Medicines in residential custodial settings

Residential custodial settings are prisons, immigration removal centres (IRC), secure training centres and schools, and secure children’s homes.

Healthcare delivery in these settings is a primary care service so the individual’s experience should reflect the community setting wherever possible and mirror that of community pharmacy.

Standards and expectations

HM Inspectorate of Prisons Expectations define the standard that people in prison are cared for by a health service. This should assess and meet their health needs while in prison and promote continuity of health and social care on release. The standard of health service provided is equivalent to that expected elsewhere in the community.

Royal Pharmaceutical Society’s Professional Standards for optimising medicines for people in secure environments (Edition 2; 2017) states supplies resulting from prescriptions, patient specific directions (PSDs) or patient group directions (PGDs) should be in the form of individually dispensed or over-labelled packs. Administration of doses from bulk stock is reserved for urgent, short-term supply and for specific Controlled Drugs.

The Royal College of Paediatrics and Child Health’s Healthcare standards for children and young people in secure settings provide standards for medicines handling in children’s residential custodial settings.

Residential custodial settings are expected to have sufficient medicines storage facilities that meet national standards, centrally and in medicines administration points. Where these are not available healthcare providers should liaise with their commissioners and custodial leads to agree an action plan to upgrade them.

Supplying medicines in residential custodial settings.

Following a risk assessment, medication may be supplied in several ways in residential custodial settings. These are discussed below.

In-possession (IP)

The person is in possession of their individually labelled supply of medicine and accepts responsibility for its secure storage. Controlled drugs (CDs) and other high risk medicines for diversion are not supplied for IP use.

Non in-possession (NIP)

These are medicines that that are stored centrally, away from the individual, and should be individually-labelled packs.

The use of individually-labelled packs is required for NIPs for the following reasons:

• Safe storage – using individually-labelled medicines (both IP and NIP) for each individual means they can be stored together in baskets or individual medicine bags, which mirrors the community pharmacy model.
• Efficient transfer and discharge – individually-labelled NIP medicines can be used on transfer or discharge in line with the requirement for continuity of medicines stated within residential custodial settings pharmacy guidance.
• Ability to audit  and detect discrepancies – it is important that the supply of medicines to individuals, especially for high risk medicines for diversion, can be audited. The use of stock supplies for all NIP medication makes it difficult to detect discrepancies, for example whether stock has gone missing or if an individual claims they haven’t received a dose.
• Safer administration –  using individually-labelled medicines is safer than administering from stock. Additional checks are possible at the point of supply using the information on the label (for example the individual’s name, medicine name, dose).
• Reducing mis-selection errors – individually-labelled NIP medicines reduce the risk of mis-selection errors from stock in the high-pressure environment of custodial settings.
• Efficient supply –  where a NIP is changed to an IP for clinical reasons or as part of rehabilitation, the labelled medicine can be supplied to the individual rather than having to wait for a new dispensed supply.

Stock medicines

There are occasions when it is appropriate to temporarily use stock medicines.  A limited stock of commonly-used NIP medicines should usually be held in an emergency cupboard to enable NIP doses to be given until the individual’s supply is dispensed. Volumes of stock held in medicines administration points should be low and used less often, facilitating stock reconciliation and management.

Stock supplies are also used for over the counter (OTC) medicines such as paracetamol and ibuprofen and for administration of individual doses under Patient Group Directions (PGDs).

Controlled Drugs

All controlled drugs, other than those used to treat substance misuse, are expected to be labelled for individuals.  The Misuse of Drugs (Safe Custody) Regulations must be followed. It is expected that Controlled Drugs are NIP except in exceptional circumstances, where following a multi-disciplinary team risk assessment, up to 7 days IP may be considered.

NHSE’s guidance for handling tramadol (PDF), and NHSE’s information for handling gabapentin and pregabalin (PDF) should be followed.  These medicines are all NIP except in category D open prisons where, following a risk assessment, they can be held as 7-day IP.

Department of Health and Social Care Drug misuse and dependence guidance states that treatment for substance misuse must be continuously supplied following planned or unplanned release. This should be via either short term discharge supplies or use of FP10s.

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