Promoting healthier lifestyles for prisoners - National Audit Office

Promoting healthier lifestyles for prisonersA good practice guide

In March 2006, the Comptroller& Auditor General (head of theNational Audit Office) publishedhis report HM Prison Service:Serving time – prisoner dietand exercise which examinedimprovements made by the PrisonService to prisoners’ diet andexercise. The report found thatprisoners have the opportunityto eat healthily and to exercise,but that more could be done toencourage them to do so.

You, as prison PE officers, are in a uniqueposition to encourage and supportprisoners to get fit and prepare for healthierlives when they go back to the community.You get to know prisoners in the course ofyour work, and they get to know you andrespect you. We know from our survey (towhich 44 prisons replied) that many of youare doing lots of good things to promotehealthier lifestyles. We didn’t have space toinclude them all, but we hope this guidegives you a few extra ideas to explore, basedon the experience of your colleagues.

AcknowledgementsWe are very grateful to all 44 prisons who responded to oursurvey earlier in the year and to the PE officers who willinglyshared their good practices with us.Thank you too, to Ian Hinds and Christine Millard whose helpenabled this guide to be produced, and to Blakenhurst, MortonHall, Stamford Hill and Wayland prisons for their assistancewith photographs.Please let us know whether or not you have found this guidehelpful. You can let us have your thoughts via our website– www.nao.org.uk/prisonlifestylesIf you have any queries about this leaflet, or wish to discussour work further please contact Jo James – Audit Manager,Jo.James@nao.gsi.gov.uk

Contents6It’s about diet as well as exercise!14How can I persuade them to eat better?22Inspiring exercise – it’s not all about weight training!30How can I persuade them to prepare for life outside prison?

Promoting healthier lifestyles for prisonersIt’s about diet as well as exercisePrisoners’ choice of food is limited to that which isprovided in the prison. Opportunities for exerciseare on site, with qualified people available to offerhelp and advice.So there’s potential to improve prisoners’ healthand lifestyles – especially those of people whodon’t know or don’t remember much aboutbalanced diets and those who can’t afford to usetheir local gym or leisure centre. Many may beable to eat better food and have easier access toexercise than they’ve had at home.Healthier lifestyles can help improvepeople’s sense of wellbeing and self-worthMany prisoners, when outside, live chaotic lives,and don’t have the benefit of a stable home. Lotsare from poorer or socially excluded sections ofthe community. They tend to be people who aremore at risk of ill health than the rest of us. Manyhave never registered with a doctor or dentist 1 sodon’t find it easy to get advice. Drug habits andmental illness are also all too common.Healthier lifestyles can help improve people’ssense of wellbeing and self-worth. Prisoners areno different – though many are at a lower startingpoint. But people have to want to improve – andlike everyone else, need lots of encouragement tostart and to persevere.

It’s about diet as well as exerciseDid you know?> Healthier lifestyles can help:lllllboost the immune system to reducefrequency and seriousness of illness;combat illness and health problems;reduce blood pressure;improve morale and self-esteem;provide a personal focus.> About 83 million meals are providedin prisons every year. In 2004-05,£43 million was spent on food and theaverage daily food allowance was £1.87.

Promoting healthier lifestyles for prisonersPrison induction packs provide an idealopportunity for setting out benefits of healthierlifestyles by:l Providing advice on what constitutes a healthydiet at the same time as explaining howprisoners fill out the weekly food order forms,and how to set about choosing food to suittheir needs.l Informing prisoners about the merits ofexercise as part of healthier lifestyle, as well astelling them what facilities are available andhow to set about taking part.l Promoting education and training in cateringand in fitness instruction, both as meaningfulactivity during their sentences as well asproviding them with stepping stones to jobswhen they leave prison.Did you know?> What can be served – and what is in it – is governed by the Prison Service’s CateringStandards. Catering services are “audited” every two years. In addition Area Catering Advisershave to visit each prison four times a year to assess how well prisons are doing, and offer bestpractice advice on a range of topics, including healthy eating.

It’s about diet as well as exerciseSome ideas to tryYou may liketo considerthe following:l Talk to catering colleagues about benefits ofincluding attractive-looking and easily readablebasic diet information in prison inductionbooklets. Colourful pictures may grab prisoners’attention better than words!l Include eye-catching information aboutphysical education and leisure facilities inprison induction literature. Make clear whenand where to find out more, and from whom.l Don’t be modest about advertising the skills,knowledge and approachability of PE officers– and peer mentors, too.l Through promoting “success stories” andachievements, encourage prisoners whohave abused drugs to take part in CARAT 2programmes (the Prison Service’s drugtreatment framework).l As part of delivering the required “TacklingDrugs through Physical Education” provisionliaise closely with CARAT and healthcare/drugstrategy departments. Encourage prisonerswith more severe drug problems to take part– remind them they’re lucky to have supportat least equal to anything they might getoutside prison.

What others do and how they do it...No-one feels good about coming to prison.Giving them a colourful induction book is morelikely to grab their attention – and that’s exactlywhat we want to do here at Standford Hill.We want them to see that they can eat healthily– and that it’s a good thing to do – and thatexercise and group activities are all part andparcel of better lifestyles.

It’s about diet as well as exerciseIt was good to see that 90 per cent of theprisoners who started on exercise referral andCARAT intervention programmes progressedon to more mainstream PE activities withmany achieving nationally recognisedqualifications. Blakenhurst

Prisoners are given a talk on diet and nutrition byPE staff during their induction process. This, togetherwith information we give them on accessing remedialgym classes, has led to an upturn in the number ofindividuals who require exercise programmes andadvice, including appropriate diets for weight loss.PE staff liaise with the Catering Manager to try to assistthe prisoner with making the right dietary choices.Wayland

It’s about diet as well as exerciseDid you know?> In March 2006, the NAO reported that prisoners received littleinformation about healthy eating apart from when they firstentered prison. NAO’s March 2007 survey showed that 42 per cent 3of prisons put guidance on healthy eating in prison inductionpacks, and two thirds of them include it in gym induction leaflets.> NAO’s March 2007 survey 4 showed that:l 96 per cent displayed what opportunities and facilitiesare available;l 76 per cent advertise how to arrange a gym induction;l 73 per cent have healthy eating posters;l 62 per cent have posters explaining what makes a balanced diet;l 56 per cent prisons display posters showing who to contact forhealthy eating advice.> Only 15 per cent provide information in languages other thanEnglish, regardless of the mix of nationalities in the prison.

Promoting healthier lifestyles for prisonersHow can I persuade them to eat better?Prisons have to provide a “suitable diet” for allprisoners – but they also have to provide food thatprisoners will eat! Not doing so can cause troubleand can risk destabilising the prison.Menus – which offer up to six choices for somemeals – are designed to enable prisoners toselect a range of different foods, and to meet awide range of different diets. But people will onlychoose wisely if they understand the benefits, andit is clear which foods are the healthier options.It is easy and comforting to choose foods that arefamiliar and remind you of home. Helping prisonersto understand more about food and try new dishesmay encourage them to eat more healthily.Getting the messages across can be hard. Somepeople think healthy eating means more salads orvegetables and don’t understand the importanceof protein, or why one should eat a balanced diet.14

How can I persuade them to eat better?Did you know?> In March 2006, the NAO recommended thatthe Prison Service should raise awarenessof the importance of healthy eating,through posters and actively promoting iton a regular basis.> Nearly all prisons now offer pre-selectmenus, compared with 50 per cent at thetime of the NAO’s report in March 2006.> Prisoners grumble about quality of food,but prison governors consider thatcomplaints about food have diminishedin recent years.> Providing food that is acceptable toprisoners makes it harder to providehealthy options.Helping prisoners to understandmore about food and try new dishesmay help them eat more healthily15

Promoting healthier lifestyles for prisonersSome ideas to tryYou may liketo considerthe following:l Use opportunities to talk through withprisoners their previous diet and lifestyle.l Display healthy eating posters inexercise zones.l Frequently rotate the publicity material– including colourful, eye-catching posterssuch as those available from British NutritionFoundation (www.nutrition.org/upload/wholeoplatesm(1)jpg) and www.nutrition.org.uk/upload/CHDHEART.pdf.l Include some posters focusing on “success”stories, and how much better those prisonershave felt since they changed their diets.l Make a point of meeting all new prisoners tofind out about their lifestyles and offer simplesteps (initially) to help them improve.l Ask prisoners how easy they find it to identifyand choose healthier food options andfeedback any findings to catering staff. Do theyknow that low-fat options are not necessarilyalso low in salt? Do they understand what tolook for and how to balance their diet?16

How can I persuade them to eat better?l Encourage good choices through offeringto help monitor food intake/exercise done(e.g. through weekly or monthly food/exercise “diaries”).l Remind prisoners that choosing healthy mealswill be less advantageous if they then eatconfectionery or unhealthy foods from theprison tuck shop.l Encourage learning through workingin kitchens, and working towardscatering qualifications.l Work with catering staff to offer specialpromotions days/competitions to try toencourage better awareness of healthierfoods and diets.Did you know?> Meals offered to prisoners in 2004-5 closely matched cateringrequirements 5 (except on salt and some other trace elements).> In 2004-05, prisoners struggled to eat healthily because theyreceived little information on healthy eating, unless they had beenplaced on a special diet for a medical reason, such as diabetes.Some food options were listed as healthy on the menus but werenot actually healthy or even the healthiest options on the menu.> Researchers working with NAO found that younger prisoners werethe most resistant to eating healthily, and that they often chosehigh fat dishes.> Wandsworth Prison told us that over the last few years there hasbeen an increasing trend towards healthier options, with relativelyhigh percentages of prisoners selecting the healthier option mainmeal followed by yoghurt or fruit afterwards.17

What others do and how they do it...We find it works well to giveprisoners some diary sheets onwhich can write down what they’vehad to eat and what exercise theyhave done, and then we can talkit through with them to see whatthey could have done differently.Of course, it only works if they writedown everything (including whatthey’ve bought from the tuck shop!)and bring the sheets the next timewe see them. WandsworthUse the grid to record your dietaryintake over the next 7 daysDay Breakfast Snack Lunch Snack Tea Snack DrinksMonTueWedThurFriSatSunUse the grid to record your exerciseover the next 7 daysDay Morning Afternoon EveningMonTueWedThurFriSatSun

How can I persuade them to eat better?Hundreds of prisoners have benefited from Blantyre House’s FiTechequipment. All newcomers are offered the option of an hour-long session– the sort of thing for which you could pay £££s outside. We measure theirblood pressure, lung capacity, flexibility and fitness level and input all ofthis, together with diet, into the PC. We share the report it produces withHealth and Catering colleagues, highlighting any issues, and the prisoneris then offered a special diet, 1-1 weight loss training – or whatever else heneeds, tailored especially for him.He gets a very helpful booklet with lots of advice and information, and sixmonths later we reassess him to measure what progress he’s made againsthis targets. The programme has been so good that we’ve offered it tostaff as well – and they’re getting fitter, too!

Promoting healthier lifestyles for prisonersPrisoners and staff can cometo Wayland’s annual two-dayhealth fairs. There are quizzes withhealth‐orientated prizes, e.g. fruitbaskets, or food hampers. Thereis always a variety of stands andeveryone can try different foods andtake away samples if they like. Thenthere are ‘taster’ sessions, such asspin cycling, organised by thePE Department.20

How can I persuade them to eat better?Other stands include assessment on acute orchronic injuries by trained physiotherapistsand a free treatment and / or sports massage,free eye testing and vision assessment, as wellas a foot massage and guidance on keepingyour feet healthy. We’ve also run sessions onmental and spiritual aspect of fitness andhealth, e.g. with presentations from a varietyof religious organisations, and meditationexperts. Last year’s health fair attracted 300prisoners... and we see many of the samepeople now making real efforts to try toimprove their quality of life.21

Promoting healthier lifestyles for prisonersInspiring exercise – it's not all about weight training!Some prisoners exercise very readily, but for PEofficers, the biggest hurdle is to encourage themore reluctant to start. Once people have takenthe first step, many go on and progress to greaterthings when they are ready.Others, however, are easily “put off” by beingsurrounded by regular users or are embarrassed bybeing seen to be considerably less able.Others can be deterred by the environment– good facilities, changing rooms and showers canall help attract newcomers.Surveying prisoners annually is a useful way offinding out in which activities prisoners have enjoyedor think they have benefited from – as well as theirviews on what they’d like to do more of, or howthey’d like to see the range of facilities extended.Doing group activities ismuch more fun than doingexercise on your own22

Inspiring exercise – it’s not all about weight training!Did you know?> Six physical education advisers monitor theprovision of physical exercise and providespecialist technical advice to prison managers.> The minimum statutory weeklyrequirements for prisoners gettingaccess to PE in prisons are:l Over 21s – 1 hourl Young offenders (18-21) – 2 hours> The Justice Board recommends 3 hoursa week for 15-17 year old offenders aspart of their “Core Learning Day”. Anyextra time should be accredited learning.Further opportunities in the evenings andweekends are also recommended.23

Promoting healthier lifestyles for prisonersSome ideas to tryYou may liketo considerthe following:l When next revising information for prisoners,decide whether the word “gym” might putoff some people who think it means weighttraining rather than a whole range of activities.l Follow-up promptly any requests forexercise inductions.l Survey prisoners – including those who do notusually take part – to find out what exerciseactivities they would like or which mightencourage them to take part.l Use “quiet sessions” or allocate sessionsspecifically for the older age groups or forthose new to exercise, so that they are not putoff by the super-fit who can do so much morethan them.l Introduce mentors (prisoners who havebecome qualified gym assists) to help andencourage those who are new to exercise.l Be pro-active in identifying prisoners who arenot doing any exercise and discuss optionswith them.l Organise special promotions for particularactivities, e.g. football tournaments, yoga sessions.l Encourage participation through organisingrecreational activities such as carpet bowls.Getting people involved and enjoyingthemselves may lead to them wanting to trydifferent, more exercise-based, pursuits.24

Inspiring exercise – it’s not all about weight training!l Promote “Walking your Way to Health”, possiblythrough letting prisoners borrow pedometersto encourage them to walk more frequently orfor longer distances.l Publish (anonymous) successes on postersaround the prison as well as in the gym.Did you know?> The range of facilities available at the 44 prisonsresponding to the NAO survey 6 include:l 91 per cent have dedicated gymnasium withCV/fitness suite and 98 per cent have dedicatedweight training facilities;l 91 per cent have a sports halll 46 per cent have outside grass pitches but only25 per cent have all-weather pitchesl 29 per cent have bowls facilitiesl 87 per cent have an exercise yard for walking> The cost of providing physical education per prisonervaried from £392 at a male, local prison to £1085 at aYoung Offenders Institution (2004-05).> Although 43 per cent of prisoners undertook someform of organised physical education activities inprison, this ranged from 11 per cent in a largecategory B male prison to 87 per cent injuvenile male institution. The averagewas 2.4 hours per week.25

What others do and how they do it...As a 'lifer' prison, the average age of our prisoners is relativelyhigh. At Shepton Mallet we’ve tried carpet bowls, table tennis,board games and Pilates classes in the gym as ways of gettingthe men more active. The most successful class has been theover-45s, where people can use the equipment that best suittheir personal fitness needs, and some light circuit training.It’s been attracting 15 prisoners a session.As part of the evidence for their qualifications, 20 prisoners atThe Verne are working with others over a range of activities.Some 28 prisoners are those who would not normally come to agym. Some have been referred by the medical staff.

Inspiring exercise – it’s not all about weight training!Fit 4 Life at Morton Hallhas proved a great hit.We’d originally seen it asbeing a way of gettingolder prisoners more active– but it’s popular with allages and fitness levels,especially in the eveningsand at weekends.Following a survey of Blakenhurst prisoners in 2005,we developed the PE programme to include morevaried and diverse activities. “Introduction to Sport”was introduced specifically to attract prisoners whodon’t usually get involved. They focused on socialdevelopment for the less confident individuals,and they’ve been well-attended. A large numberprogressed to additional recreational or educationalclasses. Overall, participation in PE has increased from42 per cent in 2005 to 55 per cent in 2007.

Promoting healthier lifestyles for prisonersGetting people walking may not sound much – but it has beengreat, especially for some of the more senior men who tend tomiss out otherwise. We started Hewell Grange’s Healthy ManWalk in the summer of 2005. We did it twice, but it’s now anintegral part of our programme. Some 25 prisoners regularly dothe 3-mile walk within the prison boundaries (including someslopes, inclines and steps!). Unlike some of the other outside sportsthat need better weather, walking can go ahead rain or shine.Giving them pedometers has helped them measure how muchbetter they are getting. Some of them are doing more exercisethan they’ve ever done. At first few elderly men showed muchinterest in walking – now over a quarter of them take part – andwe’re extending the Healthy Man Walk option to the over 40s.2

Inspiring exercise – it’s not all about weight training!We’ve been pleased to seemore of the reticent boysgetting involved in PE – westarted them off in “quiet”sessions. Quite a lot of ourboys do at least somethingnow, so much better thana few years ago. Usingheart rate monitors alsohelps them to see howwell they are trainingand how they can helpthemselves to do thingsbetter. Huntercombe YOIOur Sports and Social Club has done wonders for ourolder and less-able prisoners. They come along to ourFriday club sessions, where they can play games suchas chess or cribbage. It gets them out of their cells,meeting other prisoners etc. – it is good for them evenif they only come along for tea and a biscuit. Theyenjoy it and they tell us they feel better for it. A fewhave also shown an interest in other things, such asthe walking club we’ve just set up. Wakefield2

Promoting healthier lifestyles for prisonersHow can I persuade them to prepare for life outside prison?Roughly half of all prisoners were excluded fromschool, half have no educational qualifications,and more than a third lack basic literacy skills. Butit is never too late to learn. Acquiring new skills– and basic level vocational qualifications – booststhe ego and may be a stepping stone to beingresponsible citizens when they leave prison.Vocational qualifications are quite different fromacademic ones, involving much more “hands on”training. Once they’ve started developing skills,prisoners may well develop an interest in gettingbetter and better.Catering courses on offer in some prisons include:basic food hygiene, catering and hospitality,food preparation, budget cooking, diet andnutrition, healthy eating, international cooking and“nutritious but delicious”.PE courses may, include: Gym and Fitnessinstructors, Health Trainer, Diet & Nutrition, HealthyLiving, NVQs in Sport and Recreation, First Aid atWork and other awards.30

How can I persuade them to prepare for life outside prison?Did you know?> Providing education and training, to give offendersthe skills they will need to stand a realistic chanceof employment on release, is a key strand ofGovernment policy to reducing offending.> Prison kitchens provide employment to nearly 2,300prisoners at a cost in wages of £1.7 million annually,but it would cost prisons much more if they had touse prison officers, even after taking account of thecosts of managing and educating prisoners.> Of the 45 prisons which responded to our survey:l 23 offered catering courses;l most were Level 1 training;l 8 offered Level 2 training; andl 3 offered Level 4.

Promoting healthier lifestyles for prisonersSome ideas to tryYou may liketo considerthe following:l Publicise prisoners’ qualifications results or theirsuccesses in getting jobs after they have leftthe prison.l Encourage prisoners to take up postings tokitchens if they show an interest in food, foodpreparation or hygiene. (Often they have togain basic food hygiene qualifications if theyare to continue working in the kitchens.)l Encourage prisoners to become orderliesand peer tutors in the gym to help build theirinterest in the opportunities available.l Help prisoners boost their self-esteem andtheir experience of working with othersthrough suggesting to them that they considerbecoming mentors to others.Did you know?> Four fifths of prisons surveyed run atleast one course in fitness instructionand half run three or more courses> The UK has relatively highnumbers of adults with low levels ofliteracy and numeracy compared withother countries.32

What others do and how they do it...Inside-out – Learning for lifeWe aim to give people a taste of the real world through our communityprogramme. Prisoners work with local physical disabilities groups,residential care home. They also go out to Charlton Athletic and LeytonOrient football clubs, and London Towers Basketball team. Local communitygroups also use our swimming pool, which has been a great success.We’ve now set up a social enterprise company, Health and FitnessSolutions, where prisoners and the company are paid to deliver variousqualifications, team building and healthy living courses to externalcompanies, schools, health clubs etc. We’re providing a good service to ourclients, but most of all, it has been good for the prisoners, some of whomlater secured jobs in health clubs and other firms. Standford Hill

What others do and how they do it...We introduced a PE Passport to help trackand provide evidence of prisoners’ work asthey move through the PE cluster or to otherestablishments. Bearing our new name, theIsland Sports College and the cluster’s logo,the passport is used as a CV for outsideagencies and job interviews. We also use itfor our PE department’s Peer Tutor scheme,charting people’s development as they movebetween departments. That way we don’tlose their skills. Standford Hill

How can I persuade them to prepare for life outside prison?Our Healthy Living coursesshowed that prisonerswere keen to learn aboutand to try out new foodideas. Now we’re planningmore. Morton HallWe’ve run two very successfulcourses – Smoking Cessationand a 12-module Healthy LivingCourse covering many of thesame topics. There’s a definiteshift in the right direction.Blantyre HouseAt Wayland, we offer an Open College Network“stand alone” nationally accredited qualification:“Nutrition, Performance and Healthy Eating. Werun this as a unit within our Health and FitnessProgramme. Students are required to keep ajournal, in which they keep a log of their physicalactivity, how they feel, and what they are eating.This helps prisoners reflect on their eating habitsand analyse the cause and effect. We plan to usea similar journal for prisoners enrolled on theCARATs programme.

36I graduated in SportsScience from LancasterUniversity, thanks tohaving been inspiredto have a go at variousqualifications atHaverigg.

How can I persuade them to prepare for life outside prison?Several prisoners (including thoseleaving Coldingley, Eastwood Park andManchester) had gained employmentas fitness or leisure officers at eitherprivate or public sector facilities on theirrelease from prison.Getting a job as an orderly in Eastwood Parkwas the best thing I could have done. I foundmyself getting interested in all sorts of gym andfitness, including swimming. Having qualifiedas a pool lifeguard before I left prison, I wasable to get a job in a leisure centre, and sincethen I’ve set up my own business.

Promoting healthier lifestyles for prisonersEndnotesUseful references1 The Social Exclusion Unit estimates that half of allprisoners have not registered with a doctor beforethey come into custody.2 Counselling, Assessment, Referral, Adviceand Throughcare.3 Based on 44 prisons responding to NAO survey,March 2007.4 Based on 44 prisons responding to NAO survey5 Recommendations of the Department of Health,and the Food Standards Agency.6 Based on 44 prisons responding to NAO survey.PSO 4250 Physical EducationPSO 5000 Catering ManualHM Prison Service – Serving Time: Prisoner Diet and Exercise,Report by the Comptroller & Auditor General, HC 939Session 2005-06, www.nao.org.uk/publications/The Balance of Good Health, Food Standards Agency, 2007www.food.gov.uk/multimedia/pdfs/publicationChoosing Health: Making Health Choices Easier,Department of Health, 2004, Cm 6374http://www.dh.gov.uk/en/Publicationsandstatistics38

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