General Practice in Prison

My latest offering on this subject was given to the Parliamentary Enquiry of 2018 The parts below refers mainly to my experience 2001-2009. In 2018 returned to HMP the Mount to to find it little changed, and the nicest prison to work.  My recent 2020 experience is in London Remand Prisons. Around 2003 the NHS took over prison medical services.  In Hertfordshire, Dacorum PCT  Herts PCT) took over the medical services of HMP The Mount, Bovingdon in 2005. Before then prison's medical services were run by the Home Office, in common with most other prisons. Prison Medical Officers reported to the Governors alone. Medical officers were not usually GPs. Medical care for a vulnerable population was outside the NHS. That has changed for the better.  The NHS take-over of commissioning for Prison Medical Services    Local commissioning for prisons did not make much sense as prisoners are shunted around prisons across commissioning boundaries. In 2013 this was rationalised with the abolition of Primary Care Trusts. For England, NHS England  looks after prison helathcare  The NHS has the budgets for Prison Healthcare whilst The Governor remains responsible for all that happens in his or her prison. Our Document Archive is here In 2007/8 Dr Bulger worked and provided consultancy at HMP Wandsworth through Secure Healthcare.  This social enterprise had internal difficulties; it was bankrupt in June 2009 and Wandsworth PCT took back the contract. It is now run by Oxleas NHS Trust Archway provided medical services to HMP The Mount 2002-5. After a dispute with a Governor about the ethical treatment of prisoners, the contract was temporarily awarded to Pathfinder PCTPMS practice. Leave was granted for judicial review. Then Pathfinder and HMP The Mount was put out to tender.  In 2007 Archway Surgery and Archway Development and Consulting won back the HMP The Mount Contract APMS and took over The Pathfinder Practice. They became part of Archway surgery, now run by NHSolutions   as I retired from Archway.   HMP The Mount's medical services are now provided by West Herts NHS Community Trust.

Consultancy in Prison Health Care
We provided services for the Healthcare Commission when it handled prisoner complaints, providing reports.   Since 2009 the work has been with coroners, (Death in Custody) and Medical Defence Society reports as an expert witness and in London Prisons

Issues in prison Healthcare: (links)

• Detox and Drug Dependency
• Elderly
• Disability
• Prison Healthcare documents found on the Web

HMP The Mount and Archway's Contract.
Archway's contract was to provide medical services in the light of the new NHS approach. 
Archway Surgery's contact at  HMP The Mount finished on 31st March 2006.    In January 2008 we won the contract against Commercial and NHS competition to run these services again as part of our successful bid for Pathfinder practice.                        

Documentation and Prison Healthcare
We were originally HMP The Mount for three and a half years. Some of the documents that we used are HERE .

In June 2006 The Royal College of GPs Secure Environments Working Group has set up a search engine which  seems to have gone!

Archway's Orginal Vision at HMP The Mount
The Prison population may have diseases in unusual proportions, but not dissimilar to any inner-city general practice. We see more patients with diseases associated with ethnic minorities. We see more with hepatitis C and B, a few patients carrying HIV, and of course many more people with dependency personalities. There are a few patients with fully developed psychiatric disorders. There are a handful of schizophrenics, a few with endogenous depression, but nobody with mania at the time. Now that personality disorder has come into the health remit (broken link), there are issues as to how we should treat and manage these people, but we have the same issues in the community as a whole. Dependency is linked to the personality disorder problems. The prison population seems to age faster than the rest of us, but otherwise the diseases and problems we see are those of any inner-city general practice.

Prison Medicine is General Practice: with added security issues.
Prison Medicine should no longer be seen as a speciality in its own right. G.P.s working in prisons may wish to develop special interests in subjects useful to the prison population, such as dermatology, liver diseases, GUM, mental health and drug dependency, but no longer is reasonable to study prison medicine as an isolated speciality.

When we arrived we found a culture clash between what we did as G.P.s and what the prison service healthcare staff expected.  Healthcare staff skills and attitudes were very different by the time we left in March 2006.  Problems we encountered as listed below:

1. History taking and examination as the norm.  We surprised staff at the beginning, now some years ago, by taking such time, and insisting on doing so. We brought in our own examination couch and screen to facilitate this.  Getting the patients story was fascinating in its own right, but of course gave the clues to underlying medical problems.

2. Follow up.  Originally the Healthcare staff are were recruited from casualty.  Medicine seen as all crisis management and emergency care.   The concepts of follow up, discharge planning, medicines management with medicine reviews seemed foreign. Chronic disease management was very poor.

3.  Access. We found that staff assumed that access by prisoners to the doctors had to be actively discouraged. NHS Primary Care's  24 hour and 48 hour access targets to NHS professionals, obligatory for G.P.s, was considered to be a sign of weakness.  A complicated wait for the wait system with applications being sent, in a controlled way, from the wings to Healthcare was in place.  It often took three weeks or more, simply for a prisoner to make an appointment to find out his blood test result. There was no other mechanism for him to get the result.   Before we attempted to put an end to it, many emergency presentations were sent away because the prisoner had not made the formal application.  Changing these attitudes and views took two years.  In 2006 we set up an 0800 number for prisoners to be able to ring in on their "PIN" phone system from the wings to talk to healthcare staff, and make appointments in the normal way of a G.P. practice.  This had not been implemented when by the time we left, it seemed that progress was blocked.  Wing staff would no longer know who is contacting healthcare under the 0800 system. Medical confidentiality is difficult to maintain within a prison setting.

4.  Confused primary and secondary care divide.  Patients would have been sent directly to psychiatry, as an example This gave problems for the G.P.s as we were then expected to do the prescribing on patients we had not seen nor had referred.

Service we provided
We provided one of two doctors every morning, offering continuity of care.

The G.P.s working at the Mount undertook NHS appraisals that include an appraisal of the work carried out by the doctors in the prison.

Archway Surgery was on call one in two nights and weekends (such contracts were outlawed in the hospital service). The duty Governor could still demand that the doctor attends irrespective of clinical need. In later 2005 the local out of ours service (Harmoni) took over out of hours provision.

When we started, as in most prisons, there was no clinical computer. We put one in. G.P.s find it unsafe to work without a clinical computer.

Prisoners are not registered with a G.P. practice, and their NHS records remain with their own home G.P, if they had one; a large proportion of prisoners are from overseas. Our  enquiry about obtaining NHS numbers for these NHS patients (for use with referrals and pathology reporting computer links) opened up a whole can of worms, as yet to be resolved.  NHS Connecting for Health and NHS referrals to hospitals and pathology links demand NHS numbers.

Dispensing of medicines was done in house, using hospital type cards. NHS prescriptions (FP10s) are not used.  In our third year, we finally had the PCT introduce a pharmacist. Until then we had no pharmacist;  medications arrived from another prison. The clinical system (Microtest’s) has a dispensing module, modified to pint out labels, so we could use the hospital type cards instead of FP10s. The system was ready for the pharmacist for local drug ordering.

We were bringing in NHS systems and clinical governance. For the first time the designated diseases (such as hepatitis C and food poisoning) were notified to the Health Authority in accordance to the law.  We attempted to set up protocols for TB contacts, human bites, needle sharing, and drug dependency issues. We sought an open and simple untoward event reporting, and a complaints system for prisoners similar to that which applied to general practice.   G.P.s are the clinical lead of a team approach outside, but in the Mount we did not have a role that could direct events. We were only there for a few hours each day.  There was a "centrifugal" structure to all the care services, with nurses, doctors, pharmacist, visiting consultants and psychiatric services all looking in different directions for their clinical governance and management structures.

There were  some oddities of prison practice. The Segregation Unit ward round had to take place every day before adjudications. This ritual is a leftover from earlier times, when, well within living memory, prison doctors had to taste the food and had to certify people were fit for bread and water, birching or both. The “Seg round” and other form filling in general were assumed to be the main tasks of the Prison Medical Officer at The Mount in 2002.  The General Practice approach, prisoners as patients, has required a culture shift.   In 2005 the "seg unit" changed its name to Care and Separation Unit. CSU.  The change in name was real, and reflected what the "seg" actually did.  The care from officers at The Mount on the CSU was excellent.

The fear of a suicide in custody drives Home Office interest, creating its own paperwork. The Prison Service had a touching faith that the medical profession can divine the risk of suicide in all cases. We are dealing with some angry impulsive young men with personality disorders. They may self harm, but not often clinically depressed, and can be dangerously impulsive. A new wing based system has been introduced replacing the "2052" forms, called ACCT whose details were here

The Mount is not a remand prison. Remand (local) prisons carry greater risk of everything because of their huge turnover, with most prisoners straight off the streets.  The Mount is a category C training prison with 720 inmates, seeing double that in a year, but all have come from other prisons.  There are a few lifers but some stayed only a few weeks. Now prisoners arrive with at least 18 months go to go of their sentence.  The pressure on the prison service is such that many who would seem to be category B prisoners now seem to come to the Mount and the 18 month restriction may have to be lifted.

The Prison Service needs to avoid sending prisoners to hospital because of the security risks involved. The escort and security costs are huge. Staff shortages meant that outpatient appointments were often cancelled. It is up to the medical team to resist such pressure, while at the same time we had to help the Prison Service. We did this by reducing the need for many appointments by doing house procedures such as emergency suturing, and by using email consultations with digital photography. We set up the NHS on-line outpatient booking service, Choose and Book. There may not be any choice for prisoners, but booking on-line would be  helpful to ensure an even flow of patients to the hospital, taking pressure off the prison escort services.

We managed to fix a system to get Pathology Links (hospital computer to the clinical computer in Health, attaching to patients record) after two year’s struggle. As all local G.P. practices are using links we had problems in getting timely pathology results back, being the only local “practice” left using paper, so results were going astray.

The Prison has other health care contracts. There is X-rays on site twice a week and they are read and reported twice a week. There is chiropody and in–house dentist. An optician comes in but has limited equipment. There is a GUM doctor, and a psychiatrist and some CPN services.

Illicit drugs get into all prisons over the fence. We simply treated patients as if they are “on the out” and, like any GP we realise our patients can obtain illicit drugs if they want to. Thankfully most patients have been detoxified from major addictions by the time they get to The Mount.. Doses sold within prison tend to be smaller than on the street.  We avoided prescribing anything that has a market on the wings. We followed the British National Formulary to the letter, so “co-anything” are hardly used, and diazepam does not have any role. The difficulty was to detect the patient that must have morphine related drugs for their pain.

We developed a positive approach to dependency issues and restrain ourselves from adding to the problem. Our policy was well known to the prisoners and this was making life easier all round.  As at 31st March we did not have a single prisoner on benzodiapeines.  We think that is a record for a UK prison. Benzos and diazepam in prison is here

We were to move to treating drug dependency according to NHS guidelines. 

We were working on Quality and Outcomes Framework (QOF) for the Prison. We forget that G.P.s are used to computers on their desks for a decade or more. Some hospital trained staff saw the computer as the enemy, nothing to do with treating patients; the computer is for administrators, not for nurses or doctors. Quite apart from getting the data on, we will have to invent our own QOF data sets. Patient turnover is high and age group relatively young. The number of patients with the chronic diseases outlines in the standard GP (GMS) contracts is relatively small, and the prisoners do not stay long enough to collect the indicators. More relevant outcome measures should be applied for this population. The standard new GMS reports from the computer would not make sense: it will not be able to give figures of cholesterol every 15 months as prisoners move on. Targets on Hepatitis B and C status would be more useful, and types of prescribing monitoring.

The Future: We had hoped that Archway and prison services could be integrated as a PCT Primary Care Service/PMS project, with staff moving freely between the two parts. This would have ensured that modern primary care standards pertain to both the Prison and to Archway Practice. It would have helped with recruitment and prevent professional isolation.  The PCT put all the medical services (that is dentist, pharmacist, doctors and nurses) out to tender as an single APMS project. A number of applications were made, including ourselves working with Harmoni, the local out of hours provider.  It seems that the Primary Care model that was the basis the PCTs APMS bid was not longer acceptable to the local prison service. In March 2006 the PCT decided not to appoint any of the bidders and continues to provide as well as commission the service.  There was a major rethink by the NHS commissioners (PCT) and Prison for the delivery of healthcare services.   The Governor remains responsible for all that occurs in the prison, and so is in charge of clinical governance, but the PCT has the budget.

A new bidding process is being undertaken in November 2006 for HMP The Mount.  The PCT intends to replace doctors with nurses and to reduce doctor input to create an intensively nurse led service.

HMP WANDSWORTH  It is a remand category B prison. The first impressions are that the category B and C of a prison does not really reflect the type of prisoner.  The Mount takes prisoners from other prisons, preferably with a year or more of their sentence, including lifers, with time enough such that they can undergo training. These prisoners have unsorted medical and psychological problems.  The CAT C training prison is often the prisoner's last chance to get these issues sorted before discharge.

Wandsworth on the other hand is a local prison so it takes people straight from the courts or remand or have just been sentenced.  There is a wider range of prisoner at a remand prisoner.  The high turnover, and the fact that patients are arriving off the streets present  risks for prisoners and their doctors. Many prisoners at a Wandsworth will not be staying for long.  Escorting prisoners to hospital seems to be less of an issue for Wandsworth.  The hospital is nearby.

The contract for largest prison in the UK was  awarded to a new Social enterprise called Secure HealthCare.  This had its heart in the right place, but after three years the contract was taken away. There had been clinical governance problems, but a huge overspend forced it into liqudation and the PCT took back the contract.  We gather this is the first NHS social enterprise to suffer such a fate.

BBC Prison Service reports are here

Our Archway's Prison document store is here  

Detox and Drug Dependency

Elderly

Our Document Archive is here