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The life of a prison medical officer

Dr Marcus Bicknell describes his work as a prison medical officer - work that is challenging, that can be frustrating, but that provides a high degree of satisfaction.

Dr Marcus Bicknell describes his work as a prison medical officer - work that is challenging, that can be frustrating, but that provides a high degree of satisfaction.

Working in a prison as a medical officer is one of the more unusual careers for a GP.

Traditionally prison medical officers came from diverse backgrounds. But new rules introduced over the last five years dictate that all new prison doctors must be GP trained – and I am one of the new breed.

I was persuaded to work in our local prison in 2000. A senior colleague had run out of willing colleagues from other local practices to help him. This situation reflects the challenges which the prison environment presents.

My background was that of a salaried GP working in local projects for the homeless. I had a keen interest in treating alcohol and drug users, vulnerable patients and the mentally ill.

Going to gaol seemed like a natural progression from the chaos of homelessness!

Many prisons have an arrangement with a local practice, where partners provide surgeries in the prison well as seeing their own practice populations.

Some prisons have dedicated full time medical officers, others have hybrid arrangements. Out of hours cover varies hugely - from private arrangements with individual GPs or their practices to PCT commissioned care provided by GP co-operatives or private out of hours providers.

There is no set pathway to becoming a prison medical officer. Nor are there any specific qualifications or on-going professional requirements, other than GMC registration and annual appraisal.

But attaining the RCGP certificates in substance misuse is definitely useful, as is being approved under Section 12 of the Mental Health Act.

State run prisons have recently evolved so that their heath care departments and staff are organised by the host PCT.

Private prisons, which operate under contract to the Home Office, often have different arrangements and continue to commission care themselves.

Curiously all prescribing in prisons by prison medical officers is undertaken on a private basis.

In many ways prisons remain a backwater of primary care. There are huge amounts of unmet health needs existing in prisoners.

They include addiction, mental illness, and the consequences of trauma and infection, particularly blood borne viruses.

The prevalence of hepatitis C infection in the prison population is huge.

The defining nature of offending correlates closely with sociopathic personality disorder, recidivism and social exclusion. Yet the ‘inverse care law' applies as much to prisons as to other parts of society – if not more so.

Again the prison estate is only just starting to invest in computer technology, standard equipment for most practices over the last two decades.

More recent innovations such as choose and book, NPfit and practice based commissioning are far off most prison doctors' radar. Standards of care and models of care vary greatly.

But recent innovations which must be welcomed include the Integrated Drug Treatment Strategy (IDTS) introduced by Prison Health to improve the care and reduce harm in drug using prisoners.

Another problem in prison is communication. Foreign nationals make up a significant percentage of those detained in gaol and present unique challenges in terms of pathology and communication. This all adds to the challenge of the work.

Security is paramount in prison. There are approximately 81,000 prisoners detained in 143 prisons in England and Wales at the present time. The male estate accounts for 95% of the population in prisons ranked Category A (maximum security) to Category D (open).

Some prisons are known as Local Prisons accommodating remand, recently detained and recently sentenced prisoners.

There are also training prisons housing sentenced prisoners as well as specialist sex offender prisons and therapeutic communities.

The female estate is organised differently.

Young offender institutions house males under the age of 21, Secure children's homes run by local authorities house children.

Refuge centres accommodate illegal immigrants. All of these secure environments need GPs to provide detainees with primary care services.

I have worked in five different prisons as a medical officer and as part of an out of hours rota over the last seven years.

It is during this seven year period that I have been medical lead at HMP Lowdham Grange. I have also cared for a child offender in a local secure children's home and have provided primary care to forensic psychiatric inpatients on a secure ward.

Each establishment is unique in how it is organised both from a health care and security perspective.

However there are many common challenges The practical problem of arranging surgeries and enabling incarcerated patients to attend is well recognised.

The security implications of escorting a patient to hospital for planned or urgent care is a recurring issue.

Patient demand for opiate analgesia, benzodiazepines and Z drugs can frequently lead to difficult consultations.

Verbal and physical abuse of clinicians does occur though I have been lucky in avoiding personal injury. Most prison doctors will receive a challenging letter from a prisoners solicitor or an unfounded complaint to the GMC at some stage.

There are very few established prison medics who have avoided a coroners court following a death in custody.

I have had one GMC enquiry having declined to prescribe a heroin using prisoner both tramadol and dihydrocodeine.

I have also appeared twice in front of the coroner in the last seven years following hangings. These are definitely downsides to the job!

So why do it?

There are many reasons. Secure settings have afforded me the opportunity to develop my skills in working with society's most challenging individuals. This has been a natural evolution from homelessness and forensic psychiatry.

I am fascinated by my patients psychopathology. I believe that by not being intimidated by this client group, nor the institution in which they are detained, I am able to optimise the treatment which they receive.

I am able to develop my special interest in addiction. I enjoy working with a wide multidisciplinary team of nurses, physios, dentists ,opticians ,chiropodists , drugs workers, acupuncturists, psychologists, GU and liver specialists and psychiatrists.

The majority of these people have a fantastic sense of humour. Close working with non-medical colleagues such as Imans, priests, prison officers, independent monitors and governors, many from military backgrounds, all adds to the appeal of working in a well run gaol.

The pay could be worse - though it will never match that earned in a leafy dispensing practice.

I am excited at addressing the inequalities in health which exist among offenders. I am also stimulated by supporting local and national initiatives to help offenders lead healthy and ideally law abiding lives

Dr Marcus Bicknell is prison medical lead, HMP Lowdham Grange, and vice chair of the RCGP secure environments group

ABOUT THE WORK

• All new prison doctors must be GP trained

• No specific qualification required

• However, RCGP certificate in substance misuse very useful

• Also being approved under section 12 of the Mental Health Act

• Communication with prisoners can be a problem

• Many unmet health needs exist among prisoners

• Verbal and physical abuse of physicians can occur

• Having to attending a coroner's court following a death in custody quite common

• Being subject to a GMC enquiry a distinct possibility

• Challenge to clinical and interpersonal skills very stimulating

• Working with diverse and talented group of professionals most rewarding

Dr Marcus Bicknell

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