8. HEALTHCARE

Introduction

8.1 Our detailed inspection of the Health Centre took place shortly after the full time MO had left and the Healthcare Manager had resigned. We were therefore unable to obtain either first hand accounts of what had gone before or many statistics and it was obvious that the Centre was in something of a transitory condition.

8.2 At the time of inspection, supervision of healthcare was operating through two committees:-

• The Health Care Policy Group which was concerned with the strategic planning of healthcare met every three months and was chaired by the Governor.

• The Health Care Team Group which was involved with more routine matters met monthly and was chaired by the Deputy Governor.

Accommodation

8.3 The Health Centre was situated in a two-storey building the capacity of which had recently been increased by the provision of two portable buildings. In addition, various rooms were now being reorganised to allow for a more efficient and safe delivery of service.

8.4 On the ground floor there was a waiting area with adjacent toilet facilities for prisoners who attended for consultation with the MO or for treatment by nursing staff. The MO’s consulting room was about adequate for its purpose and a connecting door led to a spacious treatment room which was provided with appropriate equipment. An adjacent room was used for storing the medical records of former prisoners. On the same floor there was an observation cell built to category ‘A’ standards and a prisoner-free area which consisted of offices for the health centre manager and the two clinical supervisors and a duty room for the nursing staff. The two portable buildings were being converted to doctors' offices, a room for the health centre secretary and a staff smoking room; a connecting corridor led to a kitchen and the prisoners’ dining room.

8.5 The prison hospital was on the top floor and comprised a nurses’ office, a recreation area, a four bedded ward, three single cells, two cells for prisoners on special suicide supervision and four cells used by passmen but which could be vacated if required for medical use. Four separate rooms and an office on the same level were being used as a day care unit which was shortly due to be refurbished - see paragraphs 8.39-46.

8.6 The health centre contained medical equipment which was appropriate to the required range of treatments. Resuscitation equipment was held in the treatment room and was in working order and regularly maintained. Medical records and prisoners’ medication sheets were held in perspex covers in special portable canvass containers, with those for each Hall contained in individual bags. The reason for such an arrangement was that until just before the inspection, all the records for each Hall had been taken by the nursing staff for the sick parade. However, current procedures now involved selecting the records of patients due to be seen at the sick parade from the central container, which dispensed with the need to take out all the Hall records.

8.7 The clinical record consisted of a single standard sheet with identification details and space for clinical notes - though this was very limited. Letters and other documentation relevant to the medical care of each patient were kept separately in a cardboard folder (though it did not appear that these were being maintained in date order).

Comment

8.8 The health centre and hospital building were not purpose built, which was a major limitation though it was evident that attempts were now being made to improve the arrangement of rooms in order to produce a much more efficient working environment. Another limitation was the fact that the same consulting room was used by the MOs and by visiting consultants; also, the MO’s consulting room did not have a wash hand basin - which is unacceptable - nor was it possible under the present configuration for two Doctors to consult at the same time. However, a prisoner free staff working area had also been established recently, which should greatly improve confidentiality and staff safety.

8.9 The offices of the senior nursing staff had just been moved from the portable buildings to a new staff area, which was a much more satisfactory arrangement as it brought senior staff into direct contact with the nurse practitioner teams. However, it was clear that the precipitate way in which some alterations had been effected had caused concern to the visiting Psychiatrists who felt they had not been given adequate consultation. Nevertheless, we believe that the new arrangements are a vast improvement and we also commend the initiative which had produced the Day Care Unit as a result of this reorganisation.

8.10 The dining area in the hospital was not being regularly used by prisoners and further thought might be given to the use of this accommodation (together with the two other small rooms which were nearby). The decor of the hospital area was rather drab and would benefit from being brightened up.

8.11 We were not impressed with arrangements for the maintenance of the medical records, the separation of information not being conducive to the required standard of clinical care. However, we were informed that plans were in hand to introduce more comprehensive medical folders, a proposal which we suggest should be given a degree of priority. We also had difficulty in obtaining other items of documentation and as a result, our overall assessment is incomplete.

Medical Officer

8.12 Until October 1996 there had been two MOs but the full time post-holder had then left leaving a part time MO responsible for all the work. At the time of our inspection he was being supported by locums who covered out of hours needs. Surgeries were held on Mondays, Wednesdays and Fridays with urgent cases being seen on Tuesdays and Thursdays. The MO also had responsibility for the hospital in which ward rounds were held daily, except Sunday.

8.13 The MO worked mainly from the health centre but also visited prisoners in the Halls when required. Invariably he saw only those prisoners who had been screened by nursing staff and judged to require his attention. He was not involved in coordinating referrals to the Psychiatrist but felt that that was an appropriate role for him. At the time of inspection, the MO had just started to work with the drug detoxification programme - see paragraph 5.43. There was liaison with other visiting specialists; nevertheless, we formed the impression that there was little interdisciplinary consultation and activity within the health centre.

8.14 There were no statistics available to assess the workload. Referrals were made to outside specialist clinics and normally up to three patients per day could have appointments in hospital outpatient clinics. Specialist support included a dermatologist who held a clinic once a month; an infectious diseases consultant who specialised in HIV problems also attended. At one time an optician had also visited and arrangements were in hand to provide a new working contract so that that service could be re-instated.

Comment

8.15 The loss of the full time MO had placed excessive, if not intolerable, demands on the remaining postholder; it had also meant that there was little time for preventive medical work. It was our view that it was vital for an additional MO to be appointed as soon as possible if patient care was not to suffer and to allow for the development of preventive medical protocols and health promotion within the prison. We were, therefore, pleased to learn that such an appointment was made shortly after our inspection. The lack of statistics also made it difficult to assess the extent of the work being carried out by the MO, who should be much more closely involved in the upgrading of medical records - see paragraph 8.11.

8.16 We formed an impression that previously there had not been a close working relationship between the former MO and the health centre manager but the new manager appeared to be trying to improve communication and ensure that there was much more team-work, including improved relationships between the MO and the Psychiatrists (see also paragraph 8.32).

Nursing Staff

8.17 Nursing cover comprised a health centre manager, two clinical supervisors, 14 full time and two part time nurse practitioners. They were supported by a part time medical secretary and a full time clerical assistant, together with two Discipline Officers (one of whom attended in the afternoons only). Three weeks prior to our inspection, the health centre manager had resigned and pending the appointment of a permanent manager, a temporary appointment had been made.

8.18 Eight of the staff had mental health nursing qualifications but apart from one nurse who ran an asthma clinic, the nurses were not involved in any specialist areas of care (but see paragraph 8.20). As with the MO, no statistics were available to measure the workload of the nursing team.

8.19 All prisoners reporting sick were first seen by nursing staff in the Halls, though commendable efforts were now being made to provide continuity by ensuring that nurses were responsible for specific Halls over a period of time. Handover meetings were also now being held as shifts changed. Nursing cover was for 24 hours, which meant that prisoners had the opportunity to see a nurse in their own Halls every morning where arrangements would then be made if appropriate for them to be seen by the MO.

8.20 An asthma clinic had been running for 18 months during which forty four asthmatics had been identified and were being regularly followed up through a customised referral form. A similar clinic for diabetics was proposed for some stage in the future.

Comment

8.21 The nursing team members were individually committed, enthusiastic and keen to become more proactive in medical care. They were encouraged to attend courses in order to develop special skills and there was additional expertise within the team to deal with HIV, AIDS counselling and drug addiction. Members of the nursing team were also particularly keen to become more involved in drug rehabilitation - see paragraphs 5.43 and 8.39.

8.22 However, the general impression gained was that up until the appointment of the interim health centre manager, the nursing team had suffered from poor communication, low morale and a lack of direction. The offices of the health centre manager and the clinical supervisors had also been remote from the duty room, having previously been situated in the portable buildings. Also, the team had not been encouraged to develop areas of special interest, other than the asthma clinic. Equally, it was clear that health centre staff had not been encouraged to maintain close working relationships with Discipline staff in the prison, the lack of clinical involvement with the drug rehabilitation unit being a prime example.

8.23 We saw no evidence of the proactive management of chronic diseases (other than asthma) nor was there any health promotion. There was also little evidence to indicate that there had been serious attempts to audit the working activities of the health centre.

Pharmacy

8.24 New arrangements for dispensing medicines had been in operation since October 1996, the previous arrangement having involved the maintenance and dispensing of a large stock of drugs. That had proved expensive in terms of the amount of stock held and in the use of nurses’ time, who had also become involved in carrying out work for which they were not qualified.

8.25 Under the new arrangements, the MO now entered prescriptions on a medical record and prescription Kardex, with information then being entered on a daily prescription sheet which the MO signed. Prescription sheets were faxed to the community pharmacist who dispensed the prescriptions, which were individually packaged and sent to the prison in time for the evening nursing round. A great advantage of that system was that only the minimal stock of drugs was now required to be held in the prison, which greatly reduced both risk and costs. It also meant that the pharmacist was in a position to advise staff on potential hypersensitivity reactions to medication and to provide expert advice on potential interactions when an individual was being prescribed more than one drug.

8.26 Unfortunately full advantage was still not being taken of the new system. Nurses were still being required to dispense from the individual courses supplied by the community pharmacist, whereas we suggest that the medication should be given directly to prisoners from the chemist’s dispensed prescriptions. However, we recognise that the new arrangements for the pharmacy and the distribution of medication to prisoners were generally more sensible, though it was still not ideal to be dispensing drugs between 1700 and 1800 hours in the evening. It would be much better if medication was given to prisoners in the mornings at a fixed point by the nurse; that would be more efficient and would also allow any queries to be resolved during the working day. Equally, we acknowledge that the mixed regimes which exist in ‘C’ Hall would need more careful thought in this respect.

8.27 It should be possible for the MO and nursing team to consider prescribing protocols which would further reduce costs, without having an adverse effect on patient care. The pharmacist should be able to assist with such a task.

Psychiatrists

8.28 Two forensic Psychiatrists from the Murray Royal Hospital provided four sessions each week and had built up a comprehensive service over many years which had been of enormous benefit to prisoners, particularly those with psychotic problems. The close proximity of the Hospital, with its specialist inpatient facilities, was a considerable asset in the management and treatment of psychotic prisoners; for example, we were told that up to 13 convicted and 10-15 remand prisoners were treated there every year. A senior Registrar also provided additional support. At the time of inspection, however, the psychiatric services contract was due for renewal and future arrangements were unclear.

8.29 As a consequence of changes to the accommodation arrangements, there was now only one consulting room, which the Psychiatrists said was inadequate for their purposes. However, we were advised that the accommodation for psychiatric consultations was now to be provided in the Day Care Unit which should resolve this problem - see paragraph 8.44.

8.30 We were not provided with statistics which would allow any assessment of the workload of the Psychiatrists but we were told that they were in the prison for six to nine hours per week, normally on a Tuesday and Thursday. We were told also that there were approximately 100 referrals per year, of whom about four were transferred to the State Hospital at Carstairs.

8.31 Visits by the Psychiatrists did not normally overlap with those of the MO with the result that clinical meetings to discuss psychiatric cases were only ever attended by one of the clinical supervisors. The Psychiatrists had not been involved in the setting up and running of the Day Care Unit (see paragraph 8.39) and currently they did not attend meetings of the healthcare team, the reasons given being lack of consultation and their commitments elsewhere at a time when meetings were programmed.

Comment

8.32 We formed an impression that the Psychiatrists were of a high calibre and were making a very important contribution to healthcare in the prison. However, we also felt that the working relationship between the Psychiatrists and the health centre team was not as good as it should have been. The Psychiatrists left us with the impression that they believed that their work within the prison was not fully appreciated, whilst the health centre team perceived the Psychiatrists as being inflexible in their working arrangements. The lack of adequate accommodation did not help this situation and it is to be hoped, therefore, that changes in the accommodation will go some way to improving both communication and working relationships.

8.33 Whoever is successful in bidding to provide psychiatric services to the prison in the future will need to build bridges. New working protocols will have to be established or the welfare of prisoners will undoubtedly suffer. To help that process it might be sensible to make the MO the co-ordinator of referrals to the Psychiatrists, except in an emergency situation; that would also help to ensure that Psychiatrists were provided with the appropriate clinical information when seeing referrals from whichever source.

Psychologists

8.34 Two forensic Psychologists under contract from Dundee Healthcare Trust were based in the staff training unit (which was separate from the health centre). One of the Psychologists had considerable experience of working in the prison service, whilst the other had been working in that environment for just over a year. Working as a team they appeared to have a good working relationship and we formed an early impression that it was a well run and efficient department.

8.35 The Psychologists worked closely with staff in the health centre and had input into the drug rehabilitation and detoxification programme; they were also involved in the evaluation of the new experimental programme using lofexidine (see paragraphs 5.43-46). They attended all meetings of the Healthcare Policy and the Healthcare Team Groups and had input into staff training programmes as well as the incident debriefing system, in which they were involved in training and evaluation. They also worked part time at HMP Glenochil.

8.36 Until recently they had been on a six month contract which had prevented them from becoming involved in long term projects; however, a two year contract had just been obtained. Nevertheless, they expressed concern about the new policy for the general use of Psychologists within the SPS. They saw the move away from direct prisoner contact to involvement with policy and training as having a detrimental effect on prisoners' welfare, as prisoners would no longer have an individual assessment by trained Psychologists. They also expressed concern that they themselves would lose their clinical skills if they did not continue to see individual clients.

Comment

8.37 We considered that the prison was fortunate to have such a well run psychology department which had such close working relationships not only with the health centre team but also with prison management and other members of staff. That said, we formed an impression that the working relationship with the Psychiatrists was not as close as it could have been.

8.38 The new longer contract which is now in operation should allow the Psychologists to become more involved in long term planning and projects where their skills could be important to ensure successful outcomes. However, the new working arrangements for the psychology service in the SPS will require close monitoring as there could be a risk of prisoners not receiving adequate support from Psychology specialists.

Day Care Unit

8.39 A Day Care Unit opened in July 1996 with the aim of providing a safe environment which would allow prisoners to come to terms with their sentences, address their behaviour patterns and accept responsibility for their own actions. The Unit was situated within the health centre and by way of accommodation had three multi-functional rooms, an office, a day room/kitchen and a toilet/shower room. Recreational facilities were shared with the inpatient unit. It was run by a multi-disciplinary team which consisted of psychiatrically trained nurses, the MO, a social worker, a clinical Psychologist and an occupational therapist. The original intention was for the Psychiatrists also to be involved but to date that had not happened.

8.40 Referrals to the Unit were made by members of staff or by self referral. Each referral was examined by a multi-disciplinary team to assess suitability for admission to the Unit; thereafter, the needs of each individual who was accepted for admission were assessed and an individual care plan produced. Unless there were exceptional circumstances, remand and protection prisoners were not admitted to the Unit. During the first four months of its operation there had been a total of 54 referrals.

8.41 The Unit's work was based on a multi-disciplinary approach and involved small groups or one-to-one sessions. It was not a residential facility but provided outpatient places for prisoners requiring special risk observations as well as prisoners referred from the Halls. An evaluation report on its work was currently being prepared.

8.42 Staffing for the Unit was provided from the health centre's current establishment but did not have the cover of a Discipline Officer. A paper had been produced on proposals for a future restructuring and resourcing, which would allow the Unit to be open five days a week rather than the current two half days.

Comment

8.43 We formed the opinion that the Day Care Unit was a very useful facility; the latest evaluation report was not available at the time of our visit but the number of referrals during the first four months of its operation suggest a perceived need among prison staff and prisoners alike.

8.44 However, present accommodation is not suitable for the Unit’s purpose and the locks on the cell doors should be changed to allow them to be closed when interviews are being carried out. Suitable furniture should also be provided for those rooms to allow clinical and other interviews. Also, if special risk observation prisoners were to be located in the Unit during the day, observation windows should be available throughout; staff alarms are also essential. An additional room where small groups could meet would also benefit the operation of the Unit. If those changes were made, it would be possible to offer accommodation to visiting Psychiatrists which, we suggest, is essential; it would also mean that the mental health activities of the health centre could be kept in one designated area.

8.45 Extra staffing resources would also be required if the facility was to function for five days a week. The forecast of needs by the Unit’s clinical supervisor was for two nurse practitioners with mental health qualifications, one occupational therapist and a Discipline Officer with other members of the multi-disciplinary team attending as required. It would also be important to ensure that the proposed protocols for evaluating the assessment procedure and the work of the Unit were put in place.

8.46 We concluded that if the Unit was properly resourced and supported, it was likely to produce positive benefit for the mental health of prisoners as well as providing support for the healthcare team and for Discipline staff.

Dental Care

8.47 The Dentist had been working in the prison for over 21 years and attended for one morning session of three and a half hours, though extra sessions for emergency treatment could be accommodated on demand. His own assistant also attended.

8.48 Although the Dentist dealt with most treatments in his surgery, regular referrals at a rate of about one per week were also made to the oral surgery unit in Perth Royal Hospital for work which involved general anaesthetics. The workload was high, with an average of 20 patients being seen at each session; all cases were referred via the Health Centre. A large percentage of his patients were described as being in the high risk category in relation to blood/saliva borne infections. Dental equipment included an X-ray machine, a modern drill, an autoclave, an ultrasonic cleaner and a new compressor. We were pleased to note that a staff alarm had been fitted to the surgery.

Comment

8.49 The Dentist, who also provided cover for nearby HMP Friarton, appeared to be very committed to his work. However, he felt that his time was not always being fully utilised, due to delays in prisoners getting to him or cancellations being caused by the lack of escorting officers. This had been particularly noticeable over the last two years, when he had also noted a deterioration in his relationship with the MOs. He was also disappointed that Management did not involve him more in decisions about the budgets which affected his area of work.

Healthcare Summary

8.50 We had concerns about the recent functioning of the Health Centre and the lack of information on work which has been carried out by its medical team and visiting specialists. We hope that further changes and the reorganisation of the medical record system will include a strategy to address this, though the rearrangement of accommodation in the health centre and the development of the Day Care Unit were encouraging signs of much needed change.

8.51 A combination of the above and the appointment of a new health centre manager, should do much to help place healthcare in the prison on a more steady track, though the manager will also have to ensure that there is good communication between medical staff, visiting specialists and prison management, as multi-disciplinary working requires more practical cooperation on a daily basis. It will be equally important for members of the nursing team to be made more aware of the routines and environment of Discipline staff so that better working relationships might be developed.

8.52 We also believe that the role of the MO must be made more effective and the early appointment of a second MO should provide the opportunity to reassess working priorities, particularly in relation to pro-active work. It is vital that the MO’s role in coordinating care is recognised in all future planning.

8.53 The new pharmacy arrangements were a positive step in the rationalisation of dispensing within the prison but it will be important to ensure that the benefits from its use are obtained. This will include the avoidance of the dispensing of medication by nurses, which otherwise is a waste of valuable time and training.

8.54 It is our intention to re-inspect the Centre within six to nine months in order to assess the effectiveness of the new systems which have been introduced.