13 May 2019
Royal Pharmaceutical Society in Wales submission to:
Health, Social Care and Sport Committee
Inquiry into the provision of health and social care in the adult prison estate
The Royal Pharmaceutical Society (RPS) is the professional body representing individual members of the pharmacy profession from across all settings and sectors. As such, we welcome the opportunity to respond to the National Assembly for Wales’ Health, Social Care and Sport Committee’s call for evidence on the provision of health and social care in the adult prison estate.
The RPS in Wales has been supportive in principle of the changes which transferred the responsibility for the development of prison healthcare from the Home Office to NHS Wales in 2006. We recognise that this responsibility is discharged in partnership with Her Majesty’s Prison and Probation and fully support the principal aim of this partnership to ‘provide access to the same quality and range of healthcare services as the general public receives from the NHS in Wales’[1].
In this submission, we focus largely on the role of the pharmacy profession in prison healthcare and how pharmacists and their staff teams can and should support people in prison with their health conditions and health needs. We have consulted with our members working with the prison population to understand the pressures, barriers and opportunities for pharmacy services delivered across the adult prison estate.
We are pleased to respond to the following key areas which are being consdered by this inquiry:
1. The effectiveness of current arrangements for the planning of health services for prisoners held in Wales and the governance of prison health and care services, including whether there is sufficient oversight.
The delivery of healthcare services in prison environments is complex and requires significant attention and comprehensive planning. From a pharmacy perspective, it should be acknowledged that where medicines are used and required in a secure environment, there will always be inherent risks to patient safety and to the safety of healthcare staff. It is critical therefore that the right services are effectively planned for and invested in.
The transfer of responsibility for healthcare services from the Home Office to NHS Wales in 2006 offered the opportunity for the development of more patient focused, primary care based pharmacy services to the prison population in Wales based on identified need. We believe however that this opportunity has yet to be fully realised in Wales.
We believe that greater attention is needed in Wales to prison healthcare to ensure clear oversight and a strategic direction for the development of medicines management and prison pharmacy services in the adult prison estate. The scope for improving the planning and governance of prison healthcare in Wales is huge and a number of complex issues need to be addressed. For example, the abuse of medicines, controlled drugs and psychoactive substances, in the prison estate plus drug seeking behaviours are significant concerns not only to the prison population but to pharmacists and other members of the healthcare team. The trading and diversion of prescribed medicines and the risks to individuals from this practice is another risk that needs attention. Plus, the safety of staff in secure environments should be paramount at all times and standard operating procedures are needed to protect healthcare staff and to ensure the delivery of high quality care.
We believe that much more could be done at a national strategic level to address the complex issues inherent in delivering safe and effective healthcare services in the adult prison estate. We believe a national strategy including standards and governance would help to improve prison healthcare in Wales, including standards specifically for prison pharmacy. We also understand that currently only one Welsh Government official has responsibility for prison healthcare as part of a much wider portfolio. We would argue that dedicated leadership is now required at a national level for prison healthcare to ensure a greater focus on this important area of health care delivery.
The current situation in Wales regarding planning and governance of healthcare services for the prison population is in real contrast to developments in England. NHS England has invested in a coherent national strategic approach to developing prison healthcare services[2]. This includes a comprehensive strategy for prison healthcare, robust systems providing effective strategic oversight, governance and planning to secure ongoing effectiveness, quality and safety in the delivery of healthcare services, including pharmaceutical care. . It also includes establishing a single national service specification for prison health care and a medicines standards supplement for all secure environments, including HM prisons.
The Royal Pharmaceutical Society has published professional standards for optimising medicines in secure environments[3] to support the commissioning and development of safe, quality services that put patients and their needs first. While these standards are aimed at services provided in England, they can equally apply to Wales. The standards encourage a multidisciplinary approach between pharmacy, healthcare and custodial workforce to ensure medicines safety and optimisation becomes ‘everyone’s business’. The standards are referenced here to highlight areas of governance, planning and service delivery that we believe require adoption in Wales.
We recommend steps should be taken in Wales to establish effective and robust systems of governance and strategic oversight such as those provided in England for prison healthcare.
We recommend a consistent approach across the prison estate to the employment of a strategic NHS Wales team of full-time healthcare professionals, with appropriate administrative support to provide national oversight and leadership to prison healthcare in Wales. The team must include a chief prison pharmacist or equivalent director of medicines optimisation in prisons.
We recommend consideration of the RPS Professional Standards for optimising medicines for people in secure envrinoments in the devlopment of national strategic approaches to pharmautical care in prison settings in Wales.
2. The demand for health and social care services in Welsh prisons, and whether healthcare services are meeting the needs of prisoners and tackling the health inequalities of people detained in Welsh prisons.
We are aware that the prison population face the same health and social care challenges found in wider society including an ageing population, the increase in non-communicable and long-term conditions, and multi-morbidity. We recognise however that the prison environment and the prison population pose significant challenges to the delivery of pharmacy services in prison settings. Notably this includes inherent issues of personal safety, drug seeking behaviours, abuse of prescription medicines, and a concentration of complex polypharmacy required due to the high prevalence of dual diagnosis of mental health conditions and substance misuse, coupled with long term conditions.
Many of the conditions that have to be treated and supported by pharmacists in the community and hospital settings, are often exaggerated by the prison environment and are disproportionate to the general population. Alcohol and substance misuse plus mental health conditions, for example, are areas which pose significant challenges for prison healthcare and for the pharmacy team.
The most recent health needs assessment of prison health care by Public Health Wales highlighted the scale of the challenges faced by health care professionals in prisons[4]. For example, it identified that approximately, 1,200 people in prison in Wales will suffer from a neurotic disorder, such as anxiety, depression and post-traumatic stress disorder, requiring pharmacological treatment, self-help and psychological support. The same report identified that approximately 1,800 individuals in Welsh prisons had experienced problems with excessive drinking in the previous year, and approximately the same number (not mutually exclusive) will have been using one of the six main drug groups (cannabis, heroin, non-prescribed methadone, amphetamines, crack, cocaine) in the year prior to entering prison. The numbers of people in prison with substance misuse disorders also adds to the concentration of conditions that require clinical management and support.
The Public Health report pointed out at the time that while NICE guidelines were available to support treatment decisions, they may not be totally applicable to the prison environment. Since that report, NICE have issued a Quality Standard for the physical health of people in prisons[5] which includes two specific quality statements relating to medicines reconciliation[6] and medicines on transfer or discharge[7]. We advocate that these standards should be adopted consistently across the prison estate in Wales to provide a robust, nationally adopted framework for health care professionals in making clinical decisions and clinical judgements.
Overall it would appear that the burden of disease among the prison population is greater than that of the general population in society. It is currently not possible however to confidently and accurately assess demand among the prison population in Wales due to a lack of consistent measurement of demand.The most recent health needs assessment we could find was over six years ago.
We believe that robust health needs assessments of the prison population are criticalacross the prison estate to assess demand and to contribute to health board planning processes. We believe a national strategic approach should be taken, with Public Health Wales being resourced to undertake robust health needs assessments for each prison in Wales on a regular, minimum three-yearly basis.
We recommend that arrangements should be made to ensure that regular national health needs assessments across the prison estate are led by Public Health Wales and fed into local health board planning decisions for prison health and social care.
We recommend that guidance and standards including NICE Quality Standards and the RPS professional standards for medicines optimisation in secure environments are adopted to ensure consistency and equity in the delivery of pharmacy services to the prison population across all prison sites in Wales.
3. What the current pressures on health and social care provision are in Welsh prisons, including workforce issues and services, such as mental health, substance misuse, learning disabilities, primary care out of hours, and issues relating to secondary, hospital-based care for inmates.
The delivery of healthcare services in Welsh prisons, suffers from significant workforce challenges. To resolve workforce pressures in Welsh prisons, it is imperative that prison healthcare follows the same model of multidisciplinary care and the principles of prudent healthcare adopted across the NHS in Wales as spearheaded by A Healthier Wales, the Welsh Government’s 10 year strategic plan for health and social care in Wales. We believe the nursing-led model that has been advocated in prison healthcare over recent decades,needs to be re-addressed and refocused on the multidisciplinary model of care to ensure the health and social care needs of the prison population in Wales can be met now and in the future.
We believe a renewed model of clinical leadership is needed across the prison estate in Wales, ensuring a clear focus on clinical care and sharing the clinical workload appropriately across the full skill mix of the multi-disciplinary team. Due to the high volume of medicines used in prison settings, pharmacists and pharmacy technicians must be fully integrated into any multidisciplinary model of care for prison healthcare, ensuring their skills are harnessed in clinical decision making and the delivery of high quality care.
A bio-psychosocial model of care, delivered by a multidisciplinary team is needed to adequately address the most prevalent and challenging issues facing pharmacists and the wider health care team in prison settings; Mental health, learning disabilities and substance misuse. Pharmacists involvement is critical in such a team approach to help optimise medication regimens and to manage the withdrawal of drugs and reductions in prescribed medicines where clinically indicated (de-prescribing). The role of pharmacists inprescribing opioid substitution therapy in community substance misuse services is well recognised and should be replicatedacross the prison setting.
The delivery of primary care and out of hours care in prison settings is also an area ripe for development. We are already seeing a significant expansion in the role of community pharmacists across Wales in managing common ailments and delivering enhanced and advanced servicesin the community and we believe that similar opportunities must be available to the prison population. This would be in addition to the preventative care and health promotion roles that pharmacy teams could also providein prison settings.
Secondary hospital-based care is a challenge for prisons especially when medicines are initiated without understanding of the prevalence of substance use disorders within the prison population and therefore the risk to patients. Pharmacists and their teams can support this process, especially with the integrated care model that exists within local health boards. However for this to happen there needs to be adequate pharmacy staffing within prisons similar to staffing levels at HMP Berwyn.
We are aware that pharmacy teams also have a high turnover in staff due to lack of training opportunities and career progression opportunities. Turnover is also acerbated by the element of personal risk of working in a secure environment. We believe a strategic approach is needed to the development of the pharmacy workforce and the wider healthcare team involved in the delivery of prison health care services.
We recommend that as part of a funding uplift for prison healthcare in Wales, a complete re-design of health service provision within Welsh prisons takes place. The newdesign must be based on a fully resourcedmulti-disciplinary team, including large numbersof pharmacy staff, which will give resilience to and improvedquality of care within the different prison healthcare services delivered by a multi-disciplinary team.
We recommend the workforce requirements of the health care team, including pharmacy staff, are reviewed across the prison estate to ensure health care needs can be appropriately met and an equivalence with HMP Berwyn.
4. How well prisons in Wales are meeting the complex health and social needs of a growing population of older people in prison, and what potential improvements could be made to current services.
From a pharmacy perspective the increase in the ageing prison population with demographic changes parallel to the rest of the population are increasing pressures on the treatment of long term conditions. The growing need for managing polypharmacy (multiple medicines) and the demands to keep people stable and healthy as long as possible and out of the hospital system wherever possible are placing increasing pressures on the pharmacy team and the wider prison healthcare team.
As previously alluded to, the prison population is an ageing one and with the near-static funding of prison healthcare in Wales from UK Government over previous years, the needs of the older people in Welsh prisons are not being met. The same challenges exist in recruiting GPs to work in prisons as in the community. Here pharmacists would not only be able to support the care of older people whom commonly have long-term conditions but with their extra expertise in the management of medicines, they could have a huge impact of the problem of polypharmacy in the population.
Further to this with the increased number of deaths in custody due to natural causes, there is a natural requirement for end of life care and the safe and effective timely provision of medicines. Many of these medicines are controlled drugs requiring careful management. Pharmacy staff[8]are integral to the use of controlled drugs to ensure people can die with dignity in prison.
We recommend that similar to the model of employing pharmacists to support health care delivery within community GP surgeries, the same should be implemented within prisons, especially to improve the care of older people.
5. If there are sufficient resources available to fund and deliver care in the Welsh prison estate, specifically whether the baseline budget for prisoner healthcare across Local Health Board needs to be reviewed.
We understand that for prisons in South Wales, the baseline budget for prisoner healthcare requires a vast uplift to allow the adequate delivery of care. This is evident from prisons of comparable size and nature in England where funding has been driven by robust health needs analyses and therefore increased at regular intervals given the identified increasing needs in healthcare of those in the prison population.
We recommend a complete uplift in national review of the budget for prison healthcare funding within health care in Walesfor both individual establishments, informed by robust health needs assessments and to allow the creation of a NHS Wales strategic prison healthcare team.evaluation of service development needs.
6. What the current barriers are to improving the prison healthcare system and the health outcomes of the prison population in Wales.
We have alluded to many of the key barriers from no national strategy or governance of prison healthcare by Welsh Government through to an under resourced prison healthcare service that requires a multi-disciplinary workforce to care for the adult prison population in Wales.
One remaining key barrier that has not been explored is that of the multiple interfaces faced by people in prison. Within Wales, the clinical record of people in prison does not link with their GP record or hospital records. From a pharmacy perspective, this inhibits good practice for managing medicines as people transfer from the community into prison settings and vice versa. The lack of connectivity between prison health care and the hospital sector also poses significant challenges in optimising medicines when acute hospital care is needed.
We believe that partnership working and communication between custodial and health care/pharmacy teams is essential to provide seamless and safe transitions of care, particularly when controlled drugs and essential medicines are required. The RPS standards for optimising medicines in secure environments aim to ensure people have access to a supply of medicines once they leave the prison setting and that they are given written information about their medicines that is also used to info.rm their ongoing medicines needs (Standards 12 and 13)[9].
We recommend that prison health care benefits from access to the same IT architecture available in the community and integration of the SystmOne® clincial record used for people in prison with the Welsh Clinical Portal along with wider GP and hospital systems.
We trust this response is helpful to the inquiry into the provision of health and social care in the adult prison estate. We would welcome the opportunity to expand on any of our evidence and associated recommendations.
Finally we have been most pleased to see the committee has prevailed themselves of the opportunity to see prisons in Wales, as in the words of Nelson Mandela: “No one truly knows a nation until one has been inside its jails. A nation should not be judged by how it treats its highest citizens but its lowest ones.” We hope this will inspire the committee’s good work to ensure the resourced provision of care to those incarcerated in Wales.
Yours sincerely
Suzanne Scott-Thomas FRPharmS
Chair, RPS Welsh Pharmacy Board