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ss triple helix - summer 2012,  Medicine behind bars

Medicine behind bars

Mark Pickering highlights the opportunities in prison general practice.

key points

Prison GPs have replaced the 'prison medical officer' now that prison healthcare has become part of the NHS. This means there are more opportunities for GPs to get involved in prison work.

There are frustrating barriers to prisoners accessing healthcare. Patient advocacy is needed and doctors are a vital part of the rehabilitation process for people whilst they are in prison.

In prison people stop, reassess the downward spiral of their life, and ask for help. Being a part of the journey to physical, mental and spiritual wholeness is a privilege.

Prison medicine is a fascinating world of interest and challenge, with great opportunities to be innovative. There are plenty of reasons why Christian doctors can contribute positively to this vital area. Sometimes it can be more like casualty than general practice, especially in a remand prison. There may be a dislocated shoulder, a slashed wrist needing suturing, a cardiac arrest, alcohol and opiate withdrawal, acute psychosis, an outbreak of a communicable disease and new diagnoses of HIV and hepatitis B and C. If you miss pathology and procedures, prison may offer refreshing opportunities to keep your hand in. Certainly your communication skills will be tested to de-escalate confrontation, or provide motivational interviewing for ambivalent addicts.

Changing times

Prison healthcare in England and Wales only became part of the NHS in 2006 (in Scotland it happened more recently, in November 2011) and this has brought a lot of change to the system. In England, Primary Care Trusts are currently responsi ble for commissioning, and this is likely to pass to the National Commission Board before long. This has meant a transition from the 'prison medical officer' – often long term, full time in prison – to the 'prison GP', often part time and mixing prison work with community GP work. One result of this is that there is a lot more opportunity for 'normal' GPs to get involved in prison work.

Contracts for prison GP work currently come from a variety of sources, such as PCTs, individual practices, groups of practices and private companies. Uniting prison medicine with the NHS has brought good opportunities to improve standards in some areas and provide greater 'equivalence of care' with other NHS patients. On the negative side there can be a high turnover of staff with consequent loss of experience and skills tailored to the secure environment. The variety of commissioning models can mean some fragmentation between the healthcare teams, for instance if nurses and GPs in the same prison are employed by different organisations. Contracts can move from one organisation to another with the subsequent loss of continuity, all of which have their effects.

Breaking down barriers

Security considerations are obviously paramount in a prison environment, but this can mean that there are often multiple barriers to prisoners in accessing healthcare. Although there is generally good access to GPs, for instance, patients may have much less control over choosing appointment times or which GP they see, and this presents problems for continuity of care. When it comes to arranging hospital appointments, imaging or surgery, processes can take much longer, often being subject to cancella- tions for various security reasons. Many times prisoners can be under regular follow up at one hospital or have waited months for an appointment or operation, only to be moved to another prison in a different area and have to start the process all over again at the local hospital. This may be despite the best efforts of prison management, who are under many different pressures with the national prison population at an all-time high.

In these situations it is understandable that prisoners can express great frustrations at the healthcare system, especially when they are a population whose general coping skills tend to be low. Many a consultation starts with a few choice expletives and a complaint that the prisoner feels fobbed off. There is often a place for patient advocacy, doing what is possible within certain constraints to ensure that something gets done for them. Prison is the punishment – prison healthcare should not be, and we are a vital part of the rehabilitation process that goes on with people whilst they are in prison.

A broken image

Prisons are full of colourful characters. Some aggressive, violent and manipulative, some frankly pitiable who find coping with life a great struggle at the best of times. Some have committed hideous crimes, some have simply done something stupid in a moment of madness, or been led into crime through drug addiction. Many are relatively normal when you see them in the consulting room, and certainly do not appear that different from a lot of the people who regularly come through an average GP practice. Robin Fisher's excellent 2007 article in Nucleus gives some great flavours of life as a prison GP and I thoroughly recommend it. (1)

When I hear the all too frequent stories of broken homes and institutional care, dysfunctional familie s, childhood abuse, mental health problems, and alcohol and substance misuse that characterise many of the prisoners' life stories, sometimes it does not seem at all strange that they have ended up where they are. I reflect on the love and stability of my own upbringing and wonder how many of them would have turned out differently had they had the care and opportunities I had.

As a Christian I find it very helpful to keep in mind that every person, regardless of what they've done or how their lives and personalities have been twisted, is still made in God's image (2) and loved by him. That image may be scarred and obscured, but it is still there and by God's grace it can be restored. Compassionate healthcare can be a vital part of that process.

Spiritual issues

Prison can be a powerful place for helping people stop, reassess the downward spiral of their life, and ask for help. Sadly some turn to self harm and drugs (yes, they still manage to get hold of them even in prison), but for others it can be a place where they begin to look outside of themselves. Prisoners can find the support of a good prison chaplaincy very important and there are many stories of people coming to faith in prison. Being able to suggest and encourage chaplaincy involvement, where appropriate, can be very much appreciated, and a useful 'referral pathway'.

Part of Jesus' mission on earth was 'to proclaim freedom for the prisoners' 3 and although facilitating breakouts is never a good idea (and will get you into all sorts of trouble), being a part of the long process to wholeness – physical, mental and spiritual – is a great privilege.

But isn't it dangerous?

This of course was the first question my mum asked me when she heard I was going to work in a prison, and one I'm sometimes asked by other doctors considering it. Of course prison medicine is not for the faint hearted, and there is often verbal aggression and manipulative behaviour to deal with. But physical violence against healthcare staff is very rare and the environment is more controlled than a Saturday night city centre, or even an average GP practice. A colleague jokingly reminded me that if you press the emergency button in most GP surgeries, you might be lucky to get a cup of tea from a receptionist within ten minutes. But in prison, burly officers will come running from all directions. One colleague who'd recently had to press the alarm button remarked it was the first time she'd needed to do that in over three years of working full time in prison healthcare.

Is it for you?

I would love to see more Christian GPs getting involved in prison medicine. It is an area where firm compassion and targeted advocacy can make a big difference and help mend some of the most broken lives. I would be very happy to talk with anyone who is even vaguely interested. Equally you could speak directly to your local prison healthcare department and find out who provides their GPs.

If you're a hospital clinician then there may be opportunities to get involved with outreach clinics into a local prison, such as sexual health or hepatitis services. There may be room to streamline processes when prisoners come to A&E or for outpatient appointments. Good partnership between prison healthcare and hospitals will improve the experience for all concerned. And for those allied to medicine there are plenty of opportunities for nurses, dentists and physios, for example.

If you're already working in prison healthcare I would love to hear from you. A number of CMF members around the country are involved and if there is a need for networking and support then we would like to see how that can be facilitated . Contact me on mark.pickering@doctors.org.uk.

Training and Support

The RCGP has a Secure Environments Group with regional networks providing support and education. The RCGP Substance Misuse and Associated Health unit provides certificated training on drug and alcohol misuse, harm reduction, management of Hepatitis B/C and other issues relevant to prison health. See www.rcgp.org.uk Lincoln University has recently launched an MSc in Healthcare in Secure Environments. Individual modules can be built up to make a Certificate, Diploma or full MSc. See www.lincoln.ac.uk

Mark Pickering is a part time prison GP.

References
  1. Fisher R. A day in the life of a prison doctor. Nucleus 2007; Spring:30-34
  2. Genesis 1:26,27
  3. Luke 4:18
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