Towards a health-informed approach to penal reform? Evidence from ten countries all-time high (Ministry of Justice, 2019)) were recently consulted about what was needed to keep them safe and reduce the risk of self-harm and suicide. They emphasised the importance of good professional relationships between staff and prisoners in helping ensure prisoners’ mental health needs were met.32 Penal Reform International has issued guidance for prison staff to help them understand and respond appropriately to the mental health needs of adult prisoners (Penal Reform International, 2018). Produced with input from mental health experts and practitioners, the guidance aims to help prison staff understand and respond appropriately to the mental health needs of adult prisoners. It describes how prison staff can promote and protect mental health and wellbeing and enable those with existing conditions to cope in prison. The prison’s ‘social climate’ The fostering of healthy social climates in prisons has been recognised as a potential route to better mental health and wellbeing among prisoners and staff (Bennett & Shuker, 2017). Elements of practice may include: providing regular opportunities for group and individual therapy; promoting empowerment and inclusion through democratic decision-making processes; and ensuring respectful interaction among prisoners and staff. Evaluations suggest that healthy social climates help to militate against some of the negative effects of the prison environment, while helping address prisoners’ mental health needs. Positive effects have been found to include reduced self-harm, improved conduct in custody and lower re-offending levels.33 A healthy social climate in prison is also characterised by greater respect for the diversity of the prisoner community and its members’ specific health needs. This can enable a stronger focus on the distinct health needs and vulnerabilities of particular groups. This in turn could foster greater inclusion and ensure there is no discrimination in making available opportunities or information that could benefit prisoners’ overall health and wellbeing. Mental health of older prisoners Assessing and responding to the mental health needs of older offenders is a significant challenge for prison health systems and community psychiatric and social care services. It is important to ensure older prisoners have access to mental healthcare services for the timely assessment and diagnosis of dementia and related impairments. Prisons should also play their part in modifying the known risk factors for dementia, by ensuring healthy diets, keeping prisoners away from smoke-filled areas, and ensuring there are opportunities for exercise, fresh air and social interaction (Cipriani et al, 2017). Dementia remains a hidden problem in prisons for many reasons, but better screening of older prisoners could help improve diagnosis of the condition and lead to appropriate treatments and adjustments. Australian research has identified the need for a more systematic and co-ordinated approach to help manage the health burden arising from steady increases in numbers of incarcerated older people (Ginnivan et al, 2018). Dementia literacy training and screening protocols have been cited as beneficial to both staff and prisoners. Even if these adaptations and provisions are made, it remains questionable whether prisons are ever appropriate places to hold people with severe or even moderate dementia. There comes a point at which a prisoner’s level of impairment would render them incapable of either reflecting on their own offending behaviour, engaging in meaningful rehabilitation, or committing further crimes (particularly if they are also physically disabled). Regular re-assessment of mentally impaired older prisoners could help inform timely decisions about whether alternative care arrangements would be more humane and effective. 32 Independent Advisory Panel on Deaths in Custody, written evidence to House of Commons Health and Social Care Select Committee (inquiry into prison health), dated July 2018, available here: https://www.parliament.uk/business/committees/committees-a-z/commonsselect/health-and-social-care-committee/inquiries/parliament-2017/prison-healthcare-inquiry-17-19/publications/ 33 The social climate concept draws on Liebling and colleagues’ system of measuring the quality of prison life (MQPL) as experienced by staff and prisoners and analysing the resulting data to produce MQPL scores for individual prisons (Liebling et al, 2011). 26