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INTRODUCTION

This document will outline the opportunities identified within North West prisons to enhance the effective delivery of stop smoking services. It will outline the public health opportunities and benefits of delivering targeted services within a prison setting. The document will draw on examples of good practice from HMP services across the North West region and present how creative and innovative approaches can support the delivery of stop smoking services. It will focus primarily on opportunities to enhance service delivery within existing resources and will reflect on how creative use of staff across the system can increase capacity and reduce waiting lists. It is widely recognised that prison healthcare services can provide access to an ‘at risk’ group often deemed hard to reach where innovative approaches can improve health and address health inequalities in areas of multiple deprivation. In addition the document will draw on other examples of practice that challenge the perceptions of offenders being a hard to reach group and present how the prison setting presents an ideal opportunity to deliver stop smoking initiatives.

Background

This document isan output of the delivery of a Department of Health funded Public Health Inequalities Demonstration project, one of 6 such programmes nationally. This project focuses on the role of a Regional Tobacco Control Coordinator: Prisons and Criminal Justice Settingswhich was established to look toward the organisational/systems perspectives across prisons, probation services, and police custody in relation to tobacco control and stop smoking support and treatment in the North West[1].The project is part of a portfolio funded by the Department of Health and led by the UK Centre for Tobacco Control Studies (UKCTCS a UK Public Health Research Centre of Excellence and a strategic partnership of nine universities involved in tobacco research in the UK. The overall findings and recommendations being used to focus on ‘what works’, recognising complexities such as the constraints within systems for practitioners; challenges of working across organisational boundaries; and the needs of differing audiences, such as commissioners and providers.

Prisons as a Healthy Setting and Public Health Opportunity

The Healthy Settings approach was derived from the WHO strategy of ‘Health for All’ in 1980, followed by the 1986 Ottawa Charter for Health Promotion (WHO, 1980 – WHO, 1986). Both these documents were important steps towards establishing the holistic, multifaceted and multidisciplinary approach embodied by Healthy Settings programmes, as well as towards the integration of health promotion and sustainable development.

"Health is created and lived by people within the settings of their everyday life; where they learn, work, play, and love."

(WHO, 1986)

WHO have defined ‘settings for health’ as “the place or social context in which people engage in daily activities in which environmental, organisational and personal factors interact to affect health and wellbeing” (Dooris, 2006).

In 2000 the responsibility for health policy development and standards passed from HM Prison Service to the Department of Health, Primary Care Trusts becoming fully responsible for commissioning prison healthcare in 2006. This helped change the perceptions of wider offender healthcare presenting opportunities to widen the previous medical model focus and acknowledge the opportunities for addressing the wider inequalities and public health agenda (Baybutt, et al 2006).

The Choosing Health White Paper (DH, 2004) identified the need for greater focus on preventative services, fairer access to health information, resources and care, and greater emphasis on healthier lifestyles, particularly amongst disadvantaged groups. The World Class Commissioning agenda and the work of Sir Michael Marmot (Marmot, 2010) provided the context for the development of cost effective, quality services that are delivered in partnership. The report by Sir Michael Marmot stresses the importance of addressing inequality through joint work between the NHS, Local Authorities and individual communities. The report estimates the cost of inequality as £5.5 billion to the NHS and £31-33 billion to the economy. It is indicated that we currently spend an estimated £2.7 billion a year on treating smoking related illness, but less than £150 million on encouraging smoking cessation (DH, 2011). Prisons and probation present an ideal opportunity to access an otherwise hard to reach and at risk group.

It is clear that prisons can be seen in this holistic way - they are indeed both a place and a social context, albeit in a captive or controlled environment. The opportunities for health promotion are evident in that the majority of the prison population are from deprived backgrounds and in many instances engaged in a variety of risk taking behaviours. The headline findings and the best practice outlined in the 2007 document Stop Smoking Support in HM Prisons: The impact of Nicotine replacement therapy (MacAskill and Hayton, 2007) identifies that substantial quit rates can be achieved in the prison setting acknowledging that in addition to this there is prisoner interest in participation. This paper will build on these finding and the” Acquitted”: Best Practice Guidance document (DH, 2003) using the North West mapping work to present a delivery framework and a checklist for effective delivery of stop smoking services. Certainly the Prison Service Order PSO 3200 (HMPS, 2003) provides an additional lever and tool to consider prisons as healthy settings, supporting health promotion interventions and approaches that acknowledge the holistic ethos set out in the Ottawa Charter (WHO, 1986). It also provides the mechanism to consider how tobacco control activities link to other initiatives and how they fit into the wider strategic level.

In addition to this there are high levels of smoking amongst prisoners (80%). It is reasonable to consider that those in the probation system have an equally high rate, coupled with contributory factors such as high levels of mental health conditions, substance use and educational limitations. It is important that attention is given to the prisoner pathway on release, particularly those released on licence, to help prevent successful quitters relapse. This is supported by evidence from a number of studies across the wider Criminal Justice System. For example, a 2007 survey of offenders on the probation caseloads in Nottinghamshire and Derbyshire revealed that 83% of probationers were smokers compared to only 22% of the general population. (Brooker, et al 2009). In addition to this 63% of detainees in police custody in London reported dependence on cigarettes in a 2007 survey (Payne-James, et al 2010).

‘Improving Health, SupportingJustice’ : The National Delivery Plan of the Health and Criminal Justice Programme Board (DH, 2007) proposes a whole system approach and outlines that research has also shown that offenders generally do not access the health services they need outside of prison (DH, 2007). The criminal justice system offers a range of settings and opportunities that, when properly used, would allow health services to engage better the perceived ‘hard-to-reach’ sections of the population. It provides a prime opportunity to address health inequalities, through engagement with NHS health services and specific health promotion, treatment and prevention interventions.

The basic principle underpinning health provision within prisons is that services are based upon needand offered to an equivalent standard to those in the wider Community

(DH, 2003;DH, 2002; DH, 1999)

This is supported in HMP service order PSO 3050 which states that the aim of the partnership between HMP and health ‘is to provide prisoners with access to the same range and quality of services as everyone else’(HMP, 2006; DH, 1999).

COMPLEXITIES OF THE SETTING

‘Acquitted’: Best practice guidance for developing smoking cessation services in prisons (DH, 2003) acknowledges the importance of understanding the role smoking has in the lives of prisoners, in particular relief from both boredom and stress and this is supported from the mapping work to date. This is perhaps further compounded by increased stress points and the lack of variety in diversionary activities in prison;

  • Offenders as a high risk group
  • Both educational and health literacy issues
  • Lifestyle experiences and risk taking behaviour
  • Isolation – lack of , or a need for, support from partners and family members
  • Boredom and including unemployment;– access to diversionary activities and incentives
  • Culture and masculinity issues relating to men’s health and access to health services
  • Tobacco and its role as currency in prisons including issues of illicit trade
  • Mental health and well-being – depression, anxiety ; confidence self-worth ; emotional wellbeing; stress and appropriate coping mechanisms
  • Bullying – the social context, relationships and cultures of violence
  • Identity and the need to ‘fit in’
  • Control over the frequency, ability and affordabilityof smoking; impact on offenders of staff smoking – in prison and probation

Barriers / Facilitators

As has been previously outlined, smoking prevalence in prison has been estimated to be around 80%, with similar figures suggested for the probation setting. However smoking habits do change in prison and this can be both positive and negative. The feedback from the mapping exercise indicates that smokers in prison smoke a reduced amount largely due to the reduced supply and in some instances, in a reduction in the frequency of smoking. This is supported by findings from the project rapid literature review (Mac Leod,et al 2010) which cites evidence from a number of sources. The review also identifies a US study from a female prison that indicates an increase in smoking behaviour among inmates showing that 14% of prisoners started smoking for the first time when entering the prison 50% having increased their consumption (Cropsey,et al 2008 cited in Mac Leod, 2010).

From the project mapping exercise it is possible to identify a number of keys issues in the delivery of stop smoking services. The variety of delivery models is in some ways to be applauded,as there have been creative solutions to providing access to stop smoking services. However there are also a number of barriers to delivery. The key area of concern is that of capacity, an issue despite how or who delivers the service. All the prisons have waiting lists which range from 2/3 weeks to potentially 12 weeks, although drop in style services have in some instances resolved this. The number of DNA’s (did not attend) in some establishments is a problem due in many instances to regime issues and difficulties escorting prisoners to sessions or appointments.

There are positives and negatives to the mode of delivery. In establishments where the community teams deliver the sessions, the benefits are dedicated time by staff whose core role is delivery of stop smoking services. The negative to this is that staff are less familiar with the complexities of the prison system and the internal nuances, offering greater opportunities for prisoners to abuse the system and use of NRT. Where prison health care staff or gym staff deliver the sessions, the positive is that they understand the internal systems and day to day issues and are perhaps more aware of potential abuse etc. The downside is that the time is not always dedicated or prioritised to the delivery of stop smoking sessions so they are more prone to being cancelled.In some prisons, particularly local remand and female establishments, the turn round of the population presents a challenge to delivery of a structured stop smoking programme and as a result it is understandable to see lower numbers accessing services.

The abuse of NRT is an issue although most prisons have mechanisms in place to monitor the distribution and use of patches in most instances this is on a patch for patch return basis. This coupled with regular/random CO monitoring helps alleviate some of the issues. However in larger prisons, the distribution and monitoring through pharmacy is more complicated and weekly supplies are more frequent. Some prisons use compacts ( a contract) with prisoners commencing stop smoking programmes. These explain the prisoner’s commitment to the programme, outlining the use of CO validation, monitoring the use of patches and in some instances, informing prisoners of potential random cell checks. These measures are useful in terms of controlling abuse of NRT, reducing the opportunity to use it as currency. Both tobacco and NRT are used as currency and there is the potential for bullying to take place as a result. This is an important factor in understanding the role of tobacco in the prison environment.

The use of random CO monitoring is utilised in some establishments to varying success but it certainly provides an additional level of control. It should be feasible in prison to achieve the target of 85% CO validated 4 week quits and there is definitely potential to have 100% CO validation. The only barrier would be prisoners lost to follow up due to release or transfer.

Access to NRT is limited to patches in many establishments although some do actively provide access to Micro tablets, nasal sprays, inhalators and in a small number Champix. However access to Champix is not good and is often only considered in instances where a prisoner has already started on a programme on the outside or has been transferred part way through a course of treatment. Some prisons do not provide access due to the indicated additional suicide and mental health risks. Patches are generally accepted as the preferred treatment option as they are proven to be effective, easily administered and cost effective and this is reflected across the prison system. There is clearly a need to provide some consistency to the wider products available across the system as some prisons have cleared items through security whilst others have not; again these are issues that need to be considered in the training of staff.

The following checklist provides an excellent framework to support the delivery of prison specific stop smoking services. This along with the service delivery framework, will provide a comprehensive tool kit to assess current stop smoking services, outlining a set of minimum standards and identifying best practice to support enhanced delivery.

FRAMEWORK FOR THE DELIVERY OF STOP SMOKING SERVICES IN PRISON
Assessment area / Anticipated service delivery / Best Practice
Health Needs Assessment (HNA)completed and up to date /
  • HNA completed and action plan in place.
  • HNA reviewed and updated on an annual basis.
/
  • HNA completed and action plan produced reviewed and updated on an annual basis.
  • HNA used to develop a wider strategy for prison health care incorporating health promotion and addressing inequalities.

SmokingPolicy Present /
  • Smoking policy in place in line with the current PSI.
  • All staff informed of the policy.
/
  • Policy reviewed bi-annually and compliance monitored quarterly.
  • Smoking cells designated in writing in line with the current PSI.
  • Non-smoking prisoners housed in smokefree cells.
  • Prisoners have access to smokefree landings if requested.
  • Staff smoking closely monitored to ensure compliance with policy.

Core Services delivered
(see additional sections) /
  • Applications and assessment process in place to outline motivation and readiness to quit.
  • Access to weekly support sessions and provision of pharmacotherapy (with regard to pharmacotherapy minimum treatment options being access to NRT patches).
  • Minimum duration of support 6 weeks. (12 week programme recommended) 4 week Quits CO validated.
  • Referral to healthcare for prisoners with additional health issues.
  • Access to appropriate literature.
/
  • Applications and assessment process in place to outline motivation and readiness to quit.
  • 12 week structured programme in place with access to both 1:1 and group support as appropriate.
  • Dedicated staff time allocated to stop smoking service delivery and all delivery staff trained in line with North West Prisons and Criminal Justice Settings - Stop Smoking Training Knowledge and Skills Competency Framework (UCLan, 2011) and to NCSCT accredited levels - other non- health care staff trained in brief intervention and all staff trained in Very Brief Intervention (VBA).
  • Health trainers and prisoners involved in supporting the delivery. Services supported by a variety of staff across the wider prison. Protocols in place to monitor and deal with those who do not attend(DNA’s) including where necessary waiting list initiatives.
  • Systems in place to ensure timely prisoner movement and mechanisms in place to provide speedy follow up when regime/security issues prevent attendance.
  • In line with regional and local NRT protocols access to patches for the majority of prisoners with additional NRT options including combination therapies as appropriate.
  • Access to Varenicline (Champix) for selected individuals supported by healthcare (it is anticipated numbers accessing will be very low).
  • Protocols and controls in place for provision and prescribing of NRT and Champix (see below).
  • All 4 week Quits CO validated (minimum 85%) with regular weekly CO checks in place. Prisoners sign a compact on commencement of treatment outlining their commitment to the programme.
  • Incentives and diversionary activities in place.
  • Links to partners and visitor centres. Programme specific literature available (consideration given to literacy and language needs).

Pharmacotherapy support /
  • Routine access to support and NRT in the form of patches as a minimumfor all prisoners signing up to a stop smoking programme.
  • Regular use of CO monitoring.
  • Access to additional healthcare support for prisoners with additional health needs.
/
  • In line with regional and local NRT protocols - Routine access to NRT in the form of patches for all prisoners signing up to a stop smoking programme.
  • Clear patches prescribed to aid security. Controls in place to monitor prescribing of NRT supplies distributed on a minimum weekly patch for patch return basis including routine/random CO validation/monitoring.
  • All prisoners achieving 4 quit status to be CO Validated. Prisoners agree a compact on sign up to stop smoking service programmes (including notification of potential random cell searches).
  • Access to other forms of NRT and combination therapies as appropriate in consultation with healthcare lead.
  • Varenicline (Champix) available to those meeting criteria.
  • Referral protocols in place for prisoners with additional health needs.
  • Priority targeting and access to support for prisoners with long term conditions for example those with COPD.
  • PCT formularies and protocols reflect access to NRT delivered in the community and delivered in line with regional and local protocols.