Saturday, 11 August 2012

Police custody healthcare - models of service

Historically, police custody healthcare provision in the UK had been provided by the police surgeon (also known as forensic medical examiner FME).  In recent years there has been a move to include other healthcare professionals (HCPs) such as nurses and paramedics, with the current preferred model as nurse-led.  (Paramedics can have a role in provision of urgent care but as their training is specifically targeted and far narrower than that of a general nurse they are not widely employed).  This model is appropriate as many detainees will present with minor injuries or conditions which can be ably managed by a nurse with the relevant experience and training.  However, practical implementation of the model can provide areas of weak governance unless the risks are identified and managed.

It is commonplace for Patient Group Directions (PGDs) to be used as a means of providing timely access to prescription only medicines without the need for assessment and authorisation by an appropriate prescriber.  A PGD is a legal instruction that must include specified information to give defined categories of HCPs the authority to administer or supply the medicine.  They are intended to be specific and clear regarding inclusion and exclusion criteria to support permitted HCPs who do not have the skills and competence of a prescriber.  PGDs were introduced into police custody in 2003 with Home Office Circular 026/2003:

'The extension of PGDs to police station custody suites will allow named healthcare professionals, other than medical practitioners, to supply and/or administer (but not prescribe) medication for minor ailments and injuries without having to call upon the police surgeon to prescribe medication in each individual case. PGDs will therefore assist in improving the delivery of treatment to detainees by shortening response times and will ensure that treatment for minor ailments in police custody suites parallels that provided in the NHS.'

An increasingly common model of healthcare provision is for the nurse-led service to be supported by one or two FMEs covering the police force area.  This will usually mean that the majority of advice consultations between nurse and FME will be by phone and the FME will only be able to attend to a limited number of detainees if required to do so.  Providing advice to another HCP regarding a patient you have not seen based on the HCP's assessment constitutes an area of high risk for a clinician.

Healthcare providers are also now commonly using PGDs for treating the symptoms of opiate and alcohol withdrawal.  It can be seem from the HO circular mentioned above that this area of treatment was not authorised in the original circular.  In 2010 I contacted the HO to ask if they had subsequently authorised use of PGDs in this clinical treatment area and received a response that they now looked to the Department of Health for clinical policy guidance.  Following contact with the DH, a pharmacist advisor and I drafted a brief policy statement, which unfortunately coincided with a change of government and is yet to be issued.

The Medicines and Healthcare products Regulatory Agency on PGDs states:

'The majority of clinical care should be provided on an individual, patient-specific basis.  The supply and administration of medicines under PGDs should be reserved for those limited situations where this offers an advantage for patient care without compromising patient safety, and where it is consistent with appropriate professional relationships and accountability.'

It is clear that PGDs should not provide the main vehicle for provision of medicines, particularly in non-minor conditions such as substance misuse, where they can provide prompt initial treatment until the detainee can be seen by a clinician with the expertise and ability to prescribe individualised care for the patient.  It is important that PGDs have clearly defined treatment periods as, although periods of detention are usually very short, they may be longer and clear referral criteria must be set.

Any service model must be assessed and demonstrable as able to provide a good standard of clinical governance.  Expert advisors must have professional expertise in this sector and be able to demonstrate their competence for the protection of providers, staff and patients.  Staff must possess the identified clinical and professional skills necessary to practice at the level required.  Medicines policies must be robust and comprehensive.  Anything less than excellence is not good enough.

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