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	The Pharmaceutical Journal Vol 268 No 7191 p427-428 30 March 2002	This article Reprint Photocopy
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News feature

Ways that pharmacy services in prisons can improve the health of inmates

The provision of pharmacy services in prisons is currently under review in England and Wales. Similar reviews have been carried out in Scotland and Northern Ireland. Clare Bellingham visited the central dispensary that supplies Scottish prisons to find out how the services works and what lessons may be learnt in other parts of the United Kingdom

The findings of a review of the provision of pharmaceutical services in prisons in England and Wales are expected to be published within the next two months. A spokeswoman for the Home Office said that the purpose of the review is to assess the service that is currently provided and to establish whether or not there are ways to improve it.

Following a similar review in Scotland a few years ago, the way in which pharmacy services are provided changed. Investigators working on the report for England and Wales visited prisons in Scotland to see how the system works. Provision of pharmacy services has also recently

changed in Northern Ireland (see Panel below).

How it works in Northern Ireland

In Northern Ireland, pharmaceutical services are provided to prisons under a contract awarded to Boots The Chemists. The service started in June 2000 and is managed by pharmacist Harry Hanron.

The prison service currently has three establishments: two prisons and a young offenders centre. The average prison population is 900 people.

The procurement and dispensing service are provided through two branches of Boots. Prescriptions are written in prisons in the morning and are faxed to one of the Boots pharmacies. Orders for stock or sundry items are also faxed to the pharmacy. The items are then assembled. In the afternoon, the original prescriptions are brought to the pharmacy and the pharmacist checks them against the faxed documents. Once this checking process is completed, the items are delivered to the prison.

As part of the contract, Mr Hanron also provides pharmaceutical care to the prisons. This includes advice to prison and nursing staff, introduction and development of a prison formulary, running the drug and therapeutics committees, inspection of the storage of pharmaceutical items, provision of health promotion to prisoners, clinical audits and development of protocols for procedures.

Implementation of the service has resulted in a number of improvements to the provision of pharmaceutical services in prisons. These include a reduction in the medicine stock held at the prison, implementing systems for monitoring drug usage (particularly those prone to misuse) and developing a drug identification service to address misuse of prescribed medicines.

Lyndon Braddick, pharmacy adviser to the Scottish Prison Service (SPS), explains that under the old system, medicines were brought into prisons from local hospitals and kept as stock for nurses to dispense. It was decided that this was not good practice so the SPS offered a tender for provision of all pharmaceutical services. A contract was awarded to Moss Pharmacy in October 1999 and service provision was fully operational by February 2000. So, two years on, how is it going?

How it works

The central dispensary in Livingston supplies 14 prisons in Scotland

Pamela Shearin, contracts manager, Moss Pharmacy, explains that a central dispensary operates at a warehouse in Livingston which services 14 prisons. Barlinnie prison in Glasgow has an on-site dispensary because of its large size. Two distant prisons, in Inverness (also served by the central dispensary) and Dumfries, are served by local branches of Moss for geographical reasons.

Four pharmacists work at the central dispensary in Livingston and are supported by a team of six dispensers and an administrative assistant. In addition, Moss employs two peripatetic pharmacists who visit the prisons on a weekly, fortnightly or monthly basis, depending on particular prisons' needs. Their job is to conduct medication reviews and carry out health promotion work with on-site staff. Conducting medication reviews is a requirement of the contract. Ms Shearin explains that this is an essential part of the service. In the past, prisoners did not tend to have any contact with a pharmacist so did not have the opportunity to ask questions about medicines.

The pharmacists are also included on the national prisons drug and therapeutics committee. All the pharmacists originally worked in community pharmacy.

The system is based on three types of dispensing: acute prescriptions, regular repeat prescriptions and stock items. Each prison has a daily delivery. Medicines are dispensed in clear, grip-sealed plastic bags with standard dispensary labels. Stock items include analgesics, inhalers, emergency items and some antibiotics so that courses can be started immediately.

The repeat prescription system is set to a timetable so that the dispensary can spread its workload over time. Repeat prescriptions are dispensed weekly, although prescriptions are usually valid for three months. Details of repeat prescriptions are entered on to computer records, and nursing staff at the prison use the records to order medicines that are required each week. The order is then sent to the pharmacy to be dispensed. Some items, such as Controlled Drugs, have to be ordered separately.

Mr Braddick says that the computerised records have allowed data collection on the medicines supplied to prisons. "Information, for example about quantities and costs of medicines, can be used when meeting prescribers and drug and therapeutics committees to examine what is used and whether formularies are being adhered to. This is information that we did not have access to before."

Each prison is supplied with a comprehensive pharmacy manual detailing how the service works and people to contact about different aspects of service provision, and providing sample forms. The central dispensary runs a 24-hour telephone advice line providing pharmaceutical information when it is closed. Community pharmacies also play a part in the service. A number of Moss branches close to the prisons have been assigned as "contingency branches" so that if a medicine is needed urgently outside the main dispensary's working hours it can be delivered quickly from the pharmacy to the prison. Access to the contingency branches is through the advice line. "It is easier for the prisons to be able to telephone one number and the pharmacist manning the line will then contact the local pharmacy," Ms Shearin explains.

Moss is paid a fixed fee to provide the service including the professional and supply functions. The fee is not related to the number of items dispensed.

Health promotion

The establishment of the service has meant that pharmacists are becoming involved in health promotion at prisons.

A successful example is a smoking cessation scheme at Polmont Young Offenders Institute, Falkirk. In the first group which started last summer, 12 prisoners took part. A pharmacist visited the institute weekly and offered advice on the most suitable nicotine replacement therapy for each individual as well as discussing the benefits of stopping smoking. The prison also offered prisoners who stopped smoking incentives, such as extra fruit or exercise time. Carbon monoxide testing was offered. Eight of the 12 participants stopped smoking and the remainder drastically cut down. Another two groups of 12 will start the programme shortly. "It has been incredibly successful and we hope to run it in other establishments in the future," said Ms Shearin.

Mr Braddick explained the contract between Moss and the SPS specifies both a supply and professional service. "Initially, however, the emphasis was on supply because problems such as out-of-date and excess stock and incorrect storage of medicines had to be addressed." Now that the supply service is established, professional aspects can be expanded. This will include increasing pharmacists' time spent on health promotion, counselling patients and interacting with other health care professionals who work within the prisons. "As the service develops, we would like a more formalised approach to pharmaceutical care," says Mr Braddick. "We have started talking to the school of pharmacy at Strathclyde University about developing research programmes. The prison service provides a population that can be followed up over the long term so could be used to measure the impact of pharmaceutical care interventions over a period of time."

The future

Would the introduction of this type of service be beneficial in England? Differences exist that might mean it is not practical. But Moss is keen to get involved across the border: last week, it announced that it had won its first contract to supply pharmaceutical services in England (see PJ, 23 March, p385).

Mr Braddick concludes: "The introduction of the service is a major advance. The prison population is a deprived population with a variety of complex health care needs. Until the service was introduced, they had no access to pharmaceutical advice. It has also been welcomed by other health care professionals in the prison services, particularly nurses, who were previously unhappy about the dispensing function that they had to carry out. Removing this has also had knock-on benefits in that it allows nurses to spend more time on nursing duties."

Prison pharmacy is an important area of the profession that provides a service to patients who often have complex health needs. However, prison pharmacists in England and Wales are facing some difficulties (see below). Hopefully, the current review of service provision will address these difficulties and allow pharmacists to provide a much-needed service.

Pharmaceutical service provision in prisons in England and Wales

There are 135 prisons in England and Wales, varying from high security to open prisons. Steve Crago, principal pharmacist, HM Prison Bristol, explains that in the majority of cases, a dispensary is based at a central prison that also services several satellite prisons. However, this does give rise to a "two-tier system", he says. At the prisons where dispensaries are located, a full clinical service is usually offered, with the pharmacy staff being fully integrated in the health care team at the prison. The satellite prisons tend to receive little more than a supply function although the pharmacy monitors prisoners' prescriptions. At Bristol, the pharmacist visits the satellite prisons once a week to try to address this. In a minority of prisons, pharmaceutical services are contracted to local community pharmacies or hospital pharmacies but this can be more expensive than the satellite system. How medicines are actually dispensed depends on the prison, the medicine and the patient: daily, weekly and monthly dispensing are all used.

The prison pharmacy service is funded by the Home Office. Two years ago, a formal partnership between the NHS and the prison service was introduced. Its aim was that, through the partnership, professional aspects of the prison pharmacy services, such as clinical governance, health improvement and training, could be addressed.

The provision of pharmacy services to prisons is currently under review. A prison health task force and policy unit was set up by the NHS and prison service to examine different models of pharmacy in prisons. Now, 18 months on, results are expected soon. The issues the task force is examining include:

Variation in standards between prisons and establishing a service that is comparable with that offered by the NHS Variation in the level of service provision is a real problem: "Many prisons have no pharmacy service whatsover while others have a full clinical service," says Mr Crago. Some prison pharmacists are introducing new services to improve the health of inmates and redesigning old supply functions. For example, Bristol prison is introducing direct dispensing to patients, which allows patients more contact with pharmacists. The pharmacist and technicians also run asthma, diabetes and smoking cessation clinics. "This helps to move pharmacy staff nearer to the patients," he adds.

Professional isolation Pharmacists working within the prison service can feel professionally isolated but in many respects are ahead of the game: for example, they were involved with formulary development before other branches of the profession.

Underuse of pharmacists "The role of the modern pharmacist is not understood by the prison service and hence all pharmacy staff are underused," says Mr Crago.

Lack of leadership, low morale and recruitment difficulties Pharmacy prison services used to be co-ordinated through a headquarters unit with a head pharmacist but this was disbanded two years ago. Mr Crago says: "Since this happened, the service has become much more fragmented and a number of pharmacists have left the service." He estimates that there are between 40 and 50 pharmacists working in the prison service. Communication between pharmacists is now through informal networks rather than being co-ordinated at a national level. This has also meant that prison pharmacists lack professional line management and the service lacks structure. "One of the things I would like to come out of the task force review is a corporate identity and strategic direction," he adds.

However, despite the problems, Mr Crago says that being a prison pharmacist is a fantastic job that is both rewarding and challenging.