Background Older people are the fastest-growing group in prisons in England and Wales and have complex health and social care needs that often remain unmet. Objectives (1) Evaluate the efficacy of the Older prisoner Health and Social Care Assessment and Plan (OHSCAP) in improving (i) the ability to meet older male prisoners’ health and social care needs, (ii) health-related quality of life (HRQoL), (iii) depressive symptoms and (iv) functional health and well-being and activities of daily living; (2) assess the quality of care plans produced; (3) explore the experiences of older prisoners receiving, and staff conducting, the OHSCAP; and (4) evaluate the cost-effectiveness of the OHSCAP compared with treatment as usual (TAU). Design Multicentre, parallel-group randomised controlled trial (RCT) with follow-up at 3 months, with a nested qualitative study and quality audit of care plans (n = 150, 68%). Setting Ten English prisons. Participants Four hundred and ninety-seven newly arrived male prisoners aged ≥ 50 years with a discharge date at least 3 months from recruitment. A total of 14 prisoners and 11 staff participated in qualitative interviews. Intervention Randomisation to OHSCAP or TAU. The OHSCAP group had health and social needs assessed by a trained health-care worker or prison officer. Care plans were devised and subsequent actions included professional support and appropriate referrals. Main outcome measures Primary outcome measure – mean number of unmet health and social care needs as measured by the Camberwell Assessment of Need – Short Forensic Version. Secondary outcome measures – measures of functional health and well-being, depressive symptoms and HRQoL. A health economic evaluation was undertaken using service contact between baseline and follow-up and appropriate unit cost information. Results A total of 497 prisoners were recruited (248 to OHSCAP and 249 to TAU). The 404 completed follow-ups were split evenly between the trial arms. No significant differences were observed between the intervention and TAU groups in relation to the primary outcome measure. The OHSCAP did not demonstrate convincing benefits in HRQoL over TAU, and there were no significant differences in relation to costs. Audit and qualitative data suggest that the intervention was not implemented as planned. Limitations As a result of the limited follow-up period, potential long-term gains of the intervention were not measured. Some of the standardised tools had limited applicability in prison settings. Cost-effectiveness data were limited by unavailability of relevant unit cost data. Conclusions The OHSCAP failed in its primary objective but, fundamentally, was not implemented as planned. This appears to have been attributable, in some part, to wider difficulties currently affecting the prison landscape, including reduced levels of staffing, the loss of specialist support roles for such initiatives and increased prevalence of regime disruption. Future work Partnership working and information sharing across disciplines within prison settings require improvement. Research should explore the potential involvement of other prisoners and third-sector organisations in identifying and addressing older prisoners’ health and social care needs to better match community provision. Further examination should be undertaken of how the prison regime and system affects the well-being of older prisoners. Future prison-based RCTs should carefully balance the fidelity of initiatives being evaluated and testing in a ‘real-life’ setting. Trial registration Current Controlled Trials ISRCTN11841493. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 5, No. 31. See the NIHR Journals Library website for further project information.

Background People aged ≥ 50 years constitute the fastest-growing group in the prison population of England and Wales. This population has complex health and social care needs. There is currently no national strategy to guide the development of the many-faceted services required for this vulnerable population; therefore, prisons are responding to the issue with a range of local initiatives that are untested and often susceptible to failure if they are not fully embedded in and securely funded as part of commissioned services. Objectives The objectives were to establish the prevalence of dementia and mild cognitive impairment in prisoners in England and Wales and their health and social care needs; validate the six-item cognitive impairment test for routine use in prisons to aid early and consistent identification of older prisoners with possible dementia or mild cognitive impairment; identify gaps in current service provision; understand the first-hand experiences of prisoners living with dementia and mild cognitive impairment; develop a care pathway for prisoners with dementia and mild cognitive impairment; develop dementia and mild cognitive impairment training packages for staff and prisoners; and produce health economic costings for the care pathway and training packages. Design This was a mixed-methods study. Setting The study setting was prisons in England and Wales. Participants Prisoners aged ≥ 50 years and multiagency staff working in prison discipline and health and social care services took part. Results Quantitative research estimated that the prevalence rate of suspected dementia and mild cognitive impairment in the prison population of England and Wales is 8%. This equates to 1090 individuals. Only two people (3%) in our sample had a relevant diagnosis in their health-care notes, suggesting current under-recognition of these conditions. The prevalence rate in prisons was approximately two times higher among individuals aged 60–69 years and four times higher among those aged ≥ 70 years than among those in the same age groups living in the community. The Montreal Cognitive Assessment screening test was found to be more effective than the six-item cognitive impairment test assessment in the older prisoner population. Qualitative research determined that staff and prisoners lacked training in knowledge and awareness of dementia and mild cognitive impairment, and this leads to problematic behaviour being viewed as a disciplinary issue rather than a health issue. Local initiatives to improve the lives of prisoners with dementia and mild cognitive impairment are often disadvantaged by not being part of commissioned services, making them difficult to sustain. Multidisciplinary working is hampered by agencies continuing to work in silos, with inadequate communication across professional boundaries. A step-by-step care pathway for prisoners with dementia and mild cognitive impairment was developed, and two tiers of training materials were produced for staff and prisoners. Limitations Our prevalence rate was based on the results of a standardised assessment tool, rather than on clinical diagnosis by a mental health professional, and therefore it may represent an overestimation. Furthermore, we were unable to distinguish subcategories of dementia. We were also unable to distinguish between a likely diagnosis of dementia and other conditions presenting with mild cognitive impairment, including learning disability, severe depression and hearing impairment. Questionnaires regarding current service provision were collected over an extended period of time, so they do not reflect a ‘snapshot’ of service provision at a particular point. Conclusions We hypothesise that implementing the step-by-step care pathway and the training resources developed in this study will improve the care of older prisoners with dementia and mild cognitive impairment. Future work The care pathway and training materials should be evaluated in situ. Alternatives to prison for those with dementia or mild cognitive impairment should be developed and evaluated. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 27. See the NIHR Journals Library website for further project information.

BackgroundMental health professionals increasingly carry out risk assessments to prevent future violence by their patients. However, there are problems with accuracy and these assessments do not always translate into successful risk management.ObjectivesOur aim was to improve the accuracy of assessment and identify risk factors that are causal to be targeted by clinicians to ensure good risk management. Our objectives were to investigate key risks at the population level, construct new static and dynamic instruments, test validity and construct new models of risk management using Bayesian networks.Methods and resultsWe utilised existing data sets from two national and commissioned a survey to identify risk factors at the population level. We confirmed that certain mental health factors previously thought to convey risk were important in future assessments and excluded others from subsequent parts of the study. Using a first-episode psychosis cohort, we constructed a risk assessment instrument for men and women and showed important sex differences in pathways to violence. We included a 1-year follow-up of patients discharged from medium secure services and validated a previously developed risk assessment guide, the Medium Security Recidivism Assessment Guide (MSRAG). We found that it is essential to combine ratings from static instruments such as the MSRAG with dynamic risk factors. Static levels of risk have important modifying effects on dynamic risk factors for their effects on violence and we further demonstrated this using a sample of released prisoners to construct risk assessment instruments for violence, robbery, drugs and acquisitive convictions. We constructed a preliminary instrument including dynamic risk measures and validated this in a second large data set of released prisoners. Finally, we incorporated findings from the follow-up of psychiatric patients discharged from medium secure services and two samples of released prisoners to construct Bayesian models to guide clinicians in risk management.ConclusionsRisk factors for violence identified at the population level, including paranoid delusions and anxiety disorder, should be integrated in risk assessments together with established high-risk psychiatric morbidity such as substance misuse and antisocial personality disorder. The incorporation of dynamic factors resulted in improved accuracy, especially when combined in assessments using actuarial measures to obtain levels of risk using static factors. It is important to continue developing dynamic risk and protective measures with the aim of identifying factors that are causally related to violence. Only causal factors should be targeted in violence prevention interventions. Bayesian networks show considerable promise in developing software for clinicians to identify targets for intervention in the field. The Bayesian models developed in this programme are at the prototypical stage and require further programmer development into applications for use on tablets. These should be further tested in the field and then compared with structured professional judgement in a randomised controlled trial in terms of their effectiveness in preventing future violence.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

Findings suggest that alternative models of prison mental healthcare should be considered to reduce risks to the patient and the public.

Numbers of older prisoners have been increasing in recent years and there is no national strategy addressing their care. Older prisoners have more physical health needs, complex social care needs and high rates of mental disorder compared with younger prisoners. These needs are often not identified or addressed. We developed the Older prisoner Health and Social Care Assessment and Plan (OHSCAP), a structured approach for identifying and managing the health and social care needs of older prisoners. It consists of an assessment, care plan and review of needs. The current study aims to establish the fidelity of implementation of the OHSCAP as part of a larger RCT. Compliance, context and competence fidelity were audited to assess compliance with training and the manual, adequacy of completion and identification of needs and quality of care planning. Results showed that the OHSCAP was not implemented as intended with needs identified not being consistently translated into care plan actions, little evidence to suggest that prisoner involvement in the care planning process and difficulties in collaborative working. Implications with respect to effectively embedding complex interventions within prisons, along with wider policy-related issues affecting the entire prison estate are discussed.