Health Issues in Prisons & Pollsmoor Health Care: Committee Report on Oversight and Department briefing

Meeting report

CORRECTIONAL SERVICES PORTFOLIO COMMITTEE
19 June 2007
HEALTH ISSUES IN PRISONS & POLLSMOOR HEALTH CARE: COMMITTEE REPORT ON OVERSIGHT AND DEPARTMENT BRIEFING

Chairperson:  Mr D Bloem (ANC)

Documents handed out:
Committee Report of the delegation on Health Care Facilities in Pollsmoor Correctional Centre
Health Care Delivery and Management in the Department of Correctional Services
Outsourcing presentation (not presented)
Department of Correctional Services presentation on Strategic Plan 2007/8 -2011/12

Audio Recording of the meeting

SUMMARY
The Committee had sent three members on an unannounced oversight visit of the health care facility at Pollsmoor prison. It was discovered that the medical staff were severely understaffed, and those staff present did not always perform their duties ethically or professionally. Basic requirements were not adhered to. The emergency trolleys with all necessary equipment were not maintained and kept nearby. It was noted that although the situation might seem dire, it could be remedied if the basic requirements were seen to.

The Department of Correctional Services briefed the Committee on health care delivery and management in the Department. The presentation offered solutions and admitted the mistakes that had been made in the past. Those that had under performed had been properly reprimanded.  It also offered remedies regarding staff shortages and reported on the implementation initiatives that had already been taken and those that were contemplated.

The Committee was pleased that the matters were being addressed but expressed concern that the Department had waited until the Committee had done an oversight visit to become aware of the health issues and start to implement the necessary steps. Questions were raised on mentally challenged inmates held at Pollsmoor, the number of pharmacy posts filled, the use of volunteers, the overtime issues,  responsibility for basic maintenance and the steps taken to remove expired drugs, the duties of doctors and nurses and sustainability of the steps taken. Further questions were raised on the staff shortages and the competition with other departments, the bursary schemes, the possibility of using traditional medicine practitioners, and the need to check whether similar difficulties were apparent in other institutions. The need to improve management was raised. The Committee asked the department to return for a follow-up report in 90 days, and reported that it would be making a further unannounced visit during this period to do oversight for itself.

MINUTES
Introductory Remarks
The Chairperson stated that a delegation composing of Ms C Chikunga (ANC), Mr J Selfe (DA) and Mr S Mahote (ANC), was sent to Pollsmoor Correctional Centre for an unannounced oversight visit.  Their report indicated to the Chairperson that there was a serious problem that required urgent attention.  He had contacted the Inspecting Judge of Prisons, who then informed him that he had conducted an investigation a month ago and had submitted his report with findings and recommendations to the Minister.  The Judge too had expressed serious concerns about Pollsmoor.  The management of Pollsmoor was now present to give their interpretation on the position and an overview on the health situation at all prisons in the country.  Ms Chikunga requested a brief ANC study group before briefing the Committee.

Briefing by Ms Cindy Chikunga (ANC) on the visit to Pollsmoor Correctional Centre
Ms Cindy Chikunga noted that the background to the visit was a report on the prevalence of Aids and HIV and the capacity of the department to deal with these issues, coupled with complaints from health care professionals working at Pollsmoor about the facilities, working conditions and equipment in the hospital section. They had also complained that managment was not consulting properly, was not following procedures and were not doing anything about the issues raised.

The Committee therefore visited Pollsmoor hospital sections in the Admission and Medium Centres on 30 May, when it interacted with a number of different staff. There was a severe shortage of professional and other medical professional staff. Although a number of patients were mentally ill a visiting psychiatrist would attend once a month. There were 36 funded posts for nurses but only 12 were filled. The basic requirements in the health facility were not being met. Basic health precautions were not taken and health material was not available. It was felt that the nurses could improve on their ethical and professional behaviour.  There should be a policy and monitoring on storage and checking of drugs as well as for the storage and prescription of medicines. Medicines needed to be maintained and kept in favourable conditions to ensure that they were not only effective but that they also endured until the expiry date. These necessities were not adhered to. Some emergency drugs were simply not available and ordinary drugs that should be used daily, such as treatment drugs for TB had expired yet were still being kept. Members found several other discrepancies such as ampoules of medicine that had expired in 2004, entries in the drug register done casually, emergency equipment not in proper working order and rules and regulations not being followed as prescribed by law. The temperature of the fridges was not being properly controlled. Although these issues were serious many of them could be remedied if the staff that were there followed the basic procedural policies.

Mr J Selfe (DA) said that whilst it was accepted that inmates of Pollsmoor should not be able to claim better health service that any other person in the country, it must be noted that a basic level of health care must be adhered to for all. This was set out both in the Constitution and the Correctional Services Act. These rights were not being adhered to.  In prisons that were as heavily populated as Pollsmoor there were opportunities to spread communicable diseases, and the appropriate precautions were not taken. A number of staff, in an already under-staffed situation, were either on sick leave or on stress leave.  He had noted such irregularities as a syringe needle stuck into a particular drug bottle, leaving the bottle open to infection by bacteria. The fact that rudimentary medical steps were not followed indicated that the staff had not performed at the optimal standards. He was also concerned that so many people were sent for psychiatric observation were sent to this facility that did not have the capacity to deal with them.

Mr Mahote (ANC) commented that Ms Chikunga and Mr Selfe had covered everything that he had noted, including the issues with the psychiatric observations and staff performance.

The Chairperson thanked them for their clear findings and thorough work.

Response by Department of Correctional Services
Mr Vernon Petersen, Commissioner, Department of Correctional Services, noted the value of the Committee’s report. There was a need to take a collective look at the challenges from both the Department's and the Committee’s viewpoints. It was unfortunate and embarrassing the way these things were brought to light.  The Committee were aware of the fact that the outflow of medical personnel was a problem country-wide, and knew also that the Department of Correctional Services (DCS) had to compete with other departments. DCS had to acknowledge that there had been a change in policy and access to overtime had been removed, which had not received a good response from staff. The Department’s response was to create additional posts and this had increased the numbers of health personnel conservatively.  DCS had also tried to come up with a head hunting framework but this had not worked as well as was expected. It was realised that the approach had to change to deal with this and that DCS could not compete with others. It was a challenge that ordinary citizens had a right to access to public health whereas those in correctional centres did not.

The Department was encouraged by the approach of the delegation and noted that the staff that had been employed had to be able to perform. There was a poor culture of compliance and this could be because of poor submission of accountability. Part of their strategy was to establish and appoint more junior managers and supervisors on integrated compliance. It was ironic that some of the managers themselves, who were aware of the situation, had continued and there were processes in place to deal with these issues. DCS was concerned that some of the expired medicine had found its way back to the shelves and undermining behaviour would not be tolerated.  These managers had since been suspended.  However, the effect of the suspension would be felt.

Health Care Delivery and Management in the DCS: Briefing by Department
Ms Maria Mabena, Director of Health: DCS, said that she would be giving an overview of heath care delivery, management and challenges. She noted that DCS was faced with numerous challenges when it came to recruitment of medical staff, as so many other sectors required the same staff too. Sometimes those initiatives that were taken by the Department did not show positive results - for instance the head-hunting processes.  The presentation gave detailed descriptions of the findings at Pollsmoor prison in respect of facilities, equipment, pharmaceutical services, services and programmes, human resources and interventions taken by the Region (See document). Initiatives that were taken to improve the status of health in Correctional Services included appointment of a regional task team, deployment of health care professionals from the region, procurement of equipment, removal of expired medication and discussions with Valkenberg Hospital to assist. The challenges in terms of the legislation, target population, services and programmes and human resources were fully described (see attached document)..

Mr James Smalberger, Regional Commissioner of Western Cape: DCS, said that DCS was committed to acting on the findings of the report. He gave a brief overview on the interventions.  He and several members of management staff had accompanied the Committee delegation on their oversight visit to experience the difficulties first hand. A subsequent meeting focussed on the limitation of legislation, the availability of resources and the adherence to policy and procedures. At Pollsmoor there were 36 funded positions available for the position of professional nurses and only 16 positions were currently filled. The challenges experienced were the exodus of nurses that had accepted other appointments, the harsh working environment and the job stresses related to the large number of patients. DCS agreed that the lack of performance from available staff was concerning and staff should be able to deliver their best service. The Department did have a service level agreement with the Department of Health.  Several medical practitioners  visited Pollsmoor and on any working day there were at least two medical practitioners visiting Pollsmoor.  There was an agreement with Victoria Hospital to assist with after hour referral and Westlake Clinic assisted with female inmates.

The medication and protocols of the administration of the medicine had caused concern.  All the medicines that had expired and were due to expire in June were removed immediately.
An action plan developed to manage the issue of medicine and ensure continuous compliance. A regional task team was compiled of six to eleven medical staff on the team to monitor the plans that had been put in place.

All basic requirements that were not available had been ordered and would be delivered shortly. It was important to make an effort to create a conducive environment for the nurses.
The maintenance of the facility had to be compliant with the law and adjustments had already been made. To ensure compliance, the regional directorate will do a follow-up visit, and hopefully the Committee would be able to note changes in a follow up visit.

Discussion
The Chairperson appreciated the fact that problems were acknowledged, as he felt that this, together with the solutions introduced, showed progress.

Mr J Selfe concurred with the Chair on the assessment of the presentation by the Department.  He whether there was another alternative to the care of mentally ill prisoners.

Mr Smallberger replied that mentally challenged inmates were supposed to be sent to Valkenberg Mental Institution. However if Valkenberg was full they then came to Pollsmoor.  If the Correctional Centre received an offender it was required to adhere to the warrant. DCS had a team set up to address compliance and realised that they needed to everything to provide a conducive environment. They also needed to link up with the sister departments. He assured the Committee that a psychiatrist visited the prison monthly.

Mr Petersen added that several areas require specialised professionals such as psychiatrists,  and DCS hoped to introduce some kind of specialised professionals soon.

Mr Selfe asked the Department to confirm whether they only had four Department pharmacists out of forty posts, and asked, if that were true, what the implication would be on a continuing basis.

Mr Petersen confirmed that the numbers were correct, but added that there were other community service pharmacists. He mentioned that was one of the reasons that DCS wanted to go the outsourcing route to comply with the necessary requirements.

Mr Selfe was encouraged by the introduction of the volunteers from the community. However he noted that the accreditation process was cumbersome and that volunteers could be lost that way.  He suggested that DCS must find a way of simplifying the process.

Mr Petersen responded that there were difficulties related to recruiting people on an individual basis and DCS was aware that it had to expedite protocol. It hoped to provide structure with the voluntary section.  He also noted that DCS was aware of the abuse with the security environment.

Mr Mahote agreed with the National Commissioner that staff had been concerned about the overtime issue.

Mr Mahote wanted to know who was responsible for the basic maintenance. The expired drugs that had been removed and found back on the shelves were the responsibility of an essential employee.

Ms Mabena replied that everyone should know their duties, however, there were staff that were on leave and it did negatively affect the institution.

Mr Smalberger mentioned that an action plan was developed to monitor expired drugs and relevant protocol.

Mr Mahote wanted the department to specify the duties of the doctors as well as nurses.

Ms Mabena responded that doctors had clinical functions only. If they had been trained they would deal with other issues.  Nurses had various duties that included nurse assessment and development.

Mr Petersen added that they also had sessional doctors.

Mr Mahote proposed that after this report that another unannounced visit take place.

The Chairperson wanted to know why mentally challenged people were coming to the correctional facilities in the first place and that the Department should start to send out the message.

Mr Petersen agreed that it was not a place for mentally ill patients and had tried to de-institutionalise that aspect. Outside supervision could however be problematic. The first step DCS must take was to install proper measures; and in effect DCS had to become an activist for the rights of mentally challenged inmates.

Ms W Ngwenya (ANC) asked what mechanism was in place to ensure that access to health was sustainable.

Ms Chikunga felt that their measures were being taken on an ad hoc basis and that there was little evidence of sustainability. 

Mr Petersen believed that it was important to find different ways of increasing staff.  However it was just as important to strengthen junior management personnel and endorse sustainability.  He confirmed that DCS had to provide training and ensure that compliance was cultivated.

Ms Ngwenya suggested that it could be time to review the policy, based on privatisation and outsourcing.

Bishop L Tolo (ANC) required clarity on the shortage of people. He noted that he personally had sent twenty curriculum vitaes applying for jobs to the relevant person in  Limpopo yet had not received any feedback. He said that a solution should be found.

Ms Chikunga mentioned that even though the department had financed posts these remained vacant.  She asked if the Department had considered employing people on a contractual basis, or if they had offered training in exchange for employment for a period of time.

Mr Petersen replied that bursaries were available. DCS was also waiting for approval from the Director of health to approach agencies to look for professional nurses for recruitment and employment.

Ms Mabena added that the Department had offered bursaries and as a result had been left with the situation of successful candidates paying back their bursaries and then leaving the department.

Bishop Tolo commented that since there was a lack of medical doctors in the department, he suggested that perhaps traditional healers should be used. Many inmates believed in traditional medicine. He suggested that the Department speak to the Minister of Health and deploy traditional healers.

Mr Petersen responded that DCS would explore further the issue of indigenous practitioners

Bishop Tolo stressed that he had not said that they should not use medical doctors, only that there were alternatives as well.

Ms Chikunga noted that the remarks made by Mr Mahote needed to be understood in the context of the experience of the service of the health staff and his remarks had been relevant.

Mr Petersen was aware of the policies that were in place as well as the lack of adherence to those policies.

Mr Chikunga requested clarification on the Department’s definition of professional nurses, as there were three different categories of nurses according to South African law.  If they meant professional nurses as defined in the legislation, then there would always be a shortage because there was a shortage of professional nurses countrywide.

Mr Petersen responded that there would be a programme introduced that would set a new determination of nurses on 1 July. This programme would apply across the whole public service and would still not solve the problem of understaffing in the correctional services.

Ms Mabena added that the programme would also include a finalised code of remuneration; and that for sub nurses and national assistants had been submitted for approval.

Mr Petersen also added that entry level for nursing staff was at level six and the Department had been cautioned not adjust the levels of remuneration as that would mean that there would be an uneven balance, and DCS would obtain most of the medical staff.

Ms Chikunga remarked that the situation regarding healthcare in the DCS could also be evident in other institutions and that DCS should check to see if similar problems pertained in other institutions.

Mr Petersen acknowledged that there were areas that required urgent attention. He accepted that and realised that DCS must find ways of ascertaining where the problem was greatest. There had been a proposal to establish centres of expertise,

Mr H Cupido (ACDP) mentioned that there was a serious problem with bad leadership in DCS. Bad leadership would lead to further bad practices, and therefore he wanted to know if there were any leadership programmes in place to halt the problem. 

Mr Petersen replied that a mechanism was introduced whereby managers did service delivery through Project Khaedu, which exposed them to the harsh reality of service delivery and this would inspire sensitivity to the various situations throughout South Africa. DCS had also invested in leadership development, such as piloting the training of junior middle managers and the training of all senior managers, which would then be put into practice. DCS had also invested in executive and senior management development program. 

Mr M Cele (ANC) asked if the Department received its medicines via tender and how long it took for their institutions to receive them.

Mr M Ngubo responded on the procurement of drugs, reporting that DCS had a transversal contract with other departments to save on expenses and based on the need of each department

The Chairperson summarised the important issues raised and noted that the traditional healers would be looked into.

The Chairperson commented that the Commissioner had raised very important issues. He found it disturbing that this situation was only disclosed once the Committee had sent a delegation, and felt that it should have been picked up earlier by the Department. He was particularly concerned that drugs that expired in 2004 were still being held. It must always be remembered that although the prisoners were incarcerated they must be treated with respect for basic human rights.

The Chairperson continued that although generalisations should be avoided, this situation could be prevalent in other institutions. He was encouraged by the fact that the problems were being addressed. He suggested that the Committee must follow-up on the implementation of the policies, and it would be their responsibility to place time frames on everything that was to be done. He asked the DCS to report back to the Committee in 90 days on the progress and implementation on what was presented today, and a Committee delegation would also embark on an unannounced visit within the 90 days. He stressed that the Committee would assist the Department.  Disciplinary action needed to be taken against defaulting managers who failed to comply with the policies and a strong message should be sent out.
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The Chairperson postponed the briefing on Outsourcing to a future date when there would be time to properly engage with that material.

The meeting was adjourned.