How we tackled hepatitis C DNAs
Dr Janet Wilkinson describes life at HMP Holloway after giving up her practice
Two years ago, while working as a GP in a suburban practice, I spotted an advert for a GP to work in Europe's largest female prison, HMP Holloway.
Islington PCT unusually has two prisons in its area, Holloway and Pentonville, and was recruiting lead GPs for each prison. What a way to avoid the new GP contract and have no home visits!
Responsibility for health care of prisoners was transferred to the Department of Health in 2003.
I arrived with no experience of prison work, but had been in general practice since 1983 (until relatively recently, there was no need for prison doctors or locum doctors working in prisons to be formally trained in general practice).
I had worked with difficult patients before but was a little apprehensive about the women I might meet. However, the prisoners are the same people as 'outside' and there are days when I see rude patients who have aggressive outbursts and days when I receive a thank-you letter.
I believe I work within a much safer environment inside the prison. I know that if I ever had to press a panic button, I would have six to eight officers descending within a few seconds, all trained in control and restraint!
I try to treat each prisoner as though they were presenting to me in my GP surgery in London, although their charge is important to know. Those charged with murder or manslaughter, arson or contempt of court are often very disturbed and need mental health assessment. Prisoners caught bringing in drugs from abroad may have to face sentences of up to 15 years, away from their friends and family. Holloway prison looks after many of the high-profile female prisoners and I can sometimes watch News at 10 knowing who will be on my surgery list in the morning!
Prison doctors were previously isolated from their colleagues, and were sometimes not included in improvements in health care 'outside'.
My own contract is now seven sessions inside the prison, and one outside in a local GP practice, but contracts are flexible and my colleague at Holloway has chosen to work four inside and four outside.
Islington salaried GPs earn £60,000 to £68,000 for eight sessions and the lead GPs have their own higher scale up to £86,000.
The main difference I noticed on my arrival in Holloway was that there was still no IT system! Although Holloway does have some long-term 'lifer' prisoners, the vast number of women stay on average 28 days and may come in and out of a prison several times a year.
Medical records were sent backwards and forwards to the courts, and to other prisons, with inevitable loss of vital information.
Fortunately, Islington PCT funded EMIS and this has transformed the way we are able to care for women.
I am lead GP managing three other GP colleagues. We also have a doctor working full-time on our drugs detox unit. We have around 480 patients (but 12,000/year) and employ 40 nurses, two nurse practitioners and nine health care assistants.
I work with our mental health team (professor of psychiatry, consultant psychiatrists, SPRs, ASWs and RMNs) and I am the envy of most of my colleagues outside the prison in having such a rapid-access expert opinion always on hand. We have our own pharmacy, psychology and psychotherapy service, and visiting dentist, ophthalmic optician and podiatrist. Midwives help care for our pregnant women and we look after up to 17 babies below the age of nine months.
A women's health clinic copes with the vast numbers who present with GU disease and in there, some of the saddest tales of prostitution, rape, domestic violence and abuse unfold. For some patients, a prison sentence can be a relief from their dangerous world outside.
My routine is very similar to that outside the prison, but the content of consultations can be quite different:
60-70 per cent of my patients will have substance misuse problems, 60-70 per cent have mental health issues and many have both. There is an increased incidence of asthma, TB, epilepsy, STDs and self-harm and suicidal ideation.
There is a huge demand for medication. Each consultation can be a quest for a true medical history with calls to a wide number of agencies the patient having used three or four names to escape arrest.
We employ two nurse practitioners, experts in minor illness, but there is still an overwhelming demand to see a doctor who has the power to prescribe more.
The vast majority of patients are aged 18-35 only one is over the age of 65! Some of the GP contract is therefore not relevant to our patients, but although we do not yet have any targets to achieve we are working to create these.
Every day as a prison GP is challenging, but never dull and I have no regrets about my move.
Janet Wilkinson is lead GP at HMP Holloway