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					Appendix 7




Health Needs Assessment

HMP Acklington and
HMP / YOI Castington




September 2009
Executive Summary

Introduction
The local strategic context influencing prison healthcare in Northumberland is summarised
within „Improving Health, Supporting Justice‟1. This 5 year strategic plan identifies a
programme for reducing prison health inequality, improving patient outcomes and optimising
value in a prioritised, phased and affordable way. The strategic refocus from „prison health‟
to „offender pathway‟ is an explicit acknowledgement of the importance of partnerships,
health and wellbeing and continuity of care. The „offender pathway‟ is greater than a clinical
service or single discipline and relies upon multi-disciplinary, holistic pathway approaches.
Within the NHS, High Quality Care for All establishes a clear overall vision for services and
staff – to make quality the organising principle for the NHS. Quality is defined as spanning
three areas: patient safety, patient experience and the effectiveness of care. The role of each
stakeholder patients, clinicians and commissioners within this transformation of services is
pivotal and the evidence supports high impact changes should take place across:
 Transformation of services – such as use of assessment tools to target care and by
     developing proactive services that segment and target patients at highest risk

     Transforming systems such as developing systems for sharing information between
      organisations, working partnership with social care, housing, education and across
      community services and secondary care.

     Transforming staff such as provide specific clinical training, train staff in team work
      and working with other organisations , train teams in quality improvement methods and
      working with service users to manage their own care.

Against this challenging backdrop, the evidence including that from prisoners and services is
of two prison health services that face these challenges and the opportunities with
determination and effort. In our conversations, it is apparent they have come a long way on
their won journey over the past years and that they have invested in resource and in
approach to making services better and more appropriate for needs.

Methods
Health Needs Assessments (HNA) facilitate the understanding of health needs within any
given population and help identify gaps in service provision, prioritise resources and play an
important role assisting decision makers in the planning, maintaining and improvement of
services. One of the prison performance indicators is that a comprehensive Health Needs
Assessment or refresh is undertaken every 12 months. Specific objectives of this HNA are:
     To establish baseline physical health status of prisoners
     To map current prison health service provision
     To identify prisoners‟ unmet physical health needs and gaps in service provision
     To document identified gaps in service provision and how unmet needs can be
       improved
     To develop a template that can be used in future to aid compliance with DOH
       requirements for an annual HNA

1 1
   „Improving Health, Supporting Justice, A five year strategic plan for improving North East offender
health and healthcare‟, 2009-13
http://www.countydurham.nhs.uk/Files/OffenderHealth/NEOHCU_Improving_Health_Supporting_Justi
ce.doc.pdf

                                                                                                     2
The Northumberland Prisons
HMP Acklington
HMP Acklington is one of two prisons located in Northumberland. It is a category C
establishment for male adult prisoners. It has an operational capacity of 946 prisoners
(August 2008). This has specific planning and logistical implications for service provision.
The population is thus split into 2 separate sites within the compound, comprising
     460 prisoners designated Vulnerable Prisoner.
     486 prisoners designated as „main‟
        TOTAL = 946


HMP Acklington has a significant population of older prisoners which is significant in terms of
providing appropriate health care services
   The age range in the prison in is 21 to 82 years.
   Currently 126 (13.3%) of prisoners are over the age of 55 years and 3.3% (31) are over
    the age of 65 years.
   Although small, the BME population in Acklington 5.4%
   The health care unit on site is a single story unit with a number of treatment rooms and
    office space. The provision is designed to accommodate the two distinct prison
    populations and to maintain their segregation across use. In addition, three treatment
    rooms are used on wings.

   The Chronic Disease register predicts that overall, the prevalence of at least one chronic
    disease is 24% and the risk increases considerably with age.
   Indicated by both the Chronic Disease Register and the audit of Inmate Medical Records,
    HMP Acklington asthma prevalence is considerably higher than community levels and
    higher than expected prevalence
   The prevalence of CHD indicated by HMP Acklington‟s CDR is 6% overall.
   The IMR audit estimates that 41% of prisoners are current smokers. This significantly
    lower than the national average amongst prisoners of 80%. However, smoking status
    was not recorded in 44 records and it is likely that this is a significant under
    representation due to incomplete recording
   The IMR audit estimated that 25% of the prison population suffered from depression (234
    people) which compares to an expected prison prevalence of 8%
   The data from the IMR audit suggests that 26% or 242 people have received a 1st Hep B
    vaccination
   For recreational drug abuse the figure is 57%, or about 535 prisoners which is slightly
    lower than expected prevalence. Again this might be due to under reporting at reception
    screening when the question
   In summary, the view of prisoners about the health services was very positive, they
    considered the gaps were a lack of 24 hour care, rapid access to audiology/hearing aid
    services
   Some positive work taking place around a variety of health promotion issues but gaps in
    terms of appropriate smoking cessation services (The waiting list is long)




                                                                                               3
Summary Recommendations
  A prison health promotion strategy and action plan should be developed in line with
   local needs and links with PCT healthy promotion services should be strengthened.
  Revise and update the patient information leaflet to ensure that it meets prisoner‟s
   needs. Information which might be considered to include is:
       1. How to access services and likely waiting times
       2. Services available and those most likely to benefit
       3. The responsibilities of prisoners when accessing services

        Better recording of diversity and equality themes (especially ethnicity)within service use
         to enable appropriate analysis planning and delivery
        Greater emphasis on understanding the needs of an aging population
        Explore the need for increasing 24 hour nursing support
        When system one is operational, the data should be used as a priority to audit use of
         the well man‟s clinics and other services
        Staff suggested that there were a number of opportunities for nurse practitioners to
         replace off site care with onsite - examples included addressing musculoskeletal
         problems or suturing.
        Given that at present 79 men in Acklington are eligible for screening it is unacceptable
         that they will not be able to access it at present until such time that the correct pathway
         is identified. We recommend immediate efforts to resolve this at a regional and a
         national level.
        Work has been successful in addressing waiting times for both urgent and non urgent
         dental appointments. The triage was not valued by the prisoners we spoke to.
        Greater effort on promoting oral hygiene across the prison service
        Consideration of the introduction of a feedback mechanism to prisoners to enable them
         to find out the status of their appointment, waiting times etc.
        Although a relatively new service, the GUM clinic has lower numbers of patients
         accessing it. From comparative needs assessments, we know that demand is high for
         GUM provision - within the audit of Inmate Medical Records; the number of
         consultations recorded for sexual health was high.
        We recommend that the services be publicised and targeted more proactively to build
         up service use.


HMP/YOI Castington
HMP/YOI Castington is one of two prisons located in Northumberland. It is a Juvenile and
Young Offender closed establishment, accommodating 128 sentenced and unsentenced 15 -
17 year old juveniles, 40 15 - 17 year old Section 91 trainees, 120 sentenced and 120
unsentenced 18 - 21 year old young offenders.
       Castington has a type 3 Healthcare Centre with in-patient facilities and nursing cover 24
        hours per day.
       Actual Occupancy 5th September 2009 is 378 prisoners
       50% of prisoners have sentences lea that 2 years
       Although small, the BME population in Acklington (7%) is larger than the BME population
        of Northumberland (1.95%).

       GP surgery is held every week day morning and waiting times for a routine appointment
        is 7 days, for urgent appointments, next session.




                                                                                                   4
   Paper based records were still in use and a conversion to System One electronic records
    was taking place. The lack of quality data reporting had a significant bearing on the
    Health Needs Assessment
   Expressed as a percentage of total numbers of patients seen, then the proportion of DNA
    each month spans from 9% in February 2009 to a massive 80% in March 2009.
   Indicated by the IMR audit, HMP Castington prevalence of Asthma is lower than
    expected prevalence in prison populations and prevalence expected in the community.
   The IMR audit estimates that 72% of prisoners are current smokers. This lower than the
    national average amongst prisoners of 80%. However, smoking status was not recorded
    in 4 records. It is likely that this is an under representation due to incomplete recording
   The IMR audit estimated that 12.5% of the prison population suffered from depression
    (51 people) which compares to an expected prison prevalence of 8% or 33 people for a
    depressive episode and 19% for mixed anxiety and depression.
   Data suggests that 85% or 347 people have received at least a 1st Hep B vaccination.
   The IMR audit suggests that 25% of the sample have been screened for Chlamydia.
   The audit of IMR highlighted a high number of injuries in the population, both during
    sentence time and upon arrival. For example at reception screening, 8 individuals
    presented with injury on admission (20%).
   There were 5 people in the audit who were identified with eczema which would equate to
    12.5% prevalence. There is no existing baseline information to compare against but it is
    estimated that around one third of the population will experience a skin problem in their
    lifetime1 and that skin complaints can account for 15% of a GPs workload.
   The IMR suggested a prevalence of 5% of ADHD
   As noted above, there are best practice examples of supporting unnecessary use of
    services to find out information about appointments and the example offered was from
    HMP Durham and their use of a telephone line to inform them about the status and
    progression

Summary Recommendations
 Like Acklington, good work around Health Promotion had taken place including user
  representation on a health promotion committee but there was no evidence of a health
  promotion strategy provided
 Monitor take up of secondary screening and ensure consistent use of the screening tool
 There is a lack of accurate insight into patient health and use of services based on
  diversity and equality information
 Discussion take place about the feasibility of specific clinic resource for skin conditions,
 Resource should be prioritised to support the effective targeting of smoking cessation
  messages across the prison population and the use of Social Marketing be considered
 Sexual Health GUM services should be more fully publicised and targeted more
  proactively to build up service use. At the time of the next HNA, the review of service
  data should be possible to test if supply is meeting demand and need.
 Considering referrals to secondary care, the analyses of data did not provide conclusive
  evidence but it suggests that the highest area for outpatient referral was for trauma and
  orthopaedics. As in Acklington, staff suggested that there were a number of opportunities
  for nurse practitioners to replace off site care with onsite - examples included addressing
  musculoskeletal problems or suturing.
 We recommend that staff training and development skills be reviewed at available
  opportunity to see how many staff have the skills for this and what requirements will
  support their use.


                                                                                             5
Contents


Chapter                                                                                                                          Page

1.      Introduction.................................................................................................................. 7

2.      Background.................................................................................................................. 9

     2.1 National Context ......................................................................................................... 9
     2.2 Methodology ............................................................................................................. 12

3. HMP Acklington ..............................................................................................................14

     3.1 Prison Profile ............................................................................................................ 14
     3.2 Health Care Service Profile......................................................................................... 17
     3.3 Activity Data - Commissioned Services ..................................................................... 23
     3.4 Methods .................................................................................................................... 31
     3.5 Discussion ................................................................................................................ 40

3.6 Recommendations .....................................................................................................53

HMP and HM YOI Castington .............................................................................................57

     4.1 Prison Profile ............................................................................................................ 57
     4.2 Health Care Service Profile......................................................................................... 59
     4.3 Activity Data - Commissioned Services ..................................................................... 64
     4.4 Methods .................................................................................................................... 68
     4.5 Discussion .................................................................................................................. 75

4.6 Recommendations .......................................................................................................82

     Appendix 1 – Prison Health Performance Indicators ......................................................... 85
     Appendix 2 – Summary of Notes of Prisoner focus group – HMP Acklington, VPs ........... 86
     Appendix 3 – GP Appointment Schedule .......................................................................... 88
     Appendix 4 - Summary of Epidemiology – Sample of Inmate Medical Records
     ACKLINGTON .................................................................................................................. 89
     Appendix 5 - Inpatient and Outpatient Episodes .............................................................. 91
     Appendix 6 - Health Promotion in Prisons Action Planning Model ................................... 92
     Appendix 7 - Summary of Epidemiology – Sample of Inmate Medical Records
     CASTINGTON .................................................................................................................. 93

References ..........................................................................................................................95




                                                                                                                                       6
1. Introduction

The local strategic context influencing prison healthcare in Northumberland is summarised
within „Improving Health, Supporting Justice‟2. This 5 year strategic plan identifies a
programme for reducing prison health inequality, improving patient outcomes and optimising
value in a prioritised, phased and affordable way.

Noticeable is the first sentence which highlights the importance of delivering fair,
personalised, effective and safe health care as proposed by Darzi (High quality care for all:
NHS Next Stage Review final report, 20083) and the challenges posed within custodial
settings. This inherent challenge –delivering prison based health care within restrictive
environments and systems – should not limit the values or aspirations of health care teams
and commissioners. The strategic refocus from „prison health‟ to „offender pathway‟ is an
explicit acknowledgement of the importance of partnerships, health and wellbeing and
continuity of care. The „offender pathway‟ is greater than a clinical service or single discipline
and relies upon multi-disciplinary, holistic pathway approaches.

Co-commissioning plans will form the basis of joined up planning and service delivery. The
opportunities of this approach include services which are commissioned regionally to provide
economies of scale, economies of specialism and joined up services across whole systems.
Across each of the needs assessment described within this document for example, the
importance of appropriate resourcing has been consistently highlighted. In addition,
solutions were also presented that maximised current resource in different delivery methods.

The seven health outcomes identified within „Improving Health, Supporting Justice‟ (and
outcome measures) are:


   1. Improved mental health and wellbeing
      Goals
      − Reduce suicide rate
      − Reduce self harm rate
      − Increase proportion of those diagnosed with depression who access
         psychological therapies
   2. Improved sexual health
      Goals
      − Increase uptake rate for Hepatitis B immunisation
      − Increase uptake rate for Chlamydia screening
   3. Improved patient experience
      Goals
      − Proactive, meaningful and influential communication and engagement
         between patients and the NEOHCU through bi-annual consultative meetings
         with each establishment
      − Conduct a survey of family, friend and carer understanding and knowledge of
         issues regarding healthcare via the Visitors‟ Centre
   4. Improved health and life expectancy of older people
      Goals
      − Increase the uptake of an appropriate assessment for those aged 59+ years




                                                                                                7
   5.   Increased healthy life expectancy and reduced mortality from CVD and COPD
        Goals
        − Increase smoking quitters
        − Offer CVD risk assessment programme to all aged 40-74

   6. Reduced drug/alcohol misuse
   Goals
   − Reduce drug related deaths in those released from custody


   7. Improved health and healthy life expectancy of those with a learning disability
   Goals
   − Increase % of prisoners with LD accessing appropriately adjusted healthcare


Within the NHS, High Quality Care for All establishes a clear overall vision for services and
staff – to make quality the organising principle for the NHS. Quality is defined as spanning
three areas: patient safety, patient experience and the effectiveness of care. The role of each
stakeholder patients, clinicians and commissioners within this transformation of services is
pivotal and the evidence supports high impact changes should take place across:

        Transformation of services – such as use of assessment tools to target care and by
        developing proactive services that segment and target patients at highest risk

        Transforming systems such as developing systems for sharing information
        between organisations, working partnership with social care, housing, education and
        across community services and secondary care.

        Transforming staff such as provide specific clinical training, train staff in team work
        and working with other organisations , train teams in quality improvement methods
        and working with service users to manage their own care.


Each of the prisons house distinct populations in terms of age and sentences and the
delivery of services to meet these different needs is well established feature of planning.
Less well understood and recognised were the characteristics of populations in terms of
attitudes, engagement with health care, barriers and motivators to behaviour change. Whilst
not explicitly articulated by health teams, the possibilities of social marketing approaches are
considerable in understanding the different prison audiences and using actionable insight to
influence both service delivery and health message.

The reality is that many inmates will have had little or no regular contact with health services
before coming into prison and the evidence of significant health inequalities and social
exclusion amongst prison populations is strong. As well as challenges, both these features
provide opportunity and impetus for health care teams to support significant health gain
amongst prison communities.




                                                                                               8
2. Background

2.1       National Context
Since 2007, prisons have been asked to collect a series of Prison Health Performance
Indicators; designed to measure the quality of prison health services and help achieve the
objective of NHS-equivalent standards. The collection is voluntary and these Performance
Indicators are monitored on a traffic light system - Green, Amber and Red. In 2008, as part
of the wider focus on quality and transforming community services, the indicators were
renamed „Prison Health Performance and Quality Indicators‟. This change was a result of the
intention to support services to assess how appropriately prisoner needs are met, how well
commissioned services map to health priorities and how stakeholders, especially prisoners,
value these services. These areas are particularly useful to consider across the health
needs assessment. The detail is included in Appendix 1.

In 2009 reporting (27/5/09) Acklington achieved 17 Green, 14 Amber and 3 Red. The areas
of red are:

         Equality and Human Rights
         Alcohol Screening, Intervention and Support
         Health Needs Assessment

In 2009 reporting Castington achieved 18 Green, 12 Amber and 4 red. The areas of red are:

         Discharge Planning
         Equality and Human Rights
         Health Needs Assessment
         Alcohol Screening, Intervention and Support


2.1.1. Good Practice Guidelines

The responsibility for prison health care has transferred to Primary Care |Trusts with the
remit that prison health services should be broadly similar to those in the NHS, including
taking the fullest opportunity to promote health and prevent illness. This means that the
National Services Frameworks and other NHS guidance applies; as well as specific prison
guidance. The most relevant NSFs are:

NSF for Coronary Heart Disease - The NSF for coronary heart disease was launched in
March 2000 and sets 12 standards for improved prevention, diagnosis and treatment, and
goals to secure fair access to high quality services. The standards are to be implemented
over a 10-year period.

National Cancer Plan - The Cancer Plan aims to reduce death rates and improve prospects
of survival and quality of life for cancer sufferers by improving prevention, promoting early
detection and effective screening practice, and guaranteeing high quality treatment and care
throughout the country. The Cancer Plan is particularly committed to addressing health
inequalities through setting new national and local targets for the reduction of smoking rates,
the setting of new targets for the reduction of waiting times, the establishment of national
standards for cancer services, and investment in specialist palliative care, the expansion and

                                                                                              9
development of the cancer workforce, cancer facilities and cancer research as well as
promoting earlier presentation of cancer symptoms by increasing awareness amongst the
population.

NSF for Mental Health - The NSF for mental health was launched in 1999, and is a
comprehensive statement on how mental health services will be planned, delivered and
monitored until 2009. The NSF lists seven standards that set targets for the mental health
care of adults aged up to 65. These standards span five areas: health promotion and stigma,
primary care and access to specialist services, needs of those with severe and enduring
mental illness, carers' needs and suicide reduction. The National Service Framework for
Mental Health recommends better mental health assessment for prisoners. In addition, the
Department of Health‟s NHS Plan calls for more comprehensive mental health services
within prisons. Changing the Outlook: a Strategy for Modernising Mental Health Services in
Prisons, outlined how extra staff providing In-reach services would offer comprehensive care
to prisoners with severe and enduring mental illness.

NSF for Older People - The NSF for older people was published in 2001. It sets new
national standards and service models of care across health and social services for all older
people whether they live at home, in residential care or are being cared for in hospital.

Specific issues to ensure compliance with the Older People‟s NSF and Disability
Discrimination legislation include:
    Falls prevention
    Provision of disability aids and adaptations
    A review of the physical environment and its suitability for older people
    Medicines management

NSF for Diabetes - 1.3 million people in England suffer from diabetes, and the number is
increasing. The diabetes NSF is a concerted effort to make sure these people, wherever they
live, receive the same excellent standard of care. Embodied in the NSF is the central value of
the NHS Plan - that good service is the outcome of genuine partnership between the patient
and the provider. The NSF, launched in 1999, should substantially reduce the suffering
caused by diabetes.

NSF for Long Term Conditions - The national service framework for long term conditions
was published on 10 March 2005. The aim of the NSF is to improve the lives of the many
people who live with neurological and other long term conditions by providing them with
better health and social care services

NSF for Chronic Obstructive Pulmonary Disease (COPD) - Chronic Obstructive
Pulmonary Disease (COPD) is an umbrella term covering a range of conditions including
chronic bronchitis and emphysema. It is a long term condition that leads to damaged
airways, causing them to become narrow, making it harder for air to get in and out of the
lungs. There is no cure for COPD, but it can be managed through drug therapy.

NSF for Children, Young People and Maternity Services - The Children Act 2004, and
guidance documents, such as „Every Child Matters‟ and the „National Service Framework for
Children, Young People and Maternity Services‟ apply to the prison service. In particular, the
NSF establishes clear standards for promoting the health and well-being of children and
young people and for providing high quality services which meet their needs. The NSF

                                                                                            10
recognises that certain children (e.g. looked after children, homeless, teenage parents, youth
offenders) get lost in the system and it is this that increases health inequalities. The
Children's NSF suggests closer partnership working, and referencing these as Children in
Special Circumstances (CISC). There are eleven standards covering the following areas:

   −     Standard 1 Promoting Health and Well-being, Identifying Needs and Intervening
         Early
   −     Standard 2 Supporting Parenting
   −     Standard 3 Child, Young Person and Family-centred Services
   −     Standard 4 Growing Up into Adulthood
   −     Standard 5 Safeguarding and Promoting the Welfare of Children and Young People
   −     Standard 6 Children and Young People who are Ill
   −     Standard 7 Children and Young People in Hospital
   −     Standard 8 Disabled Children and Young People and those with Complex Health
         Needs
   −     Standard 9 The Mental Health and Psychological Well-being of Children and Young
         People
   −     Standard 10 Medicines for Children and Young People
   −     Standard 11 Maternity Services

Every Child Matters
The 2003 green paper “Every Child Matters” (HM Government 2003) is the government‟s
overarching approach to the well being of children and young people. It sets out five key
areas to achieve this. “Promoting mental health for children held in secure settings”
(Department of Health 2007) sets out how these five areas relate to the secure estate.
The table below outlines these key outcomes:

       Every Child Matters:            Every Child Matters Outcomes for Children in the
       Five Key Outcomes               Secure Estate
       Be healthy                      Safeguard and promote their health, both physical and
                                       mental
       Stay safe                       Ensure they are safe from harm that they might inflict on
                                       themselves or each other
       Enjoy and achieve               Enable them to enjoy, develop and achieve their
                                       individual potential so that they become fulfilled adults
       Make a positive contribution    Help them to make a positive contribution to the
                                       community at large, by not engaging in anti-social or
                                       criminal behaviour and by contributing to activities which
                                       further the public interest
       Achieve economic well-being     Promote their social and economic well-being, by
                                       helping them to acquire the basic educational and
                                       vocational skills that will enable them to become
                                       responsible, independent adults



Relevant Prison Specific Guidance exists and these include:
    National Standards for Youth Justice Services (2004)
    Juvenile Expectations (HMIP 2005)
    A Strategy for Modernising Dental Services for Prisons in England
    Developing and Modernising Primary Care in Prisons
    A Pharmacy Service for Prisoners
    Health Promoting Prisons

                                                                                                    11
2.2    Methodology

2.2.1. Aims and Objectives

Health Needs Assessments (HNA) can facilitate the understanding of health needs within
any given population and help identify gaps in service provision, prioritise resources and play
an important role assisting decision makers in the planning, maintaining and improvement of
services. One of the prison performance indicators is that a comprehensive Health Needs
Assessment or refresh is undertaken every 12 months.

The aim of this Health Needs Assessment is to provide a structured assessment of the
physical health needs of prisoners to enable health services commensurate with the general
population to be provided for the prison community. Specific objectives are:
    To establish baseline physical health status of prisoners
    To map current prison health service provision
    To identify prisoners‟ unmet physical health needs and gaps in service provision
    To document identified gaps in service provision and how unmet needs and physical
       health can be improved
    Develop a strategy to meet identified gaps in service provision to bring the service in
       line with government „green light‟ targets and best practice
    To develop a template that can be used in future to aid compliance with DOH
       requirements for an annual HNA

The Health Needs Assessment was conducted independently across HMP Acklington and
HM YOI Castington from May 2009 – August 2009 and a multi-method approach was used
as outlined below.

Epidemiological analysis, ie description of the prison and prison population
     Collect data on incidence/prevalence of disease from routine sources:
     An audit of Inmate Medical Records (IMRs).
     Summary of data from chronic disease register(s)
     Register of screening (BVV)
     Referrals to secondary care
     Disability register *                        *information from system
     Complaints forms
Comparative analysis
     Estimate expected incidence and prevalence using national sources of data.
     Comparison of actual with expected incidence/prevalence
Corporate data collection
Staff and patient feedback on healthcare services to be obtained from:
     Health Care Staff Feedback obtained through semi-structured discussion
     Service Staff Feedback obtained through semi-structured discussion
     Patient feedback obtained through semi-structured discussion with existing patient
        forums (The Prisoner Consultation Committee in Acklington)
Description of current services
Review of good practice

Consent was secured through the Caldecott Guardian regarding access to Inmate Medical
Records.




                                                                                            12
2.2.2. Structure of the report

Given the common policy context facing both institutions, the common approach and
methodology of the Health Needs Assessment across both institutions, this part of the report
is shared across both institutions. However, profiling of each prison, service description,
data reporting, analysis and recommendations will be institution specific. The structure of
this report will reflect that and commonality and difference.




                                                                                          13
3. HMP Acklington

3.1    Prison Profile

3.1.1. General Description

HMP Acklington is one of two prisons located in Northumberland. It is a category C
establishment for male adult prisoners. It has an operational capacity of 946 prisoners
(August 2008).

Accommodation: 11 living units of various designs.
Regime
    Activities: PICTA (Main & VP), Contract Services (Main & VP), Woodwork, Tailors,
     Textiles, Industrial cleaning, retail workshops, Engineering workshop, Painting &
     Decorating, Bricklaying, Amenity Gardens, Market Gardens, Laundry, Education,
     Physical Education, Waste Management, Kitchen – all include accredited
     qualifications.
    Healthcare: No full time Medical Officer, no in-patients. An Intensive Drug Treatment
     Scheme (IDTS) has been introduced.
    Accredited Offending Behaviour programmes: Sex Offender Programmes,
     Thinking Skills Programme, STOP (Substance Treatment & Offending Programme),
     and Healthy Relationships.

Acklington was audited in April 2009 and achieved 86% for Standards Audit and 88%
National Security Framework.

HMP Acklington has a dedicated Vulnerable Prisoner Unit which means that there is a
specific segregation between these prisoners and those on main location. Vulnerable
prisoners, because of the nature of their offences, are kept apart from the other population.

This has specific planning and logistical implications for service provision. The population is
thus split into 2 separate sites within the compound, comprising
    460 prisoners designated Vulnerable Prisoner.
    486 prisoners designated as „main‟
       TOTAL = 946


 Category of prison:                 C Male Adult

 Security Status:                    Cat C Trainer prison

 Sex of prisoners:                   Male
 Capacity of Prison (Certified
                                     946
 Normal Accommodation) :
 Actual Occupancy 1st July 2009      939




                                                                                             14
3.1.2. Age Structure

The largest proportion of the prison population is 25 - 34, and nearly three quarters being
under 44. The age range in the prison in is 21 to 82 years, with the average age now being
approximately 36 years of age. Currently 126 (13.3%) of prisoners are over the age of 55
years and 3.3% (31) are over the age of 65 years. As of 13th September 2009, 79 prisoners
are over the age of 60 years.

The challenges facing an aging population are significant and discussed later in the needs
assessment.

Current age range in HMP Acklington

              Age                   Sentenced
                             (Average Daily Population)
                             Number            Percent
              5 -16             0                  0
              17-24           148                15.7
              25-34           313                33.2
              35-44           213                22.6
              45-54           143                15.1
              55-64            87                 9.2
              65-74            31                 3.3
              75-84             8                 0.8
              85-89             0                  0
               90+              0                  0
              Total           943               100%

3.1.3. Diversity of Prison Population

Although small, the BME population in Acklington (5.4%) is larger than the BME profile of
Northumberland (1.9%). The Largest BME Communities are of Asian descent, followed by
black communities and then dual heritage.

HMP Acklington Ethnic Profile              Number         %     SUBTOTAL
(September 2009)
White                                        883      94.34%
White – Irish                                  3       0.32%        94.66%
Black - Caribbean                              2       0.21%
Black - African                                1       0.11%
Black – Other                                  5       0.53%         0.85%
Chinese                                        3       0.32%         0.32%
Asian – Indian                                 2       0.21%
Asian – Bangladeshi                            3       0.32%
Asian – Pakistani                              6       0.64%
Asian – Other                                 16       1.71%         2.88%
Mixed- White and Black                         5       0.53%
Mixed – White and Asian                        1       0.11%         0.64%
Mixed - Other                                  5       0.53%
Other                                          1       0.11%         0.64%
Total                                        936      100.00%




                                                                                             15
3.1.4. Sentence Length

The majority of prisoners have sentences above 4 years (65%) and the largest numbers
have sentences between 4 – 10 years (427 or 45%). The proportion of lifers is over 15%
(143 prisoners).

             Less than 6      6         12      2–3      3–4      4 - 10   10 years   Life
               Months      months     months    years    years    years    to Life
                            to 12       –2
                           months      years
Number of             1           9        72      124      128      427        38       143
prisoners
Percentage        0.11%      0.96%     7.64%    13.16%   13.59%   45.33%     4.03%    15.18%
of total




                                                                                             16
3.2 Health Care Service Profile

3.2.1. Human Resources

 Nature of Human Resources                              Numbers (wte)       Employed by
 Prison Officers
             Dedicated Officer Support on Health Unit   1 wte on detailed   Prison Service
                                                        basis
 Other Health related professions
                              Occupational therapist    Nil
                      Speech and language therapist     Nil
                                     Physiotherapist    0.50                PCT contracted
                                        Pharmacists     1.00                PCT contracted
                               Pharmacy Technician      2.00                PCT employed
                                             Optician   0.20                PCT contracted
                                           Podiatrist   0.05                PCT contracted
                                            Dietician   Nil
                                                GUM     1.00                PCT employed
 Doctors and Dentist
                                                  GP    0.50                PCT contracted
                          General dental practitioner   0.60                PCT contracted
                            GUM (Including Nurses)      0.20                PCT contracted
                                     Other specialist
 Nurses
                           Registered General Nurse     12.50               PCT employed
                       Nurse with Specialist Training   1.00                PCT employed
 Managerial/admin staff involved in healthcare          5                   PCT employed
 Mental Health
                                        Psychologist    0.10                PCT contracted
                                         Psychiatrist   0.10                PCT contracted
                                             Nurses     3                   NTW employed and
                                                                            PCT contracted

3.2.2. Physical Resources

The health care unit on site is a single story unit with a number of treatment rooms and office
space. The provision is designed to accommodate the two distinct prison populations and to
maintain their segregation across use. In addition, three treatment rooms are used on wings.

       Physical Resource                   Numbers

 Consultation room/s                           1
 Treatment room/s                              4
 Administration office/s                       1
 Dental room                                   1
 Healthcare manager office                     1
 Treatment Rooms on Wings                      3
 Dispensing Room                               2
 Waiting Rooms                                 2



                                                                                               17
3.2.3. Description of Current Health Services

Description of Reception Health Screening
 Interview between prisoner and nurse and appropriate referrals made.
 Secondary Screening offered
 Local screening tool based on adapted Grubin screening tool
 An elderly assessment takes place for every prisoner over the age of 60 years.
 August 08 – July 09
Number of reception screening: 922
Referral for further assessment by GP: 322 (36%)

      General health screen carried out.
      BP and weight taken and any existing medical conditions recorded.
      Mental Health history taken
      Substance misuse history taken
      Medication risk assessment tool completed.
      Medication compact completed.
      Labour and gym status assessed
      Disabilities assessed and recorded.
      Referrals to appropriate clinicians made.
      Consent for information sharing signed.



Description of health care nurse-led services
Nursing Staff are accessed through a triage application process – applications made
available through wings and the prison.

An 80% proportion of 1 x WTE Practice nurse runs clinics specific to long term
conditions (20% to Castington)

      Nurse Triage clinic
      Smoking Cessation Clinic
      Secondary Health Screening Clinic
      Emergency nursing clinic
      Hep Vaccination clinic
      Elderly Assessment
      Practice nursing clinic.

Description of services provided by GP
General Practice is accessed through a triage application process – applications are
made available through wings and the prison. Appointments are made and assessed
with the nurse initially and then referred thereafter. Triage is decided depending on
the appointment type: Urgent, routine, 48 Hour, Medication Assessment. A summary
of the allocation and number of each across the GP week is provided at Appendix 3
     Records are electronic and the EMIS information system is used.
     GP surgery held every week day morning.
     Rota covered by 4 Doctors.
     Telephone advice and visits available when not on site.
     Out of Hours Service is provided through Northern Doctors, Week day
        afternoons and weekends


                                                                                        18
Description of the dental service
    6 sessions held every week with Dentist and Dental Nurse (Monday,
      Thursday and Friday)
    No hygienist currently accessible

Description of out of hours cover
    No specific out of hours dental cover available,
    Patients are referred to emergency hospital admission.



Description of Pharmacy services
    Pharmacist available on weekdays.
    Drugs are prescribed by the GP and supplied at set treatment times on wings.
    Medicines are dispensed, under the supervision of a pharmacist, in the main
      dispensary/pharmacy in the healthcare building. These medicines are then
      transferred to the wings to be supplied to prisoners
    Patient Group Directives are in place for some over the counter medication
    Not currently offering a community model of pharmacy provision as there is
      no dedicated clinics for pharmacy.



Description of Podiatrist services
    1 session held every two weeks.



Description of optician services available
    2 sessions held every two weeks



Description of G.U. / sexual health services
    1session held every week with In Reach GUM Service
    1 specialist Doctor and 2x GUM specialist nursing staff
    Advice, investigation and treatment equivocal to community GUM



Description of substance misuse services
    The IDTS commenced on 1st June 2008 as part of wave 2 roll out of a
      national programme.



Description of counselling services
    Bereavement counselling provided by MIND




                                                                                    19
Description of in-reach services (in mental health, specialist nurses etc) not
already covered
     Mental Health In-reach service provided by CPNs, Psychiatrist, Psychologist.
     2 x CPN
     1 x CPN Team Leader
     0.10 WTE Clinical Psychologist
     0.10 WTE Consultant Psychiatrist
     1x WTE Bereavement Counsellor (MIND)

No out of hours facility other than referral to hospital. The prison has a camera cell
and strip cell for those identified at risk to themselves or others.




3.2.4 Services and Interventions Available to Address Physical Health Problems

      Epilepsy                                Elderly Assessment takes place
      Asthma                                  A well man clinic is provided to
      Diabetes                                 specifically address these physical
      Coronary Heart Disease                   health issues and raise awareness and
                                                support for people with long term
                                                conditions.




                                                                                         20
3.2.5 Services and Interventions Available to Address Health Promotion

Health Promotion including:               There is no prison health promotion
    Sexual Health Promotion               specialist in place
    Blood Borne Virus
    Smoking Cessation Obesity            There is a prison health promotion
       (Healthy Eating and Physical        steering group which oversees strategy
       Activity)                           and health promotion activity – meets
                                           every 2 months with patient involvement
                                          General advice is given by staff
                                          There is an identified smoking cessation
                                           specialist and resource
                                          General advice is given by staff and
                                           there is identified sexual health
                                           promotion available through the GUM
                                           service
                                          Hepatitis screening is identified through
                                           screening and consultation; vaccinations
                                           available through nurse led clinics
                                          An initiative involving prison officers in
                                           Acklington and Castington, and health
                                           trainers is part of an initiative to reach
                                           staff in harder to reach settings and
                                           spread health messages across families
                                           and clients (including prisoners). Prison
                                           Officers attended Well Being Days at
                                           Castington and Acklington Prisons and
                                           were given health MOTs including
                                           cholesterol and blood pressure tests,
                                           body fat measuring, fitness tests on an
                                           exercise bike and tips to stay healthy.
                                           Displays and leaflets were also shared at
                                           the visitor centres at both prisons to give
                                           people visiting their family and friends
                                           healthy living advice.
                                          A health promotion forum is being set up
                                           to bring together health professionals
                                           such as health improvement
                                           practitioners and nurses with kitchen
                                           staff and prison workers to focus on the
                                           health of the prisoners and encourage
                                           healthy eating.
                                          A prison Gym offers support for
                                           prisoners through targeted sessions




                                                                                         21
3.2.5. Complaints

The figures represent half year numbers during the period of 1 January 2009 to June 2009.

The total number of complaints received during the period was 89, compared to 84 for the
period 2008; an increase of 9%. The greatest number of complaints by a long way was
around medication – both in terms of delays and in terms of prescribing. Next were
complaints by IDTS / Substance misuse and then complaints around waiting times.

Complaints are taken to a variety of forums including Senior Management Team and the
monthly complaints meeting. Plans to compliment the complaints process through
distribution and use of a comments card are underway. An audit of complaints procedures
was trialled in August 2009 but the number of returns was too low to interpret. (Evaluations
were distributed to the previous ten complainants and only two were returned).



                                          No of
Type of Complaint                       complaints
Waiting Times                              7
Medication delays                          13
Medication (Prescribing)                   24
IDTS / Substance Misuse                    11
Dentistry                                  7
Service Levels (General)                   4
Complaints against Staff                   5
Treatment Received                         4
Hospital Treatment                         4
Physio Therapy                             2
GUM                                        1
Others*                                    7

*Others includes:
    Equipment
    Disability Assessment
    Requests for Results

Source: Healthcare Complaints Report to IMB




                                                                                               22
3.3        Activity Data - Commissioned Services

Contract performance data collected from service providers.

      A. GP services:

          The average waiting time from a patient submitting a request for an appointment to
           them being seen by the GP was 4 days. This is longer than the 48 hour access target
           in the community.
          Graph 1 below shows the average trend of the number of patients is slightly upwards
           (see trend line below). From January 2009 to June 2009, the average number of
           patients reporting sick per month was 279 compared to 250 for the same period
           2008.




           Graph 1: Number of Patients reporting Sick at GP June 08 – June 09
           Source: Medical Report to IMB



      B. Dental services:

          The suggested number of sessions for prison dentistry is 1 session per week per 250
           prisoners2. At HMP Acklington this equates to 3.8 sessions per week. (The
           recommended session being at least 3 hours)
          From June 2008 – June 2009, there has been an average of 31 new prisoners added
           to the waiting list each month. The range being from 25 to 45 each month.
          Graph 2 shoes the number of prisoners in treatment each month from June 08 to
           June 09; the average amount of prisoners each month over this period was 217.
          Graph 3 shows the number of prisoners seen each month. The average number of
           prisoners seen per month June 08 – June 09 was 115.
          There were 315 missed appointments (DNA; Did Not Attend) over this period3 which
           works out as an average of 26 each month.
          In June 2009, the average waiting time from a patient submitting a request for an
           appointment to them being seen by the dentist for a ROUTINE appointment was 3
           weeks for VPs and 4 weeks for mains. The suggested standard* is 6 weeks or 42
           days.
          Graph 4 shows the waiting list times and the significant progress made in the past
           year to achieve the target waiting times.




2
    From the document - “Strategy for Modernising Dental Services for Prisoners in England” DOH, April 2003.
3
    June 08 – May 09

                                                                                                               23
       Graph 2: Number of Patients in Treatment with Dentistry Jan 08 – June 09
       Source: Medical Report to IMB




Graph 3: Actual Number of Patients seen each month June 08– June 09
Source: Medical Report to IMB




  Graph 4: Waiting Times Oct 03 – April 09 Source: EMIS Clinical IT. Dental Service Figures.




                                                                                               24
   C. Optometry services:

      Graph 5 highlights there has been a gradual rise in the number of prisoners on the
       waiting list over June 08 – June 09.
      Graph 6 shows the number of visits each month and the average number of prisoners
       seen during each month was 11.3, the range being from 6 to 18.




       Graph 5: Number of Prisoners on Waiting List for Optician June 08 – June 09
       Source: Medical Report to IMB




       Graph 6: Number of Prisoners seen during last visit June 08 – June 09
       Source: Medical Report to IMB




   D. Podiatry services:

      The average waiting time from a patient submitting a request for an appointment to
       them being seen by the podiatrist was 14 days.
      Performance targets for community health services within Northumberland Care Trust
       are that 100% of patients should be seen within 13 weeks.*

* Northumberland Care Trust Provider Services Performance Report, February 2009




                                                                                      25
   E. Sexual Health / GUM Clinic

Since commencement, there have been a consistent number of attendances to the GUM
service. There is a high number of DNAs although the lower service numbers may
exaggerate their relative size. In August for example, the actual number of patients seen was
less than half of the number of DNAs.
 The wait for urgent referrals is 2 weeks although out of hours emergency treatment is
    available through secondary care
 The waiting time for routine appointments is 4 weeks maximum but commonly 2 weeks




Graph 7: Monthly attendance at GUM Feb 09 – August 09 and DNAs Source: Medical Report to IMB



   F. Out of Hours:

During the period September 08 – August 09, twenty eight out of hour‟s activity was recorded
out of 107 total emergency admissions. Twenty six percent of the total emergency
admissions were out of hours.

              Total         During Hours       OOH         OOH Emergency
                                                                                 % OOH           % OOH
 Month      Emergency        Emergency       Emergency      Admissions
                                                                               Admissions      Preventable
            Admissions      Admissions       Admissions     Preventable
 Sept'08              15               12              3                  1           20%              33%
 Oct'08               14               10              4                  4           29%             100%
 Nov'08               10                8              2                  1           20%              50%
 Dec'08                7                5              2                  1           29%              50%
 Jan'09               10                5              5                  3           50%              60%
 Feb'09                8                7              1                  1           13%             100%
 Mar'09               10                8              2                  2           20%             100%
 Apr'09                5                3              2                  2           40%             100%
 May'09               11               10              1                  0            9%               0%
 Jun'09                5                4              1                  1           20%             100%
 Jul'09                3                1              2                  2           67%             100%
 Aug'09                9                6              3                  1           33%              33%
 Total               107               79             28                 19           26%              68%

The working group examining prisoner escort and bed watch activity identified that 68% of
the out of hours admissions were preventable. The financial costs of bed watches and
escorts have entailed a forecasted outturn of £206,100.


                                                                                                 26
    G. Referrals to secondary care

A review of the EMIS data from June 08 to June 09 shows the following referrals to
secondary care took place. Appendix 5 details the type and number of referrals. The
greatest number of referrals for Outpatients was for Trauma and orthopaedic treatment, (78)
then General Medicine (46) and Ear, nose and Throat (30). For Inpatients, the referrals were
for General Medicine (46), Colorectal Surgery (18) and Gastroenterology (16).

                                          No. of referrals made

         Inpatient                                            61
         Outpatient                                          592
         Emergency                                           108
         Declined by patient                                  32
         Cancelled by security                                    5
         Cancelled by detail                                      6
         Cancelled due to transfer                                1
         Cancelled by NHS                                         0

    H. Cancelled Hospital Appointments

Forty four hospital appointments were been cancelled June 08 – June 09 period. The
majority of these were due to the patient declining the appointment (73%), the proportion
cancelled by Detail was 14% and the proportion cancelled by Security was 11%. 2% were
cancelled due to prisoner transfer.

    I.   Nurse Services

The service areas described below include smoking cessation, well man, Hepatitis B
screening/vaccination and reporting emergency sickness. [Note the data reporting period is
August 08 – August 09, different to the other data sets]
   The average number of prisoners seen each month reporting emergency sickness by
    nurse led clinics is 63. (Graph 8)
   The number of prisoners seen each month varied from 47 in August 08 to a peak of 95 in
    January 09.




            Graph 8: Numbers of Prisoners accessing Nurse reporting emergency sickness



                                                                                         27
   The data for the cessation clinic




    Graph 9: Numbers of Prisoners accessing Smoking Cessation Service
    Source: Medical Report to IMB



   An average of 18 patients each month attend the well man clinic, the range being 8 in
    January 09 and 25 in August 08




    Graph 10: Numbers of Prisoners accessing Well Man Clinic
    Source: Medical Report to IMB



   Graph 11 shows the numbers of prisoners receiving Hepatitis B vaccinations – both
    1st vaccination and 3rd vaccination.
   The difference in numbers receiving 1st vaccination and 3rd vaccination can be
    explained by transfers or new inmates who have received 1st vaccinations in the
    community or other prisons.
   An average of 14 men were 1st vaccinated and an average of 18 men were 3rd
    vaccinated each month.
   In 2008 – 09, 255 men received a 3rd vaccination compared to 305 in 2007 - 08




                                                                                      28
                                                     st     rd
       Graph 11: Numbers of Prisoners accessing 1 and 3 Hepatitis Vaccination
       Source: Medical Report to IMB



   J. Integrated Drug Treatment Services

Greater detail about the activity within the IDTS service is contained within the specific IDTS
needs assessment document.
    From June 2008 to November 2008, 43 individuals received maintenance treatment,
       all of them Methadone, 1 person received detoxification treatment and 58 people
       received symptom relief treatment.
    15 service users commenced on methadone at HMP Acklington.
    Graph 12 shows the total number of patients on IDTS and the increasing number
       across that period.




       Graph 12: Total number of patients on IDTS August 08 – June 09
       Source: Medical Report to IMB




                                                                                             29
   K. Substance Misuse

      From June 2008 to June 09, 161 individuals were assessed for help with substance
       misuse issues. From December 2008 – May 2009, 46 of these individuals were
       added to the IDTS waiting list (57%).
      The average number per month was 12.4 prisoners and of these; an average of 8.7
       were prescribed medication for the symptoms of substance withdrawal.




Graph 13: Number of Substance misuse Assessments June 08 – June 09
Source: Medical Report to IMB



   L. Mental Health

      From June 2008 to June 09, 1871 individuals seen by Community Psychiatric Nurses
       (CPN) and Psychiatry. Graph 14 highlights that the overwhelming proportion of these
       appointments was with CPNs.
      An average of 127 patients were seen each month by CPNs during this period, or
       1653 people in total.




Graph 14: Proportion of patients seen by Psychiatry and by CPN June 08 – June 09
Source: Medical Report to IMB




                                                                                       30
3.4      Methods

3.4.1. Epidemiology from data collection
       - Sample of Inmate Medical Records and Chronic Disease Register


Appendix 4 summarises the epidemiological data collected from the sample of Inmate
Medical Records (IMR) and compares this with national prevalence estimates and also
prevalence data for Northumberland by way of additional comparison.

The estimates from the IMR audit can be compared to the actual total numbers known and
recorded on the Chronic Disease Registers or other nurse records. This comparison gives
us an indication of whether numbers known to healthcare are likely to either represent under-
represent or over represent the real need for services. Alternatively the comparison could
indicate that need is greater (or lesser) in HMP Acklington than in other areas.


Chronic Conditions

The Chronic Disease register predicts that overall, the prevalence of at least one chronic
disease is 24% and the risk increases considerably with age. Prevalence amongst 25 – 34
year olds for example is 20% but this increases to 60% in the 75 – 84 year old ages.

      1. Asthma
         Benchmark national data from the Birmingham Toolkit4 suggests that we should
         expect a prevalence rate of 13% of diagnosed Asthma, giving a number of 122
         patients.

         The IMR sample estimates that we should expect 17.5% of the prison population to
         be asthmatic i.e., about 164 prisoners. The CDR highlighted 149 prisoners with
         Asthma, a prevalence of 16%.

         QOF data from Northumberland Care trusts suggests that diagnosed prevalence is
         around 6.4% which would translate to an actual prison population of 60 patients.

         Indicated by both the Chronic Disease Register and the IMR, HMP Acklington
         prevalence is considerably higher than community levels and higher than expected
         prevalence. It is possible that IMR include diagnosis of asthma which is based self
         reported conditions at reception screening, which may possibly lead to over
         recording.


      2. Epilepsy
         The IMR audit indicates a prevalence of 2% or 19 patients. This compares to an
         expected national prevalence in prisons of 0.8% or 8 patients and a community
         prevalence of 0.7% or 7 patients. The suggested prevalence in Acklington is higher
         than the expected numbers based on national estimates. The number of the CDR
         suggests a prevalence of 3% or 29 prisoners.

      3. Diabetes
         One diabetic patient was recorded on the IMR audit giving an estimated prevalence
         of 1% or 9 patients in the prison population. This is significantly lower than the
         prevalence in the community which is as high as 4.6%. National prison benchmark
         prevalence is 0.5% which would suggest a population of 5 patients. The number on

                                                                                               31
       the CDR suggests a prevalence of 4% or 41 individual with diabetes. Incidence
       significantly increases with age.

       The suggested prevalence in Acklington is slightly higher than expected numbers
       based on national estimates.

   4. CHD
       One patient was recorded on the IMR audit giving an estimated prevalence of 1% or
       9 patients in the prison population. This is significantly lower than the prevalence in
       the community which is as high as 5.1%.

       The incidence of IHD (ischemic heart disease) in prison populations is expected to be
       3% for 45 – 54 year olds and 10% 55 – 64 year olds. The prevalence highlighted by
       HMP Acklington‟s CDR is 6% overall. If the figure is broken down to age groups for
       45 – 54 year olds it is 6% and for 55 – 64 year olds it is 27%. Both are significantly
       higher than expected prevalence.

       The rate of hypertension revealed by the CDR is 11% overall and this significantly
       increases with age.

       The rate of COPD highlighted by the CDR is 16% and prevalence increases with age.


Lifestyle Issues

       Smoking
   5. The IMR audit estimates that 41% of prisoners are current smokers. This significantly
       lower than the national average amongst prisoners of 80%. However, smoking status
       was not recorded in 44 records and it is likely that this is a significant under
       representation due to incomplete recording. If all of these records were smokers then
       the prevalence would be 87%.

   6. BMI
       Data from general practice in Northumberland suggests an obesity rate of 21.8%
       which would translate to 263 prisoners within HMP Acklington. BMI data within IMR
       was very patchy and although height and weight are routinely measured, a query to
       calculate and record BMI on the EMIS system has only recently been established.
       BMI recording is therefore incomplete.

       Conversations from the prisoner focus group suggest that (over)weight is a concern
       for prisoners.


Mental Health

Characteristic                    General population                National Prison Population

Suffer from two or more mental    5% men and 2% women                 72% of male and 70% of female
disorders                                                             sentenced prisoners
Psychotic disorder                0.5% men and 0.6% women             7% of male and 14% of female
                                                                      sentenced prisoners
(Source: Social Exclusion Unit Report „Reducing re-offending by ex-prisoners‟, July 2002)




                                                                                                 32
   7. Depression
       The IMR audit estimated that 25% of the prison population suffered from depression
       (234 people) which compares to an expected prison prevalence of 8% or 75 people
       for a depressive episode and 19% for mixed anxiety and depression (150 people).

       Prevalence in Northumberland is around 10.8% which is significantly lower than
       prisons. The IMR in HMP Acklington suggests higher a slightly prevalence of
       depression.

       The IMR audit indicates prevalence of anxiety is 12% which is higher than the 8%
       predicted by national benchmark data (Generalised Anxiety Disorder). That suggests
       a population of 113 in Acklington.

       The IMR audit indicates a prevalence of 19% of insomnia which is lower than the
       54% suggested by national benchmark data.

   8. Suicide Attempts and Self Harm (Total)
       The IMR audit suggested a prevalence of 5% for suicide attempts (translating to 47
       prisoners) and 9% for non suicidal self harm (translating to of 85 prisoners).

Blood Borne Viruses

   9. Hepatitis
       Based on national estimates 8% of prisoners are likely to be positive for Hepatitis B
       and 9% for Hepatitis C.

       The data from the IMR audit suggests that 26% or 242 people have received a 1st
       Hep B vaccination. This figure corresponds with 2008 – 09 EMIS data.

       3 cases of Hepatitis C were identified through the IMR audit or a prevalence of 3%
       (translating to a population of 28) which is significantly less than expected. The data
       suggested that 8% of the sample had been screened.

   10. HIV
       Nationally expected prevalence indicates 3 cases. No cases were recorded in the
       random IMR sample.

   11. Chlamydia
       The IMR audit suggests that 5% of the sample have been screened for Chlamydia. It
       is likely that this is under reported given the use of GUM service within the prison.


Substance Misuse

Characteristic                    General population                National Prison population

Drug use in the previous year     13% men 8% women                    66% of male and 55% of female
                                                                      sentenced prisoners
Hazardous drinking                38% men and 15% women               63% of male and 39% of female
                                                                      sentenced prisoners
(Source: Social Exclusion Unit Report „Reducing re-offending by ex-prisoners‟, July 2002)

      The IMR audit recorded about 37% of prisoners having a history of alcohol abuse, or
       347 prisoners. This is lower than expected prevalence rates and it is likely that this is
       due to under reporting at reception screening where the question „Do you have a
       history of alcohol abuse/addiction‟ is asked.

                                                                                                 33
      For recreational drug abuse the figure is 57%, or about 535 prisoners which is slightly
       lower than expected prevalence. Again this might be due to under reporting at
       reception screening where the question „Do you have a history of drug
       abuse/addiction‟ is asked.

      The IMR audit also looked at which drugs prisoners had used. Cannabis, Cocaine
       and Heroin were the most often cited (28%, 27% and 26% respectively). 18% of
       people (a projected population of 169 people) were or had been IV drug users.

      Over 90% of drug users surveyed in July 2008 said they had a drug problem prior to
       entering HMP Acklington [Source: Northumberland IDTS Integrated drug treatment
       system Treatment plan 2009/10]


Consultations with Health Care

      We recorded how many consultations each prisoner had had within the past year and
       for what reason. The results were:

              Nature           Total No               Average Visits Per Person
              Physical           582                     6
              Mental Health      287                     3
              Sexual Health      32                      0.3
              Substance Misuse   16*                     0.16

              *5 patients were on daily dispensing regimes


       One individual was responsible for 24 visits to health care within the previous year.
       This audit shows that physical health is the greatest reason for consultation, followed
       by mental health. The frequency of visits per person is on average, 6 per individual
       but the range is varied.




Disability

The data on disability is voluntary and represents those who were willing to identify a
disability to be recorded on the prison database. The approximate prevalence of disability
then is 6% (55 people). The prevalence of disability increases with age and whilst 2% of
men aged 25 – 34 report a disability, 24% of men aged 65 – 74 do.




3.4.2. Baseline Assessment Tool

A baseline assessment tool was adapted from the Birmingham Tool kit and one used across
Durham prisons earlier in the year. It was used primarily as a data collection tool, designed
to segment and highlight data requirements more easy for local health care staff. Lessons
learned are that populating it early in the Health Needs Assessment Process is a significant


                                                                                             34
advantage. Doing so allows for a distribution and sharing of effort and the possibility of
refining data sources and quality.




3.4.3 Prisoner Focus Group

A fuller summary is included in Appendix 2 but this is a summary of the highlights of a focus
group which took place with 7 VP‟s immediately after their monthly Consultation Meeting with
the Prison Service. Officers left the room to allow the prisoners to speak openly and freely.

Patient Involvement / Consultation
    Valued being asked their opinions rather than through the health
       survey/questionnaire

Valued Services
    Very positive comments were made overall about the health care services within the
      prison highlighting that it was valued by the men.

Triage
     The biggest source of discontent was triage and it was felt that there were too many
       steps in the process of accessing health care which in some cases meant additional
       time was taken before a professional was seen. In addition, it was felt to be
       disrespectful to men and different to health care services outside.


Dental Services
    Very positive comments overall

      Dental triage was highlighted as a particular source of concern

      Prisoners not happy that if you are in last 6 months of sentence they won‟t treat you
       as they believe you will be seen outside.

Gym
      Particular praise for the Gym and the „Cardiac clinic‟

      Special mention for PT instructors in the gym who are very helpful and keep people
       safe.

      Over 50s Gym very welcome as is the potential of an over 50s wing.

„Planning for discharge‟
     As none of the men had experience of discharge planning, they were unable to
       comment. Their assumption however was that a „fit for travel medical‟ and drugs
       were issues immediately prior to release and that a referral to an a outside GP was
       made.

Medicines Management
 The group commented that some men had reported concerns about the „In Possession‟
  policy – specifically the limited number of medications which prisoners are allowed to
  hold (in terms of type and amount).


                                                                                             35
GUM
 GUM services – none had ever used it but were aware of other inmates accessing
  condoms.



Reception – Screening
    Variable experiences reported – some good reports about basics like Hep B
      injections and flu jabs but that it too quick and sometimes feels like a „tick box‟
      exercise.

Health Promotion
    Food relatively poor and being supplemented by purchases from shop it is therefore a
       major concern that shop prices rising out of step with outside. Recognition that there
       is now more salad and healthy options available but still not good quality. Main meals
       mostly carbohydrates.

      Knowledge that smoking cessation is available if required but the waiting list is
       several months long and the gym are available if you want to take them up.

      Holding own meds works well for some and not others. Anecdote about one inmate
       who was refused a medication that he received outside leading to a view that
       treatment is different outside than in.

‘Gaps in Services’
    Audiology/hearing aid services – very difficult to access in prison. Prisoner had to get
      a court order to receive treatment. Then had to organise it himself with the hospital.

      There is no evening „on – call‟ nurse. Anecdotes about people having heart attacks
       and having to wait hours for care. Anecdotes about self-harm happening after 7pm
       when there is only a first aider on duty.

      Suggestion about putting a service into the older men‟s wing when it is opened.

      No hospital unit.


Anything else?
    Personal hygiene is seen as an issue with other inmates not attending to it. Prison
      Officers ignoring it. Causes discomfort if you share a cell. If you try and address it
      you get accused of bullying. More should be done to raise awareness and support
      cleanliness.

      Issues of being informed about swine flu then not being able to access anti septic
       wipes.

      Would like more open consultation in the future, particularly by external parties.




                                                                                               36
3.4.4. Staff and Stakeholder Interviews / Focus Group

   −   Physical Facilities

          Better facilities on wings; the rooms available on wings are not suited to treatment
           and as a result, pressure is put on services by having to bring prisoners into the
           health centre. With an aging population, it was felt that the case for better
           „satellite‟ clinics is strengthened. IN addition, it was felt that pressure on Prison
           Staff would be lessened by providing more care closer to wings.
          Dispensing from current wing space is inadequate and not fit for purpose. Refit or
           resourcing should be prioritised here.
          Mental Health team space was felt to be inappropriate for needs and was often
           needed by other services. Facilities on wings were inappropriate for confidential
           consultation
          Waiting areas are inappropriate and standards are different to community
           settings.
          Opportunities to involve health in the development of new build facilities have
           been missed and it was felt that there had been no health care involvement in the
           discussion or planning.
          Office Space – several teams and services highlighted the lack of equipment
           (computers and telephones) which impacted on service performance.
          IT systems were anticipated to significantly change when the System ONE was
           introduced.
          Administrative support was felt to be too small to meet the needs of the growing
           team
          Lack of specific facilities within prison for mental health support – only one
           camera cell for example.

   −   Out of Hours Cover
        The lack of „internal‟ cover outside of the hours of 7.30am and 7.45pm was raised
          once – and acknowledging the role of out of hours GP service, it was felt that at
          least one health care staff member should be available within this time.

   −   Dental time

          More sessions required to reduce the waiting times

   −   Prison Officer Support

          Despite health care paying for Officer time, it is common for the Officer to be
           withdrawn, resulting in impacts on access and appointment times.
          In the past, training for Prison Officers has been positive (particularly for mental
           health issues) but capacity to repeat is limited.

   −   Partnership Working

          Communication was raised as an issue several times across conversations
             o Between the Prison and Health Care (mentioned frequently)
             o Between external GPs and Health Care
             o Between Hospitals and Health Care
                                                                                                  37
    And the difficulties highlighted were around familiarity with prison protocols and in the
    case of the prison, the tension between operating a penal environment and a health
    care environment.

−   Leadership and Support

       Staff highlighted the importance of visible leadership from clinical leaders and
        managers. This included the need for feedback from strategy and operational
        forums both internal and external to the prison organisation.

−   Elderly Population

       More chronic disease prevalent and it is anticipated that the needs of the is
        population with become more significant. Anticipate that new elderly
        accommodation will emphasise the need for specific planning to meet needs.
       Anticipated increase in dementia and age related mental health issues – has
        implications for prison staff skills as well as in terms of accommodation space

−   Discharge Planning

       Felt that there is room for improvement but the context in which health staff work
        is challenging. The nature of sentencing can make forward planning difficult. It
        was felt that information is passed on from Probation / Prison at short notice and
        that service planning is not joined up – the failure of probation to engage or
        consider health care was mentioned.


a. What do you think is done particularly well from health care point of view?

Comments were:

   Excellent team work among staff and multidisciplinary working.
   Felt that all services were good and that contracted staff responded flexibly to needs
    to provide additional sessions where possible. (limited by funding in some cases
    however)
   Dentistry was highlighted as a valued service in several instances
   Supportive management
   Gaps in health promotion but these are being addressed with the development of
    activity and a group
   The increase in GP sessions (but this has meant less nurse consultation space)
   IDTS and methadone dispensing
   Felt that good efforts are made to involve prisoners in the planning of care but
    recognised that there is always room for improvement. The Health Promotion group
    was cited as good example to learn from
   Higher level of care than the community as prisoners able to access GP, dentist and
    specialist.
   Mental health services are quicker.




                                                                                           38
b. Do you think there are any gaps in the healthcare services delivered at this
   Prison?

Gaps identified were:

   Capacity to develop smoking cessation service is under pressure
   Nurse Educator Role – join up training, best practice and capability with health
    promotion, harm reduction activity
   Not making the best use of wing base facilities – largely because they are
    inappropriate.
   Delays in appointments at times due to overstretched prison staff.
   More time for health promotion activity.
   Harm Reduction – health promotion activity and peer to peer work but dependent on
    space
   Issues of Bowel Cancer Screening programme not resolved
   More regular CPN input.
   Nurses to take up more advanced roles.


c. Do you have any suggestions for ways in which the health of patients at this
   prison could be improved?

Suggestions were

   Dietary improvement.
   Education about health issues.
   More dentist clinics.
   Health promotion advice.
   Nurse Educator / Health Promotion Specialist role




                                                                                    39
       3.5          Discussion

       (Summary of Findings and Identification of Needs)

       3.5.1. Ethnicity

       No record of ethnicity was kept in prison health records and consequently, the services have
       no way of recording or monitoring use of services amongst BME communities. There is
       therefore no way of establishing if access to services and experience of services is true for
       groups of prisoners who are more marginalized such as BME prisoners. This was one of the
       Prison Health performance Indicators which was „red‟ and therefore not achieved.




       3.5.2. An Aging Population


       Table 1: Age distribution of prisoners 2003 - 2008

       The data from age distribution across the prison population over previous years shows that
       there has been a consistent aging population within HMP Acklington. Since 2003, there has
       been an average of 127 prisoners aged over 55 years each year. The elderly population of
       Acklington is significantly higher that the English average of 2.9% (male prisoners)4


                                                                  Ages
           0 to 4   5 to 16   17 to 24   25 to 34   35 to 44   45 to 54   55 to 64   65 to 74   75 to 84   85 to 90   over 90   Number
2008        0.0%      0.0%       9.9%      37.9%      21.9%      16.6%       9.1%       3.5%       1.0%       0.0%      0.0%         955
2007        0.0%      0.0%       6.4%      40.2%      24.8%      15.8%       8.1%       4.0%       0.7%       0.1%      0.0%         905
2006        0.0%      0.0%       2.3%      41.1%      26.5%      15.6%       9.9%       3.7%       0.8%       0.1%      0.0%         841
2005        0.0%      0.0%       0.2%      42.1%      29.4%      15.4%       7.2%       3.9%       1.6%       0.2%      0.0%         944
2004        0.0%      0.0%       0.1%      41.6%      29.2%      15.1%       7.9%       4.3%       1.5%       0.3%      0.0%         952
2003        0.0%      0.0%       0.1%      36.0%      30.6%      16.9%       9.7%       4.6%       2.0%       0.0%      0.0%         904


       Without specific modelling, it is difficult to accurately predict the future population profile; a
       fact compounded by the transient nature of the population. However, there is an increased
       chance that the profile with continue to show a large older population and a good chance that
       the number of those in the prison over the age of 60 will increase.

       Given the number of prisoners with longer sentences (15% have life sentences, 4 % have 10
       years to life and 45% have 4 – 10 years), it is possible that this will contribute to an aging
       population as these men continue through their sentences.

       The nature of sentences might also impact on the profile in so far as the prison has a
       dedicated VP unit which tends to facilitate those with sexual offences. The courses that are
       run are not widely available across the whole of the prison system. These courses can
       frequently become a sentence planning request, often from the parole board so there are
       many prisoners who are keen to move to Acklington for this reason. National data suggests


       4
           Older prisoners in England and Wales: a follow-up to the 2004 thematic review, referenced later

                                                                                                                                40
that the majority of men in prison aged 60 and over (56%) have committed sex offences5. In
addition, it is also possible that as forensic technology has improved, alongside support
networks for victims, it has become easier to uphold convictions of historical sexual crime
which may result in a higher proportion of prisoners in mid – later years. This hypothesis is
untested however.

In the immediate future, changes such as the new build accommodation will mean a smaller
population during the period of building. However it is projected that once the new build is
completed, operational capacity will also increase. A reported figure is an increase of 12.
Developments such as a planned older prisoner accommodation unit will ensure that there
will be a consistent and permanent presence of older prisoners.

Planning is further complicated when factors such as the introduction of the IPP
(indeterminate public protection) prisoner status are considered. In certain circumstances,
the introduction of these orders may make it more difficult to predict how long some prisoners
will remain in the system. Whereas a prisoner has a sentence attached of X period, an IPP
is now indeterminate. This means they will only be released when the parole board are
satisfied that they are no longer a public risk. There will be additional difficulties in
incorporating this into population age planning.

In HMP Acklington, prevalence of disability it increases with age and 17% of 55 – 64 year
olds and 24% of 65 – 74 year olds report a disability. Given that identifying disability is often
voluntary, it is likely that the actual figure is higher.

In terms of supporting the North East Offender Health Strategic Goals:
       − Increase the uptake of an appropriate assessment for those aged 59+ years

Then the practice within HMP Acklington of providing an elderly screening for all older
prisoners is established and a recognised activity to help meet the needs of their older
population
.

National Evidence on Aging in Prisons

A Department of Health study conducted in 1999/2000 of 203 sentenced male prisoners
aged 60 and over in 15 establishments in England and Wales (about one-fifth of that total
population) reported that 85% had one or more major illnesses reported in their medical
records and 83% reported at least one chronic illness or disability when interviewed. The
most common illnesses were psychiatric, cardiovascular, musculoskeletal and respiratory.5

More than half of all elderly prisoners suffer from a mental disorder. The most common
disorder is depression which often emerges as a result of imprisonment.

A review by 2007 review by Birmingham University „Adult and older prisoners in the UK‟
highlights the relative invisibility of older prisoners vis a vis their younger counterparts – this
means that less attention is paid to their needs. The „Old and Quiet‟ Review6 was very
explicit in its recommendations of the need for specialist health and social care training and
interventions for staff.


5
    Prison Reform Trust, http://www.prisonreformtrust.org.uk/subsection.asp?id=273

                                                                                                  41
Related to the lack of staff awareness and skills around elderly prisoner needs, another
possible cause of social support needs is the absence of natural allies or supporters within or
outside of prisons (Tarbuck, 2001). One study found that 25% of older prisoners reported
bullying within prison (Ware, 2001). The „Old and Quiet‟ review found that „regimes and
relationships‟ frequently disadvantaged older prisoners and that 30% felt unsafe (HM
Inspectorate of Prisons for England and Wales, 2004). Nationally, the most recent review of
older prisoners7 (June 2008) highlighted the challenges facing health teams, of an aging
prison population. The Ministry of Justice was criticised for not having a specific strategy, in
contrast to the numerous strategies for older people in communities. The report highlighted
several areas of unmet needs for elderly prisoners including:

      Lack of physical adaptations
      Lack of needs assessment activity focusing on elderly populations,
      Lack of needs assessment in reception screening
      Lack of a strategic lead and identified local strategy for elderly prisoners
      Recognised prisoner carer schemes that provide training and pay for the carer role

For Health Services, the specific recommendations included:

      Every health services centre should have a lead nurse or manager who has
       responsibility for the care of older prisoners.
      Staff working with older prisoners should receive training in how to recognise signs of
       mental health problems.
      The prison should ensure that the social care needs of the ageing prison population
       are identified and fully met in conjunction with the responsible commissioner.


Good Practice examples and Resources Identified within the Report:

2.29 The production of the older prisoners training and resource pack led by NACRO and
Age Concern.
2.30 The creation of a pathway to care for older offenders: A toolkit for good practice by Care
Services Improvement Partnership South West Development Centre



3.5.3 Long Term Conditions (LTC)
The evidence strongly highlights the greater incidence of LTC within prison populations
compared with outside communities.

A 2006 paper8 examining the perceptions of prisoners to the barriers and opportunities for
managing long term conditions in a prison setting found that in some cases, the structured
prison regime allowed some to regain control over previously chaotic lifestyles but the lack of
access to a healthy diet and exercise facilities as well as lack of opportunities to practice new
health behaviours learnt whilst in prison, prevented a healthier lifestyle being adopted.
Another main theme was the ability of prisoners to negotiate access to health care services
and professionals who were key to supporting condition management strategies, support and
maintenance.

The health needs assessment identified a high prevalence of asthma at 17.5% and similar
numbers are recorded on the chronic disease register (164 estimated; 149 identified on the


                                                                                              42
register). There is a variation of 20 individuals but as noted in Appendix 4, the range is 94 –
236. Both figures are significantly higher than community prevalence.

The number on the epilepsy register is 29 or 3%, which is higher than would be expected
based on national estimates (0.8% or 8 patients). The IMR sample indicates 2% or 19
patients will be expected to have epilepsy.

The incidence of diabetes significantly increases with age amongst prisoners and the
suggested prevalence in Acklington is slightly higher than expected numbers based on
national estimates.

The prevalence of IHD (ischemic heart disease) in HMP Acklington‟s is 6% overall and the
figure rises significantly with age. For 55 – 64 year olds it is 27%. Both are significantly
higher than expected prevalence. The rate of hypertension revealed by the CDR is 11%
overall and this significantly increases with age and similarly the rate of COPD highlighted by
the CDR is 16% and prevalence increases with age.

The stock take of current services showed that there are nurse led clinics are available for
chronic diseases including asthma and diabetes. The numbers of men accessing the well
man clinic averages 18 each month but numbers are variable. The high prevalence of CHD
suggests greater needs within the prisoner population which are likely to increase with the
aging population.


In terms of supporting the North East Offender Health Strategic goal:
Increased healthy life expectancy and reduced mortality from CVD and COPD
       Goals
       − Increase smoking quitters
       − Offer CVD risk assessment programme to all aged 40-74

There is some room for improvement around improving the cessation services available and
ensuring that the Well Man Clinics provide targeted assessment, support and prevention
activity for those groups most at risk.

The data suggests that registers are relatively accurate in identifying need and that this need
is likely to increase. It is important that supply (i.e. appropriate services including nurse-led
services) takes place to match. The guidance from transforming community
services9highlights the research evidence for community services for people with long term
conditions and relevant action transferable to prison settings includes:

      encouraging self monitoring so people know when to seek help
      providing care based on people‟s level of need
      seeing service users as part of the healthcare team
      including specialist nurses as part of community teams
      considering ways to integrate health and social care


3.5.4 Sexual Health including Blood Borne Viruses

In general, there are higher rates of HIV, Hepatitis B and C and other sexually transmitted
infections within the prison population. In addition, barrier method protection, even when
available comes with stigmas and emotional and physical barriers to access and use.

                                                                                               43
The data from the IMR audit suggests that 26% or 242 prisoners received a Hep B
vaccination. This figure corresponds with 2008 – 09 EMIS data. In terms of coverage, this is
a low figure and given the identified prevalence of Hep B was lower than the expected
prevalence; it is possible that there is some under diagnosis.

The data identified a significantly lower prevalence of Hepatitis C than expected; 3% or 28
prisoners against an expected 8% prevalence. At a Confidence Interval of 95%, the highest
expected range of prevalence is 6.5%. The IMR audit suggests low numbers of prisoners
are screened for Hepatitis C and this might be a cause of the low prevalence rates.

Within Acklington, the focus group highlighted knowledge of condom availability but also
highlighted more negative attitudes towards the needing to access services.

In terms of supporting the North East Offender Health Strategic Goals:
       − Increase uptake rate for Hepatitis B immunisation
       − Increase uptake rate for Chlamydia screening

The evidence suggests that the progress on achieving Hep B immunisation could be
improved.

The newly established GUM service is building up patient caseload which confirms that there
is demand within the population. This is supported by information from the IMR audit which
highlighted the number of consultations concerning sexual health issues. The number of
DNA in August however is an issue to be explored further.

Evidence from the introduction of GUM services within other prisons suggests that with full
promotion across prison networks, the service can be a well used provision amongst
prisoners.

3.5.5 Mental Health

Offenders have very high rates of mental ill health; recent estimates suggest that up to 90%
of all those in custody will have some form of mental health need (OMHCP, 2005). To offer
prisoners the same kind of specialist care and treatment they would receive in the
community, Mental Health In-reach services have been introduced in prisons. These services
comprise multidisciplinary teams similar to Community Mental Health Teams and are
commissioned from the local Mental Health NHS Trust.

Given the prevalence of mental ill health inside prisons is ten times the rate outside, the
Sainsbury Centre for Mental Health reported that prison mental health care falls well short of
what is equivalently available in the community. As a comparison, in 2006, £20.8 million was
spent on mental health care in prisons which equated to £300 per prisoner. It is significantly
lower than what was spent in on commissioning services within the community.

In June 2009, the Sainsbury Centre also published a „The Top ten tips for PCTs‟ 10concerned
with commissioning mental health care in prisons and asked at Number 8, „Has the PCT
commissioned services to enable the resettlement of people with mental health problems on
leaving prison?‟ They proposed that continuity of care is essential for people both entering
and leaving custody and whilst recognising the difficulties of continuity of care, proposed that
key care co-ordinators should help released prisoners to navigate through the large number
of agencies they need to access.

                                                                                              44
The North East Offender Health strategic goals around mental health and wellbeing are to:

       −   Reduce suicide rate
       −   Reduce self harm rate
       −   Increase proportion of those diagnosed with depression who access
           psychological therapies

The IMR audit suggests that prevalence of depression is greater than expected and around
25% of prisoners had contacted health care services for reasons of depression. The large
qualification in this figure is that not all of these episodes resulted in a clinical diagnoses of
depression.

The audit suggested that 47 suicide attempts had been made across the total period of
incarceration (i.e. not in the previous year). Latest figures available to us were that in 2007,
3 deaths had resulted from suicide. Prisoners surveyed as part of the 2006 inspection of
HMP Acklington found 25% of prisoners, significantly more than the comparator of 12%, said
they had problems with feeling depressed or suicidal when they first arrived but fewer than
the comparator said they had received information about support for feeling depressed or
suicidal on their day of arrival.


3.5.6 Cancer Screening

One of the aims of the strategic plan for improving North East offender health and healthcare
is to:

„reduce the likelihood of severe health problems from cancer and chronic obstructive airways
disease by targeted programmes of cancer screening and smoking reduction strategies in
line with services available to the general population‟

In HMP Acklington, 79 men are currently eligible for Bowel Cancer Screening; a postal
screening programme. The experiences within HMP Acklington however are that the Bowel
Cancer Screening Programme had yet to be appropriately implemented within prison settings
where receipt of a screening test is dependent on registration with a NHS GP and postcodes
are matched to these records.




3.5.7 Provision of dental care

Prisoners valued the dentist service but perceive that the triage system in operation was not
satisfactory and added to have unnecessary waits to see the dentist. In keeping with
prisoner evaluation in 2007, there was some comment about waiting times but it is worth
noting that the waiting time for routine appointments in prison is less than the suggested
standard. (From the Strategy for Modernising Dental Services for Prisoners in England,
Department of Health, April 2003). The data highlights significant progress made in reducing
waiting times for both mains and VPs.

The guidance from „Reforming Prison Dental Services in England – a Guide to Good Practice
(2005)11 highlights the need to prioritise patients using triage systems; pointing out that
efficient and reliable appointment systems can help ensure that prison dental sessions are

                                                                                                 45
used to best effect. The range of approaches varies greatly from prison to prison however -
at HMP Askham Grange for example, the dentist will triage the patients when „the waiting
time for appointments is nearing the acceptable limit.‟ In other cases, triage is carried out by
nurses.

Locally, in Durham prisons, a telephone service, staffed by healthy care administration
provides up to date information about appointments, and is able to feedback information
quickly to prisoners. The staff and service interviews highlighted a need for increasing oral
hygiene services and oral promotion. From the data available, we cannot examine in detail
the demand for this service; the 2007 Dental needs assessment for example highlighted
demand for increased sessions.

Other best practice examples worth noting include the reduction of none attendances in
some institutions was achieved by better communication between medical staff and the
house block as well as working to more generally improve the flow of prisoners to clinics.

A final set of best practice examples around developing oral health promotion included a
range of approaches such as including dedicated time during consultations or holding oral
health campaigns.




3.5.8 Optometry Services

The number of patients being added to the waiting list has increased in number over the
period June 08 – June 09 whilst the number of patients seen has not increased accordingly.
This suggests there is a difference between demand for the service and the current supply.




3.5.8 Primary care

The prisoner focus group reported satisfaction with the GP service although the lack of
weekend provision of care (from GPs or from appropriate nurses) was an issue. The waiting
time for access to a GP was 4 days which is longer than the 48 hour access target in the
community. The number of patients reporting sick has increased slightly to 279 (January
2008 to June 2009) from 250 over the same period 2008.




3.5.9 Out of Hours Care

The main reasons for out of hours transfers are patients requiring monitoring overnight and
access to emergency services. The activity data for Out of Hours admissions (and those
preventable out of hours admissions) highlights the impact of factors including a lack of
inpatient facilities and a lack of 24 hour nursing care at HMP Acklington. Given the number
of prisoners with chronic disease and long term conditions within HMP Acklington is likely to
increase, then so too the pressures on out of hours care are likely to increase. There is
currently no provision to transfer prisoners to other institutions with in patient health care
facilities, nor is there any provision to cluster prisoners within prisons with access to
specialist health care services.
                                                                                                46
A recent paper to the North East Offender Health Commissioning Board highlighted the issue
and pressures on the services. Appraisal of options against a range of criteria (including
reducing clinical risk, reducing financial pressure and adherence to NICE and NSF
guidelines) proposed that extending nursing care to cover night time and weekends was a
beneficial option to consider.




3.5.10 Secondary care

The activity data shows that there are high levels of referrals to secondary care for certain
specialities and also high levels of cancellations.

The main specialities referred to for outpatients were:

 Speciality Area                       Number of Attendances
 Trauma & Ortho                                              58
 General Medicine                                            47
 Ear Nose & Throat                                           30
 Urology                                                     19
 Oral Surgery                                                16

Between 1st October 2008 and 31st July 2009



The highest areas for outpatient referrals were for trauma and orthopaedics. (A DoH study
suggests this is likely to be the result of assaults, self harm or accidental injury)12. The high
level nature of both these sources do not allow the HNA to recommend specific conditions,
which currently require referral to a hospital, that could possibly be treated in the prison
setting. Examples may include addressing musculoskeletal problems and orthopaedic
problems. It is possible that lower level data may identify any potential and this should be
explored further.

The rate of cancellations across for appointments to secondary care was less than 2%
(including declined appointment by patient, this rises to approximately 6 %.) This suggests a
relatively high compliance with appointments.




3.5.11 Continuity of Care – Resettlement

The importance of health and care planning has been stressed by successive research –
such for prisoners with mental ill health, for prisoners with continuing health needs and for
older prisoners. HMP Kingston13 for example, found that two main factors lead to the
successful resettlement of infirm, disabled or older prisoners. One was the very prompt
completion of a needs assessment by the local social services department and the other was
securing the necessary local authority funding for the prisoner‟s future accommodation well
before the prisoner‟s release from prison is due.

                                                                                                47
Within HMP Acklington, the Mental Health In Reach team and nurses within the health care
unit highlighted the difficulties with longer term planning for release. Additionally barriers
highlighted were a lack of understanding of offender health care systems by community
social and primary care services and incomplete partnership arrangements and relationships.




3.5.12 Patient, Public and Carer Involvement (PPI)

Work to engage patients in discussion about their care was evident in a range of approaches
– an audit of complaints, prisoner involvement in the health promotion committee, the annual
survey were some examples offered. No examples of engaging with prisoner families
through the visitors centre were offered. As with other activity, the influence of the custodial
setting on involvement strategies cannot be discounted. However the responsibility and
opportunities from involving patients in care are great.

The strategic goals of the North East Offender Health strategy involve improvements around
patient involvement (although at a regional level). There is some room for greater effort at an
institution level.

Best Practice Example – HMP Leeds
Implementing Patient Involvement within a Prison Healthcare Setting

A partnership approach was adopted through working with HMP Leeds staff; open and honest
communication was maintained whilst simultaneously respecting regulation and confidentiality. This
enabled a number of groundbreaking initiatives with patients at the heart of their inception and
implementation. At the core of the project was the creation of Healthcare Representatives (HCRs)
from the prison population. Findings and service changes included the reception care pathway being
changed because of patients needs not being met. Consulting with the prisoners highlighted that the
medical assessment process was stressful and rushed by the prisoners because they were desperate
to contact relatives

http://www.nhscentreforinvolvement.nhs.uk/docs/Involvement%20Awards%202009%20-
%20Case%20Studies%20-%20NHS%20Leeds%20and%20HMP%20Leeds%20.pdf




3.5.13 Information Management

The implementation of up to date clinical systems across the prison estate was an identified
priority for commissioners to bring enhanced patient safety, standardised activity data and
enhanced performance management. The adoption of System One was anticipated by staff
to be a real opportunity and training sessions had motivated and opened up future
possibilities.


3.5.14 Health Promotion

Effort is being made to develop health promotion activity and planning across the services
through the newly formed health promotion committee. The committee meets monthly
(alternating across Castington and Acklington sites) and has representation from prisoners
on it. Consequently, to date, health promotion has taken place opportunistically and
consequently, the opportunities for strengthening and systemising health promotion are
                                                                                                 48
significant across all service areas. Best practice for example highlights the concept of a
prison as a setting for health promotion. It follows the „settings‟ approach to promoting and
improving health, which concentrates on taking health promotion to people where they live,
learn, work, spend their leisure time or seek help. An action cycle for supporting health
promotion interventions and planning is included in Appendix 6.

No evidence of an up to date prison health promotion strategy and action plan was offered
and this is a significant gap. A strategy and developed action plan can contribute to a whole
prison approach to health. Opportunities exist for example to prevent the deterioration of
health during custody (mentioned by several inmates in the focus group) and also help
prisoners adopt behaviours to take back into the community on release.

Particular praise was received from both prisoners and staff about the gym facilities, staff and
their work to support physical activities. The gym targets different prisoner audiences
through different classes.

A specific health promotion area highlighted by prisoners was personal hygiene and the need
to raise awareness of standards and behaviour amongst prisoners.

The proportion of smokers within the prison highlights significant potential need and demand
for cessation services. The data for smoking cessation services however highlights the gap
between supply and demand.

As part of a developed health promotion approach, the opportunities for using social
marketing approaches within prison settings are considerable. Social marketing uses
detailed audience insight to understand the motivations, barriers and competition to
behaviour change. Audience specific messages can thus be constructed as well as using
that insight to develop service level interventions to segment and target different prison
audiences.




3.5.15 Medication and Pharmacy

The role of pharmacy in supporting health improvement and service development can be
considerable and we note the relevant national prison publications6 and White Papers7. The
White Paper aligns closely with the Darzi Review in promoting service development that is
more than treatment but where care is personalised, integrated of high quality and tackles
health inequalities.

It follows that pharmacy can play an important role in reducing a range of lifestyles risk
factors - obesity, smoking and alcohol consumption as well as having an important role to
play in discharge planning where medicines can be a major part of any discharge or transfer
of care and a significant risk.




6
  A Pharmacy Service for Prisoners (DH 2003):
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4007054
7
  Pharmacy in England (DH White Paper 2008):
http://www.psnc.org.uk/pages/whitepaper.html

                                                                                                          49
Moreover, the possibilities in developing the role of pharmacists to reduce service pressure is
also highlighted by the community example of Think Pharmacy First - a pharmacy minor
ailments scheme commissioned by NHS North of Tyne – is example of how pharmacy can
reduce the reliance on GP and nurse appointments, improve access and can reduce waiting
times. Think Pharmacy First offers patients who qualify the choice of going straight to their
pharmacist – without an appointment – for a consultation where they will be given advice and
free over the counter medicine, where appropriate, for minor ailments. They will be referred
to a GP where necessary.

A recent Review of Pharmacy Services within Acklington14 highlighted a clear baseline of the
service and made a corresponding set of recommendations. Consequently, this Health
Needs Assessment has not duplicated the information gathered. The recommendations
include emphasis on clarifying and strengthening lines of accountability to reduce confusion
over responsibilities, and consequently, reducing operational effectiveness, especially for the
pharmacist. Suggestions made include identifying a single named doctor to be accountable
for the dispensary services, which cannot be devolved to the pharmacist8. Its action points, it
proposes will provide a mechanism for clarifying responsibilities, free professional time and
facilitate modernisation of the pharmacy service. In addition , a Medicine Management
Forum needs is identified as needing to take a more active role in leading change through
the development of a strategy for healthcare.

The review of complaints (3.2.5.above) highlights the number of complaints received about
medication delays and prescribing. The data supplied to us was the result of an audit of
complaints in the first part of 2009). Some evidence from the Focus Groups suggests that
prisoners felt that in possession procedures could be reviewed to increase the type of
medication available. If this is not possible then it is possible that the rules and procedures
for in possession need to be communicated to prisoners.

In addition, the Review of Pharmacy Services highlighted the lack of medication reviews for
prisoners with chronic diseases, at least every 12 months.



3.5.16 IDTS

Specific needs assessment of IDTS was being undertaken and therefore not the focus of this
needs assessment. However, it is worth highlighting the key findings of the current IDTS
needs assessment. These included:

      −    A highlighted lack of opportunity for individual key working by the substance misuse
           nurses
      −    Additional funding to support the safe and effective delivery of IDTS, address capacity
           issues and support the development of a multi-disciplinary IDTS team
      −    Development and evaluation of the auricular acupuncture sessions
      −    Increased resource to support additional service from Mental Health Inreach Team or
           the provision of new services to support mental health provision across IDTS clients
      −    Greater resource to support clients upon release
      −    Development of user involvement mechanisms and activity


8
    Page 33, Review of Pharmacy Services in the Northumberland Prisons, February 2009

                                                                                               50
The high level of need and potential for increasing supply was noted within the IDTS needs
assessment:
    Results from a survey in July 2008 indicated that over a quarter of the 218
       respondents admitted to taking non-prescribed drugs within HMP Acklington –
       indicating that at least 262 of the June 2008 roll of 923 offenders classify themselves
       as drug users.
      Anecdotal evidence from prison officers suggests that the actual number of offenders
       using drugs in HMP Acklington could be in the region of two thirds on the Main estate,
       and half (having risen in the past 12 months and continuing to rise) on the VP estate.
       Using the June 2008 roll, this would equate to 322 on the Main block and 299 on the
       VP block – a total of 621 offenders.


The inclusion of new prisoners from Acklington populations into IDTS offers opportunities to
increase the referral of target groups into Hepatitis screening and vaccination programmes.


3.5.17 Training and Development

We note that in 2003, the Northumberland Prison Healthcare Initiative collaborated with a
number of local partners to develop training resources for prison health care staff and prison
officers. For health care staff, the aim was for staff to engage in routine skills development
with other primary care nursing teams in the locality and priority was given to help develop
collaboration between prison health care staff and non prison colleagues and services

A health promotion day, again with outside speakers, posters and informal networking
opportunities, was also organised. Opportunities were arranged for example for the rotation
of prison nursing staff within local accident and emergency and primary care services. These
initiatives represented a substantial effort in increasing the number of new outside contacts,
a new approach to encouraging such contacts, and deliberate inclusion of networking
opportunities.

Outcomes from the Prison Officer training showed changes in awareness, knowledge and
practice. Sixty-four per cent of prison officers who received the mental health awareness
training rated it helpful and 36 per cent very helpful. Regarding the prison officers' health fair,
fifty-seven per cent said they expected to make some use of what they had learnt in the
workplace and 22 per cent expected to use it a great deal. The success of the joint working
was acknowledged in late 2003 when the Northumberland Care trust/Prisons partnership
won the Northumberland, Tyne and Wear strategic health authority's modernisation award for
reducing health inequalities.

Healthcare staff highlighted the difficulties they face of a lack of understanding by external
staff (within Health and Social Care) and sometimes by prison staff. The point of including
this example of best practice is to highlight those features of successful approaches to
develop the capability of staff and to support collaboration between prison and non-prison
services.

More currently, the raft of Government policy and focus on strengthening the role of staff
within quality improvement makes the case imperative.
                                                                                                 51
“We must build both the capacity and capability across the whole range of
commissioning organisations... and provider organisations.... so that they have the
leadership and the skills to plan beyond the short term. These organisations must be
able to engage their clinical staff and communities in workforce planning and
education commissioning and link the workforce plans to their service plans. They
also need to be able to respond quickly to deal with changing Service requirements”

                                       A High Quality Workforce - NHS Next Stage Review15



3.5.18 Leadership

The case for developing capacity, confidence and capability is indistinguishable from the
need for transformational leadership locally within HMP Acklington. Transformational change
happens when those delivering care are motivated and inspired to do things differently. The
importance of visible leadership is helped by visible leaders and the comments from staff
engagement within this HNA highlight their belief that it is a prerequisite of transforming
services. More detail around leadership is outside the commentary of this HNA but it is worth
noting that the well-established NHS Leadership Qualities Framework9 sets the standard for
outstanding leadership in the NHS.




9
    http://www.nhsleadershipqualities.nhs.uk/

                                                                                          52
3.6 Recommendations


3.6.1 Health Promotion
  The work to develop health promotion should be supported to ensure that it continues
     and benefits from the future IT developments (in terms of understanding local needs).

    A prison health promotion strategy and action plan should be developed in line with
     local needs and links with PCT healthy promotion services should be strengthened.

    Drawing on the models in other areas, consideration should be given identifying a
     dedicated health promotion specialist post (working across a number of prisons).

    Peer to peer education and support should be developed further across health
     promoting activities.

    Social Marketing approaches should be spread across topic areas as an alternative
     means of engaging target audiences. Staff should identify and make use of training

3.6.2 Reception Screening
  There was a lack of consistency in recording information in notes and on the reception
     screening tool. With the full transfer of patient records to system one, this may be an
     opportunity to review screening to make sure it is fit for purpose and ensure staff use it
     consistently.

    Appropriate training should be given to healthcare staff on the completion of the first
     and second health reception screen forms to ensure accuracy and consistency. This
     should be regularly audited

    The available evidence is that reception screening is a stressful time for prisoners who
     may not want to discuss any medical problems, let alone mental; health issues or other
     sensitive information. The importance of a follow up screen is important within this
     context.

    Following from Reception Screening, effort should be made to ensure that every
     prisoner is offered and encouraged to take-up a general health assessment in the first
     week following reception. Monitoring uptake will allow additional analysis.

3.6.3 Patient Information
  Some discontent originated from what was perceived as poor feedback and poor
     knowledge of health care systems. There are a number of opportunities to address this:

    Revise and update the patient information leaflet to ensure that it meets prisoner‟s
     needs. Information which might be considered to include is:
        1. How to access services and likely waiting times
        2. Services available and those most likely to benefit
        3. The responsibilities of prisoners when accessing services
        4. Information about medicines, the role and contribution of pharmacy staff and
            rules / procedures specific to the prison.

    Explore and pilot a number of best practice examples reference in this HNA to support
     feedback to prisoners about waiting times and services. The dedicated telephone line
     example in Durham is an example we learned about in our interviews.


                                                                                               53
3.6.4       Monitoring diversity and equality
        The lack of accurate insight into patient health and use of services based on diversity
         and equality information is a gap. There is a raft of research and recommendations
         from the Department of Health into different health care needs of several communities.
         For example, people with disability and people from BME communities.

        We therefore recommend Health services should ask and record a patient‟s information
         to allow better analysis and interpretation of use.

3.6.5. An Aging Prison Population
 The evidence suggests that planning into understanding and meeting the health needs of
    an aging prison population should take place. Work should:
    − Include identification of the training and support needs of prison officer staff as well as
        health care staff
    − Make links across social services and which support excellence in discharge
        planning. (The evidence suggests this is particularly important for older prisoners)
    − Explore different models of service for long term condition management which include
        self care and specialisms within prison institutions.
    − Explore the carers roles within institutions (there are a number of best practice
        schemes to explore and test)
    − Explore the need for increasing 24 hour nursing support and we note both the future
        plans for telecare and the recent paper proposing increased nurse time in Acklington.
    − Related to this point is the demands made on Out of Hours services and introduction
        of both the telecare and 24 hour nursing support would reduce demands on the Out
        of Hours service.


3.6.6. Long Term Conditions
     Future needs assessments will be critical in identifying increases in diabetes, COPD,
        CHD and other conditions, to allow for rapid service realignment to meet needs.

          Improved levels of self management will need to be explored and this should include
           responses which support prisoners to practice new behaviours learnt whilst in prison.
           In future regimes for example, different ways of increasing exercise opportunities and
           healthy food provision will have to be explored. Such activity must build on other
           work in the prison environment (like gardening) where it will not be acceptable or
           tolerated that fresh produce is thrown away in skips rather than used to support
           healthier eating.

          When system one is operational, the data should be used as a priority to audit use of
           the well man‟s clinics and other services


3.6.7 Secondary Care
     The analyses of data did not provide conclusive evidence but it suggests that the
       highest area for outpatient referral was for trauma and orthopaedics. Staff suggested
       that there was a number of opportunities for nurse practitioners to replace off site
       care with onsite. Examples included addressing musculoskeletal problems or
       suturing. We therefore recommend that staff training and development skills be
                                                                                               54
        reviewed at available opportunity to see how many staff have the skills for this and
        what requirements will support their use.


3.6.8. National Bowel Cancer Screening Programme
     Given that at present 79 men in Acklington are eligible for screening it is
        unacceptable that they will not be able to access it at present until such time that the
        correct pathway is identified.

       We recommend immediate efforts to resolve this at a regional and a national level.


3.6.9 Dental Service
     In Acklington, work has been successful in addressing waiting times for both urgent
       and non urgent appointments. Whilst best practice suggests there is place for triage
       in prison dental services, the triage was not valued by the prisoners we spoke to.

       We recommend:
          − Increased effort on promoting oral hygiene across the prison service
          − Consideration of the introduction of a feedback mechanism to prisoners to
              enable them to find out the status of their appointment, waiting times etc.

3.6.10 Optometry Services

   In Acklington, the increase in patients being added to the waiting and the numbers seen
    suggests that there is still unmet demand for optometry services. We there for
    recommend increasing the number of sessions to reduce the wait time appropriately.

3.6.11 Smoking Cessation
 Resource should be prioritised to support the effective targeting of smoking cessation
    messages across the prison population.

    We make specific recommendation that exploration of Social Marketing approaches be
    considered to fully understand the needs and motivations of different target audiences


3.6.12 Sexual Health
 Although a relatively new service, the GUM clinic has lower numbers of patients
    accessing them. For comparative needs assessments, we know that demand is high for
    GUM provision. Within our own review, the number of consultations recorded from the
    audit of IMR, for sexual health was high.

   We recommend that the services be publicised and targeted more proactively to build up
    service use. At the time of the next HNA, the review of service data should be possible to
    test if supply is meeting demand and need.

3.6.13 Blood Bourne Viruses
     In Acklington, there is a lower rate of Hepatitis B Screening and vaccination than we
       would have expected and we recommend increased efforts to target men.



                                                                                               55
3.6.14 Mental Health
     Given the need within prison institutions is significantly higher (up to ten times higher)
       than outside, the provision of mental health services should be at least equivalent to
       those commissioned outside.

3.6.15 Patient / User Involvement
     We note the efforts at involving prisoners in their own care and in work across the
       health centre services. However, we believe that patient involvement should be
       greater than use of surveys to collect views. We therefore recommend that

      Together with Trust PPI Officers, local community Development Workers or Health
       Trainers, staff from the prisons produce a short patient involvement strategy and
       action plan.

      Training and best practice examples be prepared from other regional prisons and
       from across the country to identify innovative solutions to test out locally.

3.6.16 Pharmacy
     Noting the audit of complaints highlighted a number of complaints about medication
       delays and prescribing, we recommend that this is explored in more detail to identify
       where in the system the issue is.

3.6.17 Leadership
     We note the importance staff placed on being part of a strong team and their own
       responsibility in contributing towards leadership across the prison and we also note
       the importance of visible leadership from across the health care team,




                                                                                              56
HMP and HM YOI Castington

4.1    Prison Profile

4.1.1. General Description

HMP/YOI Castington is one of two prisons located in Northumberland. It is a Juvenile and
Young Offender closed establishment, accommodating 128 sentenced and unsentenced 15 -
17 year old juveniles, 40 15 - 17 year old Section 91 trainees, 120 sentenced and 120
unsentenced 18 - 21 year old young offenders.

Accommodation: Seven units of various design. Oswald Unit is a designated Section 93
Unit. Finian and Godric hold convicted and non-convicted juveniles. The other four units hold
remand and convicted 18-21 year olds.
Healthcare: Castington has a type 3 Healthcare Centre with in-patient facilities and nursing
cover 24 hours per day. Healthcare at Castington is commissioned by Northumberland Care
Trust. The Healthcare Centre has seven in-patient beds and a Primary Care area.

                                    Juvenile and Youth Offender
 Category of prison:
                                    Closed Establishment
 Sex of prisoners:                  Male
 Capacity of Prison (Certified
                                    408
 Normal Accommodation) :
 Actual Occupancy 5th
                                    378
 September 2009


4.1.2. Age Structure

Age structure not supplied




                                                                                          57
4.1.3. Diversity of Prison Population

Although small, the BME population in Acklington (7%) is larger than the BME population of
Northumberland (1.95). The largest BME communities are Black, followed by those of South
Asian heritage.

HMP/YOI Castington Ethnic               Number        %
Profile (September 2009)                                    SUBTOTAL
White                                         356    92%
White – other                                   3     1%         93%
Black - Caribbean                               6     2%
Black - African                                 2     1%
Black – Other                                   2     1%             4%
Chinese                                         5     1%             1%
Asian – Indian                                  2     1%
Asian – Bangladeshi                             0     0%
Asian – Pakistani                               1     0%
Asian – Other                                   4     1%             2%
Mixed- White and Black African                  3     1%
Mixed- White and Black Caribbean                2     1%
Mixed - Other                                   1     0%             2%
Other                                           2     1%             1%
Total                                   389         100%




4.1.4. Sentence Length
There are a large number of prisoners who have sentences below 2 years (almost 50%) and
the largest group is those with sentences below 6 months. The proportion of lifers is 11.8%.
The table reflects the relatively transient nature of the prison population.

                Less than 6      6       12         2–3      3–4          4 - 10   10 years   Life
                  Months      months   months       years    years        years    to Life
                               to 12     –2
                              months    years
Number of               50        38       49          38       21            49         1       33
prisoners
Percentage            18%     13.6%    17.5%        13.6%     7.5%        17.5%      0.3%     11.8%
of total




                                                                                                     58
4.2 Health Care Service Profile

4.2.1. Human Resources

 Nature of Human Resources                                 Numbers (wte)     Employed by
 Prison Officers
             Dedicated Officer Support on Health Unit      1.5               Prison Service
 Other Health related professions
                               Occupational therapist      x
                      Speech and language therapist        x
                                     Physiotherapist       x                 PCT contracted

                                               Optician    On demand basis   PCT contracted
                                              Podiatrist   On demand basis   PCT contracted
                                              Dietician    x
                                                 GUM                         PCT employed
 Doctors and Dentist
                                                     GP    0.5               PCT contracted
                             General dental practitioner   0.2               PCT contracted
                               GUM (Including Nurses)                        PCT contracted
                                       Other specialist    x
 Nurses
                          Registered General Nurse         12                PCT employed
                      Nurse with Specialist Training       x                 PCT employed
 Managerial/admin staff involved in healthcare             3                 PCT employed
 Mental Health
                                           Psychologist    On demand basis   PCT contracted
                                            Psychiatrist   0.1               PCT contracted
                                                Nurses     2.7               NTW employed and
                                                                             PCT contracted




4.2.2. Physical Resources

The health care centre is a single story unit with a number of treatment rooms, ward
accommodation and office space.

       Physical Resource                      Numbers

 Consultation room/s                              1
 Treatment room/s                                 2
 Administration office/s                          1
 Dental room                                      1
 Healthcare manager office                        1
 Treatment Rooms on Wings                         0
 Dispensing Room                                  4
 Waiting Rooms                                    1
 Hospital Ward                               1 (7 beds)



                                                                                                59
4.2.3. Description of Current Health Services

Description of Reception Health Screening
 Interview between prisoner and nurse and appropriate referrals made.
 Secondary Screening offered
 Local screening tool based on adapted Grubin screening tool

      General health screen carried out.
      BP and weight taken and any existing medical conditions recorded.
      Mental Health history taken
      Substance misuse history taken
      Medication risk assessment tool completed.
      Medication compact completed.
      Labour and gym status assessed
      Disabilities assessed and recorded.
      Referrals to appropriate clinicians made.
      Consent for information sharing signed.

Description of health care nurse-led services
Nursing Staff are accessed through a triage application process – applications made
available through wings and the prison.

An 20% proportion of 1 x WTE Practice nurse runs clinics specific to long term
conditions (80% to Acklington)

      Nurse Triage clinic
      Smoking Cessation Clinic
      Secondary Health Screening Clinic
      Emergency nursing clinic
      Hep Vaccination clinic
      Practice nursing clinic.

Description of services provided by GP
General Practice is accessed through a triage application process – applications are
made available through wings and the prison. Appointments are made and assessed
with the nurse initially and then referred thereafter. Triage is decided depending on
the appointment type: Urgent, routine, 48 Hour, Medication Assessment. A summary
of the allocation and number of each across the GP week is provided at Appendix 3
     Until recently, records have been paper based - System One has recently
        been installed. GP surgery held every week day morning.
     Telephone advice and visits available when not on site.
     Out of Hours Service is provided through Northern Doctors, Week day
        afternoons and weekends

Description of the dental service
    2 sessions held every week with Dentist and Dental Nurse
    No hygienist currently accessible
Description of out of hours cover
    No specific out of hours dental cover available,
    Patients are referred to emergency hospital admission.

                                                                                        60
Description of Pharmacy services
    Pharmacist available on weekdays.
    Off site pharmacy provision
    Drugs are prescribed by the GP and dispensed at set treatment times on wing
      dispensaries.
    Controlled drugs are dispensed through the health care centre with two
      qualified staff present
    Patient Group Directives are in place for some over the counter medication
    Not currently offering a community model of pharmacy provision as there is
      no dedicated clinics for pharmacy.

Description of Physiotherapist services
    0 sessions held every two weeks.



Description of optician services available
    Sessions provided on a demand basis



Description of G.U. / sexual health services
    1session held every week with In Reach GUM Service
    1 specialist Doctor and 2x GUM specialist nursing staff
    Advice, investigation and treatment equivocal to community GUM



Description of substance misuse services
    There is no IDTS service in Castington although the programme is in project
      stage.

Description of counselling services
    MIND counselling services. 1 session per week




Description of in-reach services (in mental health, specialist nurses etc) not
already covered
     2 x wte CPN.
     1 x 0.5 wte CPN
     1 x 0.2 wte CPN
     1 x 0.2 wte MIND Councillor
     1 x 0.2 wte Learning Disabilities specialist
     1 x 0.1 psychiatrist
     1 x on demand psychologist




                                                                                   61
4.2.4 Services and Interventions Available to Address Health Promotion

Health Promotion including:               There is no prison health promotion specialist
    Sexual Health Promotion               in place
    Blood Borne Virus                    There is a prison health promotion steering
    Smoking Cessation Obesity             group which oversees strategy and health
       (Healthy Eating and Physical
                                           promotion activity – meets every 2 months
       Activity)
                                           with patient involvement
                                          General advice is given by staff
                                          There is an identified smoking cessation
                                           specialist and resource
                                          General advice is given by staff and there is
                                           identified sexual health promotion available
                                           through the GUM service
                                          Hepatitis screening is identified through
                                           screening and consultation; vaccinations
                                           available through nurse led clinics
                                          A Well Man Clinic is being planned and a
                                           survey distributed amongst the prisoners to
                                           identify needs.
                                          An initiative involving prison officers in
                                           Acklington and Castington, and health
                                           trainers is part of an initiative to reach staff in
                                           harder to reach settings and spread health
                                           messages across families and clients
                                           (including prisoners). Prison Officers
                                           attended Well Being Days at Castington and
                                           Acklington Prisons and were given health
                                           MOTs including cholesterol and blood
                                           pressure tests, body fat measuring, fitness
                                           tests on an exercise bike and tips to stay
                                           healthy. Displays and leaflets were also
                                           shared at the visitor centres at both prisons
                                           to give people visiting their family and friends
                                           healthy living advice.
                                          A health promotion forum is being set up to
                                           bring together health professionals such as
                                           health improvement practitioners and nurses
                                           with kitchen staff and prison workers to focus
                                           on the health of the prisoners and encourage
                                           healthy eating.
                                          Gym support includes standard gym clinics,
                                           remedial gym sessions and now offering a
                                           session for vulnerable prisoners.




                                                                                            62
4.2.5. Complaints

The data supplied indicates a low number of complaints. The total number being 8.

1st Sept 08 to 30th Sept 09
                                        No of
Type of Complaint                     complaints
Waiting Times
Medication delays                          1
Medication (Prescribing)                   2
IDTS / Substance Misuse
Dentistry                                  2
Service Levels (General)                   1
Complaints against Staff                   1
Treatment Received
Hospital Treatment
Physio Therapy
GUM
Optician                                   1

Source: Healthcare Complaints Report to IMB




                                                                                    63
4.3        Activity Data - Commissioned Services

Note: at the time of writing, the health Service at Castington was using paper based records
and this has consequently impacted on the quantity and quality of data available.

      A. GP services:

          The graph below shows the number of appointments at the GP. The average over
           this period each month was 55.
          Waiting times for a routine appointment is 7 days, for urgent appointments, next
           session.




           Graph 15: Number of Patients making applications for the GP Nov 0 8– June 09
           Source: Medical Report to IMB



      B. Dental services:

              The suggested number of sessions for prison dentistry is 1 session per week per
               250 prisoners10. At HMP Acklington this equates to 1.5 sessions per week. (The
               recommended session being at least 3 hours)
              From September 2008 – June 2009, there has been an average of 30 new
               prisoners added to the waiting list each month. The range being from 18 to 45
               each month.
              Graph 16 shoes the number of prisoners in treatment each month from
               September 08 to June 09; the average amount of prisoners each month over this
               period was approximately 37.
              There were 74 missed appointments (DNA; Did Not Attend) over this period11
               which works out as an average of 7.4 each month.
              Expressed as a percentage of total numbers of patients seen, then the proportion
               of DNA each month spans from 9% in February 2009 to 80% in March 2009.




10
     From the document - “Strategy for Modernising Dental Services for Prisoners in England” DOH, April 2003.
11
     June 08 – May 09

                                                                                                                64
    Graph 16: Patient Access Information for Dental Service in Castington Nov 08– June 09
    Source: Medical Report to IMB



C. Optometry services:

   Graph 17 shows the patient statistics for the optician services in Castington and
    numbers on the waiting list had risen steadily to February 2009 when they were
    reduced again.
   The average number of patients on the waiting list during this period was 14.7
   The average number of patients seen during last visit each month across this period
    was 6.3




    Graph 17: Patient Access Information for Optometry Service in Castington Sept 08–
    June 09, Source: Medical Report to IMB




D. Physiotherapy services:

No service – patients are referred to Wansbeck General Hospital if appropriate and
service provided from there.


                                                                                        65
   E. Sexual Health / GUM Clinic

          Only three months reporting data was supplied for the GUM service within
           Castington.



              Apr-09           May-09         Jun-09

                    4                 8             5


   F. Secondary Care

      A review of the data from September 08 – June 09 shows the following referrals were
       made into secondary care.
      23 hospital appointments were cancelled during this period. The majority of which
       were because of the patient cancelling the appointment.

                                            Number of
                                          referrals made
       Inpatient                                         12
       Outpatient                                       164
       Emergency                                        69
       Declined by patient                                 9

       Cancelled by security                               3
       Cancelled by detail                                 1
       Cancelled due to transfer                           3
       Cancelled by NHS                                    7

Note: prisoners may have several cancellations per referral.




   G. Nurse Services

      No data was available



   H. Integrated Drug Treatment Services

      Not currently a live service




                                                                                        66
I.   Substance Misuse

Data highlighted the following number of substance misuse assessments took place from
the previous quarter reception screens.

                    Number of         Number of
                    reception         substance misuse
                    Screens           assessments
June 09             151               14
July 09             164               13
August 09           117               8




J. Mental Health

    As of September 2009, the waiting list time for routine access was 14 day maximum.
     For urgent cases, the time was less than 7 days in all cases but depending on the
     class of emergency.
    In September, 27 new referrals were made, there were 59 appointments and 49
     DNAs).




                                                                                     67
4.4      Methods
4.4.1. Epidemiology from data collection
       - Sample of Inmate Medical Records and Chronic Disease Register


Appendix 7 summarises the epidemiological data collected from the sample of Inmate
Medical Records (IMR) and compares this with national prevalence estimates and also
prevalence data for Northumberland by way of additional comparison. There are limitations in
the ability to compare against some data as the age distribution in Castington is much
younger and narrower. Where needed, these are highlighted. For additional comparison, we
have included

The estimates from the IMR audit can be compared to the actual total numbers known and
recorded on the Chronic Disease Registers or other nurse records. This comparison gives
us an indication of whether numbers known to healthcare are likely to either represent,
under-represent or over represent the real need for services. Alternatively the comparison
could indicate that need is greater (or lesser) in HM YOI Castington than in other areas.

We draw on Health Needs Assessment activity we are involved in across two other YOI to
make comparison. The differences between prisoner populations make this an incomplete
exercise (given differences in BME communities for example) but nonetheless, they provide
comparison data amongst young prison populations:


Chronic Conditions


      1. Asthma
         Benchmark national data from the Birmingham Toolkit16 suggests that we should
         expect a prevalence rate of 19% of diagnosed Asthma, giving a number of 76
         patients.

         The IMR sample estimates that we should expect 7.5% of the prison population to be
         asthmatic i.e., about 31 prisoners.

         QOF data from Northumberland Care trusts suggests that diagnosed prevalence is
         around 6.4% which would translate to an actual prison population of 60 patients.

         Indicated by the IMR audit, HMP Castington prevalence of Asthma is lower than
         expected prevalence in prison populations and prevalence expected in the
         community.


      2. Epilepsy
         The IMR audit identified one patient with Epilepsy, a projected prevalence of 2.5% or
         10 patients (with a range of 0-30 at Confidence Interval of 95%). This compares to
         an expected national prevalence in prisons of 1.1% or 4 patients and a community
         prevalence of 0.7% or 3 patients. The suggested prevalence in Acklington is higher
         than the expected numbers based on national estimates.




                                                                                            68
    3. Diabetes
         No diabetic patients were recorded on the IMR audit. The national benchmark
         suggests that there should be 0.3% of 1 patient. As incidence significantly increases
         with age, younger populations will have low incidence of diabetes.

         The figures offered for community prevalence (4.6% would translate to a prison
         population of 19) do not account for the age profile in the prison. As the number are
         very small, there is no significant conclusion from these figures.

    4. CHD
         No records of CHD (and COPD or Hypertension) were recorded within the IMR audit
         and this is to be expected within the prison population of a Young Offender Institution.

Lifestyle Issues

    5. Smoking
         The IMR audit estimates that 72% of prisoners are current smokers. This lower than
         the national average amongst prisoners of 80%. However, smoking status was not
         recorded in 4 records. It is likely that this is an under representation due to incomplete
         recording. If all of these records were smokers then the prevalence would be 83%.
         However, the range at Confidence Interval 95% is 59% - 86% and the prevalence
         rate might be lower.

    6. BMI
         Data from general practice in Northumberland suggests an obesity rate of 21.8%
         amongst the general population. The IMR highlighted a very inconsistent approach to
         recording BMI data and height and weight were not routinely measured, even when
         so; BMI was not recorded. BMI recording is therefore incomplete.

Mental Health

The two tables below highlight two sources of research which indicate prevalence of mental
disorders amongst prison populations. The Kazdin (2000) study below (Chart 1), examines
prevalence amongst US adolescent populations whilst the figures from the social exclusion
report (2002) are across the general prison population. We would expect significant
provenance across a variety of mental ill health indicators across all indicators.

Chart 1
Prevalence of mental disorders among community and delinquent samples of adolescents
Prevalence of mental disorders among community and delinquent samples of adolescents
Disorder or condition                           Community samples (%)               Delinquent samples (%)
Conduct disorder                                           2-10                              41-90
Attention deficit disorders                                2-10                              19-46
Substance abuse and dependence                              2-5                              25-50
Learning and academic disabilities                         2-10                              17-53
Mood disorders                                              2-8                              19-78
Anxiety disorders                                          3-13                               6-41
Post-traumatic stress disorders                             1-3                                32
Psychosis and autism                                       0.2-2                               1-6
Any disorder present                                       18-22                               80


Evidence is summarised from a range of studies. The levels of disorders in adolescents held in detention centres
or prisons tend to be towards the higher end of the range.

                                                                                                              69
Chart 2
Prevalence of mental ill health amongst prison populations
Characteristic                   General population                 National Prison Population

Suffer from two or more mental    5% men and 2% women                 72% of male and 70% of female
disorders                                                             sentenced prisoners
Psychotic disorder                0.5% men and 0.6% women             7% of male and 14% of female
                                                                      sentenced prisoners
(Source: Social Exclusion Unit Report „Reducing re-offending by ex-prisoners‟, July 2002)



   7. Depression
       The IMR audit estimated that 12.5% of the prison population suffered from
       depression (51 people) which compares to an expected prison prevalence of 8% or
       33 people for a depressive episode and 19% for mixed anxiety and depression. The
       rate of mental ill health amongst remand populations is higher than sentenced
       populations and this might be an influence within Castington.

       Prevalence in Northumberland is around 10.8% which is significantly lower than
       prisons.

       The IMR audit indicates prevalence of anxiety is 7.5 % which is similar to the 8%
       predicted by national benchmark data (Generalised Anxiety Disorder). That suggests
       a population of 30 in Castington.

       The IMR audit indicates a prevalence of 10% of insomnia which is lower than the
       54% suggested by national benchmark data. There might be a significant amount of
       underreporting or under diagnosis within Castington

   8. Suicide Attempts and Self Harm (Total)
       The IMR audit suggested a rate of 7.5% for suicide attempts in TOTAL (across the
       prisoners total sentence time). This translates to 30 prisoners). The rate of non
       suicidal self harm is 10% (across the prisoners total sentence time) which translates
       to 41 prisoners.




Blood Borne Viruses

   9. Hepatitis
       Based on national estimates 8% of prisoners are likely to be positive for Hepatitis B,
       and 9% for Hepatitis C.

       The data from the IMR audit suggests that 85% or 347 people have received a 1st
       Hep B vaccination.

       The data highlighted 10% or 41 prisoners had received Hep A screening and 5% or
       20 prisoners had been screened for Hep C. No cases of Hepatitis C were identified
       through the IMR audit which is lower than the expected prevalence within prison
       (general) populations.


   10. HIV
       No cases were recorded in the random IMR sample and only 2 prisoners (5% of the
       total population) had been screened.

                                                                                                 70
   11. Chlamydia
   The IMR audit suggests that 25% of the sample have been screened for Chlamydia.

Substance Misuse

   12. The IMR audit recorded about 12.5% of prisoners having a history of alcohol abuse,
         or 51 prisoners.

   13. For recreational drug abuse the figure is 82.5%, or about 337 prisoners which is
         significantly higher than the prevalence expected.

   14. The IMR audit also looked at which drugs prisoners had used. Cannabis,
         Benzodiazepine, Amphetamines were the most often cited (40%, 32.5% and 17.5%
         respectively).

   15. 12.5% of people (a projected population of 51people) were or had been IV drug
         users.

Consultations with Health Care

   16. We recorded how many consultations each prisoner had had within the past year and
         for what reason. The results were:

                  Nature           Total No       Average Visits Per Person
                  Physical           161             4
                  Mental Health      22              .55
                  Sexual Health      34              0.85
                  Substance Misuse   14              0.35

   17. One individual was responsible for 22 visits to health care within the previous year.
         This audit shows that physical health is the greatest reason for consultation, followed
         by sexual health. It is possible that since the introduction of the GUM service, this
         pattern has changed and less patients access nursing staff for this reason.

Disability

   18. No data on disability was provided for Castington.

   19. From the audit, 2 individuals were reported with Attention Deficit Hyperactivity
         Disorder and this would extrapolate to a potential prevalence of 5% or 20 people.
         Three individuals were identified with Asperger Syndrome. This would extrapolate to
         a potential prevalence of 7.5% or 30 people.

Injury

   20. The audit of IMR highlighted a high number of injuries in the population, both during
         sentence time and upon arrival. For example at reception screening, 8 individuals
         presented with injury on admission (20%).




                                                                                               71
3.4.2. Baseline Assessment Tool

A baseline assessment tool was adapted from the Birmingham Tool kit and one used across
Durham prisons earlier in the year. It was used primarily as a data collection tool, designed
to segment and highlight data requirements more easy for local health care staff. Lessons
learned are that populating it early in the Health Needs Assessment Process is a significant
advantage. Doing so allows for a distribution and sharing of effort and the possibility of
refining data sources and quality.

4.4.2 Prisoner Survey

No individual focus group took place with prisoners but a survey was distributed as part of
the staff development of a Well Man Clinic / health promotion service. Prisoners were asked
to tick their interests and add their ideas. The top expressed needs were:

   1. Mental Health (35 responses)
   2. Parenting (31 responses)
   3. Drugs (30 responses)
  =4. Smoking (23 responses)
  =4. Sleeping (23 responses)
  =6. Exercise (22 responses)
  =6. Dental Care (22 responses)




4.4.3 Staff and Service interviews and group discussion. Summary

Physical Facilities

          Despite improvements, the facilities on wings were not always suited to treatment
           and the dispensing of medication was mentioned most frequently.
          Waiting areas are inappropriate and standards are different to community
           settings.
          Office Space – Admin staff highlighted the lack of equipment (computers and
           telephones) which impacted on service performance.
          IT systems were anticipated to significantly change when the System ONE was
           introduced.

Amount of time spent on non-nursing tasks
      A number of staff highlighted the amount of non-health care tasks they have to
          undertake which ranged from looking for paperwork, transferring medical notes
          through to moving equipment and cleaning.

Developing nurse roles
       The benefits of nursing staff being able to reduce the amount of resource needed
          when transferring prisoners to Accident and Emergency was raised, by both
                                                                                           72
           training staff and allowing staff to do more wound care or suture. Related was the
           suggestion that nurse prescribing be increased.

Inpatient Care
        Reduced access to social and support facilities by patients when they are on the
           facility
        Inappropriate use of the facility was highlighted when it is used as a segregation
           facility for example. This placed pressure on health care staff and in addition,
           sometimes disrupted the care available to other patients.

Prison Officer Support

          The Health Care staff discussion certainly acknowledged the important role of the
           prison officers and their importance in ensuring the safety of the health care staff.
           However, the inconsistency in officer support (different officers on health care rota
           mean that relationships and understanding are not always allowed to develop);
           the challenges of a fixed custodial environment were cited as difficulties.


Partnership Working

          Like discussions with staff in HMP Acklington, communication was raised as an
           issue several times across conversations. However, the issues was raised more
           often in conversations with Services and staff in Castington
               o Between the Prison and Health Care (mentioned frequently)
               o Between external GPs and Health Care
               o Between Hospitals and Health Care


   d. What do you think is done particularly well from health care point of view?

  Comments were:

      Some very positive changes had taken place over recent years and it was felt that
       clinical leadership had been very positive.
      Good standards of primary care provided by the Doctors
      General consensus that the services provided were every good and that were
       necessary, service providers would try to respond to local demand.
      Gaps in health promotion but these are being addressed with the development of
       activity and a group
      Health care staff are responsive to incidents and accidents
      Immunisation / screening was felt to be effective and provided very good coverage
      The development f the GUM service was felt to be a popular and important
       development and was considered to be well used by the prisoners.
      Mental Health In reach Team was highlighted


   e. Do you think there are any gaps in the healthcare services delivered at this
      Prison?

   Gaps identified were:

                                                                                             73
    Physical environment restricts the level of service and the development of services.
     There is a lack of consultation rooms for the required services and inappropriate
     waiting areas for the prisoners
    Need to develop clinics further (example offered was Well Man Clinic) but limited by
     physical environment
    Lack of Prison Officer at weekend and after 5pm
    Health care staff don‟t receive breakaway training
    Lack of consistency with Prison Officers on health wing
    Information Management (although it was acknowledged that the new IT system,
     System One, would change this)
    Opportunities to develop oral hygiene
    Appropriate dispensing of medication on wings – lack of confidentiality, appropriate
     space and support from Prison Officers (Staff described often having to act as crowd
     controllers)
    Patient Involvement – although the recent involvement of reps in the health promotion
     work was highlighted as good practice
    Still some work needed to further develop relationships and awareness between
     prison staff and health care staff. This was at an operational level as much as
     strategic level.
    A need for greater resource to learning disability nurse (more sessions)
    Still gaps in staff team due to recruitment but it was generally acknowledged that
     recruitment and retention has improved considerably.


f.   Do you have any suggestions for ways in which the health of patients at this
     prison could be improved?

Suggestions were

    Nurse Educator / Health Promotion Specialist role
    It is very difficult to develop group type activities given the restrictions on space. This
     means that peer to peer approaches are not as developed as they might be
    Greater patient involvement
    Increased resource for the learning disability nurse to develop services and support
     across prisoner and staff groups.




                                                                                              74
4.5 Discussion


4.5.1 Data recording and availability

One of the more obvious observations from the service level data at Castington, is the
limitation of paper recording. By comparison with the data available at Acklington for
example, there are significant gaps. The move to new IT System One will provide significant
opportunity for staff and commissioners.


4.5.2 Body Mass Index

The audit of the IMR highlighted the lack of consistency in recording height, weight and BMI.
It is impossible to draw any conclusions from the information available.




4.5.3. Long Term Conditions

As expected within the age range at Castington, the audit of Inmate Medical Records
highlighted low/no prevalence of conditions including CHD, COPD and hypertension. The
prevalence of Asthma was 7.5% which was slightly lower than would be expected. A slightly
higher prevalence of epilepsy was recorded through the IMR audit (7.5%). Although
numbers are small, there may be a need to provide additional services for epileptic patients.

The number of young men who were smokers is broadly in line with expected prevalence
rates and this presents significant opportunities for cessation support.


In terms of supporting the North East Offender Health Strategic goal:
Increased healthy life expectancy and reduced mortality from CVD and COPD
       Goals
       − Increase smoking quitters
       − Offer CVD risk assessment programme to all aged 40-74

The age range at Castington means that Long term Conditions remain less of an issue for
the health care team; given the low expected prevalence amongst the young age groups.
The CVD risk assessment goal for example is not relevant to this age group. There is still
room for improvement in making the smoking cessation services available and ensuring that
the services provide targeted assessment, support and prevention activity for those groups
most at risk.

4.5.4 Dermatology

There were 5 people in the audit who were identified with eczema which would equate to
12.5% prevalence. There is no existing baseline information to compare against but it is
estimated that around one third of the population will experience a skin problem in their
lifetime17 and that skin complaints can account for 15% of a GPs workload. An audit of
psoriasis and eczema in a Doncaster Prison highlighted 20% of patients had ever been
prescribed an emollient despite its role in effective condition management.

                                                                                            75
The good practice example which is available from the Doncaster Prison was the subsequent
service development of a Pharmacist led Dermatology Clinic. Advice and appropriate
dispensing was given by the pharmacist alongside education. Subsequent evaluation found
that the service increased awareness and management of a range of skin conditions such as
eczema, psoriasis, fungal infections and acne and reduced the workloads of other staff.

4.5.5 Mental Health

One quarter of people supervised by the YOTs admit to having a mental health problem, one
quarter have self harmed in the past and around half are depressed (Audit Commission
200418, Hammersley et al 200319). This is in comparison to one in ten of the general
population of the same age (Audit Commission 2004). Chitabesan et al (2006)20 also found
one in five participants to have a learning disability. This means that there could around 80
young offenders with a learning disability in Castington at any one time.

The IMR Audit suggests that the prevalence of depression is higher than expected and
12.5% of prisoners had contacted health care services because for reasons of depression.
Typically, higher prevalence of mental ill health is found in institutions where there is a
population on remand. (The qualification in this figure is that not all those consultations
resulted in a diagnosis of clinical depression).


The North East Offender Health strategic goals around mental health and wellbeing are to:

       −   Reduce suicide rate
       −   Reduce self harm rate
       −   Increase proportion of those diagnosed with depression who access
           psychological therapies

The audit suggested that 3 suicide attempts had been made across the total period of
incarceration (i.e. not in the previous year). Research by Dalton et al (1999) suggests that
9% of young offenders are likely to self-harm. This would suggest that a large number of
offenders self-harming at YOI Castington go undetected. The Chart below draws a
comparison between the numbers of Self-Harm incidents that took place in 2008. The figures
shown have been benchmarked at an equivalent operational capacity of 500 young offenders
to enable a fair comparison.

Below – No. of Self Harm Incidents at YOI in 2008 (Note- benchmarked for comparison)




                                                                                              76
In 2005, a study commissioned by the Youth Justice Board21 on the mental health needs of
young offenders in custody and in the recommended

      Resources are required in order to provide accessible and equitable services
      Reliable assessment tools such as the Mental Health Screening Questionnaire for
       Adolescents or Mental Health Screening Interview for Adolescents should be used
      Tailored educational interventions based on individual needs and ability should be
       provided
      Staff working in the secure estate and YOTs require support and supervision
       especially after major incidents
      Continuity of care is very important and dependant on the allocation of resources,
       assessment and on the adoption of a CPA model
      A multi agency mental health strategy should be developed for YOTs and secure
       establishments
      There is a need to develop accredited evidence based treatment interventions to
       reduce offending behaviour
      There should be clear guidance around confidentiality across professional groups
       within the criminal justice system


4.5.6 Attention Deficit Hyperactivity Disorder (ADHD)

There has been an increase in the number of young children being diagnosed with Attention
Deficit & Hyperactivity Disorder which is high in the young offender population (Audit
Commission 2004). The audit of IMR suggested a prevalence of 5% in Castington or 20
people with ADHD.

Services therefore need to ensure a consistent and multidisciplinary approach to the
management of ADHD which includes making sure that local policy and protocol is supported
by best practice guidance, ensuring access to training and development for staff and
ensuring the current policy on prescription of medication is consistent with best practice.


4.5.7 Sexual Health and Blood Borne Viruses
The recent development of the GUM service provides specific and specialist treatment
options for prisoners. The absence of quality data provided for this HNA means that
commentary is limited but we do know that expected need across the populations is high.
The last quarter reporting available shows low numbers and this might be an issue of:
     The service is in its early stages of development
     The service is not appropriately advertised amongst prisoners
     The need is not present
     The service is not appropriate for prisoner needs

Screening for Hepatitis B was high across the sample and 85% had received a Hep B
vaccination and 10% had received Hep A screening. There were no cases recorded of HIV
testing in the sample (but it is possible that they may have taken place within the GUM
service setting and therefore not be recorded on IMR.



                                                                                            77
Note that UK National Guidelines for HIV Testing (2008)22 suggest that universal HIV testing
is recommended at the following settings:

            a.   GUM or sexual health clinics
            b.   antenatal services
            c.   termination of pregnancy services
            d.   drug dependency programmes
            e.   Healthcare services for those diagnosed with tuberculosis, hepatitis B,
                 hepatitis C and lymphoma.


Chlamydia prevalence is included as a national priority for local delivery (tier 2) in „Vital
Signs‟, and the National Indicator Set. This indicator can be expected to drive improvements
in performance during 2008/11. Extension of Chlamydia screening coverage sufficient to
impact on population prevalence is a key action identified by the Sexual Health Strategy
Review. The MedFash12 High level indicator set from Review of the National Strategy for
Sexual Health and HIV outlines:
        Percentage of the sexually active population aged15-24 screened for Chlamydia


The percentage tested nationally is 9.5% (in the general 15 – 24 year old population) and the
IMR audit figure within Castington is significantly higher. It is possible that a greater number
of people have been tested through the GUM services too


In terms of supporting the North East Offender Health Strategic Goals:
       − Increase uptake rate for Hepatitis B immunisation
       − Increase uptake rate for Chlamydia screening

The evidence suggests that the progress on achieving Hep B immunisation is good.

The newly established GUM service is building up patient caseload which confirms that there
is demand within the population. This is supported by information from the IMR audit which
highlighted the number of consultations concerning sexual health issues.




4.5.8 Provision of dental care

Referenced earlier in this HNA (point 3.5.7), the guidance from „Reforming Prison Dental
Services in England – a Guide to Good Practice (2005)23 highlights the need to prioritise
patients using triage systems; pointing out that efficient and reliable appointment systems
can help ensure that prison dental sessions are used to best effect. From the data available,
we note a high number of DNA within the service and again, we make the observation that in
other institutions, best practice examples worth noting include the reduction of none
attendances by better communication between medical staff and the house block as well as
working to more generally improve the flow of prisoners to clinics.



12
  http://www.medfash.org.uk/publications/documents/Progress_and_priorities_working_together_for_h
igh%20quality_sexual_health_FULL_REPORT.pdf

                                                                                              78
Again, noting the comments of staff and services, there is opportunity for further developing
oral health promotion opportunities for example, as including dedicated time during
consultations or holding oral health campaigns.




4.5.9 Primary care

The waiting time for access to a GP was 7 days which is longer than the 48 hour access
target in the community.




4.5.10 Out of Hours Care

The main reasons for out of hours transfers are patients requiring monitoring overnight and
access to emergency services.




4.5.11 Secondary care

The activity data shows that there are high levels of referrals to secondary care for certain
specialities and also high levels of cancellations.

The main specialities referred to for outpatients were for trauma and orthopaedics and it is
worth highlighting the DoH study suggests this is likely to be the result of assaults, self harm
or accidental injury24. The high level nature of both these sources do not allow the HNA to
recommend specific conditions, which currently require referral to a hospital, that could
possibly be treated in the prison setting. Examples may include addressing musculoskeletal
problems and orthopaedic problems. It is possible that lower level data may identify any
potential and this should be explored further.


4.5.12 Patient, Public and Carer Involvement (PPI)

Work to engage patients in discussion about their care was evident in a range of approaches
– an audit of complaints, prisoner involvement in the health promotion committee, the annual
survey were some examples offered. No examples of engaging with prisoner families
through the visitors centre were offered. As with other activity, the influence of the custodial
setting on involvement strategies cannot be discounted. However the responsibility and
opportunities from involving patients in care are great.

The strategic goals of the North East Offender Health strategy involve improvements around
patient involvement (although at a regional level). There is some room for greater effort at an
institution level.




4.5.13 Health Promotion


                                                                                                79
Effort is being made to develop health promotion activity and planning across the services
through the newly formed health promotion committee. The committee meets monthly
(alternating across Castington and Acklington sites) and has representation from prisoners
on it. Consequently, to date, health promotion has taken place opportunistically and
consequently, the opportunities for strengthening and systemising health promotion are
significant across all service areas. Best practice for example highlights the concept of a
prison as a setting for health promotion. It follows the „settings‟ approach to promoting and
improving health, which concentrates on taking health promotion to people where they live,
learn, work, spend their leisure time or seek help. An action cycle for supporting health
promotion interventions and planning is included in Appendix 6.

No evidence of an up to date prison health promotion strategy and action plan was offered
and this is a significant gap. A strategy and developed action plan can contribute to a whole
prison approach to health. Opportunities exist for example to prevent the deterioration of
health during custody (mentioned by several inmates in the focus group) and also help
prisoners adopt behaviours to take back into the community on release.

The proportion of smokers within the prison highlights significant potential need and demand
for cessation services. The data for smoking cessation services however highlights the gap
between supply and demand.

As part of a developed health promotion approach, the opportunities for using social
marketing approaches within prison settings are considerable. Social marketing uses
detailed audience insight to understand the motivations, barriers and competition to
behaviour change. Audience specific messages can thus be constructed as well as using
that insight to develop service level interventions to segment and target different prison
audiences.




4.5.14 IDTS

No specific IDTS service is live in Castington.

The audit of IMR highlighted the significant numbers of young men entering the prisons with
a history of alcohol and drug abuse. There was a prevalence of 82% past history of
recreational drugs and compared against a 2006 Home Office prevalence figure of 55%, it is
significantly higher.


4.5.15 Training and Development

Cross referenced to point 3.5.17 earlier in the HNA), we note the complex tasks facing health
care staff, often managing differences in organisational requirements and values.

The consultations with Healthcare staff highlighted the difficulties they face of a lack of
understanding by external staff (within Health and Social Care) and sometimes by prison
staff.




                                                                                                80
4.5.16 Leadership

Again, as noted in 3.5.18 earlier in the HNA, the case for developing capacity, confidence
and capability is indistinguishable from the need for transformational leadership locally within
Castington Prison. Transformational change happens when those delivering care are
motivated and inspired to do things differently. The importance of visible leadership is
helped by visible leaders and the comments from staff engagement within this HNA highlight
their belief that it is a prerequisite of transforming services. More detail around leadership is
outside the commentary of this HNA but it is worth noting that the well-established NHS
Leadership Qualities Framework13 sets the standard for outstanding leadership in the NHS.


4.5.17 Ethnicity

No record of ethnicity was kept in prison health records and consequently, the services have
no way of recording or monitoring use of services amongst BME communities. There is
therefore no way of establishing if access to services and experience of services is true for
groups of prisoners who are more marginalized such as BME prisoners.




13
     http://www.nhsleadershipqualities.nhs.uk/

                                                                                               81
4.6 Recommendations


4.6.1 Health Promotion
  The work to develop health promotion should be supported to ensure that it continues
     and benefits from the future IT developments (in terms of understanding local needs).

       A prison health promotion strategy and action plan should be developed in line with
        local needs and links with PCT healthy promotion services should be strengthened.

       Drawing on the models in other areas, consideration should be given identifying a
        dedicated health promotion specialist post (working across a number of prisons).

       Peer to peer education and support should be developed further across health
        promoting activities.


4.6.2 Reception Screening
  There was a lack of consistency in recording information in notes and on the reception
     screening tool. With the full transfer of patient records to system one, this may be an
     opportunity to review screening to make sure it is fit for purpose and ensure staff use it
     consistently.

       Appropriate training should be given to healthcare staff on the completion of the first
        and second health reception screen forms to ensure accuracy and consistency. This
        should be regularly audited

       The available evidence is that reception screening is a stressful time for prisoners who
        may not want to discuss any medical problems, let alone mental; health issues or other
        sensitive information. The importance of a follow up screen is important within this
        context.

       Following from Reception Screening, effort should be made to ensure that every
        prisoner is offered and encouraged to take-up a general health assessment in the first
        week following reception. Monitoring uptake will allow additional analysis.

4.6.3. Patient Information
  Some discontent originated from what was perceived as poor feedback and poor
     knowledge of health care systems. There are a number of opportunities to address this:

       Revise and update the patient information leaflet to ensure that it meets prisoner‟s
        needs. Information which might be considered to include is:
           1. How to access services and likely waiting times
           2. Services available and those most likely to benefit
           3. The responsibilities of prisoners when accessing services

       Explore and pilot a number of best practice examples reference in this HNA to support
        feedback to prisoners about waiting times and services. The dedicated telephone line
        example in Durham is an example we learned about in our interviews.


4.6.4     Monitoring diversity and equality
       The lack of accurate insight into patient health and use of services based on diversity
        and equality information is a gap. There is a raft of research and recommendations


                                                                                                  82
      from the Department of Health into different health care needs of several communities.
      For example, people with disability and people from BME communities.
 i.      We there for recommend Health services should ask and record a patient‟s
         information to allow better analysis and interpretation of use.

4.6.5. Condition management
     Future needs assessments will be critical in identifying increases in conditions and
        prevalence to allow for rapid service realignment to meet needs.
     There is little evidence of need relating to condition management within Castington
        although we suggest that the issue of epilepsy be discussed further to judge if
        additional services are required. Certainly, this can be reviewed at the point of the
        next HNA.
     To a lesser extent than in Acklington where the population has additional LTC health
        needs, improved levels of self management will need to be explored within
        Castington. This should include responses which support prisoners to practice new
        behaviours learnt whilst in prison. In future regimes for example, different ways of
        increasing exercise opportunities and healthy food provision will have to be explored.
        Such activity must build on other work in the prison environment (like gardening)
        where it will not be acceptable or tolerated that fresh produce is thrown away in skips
        rather than used to support healthier eating.
     When system one is operational, the data should be used as a priority to audit use of
        the well man‟s clinics and other services.


4.6.7 Secondary Care
     The analyses of data did not provide conclusive evidence but it suggests that the
       highest area for outpatient referral was for trauma and orthopaedics. As in Acklington,
       staff suggested that there were a number of opportunities for nurse practitioners to
       replace off site care with onsite - examples included addressing musculoskeletal
       problems or suturing.
     We therefore recommend that staff training and development skills be reviewed at
       available opportunity to see how many staff have the skills for this and what
       requirements will support their use.
     Within the institutions own ward facility, the appropriate placement of young men with
       high mental health needs or for discipline reasons was highlighted. We therefore
       recommend that this is raised at prison management meetings to ensure that the
       correct pathways are in place and are followed.


4.6.8 Dermatology
     Within this HNA, we note the high prevalence of skin conditions we noted from the
       audit of IMR. It is likely that this is an underestimation of the real figure when other
       common skin conditions are included.
     We recommend:
          − Discussion take place about the feasibility of specific clinic resource for skin
               conditions,
          − The inclusion of a broad health care service team to respond to needs




                                                                                                  83
4.6.9 Attention Deficit Hyperactivity Disorder (ADHD)

   Noting the prevalence of AHDA within the IMR, we recommend that a consistent and
    multidisciplinary approach to the management of ADHD takes place which includes
    making sure a local policy and protocol is supported by best practice guidance. This
    should include ensuring access to training and development for staff and ensuring the
    current policy on prescription of medication is consistent with best practice.

 4.6.10 Smoking Cessation
  Resource should be prioritised to support the effective targeting of smoking cessation
     messages across the prison population.
    We make specific recommendation that exploration of Social Marketing approaches be
    considered to fully understand the needs and motivations of different target audiences


4.6.11 Sexual Health
 Although relatively new services, the GUM clinics have lower numbers of patients
    accessing them. For comparative needs assessments, we know that demand is high for
    GUM provision. Within our own review, the number of consultations recorded on IMR for
    sexual health was high.
 We recommend that the services be publicised and targeted more proactively to build up
    service use. At the time of the next HNA, the review of service data should be possible to
    test if supply is meeting demand and need.
 We note that good progress has been made on Chlamydia and Hepatitis B screening
    amongst the Castington population.


4.6.12 Patient / User Involvement
     We note the efforts at involving prisoners in their own care and in work across the
       health centre services. However, we believe that patient involvement should be
       greater than use of surveys to collect views. We therefore recommend that:
           − Together with Trust PPI Officers, local community Development Workers or
               Health Trainers, staff from the prisons produce a short patient involvement
               strategy and action plan.
           − Training and best practice examples be prepared from other regional prisons
               and from across the country to identify innovative solutions to test out locally.




                                                                                               84
Appendices

Appendix 1 – Prison Health Performance Indicators




                                                    85
Appendix 2 – Summary of Notes of Prisoner focus group – HMP Acklington,
VPs

19/8/09 AS/LH

Present: 7 inmates

Patient Involvement / Consultation
   1. The prisoners stated that they had never been asked for their views in this way
       before. They noted the annual health survey which is in the form of a few questions
       and tick boxes. They felt that the answers were not helpful and some inmates
       abused the process.
   2. One person admitted to censoring some of the forms if he felt they were filled in with
       deliberate intent to be unhelpful.


   Valued Services
   1. Dentist – good dentist but triage = delay. True of all services

   2. Triage is a problem. This was shared by all the men. It was felt there were too many
      steps in the process. Have to be triaged on wing to make an appointment to see the
      same nurse in healthcare for her to then send you away to wait (up to 3 days) for an
      appointment to see GP.

      Optician and dentist have waiting lists – sometime dentist 9 months.
   3. Prisoners not happy that if you are in last 6 months of sentence they won‟t treat you
      as they believe you will be seen outside.

   4. Particular praise for the Gym and the „Cardiac clinic‟

   5. Special mention for PT instructors in the gym who are very helpful and keep people
      safe. Over 50s Gym very welcome as is the potential of an over 50s wing.


   ‘Planning for discharge’
   Some disagreement about whether this happens but these prisoners had not been
   discharged and were speaking on behalf of others. They believe that if you are
   undergoing ongoing treatment you get a „fit for travel medical‟ and your drugs. You also
   get referred to a GP outside if you have an ongoing medical condition.

   Reception – Screening
   1. Variable experiences – some good reports about basics like Hep B injections and flu
      jabs (could this be because the GP gets a fee?)


   ‘Missing Services’
   1. Audiology/hearing aid services – very difficult to access in prison. Prisoner had to get
      a court order to receive treatment. Then had to organise it himself with the hospital.

   2. There is no evening „on – call‟ nurse. If anything happens it can be serious.
      Anecdotes about people having heart attacks and having to wait hours for care.

                                                                                            86
   Anecdotes about self-harm happening after 7pm when there is only a first aider on
   duty. Suggestion about putting a service into the older men‟s wing when it is opened.


Has your health improved or deteriorated since going in?
1. Down to the individual – some has some hasn‟t gained weight. Food relatively poor
   and being supplemented by things from shop. Major concern that shop prices rising
   out of step with outside.

2. All recognised that support for smoking, gym are available if you want to take them
   up.

3. Food not much good, overcooked. Recognition that there is now more salad and
   healthy options available but still not good quality. Main meals mostly carbs and
   inmates supplement with bought items such as tinned tuna and pork luncheon meat.

4. Smoking cessation services good but months wait to be seen. Patches and other
   treatment available.

5. The expert patients programme was mentioned by one inmate as positive.

6. Holding own meds works well for some and not others. Anecdote about one inmate
   who was refused a medication that he received outside leading to a view that
   treatment is different outside than in.

7. GUM services – none had ever used it but were aware of other inmates accessing
   condoms.

Anything else?
1. To get seen quicker is main priority. There is a perception that the inmates are able
   to decide if they need the doctor or the nurse.

2. The only thing that gets in the way of healthcare are „programmes‟.

3. Personal hygiene is seen as an issue with other inmates not attending to it. Prison
   Officers ignoring it. Causes discomfort if you share a cell. If you try and address it
   you get accused of bullying. More should be done to raise awareness and support
   cleanliness.

4. Issues of being informed about swine flu then not being able to access anti septic
   wipes.

5. No hospital unit.

6. Would like more open consultation in the future, particularly by external parties.




                                                                                            87
          Appendix 3 – GP Appointment Schedule

HMP Acklington
Managed Integrated Appointment System
Monday                    Tuesday                  Wednesday                             Thursday                             Friday




                          Dr                                      Dr                                    Dr
Dr Moll                   Lawson                   Dr Moll        Gilfillan              Dr Moll        Lawson                Dr Lawson



VP                08:30   VP               08:30   VP             VP          08:30      VP             VP           08:30    VP



VP                08:42   VP               08:42   VP             VP          08:42      VP             VP           08:42    VP



VP                08:54   VP               08:54   VP             VP          08:54      VP             VP           08:54    VP



VP                09:06   VP               09:06   VP             VP          09:06      VP             VP           09:06    VP



VP                09:18   VP               09:18   VP             VP          09:18      VP urgent      VP           09:18    VP


                                                                                         09:30 -
VP urgent         09:30   VP               09:30   VP urgent      VP          BREAK      09:48                       09:30    VP urgent


                                                   09:42 -                                                                    09:42 -
09:42 -10:00      09:42   VP urgent     BREAK      10:00                         09:48   MAIN           MAIN        BREAK     10:00


                          09:54-
MAIN             BREAK    10:20            10:00   MAIN           MAIN           10:00   MAIN           MAIN         10:00    MAIN



MAIN              10:20   MAIN             10:12   MAIN           MAIN           10:12   MAIN           MAIN         10:12    MAIN



MAIN              10:32   MAIN             10:24   MAIN           MAIN           10:24   MAIN           MAIN         10:24    MAIN


                                                   MAIN
MAIN              10:44   MAIN             10:36   urgent         MAIN           10:36   MAIN           MAIN         10:36    MAIN


                          MAIN
MAIN              10:56   urgent           10:48   IDTS           MAIN           10:48   MAIN           IDTS         10:48    MAIN



MAIN              11:12   IDTS             11:00   IDTS           MAIN           11:00   MAIN           IDTS         11:00    MAIN


                                                                                                                              MAIN
MAIN urgent       11:24   IDTS             11:12   IDTS           MAIN           11:12   MAIN           IDTS         11:12    urgent



IDTS              11:36   IDTS             11:24   IDTS           MAIN           11:24   MAIN           IDTS         11:24    IDTS


                                                                                         MAIN
IDTS              11:48   IDTS             11:36   IDTS           MAIN           11:36   urgent         IDTS         11:36    IDTS



IDTS                                                                                                                 11:48    IDTS



            16                     15                        15          15                        15          15                         16




                                                                                                                             88
Appendix 4 - Summary of Epidemiology – Sample of Inmate Medical Records ACKLINGTON

                                                                           Prevalence Estimates                                                 HMP Acklington
                       Condition               Northumberland Population                           Prison 5                                             2009
                                              total 1      Expected Prison        total        Expected             No         %       95%CI               Est Total   Range         Source
Chronic Condition
Asthma (Diagnosed)                                 6.4                       60       13%                     122    17/97     17.5       9.96 - 25.1          164       94 - 236    IMR
Epilepsy                                           0.7                       7     0.80%                       8     2/97          2       0 - 4.89            19         0 - 46     IMR
CHD (history of angina or heart attack)            5.1                       48                                      1/97          1       0 - 3.04            9          0 - 29     IMR
COPD                                               2.2                       21                                      0/97                                                            IMR
Hypertension                                     15.9                      149                                       0/97                                                            IMR
Diabetes (Insulin dependent)                       4.6                       43    0.50%                       5     1/97          1       0 - 3.04            9          0 - 29     IMR
Mental Health Conditions
Depression                                       10.8                      101            8%                  75     24/97      25        16.5 - 33.3          234      155 - 313    IMR
Anxiety                                                                                   8%                  75     12/97      12       5.82 - 18.92          113       55 - 178    IMR
Insomnia                                                                              54%                     507    18/97      19       10.82 - 26.3          178      119 - 247    IMR
Personality Disorder                                                                                                 5/97          5      0.75 - 9.55          47         7 - 90     IMR
Suicide Attempts (Total)                                                                                             5/97          5      0.75 - 9.55          47         7 - 90     IMR
non Suicide Self Harm                                                                                                9/97          9     3.51 - 15.05          85        33 - 141    IMR
Disability - (mobility, hearing and visual)             more in older Pn           0.60%                       6     5/97          5      0.75 - 9.55          47         7 - 90     IMR
Lifestyle
Current Smokers                                  28%                       263        80%                     751   40/97 3    41      31.44 - 51.04         385        295 - 479      IMR
                                                                                                                     Record not included in IMR - data function only recently established on
BMI                                                        21.8% Obese                                                                               EMIS
Sexual Health and BBV
Hep A Screened                                                                                                       4/97          4      0.16 - 8.08          38         2 - 76     IMR
Hep B Prevalence                                                                          8%                  75
Hep B Immunisation (1st)                                                                                             25/97      26      17.07 - 34.47          126      159 - 321    IMR
Hepatitis C Prevalence                                                            9%                                 3/97          3       0 - 6.53            28         0 - 61     IMR
Hepatitis C Screened                                                                                          85     8/97          8     2.77 - 13.73          75        26 - 129    IMR
HIV Prevalence                                                                       0.3%                      3         0                                                           IMR
HIV Screened                                                                                                         4/97          4      0.16 - 8.08          38         2 - 76     IMR
Chlamydia Screened                                                                                                   5/97          5      0.75 - 9.55          47         7 - 90     IMR
                  Condition                                                Prevalence Estimates                                                 HMP Acklington
                                                       Northumberland Population                     Prison 5                                             2009
                                                      total 1   Expected Prison     total        Expected               No        %       95%CI              Est Total   Range       Source
Chlamydia Prevalence                                                                                                         0                                                       IMR
Substance Misuse
Past History of Alcohol Abuse                                                                                            36/97    37       27.5 - 46.72          347     255 - 439   IMR
Past History of recreational Drugs                                                  55% 2                         516    55/97    57      46.84 - 66.56          535     440 - 625   IMR
IV Drug User                                                                                                             17/97    18       9.96 - 25.1           169      94 - 235   IMR
Type: Cocaine                                                                                                            26/97    27      17.99 - 35.61          254     169 - 334   IMR
Type: Heroin                                                                                8%                    75     25/97    26      17.07 - 34.47          244      66 - 324   IMR
Type: Cannabis                                                                              8%                    76     27/97    28      18.92 - 36.76          254     178 - 345   IMR
Type: Benzodiazepine                                                                                                     10/97    10       4.26 - 16.36          94       40 - 154   IMR
Type: Ecstasy                                                                                                            5/97         5    0.75 - 9.55           47        7 - 90    IMR
Type: LSD                                                                                                                1/97         1      0 - 3.04            9         0 - 29    IMR
Type: Amphetamines                                                                                                       3/97         3      0 - 6.53            28        0 - 61    IMR
Consultations in previous year 4
Substance Misuse                                                            5 patients were on daily dispensing              16                                                      IMR
Physical                                                                                                                 582                                                         IMR
Mental Health Conditions                                                                                                 287                                                         IMR
Sexual Health                                                                                                                32                                                      IMR



Based on Pn of 939 Prisoners
No differentiation made for age structure of prison
1. QOF Database 2008 - Northumberland Care Trust
2. Home Office FOI Release 4631, 6 Dec 2006
3. Note: Smoking status was not recored in 44 cases
4. One individual responsible for 24 visits
5. From Birmingham Tool Kit Estimate Tables




                                                                                                                                                                                           90
Appendix 5 - Inpatient and Outpatient Episodes

Between 1st October 2008 and 31st July 2009


INPATIENTS
 Procedure Type                    Number of appointments
 Breast Surgery                                              4
 Cardiology                                                  6
 Colorectal Surgery                                         18
 Dermatology                                                 2
 Ear Nose & Throat                                           3
 Gastroenterology                                           16
 General Medicine                                           46
 General Surgery                                             5
 Geriatric Medicine                                          2
 Maxillo-Facial Surgery                                      1
 Opthalmology                                                3
 Oral Surgery                                                5
 Plastic Surgery                                             3
 Thoracic Medicine                                           2
 Trauma & Ortho                                             13
 Upper Gastrointestinal Surgery                              4
 Urology                                                    15
 Vascular Surgery                                            1

OUTPATIENTS
 Procedure Type                    Number of appointments
 Vascular Surgery                                            7
 Upper Gastrointestinal Surgery                              9
 Trauma & Ortho                                             78
 Thoracic Medicine                                           4
 Sleep Studies                                               4
 Rheumatology                                                3
 Restorative Dentistry                                       1
 Plastic Surgery                                            12
 Oral Surgery                                               16
 Opthalmology                                               11
 Neurology                                                   3
 Maxillo-Facial Surgery                                      2
 Interventional Radiology                                    2
 Haematology (Clin)                                          1
 Geriatric Medicine                                          3
 General Medicine                                            3
 General Medicine                                           46
 Forensic Psychiatry                                         3
 Ear Nose & Throat                                          30
 Dermatology                                                 3
 Colorectal Surgery                                          4
 Cardio-Thoracic Surgery                                     1
 Cardiology                                                  9
 Breast Surgery                                              5
 Anaesthetics                                                2
Appendix 6 - Health Promotion in Prisons Action Planning Model




(adapted from Koch,1992 , reproduced in The Health Promoting Prison, A Framework for
Promoting Health in the Scottish Prison Service, 2002, Health Education Board for Scotland




                                                                                         92
Appendix 7 - Summary of Epidemiology – Sample of Inmate Medical Records CASTINGTON

                                                                                             Prevalence Estimates                                        HM YOI Castington
                       Condition                    Northumberland Population                                       Prison 5                                      2007
                                                    total 1   Expected Prison        total        Expected                           No        %      95%CI          Est Total   Range     Source
Chronic Condition
Asthma (Diagnosed)                                      6.4                  26          19%6                                  76     3/40     7.5      0-15.66          31       0-64     IMR
Epilepsy                                                0.7                      3       1.1%6                                  4     1/40     2.5      0-7.34           10       0-30     IMR
CHD (history of angina or heart attack)                   -                          -            -                                                                                        IMR
                                                              None in juvenile
COPD                                                      -   prison                 -            -                                                                                        IMR
Hypertension                                              -                          -            -                                                                                        IMR
Diabetes (Insulin dependent)                            4.6                  19      0.30%6                                     1     0/40      -                        0                 IMR
Mental Health Conditions
Depression                                            10.8                   44              8%                                33     5/40     12.5   2.25–22.75         51       9-93     IMR
Anxiety                                                                                      8%                                33     3/40     7.5      0-15.66          30       0-64     IMR
Insomnia                                                                                  54%                                  220    4/40     10      0.7-19.3          41       3-79     IMR
Personality Disorder                                                                                                                  2/40      5       0-11.75          20       0-48     IMR
Suicide Attempts (Total)                                                                                                              3/40     7.5     0– 15.66          30       0-64     IMR
non Suicide Self Harm                                                                                                                 4/40     10      0.7-19.3          41       0-30     IMR
Speech & Language Difficulties                       Based on male Y Offenders            11%                                  45     3/40     7.5      0-15.66          30       0-64     IMR
Lifestyle - note expected prison prevalence rates are not disaggregate for younger age effects
Current Smokers                                       28%                   114           80%                                  326   29/40 3   72.5   58.66-86.34        296     239-352   IMR
BMI                                                           21.8% Obese
Sexual Health and BBV – note expected prison prevalence rates are not disaggregate for age effects
Hep A Screened                                                                                                                        4/40     10      0.7-19.3          41       3-79     IMR
Hep B Prevalence                                                                             8%                                33     3/40     7.5      0-15.66          30       0-64
Hep B Immunisation (1st)                                                                                                              34/40    85     73.9-96.07         347     302-392   IMR
Hepatitis C Prevalence                                                                                                                    -                                                IMR
Hepatitis C Screened                                                                         9%                                37     2/40      5       0-11.75          20       0-48     IMR
HIV Prevalence                                                                           0.3%                                   1         -                                                IMR
HIV Screened                                                                                                                          2/40      5       0-11.75          20       0-48     IMR
Chlamydia Screened                                                                                                                    10/40    25     11.58-38.42        102     47-157    IMR
                       Condition                                                             Prevalence Estimates                                        HM YOI Castington
                                                      Northumberland Population                           Prison 5                                      2009
                                                      total 1   Expected Prison   total        Expected                    No       %      95%CI           Est Total   Range     Source
Chlamydia Prevalence                                                                                                            -                                                IMR
Substance Misuse
Past History of Alcohol Abuse                                                                                               5/40    12.5   2.25–22.75          51       9-93     IMR
Past History of Recreational Drugs                                                55% 2                              224   33/40    82.5   70.72-94.28         337     289-385   IMR
IV Drug User                                                                                                                5/40    12.5   2.25–22.75          51       9-93     IMR
Type: Cocaine                                                                                                               6/40    15     9.93 – 26.07        61      41-106    IMR
Type: Heroin                                                                              8%                         33     6/40    15     9.93 – 26.07        61      41-106    IMR
Type: Cannabis                                                                            8%                         33    16/40    40     24.82-55.18         163     101-225   IMR
Type: Benzodiazepine                                                                                                       13/40    32.5   17.98-47.02         133     73-192    IMR
Type: Ecstasy                                                                                                               4/40    10       0.7-19.3          41      47-157    IMR
Type: LSD                                                                                                                                                                        IMR
Type: Amphetamines                                                                                                          7/40    17.5   5.72-29.28          71      23-119    IMR
Consultations in previous year 4
Substance Misuse                                                                                                            14                                                   IMR
Physical                                                                                                                    161                                                  IMR
Mental Health Conditions                                                                                                    22                                                   IMR
Sexual Health                                                                                                               34                                                   IMR


No differentiation made for age structure of prison NOTE – Pn - 408
1. QOF Database 2008 - Northumberland Care Trust – NOTE THIS DATA IS NOT DISAGGREGATED FOR AGE
2. Home Office FOI Release 4631, 6 Dec 2006
3. Note: Smoking status was not recorded in 4 cases
4. One individual responsible for 22 visits
 4. From Birmingham Tool Kit Estimate Tables
 5. Estimate prevalence for 16 – 24 age group




                                                                                                                                                                           94
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13
   A resource pack for working with older prisoners, Nacro, 2009
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_103524.pdf
14
     Review of Pharmacy Services in the Northumberland Prisons, February 2009
15
     NHS Next Stage Review: A High Quality Workforce, June 2008, Department of Health,
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_085841.pdf
16
   Marshall T, Simpson S and Stevens A, (2000) Toolkit for health care needs assessment in prisons,
Department of Public Health & Epidemiology, University of Birmingham
17
   NHS Modernisation Agency Action on Dermatology, London, Department of Health 2003 cited in
Pharmacist – led Dermatology Clinics can Improve Prisoners‟ Quality of Life, , The Pharmacutical
Journal, May 2004 (v272) http://www.pharmj.com/pdf/articles/pj_20040508_prisoners.pdf
18
   Audit Commission (2004). Youth Justice: A review of the reformed youth justice system
19
   Hammersely, R, Marshland, L & Reid, M (2003). Substance misuse in young offenders: The impact
of the normalisation of drug use in the early years of the 21st century. Home Office Research Study
No 261.
20
   Chitsabesan, P, Kroll, L, Bailey, S, Kenning, C, Sneider, S, MacDonald, W & Theodosiou, L (2006).
Mental health needs of young offenders in custody and in the community. British Journal of Psychiatry,
18, pp 534 – 540
21
   Harrington, R, Bailey, S et al (2005). The mental health needs and effectiveness of provision for
young offenders in custody and in the community. London. Youth Justice Board.
22
   UK National Guidelines for HIV Testing (2008) British HIV Association, British Association of Sexual
Health and HIV and British Infection Society, 2008, http://www.bhiva.org/files/file1031097.pdf
23
   Reforming prison dental services in England – a guide to good practice (2005), Office for Public
Management, Sarah Harvey, Beth Anderson, Stefan Cantore, Ewan King and Farooq Malik
24
   A twelve-month study of prison healthcare escorts and bedwatches, (2006) Department of Health,
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_06
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