Growing old in prison

Geoff Dobson OBE is deputy director of the Prison Reform Trust. His article examines the implications of a sizeable increase in the number of older prisoners. Major changes within the prison healthcare regime and the application of the Disability Discrimination Act are likely to bring more ECA readers into contact with older prisoners as patients or clients.

The number of prisoners can be expected to increase in the years ahead. By July 2003, the prison population in England and Wales exceeded 74,000. Home Office predictions suggest that the population will rise to between 91,000 and 110,000 by the end of the decade. This ignores the effect of the proposals in the Criminal Justice Bill currently before parliament, which include a number of potentially ‘inflationary’ measures.

This article draws largely on a recent publication by the Prison Reform Trust (PRT). Growing Old in Prison: A Scoping Study on Older Prisoners, by Ken Howse, 2003, which was funded by the Nuffield Foundation, reviews recent research to provide a profile of older prisoners in England and Wales. It then examines some of the policy issues associated with the increasing numbers of older prisoners. The report is the result of a collaborative exercise between the Centre for Policy on Ageing, a charity with expertise in work with the elderly, and PRT whose remit is penal reform.

Two other recent PRT publications may also be of interest to ECA readers. The Decision to Imprison: Sentencing and the Prison Population (2003), identifies the reasons for an increase in the adult prison population of 71 per cent from 1991-2003 and the measures that would be required to reverse this trend. Prison Overcrowding: The Inside Story (2002), describes the impact of overcrowding across the prison estate as witnessed by the Independent Monitoring Boards.

The nature of the problem

Growing Old in Prison uses an age threshold of 60 years to define an older prisoner. This is convenient for the presentation of statistics – ‘sixty plus’ is the oldest age band used in the published UK statistics. More pertinently, it is the age at which prisoners are not required to work.

Much US research prefers a much younger age threshold of fifty, or even forty-five years and for this, there may be good reasons. Perhaps it is around this age that prisoners start to think of themselves as old, as belonging to a class apart because of their age, and perhaps this is how they are regarded by younger prisoners. Nowadays, for people living in the community, this will no doubt seem rather strange, but then prison is an unrepresentative environment, with a predominantly young population.

There is one significant drawback to choosing sixty rather than fifty, namely, that it excludes virtually all female prisoners. The term elderly is appropriate because, as the report shows, many older prisoners have a biological age about ten years in advance of their contemporaries in the community, due to chronic-health problems.

Between 1990 and 2000, the number of prisoners aged over 60 in jails in England and Wales trebled. According to the latest Home Office figures, there are more than 1,200 currently in prison.

Since the length of a prison sentence tends to reflect the seriousness of the crime, it is not surprising to find that a relatively high proportion of older prisoners were convicted of violence against the person (21 per cent), with ten per cent convicted of drugs offences. Very few older people are sent to prison for robbery or burglary, theft being the most common of the offences against property, comprising 12 per cent of receptions in this age group. What really stands out, however, is the disproportionately high number of sex offenders. In 2000, one-third of the adults aged 60 or more received into prison under immediate sentence had been convicted of a sexual offence, compared with approximately three per cent of all the adults received into prison that year. More than half of adult males under sentence at any given time are sex offenders.

The number and proportion of elderly prisoners serving long sentences has increased significantly. Between 1995 and 2001, the number serving sentences of more than four years more than tripled, increasing from 318 to 966. In 2001, eighty per cent of elderly prisoners were serving sentences of four years or more. About 50 per cent of older prisoners have been in prison before. One fifth of all sentenced older prisoners are lifers.

The increase in the elderly prison population is not explained by demographic changes, nor can it be explained by a so-called ‘elderly crime wave’. The increases are due to harsher sentencing policies, which have resulted in the courts sending a larger proportion of criminals aged over 60 to prison to serve longer sentences.

More than eighty per cent of older prisoners have a long-standing illness or disability. Of these, more than a third suffer from a cardiovascular disease and more than a fifth suffer from a respiratory disease. Overall, prison healthcare facilities struggle to cope with prisoners with long-standing illnesses. Disabilities associated with chronic disease are more common in older prisoners than in older people living in the community.

The prevalence of mental disorder among older prisoners is also significantly higher than the general population. The most common disorder is depression, which often emerges as a result of imprisonment. Thirty per cent of older prisoners have a diagnosis of depression.

While suicide and self harm are generally closely associated with the high prevalence of mental-health problems among prisoners, older prisoners are less likely than those in any other age group to harm themselves deliberately. Older prisoners also present very few disciplinary problems. This would suggest that they better adjust to prison life than younger prisoners and become more easily institutionalised.

Many older prisoners have no family or community support. A third had not received a letter during the period of a three-month survey. The prospect of visits and continuing contact, for those still in touch with friends and family, is not helped by the fact that many prisoners are held a long way from their homes. At the end of February 2003, 27,000 prisoners were held over 50 miles from their committal court town and 12,500 were held over 100 miles away. This can be a particular problem for older prisoners.

The combination of being more likely to become institutionalised and often having few community links, means that many elderly prisoners will find it particularly hard to resettle on release.

These characteristics also combine to make older prisoners less visible within the frenetic and overcrowded prison estate. The stresses and demands of the prison social and physical environments make it especially hard to grow old in prison. The values of the prisoners’ social world set a premium on physical strength and endurance – so physical decline matters more in prison than outside – hence a heightened sense of vulnerability.

Many prison regimes are not geared to the needs of older prisoners, but to those of younger prisoners who make up the bulk of the prison population. This is particularly evident in education provision, vocational programmes and physical exercise. A survey by the National Advisory Council of Independent Monitoring Boards, included in Growing Old in Prison, shows that a substantial minority do not work either out of choice or because of their health. It goes on to show that educational programmes are pursued by only a small minority of older prisoners. Education provision often tends to concentrate on the basic literacy and numeracy skills, which so many younger prisoners lack, and physical education programmes, which are almost certain to be too demanding for many older prisoners, even in the absence of chronic-health problems.

As an ex-prisoner said on reading the scoping study: “I know from my own experience that prison life can be twice as difficult for older prisoners. Prisons and their regimes are not designed for people over 60 who have special health and social needs.”

Recent developments

Growing Old in Prison cites a number of important policy and practice developments. From April 2003, the National Health Service has begun to take responsibility for prison healthcare. The NHS will hold full operational responsibility for it from 2008. By 2004, each prison should have a health-improvement plan based on assessed needs.

The Prison Service has accepted that it is a service provider in terms of the Disability Discrimination Act 1995. A Prison Service Order (PSO 2855 1999) outlines its requirements to comply with the law and policies for disabled prisoners were to be implemented in three stages to 2004.

HM Prison Kingston is one of two Category B closed training prisons that hold only life-sentence prisoners. It is the only prison in England and Wales that has a specialist unit for older prisoners. A report by the HM chief inspector of prisons in 1997 commented on the elderly prisoners’ unit saying: “Clientele was similar to that which might be found in a residential care home. The unit was staffed by a mixture of discipline and healthcare staff.” The chief inspector took the view that the unit “was a sensible and humane way to accommodate a group of prisoners who were vulnerable both on account of their age and their impaired health”. An inspection in 2001 is more critical, however, and doubts whether Kingston “offers a clear model” to the rest of the Prison Service. There are two reasons for this: the nature of the accommodation and a lack of clarity about the unit’s purpose. Of the latter it stated: “The role of E wing was unclear. Staff as well as prisoners were confused as to its purpose. It seemed to be a combination of general support, sheltered accommodation, specialist care for the elderly and a nursing home. There was little that distinguished this wing from other wings in terms of daily routines and regimes.”

The chief inspector took the opportunity presented by the 2001 report on HMP Kingston to recommend that: “The Prison Service draw up a national strategy for elderly prisoners, indicating the type of regime required and how this is to be provided.”

In 1999, a joint thematic review on lifers, Lifers: A Joint Thematic Review by HM’s Inspectorate of Prisons and Probation, drew attention to the needs of disabled and infirm life-sentence prisoners. During the review, several doctors expressed concern about physically disabled and infirm lifers who required high levels of medical care not available in less secure prisons.

It is a feature of prisons that the most comprehensive healthcare services are available in more secure establishments. For lifers to progress and achieve release, special arrangements had to be made to deliver the healthcare they needed in less secure prisons and in the community after release. A postal survey of lifer centres revealed that only one Category C prison out of 19 holding lifers had 24-hour medical cover and full-time nursing provision. Such lifers should not be disadvantaged by their physical condition and it is important that the Prison Service plans for their needs.

The Prison Service, in response to the report on lifers, has now approved new money for the development of another (besides Kingston) specialist unit for older lifers. This will be a 15 bed unit at HMP Norwich for infirm lifers and it is hoped that it will open in 2004.

Although the Prison Service has recognised that (a) prison healthcare must be improved in order to meet the needs of older prisoners, and (b) prisons as physical environments must be better adapted to the needs of older prisoners with physical disabilities, there are still a number of important policy matters that remain unresolved. What is not yet clear is:

The nature of the social-care provision that should be made for older prisoners with the kinds of functional disability that make them dependent on the help of other people for essential activities of daily living;
The need for other kinds of special provision besides (a) health care and (b) the kind of social care that is intended to help with activities of daily living (ADLs).

There is evidence to suggest that the Prison Service and other service providers (including social-services departments, the National Probation Service and the voluntary sector) should be doing more for older prisoners than is contained in their current proposals for improving prison healthcare and complying with disability legislation.

The chief inspector of prisons has recommended that the Prison Service develop a strategy for older prisoners. There are several issues – besides the improvement of healthcare and compliance with disability legislation – which any such strategy will have to address. These relate to special provision, and all merit further investigation:

To what extent should the Prison Service favour the development of age-based/disability-based segregation of facilities?
Are older prisoners who need help with ADLs getting the help they need? How do the assessment procedures and aims of social services in providing care in the community compare with the provision of social care in prisons?
Are discharged older prisoners getting the kind of help they need on release? What should be the role of social services, the National Probation Service and the voluntary sector in providing help with the resettlement of older prisoners?
What, if any, special provision should be made for older prisoners who choose not to work in prison, or are unable to work in prison? What might be done for older prisoners to promote social participation and participation in meaningful activities during their period of imprisonment?

Thus, given the rapidly increasing number of elderly prisoners, a national strategy is urgently required to ensure that a system designed largely for young, energetic men, can meet the older prisoners’ very different needs. With chronic overcrowding affecting the whole prison estate, Growing Old in Prison also prompts the question as to whether locking up more prisoners into their old age is of any real benefit to society.

Geoff Dobson OBE is deputy director of the Prison Reform Trust. He can be contacted at prt@prisonreformtrust.org.uk or telephone 020 7251 5070.