DCS & HPCA – care in correctional services - Hospice Palliative ...

HEALTH CARE SERVICES IN THE
DEPARTMENT OF CORRECTIONAL
SERVICES
PRESENTATION TO HPCA CONFERENCE
18 SEPTEMBER 2012
K M MABENA

Confidential
1. Introduction.
2. Background
3. The most prevalent diseases
4. Functions of the Directorate
5. Palliative care in DCS
6. Challenges
7. Recommendations
PRESENTATION OVERVIEW
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INTRODUCTION
� Incarcerated persons represent a small proportion of the total South
African population, who are also at risk of developing health and social
problems.
� International norms and standards require that inmates must have
access to the same quality and range of health care services as the
general public receives from the National Health Services. A person’s
capacity to access these services should not be compromised by
reasons of incarceration since all people have a basic right to health,
nutrition, clean and safe environment as obligated by the Constitution of
the Republic of South Africa..
� In terms of the Correctional Services Act, (Act 111 of 1998), the
department provides primary health care services and refer patients to
external health care facilities for secondary and tertiary levels of health
care.
� The Department has been faced with a number of challenges with
regard to the provision of primary health services to the inmates.
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INTRODUCTION (Cont’)
� A number of offenders and remand detainees suffer from various
illnesses with poor prognosis which are progressive and non-reversible.
� Some offenders suffer from medical conditions which are related to
aging and are progressive in nature.
� Only a small number of these offenders are considered for placement on
medical grounds and released before they can die whilst others die in
custody.
� Seriously ill offenders and remand detainees can be categorized into
those with:
� a terminal illness with poor prognosis;
� Alzheimer’s and related dementia; and
� a serious, progressive and non-reversible illness with poor prognosis,
which has profound functional and cognitive impairments.
� On referral to external health facilities offenders and remand detainees
are discharged with recommendations that palliative care must be
provided.
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BACKGROUND
� The department is comprised of six Regions (Eastern Cape, Free
State/Northern Cape, KwaZulu-Natal, Limpopo/Mpumalanga/North
West), 48 Management Areas (similar to District) and 242 Correctional
Centres (similar to PHC facility).
� There is at least one Primary Health Care (PHC) clinic per Correctional
Centre and one in-patient facility /sickbay with beds ranging from 5-120.
� An in-patient facility is defined as a facility that has been established in a
Correctional Centre for the purpose of accommodating inmates that are
either ill or recovering from post-operative procedures and cannot be
accommodated in the general cells whilst on treatment. The facility
usually does not meet the requirements for being classified as a
hospital.
� Patients requiring palliative care are admitted in these facilities.
� The department recruits health care professionals (professional nurses,
pharmacists, medical practitioners, psychologists), spiritual care workers
and social workers as members of the multidisciplinary team.
� The health facilities have not been fully integrated into the District Health
System.

160000
140000
120000
100000
80000
60000
40000
20000
0
BACKGROUND
Total inmate population end July 2012
EC FS.NC GP KZN LMN WC TOTAL
Males 17692 20170 35537 24717 20500 24144 142760
Females 300 288 1138 471 301 777 3275
TOTAL 17992 20458 36675 25188 20801 24921 146035
Males
Females
TOTAL

1200
1000
800
600
400
200
0
BACKGROUND
Females inmates end July 2012
EC FS.NC GP KZN LMN WC
Females

5628
BACKGROUND
Remand detainees vs the sentenced population
12064
49
251
MALE FEMALE MALE FEMALE
REMAND DETAINEES SENTENCED OFFENDERS

THE MOST COMMON PREVALENT CONDITIONS AMONGST
OFFENDERS
Respiratory tract infections: TB,
pneumonia, asthma and bronchitis
Sexually transmitted infections, HIV
and AIDS
Cardiovascular (Hypertension)
Gastro Intestinal Tract Illnesses
(haemorrhoids, ulcers, gastritis)
Mental health conditions
Cancer
Seasonal viral infections
Musculoskeletal conditions
Ear, nose and throat conditions
Neurological (epilepsy)
Dermatological
Endocrine (diabetes)

FUNCTIONS OF HEALTH CARE SERVICES IN THE
DEPARTMENT
COMPONENT CORE FUNCTION
Primary Health
Care
Nutrition and
Hygiene Services
Pharmaceutical
Services
To facilitate the provision of Primary Health Care
Services (includes disease prevention, health
promotion, curative, rehabilitative and referral services
for secondary and tertiary services) .
To facilitate the provision of basic food services in line
with the applicable prescripts as well as personal and
environmental hygiene services .
To ensure implementation of the National Drug Policy
and adequate supply of safe, cost effective drugs of
acceptable quality and the rational use of medicines by
prescribers, dispensers and patients.

PALLIATIVE CARE IN DCS
� As the burden of diseases increased, the need for palliative arouse
in the Department.
� This need was further intensified after the Special Assignment
documentary in 2008.
� A relationship was established between DCS and HPCA in order to
implement palliative care in DCS.
� A recommendation was made and in consultation with KZN Region,
decision was then taken to pilot palliative care there.
� A plan was developed to address amongst others the following:
� Establishment of relationship with HPCA.
� Approval by management of KZN Region.
� Establishment of a multidisciplinary team.
� Marketing of palliative care the officials, inmates and families.
� Identification of pilot sites.
� Resourcing of the facilities.
� Training of the multidisciplinary team members and offenders (43 ).

SPECIFIC EQUIPMENT FOR PALLIATIVE CARE
SPECIAL BED FOR A BED RIDDEN PATIENT IN DURBAN
MED B.

A MIXED WARD IN DURBAN MED B FOR THE PROVISION
OF PALLAITIVE CARE. CARE GIVER CLEANING THE
WARD.

Some Of The Infrastructure Adaptations: Wall Mounted
Central Oxygen Supply Points in Durban Med B and Also A
Mobile Unit For Backup

Mixed palliative care ward in Pietermaritzburg Med A (permanent
Medical practitioner, patient and a Custodial Official

PALLIATIVE CARE IN DCS
� Ordering, storage and control of palliative care medicines.
� Convening of regular meetings to monitor progress and address
challenges.
� Development of recording and reporting tools as well as system.
� Review of visiting policies to terminally ill patients to allow for longer
hours, contact visits, frequency, etc
� Piloted successfully in Durban Westville and Pietermaritzburg.
� SLA signed between KZN Region and HPCA in October 2009.
Role and support of HPCA:
� Facilitation of training,
� Mentoring.
� Establishment of referral systems.
� Ward rounds (Durban).
� Establishment of records systems.

SIGNING OF THE SLA IN 2009 IN DURBAN: US EMBASSY REP,
ACT DEPUTY REGIONAL COMMISSIONER, CEO OF HPCA
AND DIR HEALTH

A medical practitioner caring for a patient

PALLIATIVE CARE IN DCS
� A national Memorandum of Understanding has been approved and
signed by the National Commissioner and the CEO of HPCA in May
2012.
� A need was identified to roll out palliative care starting in 2
Management Areas per Region.
� HPCA has sought funding to continue supporting the DCS in the
implementation of palliative care.
� These Management Areas are at different levels of preparation.
� A number of professional nurses are currently attending training on
palliative care.
� Spiritual Care has become part of the of multidisciplinary team in the
provision of palliative care to the inmates in DCS and the chaplains
had a training workshop on bereavement counselling.
� HPCA has facilitated a session for the drafting of Guidelines on the
Provision of Palliative Care in Correctional Services.

DR. LIZ GWYTHER HANDING OUT CERTIFICATES TO
OFFENDERS WHO COMPLETED PALLIATIVE CARE TRAINING
2011

BENEFITS OF PALLIATIVE CARE IN DCS
• Palliative care maintains quality of life by addressing physical
symptoms such as pain or nausea as well as helping with emotional,
spiritual and social needs of the terminally ill.
• The inmate population becomes more informed on palliative care.
• Improved confidence amongst health care providers.
• Provision of a higher quality of comprehensive health care to the
inmate patient population.
• Strengthening relationships amongst the patients and their families
as well as the multidisciplinary team members.

PALLIATIVE CARE AND MEDICAL PAROLE
• Correctional Matters Amendment Act- May 2012.
• Regulations – February 2012.
• Policy and procedures - February 2012.
• Launch of Medical Parole Advisory Board.
• Criteria:
� Chronic disease, progressive, irreversible and terminal.
� Medical conditions (infectious and non-infectious)
• A number of patients recommended for medical parole and
released.
• Those without external support (reluctance by families and lost
contact with friend and families) kept in Correctional facilities and
provided with palliative care.

Confidential
Health facilities:
� The designs of Correctional Centres were focused on security and
do not complement health care delivery for patients, resulting in
inadequate primary health care clinics and in-patient facilities that
are not up to standard regarding the equipment, in-patient facilities
and isolation cells. In some areas, cells and offices have been
converted into primary health care clinics.
Attitudes:
CHALLENGES
There was “Fear of the unknown” and resistance to change.
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Confidential
Human resources:
CHALLENGES (Cont’)
� The inability to recruit and retain health care professionals
(professional nurses, medical practitioners, pharmacists and
psychologists),
� Lack of a structure for other categories of health care professionals
(dietitians, enrolled nursing assistants, nursing assistants,
pharmacist assistants, emergency medical services etc).
� Lack of mechanisms to address training needs for emerging
diseases, patients’ needs such as palliative care and new treatment
guidelines; hence the Department is dependent on over-stretched
Districts.
Lack of supplies and other pharmaceuticals
� Lack of adequate and access to pain medication when required.
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CATEGORY TOTAL NO.
Prof nurses 820
Medical
practitioners
8
Pharmacists 21
Community
Service
Pharmacists
13
Psychologists 16
Spiritual Care
Workers
1427
Social Workers 650
HUMAN RESOURCE CAPACITY

Confidential
IMPACT OF INADEQUATE RESOURCES
� Limited or inadequate management of diseases which may lead to
complications and deaths.
� Increased spread of communicable diseases and deaths due to lack of
adequate prevention, health promotion and timeous curative care.
� Increased referrals to external health care providers even for infections
that could be treated at primary health care level resulting in increased
health care costs and security risks.
� Limited or inadequate provision of palliative care which leads to more
suffering by the patients.
� Limited access to medical services resulting in delays on some
interventions, e.g. prescription of pain medication.
� Management Areas without access to departmental pharmacies utilize
retail pharmacies for the procurement of medication and the costs are
higher than the public tender prices and delays in providing pain
medication to the patients.
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RECOMMENDATIONS
• Need for management leadership and commitment for palliative
to be a success. All role players to continue advocating for palliative
care in Correctional environments.
• Evidence-based practice: policies and programmes must be
reviewed and/or developed based upon established need, on
empirical evidence of effectiveness, and evaluated models of
palliative care best practices
• Health standards and continuity of care and treatment: the
department must ensure that it meets international obligations to
provide health care which is equivalent to that available to the
outside population, and to ensure continuity of care and not let
inmates suffer.
• Conditions: they must not violate the inmates rights to dignity.
• Training and support : all relevant professionals must be provided
with the knowledge, training, and support on palliative care
necessary to meet the requirements and responsibilities of their
work.

RECOMMENDATIONS (Cont’)
• International, national, and regional collaboration: South Africa
and HPCA to share knowledge and expertise on effective palliative
care within the Correctional environment both nationally and
internationally and to enhance the development of evidence-based
practices in this area.
• Funding and resources: The Department to develop and
implement national funding plans to address palliative care at
national, regional, and local levels.

Confidential
CONCLUSION
With the assistance and collaboration ALL RELEVANT STAKEHOLDERS,
the Department remains committed in improving health care services
rendered to those entrusted to its care despite the numerous challenges it is
faced with.
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Thank you