Finding the time finding the person finding a

Finding the time, finding the person, finding a new way. . ? Patricia Cadden, Senior Commissioner And Chris Hart, Independent Nurse Consultant

What we’ll be talking about • • • Introduction Reasons for commissioning the RDIC Custody Taking a moment The work to date Too busy, not enough staff, what to do? What next?

London deaths in prison custody/ detention 2013 -2016 12 10 8 2013 -14 2014 -15 6 2015 -16 2016 -17 4 2 0 Natural causes Self-inflicted Accidental (sus OD) Other Unknown at this point

2013 -2016 HMP WS HMP WW HMP PV HMP TS HMP BM HMP Isis √ Resuscitation and emergency response/roles √ √ √ Communication between doctors/nurses and prison staff √ √ √ Emergency response procedures √ √ √ ACCT management- healthcare input/recording √ √ √ Records management- meeting professional standards √ √ √ Assessment completion processes (clinical curiosity) √ √ Risk assessments- internal and for escorts out/on release √ √ √ Protocols for observations and escalation (recording of clinical measurements) Continuity of care (to and from community/hosp/court) √ Skill mix of staff in key areas √ Management of selfharm/suicide √ √ √ √ DNAR protocols- re: communicating to staff End of life care/pronouncement of death √ √ √ IRC HW √

Commissioning Chris • Observation- seeing healthcare teams/units at work • Processes- assessment/communication flows/staff support/ systems and governance • Identification- what are the actual issues? • Support- using his expertise and experience work with management and teams to agree change • Evaluate/sustain-what can be done to address cultural blocks/bring about a more dynamic workforce/new ways of working

Taking a moment

The work to date – initial phase • • 3 day initial visit Introducing the process Talking with people Observation of the detail of policy, practice and systems • To date: HMYOI Feltham, HMPs Wandsworth, Belmarsh and Thameside

Early findings – no surprises • Intense pressure on all staff arising from prison population and its needs • Difficulty balancing ‘security’ and ‘care’ • Complexity of healthcare provision • Difficulty integrating healthcare service into life of the prison • Difficulty maintaining systems • Functional, task oriented approach often misses the person

Extremely difficult for staff to see prisoner’s whole story and risk

How do we relate to the person?

How might ‘busyness’ affect us?

“No one cares”

“No one listens”

Yet…among the staff group • • • Resilience Perseverance Commitment Striving Compassion

Phase two • Designing bespoke developmental packages with staff from each individual service • Working with healthcare teams • Working with prison staff

Phase two • Providing resources • Working alongside staff • Learning and developmental forums • Reflective practice sessions

The problem of resources

What do we mean by “short staffed”? • A commonly used term • What does it actually mean? – Insufficient numbers of people to carry out assigned tasks? – More work than we’ve previously had without an expansion in staff? – Fewer staff than previously available for the same amount of work? – A combination of the above?

What do we mean by “short staffed”? • A question of staffing levels but also the ratio of staff to the amount of work to be undertaken • Situation changes i. e. fewer staff but do we adapt? • Some temporary measures but not moving into new mode of operation • Trench warfare rather than guerrilla warfare or trying to run a country estate on the budget for a semi detached semi.

“It’s all about management!” • Emotionally intelligent management • Inclusive • Incorporating methodology of shared governance • Focused on risk management and effective performance

Prioritising • What are the key problems we’re trying to solve/issues we’re trying to address? • What are the must dos? • How was this decided? Does everyone know? Do they agree?

What cannot be done? • What does this mean we can’t do? • Do the right people know we can’t do things? • Do they understand, acknowledge and support this?

Team working • Who is in my team? Do they know they’re in my team? • What is the team’s focus? • What is their role? Is this clear? • How collaborative is everyone? • What are my carrots?

Delegation • • • If someone has a task, are they ready for it? How do I/they know? What has been done to prepare them for it? Are we utilising people’s skills to the full? Have we got skills based training in place?

Communication • • What needs to be communicated? Who should do this? What systems are in place? How do people know what has happened on the previous shift, today’s priorities, who will be doing what and when?

Organisation • Do we work in a totally reactive environment? • How can we plan ahead and try and stick to those plans [bearing in mind the best plans are those that never have to encounter ‘reality’]?

Not just what can we do differently but how?

Hope • Importance of Hope • Limited ambition – sticking to achievable aims rather than leaving people feeling perpetually defeated e. g. “what have we achieved today and what can we achieve tomorrow? ”

Clinical risk indicators for suicide • • • Previous self-harm Family history of suicide Previous use of violent methods Unemployed/retired Suicide plan/expressed intent Male gender Current suicidal thoughts/ideation Separated/widowed/divorce d Hopelessness/helplessness Post natal depression Peurperal psychosis • • • Lack of social support Depression Family concerned about risk Evidence of psychosis Disengaged from services Alcohol and/or drug misuse Poor adherence to psychiatric treatment Chronic physical illness/pain Access to lethal means of harm Discharged from hospital within last 7 days

Other, specific, clinical factors in prisons • • • Previous trauma Lack of coping strategies Anxiety Poor physical health Recent stressors The prisoner might trivialise/conceal their risk indicators/vulnerability

Contextual risk factors • Predisposing factors e. g. – Previously in institutional ‘systems’ e. g. care as a child etc – The nature of the offence – Loss of support networks e. g. family relationships – Prisoners are isolated – Lack of contact with others • Bullying

Working a little differently…

What can come from an extra few minutes

What might we look for? • How robust is the Reception interview? • Does everyone get seen for 2 nd day assessment and other appointments? • What systems do we have in place – – For minimising DNAs – For medicines administration – For risk assessment – To promote multi professional working – For effective communications

Beyond the systems • Are we agreed on the core task? • How well do we work together? • What are the relationships – – Within teams – Between teams • Are our skills and competencies at the right level?

Scope for small changes • How involved are staff in making changes? • How receptive are we to ideas? • What kind of support is available to all?