The effectiveness of the Older prisoner Health and Social Care Assessment and Plan: A Randomised Controlled Trial and Nested Qualitative Study

Abstract

BACKGROUND: Older prisoners are the fastest-growing group in prisons in England and Wales, as in other developed countries, and their complex health and social care needs often remain unmet. OBJECTIVES: 1) To evaluate the efficacy of the Older prisoner Health and Social Care Assessment and Plan (OHSCAP) in improving i) the meeting of older male prisoners' health and social care needs ii) health related quality of life iii) depressive symptoms iv) functional health and wellbeing and activities of daily living; 2) To assess the quality of care plans and the fidelity of implementation; 3) To explore the facilitators/barriers to implementation. DESIGN: A multi-centre, parallel group randomised controlled trial (RCT) with follow up at three months, with an audit of care plans also conducted (n = 150, 68%). A subset of prisoners (n=14) and OHSCAP facilitators (n=12) took part in a nested qualitative study. SETTING: Ten prisons in England. PARTICIPANTS: Four hundred and ninety-seven male prisoners aged fifty or over and newly arrived in prison, with a discharge date at least three months after arrival were randomised. INTERVENTION: Participants were randomised to either OHSCAP or Treatment As Usual (TAU). The OHSCAP group had their health and social care needs assessed by a trained healthcare worker or prison officer. Care plans were devised, and subsequent actions included professional support and appropriate referrals. MAIN OUTCOME MEASURES: Primary outcome measure: mean number of unmet health and social care needs as measured by the CANFOR-S. Secondary outcome measures included measurement of functional health and wellbeing, and depressive symptoms. RESULTS: In the RCT, 248 were randomised to the OHSCAP group and 249 to TAU. The 404 who completed follow-up were split evenly across trial arms. No significant differences were observed between prisoners who received the OHSCAP and those who received TAU in relation to the primary outcome measure. Audit and qualitative data show the intervention was not implemented as planned. This was due to a ‘broken’ prison system; challenges of balancing care and custody requirements; health/social/custodial silos; and rigid prison processes. LIMITATIONS: Due to the short follow-up period, any potential long-terms gains of the intervention were not observed. Some of the standardised tools used had limited applicability in prison settings. CONCLUSIONS: The OHSCAP did not meet its primary objective but was fundamentally not implemented as planned. This appears to have been due, in some part, to wider difficulties affecting the prison landscape. Health and social care initiatives will have minimum success in prisons without the prison system being appropriately funded by the government. A cultural shift and changes to prison processes are required to successfully balance custodial and care needs. FUTURE WORK: Further work is needed to inform and develop training for prison staff and peers. Partnership working and information-sharing across disciplines within prison settings require improvement. Research should explore the potential involvement of other prisoners and third sector organisations in identifying and addressing older prisoners’ health and social care needs. Future prison based RCTs should adopt a realist approach and follow Medical Research Council Guidance regarding the evaluation of complex interventions. An older prisoner strategy should be developed to ensure that this vulnerable group is appropriately supported.

Date of Award	31 Dec 2020
Original language	English
Awarding Institution	The University of Manchester
Supervisor	Jennifer Shaw (Supervisor), Roger Webb (Supervisor) & Gavin Daker-White (Supervisor)