Opportunities for doctors in the prison serviceThe director of health care in prisons, Mike Longfield, explains the range and scope of the service for those who serve at Her Majesty's pleasureWorking in prisonBMJ 1999; 318 doi: http://dx.doi.org/10.1136/bmj.318.7178.2 (Published 23 January 1999) Cite this as: BMJ 1999;318:S2-7178
The director of health care in prisons, Mike Longfield, explains the range and scope of the service for those who serve at Her Majesty's pleasure
- Dr Mike Longfield, director of health care
Medical practice in prison is, perhaps by its nature, little known and poorly understood outside the confines of the prison service. Only 225 doctors work in prisons in England and Wales (of whom 133 are full time and 92 part time), but their potential to influence the health of some of the most disadvantaged people in society is considerable. Last year around 65,500 prisoners were in custody at any one time, a number that has been rising steadily for about five years. That number is deceptive: in the latest year for which statistics are available, around 200,000 people spent some time in prisons in England and Wales because the vast majority of prisoners spend comparatively short periods in custody. All of these people will come into contact with a prison doctor during their time in custody, and this contact offers prisoners the opportunity for consistent health care, which may well have been absent from their lives outside prison.
The doctor's role
Opposite, Patrick Keavney argues that prison medical officers are general practitioners who need even more vision, tenacity, and common sense than their non-prison counterparts, in work with a group of patients who are more likely to need some form of mental care.
I would like to add to that by first putting the role of the prison medical officer within the judicial context of the Prison Act (1952). This is the basic legal constitution for the work of the prison service and requires, among other things, that “every prison shall have a governor, a chaplain and a medical officer and such other officers as may be necessary.” This legal context underscores the fact that prison medical officers are required not only to “have the care of the health, mental and physical, of the prisoners in that prison,” as stated in the prison rules, but also to ensure that the particular circumstances of a prisoner's incarceration are not having a deleterious effect on his or her physical or mental health. Although the doctor's main activities are in primary care, with a particular emphasis on mental health, substance misuse and the control and prevention of communicable disease this takes place within a special context, where particularly vulnerable people are subject to processes that require safeguards to their welfare and health. This is the job of the prison doctor.
Prison doctors do not of course care for prisoners' health alone: they are supported by some 1500 nurses or prison healthcare officers and about 70 pharmacists. In addition, an increasing amount of care is given by visiting specialists to the prison: of the two million health consultations carried out in prisons in the course of a year, about 10% are with visiting NHS specialists such as psychiatrists, dentists, and optometrists. Most secondary care is given in NHS hospitals.
The NHS is becoming increasingly concerned with the delivery of health services for prisoners. The original model of a medical officer directly employed by the Home Office and working solely for the prison is being gradually displaced by several other models based on service contracts with NHS general practices and trusts or the independent healthcare sector.
Tackling the problems
The challenges of delivering health care in a custodial environment and the professional isolation of that environment from the mainstream of the NHS have meant that prison health care has been subject to some strong criticism over the years. These difficulties are being tackled in several ways, one of which is the introduction of the diploma in prison medicine, a three year course taught by the University of Nottingham under the auspices of the Royal Colleges of General Practitioners, Physicians, and Psychiatrists. Measures such as the introduction of national prison service health care standards have also made progress in raising standards of health care in prisons to those expected in the NHS.
About the Diploma in Prison Medicine
6 modules/year over 3 years
Each module lasts one week, full time
Genitourinary medicine and HIV
Health and safety with occupational health
Ethics and medicolegal aspects
For further details contact the course director:
Dr J Bilkhu,
Centre for Postgraduate and Continuing Medical Education,
Queen's Medical Centre,
(tel 0115 970 9377)
With this aim in mind, a joint working group of prison service and NHS representatives was set up in 1997 to look at ways of making the increasing involvement of the NHS in prison health services more consistent. The group reported at the end of last year; its recommendations are currently being considered by ministers, and an announcement on the way forward is expected soon. Whatever the details of that announcement, it is clear that prison medicine will continue to offer interest and challenges to those who would like to work with this disadvantaged group of patients, and where the quality of their work can make a very real difference.
Working in prison
- Dr P J Keavney,, general practitioner
Patrick Keavney believes that the primary care of prisoners is a general practitioner role and that to overspecialise is wrong
Nearly 6,000 of our patients are incarcerated in prison. To some “law abiding citizens” imprisonment is the easy solution to crime, though they rarely examine its consequences. All but a few prisoners will be released back into the community on completing their sentences, so it is essential to consider what happens to them while they are incarcerated and see their sentence as an opportunity to effect some form of rehabilitation. It is true that the humanity of a civilized society can be judged on the way it treats its prisoners.
Prisoners are victims too
Though imprisonment may well be the appropriate punishment for many offenders, it is a sad fact that many prisoners are also victims. Society therefore has a responsibility to reduce the causes of crime as well as to seek redress for the crimes. The duties of prison medical officers and their attached healthcare team are indeed demanding and challenging - it is not a job for the faint hearted - but the principles that govern the provision of health care for prisoners are the same as those for all patients in primary care.
Prison medicine is primary care in a special setting. It is essential, therefore, that an active relationship should be developed and maintained with primary care services in the community so that an equivalent standard of care is achieved.
Primary care has to be seen as the gatekeeper or signpost to other necessary services. To achieve this requires an appropriate assessment of the needs of the patients served, a team to deliver this care, recognition of the variety of skills required, and a range of services to addresses need, control demand, and maintain health.
Generally speaking, prisoners are physically more healthy than people of comparable age in the community. However, personality disorders, genuine mental illness, and substance misuse are more common, all of which demand a different range of services from that required for the general population.
Prison health care is not a specialty in its own right and should not be seen as such. Prison medical officers are general practitioners and should be aligned with the Royal College of General Practitioners rather than any specialist college of their own, or those of the physicians or psychiatrists.
Times of change
The prison service is going through an unprecedented changes, and the stresses on it are enormous. Funding is short, while the expectation for quality is as high as for any service. This is causing problems in delivering a new modern healthcare policy that addresses the needs of prisoners. Policy makers disagree about future priorities. Keeping healthcare needs at the top of the agenda is an important task for the healthcare directorate and the prison healthcare service as a whole.
To achieve such an agenda requires a professional work force which is qualified, trained, funded and renumerated accordingly. It requires close allegiances between national and local policy makers, a closer relationship with local health communities, and recognition that prisoners are part of the community, not excluded from it.
A wider view
Prisoners also more clearly illustrate the arbitrary boundaries between clinical and social health and the futility of concentrating on the needs of individuals without addressing those of their community.
To provide such a service requires doctors with vision who are not afraid of these challenges: challenge not only from a more difficult, demanding and manipulative patient population, but also to seek input into the institutional policies, forge the links with the local community outside and seek support from the health authority for funding specialist “provider” services to address the special needs that have been identified.
Problems of doctoring
The danger for full time prison medical officers is to become isolated and dehumanised by the prison environment. The same applies to their staff. This issue must be addressed. For part time doctors, with frequent clinical commitments outside the prison, the difficulties are to avoid being treated as a permanent locum, and not being recognised as being an integral part of the institution, not being supported, and not being funded to achieve quality objectives. Failure to contribute to the philosophy of the service and the purpose of the institution is a danger for all doctors, but the prison system provides great opportunities to achieve a genuine sense of the community that could be an example to society at large. The lessons for prisoners may be difficult to learn, but they are achievable in most cases.
For doctors with vision, tenacity, common sense, and a willingness to provide a quality service, working with prisoners is enjoyable. There are frustrations, as in all public services, and these will have to be addressed by the Government if it wishes to achieve its objectives.