any appointment system, health promotion activity or preventative work has to be accommodated within that. Consequently, services can compete for time within the structure of the day.
Within this system there is only limited time to administer medicines or associated treatments. At Huntercombe a culture had developed where nurses did not always assert their position. Professionally this meant they might compromise their practice and work outside the standard for medicines management (Nursing and Midwifery Council, 2008). There were several medicine errors and management of medicines was variable. These problems led to a meeting between the governor and the commissioner to discuss how best to safely administer medicines.
Creating staff ownership of change
The clinical leader and independent adviser planned and delivered practice focused workshops. These were an opportunity to enable staff to take ownership of changes to healthcare. Issues that were important to staff also mirrored national and regional drivers for change. The nursing team developed an action plan and staff requested further workshops, which were held six months later. All this created momentum and enthusiasm for change and staff began to feel empowered.
At times, the process of practice development felt like “one step forward and two steps back”.
Nurses did not always recognise the health needs of young people at Huntercombe. Challenges to the team to think longer term for patients and focus on health and social aspects were dismissed by some clinical staff who were comfortable working in a medical model setting. The team needed to recognise that their skills and practice had to change to help children and young people to make lifestyle choices that would enhance their health.
Learning and development
It is a challenge for nurses working in the YOI to look beyond their own population. Creating an offender health learning and development plan jointly with the local adult prison nursing team helped to support the implementation of clinical supervision and encouraged nurses to attend joint training and workshop events.
Staff needs were highlighted through induction, clinical skills training, leadership and management development and support staff development and by encouraging links with partners such as the local minor injuries department. Focusing on learning and development not only brought together nurses from the YOI with those from the local adult prison; it also enabled professional groups within and external to Huntercombe to be included in creating a model of care that focused on health promotion.
A health promotion model
During November 2008, the PCT commissioner and head of healthcare held a second away day, which gave the opportunity to ensure integration of the “bottom up and top down approach”. The aim was to consolidate some of the changes and agree a health promotion approach with young people’s needs at its centre.
The health promotion model consists of four levels that reflect the level of need set against the expertise required to meet that need (Fig 1). The required expertise ranges across professionals employed within the YOI (or prison) and its various departments, and encompasses generalist and specialist roles.
The type of work included within each level consists of:
Level 1: this includes hygiene and infection control, health and safety and smoking policies. These aspects can be carried out throughout the YOI.
Level 2: examples include providing smoking cessation training, drug awareness and mental illness awareness, and can be carried out by prison staff or healthcare support workers.
Level 3: prison or healthcare staff assess and deliver a higher level of advice and support for mental wellbeing, smoking cessation, sexual health, dental health, diet and self care. Staff are skilled in identifying need and referral to level 4 services. An educational role is important to support colleagues involved with health promotion. This is often the role of registered nurses or GPs.
Level 4: a range of specialists offer targeted assessment, advice and support in areas such as sexual health and substance use. This is often provided by specialist nurses, medical consultants and psychologists.
Once implemented, the health promotion model will work across the YOI where its priorities are reflected in HMPS (2003) including:
- Mental health promotion and wellbeing;
- Healthy eating and nutrition;
- Drug and other substance use.
As a result of staff turnover, there was less resistance to change. The healthcare department recruited forward thinking people committed to promoting health and wellbeing. Extending nursing skills contributed to a “whole prison approach”, where maintaining health extended across all departments.
Next steps for a YOI primary nursing team
Recognising the challenges and potential within the young offender setting encourages nurses to work towards a health promotion model that encompasses the “whole prison approach”. Equally, it is crucial to encourage prison colleagues and the wider PCT health promotion specialists to be supportive. This is particularly relevant following the launch of Healthy Children, Safer Communities (DH et al, 2009), which supports a common vision across statutory and voluntary organisations that work with children and young people in contact with the youth justice system.
Health promotion activities in the YOI should mirror national and local programmes. It is vital to ensure young people in these institutions receive access to the same materials and campaigns as the wider community so that when they are released healthcare messages are familiar and reinforced.
The future of nursing in a young offender setting relies on encouraging nurses to develop practice that will reduce isolation and encourage others to consider working in this demanding and rewarding area. To prevent the work of primary nursing teams remaining hidden behind locked doors and unchallenged, it is essential to establish a proactive approach so links are made with the wider healthcare agenda.
There are several implications for nursing practice outside a YOI or prison setting. Clinical staff in the community have a role in supporting prison nursing. With their skills, knowledge and experiences in dealing with offenders, or those at risk of offending, they can establish networks to manage effective release from a YOI or prison environment.
Reducing re-offending and enhancing life opportunities should be a priority for all professionals working within, and external to, the secure estate to ensure children and young people have the self care skills to enable them to access health services and maintain good health. This involves integrating professional, organisational and national priorities using a sustainable and systematic person centred approach. Only then will offender health services become more widely understood.
- In 2005, responsibility for commissioning healthcare in prisons and YOIs transferred from the prison service to the NHS to ensure inmates have access to the same range and quality of healthcare as they would receive in the community.
- Evidence shows young people in young offender institutions have a higher incidence of physical and mental health problems than the general population.
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Department for Children, Schools and Families (2007) The Children’s Plan: Building Brighter Futures. London: DCSF.
Department for Children, Schools and Families (2005a) Common Assessment Framework for Children and Young People. London: DCSF.
Department for Children, Schools and Families (2005b) National Healthy Schools Programme. London: DCSF.
Department for Children, Schools and Families (2004) Every Child Matters: Change for Children in the Criminal Justice System. London: DCSF.
Department of Health et al (2009) Healthy Children, Safer Communities – A Strategy to Promote the Health and Well Being of Children andYoung People in Contact with the Youth Justice System. London: DH.
Department of Health (2007) Promoting Mental Health for Children Held in secure Settings – A Framework for Commissioning Services. London: DH.
Department of Health, Department for Education and Skills (2004) National Service Framework for Children, Young People and MaternityServices. London: DH.
Department of Health (2002) Health Promoting Prisons: A Shared Approach. London: DH.
Her Majesty’s Prison Service (2003) PSO 3200 Health Promotion. London: HMPS.
Islington Prison Health Improvement Board (undated) Health Promotion in Prisons – Models for Service Delivery.
Lewis E, Heer B (2008) Delivering Every Child Matters in Secure Settings. London: National Children’s Bureau.
Nursing and Midwifery Council (2008) Standards for Medicines Management. London: NMC.
World Health Organization (2002) Prisons, Drugs and Society. Geneva: WHO.