Report on the Prison Oral Health Promotion Programme in Forth ValleyDecember 2009

Tina Everington Senior Health Promotion OfficerNHS Forth Valley Health Promotion ServiceEuro HouseWellgreenStirlingFK8 2DJ

Email: tina.everington@nhs.netExecutive Summary

BackgroundIn March 2005 the then Scottish Executive Health Department published the 'Action Plan for Improving Oral Health and Modernising NHS Dental Services in Scotland'(1). A key area was action to reduce inequalities in oral health with a focus on priority groups such as prisoners and the homeless.

Forth Valley has three prison establishments; HMP and YOI Cornton Vale, the main female prison, HMYOI Polmont, the main young offenders institution; and HMP Glenochil which has made progress towards becoming a community facing prison for Fife and Forth Valley.

This report outlines how NHS Forth Valley has implemented oral health promotion programmes within the Forth Valley prisons over the last three years. The report highlights successful practice and offers suggestions for future action.

Programme

The aim of the oral health promotion programme was:

To increase the level of oral health promoting behaviours undertaken by convicted prisoners and prison staff in Forth Valley prisons.

Objectives:This would be done by:

Increasing knowledge levels around positive oral health promoting behaviours Implementing a “Whole Prison Approach” including environmental changes

that enabled prisoners and staff to actively care for their own dental health Working in partnership with the dental care providers to maximise

opportunities for service delivery.

Significant developments achieved include:

Implementation of interventions to increase knowledge and skills including brief intervention for convicted prisoners during Induction and prison officer training.

Distribution of oral health packs, including toothbrush and toothpaste, to all convicted prisoners and follow up packs every three months. Pack distribution provides opportunity for one to one discussions with prisoners.

Effective model of partnership working between NHS, SPS and independent contractor.

Provision of plumbed in drinking water. Increase in availability and initiatives to encourage uptake of sugar free

products in the prison canteen (tuck shop). Easier access to fresh fruit and vegetables through the rainbow fruit bags

scheme. Resurrection of prison health promotion group in all 3 establishments Special projects such as the cooking skills course and recipe book

Recognition should be given to the operational work in the prison of the Community Dental Service oral health promoters and the Department of Nutrition and Dietetics’

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community food development worker as their enthusiasm and commitment to health improvement as been noticed within all 3 establishments.Summary of Key Learning Points

A setting based approach is appropriate for health improvement work within prisons. Comprehensive risk assessment is essential for all staff as well as compliance with SPS policies and procedures.

Individual establishments have an extensive level of autonomy. There are differences in the interpretation of what can be done at a local level to changes to the canteen sheets and it would be beneficial if a clearer direction was given at a national level on this from SPS HQ.

Oral health interventions could be maintained in prisons as standalone programmes but in doing so both the potential for oral health improvement and for addressing the broader issues within a whole prison approach is constrained. It is therefore beneficial for those working in oral health to work closely and maintain links with other NHS colleagues and agencies involved in health improvement in order to progress activity through a “whole prison approach.”

Implementing any initiative in a prison takes time and benefits from a collaborative effort. Change often does not occur through a linear progression but periods when little seems to be happening will be followed by sudden advances. Equally challenging for those addressing the inequalities agenda within the prison setting is establishing the links and creating the continuity which allows those leaving prison to maintain any positive health behaviours established and to access similar levels of service provision outside in the community.

The prison service in England and Wales created Prison Service Order 3200 to encourage a whole prison approach. Prison service orders are mandatory for prison governors and PS3200 required that health promotion must be included in local planning mechanisms. Consideration could be given to the potential benefits and challenges to incorporating health improvement activity into the objectives of both senior management and the wider prison workforce and the possibility of using current incentive schemes to engage the workforce. Discussion with senior management locally revealed both positive and negative aspects to mandatory requirements, however, there is no doubt that a formal framework and a system of review does impact on progress. Those involved in oral health improvement in prisons have a role in highlighting their support for work at a national level towards achieving a framework for implementation of the whole prison approach within Scottish prisons. Any such framework should not be promoted as a new initiative but as a tool to facilitate current SPS activity or expected interventions through the implementation of a whole prison approach. The National Strategy for the Management of Offenders already aims to deliver on many of the outcomes that would be the goals of a Health Promoting Prison programme. Having the implementation of such programmes within the objectives of the Head of Offender Outcomes within the establishments could be a means of integrating health improvement activity into the wider prison agenda. There may be a role for the SPS College in highlighting the potential of prisoner officers as health improvement practitioners and embedding this within the core competencies. There is also potential for existing monitoring systems such as Prison Visiting Committee Reports to have a specific section highlighting progress towards a Health Promoting Prison.

Current SPS toothbrush and toothpaste provision should be improved upon. There appears to be a higher status given and a greater willingness to use non SPS products. If this is phased in alongside the transfer to NHS provision it may be possible to maintain this association

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Background In March 2005 the then Scottish Executive Health Department published the 'Action Plan for Improving Oral Health and Modernising NHS Dental Services in Scotland'(1). The Dental Action Plan set out how strategic planning could deliver targeted oral health improvement. Recognition was given to the inequalities seen in oral health and a focus was placed on priority groups including prisoners and the homeless.

This report outlines how NHS Forth Valley has implemented oral health promotion programmes within the Forth Valley prisons over the last three years. The report highlights successful practice and offers suggestions for future action.

Oral health in PrisonsThe Scottish Prison Survey 2002 (2) highlighted that prisoners have significantly poorer oral health than the general population. Levels of severe decay were three times higher in the prison population than the non- prison population and in the female prison severe decay was fourteen times more prevalent than the general female population. Similar results are found in research (3,4) undertaken with remand prisoners in England.The majority of prisoners come from the poorest or most socially excluded areas of society and often have the greatest health needs (5). Life circumstances mean that they are more likely to have had chaotic lives, engaging in high risk behaviours such as alcohol misuse and illegal drug taking. The use of illegal drugs, associated with a low disposable income and a chaotic lifestyle, can easily lead to poor nutrition - including high levels of sugar consumption. Drugs themselves can lead to cravings for sweet sugary foods. A chaotic lifestyle is also less likely to include any formal oral hygiene routine (6).

Not only does poor oral health have a negative effect on physical health but general wellbeing can be severely compromised. The Surgeon General’s report Oral Health in America (7) highlighted the effect of poor oral health and its potential to undermine self image, self esteem, discourage family and other social interactions and lead to chronic stress and depression. In Scotland the burden of poor oral health is weighted to the most disadvantaged in our society, a greater proportion of who enter our criminal justice system. Improving oral health therefore should be seen as a justifiable element of any programme that aims to rehabilitate offenders, reduce recidivism and facilitate employment opportunities.

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Local ContextForth Valley has three prison establishments; HMP and YOI Cornton Vale, the main female prison in Scotland HMYOI Polmont, the main young offenders’ institution; and HMP Glenochil which has made progress towards becoming a community facing prison for Fife and Forth Valley.Over the last ten years various health promotion interventions have been supported within these establishments by NHS Forth Valley Health Promotion, including work to support the national Health Promoting Prison Framework (8). The lack of resources and formal structure to support work at both a national and local level has meant, however, that activity has been piece-meal and maintaining support from the prisons themselves has been challenging.

The Dental Action Plan and the subsequent allocation of resources to support oral health improvement in Forth Valley prisons provided an opportunity to re-establish health promotion work with the three prisons. Due to the distinct nature of each of the establishments it was agreed that a staged approach, working initially at an individual level with each prison was the most appropriate way forward.

Framework for ActionInformation was gathered on previous research and work around health improvement and prison oral health initiatives. The recommendations from the 2002 Scottish Prison Survey (2) gave a starting point for baseline activity. Extensive work had also been undertaken in England in respect of prison dental services following the implementation of the Strategy for Modernising Dental Services for Prisoners in England(9). This, along with the Prison Health Research Network’s evaluation of the strategy(10), the Office for Public Management’s guide to good practice on Reforming prison dental services in England(11) ,the Department of Health’s Health Promoting Prisons(12) and the SPS Health Care Standard 6 provided the initial elements of the approach taken. Evidence and best practice from Prison Health in Scotland (13) and the WHO’s Health in Prisons (14) have been incorporated over time. The dental documents highlighted the high levels of treatment need within the prison population. It was therefore considered important that any programme aiming to improve oral health had to consider the current model of treatment provision and offer any available support to addressing problems highlighted by the establishments in this area. The issue for Forth Valley prisons mirrored the national picture in that the dental services were often insufficient to meet demand, varying in equity of access and offered through differing models of provision.

The aim of the Prison Oral Health Promotion programme was:

To increase the level of oral health promoting behaviours undertaken by convicted prisoners and prison staff in Forth Valley prisons.

Objectives:This would be done by:

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Increasing knowledge levels around positive oral health promoting behaviours Implementing a “Whole Prison Approach” including environmental changes

that enabled prisoners and staff to actively care for their own dental health Working in partnership with the dental care providers to maximise

opportunities for service delivery.

EvaluationLocal process evaluation has included feedback on service provision, programme attendance rates and annual review against agreed outputs. It is intended that more in depth assessment of the intervention will be undertaken at a national level.

HMP Cornton ValeContact was first made with HMP Cornton Vale due to the extremely poor level of oral health within the female prison.An initial meeting was held with the Head of Health Care outlining the background to the support on offer and highlighting the way forward through a collaborative working model. The model involved all those in the prison with a stake in oral health improvement e.g. healthcare staff including the dental team, aspects of prison environment (catering and canteen sheet) and also of prison systems, such as Induction.

Following on from this, discussions took place with healthcare, the prison dentist, the Consultant in Dental Public Health and the Clinical Director of Dental Services. The aim of these discussions was to consider how the dental service within the prison could be supported. Clearer pathways to accessing emergency care outside the prison were agreed, as was input from a CDS oral health promoter. The dentist was supportive of the concept and wished to be kept informed but did not see an extensive role for himself within any oral health improvement programme due to his limited time availability in the prison.The prison health promotion group was reformed to include:

Health Centre Manager (Chair) Catering manager Physical training Instructor Health centre staff Health visitor Finance manager CDS Oral health promoter Health Promotion staff

Action plans were produced by the group allocating the DAP funding that has been provided to support the programme. The initial stage was to focus on nutrition and dental health (healthy eating being one of the key areas of the Health Promoting Prisons framework (8).

NHS Staff inputIn 2007, following discussions with SPS Human Resources and after mandatory training, an oral health promoter from the Community Dental Services began working in the prison one day a week. Health Centre staff

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supported the role in the prison, however, a fair degree of autonomy and personal initiative was required in order to progress the work. The SHPO worked at a strategic level supporting environmental changes within the prison through the Health Promotion Group, providing examples of evidence based practice to the Senior Management team and raising awareness at a national level within the SPS of the aims and objectives of the programme.

DAP funding had been used to employ a dietitian specifically for developing work with vulnerable groups such as prisoners and homeless. The dietitian and SHPO began work with the catering manager to look at opportunities for increasing healthy eating in the prison. This was then carried on through work at a national level with the catering managers and SPS senior management and the secondment of the dietitian to a national role in SPS.

Environmental ChangesThe following changes have been implemented through the action plans:

Provision of plumbed in drinking water across the prison Increase in range of sugar free products on canteen sheet Subsidised artificial sweetener and sugar free drinks on canteen sheet Increased access to fresh fruit through the launch of the Rainbow bags

which include 5 pieces of fresh fruit for 50 pence. Vegetable bags have now been added at the request of the prisoners.

Decorative permanent posters promoting fruit and vegetables through out the prison

Programmes to support behaviour change

Oral health promotion session at Induction Oral health promotion session with work parties Oral health promotion session within smoking cessation course Oral health promotion training session with prison staff Oral health brief intervention during re-supply of packs

Resources to support programmes

Dental Hygiene ProductsPrevious research has indicated that prisoners’ perceptions of the dental hygiene products provided in prisons (15) were very poor. The oral health promoter received extensive anecdotal evidence to back this up in Cornton Vale and this perception was further substantiated by the SHPO who experienced the toothbrush breaking after a single use. It was decided that an oral health pack, containing a toothbrush recommended by the CDS hygienist, fluoride toothpaste (at that time the toothpaste supplied by the SPS was only 1000ppm, this has now changed) and a dental leaflet designed for use in prisons would be given out by the oral health promoter. It was agreed that in order to increase potential for behaviour change the packs would need to be distributed through an education based intervention. A session was

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agreed for the oral health promoter within the induction programme as well as the opportunity to meet with work parties throughout the prison, undertake a brief intervention and redistribute packs on a 3 monthly basis. On average 100 packs a month are distributed.

New dental products were also placed on the canteen sheet so that these could be purchased regularly.

Oral and dental health leaflet

Over 60% of offenders have literacy and numeracy levels of less than SQA Intermediate level 1 and lack functional literacy and numeracy. (16). In view of this it was agreed that none of the current material held by Health Promotion or the CDS was appropriate. A prison induction session was used to identify the information that need to be included and a staged approach was devised for the leaflet with a focus on key behaviour changes.

Xylitol based productsA supply of xylitol based confectionary was provided to the prison in 2008 to support the smoking cessation programme. This received positive feedback from those on the programme and will be maintained with an aim to increase the products available throughout the prison via the canteen sheet.

Service EvaluationA service evaluation was begun with staff and prisoners during October 2009. Results from the staff who were involved with prisoners on the programme indicated that 88% agreed or strongly agreed that the oral health promotion service should continue. 59% indicated that they thought awareness of positive dental promoting behaviours had increased. Comments included:

Most definitely. Oral Health Promoter is very good at explaining this issue not just to prisoners but also to staff and is often sought for advice.

Yes the prisoners are paying more attention to their oral health and wanting to get their teeth cleaned and polished.

Most certainly this is the case, prior to the Oral Health Promoter attention to oral health was slip shod and many prisoners did not take care of their teeth or have access to toothbrushes/toothpaste.

The evaluation from the first prisoner sample revealed that 88% reported that they brushed at least twice a day and that 75% reported that they used the “Spit Don’t Rinse” technique.

Additional comments and feedback included:

Many female offenders have very low self-esteem often this is due to years of drug abuse and self neglect. If we manage to assist these female offenders to regain some self-esteem through improving personal hygiene this can assist in reducing re offending.

I think the Oral Health Promoter does an excellent job and is highly motivated. I feel the information session is relevant. However as prisoners are given brushes

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and paste by the prison and also have the option to buy further products, I do not see the need for packs to be issued. My main reason is that I personally feel NHS funds could be better spent on other amenities.

Current StatusOver the last year Cornton Vale has dealt with an increasing prisoner population creating challenges for every aspect of the prison. The Health Centre has focussed on meeting the immediate demands of their community and this meant that the Health Promotion Group has not met on a regular basis. Although, during this time the established oral health promotion programmes were maintained, the potential for providing a catalyst for strategic health promotion activity across the prison was reduced. The group met again in October 2009. It was agreed that:

Information on canteen purchasing trends would be collated and supplied. It was noted anecdotally that the reduced price of artificial sweetener compared to sugar had significantly increased the amount purchased. This was not reflected as much in the purchase of sugar free carbonated drinks, although it was encouraging to note that the overall levels purchased had gone down within the prison since the installation of the plumbed in water coolers.

The group would prioritise areas for action and produce a new action plan.

Future Activity Support senior management towards making permanent changes to

the prison environment within a whole prison approach (11) (13) and with a broader focus on the wider determinants of health.

The current oral health promotion programmes will be maintained as well as a new focus on aiming to achieve permanent changes to the canteen sheet to increase the range of some products and decrease others. This process has begun in some establishments however there does not appear to be a consensus across the SPS as to how far individual establishments can carry out this process. This needs to be clarified at a national level.

The SPS dietitian has supported the implementation of a Healthy Weight Management group and a successful programme has been piloted in the prison with the aim of linking in to exercise referral. There are clear opportunities here for oral health promotion through joint objectives in behaviour change.

A proposal for a life skills unit has been produced which would allow a wide range of skills based interventions including basic cookery skills to be offered. Partnership funding is currently being sought for this.

HMYOI PolmontInitial discussion took place with the Young Offender’s Institution during 2007. The health centre manager, prison dentist and catering manager and health promotion staff agreed in principle to the need for an oral health improvement

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programme. The prison dentist highlighted that he would like to undertake more preventive based work, however, this was not practical with the current demands on treatment services. A similar model to Cornton Vale was proposed with the initial focus on nutrition and dental health.

HMYOI Polmont was involved with the Healthy Working Lives scheme and its predecessor Scotland’s Health at Work scheme. A Healthy Working Lives group had just been established and the establishment therefore felt that this group and a prisoner health group were required. Although support was offered at both operational and strategic level progress was slow over the first 18 months culminating in part of the start up grant allocated to the prison being returned unspent.

In June 2008 a letter was sent to the Governor highlighting the potential support available to the prison and the uptake by the other establishments, following which the Deputy Governor contacted the SHPO and agreement was reached on how to progress the programme.

A Health Promotion Group was formed with associated sub groups including the staff health group. Action plans were produced by each subgroup and the strategic group has met on a regular basis since then.

Health Promotion Group

Deputy Governor (Chair)Health Centre ManagerSexual health nurseMental health nurseRepresentative from educationRepresentative from Phoenix FuturesWellcome dieititanManagerCatering managerResidential staffHealth promotion staff

NHS Staff inputThe oral health promoter began work in November 2007. The model was slightly different to that employed in Cornton Vale as direct referrals were taken from the dentist. Health promotion staff are permanent members of the Health Promotion Group and attend, as required, sub groups for oral health and nutrition, smoking, mental health and substance use.

The health promotion grant that was not allocated towards the action plans was used to fund a community food development worker to work within the prison.

Environmental ChangesThe following changes have been implemented through the action plans:

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Increase in range of sugar free products on canteen sheet Review of canteen sheet to reduce confectionary range Increased access to fresh fruit through the launch of the Rainbow bags

which include 5 pieces of fresh fruit. Sugar free / healthier options introduced in vending and tea bar Replacement of issue to YO’s weekend pack of full sugar fizzy drink

with fruit juice Replacement of catering size free flowing large salt dispensers with

small individual cruet sets.

Programmes to support behaviour change

Oral health promotion session at Induction Oral health promotion session following referral from dentist Oral health promotion session with work parties and pass men Oral health promotion training sessions with prison staff Cooking skills/ eating well class. A recipe book which includes

healthy eating and dental health messages has been put together and illustrated by a group of prisoners on the course. Three of the group passed their REHIS Food and Health certificate and are now involved on the course as peer educators.

Dental Hygiene Products and health education materials

A similar oral health pack to that given out at HMP Cornton Vale was distributed to convicted prisoners at the oral health education sessions and re-distributed three monthly. The distribution was stopped for a period due to security concerns at the manufacture of weapons from the toothbrushes, however, following an investigation it has been decided that the appropriate risk assessment is in place and that the current brushes are acceptable. Alcohol free mouthwash is also distributed.

The “Simple Steps” leaflet was used by the oral health promoter to outline the changes that the young offenders needed to make if they wanted to see a difference in their dental appearance.

Service EvaluationThe service evaluation has not yet been completed at HMYOI Polmont as a practical method of completion by individual prisoners has not yet been agreed. Quotes from the staff evaluation include: “More prisoners appear to be taking a responsible approach to their oral health.” In response to the question has awareness around positive oral health promoting behaviour increased: “Yes definitely. This is evidenced by the number of prisoners requesting packs.”

Current Status

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The oral health promotion programmes are being maintained. The Health Promotion Group meets every quarter. Subgroups have

been formed to lead on alcohol and Substance misuse, smoking and health, staff health, oral health and nutrition, mental health and sexual health. The subgroups meet on a regular basis to implement their own annual action plans.

Health Promotion staff are working with the Deputy Governor and the Head of Communications at the SPS to produce a communication strategy. The initial focus of this will be to increase internal communication within the establishment and widen the understanding of a whole prison approach to health improvement. This will aim to increase awareness of the current and potential role staff have in improving prison health in its broadest sense and how such work integrates into other prison targets and strategies. The opening of the new estate at HMYOI Polmont provides an opportunity to further highlight the links between environment and well-being and create an appetite to build on these changes.

A mapping exercise of all current and previous work undertaken in the prison that sits within a whole prison approach to health improvement is being undertaken between the SPS and the NHS.

The subgroups are developing the concept of a drama based education programme on the health issues faced by young men with the aim of producing a DVD for all prisoners.

Health promotion staff are working with prison officers to integrate the cooking skills project into an overall life skills programme linking in to work being undertaken by other NHS staff such as speech and language therapy.

Potential future areas of activity Following review of the mapping exercise the Health Promotion Group

will identify gaps in activity, potential links between current programmes which will allow best use of resources and a clearer outline of how all the extensive work being carried out right across the prison contributes to the key strategies in health and criminal justice. A means of integrating the monitoring of health improvement changes into existing monitoring systems will be explored.

Although the views of the prisoners have been sought in respect of individual projects e.g. the changes to the canteen sheet, it is hoped that a means of more permanent prisoner representation on the group will be achieved.

HMP Glenochil

An initial meeting was held between the Consultant in Dental Public Health, prison dentist, health centre manager and the SHPO oral health

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late in 2006. The contact had been made at an opportune time in that a new dental suite had recently opened and both the health centre manager and the dentist were interested in the possibility of a wider oral health improvement programme. It was agreed that environmental changes needed to take place including changing the fluoride concentration in the toothpaste supplied by the SPS and canteen supplies. It was highlighted that the prison hygienist had initiated an oral health education input into the smoking cessation course but had found the group work extremely challenging and that this should be considered when developing any programme. It was agreed that work would need to take place within a strategic framework and that the Health Promotion Group, chaired by the health centre manager would lead on this.

Shortly after this meeting the health centre manager moved on to a new post delaying the formation of the Health Promotion Group. The SHPO did gain agreement, however, from SPS HQ to change the fluoride concentration in the toothpaste for all SPS establishments.

In May 2008 the SHPO met with the Skills for Employment Co-coordinator who was looking to expand on what was currently provided in the prison training kitchen. Through this discussions took place with the catering manager and it became clear that the priority for the establishment at that point was addressing issues around food.

Agreement was then reached with the new health centre manager as to what support was required to take health promotion activity forward. Health promotion staff would support work aiming to address the food issues in the prison while an oral health promoter would begin delivering sessions and distributing packs in the prison. Focus groups were held with prisoners following which a list of potential areas for action was developed.Due to pressures faced by the Health Centre it proved challenging for the Health Promotion Group to meet on a regular basis. A letter was sent to the Governor at the beginning of 2009 following which health promotion staff met with both the Governor and health centre manager. A newly convened Health Promotion Group, chaired by the Governor, has now met and is beginning to prioritise areas for action.

NHS Staff inputThe oral health promoter began work with the Health Centre and dental team one day a week in the prison in May 2008. The model used was for groups of prisoners to be brought to the health centre where they would have information provided on looking after their dental health including oral hygiene and diet. This was followed by the issue of a toothbrush and toothpaste pack with a 3 monthly review.

Initial uptake by prisoners was slow and information posters and leaflets were put into each of the halls to promote the service. The Health Centre staff now

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report that a majority of prisoners use the service and regularly attend the health centre for updated information and training.

The oral health promoter now works on the same day as the dental hygienist in order for prisoners to be seen consecutively. Health promotion staff attend the Health Promotion Group and have worked with prison staff facilitating specific pieces of work e.g. needs assessment, mapping tools.

Environmental Changes Soup and a sandwiches lunch choice rather than 3 course hot meal Fruit tasting sessions Provision of trial size artificial sweetener to prisoner

Awareness Raising Programmes Focus group work has been carried out recently in partnership with

NHS Fife alcohol services for Alcohol Awareness Week.

Programmes to support behaviour change

Oral health education session at Induction Oral health education session with work parties Oral health education training session with prison staff Oral health brief intervention during re-supply of packs Oral health education session integrated into smoking cessation

course.

Dental Hygiene ProductsA similar pack to that given out at the other two prisons has been distributed at Glenochil. Unlike the previous establishments prisoners are also able to purchase dental floss at Glenochil and the dental hygienist at the prison has reported improved levels of dental hygiene in those prisoners who have seen the oral health promoter.

Service EvaluationThe service evaluation has not been fully completed at this stage, however, the staff feedback received so far has highlighted that those staff agreed or strongly agreed that the service should continue. Comments included:

Prisoners who have never brushed teeth now know that daily brushing is social norm

Great improvement in attitudes, behaviours and overall oral healthThe Health Centre Manger stated that the service from both oral health promotion and the prison dental team has improved prisoner dental health, reduced the number of people requiring emergency treatment and increased the number now being offered checkups and treatment. The number of complaints received regarding dental care has also reduced

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The prison dentist stated that he had seen a clinical difference in those who had attended the programme and that the system set up between the oral health promoter and the hygienist was clearly improving the oral health of those involved and that before and after cases were showing positive outcomes.

Current Status

The oral health programme is being maintained A small health promotion group has been meeting approximately every

two months, chaired by the Governor. A mapping exercise will be undertaken to establish what health improvement work has been or is currently ongoing in the prison and the opportunity for joint working.

A healthy eating/ cooking skills programme similar to that undertaken in Polmont has been developed to begin January 2010.

Future Activity Increase membership of health promotion group and develop health

promotion action plans. Aim to utilise the potential of the visits area as space for family focused

health improvement activity. Dental hygiene products and registration information will be piloted in

the liberation packs. Introduce fruit bags

Table 1 Figures for attendance at oral health education sessions and pack distribution in all prisons up to May 2009.

Establishment Brief Intervention Packs distributed

3/12 distribution

Attendance at staff sessions

HMP Cornton Vale

1376 685 76

HMP Glenochil 732 599 58HMYOI Polmont

1122 787 111

Considerations for future Prison Oral Health Programme developmentThe experience of working with the prisons in Forth Valley over the last three years has provided some key learning points for future activity.

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A settings based approach can be used for health improvement work within prisons, however, prisons are a unique environment and understanding must be given to staff who may find working there intimidating. Comprehensive risk assessment is essential for all staff as well as compliance with SPS policies and procedures.

Despite the overwhelmingly positive response to the distribution of oral health packs at a local level, both from the perceived quality aspect and the “higher status” of non SPS products, in terms of both cost and logistics it would seem sensible to start planning how an alternative pack could replace the current SPS toothbrush and paste rather than be given as additional provision. If this is phased in alongside the move over to NHS healthcare provision then it might be possible to maintain the “higher status” perception associated with a non SPS product and, as has been noted locally, the subsequent greater willingness to use it.

It has been evident from the work in Forth Valley that individual establishments have an extensive level of autonomy. There does, however, seem to be differences in the interpretation of what can be done at a local level to changes to the canteen sheets and it would be beneficial if a clearer direction was given at a national level on this from SPS HQ.

Although the oral health promoters have established good working relationships and systems with the local prison dental care provider, the programmes implemented in Forth Valley did not meet the programme objective of partnership working with dental care providers at a strategic level to address issues around health care provision. It is recognised, however, that the move towards national NHS provision of health care services did in some ways supersede this objective.

Oral health provides a useful starting point for general health improvement work in a prison. There is a clear clinical need in relation to oral and dental health which is both normative, felt and expressed. This gives it the potential of a “foot in the door” which due to its many associated risk factors leads naturally on to addressing other issues. These in turn are often key areas for prison health care (e.g. substance use and smoking) or are seen as important issues by prisoners (e.g. food in prisons). Oral health interventions could be maintained in prisons as standalone programmes but in doing so both the potential for oral health improvement and for addressing the broader issues within a whole prison approach is constrained. It is therefore beneficial for those working in oral health to work closely and maintain links with other NHS colleagues and agencies involved in health improvement in order to progress activity through a “whole prison approach.”

Implementing any initiative in a prison takes time and benefits from a collaborative effort. Change often does not occur through a linear progression but periods when little seems to be happening will be followed by sudden advances. Acceptance that the pace of change is frequently set by circumstances beyond the control of all those involved in the prison health improvement agenda can be frustrating and has to be taken into consideration when deciding on programme’s aims. As stated by Paul Hayton (14) “prison is an environment with a special

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difficulty in the promotion of health.” This is especially true when considering aspects of social capital and the elements of a healthy community. There can, however, also be aspects of prison life that make the implementation of health improvement interventions easier, a confined population being the most obvious example. Establishing the links and creating the continuity which allows those leaving prison to maintain any positive health behaviours established and to access similar levels of service provision outside in the community is equally challenging for those addressing the inequalities agenda within the prison setting.

As required by the SPS Health Care Standard 6 for health promotion, strategic health promotion activity is best directed by those working outside of health care in the establishment. Changes to policy and the prison environment to support health improvement are most often within the remit of senior management and all aspects of prison life need to be assessed in terms of their contribution to health. WHO Health in Prisons (14) cites the following areas which can impact on health and should be monitored by prison managers; “ 1) reception aiming to reduce stress, 2) induction to enhance coping skills, 3)general environment for cleanliness, 4) general environment to be controlled with staff in charge of the prison at all times, 5) support for prisoners, mentor or key worker schemes, 6) support and recognition for staff, 7) contact with families, friends and the outside community, 8) basic life skills such as reading, writing and arithmetic, 9) activities available including work, education and active leisure, 10) privacy and maintaining confidentiality, 11) individuality, providing choice wherever possible. The programmes implemented in Forth Valley prisons have discovered opportunities for health improvement in oral health and nutrition in a number of these areas engaging both prisoners and staff and broadening the perception of who it is in prison that is in a position to positively affect prisoner health. It is worth highlighting, however, that successful implementation can often be progressed solely through the support of enthusiastic individuals. Sustainability issues then arise when these individuals move to other areas within the estate. Consideration could be given to the potential benefits and challenges to incorporating health improvement activity into the objectives of both senior management and the wider prison workforce and the possibility of using current incentive schemes to engage the workforce. There may be a role for the SPS College in highlighting the potential of prisoner officers as health improvement practitioners and embedding this within the core competencies.

The prison service in England and Wales created Prison Service Order 3200 to encourage a whole prison approach. Prison service orders are mandatory for prison governors and PS3200 required that health promotion must be included in local planning mechanisms. Although interventions such as the Keep Well Health Checks will increase the amount of operational health promotion activity, it is important that the model of a Whole Prison Approach is not lost within this. Discussion with senior management locally revealed both positive and negative aspects to mandatory requirements, however, there is no doubt that a

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formal framework and a system of review does impact on progress. Those involved in oral health improvement in prisons have a role in highlighting their support for work at a national level towards achieving a framework for implementation of the whole prison approach within Scottish prisons. There would be clear benefit, however, in ensuring that any such framework was not promoted as a new initiative but as a tool to facilitate current SPS activity or expected interventions through the implementation of a whole prison approach. The National Strategy for the Management of Offenders already aims to deliver on many of the outcomes that would be the goals of a Health Promoting Prison programme. Having the implementation of such programmes within the objectives of the Head of Offender Outcomes within the establishments could be a means of integrating health improvement activity into the wider prison agenda. There is also potential for existing monitoring systems such as Prison Visiting Committee Reports to have a specific section highlighting progress towards a Health Promoting Prison.

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1. Scottish Executive (2005). An Action Plan for Improving Oral Health and Modernising NHS Dental Services in Scotland. Edinburgh: Scottish Executive.

2. Nugent, Z. J., Jones CM, & McCann M (2004) Scottish Prisons' Dental Health Survey 2002. Edinburgh: Scottish Executive.

3. Jones CM, Woods K, Neville J et al. Dental health of prisoners in thenorth west of England in 2000: Literature review and dental healthsurvey results. Comm Dent Health 2005; 22: 113-117.

4. Heidari E, Dickinson C, Wilson R , Fiske J. Oral health of remand prisoners in HMP Brixton, London. British Dental Journal 2007;202:E55. de Viggiani N. Unhealthy prisons: exploring structural determinants ofprison health. Sociology of Health & Illness 2007; 29: 115–135

6. British Dental Association. Dental care for Homeless People ; Policy Discussion Paper December 2003.

7.US Department of Health and Human Services (2000). Oral health in America: A Report of the Surgeon General. Rockville,MD: National Institute of Dental and Craniofacial Research, National Institute of Health.

8. Scottish Prison Service (2002) the Health Promoting Prison, a framework for promoting health in the Scottish prison service. Edinburgh :Health Education Board for Scotland.

9. Department of Health, HM Prison Service (2003). Strategy for Modernising Dental Services for Prisoners in England. London; Department of Health

10. Prison Health Research Network (2006). Evaluation for the Impact of the National Strategy for Improving Prison Dental Services in England. Manchester: Prison Health Research Network

11. Harvey, S., Anderson, B., Cantore,S., King, E., Farooq,M. (2005). Reforming prison dental services in England- A guide to good practice London office for Public Management

12. Department of Health (2002). Health promoting prisons ; a shared approach London, Department of Health

13. Graham, L. (2007) Prison Health in Scotland, A Healthcare Needs Assessment Edinburgh, Scottish Prison Service

14. World Health Organisation (2007) Health in Prisons A WHO guide to the essentials in prison health Copenhagen, WHO.

15. Heidari, E., Dickinson, C. & Fiske, J (2008). Prisoner and lay opinions of a prison-issue oral health kit, Journal of Disability and Oral Health, 9 (1) 35-41.

16. SCOTTISH PRISON SERVICE DELIVERY PLAN 2009-10, http://www.sps.gov.uk/default.aspx?documentid=67e156ce-a4c9-49f5-a526-0dab421427f6, date accessed 30/11/09.

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