 morning, and welcome to the seventh meeting of the health and sport committee in 2017. I could ask everyone in the room to ensure that their mobiles are all in silent and to use mobile devices for social media within the room in. Please don't take photographs or phone precedence. Now, agenda item 1 is subordinate legislation. We have two negative instruments today, the first instrument is National Health Service superaniation scheme, MissAsh, Scotland Regulations 2017. There has been no motion to annul, but the Delegated Powers and Law Reform Committee has made comment on the instrument. They draw attention regulations to the attention of Parliament on reporting ground 1, as regulation 1.2 appears to be defectively drafted in accordance with the Scottish Government's intention. Regulation 1.2 should have provided that regulation 31 and 40 have a retrospective effect as from 6 April 2016, rather than coming into force on 13 March 2017. The Delegated Powers and Law Reform Committee welcomes that the Scottish Government is undertaking to make the necessary amendment to provide for that retrospective effect when the National Health Service Superannuation Scheme 2008 section Scotland Regulations 2013, SSI 2013, 1.7.4, are next amended. I am trying to say that without your false teaton. Can I invite comments from members? No, is it agreed that we make no recommendations? The second instrument is the National Health Service Pension Scheme Scotland, Miscellaneous Amendments Regulations 2017, SSI 2017-20. There has been no motion to annul, and the Delegated Powers and Law Reform Committee has not made any comments on the instrument. Again, could I invite any comments from members? No, is it agreed that we make no recommendations? That is great, thanks very much. Agenda item 2 is our healthcare and prisons inquiry. It is the first evidence session on healthcare and prisons and this is a round table session. We will introduce ourselves around the table. My name is Neil Findlay. I am the convener of the Health and Sport Committee, if you could just briefly introduce yourself as we go. I am Clare Haughey, the MSP for Rutherglen and the deputy convener of the committee. Hi, I am Paul Noyce from the Mental Welfare Commission. Tom Affer, MSP for Renfisher South. Miles Briggs, MSP for Lothian. Sandra Campbell, nurse consultant for cancer and palliative care representing the Scottish Partnership for palliative care today. Donald Cameron, MSP for the Highlands and Islands. Alex Cole, Hamilton, MSP for Edinburgh Weston. I am Lib Dem, health spokesperson. Alison Douglas, alcohol-focused Scotland. Alison Johnstone, MSP for Lothian. Theresa Fife, director of the Royal College of Nursing. Richard Lyle, MSP for Arlingston and Belsong. Aisha Holloway, University of Edinburgh. Mary Todd, MSP for the Highlands and Islands. Doug Liddell, Scottish Trust Forum. I am Colin Smyth, MSP for south of Scotland and Labour spokesperson on public health and social care. Ivan McKee, MSP for Glasgow Proven. Okay, thanks very much. We did also invite Sacro to attend, but due to illness, no one could be here. So, we'll just go to questions. Questions, Alex. You convener and good morning everyone. Thank you for joining us today. I wonder if we could start by a bit of a go round from panel members as to access to healthcare in prisons. I have several dealings with HMP Edinburgh due to constituents who are in there. I have heard from their experience some quite shocking examples of where the access to appropriate primary healthcare can break down. They gave an example of an inmate who had chronic liver failure and only received medical attention two hours before he died after being complaining of abject pain for some time prior to that, aware that this is an isolated case. However, I wonder if the panel would offer their reflections on how that sort of thing can be allowed to happen and what provision there is in Scottish jails for prisoners when they start to feel unwell. I think that our report, what we've found, was that there are variations across the prisons in Scotland. And there are many examples of very good practice on people trying to address things, but there are variations in that, of course. So a prison's experience would differ according to where they are. One of the issues about access to healthcare was that when the transfer of the prison to the prison service into the NHS for health, it was based on, at the time, the review was based on what the service was and there wasn't actually a health intelligence work done about what the demand might be. So the service went in as it was, and then subsequently some of the issues that have come out in our report, like on mental health addictions and others, were not actually assessed as to what the demand was. So the demand was there, but it was actually unable to be met because the service was actually as it was at the time. So it wouldn't surprise me that there would be issues because if thought that then, you'd have a more continuous service. But the other issue is around access to different disciplines within the team and our report shows that particularly when you get near to that out-of-hours period, where there is actually difficulty in accessing a GP or others because of the nature of how the service is. So, for some prisoners, they will experience then a gap at that point and an inability or a very slow process. My final point would be, though, is that we need not just to talk about the health provision, we need to remember that, actually, there are issues around the custodial element because, actually, if there isn't enough of prison officers' time to be able to support prisoners to go to where they need to go to or to access the treatment that is there, then that, in turn, acts as a barrier. So there's two parts to it. There's actually, I think, less available health provision and then sometimes issues about how you get prisoners to be able to access therapeutic interventions or go to appointments because of, actually, some dilemmas. So both are working against the system for prisoners at the moment. Anyone else? Aisha? I think that I would concur with Theresa's comments. In the evidence that we submitted, which talked about the work that we've done with NHS Lothian, trying to look at a nurse-led model of healthcare delivery. And before we started to identify how we could respond to the need, we were then aware that we didn't actually know what the need was. So there is an issue there around what are the health needs of the prison population itself. We don't really have that full data available and it's very difficult for us to access that. So I think that that's fundamentally one of the key issues. That's very sad to hear that someone is denied healthcare, especially at each end of life. I would just like to say that there has been a lot of work done in the last few years around supporting collaborative working between the prison service and the NHS to identify patients who make with a recognition of the changing population within the prison. And there is an increasing need to have an understanding of recognition of end-of-life care or when end-of-life care may be required or when there's a change in the person's condition or deterioration. So there's been a lot of work done, there's been a lot of work done between McMillan, the Scottish Prison Service and the NHS boards. And there's actually been a nurse appointed just this year actually funded by McMillan, hosted in Forth Valley because there's been a lot of work in Glen Ocle. And I think to follow on from what's been said already about what we found in Forth Valley was there was sometimes a lack of understanding between how each organisation worked and the culture of the next organisation. So we held a very simple stakeholder event in November, sorry, in 2012. And from that we developed pathways of care around cancer, around how we could access prisoners could access investigations quickly. And also around the end-of-life care part of the journey, not just for cancer but for a normal ignorant disease as well. So a lot of work has gone on. We are replicating the work that is going on in community around supporting and disputed care planning and identification of needs which all fits with the strategic framework. So the new post that the person who's just in post will compile a scoping exercise across Scotland and work with the prisons and the staff within the prisons and the other organisations, health and social care involved there, local hospices, et cetera. How can we all work together to make sure that the journey for these prisoners who will lend their life essentially lend their life whilst still in custody have the correct support and access to services as they need it. So that's just a very brief summary of where we are. But there's a lot of work to improve end-of-life care. I'm grateful for all those comments. Can I also expand this to discuss in specifically mental health? Further research and also discussions with prisoners in HMP Edinburgh suggest that sometimes there's a gap in our knowledge as to mental ill health and the general population outside of, obviously, secure units and the state hospital, but within general prisons that we don't necessarily know how deep those problems run. There seems to be, in some cases, and maybe this is localised, but an under-reporting of suicide with sometimes those deaths being recorded as deaths by misadventure rather than suicide, so we're not entirely sure where that correlation exists. And then the provision and access that prisoners have both to psychiatric support within the general prison population, notwithstanding the fact that, obviously, being incarcerated will have an impact on anybody's mental health, but particularly for those with underlying clinical mental health needs. Could the panel offer their views on that? Can I maybe add to that that we were meeting with prisoners or ex-prisoners this morning and one of them who I spoke to said that he was first put in prison in 1984 and the difference from then until now, he said, was absolutely stark in terms of mental health. So, maybe if we could get a comment on that as we go. For the Mental Welfare Commission, we've been visiting prisons for about the last 10 years, primarily because there's a higher proportion of people in prison with mental health issues than in the general population. And I think that's, you know, borne out by virtually any studies that have been involved. I think one of the difficulties when talking about mental health is really what we mean, whether it's severe enduring mental health of which there are higher rates in prison, five, eight per cent perhaps people with schizophrenia or psychosis through to individuals with more impaired mental wellbeing. And a lot of the issues in prison that I think nurses are dealing with will be anxiety, depression, huge issues about sleep, sleep deprivation and just the reality of being in custody, which is, you know, not a therapeutic environment, it's a difficult environment that people need to survive in their own way. We visit all prisons across Scotland or we visit the mental health services and I can only speak about mental health services usually about every two to three years but we'll visit more often if there's particular issues that come up. And we talk with the largely the mental health nurses who are providing the services, often the psychiatrists who go in and we'll try and speak to as many prisoners as possible who are using the mental health services. A lot of people we speak to are actually very pleased and happy with the report that they receive. Though many often wish they could get more support and I think probably some of the other issues that come up was how quickly people get support. There can be a wait sometimes and it varies a lot across prisons about when referral comes in and how quickly and often people are seen. Prison isn't a hospital, it's largely a primary care service. If people are acutely unwell we would hope they would be transferred and get the appropriate medical care that they need. And in most situations that does seem to happen but I think the original question was saying about the level of need and numbers. I think what we know is that it is high. I think the demands on services and the prison again are high and I think a lot of that falls to mental health nurses and they're dealing with a lot of just general issues. They can be family difficulties, things that cause anxiety and as I say most prisoners are very appreciative of that. But to try and get some form of figure I think is very difficult and it's difficult to do that in the general population but certainly in terms of impaired mental wellbeing it's very high within male prisoners and probably even higher. I mean guests in the Angelina report were saying about 80% with female prisoners and I think the big issue that we find is about what is able to be done and I think nurses are able to talk. There's often a lot of self-help and a lot of general observation and support given but I think what the big gaps are in terms of low intensity psychological therapies which people might get in primary care services and also inputs to psychology, I think those are the big ones. I guess just to add to what Paul has said, obviously there's a huge overlap between people with mental health problems and drug and alcohol problems and I think really that those constellation of problems that people have need to be looked at in terms of the most vulnerable populations and what we see going back to the original question about variation is we see in terms of treatment for people with drug problems a considerable variation across the prisoner state and I think it would be fair to say that in many cases actually the treatment on offer is actually would be considered poor practice in the community and I'm thinking particularly of opioid replacement therapy which again links to issues around underlying issues of mental health because if people are not appropriately treated then often those issues of underlying say childhood trauma and other things come to the fore and we've seen that particularly in the women's prison of you know issues around self-harm etc among women who have been on opioid replacement therapy in the community and that has not been continued in prison so I think that that would be one of the key areas that we would see and in terms of and obviously there's been the report from the prison healthcare network around you know guidance for quality service delivery and we would you know be strongly suggesting that those recommendations in there need to actually be put in place in particular there's the new clinical guidelines for good practice that are coming out UK guidelines which need to be adopted in prisons so that we don't have issues around suboptimal treatment in that setting maybe if I can just add a final point around the sort of general healthcare we've been doing a lot of work recently around people with drug problems over the age of 35 and particularly looking at aspects of their general health and what we've found is that very often general health issues are not being picked up or dealt with because the presenting problem is one of drugs or alcohol and so a whole range of issues that are not being effectively dealt with in the community so you know one possibility obviously this prison is actually a potential useful point in terms of picking up those underlying health issues have not been dealt with in terms of for example Hepatitis C where you know a lot more could be done to actually you know deliver dried blood spots testing actually at the point of admission to hospital so a whole range of things could be improved and we have now I think quite good data in terms of the wider healthcare needs of that population many of whom do end up at various points within the prison system Doff Allison, the end of her, Allison? Thank you, yeah. I think I was quite surprised that the British Psychological Society noted that the government's 18-week referral to treatment time for accessing psychological therapies doesn't apply to prisoners. I just wondered if Mr Noisy might have a comment on that. I was actually quite shocked to realise that that was the case. I can't make any major comment on that apart from the fact that we are very aware that there is a huge need to increase access to psychological therapies and care for prisoners. I think that they are probably struggling with that target in the community in many ways. I'm not sure quite how other targets for physical healthcare apply within prisons. It's not something that I can comment on particularly. It just seems a question of equity and it seems discriminatory in my view. Legislative exemption. I don't know if just the British Psychological Society have noted in their evidence that the government's 18-week referral to treatment time for accessing psychological therapies doesn't apply to prisoners. We'll check that out. Okay, thank you. Can I just ask Mr Liddle? I think Neil and I were obviously speaking to the same gentleman who did say that in 8485 when he was in prison it was full of, he referred to them as criminals and gave us a list of the crimes they'd committed and he feels that the prison population has changed markedly and that you're seeing far more people with poor mental health and drug-related conditions. Now he said with a group, he was one of eight prisoners who tried to you know, get off their drug habit and he said out of the eight he was the only one that managed and he was clean in prison for eight months but when he came out within 72 hours he had a needle in his arm and I think that theme of lack of support during transition time was a huge issue and they spoke of people who were leaving prison on Friday evening with nowhere to go little money and were very quickly sucked back in to something that many of the prisoners had clearly been trying to tackle in prison. You know, they wanted access to services sometimes they were difficult to come back but there was somebody who'd obviously made huge efforts in prison and they were, you know, they were thwarted when they got out so there was also a case of someone who was let out just before Christmas and even worse time without any support so, why are we still getting this part wrong? Well, I think one element of that is actually to do more to keep, you know, larger numbers of people out of the prison system all together, I think is fair to say I think drug treatment and testing orders have played a useful role but we could certainly do far more in terms of alternatives to custody because as the person you spoke to I think was suggesting actually now you know, prisons in many respects for a large vulnerable population are people that would be better off not in that environment and actually it is very hard in terms of actually, you know, to become drug-free in that environment but also the substantial risks on liberation and it goes back I think to the point that the Royal College of Nursing was making around looking at wider aspects of this as well in terms of people's benefits, their housing often people actually, if they're in prison for a lengthy period they've lost their accommodation so all of these issues you know, mean that actually people are generally in a worse off position actually at the point of liberation rather than better so it is hugely challenging there is a new through-care system a voluntary through-care system available through Scottish Prison Service but I suppose we have questions around the extent to which it actually delivers to the needs of the most vulnerable populations who are particularly challenging at the point of release and some of that is, I suppose, for individuals who've had, you know, 20-year or so history of a drug problem we have to be, I suppose, realistic about the ability of someone to remain drug-free at the point of release and that's where I think the opioid replacement therapy would come in as well for most individuals, not for all obviously it's about choice as well for people to become drug-free in that environment but certainly the evidence suggests it is extremely hard for people to maintain that in the community but I do take your point about effective support and that's another challenge and it shouldn't be left, obviously, to Scottish Prison Service through-care staff to actually, you know, try and deliver community services there needs to be better links both going into prison and obviously on release from prison so it's about continuity of care for very vulnerable people On that issue of opioid replacement some of the prisoners suggested that they'd never actually been on opioids in the first place and that they found themselves on methadone there was a feeling that perhaps it made it easier to look after prisoners but people who had never really had a drug habit found themselves coming out of prison with one But they had been using previously because it's unlikely someone without using drugs would then be put on methadone I find that slightly hard to believe I guess it's more about making sure that that provision is appropriate I think what we see I think the figures were a thousand or so people on methadone and probably a few hundred on buprenorphine which is another substitute drug but our sense would be that provision is less than it than it actually should be but I do take your point obviously it has to be delivered in a person-centred way and I guess that's also one of the big challenges in the prison system is actually how you deliver a person-centred care to a large numbers of people when services are stretched Just one more question can you read it for me? The case the discussion was that someone had had cacodamol in their bloodstream and as an alternative found themselves on a methadone programme but I was given a sort of scenario that it's like well the description was it's like meerkat manner when prisoners are aware that prescriptions are being given out and everyone is watching everyone else to see what they come back to their cells with and without and that sometimes vulnerable prisoners are prayed upon for what they might have and you know a lot of the trade or just confiscation by stronger you know characters might happen at that point is there anything that could be done about the way prisoners are receiving drugs that they need? Well I think all of those issues are hugely problematic in the prison environment and certainly one of the things that we saw it was with Buprenofin was actually people obviously able then to take that in their mouth and take it away and then potentially sell it to other prisoners so those management issues I think it was dealt with in one prison by crushing the tablets before they were given to prisoners but all of those issues are very difficult to manage and of course the potentially as if you focus very heavily on issues around you know potential leakage then you damage the sort of person centred nature of the service but those issues have always been there and obviously they're more severe now with large numbers of people with drug problems so maybe in many respects I suppose it goes back to those individuals are much more easily managed in the community and actually potentially shouldn't be there in the first place but there's always going to be difficult management issues within the custodial environment On that certainly one of the big issues that prisoners often speak to us about is about whether they get in the right medication and we've come across a lot of issues where people coming into prison often are not continued on the medication they've been very successfully managed on in the community and there is often something that prisoners often say to us that they think we're at it they think we're trying to get drugs and there is a huge difficulty I think in trying to get that balance right and I think the amount of the amount of time being given to medication trying to just get that balance right as to watch required and not required is just a huge issue which is wonder it's very difficult to deal with and that's just the reality of it Alison In relation to alcohol I think one of the key issues is around identification of prisoners with alcohol problems We know from one study that prevalence of dependence is up to 36 percent and that compares to the general population of prevalence of 1 percent so we've got a real concentration of alcohol issues in this population and there's still not consistent identification of prisoners with alcohol issues when they enter prison so it still tends to be a sort of yes no question on entry rather than a systematic screening tool being used and the consequences of that then are unless somebody subsequently self identifies then they're unlikely to be getting access to the treatment that they need and in terms of the prison setting perhaps alcohol may be seen as less of an immediate priority because only 4 percent of prisoners say that they have access to alcohol in the preceding months so clearly drugs are more prevalent rather than alcohol but on release a lot of prisoners that that would be part of their gate happy as I've heard it described when you walk out of the prison one of your potentially one of the first things you're thinking about is having a drink or drinking to excess the perception of prisoners is that access to treatment has reduced over the last few years so we've seen a drop of the number saying that they have received treatment from 23 percent in 2011 to 14 percent in 2015 so that is concerning because clearly prison provides an opportunity to deal with alcohol behaviours that have a significant impact on the individual on their relationships and clearly on their offending behaviour given the very high proportion 41 percent who link their offending to their alcohol use who say that they were drunk at the time of their offence and that rises for young offenders so there's a real opportunity with in prison to identify and start treating people who have quite profound alcohol problems and has been raised before that then becomes an issue about the continuity of that care on release because clearly the opportunities are much more significant when people leave prison than in the prison setting I think this morning from the session we had and indeed last week that whole through care issue to me is the dominant one that is where I think the major failure is so we heard for example from SACRO this morning and people who are going who have gone through the system were assistants from SACRO ex-servicemen who previously before SACRO's intervention had a poly bag with her closing it and a 70 quid grant to leave prison and walked out the door to nothing now with the support of SACRO they had someone assisting them to get a roof over their heads someone to assist them with benefits to register with a doctor and all of that and it was the same with the young people who were on the new new routes scheme I think that's up to 25-year-olds who were getting that assistance too for everybody else that doesn't exist and they were talking about your register for benefits your benefits take a while to come therefore you have no money you can't get registered with a doctor because you haven't got an address and then within that cycle is it any surprise that people resort back to crime in order to try and feed themselves and get a roof over their head until that settles so I'm just wondering if within that whole system is that the major breakdown in the system that through care to try and prevent people coming back in and if it is why are all prisoners not offered the same support that they get for SACRO or new routes because if you're over 25 and you're not an ex-serviceman it appears you're on your own so Aisha there's so many things coming up here it's deciding which one to choose but I think there has to be a distinction we're talking about a prison population as a generic group of people and actually they're not and I guess the biggest distinction would be around gender male and female in their needs but also remand and non-remand prisoners and remand prisoners from the work that we've been doing and some of the existing evidence are a very high risk group where the things that we're talking about today are occurring more frequently because of the nature of their offences and the amount of time they're spending in prison so for example alcohol when remand prisoners perhaps go to court they are then released straight away from there they won't go back to the prison they won't pick up their mobile phone their belongings and then we have difficulty then engaging with them in the community even when services are there for these people so I think there is this a way or need to be aware that we're not talking about a group of people who have the same needs and I would strongly if I can recommend that that awareness about remand prisoners is taken into account because I think that picks up on your point about the through care because if you're sentenced you will know when you're going to be liberated and we're more able to put in place structures for remand prisoners that's very difficult and doesn't happen likewise with their induction into prison they're not aware of the services and support that are available to them Trisa then Donald I agree entirely with what Iesh has just said and that's what our report showed but there's also a gender issue in this if you may recall the nursing at the edge work we did where we demonstrated the ALS service that was up actually in other part of Scotland was around supporting women coming out of prison or not going into prison actually finding another way of having a service that would actually give them what was required for their crime and that enabled women to be more supported rather than finding themselves so far from their family and children I want to go back to the continuity point there is that you saw in our evidence in that the nurses who are working within and my colleagues made talked about the mental health nurses in particular the mental health nurses working within the prisons I always feel quite deskilled now because medications has become the issue so if you're going in thinking that you're a mental health nurse with a range of cognitive behavioural skills and you want to bring that to the fore it's what I meant about sometimes I visited a prison a while ago where the psychologist was actually in the prison waiting to do some group work but there wasn't enough custodial support to bring the prisoners to the group work so medication has become the prime issue so mental health nurses are feeling deskilled so there's going to be a recruitment issue because you don't go into mental health the past model was a medications model I'm talking about way back in the past that is not what mental health nurses today would want to do so you will find that actually they will not be attracted and there's a lot of agency workers now working within the prison and that's what they're doing is just going around giving out medicines which is just not a good way to go forward but I think that the other thing is the work we've done around forensic services about the route that goes back to the point I mentioned about remand people who are actually at that point where if they're assessed appropriately before they're put into the prisoner that work is going really well in areas that have got clinics set up where they can very quickly assess whether somebody is not actually there because of what they've done but because of actually their mental health condition sadly people will learn disability and other vulnerabilities actually in the wrong place and end up then into the system when at that point if their support can be done those nurses that are working in one of those systems recently have said to me they're just stay now have been long enough working there to see the turnaround so the recognising clients back again who they saw went through the system got out back in a very short period of time which fits what my colleagues said about being unable to get their feet on the ground and their return is so shockingly quick that they are seeing that as a day-to-day evidence so that impacts on the morale of the healthcare workforce and the actual service that people think they can provide which will affect continuity because then there is no service being provided that would be in that cognitive behavioural model I'm talking about the really close interventions that mental health nurses can bring that would make the difference Thank you to everyone for coming today I mean just to corroborate what Teresa has been saying in terms of conversations that I had this week and last week there clearly is a gap I think in mental health provision in prisons I'd like to ask a specific question it goes back to what David was saying and the interplay between addictions and mental health clearly that there's often an overlap one of the former prisoners that I spoke to who did not have any addiction issues but did have clearly mental health issues which he spoke about said that he felt that addiction was prioritised in terms of a health problem at the expense of what was purely a mental health problem in his eyes and he said that he felt at the back of the queue effectively I just wondered if anyone had any observations on that I mean obviously it shouldn't be it shouldn't be that way but I think certainly in terms of the work we did a recent study looking at the life histories of 56 problem drug users and half of that group childhood trauma came out very strongly so it is for many of those individuals actually that the drug problem is the presenting problem not the key problem so I guess one of the bits is actually to get the mental health provision right and then hopefully actually some of the the addiction issues will be resolved because that's a really common refrain from people is that they they go to services and actually they don't the services don't have the time to actually find out you know what they got to the state they're in so what you end up or services end up doing is actually dealing with the presenting issue which is the addiction rather than you know some of the underlying reasons as to why an individual got to that position in the first place so I don't know whether that answers your question but it's really not not straightforward but I think maybe it's more a question of to do with resources that obviously given the numbers of people going into prison with addiction problems that then I suppose in some way respects they will overwhelm the service and it maybe goes back to some of the issues around the dispensing of medications that we need to look at the whole prison system to see if there's better ways to actually deliver that service so that actually the workers don't spend all their time doing that and actually have more time to build those therapeutic relationships which are the bit that will actually deliver the results we're looking for There potentially one of the things that he was identifying was the provision of kind of detox services or you know treatment for the physiological kind of addiction as opposed to you know what's the recovery-oriented care which would be more the psychological therapy so I suspect that there's a deficit around those psychological therapies in general for mental health or mental health and addiction issues as opposed to you know what what prisoners may see is that kind of detox or the medical medical prescribing Clare Thank you, convener and thank you to the panel I just wanted to pick up on something that you had mentioned Neil about throughput support and just to highlight that both last week and this week I heard some really good examples of the prison services throughput support and how that had transformed lives so I think that there is a wide range of of through care services there that we need to acknowledge Can I just very quickly before we go on to my main question ask Paul from Mental Welfare Commission you said that Mental Welfare Commission had been looking at prison mental health care for the last 10 years can I ask who was the oversaw mental health provision within prisons prior to that? I'm not sure I can actually ask that we tend to visit hospitals more generally and community but mainly hospitals I think that we met with MSPS before I went with the commission about 10 years or so ago I could get those details and achieve an agreement that we would visit and I think because of the level of identified needs and issues coming out of prisons but we have debated really our role for a while within prisons and we're not an inspection agency we tend to ask prisoners about the care they're receiving and are able to react and follow through and make recommendations but certainly we have been visiting prisons prior to the transfer between SPS and local health boards we did a report about six years ago on mental health of prisoners which was looking at what the issues were then actually 2011 so not quite that so we pass on our reports obviously to the health boards in terms of the issues that we're picking up but we also share information with the HMIP the inspection service and also health improvement Scotland who when prisons are inspected took primarily look at standards in relation to health care and mental health care so we liaise quite closely and are able to pick up on issues from our visits and their visits which we find to be quite effective in highlighting issues that we're picking up so so yes we are there and we do make recommendations we tend to find the situation to be quite variable there are good bits and good points and sometimes less good points that happen often within the same prison so there is that variable picture and we try and pick up and make recommendations whether it's about situations where the actual health care and health centre facilities are just inadequate so we have wasted time where psychiatrists can't get a room they're having to to wait behind the GP so you've got wasted time there you have situations where you've mentioned before where you need that good relationship between health staff and prison officers but there's no point in having a psychologist visiting if nobody brings the prisoner across and there is that whole dynamic that needs to be working together we have been going in for a while so we have seen the situation prior to with SPS Providence Service and health boards we haven't seen huge changes I think there's a chipping away and I think there is certainly the opportunity now for nurses working within the health care teams in prisons to be much more connected with the health boards the training and to I think what we'd like to see is a lot more transferring between nurses or working in the community working in prisons and back again so you build those bridges and find out what's happening in community and within the prisons themselves that doesn't happen a lot but I think it's beginning to happen more I think one of the big things with the change from SPS to NHS is maintaining the links and relationships I think there hasn't been a massive turnover in our experience of staffing people who are in prisons have been there often for a while they have good relationship with the prison officers and a lot is built on trust a lot are built on who they know and the dynamic is an important one to maintain there is a danger with the service having moved to NHS is you get more of a gap between the two services and both services need each other to be able to do their jobs properly and I think that's something that we want to make sure continues to happen I've probably gone away from the question Absolutely because I'm still no clearer actually No sorry, yes So did who inspected mental health services because there would have been mental health services with NHS if you don't know the answer you don't know the answer We don't inspect the services we visit the services in fact I think the answer is probably the inspector of prisons Okay Can I ask following on from a little bit what you said there's an open question to the panel and this is something that we heard last week when we were talking to healthcare professionals who work within prison services and also today from prisoners who had been in several prisons during the time in custody about inconsistencies across the prison estate and varying levels of care and treatment and access to treatment and I guess I'm just looking to see if perhaps the panel can give us some insight on how we can ensure that there is consistency of access to services and consistency of services across the prison estate I think that is exactly what we said now So just in addition that was a point that I was going to raise at the end so maybe people can raise it some mentioned the sort of role of the governor and the atmosphere and the culture that's set by them so maybe if you refer that as well as part of that Exactly That's such what I was going to come to there's no doubt there are examples of very good practice and in fact there's actually when the prison system my colleague Sandra referred to one reward recently for some of the work they've been doing and I've known the work that Sandra has done as a consultant with Paltiff Care that actually has transformed end of life care in a way that is being opened to the culture of the prison I've visited many prisons over the over the years I always go into meet our members within them and I've now learned I can tell actually when I go in what the atmosphere is like I wouldn't have known this in the past I wouldn't have understood it I would go in and think you can see that there is that joined up working but I was just like yourself to quite shocked actually when I went in discovered there wasn't rooms you know so I was asking so one place I've done an amazing state of art where they had a room where the dentist would have a dental chair all the equipment they recede there was a room then for the GP a room for a therapeutic room for that then I went to another place and there was nothing like that at all so there is a difference in infrastructure that is provided for access to prisoner healthcare but without without doubt I think that it is about that relationship because that was what we were for the transfer absolutely as a college we worked alongside it we thought it was the right direction to go in and still believe that even though we've come out with the questions we've come out with because actually you had to but the worry was that you'd get a break in the relationship between the prison service and the health elements of it and I haven't seen that in everywhere so I can be done but I have seen it in some areas where there isn't such a good fostered relationship between the healthcare staff and the actual prison service and that's what would worry me and I was in a prison where I saw the group set up so I was asking questions about what's that what's that man sitting over there waiting to do and what was happening and suddenly right in front of me they were unable to escort prisoners to those actual sessions and those healthcare professionals where had come in were very very distressed that they hadn't been able to do the job they do so culture has a lot to do with it leadership without question a transformation of thinking but equally if the capacity isn't right of the healthcare workforce that's not going to work either so if you don't have the right mental health nurses and other nurses looking at the health needs then you're going to actually have a ration service within there because they will end up just doing what they can do and I have to see to the staff work extremely hard that's what it comes across they work really really hard they do the best job they can but if they haven't got enough of them to do what they're required to do then they will feel equally disillusioned and they won't be the same relationship Sandra, did you want to go on this? I know you wanted and it's been moved by the points passed No, I would just like to share some really good practice excuse me that happened around what can be achieved with collaborative working education that was mentioned earlier for the prison staff and what happened in Forth Valley as a part of the national work with the national end-of-life care project that's working with Macmillan the partnership with Macmillan Scottish Prison Service and NHS and mostly NHS Forth Valley England England OCO will be the pilot site for this post but over a year ago we had been working with the staff around end-of-life care education so the staff in the prison have access to the same education as we offer to the staff within NHS Forth Valley and we go into the prison and work with the team and provide education as does the local hospice and there was a suggestion at the national group that could we we had been teaching what's called Saging Time it's a communication skill session to elicit and manage emotional distress for all and they have a buddy system within Glenoco whereby prisoners who are perhaps less able to self-manage are supported by their peer their prisoner peers as it were and we actually taught some of these buddies around the model around communication skills that have been taught around assessing for suicide risk etc and that worked really well and alongside the prisoners we taught prison officers other staff, carers and the prisoners themselves and that model worked really well so I think where you have good working relationships between the two organisations it's to the benefit of the prisoner population Just going back to the I suppose the point about how things have changed I mean I think the leadership and governance I mean I'm struck by the fact that there was this report done in this time last year Drugs and Alcohol and Tobacco Health Service in Scottish Prisons Guidance for Quality Service Delivery Now there's a list of recommendations in that report the problem is that you know it's guidance so how do we move from understanding of actually what the problems are to actually changing it and that's I guess the frustration particularly around you know those differences in practice and we have seen some very poor practice and I won't mention particular prisons or particular health board areas but when those are challenged that often the point is made well those have to be individuals have to make those complaints themselves rather than organisations like ourselves for things to happen so I think there is a big issue about actually trying to get to grips with the prisoner's own experience and understanding of what these issues are so that we can start to move beyond you know what we know are some of the problems but how to actually address them over the long term David refers to recommendations you referred to a report that you guys did in 2011 and the recommendations from that were they implemented? They've been looked at by the co-ordinating group that for prison mental health and recommendations aren't they should be followed but it's slowly so they've been looked at yes they've not been implemented not fully implemented Alex then Marie To address a group within the prison population that we as politicians very often forget about because they're very small both in numbers and in stature and that is babies I say that and I refer members to my register of interests where I've worked for an organisation that provided the service for the mother and baby unit at HMP Caunton Vale I'd like to ask panel those panel members who have an interest in this field what they think the impact on the development and early health needs of babies of being in prison is whether they think the balance we have right now is right and whether they think that the child and family impact assessments bought in by Mary Fee in the last parliament will change things for the better so that that we find a different way of dealing with offenders who are new mothers We are on health but I know it's a health related issue but it's just that we can't go with this but Theresa I'll just keep it brief I'm not an expert on that but our work as I said in the nursing at the edge was about other ways of supporting women with children actually with babies outside of the main prison if we could do that and that actually there's lots and lots of excellent voluntary sector work that's done around enabling that because what was shocked me was when I discovered that women particularly if they had children they lose more support outside than men do so actually the visiting of men by their women or family is higher than it is for women so that isolation from their family and then trying to come back out so as I see services like ours as I mentioned earlier which is in Perthshire and others have been fantastic in transforming women and children as a better way of looking at rather than a custodial service at looking at ways of offering support because so often it was about what was happening to them which led them to do undertake crime that actually could be handled differently and that's why we did that work to try and promote a different way of looking at women and especially when there was children involved Theresa is a follow-up convener regardless of whether a baby is with the mother or not in Gwendoff Vale what support is there for perinatal mental health needs because we know that that's a problem in wider society can you explain what provision there is in prison? I can comment on that sorry Marie I was struck with almost all of the people that I've spoken to over the last few weeks and I visited in Burness prison as well as seeing the people who had come here almost everyone mentioned the issue of the point of liberation being a real risk and there seems to be an awful lot of homelessness at that point which makes it very difficult to have continuity of care makes it very difficult to engage with healthcare and there seems to be almost the more severe your crime the better the planning is so if you're in a long sentence the planning is very good if you're on a shorter sentence there will be some planning and if you're on remand as you say you're almost out into chaos and I just wondered if you if anybody I mean to me I know it's maybe not a health issue homelessness but in terms of the holistic picture not having shelter is a very basic need and I spoke to a man this morning who said that he hadn't had his own accommodation he'd been in an act of prison since he was 19 he'd never had his own accommodation in that time and he was 27 and just seems to be could do better for these people Aisha hi yeah I mean I agree we surveyed in our recent survey in a Scottish prison almost 200 remand prisoners and then we interviewed them in depth and the key thing that the all said was getting help for alcohol we were looking at alcohol interventions across the spectrum so not just dependence but harmful hazardous consumption that puts you at risk or your health at risk and the key thing that the majority of them said was I would need help when I get out of prison and not just around alcohol but around employment around housing around benefits so I mean one of the challenges that we face we have some evidence as to the effectiveness of alcohol interventions in other settings but the dynamics and the nature of prison setting with power balances and the high anxiety of it we are less sure of what's most effective there so that's one of the things we're trying to do but I think what we would look at would that that would be part of a number of things that you would have to put in place so I think thinking you can have a conversation with someone about their alcohol consumption and expect them to change that behaviour without supporting all those other things that impact on health and impact on offending and re-offending so the current model is not cost effective for us in the long term if we want to support these people I think also I mean I have a background of working in psychiatry as a pharmacist who worked in mental health for 20 years so it was very striking to me that the model of recovery orientated systems of care which we use outside of the prison which builds on people's strength and resilience is very difficult to achieve within the prison because responsibility is removed from the prisoner and you know things are they're disempowered yeah they're disempowered and they're institutionalised so that very basic tension seemed very striking to me and I just wonder how you get round that and I did wonder about not just healthcare professionals being able to come in and out of the prison but voluntary services so in terms of treatment of addiction organisations like alcoholics anonymous narcotics anonymous are very helpful on the outside do they have how easy what are the barriers to getting involved within the prison system and what about people who have had addiction problems and have turned their lives around how easy is it for them to get in and out heard from a chap this morning that you know you can volunteer as a sponsor within the prison system but once you're released you can't volunteer for the Samaritans for two years just wondered if anybody wanted to go at that I'll allow you to say that you're describing exactly what it is and I think that if we're going to have to change the way we do the model which is what I believe we have to we then have to look at how we open that up to the breadth of services I'm not saying that there should be more for you know we obviously want to have the right number of mental health nurses within there but it shouldn't be just mental health nurses it should be about that whole multidisciplinary multi-agency approach to me and there can be ways it comes back to though the culture of the prison thinking how do they change that how do they enable that and I think that that's the challenge isn't it if we don't it is the most cost it is the most cost effective model we have of watching people going out and coming back in again it seems very expensive to meet the problem worse it is and that's what the staff who are in these custody speeds are saying to me now that they are almost recognising somebody they'll think well you'll be out and back again especially if they've been remand prisoners or short term because I think your point Neil with the service people there are definite models there but there's an enormous number that fall through the gaps David then awesome Sorry I hadn't another couple of questions Sorry, sorry I'm just coming on that one just in here in terms of I think it's the point I've made already about the vulnerability of large numbers of prisoners and actually that you know the key issue is actually stopping them going to prison in the first place fundamentally for those individuals the study we've just done of older people with the drug problem this is individuals over 35 basically showed the numbers of times those individuals had gone in and out of treatment but also you know in and out of custody as well so there's I think one of the evidence talked about I think it was AFS talked about the revolving door which is a huge issue in terms of all of this and it's a narrative that runs through lots of you know the people that we're talking about of nobody staying by them over a long period of time and you talked about some of those services that are able to do that that's the real challenges to actually get services that actually stick with people rather than just you know a potentially relieved when people drop out of the service because the pressures are on them that they can't follow them up I mean it really just builds on the point that Dave was making I mean obviously we've seen a 22% reduction in Scottish Government direct funding for alcohol and drug services in the current financial year and going forward the alcohol and drugs provision is being folded into the general provision for health boards and what we know is that the things that are likely to drop off are the things about recovery oriented systems of care because they do require you know a longer term and more in depth engagement with individuals so I think that's deeply concerning if we're recognising that we're not getting the provision right if we're recognising that continuity of care is one of the major concerns if we're not managing to implement the quality service standards I'm a bit nervous about the future in that kind of financial context I wanted to ask you David a couple of specific questions about drug treatment so you've mentioned that perhaps the orange book guidelines aren't being adhered to in prison is that am I correct on that? Well basically there's draft guidelines orange guidelines and the new ones will be published very shortly but our suggestion or recommendation is that those should be adhered to and the point is really yes is that a lot of the practice in terms of drug treatment is if you like suboptimal and isn't you know of a standard you would expect in the community so that definitely needs to be addressed and obviously one way is to adhere to those UK clinical guidelines Would perhaps audit or SPSP methodology help tackle that on the ground do you think? because you've said already that there have been guidelines but the gap between practice that's right somewhere it hasn't been closed yes I think yeah yeah I mean why I'm looking at that it could be through the health improvement Scotland as part of the you know the current prison inspection regime but I think I think and certainly we've been involved in a couple of those I think it's important that they have the expertise around mental health and addictions given that that's such a large proportion of the population the other specific question I wanted to ask you is about naloxone provision so obviously there's a quite serious risk of overdose at the point of liberation and I wondered what you thought about that strategy yeah yeah no no no that that's yeah absolutely I mean we've been working really hard and actually we've been in prisons with our staff we've been in prisons over the last couple of months actually training night staff in naloxone because of one of the issues is that you know if someone overdoses in the night there's no medical cover so in fact that you know there would be no one to administer naloxone so that's in I suppose internal issue that hopefully is being resolved but one of the issues we've been working working with Scottish Prison Service and others on is actually ensuring that every prisoner who's at risk of an opioid overdose or has peers that are at risk should be given the naloxone I think we could work a lot harder at actually making that more of an opt out rather than an opt in in terms of delivering those those numbers and I think there's ways to do that we're obviously you know as I say working closely with Scottish Prison Service on that to increase the numbers but yeah I think it's an important area and obviously as we've seen as you say the point of liberation is a high risk as it is in terms of coming out of hospital or a residential facility those are high risk moments in terms of those transitions for people Thanks My final question is for Sandra actually because I spoke to a number of people this morning about the possibility of peer support and volunteers and lived experience being shared within the prison and the final thing we got onto was that people could the prison population could be trained to deliver social care and that that would give them some skills it would give them an opportunity to work within the prison and it would give them some skills to take when they leave the prison and I just wondered if you could tell me a little bit more than that it sounds like you had mentioned a project something like that that there I think we've learned from models in England whereby and but and I can only really talk from the end-of-life care perspective so bear with me but certainly when a prisoner is you know they need their condition deteriorates and their needs increasing there are increasing needs around assistance with washing and you know and activities of daily living essentially and um the closest people to them sometimes in the prison if they've been there for the number of years there are other prisoners and that essentially become that is who their family is for some of these prisoners so they have these buddy systems and these buddy prisoners is it well where support that individual to live as long as possible as well as possible if that makes sense so locally in Glenoco we have adopted the the staff there have adopted that model to a to a degree there are social carers within the the prison one of the nurses has has been appointed with particular focus on rehabilitation and supporting people who are have multiple comorbidities the the prison staff are supported to understand the changing needs and look at anticipatory care planning for these particular individuals so along with alongside that some of the the prisoners do work and help with the with the with the care of the of the prisoners and I think that's a very good model obviously that has to be very well supervised and supported and has to be safe but that certainly is is a person-centred approach because these prisoners are but these other prisoners' families so so I do think it does give them skills when they leave the prisons on the issue of social care I mean for many older prisoners and there's going to be more of them if they weren't in prison they would be in a care home they'd be in shelter thousand or very shelter thousand or something similar so should we not be creating a new environment for that group of prisoners that's in effect a secure care home because I think prison is the last place that people with mobility problems with particular conditions last place they should be I mean just the design of a prison beds stairs halls eating you know all of that toiletting just seems completely not conducive to dignified care when people have what social care needs so should we be creating a new model that is effectively a secure social care units and obviously I can't comment that in the wider sense but I hear what you're saying and certainly on a smaller scale within Glenocl again they've modelled this on English prisons whereby groups of prisoners with particular needs are managed together in the same particular wing and that's where there are social care staff there to be able to support these prisoners but the whole environment is difficult width of cells for access for wheelchairs etc beds etc is not conducive to good care Collin then Ivan I want to convene a continuity of cares obviously being touched on a number of times I'm noticing that the BMA's submission they highlight the fact that one of the barriers to that continuity of care is obviously workforce issues and the RCN in their submission also state that staffing is a very real pressure in delivering adequate healthcare in Scotland's prisons so can I ask the panel if there are specific workforce issues in relation to staffing prison healthcare and what does this mean for prisoners access to healthcare and also is there a recognised workforce model for healthcare in prisons There isn't a recognised workforce model it was when I said when the review happened Collin that's when actually it was as it was transferred over so there is work to be done about what is the nature of the team that works within prison healthcare but going back to Marie's point it was very much around to me about that multi agency and looking at a different way of working so that's what I would go for I think that we do now with there are shortage of registered nurses in Scotland per se anyway so if you have a recruitment and retention issue in some areas prisons will suffer from that because it takes a particular people to want to work within the prison service and when you meet them and they absolutely love it and see it as their job to do it's amazing but as I mentioned what we're seeing as the morale is if you can't do the job that you came in to do then we are going to end up not being able to recruit so particularly in areas like mental health nurses but also actually what would be the equivalent of community nurses because actually as everyone has said here it's the community it's community care that you are providing so the more general care so we are seeing an issue or recruitment or retention we're seeing over dependence on agency within nursing but also what our report found was I think I mentioned earlier on is that we actually don't have enough GP cover and that out of hours provision that I think a number of people are referring to you know don't you know that's it's very slow you know waiting on a call out and I think that's that's a big big gap so the night staff that are around will be very very under pressure if something happens because they'll be waiting for someone to turn up and do what's required I think there are new ways of protocols going back to my your colleague mentioned about drug provision I just think that it's been away but one of the reasons we were for the transfer was that I did work with the prison service prior to the transfer and found we couldn't change the models so I was for the transfer because I believe the transfer would actually lead to the change in the models of care to my I suppose five years on I'm not seeing that across the board so I think the shift has to be different and it has to reflect the way we give care in the community to people within the context of the prison service and rethink the model and I think that's the opportunity we have to do now that's what I would prefer not just to talk about how many nurses actually look at the kind of model we should have David Just to add to that one of the things that happened in when the transfer occurred was that there was provision at that point through Phoenix Futures every prison had a social care service and actually initially that was also a through care service as well within the prison at the point of prison transfer without fail every health board took that service in-house and no longer had that voluntary sector social care model so I think you know that those flexible models we should be looking at as well so it isn't obviously it's just not a medical issue it's a medical and social care as the point has been been made strongly here Colin, you've finished the one back in I just want so did you follow up on that so what work is really taking place at the moment to develop that particular model or models cos obviously different prisoners will have different needs but is there a piece of work being done at the moment to develop a model across the service or is that a gap? I think it's dependent upon the board to be honest with you Colin I think that there was a national provision provided but it was really not clear where it was to sit and it sits within Health Improvement Scotland I think it's time to look at where the leadership of the national sits but within the board to be honest with you it depends on who's got the lead and where people have got a defined lead role within the board for prison services you'll find more happening where you've actually got a variation in boards you'll find less happening so that's I think it comes back to it was handed over to the board some boards have got more prisons than others so it was a big agenda for them and you could see that they knew and I remember some of the people that took it over they were determined but I think that integration if you recall hadn't happened integration health and social care hadn't happened with the NHS at that point so to me there's a golden opportunity now to rethink what's been done and actually just think differently about how we provide that service but at the time the NHS operated by taking things back in I'm afraid and I personally think that that was a mistake at the time but it was a big in fairness it was a big change so I think actually I know I'm no expert on this but I met people they happen to learn very fast they weren't skilled in caring for prisoners because it was very separate and suddenly it became part of their service we've got 15 minutes I've got four further members who went in so Ivan, then Richard then Tom, then Miles so Ivan, thanks thank you for coming along today and just first I want to say thank you to the clerk for organising the session this morning with the ex-offenders it was some quite harrowing tales we heard but people have been let down with issues by the system there I wanted to just dig a wee bit deeper into was round about re-offending so in particular whether there's any evidence that people have got data round about the issues of where we do best practice whatever we perceive that to be or do things differently on provision of mental health services or addiction services in the prison environment and in through care post release any data round about what impact that has on re-offending rates whether there's any international examples that we can draw on because clearly Scotland and the UK in general has my understanding that a higher significantly higher prison population than many other countries who are clearly doing something a bit different clearly there's wider context there but anything specifically on as I say investment in health services and the addiction services because clearly if you impact the re-offending rates that impacts the overall cost because prisons are a very expensive place to keep people which is a virtuous circle from an investment point of view so anybody want to pick that up? I think the answer is from the evidence base we understand that there is a relationship there but not we haven't really unpicked the cause and effect of that we do see higher rates of offending in people who have increased alcohol, drug, mental health problems one of the challenges that we have as researchers is to try and standardise the studies that we do to understand what the impact is of the things that we do on health outcomes but also non health outcomes such as employment housing homelessness family relationships the wider society and there is international work going on that's looking at standardising for alcohol a set of outcomes that we would measure for trials across the board that everyone would use internationally I'm involved in that piece of work and that should hopefully help us start building that evidence but unfortunately it's not explicitly there yet We're talking about a lot of stuff and a lot of ideas for improvement but without that evidence base it's kind of hard to know exactly what sort of works I think one of the challenges also is that when we're doing work of that nature it's difficult to follow up prisoners 6, 12, 18 months later so sometimes there's evidence there in the initial stages that something's going on but then the longer term effect of that it's difficult for us to identify what the impact has been Thank you for good practice guidance and documents that tell us what good practice should look like so it's not difficult to compare what we have with what should be generally in place I talked about the clinical guideline so I think there's enough there to be going on with in terms of knowing what services should look like I understand that, that's what you're questioning Is there data that says if you do this this is the result you will get in terms of re-offending, race improving and consequently cost savings because the reason for that question is if you get to the cost saving number then it makes it much, much easier to justify the investment up front Yeah, certainly there is data around the drug treatment and testing orders in terms of you know the numbers that go through those successfully so there is that data in terms of you know moving away from prison but I think in the prison context it is very complicated to actually put that in place The evidence that we submitted to the committee the follow-on piece of work that we are developing now will hopefully try and answer some of those questions we will be looking at health outcomes and also offending behaviour with a health economic analysis Okay, thanks, Richard Yeah, thank you, convener basically I know the RCN report that there's concern over the factor of G4S taking individuals to hospital or on one occasion one patient had their appointment reschedule four times due to the fact that G4S being on no show what would you suggest that or what would the panel suggest that we try to improve the service because the factor that you know at the end of the day that puts strain on the the prisoner and also put strain on the NHS I think that that's what we were talking about everyone about that collaborative partnership working there's no doubt about it we gave that example there were many examples of where prisoners weren't able to access their healthcare because they weren't able to be escorted or appointments had not been kept because they hadn't been so again there are variations in this from what I understand and I'm meeting with a group of stakeholders next week with IS is going to facilitate for us which will have more information on what that experience of prisoners is about not being able to get access to their healthcare so there isn't for me it's about if you're looking at the custodial service and the escort of prisoners it's all the same linking it to the health interventions so if you're delivering a health intervention you need to know that custodial service can deliver the health intervention the day I mentioned that I saw on prison in Venice it was actually because they were short of custodial officers it wasn't that they weren't wanting to do it but they were actually short of people themselves to be able to do that safely and to do that in that way so we raised that because it came back to us all the time questions about whether particularly the escort service was able to function to meet the needs of prisoners and we don't believe it is everywhere I can't say that as a cross board but there seem to be some notable gaps One of the other questions I have prior to coming to this place about six years ago I had the distinction of being an out of our driver for NHS out of our original that Theresa and basically and refer to the point you made and David made in that case we had what we called a one hour call and a four hour call and actually during the one night I actually when I was doing an overnight I actually had to go to a local prison and take the doctor there to visit and that actually took us about took about three hours out the whole time of the shift for the doctor to go at the prison so what and of out of ours what do you believe should be improved you know within the prison estate I think that goes back to the same model that was produced by Sir Lewis on behalf of the Scottish Government that is the out of ours model that's for out in the community which is a range of roles that in fact could do what's required like advanced practitioners pharmacist pharmacy roles so there's a whole model within there that's actually so what I would do is take that model and apply it to the prison in the context of how you provide that because when I first got involved with prison work it was over that there was actually one cheap pay before we had out of ours to be called out and it became impossible so to rely on that as a model to actually get access to treatment I think it's got to be a multidisciplinary team model and I think that that could work but it just means looking at that work which is there very clearly set out and applying it to the prisoner world Good morning panel my question I think would probably be best answered by David Liddo we know and it's specific it sort of concerns blood-borne viruses specifically hepatitis C we know that at a UK level around 90% of UK hepatitis C infections are found in people who inject drugs and we know 60% of people who inject drugs will spend time in prison and the 2012 study suggests that prevalence of HIV in Scottish prison population is at 19% now the refreshed and sexual health and BBB framework from a couple of years ago states that the Scottish Government is to work with NHS boards and the SPS to introduce up to out BBB testing for all new prisoners during the induction period however in the submission from the STF Hepatitis C in HIV Scotland it states that blood-borne virus testing is inconsistent and poorly managed overall in prisons now clearly if we're going to realise the WHO goal of the eradication by 2030 making sure testing in prisons is absolutely vital I just wonder what distance you feel we have yet to travel before realising what is set out within the framework well obviously as you say there's a huge opportunity there of people going into prison to pick those up who haven't been diagnosed so far and now obviously there are significant numbers of individuals both those that continue to inject and those that potentially stopped injecting many years before our argument was really around introducing dry blood spot testing at the point of admission and just do that routinely for individuals obviously whether with their consent and that would be a way of picking up appropriate numbers of people with HCV and actually appropriately then treating them within the prison context and what do you think of the kind of do you think specifically the blood spot testing but is the primary barrier that's resulting in this as you describe inconsistent and poorly managed overall approach? I think it goes back to that wider issue of underlying health needs certainly in terms of people with drug problems not being looked at routinely it's the presenting problem of addiction which tends to be the focus of attention not the underlying health issues so I mean it's the broad issue really I suppose of in terms of improving the overall level of primary care for individuals in terms of the general health and the mental health and then what about within the prison population do you think there's still a in terms of knowledge of treatments available obviously the prospective interfere on puts many people off has put many people with HCV positive off and treatment but given the treatments that are now available and how quick and effective they are do you think there's enough awareness within the prison population? It certainly worked that we're engaged in what we had that we were involved in a men's health day recently in Lomos prison and that was one of the things that we were doing just you know seeking to raise awareness but I think yes I mean it within the individuals at risk of HCV and those with HCV yes you know it's definitely the cases that you know they need to prove the awareness of the new treatments that are available that are obviously that the efficacy of those is very high I could just finalize do you think stigma is still a big challenge within prisons and issues of confidentiality and privacy over testing? Yeah absolutely we yeah as part of certainly that you know that the the health visits that we've done you know we've certainly picked up individuals who are actually not disclosing their BBV status for for you're talking specifically about bloodborne viruses so yeah you know that they're not disclosing their status for fear of the stigma particularly with HIV but also also with HCV as well but more so with HIV You convener I wanted to sort of reiterate what Theresa Fife had said about those who work in the health service because I thought in the prison health service because when we met them last week I really picked up how passionate they actually were about the nursing role they have but one of the things which kept being sort of brought back to by a lot of what they said was the lack of a comprehensive clinical IT system to actually get access to records and actually like you would any patient and I just wondered if a panel had anything specific and they'd like to highlight on that issue We said though that we thought by the transfer into the NHS that in fact the prison health care service would actually start to develop some of the common elements of recording and everything but it just didn't happen in the same way and again I think it's about actually just recognising that this health service model why would it change except for how you deliver it in the context of prisoner health care but why would the principles of what you provide within a community care model or healthcare model be different from what you would provide for prisoners that was the point of the aspiration of transfer I was to actually improve that and record keeping and use of technology would actually enable that and that's what I meant by the out of hours work because if you have technology you can have actually protocol driven support for various treatments that actually can be delivered by others rather than wait for that person to arrive there's all kinds of ways you can transform care by that So can I add to that actually with regards patients of prisoners with chronic conditions who would perhaps be expected to die or we wouldn't be surprised if they died within the coming year we have been working with the teams to advocate the use of any what we call anticipatory care plan so the document is the same document that we use within for all other patients within within Fort Valley and the staff are familiar with that document and it's about it supports communication with the prisoner but also if the prisoner is in and out of happens to be admitted to hospital or whatever and what you want to do is avoid an inappropriate admission as well so that can act as a communication tool between teams but certainly beneficial to get the best outcome for the prisoner Is that all paper based? Scuse me we can do it electronically as well and we're just about to test as part of his the health improvement Scotland improvement work around anticipatory care planning in the wider context we are testing the use of the new documentation and prisoners are in within that category they're one of the categories that we're about to test correct so final point what we heard over the last few weeks is that there's a general view and I think this is a general view that's been held for some time that we are locking up large numbers of people for medical problems rather than criminal justice issues would anybody disagree with that point? No? Well thank you for your attendance Alison's going to disagree go Alison go for it Can I just ask one very quick final question convener because it's something that I Since it's you Alison yes of course thank you very much I just like to I believe that the cabinet secretary has suggested a five year timescale for a move to smoke free prisons and I just wondered perhaps Mr Little if you could comment on that Yes I think you need to speak to action on smoking and health in terms of the detail of that yeah but I think certainly what I would say in terms of people with a history of a long term history of drug problems is that smoking is the norm and even when people have we have a training programme for people with a history of drug and alcohol problems to trainers workers and actually most of those individuals still after being in recovery for a lengthy period continue to smoke so I think that there is a big challenge in terms of the vulnerable populations that we're talking about in terms of their issues around and smoking and how they're dealt with so quite how that's managed I think is a significant issue as it is in other institutions yeah because it you know Just to say I personally don't know about this particularly here but I do have a colleague I'm happy to give the committee the details there's a piece of work going on at the moment over at the MRC unit Glasgow University and they're looking at smoke free prisons so I can give you those details Thank you Maybe we'll move to your smoke free Parliament at some time as we are listening and could I thank everyone for their attendance this morning it's been much appreciated okay thank you very much and we'll suspend briefly to for the panel to leave agenda item 3 is an opportunity for the committee to discuss the recent informal evidence sessions that took place as part of the healthcare in prisons and inquiry last week we met with prison healthcare staff and this morning we met with former prisoners I want to put on the record my thanks to all those who came along to what were very helpful and informative sessions their time was greatly appreciated by us could I invite comments from members on the themes that have emerged from those meetings and indeed today's evidence session who would like to start Miles that on a positive note that actually last week's evidence session I was really taken by some of the work which the nurses reported has actually taken place some of the reforms which have been put in place and to some extent the criticism they've had doesn't really necessarily pick that up so I think it's important that a lot of good works happening is just the right of reform maybe isn't what some would like to see but that's actually taken place and for for what the nurses told me it has actually transformed a lot of the experience prisoners currently face in prison the issue of appropriateness was raised by David Liddell in particular and one of the ex-prisoners I met with this morning said that some halls are now like mental health wards and obviously issues around access to appropriate healthcare delays for various reasons including you know staff who would accompany on that visit can sometimes be a barrier as well One of the issues that I picked up on last week and I suppose we touched on a little bit this week was about staff actually their time not being utilised well enough the dentists in particular were talking about they had a 50% downtime because of transferring prisoners from halls to the healthcare facilities about the logistics of having particular groups in you weren't allowed to have other particular groups in I think that in the Edinburgh prison you couldn't have females and males in the health centre at the same time and so it actually meant that there was a lot of time that was wasted and the healthcare staff found that really frustrating so I think that there's a logistics issue there between healthcare and SPS that needs to go out to them I think that the main theme that emerged for me was this issue of when people leave prison and that we are actually a number of them said that the there are health needs whilst there are problems within prisons addressing health needs they generally got healthcare within the prison setting but that all fell down when they left the prison setting because of the lack of support in order to help them once they were liberated from prison so if they left prison there was supposed to be a system in place that helped them to get benefits sorted out get housing sorted out get access to a GP and and any other services that they require that kind of system in many cases appears to be falling down unless there are organisations like SACRO and others who are there helping the prisoner on release and those who don't have that system were expressing their frustration about it falling down and then the knock-on consequence putting them back into the criminal justice system because they don't have a roof or over their head they don't have money their health deteriorates and all of that circle starts again now that was not 100% across the board the experience of people but it was a general theme that I picked up certainly in my discussions with both staff who were expressing their frustration at it and prisoners who had went through the system any other issues that people would like to raise we have extensive notes of what we heard so we will put a lot more on the record but if there are any issues people want to raise Marie I think I would agree with the issue that you raised there and also I put on the record what I think is a particular tension between the models of care within prisons and outside of prisons I think last week we heard a great deal about computer systems not speaking to each other and I think it would be remiss if we didn't flag that up in our report and the final thing that I heard a lot about last week was not just access to dental health care but the sort of the basics that would promote dental health like access to sugar-free drinks and types of tooth brushes or floss or you know interdent brushes these are I think in many prisons considered a luxury and have to be you know there has to be some negotiation around getting them and actually I would say promotion of dental health should be a healthcare issue not a luxury yeah there was the whole issue about canteen lists where things are voted on to go on a list of provisions that the prisoners can buy in healthcare items were on those lists also prisoners voting for things that you know sugary drinks and whatever that would deteriorate their teeth and the dentists were really frustrated at that but I suppose that's maybe a kind of issue about I say it reluctantly some sort of element of democracy within prisons which is an alien concept I know but you know I think people would understand what I'm talking about there Okay, we will capture all of that and much more in the notes we write up on this as agreed previously we will now go into private session