Introduction and the existing evidence base
The Scottish Government has recognised the increasing need for social care support among the prison population and is committed to developing personalised social care support, ensuring that the "deprivation of liberty should not contribute to deprivation of other rights as a citizen" (Levy et al., 2018). Steps have already been taken towards improving social care and integrating health and social care support following the model of provision outside of prisons. As part of this initiative, Alma Economics has been commissioned to provide quantitative estimates of the level of social care support needs of the prison population in Scotland, based on statistical techniques informed by qualitative research.
Whilst it is the ageing demographic of the prison population in Scotland that is perceived to be the key driver of elevating the importance of this issue, demographic change is only part of the problem to be addressed. Moreover, the prevalence of physical and mental health conditions among the prison population is high, especially when compared to the non-prison population, and the prison environment can both exacerbate these problems and be the initial trigger. A review of the existing evidence base highlights issues of physical disability, social care needs due to ageing and increasing frailty, the prevalence of mental health and substance abuse issues, and the frequency of hidden disabilities and head injuries as key drivers for care needs. There is also evidence that many conditions are under-recognised in prison settings.
Extensive review of existing evidence identified the absence of evidence specifically on precedents for statistical modelling of the type conducted in this study. The techniques applied are therefore innovative in this particular context but are well established in other fields of economics. Moreover, qualitative research with stakeholders has been used to provide further understanding of statistical results, so this study represents a combination of quantitative and qualitative research.
The quantitative approach taken in this study
This study makes use of detailed publicly available data from the Scottish Household Survey on a representative sample of individuals in Scotland, alongside individual-level data provided by the Scottish Government on individuals receiving social care, and a snapshot of individual-level data on the current prison population in Scotland. This is augmented by SPS survey results.
This data is then used to create probability models to extrapolate from the non-prison population in Scotland to the prison population, while controlling for age, gender, and deprivation levels. Different methodologies are used to provide a range of quantitative estimates under different assumptions. To provide an estimate of the uncertainty regarding estimates, sensitivity analysis has been performed to create ranges around estimates.
Qualitative research with social care stakeholders
Qualitative interviews were conducted with a range of stakeholders in the Scottish Prison Service (SPS), NHS, and social care representative bodies outside of prisons. A key finding from these discussions was that according to most stakeholders there are unmet social care support needs in Scottish prisons.
Stakeholders raised the problem of addressing invisible disabilities and suggested there is too much focus on a narrow definition of social care as physical care needs. In addition, stakeholders provided a range of suggestions for maximising the chance of successful, comprehensive delivery of social care in Scottish prisons, including improving governance, partnering and skills, as well as reducing the stigma associated with receiving care.
Results and conclusions
The central, and preferred, estimate produced by this study is that 7-10% of the prison population in Scotland have social care needs. This is based on extrapolating from the non-prison population based on characteristics including age, deprivation levels, gender and the premature ageing of the prison population.
It should be noted that there are a wide range of estimates available outside of the central estimate. Extrapolating from the non-prison population receiving social care produces an estimate that around 3% of the Scottish prison population would have met eligibility criteria thresholds for support outside of prison. Focusing on social care data recorded in the SPS prison records system, PR2, provides the highest estimate in the range, with a result of 13%. All of these estimates apply to the same definition of social care, although the lowest estimate also factors in eligibility criteria.
Going beyond the scope of the current study, there is the question of whether preventative social care support should also be considered, so that individuals who do not currently have social care support needs become less likely to develop them. For example, more could be done to support and encourage people in custody to participate in the prison community, including purposeful activities such as work or education, socialise more and manage complex relationships, as well as preparing for their transition back into the wider community.
Delivering preventative social care would involve providing services to a larger proportion of the prison population in Scotland than under the approach of only working with existing needs. However, it should be noted that the cost per individual is likely to fall as increasing numbers of individuals receive support. This is because a small number of individuals need very high levels of support (at high cost), but reducing eligibility criteria means working with individuals with lower levels of support needs. Going further, preventative care involves working with individuals where small amounts of support, e.g. providing structured group activities, can reduce their chance of developing social care needs. Lastly, effective preventative care may reduce total funding requirements depending on the success of preventative activities.