Could you give a general overview of the work and what led you to do it?
HW: We were asked in 2019 to look at rapidly prioritising adult social care innovations, and one of the top five innovations prioritised was a prison social care peer support initiative where prisoners were trained to provide something called non-personal social care to other prisoners. We looked into these initiatives a bit more and found that such schemes were already happening in different prisons across England and Wales in different ways, but there had not been an evaluation on what was known about them in terms of effectiveness, cost effectiveness and experience. That’s what kicked the study off.
What do you mean by non-personal social care?
HW: In this context it means a prisoner helping a fellow prisoner to do things such as cleaning their cells, helping them to move around the prison, or perhaps accompany them to appointments. The person providing that non-personal social care would generally be described as “a buddy”. It's much more the sort of everyday support that people might get from their family and friends if they were in the community. It doesn’t mean more personal social care – like dressing and showering – which is meant to be delivered by professionals from the local authority or the health care service. That is not delivered by peers.
How did you carry out the research?
HW: We firstly analysed inspection reports by His Majesty’s Inspectorate of Prisons (HMIP) to look at social care in prisons overall and what peer support was being offered. We then looked at the existing evidence to see what peer support was provided in prisons more generally, which led to us doing an empirical study.
CSJ: We looked at what we could find from this country but also internationally from around the world. There were around 20 studies in England and Wales, but very few studied social care interventions. We found big gaps when it came to understanding the effectiveness of peer support services in prison for social care, which was a good incentive for us to try and fill them.
HW: This study looked at what peer-supported social care is provided in prisons in England and Wales, how those peer support services are used, how people feel about delivering and receiving them, and how to measure impact and cost of services. We carried out 71 interviews with a range of different people, including national stakeholders, prison leads from 18 prisons and interviews with staff, buddies (the people providing the support) and recipients (those receiving the support) from five prisons. We also undertook a workshop and a cost survey.
What were your key findings?
HW: We found that buddies – the prisoners providing social care peer support – are used across lots of prisons in England and Wales, and they're filling an important gap in social care provision. We found, however, that the ways such schemes are implemented differ from prison to prison. For instance, some prisons didn't have training for the buddies or more formal employment processes (such as application processes and interviews), whereas others did. There were lots of things that influenced variation across prisons, for example when buddies could be out of their cells, as some prisons restricted their access more than others.
But in terms of experience, we found overall that buddy schemes are very much valued by staff, buddies and recipients, and there was general positivity about the need for these schemes in terms of filling a gap in social care provision. For the recipients, they may help people to maintain independence, to participate within the prison regime, and receive more of the support they need. And for buddies, the schemes may help them to self-develop skills that may be helpful for future employment or personal development.
However, there were some potential risks that need to be mitigated against. This can include risks to the recipients, but also risks to the buddies in terms of them being exploited. We've got to be careful of the risks and the barriers that may stop people doing this job or stop people receiving care.
CSJ: There's no gold standard of what a good buddy system should and shouldn’t look like. When it comes to improved self-esteem of people involved with these schemes, there is evidence – but it's not very strong evidence, because it hasn't been tested very much. If they've been having these responsible roles within prison, it gives them more of a feeling of self-worth. And then when they're released from prison, they may have a more positive outlook on life and maybe lead to less reoffending.
We don't really know much about the cost-effectiveness of such schemes – that is very difficult to get hold of, as we found out. It's not always clear what the costs of these schemes are because of the way they’re budgeted within prisons.
HW: Interestingly, we also included a case study about a prison that does not have these formal schemes. Although there was not perceived to be a need for peer support there, when we spoke to recipients at that prison, every single one of them was receiving some sort of buddy support, even though this was not a formal arrangement.
What evidence is there of the scheme having an impact on behaviour after it’s over – you mentioned a possible beneficial effect on the rate of reoffending?
CSJ: The evidence is quite thin. There have been a couple of studies of other peer support schemes that try to look at reoffending rates, but they had very small samples and didn't have a comparator group.
HW: We have a number of examples from the buddies of how it's helping them in relation to self-development and career prospects. So there's quite a lot of qualitative evidence about the sort of the potential benefits, but we just don't know in terms of the numbers. Does it actually impact on it and for how long?
What surprised you most in your findings?
CSJ: The lack of continuity between the records of different prisons, and also between the prisons and the community – and how that information just gets lost or isn't known about. In many places it's uncoordinated, and it puts individuals needing social care support at risk. I was also surprised by the lack of formal monitoring and evaluation of such initiatives, as I was about costs not being routinely collected. Such schemes should be seen as a good thing but there are no standards around them.
HW: It is a role with big responsibilities and I was surprised that some buddies were doing it with little training or guidance. Staff in prison also don't always have much training or time when it comes to social care or the buddy role. In turn, they can create barriers to buddies doing their role, essentially because they don't understand it. Some of the barriers are coming from that lack of shared understanding about what's expected and appropriate. There are also differences in how people perceive prisons, social care and prisoners more generally (including within prisons themselves), and those different attitudes can affect how people see these roles.
On the opposite side, there are some good examples of training taking place, but it's not standardised across the board in terms of minimum training for this role.
Are there any limitations to what you found?
CSJ: I've worked for many years looking at health data, and to a lesser extent social care data, but in this area we knew from the start that there was going to be very little data that would give you an answer straight away. That lack of data was a limitation, but we anticipated that early on.
HW: We designed the study with this data availability issue in mind. We also looked at 18 prisons and national perspectives, so it’s potentially not representative of all prisons across the country. However, we did make good attempts to cover prisons from different geographies as well as make good choices on types and categories of prisons. Most of the prisoners we interviewed did end up being white British or mostly older adults with social care needs, so there's a question on whether we've represented some of the younger adults with social care needs as much as the older adults, or people from other ethnicities.
These schemes focus on non-personal care, but did they reveal anything about the personal social care that prisoners are meant to be receiving from others?
HW: Yes, they did. Some were receiving both types of care (personal and non-personal) and spoke about how it was beneficial to have that combination. Some prisoners needed personal care that was local authority and professional social care led, but in some cases people felt there were delays in receiving this care or that some people were not receiving it. This potential unmet need might explain why another potential risk was identified – which was the potential to overstep boundaries.
Buddies have a clear boundary that they shouldn't provide personal social care support – only the non-personal care. Everyone we spoke to discussed maintaining those boundaries and staying within them, but people did speak about the risk that people may feel the pressure to overstep those boundaries, if somebody's personal care was not being met. For example, if somebody falls and they're not allowed to pick them up, but then somebody can't come to pick them up, who is going to pick them up? They're not going to want to leave them there for several hours.
What are your main recommendations from this work?
HW: There is a need for the production and piloting of national guidance for peer supported social care. There's a prison service instruction that gives some guidance on peer support, but it's not purely for social care. National guidance that looks purely at peer supported social care, and how it should be implemented in prisons, would be helpful.
We also recommend collecting data at a national level to enable monitoring and evaluation, but we acknowledge that this is going to require additional resources. Prisons are very stretched and to ask them to do a whole lot of monitoring along on top of everything else is going to be a very difficult ask. We have developed an evaluation guide that outlines operational, cost and outcome data that needs to be collected to enable regular monitoring and/or evaluation in future.
We think that the responsibility for monitoring peer supported social care could belong to HMIP in their role of inspectors.
For service implementation and mitigation of risks, we've got to think what needs to happen for these schemes to be implemented across prisons in future. We recommend having dedicated staff roles that offer protected time for social care and the buddy scheme, as well as appropriate funding to support these schemes. We also recommend better collaboration between organisations (so prison, local authority, relevant external organisations), alongside the formalisation of employment processes, training and supervision.
Finally, why would you say this research is important?
CSJ: It is alarming to see the state that prisons are in at the moment and the problems with staffing. You don't want to exploit prisoners to fill in gaps with what staff should be doing, but it probably helps with some of the support, because they’re able to provide it themselves. It's also got implications for wider peer support programmes. We’ve just discussed the social care aspect, but there are other peer support programmes. They have units for people who've got drug addictions, for instance, and there's support and learning needed in those areas as well.
HW: Our research sheds light on what's happening with peer support social care in prisons in England and Wales. The findings probably support what some people would expect – essentially that it’s very beneficial, but there are also some risks and potential variation – but the fact that we've done this research in a systematic way gives some confidence about how they're being implemented and experienced in a wide range of prisons.
It's really important to start building the scientific evidence base on these schemes, because otherwise they're going to continue to be used and they're going to continue to be more important as the population ages. We may see more older people in prisons, as well as more younger people with social care needs. The demand for these services may only just be starting.
* Early findings for this work on peer support for adult social care in prisons in England and Wales – which are currently undergoing peer review – can be found in summary form here.