DELIVERY
Medical and health care services in Canada's federal prisons D.J.R. ROWE The provision of medical and health care services to inmates of Canada's federal penitentiary system,* judged by a federally appointed advisory committee as recently as 1975 to be in need of urgent reforms, has been undergoing extensive improvement in the past 3 years, according to Dr. Daniel Craigen, director-general, medical and health care services, Canadian correctional service (CCS). There are 12 maximum security prisons (16 including the regional psychiatric centres at Kingston, Abbottsford, BC and Montreal, and the one at Saskatoon scheduled to open this August), 13 medium security prisons and 26 minimum security institutions and community correctional centres. There are health care centres (HCCs) in the 25 maximum and medium security prisons, of which the largest is at Dorchester Penitentiary in New Brunswick, with 12 staff and 37 beds. Minimum security facilities are usually served by arrangements made with communities closest to them and do not have HCCs as such. Institutions have capacities of from 13 to more than 500 inmates. The total inmate population at any time does not exceed 10 000. (Provincial prisons, not dealt with here, are for those serving sentences under 2 years).
professional bodies to nominate a national health services advisory committee. This committee has issued two reports, in May 1974 and November 1975, and we have implemented a ma-
ston, who is also a member of the new body. (See also Botterell report, health care service in Ontario correctional system, CMAJ 109: 319, 1973). His seven-member group, whose CMA appointees were himself, Dr. A.L. Kerr of Montreal and Dr. J.W. Ibbott of Vancouver, crossed the country to visit most of the 56 federal prisons and correctional centres, observing and talking with health care personnel, prison officials and inmates. Findings
Dr. E.H. IBotterell, advisory committee chafrman
jority of its recommendations (41 out of 76 in the second report). Now, we've formed a medical advisory committee Sought help (tentative name) of eight people to report back on what we've done so far." Dr. Craigen said the CCS had been This group was due to meet for the concerned over the need for improve- first time in February 1978. The second ment in the system as far back as 1971, report, although completed 2 years ago, when it asked the Canadian Psychiatric was made public only in December Association to nominate a committee 1977. (The new advisory committee to report on psychiatric services. was appointed directly by the CCS, "While they began their work," said which did not ask for nominations Dr. Craigen, "we asked CMA, the Ca- from the CMA or other professional nadian Nurses' Association and other bodies.) Chairman of the advisory committee *Formerly Canadian Penitentiary Service, now was Dr. E.H. Botterell, retired dean of Canadian Correctional Service, following amalgamation of CPS and the National Parole Service medicine at Queen's University, King578 CMA JOURNAL/MARCH 4, 1978/VOL. 118
They found serious faults in the dayto-day operation of health care centres and in facilities for institutions without full-time centres, including the use of untrained staff lacking professional qualifications; and fundamental inadequacies in the administrative structure of medical services. None the less, Dr. Botterell, in a recent interview with CMAJ at his home in Kingston, emphasized that the visits to penal institutions had uncovered "no horror stories." The second (1975) report, indeed, stated that "the medical, dental and nursing resources available for the care of the sick have improved and are on a par with those available to civilians." Deficiencies identified by the advisory committee included: * Senior health care officers in charge of federal penal health care centres were only occasionally (in 5 out of 25 centres) registered nurses and in most cases lacked professional qualifications. * A number of physicians on staff were not registered with colleges in the provinces in which the prisons were located. * Medications, including controlled drugs, were inadequately supervised and were often dispensed in keeping with the standing orders of a physician
NL.,dL (amoxicillin) AMOXIL. (amoxicillin). -. A new generation broad-spectrum penicillin. INDICATIONS: Infections due to susceptible strains of the following microorganisms: Gram-negative-H. influenzae, E. coIl, R mirabilis and Ngonorrhoeae. Gram-positive-Streptococci, D.Pneumoniae and penicillin-sensitive staphylococci. In emergency cases where the causative organism is not yet identified, therapy may be initiated with AMOXIL on the basis of clinical judgment while awaiting the results of bacteriologic studies. DOSAGE AND ADMINISTRATION:lnfections of the ear, nose and throat due to streptococci, pneumococci, and penicillin-sensitive staphylococci; infections of the upper respiratory tract due to H. influenzae; in fections of the genitourinary tract due to E. coli, R mirabilis, and S. faecalis; infections of the skin and soft tissues due to streptococci, penicillin-sensitive staphyloc.occi and E. coli: Usual Dose: Adults-250 mg every 8 hours. Children-25 mg/kg/day in divided doses every 8 hours. This dosage should not exceed the recommended adult dosage. In severe infections or infections caused by less sensitive organisms: 500 mg every 8 hours for adults, and 50 mg/kg/day in divided doses every 8 hours for children. Infections of the lower respiratory tract due to streptococci, pneumococci, penicillin-sensitive staphylococci and H. influenzae: Usual Dose: Adults-500 mg every 8 hours. Children-SO mg/kg/day in divided doses every 8 hours. This dosage should not exceed the recommended adult dosage. Urethritis due to N. gonorrhoeae: 3 g as a single oral dose. Patients with gonorrhea, with a suspected lesion of syphilis, should have darkfield examinations before receiving AMOXIL, and monthly serologic tests for a minimum of four months. For chronic urinary tract infections, frequent bacteriologic and clinical appraisals are necessary. Smaller doses than those recommended above should not be used. Stubborn infections may require several weeks' treatment, sometimes at higher doses than recommended above. Concurrent bacteriologic sensitivity monitoring is recommended. Cont inued clinical and/or bacteriologic follow-up for several months after cessation of therapy may be required. Treatment should continue for 48 to 72 hours beyond the time patient becomes asymptomatic or bacterial eradication is obtained. At least 10 days' treatment is recommended for infections caused by beta-hemolytic streptococci to prevent acute rheumatic fever or glomerulonephritis. CONTRAINDICATION: In patients with a history of allergy to the penicillins or the cephalosporins. PRECAU. TIONS:Periodic assessment of renal, hepatic, and hematopoietic function should be made during prolonged AMOXIL therapy. AMOXIL is excreted mostly by the kidney. The dosage administered to patients with renal impairment should be reduced proportionately to the degree of loss of renal function. The possibility of superinfections with mycotic or bacterial organisms should be kept in mind during therapy. If superinfections occur (usually involving Aerobacter, Pseudomonas or Candida), the drug should be discontinued and appropriate therapy instituted. ADVERSE REACTIONS:As with other penicillins, presumably the most common untoward reactions will be related to sensitivity phenomena, similar to those observed with ampicillin. They are more likely to occur in individuals who have previously demonstrated hypersensitivity to penicillins and in those with a history of allergy, asthma, hay fever or urticaria. (See Product Monograph which is available on request).SUPPLI ED: AMOXIL-250 Capsules (250 mg amoxicillin) in bottles of 100 and 500. AMOXIL-500 Capsules (500 mg amoxicillin) in bottles of 100. AM OXIL.l2sSuspension(125mg amoxicillin per 5 ml) in bottles of 75, 100 and 150 ml. AMOXIL-250 Suspension (250 mg amoxicillin per 5 ml) in bottles of 75, 100 and 150 ml. AMOXIL Pediatric Drops (50mg amoxicillin per ml) in bottles of 15 ml. AYERST LABORATORIES Division of Ayerat, McKenna & Harrison Limited Montreal, Canada Made in Canada by arrangement with .Reg'd BEECHAM, INC.
by unqualified people in daily pill parades. * Guidelines for routine examinations and handling of prisoner requests and complaints were unclear. * Facilities were often cramped and unpleasant. * Record keeping was "catastrophic" and not problem-oriented. * Equipment and supplies lacked proper control and inventory. * Medical and other health care staff were expected to be involved with maintaining security, leading to a climate of adversary relationships between inmates and health care personnel. * There were only two regional reception centres, in Ontario and Quebec, where inmates could spend the first few weeks of sentences while undergoing detailed medical and psychologic examination, and the facilities of the Ontario centre were judged "deplorable". As for the overall administrative structure, the advisory committee was seriously concerned about the split, or dual administrative system, separating psychiatric services from all other medical and health care services, the accountability of the health care officer and the institutional physician mainly to the prison director rather than to the chief physician in the region (deputy regional director of medical and health care services) and the junior status of the national director of medical and health care services. First report The first report of the Botterell committee in 1974, which followed announced federal plans for changes in the prison health care system, "related primarily to the development of an organizational structure and administrative relationships Which will allow redevelopment of the medical and health care services in effective and professional fashion." "That's the key word - 'professional'," Dr. Botterell told CMAJ. "What bothered us most was that people without professional qualifications, neither RNs nor RNAs, were senior health care officers (CCS term for senior person in the health care centre.) Neither the institutional physician nor the director of the institution could remedy this." At the time of the first Botterell report, only five senior health care officers (HCOs) were RNs. As of this writing 12 senior HCOs are RNs in the 25 health care centres and official policy is not to hire more RNAs, while sending present staff to qualify as RNs. Dr. Botterell and his fellow committee members were not operating under the federal government oath of secrecy,
which is mandatory for all federal civil servants and government contract holders. "In fact," Dr. Botterell said, "there was openness to our inquiries right up to the highest government level." After the goals of professionalizing and upgrading the service, the committee turned to the problems of responsibility and accountability in the chain of command - the military term here intended as a reminder that health care professionals must to some degree be involved with a system involving both security and coercion when they are working in prison. "The medical and health care service had to have sufficient recognition and seniority from the CCS, so that efforts to improve the situation would receive the fullest consideration by security and management," said Dr. Botterell. "It's interesting that there was no provision in our own Canadian Penitentiary Act or the regulations at that time that the director of a prison should be responsible for the health of the inmates." This now is clearly stated in a policy and procedures manual, issued in August 1977 by the director general, medical and health care services, under the authority of the commissioner of correctional services. The manual also states that medical judgements are the prerogative of the medical staff and that health care staff are not to be employed in security duties. "In the military," said Dr. Botterell, "the regimental medical officer is responsible to the commanding officer of the regiment for the performance of his duties - but he is also professionally responsible to the assistant director of medical services for the division which means that his CO will not override medical judgement without pressing reasons. "But in the CCS, the institutional physician and senior HCO were responsible only to the prison director. So we said they should be professionally responsible to the senior physician in the region. Then we urged making the director of medical and health care services in Ottawa a director-general, reporting directly to the commissioner o. penitentiaries" (that official's title now is commissioner of correctional services). These recommendations were among the first to be accepted, although for reasons dealt with later in this article, physicians' direct reporting status is still somewhat unclear. Dr. Craigen was made a director-general in 1974. Dr. Botterell's group also favoured the continuing decrease in the number of full-time physicians in the system. "Doctors should work in prisons as large a proportion of their time as necessary to become committed to what they are doing and not so long as to
CMA JOURNAL/MARCH 4, 1978/VOL. 118 581
At the CMA annual meeting in Quebec City in June 1977, General Council accepted seven recommendations, which are now CMA policy. Subsequently these resolutions were forwarded to the then commissioner of penitentiaries, the late A. Therrien (since succeeded by D.R. Yeomans), who responded with written comments. In' a recent intervie.v with Dr. Daniel Craigen, director-general, medical and health care services, CCS, these comments were updated. The following are the seven resolutions and the official comments: All physicians practising medicine in the Canadian penitentiary system must obtain at least temporary licence from the respective college of physicians and surgeons of the province prior to commencing practice. COMMENT: Only one physician is not so registered at present. However, the director-general reserves the right, in special circumstances, or in relation to a particular individual, to employ a doctor who may be licensed in a province other than the one in which he is employed. All medical personnel, primary care physicians, psychiatrists, surgeons, should be professionally accountable to the professional regulatory licensing body and not be considered as subordinate to lay prison administrators. COMMENT: All medical personnel are professionally accountable to the regulatory licensing body of the province where they are registered. Institutional physicians must also satisfy the senior regional physician and the directorgeneral of their professional competence. A licensed physician must be allowed to exercise his judgement in discharging his professional responsibilities. COMMENT: It is clearly laid down in
medical director varying the security in the interior according to his own judgement. There should be no interference within regional psychiatric centres by the penitentiary service in terms of admission, discharge and clinical services. COMMENT: A further section of the policy document states that the directors of the centres "...are to have control of all admissions and discharges, based solely on the health needs of the patient". The chief executive of the regional psychiatric centres should report to a board of governors or equivalent as is customary in all Canadian hospitals. COMMENT: The chief executive of the Pacific regional psychiatric centre already reports to a board of governors. This policy will be pursued in the other centres. All provincial medical associations should be prepared to monitor the medical services delivered in the prisons of the respective provinces. COMMENT: As noted above institutional physicians are professionally accountable. The National Health Services Advisory Committee (NHSAC) conducted a thorough scrutiny of the services, and I believe that the ongoing monitoring of these services can be adequately carried out by the senior medical staff of this department. However, a number of members of the NHSAC and others have been invited to form a medical advisory committee (tentative title) to meet first in February 1978 to review the implementation of the recommendations contained in the reports. We have invited scrutiny, and welcome any interest any provincial medical association wishes to take on this resolution.
become 'institutionalized' themselves," he said, wryly.
Second report The Botterell committee's second report, a longer one, was completed in November 1975, a year-and-a-half later. This report "results from a study in detail, 1973-75, of how the inmate obtains medical and health care services, and the nature and quality of the services and therapies provided... It produced 76 recommendations, many of them new ones concerned with improving day-to-day medical matters, but a number of them urgent calls for the implementation of more of the 1974 points - singling out as "of primary importance" the regular provision of expert consultants in the various medical fields to the director-general in Ottawa. In January 1978, CMAJ visited
Director-General Dr. Daniel Craigen (who had been an ex-officio member of Dr. Botterell's committee) and his staff of 15, and found him still smarting over press coverage following the second report's release to the public on Dec. 20, 1977.
The story, which appeared with a Canadian Press byline in the Globe and Mail and many other Canadian papers Dec. 21, began: "A national advisory committee says there is 'chaos' in the medical and health care services of the Canadian Penitentiary Service." It noted that the solicitor-general said "most of its recommendations are being implemented", but gave no details of the implementation. In fact, Dr. Craigen said, "Forty-one of the 76 recommendations are in effect, 20 are partially in operation and a further 10 will be implemented in 1978 or 1979, in consultation with the 582 CMA JOURNAL/MARCH 4, 1978/VOL. 118
new medical advisory committee, which includes Dr. Botterell and seven others, some from the original committee." Dr. Craigen said the five recommendations felt to be not feasible would also be discussed at the initial February meeting of the new body.
New ideas Reference to the massive policy and procedures manual issued by the CCS medical branch last summer confirmed Dr. Craigen's assertion; it also turned up a few ideas not recommended by the Botterell group, such as: "The stiedical and health care services branch should be represented on committees involved in planning for new institutions or renovation of existing ones." The document urges that criteria be developed by the branch for health care centres design, "bearing in mind the CCS policy of creating small institu-
tions for a maximum of 200 inmates ... The manual also lays down guidelines for transfer of inmates for treatment not available in health care centres - which are not hospitals and provide mainly ambulatory care. It directs that all inmates are to have a preliminary medical examination within 24 hours of reception and a comprehensive examination, including dental, within 7 days. Records are to be problem-oriented and confidential except for essential disclosures authorized by the director-general. Nevertheless, and despite the improvement, CMAJ asked, what about the fact that, although 12 RNs now are senior HCOs (as against 5 in 1974) this still leaves 13 health care centres with less-qualified people in charge? "The change has had to be gradual," said Dr. Craigen. "You can't just pick up experienced prison health care staff like that. When we started to increase the number of RNs, we began sending 15 or 16 HCOs each year for training. Since the normal centre has no more than 7 staff (the largest, Dorchester, has 12), that means there'll only be one person on duty during the night shift. Although only 12 are in charge, there are about 100 RNs in the system now, and if you count registered psychiatric nurses it's about 150." Wouldn't it be possible, CMAJ asked, to transfer some of these RNs to take charge in the remaining centres? Union problems intrude here, said CCS chief nurse Marjorie Carroll. "Nurses and health care officers belong to different unions. We have promised senior HCOs they wouldn't be pushed out, but retrained, with financial assistance wherever possible. The majority of unregistered senior HCOs are in Quebec; there is a pilot project going on to put an RN beside a senior HCO in a number of institutions there, but this has to be handled very carefully." Stilt inadequate
As for the Botterell report complaints about the regional reception centres, Ms Carroll said the Ontario centre at Old Kingston Penitentiary is still inadequate. It shared the building with the medical surgical services hospital, but there should be an improvement, she said, after the unit moves into a new hospital facility being built at Collins Bay (Kingston) psychiatric centre. Establishment of more reception centres is difficult, she said, especially in prairie areas where sheer distance is a problem. Dealing with the Botterell committee's second report reiteration that the director general appoint a regular group of
Compared with the general public, federal prisoners benefit from a higher physician-to-population ratio.
Medical and health care services in Canada's federal prisons D.J.R. ROWE The provision of medical and health care services to inmates of Canada's federal penitentiary system,* judged by a federally appointed advisory committee as recently as 1975 to be in need of urgent reforms, has been undergoing extensive improvement in the past 3 years, according to Dr. Daniel Craigen, director-general, medical and health care services, Canadian correctional service (CCS). There are 12 maximum security prisons (16 including the regional psychiatric centres at Kingston, Abbottsford, BC and Montreal, and the one at Saskatoon scheduled to open this August), 13 medium security prisons and 26 minimum security institutions and community correctional centres. There are health care centres (HCCs) in the 25 maximum and medium security prisons, of which the largest is at Dorchester Penitentiary in New Brunswick, with 12 staff and 37 beds. Minimum security facilities are usually served by arrangements made with communities closest to them and do not have HCCs as such. Institutions have capacities of from 13 to more than 500 inmates. The total inmate population at any time does not exceed 10 000. (Provincial prisons, not dealt with here, are for those serving sentences under 2 years).
professional bodies to nominate a national health services advisory committee. This committee has issued two reports, in May 1974 and November 1975, and we have implemented a ma-
ston, who is also a member of the new body. (See also Botterell report, health care service in Ontario correctional system, CMAJ 109: 319, 1973). His seven-member group, whose CMA appointees were himself, Dr. A.L. Kerr of Montreal and Dr. J.W. Ibbott of Vancouver, crossed the country to visit most of the 56 federal prisons and correctional centres, observing and talking with health care personnel, prison officials and inmates. Findings
Dr. E.H. IBotterell, advisory committee chafrman
jority of its recommendations (41 out of 76 in the second report). Now, we've formed a medical advisory committee Sought help (tentative name) of eight people to report back on what we've done so far." Dr. Craigen said the CCS had been This group was due to meet for the concerned over the need for improve- first time in February 1978. The second ment in the system as far back as 1971, report, although completed 2 years ago, when it asked the Canadian Psychiatric was made public only in December Association to nominate a committee 1977. (The new advisory committee to report on psychiatric services. was appointed directly by the CCS, "While they began their work," said which did not ask for nominations Dr. Craigen, "we asked CMA, the Ca- from the CMA or other professional nadian Nurses' Association and other bodies.) Chairman of the advisory committee *Formerly Canadian Penitentiary Service, now was Dr. E.H. Botterell, retired dean of Canadian Correctional Service, following amalgamation of CPS and the National Parole Service medicine at Queen's University, King578 CMA JOURNAL/MARCH 4, 1978/VOL. 118
They found serious faults in the dayto-day operation of health care centres and in facilities for institutions without full-time centres, including the use of untrained staff lacking professional qualifications; and fundamental inadequacies in the administrative structure of medical services. None the less, Dr. Botterell, in a recent interview with CMAJ at his home in Kingston, emphasized that the visits to penal institutions had uncovered "no horror stories." The second (1975) report, indeed, stated that "the medical, dental and nursing resources available for the care of the sick have improved and are on a par with those available to civilians." Deficiencies identified by the advisory committee included: * Senior health care officers in charge of federal penal health care centres were only occasionally (in 5 out of 25 centres) registered nurses and in most cases lacked professional qualifications. * A number of physicians on staff were not registered with colleges in the provinces in which the prisons were located. * Medications, including controlled drugs, were inadequately supervised and were often dispensed in keeping with the standing orders of a physician
NL.,dL (amoxicillin) AMOXIL. (amoxicillin). -. A new generation broad-spectrum penicillin. INDICATIONS: Infections due to susceptible strains of the following microorganisms: Gram-negative-H. influenzae, E. coIl, R mirabilis and Ngonorrhoeae. Gram-positive-Streptococci, D.Pneumoniae and penicillin-sensitive staphylococci. In emergency cases where the causative organism is not yet identified, therapy may be initiated with AMOXIL on the basis of clinical judgment while awaiting the results of bacteriologic studies. DOSAGE AND ADMINISTRATION:lnfections of the ear, nose and throat due to streptococci, pneumococci, and penicillin-sensitive staphylococci; infections of the upper respiratory tract due to H. influenzae; in fections of the genitourinary tract due to E. coli, R mirabilis, and S. faecalis; infections of the skin and soft tissues due to streptococci, penicillin-sensitive staphyloc.occi and E. coli: Usual Dose: Adults-250 mg every 8 hours. Children-25 mg/kg/day in divided doses every 8 hours. This dosage should not exceed the recommended adult dosage. In severe infections or infections caused by less sensitive organisms: 500 mg every 8 hours for adults, and 50 mg/kg/day in divided doses every 8 hours for children. Infections of the lower respiratory tract due to streptococci, pneumococci, penicillin-sensitive staphylococci and H. influenzae: Usual Dose: Adults-500 mg every 8 hours. Children-SO mg/kg/day in divided doses every 8 hours. This dosage should not exceed the recommended adult dosage. Urethritis due to N. gonorrhoeae: 3 g as a single oral dose. Patients with gonorrhea, with a suspected lesion of syphilis, should have darkfield examinations before receiving AMOXIL, and monthly serologic tests for a minimum of four months. For chronic urinary tract infections, frequent bacteriologic and clinical appraisals are necessary. Smaller doses than those recommended above should not be used. Stubborn infections may require several weeks' treatment, sometimes at higher doses than recommended above. Concurrent bacteriologic sensitivity monitoring is recommended. Cont inued clinical and/or bacteriologic follow-up for several months after cessation of therapy may be required. Treatment should continue for 48 to 72 hours beyond the time patient becomes asymptomatic or bacterial eradication is obtained. At least 10 days' treatment is recommended for infections caused by beta-hemolytic streptococci to prevent acute rheumatic fever or glomerulonephritis. CONTRAINDICATION: In patients with a history of allergy to the penicillins or the cephalosporins. PRECAU. TIONS:Periodic assessment of renal, hepatic, and hematopoietic function should be made during prolonged AMOXIL therapy. AMOXIL is excreted mostly by the kidney. The dosage administered to patients with renal impairment should be reduced proportionately to the degree of loss of renal function. The possibility of superinfections with mycotic or bacterial organisms should be kept in mind during therapy. If superinfections occur (usually involving Aerobacter, Pseudomonas or Candida), the drug should be discontinued and appropriate therapy instituted. ADVERSE REACTIONS:As with other penicillins, presumably the most common untoward reactions will be related to sensitivity phenomena, similar to those observed with ampicillin. They are more likely to occur in individuals who have previously demonstrated hypersensitivity to penicillins and in those with a history of allergy, asthma, hay fever or urticaria. (See Product Monograph which is available on request).SUPPLI ED: AMOXIL-250 Capsules (250 mg amoxicillin) in bottles of 100 and 500. AMOXIL-500 Capsules (500 mg amoxicillin) in bottles of 100. AM OXIL.l2sSuspension(125mg amoxicillin per 5 ml) in bottles of 75, 100 and 150 ml. AMOXIL-250 Suspension (250 mg amoxicillin per 5 ml) in bottles of 75, 100 and 150 ml. AMOXIL Pediatric Drops (50mg amoxicillin per ml) in bottles of 15 ml. AYERST LABORATORIES Division of Ayerat, McKenna & Harrison Limited Montreal, Canada Made in Canada by arrangement with .Reg'd BEECHAM, INC.
by unqualified people in daily pill parades. * Guidelines for routine examinations and handling of prisoner requests and complaints were unclear. * Facilities were often cramped and unpleasant. * Record keeping was "catastrophic" and not problem-oriented. * Equipment and supplies lacked proper control and inventory. * Medical and other health care staff were expected to be involved with maintaining security, leading to a climate of adversary relationships between inmates and health care personnel. * There were only two regional reception centres, in Ontario and Quebec, where inmates could spend the first few weeks of sentences while undergoing detailed medical and psychologic examination, and the facilities of the Ontario centre were judged "deplorable". As for the overall administrative structure, the advisory committee was seriously concerned about the split, or dual administrative system, separating psychiatric services from all other medical and health care services, the accountability of the health care officer and the institutional physician mainly to the prison director rather than to the chief physician in the region (deputy regional director of medical and health care services) and the junior status of the national director of medical and health care services. First report The first report of the Botterell committee in 1974, which followed announced federal plans for changes in the prison health care system, "related primarily to the development of an organizational structure and administrative relationships Which will allow redevelopment of the medical and health care services in effective and professional fashion." "That's the key word - 'professional'," Dr. Botterell told CMAJ. "What bothered us most was that people without professional qualifications, neither RNs nor RNAs, were senior health care officers (CCS term for senior person in the health care centre.) Neither the institutional physician nor the director of the institution could remedy this." At the time of the first Botterell report, only five senior health care officers (HCOs) were RNs. As of this writing 12 senior HCOs are RNs in the 25 health care centres and official policy is not to hire more RNAs, while sending present staff to qualify as RNs. Dr. Botterell and his fellow committee members were not operating under the federal government oath of secrecy,
which is mandatory for all federal civil servants and government contract holders. "In fact," Dr. Botterell said, "there was openness to our inquiries right up to the highest government level." After the goals of professionalizing and upgrading the service, the committee turned to the problems of responsibility and accountability in the chain of command - the military term here intended as a reminder that health care professionals must to some degree be involved with a system involving both security and coercion when they are working in prison. "The medical and health care service had to have sufficient recognition and seniority from the CCS, so that efforts to improve the situation would receive the fullest consideration by security and management," said Dr. Botterell. "It's interesting that there was no provision in our own Canadian Penitentiary Act or the regulations at that time that the director of a prison should be responsible for the health of the inmates." This now is clearly stated in a policy and procedures manual, issued in August 1977 by the director general, medical and health care services, under the authority of the commissioner of correctional services. The manual also states that medical judgements are the prerogative of the medical staff and that health care staff are not to be employed in security duties. "In the military," said Dr. Botterell, "the regimental medical officer is responsible to the commanding officer of the regiment for the performance of his duties - but he is also professionally responsible to the assistant director of medical services for the division which means that his CO will not override medical judgement without pressing reasons. "But in the CCS, the institutional physician and senior HCO were responsible only to the prison director. So we said they should be professionally responsible to the senior physician in the region. Then we urged making the director of medical and health care services in Ottawa a director-general, reporting directly to the commissioner o. penitentiaries" (that official's title now is commissioner of correctional services). These recommendations were among the first to be accepted, although for reasons dealt with later in this article, physicians' direct reporting status is still somewhat unclear. Dr. Craigen was made a director-general in 1974. Dr. Botterell's group also favoured the continuing decrease in the number of full-time physicians in the system. "Doctors should work in prisons as large a proportion of their time as necessary to become committed to what they are doing and not so long as to
CMA JOURNAL/MARCH 4, 1978/VOL. 118 581
At the CMA annual meeting in Quebec City in June 1977, General Council accepted seven recommendations, which are now CMA policy. Subsequently these resolutions were forwarded to the then commissioner of penitentiaries, the late A. Therrien (since succeeded by D.R. Yeomans), who responded with written comments. In' a recent intervie.v with Dr. Daniel Craigen, director-general, medical and health care services, CCS, these comments were updated. The following are the seven resolutions and the official comments: All physicians practising medicine in the Canadian penitentiary system must obtain at least temporary licence from the respective college of physicians and surgeons of the province prior to commencing practice. COMMENT: Only one physician is not so registered at present. However, the director-general reserves the right, in special circumstances, or in relation to a particular individual, to employ a doctor who may be licensed in a province other than the one in which he is employed. All medical personnel, primary care physicians, psychiatrists, surgeons, should be professionally accountable to the professional regulatory licensing body and not be considered as subordinate to lay prison administrators. COMMENT: All medical personnel are professionally accountable to the regulatory licensing body of the province where they are registered. Institutional physicians must also satisfy the senior regional physician and the directorgeneral of their professional competence. A licensed physician must be allowed to exercise his judgement in discharging his professional responsibilities. COMMENT: It is clearly laid down in
medical director varying the security in the interior according to his own judgement. There should be no interference within regional psychiatric centres by the penitentiary service in terms of admission, discharge and clinical services. COMMENT: A further section of the policy document states that the directors of the centres "...are to have control of all admissions and discharges, based solely on the health needs of the patient". The chief executive of the regional psychiatric centres should report to a board of governors or equivalent as is customary in all Canadian hospitals. COMMENT: The chief executive of the Pacific regional psychiatric centre already reports to a board of governors. This policy will be pursued in the other centres. All provincial medical associations should be prepared to monitor the medical services delivered in the prisons of the respective provinces. COMMENT: As noted above institutional physicians are professionally accountable. The National Health Services Advisory Committee (NHSAC) conducted a thorough scrutiny of the services, and I believe that the ongoing monitoring of these services can be adequately carried out by the senior medical staff of this department. However, a number of members of the NHSAC and others have been invited to form a medical advisory committee (tentative title) to meet first in February 1978 to review the implementation of the recommendations contained in the reports. We have invited scrutiny, and welcome any interest any provincial medical association wishes to take on this resolution.
become 'institutionalized' themselves," he said, wryly.
Second report The Botterell committee's second report, a longer one, was completed in November 1975, a year-and-a-half later. This report "results from a study in detail, 1973-75, of how the inmate obtains medical and health care services, and the nature and quality of the services and therapies provided... It produced 76 recommendations, many of them new ones concerned with improving day-to-day medical matters, but a number of them urgent calls for the implementation of more of the 1974 points - singling out as "of primary importance" the regular provision of expert consultants in the various medical fields to the director-general in Ottawa. In January 1978, CMAJ visited
Director-General Dr. Daniel Craigen (who had been an ex-officio member of Dr. Botterell's committee) and his staff of 15, and found him still smarting over press coverage following the second report's release to the public on Dec. 20, 1977.
The story, which appeared with a Canadian Press byline in the Globe and Mail and many other Canadian papers Dec. 21, began: "A national advisory committee says there is 'chaos' in the medical and health care services of the Canadian Penitentiary Service." It noted that the solicitor-general said "most of its recommendations are being implemented", but gave no details of the implementation. In fact, Dr. Craigen said, "Forty-one of the 76 recommendations are in effect, 20 are partially in operation and a further 10 will be implemented in 1978 or 1979, in consultation with the 582 CMA JOURNAL/MARCH 4, 1978/VOL. 118
new medical advisory committee, which includes Dr. Botterell and seven others, some from the original committee." Dr. Craigen said the five recommendations felt to be not feasible would also be discussed at the initial February meeting of the new body.
New ideas Reference to the massive policy and procedures manual issued by the CCS medical branch last summer confirmed Dr. Craigen's assertion; it also turned up a few ideas not recommended by the Botterell group, such as: "The stiedical and health care services branch should be represented on committees involved in planning for new institutions or renovation of existing ones." The document urges that criteria be developed by the branch for health care centres design, "bearing in mind the CCS policy of creating small institu-
tions for a maximum of 200 inmates ... The manual also lays down guidelines for transfer of inmates for treatment not available in health care centres - which are not hospitals and provide mainly ambulatory care. It directs that all inmates are to have a preliminary medical examination within 24 hours of reception and a comprehensive examination, including dental, within 7 days. Records are to be problem-oriented and confidential except for essential disclosures authorized by the director-general. Nevertheless, and despite the improvement, CMAJ asked, what about the fact that, although 12 RNs now are senior HCOs (as against 5 in 1974) this still leaves 13 health care centres with less-qualified people in charge? "The change has had to be gradual," said Dr. Craigen. "You can't just pick up experienced prison health care staff like that. When we started to increase the number of RNs, we began sending 15 or 16 HCOs each year for training. Since the normal centre has no more than 7 staff (the largest, Dorchester, has 12), that means there'll only be one person on duty during the night shift. Although only 12 are in charge, there are about 100 RNs in the system now, and if you count registered psychiatric nurses it's about 150." Wouldn't it be possible, CMAJ asked, to transfer some of these RNs to take charge in the remaining centres? Union problems intrude here, said CCS chief nurse Marjorie Carroll. "Nurses and health care officers belong to different unions. We have promised senior HCOs they wouldn't be pushed out, but retrained, with financial assistance wherever possible. The majority of unregistered senior HCOs are in Quebec; there is a pilot project going on to put an RN beside a senior HCO in a number of institutions there, but this has to be handled very carefully." Stilt inadequate
As for the Botterell report complaints about the regional reception centres, Ms Carroll said the Ontario centre at Old Kingston Penitentiary is still inadequate. It shared the building with the medical surgical services hospital, but there should be an improvement, she said, after the unit moves into a new hospital facility being built at Collins Bay (Kingston) psychiatric centre. Establishment of more reception centres is difficult, she said, especially in prairie areas where sheer distance is a problem. Dealing with the Botterell committee's second report reiteration that the director general appoint a regular group of
Compared with the general public, federal prisoners benefit from a higher physician-to-population ratio.
