8. HEALTHCARE

Introduction

8.1 In line with SPS policy, the overall strategy for the provision of health care within the prison came under the Health Care Policy Group which was chaired by the Deputy Governor. The group had only recently been set up and it was, therefore, too soon for us to offer any comments on its operation.

8.2 Until earlier this year, there had also been a Drug Strategy Group but this was not operational at the time of inspection. We believe, however, that consideration should be given to its re-introduction (see also paragraph 5.22).

Accommodation

8.3 The Health Care Unit was situated on the ground floor of ‘A’ Hall and comprised three main areas - viz, a consulting area, a treatment room and an office/interview room which contained a SPIN terminal. Off the treatment room were a further three small rooms, one of which was used as a staff room but also contained storage space for medical records. A second small room, which was in essence a large cupboard, was used as a pharmacy store. The third room was used for record storage.

8.4 The consulting area was entered directly from the corridor and there were also points of entry from the treatment and interview rooms. There was no waiting room for prisoners and those who were to see the MO were expected to stand in the corridor. The area did have a hand wash basin but not an examination couch, with a trolley being used instead, and the diagnostic equipment available to the MO and the nursing staff was old and worn.

8.5 The treatment room was relatively narrow and was furnished with wall cupboards, a desk and a work top. It held the resuscitation equipment, which was checked monthly, and though this equipment was adequate, it did not include a defibrillator. Again, there was no examination couch in this area and no proper facilities for applying treatments and dressings.

8.6 The interview room, which was used by the visiting psychiatrists, was small and there was just about room for a desk and two chairs. It also contained the SPIN terminal and consequently access to it was restricted when the interview room or consulting area were in use.

8.7 The Female Unit had its own spacious consulting room with good examination facilities.

Comment

8.8 The accommodation provided for the medical staff was inadequate, a situation which was further being exacerbated by over-population. With the entrance to the Health Care Unit opening directly into the consulting area, which could also be accessed through entry points from the treatment and interview rooms, it was likely that consultations could easily be interrupted which would not help patients feel relaxed. The treatment room did not give the impression of a dedicated area where treatment could be provided in a clinically acceptable way, whilst the interview room used by the psychiatrists was claustrophobic and in our view, did not provide a suitable environment for carrying out therapeutic interviews.

8.9 It was, in fact, a tribute to all the staff involved that they had managed to maintain any standard of health care in such unsatisfactory conditions. We have, therefore, suggested at paragraph 13.3 that consideration should be given to including some additional health care accommodation in any new Operations Room/Visits/Staff Facilities complex.

8.10 In addition to the accommodation problems, the equipment showed major shortfalls with the lack of a proper examination couch being a serious omission. Similarly, the diagnostic equipment was worn and damaged. We suggest, therefore, that there should be a review of the current equipment with the aim of bringing it up to a medically acceptable standard, including the purchase of a defibrillator so that medical staff do not have to rely on one being provided by emergency ambulance crews.

Medical Officers

8.11 Medical cover for the establishment was provided by Aberdeen Industrial Doctors Limited with two named MOs normally sharing responsibility for the routine daily work as part of the prison health care team. Out of hours medical cover was provided by additional doctors from the contracted company sharing the rota.

8.12 Apart from Sunday, daily surgeries were held in the Health Care Unit; female prisoners were seen in their own medical room within their Unit. The number of prisoners seen in any one day ranged from 5 to 30, with the average being 10. All prisoners reporting sick were seen initially by members of the nursing team and where appropriate, prisoners were referred on for a medical opinion; from the comments of the nursing team, the majority of those reporting sick were seen by an MO. All admissions were routinely seen by the MO within 24 hours or on the day of admission if there was serious concern about their physical or mental health.

8.13 From the perspective of the medical staff, there was good co-operation and support from other members of the team including the visiting psychiatrists. The MOs did, however, feel disadvantaged by the inadequate accommodation provided for carrying out their work and with the old worn out diagnostic equipment - see paragraphs 8.8-10.

8.14 The lack of inpatient facilities within the prison resulted in the MOs referring a higher than expected number of prisoners to hospital. This they found frustrating since often prisoners only required observation rather than intensive hospital treatment. That said, the service which the prison was given by Aberdeen Royal Infirmary and the Royal Cornhill Hospital was highly regarded by the MOs.

8.15 Apart from psychiatrists, there were no visiting specialist clinics. Referrals were made for the services of an optician or chiropodist as the need arose and these attended periodically.

Comment

8.16 We formed the opinion that the prison was well served by the MOs. The out of hours rota appeared to work well and the nursing team carried out its work secure in the knowledge that medical assistance was always quickly available if required. We were also impressed by the service which was provided to prisoners by the local hospital specialists.

Nursing Team

8.17 The nursing team consisted of four nurses, one of whom was the Clinical Supervisor; three of the team had had mental health training. The staff worked a shift system but this was unable to provide 24 hour nursing cover with the existing numbers of staff. When gaps in the arrangements occurred due to staff absences, agency nurses were engaged - where possible, those with previous experience of working in the prison.

8.18 The main nursing duties involved staffing the Health Care Unit, interviewing prisoners reporting sick, dispensing and giving medication, interviewing new prisoners and liaising closely with other members of the prison staff such as social workers and the recently-appointed drugs co-ordinator. The nursing team also had close links with the visiting psychiatrists and the psychologist.

8.19 The interviewing of prisoners who reported sick normally took place in the Halls. The nursing staff dealt with those whom they felt fell within their competence to diagnose and treat but the majority were usually seen by an MO. The dispensing of medicines by the nursing team was carried out four times daily. Prisoners from ‘A’ Hall came to a door at the back of the Health Care Unit but remand and female prisoners were attended to in their respective accommodation areas.

8.20 Admissions to the prison underwent a standardised interview by a member of the nursing team. In the case of male prisoners, they were seen in a medical room in the reception area but this was a small and cramped facility which did not allow for any proper physical examination, though it did contain a wash-hand basin. Female prisoners were seen in their unit in a medical room which was spacious and equipped to a suitable standard and included an examination couch. In all cases, the examining nurse opened a new medical record if one did not already exist; if a prisoner had existing records then these were incorporated into the new style A4 system.

8.21 A member of the nursing team made contact more or less on a daily basis with other health care professionals and support staff such as the drugs co-ordinator and this allowed an exchange of information about prisoners who gave any cause for concern. Information from visiting psychiatrists was also available to the nursing team within the medical records after the psychiatrists had interviewed the prisoners.

Comment

8.22 It was our impression that the nursing staff were well led and worked effectively as a team; they also appeared to have a good working relationship with other colleagues within the prison. The small numbers and the need to staff the Health Care Unit did, however, reduce the opportunity for them to spend time in the Halls getting to know prisoners in greater depth. Lack of time also reduced the opportunity to develop preventive medical protocols or run special clinics. We suggest, therefore, that there should be an increase of two members in the nursing team which, in our opinion, would enable the team to extend its work in the field of prevention, including suicide. It would also allow for 24 hour nursing cover which is essential if prisoners at risk are to be properly monitored and supported.

8.23 Reference has already been made to the poor accommodation in which the nursing team worked. The lack of an office for the Supervisor, the inadequate treatment room and the absence of a ward with beds severely limited the opportunity to extend the work of the nurses which would in our view have improved the health care provided for prisoners - see paragraph 13.3.

8.24 We believe that the practice of using nursing staff to carry out secondary dispensing is not a good arrangement and therefore, we fully support the proposal put forward by the Clinical Supervisor to put an end to this practice by using the pharmacists of Aberdeen Royal Infirmary - see paragraph 8.36. In our view, such an arrangement would provide a viable alternative to the present system.

Medical Records

8.25 The medical records used were the new A4 style which had been introduced in 1997. The nursing staff had successfully transferred existing old records to the new format and where old records did not exist, an A4 record was raised. The records were available when admissions were being interviewed by a member of the nursing team but not when prisoners were being interviewed when they reported sick.

8.26 The MO and the nursing team made entries in the records in historic sequence and there was a separate section for the psychiatrists to make full entries of their contacts with prisoners. In addition, entries were made in the general section to advise medical and nursing staff that a prisoner had been seen on a particular date by a psychiatrist. The medicine charts and prescription sheets were kept in the records when they were no longer active. When in use, the records were kept in dedicated binders in the treatment room.

8.27 The storage of current medical records used a hanging filing system in cabinets in one of the small rooms off the treatment room. This was, however, proving to be too limited for the purpose and there was a proposal to introduce a new storage arrangement. This potential change was also seen as an opportunity to introduce colour coding to the system to help identify particular types of records and prisoners’ characteristics.

8.28 When a prisoner was transferred to another establishment, the medical record went with him. On discharge from that establishment, the records were returned to Aberdeen for storage, if it was the nearest prison to his home.

8.29 The records were not used as a source of morbidity information or workload activity. These types of information were not, in fact, available, nor was there an analysis of referrals and outcomes of medical or nursing interventions to which we could refer.

Comment

8.30 The medical records in the establishment were well maintained and we were pleased that they served to provide good communication between the health care professionals. We were particularly impressed by the way in which the psychiatrists provided full information where appropriate to the health care team.

8.31 The storage arrangements for the records were, however, barely adequate and it was clear that better arrangements should be made as soon as possible.

8.32 We regret that there was such a paucity of information about clinical activity in the prison. We suggest, therefore, that better planned care could be offered within the establishment if more information was available on which planning could be based.

Pharmacy

8.33 The pharmacy was situated in a small room in the medical unit. There was just about sufficient room for the drug stock and dressings but the total storage space was very limited and generally cramped.

8.34 Stock for the pharmacy was ordered weekly in bulk from the pharmacy at Aberdeen Royal Infirmary. If a drug which was not in stock was required as a matter of urgency any day thereafter, arrangements could be made for its collection from the hospital at short notice. The pharmacy stock was checked monthly by the Clinical Supervisor and was inspected every six months by a pharmacist from the Infirmary.

8.35 When prescriptions were made out by an MO, they were dispensed by members of the nursing team from the stock supplies - but see paragraph 8.24. The pharmacy stock and the treatments prescribed were not based on a prison formulary but we were advised that it was the intention to use the SPS formulary when it became available. In the meantime, the range of treatments was designed to be as cost effective as possible and generic prescriptions were issued as a general rule.

Comment

8.36 At the time of our inspection, negotiations were in hand with the pharmacy of Aberdeen Royal Infirmary to dispense the prescriptions for the prison on an individually named basis, a proposal which would involve the daily dispensing of prescriptions by a hospital pharmacist on receipt of a faxed request from the prison. Such an arrangement would overcome the problem of secondary dispensing by members of the nursing team and would also enable a tight control to be kept on all prescribed treatments. In addition, it would reduce the stock of medications held in the pharmacy store with a weekly check by the named pharmacist and would have the advantage of freeing up nursing time which could be more effectively employed in nursing activities and preventive health care work. It was also the intention for a named pharmacist to have overall responsibility for monitoring prescriptions and drug usage, as well as providing advice to the members of the health care team.

8.37 It is likely that in pure financial terms, the proposed changes could increase pharmacy costs within the prison. However, we were of the opinion that the benefits from the change in terms of better dispensing arrangements and the more effective use of professional nursing time, more than outweighed any likely increased costs.

Dentist

8.38 The dental surgeon attended the prison on one afternoon each week and brought along his own dental nurse. He had his own dental practice where he had in the past treated prisoners who required more specialist treatment or general anaesthesia but he no longer used his practice surgery for that purpose and now normally referred such patients for specialist hospital care.

8.39 The dental suite was spacious and the equipment was satisfactory if not very modern. X-ray equipment was available as well as the usual facilities for sterilising dental instruments. The dentist normally saw about 12 patients each session and he was allocated an Officer to collect and escort prisoners, which helped the smooth running of his surgeries. There could, however, be delays in patients arriving and there was no proper waiting area.

8.40 There was not a long waiting list and non-urgent patients normally waited no more than two weeks. Cases where more urgent treatment was required were dealt with more quickly and added to each weekly surgery. If the waiting time became extended, the dentist was willing to provide an extra session though this was rarely necessary.

Comment

8.41 The dental arrangements for the prison appeared to us to be very satisfactory. The only change which we considered would improve the arrangements would be the provision of a waiting area.

Psychiatrist

8.42 The prison was provided with three psychiatric sessions per week and referrals could be made by any member of the health care team to one of several visiting consultant psychiatrists. We were also told that the consultants saw up to 85% of those prisoners who were considered to be a suicide risk

8.43 The psychiatrists indicated that the majority of prisoners seen were those who were suffering from anxiety/depression or drug withdrawal problems: psychotic illnesses were comparatively rare. Where necessary, the consultants were able to admit patients to the nearby Royal Cornhill Hospital, but it was stressed that this did not obviate the future need for a DCU for vulnerable/at risk patients within the prison.

8.44 There was psychiatric representation on both the Health Care Policy Group and the SRMG.

Comment

8.45 Overall, we thought that the establishment received a first class service from the consultant psychiatrists which was well supported by the excellent back-up facilities of the Royal Cornhill Hospital. However, the appointment of a dedicated Community Psychiatric Nurse who could assist within the prison and with through-care in the community after release, would be a considerable improvement in future - when funds permit. Consulting facilities in the Health Centre were extremely cramped though we noted that a staff alarm had recently been fitted.