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Health of people in the criminal justice system

About

What is covered

This pathway covers assessing, diagnosing and managing physical health problems of people in prison or young offender institutions (YOIs). It aims to improve health and wellbeing in the prison/YOI population by promoting more coordinated care and more effective approaches to prescribing, dispensing and supervising medicines.
Please note: Recommendations on ongoing mental health care will be included in NICE's guideline on mental health of adults in contact with the criminal justice system, due to publish in March 2017. Those recommendations will also be incorporated into this pathway.

Who is it for?

  • Practitioners and managers working in prisons or young offender institutions
  • Providers of care and support to people in prisons or young offender institutions
  • People in prisons or young offender institutions, and their families and carers.

Updates

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on managing the physical and mental health of people in prison, and the mental health of people in the criminal justice system

What is covered

This pathway covers assessing, diagnosing and managing physical health problems of people in prison or young offender institutions (YOIs). It aims to improve health and wellbeing in the prison/YOI population by promoting more coordinated care and more effective approaches to prescribing, dispensing and supervising medicines.
Please note: Recommendations on ongoing mental health care will be included in NICE's guideline on mental health of adults in contact with the criminal justice system, due to publish in March 2017. Those recommendations will also be incorporated into this pathway.

Who is it for?

  • Practitioners and managers working in prisons or young offender institutions
  • Providers of care and support to people in prisons or young offender institutions
  • People in prisons or young offender institutions, and their families and carers.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Physical health of people in prison (2016) NICE guideline NG57

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Questions for first-stage health assessment

Topic questions
Actions
Prison sentence
1. Has the person committed murder, manslaughter or another offence with a long sentence?
Yes: refer the person for urgent mental health assessment by the prison mental health in-reach team if necessary.
No: record no action required.
Prescribed medicines
2. Is the person taking any prescribed medicines (for example, insulin) or over-the-counter medicines (such as creams or drops)? If so:
  • what are they?
  • what are they for?
  • how do they take them?
Yes: document any current medicines being taken and generate a medicine chart.
Refer the person to the prescriber for appropriate medicines to be prescribed, to ensure continuity of medicines.
If medicines are being taken ensure that the next dose has been provided (see access to medicines in this pathway).
Let the person know that medicines reconciliation will take place before the second-stage health assessment.
No: record no action required.
Physical injuries
3. Has the person received any physical injuries over the past few days, and if so:
  • what were they?
  • how were they treated?
Yes: assess severity of injury, any treatment received and record any significant head, abdominal injuries or fractures.
Document any bruises or lacerations observed on body map.
In very severe cases, or after GP assessment, the person may need to be transferred to an external hospital. Liaise with prison staff to transfer the person to the hospital emergency department by ambulance.
If the person has made any allegations of assault, record negative observations as well (for example, 'no physical evidence of injury').
No: record no action required.
Other health conditions
4. Does the person have any of the following:
  • allergies, asthma, diabetes, epilepsy or history of seizures
  • chest pain, heart disease
  • chronic obstructive pulmonary disease
  • tuberculosis, sickle cell disease
  • hepatitis B or C virus, HIV, other sexually transmitted infections
  • learning disabilities
  • neurodevelopmental disorders
  • physical disabilities?
Ask about each condition listed.
Yes: make short notes on any details of the person's condition or management. For example, 'Asthma – on Ventolin 1 puff daily'.
Make appointments with relevant clinics or specialist nurses if specific needs have been identified.
No: record no action required.
5. Are there any other health problems the person is aware of, that have not been reported?
Yes: record the details and check with the person that no other physical health complaint has been overlooked.
No: record no action required.
6. Are there any other concerns about the person's physical health?
Yes: make a note of any other concerns about physical health. This should include any health-related observations about the person's physical appearance (for example, weight, pallor, jaundice, gait or frailty).
Refer the person to the GP or relevant clinic.
No: note 'Nil'.
Additional questions for women
7. Does the woman have reason to think she is pregnant, or would she like a pregnancy test?
If the woman is pregnant, refer to the GP and midwife.
If there is reason to think the woman is pregnant, or she would like a pregnancy test: provide a pregnancy test. Record the outcome and if positive make an appointment for the woman to see the GP and midwife.
No: record response.
Living arrangements, mobility and diet
8. Does the person need help to live independently?
Yes: note any needs. Liaise with the prison disability lead in reception about:
  • the location of the person's cell
  • further disability assessments the prison may need to carry out.
No: record response.
9. Do they use any equipment or aids (for example, walking stick, hearing aid, glasses, dentures, continence aids or stoma)?
Yes: remind prison staff that all special equipment and aids the person uses should follow them from reception to their cell.
No: record response.
10. Do they need a special medical diet?
Yes: confirm the need for a special medical diet. Note the medical diet the person needs and send a request to catering. Refer to appropriate clinic for ongoing monitoring.
No: record response.
Past or future medical appointments
Has the person seen a doctor or other healthcare professional in the past few months? If so, what this was for?
Yes: note details of any recent medical contact. Arrange a contact letter to get further information from the person's doctor or specialist clinic. Note any ongoing treatment the person needs and make appointments with relevant clinics, specialist nurses, GP or other healthcare staff.
No: record no action required.
12. Does the person have any outstanding medical appointments? If so, who are they with, and when?
Yes: note future appointment dates. Ask healthcare administrative staff to manage these appointments or arrange for new dates and referral letters to be sent if the person's current hospital is out of the local area.
No: record no action required.
Alcohol and substance misuse
13. Does the person drink alcohol, and if so:
  • how much do they normally drink?
* how much did they drink in the week before coming into custody?
Urgently refer the person to the GP or an alternative suitable healthcare professional if:
  • they drink more than 15 units of alcohol daily or
  • they are showing signs of withdrawal or
  • they have been given medication for withdrawal in police or court cells.
No: record response.
14. Has the person used street drugs in the last month? If yes, how frequently?
When did they last use:
  • heroin
  • methadone
  • benzodiazepines
  • amphetamine
  • cocaine or crack
  • novel psychoactive substances
  • cannabis
  • anabolic steroids
  • performance and image enhancing drugs?
Yes: refer the person to substance misuse services if there are concerns about their immediate clinical management and they need immediate support. Take into account if:
  • they have taken drugs intravenously
  • they have a positive urine test for drugs
  • their answers suggest that they use drugs more than once a week
  • they have been given medication for withdrawal in police or court cells.
If the person has used intravenous drugs, check them for injection sites. Refer them to substance misuse services if there are concerns about their immediate clinical management and they need immediate support.
No: record response.
Problematic use of prescription medicines
15. Has the person used prescription or over-the-counter medicines in the past month that:
  • were not prescribed or recommended for them or
  • for purposes or at doses that were not prescribed?
  • If so, what was the medicine and how did they use it (frequency and dose)?
Yes: refer the person to substance misuse services if there are concerns about their immediate clinical management and they need immediate support.
No: record response.
Mental health
16. Has the person ever seen a health professional or service about a mental health problem (including a psychiatrist, GP, psychologist, counsellor, community mental health services, alcohol or substance misuse services or learning disability services)?
If so, who did they see and what was the nature of the problem?
Yes: refer the person for a mental health assessment if they have previously seen a mental health professional in any service setting.
No: record response.
17. Has the person ever been admitted to a psychiatric hospital and if so:
  • when was their most recent discharge?
  • what is the name of the hospital?
  • what is the name of their consultant?
Yes: refer the person for a mental health assessment.
No: record response.
18. Has the person ever been prescribed medicine for any mental health problems? If so:
  • what was the medicine
  • when did they receive it
  • when did they take the last dose
  • what is the current dose (if they are still taking it)
  • when did they stop taking it?
Yes: refer the person for a mental health assessment if they have taken medicine for mental health problems.
No: record response.
Self-harm and suicide risk
19. Is the person:
  • feeling hopeless, or
  • currently thinking about or planning to harm themselves or attempt suicide?
Yes: refer the person for an urgent mental health assessment. Open an Assessment, Care in Custody and Teamwork (ACCT) plan if:
  • there are serious concerns raised in response to questions about self-harm, including thoughts, intentions or plans, or observations (for example, the patient is very withdrawn or agitated), or
  • the person has a history of previous suicide attempts.
Be aware and record details of the impact of the sentence on the person, changes in legal status and first imprisonment, and the nature of the offence (for example murder, manslaughter, offence against the person and sexual offences).
No: record response.
20. Has the person ever tried to harm themselves and if so:
  • do they have a history of suicide attempts?
  • was this inside or outside of prison?
  • when was the most recent incident?
  • what was the most serious incident
Yes: refer the person for a mental health assessment if they have ever tried to harm themselves.
No: record response.

Examples of critical medicines where timeliness of administration is crucial to prevent harm from missed and delayed doses

This table contains examples only and should be used in conjunction with clinical judgement. It is important to assess each person on an individual basis.
Area
Medicines
Cardiovascular system
Anticoagulants
Nitrates
Respiratory system
Adrenoceptor agonists
Antimuscarinic bronchodilators
Adrenaline for allergic emergencies
Central nervous system
Anti-epileptic drugs
Drugs used in psychoses and related disorders
Drugs used in parkinsonism and related disorders
Drugs used to treat substance misuse
Infections
As clinically indicated, such as anti-infectives or anti-retrovirals
Endocrine system
Corticosteroids
Drugs used in diabetes
Obstetrics, gynaecology and urinary tract disorders
Emergency contraceptives
Malignant disease and immunosuppression
Drugs affecting the immune response
Sex hormones and hormone antagonists in malignant disease – depot preparations
Nutrition and blood
Parenteral vitamins B and C
Eye
Corticosteroids and other anti-inflammatory preparations
Local anaesthetics
Mydriatics and cycloplegics
Glaucoma treatment

Glossary

Assessment, Care in Custody and Teamwork
a diagram of the body on which physical injuries can be recorded
the transfer of any prescription medicines from the individual person for whom they were prescribed to another person for misuse
a prescription form – people who are released from prison unexpectedly can take an FP10 to a community pharmacy to receive their medicines free of charge until they can arrange to see their GP or register with a new GP
medical emergency bags containing equipment and medication for dealing with common medical emergencies – the equipment may include dressings, automated external defibrillator, and oxygen; it may also include medicine, for example for treating allergic reactions (anaphylaxis)
medicine is said to be held in-possession if a person (usually in a prison or other secure setting) is responsible for holding and taking it themselves
the process of identifying an accurate list of a person's current medicines and comparing them with the current list in use, recognising any discrepancies, and documenting any changes, thereby resulting in a complete list of medicines, accurately communicated (adapted from definition by the Institute for Healthcare Improvement)
a group of professionals from different disciplines who each provide specific support to a person, working as a team – in prison settings, a multidisciplinary team may include physical and mental health professionals, prison staff, National Probation Service and/or community rehabilitation company (CRC) representatives, chaplains, and staff from other agencies, such as immigration services and social care staff
substances taken for a non-medical purpose (for example, mood-altering, stimulant or sedative effects)

Paths in this pathway

Pathway created: November 2016 Last updated: November 2016

© NICE 2017

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