Development of Healthcare at HMP Littlehey

Nursing attracted Mr Anthony Blades when he left school after his ‘A’ levels. It became his first job, which he continued in the RAF as a Service Nurse which included an operational tour in Kosovo on helicopters, adding casualty medicine and aero-medical evacuation to his growing experience. On leaving the RAF, he joined the local NHS Trust as an Operational Manager and later broadening his skills in project management before, as he says, ‘stumbling’ across a job with the Prison Service. Anthony Blades is the Head of Healthcare Services, HMP Littlehey and his task is to ensure that prisoners have a standard of care that is comparable to that found in the wider NHS. Littlehey is a cat C training prison for adult men, presently accommodating 726, but is being developed to include a young offenders' establishment for 480. Mr Blades has been in the post for nearly five years.

We met to discuss your job here at HMP Littlehey just over two years ago ( CR 43 Edition November 2006 p12) and you explained then that the prison was one of the first to go through the commissioning process of bringing the prison within the care of a NHS  Primary Care Trust (PCT). Has it been a success?
Anthony Blades (AB) When we spoke before I told you about the strategic plan, a health delivery plan, which was to run from 2004 to 2007, designed to ensure that the standard of clinical care delivered in the prison was comparable to that found in the wider NHS. Well, the result was that we delivered on most of that plan. Currently, we are going through a process with our partners in the PCT, of re-evaluating where we are, in terms of the services we deliver and what our commissioning priorities should be over the next three years.

I remember we spoke about the difficulties of recruiting healthcare staff into the prison. Has the advent of the PCT changed that situation?
AB In many ways our partnership with the PCT seems to have legitimised what we do here. We have been able to recruit and retain good quality clinical staff and we haven’t had a vacancy for over two years.

What level of staff do you have here?
AB There are three members of staff in pharmacy, then there are four nurses, a healthcare officer, an assistant and a nurses manager. All the services have settled down well and we have an established partnership with a local GP practice.

I would be interested to hear how you went about the business of creating a partnership with a GP practice. How did you go about that?
AB The selection process was undertaken by the PCT and they directly commissioned the GP service. In terms of the provision, we have doctor appointments in the morning supported by nurse led clinics. We also have telephone support and the possibility of clinics in the afternoon until 6 o’clock, after which we become part of the NHS emergency care network. The local GP practice provides the same level of care expected by the general public in any other part of Cambridgeshire and that’s how it should be because the prison is part of the county; it just happens to be behind walls.

But are there no special difficulties, unusual constraints not experienced by the general public when they need medical attention?
AB It’s very difficult to deliver healthcare within a prison. There are a number of tensions, not just across this establishment,  but across the estate as a whole. There is always more to do and we work in partnership with the PCT to deliver that work. I always regard the task as ‘work in progress’.

Is it a fact that, as people outside prison do not have access to all the NHS facilities all of the time the same applies to people inside?   
AB The quality of healthcare in prison is measured by something called the Prison Health Performance Indicator, which is a ‘traffic light’ rating submitted to the Strategic Health Authority to measure how we are performing. That covers everything, the whole gamut of clinical care. One of those is dentistry and the standard wait for an appointment is six weeks. Now, wherever a person lives in the country, there might or might not be access to an NHS dentist. I think that’s an interesting example of how healthcare varies nationally. We hear in the press about postcode lottery, specifically what some PCTs will subscribe, while others will not. It is very variable around the country and how prisons match regional variations is quite interesting.

If I can’t find an NHS dentist in my own town I can go to another town for treatment, a prisoner can’t do that can he?
AB I think the whole issue about choice in the NHS hasn’t been translated into the prisons. Prisoners don’t have a great deal of choice with their healthcare needs, but I think the introduction of the PCT partnership has energised the situation. Prisoners do have a voice on a number of different levels and we do have prisoner focus groups who can speak directly to the management.

Is the clinical IT system up and running?
AB Yes, we do have a clinical IT system connected to the NHS. It was certainly an effort to get it up and running, but it has absolutely revolutionised how we deliver care. We tend not to use paper where possible, that is everything is done electronically much as it would be in a GP practice. Prisoners’ health records and any intervention carried out is recorded electronically.

So when a prisoner leaves the establishment his health record can be transferred electronically to his GP?
AB Interestingly there are a number of different methods and the Prison Service seems to be moving towards System 1, which is a different IT system to what we currently have; that is everything is held on a central server. So, to answer your question in terms of information, discharged prisoners may well take a printed copy of their medical records out with them and if their GPs need further information, we could certainly supply that.

When we spoke last, the dentist surgery here was being modernised and the treatment room upgraded. Is it all finished?
AB All completed and we have recently converted two areas on the larger residential wings to be clinical rooms. I think that last time I told you about co-opting our caterers and the gym staff in helping to encourage the prisoners to adopt a healthier lifestyle. That continues and is going well.

What have you observed that enables you to say that with such authority?
AB Well, what we have seen is healthier prisoners and we are able to engage with them in a more productive way. A prime example of that being in the gymnasium where a lot more prisoners now go to enjoy themselves and engage with the PTIs but would be reluctant to go along to healthcare for a ‘well man’ check. So we do healthcare checks in the gym, basic observations like blood pressure and body mass index and if we spot any issues, react accordingly. Generally, we are trying to persuade prisoners to take responsibility for their own healthcare and medication as do members of the general public. Linking the gym and catering into healthcare is a more proactive and enlightened way about going about our business.

One can’t help noticing the extensive building that is going on here at Littlehey. What is the development all about?
AB Contractors are building a 480 bed establishment to house young offenders, to be ready by January 2010.  It will include a healthcare centre to run parallel with the one we have now. Our whole approach to healthcare will change as will the way we deliver our services because the two elements of our work will be different. Where in the existing part of the prison we have to manage an ageing population with long term conditions and chronic disease, in the new building we shall have young and mostly unfit lads with different healthcare needs. Looking ahead, we foresee opportunities for early intervention work and health promotion.

Is commissioning a new healthcare centre a complicated business?   
AB Working with the PCT, we have put together an extensive bid, ranging from salary costs to the amount of Elastoplast we are going to need. As you might imagine, it has been quite a piece of work. The cost will be borne by the Prison Service and my core team will grow significantly as will all the services in the prison, including security of course.

Will you have to recruit some senior staff? You can’t be in two places at the same time.
AB We are going from a position where we have one clinical nurse manager to look after the existing centre with another to cover the new and a third to cover drug strategy.
Also we want to put in an integrated drug strategy manager who will be responsible for the rehab programmes we currently have in place and will be developing. There will certainly be plenty to do. In terms of equipment, we have bid for what we need including a dental surgery. We have made a study of the equipment available in the market to make equipment selection, forwarded that to the planners and they have approved. At the end of the day, we want the new healthcare centre fit for purpose. It’s a lot of responsibility ans a massive challenge.

I am surprised to hear that the healthcare manager here is responsible for drug strategy?
AB It is very innovative and it has got me onto a steep learning curve. We are a Cat C trainer, with a certain population and we manage drug strategy accordingly. That is going to have to change when the young offenders arrive, how I’m not quite sure. We shall definitely be looking to involve other key stake holders, like security, that is to engage them early on in drug strategy. How and where we deliver care to prisoners, that is, making appointments, treatment or coming for their regular medication, is an important consideration. Previously, it has been done centrally, that is, a large number of the prisoners would gather at healthcare and that was recognised to be a hotspot for bullying and other potential issues about order and control. So we have changed that by creating two clinical treatment rooms in the larger residential areas.

Are you able to give a satisfactory service from there?
AB At the moment we are finalising the arrangements, but we shall run a number of our clinics out of there and develop the service in due course. So, there is a lot to do here at Littlehey and it makes for an extremely exiting time

Mr Blades, thank you for taking time out to speak with the Review.