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HM INSPECTORATE OF PRISONS Report on HM Prison Barlinnie
6. HEALTHCARE
Medical Arrangements
6.1 During the last inspection in November 2000 there were two full-time and six part-time medical officers. Questions were raised then as to whether this number of staff were required. On this occasion there was a total of only two full-time medical officers in post (a third having left the previous week). There was some locum cover to make up for the shortfall in doctor hours resulting from the loss of one of the doctors.
6.2 The medical service is provided under contract by a private company, 'Medacs'. The contract provides for 116 hours of medical time per week, divided into three sessions each weekday and one session on Saturday mornings. Out of hours cover has been subcontracted and the medical officers are not expected to provide cover during periods of holiday or sick leave. The doctors are not involved in wider prison management issues and do not run any specialist clinics apart from their involvement in the methadone and drug detoxification regimes. Changes to the population in the Halls are not routinely communicated to the doctors.
6.3 Most prisoners are seen in the Halls by the medical staff, although some consultations take place in the health centre. Prisoners who are assessed by nursing staff as requiring a medical opinion are seen within seven days and urgent cases sooner depending on the degree of urgency. All admissions are seen within 24 hours in accordance with Health Care Standard 1.
6.4 One doctor had been in post for two years and another for fourteen months. In addition to his work in the prison one doctor did some sessional work in a general practice and the other worked for a company which provided out of hours cover for general practitioners including the prison. Although the number of doctors had been reduced, they felt that this was sufficient to deal with the workload of the prison.
6.5 However, doctors' clinics were being cancelled at short notice and if this situation continues it could lead to a deterioration in the standard of medical care being provided. Full-time medical staff should also participate in the various meetings relating to medical care in the prison.
Accommodation and Equipment
6.6 The health centre has been refurbished since the last full inspection. There is now a lift to the second floor, the waiting area has been enlarged and there is a customised pharmacy. Various other changes have also been made: the Mental Health Team is now based on the ground floor, a doctors' room has been lost as a result of the refurbishment and the record storage area has been enhanced allowing the administrative staff to access the 80,000 records held there.
6.7 On the second floor, improvements have been made to the eight observation cells which now include a cell fitted for a disabled prisoner. The former two-bedded ward has been changed to a recreation room for protection prisoners who are in-patients.
6.8 The rest of the facilities on the ground floor consist of the health care manager's room, a clinical managers' room, two administrative offices, one of which doubles as a doctors' office, treatment room, nurses' station, doctor's consulting room, an x-ray room with a developing room attached, a staff kitchen, several storage rooms and toilets including one for the disabled.
6.9 In addition to these facilities, the second floor has an eight bedded ward with a nurses station and a room currently used to house one chronically sick prisoner. There is also a rest room with some exercise equipment, a doctors consulting room, a kitchen, toilets and shower facilities.
6.10 The health centre was well equipped and fitted with all the equipment appropriate for the range of work carried out there. It has all the necessary resuscitation equipment which is checked regularly. However, the defibrillator is very heavy and unsuited for rapid transportation to the scene of an emergency. It should be replaced. There was no systematic training or refresher training in cardiac resuscitation and they should be addressed. There are alarms fitted to all the rooms to which prisoners have access.
6.11 Overall, much work has been done to improve the health centre facilities. The proximity to Reception has also enabled the health centre to be used for the examination of all prisoners on admission.
Medical records
6.12 The medical records have now been converted to A4 size. From the random sample of records examined, they appear to be maintained to a satisfactory standard. The storage facilities are excellent and the administrative staff deliver a very good service to the clinical staff.
6.13 A study was made of a random sample of written complaints about medical treatment over the preceding twelve months. Of these, the majority were related to methadone prescriptions or the detoxification programme. The remainder were concerned with treatment. One related to a delay in diagnosis, which caused some concern, but without more information it is not possible to draw any firm conclusions about the quality of care in this particular case. On the whole the complaints were dealt with appropriately.
6.14 There is no comprehensive database of clinical information and consequently this could not be used to analyse the problems facing the medical staff. This should be addressed. An assessment of the health needs of the prisoner population based on health records and treatment programmes is outlined at paragraphs 6.39 - 6.41 of this report. The quantity and quality of data available on the work of the health centre is very limited, and on the basis of the information available it was not possible to draw firm conclusions as to how effective the work of the health centre was.
Suicide Risk Management
6.15 Since the last full inspection in 1997 the ACT strategy for the management of suicide risk has been introduced. In 1997, although the prison had adopted a very pro-active approach to the prevention of suicide it was still seen primarily as a health care issue rather than a task in which all staff should play a part. The introduction of ACT in 1998 has been instrumental in introducing a culture where suicide is seen as the concern and responsibility of all staff. This is to be greatly welcomed.
6.16 The issue of self-harm and suicide remains a challenge for the prison. ACT procedures were initiated on 691 occasions during the 12 months prior to the inspection. There had been four deaths in custody (subject to FAI) during this period.
6.17 ACT is overseen by an ACT Group chaired by the Deputy Governor, with the Health Care Manager as ACT Co-ordinator. The ACT Group is multi-disciplinary and meets every two months. There is input to the group by the Listeners: this is a group of volunteer prisoners who after a careful selection process and training by the Samaritans are available to talk to fellow prisoners in confidence.
6.18 A wide range of individuals and areas were consulted for the purpose of this part of the inspection including the Deputy Governor, the ACT Co-ordinator, health care staff, discipline staff and Listeners as well as the supervisor who co-ordinated their activities. The minutes of the ACT Group which meets every two months were examined as was a random sample of the ACT documentation.
6.19 In March 2002 an independent audit took place of the ACT procedures in the prison. This established that ACT was being implemented satisfactorily although a number of suggestions were made. As a result, a plan was drawn up to address these issues and action has now been taken.
6.20 When a prisoner is considered a high-risk case he is normally placed in the hospital ward and allowed free association within its confines. Anti-ligature cells are used only when the ward area is considered inappropriate. As his mental state improves he is transferred to the High Dependency Unit in Letham House prior to a move to a normal prison environment.
6.21 The Listener Scheme has a high profile in the prison, demonstrated by the fact that a Listener participates in the induction process for newly admitted prisoners. There is also publicity about the scheme throughout the prison. At the time of inspection there were six Listeners and an additional six had recently been recruited. They were very content with the support they received from both management and the Samaritans. The main problem seemed to be the lack of a suitable room being made available to them in the Halls when they went to see a distressed prisoner.
6.22 The arrangements for suicide risk management had improved considerably since the inspection of 2000 and were now very satisfactory. Of particular note was the way in which the ward was used and the close links with the High Dependency Unit.
Psychiatry
6.23 The consultant psychiatrist attends the prison twice each week. Other psychiatrists who form part of his hospital team assist him. The attending psychiatrists meet with the Mental Health Team (MHT) prior to their consultations to establish priorities. Prisoners are normally seen in the Halls and not the health centre. The MHT co-ordinator organises the referrals and this appears to work well. Patients are normally seen within two weeks of referral, and sooner if urgent assessment is required. The psychiatrists have good links with the local community through the Community Psychiatric Nurses.
6.24 Overall the psychiatric service to the prison supported by the MHT is satisfactory and works well.
Pharmacy
6.25 Since the last full inspection the pharmacy arrangements had changed. The contract is now operated by Moss Chemists who provide a pharmacist on site, assisted by a pharmacy technician. The pharmacy is situated in the health centre in a customised room fitted with metal grills and secure cabinets. Since it acts as the equivalent of a community pharmacy it carries a considerable stock.
6.26 The pharmacists dispense the doctors' prescriptions as well as carrying out regular audits on the prescription Kardexes. However, information on prescribing statistics was not readily available during the inspection.
6.27 The workload associated with the distribution of medication, including methadone and drugs used in de-toxification is considerable. Approximately half of the prescribed medication is self-administered but this still represents a heavy workload for nursing and pharmacy staff. It takes up time which might be better used for other activities. One compensating factor, which relieves some pressure on nursing staff, is that there is no requirement to fax prescriptions to a central pharmacy since the pharmacists directly handle the doctors' prescriptions. The use of a photograph for the identification of a patient prior to the administration of a medicine should be introduced to all areas of the prisons. The pharmacists are keen to be more active in the provision of advice as well as monitoring prisoners on long term medication. This would seem to be a very useful service which they could provide and which should be encouraged. Overall, the pharmacy arrangements in the prison are working very well.
Dentist
6.28 There are five dental sessions each week. Two dentists from the same Practice provide these sessions. They work from a surgery in the health centre, which has been inspected independently and passed as up to national standards in the prevention of cross-infection. The dental chair and the fittings of the surgery are showing signs of wear and need replacement.
6.29 The dentists work closely with uniformed staff assigned to the health centre and the surgery sessions appear to go smoothly which allows the dentists to make maximum use of their allocated time. However, some prisoners complained about dental waiting times but examination revealed that this was usually three weeks (and currently four weeks for non-urgent appointments). If necessary the dentists would provide extra sessions and any urgent cases were always accommodated. It was of concern however, that prisoners on occasions missed their appointments because they were not forewarned by Hall staff.
6.30 Overall, the dental service in the prison is very satisfactory but a list should be placed in the Halls of those prisoners who are due to visit the dentist and this list should be put up in good time to give prisoners sufficient advance notice.
Ophthalmic Services
6.31 The optician attends for two hours every fortnight. He has recently been absent for an extended period but has now restarted his session. Since the waiting list had grown unreasonably long, a recent policy was introduced to prioritise patients. Remand prisoners and prisoners serving less than six months can only see the optician if the medical officer makes the request. Those sentenced prisoners serving longer than six months can request to see the optician at two-year intervals. Any prisoner with glaucoma or diabetes mellitus will be monitored on a regular basis, as they would be in the community.
6.32 Currently the waiting time to see the optician is four weeks but urgent cases are seen within a week.
Chiropody
6.33 The prison has been without a chiropodist for several months, although this has now been remedied, and a chiropody service was due to resume in May 2003. At the time of the inspection there were fourteen prisoners awaiting treatment. The chiropodist will provide a weekly session initially.
Physiotherapy
6.34 The prison does not have any physiotherapy sessions. At present one of the physical training instructors does provide a limited service.
Nursing
The Nursing Team
6.35 The Health Centre Manager is a qualified and experienced nurse. Four clinical nurse managers support the Centre Manager and there are 27 practitioner nurses in post. It is encouraging that the practitioner posts include a good number of registered mental health nurses as these staff can address mental health needs. There are three vacant posts and three nurses are on long term sickness absence.
6.36 Maintaining adequate numbers of nurses continues to be difficult and there have been severe difficulties in recruiting and retaining nursing staff. At one point there was a vacancy level of 52% (14 vacancies). To fill the vacant posts, registered nurses with limited experience since registration have been recruited and this has required a rigorous programme of supervision and support as staff gain new skills.
6.37 Staff newly recruited to the nursing team confirmed that they had been well supported by clinical managers and the nursing team. However, there has been considerable delay in newly appointed nurses receiving the SPS Induction Programme that prepares them for working in the prison service. This delay has been for a period of several months. The in-post team who worked through the difficult period of high vacancy levels maintained the nursing service and ensured health care standards were achieved.
6.38 A system of staff appraisal is in place and nurses confirmed that there is good access to further nurse training programmes and opportunities for staff to maintain their professional development and competencies.
Health Profile
6.39 Health records and treatment programmes indicate that the predominant health problems in Barlinnie are mental health and illnesses arising from substance misuse. As detailed in Chapter 4, on one of the days of inspection, 171 patients received a single administration of methadone and an additional 95 patients were given a detoxification prescription. In addition to requiring treatment for addiction, those who abuse substances often present with a range of health needs including blood borne diseases, weight loss, diet deficiencies, abscesses, poor dental health, skin problems and infestations.
6.40 The occurrence of minor illnesses, such as headaches, sore throats, coughs and colds, earache, toothache, impaired hearing and vision, are ongoing and present on a daily basis to the nurse. These are comparable with those that occur in the community. As confirmed in the SPS prisoner survey a high percentage of this population smoke, with the associated health risks that this presents. Promoting the cessation of smoking has been a key aspect of health promotion activities. A project grant has recently been awarded to the team and this will enable a selected group of prisoners to be supported in a more focused way.
6.41 Overall, the health needs arising in the prison population present a significant challenge for those managing health care in terms of the required range of skills knowledge and competencies and also in terms of financial resources and physical buildings.
Health Assessment
6.42 Given the problems associated with this population, a health assessment of each prisoner on admission is an important element of health care. These arrangements are robust. The assessment is undertaken by a registered nurse and/or doctor and the prisoner is afforded a one to one interview in the privacy of a consulting/treatment room. The health assessment documentation is well designed and maintained. The health team has audited standards for health assessment, established by SPS, and appropriate follow up has been initiated.
6.43 Arrangements are in place in the health centre to resolve difficulties which can arise when a prisoner does not speak English. Interpreters are available from the Glasgow area, and nurses indicated that this service had been used on a number of occasions. However, it appeared that there can be some delay in engaging an interpreter and this should be resolved. Help with interpretation is sometimes obtained from staff who speak different languages or from other prisoners, friends or family. These arrangements may be helpful in some circumstances, but issues around confidentiality of medical information can arise and they are no substitute for proper access to an independent and impartial interpreter.
Access to Health Care Services
6.44 Patients have access to a range of health care services. In the event of general illness the prisoners see a nurse who will assess the presenting problems and implement appropriate treatment. If necessary the patient will be referred to the doctor. When a nurse assesses that a presenting health problem requires an urgent consultation with a doctor, this can be arranged outwith the daily clinic schedules. In the event of accident or emergency there is a registered nurse on duty 24 hours each day of the week. Nurses can provide emergency response and refer to a doctor on call or transfer a patient directly to hospital.
6.45 In response to the level of morbidity, mental health nursing services are available to each Hall, and this has enhanced the opportunity for ongoing assessment and monitoring for these patients. There are particularly strong links between the health centre team and the staff in Letham Hall where vulnerable prisoners are held.
6.46 A large part of the nurse's time is taken up by the administration of medicines and this is an appropriate element of treatment. There is however scope for registered mental health nurses to be engaged in additional aspects of therapeutic care such as one to one and group work, but opportunities are limited by lack of available time and the rapid turnover of patients.
6.47 A multidisciplinary mental health team is in place and appears to be working well. There is good liaison with community psychiatric nurses, demonstrated by the ability to fast track through prison Reception those that are identified as having a mental health problem. The arrangement affords vulnerable patients access to appropriate health care, and in such situations the patient may go directly from Reception to the "in patient" facility where a more in depth assessment can be carried out. The multidisciplinary mental health team also works well in the areas of throughcare, transfer and release. Two community psychiatric nurses come into the health centre for a weekly meeting with the mental health team.
6.48 Arrangements are in place for patients to be referred to external hospitals for secondary care if necessary. There is no evidence that waiting times for a hospital appointment or admission are longer than those experienced in the wider community.
Quality of Health care and Nursing Services
6.49 As outlined earlier in this chapter there is documented evidence that the SPS Standards have been subject to an audit earlier this year and that steps have been taken to improve any detected shortfall. The majority of a randomly selected number of prisoners, who were users of health care services, voiced satisfaction with the health care they have received.
6.50 Records in relation to nursing care were well maintained and care plans in place for those in the residential hospital care unit.
6.51 The administrative staff give excellent support in providing the health care team with patient records, this is an extremely valuable service in a situation where there is significant movement in and out of the prison. The easy availability of patient records supports continuity of care and ensures that decisions about treatment, embrace the patient's medical history.
6.52 The placement of two student nurses with the health care team, for training purposes, is a positive indicator that the nursing team and the health care environment is deemed suitable by the training institution and that the criterion for such placements have been met.
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