A Review of the Healthcare and Social Care Needs of the Older Prisoner Population in England and Wales

Abstract

In recent years, research on older prisoners in England and Wales has expanded significantly, and the term “older prisoner” is now well entrenched in the prison-based literature. Those prisoners who are over the age of 50 are now the fastest growing demographic in the prison system and they present with a wide range of specific health and social care needs. This paper provides an overview of the main challenges facing older prisoners in the context of their health and social care needs, including the development of mental health problems such as Alzheimer’s and dementia, as well as challenges related to mobility and engaging in structured activities in prison. This paper also considers the issue of dying in prison for older prisoners as well as the challenges of resettlement and reintegration post-release.

1. Introduction

Over the past two decades, research on older prisoners in England and Wales has expanded significantly, reflecting the need for new policies and practices to meet the complex health and social care needs of this demographic (Crawley and Sparks 2005, 2006; Hayes et al. 2013; HMIP 2004; Omolade 2014; Tucker et al. 2018, 2021). The combination of longer sentences and an ageing prison population means reform is necessary to address these challenges effectively. The current prison population in England and Wales has reached record highs, with a significant proportion of prisoners aged 50 or over—nearly 17% as of November 2023 (Prison Reform Trust 2024). While the term “older prisoner” varies globally, researchers in England and Wales often use age 50 as the starting point due to the phenomenon of “accelerated ageing” in incarcerated populations—where prisoners at age 50 can experience health conditions akin to those of individuals a decade or more older (Fazel et al. 2001; Omolade 2014; Sterns et al. 2008). Ridley (2022) identifies four categories of older prisoners that highlight varying health and social care needs: first-time prisoners serving long or short sentences, repeat offenders with prior custody experience, and long-term inmates who have aged in prison.

The growing presence of older adults in prison suggests a range of unique challenges for the prison system, including a need for age-sensitive health and social care practices (Ridley 2022). Several factors contribute to this increase in the older prisoner population. Firstly, the ageing general population, along with a rise in the overall number of incarcerated individuals, is partly responsible (Omolade 2014). Additionally, longer and mandatory prison sentences contribute to individuals ageing in prison (Crawley and Sparks 2006; Gavin 2012; House of Commons Justice Committee 2020; HMIP 2004; Price 2024). Lastly, historical prosecutions, particularly for sexual crimes, have led to more older individuals entering prison (Crawley and Sparks 2005).

This paper aims to examine the specific health and social care challenges faced by older prisoners in England and Wales and considers how these challenges are met by social workers. From a healthcare perspective, these challenges include both age-related physical and mental health risks such as hypertension, diabetes, Alzheimer’s, and dementia. Social care challenges, such as those related to mobility, purposeful activity, and resettlement are also considered, especially in the context of the Care Act (2014) and its provisions. The Act is critically examined and some of its shortcomings are highlighted. This paper also considers the issue of dying in prison and the role that social workers can play in helping older prisoners die with dignity.

2. Legislative Framework for Social Care in Prisons: The Care Act (2014)

Prior to the Care Act (2014) in England (and the Social Services and Well-Being (Wales) Act (2014) in Wales), the responsibility for addressing the social care needs of prisoners was ambiguous, with many prisoners excluded from social care services due to residency restrictions (Tucker et al. 2021). Studies revealed that only about a quarter of prisoners were receiving necessary assessments or social care support from Local Authorities, resulting in limited access to showers, workshops, educational programs, and recreational facilities for many (HMIP 2004, 2008, 2009). Between 2013 and 2014, HMIP identified that care plans were often absent in prisons, leaving those in need without structured support. Furthermore, there were discrepancies in ensuring prisoners had the same access to education and rehabilitative programs as their counterparts without social care needs (HMIP 2018).

The Care Act (2014) clarified that Local Authorities are responsible for identifying, assessing, and addressing the social care needs of all prisoners, independent of their previous residency. Upon entry into prison, prisoners are to be screened by a healthcare professional or a trained healthcare assistant, aiming to identify any social care needs. If needs are identified, the Local Authority is required to create a care plan specifying the individual’s needs and how they will be met. This framework acknowledges that some prisoners, especially those serving long sentences, may develop social care needs over time and emphasizes the importance of allowing prisoners to self-refer for reassessment as these needs arise (HMIP 2018).

Social care support in prisons adheres to a model known as prevent, reduce, and delay. This model operates as follows:

Prevent (primary prevention) focuses on those without specific care needs by providing services to help prevent the development of future needs.

Reduce (secondary prevention) targets individuals at higher risk of developing needs, offering more directed support to reduce the progression of conditions.

Delay (tertiary prevention) involves interventions aimed at minimizing the impact of established conditions, particularly those associated with ageing, to support skill maintenance and independence where possible (Department of Health and Social Care 2024).

Despite the Care Act’s directives, defining social care in the prison context remains challenging, as it is a somewhat imprecise term which lacks definition (Uribe et al. 2023). Prison Service Instruction 03/2016 provided guidance on what constitutes adult social care within prisons, encompassing physical or mental health support for areas such as nutrition, hygiene, toileting, appropriate clothing, and maintaining a clean cell environment. It also includes access to relationships, education, employment, and recreational facilities (also see The King’s Fund 2024). This framework treats the prison as a living environment, with basic care needs met by the combined efforts of health services, social services, and prison staff. Informal support systems, like Buddy schemes where trained inmates assist peers, also contribute by providing low-level social care and can help prevent unnecessary referrals for assessments (Walton et al. 2023). When formal social care is required, Domiciliary Care Workers offer direct assistance.

Since the enactment of the Care Act (2014), partnerships between prisons and Local Authorities have strengthened, resulting in more consistent referrals and self-referral options for prisoners needing social care. While the implementation of care plans has shown progress in some prisons, it remains inconsistent and heavily influenced by geographic disparities. This uneven provision, commonly referred to as a “postcode lottery” (HMIP 2018, p. 10), poses a challenge to equal access, as many social care needs, particularly among older prisoners, remain unmet (HMIP 2018). With older prisoners forming a significant portion of those referred for social care, their needs—often more extensive than those of younger prisoners—highlight the importance of embedding social workers within the prison system. Proposals have suggested ensuring at least one full-time social worker per prison facility to address these needs adequately. Such a suggestion could, however, prove problematic from a resource perspective. Funding to Local Authorities from central government has been subject to significant cuts over the past 10 years, and while social care in provision in prison emanates from the Care Act (2014), the funding for such care is not ringfenced. Social workers are employed by Local Authorities, not by His Majesty’s Prison and Probation Service (HMPPS), and it is the Local Authority which is responsible for and decides on social care provision. Some Local Authority areas have more than one prison. Others have none. Therefore, Local Authorities will determine how resources are allocated. In areas with only one prison, the healthcare team at that facility will most likely assume responsibility for social care. While the Care Act (2014) supports equivalence of care for prisoners, resource limitations can hinder its effective implementation, particularly in jurisdictions with multiple prisons.

Other challenges in social care provision include leadership, assessment procedures, care planning, environmental adaptations, and continuity of care packages (HMIP 2018). A substantial number of prisoners still require daily assistance for tasks like toileting, nutrition, hygiene, dressing, and navigating the prison safely (National Institute for Health Research: School for Social Care Research 2020). Although informal peer support is helpful, prison staff and inmates may lack the training necessary for comprehensive care, underscoring the essential role of trained social workers.

3. Healthcare for Older Prisoners

Age-related health risks such as infections, hypertension, diabetes, dementia, and cancer are prevalent, exacerbated by factors like lifestyle choices, substance abuse, limited screening, and the inherent stress of prison life (Fazel et al. 2001; Munday et al. 2019). Accelerated ageing often means that a prisoner’s “health age” can exceed their actual age by up to a decade. Many older prisoners thus present with long-standing illnesses or disabilities, and chronic conditions are commonly noted in their medical records (HMIP 2004). Despite the unique healthcare needs of this population, HMIP (2004) found that many prisons lacked designated healthcare professionals for older prisoners, with little awareness among staff regarding the distinct needs of older individuals.

A 2014 review by the House of Commons Justice Committee highlighted critical gaps in addressing healthcare needs for older prisoners. These included inadequate initial health assessments upon arrival, delays in medical evaluations and treatment, a lack of continuity in prescribed medications, and delays or restrictions in hospital referrals and external medical consultations. Furthermore, many prisoners reported barriers in accessing mental health services and rehabilitation programs (House of Commons Justice Committee 2014). Prisoners have disproportionately high levels of mental health concerns, including higher risks of depression, personality disorders, substance misuse, self-harm, and suicide, when compared to the general population (Gavin 2020). In total, 45% of prisoners over age 60 are diagnosed with at least one psychiatric disorder, with common conditions including depression and major depressive episodes (House of Commons Justice Committee 2014). However, prison is often not an optimal setting for effective treatment of these conditions. The absence of screening for dementia and cognitive impairment in over 70% of prisons in England and Wales further limits the support available for older inmates with conditions such as Alzheimer’s and dementia (Heathcote et al. 2024).

4. Social Care Challenges and Interventions

Older prisoners face distinctive social challenges. First-time older prisoners often encounter “entry shock,” marked by distress from the lack of privacy, unfamiliar routines, and overall anxiety about their situation (Gavin and Porter 2023, p. 209). Conversely, long-term inmates who have aged within the prison system may experience isolation from family and friends, the prospect of dying in custody, and declines in physical and mental health (Ridley 2022). Repeat offenders may demonstrate more resilience and familiarity with prison life, having developed coping mechanisms over years of incarceration.

Social workers play a role in addressing these needs. They assess the complex social and health needs of older inmates, often coordinating with external agencies to support housing, healthcare, and employment post-release. Social workers also advocate for prisoners’ rights and welfare, especially in terms of mobility and accessibility within the prison environment, which remains largely designed for younger inmates (Turner and Peacock 2017). Prisons from the Victorian era which are still in use pose structural challenges that may necessitate major adaptations, such as the installation of ramps and wheelchair-accessible facilities, to support the mobility needs of older inmates (Moran et al. 2022). This can sometimes prove problematic as some prisons are listed buildings which means that alterations such as widening doors to allow for wheelchair access or installing lifts simply cannot be made. However, even some newer modern prisons are often unsuitable for older people (Turner and Peacock 2017). This can result in social workers having to bring in equipment which may aid with mobility, for example, hoists to help elderly patients out of their bed. In 2024, the Prison Reform Trust’s report, Growing Old and Dying Inside, underscored these issues, calling for national strategies and additional resources to support older prisoners, including specialized housing, preparation for release, and health screenings (Price 2024). Implementing these recommendations could create a safer, more dignified environment for older inmates and better prepare them for life post-incarceration.

To improve assessment and care for older prisoners, the Older Prisoner Health and Social Care Assessment and Plan (OHSCAP) was developed. Managed by prison officers or healthcare staff, the OHSCAP involves an assessment, care plan, and review system designed to address ongoing health and social care needs that may arise with ageing. However, research has found that the OHSCAP has not significantly improved service delivery for older prisoners. Staffing shortages and rigid prison procedures have hindered its effectiveness (Forsyth et al. 2021, 2023a), and some argue that it may conflict with prison priorities of security and disciplinary objectives (Forsyth et al. 2023b). Older prisoners face multifaceted healthcare needs, and a heightened likelihood of complex health conditions compared to both younger inmates and non-incarcerated peers (Ridley 2022; Turner et al. 2018).

Engagement in education, training, employment, and other structured activities is essential for prisoners, particularly for preparing them for eventual release by building employable skills and encouraging socialization. For older prisoners, staying active is crucial for maintaining health and mitigating the effects of accelerated ageing—active participation is an essential component of successful ageing (Avieli 2022). Research indicates that structured activities and prison-based employment can play a significant role in reducing distress among older inmates, providing them with purpose and helping them stay mentally and physically engaged (Baidawi et al. 2016). However, participation in work activities may be limited due to retirement, health challenges, or other age-related limitations, necessitating a prison regime that offers suitable alternatives.

HMIP (2008) found that while older prisoners were often free to engage in activities during the day, age-specific programming remained scarce. Although prisoners can continue working beyond the traditional retirement age, those who do are often newer entrants to the prison system. Many older prisoners with mobility limitations cannot participate fully in prison regimes and may benefit from alternative forms of activity. Notable models, such as the Day Centre at HMP Isle of Wight and the Diversity Centre at HMP Dartmoor, illustrate effective practices in supporting older inmates. At HMP Isle of Wight, a specific regime offers older prisoners monthly forums, tailored educational and employment opportunities, a dedicated gym session for those over 50, and a specialized library with resources in literacy, art, and numeracy (House of Commons Justice Committee 2014). Social workers often support these efforts by promoting social activities and organizing support groups tailored to older prisoners, which helps reduce loneliness and foster social connections within the prison environment.

5. Resettlement and Reintegration

Older prisoners often face unique challenges in adapting to life after release. Long periods of incarceration can lead to “re-entry shock” as they navigate an outside world that may have transformed significantly since their imprisonment (Gavin and Porter 2023, p. 209). Social workers can advocate for older prisoners throughout this transition, addressing needs related to housing, mental and physical health, finances, and maintaining family connections. By coordinating these efforts both before and after release, social workers can help reduce the risks of recidivism, promote rehabilitation, and facilitate reintegration into society. The opportunity for prisoners to connect with post-release care services prior to their release, including social services and other support networks, enhances the likelihood of a smoother transition and successful reintegration into the community (National Institute for Health and Care Excellence 2018).

Resettlement involves efforts to support offenders both in custody and after release, with the goal of reducing recidivism and enhancing community safety through coordinated work with prisoners, families, and agencies (Gavin 2015; Gavin and Porter 2023; HMIP 2001). This process is particularly complex for older prisoners, who may face challenges related to health, housing, and social isolation upon release. Social workers play a role in preparing older prisoners for community reintegration by connecting them with housing, health care, financial support, and other social services. This pre-release support is critical for preventing post-release issues, such as homelessness or unaddressed health needs, and ensuring that older prisoners have access to essential services like home care, nursing, or assisted living (National Institute for Health and Care Excellence 2018).

Social workers provide release plans for older prisoners who are identified as having specific care needs. This plan includes a comprehensive assessment, and the Local Authority of the prisoner’s post-release location is notified of the individual’s requirements. This collaboration helps ensure continuity of care and creates a structured support system for the prisoner upon release. While Local Authorities may reassess the individual’s needs, social workers assist the prisoner in understanding and accessing available services, empowering them to engage effectively with post-release support systems.

6. End-of-Life Care and Dying in Prison

Between April 2016 and March 2020, there were 240 hospital admissions of older prisoners diagnosed with conditions requiring palliative care, and in 2023, prisoners aged 70 and over were more likely than any other age group to die in custody (HMPPS and MOJ 2024). For older prisoners with little hope of release, the prospect of dying in prison can be distressing, with some prisoners expressing a deep desire for release to avoid dying in custody (Crawley and Sparks 2006). Social workers play a role in facilitating end-of-life care by collaborating with healthcare staff to provide palliative or hospice care within the prison and ensuring that terminally ill prisoners have access to necessary support and pain management. While there is significant hospice involvement in the prison healthcare sector, it is not standardized nationally and is delivered on a somewhat ad hoc basis (Jones 2020).

Prison Service Instruction 03/2016 mandates that end-of-life care should be extended to prisoners, allowing terminally ill prisoners the choice to receive palliative care in a suitable environment, whether that is in their cell, an alternate prison, or a hospital, as appropriate. The Dying Well in Custody Charter (NHS 2018) advocates for dignified care for terminally ill prisoners, emphasizing respect, open communication, and support tailored to individuals’ spiritual and cultural needs. The charter also stresses timely assessments, medication reviews, access to round-the-clock clinical advice, and robust training for prison staff (Davies et al. 2023). In some instances, social workers may advocate for compassionate release for terminally ill prisoners, enabling them to spend their remaining time in a healthcare setting or with family if possible.

7. Equivalence of Care

The principle of equivalence of care dictates that prisoners should receive healthcare comparable to that available in the community. This principle is well established and recognized by international guidelines, including the United Nations (2015), the Council of Europe (2006), and the World Health Organization (2023). However, achieving “equivalent care” in prison settings poses significant challenges due to the high prevalence of physical and mental health issues among inmates. While the focus should be on outcomes rather than processes (Charles and Draper 2012), the reality is that prison healthcare budgets are often limited (Birmingham et al. 2006). Research has revealed numerous criticisms from prisoners regarding the standard of mental health care they receive (Gavin 2020). A key challenge is the presence of inmates with acute and severe mental illnesses who require inpatient care, but whose timely transfer is often not facilitated. Compounding this issue, many of these patients may not be adequately identified during reception and end up on general prison wings (Birmingham 2003; Gavin 2020).

Social care for prisoners also aims for equivalence. Prison Service Instruction 03/2016 outlines a commitment to providing social care that aligns with community standards, as mandated by the Care Act (2014). This instruction emphasizes that prisoners with needs arising from illness, disability, or age should have “equivalent access to care and support services as in the community” (Prison Service Instruction 03/2016 2016, 1.8). However, the National Women’s Prisons Health and Social Care Review (HMPPS and NHS 2023) identified significant disadvantages faced by women with social care needs, particularly those with reduced mobility, neurodiversity, or advanced age. Many women described the prison environment as unfit for purpose, and health and social care providers acknowledged inconsistencies in service provision. There is a pressing need for improved data collection and reporting regarding women’s health and social care needs.

The issue of equivalence of care becomes particularly contentious in the context of end-of-life care. Although some instances of good practice exist, systematic equivalence in palliative care provision remains elusive, with significant structural barriers still present (Lillie 2018). Jones (2020) identified several cases of inequitable care compared to community standards, including inappropriate use of restraints on dying inmates (20 out of 95 cases) and delays or refusals in considering early compassionate release for those nearing the end of life (15 out of 95 cases). While The Dying Well in Custody Charter represented a positive step forward, its aspirations have yet to be fully reflected in prison regulations, indicating that community standards for palliative care are not yet formally integrated into prison practices (Robinson 2023).

8. Conclusions

This paper has considered the health and social care needs of the older prisoner population in England and Wales. While the process of identifying these needs is relatively straightforward, addressing them requires a nuanced approach, due to the complexity of the prison environment as well as the unique vulnerabilities of this population.

The growth of the older prisoner population, as well as the rising levels of physical and mental health concerns of this population, has increased the demand for tailored health and social care services. The introduction of the Care Act (2014) marked a pivotal step forward in extending social care services to prisons, but its implementation has fallen short of fully addressing the distinct and often social care needs of older prisoners. Furthermore, palliative care services, which are essential for ensuring dignity and quality of life for terminally ill prisoners, remain underdeveloped and inconsistent throughout the prison estate.

This situation underscores the urgent need for a broader reassessment of how older individuals are managed within the criminal justice system. A key area for consideration is the appropriateness of sentencing older individuals to incarceration, particularly in cases where non-violent offences or declining health suggest community-based sanctions might be more effective. Community-based sanctions can help reduce the strain on prison resources and can also allow older offenders to remain integrated within supportive networks, fostering rehabilitation and reducing recidivism.

For those older prisoners who must remain in prison, the establishment of specialized prison wings or dedicated facilities is critical. Such spaces should be designed to meet the complex intersection of healthcare, social care, and palliative care needs, providing a more age-appropriate and compassionate environment. These facilities could incorporate age-friendly infrastructure, specialized staff training, and integrated health and social care models to improve outcomes for this vulnerable group.

The challenges presented by the ageing prison population demand innovative, empathetic, and evidence-based solutions. Policymakers within the health and social care system, and in the criminal justice system, must work collaboratively to rethink the treatment and positioning of older prisoners, ensuring their rights and dignity are upheld while balancing the broader goals of justice and public safety. By addressing these issues holistically, there is an opportunity to create a more equitable and sustainable approach to care for older individuals in custody.