Ep 27. INNOVATORS - Improving care for prisoners in the rheumatology clinic

Roz Benson (digital learning editor) talks to consultant rheumatologist Dr Lizzy MacPhie and Resident doctor Nouran Abdou about a recent project digging deep into the reasons prisoners face difficulty in accessing care in the rheumatology clinic. 

This excellent project showcases how quality improvement can be a tool in helping to approach and reduce health inequalities.

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Transcript

BENSON, Rosalind (LIVERPOOL UNIVERSITY HOSPITALS NHS FOUNDATION TRUST)
 
Hi, I'm Ros Benson. I'm a consultant rheumatologist in Liverpool and also the BSR Digital learning editor. Now in this next episode of our Innovator series, we're going to be turning the tables and I'm delighted this time to be chatting to Lizzy Macphie in our guest Hot seat and alongside her Nouran Abdou who is an F1 doctor working in the Medway Maritime Hospital. So welcome to you both.
 Today, we're going to be talking about a project which I've been really lucky to hear about on a couple of occasions, and I think it's very exciting, innovative and it also important for highlighting health inequalities. It's a QI, project quality Improvement project, which focused on prisoners attendance to the rheumatology clinic. Now we're going to go into it obviously in a bit more detail, but to start with, in true innovator, pod style, I'm going to have some getting to know you questions with our panel. So Lizzy, I'm going to come to you first. What is your favourite joint and why?

Macphie Elizabeth (LSCFT)
Oh, it's very odd to be in this seat to being asked the questions.
But so what's my favourite joint? Well, it has to be the knee joint. I think there is nothing more satisfying than a really great big juicy, swollen knee and then aspirating in clinic and seeing if you can reach, reach your target or I think the most I've had taken off in here is about 150 mills. I'm always there trying, can I beat my 150 mils. And then you look at the patient afterwards with this sense of relief and you can see they needed that. So yeah. So that's my reason for enjoying the knee joint.

BENSON, Rosalind (LIVERPOOL UNIVERSITY HOSPITALS NHS FOUNDATION TRUST)
Yeah, I think I'm with you on that one. And then you have to gauge whether or not the patient wants to see your synovial fluid or not, don't you?
And Nouran. What's your favourite joint and why?

ABDOU, Nouran (MEDWAY NHS FOUNDATION TRUST)
Truly unoriginal because it's the same as you two, but it's because I just absolutely love the shape of the Patella bone. It's the most unique bone in my opinion, and there's just so much that can go wrong with the knee joint and so many surgical and treatment options and new replacements are just so cool. So I absolutely love the knee joint.

BENSON, Rosalind (LIVERPOOL UNIVERSITY HOSPITALS NHS FOUNDATION TRUST)
Well, we're all starting off on a good level playing field. I think with that. So now, Lizzy, what's been the best thing that you've been taught in your training?

Macphie Elizabeth (LSCFT)
 So I think the best thing I was taught was actually something that was from my grandfather who was a fantastic GP and though officially it wasn't in my official training, he was my a big reason behind why I ended up as a doctor.
 And I've since heard that maybe his advice was maybe borrowed from someone else, but he always passed it off as his advice, but I think it was very good advice and that was to listen to the patient, because if you listen carefully enough, they will always tell you what the problem is.
 And I think that's a really, really big tip for especially like rheumatology, because it is, it is so much about the history taking and listening to your patients and giving them space and to tell you what's going on.

BENSON, Rosalind (LIVERPOOL UNIVERSITY HOSPITALS NHS FOUNDATION TRUST)
Yeah, absolutely. And Nouran, what would you say in your training has been the most useful thing so far that you've learnt?

 ABDOU, Nouran (MEDWAY NHS FOUNDATION TRUST)
 I was honestly taught so many amazing things in training, but I think the best thing I was taught was that no two patients will ever be the same.
 Before I started, you know, clinical years and was exposed to patients regularly, I never really believed that because I thought two patients coming in with the same symptoms, same conditions that we treat with the same therapies couldn't be that different. But I honestly couldn't have been more wrong because since actually starting working, I've learnt that each patient really does have their own specific wants and needs, individuality, personality and that means that no two patients will ever be the exact same, and I've seen how treating patients according to their specific individual wishes is really central to a good patient care and good outcomes. But I think that makes work really exciting, because it means that no two days at work will ever be exactly the same.

BENSON, Rosalind (LIVERPOOL UNIVERSITY HOSPITALS NHS FOUNDATION TRUST)
 That's great. So we just need to all hold on to that, don't we? That's excellent. Nouran I think if I come to you now, first of all, can you tell us a bit about your job role, but also then particularly how you've came about doing this Qi project?

ABDOU, Nouran (MEDWAY NHS FOUNDATION TRUST) 
Current job role is that I'm an FY1 doctor working in Kent on a respiratory placement which I'm absolutely loving. But when I undertook this project last year in April, I was a final year Med student working on a community rheumatology placement with Doctor MacPhie as part of our final year curriculum in Manchester, we have to carry out, you know, a quality improvement project in four weeks because they wanted us to develop our Qi skills before we started working and have to do it. And I specifically emailed Dr Macphie and asked to do it with her because she always gave medical students, like, great opportunities for research and audits and extracurriculars in medical school. She had actually just encouraged me to carry out a population health project where we created a bunch of really cool posters on the symptoms, management and diagnosis of common rheumatological conditions that we did in layman's terms.
For a population health event in Preston. We had also just attended a health inequalities workshop where we talked about all the factors that influence poor health outcomes and deprived communities in the north. So we really were feeling absolutely fired up about health inequalities.  I personally want to work with marginalised communities in the future because I really would love to improve the quality of care they receive, so I inquired with her about doing a project on health inequalities, but we were really struggling to find an appropriate target population for a couple of days because obviously.  It had to be something that could have been coded and the data on the electronic patient records that we could search specifically and find. Then, lo and behold, a prisoner walks into our clinic that morning with two guards talking about how impossible it is to get to appointments from the prison. And as soon as they walked out of the clinic, Lizzy and I looked at each other, and it just felt like a light bulb moment.

BENSON, Rosalind (LIVERPOOL UNIVERSITY HOSPITALS NHS FOUNDATION TRUST)   
That's brilliant, isn't it? Shows that sometimes you can really scratch around for an idea for a project and actually just look to your clinic and it's there, isn't it? Often there's problems everywhere that we need to try and fix. So we're going to get down into more of the details about the specifics of the project in a minute. But Lizzie, can I come to you a bit more of a bird's eye view about what your role is and also how your role then plays into supporting medical students.

Macphie Elizabeth (LSCFT) 
Yeah. So obviously by day, I'm a consultant rheumatologist by night is how I often put it. I work for the ICB, so I do three sessions for the ICB and my role is a clinical care professional lead and I have the small job of linking up health and social care and the voluntary sector. But a big part of that role is tackling health inequalities together with our fantastic population health team at the ICB and loads of, you know, great colleagues. So I'm not trying to do this single handedly. I don't want to sound like a maverick or but it's really, really exciting work and I sort of thought I knew a bit about health inequalities. And then when I started doing this work and did our population Health, Leadership Academy, I suddenly realised I really only had scratched the surface. So this really got me thinking about health inequalities and what we can do. Sometimes very, very simple things, and hopefully this this project will demonstrate that that that's how we can start to tackle these issues.
 We're also really, really fortunate that we, we do have lots of medical students coming through. We have them coming through just to learn about rheumatology, just as the rotation and as they come through. We always encourage them if they want to get in a bit more involved and delve a bit more deeper into rheumatology, spend a bit more time with the team, then they have these four week blocks during their final year where they can come and either do a QI pep with us or they can do a population health and again, I'm just very fortunate because the ICB role they can come along to some of the health inequalities, workshops and things and.
Health boards that I attend just to see a different side of things. So it's it's really the combination of all those hats that's provided an opportunity for us to really delve deeper into this. But you don't need to be wearing a fancy ICB hat or, you know, have a particular field in, in health inequalities. This is relevant to us also.
I just have a few more connections out there, which I suppose just give me a bit more of a push in that direction, but that's what this podcast is about to get everyone to think about this topic.

BENSON, Rosalind (LIVERPOOL UNIVERSITY HOSPITALS NHS FOUNDATION TRUST)
Yeah, absolutely. It gives us definite food for thought. I mean, I think.
You know, knowing a bit about your area from discussions, you have a rheumatology service which delivers care to patients that are often prisoners. So can you tell us a bit more about your geographical location you're in?

Macphie Elizabeth (LSCFT)
Yeah, so I work in Preston. We're a community based service and we serve a population of 395,000 and we have 3 prisons or male prisons that fall under our geography and across them. They have a total of 2700 inmates.
And actually it's really interesting because through this project I didn't realise that two of them were effectively on the same site. They're different prisoners, prisons, different category prisons. But they are effectively next door to each other.
And I'm embarrassed until I came to do this project I didn't realise quite how close they were so that was a really interesting point. So it's a decent sized prison population and because of the way it was set up, they all come to us if they get referred, we don't have huge numbers of referrals, but we were very aware that it was a struggle sometimes to see our prisoners and engage with them.
But the key really for me for this project for how we've got new and to get involved with this project is we we've sort of thought and known about this for a while. But we've not had the resource to dig deeper, so medical students just offer this fantastic opportunity for sometimes pick up an idea or a problem that you've identified that you've just not had the headspace at the time to plough that additional resource into. So it's been a real win for us because it's got new and more impassioned about health inequalities and it's provided us with some really, really helpful information.

BENSON, Rosalind (LIVERPOOL UNIVERSITY HOSPITALS NHS FOUNDATION TRUST)
So do you think you could talk us through a bit of what the complexities are of this particular population and why delivery of care is difficult to them?

Macphie Elizabeth (LSCFT)
Yeah. So for us, you know, one of the big things for us is just prisoners coming to their appointments. So you know time and time again we have a select group of prisoners under our care or we've got a new patient referral and they just don't come and it's so frustrating. And it can be really frustrating when you know someone is really struggling and you just think, oh God, that that they're not going to come to their appointment today and then they don't. And we, I suppose it's just how much resource you put into trying to chase because it does become a bit of a sort of self-fulfilling prophecy that they just keep not attending. And then when they do, you know, they'll obviously they'll have to come with guards. That's always a prerequisite because of the category prisons that we deal with.
So they'll always have two guards with them. They'll often come and they won't have a list of their medications, so prisoners can't remember what they're taking. You try and phone through to the medical team at the prison and you can't get through. We have various numbers, but they are really big and they are busy and they're understaffed. We know that.
The other really big thing is we've got one of our prisoners who just can't get in touch with us, gets really frustrated. So he writes to his consultant on a fairly regular basis because that's the only means by which he can communicate with us under in between appointments. And sometimes he will voice his frustration, frustrations about you know, I've not been to my appointment. I know it was meant to be seen.
And so that's sort of flagged to us the problems that they have because they don't have access to the advice line like a lot of our day-to-day patients.
And then one of the other frustrations for us has been the escalation of medications. So getting monitoring Bloods done. We've really struggled and sometimes you know, people will get a prisoner along to clinic and then when we have a look we can see they've not had the blood stump for the methotrexate or we've asked for their dose of methotrexate, methotrexate to be escalated at the last appointment. And it hasn't happened. So it's it really is that communication back and forth? And I don't, I don't know. You know, if everyone's aware, but one of the challenges with appointments with prisoners is they're not allowed to be given the details of their next appointment. So most patients, obviously they go to the front desk, they book their appointment. They know when they're going to be seen, you know, we'll see you in six months. They book it. They know. They get the text reminder to say and then what happens with our prisoners is they can't do that. They're not allowed to know and that's because of again, the category prisons that we're dealing with. If they know about when their next appointment is, then it's a potential threat. You know, threat of break out sounds all dramatic, doesn't it? But, but that is the reality with they're not allowed. We're not even allowed to say to the prison guards we're not allowed to quietly say to the prisoner prison guards. Here's your appointment. Here's the appointment letter for the next appointment. Can you give this to the medical team? So there's so many complexities and frustrations, and not just for us as a team. You know, most importantly those are impacting on that patients care and how they're managing their condition.

BENSON, Rosalind (LIVERPOOL UNIVERSITY HOSPITALS NHS FOUNDATION TRUST)
Yeah, absolutely. And so you were saying this directly on a patient clinician basis within your service and no, and I think you did some reading further around this area is these were these themes that you were picking up and some of the research that you did about this?

ABDOU, Nouran (MEDWAY NHS FOUNDATION TRUST)
Yes, absolutely. I was actually already aware from previous research projects and reading that the literature shows that prisoners have really, really poor health compared to the general population across, you know, almost all parameters from physical to mental health. And of course this can be because of their socioeconomic status and their environment and also related to lifestyle factors with their imprisonment. So as you can imagine managing chronic diseases in prison can be almost impossible. When they are missing appointments not going to follow-ups, we can't get them bloods for their biologics. We can't coordinate effectively between our healthcare centres and the prison because of communication difficulties. But we thought, you know, instead of accepting what's been referred to as an inferior healthcare system in the literature, we could actually use prison as an opportunity to access to address, these existing healthcare needs. And referring them on to appropriate services for their diagnosis and treatment of their rheumatological conditions. So that's why with the broader health inequalities that prisoners are subject to in mind, we wanted to carry out this project. With the aim of finding out how prisoners rate of attendance of rheumatology clinics and which factors actually influence their failure to attend. Because if we find out exactly why they're not coming to clinic and we can try and suggest and implement appropriate changes to the service to improve their attendance rates and hopefully in the future that would then improve their health outcomes too.

BENSON, Rosalind (LIVERPOOL UNIVERSITY HOSPITALS NHS FOUNDATION TRUST)
 Super. So it's a really good aim that you had for the start of this project with, I mean it really well explained background as to the importance of it and the need for something like this. So I think now down to the nitty gritty. So we've got a big idea and a clear problem. How about how did you go about starting to undertake this project?

ABDOU, Nouran (MEDWAY NHS FOUNDATION TRUST)
So we did this project last year and it was relatively easy to start because. We had to start with identifying the patients who were prisoners and all we had to do for that is look up the prisoner addresses on the electronic patient records system. So we already knew that Minerva serves HMP Garth HMP Preston, HMP Weimer. So we searched the addresses for those, and then the patients who were at those addresses came up, so we identified the patients that were still delivering active care to by looking through the notes. And then we included 15 patients with a total of 56 appointments. And we found a 44.6 rate of attendance, which is pretty shocking really. The admin team would clearly know on the appointment calendar whether patients attended or didn't attend the clinic appointment. So actually finding out whether they came or not was easy. But what was a little bit more difficult was finding out the actual reasons why they missed appointments. This involved reading through, you know, a bunch of clinic letters where patients may have stated why they missed the previous appointment or why they couldn't attend the next one. I also had to read through all the notes from the admin team that they meticulously noted on EPR. Because they liaised with the prison and they would always put, you know, for example, there was no transport available or not enough guards available to bring the prison prisoner. Because unfortunately each patient requires 2 guards to accompany them, but then also they had to ensure that the prison was well, manned. So if those two guards bringing the prisoner to their appointment meant that there wouldn't be enough guards at the prison, the prisoner wasn't going to get brought to their appointment.
And I actually distinctly remember one handwritten letter as Lizzy mentioned.
Sometimes they would hand write letters and then the admin team would scan them into the notes so you'd be able to access them and it was this one patient, this elderly gentleman who was reporting his excruciating joint pain andleading for help and for medication for it because he'd missed so many appointments because of the logistical challenges to bring him to Minerva. So it was genuinely, really heart breaking stuff. But it fires you up even more to try to do something about it.
So what we had to do was we had to find out, you know, who, who the prisoners are. Why they're not attending appointments and then come up with a process map for the appointment booking process?
Which Doctor MacPhie helped me with because she told me the exact way the appointments were booked, that Minerva Healthcare Centre.
And basically patients are referred by primary to secondary care. They're clinically triaged, an appointment letter sent to them, a text reminder sent before the appointment, the attendee appointment, and then they.
We are meant to book their next appointment at reception before they leave and then obviously a clinic letter sent to the patient with the details from the appointment they just had and then patients have Open Access to an advice line into the admin team to call anytime they would like with advice and things about their medication, about their joint pain, how to manage it, et cetera. So after we'd mapped out this process, we identified key places within it that were problematic.
For prisoners, so, for example, the appointment letters sent to the patient that often never happened for prisoners, they never received their appointment letters, text reminders sent, prisoners don't have phones.
They can't book their follow up appointment at the reception before they leave because they're not allowed to know for security reasons. As Lizzie mentioned, when their next appointment is, they don't have access to the advice line to call us like this patient who had been writing handwritten letters about his excruciating pain. If you was outside prison, he could have called up the advice line and tried to seek some advice on how to manage it, but unfortunately because he's at the prison, he didn't have direct access to the advice line, so we managed to identify the key areas that were problematic by this process map, and then from that we created the driver diagram.  So that we could find out exactly what we needed to work on and how we were going to work on it to improve the non attendance rates. So we came up with a very modest aim. We thought, you know, we'll try and keep it small, try to make small incremental changes because that's where you have to start really, isn't it? If you're making small incremental changes every day, then in a year you'll have improved the service massively, hopefully. So our aim was to reduce the non attendance rates by just 10% in the following six months after the project.
And we identified three key areas that we're going to be an issue in this process and this was the prison organisational challenges like the transport difficulties, the staffing shortages, etcetera. Patient compliance, we found that almost 1/5 of appointments weren't attended because patients actually refused to attend the appointment, so this was something we were going to have to work on as well. And then the third primary thing was communication barriers. We had major difficulties in getting in contact with the prison through the landline and through e-mail. We understand they're really busy, of course, but we just thought something has to be done about this if we're able. So after identifying with three key areas, we came up with a few points that we could do to reduce the non attendance rates. And this was things like. Minerva's admin staff to contact the prison twice before the patient's appointments as reminders, and also to pinpoint any issues and bringing them to the appointment to see if we could help out in any way to ensure the appointment happens. And stuff like the liaison with the prison staff regarding a scheduling system that can coordinate, coordinate the medical appointments with available transport resources and staff schedules, and liaising with the prison on the possibility of setting up designated days or times for blood monitoring draws because we couldn't get our patients started on biologics because they weren't getting the appropriate blood work. So it was just little things that we could do here and there. Overall, improve the process for prisoners.
 

BENSON, Rosalind (LIVERPOOL UNIVERSITY HOSPITALS NHS FOUNDATION TRUST)
Well, thank you for explaining that so well. So I guess I always like the phrase low hanging fruit when discussing quality improvement projects, because I think that obviously there's a lot here when you're dealing with different stakeholders and different organisations that are outside of your control. So prison staffing numbers, you have no control over, do you? So actually to be able to start with things like admin staff.
Spending time making a couple of phone calls before an appointment is something that actually is small, but could actually have incremental changes so.
And then thinking about some of the bigger things which require significant stakeholder engagement, sort of next steps. So Lizzie, I'm going to come to you now because I know that stakeholder engagement is key to a successful quality improvement project. So who were your significant stakeholders in this and how did you go about engaging them in what was clear? You know there's a need for this project.

Macphie Elizabeth (LSCFT)
Yeah. So I mean, I bang on about stakeholder engagement all the time when I'm sort of trying to endorse, you know, good Qi and the importance of also involving patients in the discussion as well, so.
I think the stage that we're at with Nouran with what she did was very much about collecting the data, understanding the problem and investigating what we've then tried to do over the last six months is to try and engage with the prisons and try and say, look, you know, can we come present this data to you and have a conversation about how we can improve the pathway, recognising the challenges we're all facing?
The so. So that's been to be polite, frustrating. So I've envisaged all the same problems that our secretary's doing such so I've reached out via various different routes and I managed to get eventually to find the GP who runs the medical service to only just at the start of the year. Find out that she's moved on from her roles. I've got to start all over again which is really frustrating.
But it is really difficult because you get names of people and then you don't know quite who someone is and so we're not doing very well with the stakeholder engagement with the prisons because it's about getting the right people. But we have the name of someone who's now taken on as the lead GP and we're hoping to set up some discussions as to how to take this forward.
We have sort of thinking outside the box, you know, if our prisoners in rheumatology, our prisoner patients are having problems, then it's probably a bit of a system wide thing. So I've been linking in with the chief nurse from our acute trust and she's been doing some work to also understand.
So, we've been sharing the learning as we've gone through, she's not been able to gather data to the extent that we have, which has been really helpful to share and we're putting our heads together, you know is there a means by which we need to have a think about how many appointments the prison across the board are having to take prisoners to you know because we've got to be mindful there may be certain days where there's more demand on the prisons to get patients to appointments.
So that's the sort of stakeholder engagement with the acute trust.  Obviously the patience is a struggle, and that's what we're keen to pick up as a discussion with the with the prisoners to say, look, you know, if there something else that we can do here to help us understand, you know how it is impacting on patients and get them part of the discussion. But lo and behold, opportunities always arise. So last week I had a patient in prison, a patient in clinic, who has been released from prison but is now working as a volunteer, with the prison getting people. So he works for recycling lives and he engages with people as they've been released and getting them back onto the straight and narrow and supporting them. And I found out that patients do have means by which we can contact them. So you can e-mail a prisoner through a particular service. And there's actually one of the prisons that we found out is that they do actually have phones in their cells.
So through my ICB connections I've now thought, OK, well, I might not be able to engage with prisoners who are active prisoners at the moment.
But we might be able to find out a bit more from people who've had a lived experience of these prisons that we support. So we're looking at a different way now of engaging people into the conversation. So I've taken some contact details, if you can imagine. And we're going to be reaching out to a few individuals we've met through other routes to say, well these are the problems. Have you got any thoughts, suggestions so that when we finally do get, you know, the opportunity to meet up with the prison teams, we can start to float some ideas.
So it's a bit about working around some of the challenges and the barriers and you know it's been really frustrating because I speak every couple of months, we exchange emails and we've had a look at the data and unfortunately sending a few more reminders by the admin team is not having the impact that we hoped it would. So unfortunately, that change hasn't had as big an impact on things, which is a real shame and the nurses have worked really hard to say, well, if we can't do it if the patient can't come face to face, can we do a telephone? Can we do an online appointment? But there’s still that issue that they've got to get the prisoner to the medical centre to then use a laptop or a computer to do the online appointment. So the things that we thought would be low hanging fruit and make a big difference or having quite the impact that we hoped they would.
The other thing that I thought was probably worth highlighting you around, which is something that you found was prisoners, when they refuse to come for their appointment. So this was really interesting. We found that there was a little bit of a pattern emerging as to the timing of their appointment. The time of day, so if they were down for like a first night, nine o'clock, 9:30 appointment. If the prisoner doesn't know they've got an appointment and they're getting transport, they have to be woken up much earlier and then suddenly they're told, get dressed. You've got an appointment, you need to go early. And that's when patients were quite often refused to come because they're not in the right mindset.
I think there was a there was an explanation in one of the patients notes that they, well, they didn't want to go because that that was their day when they went and did book club or there was some reason why there was something that they did not want to miss and they weren't prepared to sacrifice going to that appointment for that activity, which they look forward to so much. So I think that was a really interesting thing for us. And we have been tried to be mindful about appointment times. But again, it's the challenges of when our new patient appointments are unavailable. So what we're trying to do a bit of work around there to identify some more appropriate slots so that we don't have these early morning appointments.

BENSON, Rosalind (LIVERPOOL UNIVERSITY HOSPITALS NHS FOUNDATION TRUST)
Like a really useful thing to have identified with the data you've drawn. I mean, I think really getting data at the beginning of this is so useful, isn't it? Because it clearly shows a problem, which means that you're then able to better translate an inkling that you've had along with your colleagues, to the people that need to know in terms of the stakeholders and in the prison organisations as well. So I mean this is just very impressive, the thinking and the work that's gone behind this.
So I mean, you've talked about the difficulties of some of the change ideas and this is why you generate lots of change ideas, isn't it? Because some will work and some won't? And are there any other things, in terms of change idea implementation that you wanted to touch on or discuss?

ABDOU, Nouran (MEDWAY NHS FOUNDATION TRUST)
Really good for Lizzy to be able to bring the results to the team and get everyone thinking about it because ultimately, I don't think many people actually realise the difficulties in getting prisoners and other marginalised communities healthcare access. It's not something that you would necessarily notice unless you were specifically looking for it. So it was really good to bring the data to them and help them understand the numbers.
Unfortunately, one of our primary aims was that if we had enough numbers, Lizzy was going to try and liaise to get a clinic established at the prison. But because we only had in April 2024, 15 active patients at the time it became clear that we didn't have enough numbers to justify setting up a clinic at the prison because obviously that was going to be a lot of resources spent. But maybe that could be something in the future that we could think about, but it did provide us the opportunity to make some small changes. How appointments are booked, booked even additional reminders to the prison team about appointments like avoiding early appointments and being able to open a dialogue with prisoners about sort of their preferences and really involving them as stakeholders in their own care. Because the research does show that involving them improves health outcomes greatly.
So just little things to improve their care even if we can't massively improve their attendance rates in just six months. It was really useful for Lizzy to let them know about it at the clinic and she has a link to the weekly prison MDT on teams, so I think she's been exploring if we can join that, which I'm sure she'll touch on. And as she said, she recently had a look at the data over the last six months and there hasn't been a significant improvement, but.
It is still an improvement for us to be aware of the issues and try to improve the care that we deliver to prisoners individually.
Because if they feel like we really care about their treatment, their management, that might improve their compliance and we found that patient compliance was a massive issue. So if we can even just improve their compliance a little bit, then I'm sure that would improve health outcomes in the long term as well.

BENSON, Rosalind (LIVERPOOL UNIVERSITY HOSPITALS NHS FOUNDATION TRUST)
Yeah, absolutely. Now, Lizzy, was there anything you wanted to say about the pain MDT at all? If I move on to another?

Macphie Elizabeth (LSCFT)
Yeah, so, so this was again, it's one of these things you start digging this and you start asking round and we found out rather embarrassingly that our community team who we work alongside already tap into this weekly MDT that happens at the prison, which is online and they will sometimes get called in because you can imagine drugs that are prescribed for pain are things that they're desperately trying to reduce because they're tradeables in prison. So they've done a lot of work and work very closely with the lead GP at the prison. So it was like Oh yeah, we joined their weekly MDT. I was like what? So again all this is sort of fallen a little bit, this great idea that we thought we're going to be able to tap into their MDT because of our lead GP moving on. But we've got the new guy. So we're hoping to tap into that, but it's again it's just talking to people and just going, oh, goodness right. Didn't know that existed and we're not going to join a weekly MDT, but we'll be called in.
So my consulting colleague Dr Madan is taking the lead and I really need to give Aisha a huge shout out because Aisha has banged on about this for the last three years. It's been on her PDP for her appraisal that she's wanted to look into this in greater detail, but she just hasn't had the time to sort of really understand the depth of the problem. And you know, I remember when we put this, we talked about this at job planning. A few years ago, she said I want to set up an MDT, you know, and want to take one of the nurses and do a clinic at the prison.
And it was her patient, actually, who writes the letters to her, to communicate in between appointments. And I said, look, and, you know, have we got enough patients to do this? I said, yeah, I'm sure we have them. They're always missing their appointments. And I said, well, we need the data to show. So as I said, it has been for quite some time on all of our radars, but particularly passionate about this has been Aisha. So it's been great to provide her with the mechanism to really, you know, look at alternatives, I think in an ideal world.
We go and do a collect, but we've just got to be realistic about the resources and the demand, especially when we're covering 3 prisons because we haven't got the resources. So yeah, exciting times.

BENSON, Rosalind (LIVERPOOL UNIVERSITY HOSPITALS NHS FOUNDATION TRUST)
And that's well, that's often the reality, isn't it? With stretched resources, what we'd like to do isn’t always feasible. So we have to think flexibly, which is clearly what what's been going on. And I guess just so interestingly, hearing about the pain, MDT. But with this recognition that there are health inequalities that prisoners face, is there other things or good practise that we can see from other regions of the country or other specialties and what they have successes they might have had with reaching these populations?

Macphie Elizabeth (LSCFT) 
 So I mean, speaking to the sort of contacts I've had at the acute trust, they are struggling as much as ourselves, but I think Nouran you picked up some stuff on your literature reviews that certainly there's people looking at other ways of doing things, aren't there?

ABDOU, Nouran (MEDWAY NHS FOUNDATION TRUST)
So I think the literature mainly said that it was really important to involve prisoners as stakeholders in their care, which builds their autonomy, builds empowerment and is the best thing to get them to want to attend appointments and want to manage their own chronic health conditions. Because even for someone outside of prison, it's really difficult to manage a chronic health problem.
Holistically, so as you can imagine, it's even more difficult for prisoners.
So the majority of the literature said it was really important to empower them to take care of their own health.
I don't recall any specific examples except for things that did try to set extra reminders for prisoners and try to create more communication between the healthcare facilities and the prison.
But as Lizzy said, even they struggled a lot to get significant changes because of the logistical challenges and the difficulties. So I think that can be a little bit disheartening.
But on the other hand, it also shows us that we have a lot more to learn and a lot more to work on and that there's space for a lot of improvement in the future. So I think if we see it like that, we can try and turn it into something positive hopefully as well.

BENSON, Rosalind (LIVERPOOL UNIVERSITY HOSPITALS NHS FOUNDATION TRUST) 
 Yeah, absolutely. Nouran you did this as a coming to the end of your medical degree, didn't you? So what is there any advice you'd give to another medical student listening who has an idea for a project or an area of interest that they're keen to develop?

ABDOU, Nouran (MEDWAY NHS FOUNDATION TRUST)
 Honestly, I think the best advice to give medical students that are interested in, you know, quality improvement or research or medical education, whatever it is, is to come up with ideas for projects and e-mail a few consultants that are interested in their area. The idea to see if anyone has the capacity to supervise a project because out of all of the times I've done that and I've done it quite a few times.
 Consultants have had the capacity and been able to agree to supervise me. Almost all of the time because they also want someone to run the data they want someone to help them on the projects that they want to do as well.
 Manchester Uni was great, actually because it had a module every year for us to carry out a research project or an audit that they released titles for and you can pick whatever project you wanted from them. It was sort of first come, first served, but I always tried to come up with my own project and a specialty that I was interested in because that would, you know, increase your motivation to work on it and hopefully to take it to conference to try and publish it.
 So yeah, honestly, my best advice is just come up with your ideas. e-mail some professors or some supervisors and usually they will be more than willing to help. Actually the only know I ever got was from a professor that said that she'd actually retired now, so could no longer take on students. So yeah.

BENSON, Rosalind (LIVERPOOL UNIVERSITY HOSPITALS NHS FOUNDATION TRUST)
Well, it's shown that your tenacity has served you well, I think, and I think we'll continue to do so.
So well done, Lizzy. With this project in mind. What are your future plans and what do you, what do you hope to do with it?

Macphie Elizabeth (LSCFT)
Well, I've sort of mentioned a few things, so we're keen to understand things from the patient perspective and we've got a few routes to try and do that, but also most importantly to build those links with the prison medical team and a really share the work more broadly. So it's great to have this opportunity to share this for others podcast. We've got an electronic poster that's been accepted for conference in April, so come and find us when we're when we're at conference.
And we're presenting it at our research and Qi day for the trust. I'm very fortunate to have the links across our ICB to spread it more widely at that and we presented it at the Northwest Regional meeting. So it's really just sharing it as a get. People fired up, get them thinking about it.

BENSON, Rosalind (LIVERPOOL UNIVERSITY HOSPITALS NHS FOUNDATION TRUST)
 Yeah, absolutely. Because I think this is probably a problem shared by many of us that have got prisons within our patch and it would be useful to see if there's other ideas and successes that people have had in engaging with prisons locally as well. So I guess to bring this to a close now, as they're really reflecting on this bit of work that you've, when I say a bit of work, large piece of work that you've undertaken.
 Have you got any top tips to anyone who was thinking about how to address the health inequalities in different areas of medicine within the prisoner population.

Macphie Elizabeth (LSCFT)
So I'll, I'll go first. I think for me it's getting people to recognise as loads of focus now on health inequalities. I think it brought it to the forefront and we shouldn't be thinking about these populations as hard to reach. These are populations that cannot reach us for whatever reasons. I want people to think about those social injustice and get impassioned and angry about it. Because when you're angry and impassioned about it, you want to make a difference which you heard so eloquently from Nouran
at the start of this podcast. This isn't about deprivation. These aren't deprived communities. It's the communities that are disadvantaged and we need to be recognising that and whether we like it or not, we need to adapt to their needs and to do things differently. You know, we cannot expect everyone to fall in line with how we deliver those services in these situations. And we know that these are the patients who have worse patient, worse outcomes and then they'll end up you know, presenting acutely to the front door. So, so getting passioned this will touch lots of areas of your work, so where you see those cannot reach populations and think about what you can do about it.

BENSON, Rosalind (LIVERPOOL UNIVERSITY HOSPITALS NHS FOUNDATION TRUST)
Yeah. Thanks very much, Lizzy. Nouran is there anything else that you would like to add?

ABDOU, Nouran (MEDWAY NHS FOUNDATION TRUST)
No, I completely agree with Lizzy. Honestly, I think most people my age, especially to get, you know, our generation involved, have a particular social justice issue that they're really interested in. So whether that be, you know, a particular ethnic backgrounds or a prisoners like me, I think getting people to look into that particular social justice issue that they're really interested in medics, I mean and try to use that two Qi projects or research projects to raise awareness on the matter and then hopefully move people to action is really, really important because the majority of people you speak to do care about these things. They just don't have the information or the resources or the knowledge to move them into action. So I think hopefully we can do more things like this in the future, raise people's awareness, give them some knowledge and empower them to act because it's absolutely imperative that we improve healthcare access.

BENSON, Rosalind (LIVERPOOL UNIVERSITY HOSPITALS NHS FOUNDATION TRUST)
 Well, thank you both for joining this podcast. It's been a pleasure to speak with you and to listen to this project and the next innovator series will be back to our usual host of Lizzy and look forward to listening to that and do subscribe. If you're enjoying listening to these. Thanks very much.