The healthcare needs of people in prison are largely absent from UK medical education, despite prisoners being a high risk group of patients, writes Gautam Chadalavada
For many of us, our only insight into what life is like in prison is through what we have seen on TV. This was certainly the case for me before I started a four month rotation in forensic psychiatry. It’s not a typical job for a foundation year 2 doctor, but I expected to learn a lot even if many would consider the experience unnecessary. Now, after doing the rotation, I’d argue that understanding the provision of healthcare for prisoners should be a key part of clinical training; especially as healthcare professionals are capable of improving it.
Around 80 000 people are currently in UK prisons, and while this may seem a small population to focus on, I have regularly come across patients in hospital who were prisoners during my training. My peers and I were woefully unprepared for caring for these patients; we had no understanding of what their access to primary care or secondary care was like, and had received no teaching or guidance on how to communicate with prison officers. Indeed, it seemed that very few people had this knowledge, and this was despite my hospital at the time being the closest secondary care service for three large prisons. There is clearly a void in UK medical education about this population that needs addressing.
The majority of the UK health workforce may never work within prisons, but the degree to which this population needs healthcare is high. They are a very high risk group of patients, with the average age of death for a prisoner in England being 56 years old. They have a 50% higher standardised mortality rate than the general population and this figure is even higher for ex-offenders and those on community sentences.
Investigation by the charity INQUEST has raised concerns that many of these deaths are actually preventable and avoidable if not for lapses in care. This is particularly troubling, as the aim of prison is not to inflict neglect or poor healthcare. To do so is in contradiction to both UN and European law and the values of medical professionalism—the Royal College of General Practitioners, for example, has previously set out a statement calling for equivalence of healthcare in secure environments. The failings that prisoners experience in their health and access to care have been recognised by the House of Commons Health and Social Care Committee, but it remains to be seen if their recommendations will be fully implemented to combat the severe underfunding and overcrowding the prison service has faced.
Clinicians can help achieve the goal of equivalence of care for people in prison by educating ourselves about their situation. Leaving prison for assessment in hospital is a huge hurdle for many patients. Firstly, there has to be enough staff to allow two officers to accompany them for their assessment, and, secondly, they are not told about the appointment until the very day they have to leave for it. Frequently, appointments have to be cancelled or rescheduled due to a lack of officers, meaning that it may be several months or even years before they are seen for the initial GP referral.
Next, there is the shock of an unexpected appointment while also being handcuffed and led there. While we should get officers to use a long chain and aim for privacy in a consultation, this is rarely done. The large scale take-up of video consultations caused by the covid-19 pandemic could help to address this; if a patient is not leaving prison they could be told about the appointment ahead of time, and there is no need to rely on officers who are in short supply. The appointment could even be held in conjunction with staff in the prison.
When patients do attend hospital, we must also be aware that there is a separate prison formulary to be used. The alternative is patients being told they need a medication, then finding out they are not allowed it on return to prison.
Mental health is also a hugely challenging area. The Mental Health Act does not apply within prisons, but this combined with the shortage of psychiatric beds means that people in prison can end up locked in a cell to deal with their psychosis in the wait for one. Clinicians should take any opportunity to assess and treat mental health early, even if it’s picked up during an admission for physical health. An initial discussion about it may be more than patients will have prompt access to in the stretched prison service.
The patients I met on this rotation had often received little or no investment in their lives, whether that be from their own families or society at large. As clinicians we can play a part in breaking this pattern, and it starts by educating ourselves about healthcare for people in prison and incorporating this into training.
Gautam Chadalavada is a foundation year 3 junior clinical fellow working at Guy’s and St. Thomas’ Trust. He has a keen interest in medical education and hopes to pursue this alongside his clinical career.
Competing interests: none.