Published: 10/04/2003, Volume II3, No. 5850 Page 24 25 26
All PCTs must take responsibility for prison healthcare by 2006. But the change involves delicate negotiations between two very different cultures. Lynne Greenwood reports
The smokers among the 360 male inmates at Whatton Prison, a category C jail 10 miles east of Nottingham, have recently discussed whether they want to stop. An official smoking cessation programme is being offered for the first time, with patches and tablets - chewing gum poses a security risk - to ease the craving.
It is one of the health promotion programmes organised by the prison's healthcare centre, which has recently undergone a radical overhaul under the supervision of Rushcliffe primary care trust, in whose area the prison lies.
Healthcare manager Simon Harris, a former paramedic, says: 'The men in here now receive exactly the same healthcare treatment as patients in the community.'
That was not always the case and everyone involved believes the new service is a vast improvement on the previous regime. Earlier this year, a patient satisfaction survey among prisoners - all sex offenders - showed more than 90 per cent were happy with the healthcare they now receive.
Rushcliffe, along with a handful of other trusts, is well ahead of the government deadline of April 2006, by which date all prison healthcare must be devolved to PCTs. West Lincolnshire PCT provides healthcare at Lincoln Prison and Moreton Hall women's prison. And Nottingham PCT provides healthcare for Nottingham Prison.
In 1999, The Future Organisation of Prison Health Care recommended a transfer of responsibility for prison health services to the NHS.
The government is keen to stress that the devolution to PCTs by April 2006 must not be seen as an NHS takeover but a partnership in which the balance of responsibility has been moved.
Those involved in the process at Rushcliffe and Whatton admit it was not easy - 'two huge contrasting cultures coming together' - but the evident progress has made the effort worthwhile.
Whatton has a relatively stable population of prisoners. At 45, their above-average age - compared to many prisons with an ever-changing and younger population - made the prison a good choice for the introduction of healthcare changes.
The process began early in 2002 after Colin Murphy, director of residence at Whatton, assumed responsibility for the prison's healthcare centre for the first time and was dissatisfied with the current health service.He contacted the East Midlands prison taskforce - established to work between the NHS and the prison communities - whose then regional manager, Kate Caston, put him in touch with Rushcliffe PCT. From then on, Ms Caston became instrumental in enabling them to work together.
Trudi Cameron, then head of planning and commissioning at Rushcliffe, visited the prison and instigated an infection control audit, a review of pharmacy practices, a health analysis and health improvement plans. The problems, she discovered, were compounded by a staffing crisis, which were alleviated by seconding an experienced nurse from the PCT.
'She was a mature nurse who was very concerned about many issues within the prison, which she felt did not reach acceptable NHS standards of care, ' says Ms Cameron, recently appointed service improvement lead for the mid-Trent cancer network.
Ms Cameron established a healthcare action group, whose members included the PCT chief executive, the prison's director of residence, the regional prison taskforce manager, chair of the board of visitors, the prison doctor, healthcare manager and pharmacist. The group's task was to put together a service-level agreement between the PCT and Whatton, and later to monitor the health improvement plan.
The process lasted for seven months and 'it took a huge amount of time in negotiations and in setting up a three-year agreement, ' says Ms Cameron.
'Anyone going through this process must allocate dedicated time. They must also be prepared for the different cultures and be open and honest in talking through any differences.'
Ms Caston, now head of commissioning for secure services at Nottingham City PCT, agrees: 'The most important aspect is making sure the PCT and the prison understand each other's responsibilities. They must spend time forging an understanding around priorities - for the prison the number one priority will always be security. But this needs to be seen as a challenge, not an obstacle.
The ultimate partnership has to be very strong and needs someone from both camps who is very keen to drive it through.'
In this case, it was Ms Cameron for the trust and Mr Murphy at Whatton, she says.Ms Caston acted as an objective arbiter, trusted by both sides and privy to their concerns - a role seen as a vital component to the success of any agreement. She oversaw discussions at the highest level, particularly in the areas of risk management - which areas would fall to the PCT and which to the prison.
In July 2002, the PCT appointed its first healthcare manager for Whatton - Simon Harris, who had been a paramedic for 10 years with East Midlands Ambulance Service trust.
The PCT agreed to pay one-fifth of Mr Harris's salary, with the prison covering the remainder. The trust also agreed to provide staffing cover for shortterm sickness and plans to build a bank of nurses with experience of working in the prison.
Prison nurses are offered the chance to study triage in an NHS community setting, either in a local walk-in centre or a GP practice. Rushcliffe will also provide funding for and access to its training programmes for prison healthcare staff.
So how does the new healthcare centre operate inside Whatton Prison? The centre, which includes a treatment room, dental suite, clinics for physiotherapists and occupational therapists and an administration office, is open from 8am-5pm, Monday to Friday, and 8am-12.30pm at weekends.
The prison no longer employs an in-house medical officer. Instead, a GP from a practice within Rushcliffe PCT visits three times a week for two hours, seeing patients who have already been triaged to ensure that a consultation is appropriate.
A dentist visits once a week for a whole day, a physiotherapist or occupational therapist once a week, an optician twice a month and chiropodist once a month.
Mr Harris has also introduced a healthcare assistant into his team - previous prison healthcare staff had all been medically qualified - who has been trained to carry out basic observations, ECGs and phlebotomy as well as administrative duties.
'In the past, a lot of time was wasted by qualified staff on jobs which could have been done by a more appropriately trained member of staff, ' says Mr Harris.
Other changes include the introduction of selfmedication - the majority of patients now receive prescribed drugs for 28 days, instead of the previous daily visit required to receive one tablet.
'There will always be exceptions - we have a couple of patients for whom this is not appropriate. One of them is given seven days' medication in a 'dosette' box and the other 14 days, ' says Mr Harris. Since its introduction, there has not been a single case of a patient taking an overdose and there has not been a suicide at the prison for two years.
Chronic disease management for patients with diabetes, coronary heart disease and chronic obstructive pulmonary disease has also been introduced, another step towards encouraging patients to be more knowledgeable about their conditions.
A vaccination programme for hepatitis B and meningitis C, and a flu immunisation programme were both successful. Out-ofhours cover, previously supplied by a prison medical officer on call, is now provided by the Nottingham emergency medical service, which has around 320 GP members and is used by many practices in the area.
One of the early concerns among the prison service following the government's decision to transfer responsibility to PCTs was that their healthcare budget would be transferred to the NHS - but not necessarily spent entirely on prison health.
A large proportion ofWhatton's healthcare budget, which Mr Murphy will not reveal, has been handed to the PCT. But the prison still pays for dentistry and ophthamlmology. The issue of running costs is still subject to 'delicate negotiations', says Trudi Cameron.
Mr Murphy is pleased with the improvements.
'When I walk into the centre now, there is a completely different atmosphere - well ordered and safe, with a dedicated team who have created a good relationship between staff and prisoners. In the past 12 months, I have not received one complaint about healthcare. Before the changes there would be a handful of complaints every year.'He adds: 'As the prison service moves further towards the resettlement of prisoners, helping them to take responsibility for their lives when they are released, their own health and well-being becomes an important factor.'
Ms Cameron agrees. 'This has been the most rewarding piece of work I have done this year, to enable a group of vulnerable people to receive a better standard of healthcare.They have committed offences, but that does not take away their rights to the health service which is offered to anyone else in the community.The enthusiasm and the will to make it work has been incredible.'
A taste of porridge: health needs of prisoners in England and Wales
The prison population in England and Wales averages 72,000 on any one day.
Ninety per cent of prisoners have a diagnosable mental health problem, including personality disorder, substance misuse, or both.
Eighty per cent of prisoners smoke.
Twenty-four per cent of prisoners have injected drugs - of these 20 per cent are infected with hepatitis B and 30 per cent with hepatitis C.
Ninety-four prisoners took their own lives in 2002, representing a rate of 132 deaths per 100,000 prisoners (this is official classification - it is not known whether all were intentional suicides).
Twenty per cent of women in prison ask to see a doctor or nurse every day.
Source: Department of Health