1 – The critical lack of appropriate medical care and rehabilitation within the prison system

 

The prison healthcare system is now in a critical state and I feel we have a responsibility to raise awareness of the suffering caused by this travesty.  

 

The Ministry of Justice has recorded 46,859 incidences of self-harm (equating to one every 11 minutes) and 310 deaths in the twelve months to the end of March 2018. These figures are expected to rise. The House of Commons Committee of Public Accounts – Mental Health in Prisons highlighted that 90% of those imprisoned have mental health problems. I am aware of prison inmates not receiving prescribed medication, medicines being administered at incorrect times/doses with the potential for serious harm to those individuals, basic medical needs not being met and substance dependency issues not being appropriately managed. This combination of factors, compounded by the dire lack of mental health support, is inevitably a catalyst to the mental health crisis in our prison system which is reflected in the aforementioned statistics. This also fuels violent behaviour and perpetuates the use of drugs by inmates in order to self-medicate their mental distress. The United Nations (1990) Basic Principles for the Treatment of Prisoners set out that “prisoners shall have access to the health service available in the country without discrimination on the grounds of their legal situation” which is not reflected in the current prison healthcare system. I am in the process of securing a joint meeting with Lord Ramsbotham and Prison Minister Stephen Buckland QC to discuss this further.  I would be grateful for any assistance you could offer in raising awareness of this crisis amongst your political colleagues here in Wales.    

 

2 – Screening for Attention Deficit Hyperactivity Disorder (ADHD)

 

Numerous studies have concluded that the prevalence of ADHD amongst the substance misuse population and prison population is approximately 25% and 40% respectively.  The Royal College of Psychiatrists (RCPsych) has published “ADHD in adults: good practice guidelines” which states that “medication is recommended as the first line treatment of ADHD in adults with moderate to severe impairment” (NICE 2008). The RCPsych published a paper this year which discusses the link between crime and ADHD; it concludes that management of this condition “may lead to improvement of behaviour in prison settings and potentially even prevention of further crime by prevention of recidivism. And indeed, this is something that not only the CJS but, also, the medical community and general public, cannot afford to ignore”.  Some Probation Services in England now screen for this condition and the All Party Parliamentary Group for ADHD advise that people aged between 12 and 20 arrested for impulsive crimes should now be screened for ADHD.

 

There is a dearth of ADHD services UK wide, in particular here in Wales and it is a lottery as to whether local CCGs will support funding for ongoing prescribing of those diagnosed with the condition. Dr D Reddy is a Consultant Psychiatrists specialising in ADHD (based in Swansea) and he would welcome the opportunity to discuss this matter with you further.    

 

3 – Cwm Taf UHB Community Drug and Alcohol Team (CDAT)/ Mental Health Services

 

I currently work as a Speciality Doctor in CDAT for Cwm Taf UHB. I am one of three doctors in the team; the other two doctors are Consultants Psychiatrists with an interest in Substance Misuse. Cwm Taf CDAT is scattered over four sites - Keir Hardie Hospital in Merthyr Tydfil, Rhondda Integrated Substance Misuse Service (RISMS) in Trealaw, Ysbyty Cwm Cynon and Pontypridd. I am based at the two main sites, namely Keir Hardie and RISMS. CDAT also works closely with a third sector service, namely Barod, who provide non-specialist allied services for our clients.

 

Many of the deficiencies and challenges faced by Cwm Taf CDAT service are common to other CDAT services UK wide. There is insufficient psychotherapeutic support available for our clients and considerable emphasis is placed on pharmacological interventions to manage substance misuse/mental health difficulties. Consequently 75% of our clients are previously known to the service. We do not have in-house counselling or a psychology support within CDAT. However, a Specialist Nurse Therapist, trained in trauma based therapy, has recently been appointed, which is a small but positive development. 

 

Over 50% of our clients have a co-occurring illness (a dual diagnosis of a serious mental illness with coexisting substance misuse issues) and they, in particular, are in a vulnerable position by not receiving psychotherapeutic support. This is further compounded by the fact that continued use of substances is generally seen by the Community Mental Health Team (CMHT) as a bar for referral to their service.  This is again common practice amongst CMHT services UK wide. Post Traumatic Stress Disorder (PTSD) is of particular concern as the majority of our clients have experienced severe and recurrent traumatic life events, usually from their early childhood, which has contributed to their substance misuse difficulties. In addition, we are only detecting a very small proportion of our ADHD client population. This is because we don’t screen for this condition routinely due to the absence of an allied specialist ADHD service to support the ongoing medical needs of these clients.   

 

A few weeks into my current position I became acutely aware of the absence of policies and procedures within the Cwm Taf CDAT service.  As a result there was considerable variation in service provision at various CDAT localities. My perception is that clients have a very good standard of care in Keir Hardie CDAT, especially in light of the resources available. However, the RISMS service have complex challenges such as a different client demography, geographical factors, higher client numbers, no in-house nurse prescriber and an acceptance of the status quo.

 

I discussed my observations over the phone with Dr Richard Quirk (acting Deputy Medical Director at the time) on 9 October 2018 and 20 March 2019 - Dr Quirke is also a former GP. He advised that I adopt the “followership” model of implementing changes to the service.  I went on to raise the following points with my CDAT consultant colleagues directly:

 

·         The need to agree a minimum interval for client review/follow-up by the Doctor and Key Worker to monitor progress

·         Blood tests -  the need for standardisation of blood testing for screening/monitoring of our clients and agreement on how the results are accessed, actioned and frequency of testing

·         Have an agreed policy for Hepatology referrals in line with NICE/British Society of Gastroenterology guidelines

·         ECGs – as with blood tests above. Also the importance of connecting our cardiograph machines to the Wales Clinical Portal system to enable the Cardiologists to have access to the ECGs to allow specialist interpretation of complex traces

·         Have an agreed Pabrinex injections schedule for our clients receiving alcohol detoxification

·         How to raise awareness, amongst CDAT staff, of physical health issues commonly encountered in our client population, with a view to improving early recognition and management of these conditions

·         Improving the relationship with the Primary Care service to encourage shared care approach for our clients to optimise their physical health needs

·         Improving the relationship with CMHT in order to access further support for our co-occurring clients   

 

I met with my CDAT consultant colleagues on the 12 June 2019 to discuss these points in further detail. I had previously raised some of these points at our monthly departmental Clinical Governance meetings. As documented in the minutes of the last meeting which was held on the 1 July 2019, there are positive developments now taking place. 

 

I also discussed these governance matters with the following senior representatives from Cwm Taf UHB :

 

22 May 2019 – Stephen Webster, Director of Finance (and member of the Cwm Taf UHB Executive Board). We met on the senior doctor induction day and I had the opportunity to discuss the challenges of my current role within CDAT.

 

7 June 2019 – Danielle Horrigan, Specialist Cardiac Physiologist. As a result of this meeting ECGs can now be uploaded directly onto the Welsh Clinical Portal system allowing direct reporting of complex traces by Cardiology (in line with GDPR).

 

18 June 2019 – Alan Lawrie, Director of Primary Care and Mental Health Services (and member of the Cwm Taf UHB Executive Board). We discussed the points outlined above, governance matters and my Appraisal/Revalidation requirements.

 

25 June 2019 – Julie Denley, Assistant Director of Operations – Mental Health. As in my discussion with Alan Lawrie

 

28 June 2019 – Karen Winder, Head of IT Clinical Systems – As a result of that meeting specialist referral reports, blood test results and radiology results will now be sent directly onto the CDAT IT system. This safeguarding measure will ensure results are seen and actioned in a timely manner.

 

October 2018 – I contacted the Hepatology Consultant team to request clarification on how to implement the new NICE/British Society of Gastroenterology guidelines for our alcohol related liver disease population in order to improve the management of this condition – Cwm Taf UHB has the highest mortality rate in Wales for liver disease. I eventually obtained clarification from Dr Andrew Yeoman, Consultant Hepatologist for Aneurin Bevan UHB at the launch of the “Love Your Liver” campaign in the Welsh Assembly on the 14 November 2018. I am also due to meet Dr Dai Samuel, a newly appointed Consultant Hepatologist for Cwm Taf UHB, on 12 July 2019 to discuss this further.

 

Finally, I am currently assisting the Mental Health Directorate with developing a physical health protocol based on the RCPsych “Improving the Physical Health in Serious Mental Illness” guidelines.  I hope this will improve the physical health care of clients afflicted with a mental illness. I am meeting with Dr Stuart Hackwell, Assistant Medical Director for Primary Care, on the 19 July 2019 to discuss ways of improving communication between CDAT/Mental Health Service and the Primary Care services in Cwm Taf UHB with a view to improving and optimising a shared care approach to address the physical health needs of our mental health clients.    

 

There are noticeable and positive changes already taking place within the CDAT service since senior representatives from the Cwm Taf Mental Health Directorate visited the four localities last week. CDAT team members seem open to and many even embrace these governance changes.  I have a constructive and harmonious relationship with my CDAT colleagues and I wish to continue this going forward. I am also well placed to assist with supporting these ongoing constructive developments in my current position within the team.

 

Thank you again for your time.  

 

 

Yours sincerely

 

 

Dr Gwyn H Roberts  MB BCh  FRCS (Edin)  MRCGP  Dip PallMed  Dip Occ Med  DRCOG  DCH