Abstract
The provision of health care for prisoners has historically been the responsibility of the prison service; however, over recent years this has been delegated to NHS organisations (National Audit Office, 2017). The healthcare team consists of nurses, health care assistants, a pharmacist and a doctor. The higher incidence of mental health problems in prisoners is well documented. Recent evidence shows that 10% of men and 30% of women had a previous psychiatric admission before prison (Prison Reform Trust, 2017). These problems are further compounded by a high prevalence of illegal substance abuse, with over 80% of male and female prisoners reporting active drug abuse (Office for National Statistics, 1997). In addition, the increase in sentence length and more ‘late in life’ prosecutions for historic sex offences has increased the average age of prisoners, who may have complex medical needs (Prisons & Probation, Ombudsman, 2017). These factors combined add further challenges to the prison healthcare team when providing medical care for inmates. A Foundation Year 2 doctor describes below her experience of working with the team at a local male prison.
A day in the life of a prison GP
As the rolling English countryside flew past my window on a quiet Monday morning, I envisaged helicopters circling and sirens blaring. Images played in my mind of a huge manhunt for an inmate on the loose in a bright orange jumpsuit. My interest in prisons began after season one of the TV series Prison Break and my fascination developed from watching nearly every prison documentary ever made; from Louis Theroux to Trevor McDonald. On arrival, I was welcomed by the healthcare assistant, who escorted me through door after door, with the distinctive sound of metal keys echoing through the corridors. Posters on the back of doors were plastered with mugshots of the ‘most dangerous’ inmates, and there were, what felt like, hundreds of sniffer dogs. I was taken to the medical unit and spent the day there observing the team.
The morning clinic began with the 13-week review for methadone. These reviews are run by a multidisciplinary team, with the inmates receiving huge support from the alcohol and drug liaison service. They assessed the opiate dependent inmates, with the long-term goal of reducing their reliance on opiates. The team created supervised plans that could be adhered to during their sentence and, if necessary, into the community after their release date. I witnessed ‘shared decision making’ in full flow, as the inmates were heavily involved in the discussions around increasing or reducing their doses. Their opinion about the matter was sought; they were listened to and respected. Distributing prescribed medications, however, is heavily supervised and done through the ‘Hatch’ on the wings, via the pharmacist. Prisoners often stockpile or divert prescription medications, and receive ‘strikes’ for misdemeanours relating to this. There were constant requests for Zopiclone, Pregabalin and Gabapentin. GP prison work is hugely drug-abuse related and controlling access to these potentially dangerous medications is vital.
Achieving control around illegal substances is a vast problem in the UK prison service, and something openly discussed during my day. The Ministry of Justice reported that 225 kg of drugs were confiscated in the UK by prison officers in 2016 (BBC News, 2017), with the newest major substance of abuse being Spice; thought to be a hallucinatory cannabinoid synthetic. The GP explained that all the ‘code blue’ (collapse) and ‘code red’ (blood) events over the past year had been Spice related. Many of the patients I saw admitted to using Spice, and just how easily attainable it is, was apparent, with one patient being described as a ‘walking pharmacist’. Drones drop packages into the yard daily. Patients manage to overdose on medications that they have never been prescribed, and it slowly becomes the norm for inmates to use these substances. I saw the GP become much more paternalistic in approach, especially with repeat offenders and mental health problems.
At lunchtime, we celebrated a nurse’s birthday and it felt like any other hospital ward. This swiftly changed as we made our way down to the high security segregation unit for a ward round. Those inmates at high risk to themselves or others are placed here; isolated for nearly 24 hours a day, with a small concrete yard for exercise. The atmosphere was much more like Prison Break, with lots of banging on windows and heckling. It was not intimidating, but it was a much more threatening environment. By law, a doctor is required to see these inmates every third day and we were taken round by an officer to see 20 of them individually. We consulted with one prisoner through the metal hatch, as he needed six officers present when let out from his cell owing to his aggression. Ailments ranged from toothache, to stomach ache to, again, medication requests. I found this ward round fascinating; it was fast moving and alien to anything I had ever seen before. The GP was firm, yet fair and he treated each inmate with respect. I asked him if he thought this environment influenced his clinical decision making, and he explained that if a patient needed an investigation he, or she, would get it.
The afternoon clinic was a regular GP clinic with 10-minute appointments and a huge variety of issues. Prison doctors face the same problems as regular GPs; from patients not attending appointments, to time constraints and the ever increasing workload. In April 2017, 87 inmates did not attend their appointments in this prison, which is a staggering statistic. It is easy to make judgements about the prisoners, the crimes committed, their attitudes and attire. I felt curious to know more about their crimes, but as the afternoon progressed this seemed less important. You do not gain much by knowing this, and it should not impact on clinical judgement. Their attitudes were hugely varied, with comments ranging from ‘jail saved my life’, and ‘keep yourself to yourself as long as you don’t get in debt’. There were plenty of consultations based around depression and anxiety, and there was a separate unit to deal with those needing further psychiatric input.
The experience was captivating and I would highly recommend GP trainees or those considering primary care to spend a day at a prison. Healthcare is the responsibility of the local NHS trust, so depending on where you work I would recommend contacting the prison and asking for the prison Sister. From my experience, they are extremely welcoming and enthusiastic about promoting their profession. Working with the team gives you great insight into the life of a prison doctor. It is something you could take up one day a week or as a locum.
The setting and the work itself can be demanding and highly emotive. It is difficult to give advice about how to prepare for the prison environment. It is likely to be a completely new experience for everyone, and I advise an open-minded approach. Free healthcare is a key founding principle of the NHS and a basic human right, and prison doctors truly reflect this principle in their daily work. I look forward to starting my GP training and hope to have an opportunity to work in prisons in the future. I believe this work is highly rewarding, with a significant impact on the lives of inmates, both physical and psychological.