Introduction
Until very recently there were no policies specifically directed at improving the welfare of older people in prison. Lately, a few reports and papers have emerged which draw attention to these needs and argue for their better recognition, and in October 2007 a toolkit for good practice in care for older offenders was published by the Department of Health (DH 2007). There is growing awareness within the academic and policy literature of the high levels of mental and physical health problems experienced by prisoners of all ages. Increasing numbers of older prisoners also bring to the prison service additional problems of disability and age-related illness. Prisons are poorly equipped to meet the health care needs of older prisoners, almost all of whom will be released, often with very little in the way of community support. This article draws upon current literature to give an overview of the population of older prisoners and their needs, and outlines some of the implications these have for the way they are served in prison and on release.

The population of older prisoners
Much attention has been paid in the media recently to the growing number of people in prison in England and Wales and to the pressures this imposes on the prison service (see for example, The Independent, 6 November 2007). While attention is rightly paid to the large number of young people in prison, much less attention has been paid to the growing number of older people who are in prison, often for very long sentences.

There are currently almost 80,000 people in prison in England and Wales (Ministry of Justice 2007). Of these just over two thousand are aged over 60, and just over one thousand are aged over 65 (Prison Reform Trust, 2007). All but a few of the older population in prison are male (Home Office, 2003, cited in DH 2007).

Most older prisoners are detained for a narrow range of serious crimes. Just over half have committed sex offences; one in five a crime of violence, and one in ten are in jail for drug offences (Prison Reform Trust, op cit). Increasingly, older men are being jailed for serious offences committed many years previously.

Sentence inflation
There is no ‘elderly crime wave’ (Prison Reform Trust, op cit). Rather, there has been a general increase in length of sentence imposed by the courts, and an accumulation of older male prisoners. The Prison Reform Trust has identified a process of “sentence inflation” (Op cit) - rather than a deliberate targeting of older offenders. Harsher sentencing policies generally have also seen this group become - almost as collateral to mass incarceration - the fastest growing sector of the prison population (Her Majesty’s Chief Inspector of Prisons (HMCIP) 2004). In her analysis of factors influencing the growth in the number of older prisoners, Frazer (2003) expressed this as a " ‘stacking effect’ due to the accumulation of both ageing long-term and life prisoners and ‘new entrants’ serving longer sentences” often for sexual offences.

The health needs of older prisoners
Very little empirical research has been undertaken on the health needs of older prisoners in the UK. Fazel and colleagues surveyed the health records and self-reported health status of 203 men in prison aged 60 and over. They found that 85% had at least one chronic illness recorded in the medical notes and 83% reported at least one long standing illness in interview. The most common complaints were psychiatric, cardiovascular, musculoskeletal and respiratory disorders (Fazel et al 2001b). Three quarters were prescribed medication, but only 18% of those with psychiatric illnesses received any treatment (Fazelet al 2004).

Mental disorders are particularly common amongst prisoners of all ages (Birmingham 2003, Rickford & Edgar, 2005), but are especially so amongst older prisoners. Fazel and colleagues’ survey found that 53% had at least one diagnosable psychiatric condition, and 30% had depression, including 17% who had experienced a major depressive episode (Fazel et al 2001b). These figures are much higher than those found in comparable populations in the community (Fazel et al 2001b).

Though prisons have a public duty to protect the public and to rehabilitate offenders, in practice they often struggle with health needs they are not resourced to meet (Smith 1999, Reed & Lynne 2000, Birmingham 2002, White 2002, Rickford 2003, Fazel et al 2004, Stephenson 2004, HMCIP 2004, Rickford & Edgar 2005, All Party Parliamentary Group on Prison Health 2006, Kmietowicz 2006, Prison Reform Trust op cit). For some offenders, the experience of prison itself is likely to exacerbate their health problems, so that their time in prison will serve only to increase the risks they pose to themselves and others on release.

Care in prison
Life in prison can be hard for anyone, but older prisoners are especially vulnerable. It has been suggested that prisoners may have a health status about ten years greater than their age peers in the community (Rosefield, 1995, cited in Howse 2003). Prisoners are often detained far from home and can be moved at short notice. Bullying and substance misuse are common, and many older prisoners are held in ‘vulnerable’ wings away from the predatory attentions of younger inmates. Even there, proper access to exercise, social contact or education is sometimes difficult if prisoners have mobility or other health problems, or if they feel intimidated (HMCIP 2004). Crawley & Sparks have termed the oversight of older prisoners’ particular needs as a form of “institutional thoughtlessness” (Crawley & Sparks 2005).

Discharge and resettlement
Preparation for discharge that takes into account the needs of older prisoners is often limited, inadequate or absent (HMCIP 2004), though there are a number of voluntary organisations, such as Age Concern† and Restore 50plus° that contribute positively at a local and a national level. Some Age Concern organisations are developing tailored services inside prisons (for example, see Evans 2005). But they face considerable challenges. Many older prisoners have led chaotic lives and have been in and out of prison a number of times. Some lack basic self-help skills. Some are not registered with a GP, and some need education in benefits awareness, and pension rights. All will have lived for some time within a total institution in which every minute of the day is governed by the regime. On discharge local authorities are often reluctant to offer needs assessments to ex-offenders on the grounds that they are not normally resident in the jail. Probation services are not equipped to serve the health and social welfare needs of older frail ex-offenders (HMCIP 2004).

Options for care
The NHS is in the process of taking over responsibility for commissioning primary care services in public sector prisons. As such many primary care trusts are exploring ways in which the health needs of prisoners can be met and how equal standards of access and service can be applied. The recently published guide to the care of older offenders (DH 2007) is an important landmark in the development of properly dedicated services and makes specific recommendations on how prisons should address key principles within the National Service Framework for Older People (DH 2001). It is however, not mandatory and depends crucially on good joint working between the health services, local authority and prison services.

In the USA, a number of dedicated older persons’ prisons have been built that function as a form of secure nursing home provision for prisoners who have additional social, medical or nursing needs (Howse 2003). Inmates in these establishments are relatively free from the persecution of younger, fitter, prisoners, and are able to access facilities dedicated to their needs and increasing frailty. However, there are as yet few prisons in the UK adapted to the needs of older or disabled prisoners and there is limited recognition of their needs as a distinct group (Crawley 2005, Wahidin & Aday 2005), though some prisons hold significant numbers of prisoners who are old or frail, or who, on retirement, are locked in their cells for most of the day. (HMCIP 2004).

Conclusion
Individuals who have been through the prison system may draw little sympathy from society, and older prisoners, especially those who have committed sex offences, are likely to draw less. Yet older prisoners have rights of equal access to treatment and services under the National Service Frameworks for Older People and for Mental Health, and the Disability Discrimination Act. Moreover, almost every prisoner will be released at some time, and many will present with health and social care needs that have been exacerbated by their experience in prison. Recognition of the problem is improving, but without a dedicated national strategy for care to older prisoners and ex-offenders, progress will continue to be piecemeal.

References

All Party Parliamentary Group on Prison Health, (2006) The Mental Health Problem in UK HM Prisons, London: House of Commons, via kate@butlerkellyltd.co.uk.

Birmingham, L (2002) Doctors working in prisons, British Medical Journal, 324, 440.

Birmingham, L (2003) The mental health of prisoners, Advances in Psychiatric Treatment, 9, 191-201.

Crawley, E., (2005) Surviving the prison experience? Imprisonment and elderly men, From Prison Service Journal, 160, http://www.hmprisonservice.gov.uk/resourcecentre/prisonservicejournal/index.asp?id=3833,3124,11,3148,0,0 (Accessed 6 December 07).

Crawley, E & Sparks, R (2005) Hidden Injuries? Researching the experiences of older men in English prisons, The Howard Journal, 44(4), 345-356.

Department of Health (DH) (2001) National Service Framework for Older People, London, Stationary Office.

Department of Health (DH) (2007) A Pathway to Care for Older Offenders: a Toolkit for Good Practice, http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_079928 (Accessed 30 November 2007).

Evans, C. (2005) Age Concern Leicestershire and Rutland - HMP Gartree Older Prisoner’s Advocacy and Support Project, The Prison Service Journal, 160, http://www.hmprisonservice.gov.uk/resourcecentre/prisonservicejournal/index.asp?id=3834,3124,11,3148,0,0.

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Frazer, L. (2003) Ageing Inside: School for Policy Studies Working Paper Number 1, Bristol, University of Bristol, School for Policy Studies.

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Stephenson, P. (2004), Mentally ill offenders are being wrongly held in prisons, British Medical Journal, 328, 1095.

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Footnotes

* CAMH are currently in receipt of a Research for Patient Benefit grant to investigate the mental health needs of older prisoners in four prisons in the West Midlands, due to run till August 2009; and are also working with the West Midlands Strategic Health Authority to investigate workforce development needs in prison healthcare.

† See http://www.prisonreformtrust.org.uk/subsection.asp?id=592

° See http://www.olderprisoners.co.uk/?pageid=145