Written evidence submitted by the British Medical Association (COR005)
- We write as chairs of the British Medical Association’s Forensic and Secure Environments Committee and its Medical Ethics Committee regarding the Home Affairs Committee’s ongoing inquiry into COVID-19 preparedness.
- The BMA has engaged with Government and relevant health bodies on preparedness throughout the emergence of COVID-19. Our concern is for all those working across all healthcare settings and their patients. Secure settings such as immigration removal centres (IRCs), prisons and young offender institutions (YOIs) are challenging environments for healthcare workers to treat people in at the best of times, with workforce shortages and often dated or under-resourced facilities. COVID-19 poses a significant risk to all; however, given your committee’s inquiry into COVID-19 preparedness, we are keen to raise some specific issues related to secure environments, the staff working across them and the often highly vulnerable patients they are treating.
Personal Protection Equipment (PPE)
- All healthcare workers should be protected against COVID-19 while at work, so that they can continue to treat patients throughout this period; this should of course include all secure settings. It is crucial that the right equipment is available to deal with this pandemic and that staff are appropriately fitted with PPE. Those giving out supplies, be they in hospitals, community or secure settings, must listen to doctors and other frontline staff when they say they require more equipment. Without this protection there will be a depletion of staff numbers. It must be recognised that staff members who succumb to COVID-19 infection may not be able to return to work during this outbreak (and may not be able to return to work at all in the event of death from COVID-19), so preserving their good health is of paramount importance. In terms of guidelines around the appropriate use of PPE, we believe that WHO guidance should be adhered to as minimum standard and the BMA is currently seeking clarification on any deviation from this. We ask that the Committee explore the availability of appropriate PPE in secure settings. We have reports from some members that while some prison officers have received PPE, a number of healthcare staff have not received sufficient supplies. This situation is not acceptable and risks the health of all those within the facility, as well as the families of those working there.
- The BMA has called for all healthcare workers to be prioritised for COVID-19 testing. This will enable any healthcare worker who has COVID-19 symptoms to know within 48 hours whether or not they can return to work, and thus continue to support patients and the NHS at this time of increased demand. Government has commited to this approach but we remain greatly concerned that while it is happening in some geographies, in others there are still delays and a lack of availability. In addition, within the secure estate – given the close confines of the environment and the potential for outbreaks - we believe all staff, not just healthcare staff, must be prioritised for testing. In respect of staff having to self-isolate for 14 days if a household contact has symptoms, in order for staff not to be off work unnecessarily, we believe that symptomatic household contacts of staff should also be afforded testing.
Guidance and best practice across the secure estate
- The close confines of accommodation within IRCs and other secure environments are likely to increase the risk of transmission. Therefore, every effort should be made to minimise the increased risk posed by these close confines. This should include minimising the number of prisoners being detained, both in terms of those being placed in IRCs and prisons. In respect of prisons, careful consideration should also be given as to ceasing the use of short-stay recalls.
- We have reports from doctors working within the secure estate of individuals with symptoms still being referred for a medical appointment and while doing so being held in waiting areas with numerous others awaiting appointments. This suggests a lack of preparedness planning within some facilities and the need to ensure all staff are familiar with isolation protocols. Other member reports highlight that individuals housed within secure facilities suspected of being infected with COVID-19, and who are placed in isolation as a result, are having their testing unnecessarily delayed. This is due to a process where patients have to reach a critical mass before testing is arranged for a group of patients, rather than testing each individual as they go into isolation. This approach, while potentially seeming more efficient, ignores the best interests of those individuals forced to wait and could be damaging to their health and wellbeing. This also reduces capacity in isolation areas, if people are housed there unnecessarily.
- Being isolated in an IRC or prison environment will be more psychologically distressing than self-isolating at home due to the lack of access to social support mechanisms. The potential for self-harming or self-inflicted death is very real under these circumstances. Testing individual patients as they are placed in isolation will help the individual come out of isolation earlier than the recommended 7 or 14 days if they test negative and will help the patient understand the reason for ongoing isolation if they test positive. Testing will also be more cost-effective than dealing with the consequences of prolonged and unnecessary isolation.
- It is important that both the WHO Europe and UK government COVID-19 guidance for all secure settings is disseminated across those settings. This should be supported by the sharing and promotion of best practice and the requirement that all secure facilities have their own individual COVID-19 plan in place. These plans should include approach and preparedness for isolation, workforce shortage planning, testing, and availability and fitting of PPE for all staff.
- Within the secure environment are a significant number of already vulnerable people. With high levels of self-harm and mental ill-health, it is crucial that adaptations made to combat COVID-19 also include consideration of mental health and wellbeing. This is particularly important when it comes to the use of isolation and restrictions around social contact. While these approaches may be a necessary tool in tackling the spread of COVID-19, support packages for those in isolation must be considered, in addition to testing as soon as possible to reduce unnecessary time spent in isolation. In addition, preparedness planning for IRCs, prisons and YOIs should include identification of those who may be particularly vulnerable, in order that that they can be offered additional support.
- In IRCs, YOIs and prisons historically the medical workforce has been under-resourced, and doctors often report to us that they are being asked to cover increasing numbers of patients because of staff shortages. Given that the healthcare workforce across secure estates is already stretched, any further reductions could prove catastrophic to the care that is available. Currently all staff in secure environments are required to go through extensive vetting and security clearance, which is both detailed and time-consuming. While it is of course necessary to have such procedures, should staff levels be reduced through ill-health, finding replacements at short notice will be even more challenging, because any additional or temporary workers, such as locum doctors, would need time to go through this process and may not be able to work independently without it. We ask that your committee raise the issue of what plans are in place to ensure additional healthcare staff can be deployed into secure settings should the need arise. In particular we are keen to see practices for streamlining security clearance in advance for potential staff who would be prepared to work in secure settings, should the need arise.
- We hope that highlighting these priority areas is helpful ahead of your next evidence session. The BMA is keen to continue to support your inquiry and would be happy to provide evidence if required.