On-site haemodialysis for prisoners with end-stage kidney disease

Introduction

To cater for the needs of prisoners with end-stage kidney disease, nurses at HMP Full Sutton have created an on-site haemodialysis programme. The article describes the programme, why it was set up and what benefits it has had.

Kidney disease and dialysis

Chronic kidney disease (CKD) affects around three million people in the UK; its biggest causative factors are uncontrolled diabetes and high blood pressure (Kidney Care UK). CKD is classified in five stages according to how well the kidneys are working. In stage 5 CKD (also known as kidney failure or end-stage kidney disease), kidney function is <15% and patients need to undergo dialysis and/or a kidney transplant to stay alive (Kidney Research UK). In the UK, there are almost 30,000 people on dialysis (Kidney Care UK).

There are two main types of dialysis:

• Haemodialysis – this is the most common form of dialysis and the blood is cleaned using an external machine and a filter;
• Peritoneal dialysis – a fluid is placed into the patient’s abdominal cavity to remove waste products.

Most people on haemodialysis have it three times a week for three to five hours at a time; this can be done in hospital, in a special unit or at the patient’s home (Kidney Care UK). The frequency at which dialysis takes place can be increased, if needed, to manage the disease as it progresses.

Home haemodialysis affords more flexibility in terms of frequency of treatment and length of sessions, and spares patients the burden of travelling to and from hospital (Kidney Care UK). However, patients and/or carers need to be trained to perform it and it does not suit all patients.

Spectrum at HMP Full Sutton

Spectrum Community Health CIC is a social enterprise that delivers a range of community and offender healthcare services on behalf of the NHS, local authorities and other partners. It provides healthcare services at HMP Full Sutton, a high-security prison for adult men in Yorkshire. In March 2018, the prison had a population of 558 prisoners.

Prisoners at HMP Full Sutton serve sentences ranging from four years to life, including whole-life terms. The demographic includes a number of older people. Among those engaged with Spectrum’s healthcare services, 15% are over the age of 60 years. In all likelihood, the prevalence of long-term conditions and age-related illnesses is higher than in the general population – but there is little data on the prevalence of long-term conditions in prison, both in general and at HMP Full Sutton in particular. Many prisoners need specialist care and support to manage long-term conditions such as diabetes, heart disease and CKD.

An important feature of healthcare provision in a high-security prison is that prisoners who need to attend a hospital appointment must be escorted by at least two prison officers and guarded while they are in hospital. If, for any reason, the prisoner cannot be escorted on the day – for example, if the availability of prison staff is limited – the treatment has to be re-scheduled. This is a significant issue in the case of patients with stage 5 CKD, who rely on haemodialysis and for whom a missed appointment is potentially fatal.

On-site dialysis

In 2011, Spectrum nurses working at HMP Full Sutton launched a home haemodialysis programme – the first of its kind in a UK custodial setting. The aim was to improve access to dialysis for prisoners with end-stage kidney disease, thereby reducing their need for hospital visits. A dialysis suite equipped for two to three patients was set up and three Spectrum nurses were trained. I previously worked as a dedicated renal nursing at York Teaching Hospitals Trust and trained nurses to provide home haemodialysis. This allowed me to train our prison nurses in the same way and built on relationships with the trust to support the Full Sutton patients. On 11 April 2011, the first prisoner underwent dialysis at the prison.

To be accepted for on-site haemodialysis, patients need to fulfil three criteria. They must:

• Have stable kidney disease;
• Have suitable vascular access;
• Have uncomplicated dialysis needs.

The programme is essentially a nurse-led service, as the prison is geographically isolated; however, there is access to the prison’s GP if needed. Close relationships are also maintained with renal services in the local hospital.

Benefits of the programme

Providing dialysis on site results in better health outcomes for patients, not only because it improves access to treatment but also because it:

• Brings care closer to patients;
• Results in a faster and more-responsive service;
• Provides continuity of care and makes follow-up easier;
• Helps patients adhere to treatment and manage their disease.

The proximity and responsiveness mean that complications of end-stage kidney disease and side-effects of dialysis – such as breathlessness, fatigue, low blood pressure and oedema – can be dealt with more promptly or even avoided altogether. Reducing the need for hospital visits has the added benefit of preserving patients’ dignity and comfort. Overall patients are much better supported, as demonstrated by the case study in Box 1.

In terms of benefits for the institution and healthcare provider there are cost savings as prisoners do not need to be escorted to hospital. Since the project began, HMP Full Sutton has saved an estimated £100,000 per year on escorts.

The programme today

The home haemodialysis programme was celebrated at the Nursing Times Awards 2017. Since it was launched in April 2011, three patients have received dialysis at HMP Full Sutton. Out of these three patients:

• One has died;
• One now needs to have dialysis in hospital due to a deterioration in his condition (his case is described in Box 1);
• One has been released.

“A service that makes an enormous difference to people and oozes compassion for a ‘forgotten’ patient group” (Judges’ feedback)

As of September 2018, Spectrum nurses at HMP Full Sutton are not providing on-site haemodialysis because there are no prisoners who require it and fit the criteria, but the service remains available for suitable patients in the future.

Some prisoners with long-term conditions who serve long sentences die in prison. For these patients, the aim is to provide good-quality end-of-life care. This is made possible through the links with the local hospice, which provides training and advice.