For the past few years, three of the Royal Pharmaceutical Society's inspectors have accompanied the medical inspectors of prisons on their inspection visits. This report, prepared by the Society's lead inspector, Ms Jill Williams, summarises their findings, concluding that the service lacks direction and is in need of review
The professional standards inspectors of the Royal Pharmaceutical Society of Great Britain have taken part in inspections of prisons conducted by HM Chief Inspector of Prisons since December, 1997. Up to April, 1999, pharmaceutical services have been inspected in 30 prisons.
The service should comply with the Medicines Act 1968, the Misuse of Drugs Act 1971 and their attendant regulations and statutes. Pharmacists providing the service must have full professional control and independence with regard to that service and it must be in compliance with the Society's Code of Ethics and any professional standards laid down by the Society. Health Care Standard 9 and any reviews of this standard should have been met.
Pharmaceutical services provided to the prisons visited fell into four groups:
(a) an in-house service under the supervision of a pharmacist based in the prison
(b) a satellite service provided to a prison by a nearby prison with a type (a) service
(c) a service provided by outside contractors such as hospital or community pharmacists or independent companies.
(d) a service with no pharmaceutical input
There appeared to be no standard policy in the prison service with regard to service providers or the form of contract required. The two prisons where there was no input from a pharmacist reported that they were in the process of providing pharmaceutical services.
Premises and equipment In general, the standards found in dispensaries were good, with a few exceptions that have been dealt with in individual reports. Examples of the exceptions were poor organisation, cluttered work areas and poor decoration. In a minority of cases the standard of cleanliness was not satisfactory.
More problems were found with treatment rooms that did not comply with current National Health Service and Prison Service building design standards and were often inadequate for the purpose they served. In one prison, offices without adequate work surfaces or running water were being used as treatment areas. Some rooms had no security hatch and treatments were handed to patients at the door; others had treatment hatches that were so small that adequate interaction with patients was impossible.
Inspectors frequently commented on a lack of refrigerators and failure properly to audit refrigerator temperatures. Thermolabile products must be stored to the manufacturer's requirements and failure to do so can result in a marked deterioration of the product so that its efficacy could be affected. In hospital and community pharmacies it is a professional requirement to audit refrigerator temperatures. It should also be a requirement in prisons.
Computerised patient medication records It is good practice to have complete patient medication records held on computer at the prison. This was not always the case. Records were complete in those prisons that had an in-house service under the supervision of a pharmacist. If the pharmacist provided services to satellite prisons then records were usually maintained on the pharmacist's computer. Health care staff in the satellite prison did not then have access to these records. If records are incomplete important drug interactions may be missed or possible prescribing errors not noticed.
Disposal of waste medicines Proper provision for the disposal of waste medicines and chemicals had been made.
Storage of medicines Good practice was followed in most establishments, with medicines stored in lockable cupboards and external and internal preparations segregated. Medicines were properly labelled and kept in an orderly manner. Stock rotation and date checking systems were being operated.
In a minority of establishments these good practice policies were either not in place or not followed. Medicines without batch numbers or expiry dates are not safe to use. We were told of an occasion where a patient had been issued with an external preparation instead of his normal laxative because of poor storage.
Supply of medicines Medicines are supplied against the written directions of a doctor. In general, prisons were using the correct stationery (HRO13/96) but some four or five were still using the small card system, which is inadequate because there is insufficient room on the cards for safe annotation.
There were some complaints that staff were not annotating the forms correctly, especially with regard to records of medicines supplied to those reporting "special sick". If these records are not kept correctly, then pharmacy staff do not have a complete record of medication. This can prevent the identification of possible cases of substance misuse and interactions with prescribed medication. Medication records should enable pharmacy staff to identify these problems and resolve them.
The dispensing of prescriptions was generally done under the supervision of a pharmacist. This is, of course, good practice. But in some establishments medicines were procured directly from a wholesaler and were dispensed by unqualified staff. This is in contravention of HCS 9. Such a procedure would be legal only if a doctor supervised the supply of medication.
Some secondary dispensing was occurring, generally in prisons that did not have a pharmacist on site. If prisoners are supplied medicines which have not been dispensed under the supervision of a pharmacist and are not properly labelled, errors can occur. In accordance with the Medicines Act 1968, for a medicine to be properly dispensed it must be appropriately packaged by, or under the supervision of, a pharmacist. Failure to do so is an offence. The label must include (among others) the patient's name, name of medicine, strength, dose, warning instructions, date of dispensing and address from where dispensed. All this must be on the container when the medicine is supplied to the patient. This must be contrasted with secondary dispensing - any procedure which takes medicine out of the patient's medicine container but does not immediately administer it to the patient or which deviates from a protocol laid down by the appropriate pharmacist with regard to a prepack. Examples are the splitting down of a patient's dispensed medicine into cups or plastic bags to allow a smaller supply to be made or the issue from stock of a supply that would permit subsequent self-administration by the patient.
Safer systems were in place at establishments where the pharmacist providing the service had professional control, even if based at another prison.
The supply of medication in Venalink packs and patient named packs significantly reduced the problems of secondary dispensing.
Establishments that had agreed proper written procedures for "in-possession" medication and "special sick" medication had fewer problems and there was less likelihood that inappropriate or unlawful supplies were made to patients by health care workers.
Control was better in areas where the administration of medication took place, eg, treatment rooms, ward trolleys and in-patients departments when a system of agreed stock levels was in place.
Use of pharmacy staff Pharmacy staff's skills in the supply and administration of medicines were not widely used. A pharmacy service should not be limited to the supply of medication; pharmacists should also meet and advise patients. Such contact has been shown to improve compliance. Some pharmacists working in prisons were providing this more complete service but this could only occur when the establishment had an in-house pharmacist.
Pharmacists providing a service to satellite prisons should visit them at least monthly to check prescriptions and stock levels. This good practice, which provides more professional control, occurred in only a few prisons. In many more, inadequate resources or the reluctance of some governors to allow the pharmacist to visit satellite prisons prevented a proper professional service.
Out-of-hours provision Provision of services out of hours varied greatly. Best practice was to have an out-of-hours cupboard holding a restricted list of medicines coupled with strict key security and proper records kept of the removal of any drugs. These records should be regularly audited by the pharmacy staff. The worst practice found was that any member of the health care staff had access to medicines. Some prisons reported discrepancies in out-of-hours stock levels. Tighter security would have enabled audit trails to be completed.
Controlled Drugs Generally, stocks of Controlled Drugs were kept to a minimum and proper procedures were in place for obtaining drugs and complete records were kept.
Development of pharmacy services There appeared to be a problem in some establishments in integrating the pharmacy service into the wider health care service and the full potential of the pharmacy service was not being utilised. Pharmacists reported that some governors did not understand the complexity of a proper pharmacy service and did not see beyond a "supply of medicines".
Prisons with in-house pharmacists had a clear advantage and examples of good practice were in evidence. These included pharmacy clinics, where the pharmacist screened patients to assess whether they needed to see a doctor, closely mirroring the situation in the community, and the provision of comprehensive formularies for health care centres. Smoking cessation clinics and well man clinics are other areas where pharmacy skills could be utilised.
The development of services to satellite prisons was limited, since the pharmacists only spent short periods of time at the satellite. Those prisons where the visiting pharmacist made input into the development of policies and formularies and which had drug and therapeutic committees tended to have smooth running departments.
The structure of the prison pharmacy service needs review. There is now no pharmacist at prison service headquarters. The consequences of this were clear during inspections. The pharmacy service appeared to lack direction, with initiatives only taking place at local level. Prison pharmacists have maintained regular meetings despite the absence of a head pharmacist and their expertise and enthusiasm should be used in the development and implementation of a national policy for the future.