Report of North West Case Studies of Best
Practice and Innovation
Prepared as part of the
Tobacco Control
in Prisons and Criminal Justice Settings:
Regional Coordinator Pilot Project
November 2011
Michelle Baybutt, Susan MacAskill and Stephen Woods
ACKNOWLEDGEMENTS
The Project Team would like to thank all those who have contributed to the development of
the case studies; and Aileen Paton and Debbie Cocker for valuable administrative support.
The project is part of a portfolio funded by the Department of Health and led by the UK
Centre for Tobacco Control Studies (UKCTCS www.ukctcs.org): a UK Public Health Research
Centre of Excellence and a strategic partnership of nine universities involved in tobacco
research in the UK.
CONTENTS
Page No
INTRODUCTION
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TOBACCO CONTROL IN CRIMINAL JUSTICE SETTINGS: A DEMONSTRATION PROJECT
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CONTEXT
Police Custody, Prison and Probation: Settings for Health?
The Opportunity for Public Health
Prison Service Orders and Prison Service Instructions
Context Across the CJS: England and Wales
Context: North West
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DEVELOPMENT OF CASE STUDIES
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CASE STUDY 1: HMP YOI STYAL
Introduction
Smoking Cessation Support at HMP YOI Styal
Good Practice Example: “InfoLink” Programme
Conclusions: HMP YOI Styal Stop Smoking Services
Recommendations: HMP YOI Styal Specific
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CASE STUDY 2: HMP FOREST BANK (PRIVATELY MANAGED PRISON)
Introduction
Stop Smoking Services at HMP Forest Bank
Conclusions: HMP Forest Bank
Recommendations: HMP Forest Bank Specific
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CASE STUDY 3: HMYOI HINDLEY
Introduction
HMYOI Hindley: A No Smoking Environment
Stop Smoking Support in YOI Hindley
Conclusions: HMYOI Hindley
Recommendations: HMYOI Hindley Specific
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RECOMMENDATIONS: RELEVANT ACROSS PRISONS
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CASE STUDY 4: POLICE CUSTODY
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Introduction
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Police Force Policies: Association of Chief Police Officers (ACPO) Guidance
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Nicotine Dependent Detainees: Faculty of Forensic and Legal Medicine (FFLM)
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Her Majesty’s Inspectorate of Constabularies/Prisons (HMIC and HMIP) ‘Expectations’ 22
Progress: Provision of Nicotine Replacement Therapy (NRT)
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Pressures on the System – Contextual Issues
Opportunities: Pilot Activity
Conclusions: Police Custody
Recommendations: Police Custody Specific
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CASE STUDY 5: PROBATION
Introduction
Rationale: Beyond the Health Benefit
Good Practice Example: Offender Health Trainers
Good Practice Example: Tomorrow’s Women
Good Practice Example: Approved Premises
Conclusions: Probation
Recommendations: Probation Specific
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REFERENCES
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USEFUL LINKS
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INTRODUCTION
This report will explore opportunities within Criminal Justice Settings (CJS) in relation to the effective
delivery of stop smoking services, and engagement with a group normally considered ‘hard to
reach’. It outlines the public health opportunities and benefits of delivering targeted services as
identified by the Project Coordinator with particular emphasis on three settings in the North West,
prisons, police custody suites and probation,. Examples of good practice are presented alongside
ways in which creative and innovative approaches can enhance and better support the delivery of
stop smoking services and more positive environments to support quitting. The report challenges
the perception that offenders are a ‘hard to reach’ group by presenting three settings that are ideal
opportunities to engage offenders and deliver stop smoking initiatives located in the criminal justice
pathway. The report is a summary of key learning captured through the initial phase of the
Coordinator’s work on the project. It is anticipated that the learning will inform future practice and
contribute to the evidence base in this field.
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TOBACCO CONTROL IN CRIMINAL JUSTICE SETTINGS: A DEMONSTRATION PROJECT
Smoking levels are high among offenders in the CJS (around 80%) however substantial quit rates can
be achieved in prison settings, as shown in key findings and best practice outlined in Stop Smoking
Support in HM Prisons: The impact of nicotine replacement therapy (Department of Health, 2007).
The Prison Service Order PSO 3200 (H.M. Prison Service, 2003) provides an excellent lever to
consider prisons as healthy settings, supporting health promotion interventions and approaches that
acknowledge the holistic ethos set out in the Ottawa Charter (WHO, 1986). It also provides the
mechanism to consider how tobacco control activities link to other initiatives.
This report is part of a Department of Health funded Public Health Inequalities Demonstration
Project, which in turn forms part of a portfolio of projects funded by the Department of Health and
led by the UK Centre for Tobacco Control Studies (UKCTCS www.ukctcs.org): a UK Public Health
Research Centre of Excellence and a strategic partnership of nine universities involved in tobacco
research in the UK. The project focused on the role of a North West Tobacco Control Coordinator:
Prisons and Criminal Justice Settings. Through the appointment of a Tobacco Control Coordinator for
the North West Region, hereon referred to as the Coordinator, the project focussed on the
organisational systems across prisons, probation and police custody in relation to tobacco control
and stop smoking services and treatment. Based on the coordinator role, the project aimed to:
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Develop and share knowledge across the system;
Target particular groups across the system such as offenders, their families and staff;
Develop functioning systems for the provision of support and care pathways across the
offender journey within the Criminal Justice System and into the community;
Provide substantial learning for the Department of Health (DH) in terms of implementing
effective reach and provision in these settings and identify replicable and achievable
principles for delivery, pathways and monitoring;
Make recommendations to contribute to a national plan and to the prisoner section of the
Annual NHS Stop Smoking Services Service and Monitoring Guidance.
The findings and recommendations focussed on ‘what works’, recognising complexities such as the
constraints within systems; challenges of working across organisational boundaries; and the needs of
differing audiences, such as commissioners and providers. A full report evaluating the coordinator
role is being submitted to DH.
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CONTEXT
Police Custody, Prison and Probation: Settings for Health?
It is well recognised that good health and well-being are central to successful rehabilitation and
resettlement and this requires an environment that is supportive of health and a ‘whole systems’
approach that moves beyond a focus on health services (Department of Health, 2002; Ministry of
Justice, 2010).
The concept and practice of ‘healthy settings’ has developed to become a key element of public
health strategy (Dooris, 2004).The settings approach has its roots within the World Health
Organization (WHO) Health for All strategy (WHO, 1986) and, more specifically, within the Ottawa
Charter for Health Promotion (WHO, 1986) which encouraged a move towards a more holistic model
of health. With its five-fold focus on building healthy policy, creating supportive environments,
strengthening community action, developing personal skills and reorienting services, the Charter
stated that ‘health is created and lived by people within the settings of their everyday life; where
they learn, work, play, and love’.
The WHO has defined ‘settings for health’ as ‘the place or social context in which people engage in
daily activities in which environmental, organisational and personal factors interact to affect health
and wellbeing’. Adopting an ecological model of health, a systems perspective and a ‘whole system’
focus on organisational development and change, the settings approach aims to address the
interplay of factors and to integrate a commitment to health within the culture, structures and
routine life of settings (Dooris, 2006). Therefore, criminal justice settings offer an ideal opportunity
to engage a group of people normally considered hard-to-reach who are, in the main, from deprived
backgrounds and known to have high risk taking behaviours (Social Exclusion Unit, 2002) thus, going
some way to tackling health inequalities.
The Opportunity for Public Health
A ‘whole systems’ approach was proposed in Improving Health, Supporting Justice: A National
Delivery Plan (Department of Health, 2007). It identifies that offenders generally do not access the
health services they need outside of prison. Offenders are recognised as having greater health needs
based on a number of factors which include higher risk taking behaviour (drugs, alcohol and risky
sexual practice) and disengagement from education and health services (Social Exclusion Unit, 2002).
The criminal justice system as a ‘whole’, therefore, offers a range of settings and opportunities that
would allow health services to engage better with those considered ‘hard-to-reach’. It provides a
prime opportunity to address health inequalities, through engagement with NHS health services and
specific health promotion, treatment and prevention interventions.
Those in contact with the Criminal Justice System, like any excluded group, are entitled to an
equivalent quality and range of health care as the general population, designed to increase effective
uptake, tackle health inequalities and support socially excluded and vulnerable groups. Moreover,
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there is an ideal opportunity to engage with offenders while they are within the criminal justice
system in a way that may be more difficult following release and resettlement (Department of
Health, 2011).
The challenges of delivering healthcare and health promotion across criminal justice settings are
numerous. They include the public and professional perceptions of the criminal justice system, with
conflicting views regarding the purpose: on one hand, the punitive aspects of the system and on the
other the opportunities for reparation and rehabilitation. The public perception of investing in
offender health care may well be: ‘the money is better spent elsewhere’. However, the long term
benefits of tackling an ‘at risk’ population are evident: by reducing inequalities and encouraging
personal responsibility for health, the risk of developing life threatening disease can be reduced. In
addition to this, it is important to acknowledge the contribution improving offender health can make
to preventing reoffending.
However, when in custody, the environment can play an important role in the health and wellbeing
of an offender – both positively and negatively. An issue of particular concern and not confined to
the prison setting, is the use of tobacco as a coping strategy, particularly to relieve boredom and
stress, due to perhaps unemployment or limited diversionary activities. Tobacco has a role of
providing currency in the prison setting, thus making interventions more challenging in an
environment whereby it is a valuable commodity. Consequently, this adds to cultures of violence,
when bullying for tobacco can be commonplace. Prisons demonstrate high levels of smoking among
prisoners (approx. 80%) (Social Exclusion Unit, 2002). It is reasonable to consider that offenders in
contact with probation services have a similarly, if not equally, high rate coupled with the same
contributory factors such as: high levels of mental health conditions, substance use and educational
limitations as prisoners. Evidence from a number of studies, for example, a 2007 survey of offenders
on probation caseloads in Nottinghamshire and Derbyshire revealed that 83% of probationers were
smokers compared to only 22% of the general population (Brooker et al, 2009); and, 63% of
detainees in police custody in London reported dependence on cigarettes in a 2007 survey (PayneJames et al, 2010).
Whilst the benefits of tacking health inequalities across the criminal justice system are clear, it is
important to outline the current context and its impact on progress at the time of this report. The
constraints produced by the prevailing economic climate present a number of challenges to
addressing public health inequalities, including in relation to offender health. There is clearly an ongoing period of transition, as cuts to services and the impact of reorganisation becomes more
evident. The restructuring planned in relation to the commissioning of offender health currently
involves a degree of uncertainty, apprehension and frustration across partner organisations. The
move of public health into local authorities is still taking shape and it is difficult to see how offender
health will sit alongside other priorities in the development of Health and Wellbeing Boards. The
transfer of prison health care teams to provider organisations further adds to this uncertainty.
However, there are opportunities within the current, changing landscape, with the potential
becoming more apparent over time. It is clear the future has to be with a foundation of robust and
integrated delivery across all partners.
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Prison Service Orders and Prison Service Instructions
Prison Service Orders (PSO) and Prison Service Instructions (PSI) are long-term mandatory
instructions that set out the rules, regulations and guidelines by which prisons are audited.
PSO 3200 Health Promotion (HMP Service, 2002 sets out how H.M. Prison Service, in partnership
with the NHS, should ensure that prisoners have access to health services that are broadly
equivalent to those of the general public in order to:
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Build the physical, mental and social health of prisoners (and where appropriate staff) as
part of a whole prison approach.
Help prevent the deterioration of prisoners’ health during or because of custody, especially
by building on the concept of decency in our prisons.
Help prisoners adopt healthy behaviours that can be taken back into the community upon
release.
HM Prison Service (2003)
PSO 4950 Regimes for Juveniles defines the principles upon which regimes for young people should
operate. Prison Service Instructions are mandatory instructions which have a definite expiry date.
They are also used to introduce amendments to Prison Service Orders. Following the introduction of
the smoking legislation and the release of the PSI 09/2007 Smokefree Legislation: Prison Service
Application (H.M. Prison Service, 2007) the requirement was established for units holding under 18’s
to become smokefree environments. HMYOI Hindley, a young offenders institution in the North
West, in line with the PSI has been smokefree since September 2009.
Context Across the CJS: England and Wales
Prisons: The prison population for England and Wales was approximately 85,374 (30th June 2011:
Ministry of Justice, 2011) comprising:
 81,189 males in prison - a rise of 1% over the year.
 4,185 females in prison - a fall of 2% over the year.
Probation: The annual total probation caseload (court orders and pre and post release supervision)
increased by 39% between 2000 and 2008 to 243,434. Since then the probation caseload has fallen
slightly to 237,507 (Ministry of Justice, 2011).
Context: North West
The North West currently has 24 Primary Care Trusts, 16 prisons, 5 Police Constabularies and 5
Probation Trusts. The 16 prisons contain all types of prisoner: adult, young offender and juvenile,
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male and female, and from high security establishments, through to a category D open
establishment.
DEVELOPMENT OF CASE STUDIES
The three prison Case Studies were developed by the Project Coordinator undertaking a mapping
exercise which involved:
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a scoping activity to determine a baseline of the stop smoking service available in each North
West prison;
follow-up with each prison to determine progress over the life of the project.
A number of opportunities across the criminal justice system to support and develop the delivery of
stop smoking services can be demonstrated. All the North West prisons (16) have established stop
smoking services demonstrating a variety of delivery models. The project has identified that there is
scope to consolidate good practice and provide consistency across the prison system. The following
case studies highlight areas of good practice and innovation drawn from the inaugural project
mapping activity.
Two additional case studies were developed in police custody and probation settings. The case study
focussing on Police Custody highlights very limited provision for smokers, but is developed from
insights into current policies and documents, locally and nationally, as well as opportunities
identified by the Tobacco Control Coordinator. The probation case study is based on connections
made by the Coordinator during the course of the project.
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CASE STUDY 1: HMP YOI STYAL
Introduction
This prison was identified as a case study because it is part of the female estate, and despite a
history of smoking cessation support provision, numbers had declined at the time of the mapping
exercise. The case study highlights key issues and developments in delivery and wider organisational
changes which resulted in increased engagement with the target group.
HMP YOI Styal is one of the largest women’s prisons in England and Wales with a current
operational capacity of 459 (Justice.gov Prison Finder, 2011). It is the only female establishment in
the North West and as a result, draws from a wide geographical area spanning North West England,
Wales and beyond. This presents further complexity when referring women to localised stop
smoking services. The demographic makeup at the prison is varied with an age range of 18-65 and an
average age of between 25 and 35. Women from BME communities make up 28% of the population
and Foreign Nationals, 21%. There is a Mother and Baby Unit (MBU) run by Action for Children which
has places for 22 mothers and 23 children. Women selected to use the MBU move there towards the
end of their pregnancy and are able to keep their babies with them until they are 18 months old. The
MBU is a smokefree unit though currently smoking mothers have access to outside smoking areas.
The healthcare contract at HMP YOI Styal is delivered by East Cheshire NHS Trust, with specialist
services provided by Greater Manchester West Mental Health NHS Foundation Trust. The current
contract has been operating since April 2009, with varied clinic sessions available, including stop
smoking sessions.
Smoking Cessation Support at HMP YOI Styal
Healthcare staff have been trained by the (PCT) Community Stop Smoking Team to deliver sessions
that have been operating once a week both in the healthcare department and on the prison’s Waite
Wing. Week one involved history taking and initial assessment and if appropriate, patches were
issued on the second visit.
At the time of mapping review, prisoners were reviewed on reception and offered access to the
service should they show initial interest. Carbon Monoxide (CO) monitoring was undertaken at
sessions and on commencement of the programme, but there had been no random use of testing as
a potential control. The NRT provided was mainly patches (Niquitin patches 7/14/21 days) although
inhalators are available. There was no use of CHAMPIX. It was also noted that:
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the number of DNAs (did not attend) across all clinic appointments were substantial;
difficulties in delivery were due to capacity, staff rotas and more recently staff sickness;
regime and wing issues presented problems particularly in relation to prisoner movement in
order to attend sessions;
access to clinic rooms and booking problems hampered service delivery;
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capacity to deliver the service consistently was a major issue with acknowledgement that
there was a need to refresh and revitalise training including training additional staff;
more dedicated staff time needed to be allocated to the service and a more pro-active
approach adopted;
many of the prisoners may attend the group sessions more from a socialising perspective
than from a desire to stop smoking;
the quick turn around of some prisoners presented a problem, as they may have moved on
before completing a course, or indeed able to access a course.
there are currently no prisoners involved in the delivery of stop smoking support although
this has been considered;
HMP Styal does not have a health trainers programme although the prison has commenced
work with the PCT to roll out the “InfoLink” training in order to provide ‘health champions’
across the prison (see below);
there is no support for staff in relation to stop smoking services;
there are no additional incentives offered to women on the programme (for example,
additional gym sessions) although possibilities have been discussed;
access to leaflets is good and the prison are using the Department of Health information and
easy to read options that acknowledge literacy issues. There is also access to Language Line
and leaflets in languages other than English, in recognition of the number of Foreign
National prisoners. The prison facilitates “Well Women” sessions that had been identified as
a potential opportunity to introduce the issue of stopping smoking and make links to
protecting children and young people from exposure to second hand smoke.
Following the initial project mapping of the stop smoking service, a development meeting was
convened and facilitated by the project coordinator to explore the delivery of the stop smoking
services at HMP Styal. The purpose of the meeting was to explore the low numbers accessing the
service and discuss the historic barriers and challenges to delivery. The meeting had representation
from the prison, Public Health, Commissioning and the Community Stop Smoking Team. All were
keen to progress the service. It was clear that a number of key changes have already taken place
since the initial review and subsequently additional changes took place following the development
meeting:
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the number of women accessing the service had increased;
additional staff (7) have now been trained to increase the capacity of the service alongside
the development of a training programme, agreed with the Community Stop Smoking
Service, who will provide on-going training updates;
future training sessions will include two members of the Integrated Drug Treatment Service;
the increased capacity should alleviate problems arising from annual leave, sickness and
staff rota issues providing delivery of a consistent service;
sessions are now run on a weekly 1:1 basis;
women now receive access to NRT on their first visit, if they are assessed as being motivated
to quit;
“Healthy Beginnings” packs now include information on local stop smoking services and
cover over 30 destinations that women are released to;
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new appointment cards have also been introduced that can record information including on
transfer to other establishments and/or release;
the Prison Health Promotion Group is developing a Health Improvement Plan which links to
the Prison Operational Development (POD) group to provide a holistic approach to
addressing health related issues;
The prison is exploring incentives for women joining the Stop Smoking Programme including
extra dental support in the form of additional scale and polishes. Other suggestions have
included access to beauty salon treatments, Zumba classes, priority access to environmental
work programmes, and potentially, access to a smokefree house;
the prison is considering the links with parenting skills to look at providing targeted
information around protecting children and young people from the dangers of exposure to
second hand smoke;
the prison is also exploring further the potential for smokefree house(s) in addition to the
MBU and potential smokefree avenues.
Good Practice Example: “InfoLink” Programme
The prison is working with the PCT Public Health team to roll out delivery of the “InfoLink”
programme operating across the Central and Eastern Cheshire PCT area. “InfoLink” is a resource for
health professionals, other professionals, members of the public and volunteers. An online resource
programme, it provides training, guidance and support for people to become ‘champions’ for health
and well being and is increasingly being recognised as a reputable brand across the PCT area. The
project was created to encourage individuals to make lifestyle changes and provides services that
are close at hand which are delivered by people with whom clients have an existing relationship.
Built around a health trainer model, the “InfoLink” service provides access to free information and
support. Access to the service is easy, quick and simple, providing advice and evidence on the
benefits of making changes and the difference that can make.
In order to become a Champion, candidates attend a one day training programme, which is based on
Level 2 of the Royal Society of Public Health (RSPH) qualification (the course is in the process of
being accredited). Thus, the course provides an accessible route into training, as many other courses
run over five days, which can often act as a barrier. Those on the course learn what constitutes
health promotion, how to carry out a health promotion campaign, how to order resources,
communicating confidently, and how best to use the information provided by the “InfoLink”
website. The training covers five core areas of evidence-based health promotion, which have clear
links with the health trainer model; weight management; stop smoking; five ways to wellbeing; and
general cancer awareness. This is supported by a ‘Champions Toolkit’ and access to the information
provided via the website.
An “InfoLink” Champion can:
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relate to and interact with individuals requesting local health and well being information and
service access information;
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provide clear, accurate signposting information based around the information provided by
the individual;
provide leaflets or written information, as appropriate in response to requests
put together simple health promotion displays, using support and guidance outlined in the
‘Champions toolkit’;
record requests for information on the relevant monitoring sheet.
The programme provides a well written evidence-based programme of training and support that can
be rolled out to a variety of settings to both professional and community/volunteer staff. Training
has been delivered to probation and prison staff to equip them with the core skills to support health
and well being. This training, coupled with additional stop smoking brief intervention, can equip staff
working in prison, probation and the wider criminal justice system with the skills and knowledge to
carry out an initial assessment of an individual’s smoking, identify their motivation, and discuss their
options to quit if appropriate.
Conclusions: HMP YOI Styal Stop Smoking Services
From the initial review and the subsequent development meeting, it is clear there are a number of
pressures to the delivery of stop smoking services. However progress since the initial review has
been substantial, all of which has been achieved within existing resources. Credit should be given to
the staff involved who have taken on board all the issues and put improvements or mechanisms in
place to help resolve them.
In addition to an increase in attendance at stop smoking clinics, the prison is exploring further the
potential for smokefree houses and potential smokefree avenues. Good engagement with the PCT
and the roll out of the “InfoLink” programme are t examples of good practice. The Community Stop
Smoking Team has provided access to a training programme to increase capacity and support the
delivery of a consistent and quality service. Wider development in relation to health promotion has
meant there is a more holistic approach to the delivery of health support across the site.
Recommendations: HMP YOI Styal Specific
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Develop mechanisms to monitor the health and well-being of prisoners on the stop smoking
programme;
Improve access to a wider range of NRT for prisoners;
Ensure mechanisms are in place to reduce those currently recorded as ‘lost to follow up’;
Introduce a system of incentives for prisoners engaging with the stop smoking programme;
Integrate protecting children and young people from exposure to second hand smoke into
current parenting classes utilising the ‘take 7 steps’ campaign;
Provide smokefree living environments for prisoners joining the stop smoking programme;
Extend the use of the “InfoLink” programme and train all staff in stop smoking brief intervention.
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CASE STUDY 2: HMP FOREST BANK (PRIVATELY MANAGED PRISON)
Introduction
This case study explores the stop smoking service at HMP Forest Bank, a privately managed prison.
The stop smoking service works with the prison gym to link with a 12 week physical activity
programme. Therefore this case study provides prison specific information, outlines key
observations and draws upon examples of current practice while identifying key learning that may
be used to influence the future development of stop smoking services more broadly in the prison
setting.
Forest Bank is a busy local prison (capacity of 1424 as of 26th March 2010: Justice.gov Prison Finder,
2011) with a high turnover of prisoners. The 2011 Health Needs Assessment indicates smoking rates
of 80% equating to 1017 prisoners with around 43% wishing to quit (547) ( Carr, 2011). The Primary
Healthcare Team are employed by Sodexo Justice Services, managers of the prison, and work in
partnership with the PCT.
Stop Smoking Services at HMP Forest Bank
Historically the stop smoking services have been delivered via the Physical Education team involving
two members of staff. At the time of the mapping review the two staff had not completed the full
smoking advisor training programme although additional training dates were booked. The
programme focused around physical activity and was run as a cardio-vascular session integrated
with smoking cessation. The programme was a 12 week course, so for new prisoners wishing to quit
there was potentially a 12 week wait or longer until the next course could be accessed. At the time
of review staff had already booked the next two courses with up to 28 prisoners booked on each.
The sessions ran over two set days, Tuesday and Thursday. Tuesdays comprised an induction session
covering fitness, registration and then on-going programme input and support while Thursday
covered a fitness programme and CO monitoring (CO monitoring was undertaken later in the day
where possible, to aid the recording of more accurate readings). Mixed circuits and spin classes were
designed to offer variety and add additional fun to the sessions, and each programme was
developed in relation to individual needs and ability.
The service was receiving approximately 3-4 new referrals each day and PCT data showed a good
60% quit rate (Quarter 2 2009/10 PCT Data).). The next two courses were already booked up so
whilst this means prisoners have to wait, it indicates interest and engagement in accessing stop
smoking services. The gym staff have been considering access criteria for the course in order to
identify those most motivated, to reduce DNA’s and thus improve overall throughput.
Prisoners not achieving quit status after the 12 weeks, or those struggling on the programme, were
referred to healthcare for additional or alternative support. Healthcare also picked up referrals
where illness was an issue i.e. COPD/respiratory issues. There were instances where a small number
of prisoners were prescribed NRT via the healthcare team which were not counted in the quit data
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submitted to the PCT. There were 85 prisoners on the programme between March and November
2010 and 54 completed the course and quit, all of which were CO validated (63.5%) (Carr, 2011).
There were instances where prisoners were released or transferred before completion of the
programme and a substantial number of these would have been recorded as lost to follow up.
NRT patches were used as part of the stop smoking sessions, which appeared to work well. Other
options were available to those referred to healthcare or those with specific needs and health
issues, although these appear to be few and far between. Champix was not widely used, although
there was potential access via healthcare where deemed beneficial (during service mapping the
pharmacist confirmed only one case to date).
In 2009, NHS Salford offered Forest Bank the opportunity to sign up to a Locally Enhanced Service
(LES) for smoking cessation with payments per 4 week quit, validated with a Carbon Monoxide test.
The payments are made on a rising scale starting at £40 per 4 week CO validated quit for the first 10
quits, £50 each for the next 10, up to a maximum of £110 each for over 100 quits. The prison signed
up to the LES in August 2009 and is monitored quarterly. This approach has been used to encourage
service development and an increased level of activity.
Since the initial review:
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the existing gym staff have completed extended training facilitated by the PCT Stop Smoking
Service. The training has now been structured to consider the delivery of stop smoking
services in the prison environment reflecting the needs of prisoners and the complexities of
the setting and in line with the North West Training Knowledge and Skills Competency
Framework being developed by the Demonstration Project;
two staff are involved in the delivery, working on a rota basis to provide cover for shift
changes, annual leave and sickness; service delivery has been re-structured to offer
additional access to stop smoking sessions dedicated to stop smoking;
prisoners now access the physical activity programme at weekends which has more than
doubled the capacity of the service thus, substantially reducing waiting lists.
prisoners are allocated a week’s supply of NRT at each session (this is not currently offered
on a patch for patch returns basis) with weekly CO monitoring reducing any potential abuse
of patches. In addition to this, released prisoners or those being transferred are given
sufficient supplies to bridge any delays or gaps in accessing treatment services.
Recent improvements to the delivery model have further increased access and capacity resulting in
additional interest from prisoners. There is good engagement across the age ranges with success
rates evenly distributed and many of the older prisoners showing particular motivation to quit.
Despite difficulties in monitoring the physical progress of individuals (largely due to capacity and
gym throughput of 3,000+ volume) staff have acknowledged considerable improvements in the
overall health of participants in the programme: prisoners note being able to equate stopping
smoking with improved physical and cardio ability and for many, weight loss has been of particular
benefit alongside a general feeling of wellness and being better able to deal with stress.
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Whilst prisoners have access to information and advice there would be added value in providing
more targeted information in relation to diet and nutrition. Anecdotally, staff suggested that it
would be useful to focus more on the benefits to prisoners of stopping smoking specifically in
relation to increased cardio ability, an example being the running bleep tests. Another example,
given by gym staff, is the impact smoking has upon general fitness levels commenting particularly
that during football practice, young smokers often struggled to keep up with older non-smoking
prisoners. For some, they recognise, this reality has provided the additional motivation to quit and
improve overall abilities body image and reduce weight.
Conclusions: HMP Forest Bank
Substantial progress has been made since the initial project review. Evidently, it has been possible to
improve access and increase capacity of the stop smoking service from within existing resources.
Prisoners are clearly motivated by the health value of access to the gym and a 12 week cardio
programme. Engagement has increased and the number of DNAs has reduced indicating that those
prisoners joining the programme are feeling supported and well motivated, with this clearly
reflected in the high quit rates being achieved. There is scope to further enhance delivery in some
areas as indicated and reflected in the following recommendations. There is also a sound
commitment from the PCT to support these developments and maintain training for staff.
Recommendations: HMP Forest Bank Specific





Explore mechanisms to monitor prisoners on the stop smoking programme in relation to their
improved physical health and well being.
Where appropriate, improve access to a wider range of NRT for prisoners.
Ensure mechanisms are in place to:
− include all 4 week quitters in the data submitted to the PCT, specifically those prescribed
NRT via healthcare;
− reduce those currently recorded as lost to follow up.
Provide appropriate and targeted advice and information around diet and nutrition for those on
the Stop Smoking Programme.
Review the provision of NRT and consider the introduction of a patch for patch exchange to
provide an additional control to any potential abuse of NRT.
13
CASE STUDY 3: HMYOI HINDLEY
Introduction
This case study will focus on a juvenile establishment, which is in effect a smokefree prison setting
under current rules. It will highlight a specific key issue that the young people are abrupt quitters:
despite 96% of the young people smoking on entry only around 18% access support from the stop
smoking Service (Renwick, 2010). The case study draws on information provided by the Prison
Health Needs Assessment (PHNA) (Renwick, 2010); the initial mapping exercise; staff feedback on
service delivery; and opportunities and challenges in relation to young people’s needs in the prison
setting.
HMYOI Hindley is located approximately four miles south east of Wigan. Opened in 1961, the prison
was re-assigned in 2009 and became a single juvenile estate, accepting 15-18 year old remand and
sentenced males from throughout the North West. It is the largest juvenile prison in the country
with an operational capacity of 440 (June 2009; Justice.gov Prison Finder, 2011). HMYOI Hindley
provides twenty-four hour medical cover and has provision for thirteen inpatient beds. Where
possible health needs are met within the prison, with referral to external agencies and services as
required.
Approximately a third of the young men at Hindley are Looked After Children (LAC) and around 5060% have some form of communication need or impairment, for example Asperger’s /autism. Many
also have socialisation issues, having difficulty understanding sarcasm and humour etc. This can
impact on their understanding of the nuances of adult conversation, which can lead to difficulties in
dealing with and managing behaviour. It is acknowledged that young men face difficulties in
adjusting to the environment and there are often association issues and potential for bullying to take
place. In addition to this, some young men have other substance related issues involving, for
example, alcohol, cannabis, or other illegal drugs. This can be potentially exacerbated by having to
stop smoking on entry to the prison, as they seek alternative coping mechanisms.
The cycle of reoffending is a considerable concern at the prison with high numbers of young men
being repeat offenders. In addition to this many have been exposed to fairly chaotic and unstable
lifestyles with very little structure to their day. This often results in sleep problems and a substantial
period of adjustment to the structured prison regime.
HMYOI Hindley: A No Smoking Environment
HMYOI Hindley became a no smoking establishment in 2007, in line with national guidance and PSI
09/2007. The recent PCT Health Needs Assessment (Renwick, 2010) acknowledges that 96% of the
juvenile population at HMYOI Hindley enter the prison as smokers. Given the high levels of smoking
in the prison population, a comprehensive cessation support package is required, to include both
nicotine replacement therapies as well as individual and group support. At present all juvenile
smokers entering the establishment are offered nicotine replacement patches at reception and are
14
monitored weekly thereafter if they engage with support. However, there is no further group or
individual input given to support the young people. Provision of group support during their sentence
and a pre-release motivational intervention may help maintain the abstinence of smoking following
release.
Stop Smoking Support in YOI Hindley
Despite the fact that 96% of prisoners enter the prison as smokers, the numbers of young men
accessing support from the stop smoking service is relatively small. Approximately 18% access NRT
and on-going support with the vast majority choosing to be abrupt quitters. There is access to NRT
for all prisoners and assessment is undertaken at reception and induction. This includes a health
education programme which incorporates stop smoking support. Staff estimated that around half of
the young men say they don’t want to give up smoking, with many stating that they would return to
smoking on release.
Historically support has included access to relaxation techniques and acupuncture, with programmes
tailored towards individual need. Currently only nicotine patches are available and many only use
these for relatively short periods. There are no extended programmes available as these are not
considered necessary, with only a small percentage [18%] accessing support and those who do are
provided with patches to help with stopping. Patches are used on a daily patch for patch basis, thus
reducing opportunity for abuse of patches as currency. The young people at HMYOI Hindley are not
involved in the service delivery as the relatively small numbers accessing support means this is not
considered necessary.
There is no structured stop smoking support to staff. Historically there had been attempts to deliver
staff sessions supported by the Community Stop Smoking teams. However, despite initial interest,
the uptake of these dwindled. It was suggested by the Reducing Reoffending Action Plan group that
health trainers may be able to facilitate staff sessions in the future. The prison has two newly
appointed health trainers available which will help support a number of developments across an
extended remit. The prison are also considering training young people serving longer sentences, up
to Royal Society for Public Health level 1 so they can then offer linked support.
Currently, HMYOI Hindley does not offer any additional incentives as the low numbers means this is
not necessary. The young men do have access to a range of support techniques irrespective of
whether they are on a stop smoking programme or not. These include:







Pumping Pad – cell based physical activity routines.
Yoga and Relaxation.
Music /Meditation tapes and exercises.
Replacements – study, reading, games, mints, fruit, water.
Structured programmes for the day.
Sleep hygiene programmes, including access to Horlicks.
Puzzles/diary-keeping/writing and drawing.
15
Literature on stopping smoking is not readily used due to difficulties with literacy; all the information
is delivered as part of a tailored verbal input. There may be scope to produce a prison specific
information leaflet designed by and for young people.
At the moment there are no established links with the Visitor Centre. However, it is envisaged that
the introduction of Health Trainers may help facilitate this and also provide the opportunity to
create links with Partners of Prisoners and Families Support Group (POPS). Partners and families are
informed of the no smoking regime and can provide additional support to young men having to quit.
Conclusions: HMYOI Hindley
It is clear there are a number of factors which influence how the no smoking culture is embedded at
HMYOI Hindley:






the young people have not been smoking as long as their counterparts in the adult prison
population;
due to their age the young people are perhaps more compliant with the legislation;
many of the young men have previous knowledge that the prison is a smokefree
establishment and as such non-smoking is an accepted part of the regime;
most of the young people are serving much shorter sentences than those in the adult system
making it easier to give up (even if only for the duration of their short sentence) and for
many of the young men there is an anticipation that they will return to smoking on release;
limited access to illicit supplies and the associated cost;
there is acknowledgement that there are benefits to stopping smoking, both financial and
physical.
Despite around 96% of prisoners being smokers on entry, uptake of support for stopping smoking is
very low in the prison. Staff encourage the young men to explore alternatives to smoking and there
is a range of techniques to support this which is particularly important at significant pressure points
during the day.
Recommendations: HMYOI Hindley Specific




Further develop links with Youth Offending Teams (YOTs) to provide access to support and
prevent potential relapse.
Train YOT teams in Stop Smoking Brief Intervention to build capacity across the workforce and
encourage referral to community Stop Smoking Teams.
Develop the YOT nurse role to equip staff with the skills and knowledge to act as Stop Smoking
Advisors utilising existing 2 day course and online accreditation with the NCSCT.
Integrate stop smoking into the parenting programme, focusing on the risk of exposure to
second hand smoke for children and incorporating the Take 7 Steps Out programme.
16



Develop links with parents, partners and other family members to provide access to information
about stop smoking services to support prisoners on release and prevent potential relapse.
Review the stop smoking input at induction to ensure information is valid and up to date.
Display information regarding the stop smoking support in the newly refurbished healthcare
reception area.
17
RECOMMENDATIONS: RELEVANT ACROSS PRISONS
In addition to the recommendations specific to individual prisons, the following themes are relevant
to all prisons:






disseminate appropriate prison and offender-specific resources and programmes (i.e.
relaxation techniques, parenting programmes) across the North West prison and offender
system;
develop links with partners and other family members to provide access to information
about stop smoking services that support prisoners on release and prevent potential
relapse;
deliver stop smoking brief intervention training across the criminal justice system to equip
staff with the skills and knowledge to (1) carry out initial assessment, (2) identify motivation,
(3) provide options to quit, and (4) ensure on-going referral to services is delivered in line
with established national and regional guidance;
roll out “InfoLink” to staff across the criminal justice system ensuring this is linked into the
delivery of a structured stop smoking brief intervention programme;
support prisons to introduce access to smokefree living environments for prisoners and
where appropriate, offer additional incentives to those on a Stop Smoking Programme;
integrate protecting children and young people from exposure to second hand smoke into
current parenting and education classes, and illustrate using the ‘Take 7 Steps Out
Programme’.
18
CASE STUDY 4: POLICE CUSTODY
Introduction
The purpose of this case study is to explore the provision of nicotine replacement therapy in police
custody suites. It outlines the current situation in relation to detainees in custody including a review
of current police custody and smoking policies. The case study will provide some background,
context and feedback from North West police custody contacts. Whilst custody may be the first
point of contact with the criminal justice system for many detainees, it is perhaps not usually
considered an environment to deliver brief intervention in relation to stopping smoking. An
individual’s contact with police custody is often at a point of crisis and custody suites are generally
very busy. As a result there is arguably limited capacity to carry out any structured intervention.
However, there may be scope to explore routine provision of NRT to smokers in police custody in
order to support withdrawal and potentially engage and motivate detainees to consider stopping
smoking in the future.
A 2007 study conducted with detainees in police custody in London indicated that around 63% of
detainees were smokers, based on self reported dependencies (Payne-James et al, 2007). Therefore
police custody provides an ideal point of contact and can act as a gateway to services for individuals
who may or may not have considered stopping smoking. The routine provision of NRT particularly,
could act as a trigger for detainees to consider access to on-going stop smoking support.
‘… Working in partnership, the police service can provide the gateway to health engagement.
Many behaviours that lead people to have contact with the police are driven by both physical
and mental health needs. As the initial point of contact with the CJS [criminal justice system]
for most people, we will work with the police service to implement a framework encouraging
their role as a first gateway to health and social care.’
(Department of Health, 2007)
There are 43 police services with 603 custody suites in England and Wales (Lennox et al, 2009).
However, due to pressures produced by the prevailing economic climate this number is likely to
reduce as services review provision and some custody suites are closed. For example, across
Lancashire the number of police custody suites will reduce from eight to six. Home Office data
(Home Office, 2011) for the North West Police Forces provides an outline of the number of recorded
offences based on a rolling year for the 12 months to 31st March 2011: Cumbria 27,048,
Lancashire102, 503, Greater Manchester 227,838, Cheshire 63,729 and Merseyside 100,113. The
total number of recorded offences for the North West region is 521,228 (Home Office, 2011). The
average length of stay for a detainee in custody is around 6 to 7 hours and potentially over 48 hours.
In addition, detainees in police custody are placed under the responsibility of a Custody Officer
whose duties includes an assessment of risk with questions relating to health:
19
•
•
•
•
•
•
Do you have any illness or injury?
Have you seen a doctor or been to hospital for this illness or injury?
Are you supposed to be taking any tablets or medication?
What are they? What are they for?
Are you suffering from any mental health problems or depression?
Have you ever tried to harm yourself?
(Association of Chief Police Officers, 2006)
Should a detainee require medical attention, it is provided through access to a Forensic Medical
Examiner (FME), usually GPs contracted to cover custody suites, or alternatively another Health Care
Professional (HCP). Custody suite healthcare is provided by either NHS providers or by private
healthcare agencies. Information regarding the smoking status of detainees is not routinely
collected. However, Lancashire Constabulary have been piloting the use of a health questionnaire in
four custody suites, which following discussion with the Demonstration Project now includes two
smoking related questions: are you a smoker; and, are you receiving support to quit?
Police Force Policies: Association of Chief Police Officers (ACPO) Guidance
Guidance on the safer detention and handling of persons in police custody (ACPO, 2006) produced
on behalf of the Association of Chief Police Officers (ACPO) and the Home Office by the National
Centre for Policing Excellence, indicates that Forces should apply a no smoking policy in Custody
Suites. In line with this and the 2007 legislation all constabularies have adopted a no smoking policy.
A review of 20 police force policies available online, conducted by the Demonstration Project
Coordinator, indicated a considerable majority are completely non smoking environments for both
staff and detainees, however there are instances in which detainees are, in exceptional
circumstances, allowed to smoke in exercise areas, and in some circumstances, custody cells. The
following is an extract from two force policies dated 2006 and 2009 and indicates that detainees can
smoke in exceptional circumstances (N.B. these may have been reviewed but still appear active on
the relevant force websites):
‘Smoking is prohibited in the Custody area; this includes smoking by staff and visitors as well
as detainees. It is recognised that in some exceptional circumstances it may desirable to
allow a detainee to smoke and there is therefore some discretion for Custody Officers to
permit a detainee to smoke whilst held in custody i.e. where they are being held for
significant periods of time and/or for serious offences, or are particularly difficult detainees’
(Suffolk Constabulary, 2005)
20
‘In these instances, the Custody Officer must fully risk assess any danger to custody staff and
wherever possible smoking should be within the exercise yard area. The Custody Officer
should ensure that staff are not put at risk of passive smoking and will therefore need to
consider if they have the appropriate staff to undertake an escort to allow the detainee to
smoke. Only in exceptional circumstances should a detainee be allowed to smoke within a
cell and again this must be fully risk assessed. Consideration also needs to be given to the
impact of such a decision on the other detainees being held in custody who are not allowed
to smoke. Any decision to allow a detainee to smoke must be recorded and justified in the
custody record’.
(Suffolk Constabulary, 2005)
Other forces suggest that if an individual detainee experiences withdrawal and specifically increased
anxiety, decreased cognitive performance, irritability, mood swings, disorientation, and depressive
symptoms or increased aggression then advice should be sought from the Custody Officer in charge
and/or Forensic Medical Examiner (FME) or HCP as appropriate. In these instances NRT could be
provided as in the following the policy excerpts:
‘Where appropriate, following a risk assessment of the detainee, the Custody Officer in
charge of the Custody Suite shall consider any request from a detainee for nicotine
replacement products, typically patches. The Custody Officer may seek the advice of a Force
Medical Examiner (FME) or healthcare professional (HCP) who will advise on the effects of
nicotine withdrawal. This advice may be by telephone or in person, and the Custody Officer in
charge will be guided by the advice of the FME or HCP’.
(Thames Valley Constabulary, 2008)
‘..... operates a no smoking policy in all custody areas of the force. However custody officers
may, in exceptional circumstances, permit a detainee to smoke. An exceptional circumstance
might be where the detained person has indicated they are nicotine addicted and there are
legitimate medical grounds which exist, the advice of a healthcare professional would have
to be sought in this instance’.
(West Mercia Constabulary, 2009)
‘Administration of cigarettes (as permitted in exceptional circumstances) must be properly
detailed on the custody record. The detainee must smoke away from the custody area and
must be under escort, other security measures may be required, e.g. handcuffs’.
(West Mercia Constabulary, 2009)
21
Nicotine Dependent Detainees: Faculty of Forensic and Legal Medicine (FFLM)
The FFLM has the following faculty view on nicotine dependent detainees in Police custody:
‘The vast majority of smokers can refrain from smoking for a period, but it should be
remembered that the effects of withdrawal from any substance, including nicotine, are likely
to be exacerbated by the circumstances of acute enforced detention and may affect the legal
process. Many of the features of nicotine withdrawal are indistinguishable from anxiety.
Certainly craving for nicotine can result in dysphonia and threats of self-harm’.
‘Nicotine gum (as a form of Nicotine Replacement Therapy – NRT) is available to buy over the
counter by members of the public. Although there are a number of contraindications to the
treatment there is no requirement to involve doctors. If an individual chooses to smoke or
take NRT, he/she takes responsibility for any effects subsequent to this action’.
(Faculty of Forensic and Legal Medicine, 2008)
Her Majesty’s Inspectorate of Constabularies/Prisons (HMIC and HMIP) ‘Expectations’
Her Majesty’s Inspectorate of Constabularies/Prisons (HMIC and HMIP) carry out a programme of
inspections of Police Custody suites both on a programmed and unannounced basis. These include
individual published reports for each inspection and periodic ‘thematic reports’ on emerging trends
or findings of particular importance. These inspections look not only at the implementation of
statutory requirements but also at conditions of detention and the treatment of detainees including
access to and provision of custody healthcare.
One of the criteria set out in HM Inspectorate of Prisons and HM Inspectorate of Constabulary
‘Expectations’ Criteria for assessing the treatment and conditions for detainees in police custody
(HMIC 2009) relates to the smoking policy:
A no-smoking policy for staff and detainees is enforced that respects the right of individuals
to breathe clean air in the custody suite.
Staff: ask them:
 what the no smoking policy is and whether it is followed
 whether nicotine replacement is provided to detainees on request and whether
they are informed of this on arrival
 whether nicotine replacement is provided by a healthcare professional.
Documentation:
 check that there is a no smoking policy.
Observation:
 if a smoking area is provided, check it is appropriately supervised. Observe what
detainees are told about the no smoking policy and the availability of nicotine
replacement.
22
Detainees: ask them if they:
 know what the no smoking policy is
 are able to request and receive nicotine replacement.
The inspections include the use of a detainee questionnaire which includes a question relating to
smoking:
If you smoke, were you offered anything to help you cope with the smoking ban there?
 I do not smoke
 I was allowed to smoke
 I was not offered anything to cope with not smoking
 I was offered nicotine gum
 I was offered nicotine patches
 I was offered nicotine lozenges
A review of these on-line reports shows the percentage scores for detainees responding to the
question ‘I was not offered anything to cope with not smoking’ ranged from 62% to 87%. A number
of the reports reviewed have identified the provision of NRT and recommended extending access.
However it has not been possible to establish if there is a national HMIC recommendation on the
provision of NRT, although the Expectations themselves ‘offer a guide to senior police officers and
police authorities as to the standards that the two inspectorates expect to find in these settings and
the sources of information and evidence upon which they will rely’ (HMIC, 2009)
Progress: Provision of Nicotine Replacement Therapy (NRT)
In response to their HMIC inspection one of the police forces reviewed (Avon and Somerset) has
now developed a procedural guidance document for the provision of nicotine replacement therapy
in custody suites. The force now provides routine access to micro tablets after the first 4 hours in
custody. Other forces do provide access to NRT and in most instances this is administered after
consultation with a health professional and/or the custody officer. It appears that even in suites
where access is available, the numbers receiving NRT are relatively small. As patches are slow to
release nicotine, effective use of NRT in police custody would require alternative forms of treatment.
Perhaps the most beneficial in terms of speed and administration is the use of micro tablets or mini
lozenges. The release of nicotine is quicker and the risks in relation to choking are very low. Nasal
and oral sprays present additional problems in terms of security and ease of application. Nicotine
gum is another potential option but the risk of choking is perhaps of greater relevance.
Pressures on the System – Contextual Issues
Police forces are facing substantial funding constraints and, through a review process, some forces
will be reorganising their custody processes and reducing the number of custody suites. In addition
to this some forces have decided to review their arrangements for the provision of healthcare. This
23
is particularly timely as some existing contracts are being reviewed. There is clearly an on-going
period of transition as cuts to services and the impact of reorganisation becomes evident.
Forces are faced with a number of key decisions and in relation to the provision of NRT they have a
number of other more pressing priorities in keeping detainees safe and well, so that adding
additional pressures to current procedures and practices is difficult. In the North West it may be
possible to explore the issue of NRT in custody via the Regional Custody Forum. Initial requests have
been met with some resistance, not due to of a lack of interest, but because of the issues listed
above. The future development of the Regional Offender Health Team (ROHT) may provide the
mechanism to move this forward.
Opportunities: Pilot Activity
There is support from the pharmaceutical industry to explore supporting a pilot programme to
provide routine access to NRT in selected police custody suites, covering treatment costs and
removing potential commissioning barriers presented by the prevailing economic climate. This
would need discussion on the pilot scope and the development of agreed protocols and guidelines.
There would also be a need to look at any staff training needs and how these may be resolved.
Conclusions: Police Custody
Whilst police custody may be the first point of contact for many detainees, it is perhaps not an
environment to deliver brief intervention for stopping smoking. An individual’s contact with custody
is often at a crisis point, custody suites are generally very busy and as a result it is suggested that
there is little capacity to carry out such structured intervention. There are a number of police forces
which do provide access to NRT and there is some evidence (HMIC, 2009) to suggest that this
potentially offsets the impact of detainees experiencing withdrawal and specifically, increased
anxiety, decreased cognitive performance, irritability, mood swings, disorientation, and depressive
symptoms or increased aggression.
The HMIC routinely assesses provision of NRT and has in some instances recommended the
extension of access in its inspections of custody suites (HMIC, 2009). As the average length of stay in
custody is between 6-7 hours, detainees who are nicotine dependent would benefit from being able
to access support and NRT (HMIC, 2009). However, there needs to be consideration given to the
most appropriate and effective forms of therapy provided to reduce any associated risks and provide
speedy delivery of nicotine.
It is essential that alongside the provision of NRT there should be access to information about local
Community Stop Smoking Teams, as access to therapy in police custody may present detainees with
a trigger to consider stopping smoking in the future. It is recognised that there are a number of
constraints to providing access to NRT, specifically the current economic climate and a period of
rapid transition coupled with commissioning constraints. It is however, feasible to harness support
from the pharmaceutical industry to support pilot work in selected custody suites.
24
Recommendations: Police Custody Specific






Present to the Regional Custody Forum the issues contained in this case study and explore
potential to undertake a pilot for the routine provision of NRT in police custody across the North
West.
Undertake a review of (North West) police custody smoking policies to establish a clear
understanding of current practice.
Scope feasibility to undertake a pilot programme, supported by the pharmaceutical industry,
across selected police custody suites.
Develop procedural guidance to support the routine provision of NRT in police custody suites.
Develop access to information and referral links to Community Stop Smoking Teams for
detainees who smoke.
Roll out the Multi Agency Screening and Assessment Tool being piloted in North West police
custody suites to provide data on the health needs of detainees, including smoking status.
25
CASE STUDY 5: PROBATION
Introduction
This case study outlines the opportunities within the probation setting for the effective delivery of
targeted stop smoking services and engaging with people normally considered ‘hard-to-reach’. It
draws on examples of good practice from probation services across the North West region with a
primary focus on the use of offender health trainers.
Rationale: Beyond the Health Benefit
The NHS Health Trainer service was launched in 2005 with the aim of tackling health inequalities
through helping disadvantaged and hard-to-reach communities access local health services and
make healthier lifestyle choices. Whilst the main focus was on disadvantaged geographical
communities, the initiative also signalled an opportunity to develop services with target groups such
as offenders in prison and probation settings (Baybutt and Dooris, 2011).
Locating a Health Trainer service in the Probation Service reflects and legitimises a socio-ecological
‘settings’ model of health, which prioritises the integration of health within the culture, structure,
processes and routine of an organisation. It is evident that Heath Trainers in this setting are ideally
placed to encourage offenders to improve their health and reduce reoffending (Baybutt and Dooris,
2011).
As emphasised by a Government review of health inequalities (Department of Health, 2008), “a fair
society means helping people to make healthier choices in many different aspects of their lives,”
acknowledging that “some people live in circumstances that make it much harder for them to
choose healthy lifestyles.” Health Trainers represent a visible link between professionals and
disadvantaged communities. Their selection is based not only on their abilities, but also on their
knowledge and understanding of the communities with which they work – many living in the same
geographical areas or being from the same population group. Half of clients are drawn from the
most deprived 20 per cent of local authority areas and nearly 90 per cent of Primary Care Trusts
currently have a Health Trainer service (Marmot, 2010).
Health Trainers support and encourage individuals on a one-to-one basis to make changes to their
lifestyle, improve their health and wellbeing and minimise health risk. Broadly, the aims of Health
Trainer services (DH, 2006) are to:



build the workforce with the right skills to tackle health inequalities;
work with individuals to carry out an initial health assessment, leading to the development
of a personal health plan;
provide one-to-one support to enable individuals to achieve a positive impact on their
health by making changes in their behaviour;
26

target individuals whose lifestyles carry a number of risks and help them to access and use
local health services and personal health support.
It is widely recognised (DH, 2004) that health trainer services provide an innovative approach to
improving health and addressing health inequalities in areas of multiple deprivation. The use of
health trainers allows people to address their health and lifestyle choices with trained staff drawn
from their own community, in this case, ex-offenders.
Good Practice Example: Offender Health Trainers
The Borough of Rochdale sits in North of Manchester within the boundaries of Greater Manchester.
Using the Indices of Multiple Deprivation (IMD) it can be classed as one of the most deprived areas
in England. In addition to this the Greater Manchester Probation Trust (GMPT) has at any one time
around 1500 people subject to supervision across the Rochdale Borough (Baybutt and Dooris, 2011).
The Offender Health Trainer Demonstration Project commissioned by the North West Health Trainer
Partnership provides the opportunity to use members of the community to support the community,
utilising ex-offenders as Health Trainers – Offender Health Trainers (OHT’s). This not only harnesses
their understanding, skills and knowledge but also builds the workforce from within. Health Trainers
support and encourage individuals on a one-to-one basis to begin to make lifestyle changes that help
to improve their general health and well being and in turn minimise risk. One of the core target
areas for health trainers is smoking.
Many offenders are at risk of poor health as a consequence of a specific cause or behaviour. The use
of OHT’s helps identify these and provides the opportunity to identify personal goals and plan
responses. It is clear that the OHT’s work very much on an individual basis, establishing achievable
goals that can lead to substantial step changes.
The Offender Health Trainers all have an offending background and have been recruited to criteria
agreed in the development of the project. This provides a workforce that is grounded in the
community it serves, providing firsthand experience of the client group essential in appreciating the
complexities of the problems that offenders present with. They are all trained within the Health
Trainer programme to NVQ level 3 with additional training facilitated as appropriate for example,
brief intervention around stop smoking.
Due to their knowledge and skills base the OHT’s are well placed to identify and understand lifestyle
challenges and associated behaviour changes, assessing motivation to change and helping build
evidence of effective responses both in addressing health issues and reducing reoffending. The
OHT’s are able to engage clients on a more informal level generating conversations that often
identify the issues and triggers to change.
The potential to bridge the two agendas of health and offending behaviour is clear. Many clients
present a desire to stop smoking with the service data reflecting this. Additionally, the OHT’s have
received brief intervention training and in some areas can provide access to NRT. The local stop
27
smoking services have delivered a programme of smoking cessation training targeted to the needs of
the client group and the setting.
The following case study produced by one OHT further outlines the impact addressing stop smoking
issues can have:
Daniel: Age: 28
Alcohol Intake: 7-8 Units per day Cigarettes: 20 per day Exercise: None
ALL PREVIOUS OFFENCES ALCOHOL RELATED
_______________________________________________________________________________
First Appointment: 23/02/2010
Daniels offender manager had indicated that his drinking had increased dramatically in previous
weeks and on her suggestion, he had agreed to see a health trainer when he attended. He had
obviously been drinking that day, after talking to Daniel for some time it was obvious that he used
to be very active but was now spending practically all his time in his flat drinking and smoking. He
had previously been a regular at his local gym but could not now afford it and although doing no
exercise he was in fact losing weight. Daniel did not believe his drinking was a problem, I decided
that if we could get Daniel out of his flat to do some exercise we could break the routine he had
got into. I suggested to him that we could give him a swim pass, he accepted and agreed to go
three times that week.
Next appointments: 04/03/2010 - 10/03/2010
Daniel had been swimming four times that week and also had not been drinking as much as he
usually would have and going to the swimming baths had renewed his interest in exercise. He
indicated that he would like to give up smoking, I gave Daniel vouchers for nicotine patches,
congratulated him on the progress he had made and agreed to see him in one weeks time. Daniel
told me that he had only smoked and drank on the previous Saturday, and he was now concerned
that he was underweight. I referred him to a nutritionist at Birch Hill Hospital.
Although he was enjoying his swimming he wanted to join the gym, I pointed out that with the
money he had saved from giving up smoking he would be able to join the gym. However because
he had concerns about his weight I contacted his GP about Exercise Referral, issued him with
more nicotine replacement and agreed to see him a week later.
Next appointments: 18/03/2010 - 01/04/2010
Daniel said that he hadn't smoked at all the previous week and had only drank three cans on the
Sunday; He had been swimming three times and had paid to go to the gym twice. He explained to
me that his order with the probation service was now finished but wanted to continue seeing me
for support. I gave two weeks on nicotine replacement and agreed to see him two weeks later.
Daniel said that he hadn't smoked or drank for two weeks, and wanted to reduce his nicotine
replacement because some day's he wasn't using it. He was using the gym more frequently and
also enquired about coaching the community. I gave him the relevant information, reduced the
nicotine and agreed to see him three weeks later.
Next appointments: 29/04/2010 - 13/05/2010
Daniel is not smoking and not using his nicotine replacement as often as he was but still likes to
28
have some on him just in case. He told me he had a few drinks at the weekend whilst watching
the football but none for the rest of the week. He is still going to the gym 4-5 times a week but
not swimming as much. I enquired about the coaching in the community scheme he said he had
not applied because they wanted to do a CRB check. I advised him to apply anyway as he had
nothing to lose and reduced his nicotine replacement even more as he was hardly ever using it at
all now. Daniel said he had not smoked or drank since our last appointment and he is still
attending the gym 4-5 times a week. He has received a date to attend an exercise referral
assessment which means now he will receive twelve weeks free gym sessions. I asked Daniel to do
a co2 test which the reading came back as 1 which is the reading of a none-smoker. He was hardly
ever using his nicotine replacement now and we agreed together that he no longer needed to see
me as regular as he had. We made no further appointment but Daniel has been given my contact
telephone number in case he ever needs any further support. Daniel thanked me and told me he
would ring me if he needed any further help.
June 2010
Daniel contacted me in June to tell me he had gained employment as a scaffolder and was doing
well.
Source: Baybutt and Dooris, 2011
Project Extension: The Offender Health Trainer Project has been extended to Bury and Oldham
Probation Services after securing additional funding from the North West Innovation Fund. This has
widened the access and has allowed for further links to be made with the local prison HMP Buckley
Hall. This will enable potential to bridge the gap between prison and probation settings, thus
strengthening the potential to reduce relapse on release for smokers who have quit in prison. The
project is also exploring the opportunity of links with police custody suites.
Many offenders are not registered with GPs or other services (Social Exclusion Unit, 2002). The OHT
project offers great potential to signpost people into services from which they have been previously
disengaged.
Other added benefits have included linking in partners and family members with the stop smoking
sessions and having health-focused events at the Middleton Probation Office. Similarly, sessions
have also been delivered at the women’s approved premises.
Good Practice Example: Tomorrow’s Women
The Tomorrow’s Women project is based at Sefton Women’s Advice Network (SWAN) centre. The
project commenced in October 2010 and is an unfunded collaboration between probation and the
SWAN centre. The project operates one day each week supported by a Probation Service
Officer/Tomorrow’s Women Project Co-ordinator. The project has been designed to address the
reasons why women offend and to meet the needs of women who may be at risk of offending,
recognising that women’s needs are often different from men’s. Referrals to the project are made
through a variety of partners, including probation, courts, police and HMP Styal.
29
The project supports and encourages all women who access the centre, some of which may choose
to work with a mentor; those women who are subject to a Community Order will work with their
Offender Manager. Together, Merseyside Probation Trust, the SWAN Centre and locally based
agencies, support women in developing an individual plan to help them avoid future offending. This
is facilitated by a range of group work, complimentary therapies and activities that are both practical
and creative to promote self confidence, responsibility and a sense of community. Support can, for
example, include the following:









Healthy Lifestyle Checks
Sexual Health Check-ups
Counselling
Positive You course
Healthy cooking on a budget
Range of complimentary therapies
Facials, manicures/pedicures
Drop in facility
Exercise classes – Sumba/Yoga/Tai Chi
The project includes smoking in the health check, but currently does not provide access or referral to
local services. Discussions are underway to extend this provision and consider training project staff
and SWAN Centre team in stop smoking brief intervention supported by the local stop smoking
service in Sefton. This will provide the skills to identify individual issues, assess individual motivation
and provide referral to local stop smoking services.
Good Practice Example: Approved Premises
The Roy Castle Foundation ‘FAG Ends’ have been providers of stop smoking sessions to Approved
Premises (AP) specifically Merseybank AP, on Merseyside. There are 69 beds across the 3
Merseyside Approved Premises. These sessions provided access to the full range of stop smoking
services. The initial uptake was notably good but interest and numbers have diminished over time
becoming difficult to justify input for potential results.
Many offenders in Approved Premises (formally known as Bail hostels) are subject to extended
curfews and as such are more easily accessible for stop smoking services. The hostels provide access
to useful activity during periods of curfew. Therefore, the setting and circumstances are well placed
to deliver structured sessions either on a 1:1 basis or via group interventions. However, the numbers
accommodated in approved premises across the North West are relatively small: 16 hostels
accommodating over 300 offenders. Whilst the numbers are relatively low, access to this ‘at risk’
and ‘hard-to-reach’ section of the community provides a great opportunity.
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Conclusions: Probation
There are considerable opportunities across the probation setting to deliver stop smoking
interventions. The use of offender health trainers clearly indicates a creative and innovative way to
engage a group described as ‘hard-to-reach’ in a community environment familiar to them.
Recommendations: Probation Specific





Support early referral of quitters to an Offender Health Trainer (OHT) on release from prison to
help reduce the potential for relapse: consider links being made prior to release;
Develop Offender Health Trainers as Stop Smoking Advisors to increase uptake of NRT and
provide more immediate access to support and treatment supported and governed by the
community stop smoking teams;
Explore opportunities for delivering targeted stop smoking interventions in each of the North
West 16 Approved Premises: as a minimum, establishing access to information, protocols and
clear pathways into services;
Pilot the delivery of stop smoking brief intervention training programmes to staff at the SWAN
Centre and Tomorrows Women project and extend this across similar services and venues that
target women;
Incorporate support in relation to the impact of second hand smoke on children into training
where appropriate (e.g. the ‘take 7 steps’ initiative).
31
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USEFUL LINKS
www.uclan.ac.uk/hsdu
Healthy Settings Development Unit, University of Central Lancashire
(On-going Projects >>‘Tobacco Control in Prisons’ pages)
www.ctcr.stir.ac.uk
Centre for Tobacco Control Research, University of Stirling
www.smokefreenorthwest.org
Smoke Free North West
www.ukctcs.org
UK Centre for Tobacco Control Studies
www.ash.org.uk
ASH Action on Smoking and Health
www.nosmokingday.org.uk
No Smoking Day 2011
www.roycastle.org
The Roy Castle Lung Cancer Foundation
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