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PRISONER HEALTHCARE
The aim of the healthcare service is to provide prisoners with access to the same quality and range of health services as that available to those entitled to General Medical Services in the community and which are appropriate to the prison setting.
The provision of healthcare is a statutory obligation on the Irish Prison Service as defined in the Prison Rules 2007.
Prisoners have been identified, in health strategy documents, as having significant health deficits relative to the “average” health status of the general population and as such should be considered a ‘special needs’ category. Imprisonment can provide an opportunity to address these deficits.
General Overview of Service Developments
The key services provided by prison based healthcare services are primary care and chronic disease management, addiction and mental health.
Throughout 2008 there continued to be significant developments in healthcare service provision in prisons including:-
• The implementation of the nursing management structure
• The introduction of professional pharmacy services to all prisons, with the exception of Cork prison (which is due to be introduced in 2009).
• The opening of an additional 10 beds in the Central Mental Hospital for the treatment of acutely mentally ill patients (including prisoners)
• Addiction counselling services rolled out to 13 prisons/places of detention
• Addiction Nursing posts assigned to Mountjoy Prison,
• Contract awarded for the provision of Drug Treatment Pharmacy Services in Mountjoy/Dóchas,
• The publication of a Drug Treatment Clinical Policy to provide guidance to practitioners regarding various clinical issues that may arise in treating addiction in prison.
Prisoner Medical Records System (PMRS)
Management of healthcare risk, through effective record keeping has been a focus throughout 2008 and this has been achieved in the main by the implementation of PMRS. This provides all healthcare staff with access to the patient medical record, which facilitates better clinical decision making.
Healthcare Structure
The Irish Prison Service Healthcare Standards which were developed in 2004 and represent an outline of practical provision of care at institutional level were externally audited in 2007 and reported on in 2008. The Healthcare Directorate have focused their efforts this year on improving the application of this standard.
Primary Care
Prison doctors are responsible for the primary medical care of all prisoners including:
• The medical assessment of all new receptions within a specific time frame
• The ongoing general medical care of prisoners
• Prescribing a course of treatment and monitoring that treatment for its duration
• Referral for specialist opinion where appropriate
• Liaison with other professionals involved in the overall therapeutic care and well-being of the prisoners
• Screening prisoners for relevant diseases
• Ensuring the provision of vaccination programmes for prisoners
The Irish Prison Service currently employs 20 doctors on a full and part-time basis while other specialist services are provided using private contract arrangements and service level agreements with the HSE.
Nursing
Implementation of the nursing management structure was completed in 2008. There are now Nurse Managers in all the closed prisons and complex Nurse Managers in the three main prison complexes; Mountjoy, Cloverhill/Wheatfield and Midlands/Portlaoise respectively. This has significantly impacted on the coordination, organisation and quality of healthcare services in the prison system. It has enabled the development of accountability structures to ensure better healthcare risk management and that the centrally generated healthcare policy is applied at a local level. In addition it has facilitated practice development initiatives such as nurse led vaccination, diabetic, phlebotomy, mental health, men’s health, viral screening clinics, etc., to evolve in line with healthcare strategy.
These initiatives will improve access to and provision of a high quality of care for prisoners, who have a well documented need.
Community links to nursing and other services are essential in providing effective throughcare and discharge planning as prisoners will at some stage return to their communities. Having effective links in community settings will ensure safe handover of care and reduce risk to both the prisoner and the community at large.
2008 also saw the development of Addiction Nursing posts, mainly in Mountjoy as that facility had a significant number of prisoners requiring drug treatment.
Pharmacy Services
Following a tender competition, and the award of contracts, professional pharmacy services have been introduced to all prisons, with the exception of Cork Prison (which is due to be introduced in 2009). The awarding of these contracts ensures that all prisoners in these institutions now have access to professional pharmacy services, on an equivalent basis to that available in the community, taking into consideration the constraints that custody imposes. Both the technical (supply) and professional (pharmaceutical care) elements of pharmacy service provision are now provided as part of these contracts.
While ensuring that all prescriptions are monitored and checked by a pharmacist, and dispensed on an individual patient basis, the introduction of pharmacy services also supports more effective through-care, as each prisoner’s dispensed medicines are now sent with him/her on transfer to another prison, thus ensuring continuity of essential treatment. Similarly, where appropriate, a prisoner’s dispensed medicines can be given to him/her on full or temporary release thereby supporting the continuity of necessary treatment until the prisoner can engage with the community healthcare services.
Professional In-reach Services
Cost benefit analysis has demonstrated that specialist tertiary services are best provided using an in-reach model of care. Where practical this is facilitated through Service Level Agreements with the Health Service Executive (HSE) or other relevant provider.
The development of such in-reach services has reduced direct costs incurred in escorting prisoners to external healthcare services and minimises disruption to HSE outpatient services (indirect cost saving to HSE). The provision of in-reach services has also been successful in facilitating a more integrated care pathway with community and statutory services.
Specific examples of professional in-reach services in place by the end of 2008 include the following:
• Dublin Dental Hospital (DDH) provides in-reach dental services in the 7 prisons in the Dublin area.
• The Central Mental Hospital, Forensic Mental Health Service provides 21 consultant-led in-reach sessions weekly by arrangement at all Dublin prisons and also in Portlaoise and the Midlands prisons.
• A consultant-led addiction service provides in-reach addiction services to Cloverhill, Wheatfield and the Mountjoy complex.
Drug Treatment
The Irish Prison Service Drugs Policy & Strategy, entitled “Keeping Drugs Out of Prisons”, continues to be implemented. The aim of the strategy is to eliminate supply and reduce the demand for drugs within the prison system through education, treatment and rehabilitation services for drug addicted prisoners. Particular initiatives include the provision of detoxification, methadone maintenance, education programs, addiction counselling and drug therapy programmes.
Working to fulfil the commitments contained in that policy involves the implementation of stringent measures to prevent drugs from getting into prisons while, at the same time, continuing to invest in services within prisons to reduce demand for illicit drugs in the prisoner population as well as meeting prisoners’ treatment needs.
Drug rehabilitation programmes for prisoners involve a significant multidimensional input by a diverse range of general and specialist services provided both by the Irish Prison Service and visiting statutory and non-statutory organisations.
The Irish Prison Service has committed significant investment in recent years to respond to addiction issues in the prison system. The most significant recent development has been the awarding of a contract for the provision of addiction counselling services to Merchants Quay Ireland. During 2008 this contract was rolled out, and addiction counselling services are now available in prisons and places of detention where prisoners require such a service. The addiction counselling service delivers approximately 1,000 hours per week of prisoner access to addiction counselling.
Dr. Mike Farrell and Dr. John Marsden’s report on Prison Drug Treatment Services in Ireland (March 2008), which was jointly commissioned by the Irish Prison Service and the Irish Medical Organisation, identified “system –wide evidence of the active Irish Prison Service investment in responding to drug problems in the prison system”. It highlighted the high level of need for addiction services among the prison population and the upward increase in the number of prisoners treated. This clinical evaluation confirmed that the Irish Prison Service drug treatment services are to the forefront internationally, particularly when judged against the numbers receiving methadone maintenance treatment.
The report also identifies the need to match the growth in drug treatment service provision with a commensurate development in pharmacy service provision. Since the report professional pharmacy drug treatment services have commenced in Mountjoy Prison and the Dóchas Centre.
The report attests that prison settings are a very important component of the overall response to drug problems in Irish society and that there is often a lack of recognition from other services in the community of the scale of activity and commitment of all prison staff in tackling such problems.
At present, any person entering prison giving a history of opiate use and testing positive for opioids is offered a medically assisted symptomatic detoxification if clinically indicated. Patients can, as part of the assessment process, discuss with healthcare staff other treatment options. These may include stabilization on methadone maintenance for persons who wish to continue on maintenance while in prison and when they return to the community on release. Prisoners who on committal are engaged in a methadone substitution programme in the community will in the main have their methadone substitution treatment continued while in custody.
Methadone substitution treatment is available in 8 of the 14 prisons (accommodating over 80% of the prison population). The graph below provides the number of prisoners who received opiate substitution treatment with methadone (detox, stabilisation or maintenance).
Methadone Treatment in Prisons
Drug users present with multiple and complex problems. The evidence would indicate that a multidisciplinary approach is needed to effectively care for this group and that maintenance of a personalised therapeutic relationship yields the best outcomes. With this in mind, specialist addiction nursing posts were developed in the Irish Prison Service with a view to streamlining care and through-care back into the community.
In 2008, a contract was awarded for the provision of Drug Treatment Pharmacy Services in Mountjoy/Dochas. Pharmacists are responsible for all aspects of drug treatment (mainly methadone) dispensing, administration, recording, ordering, storage, etc., thus ensuring that drug treatment is provided on an equivalent basis to that available in the community while meeting all legal and professional requirements. On average the pharmacists dispense and administer methadone to 220 patients each day, as well as participating in local clinical healthcare teams.
The Medical Unit in Mountjoy Prison has 9 places specifically allocated for the therapeutic drug free programme. This programme is 6 weeks in duration; the model used is a collaborative one using prison based staff and the community/ voluntary sector. Its aim is to assist prisoners in achieving a drug free status.
The Irish Prison Service has become the largest single provider of drug treatment in the State, treating on average 650 patients per month, and an annual total of 2,014 in 2008; of that figure 241 were newly diagnosed and had never been seen in a treatment facility in the community. Mountjoy has developed a coordinated approach to the management of addiction and has established a clinical addiction team, comprising a consultant psychiatrist in addiction, a GP expert in addiction, addiction nurses, drug treatment pharmacy services, and addiction counsellors. This has resulted in a more streamlined service, better assessment and through-care outcomes.
Mental Health
The prevalence of severe mental illness is significantly higher among prisoners compared to the general population. A study of psychiatric morbidity among Irish prisoners, Kennedy et al (2004), found rates of psychosis to be 7.6% among male remand prisoners, while sentenced prisoners exhibited levels of psychosis at 2.7%.
In view of the limitations of the prison environment, it is desirable that prisoners with a severe and enduring mental illness are afforded care in the most appropriate settings.
To properly discharge our responsibilities to prisoners with a mental health illness it is essential that we continue to integrate and further develop services, with statutory and voluntary partners. The provision of mental health service in prisons must form part of the overall community response.
A recurring difficulty, which has impeded progress on providing appropriate treatment to acutely mentally ill prisoners, has been the lack of capacity at the Central Mental Hospital (CMH) for prisoners. The waiting list for the CMH is reviewed weekly on the basis of reports following assessments and the relevant priority is attached to each likely admission. During the second half of 2008, the number of prisoners on the waiting list seeking admission to the CMH averaged 15 weekly. The Irish Prison Service and the CMH had numerous discussions seeking to resolve this matter. Subsequently the HSE agreed to open an additional 10 beds in the CMH in November 2008. The availability of the additional beds has been of considerable assistance to prison management and healthcare staff in tackling the waiting list for prisoners who require admission to the CMH. The number of prisoners on the waiting list for CMH reduced significantly following the opening of the new beds.
Current arrangements with the CMH provide 21 consultant-led in-reach forensic mental health sessions weekly. The prisons attended by the CMH are Arbour Hill, Cloverhill, Wheatfield, Mountjoy, Dochas, Training Unit, St. Patrick’s Institution, Portlaoise and the Midlands. In-reach consultant led psychiatric services are also in place in Cork, Limerick and Castlerea Prison. Clinicians in other prisons (outside of CMH catchment area) arrange transfers to CMH services (mainly via Cloverhill) where a prisoner requires a forensic assessment or access to an admission bed in the CMH.
A Prison In-reach and Court Liaison Service (PICLS) was established in 2006 in Cloverhill Prison by the forensic mental health services in response to the high rates of psychiatric illness amongst remand prisoners. This has proved successful in detection, early treatment and more appropriate disposition of prisoners with mental illness. It provides full-time psychiatric care five days per week, with a team composed of psychiatrists and psychiatric nurses employed by the HSE. In 2008, ninety-one patients were diverted to more appropriate community settings (67 community mental health facility, 24 general psychiatric hospitals).
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