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8. HEALTHCARE

Outcome

Healthcare is provided to the same standard as in the community outside prison, available in response to need, with a full range of preventive services, promoting continuity with health services outside prison.

8.1 Not fully met. Waiting times to see the doctor are good, and the Health Centre is clean and tidy. The addiction service generally is good. However, the referral system to the Health Centre is poor, and no appointments for healthcare are provided. Access to the dentist was very poor due to refurbishment of the dentist's room. The process for administering methadone is unsafe, and there is no system in place to manage chronic disease.

Health Services

Primary Health

8.2 Primary health care is delivered by a team of four Practitioner Nurses, an Addictions Nurse, a Health Care Manager and three part time doctors. An Administrator has recently been employed. The nursing team are employed by the prison, and the medical team and out of hour services are provided through Medacs who subcontract this service to a local practice.

8.3 The nursing service is available Monday to Friday (7.00am to 9.00pm) and at weekends (8.15am to 5.00pm). The medical team deliver a GP clinic for one and a half hours each week day and for one hour on a Saturday. This has increased by 2 hours 30 minutes each week in the last year. Clinics are now less rushed and prisoners are seen more quickly.

8.4 Most primary health care is delivered in the "Health Care" area. This area comprises a dental suite (out of use at the time of inspection as it was being refurbished), a store room (also out of use due to refurbishment), a small counselling/meeting room, a prisoner toilet, a staff toilet, a general administration office, a treatment room (which doubles as a medication administration hatch area), a small but adequate GP clinical room and a waiting area.

8.5 The waiting area is little more than a corridor. There is no signage advertising it as a waiting area, and no access to drinking water. Wooden seating is attached to one wall. Minimal health promotion literature was available and there was no information advertising services or the health care team. There is little privacy in this walk through area for prisoners waiting to see the doctor.

8.6 All health care areas were bright, clean and tidy.

Referral to Health Care Services

8.7 All prisoners receive a health care assessment by a nurse on admission to the prison. These are reviewed by the GP within 24 hours. Thereafter prisoners who wish to see a doctor or dentist have to report "sick" to an officer in the hall before 8.00am. Each hall then telephones their individual "sick" list names to the officer in 'A'1. He collates all names and passes this to the "health care" officer. This officer ensures that all those identified are taken to "health care" where they are seen by a nurse that morning. Prisoners were positive about this process but they were less positive with regards to follow up by a doctor. They spoke of the nurse as the "gate keeper" to the doctor and the fact that they could only access the doctor if the nurse thought it was appropriate.

8.8 The majority of prisoners are seen by the doctor within three to five days of the initial request. SPS Policy states that "prisoner self referral arrangements will be in place". The reporting sick process does not meet either SPS Health Care Standard 2 (Primary Care Services) or 10 (Prescribing for Clinical Management of Drug and Alcohol Dependency). This process is also the only way that prisoners have of accessing the Addictions Nurse, podiatry, counselling services, mental health support and enhanced addictions casework service. The process lacks confidentiality and there is an over reliance on a hall officer to pass on information. The referral process to see health care specialists should be reviewed.

Optician

8.9 An optician does not attend the prison. All appointments are made with service providers in the community. Nine prisoners are currently waiting to be seen and they can wait for up to 12 weeks. The waiting time to access this service in the community is three weeks.

Podiatry

8.10 A podiatrist from the local NHS Trust attends the prison on a regular basis. On average two to six prisoners will be seen at each visit. This service has recently been introduced, but it is not advertised within the prison.

Dental Services

8.11 A Dentist and Dental Nurse attend the prison for two sessions per week. A Dental Hygienist usually attends monthly, but that had not been happening recently. At the time of inspection the dental suite had been out of commission for one month due to refurbishment. The waiting list for routine dental work was 60 prisoners, and the waiting list for toothache was 32 prisoners. This means that almost one half of prisoners in Dumfries are waiting for dental care. Prisoners requiring emergency care are seen at a local surgery. It is recommended that steps are taken to reduce the waiting times to see a dentist.

Mental Health Services

8.12 A Consultant Psychiatrist attends the prison for up to two sessions per week, depending on need. There is evidence of good working links with community Mental Health Services. A recently employed Practitioner Nurse is mental health trained; however she is not employed by the prison as a Mental Health Nurse. At the time of inspection there was a waiting list of 14 people requiring assessment - this equates to a four week waiting list before assessment can take place and the case is discussed at the Multidisciplinary Mental Health Team Meeting ( MDMHT). There is very little one-to-one support available for prisoners with mental health problems. This should be addressed.

Nurse Led Services

8.13 There is no evidence that individual nurses take responsibility for specific lifelong conditions such as diabetes or asthma. Prisoners who suffer from these conditions are triaged by a nurse and then seen in the GP clinic when they become unwell. However, a member of the nursing team was in the process of establishing and piloting a well man service specifically targeting older prisoners.

Addictions Nurse Service Provision

8.14 The Addictions Nurse has established close links with community Blood Borne Virus ( BBV) and Sexual Health Services. The nurse works closely with Phoenix Futures and together they deliver smoking cessation group work sessions. A BBV and sexual health screening service is also available.

8.15 The Addictions Nurse also promotes harm reduction within the prison and a range of harm reduction equipment and literature is available.

Emergency Equipment

8.16 All nursing staff attend annual resuscitation training. Although medical staff have not taken part in this training as part of the Medacs Contract they do undertake it annually as part of their NHS Trust commitment. There is one set of emergency resuscitation equipment situated in the health care treatment room. Should this be required the nurse on duty must run from the area he/she is working in, collect the equipment and then run to where the prisoner requires help: this could be up five floors if the prisoner is located in 'C'5. The equipment is heavy and the nurse must lock and unlock all doors in which he/she passes. An adequate amount of emergency medical equipment should be available throughout the prison.

Training

8.17 Nursing staff have undertaken a range of training in line with the national nurse training strategy. The health care department has supported various general and mental health student community placements. This is an area of good practice.

Management of Medicines

8.18 Medicines are stored as required by current legislation. Prisoners are also encouraged to keep their medication in their possession. For those on supervised medication administration times are as follows:

8.19 The timing of weekend medications, particularly the practice of administering anti-depressants and night time sedation from 16.15hrs onwards should be reviewed.

8.20 When an officer is the second signatory for the administration of Controlled Drugs they undertake this practice with no knowledge of, or training in, standards of practice of administration of medicines. This practice should stop.

Clinical Prescribing

8.21 Although a range of clinical prescribing support is available such as detoxification, stabilisation and maintenance, there is little evidence to suggest that a prisoner's individual needs are taken into account. The majority of prisoners on admission receive a six day detoxification programme. This falls outwith current SPS health care policy which advocates prescribing support for between 12 and 18 days.

8.22 At the time of inspection 27 prisoners were in receipt of a methadone prescription. When prisoners receiving methadone require individual support, if for example they are misusing, the methadone is reduced or stopped.

8.23 Links have been made with Cameron House (a community provider) to ensure continuity of care for prisoners with alcohol problems who require support in the community. This is an area of good practice.

Secondary Care

8.24 The Health Care Administrator organises hospital and other external appointments. Two hospital escorts are planned on any given day. In the last year 234 prisoners were listed for a hospital appointment: 42 were either cancelled, the prisoner refused to attend or RCS were unable to provide an escort. The hall officer, security staff and reception officer are informed on the morning of the appointment. In the majority of cases the prisoner is informed half an hour before his appointment or when the RCS van arrives at the prison. This timing does not allow a prisoner time to change or freshen up. The reason why a significant number of prisoners fail to attend hospital appointments should be examined. The process of informing a prisoner of his hospital appointment should also be reviewed.

Special Diets

8.25 A number of prisoners were in receipt of a special diet (diabetic, nut allergy, religious observance). Special diets are introduced following a health care assessment and receipt of the medical notification form in the kitchen. During the inspection a prisoner with a severe nut allergy had been in the prison for three days yet the kitchen was not aware of his need for a diet. The process for notification of prisoners special dietary requirements should be reviewed to ensure the kitchen are notified in a timely manner.

Addictions

8.26 Dumfries statistics for 2007-08 indicate that 59% of prisoners test positive for illegal substances on admission to the prison.

8.27 An Addictions Co-ordinator is in post. The Addictions Co-ordinator attends the quarterly SPS addictions strategy meetings, represents the prison at local ADAT meetings and acts as a 'broker' between health and addictions teams in the prison and the Tactical Tasking Security Unit. The 'broker' role means that only one person has oversight of a level of information which should be available to all who deliver addictions interventions in the prison.

8.28 A monthly addictions team meeting, co-ordinated by Phoenix Futures, is held in the Links Centre. Individual prisoners are discussed at this meeting. In attendance are a range of providers and agencies, including the addictions nurse. Jobcentre Plus, Phoenix Futures, the Throughcare Addictions Service ( TAS), Apex, an addictions counsellor, Independent Living Support, and Dumfries and Galloway Citizens Advice Bureau. The group not only discusses a large number of prisoners, but also actively tries to engage new service providers. Follow up is also given by the TAS provider on how some prisoners are coping in the community. This level of joint working is an area of good practice.

8.29 The Phoenix Futures team comprises a team manager, senior practitioner, part-time drugs worker and part time administrator. They are based in the Links Centre. Office space and access to SPIN is adequate. They offer a range of services in the Links Centre and in 'D' Hall. Other staff who work closely with this team are a full time addictions nurse and an addictions counsellor from the local ADAT who works in the prison 2.5 days per week. This is a well integrated addictions team who have established close links with colleagues in the prison and in the local community.

8.30 Enhanced addictions services are now available to all prisoners serving more than 31 days, including sex offenders. A gap still remains however in relation to prisoners serving less than 31 days.

8.31 Prisoners are able to access support in relation to drugs, alcohol and smoking. Interventions include: the national harm reduction awareness session; addictions ICM assessment; one-to-one work, paraphernalia care planning; care plan reviews; alcohol counselling and group work; and smoking cessation support. The employment of an addictions counsellor has enabled CBT, relapse prevention, anxiety and coping strategy support to be delivered. This is an area of good practice.

8.32 Prisoners access addictions services through the Core Screen process at the start of their sentence. Should they wish to access services thereafter they speak to a hall officer who will then contact Phoenix Futures. There is no formal confidential referral process and no secondary assurance process to ensure that all referrals are passed on. This should be reviewed. There is also no information on residential area notice boards about how to access this service.

8.33 Due to difficulties associated with keeping different prisoner groups apart a number of group work sessions which had previously been planned are now delivered on a one-to-one basis. This ensures that prisoners needs are met in a safe environment. Similarly, although the establishment is contracted to deliver two smoking cessation sessions four have been delivered in the last year.

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