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Working as a gp in a high-security mental health unit

Rampton Hospital is one of just three high-security units in England for people with severe mental health problems. Dr Tom Humphries explains what it's like to be the first GP for the hospital's 350 patients

Rampton Hospital is one of just three high-security units in England for people with severe mental health problems. Dr Tom Humphries explains what it's like to be the first GP for the hospital's 350 patients

After a trip to the pub with friends one night, I came home and needed a little time to unwind before going to bed. I took a look at the GP job adverts just to get a feel for current rates of salaried pay and saw this post, advertised as 'an opportunity to establish a general practice service in Rampton High Security Hospital'.

I was a salaried GP in a practice at the time and diabetes clinical lead for the PCT. The skills required seemed to match what I had to offer: experience, an interest in chronic disease management, knowledge of service standards and QOF, presentation skills, and I'd done a little bit of psychiatry so at least I'd understand what was going on. Two-and-a-half days a week and a good salary – the post had definite appeal.

The patients

Having got the job – a new role created after a psychiatric colleague recognised the importance of physical healthcare in a secure environment – I set up the GP service at the hospital and have now provided it for just over a year.

Despite the high security, Rampton is a hospital, not a prison. Patients are there to be treated, not just detained. With only 350 patients, mostly younger men, I expected my post to be quiet. However it is well recognised that people with mental health problems have a much higher occurrence of physical health problems. But until you see how true this is for yourself, it is hard to believe. I allow 30 minutes for each consultation – a real luxury by GP standards. However this extra time is needed by many of the patients, as all of them have serious mental health needs. Rampton is one of three such hospitals in England.

Developing trust

Many of the patients are still mentally unwell, but that doesn't mean they can't hold an informed discussion about their physical healthcare. For many, a lot has been 'done to them' since being detained.

Removing a person's autonomy can be an important part of managing the psychiatric problem, but this means patient empowerment is not an obvious first strategy. People need time to develop trust in me as a GP and to realise I am there for their good rather than as part of the system that detains them.

A different dynamic

This is a rather topsy-turvey world, where the psychiatry consultants refer to me as the specialist GP and I give them advice about physical healthcare. The responsible medical officer (the patient's psychiatrist) is, as the title suggests, responsible for all aspects of a patient's care while they are detained. However, they may delegate some of that responsibility to me.

Disease management

My consultations are very largely based around chronic disease management.

There are more than 55 patients with diabetes out of 350 patients – more than 15% in a young population. We would expect to see nine people with diabetes in an equivalent population in the community. We know that schizophrenia and depression are both associated with a high incidence of diabetes – add to this a poor diet and lack of exercise for most of the patients and the incidence of diabetes rockets. This is a major challenge for healthcare in people with long-term mental health problems, and clearly will require much time and investment for the future. We recently banned all the patients from smoking and it has gone amazingly smoothly, though we are noticing effects from it such as an increase in food consumption. There are issues around food and its availability here, such as from the shop, and looking at this is another of my roles.

Reflections

So what have I learned after my first year?

People with mental health problems mostly want to and are able to discuss their physical health problems. They want to know and understand what is happening to them, although in the past this has only been given in a limited way through doctors who are trained primarily in psychiatry. Placing people in an environment with very little exercise, a lot of time to be bored and ready access to high-calorie foods not only creates excessive obesity problems but a wide range of metabolic and other diseases.

Addressing these problems is the key to providing high quality physical healthcare for this vulnerable, though potentially dangerous, group of people. Bringing high-quality general practice to these patients has been interesting and fulfilling. There are a lot of challenges to face if their lifestyle and conditions are to be improved. I am fortunate to be involved in discussions about this. Hopefully in the future there will be agreed quality standards for physical healthcare in detained patients. I hope my job will help to achieve this.

Pioneering

Although this is still a pioneering area and there are only a few GP jobs in the highest security hospitals, there are many more posts developing in regional secure units and detained psychiatric units throughout the country.

I've also learned how rewarding it can be to work in a new environment after 15 years in general practice.

Dr Tom Humphries is a GP at Rampton Hospital and diabetes clinical lead for Derbyshire County PCT. He is also part of the Derbyshire QOF Assessment Team

Dr Tom Humphries: people with severe mental health problems want to discuss their physical health problems Dr Tom Humphries

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