Cardiff and Vale University Health Board response to the Health, Social Care and Sport Committee inquiry into the provision of health and social care in the adult prison estate

Introduction

1. Cardiff and Vale University Health Board (CVUHB) welcomes the opportunity to contribute to the Health, Social Care and Sport Committee’s inquiry into health care provisions in prisons in Wales.  This paper provides the Health Board’s written response to the areas highlighted by the Committee as part of their inquiry.

Background

2. HMP Cardiff, is a category B prison serving the courts in the Eastern half of South Wales. The prison is a remand facility with high turnover of prisoners. It has an average of 252 receptions per month and an estimated 3024 annually. The age distribution of the prison population on 1^st May 2019 was:

Age Range	Number of Prisoners
18 – 30	295
31 – 40	252
41 – 50	112
51 – 60	38
61 – 70	5

3. CVUHB provides a range of services to men residing at the prison.  These include:

· 24/7 primary health care services comprising nursing and GP staff.  The out of hours services at weekends is a contract service through which a GP is either available by phone or in person. 

· Mental health team based on site during weekday daytime hours, comprising a range of nursing, medical and allied health professionals staff.

· Visiting community dental service.

· Visiting optician.

· Sexual health services including patient testing and education sessions.

· Visiting podiatrist.

4. Approximately 45 WTE CVUHB staff representing a range of grades and professions are permanently based at HMP Cardiff, focusing on physical and mental health needs. 

Responses to each of the areas being addressed by the inquiry are as follows:

The effectiveness of current arrangements for the planning of health services for prisoners held in Wales and the governance of prison health and care services, including whether there is sufficient oversight.

5. There is a Partnership Board in place, agreed and established between CVUHB and HMPPS, which meets on a quarterly basis and is supported by a range of operational groups (either health led, prison service led, or jointly managed).  Over the last two years our organisations have taken steps forward in developing our relationship and partnership working.  Annually agreed objectives are in place, reflecting issues at the health and justice interface.  The Partnership Board reports back into each organisation through corporate business routes. 

6. CVUHB is confident that the governance arrangements for conducting business are robust.  Both organisations work well together to address and resolve day to day operational challenges and the Governors at HMP Cardiff are good patient advocates.

7. Future planning of health services and future proofing of services is challenging.  Configuration and classification of prisons as well as daily regime changes are led by the prison service. 

8. Whilst there has been good partnership working to respond to the day to day requirements, it is recognised that there is more work to do to on the future planning of health services to ensure they are able to meet the needs of the men at the prison. This includes looking at the models of care and the resources required.  CVUHB and HMPPS are jointly committed to progressing this.

The demand for health and social care services in Welsh prisons, and whether healthcare services are meeting the needs of prisoners and tackling the health inequalities of people detained in Welsh prisons. 

9. As HMP Cardiff is a remand facility, there is a high proportion of prisoners who have short sentences and therefore being able to meet all their needs during the time they are at the prison can be challenging. There are good working arrangements in place to respond to the day to day requirements, however there are plans to undertake a more detailed assessment of need to inform the planning of services on a longer term basis. This will take into account the way in which services are currently delivered and whether these need to be revised, as well as considering the resource requirements.

10.All of the men received at HMP Cardiff are provided with an initial health screen, which takes place over the first two days from arrival and involves an assessment of all physical and mental health needs.  Most of the men arriving at HMP Cardiff have poorer health than the general population but being a remand prison the men are generally young.  We see high numbers who are alcohol and drug dependant (including prescription drug), and have mental health needs. We also see high rates of Blood Borne Viruses (BBV), such as Hepatitis C. Chronic diseases such as diabetes and asthma are also common amongst this population. As part of the review of services we will be undertaking this year, we will look in particular at the needs in relation to substance misuse and mental health.

11.The table below illustrates the demand for primary care services:

	January 2019	February 2019	March 2019
Admissions to HMP Cardiff	324	308	300
Number of referrals to In-reach Mental Health Team	246	161	216
Number of GP Appointments Available NB this is the number of GP appointments (including urgent appointments) that were available as there is no way currently of counting requests for appointments.	408	432	372

12.In terms of delivering equivalence, in many areas our delivery of services is equivalent to the services offered in the community.  We can, for example, offer a same day GP appointment for urgent needs and a GP service is available out of hours.

Month 2018	Average days waiting for a routine GP appointment
January	8
February	7
March	9
April	10
May	14
June	12
July	11
August	16
September	16
October	16
November	10
December	14

13. There are other areas where we struggle to meet demand, including our Primary Mental Health and Substance Misuse services.

14. Mental Health services work towards providing primary mental health support at an equivalent level to those received in the wider community. The Welsh Government targets under Part 1 of the Mental Health Measure require an assessment to be undertaken within 28 days but this can be a challenge. Whilst the vast majority of men are seen within this timeframe, many leave prison without the assessment taking place due to the level of turnover.

15. The Mental Health team have very limited resources to meet the Primary Mental Health targets as it was historically set up and funded to provide secondary mental health care and treatment.  It is unable to provide the short term treatment and support as comprehensively as the Measure requires due to a lack of trained Psychological Therapists within the service.

16. There is also a lack of Crisis Resolution support within Mental Health services at HMP Cardiff. The Mental Health team struggle to find capacity to support urgent responses and there is no out of hours provision for Mental Health crisis support within the prison.

What the current pressures on health and social care provision are in Welsh prisons, including workforce issues and services, such as mental health, substance misuse, learning disabilities, primary care out of hours, and issues relating to secondary, hospital-based care for inmates. 

AND

How well prisons in Wales are meeting the complex health and social needs of a growing population of older people in prison, and what potential improvements could be made to current services.

17. There are a number of pressures and challenges around providing healthcare in a prison setting, including:

a. The difficulty in ensuring prisoners are able to complete treatment as they are usually housed at HMP Cardiff for a short period due to its remand function.

b. Reliance on prison staff to support clinics within the prison (such as escorting men to and from clinics, and providing a security presence at clinics) which can impact on the number of patients who can be seen during health care sessions.   This hampers delivery of care and can lead to patients missing required treatment.   Justice and Health appointment systems are not aligned/integrated, and men also frequently do not attend health appointments due to a clash with other appointments such as legal or family visits.

c. High numbers of prisoners who are drug dependant and/or have mental health needs.

d. Blood Borne Viruses (BBV) testing is a challenge due to no designated staff to do this, and this impacts directly on the Health Board’s ability to deliver against the World Health Organisation (WHO) BBV elimination targets.

e. Prisons have a significant role to play in helping to deliver elimination of Hepatitis C (and B) in Wales.  The prevalence in most Welsh prisons is approximately 10%.  Many of these individuals come from marginalised communities and/or are individuals that do not access traditional health care models very easily or readily.  Prison provides a good opportunity to test and treat these individuals and thereby reduce the number of infected individuals in Wales.

f. Prison lock-downs or custodial staff shortages can result in BBV sessions/clinics within the prison being cancelled.  This means that we miss opportunities to test at risk individuals and treat those that are infected.  Each missed opportunity is also a general risk to the wider community due to the risk of onward transmission. 

g. Due to the movement of prisoners across the prison estate the healthcare staff can experience challenges in ensuring that the prisoners receive the appropriate treatment and follow up.  Lack of timely notification about movement of men or release dates also hampers forward planning of care (e.g. being released without medications).

h. Missing medication or not completing treatment is a problem because patients may not achieve cure but also may develop resistance, which means they may be more difficult to treat.   This also threatens the whole elimination programme as resistant infection could then be spread in the community.

Workforce

18. We have a number of main workforce challenges, including:

a. Retaining staff at Band 5 nurse level due to a lack of varied work and a lack of progression opportunities.

b. Lack of varied work for the small staff complement means that nursing work focuses on the dispensing of medication to large numbers of men, taking up approximately half the nursing time each day.  Due to the remand status of the prison, men cannot have their medication ‘in possession’ as readily as in prisons with more stable populations.  While dispensing medication is a routine nursing duty, a disproportionate number of hours are given to this, with nurses finding more job satisfaction in providing more ‘hands-on’ care to patients, e.g. wound care or the management of chronic illness.

c. Lack of progression opportunities – prison nursing often attracts talented, caring and resilient nurses who thrive in the challenging custodial environment.  The low staffing complement means that higher banded roles rarely become available, and excellent staff are quickly recruited by other clinical teams.  There is work in progress to support a sustainable future workforce plan.

d. Attracting salaried General Practitioners (GPs) – we consider ourselves fortunate that our service is supported by 2.18 WTE GPs (four individuals) but are aware that this is a specialist area which has been hard to recruit into.

e. Whilst we have nurses who have been trained in asthma and diabetes care we currently do not run Chronic Disease Nurse-led Clinics due to staffing/resourcing pressures.   

19.Referrals can be made to Local Authority Social Care if we feel that we cannot meet the complex needs of a prisoner within the healthcare service.  If extra support is needed for their discharge into the community we have a single point of contact.

20.We have excellent links with Palliative Care services and work jointly with District Nursing services when caring for those at end of life.

21.Our vision is to enhance the skills of our nurses through training programmes that are available through Macmillan following a meeting with the Macmillan Strategic Partnership Manager of Wales.

Mental Health

22.The Mental Health team has been fortunate to have a stable workforce over the past few years.  There have been no major issues with recruitment and retention of staff.

23.There has been an increasing demand for more dedicated prescribing time from Mental Health services and a review of the workforce is currently being undertaken by the Mental Health Clinical Board to ensure resources are being used effectively.

Substance Misuse

24. The UHB currently provides specialist substance misuse services including substance misuse prescribing, and a substance misuse specialist nurse.  This is supplemented by an additional full time substance misuse nurse, funded through the Substance Misuse Action Fund and commissioned by Cardiff and Vale Area Planning Board.  The Police and Crime Commissioner also funds a substance misuse Tier 2 service within the prison as part of the Dyfodol contract which provides psycho-social interventions and liaises with other services to ensure continuity of support on release from prison.

25. Total receptions in HMP Cardiff from 1 April 2018 – 31 March 2019 was 3993. This number may not be unique individuals as some men come in multiple times during a year.  The substance misuse nursing service accepted 1835 men onto their caseload during this period and there are currently 150 men on the nursing caseload requiring opiate substitute treatment.

26. All individuals requiring substance misuse interventions are assessed by the tier 2 team on the first and second day of admission, with the relevant treatment for that individual being initiated as quickly as possible, which is usually within 2 weeks due to the numbers of men and limited nursing capacity.  Following a review of substance misuse treatment in 2018, prisoners now have access to opioid substitution treatment prior to release, in order to reduce the risk of individuals being released and overdosing on narcotics.   The nursing and medical team in the prison also arrange for prescriptions to be continued for individuals on release.

27. The main issues in relation to substance misuse are:

a. Capacity, due to the large percentage of prisoners with substance misuse issues

b. Communication between the various elements of the substance misuse service (NHS staff/Dyfodol workers and community substance misuse services use different IT systems)

c. Individuals being released or moved at short notice which impacts on planned treatment/arrangements for continuity of care

Primary Care Out of Hours

28.There are pressures in ensuring provision of Primary Care Out of Hours services due to the limited options for providing this service.  In Cardiff this is currently a contracted out service and there are not many providers who specialise in this area.  We are conscious that although our current arrangements are robust there is a risk in this area, due to the limited field of alternative providers, should the current provider withdraw from the contract at any point.  Due to the stringent vetting requirements needed in the prison incorporating this service into the UHB’s general out of hours service would be difficult.

Secondary Care, (hospital based services)

29.The main challenge is transferring men to hospital and the pressure this places on the prison to provide security escorts.  CVUHB has commitment from the Prison Service of up to four escorts per day.  The current level of resource does not always enable all requests for clinic appointments outside the prison to be accommodated; therefore prisoners are reviewed and prioritised based on their level of need.

30.The workforce levels and overall funding for the prison healthcare service has an impact on the provision of hospital based services.   For instance, the service does not currently have an on-site physiotherapist so all patients with possible musculoskeletal (MSK) issues have to be sent to hospital, which can frustrate prison staff and impact on their relationship with healthcare staff.  A greater provision of nursing staff would also allow for improved triaging of patients, resulting in more efficient use of GPs and ensuring that health issues are tackled in a preventative, rather than reactive, fashion, reducing the number of patients who deteriorate and need to access hospital-based care.

Date	Total external (hospital) appointments	CVUHB	Other Health Boards
Jan 2019	51	38	13
Feb 2019	50	36	14
March 2019	59	54	5

If there are sufficient resources available to fund and deliver care in the Welsh prison estate, specifically whether the baseline budget for prisoner healthcare across Local Health Board needs to be reviewed.

31. The baseline budget for prison healthcare does need to be reviewed.  Expenditure for healthcare at HMP Cardiff for 2018-19 was as follows:

Pay Non-Pay or Income	Income/Expenditure type	Total Budget (£)	Total Income / Expenditure (£)
Income	Substance Misuse Grant	(58,876)	(58,876)
	Other income	(5,952)	(6,776)
Total Income		(64,828)	(65,652)
Direct Pay	Management, admin & clerical	82,295	84,084
	Medical and Dental	302,392	295,279
	Nursing (registered)	864,701	892,722
	Nursing (unregistered)	215,072	258,268
	Other pay	124,426	162,988
	Mental Health Inreach provision	280,548	280,548
Total Pay		1,869,434	1,973,889
Non-pay	Clinical	174,886	196,389
	Other	107,978	112,925
Total Non-pay		282,864	309,314
Grand Total		2,087,470	2,217,551

32.The current budget allows for the provision of the existing service, which doesn’t deliver in all areas e.g. chronic disease management. There is little scope for innovation. The budget level was historically set when health staff TUPE’d into heath boards in 2012 when there was a lower level of remand related receptions 

33.As HMP Cardiff is a remand facility, staffing establishments have not been changed to reflect the change in service model being delivered.

34.Despite the acknowledged high level of mental ill health within the prison population it should be noted that the funding for Mental Health services is only 13.5% of the overall prison health allocation.

What the current barriers are to improving the prison healthcare system and the health outcomes of the prison population in Wales

35. We have made some good progress in terms of improved number of GP daytime clinics, maintenance on opiate substitution therapy, and BBV screening but this has been done without any additional resource to prison health services.  As a consequence some areas of our services are extremely fragile as a result.  We need to ensure that services are properly resourced so that the healthcare provision is robust and can be delivered reliably and consistently.

36. We are very good at responding to operational issues, but having better foresight into establishment changes and the overall direction of HMPPS would be helpful.

37. Recruitment and retention of staff to work in a prison environment, as detailed above.

38. The electronic records system used in prison, System 1, does not provide the level of information reporting desired to ensure good information with which to plan healthcare services for the prison. This is partly due to the resource available to operate and analyse the system.

Summary and Key Messages

39. We have a positive working relationship with colleagues at HMPPS Wales and the Governor and her team at HMP Cardiff.  Together we are aligned in our work to keep men safe and treated with dignity and respect.  However this is a challenging environment.    In summary:

a. It is difficult to future plan services

b. The impact of prisoner movement through the prison estate has an impact on Health Boards’ ability to deliver healthcare

c. Mental health provision, particularly primary care mental health, is inadequate

d. Substance misuse provision is not in line with services provided in the community

e. We have great staff but we struggle to retain certain groups.

40.We recognise the need of all sectors (health, housing, probation) to work together, supporting health outcomes to ensure we do not solely rely on prison health (or imprisonment) to meet health needs.  This is critical given the issues faced in prison in terms of completing treatment and because patients can often move between services before, during and after treatment. This is an area which nationally we would welcome more focus on.