Key themes that emerged following analysis of the qualitative interviews are presented below.
Continuation of Community Prescriptions
The threats to continuing prescriptions initiated in the community upon reception into prison emerged as a key theme and the process of confirming medications with the community GP in an effort to ensure seamless continuity is discussed below.
“GP confirmation” of prior community prescribing
“GP confirmation” (GC) is the process whereby a patient’s GP contact details are obtained to enable healthcare staff to obtain current management plans for LTCs. Such ‘confirmation’ is by facsimile transmission and transfers community GP clinical data typically pertaining to prescribing and referral information.
There was variation across the four prisons regarding exactly which healthcare staff are responsible for seeking and obtaining GC. Participants explained that GC is typically received, via fax, in the form of a detailed account from the new prisoner’s previous community doctor confirming any LTCs, medications (both historic and current), and any outstanding appointments with secondary care services. There was variability reported in the quality of information received from community GPs. In the worst scenarios, GC was limited to just a brief overview of the new prisoner’s current conditions and medications.
There was also variability between the prisons in whose role it was to obtain GCs. Participants from Prison 4 reported that pharmacy technicians are tasked with obtaining GCs, whereas participants from Prison 3 reported that administrative healthcare staff are responsible for such tasks. Participants from Prison 2 explained that nurses chase the GC, whereas at Prison 1 it seemed to be the responsibility of healthcare assistants. Crucially, whilst there was no clearly articulated reason for such differences between prisons, there were no apparent differences in the quality of clinical data received according to the professional background of healthcare member communicating with the GP practice.
All participants were aware of at least some of the problems faced by staff when attempting to obtain GC, of which one key theme emerged pertaining to a perception that staff within community general practices tended to be obstructive. For instance, some community practices do not fax patients’ details back to the prison when requested:
“…the pharmacist always chased up GP information the next morning and fax all the patient’s…our patient signs their consent to the doctor giving us information and then we get the information from the GP, which is very frustrating because very often we’re waiting a long time for it” (Participant 3)
It was not clear whether such a delayed response on the part of some community GPs was intentional, but the frustration was reported from participants from each of the four prisons and is articulated by Participant 3:
“…this patient we’re looking after, on your behalf, we can’t look after them until you let us know, you know it can almost end up getting a bit “snotty” with them, and you don’t want to, but it’s just frustrating. I mean some are very good and it does tend to be the same ones that are very good and the same ones that aren’t, and that makes you realise that they do need a bit of a kick really.”
Processes for seamless continuation of community prescriptions
Participants were asked regarding the process for continuing community prescribed medication for a patient newly received into prison. A narrative emerged pertaining to what circumstances enables such prescribing processes to be easier and more efficient, since within the same prison and on the same evening reception clinic there is variability in individual prisoner behaviours regarding both whether they bring community prescribed medication to prison, and if so in what form of packaging it is presented. The ideal scenario is when a new prisoner brings in a clearly labelled medications blister pack showing the following: prisoner name; medication name; dosage details and packaging highlighting that the medication is not beyond the expiry date. This reportedly makes it easier to manage risk, since decisions can be informed by correct and up-to-date information regarding the new prisoner’s current medication needs. Also, with medication in blister packs it is not possible to substitute with medication that would have currency within a prison since it would entail breaking seals that could not be subsequently resealed. With tablets dispensed into medication bottles, they could be substituted for such medication. Thus the theme emerged of a readiness to administer medication without delay when it is presented in the correctly labelled blister pack:
“…we sort of already have the confirmation then, so we can prescribe straightaway” (Participant 7)
Participants explained that if medication is not received in the form described above then GC is necessary before prescriptions can be issued and dispensed. Therefore, when community General Practices fail to send the GC in a timely manner, prescribing and dispensing can be delayed unnecessarily:
“…where the practice has been correctly identified but the practice doesn’t play ball, they request consent, the GP consent form and one or two days they haven’t sent what you have requested, that’s an unnecessary delay” (Participant 19)
Although unnecessary delays to the continuation of medication do occur, some participants emphasised the efforts healthcare staff go to in order to avoid them:
“…we get the patient’s family or friends, whoever, to actually bring the meds in so we have them” (Participant 10)
Furthermore, some participants from the two female prisons explained that healthcare staff will even go to the lengths of sourcing medications from external ‘24-hour’ pharmacies and sometimes task taxi drivers with the job of collecting and delivering medications. It was not explicitly clear why only two out of the four prisons went to such lengths, but both are female establishments housing a considerably lower number of prisoners. Therefore, it is possible that there was sufficient staff resource to permit this labour-intensive process.
Issues pertaining to both the process of holding stock medication and accessing out-of-hours medication that is held in prison pharmacies are presented below.
Respondents discussed the various medications kept in stock within the four prisons. Across all prisons, it was reported that most stock is made up of the following medications: analgesics; inhalers for the management of asthma; anti-angina sprays; anti-epileptic medications; medication to treat diabetic hypoglycaemic or hyperglycaemic episodes; medications to ameliorate withdrawal symptoms from substance or alcohol use.
Although most participants reported such stock is adequate in meeting acute medical need, it was argued that more medications are needed to ensure continuity of prescribing and that if stocked, waste would be reduced:
“We have a stock list, it’s very basic…” (Participant 1)
“The majority are obviously all your symptomatic relief medications, antibiotics, there are, from what I recall, antidepressants, some but not all. Aspirins, heart medication but it’s quite limited in that sense...Bog standards like your Gaviscon, obviously your methadones, buprenorphine, I think and then obviously your emergency drugs” (Participant 6)
Whilst some participants articulated that stocklists are based on the prevalence of conditions among the establishment’s prisoners, such a view was not uniform. Rather most participants were unable to explain the process informing which medications are stocked. Such lack of clarity was even illustrated by a pharmacist, whose role it is to manage stock medication. When asked if there is a particular reason behind which medications are stocked, Participant 10 responds:
“Erm…no, I don’t think there is, I could be wrong, but I don’t think there is anything like that, like I said, if it’s a long-term condition, it tends to be the same drugs that are prescribed all the time, unless they’ve got somebody who doesn’t get on with a particular med and is prescribed something a bit different by a consultant…it’s just the same that you would see if you went into a community pharmacy outside”
However, Participant 7 – an Advanced Nurse Practitioner from Prison 4 – did seem confident about the reasons that inform medication stock at the first night centre, namely the need to manage acute drug/alcohol withdrawal symptoms:
“So it’s just, yeah, it’s with a, no, it wouldn’t be disease prevalent so much, but I think, you know, you're primarily tackling, on first night centre, you're tackling life-threatening withdrawal, really. So we’re looking at substance misuse rather than long-term conditions.”
QOF compliance in prison
Issues pertaining to compliance with QOF monitoring in prison settings are presented below.
QOF staff knowledge / understanding
When participants were asked about QOF completion in prisons, there was no system across healthcare to facilitate such monitoring. Rather, completion tended to be driven by a small number of participants with senior prescribing skills (i.e. GPs and Advanced Nurse Practitioners) who had substantial knowledge regarding the purpose and utility of QOF monitoring:
“…when I was the GP, probably more when I was the lead GP here, I drove the QOF agenda, I spent hours of my own time going through people’s records to see if I could repopulate QOF unmet needs to get the QOF points up and at one point we had almost all the QOF points that we reasonably could…” (Participant 13)
By contrast, healthcare staff who did not have a prescribing remit were either unaware of the process of QOF monitoring or felt that it was not a prison healthcare responsibility to undertake. Such a lack of role legitimacy was highlighted by the following view provided by a senior practice nurse:
Researcher: “Do you know anything about QoFs?”
Participant 19: “I have a rough idea about QoFs but don’t ask me that now because we are still at a very, very infantry stage on QoFs in this establishment”
Researcher:“So it is not actually being used right now”?
Participant 19: “We are aware of them, they get mentioned, but we are not yet at the stage where I can say or have a discussion on it, no”.
QOF completion barriers
In addition to the view expressed above that there was little point completing QOF templates as there was no compulsion to meet QOF targets, staff commented that they didn’t have time to undertake QOF clinical activity. Such a barrier tended to be highlighted by participants from a nursing professional background:
“Well, I think it should really be, you know, within the week of them telling us. Ideally. But I think, in reality, you know, our use of QOF tools is probably not as good as it could be. And I think that’s, you know, resource, people are out of practice, staff turnover… Training issues and it’s time constraints as well” (Participant 7)
High prisoner turnover was also identified as a barrier to undertaking QOF activity:
“There’s often been talk of QOF in prions but QOF is based on a yearly assessment of your chronic disease, and most of our prisoners aren’t here for a year so your stats would permanently be changed. You know QOF is based on what percentage of your diabetics have had their relevant checks done, but if the vast majority of those don’t stay with you over a year, then you can’t improve your stats, your stats are at the mercy of the fact the prisoners move on" (Participant 1)
The issue of high prisoner turnover being more of a barrier in male remand prisons was highlighted by Participant 1:
“I can’t comment on a different gender prison, because I’ve never worked in a female prison, but turnover is a major problem, I mean we get a turnover of 50 prisoners a day so we have 1037 prisons here now, but in a year, we’ll have 4000 people through our doors, so it’s a huge turnover; in a previous study that I saw from our prison, the average stay of prisoners is about 80 days, so you can do a lot in those 80 days but you can’t really improve massively chronic disease, you can stabilise people and you can educate them and put the wheels in motion but you can’t monitor it long-term…as far as long-term prevalence goes we don’t have the stats for that.”
GP participants tended to be more supportive regarding the use of QOF monitoring in prisons:
“…it [QOF] did set a standard, an agreed standard for ensuring that the right questions were asked in a consistent way, and the right tasks were done in a consistent way and it cross-referenced that with community general practice as well because we were working to the same sort of QOF standards, so I think its main advantage was that (inaudible) to a nationally agreed consistency for approach to conditions” (Participant 12)
Many participants talked about alternative methods of recording information pertaining to prisoners’ LTCs. It was revealed that some prison healthcare departments preferred to create and complete their own LTC templates in place of QOF templates:
“…they’re all getting done, but they’re getting done under the templates as opposed to the QOFs...The senior matron did them for the whole directorate. He made the templates” (Participant 4)
Benefits of access to community QOF and wider clinical data
The majority of participants felt that having sight of community QOF data (through linked community and prison GP records) would be invaluable and offer a range of benefits to healthcare staff within prisons. Some participants explained how such visibility could help to reduce duplication of QOF-related work:
“I would prefer us to be managing those around need rather than just well our process is that everybody comes in who has diabetes or asthma or whatever goes into this clinic within, again within that period of time, if we could see that somebody, you know three months ago had had their chronic disease management reviewed and the tests done and everything was, was ok, then I don’t see that there’s any reason to then do that until it is due to follow on from that" (Participant 12)
Participants also identified potential benefits to patients in prison, citing that less hospital appointments would be missed and LTC reviews would be conducted on time to better monitor prisoners’ health. For instance, by being able to see community QOF data, prison clinicians would have access to information regarding patients’ last reviews for any conditions they may have. Therefore, they would see when their next review is due and schedule a prison clinician to conduct this.
“...it’s quite good for things like registers and people needing flu vacs and the percentages that have had it and things like that” (Participant 15)