Hanham Health Secure Environment Work
Hanham Health has developed considerable enthusiasm for and expertise in the delivery of healthcare within a secure environment. We provide highly specialised GPs, nurse practitioners and dedicated admin support to two local prisons, HMP Eastwood Park and HMP Leyhill and also a local secure unit for young people, Vinney Green Secure Unit.
HMP Eastwood Park
HMP Eastwood Park, in the village of Falfield, is close to the busy centres of Bristol, Bath and Gloucester, and within easy reach of the M5 motorway. HMP Eastwood Park is a closed remand prison situated 15 miles north of Bristol in South West England. It is a Category B female prison and usually has between 300 – 400 prisoners. It has a Mother and Baby Unit; a Juvenile Unit and an Integrated Drug Treatment Service (IDTS). On average, 70% of the prisoners are addicted to Class A drugs and/ or alcohol and come from some of the most disadvantaged backgrounds in British society. The population changes constantly, with the average length of stay being 21 days.
Hanham Health has contracted to deliver primary care, substance misuse and specialised sexual health services to the women at HMP Eastwood Park. We bring a community model of Primary Care to a very complex and transitory group of patients, often with a poor understanding of how to access health care, and to use the window of opportunity when these women are in prison to provide them with comprehensive medical care including screening procedures and medical education.
Hanham Health took over responsibility for providing doctors to work in HMP Eastwood Park in October 2005. It remains an ongoing project, but has already established itself as an excellent working model. The scheme is being expanded to include chronic disease management clinics for conditions such as diabetes; asthma; coronary heart disease, etc, although this can be challenging given the average short stay in the remand prison environment.
The project was initially led by Dr Stephen Illingworth and Mrs Cath McCarthy, the Managing Partner, both from Hanham Health. As the project developed, Mr Tom Hastings was employed to manage the prison healthcare centre, effectively as a Practice Manager. The work steadily expanded to include other people who visit on a regular basis, such as the midwife, optician and other specialist members of the team. Dr Rupa Parmar is the Lead GP Partner. Dr Lizzie Stafford and Dr Ellie Carslake are the other two salaried GPs who have dedicated time in the prison.
There are two Hanham Health GPs in attendance every morning from Monday to Friday and one doctor in the afternoon. The full team includes nurse practitioners; fully qualified nurses; healthcare assistants; a specialist substance misuse midwife; a comprehensive mental health team supported by a consultant psychiatrist; an optician; an ultrasonographer; a podiatrist, as well as admin and housekeeping staff. A local physiotherapy department provides a secondary service off-site to which patients can be referred to if needed.
The Prison Service has been fully supportive of this innovative approach to prison healthcare, quickly recognising the enduring benefits to the prisoners and, by extension, the prison staff. This is now an all-embracing initiative which has the full support of many departments within the prison, from the education department to the kitchen department which has willingly become involved in the preparation of special diets, as well as the promotion of a healthy eating lifestyle, etc. The culture within the prison has changed to encourage rehabilitation and to take responsibility. The prison’s aim is now very much to provide optimum, focussed primary care to treat patients while in detention, and thus help prepare them for potential integration back into the community.
The GP team at HMP Eastwood Park has developed links with Bristol University where final year medical students can come and spend several weeks towards the end of their training studying custodial medicine as a specialist subject. Hanham Health is a training practice which is also developing plans for GP Registrars to extend their training by two to three months so they can also have experience of working in the prison environment. Our work in the prison targets all prisoners to make the best possible use of their period in detention. There is a particular emphasis on the most chaotic individuals who may hitherto have chosen to have erratic or no contact with state medical care. The work is also aimed at educating prison staff; developing links with community health services, and involving external groups such as Bristol University and General Practice (GP) Registrars with special interests in substance misuse and custodial medicine. The aim is to open up prison medicine to the same levels of medical scrutiny as are experienced in community general practice, simultaneously exposing needy patients to the best range of medical care possible. Arrangements are made as a matter of course for patients to attend any pre-existing hospital appointments. Effort is made to ensure that no patient is disadvantaged by being in prison: on the contrary, the majority of them are exposed to the most comprehensive and wide-ranging medical care that they will ever have had access to, and it is hoped that the medical benefits will outlast their period of detention.
Patients come to the welcoming environment of the Pathways Medical Centre within the prison. The centre is modelled on a community practice and is well-equipped and provides a calm and neutral environment where confidentiality can be respected. Doctors are available on site Monday to Friday from 8:00 am to 5:00 pm and there is an out of hours service delivered by the same GP Practice which provides 365 days per year continuous cover, along with an on-site experienced nurse. (Participation in the OOH is separately remunerated)
It should be noted that there are a significant number of foreign nationals, many of whom are unable to speak any English. The team works closely with a prison officer who has considerable experience in this field and has close links to immigration; foreign embassies and interpreting services. Doctors are able to access the Big Word language line from the National Health Service which provides 24 hour access to live interpreters in any language. This maintains confidentiality in sensitive situations and is an invaluable resource, as used in the community model. Interpreters are also arranged to accompany prisoners to external medical appointments as required.
This initiative is vital work which is spearheading the British approach to custodial healthcare, providing comprehensive and pro-active care on the community model for one of the most neglected groups in British society. A detailed assessment is carried out on every new arrival which is used to augment any known medical history. A multi-disciplinary action plan can then be developed, optimised to the needs of that particular patient.
The team have been particularly keen to ensure that the patients are offered blood-borne virus testing with the very significant support of the Integrated Drug Treatment Service; an accelerated vaccination programme, and onwards referral where necessary. Dedicated sexual health appointments are offered for Sexually Transmitted Infection screening. It should be noted that cervical smear testing is offered to every new arrival where appropriate.
The team aims to have emergency care available around the clock via an on-call rota. There are significant levels of deliberate self-harm and there is a dedicated mental health team available with a psychiatrist, community psychiatric nurses; psychologists; occupational therapists (including the use of art and music therapy) as well as administrative support. There is also a dedicated medicine management team with a pharmacist and specialist nursing team.
The Integrated Drug Treatment Service team includes nurses who specialise in the assessment and management of substance misuse. They are supported by Counselling, Assessment, Referral, Advice, and Throughcare services (CARAT) which provide support to the women and fulfil the vital role of linking up with the community drug and alcohol services (confirming prescribers; looking into rehabilitation placements, etc) as well as the probation services.
All of the GPs that work in the prison are supported by the practice to obtain both Parts One and Two of the Royal College of General Practice Certificate in the Management of Substance Misuse in Primary Care. This is open not only to doctors but to nursing staff and pharmacists as well. This training means that all staff are aware of the latest guidelines for the management of substance abuse. In trying to provide a community model of general practice, all the GPs working at HMP Eastwood Park work in a large community general practice based between Bristol and Bath.
There are user groups within the prison so the team can get feedback from the prisoners themselves as to how best to improve the service delivered.
GPs and nurses regularly attend external meetings to ensure that care provided is based on the latest models, for example, the programme of blood-borne virus testing and treatment as well as offering brief interventions to encourage abstinence or reduction of those identified as problem drinkers through use of the Alcohol Use Disorders Identification Test (AUDIT) screening tool. This includes maintaining awareness of national and international best practice and making it an integral part of custodial healthcare in the HMP Eastwood Park model.
We aim to improve the entire process of providing quality Primary Care on the community model to the most needy in detention. It is worth emphasising that the women in HMP Eastwood Park are viewed first and foremost by the medical staff as patients, and hence treated as such. Medical care is provided absolutely on the basis of need, and is completely independent from the parallel process of legal justice.
We are extremely proud to have just won the World Health Organisation ‘Health In Prisons Project Best Practice Awards 2011’ for our work in HMP Eastwood Park.
HMP Leyhill is close to the busy centres of Bristol, Bath and Gloucester, and within easy reach of the M5 motorway at Junction 14.HMP Leyhill is the only minimum-security prison in the South West of England. It was built in the late 1970s and extended in 2002 enabling the prison to cater for 532 prisoners. The reception criteria is adult males after re-categorisation to category D and the population includes up to 110 life-sentence prisoners.
Hanham Health has contracted to deliver primary care, substance misuse and specialised sexual health services to the men at HMP Leyhill. We bring a community model of Primary Care to a very complex and transitory group of patients, often with a poor understanding of how to access health care, and to use the window of opportunity when these men are in prison to provide them with comprehensive medical care including screening procedures and medical education.
Hanham Health models its healthcare provision on a primary care setting but with the provision of specialist on-site services which are readily accessible to the prison population. Dr Chris Pocock is the Lead GP.
In HMP Leyhill a significant proportion of prisoners are sentenced for long periods, and indeed nearly a quarter of the population are serving life sentences. It is important to ensure that people who have been sentenced to a period of time in a secure environment are allowed to access the same excellent quality of healthcare that they should expect to receive in the community. However there are specific health needs within the prison environment that need to be catered for e.g. a higher prevalence of complex mental health problems, blood borne viruses and history of substance misuse. We therefore ensure that these needs are met on site so that prisoners can access the care they need when they need it.
All prisoners are assessed by healthcare staff on arrival and their health needs identified by use of a dedicated new reception template. During their first two weeks at Leyhill they are guided through a comprehensive induction to the prison which incorporates educational events to heighten awareness of blood-borne virus risk, sexual health, testicular cancer self-checks and maintaining a healthy lifestyle.
As part of the reception process particular prisoner demographics and health needs are identified. These include those with chronic diseases such as asthma, COPD, diabetes and cardiovascular disease whose needs are met through provision of dedicated chronic disease clinics to optimise their clinical care. Patients who are over 50 are reviewed in an older person’s clinic. All new prisoners are screened for learning disabilities and once identified they can access the help they need from a dedicated nurse with specific training in this field. Mental health problems are identified and those patients with specialist needs can access on-site care from a dedicated mental health team based in healthcare. Prisoners who are current smokers are offered smoking cessation led by a trained healthcare assistant.
Staff involvement and education is a fundamental part of healthcare provision at HMP Leyhill and the ethos is to provide a supportive transparent service that is regularly performance assessed by the prison service. The team has forged close links with the prison through weekly meetings with prison governors, primary care through Hanham Health which provides GPs with a special interest in prison healthcare.
The healthcare model has been designed around several existing gold standards. Firstly primary care services which are assessed against the national quality and outcomes framework and follow NICE guidelines. Hanham Health is a twenty doctor practice in Bristol and provides support through regular clinical educational meetings where visiting consultants from secondary care are invited to speak to ensure the continuous professional development of its doctors. The PCT has provided funding for doctors to attain the RCGP certificate in substance misuse to provide expert clinical management for prisoners with a history of substance misuse. Working closely with the GPs is a nurse specialised in substance misuse, part of the integrated drug treatment service linked with neighbouring Eastwood Park prison. In addition, prisoners receive support from the on-site Counselling, Assessment, Referral, Advice and Throughcare service (CARAT) which delivers relapse prevention therapy and enables prisoners to access the follow-on care they need upon release.
The needs of an ageing population have meant that healthcare has developed its ability to provide palliative care. This has involved forging close links with community care teams, St Peter’s hospice, district nurses and prison officers. Caring for terminally ill prisoners has developed the relationship and understanding between prison officers and healthcare staff. Palliative care provision follows the Gold Standards Framework as devised by Dr Keri Thomas. Expert service support is provided by a consultant-led palliative care team from St Peter’s hospice.
Chronic disease management is primarily a nurse-led specialist service through dedicated protocol-based clinics. The protocols were written by the GPs and chronic disease specialist nurses based at Hanham and are revised annually according to NICE guidance. The clinics are supported by the specialist nursing team at Hanham Health and at Southmead Hospital.
Specialist mental health services are provided by a full-time on-site community mental health nurse and counsellor training in cognitive behavioural therapy. The service is overseen by a community psychiatrist with a specialist interest in prison healthcare who runs a monthly clinic for complex cases. When not on site the psychiatrist is contactable easily by phone for advice. The service is also supported by a band 7 psychiatry nurse specialist who runs medication review clinics on a monthly basis.
All staff who work in healthcare are involved in the running of the service. There are monthly staff meetings for all staff chaired by the healthcare manager where the current service is reviewed, new ideas discussed and an opportunity to table any issues that people wish to bring. Regular significant event meetings are arranged where reported events are discussed so as to continually ensure the safety of healthcare delivery and educate the staff. Prison doctors attend quarterly secure environment group meetings incorporating doctors from other prisons in the region so as to share information and best practice.
Healthcare at Leyhill engages the patients in the provision of the service through implementation of a simple questionnaire. It was introduced in May 2010 and designed to be accessible and simple to complete and was handed out to all residents by healthcare staff. The results are discussed through the regular clinical governance forum and with healthcare staff. Through this the service can be tailored further to the needs of the prisoners.
HMP Leyhill have been Highly Commended in 2011 by the WHO for the development and delivery of best healthcare to meet the needs of prisoners at HMP Leyhill through integration with community healthcare services.
Medical Team at HMP Eastwood Park win International WHO Award
The medical team of Pathways Healthcare Centre in HMP Eastwood Park, is celebrating after having won a prestigious international competition organised by the World Health Organisation (WHO). The competition forms part of the WHO's Health In Prisons Project (HIPP), the role of this project is to support Member States in improving public health by addressing health and health care in prisons, and to facilitate the links between prison health and public health both at national and international level.
The winning team includes Bristol Community Health. All of the staff have worked hard since 2005 to bring a community model of medical care to the all-female prison, mirroring the care and environment of a normal NHS practice. Dr Stephen Illingworth and Mrs Cath McCarthy were the original architects of the scheme at Eastwood Park. Speaking of the award, Dr Illingworth said: "This is very much a team effort involving a number of overlapping providers including Bristol Community Health, Hanham Health but also HM Prison Service; South Gloucestershire Primary Care Trust; Bristol Community Health; Lloyds Pharmacy; Serco Health and Avon and Wiltshire Mental Health Team. I am very proud of the whole team. It is a tremendous achievement to have our work recognised by the World Health Organisation in such a world-class competition."
Dr. Lizzie Stafford, who entered the team in the competition, said: "We are really proud of what we have achieved. Many of the prisoners come from difficult backgrounds and often have a number of medical issues when they are admitted. We have worked closely with the prison Governor and the staff to use time wisely and ensure the prisoners is given a comprehensive health check and the best possible medical care."••
HMP Eastwood Park is a remand prison and the average length of stay is less than a month, working within this tight timescale makes things more complicated. Dr Ellie Carslake, also a member of the winning team, said: "The team seeks to make the best use of the time that patients are in the prison to address their medical needs and provide the support and education that will help them to access health care more appropriately when they return to the community."
The ambitious and ground-breaking work at HMP Eastwood Park was a clear winner in the international competition. The judges were struck by the breadth and depth of the care that was provided by such a small team and recognised that the concept could be used more widely to the benefit of prisoners elsewhere.
We provide healthcare coordination, nursing and GP services to the 24 residents of Vinney Green Secure Unit for young people.