Inspection findings regarding the health and wellbeing of women in prison (2019 – 2021) from Her Majesty’s Chief Inspector of Prisons

1. Her Majesty’s Inspectorate of Prisons (HMI Prisons) is an independent inspectorate whose duties are primarily set out in section 5A of the Prison Act 1952 and include reporting on the conditions for and treatment of women in prisons and young offender institutions (YOIs) in England. As part of our inspections of all prisons and YOIs holding women, we inspect health and social care outcomes in partnership with the Care Quality Commission (CQC) and the General Pharmaceutical Council.¹
2. Our response below sets out our findings regarding women’s physical and mental health; exercise and healthy living; and self-harm and suicide prevention. The information set out below is based on our findings from:
   • six full inspection reports published during April 2019 to May 2020;
   • six visits which were conducted during the COVID-19 pandemic using an adapted
     inspection methodology, published between June 2020 and April 2021;² and
   • our thematic review of prisoner’s experiences of the restrictions which were introduced
     during the pandemic, where fieldwork was conducted in two women’s prisons.³
3. Overall, inspectors found that the quality of physical health provision for women was mostly good during 2019-20 and the quality of provision continued throughout the pandemic. However, due to restrictions on health services during the pandemic, there were some women with unmet needs. Inspectors found some weaknesses in mental health provision and support for women at risk of self-harm and suicide, some of which had been identified before the pandemic. Most
   women who inspectors have spoken to stated that the restrictions which were introduced during the pandemic have negatively impacted on their health and well-being.

Findings from inspection reports published during 2019-20

4. Inspectors found that physical health provision for women had improved during 2019-20. Women’s healthcare needs were mostly met, although some women experienced long waits for routine GP and dental appointments. Partnership working and governance was mostly good and the provision for promoting good physical health was positive. All women had appropriate screening on arrival with a follow up assessment within their first few days in prison. A range of primary care clinics were available and women received appropriate health care support in preparation for their release. Most prisons we inspected during 2019-20 had arrangements for the delivery of social care packages.
5. A high proportion of women reported mental health problems in our prisoner survey (as high as 78% in one prison), but the quality of mental health support varied. For example, in some
   prisons, inspectors found a lack of psychological support, confidential therapeutic spaces and groupwork programmes. Staff shortages had led to long delays in women accessing mental health support and more training was needed for some prison staff so that they could recognise and support women with mental health needs. However, most prisons held multi-disciplinary complex case meetings to identify and support women with varied needs, including with their mental health. Inspectors did find some examples of good practice, such as the development of a prison wide, trauma informed model of care and a counselling service for women who had experienced child loss and separation. One prison provided support to women up to six months after their release.
6. Mother and baby units (MBUs) provided good facilities and services for pregnant women and new mothers. Inspectors found that all women in MBUs had access to midwifery and there were specialist midwives at two prisons, one of whom had expertise in supporting women to overcome substance misuse. Some prisons had recognised the need to further develop their perinatal and maternity services.

Findings from reports published during the COVID-19 pandemic

7. Similarly to before the pandemic, inspectors found that the quality of physical health and social care provision was mostly good, as was the support for women on MBUs. Women’s health applications and hospital consultations were prioritised based on their needs. Some primary care clinics still operated on a risk-assessed basis. However, some physical health care provision was limited during the pandemic, which meant that there were some women with unmet needs. For example, at one prison, inspectors found that access to health care was more restricted and women faced delays in accessing health care professionals and interventions. In addition, many women’s physical healthcare needs increased during this time – women who spoke to inspectors reported that their physical health had deteriorated. This included exacerbated skin problems, excessive weight gain and women with conditions such as asthma and epilepsy found they had worsened. At one prison which inspectors visited, 71% of women had told the healthcare provider that their physical health had deteriorated since the start of the pandemic.
8. Mental health provision was not adequate to meet the high levels of need in some women’s prisons before the pandemic. It was therefore concerning that the range of mental health
   services was limited during this time. Inspectors found that mental health support had continued for most women who were already receiving support, but not all women with mental health needs had accessed support prior to the pandemic. Inspectors were therefore concerned that many women had unmet needs due to the reduction and withdrawal of services. For example, in one prison we visited in March 2021, 75% of women we surveyed said they had a mental health problem, but only 15% said it was easy to see a mental health worker. Several women told inspectors that they had experienced long waits to get mental health support and their needs were not being met. In addition, most women told inspectors the poor regime was having a debilitating effect on their mental health and emotional well-being. In one prison, 68% of women
   said their mental health had deteriorated since restrictions were introduced. Many women talked about their struggles with their lack of time out of cell; interventions such as regular therapy; and opportunities to seek support from their peers and staff, which had increased their distress.

Findings from inspection reports published during 2019-20

9. The time women spent out of their cells varied but was reasonably good overall. For example, we found a third of women were locked in their cell throughout the working day in one prison, whilst in another establishment, this was much lower at only 3%. In closed prisons, employed women tended to spend eight to ten hours out of their cell during weekdays, which lessened at the weekend. Women did not spend enough time in the open air – the time provided for women to go into the open air in most prisons was 30 minutes a day, which was too short. Few women said they went outside for exercise at least five times a week.
10. Physical education (PE) provision was good at most prisons inspected. At an open prison, women could access exercise equipment outside and a fully equipped well-being centre. The range of exercise classes was good across all inspected establishments and some sessions were tailored to specific groups, such as younger women or those with health conditions. One prison offered specific sessions for pre- and post-natal women, which was positive.

Findings from reports published during the COVID-19 pandemic

11. . The time women spent locked in their cell increased significantly throughout the pandemic. Most women spent up to 23 hours a day locked in their cell during the earlier months of the pandemic and the regime for women who needed to isolate due to COVID-19 symptoms had been very poor at some establishments. For example, at one prison inspectors visited at the beginning of the pandemic, we found that women who were isolating had not spent any time in the open air and could only shower once every three days. At our most recent visit to a women’s prison in March 2021, women were still only allowed out of their cell for 75 minutes each day, which was often curtailed. This limited time out of cell meant women often had to choose between completing daily chores or spending time in the open air. Many women said that they had become tired of the repetitive in-cell activities given as distraction tools and some described resorting to unhealthy coping mechanisms including self-harm. The small proportion of women in employment spent more time out of their cells, which supported their well-being.
12. All prison gyms were closed at the beginning of the pandemic. PE staff at some prisons led exercise classes outside and provided in-cell activities related to fitness and nutrition. However, some women told inspectors they missed activities they previously found therapeutic and which helped them to manage their feelings, such as walking in the grounds. Additional snacks were given to women during the pandemic which were often unhealthy. Women complained about weight gain as a result, which had diminished their self-esteem. Inspectors found women were worried about the long-term health implications of their lack of opportunity to eat well or
    exercise.

Findings from inspection reports published during 2019-20

13. Incidents of self-harm amongst women in prison remained high, and some women self-harmed repeatedly. For example, at one prison we inspected, 17 women accounted for 80% of all self-harm incidents which took place in the previous six months. The quality of care and support for women at risk of self-harm was reasonably good. At all inspected prisons, we found that weekly meetings were in place to develop support plans for women most at risk of self-harm or those with a complex range of needs. Most staff knew women well and understood their triggers. However, in one prison, inspectors were concerned about the lack of proactive help given to women to avoid an escalation of self-harming behaviours. Peer support for women at risk of self-harm was mostly good, but the Listener scheme was not fully effective in some prisons.⁴ Case management for women at-risk of self-harm needed improvement, as the quality of some record entries were inadequate.
14. Strategic oversight was reasonably good, but some prisons needed to improve their data analysis and develop a prison-wide strategy for reducing self-harm. We were concerned that more needed to be done to support a small number of women with the most severe and complex needs, including timely transfers to secure hospitals or specialist treatment facilities.

Findings from reports published during the COVID-19 pandemic

15. The reported levels of women’s self-harm were already high and had increased during the first six months of the pandemic. Some women told inspectors they had started to self-harm more often as a way of managing their increased stress, low mood and anxiety during the pandemic. At one prison we visited, some women told inspectors they had considered suicide. The quality of support for women identified as being at risk of self-harm remained reasonably good. However, in some prisons, women at risk of self-harm felt isolated from others and were frustrated at the lack of meaningful opportunity to receive support from staff and talk to them about their well-being. For example, at one prison visited in March 2021, only half of the women managed under an ACCT felt well cared for by staff.⁵ The Listener scheme had also stopped being delivered in some of the prisons we visited, which was a major gap. Case management for women at-risk of self-harm and suicide continued to vary in quality, which was also a concern before the pandemic.

16. Efforts to contain the spread of COVID-19 were generally successful, but the prolonged and severe restrictions which were introduced have negatively impacted on the health and well-being of most women. The significant and far-reaching effects of COVID-19 restrictions on women’s well-being needs to be recognised. In order to improve health and well-being outcomes, all establishments should be working at pace safely to relax current restrictions and return to full and purposeful regimes. A comprehensive range of health services, including timely mental health support should be provided, as well as additional support to mitigate the impact of the restrictions on women’s physical and mental health. Improvements are needed to reduce levels of self-harm and to support women at risk of self-harm and suicide.

Charlie Taylor
Chief Inspector of Prisons
April 2021