8. Healthcare

Introduction

8.1 The provision of healthcare for such a large throughput of prisoners continued to pose a major challenge. Over the past two years, however, new procedures had been introduced to improve the screening and assessment of admissions, though with the sheer weight of numbers involved this could only be a limited process - even when supported by a structured pro forma. There had also been many other changes during this time which had helped greatly to raise the standard of medical and nursing care.

8.2 A Health Care Management Group had recently been set up under the chairmanship of the Deputy Governor; it met regularly and had responsibility for the overall management of health care in the prison. It also had the potential to be a catalyst for further change and innovation.

Accommodation

8.3 The health centre was based in a building which also included the Reception area. Although this made the admission process easier, there was a relatively small prisoners’ waiting area and that lack of space contributed to delays in processing prisoners on admission.

8.4 At the time of inspection the health centre was in the process of being refurbished, a situation which had caused some difficulties for staff in the preceding months. It was situated on two floors; at ground level there was a waiting area, doctor’s consulting room, nursing station, treatment room, administration offices, records storage room, dental surgery, pharmacy, X-ray room and a small staff room. The second floor comprised a ward area with eight beds and a smaller two bed area for high dependency patients. Between the wards was a nursing station with large glass panels which provided good visibility of both areas. Additionally, there were eight observation cells, a communal room and an area where the Mental Health Team was based. There was another area which could be opened up in an emergency but a proposal had been made to develop it as a special unit for housing elderly prisoners, whose numbers had been increasing in recent years.

Comment

8.5 The health centre suffered from not being a customised building. There was, for example, no lift to the ward area on the second floor and some of the offices were small and cramped - most notably the pharmacy and the room where the records were stored. The ongoing refurbishment work made it difficult to assess the standard of accommodation, but our overall impression was that it was adequate for its purpose, though the ward area would benefit from redecoration. Many of the beds in the wards were also being taken up by prisoners on crutches who were being held there because of the problems they had in slopping out in the Halls. That situation was having a serious effect on turnover though the numbers involved should reduce when ‘D’ Hall re-opens.

8.6 We support the proposals for the extra eight bedded ward which would enable the existing ward area, which has an excellent facility for continuous observation, to be used for managing prisoners who have been identified as being at high risk from self harm.

Medical Officers

8.7 There were ten MOs working in the prison, one of whom one was full-time (though he had not yet been given a contract). There was also a full-time locum. Those prisoners who required to be examined by a doctor were normally seen in the health centre, the only exceptions being those in ‘C’ Hall who were seen in the Hall by a part-time MO with specific responsibility for that area. Surgeries were held in the health centre every morning except Sunday and included some of the prisoners who had been admitted the previous night or those who had been seen in Halls by members of the nursing team the previous day and had been assessed as requiring a medical opinion. When necessary, however, prisoners were seen in their cells by the duty doctor.

8.8 There were also daily rounds in the ward area on the upper floor of the health centre, and a doctor normally sat in with the nursing team when it carried out the screening of admissions. However, the sheer weight of numbers involved meant there was not time to carry out a full medical examination. On average, about 30 to 40 prisoners attended the MOs’ morning surgery.

8.9. Those who required a specialist opinion were referred by the MO to Glasgow Royal Infirmary, the exception being those who required a psychiatric opinion - who were referred to the visiting psychiatrist. It was also possible for the MOs to obtain a radiological opinion through the service provided by the visiting radiographer and radiologist. An optician attended the health centre on demand and there was provision for the regular attendance of a chiropodist. On average, ten prisoners were admitted to hospital each month with between 50 and 60 attending out-patient clinics.

8.10 The MOs were able to make extensive use of the ward facility to manage patients who required continuous nursing care or nursing observations. There was a wide variation in the number of admissions per month, ranging from 50 to 90.

8.11 Protocols had been introduced by the medical staff in conjunction with the nursing team for the management of alcohol and drug withdrawal; we were told that their use allowed most prisoners to be managed in the Halls during the withdrawal period. We were, however, unable to obtain accurate information on the number of fits or seizures which were experienced in the course of these withdrawal regimes. Guidelines had been produced for the use of lofexidine to assist in keeping the side effects of withdrawal from opiates to a minimum.

Comment

8.12 The large number of doctors involved makes it essential for them to have strong leadership and for their work to be properly co-ordinated. The current full-time MO was in an ideal position to provide this, but without a contract and appropriate job-description it is difficult to see how this can be achieved. He would also benefit from the support of a full-time colleague, again with a contract, rather than a locum who would otherwise find it difficult to provide the appropriate continuity and support.

8.13 We formed the impression that the lack of a designated team leader was hindering the development of an agreed and co-ordinated policy among the medical staff. For example, a drug prescription formulae had been produced by the full-time MO but at the time of our inspection, it had still not been introduced. Equally, the approach to the treatment of drug withdrawal was not always uniform; previously agreed guidelines would go a long way to setting out the ground rules for this.

8.14 We were told that arrangements for the admission of YOs on a Friday evening, which meant that they were kept over the week-end prior to admission to Polmont and Longriggend, were placing a considerable demand on the medical team.

8.15 While procedures for the medical examination of admissions had improved, we believe these could be improved further. Understandably the medical assessment for evening admissions was only a brief screening process, but the inclusion of new admissions who require more detailed assessment with the morning surgery was not an ideal arrangement. In our opinion, all admissions should be seen by a doctor the day following admission, in a designated session.

Nursing Services

8.16 The health centre manager was responsible for 30 practitioner nurses and was supported in this work by four clinical supervisors: there were also two administrative assistants.

8.17 The policy within the team was to replicate, as far as possible, a primary medical care approach to nursing care. This involved devolving responsibility to nursing staff in the Halls working closely with other professionals and to this end the nursing complement was divided into three teams. One team covered ‘A’, ‘E’ and Letham Halls, another ‘B’ and ‘C’ Halls and admissions, whilst the third team looked after the in-patient area and was also involved in the mental health and drug reduction programmes.

8.18 The policy of devolving responsibility was supported by a fully equipped nursing station in each Hall, which gave each duty nurse a base from which to work and allowed for basic care and screening. The objective of this policy was for nursing staff to develop close contacts with prisoners and staff and in particular to help potentially vulnerable prisoners. The Hall nurse was also responsible for the issuing of all medication prescribed by a doctor and for making entries in prisoners’ medical records. At the time of the inspection, the entries by nurses were made in the same part of the record as the medical staff, but we were informed that it was the intention that when the new comprehensive A4 record system became available, a special section would be maintained for nursing notes and individual care plans.

8.19 The nursing staff working in the Reception area carried out an initial screening assessment on newly admitted prisoners, normally with a doctor present. Where there was concern about a prisoner, the doctor’s advice was sought.

8.20 Nurses were not involved in the running of specialist clinics, though they monitored individuals who were suffering from asthma or were mentally vulnerable. We were told, however, that they were being encouraged to develop areas of special interest so that programmes to monitor chronic diseases could be developed in future.

Comment

8.21 The accommodation allocated for each nursing station was cramped, especially if a doctor was also present and required to carry out a detailed examination.

8.22 There was also a number of other problems associated with the decentralisation of nursing care. Firstly, the nurses did not have ready access to the nursing record when treating prisoners in the Halls or elsewhere outside the health centre. Apart from relevant information not being available at the time when a patient was seen, it involved nursing staff going to the health centre to update the record (or possibly running the risk of omitting to do so). Secondly, the fact that all medication was kept in the health centre also required the nurse to make regular visits to it to collect the medication for issue to the prisoners. A possible solution to these problems would be for a nursing record to be maintained in the nursing station which could later be added to the notes when the prisoner moved. Vital information could still be entered in the main record as usual, which would make it available to the medical staff and other nurses when the prisoner was seen at the health centre - it would also reduce the risk of notes getting lost. An alternative solution would be to decentralise the filing of the medical records and keep them in the nursing station in the Halls in suitably secure cabinets. It might also be possible for a supply of drugs which were not suitable for self administration to be kept in the nursing station on a daily basis.

8.23 We commend the development of the special mental health nursing team and were particularly impressed by the new policy which involved members of the mental health team visiting Glasgow Sheriff Court to identify high risk prisoners prior to their admission. This is an initiative which would justify careful evaluation and it could be an example of good practice for other establishments.

8.24 There would be advantages in having a regular staff of experienced prison Officers with specific responsibility for the health centre, rather than a constantly changing group as at present.

Medical Records

8.25 The medical record system had been reorganised over the preceding 18 months. Each prisoner’s record was now held in a wallet folder which contained the current clinical record, previous records, correspondence and investigations (whereas previously the various parts of the record had not been integrated). The space on the card for entering each consultation was limited and the correspondence and other clinical information was held loosely in the wallet with no attempt to file the information chronologically. Nurses and doctors entered information in the clinical records, but there was no summary of the more important events in the prisoners’ medical histories. Prescribing information was held separately on a special drug sheet (Kardex).

8.26 We were unable to obtain detailed information from the record system on the most frequent medical conditions suffered by the prison population. However, it was clear from other sources that a significant proportion had drug or alcohol problems.

Comment

8.27 The limited entry space, lack of chronological filing within the records, as well as the lack of a clinical summary meant that the record system would benefit from the introduction of an A4 record system which is the standard system used in primary care in the NHS. There should also be a clear record of past and current medication in the record, including any information on drug sensitivities. We were told that a new admission log sheet was to be introduced which along with other information, would provide a comprehensive summary of important medical data. If this is done it should enable the collation of useful morbidity statistics for the effective planning of medical services in the prison.

8.28 The introduction of named nurses based in nursing stations in the Halls had clearly provided the health centre team with a problem on how best to make the records available. There are arguments to support continued centralisation and counter arguments to support the alternative decentralisation of the records, but whichever solution is arrived at, it is important that missing records are kept to a minimum. The provision of a records clerk who would be in charge of maintaining the filing system would go a long way to resolving this problem if the records continue to be held centrally; if a solution is found in decentralisation, we believe it would be essential to introduce a marker or tracer system to prevent loss and to reduce misfiling.

8.29 It is vital for the monitoring of the work of the health care team and the planning of appropriate medical care for the prisoners as a whole, that an information system on the moribidity of the population is introduced soon.

Pharmacy

8.30 The pharmacy was based in a small room which contained the pharmacy stock and a computer for labelling the individual patients’ prescriptions when it was appropriate to supply a complete course of treatment. Drugs and preparations were obtained on a weekly basis from the pharmacy of Glasgow Royal Infirmary.

8.31 Approximately 300 prisoners were on prescribed medications at any one time and where possible, prisoners were given a weekly supply of treatment for self administration. The remainder were given their prescribed medication from the stock supply when the nursing rounds took place. Prisoners were also supplied with any essential items, such as inhalers, when they were seen on admission.

8.32 At the time of inspection, negotiations to improve the arrangements for the pharmacy and the monitoring of prescribed medicines were underway. There was the possibility of either employing a full-time pharmacist or having a pharmacy technician supported by a pharmacist at Glasgow Royal Infirmary, the use of a community pharmacist having been ruled out on grounds of cost.

Comment

8.33 It is inappropriate for a member of the nursing team to have responsibility for the operation of the pharmacy and the dispensing of drugs and we entirely support the efforts to find a solution to this problem, which should be resolved of a matter of some urgency. The introduction of a formulary would also lend further impetus to the attempts to rationalise the pharmacy stock; it might also help to contain drug costs.

Psychiatrist

8.34 Service was provided by an experienced forensic psychiatrist, a CPN and a team of registrars in training from the Douglas Inch Clinic in Glasgow and was based round twice weekly sessions. The psychiatrist also provided input into the multi-disciplinary Suicide Risk Management Group.

8.35 Prisoners were normally seen in their cells, an arrangement which allowed the psychiatrist to make a more reliable assessment of the individual’s mental state.

Comment

8.36 The psychiatrist referred to the wide catchment area from which the prison population was drawn. When a prisoner with a psychotic illness required admission to a psychiatric hospital in which the psychiatrist did not have beds, a considerable and often protracted effort was required to arrange for the necessary transfer.

8.37 We believe that an increase in the number of CPNs is highly desirable, both for the treatment of the numbers of those arriving within the prison with mental health and drug associated problems and for throughcare back into the community - see also paragraph 5.42.

Dental Surgeons

8.38 The establishment had two dental surgeons who worked two sessions on four mornings each week. Their surgery contained good quality dental equipment, which included a modern X-ray machine.

Comment

8.39 The demands on the dental surgeons’ services were increasing to the extent that they said that they were, in the main, only able to provide emergency treatment. Though there had been an attempt to overcome the backlog by providing some additional sessions on a temporary basis, at the time of inspection the list for dental treatment was beginning to rise to unacceptable levels. Either more sessions are required on a permanent basis or an extra dentist should be employed.

8.40 The dental surgeons said they felt isolated and had not been involved in the future planning of the service which they were providing. They also referred to the particular dental difficulties caused by drug addicts who were withdrawing from opiates and the number of sessions wasted by patients failing to turn up on time.

Healthcare Summary

8.41 On the whole, we were impressed with the arrangements for the provision of medical care. The health centre appeared to be well organised and worked efficiently, though we were concerned that that the full-time MO had not at the time of inspection been given a contract; such a formal appointment is essential in order to provide the opportunity to establish a recognised leader and to ensure the proper co-ordination of the medical team and we therefore so recommend.

8.42 The use of the mental health team to screen prisoners at Glasgow Sheriff Court is an excellent example of pro-active health care; separately, we believe that members of the nursing team should be encouraged to develop specialist skills to allow for more pro-active work concerned with the prevention of chronic diseases. Though the provision of working stations in the Halls and the use of named nurses is generally beneficial, it is important that Hall nurses maintain good communications with other staff.

8.43 Professional control over the pharmacy and the dispensing of drugs is essential and we recommend that a solution to this problem be found as soon as possible. Also, although the medical record system had been greatly improved, it would benefit from the future use of A4 folders and properly collated records.

8.44 There is an opportunity further to develop the suicide strategy prevention by taking advantage of the space available on the second floor of the health centre to provide an additional ward facility; this would allow the existing ward to be used for the management of patients considered to be at risk of suicide in an open environment.

8.45 Greater use of CPNs to work within the prison as well as in the community would be a great step forward in the management of vulnerable prisoners - as well as for those with addiction problems.