This article appears as the first in a series of extracts from the RCGP’s new Working with Vulnerable Groups. Editor Dr Paramjit Gill writes:
Over 40 years ago, Julian Tudor Hart formulated the inverse care law, stating that ‘the availability of good medical or social care tends to vary inversely to the need for it in the population served’. This still applies today with many social groups facing substantial health inequalities and the gap in life expectancy is widening between them. For example, the average life expectancy for single homeless men is still 47 years, a whole 30 years below the national average, whereas for people with intellectual disability, the gap is 16 years.
The underlying reasons for these striking inequalities arise from a complex interaction of factors including housing, income, education, social isolation, and disability. This requires an integrated approach between different bodies and agencies at both national and local level. And General Practice is a core element of the new NHS and its role in tackling these inequalities is to increase in the coming years.
Over the next few weeks, we provide a focus on a number of vulnerable groups and what you can do to address these inequalities.
The sheer number of people in contact with the criminal justice system means that many doctors treat offenders, and all treat-ex-offenders. There are nearly 86,000 patients in prison in England alone and nearly 200,000 pass through English prisons every year. This makes prisoner health relevant to all GPs in the UK.
There is a large burden of pathology amongst prisoners, principally because of socioeconomic factors and poor engagement with healthcare services in the open community. Social exclusion begins at a young age, leading to poor literacy and a lack of qualifications. Delinquency and drug use often follow, leading to acquisitive and later violent crime. This may be further complicated by mental ill-health, which is diagnosable in almost all prisoner patients.
Health improvement can reduce re-offending both through improving self-esteem and through the development of therapeutic alliances with caring staff – often the first time that these vulnerable patients may have been treated with respect and kindness by authority figures.
Stabilising lifelong conditions and substance misuse, treating conditions such as viral hepatitis and input from the mental health team may all contribute to health gains during imprisonment.
Substance misuse is the most common threat to health among prisoners and prescription medicine abuse is common. Patients may present with factitious symptoms to obtain prescriptions for drugs with potential for abuse. Diversion leads to a shadow economy and possible bullying.
Whilst detoxification (supported by psychosocial interventions after a period of stabilisation) is the norm, more chaotic patients may have maintenance opiate substitution restarted before release in order to reduce the risk of drug-related deaths on release due to overdose following loss of opiate tolerance.
This means that clear communication between prison healthcare, GP practices and community drug treatment services is essential for safe prescribing and good continuity of care.
Death in custody
When things go wrong and a prisoner dies in custody, there is an initial assumption that a crime has been committed, and until the police are satisfied that this is not the case, healthcare investigations cnanot begin.
Parallel to the clinical reviews is the investigation by the prison and probation Ombudsman (PPO), which scrutinises the care given to the patient by all staff in the prison. Ultimately, all prison deaths result in a coroner’s inquest, usually in the presence of a jury. This scrutiny is in place to ensure that nobody dies as a result of abuse or poor care in the detained setting.
So-called ‘suicide watch’ is actually called Assessment, Care in Custody and Teamwork (ACCT), procedures for which are in place in all English prisons to help reduce the risk of suicide and there are a number of Prison Service Orders (PSO) and Prison Service Instructions (PSI) to be followed in addition to the ever-increasing number of NHS-based guidelines.
The high prevalence of mental, physical and psychosocial pathology in the prison setting makes for a rewarding environment for clinicians who want a challenge. The need to avoid unnecessary outside appointments, whilst ensuring that patients receive equivalent care, offers the opportunity for the development of Special Interests, including some more usually found in the secondary care setting.
If you are interested, contact the healthcare department in your nearest prison to arrange a visit. It is vital that strong links are fostered between prison healthcare departments and their neighbouring practices.
- A young man turns up at your practice, he is living in temporary probation services premises. He has travelled from the other side of the country today. He arrives at the practice at 6pm stating he was prescribed antipsychotic medication, self-harmed in prison and needs medication to help him sleep otherwise he is going to lose it. He states he has lost his documentation from the prison healthcare team and appears distressed and disorientated. How would you deal with this complex situation?
- Jimmy is an emaciated 32-year-old heroin user who has just been released from custody for after his twenty third shoplifting charge. He says that is on 40ml methadone daily and mirtazapine for depression. He requests sleeping pills because he cannot sleep. Until four months ago, he was in treatment with a community drug team at the local homeless (or no-fixed-abode) practice, but he stopped attending because he knew the police were looking for him. He has a painful leg ulcer due to venous insufficiency following a DVT due to groin injecting. He thinks he may have hepatitis C from sharing needles. You see him in your surgery on a Friday night. He is suffering chills and is nauseated due to his withdrawal symptoms. He says that he is not using illicit drugs, but feels he may relapse. How would you develop a management plan for Jimmy?
- An ex-prisoner arrives at your practice and claims to be taking clonazepam 2mg tds for epilepsy. He has a history of opiate addiction, is prescribed MMT 80ml daily and was drinking 2 bottles of sherry daily before arriving in prison six weeks earlier. He says, ‘I’ve had three fits at HMP Elsewhere so you can’t stop the clonazepam: I need it.’ What action would you take? Neither the GP nor prison records show any evidence of a formal diagnosis of epilepsy. Another patient tells you that he has bought clonazepam from outside a pharmacy in your area (but refuses to give any names!) What action would you take?
Dr Iain Brew is the lead GP for Leeds prisons and a GPSI in Hepatitis C.
This is an extract from the book Working with Vulnerable Groups, edited by Paramjit Gill, Nat Wright and Iain Brew published by the RCGP.