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Healthy changes can start inside

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Kate Henderson-Nichol, MA, RN, RM, RHV, AdvDipCoun, Cert Supervision, Coaching and Mentoring.

Prison Health Development Co-ordinator, North East Leeds Primary Care Trust

The drive to develop health care in the Prison Service to bring it in line with the high standards prevalent in the NHS continues to have a high profile. It is a major part of the primary care trust agenda and has included giving primary care trusts (PCTs) the responsibility for health-care delivery in the jails in their area, effective from last April.

The drive to develop health care in the Prison Service to bring it in line with the high standards prevalent in the NHS continues to have a high profile. It is a major part of the primary care trust agenda and has included giving primary care trusts (PCTs) the responsibility for health-care delivery in the jails in their area, effective from last April.



This feature focuses on the needs of young men aged 15 to 18 years (referred to as trainees), whose health requirements are comparable to their contemporaries in the free community.



The major difference is their preponderance for risk-taking behaviours, with associated criminal activity, and the fact that many do not realise that they can make choices. But they have often never had the opportunities or attained the personal life skills to enable them to make positive choices.



The move towards improving the health of prison populations is underpinned by the development of partnerships across the country over the past two years. This has been achieved through multiprofessional prison health development steering groups, which have brought together prison establishments and the health authorities (now replaced by PCTs).



Public health approach
The work of the Leeds group - which includes HM Young Offenders’ Institution, Wetherby, HMP Wealstun and HMP Leeds - resulted in the formulation of a Prison Health Improvement Plan. It centres on developing a coherent integrated approach to strategic planning for health improvement, well-being, health-care service provision and treatment within the prison health-care system.



One way to develop prison health care is to take a public health approach: this involves looking at the broader picture, examining a range of issues and determinants of health and ill health, such as employment, education, housing, culture, diet and nutritional status, fitness, life skills and lifestyle.



This is crucial, given the increasing emphasis on the need to improve the outcomes of prisoners’ resettlement processes. There is evidence that 60% of those offenders who are reconvicted are unemployed and homeless; the figures also show that they are twice as likely to be reconvicted than those with stable accommodation (Yorkshire and Humber Region, 2002). On release, 70-80% of ex-prisoners are ineligible for 95% of jobs available in the free community because they have not attained key stage level 2 (usually attained at age 11).



Traditionally, health-care delivery in prison settings, as in the NHS, has followed a primarily medical model, However, unlike the Prison Service, the NHS has seen a switch to a more holistic approach, based on recognition of health as ‘a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity’ (WHO, 1948).



In terms of providing health promotion, it is generally recognised that many trainees have lifestyles that inevitably put them at risk of ill health. The majority have also had little or no regular contact with health services before entering a custodial setting.



Cultural shift
Among the strategies to improve health-care provision in prisons is the ‘settings’ approach or ‘whole institution’ approach.



This is a tripartite strategy that lays the basis for a cultural shift for addressing health issues (Marshall et al, 2000). It aims to tackle this on three fronts by:



- Creating ‘healthy policy’



- Developing health promotion strategies



- Patient education.



At HMYOI Wetherby, a health-promoting approach is rapidly emerging. This has involved strengthening links between all departments that can affect health improvement in its broadest sense, and bringing together the gym, education, chaplaincy, sentence planning and the drugs and substance use service.



Links are further being strengthened through the development of a public health ethos, which involves working with North-East Leeds PCT health promotion specialists who have a remit that covers prison health care and who provide strategic and operational support to those delivering health promotion.



Last year saw the launch of the Up Front project, which has pushed back the boundaries of health promotion. (The name was chosen by local young people in the community as they wanted to be able to talk to health professionals who could be up-front with them.) The programme now includes the young men within the juvenile custodial setting at Wetherby.



The project has brought together a multiprofessional group of midwives, school nurses and professionals with social and youth work backgrounds, for most of whom working in a custodial setting for young people is a new venture.



The programme aims to create a calm, non-judgemental environment that fosters mutual respect, understanding and trust and offers young people access to information. It is hoped that empowering young people will enable them to make informed choices and encourage individual responsibility, awareness and decision-making.



Making connections
Health, social, voluntary and youth services are all involved in the project and visit Wetherby once a month, covering a wide variety of topics in groups of up to eight trainees. The topics covered range from sexual health, healthy lifestyles, cancer awareness, drugs and substance misuse to aromatherapy, reflexology, self-awareness, self-esteem and hygiene.



The trainees’ response to the service, which has been evaluated through verbal and questionnaire feedback, has been extremely positive.



Recognising and addressing the gaps in service provision for these young people is a start. Another key issue is about applying our knowledge about adolescence and making the connection between developmental milestones and offending behaviours.



Understanding the norms of adolescence will provide a context for understanding where behaviour strays from normal limits and why young people become drawn into criminal activity. Adolescence is not a condition that requires a cure; rather it is a set of patterns of physical, emotional, psychological and spiritual changes that require understanding - they occur over a period of years and mark the transition from childhood to adulthood.



To address the needs of the adolescents, HMYOI Wetherby provides a skill mix of staff, including RSCNs, RNs (one with a school nursing background) and RMNs, and the unit is managed by an RN(LD). While some trainees experience acute mental illness, the behavioural disturbances of the majority are either linked to drugs and substance misuse, or to the fact that the trainee has learning difficulties; they may also be linked to unresolved child-protection issues.



Training issues
Professional development planning is a key component in enabling health-care staff to provide the highest levels of care for this group of young men. All staff at Wetherby have the chance to undertake appropriate training and education programmes through links established with local higher education providers and local professional development departments.



Staff are also encouraged to make use of shadowing opportunities with local secondary and primary care providers to update skills. Prison officers and health-care staff are also included by local child-protection agencies in their training workshops.



Working with this group of young people or, indeed, in any prison, is not for the faint-hearted: it involves interacting with a young man and seeing him in the context of his background, while reconciling knowledge of this person with the behaviours of which he is capable both inside and outside the establishment.



Professionals working in a juvenile settings require appropriate support. Sickness absence and staff turnover among prison officers and health-care staff are a perennial issue. This risks making the workforce unstable, which can only impinge on the quality of care and supervision provided to trainees and adult prisoners.



Working takes up a significant part of people’s lives. It makes sense, therefore, to have systems in place to support staff and to make them feel that their contribution is valued.



In recognition of this, Wetherby has begun a pilot project that includes providing a mentorship service for staff: health-care workers have been first to benefit, and this will later be extended to prison officers.



Organisations have only recently begun to acknowledge that investing in staff is as valuable as investing in the organisation itself. This is where mentoring, supervision and coaching come into their own. The pilot is currently in its embryonic stage but thanks to the support of the governors of the establishment and North East Leeds PCT, staff mentoring has begun.



Department of Health. (2000) The NHS Plan. London: The Stationery Office.

Marshall, T., Simpson, S., Stevens, A. (2000) Health Care in Prisons: A health care needs assessment. Birmingham: Department of Public Health and Epidemiology, University of Birmingham.

Yorkshire and Humber Region. (2002) Regional Resettlement Framework: Consultation document. Leeds: YHR.

World Health Organization. (1948) Constitution of the World Health Organisation. Geneva: WHO.
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