Project Herald 

Report: 7
Date: 06 March 2008
By: Assistant Commissioner Territorial Policing on behalf of the Commissioner

Summary

This report seeks to provide clarification to queries raised by MPA members regarding the proposals for Healthcare in Custody presented to the Committee at its meeting on 7 February 2008.

A. Recommendations

Members are asked to note the information below which seeks to provide clarification on these matters and offer further explanation regarding the proposals and plans to date within Project Herald.

B. Supporting information

1. The queries raised regarding the future provision of Healthcare in Custody by MPA members were as follows:

• The implementation plans.
• Supervision arrangements – including cover capacity, sickness, leave and resilience.
• Quality Impact Assessment – including outsourcing and the use of Agency staff.
• Challenges of Recruitment and Training.
• Risks and contingency plans.
• Role Boundaries.
• New arrangements for Doctors.
• Comparison of Pilot at CX

Implementation Plan

2. A full implementation plan has been created which includes a full breakdown of the following:

• Communication / Consultation / Awareness Strategy
• Forensic Medical Services review
• Offender Health Strategy
• FME Contracts & Conditions of Service
• Nursing Contracts & Conditions of Service
• Recruitment Strategy
• Training
• Job Descriptions, role requirement and Competency Frameworks
• Clinical Guidelines and Protocols
• Forensic Practice Guidelines and Protocols
• Patient Group Directions
• Legal Framework
• Manual of Guidance
• CX Extension of Practice
• Information Technology Systems
• Cost Management

3. The detail outlined within a number of these will be subject to further consultation with FMEs, The Nursing and Midwifery Council, The Royal College of Nursing, Skills for Health and The Council for the Registration of Forensic Practitioners.

Deployment Prioritisation

4. 200 Nurses for 32 Borough Teams were approved in November 2006, with deployment over a 3 year period, 08/09 – 11/12. Introducing 3 Nurse Managers and 11 Teams of 6 Nurses in years 1 and 2 followed by 2 Nurse Managers and 10 Teams of 6 Nurses in year 3 will ultimately provide each Borough with a dedicated Healthcare Team of Nurses providing 24/7 clinical care.

5. The rollout of each year will have a staggered training and deployment programme, introducing up to 3 BCU Teams together, which will additionally allow for any back grouping required during induction training.

6. As the Borough Based Custody Centre (BBCC) programme is a 10-year initiative there is likely to be some re-location of the Nursing teams within this time. However those Boroughs with currently more than one site have a dominant site in terms of cell capacity, which is not likely to change.

7. Each Nurse Manager will be responsible for 4 Borough Teams and these clusters will have an on-call FME (please see paragraph 14 and 15 for contractual arrangements) to provide support to the nursing teams and attend the satellite sites and hospital calls.

8. Therefore this distribution of workload within the Healthcare Team will ensure a 24/7 permanent nursing team in each of the BCU main sites and the satellite stations will continue to be supported by FMEs. As boroughs progress with the BBCC programme and the number of satellite sites used for custody detention reduces, it is likely that the geographical boundaries covered by FMEs will further increase, reducing the overall number required.

9. In order to ascertain the prioritisation of the deployment rollout programme for BCU’S a number of factors have been considered:

• Geographical location
• Prisoner Throughput
• Number of Examinations
• DIP Boroughs
• DDO deployment
• BBCC programme schedule

The Role of Nurses and FMEs

10. Since The Police and Criminal Evidence Act 1984 Codes of Practice were amended in 2003, previous reference to “Police Surgeon” has been replaced by the term “Healthcare Professional”. As both Physicians and Nurses are included in the definition of a Healthcare Professional, healthcare delivered in custody can now be multi-disciplinary. The introduction of The Police Reform Bill and Statutory Instrument 2000 further enable nurses to take forensic samples and administer medications within custody. The statutory responsibility for health and welfare remains that of the custody sergeant.

11. There are two Acts of primary legislation which still override the PACE 1984 Codes of Practice.

1. The Terrorism Act 2000
   Although Code C, “Care and Detention” of the PACE 1984 Codes of Practice is applicable to terrorist prisoners, the act overrides Code D “Identification”. Therefore nurses can undertake clinical examination of terrorist prisoners but a physician must take intimate samples. The introduction of Code H for Terrorist Prisoners acknowledges Healthcare Professionals but as Code D remains applicable to samples and therefore remains overridden by the primary legislation Act.
2. The Road Traffic 1988
   Section 5 - All healthcare professionals including Nurses can take samples for excess blood alcohol in a police station but if a detainee is in hospital the sample must be taken by a physician. Section 4 - Assessments to determine any medical cause of impairment have to be undertaken by a Physician.

12. The Home Office has confirmed the Department of Transport is proposing to have the Road Traffic Legislation amended to allow all healthcare professionals to undertake these roles in the future.

13. The roles therefore of FMEs and custody nurse practitioners within custody will have the same foundations and therefore be very similar as 96% of the workload can be undertaken by either group. This is not suggesting that there is little difference between the two professions but that instead it is the custodial environment in which they both practice that determines the threshold for the scope of practice. For example, those detainees who require extensive investigation or assessments must be still be transferred to an appropriate hospital setting.

FME Contractual Arrangements

14. At present there are 4 levels of FMEs from Assistant up to Principal FME of which there are 19. The Principal draws up the rota and sets the vacancy factor within the group in consultation with other group members. Groups currently range from 4 to 12 members, and at any one time, across the MPS area there are 19 FMEs on call on a fee per case basis. This is neither sustainable nor efficient, as the MPS has experienced an 18-20% increase in costs each year with 65% of examinations being carried out lasting no more than10 minutes in duration.

15. The new contractual arrangements for FMEs will affect their conditions of service rather than their clinical role and are designed to maintain the FME's independent status as contractors from tax and employment law perspectives. There will be one FME contract applicable to all that is remunerated by a sessional rate thus allowing better budgetary control over expenditure. The Forensic Medical Services (FMS) department within TP Emerald will take over the co-ordination of the rotas to ensure an even balanced and consensual distribution of workload amongst the FMEs within the groups whilst at the same time ensuring a safe and appropriate delivery of service.

Recruitment and Selection of Nurses

16. A recruitment strategy has been identified to determine the profile of nursing in terms of qualifications, skills and desirable experience required for both the nurse and nurse manager roles. Role definitions have been outlined to support the established job descriptions used to grade the posts as P & V through Hay.

17. Marketing and advertising are engaged due to the scale of the recruitment needed for the number of nurses needed and the requirement for a rolling process with an anticipated launch of early April 2008. The advertising will be within London papers and the Nursing Standard and Nursing Times magazines, both national Nursing Journals. A micro-site will be established to support the recruitment providing supportive information and online application availability. During the four-week advertising period it is anticipated that two open events will take place to encourage potential applicants to gain further insight into the role, reducing the likelihood of unsuitable applications. Marylebone and Hendon are both sites being explored for this purpose. Following a short-listing exercise based on set criteria of relevant skills, qualifications and experience, interviews will be held concurrently over a two-week period. Five panels, each with an appropriate clinician, HR representative and member of the Custody Directorate, will select the teams for Phase 1 (anticipated June 2008). Taking into account the vetting process and notice periods nurses are likely to have to give employers (3 months), training and deployment for phase 1 is anticipated to commence in February 2009.

18. A risk anticipated is that due to the security vetting process requirements for this role, extensive delays may ripple across the whole implementation programme. It is anticipated that the phased approach to deployment within each year will accommodate some resilience to this even if some re-allocation of staffing within BCUs is required for a temporary period. Other contingency arrangements will include an agreed flexibility on any external training arrangements to avoid any additional charges / fees incurred. Additionally preference of up to 3 Boroughs will be taken for each successful candidate to provide increased flexibility of deployment

Training

19. The nurses recruited will require a 3-week training programme prior to deployment including the following specific forensic healthcare topics identified by the Skills for Health Competency Framework:

• Advise on fitness to be detained
• Advise on fitness for interview
• Obtain and handle forensic samples
• Intimate body searches
• Examination of alleged perpetrators of sexual / physical assault
• Verification of life extinct
• Fitness for travel on a transfer
• Assessing and recording forensic interpretation of injuries
• Examination and assessment under Road Traffic Legislation
• Safeguarding children and young people

20. Additionally to provide a comprehensive framework of clinical skills and knowledge for this role the programme should also include:

• Investigative Interviewing Techniques
• Presentation of Evidence
• Legislation
• Crime Scene Awareness
• Safety Training Level 1 & 2
• NSPIS and AWARE

21. The content of this training proposal incorporates the MPS role and skill expectations guided by Skills for Health “Healthcare in Custody Competency Framework” and ACPO and Centrex guidance “Safer Detention and Handling of Persons Detained in Police Custody”. A scoping exercise is currently taking place to identify the most appropriate training providers. The training will take place within the MPS estate and provisional reservations are being made for February / March 2009 at Hendon. The clinical aspects will be compared with established training courses available and if found to be suitable, may be utilised or alternatively a provider for each section will be identified using internal and external expertise.

Supervision

22. Currently the FMEs are aligned to FMS and the nurses at Charing Cross are aligned to the BCU who provide their line management. The clinical support for nurses has been via occupational health and the role boundaries being influenced by both borough staff and FMEs.

23. It is proposed to bring the nurses and FMEs together as an integrated multidisciplinary healthcare team aligned to the Forensic Medical Services, renamed to Forensic Healthcare Services, within TP Emerald. Clinical governance and line management of all nurses would then be centralised along with the administrative support for FMEs. All clinical guidance, procedures and policy will be directed centrally for all Healthcare Professionals via a Forensic Healthcare Services Intranet page which will additionally be used to correlate performance data from BCUs. The nurse managers will be responsible for the compliance of clinical standards on each BCU and the appraisals of their four teams. Day to day the custody sergeant as overall manager of the custody suites will have responsibility for the nurses and liaise closely with the nurse managers on clinical or performance issues raised. The nurse managers will be line managed by Forensic Healthcare Services Manager, via the Head of Profession for Healthcare.

Comparison with Charing Cross (CX) Pilot

24. The pilot at Charing Cross, which commenced in 2001, was implemented to provide an additional monitoring support to vulnerable detainees. Following the legislation changes in 2003 the role was not enhanced to reflect the extended scope of practice, which could then be delivered. The role to date has remained supportive with the FMEs additionally examining the detainees. The future role of nurses will be autonomous whilst practicing in accordance with the relevant legislation, guidance and clinical competency frameworks (PACE, the Reform Bill, Medicines Act) (CENTREX, ACPO, Home Office, NMC and RCN) (Skills for Health and MPS). For this reason any evaluation of the CX pilot would not be appropriate as a comparator for the future role. A request has been made for the team at Charing Cross to be re-aligned to TP Emerald from 1st April 2008 and if agreed enhancing the practice at Charing Cross prior the implementation of phase 1 will demonstrate the capability of this role and afford those currently at Charing Cross the opportunity to develop into the proposed nurse manager post. The nurses at Charing Cross will require the same training outlined for the new nurses in order to extend their current practice.

Resilience, Sickness and Leave

25. The provisions of 6 nurses per team include the recommended allocation of working time, annual leave, sickness and training etc to provide a 24/7 service. Short notice sickness will be managed in accordance with MPS policy and the nurse managers will be responsible for allocating appropriate cover according to circumstances. For example, the on call FME maybe asked to attend for the retrieval of intimate samples of forensic evidence and other cases referred to hospital for assessment. Alternatively the shift may be covered by overtime. This will incur additional overtime costs as operational staff and therefore sickness management policies need to be strictly adhered to given the volume of staff within the wider healthcare team. It is not anticipated that is likely to cause operational voids, where short notice cover may be required given the numbers that will be available within the MPS. Restrictions of one member of each team being on leave at any one time will be managed within the duty rosters created by the nurse managers.

Quality Impact Assessment

26. The three year phased transition to fully implement a multidisciplinary healthcare team across the MPS will undoubtedly create change, challenge existing practice, and set new parameters and standards for both clinical care and delivery. This process, although perceived as threatening to some existing FMEs, is vital if we are to meet the expectations of a high quality service that meets the needs and demands of policing today within a safe environment, which the public expects. To improve quality, existing practices will be scrutinised with FMEs to establish areas for improvement creating uniformity of standards and best practice across the MPS.

27. There has been a diverse response to a multi-disciplinary team from existing FMEs including an encouraging amount offering their support to balance those demonstrating resistance. The perceived threat to their role and loss of financial income which some have described, will require patience, understanding and empathy of their situation whilst remaining focused on pursuing the optimum service envisaged. Close working with those in support of the team process is planned to demonstrate transparency and encourage the co-operation of all.

28. During consultation events held in January and February 2008 some individual FMEs were of the opinion that a number of FMEs would not wish to continue to provide their services to the MPS if nurses are introduced. Whilst this has been the initial reaction experienced by the majority of Police forces who have already introduced nurses in this way, the numbers who actually leave amount to less than 10%. The number of current FMEs we have is likely to provide resilience in managing such a reduction. Additionally as the first phase of implementation of nurses is likely to be February / March 2009, the current FMEs will have experienced a new way of working on sessional rates. The introduction of nurses then will offer FMEs a more specialist role, covering a wider area, whilst remaining on this sessional rate.

29. However any loss of FMEs would be perceived as a risk to which we would not wish to be complacent, therefore discussions are being held with service providers to establish a robust and efficient contingency plan. The provision of healthcare staff needs to be available at short notice to manage any major loss of FME services during the three-year period of implementation of our multi-disciplinary healthcare teams.

30. Private service providers are only considered the most appropriate means of managing such risk in the short term. Fully outsourcing the service, although providing benefits related to having no management responsibility for staff, is not thought to be a viable option long term. Those forces that have fully outsourced their services have experienced increased costs and varying degrees of quality and standards.

31. Direct employment of the nurses will afford the MPS the ability to determine standards, training, practice and operational performance, outweighing the additional management responsibility. Agency staff should not be used without appropriate training and security vetting and therefore would not be a viable option.

C. Race and equality impact

The project is likely to introduce greater female representation within healthcare provision for detainees because a greater proportion of nurses tend to be female whilst the majority of current FMEs are male. An Equality Impact Assessment was attached to the report considered at the February meeting.

D. Financial implications

(For ease of reference the financial implications are shown below - the information is the same as reported to the February meeting )

1. There are no capital costs associated with the implementation of this initiative. Any capital costs relating to the transfer of function to the new BBCCs has been to date, and will be in the future, covered in the business cases prepared for the delivery of each BBCC.

2. The table below shows the current and estimated costs of providing nurses in custody suites, together with the savings identified to offset the increased staffing costs. It is based on a phased rollout, recognising the need to stage recruitment over a number of years, and assumes the employment of 50 nurses in 2008/09, 75 nurses in 2009/10 and 75 nurses in 2010/11.

Table 1: Herald - estimated costs of deployment of nurses in custody suites

3. Training and recruitment costs, together with one-off accommodation costs (such as lockers) have been included in the table as costs to be covered from within TP budgets.

4. Investment Board has agreed £6.35million from the MMP budget for transitional funding through the implementation of the full Herald staffing model. It will be necessary to utilise £1.1million of this fund in 2008/9 to cover the transitional costs of introducing the nurses before savings can be achieved from 09/10 and beyond.

5. The savings in years 2009/10 and 2010/11 will contribute to the start-up costs of the implementation of the full Herald model, which has yet to be presented to the MPA. It is suggested therefore that the savings are not available to off-set any other shortfalls in TP or MPS budgets for future years.

E. Background papers

• August 2007 – Project Herald Business Case to Investment Board,
• February 2008 – Project Herald – Changes to MPS Forensic Medical Provision to CoP.

F. Contact details

Report author(s): Karen Swinson, Emerald Custody Directorate, MPS

For more information contact:

MPA general: 020 7202 0202
Media enquiries: 020 7202 0217/18

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