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Stella Simpson is principal pharmacist at HMP Holloway and Avni Shah is prescribing adviser at Islington PCT |
The setting is the largest women’s 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 length of stay for prisoners is 28 days. Most prisoners are between the ages of 20 and 29 years but 13 per cent are under 19 years of age. Only 8 per cent of women are over 50 years.
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 because 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 also varies considerably from establishment to establishment.
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, the North London Forensic Service and the Women’s Health Clinic 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”1 document published in 2003 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 administering 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.
Education and training
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. All members of the pharmacy team 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 we 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 preregistration 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.
References
1. Department of Health. A pharmacy service for prisoners. London: Department of Health; 2003. |
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