ITEM 5 Prisoner Healthcare
North Lanarkshire Council · 22 May 2024
Back to IJB Performance, Finance and Audit Committee — 22 May 2024 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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1 REPORT Item No: 5 Prisoner Healthcare, HMP Shotts SUBJECT: Prisoner Healthcare TO: IJB Performance Finance Audit Committee Lead Officer for Report: Ross McGuffie, Chief Officer, NL HSCP Author(s) of Report Hazel Mitchell, Service Manager, AHSU Tracey Hughes, Senior Nurse, AHSU DATE: 22 May 2023 1. PURPOSE OF REPORT This paper is coming to the IJB PFA for noting. This paper is to inform the Board of the health service improvements undertaken in the prison, in compliance with the local Service Model Review, and in parallel with the HIS recommendations. Also to note on-going work and next steps. For Approval: ☐ For Endorsement: ☐ To Note: ☒ 2. ROUTE TO THE BOARD This paper has been prepared by Hazel Mitchell, Service Manager, and Tracey Hughes, Senior Nurse, to update the Board on the current prisoner healthcare service, and to update on on-going service improvement plans and workstreams. The paper has been reviewed by Jamie Quin, General Manager, AHSU, & Maggs Thomson, Head of Health, NHSCP. Prepared By: ☒ Reviewed By: ☒ Endorsed By: ☐
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2 3. RECOMMENDATIONS: (1) It is recommended that the IJB PFA recognise the service changes and improvements made in the Prison Health centre at HMP Shotts in accordance with the recommendations made by HIS. (2) It is recommended that the IJB PFA recognise the service changes and improvements made in the Prison Health centre at HMP Shotts in accordance with the local recommendations and actions identified in the Local Service Model review, including the efforts made by the AHSU to address the recruitment & retention issue within Prisoner Healthcare. (3) It is recommended that the IJB PFA endorse the future work streams of the Prisoner healthcare team. 4. VARIATIONS TO DIRECTIONS? This section outlines if the report requires a direction to be issued to the Local Authority, the Health Board, to both, or that no direction is required 5. BACKGROUND/SUMMARY OF KEY ISSUES Background The Prison Health centre based within HMP Shotts serves a population of 540 male patients. The service is to provide these patients, many with advanced Mental Health and Addictions issues, with a primary care level service, equivalent to that of patients in the community. In terms of health equalities, it is estimated that the prison population has an average health age of 10 years higher than their actual age. Prior to the introduction of the Adult Health Services Unit (AHSU) into the NHSCP, Prisoner Healthcare was a hosted service within the Motherwell locality. The Service Manager within the Motherwell locality worked remotely and was responsible for the daily operations of the service, with a Senior Nurse based on-site, whose sole remit was to oversee the professional aspects of healthcare provision within HMP Shotts. In 2021 operational responsibility for Prisoner Healthcare transferred to the AHSU. For consistency in management and governance purposes, it was agreed that both the operational and professional management of prisoner healthcare would replicate that of the other services, whereby both the Service Manager and Senior Nurse would work remotely and have Prisoner Healthcare as part of their portfolio. Within a few months of the service reporting via the AHSU, it was identified that there were issues with staffing, including cultural issues as well as training, recruitment and retention. This impacted on the level of care being able to be Yes ☐ No ☒ N/A ☐
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3 delivered to patients within the prison. It was agreed locally to undertake a local Service Model Review to address these issues. 5.1) Service Model Review Commissioned in January 2022, this was a comprehensive service review of Prisoner Healthcare and encompassed the following 8 standards: Standard 1: Effective Management of Resources & Staff Governance Standard 2 Primary Care & chronic disease Management Standard 3: Mental Health & Addictions Standard 4: Medicines Management Standard 5: Infection Prevention and Control Standard 6: Person Centred Health and Care Standard 7: End of Life Care Standard 8 : Deteriorating Patient From this Action Plan 31 recommendations were made, all of which are now complete and signed off. **Please see Appendix 1 – Service Model Review Baseline Update – April 2024 5.2) HIS Inspection The scheduled HIS inspection took place in May 2022. This followed the approved national process with all relevant self-evaluation tools having been complete and submitted in advance. The Lead Inspectors from HMi spent 11 days on-site at HMP Shotts, 5 of those within the Health Centre. While the preparatory work and the information transparently given to the inspection team by the management team, in particular the Service Model Review, demonstrated the AHSU management team’s awareness of the improvements needed, the HIS report was returned to HMP Shotts with 64 recommendations for improvement. Twenty-two of these recommendations were categorised under: Standard 9: Health and Wellbeing - The prison takes all reasonable steps to ensure the health and wellbeing of all prisoners The HIS Inspection team met with the AHSU management team and discussed all 22 of these recommendations. The HIS team were understanding of the extreme staffing issues in prisoner healthcare at this time and acknowledged that this was a
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4 factor contributing to many of the recommendations whereby Health were classified as being below the required standard and required significant improvement. Of the 22 recommendations for improvement, 11 of these were classified as “Priority” areas. The AHSU management team worked well in collaboration with the prisoner healthcare team, and SPS to ensure these actions were addressed in a timeously manner. The Service Manager and Senior Nurse temporarily based themselves within the prison for a period of 5 months to provide leadership and initiate actions as efficiently as possible. The team met with HIS a further twice between the initial inspection and August 2023 to review the progress made. As of September 2023 HIS officially signed off the plan as complete with no further review required until the scheduled inspection in 2027. Commendations were made at the efforts made to address the recruitment, retention, and overall staffing issue in the prison. As of April 2024, 20 of the 22 recommendations are 100% complete, with the remaining 2 on-going and as part of a Pharmacy review. 5.3) Workforce There is a historical recruitment/retention issue within prisoner healthcare, both nationally and locally in Lanarkshire. Post covid pressures impacted greatly on the service as the lack of available workforce and availability of high vacancy rates, a huge focus was placed on re-establishing and stabilising the clinical workforce within the prison. The current FE in the prison is 28.88 wte Through 2020 to 2022 seen consistently low staffing numbers, at one point recorded a low of 67% substantive staffing, with only 19.49 wte in-post. In some month’s sickness rose as high as 27%, with supplementary staffing reaching 36% in an attempt to backfill these gaps. This left the team and the patients vulnerable with staff unable to fulfil the requirements of a Gold standard health centre, with some tasks having to be withdrawn on a daily basis to focus on delivering the essential services to keep patients as safe as possible. It created a gap in stability and consistency of care which was a concern to NHSL, SPS, and HIS. The management set up a recruitment drive by holding Open Days. These were advertised nationally in NHSL communication channels and social media. They run in collaboration with SPS to allow staff with any interest or curiosity to visit the establishment in an attempt to eliminate any preconceptions about the lack of safety. A tour of the facility was conducted with presentations from Senior personnel from both NHSL & SPS. A similar event was also derived for students, aimed at graduates and NQNs. This was a staffing group previously avoided by prisoner healthcare. A recruitment drive in collaboration with Staffbank was devised and allowed staff to book “shadow shifts” whereby they would come and work some shifts alongside a
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5 designated “buddy” to allow them to trial working the service while not compromising safety of neither staff nor patients. This was SPS approved. A new training and induction programme was devised, as was the role review and development of the Band 5 nursing role. This allowed us to use previous feedback that the role was heavily focused on medicines administration and therefore not challenging to nurses who want to clinically advance themselves. New “named nurse” profiles were developed allowing each nurse to be responsible to named patients, ACPs, and chronic disease management. Collaboration with Practice Development and Organisational Development has allowed the staff to undertake many more training opportunities and in turn, aswell as making the role more interesting, it has provided much more advanced and progressive patient centred care to the patients. So far in 2023 we have recruited 2 substantive and experienced Team Leaders, providing leadership and stability for the teams. 4 NQNs, 2 experienced RGNs and a Band 6 Addictions Charge Nurse. In addition to this, following an Options Appraisal exercise, the first full-time dedicated ANP has recruited for HMP Shotts. We have also see the addition of a Band 5 Health Improvement Practitioner and a part time Band 7 OT vis Act 15 monies. Staffing culture and psychological safety was a key part of the management response to recruitment and retention. Staff meetings, questionnaires, feedback sessions were organised as a priority and continued throughout 2023. During the staffing crisis of 2022/23 whereby the organisation saw a sharp increase in Agency use/costs, the prison used the equivalent of 1 wte per week. For safety and consistency purposes this was the same staff member who had years of prison experience. This was used within framework and ceased completely in August of 2023. As at March 2024 the in-post figure was 25.52 wte, equating to 88% substantive staff, with 2 additional vacancies being deliberately backfilled by long term bank. These bank staff are retirees who bring much needed leadership and clinical skills to support our NQNs in their first year of nursing. Supplementary staffing was recorded as 7.35% and sickness was below the organisational target at 3.95%. 5.4) Finance The financial position as at Month 11 of the 2023/2024 financial year is as follows: Annual Budget YTD Budget YTD Actuals YTD Position PAYS £1,602,525 £1,470,380 £1,416,628 £53,752 NON PAYS £436,188 £399,839 £1,194,155 (£794,316) TOTAL £2,038,713 £1,870,219 £2,610,783 (£740,564)
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6 The Pays budget is reviewed/scrutinised/managed accordingly in-line with allocated funds. The £800k overspend within non-pays is within the Medicines Management/Pharmacy remit of the prison health centre, to be discussed below in Section 5.5 All other areas of the prisoner healthcare budget are reviewed and managed accordingly within the SFIs and allocated budget. 5.5) Pharmacy Pharmacy costs have traditionally been the highest area of non-pay spend nationally in all prisons. The nature of the patient cohort results in high volumes of prescribed medication for Mental Health, Pain, & Addictions purposes. The non-pay spend relating to Pharmacy/Drugs is as below: Annual Budget YTD Budget YTD Actuals YTD Position Drugs £298,974 £274,060 £832,950 (£558,891) Misc. £69,519 £63,726 £310,260 (£246,534) TOTAL £368,493 £337,786 £1,143,210 (£805,425) The £559k overspend is for the actual drugs bought, with the £246k miscellaneous overspend being the management fees for the contract. Prior to 2023 the National contract for pharmaceutical supplies was held by Lloyds group. Upon expiry of this contract Lloyds did not want to renew this, Boots uninterested in tendering also. Upon first tender request no supplier submitted any interest. With time against the national team, and a high risk raised on the SPS register regarding potential prisoner riots, a second attempt at sourcing a contracted supplier was met with a bid from M&D Green. This new bid came in 2 parts, the processing and management of drugs by M&D Green, and the delivery from Pheonix Healthcare. This new contract came with an almost 22% increase in costs, aswell as a £35k per month management fee. This contract came into effect from June 2023 and none of these factors were uplifted in the Annual budget, creating a potential £600k annual cost pressure. Drug spend for the same period last year was £267k. With the previous contract, 6 hours of Clinical Pharmacist time was allocated to the prison health centre to help review prescribing habits, this was removed from the new contract, leaving a vulnerability within the service, and no additional monies have been received to recruit to this internally. Having no direct pharmacy input is not consistent with primary care health centres in the community, leaving an inequity to the prison population, as they have no access to pharmaceutical advice without having to request an appointment at the health centre. The introduction of Buvidal to the prison has seen many positive outcomes, commended by both SPS staff and prisoners. At present we have 95 patients using
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7 this type of Opiate replacement, given once a month by injection, this is seen as the Gold standard treatment and negates the need to take oral methadone on a daily basis. However, with no additional budget this has placed an estimated cost annual cost pressure of over £2.5k per patient in the service. It is anticipated the number of Buvidal recipients will increase over time once the true benefits are formally assessed and published. The prison processes and dispenses over 500 prescribed items per week. This is resource intensive and very expensive. Traditionally the issuing of these medications took place on a Friday. It required the whole staffing complement to complete it. The volume led to high risk of error, and any missing items meant that patients were left without medicines over the weekend. Discussions and planning with SPS saw a new agreement whereby this would take place twice weekly, mid week. This took meticulous planning with the pharmacy provider, but has reduced error, allowed for a quicker response to get missing medications delivered, and eased the staffing pressures to undertake the task. In a response to this the Prescribing Action Group has been re-established to try and manage the number of items prescribed, and to review the actual items prescribed. Pain and medicine management pathways are being developed, whereby prescribing rules deter expensive Gold standard drugs being used as a first line treatment where clinically avoidable. This will also review prescribing habits, and any new guidelines to be discussed and actioned. A substantive ANP has been recruited to help provide consistent clinical cover to patients, working closely with the GP clinical lead in an attempt to reduce prescribing volumes and costs. It is hoped to undertake a Pharmacy/Medicines management review in the imminent future to tackle as many of the aforementioned issues as possible. This will need to be done collaboratively with the NHSL Pharmacy department. 5.6) Other Notable Service Improvements; 5.6.i) Chronic Disease Management/National Screening The Senior Nurse and Team Leaders have implemented a CDM and national screening programmes into the prison. This means that patients are now receiving all annual reviews & scheduled and unplanned appointments with named nurse, to ensure that all health management is in a preventative, rather than responsive manner. This also tackles the health inequalities issues that exist in a prison, and provides the patients with health education on how to manage their conditions, aswell as understand the need to identify symptoms and escalate accordingly. The relevant documentation has now been electronically uploaded into the Vision system with individual patient care records being held and managed accordingly. The following specialist services are now implemented and endorsed in the Health Centre: Diabetes (clinics & awareness)
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8 Sexual Health (clinics & awareness) Keep Well clinics Asthma – initial stages of implementation Hypertension – initial stages of implementation National Bowel Screening Prostate Screening Routine eye tests Treatment Room services 5.6.ii) Clinical Assessment Tools To ensure compliance and consistency of patient care, the service revisited the requirement for clinical assessment tools and their purpose. The Senior Nurse worked with e-health to upload all relevant documentation into Vision and devised a robust training plan for all staff to ensure competence in the use of these documents. Use of these documents including ACPS, NEWS charts, Wound charts & MUST tools have been promoted and endorsed and are now part of everyday practice. This has improved patient outcomes and compliance with national standards. 5.6.iii) Staff Training As part of the programme to fully utilise new increased staffing has been devised in collaboration with the Practice Development & Organisational Development teams. This includes Mandatory and other relevant desired training, including both practical on-line sessions.
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9 Clinical Supervision has been a large focus this year, specifically for the NQNs, but also for the development and advancement of the more experienced nurses. In-house training has also taken place with different disciplines leading sessions for each other, this includes examples such the Psychology team session held for staff to discuss the management of patient’s with complex Personality Disorders. 5.6.iv) Clinical Escalation and Call Before Convey Model The clinical escalation route for OOH period was reviewed and redesigned to allow staff to call the FNC and use the Consultant Connect option before
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10 conveying a patient to hospital. Collaborations have also been enacted and DNs and OOH GP have attended the hospital as per request in the past year to enable OOH care to be delivered to deteriorating or sick patients to avoid a prisoner transfer to hospital. A “Call Before Convey” pilot was launched in 2023, whereby the patient and potential hospital transfer is discussed prior to an ambulance being called (unless it’s a 999 emergency). This was launched in July 2023 and by December ED attendances had reduced from 31 per month to 7. 5.6.v) Complaints Patient complaints have by nature always been exceptionally high in prison health environments. Between 2020 & 2022, an average of over 50 complaints per month was received. A full analysis of these complaints were carried out. The health team have worked very hard at patient engagement throughout the 2-year service review and improvement plan. By listening to patient views, increasing staffing levels, improving staff training, and providing a higher standard of patient centred care, the number of complaints have dropped accordingly. By December of 2023, 15 complaints per month were being logged. The main reason for these complaints is medication related. 0 5 10 15 20 25 30 35 HMP Shotts ED attendances July 23 - Dec 23
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11 5.7) Associated Risk As the improvements undertaken above were all necessary for patient care, staff governance, and as per HIS recommendations, any reduction to staffing levels within the prison would create a clinical risk to the successful delivery of the service. This will be discussed as per the finance cluster review meetings. 5.8) On-going Working Groups Programme Board – Chaired by Head of Health, purpose of co-ordinating and ensuring delivery of all on-going workstreams, including the aforementioned reviews, aswell as upcoming local & national projects. Attended by senior management representing operational & professional leads, primary care, mental health, psychology, addictions, pharmacy, and health improvement representation. Attendance by SPS senior management also requested. Held quarterly. SPS Strategy Meeting – Chaired by AHSU GM, purpose of collaborative development of operational and strategic purpose between Health & SPS, respecting governance and objectives of both individual organisations. Attended by operational senior management of SPS, including Governor and Deputy, GM, ADN, Service Manager & Senior Nurse in AHSU. Clinical Lead and Head of Psychology also attend. Held bi-monthly. HOLM Meeting – Chaired by Clinical Lead GP, purpose of addressing all “on the floor” issues relating to delivering healthcare in a non-health controlled environment. Attended by Service Manager, Senior Nurse, Team Leaders, Pharmacy, First line SPS management. Held Bi-monthly. Prescribing Action Group (PAG) – Chaired by Clinical Lead GP, purpose of reviewing the prescribing legislation and habits within the health centre. Attended by Service manager, senior nurse, Team Leaders, pharmacy, GPs, medical and non-medical prescribers. Held bi-monthly. Team Meetings – Chaired by Team Leaders, held for each service and attended by relevant staff cohorts within PCT, MH, Addictions, Psychology. Held monthly.
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12 IPM Meeting – Chaired by Independent Prison Monitors on behalf of NSS, with purposes of representing prison population, attended by Service Manager and Prison Governor – Held quarterly. All National Groups as instructed by NSS are attended as necessary. 5.9) Next Steps Continue to provide service delivery as per new model above Continue with staff training & development programmes Continue to roll-out CDM services to various specialties Continue to work collaboratively with SPS Complete national TOM benchmarking and evidence gathering, making any service changes/improvements as requested Complete MATS standards benchmarking and evidence gathering, making any service changes/improvements as requested Represent the Prison Healthcare service at finance cluster review meetings 6. CONCLUSIONS The AHSU, in collaboration with SPS, and on-site staff, have successfully undertaken a Service Model Review to implement an improved Prisoner Healthcare service to the population of HMP Shotts. This includes stabilised staffing models, improved staff training plans, and improved patient centred care for all patients, in particular those with identified existing health needs. 7. IMPLICATIONS As previous mentioned in section 5.7, any reduction in budget to the Prisoner Healthcare service, could result in a significant adversity in the ability to fulfil the service provision as per national guidelines. The fragility of the staffing budget would not allow for any reduction in FE otherwise the implication of reverting to an unsatisfactory outcome for patients. 7.1 NATIONAL OUTCOMES Link(s) to National Health and Wellbeing Outcomes People are able to look after and improve their own health and wellbeing and live in good health for longer ☒ People, including those with disabilities or long-term conditions, or who are frail, are able to live, as far as reasonable practicable, independently and at home or in a homely setting in their community ☒ People who use Health and Social Care Services have positive experiences of those services, and have dignity respected ☒
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13 Health and Social Care Services are centred on helping to maintain or improve the quality of life of people who use those services ☐ Health and Social Care Services contribute to reducing health inequalities ☒ People who use Health and Social Care Services are safe from harm ☒ People who work in Health and Social Care Services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide ☒ Resources are used effectively and efficiently in the provision of Health and Social Care Services ☒ 7.2 ASSOCIATED MEASURE(S) HIS Recommendations NSS published guidance for prisoner health MHWC Recommendations Safe Staffing Legislation 7.3 FINANCIAL Any reduction in staffing budget would adversely affect service provision and performance. £600k annual cost pressure in drug/medicines management provision This paper has been reviewed by Finance: Yes No N/A 7.4 RISK ASSESSMENT/RISK MANAGEMENT Relevant Risk Register Details Current Risk Level Risk Owner Choose an item. 7.5 ENGAGEMENT & PARTICIPATION Please tick the engagement and participation objectives that link(s) with this piece of work and provide further details on the engagement and participation that was undertaken. Objectives Further details
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14 ☐ Involve stakeholders in the development work aimed at achieving the national outcomes ☐ Provide stakeholders with information on how to get involved ☒ Ensure a diverse range of engagement and participation and opportunities are in place to suit different needs Staff, patients & SPS involved in service review process ☒ Measure how well we involve community stakeholders in the planning, design and delivery of our services IPMs, SPS and patients involved ☒ Provide regular feedback on how stakeholder engagement and participation is shaping and influencing service development and delivery Monthly meetings with SPS and review meetings with HIS ☐ Provide support to enable stakeholder representatives to participate meaningfully and confidently at meetings ☐ Develop participation guidelines to ensure a common understanding and set of expectations for both stakeholders and partnership staff ☐ Support engagement planning and participation in localities, taking account of other engagement activity and local plans across the Community Planning Partnership 7.6 INEQUALITIES & FAIRER SCOTLAND DUTY EQIA Completed & Fairer Scotland Impact Assessment Form Completed and attached to report: Yes No N/A EQIA added to website: Yes No N/A
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15 8. BACKGROUND PAPERS HIS Review – HMP Shotts, published May 2022 Inspection report available on request 9. APPENDICES None. . CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact the following; Hazel Mitchell, Service Manager, AHSU, NHSCP Hazel.Mitchell@lanarkshire.scot.nhs.uk Tracey Hughes, Senior Nurse, AHSU, NHSCP Tracey.Hughes@lanarkshire.scot.nhs.uk