Documentary analysis is a well-established way of gathering data and can take a myriad of forms. The approach can include the systematic analysis of organisational and institutional reports . In understanding how prisons can be configured to be more health-enhancing than depleting, prison researchers have largely neglected documentary methods, opting instead to pursue empirical approaches [29,30,31]. These studies have offered a great deal, but have tended to focus on a single prison or small numbers of prisons which makes transferability of findings challenging given the heterogeneity of most prisons. Using a more cross-sectional approach provides wider insight into activities designed to ‘promote health and well-being’ in prison establishments in England and Wales identified by HMIP.
Prison inspectors work to a set of “expectations” relating to the level and quality of service that it expects to find in prisons [20, 32]. It is, in effect, the criteria by which prisons are assessed and evaluated. The public repository hosting the HMIPS reports was accessed via the internet. As this repository contains the full range of inspection reports carried out by HMIPS since 2012 the relevant reports were identified by filtering by the name of each institution within the female estate. The most recent unannounced inspection report for each institution was downloaded. Because of the limited number of inspection reports available for analysis, no further sampling was undertaken and all of the existing thirteen reports were included in the analysis. The inspection reports were downloaded during December 2020 and included reports published between 2017 and 2020. To target the Inspectorate’s reporting of the promotion of health and wellbeing, a subsection of the report was focused on. Section two of the report describes the second healthy prison test of ‘Respect’. This contains the subsection ‘Health services’ and within this section, under the ‘Governance arrangements’ heading, HMIP state the expectation that the promotion of physical and mental health will be demonstrated by the prison . Consequently, this section was the unit of analysis for each of the thirteen reports.
The standards of treatment and conditions that the prisons were expected to achieve included:
Women are cared for by a health service that accurately assesses and meets their health needs while in prison and which promotes continuity of health and social care on release.
Women benefit from evidence-based health services which are safe and accessible and which maintain decency, privacy and dignity and promote their wellbeing.
Patients are treated with respect in a professional and caring manner which is sensitive to their diverse needs, by appropriately trained staff.
Women are aware of the prison health services available and how to access them.
All women receive information about health promotion and the control of communicable diseases .
Analysis of the data was undertaken on NVivo 12 using thematic analysis . The data were inductively coded initially by one member of the research team, then checked by another member of the team, resulting in 24 open codes. These were discussed and reviewed by all members of the team resulting in a number of more substantial, cohesive themes.
This section reports the thematic categories derived from data analysis. Where appropriate quotations have been used to illustrate key points and issues. The prisons have not been identified in the reporting of the findings.
Health promotion models and approaches
Health promoting activities were taking place in the majority of prisons. This ranged from the simple provision of information in the form of leaflets and displays of literature to a more structured calendar of activities across the year in some prisons which could also mirror the national campaigns taking place in the community:
“There was also a schedule for promoting national health campaigns.” (Prison 12)
These included presentations, awareness raising events and an educational sexual health programme focusing on lifestyle choices. A small number of inspection reports described the use of peer support with ‘health champions’ providing ongoing support and information for the women.
In a small number of institutions, Inspectors described the ‘healthy lifestyle’ support that was available with a focus on exercise and healthy eating. The majority of inspection reports made reference to smoking cessation services in response to the implementation of the smoking ban in prison in 2017:
“The prison had been smoke free since September 2017, aided by well-planned smoking cessation support, which was still available.” (Prison 3)
All of the thirteen inspection reports referred to the health screening programmes employed within the institutions. These included screening for blood-borne viruses, cancer and hepatitis as well as immunisation programmes and systems to manage communicable diseases:
“Effective systems were in place for the management of communicable diseases. Women had good access to age-appropriate screening programmes, including for breast cancer and blood-borne viruses, as well as to immunisations.” (Prison 10)
Reproductive health was also a key focus of the services provided to women with sexual health support available in the majority of institutions, including the provision of barrier protection. The reports revealed that barrier protection was not universally available in a number of prisons, frequently not advertised, and available only from health care staff:
“Sexual health screening and treatment were offered and barrier protection was available, but not well advertised.” (Prison 12)
In some prisons, barrier protection was only available to women going out on temporary licence or being released. A small number of inspection reports described the information provided to women around menopause, and one inspection report described the ‘excellent’ care provided through the perinatal and maternity pathway used in the prison including antenatal education and postnatal support services.
Whole-prison approach to health promotion
A joined up approach to health promotion was only cited in a minority of these reports where health promotion was ‘an integral part of the prison’s well-being strategy’ and a comprehensive plan informed by wider national and local initiatives was employed. However, the level of partnership working between the prison and the local primary care and mental health care providers was widely noted in the inspection reports. This constructive working relationship was facilitated through regular strategic meetings which provided effective oversight and governance of the health care service:
“Commissioners and health providers attended quarterly contract meetings where they could identify and act on key issues.” (Prison 5)
In a small number of inspection reports an explicit reference to a lack of a whole prison approach to health promotion was made by Inspectors:
“There was no strategic prison-wide plan for health promotion or any named lead staff member responsible for this area of work.” (Prison 2)
This resulted in health promotion activities that were ‘too limited’ or provided on an individual basis.
Around half of the prison inspection reports indicated that the women had an active role in the management of their health while in prison. Some institutions had formal processes in place which allowed the women to take part in consultations through patient participation groups and forums. In some prisons there was a prisoner healthcare representative on the health council and therefore part of the consultation process. There were concerns noted by inspectors of one prison that the consultations were not regular nor did they involve prisoners from across the whole prison. In one prison a new patient participation group was set up as a result of the inspection there.
Surveys were another method used to gather the views of the prisoners and in some cases these had led to impacts on the delivery of services:
“Effective patient engagement, with regular health improvement groups and surveys, has influenced service delivery improvements.” (Prison 8)
But it was also noted that the issues raised through these channels could be ‘raised repeatedly without being properly resolved’ and an example of surveys being completed in one institution but then not evaluated was described.
A confidential complaints process was in place in nearly all of the institutions, offering a route through which women could raise individual issues and concerns. In the majority of prisons the complaints process was managed appropriately with a polite and timely response:
“Health care complaints were managed through a confidential system and passed on to individual health care managers...Investigations were sensitive, addressed concerns raised and provided clear responses.” (Prison 11)
However, in several prisons the system was not confidential, responses were slow, and women were not fully aware that the system was available to them:
“Patients submitted complaints through the central hub, which was also not confidential. The complaint responses we sampled had been investigated properly and were polite, but information on how women could escalate their complaint was not always clear.” (Prison 10)
In a small number of institutions the inspection resulted in a new confidential system being put in place.
In the majority of the prisons inspected the relationship between prisoners and staff was described as ‘caring and compassionate’ with a sense that the staff ‘knew their patients well’. There were examples of the needs of women being met through appropriate onward referral and an understanding of the impact of wider inequalities on some women with appropriate use of capacity assessments to ensure women understood their treatment, and interpretation services used where women did not speak English.
However, the inspection reports from a small number of institutions illustrated that the needs of some women remained unmet. Specific examples provided in the reports were the needs of older women or those with long term conditions for whom there was a lack of care planning and involvement of the women in the management of their condition:
“...we found not all patients with complex needs had a care plan. This meant not all staff were aware of individual prisoners’ care needs.” (Prison 2)
In some prisons the lack of health-related information available in a range of community languages was noted by inspectors. In one prison, information in other languages was available only on request which also excluded those for whom English was not their first language:
“Health service information was available in reception but it was only in English.” (Prison 1)
In one prison health information was not available in an easy read format, and in another the information about health services was only given to women who had not been in the institution recently.
Environment and culture
In the majority of inspection reports it was noted that the welcoming and clean environment of the health care centre was a strength of the service with comparisons made to the delivery of similar services in the wider community:
“The health centre operated similarly to a community practice, with a reception desk and an open waiting room, and was a welcoming area.” (Prison 4)
The majority of institutions were described as having a ‘cohesive staff group’ where, if vacancies were unfilled, agency staff were used on a consistent basis to offer continuity in provision from a team with an appropriate mix of skills. A good range of services were accessible seven days a week in most institutions, though one report noted that the service was ‘not suitable for those requiring 24 hour nursing care’ and one institution was only processing applications for health care services on week days. This, however, was reviewed as a result of the inspection.
For a small number of institutions, the Inspectors also noted other adverse environmental factors. For example, delivery of clinical services taking place in multiple areas leading to clinical and logistical challenges, or clinical areas not being as clean and tidy as other areas in the prison:
“The health centre was located over two floors and comprised clinical rooms, inpatient beds and several offices. On the ground floor, inpatient beds were on the same corridor as the busy outpatient area, which was inappropriate.” (Prison 7)
Some level of integration of the health care services with the rest of the prison was described in a small number of inspection reports with regular contact between prison managers and service commissioners.