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General practice behind bars

Dr Jenny Schaefer is a prison GP. She describes her working week looking after prisoners in Bristol - and reveals how even the hardest of criminals suffers from man-flu…

How long have you been a prison GP?

I started at HMP Bristol in May 2009. It’s an all male, Category B prison built in Victorian times, housing about 600 prisoners.

How did you become a prison GP?

It’s a miracle that I ended up here at all. As a medical student I had a placement with a GP who took me on his rounds in Dartmoor Prison. I can clearly remember walking through the wing, vowing to myself that I would never work in prison, for two main reasons. Firstly I didn’t think I could ever have a sufficiently suspicious mind to consider, as he did, possible secondary gain coming into the differential diagnosis. Secondly, I was a female 23 year-old in an all-male environment. Now I’m older neither of those are such an issue for me!

In May 2009 I approached the GP who was then the provider of GPs to Bristol prison, and he gave me locum work there. Then when I left the detox unit where I was working, in April 2010, it happened to be at the same time as one of the full-time GPs retiring, and I took on a more regular role. I’d been a GP for 20 years by this time, but I’ve always had a portfolio career, spending two years in Namibia, and also, for the past ten years, working in a drug and alcohol detox and in a health service for homeless people. I had adapted my working week to suit my young family, but was in danger of becoming deskilled. My appraiser advised me that I would have to do some ‘normal’ general practice and, apparently, an all-male prison counted.

There is a rigorous security clearance procedure involving lots of form-filling.

I was required to have the RCGP Certificate in Substance Misuse Part 2. Also, to ease me in, my employer provided written guidelines, mainly related to prescribing.

There is also specific training that the prison itself requires each staff member to undertake. For instance, personal protection, breakaway, key training (there are a lot of locks), ‘challenge it, change it’ (discriminatory/bullying behaviour), ‘safer custody’ (prevention of suicide and self-harm in prisoners) – I particularly enjoyed these training sessions because healthcare staff were learning alongside prison officers whose experience of prison life and prisoners is very different. And also of course computer system training in SystmOne, which is shared by most prisons and allows excellent continuity, as prisoners are forever being transferred from one prison to another and paper drug charts do not always get transferred with them.

Do you work full-time in a prison or alongside another primary care position?

I recently reduced my hours in the prison so that I could take up a salaried position as a GP in the centre of Bristol. I now work two mornings a week in HMP Bristol. There is a full-time GP and three other GPs who work part-time. Between us we provide two GPs in the morning, one GP in the afternoon and a session on Saturday and Sunday, and also one GP for a special two hour session 6-8pm weekdays to welcome in new prisoners who have specific needs to do with substance misuse.

How does primary care in a prison work?

I’m sure all prisons have their own way of working. At HMP Bristol the nursing management oversees a team of frontline nurses who staff the wings. Prisoners will attend the treatment room hatch for medication at set times of day. If they wish to discuss health issues they need to put in an application (an ‘app’) to see someone from Healthcare. Then he is triaged in the nurse’s clinic, and may be added to the GP clinic list if appropriate. I almost always have a nurse with me in the room, for security but also as a witness to the proceedings. I write even more copious notes than I would do in usual general practice, as the client group has a tendency to take advantage of even the slightest lack of clarity. If there are particular concerns about a patient’s risk to staff, a prison officer will stand outside the room.

There is a phlebotomist, a visiting hepatitis C specialist nurse, a visiting dentist, a visiting sexual health consultant and a nurse whose main role is to ensure everyone is immunised against Hep B. We are in the process of devising nurse-led chronic disease clinics.

We also have a large Mental Health team provided by the NHS (Avon and Wiltshire Partnership) for those with severe enduring mental illness, and we work closely with them.

What does a typical day involve?

I lock my phone in the boot of my car. Phones are strictly prohibited. A prisoner who gets hold of a phone will go to great lengths to hide it – I even have to be cautious in prescribing haemorrhoid ointment in case I am just providing a lubricant to allow the phone to be hidden more effectively. I put on my ID card and belt with chain, pass through the double door (like an airlock) and collect my keys from the office. Then I check in at the doctors’ office, to see if there is anything handed over, and if necessary visit the Brunel Unit. Here there might be someone newly returned from hospital, or someone newly received into the prison, with a medical condition or prescription to review. Then I go to the wing, to conduct a clinic of patients already triaged by the nurse. They will generally come to me as they might in general practice, but home visits just mean a walk down the corridor to a patient’s cell. Later, like any other GP,  I will write repeat prescriptions or referrals, look at pathology results or hospital letters, or liaise with colleagues either in the prison or in secondary care.

At any time this might be interrupted by a radio call ‘Code Blue’ (difficulty breathing eg someone found with a ligature round his neck, or someone having a fit) or ‘Code Red’ (where there is blood involved, usually through self-harm). There are big bags of equipment to grab and the healthcare staff run to whichever location the radio has announced.

On Tuesday mornings I take part in the Relapse Clinic, where, with a nurse and a specialised prison officer I see prisoners who have begun to take drugs illicitly since they’ve been in prison, having been detoxed off methadone or buprenorphine during their sentence. We try to motivate them to stop, supported by substitute medication and CARATS workers who run groups and one-to-ones on such subjects as ‘cravings and triggers’, ‘harm reduction’ etc.

The 6-8pm session serves the prisoners who have come from the court that day, and who may not get through the night comfortably due to drug or alcohol withdrawal symptoms. They are assessed and a standard small dose of methadone and/or diazepam prescribed, according to physical findings and urine drug screen. The following day their outside prescription will be confirmed, if they have one, and the dose adjusted accordingly. Chlordiazepoxide and the usual vitamins are given for alcohol detox.

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