Brian D. Conroy RGN
Her Majesty's Prison & Young Offenders Institution, Glenochil
In an environment such as a secure, long-term, adult male prison, there exist numerable constraints upon the delivery of health care. However no one should be under the misapprehension that health care provision in prison differs in any way from health care provision in the community. Prisoners have access to a comparable level of care whilst in custody as they would expect to have access to in any community based environment.
The most noticeable drawback in providing this level of care lies mainly with the fact that a prison is by definition intended to be a (safe) and secure environment. Prison life involves set regimes and stringent security regulations. To clarify the many constraints, imagine the average adult male, in a community setting, with a medical complaint that is giving him concern. He would simply arrange an appointment with his GP or practice nurse, attend his appointment and have a consultation, pay for any prescription then return home and follow any further instructions given him by his GP. In prison however, security, transport, manpower, medication, logistical, police, compliance and peer pressure issues, amongst a multitude of others, would surround a prisoner with the same complaint. This simple model is intended to familiarise the reader with the difficulties involved in managing illness in prison. For the purpose of this discussion we will be concentrating on Chronic Obstructive Pulmonary Disease. Situational information relating to the reality of prison life will be incorporated as this does directly influence both the delivery of basic care and the application of clinical intervention.
Her Majesty's Prison & Young Offenders Institution, Glenochil, in Stirlingshire, Scotland is a high security establishment housing both adults and young offenders. Previous to its use as a prison it was a colliery facility under the National Coal Board. It has been utilised as a prison for approximately 34 years. There is a current adult population of approximately 450. (A prisoner is considered adult after the age of 21 years) Of those, it is estimated that 90% are smokers. Currently there are around 22 adult prisoners diagnosed with COPD of varying degrees of severity. (There is an ongoing programme for identification of and differentiation between COPD patients and asthma patients) Every one of those identified as COPD is aged over 45 years. This equates to a prevalence of almost 5% amongst the current population. This appears to reflect reasonably conclusively on the current estimates of COPD prevalence amongst men over the age of 45 years as in the UK at present, COPD is thought to affect about 6% of men and 4% of women, over the age of 45 years.(1)
Given the huge percentage of smokers amongst our population however, this percentage may well become significantly higher in the future amongst that population as cigarette smoking is without doubt, the most important risk factor(2), and that by 2020, COPD is predicted to be the fifth most common cause of death in the UK (3)
Unfortunately, cigarette smoking is a major pastime in prison and despite a recent anti-smoking incentive (prisoners were furnished with various nicotine replacement products) there has been no significant reduction in the number of smokers. It became evident that many prisoners availing of the offers of NRT were doing so as a means of self-funding. (The NRT products were "sold on" to other prisoners for cash). It was assumed that the proceeds invariably helped pay for illicit substances. This digression serves to further strengthen the issue of the difficulties of delivering care and ensuring compliance in prison.
Chronic Obstructive Pulmonary Disease is a major health burden, both nationally and internationally, with the majority of cases being the end result of a prolonged and often heavy smoking history. In the UK alone, it causes significant morbidity and accounts for approximately 10% of all working days lost.(4) It is also responsible for approximately 30 000 deaths each year.(5) Within the confines of a prison, the burden of COPD on the patient, staff resources, patients' families and other inmates is quite substantial. It can have a very disruptive effect on the normal prison regime and it does attract a considerable amount of nursing and GP intervention, not to mention spiralling, and often unnecessary, costs in relation to pharmaceutical products. (It is probably second only to a massive substance abuse problem prevalent in many Scottish penal establishments). As described previously, the prison is 34 years old and, unfortunately, the very restrictive architecture of a typical cell allied with poor ventilation, poor air conditioning, restriction of access, proximity of other inmates and security aspects all make for an extremely inadequate situation where the treatment and throughcare of a patient with exacerbated COPD is concerned. We do not, unlike some prisons, operate a typical hospital wing where more adequate treatment and monitoring could be performed. Currently, a client presenting with a serious exacerbation of COPD will require hospitalisation.
There also exist difficulties of a psychological nature whereby a prisoner suffering an exacerbation of his COPD will, by the very nature of his condition, be excluded from or decline to attend familial visits. This situation does tend to aggravate the prisoner's psychological wellbeing given that a familial visit is often a rare occurrence and, ideally, is one area of prison regime that should be encouraged and adhered to. The goals of COPD management, in spite of these restrictions, remain the same as standard guidelines. These are; early and accurate diagnosis, best control of symptoms, prevention of deterioration, prevention of complications and improved quality of life.(6) Each of these goals is dealt with in turn and the various limitations will become evident. For instance, a massive problem exists in the current availability of healthcare staff within the establishment(s) who are fully conversant and comfortable with both understanding these diseases and treating them. Spirometry is available in Glenochil as part of regular asthma clinics. It is intended that in the very near future a regular COPD clinic will be commenced and spirometry will be utilised to its potential. As mentioned previously, there is a programme currently in place in HMP Glenochil to categorise those inmates who are suffering from asthma and those who are suffering from COPD. This is the first step in an awareness teaching process whereby healthcare staff will be mindful of which clients have asthma and which clients have COPD and will be able to apply proper care and treatment.
There is now clear evidence that the pathogenesis and pathophysiology of asthma and chronic obstructive pulmonary disease are not the same, and therefore, patients with these conditions should be treated differently. There is much evidence indicating that anti-inflammatory and bronchodilator therapies do not have the same efficacy in patients with chronic obstructive pulmonary disease as in patients with asthma: anti-inflammatory medication is essential in the treatment of (chronic) asthma, whereas this has not yet been shown for patients with chronic obstructive pulmonary disease. Longitudinal studies in general practice have shown that the two conditions have different prognoses: asthma is often fully remittent, especially in childhood, whereas the progress of chronic obstructive pulmonary disease seems to be irreversible. Therefore it would seem useful to develop practical guidelines that made a clear distinction between asthma and chronic obstructive pulmonary disease.(7)
The distinguishing criteria, which we use as reference, are already widely documented and describe different aetiologies and pathologies. There are also substantial differences in the approaches to treatment with specific drugs. As a basic rule, and prior to spirometry measurements, we can identify fundamental differences between COPD and asthma using the following principles:
The onset of COPD usually occurs after the age of 40 years whereas with asthma the onset is normally at below the age of 30 years in 70% of cases. There is usually always a long history of cigarette smoking in patients with COPD but this has only been the case in some asthmatics. There is a chronic, progressive pattern of symptoms with COPD as opposed to a paroxysmal pattern in asthma and airflow obstruction in COPD is largely fixed whereas in asthma this airflow obstruction is largely reversible. There is a very good response to anticholinergic therapy but a poor response to corticosteroids in COPD. In asthmatics the reverse is often the case.(8)
There is an intention to incorporate these guidelines, to include spirometry intervention, in the formulation, implementation and continual updating of a protocol specific to the care of COPD patients held in prison. This will obviously be based on current medical guidelines and will involve extensive research and investigation into a multitude of existing constraints. This documentation, once complete, will be presented to the healthcare policies group within the Scottish Prison Service for implementation establishment wide. In the future this will ensure universally accepted regimes of treatment and will outline common guidelines encompassing all (relevant) aspects of prison regulations and security.
Among those guidelines, and obviously to maintain best control of symptoms and prevention of deterioration, diagnostic spirometry will be perhaps the main consideration. As an adjunct to spirometry results, procedures to improve lung function will be established and implemented as per The British Thoracic Society Guidelines. The diagnosis of COPD is usually suggested by symptoms but can only be established by objective measurement, preferably using spirometry. Unlike asthma, airflow limitation in COPD as measured by the FEV1 can never be returned to normal values. However, treatment can improve both symptoms and measured airflow limitation.(9) Naturally, proper steps will require to be taken to ensure that there is at least one practitioner nurse per establishment who specialises in respiratory care and spirometry interpretation in order to maintain professional supervision and monitoring. It must be further stressed that we cannot underestimate the limitations involved in a prison environment and should always be prepared to use our skill and judgement in determining those restrictions when it comes to more critical care.
The needs of COPD patients are plentiful and where the intended professional training criteria may be met in the future, a prison cell and the "baggage" that accompanies it, will always be a burden to those professionals trying to control symptoms and prevent deterioration of an individual's condition. We have equal access to pharmaceutical provision and GP intervention and we can administer therapies to improve and maintain a client in a stable condition.
FEV1 measurements of 80% of predicted (mild COPD) would be treated with a short-acting B2-agonist or inhaled anticholinergic as required depending upon symptomatic response. FEV1 measurements of 40% of predicted (severe COPD) would be treated with a combination therapy with regular B2-agonist and anticholinergic. A steroid trial would be performed and consideration given to the addition of other agents and the client would be assessed for (and provided with) a home nebuliser.(10) Conditions requiring specialist referral, in accordance with BTS guidelines, such as severe COPD, cor pulmonale, O2 therapy, rapid decline in FEV1 etc. would naturally be referred to hospital. But less marked conditions within the confines of prison would also be given full consideration given the inability of healthcare staff to keep a constant vigil and the intrinsic patterns of non-compliance or poor compliance with treatment. The question also arises regarding a client requiring long term oxygen therapy. At present there would be no possibility within this establishment of facilitating long term oxygen therapy. We currently have at least two clients who have a very poor prognosis. The past history of both includes a very heavy smoking pattern since their teenage years, episodes of poor compliance with treatment regimes, unwillingness to change their form of treatment and unwillingness to stop smoking. It is foreseeable that they will both require intensive treatment in a few years and this may include long term oxygen therapy. Should this situation arise it will involve a transfer to a more appropriate establishment that can facilitate this type of care or, indeed, to a hospital.
In summarising, this whole discussion is intended to offer an insight into the machinations of a typical high security penal establishment. The constraints on the delivery of care to COPD patients are evident and there is an important requirement that this is recognised. Future prognoses suggest that COPD is set to become one of the most significant conditions causing morbidity. With rising prison populations and prisoners in the main originating from lower socio-economic classes, the prevalence of COPD in prisons will mirror the prevalence of COPD in communities. It is even feasible that the percentages in prison will in fact surmount those in the community given the realities of life in prison, which have already been covered. Healthcare in prison is excellent. Practitioner nurses are very well trained and expert medical services from GP's and hospital physicians are always available. But much more needs to be done by way of specialist training for practitioner nurses. Appropriate equipment needs to be made available to all establishments for throughcare of COPD patients and access to better facilities for this type of care has to be a major consideration.
We will not, in the foreseeable future, have an architecturally more suitable establishment(s) so it is vital that the aforementioned points are addressed. We will probably always be fighting a losing battle regarding smoking cessation, as this is such an inherent part of prison life. Health education in prison is a major ongoing project and Wellman and Wellwoman clinics are becoming more and more common. These will serve to help identify COPD patients together with those in the "at risk" category and allow appropriate follow-up care.
1. (Postma and Siafakas,1998)
2. (Pride, 1990; Lewis and Cochrane, 1991; Doll et al, 1994; Barnes, 1995; Godley, 1995)
3. (Bellamy & Booker, 2000).
4. (Pearson et al, 1994; Burrows et al, 1997)
5. (Brewis, 1991; Office of Population Censuses and Surveys, 1992; Anderson et al, 1994)
6. (British Thoracic Society Guidelines for the Management of COPD. Thorax 1997; 52 (Suppl 5): S1-S24)
7. (CP Van Schayk. Diagnosis of Asthma and COPD in General Practice. British Journal of General Practice, March 1996, P.193-197)
8. (Dr Michael Rudolf. Is it COPD? - Avoiding Misdiagnosis. PULSE Supplement Part 1, 1997, P.8, Table 2)
9. (British Thoracic Society COPD Guidelines Summary. Thorax, 1997; 52 (Suppl 5) : S1-S32).
10. (British Thoracic Society COPD Guidelines Summary.Thorax,1997; 52 (Suppl 5):S1-S32).