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Different types of prisons face different challenges
when designing new policies
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In this issue:
Original paper, p232 PDF (70K)
Exploring the views of prisoners attending a pharmacist-run dermatology
clinic
Article
p234 (How
prison pharmacy is changing) |
Over two years ago HM Prison Service and the Department of Health published “A
pharmacy service for prisoners”, outlining recommendations to improve
pharmacy services in prisons in England (PJ, 12 July 2003, p37). One
of these recommendations stated that people in prison who are using medicines
should normally, and as a matter of principle, keep their medicines in
their own possession.
This week the National Prescribing Centre has published a guide to help
those responsible for implementing local policies in England and Wales
to comply with this recommendation. Commissioned by Prison Health, the
guide outlines the benefits to both patients and staff when patients
take responsibility for their own medicines (referred to as “medication
in-possession”) and explores the practical issues that must be
considered in a prison environment.
“Medication in-possession is not a new concept,” says Annie
Coppel, director of publications and corporate governance at the NPC. “A
survey carried out by the Prison Service and Department of Health in
2003 found that the vast majority of prisons in England and Wales had
some kind of medication in-possession policy in place. The problem was
that the prisons were adopting a negative approach to patients keeping
hold of their medicines.”
She explains that instead of it being routine for patients to hold and
administer their medicines, unless considered inappropriate following
a risk assessment, prisons were generally not allowing patients to hold
their own medicines, unless an assessment had determined that they could.
She explains that the NPC guide aims to help local prisons and primary
care trusts work together to reach a position where most patients normally
hold and administer their medicines.
Ms Coppel explains that while developing the framework the NPC carried
out a survey of 138 prisons in England and Wales in spring 2004. Of the
54 per cent of prisons that responded, 77 per cent already had an approved
policy in place for prisoners to be in possession of their own medicines
and 19 per cent were in the process of developing one.
“Some prisons are much further down the road than others,” she
says, “and
it is clear that more support is needed to help some make a start, and
others to make further progress. Our guide aims to help them at whatever
stage they are at with medication in-possession.” She adds that
most of the prisons that responded were approaching the issue from a
negative rather than the positive default direction.
“‘A pharmacy service for prisoners’ stated that for
effective and efficient patient care the level of risk needs to be correctly
identified,
assessed and managed more positively. Medication in-possession will help
patients to get the most of their medication, to understand what they
are taking and why,” she says.
Due to the nature of the prison environment, the risks of suicide, self-harm,
bullying and abuse must be considered. However, benefits of medication
in-possession have been shown to outweigh the risks, as long as the risks
are properly managed (see Panel).
Benefits for patients in prison
The National Prescribing Centre’s guide
outlines the potential benefits for patients in prison when they
have responsibility for
their own medicines. These include the following;
· Being able to take an active role in
managing their own care in prison and on discharge
· Being able to use medicines and associated devices at
the appropriate time
· Improved contact and partnership with health care professionals
· Increased access to education and counselling about their
condition and medicines
· Improved concordance with advice and medicines
· Reduced likelihood of missing doses on transfers, court
visits or on release
· Improved health and better management of long-term conditions
· Reduced time spent in queues at treatment times where other
prisoners can see what medicines are being supplied which may increase
patient vulnerability and bullying |
Risk assessment
“A pharmacy service for prisoners” recommends that each
prison should have a policy and risk assessment criteria, developed through
the drug
and therapeutics committee, for determining on an individual basis when
medicines and related devices may not be held in the possession of the
patient.
According to Ms Coppel, the risk assessment is a key element of a successful
medication in-possession policy. She emphasised that, as well as being
robust and appropriate to both the patient and the environment, the assessment
must be ongoing. “An event like a prisoner receiving some bad news
could be enough to change the risk assessment that means it would no
longer be considered safe to allow them to be responsible for their medicines,” she
said.
There is currently no validated risk assessment tool that would meet
the needs of the populations of the different categories of prisons.
Ms Coppel explains that the drugs and therapeutics committee is responsible
for developing the risk assessment criteria under which medicines may
not be held in the patient’s own possession, and each prison will
be able to use these criteria to develop a tool adapted to the individual
environment.
The guide acknowledges that additional considerations may need to be
taken into account depending on the type of prison. In local prisons
patients tend to be less settled and less well known to staff because
they have high levels of transfer. The guide says that extra care may
be needed when introducing medication in-possession to patients in these
establishments, although there may be more stable wings where staged
implementation may be possible.
Women’s prisons tend to have a high proportion of patients with
mental health problems and a history of self-harm, and in juvenile establishments
issues of consent must be considered.
The NPC’s guide provides advice on the development of tools for
risk assessment, such as involving all staff who will be using it in
its development, and linking up with establishments of similar type to
share practical experience and learning.
Another factor to consider is those medicines that are less suitable
for in-possession use, as some are more toxic and prone to misuse that
others. “Medicines are perceived as currency in prisons,” Ms
Coppel explains, “and issues such as bullying and patient confidentiality
need to be carefully considered.”
However, many prisons use local formularies for their preferred choice
of medicine within a class, and the National Institute for Health and
Clinical Excellence guideline on self-harm advises prescribing the drugs
least dangerous in overdose that remain effective.
Developing a local policy
When developing a local policy for medication in-possession the guide
recommends that consideration is given to the following factors.
Duration of supply The amount of medicine supplied to a patient will
vary depending on both patient specific issues and medicine specific
issues. For example, the length of a course of antibiotics will depend
on the condition being treated. For new arrivals to the prison, a shorter
supply may be more appropriate, and a follow up is needed to assess
compliance and remove any surplus medicines.
Storage of medicines Patients in single cells can generally ensure their
cell door is locked when they leave, but patients who share a cell may
be anxious about leaving their medicines unattended. Some prisons have
provided lockable cupboards in shared cells, although this has implications
for extra workload for staff conducting cell searches. The risk of prisoners
holding keys also needs to be
considered.
Patient agreement The principles of the medication in-possession policy
need to be clearly explained to patients and their agreement must be
obtained. A policy should be in place for managing patients who abuse
the privilege.
Other factors to be taken into account include medicines packaging,
patients being transported elsewhere (eg, being escorted to court), and
the relationship of a medication in-possession policy to other medicines
management policies.
A system for the management of any critical incidents also needs to be in place.
To help to improve the quality of the service continually, the guide states
that audit should be an integral part of the policy, and that the findings
should be shared.
Ms Coppel says that the NPC will be inviting pharmacy leads and other key personnel
to a conference in November to discuss the challenges that may face the prison
service in implementing medication in-possession in different categories of
secure environment.
Steady progress in Scotland
Sandra Hands, project manager, nursing services
review at the Scottish Prison Service Headquarters, explains
that since the drugs
and
therapeutics committee launched “A protocol for in-possession
medication” in 2000, it has been mandatory for all 15 Scottish
prisons to have a medication in-possession policy.
Before this many prisons had their own informal arrangements
and Ms Hands believes that good communication between the prisons
and
the sharing of ideas has helped them to establish their national
policy.
Ms Hands has just completed a new survey showing that 75 per cent
of patients in Scottish prisons currently have responsibility for
their own medicines. Taking into account excluded medicines
(eg, methadone, dihydrocodeine, opiate-based analgesics) and patients
who are not suitable for medication in-possession, a figure of
80 per cent should be achievable. Ms Hands says that there has
been
no evidence of bullying triggered by the policy and that no prisoners
have used their own medicines to commit suicide, although there
was one case of accidental overdose. “The policy gives patients
more responsibility for their own health care and helps them understand
how to take their medicines when they are released,” she
says.
Although patients in prison in Scotland are currently assessed
for suitability to look after their own medicines case-by-case,
Ms Hands
says that they would eventually like to see patients have responsibility
by default, as proposed in England and Wales.
Pharmacy services are delivered somewhat differently to prisons
in Scotland in that they are all contracted to Alliance Pharmacy,
and
mainly supplied from a central dispensary (PJ, 30 March 2002, p427).
Ms Hands says that last month Alliance Pharmacy had its contract
with the Scottish prisons renewed for another five years. |
How prison pharmacy is progressing in Wales
There are four state prisons in Wales; Cardiff, Swansea, Usk
and Prescoed, and one private prison, Parc prison in Bridgend.
Cardiff
prison provides the pharmacy services for Usk and Prescoed prisons
via a satellite service.
According to Dana Tait, principal pharmacist at Cardiff prison,
publication of “A pharmacy service for prisoners” greatly improved
awareness of prison pharmacy in Wales, especially among pharmacy
staff in other fields of the profession. However, she is disappointed
that things have not moved forward as rapidly as they might have
done. “It has been two years since ‘A pharmacy service
for prisoners’ advised prisons to develop a network of regional
leads,” she points out, “and Wales still has not got
a professional pharmacy lead for prisons.”
She says that despite there being “blanket” representation
in the Welsh Assembly, there is not one regional lead to attend the
pharmacy development meetings in England. “A lot of work is
under way and ongoing but each prison is doing their own thing with
little co-ordination,” she explains.
Rowena Williams, prison health care project co-ordinator at the
Welsh Assembly Government, points out that “A pharmacy service for
prisoners” has not been formally adopted in Wales. She said
that although Wales was consulted on the document and the principles
are broadly accepted, it could not be implemented as it was written
in an English context. She says that the chief pharmaceutical officer
for Wales has commissioned a review of prison pharmacy services
in Wales that will be looking at, among other things, professional
leadership
issues. She says that although they are working in tandem with
England on prison health services, the direction and speed of travel
will
depend on the other priorities of the WAG for health in Wales.
Medication in-possession, however, is an area with which Cardiff
prison is familiar. Miss Tait says that Cardiff prison has had
a medication in-possession policy for over 10 years, and that every
prisoner looks after their own medicine by default, unless there
is a reason to the contrary. “A survey we carried out in January
showed that 58 per cent of prescriptions issued for residents of
Cardiff prison were written for in-possession,” she says. “A
local prison such as Cardiff, with a high turnover of residents,
should be able to reach a level of 70 per cent.” She hopes
that the NPC framework may help to improve these figures. “The
framework will hopefully provide more uniformity to what the prisons
are doing independently,” she says.
Medicines management For the past seven months
Miss Tait has also been running a medicines review clinic at
the prison, funded by
the Welsh Assembly Government. Miss Tait designed the project together
with a pharmacist from Cardiff Local Health Board, and has reviewed
40 patients since January. She explains that patients were identified
for review by their prescriptions to ensure that, for example,
patients with depression were treated in accordance with NICE guidelines. “Patients
were initially reluctant to attend,” she says, “but
the feedback we have received shows that they found the service
useful and would recommend it to others. Feedback from nursing
and medical staff was also positive, and one doctor said that it
he thinks the service has adds an extra safety aspect to patients’ medicines.”
Miss Tait hopes that these results will help the service to be
commissioned by the LHB. |
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The
Pharmaceutical Journal