A consultant-led orthopaedic/trauma clinic that was tested in a prison setting has significantly improved the care received by inmates
The North Tees and Hartlepool NHS Foundation Trust Orthopedic Outpatient Service regularly treats men in a local prison in trauma and elective clinics. These appointments were often delayed, canceled or absent due to pressure from the prison and the number of escorts the prison can accommodate at any one time. Meetings were held with the prison service to determine how we could improve care; it was decided that an orthopedic/trauma clinic should be held in the prison, and it was trialled for six months. The absent inmate rate decreased, men were seen more quickly, and inmate feedback on service was positive in all aspects of the care provided. The clinic has now become permanent.
Quote: Maddison T, Jevons RP (2022) Better access to outpatient orthopedic services for incarcerated people. Nursing schedules [online]; 118:4.
Authors: Tracy Maddison is an outpatient service matron; Richard P Jeavoirs is an orthopedic consultant specializing in shoulder and elbow and trauma services; both at North Tees and at Hartlepool NHS Foundation Trust.
- This article has been double-blind peer reviewed.
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It can be difficult to ensure that prisoners receive the health care they need. The Orthopedic Outpatient Service in North Tees and Hartlepool NHS Foundation Trust regularly treats men from Her Majesty’s Prison Service (HMPS) – in particular the men’s prison, Her Majesty’s Prison Holme House – in its general trauma clinics, hand and elective traumatology.
Many prisoners were registered as “not present”, had appointments canceled and rescheduled, or, when they arrived, were too late for emergency surgery and had to be registered for elective surgery. Several incident reports had been filed against the prison by the medical staff of the outpatient orthopedic service using an internal incident system; however, as the men were incarcerated, the normal protection policy did not apply. This experience mirrors the work of Aldridge et al (2018), who stated: “Prisoners are subject to health inequalities, their health, outcomes and access to care are worse than the general population. Edge et al (2020) also noted that: “It is the people, in prison, who continue to access most of their secondary care through external hospital services”.
Discussions with the prison health care manager, a prison warden and a commissioner took place over several weeks in May 2020, after which we decided to look at the pathways we had for inmates and how we could improve the care they received. Before committing to action plans, we had to decide:
- What actions should be taken and by whom;
- What would be the benefits for HMPS and the local foundation?
- If the initiative was sustainable.
A team – consisting of the HMPS Head of Health Care, HMPS Administrative Staff, an Orthopedic Trauma Consultant, the Orthopedic Outpatient Service Matron, the Orthopedic Outpatient Service Registrar, the Deputy Governor of the Prison and commissioner – performed a table-top exercise looking at the inmate’s entire journey, documenting the main drivers of change (Box 1) and discussing them at length.
Box 1. Drivers of change
- The men in prison had many hospital appointments canceled leading to delays in surgery and long stays – up to five appointments could be canceled before entering hospital
- Prisoners reportedly miss appointments, either because of prison pressure or by choice
- Demand for prison escorts has exceeded capacity – each prisoner under escort needs at least two prison officers and a driver. However, the prison could only accommodate two escorted men at a time.
- Many inmates experience anxiety and mental health issues when leaving the prison environment
The taken procedures
In June and July 2020, many meetings took place, both at the trust and at the prison. It was agreed that a six-month trial of consultant-led clinics within prison health care would be carried out from July 2020 to December 2020. A Senior Health Assistant (HCA) would attend, along with the consultant to make requests and/or care of plaster casts. There was a financial cost to HMPS, but the prison did not state internal costs for consumables, such as dressings, and governors felt the benefits outweighed the cost.
HMPS health staff arranged to have all dressings, pharmacy stock and casting materials on site that would be required to run an outpatient clinic for trauma and elective patients. In addition, the prison care team asked the visiting radiologist to report to the prison on the same day as the orthopedic consultant. This has ensured a more streamlined approach to trauma patient care and reduced wait times for decisions.
Senior HCA officials who visited the prison were met by the prison health care team and had informal visits before the trial began. This helped ease any anxieties they might have felt about entering the prison environment and ensured they were familiar with the workspace and the processes in place. The team at the prison’s front door received the product numbers of the consultant’s laptop and dictaphone, as well as the main HCA’s portable plaster saw; this meant that these three objects could enter the prison each session without the need for additional paperwork.
The trial was a success; each prison clinic can see up to 10 men and all inpatients under prison health care. Inmates are seen more quickly and the rate of inmate non-attendance at the orthopedic outpatient service has been reduced from 90% to 5%. Some men still refused the appointment, but the risk of delaying surgery is reduced; no inmate seen at this clinic has suffered a delay in surgery. The men gave positive feedback and could see the benefits of the service.
There is a good working relationship between HMPS and the trust, and HMPS healthcare staff have been up-skilled – they can now apply basic casts for initial pain relief and immobilization, as well as provide ongoing care to patients with casts. This reduces the need for men to attend the trust to have the plaster applied. Monthly prison clinics are now part of the consultants’ work plan. In addition, training sessions have been organized and also allocated for the future.
The benefits that were realized in the trial were beyond what was hoped for, but we felt that some feedback from men using the service would be valuable.
By the end of the trial in December 2020, 27 men had been seen at the prison clinic. Using a semi-structured qualitative questionnaire and interview, 22 of the 27 men were interviewed by the health care manager – the other five detainees had been released.
Interviews were conducted individually in the inmates’ living blocks, as the interviewers felt that the men would be more comfortable answering questions outside of the health care facility and in a more neutral environment, reducing thus the risk of bias. Box 2 highlights the questions that were asked and Box 3 summarizes a selection of prisoners’ responses; no negative response was obtained from the respondents.
Box 2. Questions asked
- Were you satisfied with the consultation and your injury management plan?
- How do you think the treatment you received compares to your hospital treatment?
- Following the application of the back slab/plaster, did you notice a difference? If yes, what difference?
- How can we improve the service?
Box 3. Detainee responses
“Yes, I was happy with the plan. It was good to know that someone recognized that I needed help.”
“I feel relieved to have been seen at the clinic and to have been put at ease by the consultant.”
“Makes life easier to be seen here and not have to leave the building. It’s not a pleasant experience to go to the hospital, without the added stress of people staring at you and judging you for being a prisoner.”
“My mental health suffers when I’m out of a routine… I couldn’t stand sitting in a waiting room and I self-harmed to cope with the stress.”
“The pain got better after applying the back slab and I didn’t have to queue at the hatch for pain relief.”
“I believe that more services should be offered in prison to avoid people having to go to hospital.”
The plan was to roll out this service to other specialties of the trust’s outpatient services, but the Covid-19 pandemic interrupted access to prisons for a time. At this stage, we have tested video/virtual clinics. These have worked for orthopedics and traumatology as a palliative and may be what some specialties, especially medicine, may use; however, in orthopedics, the trust has decided to hold virtual prison clinics, with face-to-face clinics as needed. Our collaborative work has made a difference for both inmates and prison staff, and will continue.
- It can be difficult to coordinate health care so prisoners get the care they need
- Collaboration between an outpatient orthopedic service and the prison administration can improve the care of prisoners
- Holding clinics on prison premises can benefit staff and patients
- Care appointment attendance rates improve when clinics are held in prisons
- Since prison escorts are not required for hospital clinics, costs can be saved
Aldridge RW et al (2018) Morbidity and mortality among homeless people, prisoners, sex workers and people with substance use disorders in high-income countries: a systematic review and meta- to analyse. The Lancet; 391:10117, 241-250.
Edge C et al (2020) Clinicians and secondary care staff play a key role in providing equivalent care to inmates: a qualitative study of inmate experiences. ECMedicineClinical; 24:100416.