« Previous | Contents | Next »
Listen
HM INSPECTORATE OF PRISONS: Report on HM Prison Peterhead
5. HEALTH CARE
Introduction
5.1 During the March 2002 intermediate inspection the large number of elderly prisoners was highlighted as an area impacting on health care. The nature of the offences committed was also putting additional pressure on mental health facilities, and to some extent this is reflected in the provision of three psychiatrists.
5.3 The intermediate inspection also reported that prisoners were "seen promptly" and were "well treated" by medical staff. That view was challenged on this occasion by prisoners who said that there were difficulties in obtaining appropriate medication. They also claimed that it was difficult to access a doctor. Around 50 complaints about health care had been received from patients during the past year. Based on a sample of these complaints and discussions with staff and patients it appears that the common themes emerging from these complaints were again, 'not able to see the doctor,' 'not able to influence the nature of medical prescribing,' 'access to medicines' and 'failure of communications'. These complaints reflect the issues that were raised during group meetings with prisoners.
5.4 An internal health care standards audit was carried out in January 2003. This was made available to the inspection team.
Health Centre
Accommodation
5.5 Accommodation consists of a large consulting room which is used by doctors and nursing staff. A small office and pharmacy is attached. In the corridor opposite is a treatment room which is also used by the visiting physiotherapist, chiropodist and optician. There are two interview rooms, a small room with a computer used by the clinical manager, and a store room. In addition there are four cells to house prisoners whose medical condition requires them to be looked after separately from other prisoners for a period. There are two anti-ligature cells. As part of the cell area there is a common room for any prisoners housed in the health centre including, when appropriate, prisoners on 'ACT' (the SPS anti-suicide strategy). There is also a dental suite. Finally there is a small kitchen and the usual facilities including a toilet for the disabled. Access to the health centre includes a wheel chair ramp.
5.6 All the equipment was of a satisfactory standard including the emergency equipment which was regularly checked.
5.7 The health centre was clean, well maintained and a friendly and safe environment. Although there is an alarm system fitted to most rooms where prisoners are treated or interviewed, the treatment room and dental suite do not have any such personal safety measures. This should be addressed.
5.8 One of the cells is occasionally used as a waiting area. The cell is small and easily crowded and has internal sanitation which is on full display. Measures should be taken to cover this when the cell is being used as a waiting room.
5.9 One of the prisoners being held in the health centre accommodation at the time of inspection reported that he found difficulty getting in and out of bed. A bed which can be raised and lowered should be purchased for the health centre.
5.10 The health centre met the requirements of Health Care Standard 1.4 and this was in keeping with the results of the internal audit.
Staffing
5.11 The health centre is managed by a clinical nurse supervisor who is a registered general and mental health nurse. This role covers not only day to day nursing work but also has an element of time allocated for management of the Centre.
5.12 In addition to the clinical supervisor there are four registered nurse practitioners and one registered mental health nurse forming the nursing team. The health centre has one full time administrator who along with a practitioner nurse provides support for the implementation of the pharmacy contract. It is of note that the deployment of the registered mental health to mental health needs is often hindered by the demands of the day to day delivery of a general health service.
5.13 The team is well motivated and committed, and members appear to work well together. There is a good mix of skills to meet the variety of presenting health needs. There is also an impressive training schedule to ensure ongoing training and development of nurses. On the other hand, an additional Registered Nurse would allow a more meaningful time commitment to management issues and a more useful deployment of the Registered Mental Health Nurse.
On the wider issue of staffing within the prison, the medical officer expressed some concern about the provision of escorts of prisoners and believed staffing should reflect the special needs of the prison population. The internal audit also found that the prison fell short of Health Care Standard 2.2 in relation to hospital appointments being kept.
Medical Records and Health Care Information
5.14 The health care system is entirely dependent on manual methods for recording and monitoring purposes. This is in stark contrast to general practice in the community where virtually all general practitioners now have the facility to hold clinical information on computer. This is especially disappointing as the records had been summarised in preparation for transfer to GPASS (the NHS GP computing system) after the last inspection. It seems however, that there is no possibility of this happening in the near future. A clinical computer system should be introduced at the earliest opportunity if good quality preventive care is to be carried out in the prison.
5.15 A study of a 10% random sample of the medical records showed them to be extremely well maintained. The manual entries were complete and legible, and specialist reports filed in date order.
5.16 The accident report book for prisoners was also well maintained. There were a total of 32 entries for the preceding 12 months, all of which were for relatively minor injuries. Out of this total about one third were likely to be prisoner on prisoner assaults. This is an indicator of a relatively safe prison.
5.17 It was difficult to obtain certain organisational information, which meant that it was not easy to test the claim of prisoners that access to the medical officer was restricted by the nurses. This was an area of health care delivery not covered by the January 2003 audit. On the basis of a study of the appointments book, and discussions with individual prisoners, health care staff and the medical officer, it emerged that a prisoner who was assessed by nursing staff as requiring a medical consultation would normally be seen within five days. Staff declared that more urgent cases would be seen within one to three days, while emergencies were dealt with immediately. In light of a lack of effective information, the waiting time for consultations with the medical officer should be monitored.
5.18 It was also difficult to assess how the nursing triage was being carried out and how much pressure nursing staff were under to restrict access to the medical officer since there was not a surgery every morning. The medical officer was satisfied that the triage system was working effectively and the 10 to 12 patients seen during each consultation had been appropriately selected. The triage system should however be monitored because prisoners believe that the nursing team is an obstacle to their seeing the medical officer. The monitoring of waiting times and the triage system should also help to establish the appropriate level of medical officer input and highlight genuine problems.
Mental Health
5.19 During the last inspection there were concerns about the lack of a mental health trained nurse, other than the clinical manager. This has been addressed. There were also concerns about the absence of a Mental Health Team. This has not been addressed. Health Care Standard 3.3 presumes the existence of such a team.
5.20 The prison is served by three psychiatrists who hold weekly sessions. Two were interviewed, and both were content with the support they received from the medical officer and nursing team. Referrals could come from either and worked well. Their waiting list was not a problem in that all urgent cases were seen within a week and routine cases within four weeks. They did however note a lack of effective clinical psychology support. The other concern that they expressed was the fact that the contract for psychiatric services had not yet been finalised.
5.21 The psychiatric service in the prison met the requirements of Health Care Standard 3.2.
Pharmacy Arrangements
5.22 The pharmacy is a small room adjacent to the administrative assistant's office, and is accessible only from this office. It holds such items as dressings, needles, syringes and specimen bottles. It no longer stores treatments which the nurses were previously allowed to hand out based on their assessment of need. It also has a locked cabinet for controlled drugs. A pharmacist from the contract chemist visits the prison every fortnight to audit the kardexes and discuss any problems relating to prescribing.
5.23 As noted above, many prisoners were very vocal in their complaints about their medication. The basis for these complaints was threefold, namely the medication did not always arrive on time; it was not possible to be prescribed the analgesics which they considered to be effective; and spot checks were carried out and if they did not have the correct amount of tablets they were put on report and the privilege of "in possession" medication taken away. These are addressed below.
5.24 There have undoubtedly been problems in the late or non-arrival of some medication and this should be addressed as a matter of urgency.
5.25 While drugs of abuse do not appear to be a major problem in Peterhead there is likely to be a grey area of addiction problems. This manifests itself in the pressure being put on the medical officer, by prisoners, to prescribe opiate-based analgesics. The SPS policy is clear on the prescribing of such drugs and the formulary restricts their use to medical emergencies
5.26 Prisoners sign a contract relating to when they are allowed to have "in possession" medication. This clearly states among other things that they must stick to the required doses. For drugs which could cause abuse problems health care staff carry out the spot checks. If prisoners fail to adhere to this contract, particularly with such drugs as tramadol or psychotropic drugs then appropriate action is taken.
5.27 The recent decision not to allow nurses to give prisoners over the counter medication is a backward step and experienced and well-trained nursing staff should be considered competent to do this. Medication was also handed out publicly in the halls; a way should be found in the halls to change this practice. It would also be worthwhile considering putting a photograph of the prisoner on the Kardex to ensure the right person receives the right medication.
Other Health Care Professional Staff
5.28 The dentist attends one afternoon each week. He works in a well equipped surgery and brings his own dental nurse. The surgery and equipment have been checked by the local health board and conform with its cross-infection prevention policy. Emergencies are dealt with within 24 hours outside the sessional arrangement. Patients are provided with written information that the dental waiting time can be up to six weeks. In practice the longest waiting time was six weeks and a study of the records showed for most patients it was no longer than four weeks.
5.29 The physiotherapist attends for three sessions each month. She uses the treatment room which has a specialist physiotherapy couch as well as ultra sound equipment. The waiting list shows the maximum waiting time is three weeks which compares favourably with the community.
5.30 The optician attends every four weeks. The current waiting list shows the longest waiting time to be three weeks. The optician will extend his session to keep the waiting list under four weeks.
5.31 The chiropodist attends every two weeks. At the time of the inspection the longest waiting time was six weeks though a study of the appointment book showed it was more usually three weeks.
5.32 Overall, the provision of these health care services is very satisfactory.
Suicide Prevention
5.33 The Clinical Manager is the ACT Co-ordinator for the prison with the Deputy Governor acting as Chair of the ACT Group. Minutes indicated that that meetings had been held in January, March, April, August and October 2002. The minutes showed that an external audit of the operation of ACT had been carried out in January 2002. A report to the group at the meeting in March noted that ACT standards had been met. The minutes of the meetings indicated no serious concerns about the way ACT was operating. The minutes for June, July and August 2002, indicated that there were on average four prisoners on ACT each month. During the inspection there were two prisoners on ACT in the anti-ligature cells. A study of the ACT documentation found them to be properly completed with clearly set out care plans.
5.34 ACT is operating effectively in Peterhead and fully meets Health Care Standard 3.4.
Health Care Needs
5.35 Minor ailments are reported to the nurse on a daily basis, and these ailments are consistent with what would occur in the community. There were nine emergency hospital admissions from 1 July - 31 December 2002.
5.36 Statistical information collected by the health care administrator provides evidence that there is a high incidence of chronic disease. Evidence of chronic disease is further supported by the profile of prescribed medication for patients. There are 287 patients on medication. The content and nature of this prescribing demonstrates that most of the medicines are for the treatment of chronic disease. The prescribing patterns also demonstrate that some patients have multiple health problems.
5.37 There is evidence that on average 30 prisoners each month attend appointments at local hospitals for secondary health care. We have noted earlier (paragraph 5.23) that the internal audit found that the prison fell short of Health Care Standard 2.2 in relation to hospital appointments being kept.
5.38 The health needs of the elderly prison population are evident only when they present themselves to the health centre. Given the ageing prisoner population there is a need to develop more active services for the elderly that detect disease, failing vision, hearing loss and changes in mobility. This service should also seek to promote well being, socialisation and mental health. It is also unsatisfactory for the physical and mental well being of elderly prisoners who are unable to work, to lock them in their cells for much of the day.
5.39 There are prisoners who are registered disabled and each disability presents a unique challenge for the delivery of care. The needs of prisoners with learning difficulties should also be addressed.
Emergency Services
5.40 On being notified by Officers that a medical emergency has arisen, the first line of response is from the nurse on duty who will assess and implement appropriate emergency treatment and referral. The nursing service does not operate a 24hr service and emergencies arising between 22.30 hrs and 07.30 hrs Monday to Friday and between 17.30 hrs and 07.30 hrs on Saturday and Sunday will be responded to by the Officer on duty who has first aid skills. The Officer will contact the Ambulance Service or the general practitioner as appropriate.
5.41 The health centre has emergency equipment and nurses are trained to provide cardiac resuscitation. Should a mental health emergency arise there is an on-call service from a psychiatrist.
The Provision of Health Information
5.42 Throughout the health centre there is a good supply of health promotion leaflets, posters and literature. The issuing of information to prisoners about available health services with expected waiting times is welcomed.
« Previous | Contents | Next »