Justice Committee

Meeting date: Tuesday, November 20, 2012

Official Report 563KB pdf

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Prison Healthcare

Good morning. I welcome everyone to the 33rd meeting in 2012 of the Justice Committee. I ask everyone to switch off mobile phones and other electronic devices completely, as they interfere with the broadcasting system even when they are switched to silent.

I have received apologies from David McLetchie.

Agenda item 1 is a round-table discussion on the transfer of prison healthcare to the national health service. Members will recall that the committee identified the issue as one to explore further.

It can be seen that our nine witnesses are interspersed—that is a wonderful word—among members around the table to encourage more open and informal debate. In fact, we want to hear more from the witnesses than from committee members. The witnesses are welcome to address one another directly if they want to add a point or to challenge. Initially, that should be done through me, but we usually find that a rhythm gets going, and we just leave people to it, as long as there is not a punch-up.

I will let everyone around the table briefly introduce themselves and say who they represent.

I am the deputy convener of the committee and a Labour MSP for North East Scotland.

I should say that the microphones will come on automatically. We have a whizz kid working the switch.

I am the clinical director for Glasgow city community health partnership with responsibility for prison healthcare.

I am a member of the committee and the MSP for North East Fife.

I am healthcare manager at HMP Barlinnie.

I am the member for Edinburgh Western and a member of the committee.

I am the planning lead for prison health and police health in NHS Grampian.

I am a Highlands and Islands MSP and a member of the committee.

I am the divisional medical director of primary care in NHS Lanarkshire and a senior medical adviser to the primary care directorate of the Scottish Government.

I am the health strategy manager at the Scottish Prison Service headquarters.

I am acting assistant director of health and care at the Scottish Prison Service.

I am the MSP for Glasgow Kelvin.

I am an associate specialist in public health medicine at the Information Services Division.

I am an MSP for North East Scotland.

I am director of operations for Phoenix Futures Scotland.

I am an MSP for South Scotland.

I manage the willow service with NHS Lothian.

I am Christine Grahame, the convener of the committee, and I represent Midlothian South, Tweeddale and Lauderdale. That is a very short title.

Before I open the discussion, I will quote from Dr Lesley Graham’s report entitled “Prison Health in Scotland: A Health Care Needs Assessment”. In the report, Dr Graham says of prisoners:

“They are risk takers in every sense, with their liability to addiction, sexual disease, physical or emotional trauma, many with significant brain damage, and at a much higher risk of early death. The majority smoke, have drug problems and mental illness. A significant minority report alcohol problems and experience of abuse. Their lives are chaotic. Their health, in physical, mental and social dimensions, is poor. Experience of prison can erode, preserve or strengthen the first two, but reliably destroys social well-being.”

That is some issue to tackle, and I thought that I would put that passage on the record because it encapsulates the situation that you all face.

I would now like you to discuss the benefits and disbenefits of the transfer of healthcare from the SPS to the NHS. Are there any volunteers? This is like being at school. If nobody volunteers, I will pick somebody in a yellow jumper.

Maybe I can ask a question. Healthcare has been transferred from the SPS to the NHS. What practical changes have been delivered? What challenges were identified at the outset?

Before witnesses respond, I should thank you all for your helpful written submissions.

Phoenix Futures has had a contract in Scottish prisons since 2005 to provide enhanced addiction casework services. We work with the type of individuals who were identified in Dr Graham’s report, who have alcohol, drug and smoking issues.

On a practical level, the transfer of our contract from SPS to the NHS when healthcare transferred on 1 November last year has resulted in on-going uncertainty about the future of services, for our staff and for the thousands of individuals with whom we work.

NHS Lanarkshire took on responsibility for HMP Shotts, and we found that we were looking after a fairly stable prison population, which allowed us to plan services more effectively for the longer term. The process of transfer was good. Work with the SPS and the various other partners who were involved in the transfer went smoothly. There was a spirit of partnership as we tried to develop services.

We have been striving to ensure that being in prison is no barrier to receiving healthcare and that what prisoners get inside Shotts is equivalent to what people get in the general population. I can give practical examples, if members would like me to do so.

Please do.

It is fair to say that dental care is of great importance to the prison population, for a number of reasons. We have brought the standard of care, and access to care in particular, much closer to the standard that the general population enjoys. As a result, the number of complaints about dental care has substantially reduced.

We have also tried to get addiction care much closer to the integrated community model that we have in Lanarkshire. We are taking small steps, but we are making progress.

I can make exactly the same point about dental care—indeed, we made it in our submission. We have not only increased the number of times that prisoners are seen by dentists but ensured that they are seen by community dentists from NHS Grampian, who have a particular interest in the homeless and substance-misusing population outwith the prison. Prisoners get similar care in the prison to what they would get outwith the prison, and there is throughcare because of prisoners’ familiarity with practitioners.

That link is a key benefit of the transfer to the NHS. This is anecdotal evidence, but I think that it holds water. Female prisoners were sometimes reluctant to access services when they were out in the community and I have heard that some women tried to get back into prison so that they could access basic services. However, if a prisoner is provided with a service by someone who is branded “NHS”, a barrier is broken down, and when they go out into the community they understand that the NHS provides their health services. The transfer has been good from that point of view.

Dr Groden, are you wiggling your finger because you want to comment? Witnesses should make it plain to me when they want to come in, so that I know that they are not just nodding in agreement.

There have been a number of developments in NHS Greater Glasgow and Clyde since the transfer, and they are on-going. One of the first big pieces of work was a health needs assessment, which was undertaken by public health specialists, to identify the needs of the population.

That particularly good piece of work has helped us to identify the learning disability support posts in prisons that are being advertised at the moment. Those people will not only identify and work with individuals with learning disabilities but raise awareness among the prison workforce, including by training SPS staff in identifying those who have learning disabilities and in how prisoners can access support and community services on their release.

We also deal with addictions. One of the advantages of our approach is that we have been able to select doctors on the basis of interviews and match some of the needs with some of their skills. Two of our general practitioners are very experienced community addictions doctors and are now working at Barlinnie and Low Moss. That added advantage supports the addiction services available in those prisons.

Those are just a few examples of the work that is being carried out.

You said that you interviewed for those posts. What happened before?

We interviewed the individuals on their transfer. For example, one doctor transferred under Transfer of Undertakings (Protection of Employment) Regulations 2006 arrangements from Medacs Healthcare. An agency previously had the contract to provide medical cover to prisons. As I was not involved at that time, I do not want to comment on who was in the service or how stable the doctor population working in the service was, but when we took it over we held a recruitment exercise to get doctors to work in it.

Perhaps someone else might be able to elaborate on that.

SPS had a number of national contracts for medical services including those provided by doctors. There would have been a similar national contract for dentistry, for example; indeed, the pharmacy contract is still continuing. At that time, it was not the responsibility of local boards but a completely separate thing.

As a healthcare manager, I went through the transfer from the SPS to the NHS and now see significant improvements for prisoners with regard to, for example, the links that we can make with the health service. In particular, our new information technology systems mean that we can very quickly get information on prisoners who are coming in, which allows us to continue care and to link with those who provide care in the community. Similarly, the systems provide us with blood results and various other hospital results to allow us to treat prisoners far more quickly than we could have before.

Education for GPs and staff who provide nurse-led clinics, which is now on a par with that in the NHS, was hard to get under the SPS. We now have expertise in the services; indeed, as Richard Groden has pointed out, we found in our health needs assessment that many services that we were delivering were of a good standard, and we are now trying to improve our weaker areas. Some of the new IT systems, the education provision and the induction process that staff have gone through have empowered us in improving overall care.

I take it that the induction process is similar to the interviewing process that Richard Groden referred to.

Yes.

Just to clarify what happened prior to the transfer with regard to recruiting medical officers, I should point out that SPS’s national contract for the provision of medical services in Scotland’s publicly run prisons came to an end at the point of transfer and that it was then up to individual health boards to recruit doctors to provide services in the establishments in their patch.

The national contract for the provision of pharmaceutical services also transferred to the NHS. A number of different things happened with the provision of services: nursing staff transferred under Cabinet Office statement of practice arrangements; doctors finished providing services because of the contract; and the national contract for pharmaceutical services and the Phoenix Futures contract both transferred to health boards.

I understand the legal aspects. However, is there any continuity? Will someone in prison be treated by the same GP when they leave prison?

As far as providing services is concerned, no.

10:15

Just so we do not go off at a tangent in our thinking, will you clarify what you mean when you talk about pharmaceutical services?

The provision of professional services and of medicines.

I can elaborate on the general practitioner provision, and who the GPs are likely to be.

We have a range of people in NHS Greater Glasgow and Clyde who work from two sessions a week up to full time. We also have a bank of locums who work in the community and are able to come in and supplement the numbers that we have in the prison or fill in any gaps that we have in the rota.

All of those doctors will be working as general practitioners, bar the two who work in addictions, and they also have extensive general practice experience. However, those GPs will not necessarily still be the individual prisoner’s GP when they move back into the community.

There is a lot of evidence that there was a lot of unmet need and that the prison service was providing healthcare through triage and crisis intervention, so I am heartened to hear what you are saying about the more holistic approach.

Earlier this year, a prison visitor told me about the provision of dentists in Barlinnie and said that one of the prisoners had asked her to take up his case. We went to the health centre to check up on what we had been told. Although two dentists hold clinics in Barlinnie every day, there is a huge demand. Only those who are graded as emergency cases are seen immediately, and those who are graded as urgent cases have to wait longer. When we asked what constituted an emergency, we were told, “It’s if your face is so swollen that you are having trouble breathing or they think septicaemia is setting in”—that is a direct quote. I hope that things have improved significantly since then. I seek reassurance that proper dental treatment is available.

Dr Gibbons might like to reply first, as he is from HMP Barlinnie.

Dental services have been considered closely, and the NHS has recently decided to invest money in the provision of additional sessions in the afternoons. We hope that, over a six-month period, those additional sessions will bring down the waiting list.

We must also be clear about the fact that every prisoner lists themselves as an emergency and says that he has toothache because he thinks that that is a way of being seen more quickly. That causes a lot of problems for the guys who genuinely need to see the dentist. We are doing some educational focus sessions with the prisoners to get away from that culture, but the culture is well established and it will take some time for people to change the way in which they go about accessing the service.

I would like to comment on dental emergency as a category. In the community, dental emergency constitutes severe pain or dental haemorrhage. Those are the only criteria for a dentist to see any patient as an emergency, and the treatment should be carried out within 24 hours—not immediately, which would be the case with a medical emergency. It is important to bear that in mind when we are talking about dental care in the prison environment.

It is worth reflecting on Dr Groden’s point, because it is important to remember that we are talking about equivalence of care. Although we want continually to improve our care in any dimension in which we deliver it, we should not set up an inequality in the provision of care. That is unrealistic.

Absolutely, but there is a long way to go before we get to that point.

We have heard the definition of emergency cases. What is the definition of urgent cases and what is the timescale for their treatment? Would you expect to meet those timescales in the prison as well as you would outside the prison?

We try to ensure that emergency cases are seen within 24 hours. We also have provision during holiday periods to take people out to the dental hospital, should that be required. When normal Monday-to-Friday services are on, people are seen fairly quickly. Certainly, someone would be seen by a GP and given some sort of pain relief or analgesia if they had to wait from, say, a Saturday morning to a Monday morning.

Dentistry is important but I want to move on to addictions, which is the major issue for us when we look at people who are churning through the system. I also want to look at mental health problems—separately perhaps—because that is a huge psychological and psychiatric issue.

Has the handling of those issues changed in any way since the transfer of the contract? Marion Logan is out of sync with everybody else here—that is not a bad thing and I would like to hear about it. You do not think that everything in the garden is rosy and that it has all been good. That is not special pleading, is it, on behalf of Phoenix Futures?

No, it reflects the issue that we have within the prisons. It is a massive service, there is huge demand and on-going uncertainty causes issues.

You make a point in your submission that the voluntary sector has in effect been ignored in all this and pushed to the side—I am paraphrasing. Would you like to talk about the interlinking between what is happening in the prison and what happens outside, particularly in relation to the addictions and throughcare, so that you can challenge some of the other people on the panel? I like a little bit of a fight—we want to hear about some of the difficulties, not just the benefits. There must be things that are not quite working.

Ultimately, one of the expectations of the transfer was that it would improve throughcare in particular—it would improve that link between the healthcare aspects of dealing with addictions and the more holistic aspects of dealing with someone’s on-going recovery. One of the unintended consequences of the transfer is that that has not happened.

The partnership that Phoenix Futures has had within the prisons with SPS staff, NHS staff and the other organisations that work in the prisons is really important. The point that I was making in the submission is that it would not reflect the community and it would not be in the best interests of those individual prisoners with drug, alcohol or smoking issues if their issues were seen as being wholly under the remit of healthcare services, because that is not how it is in communities.

The need for the voluntary sector to be part of an individual’s recovery journey has been widely recognised, not least in the debate on the drugs strategy a few weeks ago that reinforced the road to recovery strategy. An unintended consequence of the transfer has been the on-going uncertainty regarding the continuation of the enhanced addiction casework service. Its continuation would mean that we do not end up with just a medical model for addiction work within the prisons.

My comments are quite specific to the service that I manage. I do not have the breadth of knowledge to comment on the wider debate that has been taking place here. The service that I manage provides integrated services. It is a real challenge for all of us within the NHS, the City of Edinburgh Council and the voluntary sector. We like to think that we are good at working together but it is very difficult. Providers often end up delivering services in parallel to one another rather than on an integrated basis. That is one of the issues that has been highlighted here—partnership working is very complex and very difficult.

Mr Pearson asked earlier about the practical changes and some of the challenges around the transfer. One of the continuing challenges is around partnership working and ensuring that the partners are equal, because essentially the bigger players in this area are used to being the bigger players. We are having to shift some of those attitudes. There are really good examples of where that has worked well. I like to think that the willow service is one example of that, but there are others.

Which are?

I can speak about willow in particular—

You said that there are other examples—what are they?

The 218 service in Glasgow is one. I do not want to talk about lots of services—I do not know enough details about them. However, willow and the 218 service have very close and integrated services. We sometimes see integrated services working really well in drug treatment and testing order services, too. There is a massive challenge around partnership working. It is not an easy thing for any of us, but there has been a lot of effort to move things forward. We have heard some really positive examples today of how that has worked well.

One of the continuing challenges will be the provision of equivalent care to a broad and complex population. Equivalence in care may not ensure equal outcomes for specific people in the population. People are taking account of that but it continues to be a challenge for us. Lesley Graham talked in her submission about outcome measures and indicators, and the issue of what success is. Some of what we are talking about today is fairly anecdotal because we do not have national indicators for success in this area. One of the challenges in that is ensuring that our outcome measures are gender specific, in that we ask the right questions to ensure that we get the correct answers on what progress is and what success will look like. That might mean asking different questions for women than for men, particularly on mental health and addictions.

Why is returning to prison not mentioned as one of the things that can be measured? You were asked about measuring outcomes. One simple outcome to ask about is whether, despite all your endeavours, people go back to prison. That is easily measured.

Returning to your initial comment about addictions, I draw the attention of the committee and others to a series of research projects that I commissioned, along with NHS Health Scotland, to look at alcohol problems in particular. “Prison health needs assessment for alcohol problems”, which was work led by the University of Stirling, is noted in the briefing paper. That evidenced a high prevalence of alcohol problems.

We looked at the literature on effective interventions because we recognised that there is a range of interventions—whomsoever they are delivered by. We interviewed staff and prisoners and there was recognition on both sides that alcohol had been in the shadow of drugs. There was a perceived lack of full integration of the service as it was delivered then. There was a sort of medical stream, then there was the addiction casework service stream—that is not to say that it should not have been so, but there was a bit of a disconnect. I see an opportunity here for addiction services to become fully integrated and for leadership to bring that about. I echo Kirsty Pate’s point about partnership working. Throughcare is another area that needs attention and effort.

Along with NHS Health Scotland and others I have been working since then with alcohol and drug partnerships and community justice authorities to try to get those strategic partnerships working. Indeed, on the back of that work, £750,000 was sent out to ADPs to enhance alcohol and prison work. Quite a lot of progress has been made in mapping out what the problems are and even setting out an effective model of care. That is on the alcohol side.

The main thrust of my submission is exactly what we have been discussing, which is how we measure success. I can speak to that now or come back to it later.

Just go for it.

One of the big questions is whether the health of prisoners is better, worse or the same. It was difficult enough when I was doing my prison health needs assessment in 2007, which I outlined in my submission. There was a lack of a fully electronic healthcare system across all the care that was being delivered. There have been steps forward, though, and I am happy to hear from Mr Gibbons that progress is being made. There is now a bespoke IT system called Vision, which is hosted by NHS Grampian. However, I perceive that there are still gaps in the data that can be collected, particularly on mental health and some of the addictions. We do not have any reporting, other than health improvement, efficiency and governance, access and treatment—HEAT—standards, for what goes on in prisons. There is no routine reporting system.

10:30

The prison healthcare network that has been set up has just established a work stream. We have already identified a good few possible indicators—something like 60—that we could narrow down, so progress is being made but we cannot yet fully answer the question: has the health of prisoners stayed the same, got better or worsened?

With a view to them not reoffending. Of itself, improvement in prisoners’ health is a good thing but, as the Justice Committee, we are also considering reoffending.

Absolutely. One of the principles of the work is that, by addressing health, healthcare needs and wider needs, we will have a triple win of reducing reoffending, reducing health inequalities and, we hope, improving the health and wellbeing of prisoners and their families.

I clarify that the enhanced addiction casework service was not provided in all prisons by Phoenix Futures. Initially, three prisons—Low Moss and the two private prisons, Kilmarnock and Addiewell—had other arrangements. However, the point is the service delivery rather than the provider. It is stated in the memorandum of understanding that health boards will continue to provide that service and how that happens in future will be entirely up to them.

I know that work is happening because I have been actively involved in work in Forth Valley NHS Board. I will share that model with the committee. It is about integrating the health services, the enhanced addiction casework services and the wider throughcare services and having a pathway of care from admission to liberation. It also takes into account the research that Dr Lesley Graham discussed, in particular, the alcohol research and the funding that has been allocated to alcohol and drug partnerships to support that.

Forth Valley NHS Board is currently sharing that work across alcohol and drug partnerships. It will also be shared with the network at the January meeting as a best-practice model. It is only in draft form at this stage, but it looks like something that health boards could adopt in their geographical areas.

You did not mention what happens thereafter. You went from admission to—

Across the sentence.

My understanding from reading the papers is that it takes months and months, if not years, of support to stop people simply regressing. What happens thereafter?

Absolutely. Part of the pathway is about multi-agency working and the wider holistic approach not only from the health and addiction services, but wider services. In prison, we call it integrated case management. That takes into consideration the individual, their needs and their family and wider training, employability and learning. It also goes into the throughcare services in the community.

I have been reading the submissions, which are interesting. There is certainly improvement with throughcare, but there is obviously a little bit of concern regarding Phoenix, the voluntary sector and the professional NHS sector.

I was interested in what Dr Graham’s paper said about mental health and suicides. It was quite horrific to read about the risk of suicide among men in the prison population being 3.5 times higher than in the general population.

I have a question about research and throughcare. Ms Parker mentioned that a draft report is under consideration. When I was on the Equal Opportunities Committee, I visited Barlinnie and Cornton Vale to speak to prisoners.

We are talking about reoffending. How difficult would it be to keep track—that is probably the wrong phrase—of somebody with addiction problems that were certainly not cured but for which they got attention in prison so that we could produce a proper research paper? Can we track somebody who received medical attention and care in prison, whose health improved—obviously, it had to—and who was released and then reoffended? Is their addiction worse or less? How difficult would it be to produce a proper research paper to let us know exactly? The Justice Committee is looking at reoffending, but the wider issue is the health of the population.

It would be good for the committee to recognise that the transition is in its early stages. It has been a significant and, particularly for staff, arduous change because of the scale of the changes. To return to Marion Logan’s point, I do not see addiction services being based on a medical model in the future. The model will be multidisciplinary and will involve engagement with the third sector. People would welcome that, but I do not know whether we have yet identified a model that is absolutely perfect for all things—we are still working through some of the issues.

It is difficult to track prisoners. I can speak only about how busy Barlinnie is as a local prison. We get prisoners from all over Glasgow who come in literally off the streets, and we have to try to trace where they have been. When prisoners come in, they are not always able to tell us where they have been. Some of them are intoxicated and some are in a fairly bad way.

We still have a piece of work to do with the Scottish Prison Service on the transfer of prisoners, as we are still getting prisoners transferred from Lanarkshire NHS Board and Ayrshire and Arran NHS Board to Glasgow, from the private prisons. When our numbers decrease, we take in more prisoners and it is the same with the Grampian region. If there are various estate issues within the SPS, we receive prisoners from all over Scotland.

Trying to tune into every prisoner’s health board and addiction services provider is a very difficult task for our staff. There may be an opportunity in the future to look at healthcare in a more significant way in the transfer of prisoners. Just now, the transfers are based mainly on their security issues as opposed to their healthcare needs, and such an approach would be helpful in the future.

As no one else wants to comment, I will bring in John Finnie, who has been waiting a while.

I will be unashamedly parochial. Inverness is mentioned in Ms Logan’s submission. I am also grateful to Ms Parker for her comments. I read the Phoenix Futures submission as a promotion—I could say, cynically, that it is a bit of an advert—and I highlighted a couple of phrases that concerned me, one of which you have used this morning. You state:

“To assume that Prison Addiction Services are best run by the NHS without voluntary sector involvement negates the added value of having non-statutory involvement”.

A bit more concerning, over the page you state:

“However, to assume this can be achieved without drawing on our wealth of experience, and to support our continued involvement in working with individuals on their recovery journey is to misunderstand both the recovery journey and the role different types of organisations have to play at different points of that recovery journey.”

You would be surprised at the attention that people outwith the Parliament pay to the detail of specific issues; therefore, I must address the implication that the removal of Phoenix Futures from the provision of services in Inverness will result in some diminution of the service. I know that the reality is that NHS harm reduction, Phoenix and others are actively involved. Would you care to comment on that?

My point is not that the NHS could not provide the same services and do the group work and the one-to-ones—the purpose of the service was to offer something different from what the NHS’s addiction nurses are providing. I am thinking particularly of the role that methadone plays in the prisons. The point of my submission was to illustrate—as I have said before—that one of the unintended consequences of the transfer will be continued uncertainty. I take the point that the transfer is still in its early days and is massive, but—

I do not understand what the uncertainty is—maybe I should have said that. Where is the uncertainty?

Our staff and the thousands of people whom we work with do not know how much longer we will be providing the service because there is uncertainty around the contract. We have been living with uncertainty since last year.

Is that not the case with most contracts in the voluntary sector?

No. Most contracts have a start date and an end date. We had our end date, and now the question has been raised about whether what we understand about the contract is correct. My point is that the role that the staff play and the experience that they have gained is much valued within the prison estate. I am not saying that other providers could not provide the same service, but different organisations can have different roles within addiction services. On numerous occasions, the Government has recognised that the voluntary sector has as important a role to play as the statutory sector.

I want to broaden out from Inverness and the services that Phoenix Futures provides. We have talked about the role of the voluntary sector—Mark McEwan wanted to say something about that.

I want to talk specifically about the expertise that is perceived to be at risk. Although I work in NHS Grampian, I have been working with a number of health boards on the issue that Ruth Parker outlined about the Lanarkshire model of looking at the whole pathway. NHS Highland has transferred in the staff from Phoenix under TUPE so that their expertise has been retained and developed.

One of the key issues for me is that the prisoner journey starts in the community and, for most, it ends in the community. They are arrested in between, and they go through the courts and the prison system, but they return to the community. That is why the system has to be integrated.

I am uneasy about the idea of a national contract with the voluntary sector because I would like to think that when prisoners are released from the prison setting, they get something similar in the community, and that will be difficult if the national provider does not have a local community base from which to provide that. That is one of my on-going concerns.

We are not just talking here about Phoenix.

No.

I understand your point. You are talking about the voluntary sector and how localised provision would be useful.

Marion Logan made an interesting point about the voluntary sector. The scheme has only been running for about a year.

I ask Dr Groden and Dr Smith whether they want to hear the questions from Graeme Pearson, Jenny Marra and Roderick Campbell before they come in.

Yes.

I will take some questions then.

I have a question about the submission from Dr Lesley Graham. In the middle of the second page, she indicates her involvement in the national programme board for prisoner healthcare and talks about reaching agreement

“that Performance Management for prisoner healthcare would be as for the NHS ... but ... not ... the objective of agreeing a set of monitoring indicators.”

She goes on to say that it was “a high priority”. Therefore, from December 2011 to the present day, performance management for prisoner healthcare was a high priority, but we seem to be waddling along and not getting very far. Given the statistics about suicide that are quoted on page 1 of her submission, to which Sandra White referred earlier, that seems to be a ridiculous thing to say.

In our discussions so far, we have talked about the movement of healthcare, and I believe that the changes that you are trying to bring in will be useful. I keep hearing about multi-agency integrated services, person-centred needs partnerships, multidisciplinary and holistic approaches, models, route maps, pathways and the journey, but I do not have the impression that we have a national strategy for dealing with prisoners’ addiction needs, which seem to be one of the major reasons why they are in custody. Although you are all taking a bite of certain wee bits, and it is great that prisoners will get good dental care and so on, I do not see what we are doing about the major problem, which is that almost 25 per cent of the prison population have addiction issues.

10:45

We already know about the alcohol problems. Where is the move forward on that in the new NHS approach to healthcare in prisons? I do not see that issue as a problem for the NHS alone, but what will you do to move us forward effectively?

The Phoenix Futures submission mentions phrases such as “effective illustration” and

“served Scotland well over the past few years”.

However, the number of problematic drug abusers in Scotland has risen from 55,000 a decade ago to 59,000, the number of methadone users in the country is rising and the cost attributed to that problem is growing exponentially.

I am sorry for depressing everyone around the table. I ask you to cheer me up and fill me with confidence by telling me that the collaborative approach has just not been mentioned yet.

I agree with you, and I think that every member of the committee does. That is the real issue, and we should measure the outcomes at the end. The measurement should address the question whether someone is back in prison because of their addictions; we can then find out what is really going on. We have not got to that stage yet.

I will start with Marion Logan, but there are other people on the list. I will write their names down or I will get lost.

With regard to the transfer, we were not starting from the beginning as we already had partnership linkages with a lot of other organisations. The throughcare arrangements—while they were not perfect in any part of the country—were able to link an individual with services in the community. Some of those arrangements, which were put in place to ensure that an individual’s support and care continue on release, worked very well, and some needed to be improved.

One consequence of the transfer is that more individuals, particularly those who have not had any prior experience of working in a prison, are having to skill themselves up to deal with what that involves. The models were there and the throughcare arrangements were in place, so we were not starting from the beginning. It is disappointing that some of the models that are being discussed will not have anything new in them.

I also raise the point about record keeping and being able to evidence achievements. The prisons, and certainly the addiction services, comply with the HEAT targets that are set for waiting times. The Phoenix staff submit to those targets, so we get statistics on how quickly people are seen. The SMR—substance misuse record—25 database is also used in the community. Forms are completed, so there is information that allows us to look at the whole volume of work. A number of organisations record outcomes information, so it exists. The question is whether, collectively, we are interested in looking at it.

What about your success in ensuring that someone does not reoffend? What records are there on that?

It would be possible to see that if the collective will existed among organisations to report that information. The information is collated using the various tools that are available in statutory and non-statutory services, but no one brings it all together to examine it and ask what it means. It tends to be reported on an individual organisational basis rather than on a collective basis. Every organisation would certainly be able to submit that information.

I find that quite breathtaking, and that is where we come to the crunch. All that public money is being spent, and many people in the voluntary and statutory sectors are putting in a lot of effort. However, we are sitting here and no one can tell us how effective all that is—over a period of time—in addressing the issue of the revolving door into prison.

I see that Dr Graham might be able to help us.

I have—

You are on my list too, Dr Groden.

I was just going to answer that very point.

Did Dr Graham want to answer a different point?

I wanted to go back to the lack of progress and how we measure outcomes.

We will deal with the point about measuring reoffending first.

I have some information on the effectiveness of opiate substitution therapy, particularly in Greater Glasgow and Clyde. Some of the outcome measures are the number of drug-related deaths, the number of deaths where methadone was in the person’s system, and the healthcare and criminal justice costs for those not in treatment versus the costs for those in treatment for less than one year and those in treatment for more than one year. We can see the reduction. The information is in the 2009 report “Assessing the Scale and Impact of Illicit Drug Markets in Scotland”, which was commissioned by the Scottish Government.

The outcomes are that the healthcare cost for those with drug addiction problems who are not in treatment is £3,005, which reduces to £1,536 for those who have been in treatment for less than one year, and to £1,173 for those who have been in treatment for more than one year. The criminal justice costs go from £12,713 to £1,536. Those figures, which were produced by the Scottish Government in 2009, evidence the benefit of substitute prescribing for this population.

Dr Groden will know that drugs deaths have reached an all-time high in the past 12 months. I would not like to begin to visit the numbers that you have just quoted in terms of costs and so forth, because I think that guessology would be involved rather than science.

My question is not so much whether there are benefits in terms of financial savings, crime reduction and so forth, but where the collective strategy is, on all your parts, to reduce the problem. Let us accept that all that you have said is true, and that it has been a plus. How do we begin to deflate the problem, which we seem to accept is just part of life? How do we take everything that has been said in the past couple of hours and make it have an impact on the group that we are discussing, rather than merely managing the situation?

Dr Groden, do you want to answer that before I go back to Dr Graham?

I am happy to answer that. I think that there is a big opportunity. I accept that it takes time to influence a change, but we can do that by having a continuum of service.

As a GP in the east end of Glasgow, I see these individuals both in the prison setting and outwith it, and they do not change. It is the same people and there is a revolving door. You talked about further sentencing and the rates of readmission to prison. A number of these people are readmitted because of outstanding warrants; they are readmitted not because they have committed a further crime but because of something that they did before their previous admission. For me, there is something significant in that, given my experience of seeing these people. They come in and see me in my practice, then I do not see them for three months, and then they reappear.

We have communication with the Prison Service and we have tightened up the continuum of care within the prisons, with better contact with GP practices and those who deliver services to the community. That applies both at the point of entry into prison and when people are released, to ensure that they continue to receive appropriate care in the community setting, because it is when people are released that they are most vulnerable. We no longer let them go out and try to find their own GP, who may or may not be willing to prescribe methadone for them. They have a planned release in order to ensure that what is provided is better than that. There is an opportunity there.

We manage and are involved in delivering the continuum of services to these individuals in Greater Glasgow and Clyde. As Mr Gibbons said, the biggest challenge is when people move around the country. In such cases, there is a real difficulty in accessing services for them, because we are not familiar with the services throughout the country.

But you accept that, as was mentioned earlier, there is an absence of what, for want of a better term, I will call performance indicators that reflect whether reoffending is reducing or otherwise. The absence of those indicators is quite incredible.

I absolutely accept that, yes.

So what do we do about it?

I cannot answer the question about the lack of progress. The prisoner healthcare network has been taking that work forward, and it is not represented here today.

However, I believe that we have moved forward, particularly on the alcohol front, in relation to what works, the evidence and a way forward, which we are continuing to push. I agree that, although there is some evidence on outcomes and the prevalence of problems, as Ms Logan said, it is not comprehensively brought together and it is not complete. I would like that to happen.

On information on reoffending, there is the potential to bring the two areas together by linking the prisoner records system with healthcare systems and mortality information. That is the basis of the work that I did when I was in the Scottish Prison Service. When I went back into the NHS to explore whether I could do that in relation to monitoring the Scottish Government naloxone programme, I found that there were no permissions for that and that I could do it only while I was in the SPS. Although the Information Services Division has been working on that area, we must go into the Scottish Prison Service and manually search records, which is laborious. There is therefore work to do on information-sharing protocols between the Prison Service and the NHS in order to achieve what are common goals. I see a way forward, but the problem is getting there.

I would like somebody to comment on that. It seems to me that what you describe should not be difficult to do. Can somebody from the prison side tell us how we go about doing that?

I will just explain where we were on healthcare records prior to the transfer. We relied heavily on a manual healthcare records system, which made it difficult to gather and interpret information. The introduction of the Vision system on 1 April this year will ensure a more consistent way of recording health information. However, that development has still a wee bit to go. We probably still do not have the software design to gather the right information for mental health engagement and addictions engagement. The system is currently not used for prescribing, and a manual prescribing system is still in place. The new IT system will replace that, although we still have a wee bit to go.

On the workstream for performance management, we must wait for the network to pull together the indicators in order to get a consistent model for recording information.

It is breathtaking that there is still a manual prescription system. Sandra White has a question, but is it on that particular point? Jenny Marra and Rod Campbell are waiting.

It is on that particular point. My first question on the issue was about difficulties, but it seems that the NHS and the SPS are coming together on a records system, although the IT needs to be improved. Perhaps the committee could write to the Cabinet Secretary for Justice to chase up what is happening about the IT system. We need to have the records together. That would be a real improvement.

Your suggestion about writing would follow on from this round-table discussion. Sometimes in these discussions little gems of suggestions float to the surface, and the one that you have made is one such.

Jenny Marra will be followed by Rod Campbell, after which I will take the other two witnesses, who have been waiting quite a while.

I want to ask about speech and language therapy provision in prisons. The committee had a round-table evidence session a few weeks ago in which we looked at prisoners’ communication issues—language skills, confidence and all sorts of related things. What provision of speech and language therapy was there before the transfer? What plans are there for that therapy post the transfer?

I do not know whether I have the full details, but, prior to the transfer, a speech and language therapy service was available at Polmont prison and I think that there was a call-in service at Inverness prison. I do not think that there was much more in terms of consistent speech and language therapy services. However, if someone had a specific need in that regard, I am sure that health service colleagues would have engaged with them and tried to get a service brought in for them.

Before I let Jenny Marra back in, Dr Smith and Mr McEwan want to come in on that point.

I will confine myself to commenting on the post-transfer aspect. It has been noted that services from allied healthcare professionals, including speech and language therapists, physiotherapists and occupational therapists, have increased and improved at Shotts prison in Lanarkshire since the point of transfer. However, much of that work is done through individual needs assessment. For example, if one of the clinicians closely managing patients identifies that an allied healthcare professional needs to become involved in an individual’s care, they will come in to provide that care.

11:00

I was going to make exactly the same point, as that is what happens in Grampian. Perhaps this will cheer up Mr Pearson—

I do not know whether that is possible, but go for it.

Yes, go for it.

I will try my best.

In preparation for HMP Grampian opening at the end of the year, I am doing a review of all the services that we currently provide, and the involvement of the allied health professions is exactly as has been said. We have looked at what went on before and it was the same situation, in that services were provided almost as required. For speech and language therapy, generally the issue is to do with swallowing-related problems. In doing that exercise, I have found absolutely no problem in engaging fellow professionals on issues related to mental health, substance misuse and the whole range of services that we provide. If the transfer has done one thing, it has raised the status of prisoner health higher than I have ever known it over the past four or five years. Although some things may have been frustratingly slow in the first year, one good thing that the transfer has done is that it has raised the profile of prisoner health nationally across the health field—

Is Graeme Pearson smiling now?

Yes, that is true. I acknowledge that that is going on in prisons.

Well, it was not a smile, but it was close.

As good as it gets.

At any level, if I ask for engagement on a medical input, the medical directors are pushing each other out of the way to get there, and the same applies to dentistry, psychology and so on. I think that there is a very positive vibe around prisoner health at the moment.

Are Dr Smith and Mr McEwan both saying that a speech and language needs assessment is done of every prisoner in their care?

No, I do not think that that is what I said. When an assessment of a prisoner is made and it is thought that the prisoner needs input from any particular type of professional, that professional will come in from the NHS family to provide the care.

How does that assessment come to be made? Does that happen on admission to the prison?

I can speak for Shotts prison, which is slightly different from other prisons in that it has a long-term, very stable population. As healthcare needs arise or as people are assessed on admission, a care plan, if you like, is made for each individual. The relevant professionals who will be involved in delivering that care plan are identified and brought in.

I think that Mr Gibbons wants to make a similar point about assessment.

Let me first just clarify something that Dr Smith said. He referred to assessments being made as healthcare needs arise. Where a prisoner is ill and is taken in for a medical assessment, a wider assessment might be made at that point. However, a prisoner could conceivably be in Shotts prison for 10 or 12 years with a very bad stutter or stammer that could be helped by speech and language therapy but a needs assessment might never be made. Is that correct?

I suspect that the needs assessment would be made only if the problem was brought to the attention of the clinical staff working in the area.

Now that the prison health system has been transferred over to the NHS, is there scope or the budget to provide a whole healthcare needs assessment for every prisoner in the system?

I think that the fiscal results of that would be quite challenging.

I was going to make a similar point. We would normally pick up whether a prisoner has a specific need when they are admitted to prison or attend one of the on-going clinics, where people can be referred to the GP or nurse. If someone raised an issue, we would certainly engage with any specialist service for them. That is how it would normally work.

I think that an assessment is made of every prisoner anyway, because when they enter the prison system they will see a member of the nursing staff and a doctor within the first 24 hours. That would be one of the first opportunities for an issue to be picked up. Obviously, there is also on-going monitoring of prisoners in that they can refer themselves and are under the general monitoring of the nursing staff within the prison.

Going back to the point about the increased profile of prisoner healthcare—it has never been higher—I think that many of the managers who work in prison healthcare feel that the NHS coming in has empowered local management to push for changes that had been difficult when they were part of the SPS. That has been a positive step.

Lots of posts have come up in areas such as learning disability and alcohol services. In Glasgow, people are being appointed to look at improving services for people with learning disability and alcohol issues. Part of that improvement will be to try to carry out some quality research. Some of my colleagues care passionately about the people for whom they are trying to care and, as someone who works in a prison, it seems to me that the research that has been done has been based on England, Wales and here, there and everywhere. Historically, there has not been a lot of quality research in prisons, but I see a vast improvement coming. When that starts to take place, we will be in a much better position to form action plans.

You are talking about the available data, and it strikes me that, with the NHS coming in to provide the services, there is an ideal opportunity to create that evidence base and provide that data by doing a full healthcare needs assessment of every prisoner in our prison population.

I will use the alcohol problem as an example. Every prisoner who comes in sees a nurse on reception and a doctor within 24 or 48 hours. However, on alcohol the question that has been asked is, “Have you got an alcohol problem? Aye or no?” That has been it. We have tried to say that that really is not enough because it does not unearth problems, and that the proper, validated screening tool should be used, which does not take very long. That is the recommendation that we have put forward in the model of care.

We also recognised that the timing of the assessment is important. When a prisoner comes in, the thing at the top of their mind is not “Oh, yes, I’ve got a bit of an alcohol problem.” There is a similar situation with learning and speech difficulties. A validated screening tool is built into the assessment process. It may not necessarily be used at the point of admission—that may not be appropriate—but it should be used at some point.

When are you going to put these recommendations forward?

Do you mean the recommendations on alcohol problems?

Yes.

The research is reference 3 in my submission, “Prison health needs assessment for alcohol problems”, which was published two years ago. We have been driving that forward with Health Scotland and the Scottish Government to promote that agenda with both the alcohol and drug partnerships and the community justice authorities. Indeed, we had another big meeting just last week. We are trying to promote that, along with what Ms Parker has been referencing, as joint working to get pathways in place. A lot of work is going on to push that forward.

We are getting into jargon with words such as “pathways”, although I am not blaming you for that. I think that you are saying that you have a recommendation that the series of questions that are asked at the assessment that Jenny Marra referred to should be more pertinent, instead of just asking for an aye or a no. Why can that not just be put into practice? What is the problem?

That is up to health boards.

I mentioned the review and redesign of services that is happening in health boards across Scotland, which are at various stages. I cited Forth Valley NHS Board as being actively involved. It is taking forward the advice and recommendations from the research to include a more robust process at the admission stage to identify significant needs, particularly in relation to alcohol, and to be able to respond to that with appropriate intervention.

Where will this end up? Who will sit on the relevant group? When will it actually be done?

It will be at different stages as health boards take it forward as part of the redesign of their services. I can only speak for the board that I have been actively involved with, which is NHS Forth Valley, and it is looking to take the work forward in, probably, 2013.

Next year.

It is in draft form at the moment.

Is it the same with you, Dr Groden?

Yes. I want to highlight the keep well checks that are on-going in the prison establishment, which are part of the national keep well programme, covering such things as alcohol use. One challenge is always whether people come forward for the health checks—we are dealing with voluntary participation in those assessments.

I want to keep to Jenny Marra’s question, which is what questions are asked when prisoners, including returnees, come in for that assessment. It seems that some simple things could be asked to get a real answer, rather than a fantasy one. Does the panel have any other comments? What happens in Barlinnie prison? Are the right questions asked?

The admission process and the questions that are asked are fairly comprehensive, but there is a need to review what is said at admission and then to provide more quality time with guys or ladies coming into prison. The admission process is very busy. For example, on a Monday between six and 11 o’clock—and sometimes up to midnight—Barlinnie receives up to 100 prisoners from the courts. You can imagine how quickly those admission processes take place. Guys come in who are fairly apprehensive and quite worried about what is going to happen to them; some of them have not been in prison before. That is not the right time or place to provide a quality service. You are trying to ensure that somebody is safe and to pick up whether there are any major, life-threatening issues, such as whether the guy is diabetic or has a nut allergy—all sorts of things are picked up by that assessment.

We know that the process is fairly robust and that it works fairly well, but you need a process coming behind that in order to do some of the qualitative work that is needed to follow that up. We need to form that strategy; Mr Pearson is right that there is a bit of work to be done on the model, but people are striving to get there.

There may not be a national strategy across health boards. What is suitable for the Highlands and Islands might not be suitable for Glasgow and how certain things are approached there. The approach might be slightly different in different areas. For example, long-term prisons take people who have already been in Barlinnie for a year and whose health problems are pretty much sorted before they go there, although of course they may develop problems when they get there. However, in local prisons, complexities can arise and the speed at which things happen is very fast. When you talk about a full prisoner assessment on admission, you must remember that some of those guys may be in prison for only 14 days before they are away again.

I did not necessarily mean on admission.

Okay. You are right about people who have stayed with us for any length of time—we need to quickly develop models that meet the needs of different prisoner groups.

If that is done in the prison is there a barrier to sharing that data with the health service?

No.

There should be none.

There is no barrier with the NHS, which is providing the service, and there is linkage.

That is an interesting observation. In a former life, I was a GP. At the time, I was aware that prisoners who came out of prison left with very little information about what happened in relation to their medical treatment during the course of their stay. The transfer of prison healthcare to the NHS offers us the opportunity to take a much more integrated approach.

The one word that I have used in relation to all the approaches to the transfer of prisoner healthcare is “consistency”. We now have the opportunity to ensure that we offer the same approach to very high-risk individuals, whether they are seeking care in the community or in prison. Soon we will have the opportunity to do that with people who are in police custody, because the same service—health—will be responsible for looking after them. We will be able to communicate more effectively between the different aspects.

11:15

For example, if we give the alcohol and drug partnerships that exist in each board area responsibility for the delivery of care to people who have addictions, we will get a consistent approach not just in board areas but throughout the country, because everyone is following the same national strategy.

There is a tremendous opportunity, but it is right that what happens is measured in some way, and we need performance indicators to underpin such measurement.

In her submission, Lesley Graham talked about mortality rates and said:

“The greatest number of deaths occurred shortly after release from prison”.

What information do you have on causes of death? Now that the NHS is working in prisons, we are aiming for as seamless a transition as possible when prisoners come out. Can you talk more about the conclusions on those mortality rates?

Are you asking what the people who die shortly after coming out of prison are dying from?

Yes.

It is unfortunate that there is no routine reporting system. Research has shown that the causes of death are predominantly the ones that I mentioned. There is drug-related mortality. We have been monitoring that in relation to the Scottish Government’s naloxone programme, because drug-related mortality in people who have recently been released from prison is a monitoring indicator. I am happy to report that the numbers have been falling. Ms Parker might back me up on that; it is emerging information.

As well as drug-related mortality, suicide levels are high. There is also alcohol-related mortality.

Could we do more to tackle such issues during preparation for discharge?

I am not at the operational front of things, but I am an ex-GP and I can speak from first principles. Prison is an artificial environment for people who have alcohol problems, and going back into the community presents many challenges to do with re-establishing relationships, employment, housing and so on. There is a high risk of relapse into heavy drinking. More needs to be done, not only on throughcare in general and looking at elements such as housing but on preventing relapse. There are various intervention strategies in that regard.

On drug-related mortality, the naloxone programme is in place and the SPS issues naloxone kits—naloxone is an opioid antagonist and can reverse the effect of overdose—so there is work on that front. I do not know what is being done on the mental health front.

Are you optimistic that the death rate will fall? Will we see an improvement in the statistics?

I wish that I could repeat the one-off piece of research that I mentioned. I had a vision of a prisoner healthcare database, so that we could run the figures at any one time. The approach would require a link between the SPS’s prisoner record system and various healthcare records, not just those in the Vision system but hospital admission and mortality records. Such data would enable us to answer your question, but we do not have them.

Alison McInnes, Graeme Pearson and John Finnie wanted to come in, but I wondered whether they would relinquish their chance to ask another question, unless they feel that they must say something. I want to ask all the witnesses what one thing they would want the committee to include in its short report. From what you have heard this morning and from your own perspectives, what should we be looking at? I do not mean that the committee should address only one aspect; I mean that I want to hear one suggestion from each of you.

My comment follows on from the discussion that has just taken place—I did not have the opportunity to come in. People talked about speech and language problems, alcohol problems, drug problems and mental health problems. Different organisations get different funding streams to do different things, so they tend to report on different issues. A prisoner is a citizen who might have a broad range of problems, but we tend to report on individual problems. That is not the reality of that individual’s life, because they live with those problems all the time.

I will try to be brief, convener. I absolutely agree that we should be able to look at offending outcomes for people, but we should also be able to talk about improvements in their mental health or their addictions, how they live their lives and how they function in general. At the moment, our funding streams do not allow us to report in that way. Instead of reporting through a national strategy, we all report on national outcomes through our CJAs, HEAT targets and suchlike. Leadership is now coming from the Cabinet Secretary for Justice, who supports the recommendation of the commission on women offenders that we start to work with people as individuals in places where they can access the whole range of services that have been picked up on. As a result, instead of people having to report on outcomes with specific regard to their funding, they can start to report on what are very varied and complex outcomes for individuals. The fact is that we need to recognise the complexity of the problems in this group.

My final plea to those who might get together to examine measurement tools is that we do not forget the specific needs of women in that population. In that respect, we need to ask different questions about mental health and trauma.

The committee is well aware of that. As you know, we have paid huge attention to the issue of women offenders.

My plea is for a continuing partnership between statutory and voluntary organisations in the provision of care and support for prisoners.

I think that members know what I am going to say: I would like to see progress in measuring the health and healthcare needs of prisoners and the associated health and reoffending outcomes.

How?

That is a long story.

Well, we have not got time for it. Perhaps you can tell us about it in writing.

I take it that you also want more progress in research. I recall someone saying that, apart from your research, there has been only United Kingdom or English research on this matter.

Evidence can be obtained from routine reporting, ad hoc pieces of work such as the prisoner survey and indeed research, all of which are important in their different ways.

We have an opportunity to introduce a circular model of throughcare, in which we not only make referrals to community services but get feedback to inform wider outcomes. I also suggest that the work that health boards carry out be used to track individuals’ recovery through their sentence and when they go back into the community, and that health outcomes inform justice outcomes to reduce reoffending.

Would it be possible to get a background paper on what NHS Forth Valley is doing in that respect?

Certainly.

That would be useful.

Data sets should be improved a wee bit more, and the software for the Vision IT system should be significantly developed to ensure that all types of health interventions in prison are captured. If that happens, we will be able to share that information with community partners.

Now that a good IT system has been established, I would like the data that we want to collate centrally and which we would use to benchmark ourselves against to be identified and agreed.

Who would do that?

It is not beyond the realms of possibility, but the co-ordination of such work will require some central resources.

Although a lot of really good stuff is going on in separate health boards, I would like that activity to be more joined up across boards. I also want to highlight the use of telemedicine, which I mention in my submission. I know that NHS Tayside is providing teleneurology in prisons; NHS Lothian is using telemedicine to provide forensic psychiatry; and NHS Grampian is looking to deal with the unscheduled element through telemedicine. I think that we can improve the service in that field but, as I have said, I want the good work by separate health boards to be drawn together.

Do health boards not meet and share good practice? How would they draw that work together?

Through the network.

We should use the prison health network. We certainly need to be a bit more active in sharing good practice.

There is a good opportunity. We are at a place where we could marry ideas and form a very positive model to take forward. Politically, people should not be put off some of the strategies that already exist, which my colleagues and I have found to be very effective. Substitute prescribing gets a very negative name because of the costs, for example, but I still remember the Prison Service before substitute prescribing, when conditions for prisoners were awful and deaths from suicide and self-harm were much higher than they are now. The number of such deaths is much lower now than it was 10 years ago. With some strategies, we should not throw the baby out with the bath water. There must be a measured approach, as some of the strategies that are in place are very effective.

Throughcare is a key area but, coming up with something different, I think that we need to look at some of the processes we have inherited around prison healthcare that we have to follow as a matter of agreement. They take up a lot of resources that could be better channelled to delivering care to individuals rather than to just processing people through the system. Until we get national agreement on which processes we need and which we have done historically but could perhaps do in a different way or dispense with, we will always struggle with having enough resources and bodies to deliver the type of care that we all aspire to deliver and which we have heard about today.

This is just an investigative and exploratory round-table discussion. If we were to return to the matter, when should we summon you back, as it were? When will things have moved on? You talk about boards speaking to one another, IT systems and so on. We may have preliminary thoughts, but what should the timescale be for seeing whether issues have moved on? We can all talk for ever, but let us get some progress.

I think that the Justice Committee should set the targets, given that it wants to see change. If you want to see change, you should set the targets for that. A realistic target would be to see progress within six months.

I would agree.

We must think alike: I was thinking about six months. That is interesting. Having had this discussion, perhaps we would like to ask the same questions in six months’ time, look at the record of what has been said and see whether there are the same answers.

Is there anything that any committee member was itching to ask but has not been asked, or will we move on?

I am sorry—I know that you want to move on.

I want to pick up on something that the chief inspector of prisons has regularly reported on in his reports on Cornton Vale, mental health issues, and the complex needs of women in Cornton Vale. He has often commented that there are people in Cornton Vale who ought to be receiving treatment elsewhere. It is clear that there were constraints in the old system. What capacity is there in the new provision of mental health services to deal elsewhere with the most complex problems in Cornton Vale? Is there enough dialogue to make that happen?

I will answer that question in a broad sense rather than in relation to Cornton Vale.

The health boards are looking at training and education for prison staff and nursing staff—by which I mean non-mental health nursing staff, such as general nurses—to manage people with complex needs. We have quite a high population of people with behavioural issues who create many problems. In particular, many have a personality or borderline personality disorder. Money has been invested in specialising and getting training for staff in health boards to help them to manage people and improve that management, and I think that that will make a significant difference. There are also plans to link in with the duty forensic psychiatrists so that we can get out-of-hours services and things that would help us to deal with emergencies and getting people to hospital fairly quickly.

Before the transfer, one of the things that the NHS did quite well was that it identified people with acute mental illness and got them into hospital, but where there were doubts about their behaviour—particularly a personality disorder—the issue was always quite difficult. I can see huge improvements being made in that area, even through having a knowledge base that will help us to better manage people who might not be best placed in hospital but could be managed better in prison.

11:30

We need to move on so, although Graeme Pearson and John Finnie are about to ask questions, I ask our witnesses to answer them in writing later—similarly, if they would like to answer Alison McInnes’s question more fully, they could do that in writing, too. The Official Report will be available to read in a few days.

My question for Ruth Parker might need only a one-line response. HM inspectorate of prisons for Scotland has reported that healthcare services in Dumfries operate under difficult conditions. Will someone in your organisation pick up on that comment and will they work through what those difficult situations are and repair them?

That is certainly not going to be a one-word answer. I ask Ruth Parker to respond in writing.

In his submission, Mr McEwan said:

“In common with other health boards, Grampian has promoted the re-registration of prisoners returning to communities among GP practices.”

I recently dealt with a situation in which three practices were declining to register people on the basis that they did not have photo identification. Are there difficulties elsewhere?

Those questions are on the record. Anyone who wants to answer them can write to the committee.

I thank our witnesses for their attendance. The session has been interesting. We were not seeking solutions today; we wanted only to hear about problems. We have heard about some and no doubt our witnesses will let us know if any have been missed.

The committee must decide whether to write to the minister to raise the issues or, alternatively, to write a little report. There is a lot to read, so I suggest that we have the discussion about that decision next week. Is that agreed?

Members indicated agreement.

We will suspend for eight minutes.

11:32 Meeting suspended.

11:38 On resuming—