|
Stella Simpson, BPharm, MRPharmS, is principal pharmacist
at HMP Holloway and Avni Shah, BPharm, MRPharmS, is
prescribing adviser at Islington PCT.
Correspondence to:
Stella Simpson
Pharmacy Department, HMP Holloway,
1 Parkhurst Rd, London, N7 ONU
e-mail: stella.simpson@hmps.gsi.gov.uk
|
Pharmacists and technicians at HMP Holloway specialise in different
clinical areas and contribute to projects as part of a multidiciplinary
health care team |
The setting is the largest female prison in Europe, accommodating 530
women and young offenders. Twelve thousand women pass through HMP Holloway
per annum, 65 per cent of whom are on remand and unsentenced. The average
stay of prisoners is 28 days. The average age of prisoners is 20–29
years but 13 per cent are under 19 years of age. Only 8 per cent of women
are over 50 years.
In publishing “The future organisation of prison health care 1999”,
the Government emphasised a commitment to providing a health service
to prisoners equivalent to that provided in the wider community. As a
result the Home Secretary and Secretary of State for Health agreed that,
as of April 2003, funding for prison health should transfer from the
Home Office to the Department of Health. Following on from this, it is
intended that responsibility for commissioning health care in prisons
transfers to all primary care trusts, using a phased approach, by 1 April
2006.
The Islington PCT, HMP Holloway and HMP Pentonville partnership was selected
for piloting the transfer of responsibilities in the first wave from
1 April 2004. The response of Islington PCT and the two prisons has been
to work closely together on strengthening relationships and making incremental
improvements in health care over time. A
Prison Healthcare Commissioning and Modernisation Partnership Board has
been established to oversee implementation of the “Prison health
delivery plans”. Pharmacy services are an important part of these
plans.
The health care needs of this prison population are generally more complex
than those of the general population. Frequently women have had little,
if any, access to health care services before admission due to their
lifestyles and around 70–80 per cent of the HMP Holloway population
are struggling with mental health or drug-related problems. The women
can often be abusive to staff or exhibit challenging behaviour, requiring
well-developed interpersonal skills to manage. Often this behaviour is
a reaction to fear or anxiety resulting from their imprisonment and the
loss of autonomy.
Providing health care to women in the prison environment poses particular
challenges as the primary purpose of the organisation is security and
rehabilitation, rather than health care. There are often conflicting
agendas between the establishment and those of health care, which require
a certain flexibility and creativity to resolve.
Pharmacy practice within the prison environment varies considerably from
establishment to establishment. “A pharmacy service for prisoners”1 produced in 2003 (by the Department of Health and Prison Service) highlights
certain
priorities for the development of prison pharmacy services.
Challenges
Working as a pharmacist in such an environment provides many challenges
and experiences unique to a prison. The main outcomes to be achieved
from implemented developmental strategies are to provide a service
equivalent to that which exists in the community, to raise the profile
of the department within the establishment and to ensure that staff
resources are used appropriately. Professional isolation of prison
health care staff has been a problem in the past and to move forward
it is necessary to provide a nurturing environment for the staff, to
identify training needs and underpin learning with continuing professional
development.
The pharmacy service is designed predominantly to provide primary care
services to prisoners. However we also have secondary and tertiary care
medical services (eg, the Community Mental Health Team [CMHT], the North
London Forensic Service [NLFS] and the Women’s Health Clinic [WHC] — provided
by the Royal Free Hospital). The dispensary systems used within the department
are, however, much more akin to those of a hospital pharmacy service
rather than a community pharmacy.
Historically the prison pharmacy department was an enclave of the prison
where prescriptions went in and medicines came out, as if by magic. It
was used almost exclusively as a supply service and the clinical skills
of the pharmacists and technicians were not used. If pharmacists attempted
to intervene in prescribing practice they were met with suspicion and,
in some cases, hostility.
This is no longer the case. The pharmacists and technicians at HMP Holloway
are completely integrated into the multidisciplinary team. Each clinical
area has a named technician who works with the medical staff to optimise
medicines supply.
We are currently developing the “in-possession medicines” policy.
Historically there has been unease among prison service staff over prisoners
being in possession of their
medicines — a concern that generally remains today. This concern
stems from the large amount of trading of medicines that occurs between
prisoners and the relatively high incidence of self-harm, especially
among female prisoners. However, the majority of prisons allow some degree
of in-possession medicines and the incidence of suicide associated with
medicines, is low.
The “Pharmacy service for prisoners” document recommends
that medicines in use, together with associated monitoring and administration
devices, should be held in the possession of prisoners. At HMP Holloway
we have developed risk assessment criteria that focus on the ability
of a patient to manage responsibly the administration of her medicines
and related devices. We understand the high risk of medicines abuse within
the prison setting — and this currently occurs to a high level,
even with supervised administration. We counter this risk by the use
of a robust risk assessment tool and having prescribing policies that
provide limitations for the supply of psychoactive and other abusable
or tradable medicines.
The “in-possession medicines” project is to be led by the
technicians, who will deliver medicines direct to patients and counsel
them. They will be supported by pharmacists, who will run clinics in
a range of therapeutic areas, carry out medication reviews and enhance
patients’ understanding of their medicines.
The aims of the project are to:
· Improve patients’ knowledge and understanding of their
medicines
· Improve compliance and hence clinical outcome
· Facilitate development of better self-care by patients
· Reduce nursing time spent administrating medicines
· Reduce the cost associated with wasted medicines
· Improve medicines management
· Give patients access to pharmacy services
Electronic recording systems
In the past, prison record keeping systems posed a substantial risk
to the management of patients and the professional accountability of
the
staff, with nurses hand delivering prescription charts to the pharmacy
and the pharmacy rushing to complete these all in the later part of
the day.
Last year Islington PCT funded the installation of the IT software “Egerton
medical information system” (EMIS), a primary care GP medical record
system. This has revolutionised the service at Holloway with the introduction
of electronic patient medical recording, electronic delivery of prescriptions
to the pharmacy and improved access by all clinical staff to medical
records.
Consequently, the pharmacist can now screen the charts on the computer
system, record interventions or clarification requests directly on to
the patient’s record, and can look at aspects of the consultation
to determine the indication of the prescribed drug. This has reduced
any unnecessary contact with the doctors and speeds up the dispensing
process.
The computer software also enables us to undertake clinical audits and
monitor our adherence to national service framework (NSF) and National
Institute for Health and Clinical Excellence (NICE) guideline implementations,
as well as to locally agreed guidelines.
The clinical governance team was set up in 2002 and includes representatives
from both the clinical and prison service staff. The principal pharmacist
is currently the clinical governance lead. This role has allowed her
the opportunity to gain additional competencies and has encouraged a
multidisciplinary approach to health care service development. The core
aim of the clinical governance group is to make sure systems are in place
to monitor and continually to ascertain improvement, and to provide a
high quality health care service to the women at HMP Holloway.
There is a well-developed drug and therapeutics committee at HMP Holloway,
like those in hospitals. This is a multidisciplinary team, with representatives
from the PCT, and is chaired by the principal pharmacist. The role of
the DTC is to ensure that evidence-based and cost-effective therapeutic
interventions are embedded within the establishment. This is achieved
through development of a formulary, and via written protocols to guide
professional medical practice and clinical management for certain conditions.
NICE and NSFs are a standing agenda item and processes have been put
in place to implement their guidance.
Support and advice is available through a dedicated prison health development
manager, prescribing adviser and links in with the PCT Medicines Management
Committee, for which prisons are a standing agenda item. Similar links
are in place with other prisons in Islington and with the regional prison
pharmacy lead. Education and training
Further education and training for staff is encouraged at HMP Holloway |
Education and training are important for all health care professionals
within the prison. Until recently, prison staff were professionally
isolated and had little access to training. Within the pharmacy team,
all members have access to London education and training programmes.
The Centre for Pharmacy Postgraduate Education has developed specific
training programmes for prison pharmacy staff.
There is support for pharmacists who wish to take up the opportunity
of obtaining a postgraduate qualification, such as a clinical diploma,
or for those who wish to take on supplementary prescribing. Technicians
are also encouraged to develop their role further through national vocational
qualifications, accredited checking, and continuing professional development
(CPD) facilitation and management.
The principal pharmacist, with this kind of support, has been able to
obtain a postgraduate certificate in psychiatric therapeutics and is
currently undertaking a supplementary prescribing course. Two technicians
are completing the accredited checking technician course. All staff have
their set objectives and personal development plan which are reviewed
annually during appraisals, using the prison service’s staff performance
and development record system.
The prison setting has been a perfect example of pushing the public health
agenda forward. We have a dedicated nurse for hepatitis B immunisation
and are working with the PCT on promoting smoking cessation. There is
a strong commitment to providing high-quality mental health services
for the women at HMP Holloway. There is an in-house community mental
health team that takes referrals from primary care practitioners and
prison officers as well as self-referral. There is an inpatient unit
with qualified mental health nurses and 24-hour medical supervision,
and a tertiary service provided by North London Forensic Services.
Working as a pharmacist within the prison service provides particular
challenges, which are a result of both the environment in which we work
and the complexity of the medical and mental health problems of our patients.
A career in prison pharmacy was once commonly considered inferior to
one in other pharmacy sectors. However, with recent developments, such
as closer working with PCTs, changes in legislation enabling the pharmacists
to expand their roles, emphasis on multidisciplinary team working and
active clinical governance systems, challenges have become less insurmountable.
The prison pharmacy staff have the same access to CPD as NHS staff and
are supported in their attempts to improve the quality of the service
provided to patients.
With the extended role of technicians who now manage the dispensary and
play an active role in the “in-possession” project, the pharmacy
team at HMP Holloway is expanding. Our plan is to increase the team of
technicians to five, which will give the clinical pharmacist and the
principal pharmacist scope to develop their clinical roles through, for
example, pharmacy-led clinics (eg, hypertension, cardiovascular disease
risk management, diabetes, chronic asthma and many other therapeutic
areas).
The Royal Pharmaceutical Society is looking into the possibility of allowing
pre-registration training in a prison setting. We hope to introduce,
in co-ordination with our local mental health trust and PCT, rotational
training for technicians and pharmacists in the near future to encourage
sharing of good practice and to enable them to experience the specialist
discipline of prison pharmacy.
Reference
1. Department of Health — Great Britain. A pharmacy service for prisoners. London: Department of Health; 2003. |
The
Pharmaceutical Journal