Prison

Service Clinical Governance – Quality in

Order Prison Healthcare

ORDER
NUMBER

3100

Date of Issue Click on Number for link to reference

/ Amendment
16/01/2003
Amendments can be tracked in the Numerical Index.

PSI Amendments should be read before and in conjunction with PSO

INTRODUCTION FROM THE DIRECTOR OF PRISON HEALTH

CLINICAL GOVERNANCE – QUALITY IN PRISON HEALTH CARE

Introduction

1. This PSO sets out requirements for Governing Governors to ensure

that arrangements are being made for clinical governance in prison
health care. Governors are not responsible for setting up the detailed
arrangements for clinical governance – this falls to the clinical
governance lead and health care team – but Governors are
accountable for ensuring that the agenda is taken forward. Governors
may find it helpful to use the checklist at Appendix 1, which has been
based on documents used by NHS Chief Executives.

2. Some prisons are already engaged in clinical governance activities,

and we would encourage others to make progress as soon as possible.
To help in this, Prison Health Regional Teams have been given
 resources to enable them to work with prisons to introduce and develop
clinical governance. A contact list for Regional Teams is given at
Appendix 2.

3. Although clinical governance is focused around health care in prison,

Governing Governors have an important role to play in ensuring that
health care staff move the agenda forward, and in integrating it fully
into prison management structures.

Performance Standards

4. As clinical governance is about making sure proper arrangements are

in place for managing, monitoring and improving health care, this PSO
supports delivery of the Health Services for Prisoners Standard across
the board. In particular, it will strengthen compliance with required
outcomes set in the Standard around adhering to ethical and
professional codes of practice and developing local services in line with
NHS Standards.

5. The PSO also introduces new audit baselines to monitor clinical

governance as a discrete activity in prisons. These are set out below
as mandatory actions.

Output

6. This PSO requires all Governing Governors and Directors and

Controllers of contracted out prisons to ensure that systems to support
clinical governance are in place in health care which deliver
management and monitoring of care, dedication to improving quality of
clinical care, and strategies for identifying and reducing risk.

Impact and Resource Assessment

7. Many of the activities classed as ‘clinical governance’ are already

being undertaken by staff (for example – continuing professional
development, audit of significant events in health care) and should not
present a significant resource need or change in practice, as existing
practices may be adapted to the purpose.

8. However, to support the initial implementation of clinical governance in

prisons, a total of £180,000 per annum has been made available for
the next two years. This has been allocated to Prison Health Regional
Teams on a pro-rata basis for work with prisons in their Regions. It is
expected that this funding will result in a baseline assessment and a
planning document for each prison.

Implementation Date
9. Governing Governors should ensure that baseline assessments
undertaken with NHS partners are completed (these are currently
ongoing), and be in a position to provide the framework document and
designated clinical governance lead details, by 30 September 2003.
Implementation is ongoing, but review documents will be required
annually from 1 April 2004. These will be integrated into Primary Care
Trust (PCT) review documents.

Mandatory Action

10. Governing Governors must ensure that arrangements are put in place
to develop clinical governance activity in prisons. This must include:

i) An identified clinical governance lead in health care.

ii) A framework/management document setting out the proposed

arrangements

iii) A baseline assessment carried out by the prison with the

relevant Prison Health Regional Teams

iv) Annual review document of progress from 1 April 2004

Audit and Monitoring

11. The contents of the PSO Clinical Governance - Quality in Prison

Health Care are the subject of compliance by the Prison Service
Standards Audit Unit.

Contact Point

12. Further information can be obtained from Prison Health by contacting

either Julie Bishop (020 7972 3926) or Sinead O’Brien (020 7972
3919).

NOTE FOR ESTABLISHMENT LIAISON OFFICERS

ELOs must record the receipt of the Prison Service Order - 3100 in their
registers as issue 163 as set out below. The PSO must be placed with those
sets of orders mandatorily required in Chapter 4 of PSO 0001.

Issue Date Order Title and / or Date ELO signature

no. no. description entered in
set
163 16/01/903 3100 Clinical
Governance-
 Quality in
Prison
Healthcare

John Boyington
Director of Prison Health
1.UNDERSTANDING ‘CLINICAL GOVERNANCE’

What is clinical governance?

1.1 Clinical governance was developed in the NHS, and defined as:

‘a framework through which NHS organisations are accountable for

continuously improving the quality of their services and
safeguarding high standards of care, by creating an environment in
which excellence in clinical care will flourish’.

1.2 Put very simply, clinical governance is about making sure that there
are proper arrangements in place for managing, monitoring, and
improving health care.

1.3 NHS bodies use ‘clinical governance’ to ensure quality of care, but it is
equally applicable to other organisations that have a health care
component – including prisons.

Key elements of clinical governance

1.4 There is no single set of tasks that define ‘clinical governance’,

although there are typical elements. These elements can be organised
under three broad headings which together map out clinical
governance:

 Responsibility and accountability for clinical care

 Programme of quality improvement
 Risk management

1.5 The main elements are:

 Clear management arrangements for health care

 Opportunities for staff training and development (Continuing
Professional Development - CPD)
 Compliance with national standards
 Learning from complaints and serious incidents; risk management
 Staff responsibility at every level for quality of care
 Acting on complaints and problems
 External accountability for the quality of care (clinical audit)

1.5 How these are met will vary from place to place, and depend on the
mix of staff, type of care offered, and management structure and
systems. It is important to remember that no single system is applied
everywhere in the NHS – different organisations combine different
approaches and ideas together – but in general, all systems
incorporate the above areas.

Why clinical governance in prisons?

1.6 Governing Governors are familiar with adopting various systems and
approaches for managing the different aspects of prison activity –
security, finance, etc. Clinical governance is the most effective system
for managing and improving health care in the prison. It has the
following benefits:

 Although there are standard elements to it, it is flexible enough to be

applied in any health care setting, and can be adapted to the particular
requirements of a prison setting.
 As its name suggests, clinical governance is a combined approach to
both the management of health care and its clinical quality. It covers
such aspects as staff development, risk assessment, and improvement
in clinical practice.

 Other systems for monitoring and managing health care, such as

Standards Audit, or complaints, can be incorporated into it. Clinical
governance can thus be used as a framework that contains existing
practices and incorporates new ones.

 Clinical governance is already well established in the NHS, and there

is a great deal of local and national experience that can be drawn
upon. It forms the basis of the NHS quality agenda, and feeds directly
into monitoring systems and delivery commitments, such as National
Service Frameworks (NSFs), and the NHS Plan, which include
provisions for prisoners. This aspect of clinical governance will
become more relevant as prison health moves into the NHS over the
next few years (see below, 3), and Primary Care Trusts (PCTs) become
the commissioners of prison health care.

2. STAKEHOLDERS AND ROLES

2.1 The Governing Governor’s support is vital to the development of

clinical governance in prisons. He or she can provide leadership and
support to the clinical governance lead and health care team as they
take systems forward. The Governing Governor is responsible for the
overall performance of health care in prison, which is measured against
performance standards, whilst members of the health care team are
responsible for individual clinical performance. The Governing
Governor’s role will remain just as important as prison health moves
into the NHS – he or she will still have overall accountability for
ensuring that health care is being appropriately delivered within the
prison.

2.2 Regional Prison Health Teams have a brief to help prisons implement
clinical governance. They have been resourced to do this by the
Directorate of Prison Health.
2.3 PCTs, NHS Trusts and other bodies that have input into prisons have a
role in supporting prisons in developing clinical governance. PCTs and
Trusts have clinical governance leads who can advise on activities.
Some are already working with prisons and Regional Teams to take
developments forward.

2.4 At a national level, the Prison Service Director General is responsible

overall for assuring that the quality of clinical care in prisons is
acceptable. The Directorate of Prison Health has developed a
programme for the implementation of clinical governance, which has
included guidance to health care staff, support and development work
with some Governing Governors and Area Managers, resources to
Regional Teams, and publicising good practice through the Prison
Health Newsletter.

3. TRANSFER OF PRISON HEALTH TO THE DEPARTMENT OF HEALTH

3.1 From 1 April 2003, responsibility for funding prison health care in
England will be transferred from the Prison Service to the Department
of Health. Initially, prisons will still retain local budgets for health care
but within the next 3-5 years these budgets will be transferred to local
NHS Primary Care Trusts, which will then assume full funding
responsibility for prison health care.

3.2.1 Funding responsibility for prisons in Wales is being discussed with the
Welsh Assembly Government.

3.3 Clinical governance development in prisons can only benefit from the
transfer, as prison and NHS quality agendas become more integrated.
NHS performance monitoring systems will eventually extend to include
prison health care. There is still a great deal of work to be done to
establish the exact role of the NHS in relation to prison health – for
example, with CHAI (Commission for Healthcare Audit and
Improvement) and the Health Ombudsman, or for changes to the role
of Standards Audit and other Prison Service monitoring arrangements
once the handover is complete.

3.4 Until local health care resources are transferred to PCTs, Governing
Governors will continue to have responsibility for overall health care
delivery in prisons, and this will be reflected in clinical governance
requirements. Once PCTs take on full local funding, Governing
Governors will still have important responsibilities for working in
partnership with the local NHS to support the delivery of good quality,
needs-based health services to prisoners.

4. SUPPORT AND RESOURCES

Resources

4.1 Much of the activity that falls under the clinical governance heading is
either currently being carried out, or has little or no resource
requirement. The Health Services for Prisoners Standard, for example,
sets out requirements for health care staff to fulfil continuing
professional development activity, also a key element of clinical
governance; and so there should already be a provision for this in
prison baseline. Identifying a clinical governance lead, one of the
mandatory actions for prisons, again should have little effect on
resources. And many of the activities that are already being carried out
as part of the prison regime – a system for dealing with complaints, or
for auditing significant events – can be adapted or included as
examples of clinical governance activity.

4.2 However, the Directorate of Prison Health accepts the need for
specific resources to enable prisons to develop sound clinical
governance systems, and a total of £180,000 per annum has been
made available for 2 years from early 2003 for this purpose. The
money has been allocated on a pro rata basis to Prison Health
Regional Teams to support prisons in their Regions in this process.
The funding has been made available prior to issuing of this PSO
because several prisons have already made significant progress in
setting up clinical governance, and it is important that these
establishments are allowed to maintain the momentum of change,
whilst others are given the opportunity to make preparations.

4.3 It has been requested that prisons and Regional Teams either carry
out or update existing baseline assessments with some of the
resource. Baseline assessments will give an indication of the clinical
governance requirements specific to each prison. This PSO makes it
mandatory for Governing Governors to ensure that baseline
assessments take place.

Other Support

4.4 The following can offer help and support both to managers and clinical
staff:

 Prison Health Regional Teams will be working directly with prisons

to help develop clinical governance. They can also help to foster
links with other organisations, such as the National Clinical
Governance Support Team. The CGST runs clinical governance
training programmes for health care staff, and teams from 2
prisons, HMP Wormwood Scrubs and HMP Lincoln, have
undertaken courses.

 The Directorate of Prison Health issued ‘Clinical governance -

getting started’, guidance designed for the prison health care team,
 in January 2002. This has information about professional and
internet resources. Each health care centre should have a copy.

 NHS organisations have been involved in clinical governance since

1999. They have a variety of in-house clinical governance
packages and guidelines. Your PCT or local NHS Trust clinical
governance lead should be able to provide advice on this.

Queries

4.5 For further help or advice, you should contact your Prison Health
Regional Team in the first instance. A contact list is given in Appendix
2. Alternatively, you may contact the Directorate of Prison Health by
telephoning either Julie Bishop (020 7972 3926) or Sinead O’Brien
(020 7972 3919).
APPENDIX 1: SUGGESTED FRAMEWORK FOR MANAGING CLINICAL
GOVERNANCE

Process When PCT/NHS Process Lead Outcome

established/ involvement monitored/linked
to be to Management
established Board/Committee
Clinical Audit

Evidence based
practice

Risk management
programmes

Significant event and

clinical complaint
monitoring
Clinical
leadership/supervision

Systems for dealing

with poor performance

Continuing
professional
development,
Support and
mentorship for staff

Compliance with
national standards
APPENDIX 2: NHS REGIONAL PRISON HEALTH TEAMS CONTACT LIST

NHS Region Prison health Address Telephone

lead
Northern & Paul Fallon Northern & Yorkshire 0191 301 1424
Yorkshire Regional Office, John
Snow House, Durham
University Science Park,
Durham, Dh1 3YG
North West Dr Peter Elton Bury PCT, 21 Silver St, 0161 762 3074
Bury, Lancs, BL9 0EN
East Midlands Dr Nick Government Office for the 0115 971 4760
Salfield East Midlands, The
Belgrave Centre, Stanley
Place, Talbot St,
Nottingham, NG1 5GG
West Dr Mike Wall West Midlands Regional 01785 256 727
Midlands Prison Task Force, Officers
Mess, 24 Gaol Road,
Stafford, ST16 3AN
South West Dr Ruth Public Health Team, 0117 900 3533
Shakespeare Government Office South
West, 2 Rivergate, Temple
Quay, Bristol BS1 6ED
South East Dr Yvonne South East Public Health 01483 882 327
Arthurs Group, Government Office
for the South East, Bridge
House, 1 Walnut Tree
Close, Guildford, Surrey,
GU1 4GA
London Penny Bevan NHS London East 020 7725 5347
Regional Office, 40
Eastbourne Terrace,
London W2 3QR
Eastern Barbara Eastern Regional Office, 01223 597 613
McLean Capital Park, Fulbourn,
Cambridge, CB1 5XB
Wales Peter Lawler Welsh Assembly 02920 823 303
Government, Cathays
Park, Cardiff, CF1 3NQ