management of diabetes within a secure environment...prison who have diabetes is in pro-portion to...

62 PRACTICAL DIABETES VOL. 31 NO. 2 COPYRIGHT © 2014 JOHN WILEY & SONS

IntroductionDiabetes is currently one of thegreatest health challenges withinour society globally.1 It encompassesall of human society, whatever age,gender, colour or ethnic origin. Aprison environment can be identi-fied as one in which diabetes will bedistinguished as a common healthconcern, as is the case outside thissecure setting.

A number of possible factorshave been highlighted regarding themanagement and implementationof high quality care to people withina prison setting.2 There are a multi-tude of care challenges related tothis setting and health professionalsbased in this arena face a multitudeof conundrums. Historically, it hasoften been deemed that health careis weaker, and that this shortcomingis related to health care amenities –specifically with reference to chronicdiseases such as diabetes.3 An auditof care commenced in 2009,4 inresponse to what was being identi-fied in this sector,5 was thenreported upon in 20116,7 andshowed that a wide range ofstrengths and weaknesses related tothe specific care of prisoners with adiagnosis of diabetes.6,7

It was clearly seen to be essentialthat the scope and multitude of careservices offered to prisoners with diabetes within a secure settingneeded to be assessed and evaluated.

This would identify ways in which thecare and management of prisonerswith a diabetes diagnosis could be improved and complemented further within current practice.

There are 90 prisons in the UnitedKingdom with an approximate yearlypopulation of 90 000, of whicharound 6% have a known diabetesdiagnosis.8 In 1997, Reed and Lyne9

reported that prison health care pro-vision was suboptimal and now, morethan 15 years later, this is still thenorm – specific care for prisonerswith diabetes does not reach therequired standard, a trait furtheridentified by Booles7 and Nagi et al.10

However, this setting ought to be seenas a potential window for prisoners to access health care and education to improve their lives, and, for thosewith diabetes, this will clearly enable apositive step forward resulting in aworthwhile impact on their diabetescare and management.

It must be highlighted that thepopulation within this environmentis often very fluid and that prisonersare frequently moved/transferredbetween institutions. This will possi-bly impact on their diabetes careand management; internal commu-nication within this arena may needto be strengthened to create an envi-ronment which is of benefit to thehealth of this prisoner group. It has also been seen that prison popu-lations change in respect of age

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Management of diabetes within a secure environment

AbstractMany people situated in a wide variety of environments are affected by diabetes. The secureenvironment, of which prison is one, is an area in which the care and management of diabeteshave been currently identified as being quite variable in terms of practice. This clearly needs tobe investigated in order to strive for the implementation of gold standards of care for thisclient group. This article pinpoints the current strengths and weaknesses, as well as suggestingpotential recommendations to improve current clinical practices regarding the care andmanagement of prisoners with diabetes. The focus is primarily on the United Kingdom, but anumber of the points made, as well as the potential care recommendations, could beimplemented globally. Copyright © 2014 John Wiley & Sons.

Practical Diabetes 2014; 31(2): 62–66

Key wordsprison environment; diabetes education; dietary management; knowledge; hypoglycaemiamanagement; screening; teamwork

Keith BoolesSenior Nurse Lecturer, Faculty of Health Sciences,Staffordshire University, Shrewsbury Campus,Shrewsbury, UK

Correspondence to: Keith Booles, Senior Nurse Lecturer, Faculty of HealthSciences, Staffordshire University, ShrewsburyCampus, Shrewsbury SY3 8XQ, UK; email:[email protected]

Received: 12 December 2013Accepted in revised form: 23 January 2014

and fitness. Robson11 in 2009showed that this group were oftenyounger and fitter, but this picture isclearly changing to an older and lesshealthy group,8 and the incidence ofdiabetes will therefore become ofincreasing concern within a secureenvironment.

In 2013, Diabetes UK12 identifiedthat there were approximately 3 mil-lion people living with diabetes inthe UK and it was expected that thisfigure would rise to around 5 millionwithin the next 20 years. Prisons arefull of people similar to those whoare already in our society except thatthey have either committed a crimeresulting in a period of imprison-ment or are awaiting a court deci-sion while on custodial remand.13

Therefore the number of people inprison who have diabetes is in pro-portion to the number of those withdiabetes in our society. The NationalService Framework for Diabetes14,15

stated that all those with a diagnosisof diabetes need to be cared for andmanaged on the basis of the 12 stan-dards identified; and Standard 4clearly identifies prison and diabetesas an area that needs attention.

Cracks in care provisionUnfortunately, in 2013, there arestill cracks within both care provi-sion and management of diabetes inthis environment and these clearlyneed to be evaluated for the benefitof any prisoner with diabetes. Theirsentence is for a crime or potentialcrime, and it is vital that they shouldnot suffer a health sentence as wellwhile in a secure setting due to poor-standard diabetes care and manage-ment which could ultimately causefuture long-term diabetes effects.

An audit carried out by Boolesand Clawson6 underlined a variety ofareas of weaknesses in care provisionseen in a secure setting. These incor-porated: lack of individual diabetescare planning and management;inadequate dietary management andsupport, including the absence ofdietetic assessment on arrival atprison; poor handling of both hypo-glycaemic or diabetic ketoacidosisevents in prison with regard to pris-oners’ understanding and knowl-edge; and the dearth of informationamong prison staff on ways in whichto respond to these clinical episodes,

when encountered, and how to safe-guard against them. Another con-cern related to blood glucose moni-toring which was often not carriedout on an individual basis for indi-vidual assessment, but instead, for allprisoners with diabetes, was donebefore meals and at night beforesleep. Specialist care very often didnot underpin care, and limited serv-ices were enabled to enter this securesetting. Prisoners usually went to hospital clinics but only if there wereproblems. These factors resulted invery inadequate frequency of healtheducation processes such as foot careand eye screening, thus clearly notmeeting the identified governmenttargets of annual screening in boththese areas. In addition, in normalpractice within this setting the signif-icance of exercise was not identifiedas a health benefit. Could it beviewed that those prisoners with diabetes have been forgotten?Frequently, local diabetes serviceshave not been informed that therewere prisoners within their local prisons requiring health support –a clear communication disparity/breakdown. These pointers were alsorecognised by Nagi et al.10 withintheir research.

Call for a care provision redesignSo, clearly, in the UK it was evidentthat the care required by this vulner-able group needed to be evaluatedand appraised, with proposed carerecommendations implemented.Both Nagi et al.10 and Mills16 haveillustrated that care process redesignwithin this setting will have a positiveimpact for these prisoners physically,psychologically and emotionally. Ifprisoners feel that their health iswell managed, they could perceivethis as beneficial to them – and, inthe case of some prisoners with dia-betes, this could result in a reduc-tion in future returns to prison. Theprocess highlighted by Nagi et al.10

could also have a positive effect onthe health care team, includinghealth care workers, social workersand prison staff.

This potential positive tool couldenable the prisoner with diabetes tobecome more attuned to their individual diabetes needs. Thiscould have a beneficial effect upon

their long-term health – i.e. fewerdiabetic incidents and a reduction in long-term complications such asnephropathy, retinopathy, neuropa-thy and cardiac/cerebral vascularconditions, resulting in both ahealthier and a longer life span.

The suggested redesign couldincorporate activities such as specificdiabetes education programmes –e.g. DAFNE courses for those withtype 1 diabetes and DESMONDcourses for those with type 2 diabetes.These would explore areas such as:dietary education including carb-counting; blood glucose monitoring;the importance of exercise, foot care,and eye screening; and specialistpractice appointments/review – all of which could potentially reduce the incidence of long-term complica-tions, hypoglycaemia and diabeticketoacidosis events.

While these courses may need tobe adapted slightly due to the fluidnature of the prison population,such diabetes education pro-grammes could nevertheless resultin a healthier and better quality oflife for prisoners with diabetes.Clearly, these programmes will provide prisoners with long-termbenefits. They could not only have adirect impact on prisoners, but mayalso have an indirect or actualimpact on their partners and fami-lies, and society as well.

Booles and Clawson’s audit in20104 identified strengths and weak-nesses relating to the clinical caremanagement of prisoners with diabetes, and highlighted limitationswithin secure settings – that is, areluctance to share good practiceand recognise that support, guid-ance and further knowledge in man-aging prisoners with diabetes areneeded. It could be suggested thatthis, sadly, is not unique to organisa-tions within the prison sector as it ishas been identified that good prac-tice is not necessarily followed in thegeneral health care sector either.This could be because it is notencouraged. Additionally, peoplecould be reluctant to share theirexperience, skills and understand-ing, fearing these may not work forothers – or perhaps some people areselfish and do not want to share whatthey do well at the risk of being crit-icised for their practice methods?

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Good practice attributesPositive care activities are shown byNagi et al.,10 Mills,16 and police cus-tody practice in Lothian and theBorders.17 These activities included:support groups for diabetic prison-ers; the creation of a diabetes regis-ter to be held in the appropriateprison(s); and the availability ofblood glucose meters for all prison-ers with diabetes. However, as hasbeen highlighted previously, thereappears to be an unwillingness topass on or disclose facts/data toother secure settings, even within agiven locality. 6,7

Challenges encounteredThere are particular diabetes carechallenges within a prison environ-ment. These include the following.• Prisoners with diabetes are notbeing managed by their usual dia-betes care team and GP, and theremay be difficulty in accessing spe-cific diabetes information relating tothe individual prisoner.• Lack of care continuity and varia-tion of health care provisionbetween prisons result in care fail-ures in diabetes management.• Prisoners with a diabetes diagnosisoften do not have a key worker forsupport and guidance.• Poor relationships and communica-tion between local diabetes servicesand GPs could result in the specificcare and management of prisonerswith diabetes being not up to the standards identified in the DiabetesNational Service Framework.15

• Poor communication within theprison setting between health carestaff and prison officers results inpoor knowledge sharing as well aspoor staff training on specific careissues, such as the care and manage-ment of prisoners with diabetes –including important areas (e.g.hypoglycaemia, blood glucose moni-toring, dietary management, exer-cise and treatment strategies used).• Prisoner movements are frequent(such as to court and between pris-ons), and these can result in bothmissed treatment and dietary needs,causing poor diabetes consequencesfor the individual prisoner. (Thisobservation also links with the previ-ous four points immediately above.)• Poor hypoglycaemia recognitionwhich is linked to seclusion and

segregation for bad behaviour of theprisoner with diabetes. This is anacute diabetes emergency which canresult in uncharacteristic behaviourdue to confusion related to lowblood glucose levels causing poten-tially violent episodes which – if nottreated and managed correctly –could result in prisoner death.• The impact of other drugs usedfor the management of diabetes,such as antipsychotics and steroidswhich can cause blood glucose levelsto increase or decrease with result-ant care consequences for the pris-oner with diabetes.• Prisoner use of insulin to manipu-late prison and health care staffwithin this setting, such as overdoseor refusal to take treatment.

So, can the care and management ofprisoners with diabetes be improvedand strengthened for their direct benefit? Booles and Clawson4 in theiraudit highlighted that there are anumber of achievable strategies thatcan be employed in this goal. Theserecommendations are already beingimplemented in some specific secureenvironments in the UK, such asHMP Wakefield10 and HMP Risley.16

These examples should now beshared throughout this sector. Theycan clearly become beacons lightinga route through the care darkness.4,7

A direct and positive impact wouldthen result on the life of a prisonerwith diabetes, changing not onlytheir life in prison but also in societyafter their subsequent release.

Suggested recommendationsFollowing the audit by Booles andClawson,4 a number of recommen-dations were identified that couldbe potentially implemented in allprison and detention environments.These recommendations also drewfrom current good practices withinUK prisons.10,16 It is clear that thefollowing practice changes/recom-mendations are to be encouragedand shared throughout UK custo-dial settings. • Policies and procedures should bepresent within all custodial premisesin relation to care strategies for pris-oners with diabetes; these guidelinesmust follow those of NICE.18

• There should be a prison registerof all patients with diabetes to

increase staff awareness and enableprisoners to receive quality care. Aregister will also strengthen theprocess of information transfer asmany prisoners often move prisonsand delayed information sharing canhave serious health consequences forthe diabetic prisoner. This has beenaddressed by Nagi et al.10

• There needs to be a standardisedapproach to screening all prisonerswith diabetes on arrival at any prison.This should include treatment path-way, diet taken, the blood glucosemonitoring process, and hypogly-caemia recognition and manage-ment. The process should always becarried out by a knowledgeable practitioner within the prison.• Dietary assessment should bedone on arrival at prison so that this aspect of diabetes care can beinitiated immediately to ensure glycaemic control is maintained. If undertaken, it will potentiallyreduce the incidence of hypogly-caemia and diabetic ketoacido-sis/hyperglycaemia events for theindividual prisoner. This assessmentmust be done by a knowledgeablepractitioner at the prison. A reviewof the times of prison meals as wellas access to appropriate snackswould be beneficial, and this mayalso require access to blood glucoseself-monitoring provision under thedirect supervision of trained prisonhealth staff. • There needs to be a review of pris-oners in terms of their diabetes,which should be in line with that ofgeneral practice and acute hospitalcare. At a minimum, prisonersshould be seen and reviewed every6–12 months. This could be done bysetting up clinics within the prison sothat prisoners with diabetes haveaccess to a multidisciplinary team –diabetologist, specialist nurse, dieti-tian, retinopathy nurse assessor, podi-atrist and a diabetes educationist –over a morning or afternoon. Thiscould also enable implementation ofa diabetic education programme.These measures will result in botheconomic and staffing time savingswithin a prison setting, as well asreducing possible security risks. Thisprogramme has been initiated suc-cessfully by Nagi et al.10 and Mills.16

• Blood glucose monitoring must beclient focused to ensure that the



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data collected can be used toimprove the diabetes managementand care of each individual prisoner.Each prisoner should have access totheir own meter and relevant equip-ment at all times. This requiresdirect supervision from trainedprison health staff in respect of self-monitoring of blood glucose levels. • Retinal screening must be carriedout annually, as set out in govern-ment health guidelines, and can bepart of the clinic days identified inthe preceding point (see bulleteditem immediately above). This prac-tice is currently happening withinprisons in both South Wales andSouth West England. Manufacturersare now looking into creating a moreeasy-to-use and secure retinal screen-ing process.• The management of hypogly-caemic events must be standardisednationally. There must be communi-cation with all diabetic prisonersabout their hypoglycaemic events,what happens, and whether theyhave any warning signs. This infor-mation needs to be recorded andshared, and accessible to all relevantpersonnel. It can be strengthened byeducation sessions on hypoglycaemiaand how it should be managed.Accessibility to specific tools such asstandardised ‘hypo boxes’ within allclinical areas of prisons is essential,and these tools must be checkeddaily by appropriately trained prisonhealth staff. It must also be manda-tory that all prisoners with diabeteshave access to hypo treatment andsnacks within their cells when theyare there, especially in locked-downscenarios and at night.• The roles and responsibilities ofboth clinical lead for diabetes anddiabetes specialist nurse must beidentified within the custodial arena. • Staff training for prison personnelmust be evaluated and revised, espe-cially with regard to the manage-ment of hypoglycaemic events.• All prisoners with a diabetes diag-nosis must be given adequate time toexercise each day.• Education of prisoners with dia-betes needs to be strengthened inareas such as care independenceand the recognition of hypogly-caemic events. • All staff working in this environ-ment should be educated about the

dangers of insulin in terms of over-dose and treatment refusal, as wellthe effects that other drugs mayhave on blood glucose levels.• All staff should undertake thesafe insulin and hypoglycaemiae-modules available on the NHSDiabetes website.• The development of specific localuniversity degree-based diabetescourses for prison health care staffwill strengthen knowledge andcare. This has happened within anumber of UK areas, Shropshireand Staffordshire among them.• All prisoners who are going tocourt or are being transferred toanother prison should have dietaryand treatment assessment prior toleaving. Both their treatment anddiet needs require specific manage-ment before any event.• Create a support and knowledgenetwork throughout prison settingsnationally for those health care professionals providing diabetescare to prisoners in secure environ-ments. The development of anational forum linked to groupssuch as the RCN Diabetes Forumand Diabetes UK would strengthenthis process.• Create diabetes care championswithin this environment who wouldshare their knowledge and experi-ence throughout this area of practice.

Governmental considerationsIn reflecting on governmentalchanges related to the Health andSocial Care Act 2012,19 a number ofspecific points can be identified.Diabetes care in prisons is variablewithin the UK and requires review toreduce its fragmentation by incorpo-rating improved communicationwithin and outside secure environ-ments. This would be enhanced bythe sharing of good practices as iden-tified by Nagi et al.10 and Mills.16 The2012 Act clearly identifies that theNHS must respond to the needs of allpatients with diabetes in whateverenvironment they are set, includingprison. The Care Quality Commissionmust respond to the care inequalitiesencountered within prisons, and com-munication must be strengthenedbetween all organisations. By under-taking these actions, variability in carefor prisoners with a diagnosis of dia-betes will be reduced.2,4,5,7,14,15,20

Services need to evaluate the careneeds required and become moreinnovative in meeting the needs ofprisoners with diabetes. Prisonersmust have a voice regarding theircare. Being in prison or remand forany reason does not mean that a pris-oner’s health should suffer as a resultof care not being of the highest stan-dards. By reflecting on and challeng-ing current practices, care will strivetowards meeting the guidelines sug-gested within the Health and SocialCare Act of 2012.12

ConclusionPrison environments are small andunique communities but, similar tosociety outside these areas, they con-tain individuals with type 1 or type 2diabetes who require support in themanagement and care of their con-dition. This view is supported byboth Nagi et al.10 and Mills16 whoprovide examples of care changesneeded within the UK. Prisonersrequire extensive supervision andadvocacy with regard to their dia-betes needs during their time withindetention. Care in this domain hasmany challenges which are exclusiveto health care workers managingprisoners with diabetes.

Prison officer dependability is key:even though their specialist knowl-edge base is limited, they will have aprominent role in the care of prison-ers with diabetes. It is essential thatthey are supported so that they can undertake this role more effec-tively – through improved communi-cation, relationships and knowledgeexchange with those groups in societyoutside the prison environment whocare for and manage people with dia-betes. This can only occur if all groupstalk together, thus breaking downthose walls which still exist – as washighlighted by Booles and Clawson.4Current evidence10,16 draws attentionto the significance of excellent cooperation as well as first-rate dis-semination of information betweendetainee, health care professionaland prison staff. It is a great tribute toall staff that this process is now hap-pening in practice, but further expan-sion is required so that it encapsulatesall prison environments within theUK to enable a gold standard of careto be reached for the prisoner withdiabetes. This could also be enhanced

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by organising networks within thisenvironment to share knowledge,skills and experiences countrywide.

The original audit6 highlightedan extensive scope for the advance-ment of the diabetes service withinthe detention services, whatever thesetting; a recent NHS Diabetesreport20 has implied that all diabeticpeople in our society deserve goldstandard care wherever they happento be based. Care must have no wallsand those barriers encounteredmust be overcome in order that thisgoal will be clinically overcome.4

As Booles and Clawson4 identi-fied, diabetes care should never besurrounded by walls and hiddenfrom view, wherever it is based andgiven; all barriers must be brokendown so that everyone with diabetesreceives gold standard care, as iden-tified back in 2001.15

The suggested recommendationswithin this review article, as well aswhat is currently happening in prac-tice within prisons, must be dissemi-nated throughout the UK, andbeyond, to ensure the care and management of any prisoner withdiabetes are of a gold standard.

Clearly, greater prisoner empow-erment in respect of diabetes man-agement is essential, this beinglinked with greater education bothof prisoners with diabetes and of theprison staff who are playing a role inthat person’s time within detention.Improved communication betweendiabetes services outside prison and

those within the prison setting needsto be established; this process con-tinues post prisoner release, andcould be enhanced by greater use oftechnology between detention cen-tres and health services in the widersetting than is currently seen.

By undertaking such actions, thesewalls will be broken down so that diabetes care is equally available forall people wherever they happen tobe at any stage of their life. However,a more in-depth and wider researchproject is needed to examine all diabetes services at all levels withinthis sector – to develop specific guid-ance and to share existing currentguidance and best practice.

Declaration of interestsThere are no conflicts of interestdeclared.

References1. World Health Organisation. Diabetes statistics.

Geneva: WHO, 2013.2. Department of Health and HM Prison Service.

Developing and Modernising Primary Care inPrisons. London: HMSO, 2002.

3. Condon L et al. A review of prison health and itsimplications for primary care nursing in Englandand Wales: the research evidence. J Clin Nurs2007;16(7):1201–9.

4. Booles KD, Clawson P. Audit of the quality of dia-betes care in the prison setting across the UK.London: RCN, 2010.

5. Royal College of Nursing. Health and nursing care inthe criminal justice service. London: RCN, 2009.

6. Booles KD, Clawson P. Breaking down barriers:Diabetes care in prisons. J Diabetes Nurs2009;13(10):388–89.

7. Booles KD. Survey on the quality of diabetes care inprison settings across the UK. J Diabetes Nurs2011;15(5):168–76.

8. Berman G, Dar A. Prison population statistics.London: HMSO, 2013.

9. Reed J, Lyne M. The quality of health care in prison:results of a year’s programme of semistructuredinspections. BMJ 1997;315:1420–4.

10. Nagi D, et al. Diabetes service redesign in WakefieldHM high-security prison. Diabetes & Primary Care2012;14(6):344–50.

11. Robson S. Providing diabetes care in prisons:Experiences of joint working with prison healthcare. J Diabetes Nurs 2009;13(10):396–9.

12. Diabetes UK. Diabetes in the UK, 2013. London:Diabetes UK, 2013.

13. Diabetes UK. Prison position statement. London:Diabetes UK, 2005.

14. Department of Health. National Service Frameworkfor Diabetes: Delivery Strategy. London: HMSO, 2002.

15. Department of Health. National Service Frameworkfor Diabetes: Standards. London: HMSO, 2001.

16. Mills L. Diabetes in prisons – can we improve thecare provided? J Diabetes Nurs 2013;17(6):239.

17. NHS Lothian. Treating diabetes in custody. 2008.www.allmediaScotland.com [accessed 26 Feb 2009].

18. National Diabetes Support Team. NICE and dia-betes: summary of relevant guidelines. London:NDST, 2006.

19. Department of Health. Health and Social Care Act.London: HMSO, 2012.

20. NHS Diabetes. Commissioning Diabetes withoutWalls. Leicester: NHS Diabetes, 2009.

● Diabetes management in prisonrequires: greater prisonerempowerment; improved dietaryscreening; and improved blood glucosemonitoring

● Diabetes education in prison needs:improved prison staff knowledgeregarding diabetes and hypoglycaemia;and diabetes education programmesfor all prisoners with diabetes

● Diabetes prevention care in prisonrequires: more exercise; better dietaryoptions; and in-house screening ofeyes, feet, diet and diabetes treatment

Key points

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