Patients who are in prison are entitled to the same level and quality of health care as NHS patients in the community.
Providing this care poses a unique set of challenges to doctors due to both the prison environment and the complex medical and social backgrounds of their patients. This combination of factors increases the risk of unsatisfactory outcomes for patients, and puts doctors at increased risk of criticism or complaints.
The patient population
Prisoners are an exceptionally vulnerable patient group. They have higher rates of mental and physical health problems compared with the general population, and being held in prison is associated with increased suicide rates and high levels of mental health problems.1
Illicit drug use, higher smoking rates, and alcohol misuse are recognised problems, and patients may have chronic conditions that have gone untreated or may be mistrustful of authority figures such as doctors. The influences in prison can put vulnerable people at an even greater risk of harm.
The prison environment
The prison environment can also be detrimental to the health of prisoners. Overcrowded prisons in which prisoners are kept in close proximity to others may increase the risk of the spread of infectious diseases such as TB. A lack of exercise and privacy, access to drugs, and a risk of violence are all common problems.
Doctors working in the prison environment often work in isolation without appropriate support systems in place. The workplace can be unfamiliar or intimidating, facilities may not be the same as in the NHS, and security measures may be either intrusive or inadequate. Doctors may also have threats made to their own safety.
All doctors providing primary care to prisoners should be GP-qualified and on the Performers’ List. Prescribing for patients in prison often poses challenges due to the complex health needs of patients, and can be complicated by the diversion of medication by patients and the black market. Patients may attempt flattery or manipulation in seeking the prescriptions of certain medications.
Patients in seclusion pose a particular risk, as an assessment may be more difficult and deterioration in their condition may go unnoticed. The treatment of patients in emergencies, such as a cardiac arrest, is an area in which Medical Protection has seen a number of cases where doctors have been criticised.
Patients may need to transfer to a hospital setting in an acute clinical emergency, or for routine specialist referral or review. The security risks involved with sending prisoners to hospital, and the resource implications, can affect the timeliness of the transfer and doctors may feel under pressure about their clinical decision-making. Delays and cancellations of appointments can put patients at risk of harm.
Reducing your risk
Keeping up to date with relevant guidance and ensuring good communication are key to reducing your risk. NICE has published guidance on the physical and mental health of people in prison, which says that a comprehensive extended physical and mental health assessment should be carried out on entry into and release from custodial settings.
The RCGP has published guidance for clinicians on Safer Prescribing in Prisons. Although the setting may be unique, the same principles of good medical practice, as set out by the GMC, apply. This may be complicated as doctors seeing patients in prison have a dual obligation both to their patients and to their patient’s employer, who must ensure the safety of the wider prison population. All prison health staff should be aware of relevant prison service orders (PSOs) and instructions (PSIs).
Keeping good medical records is essential in helping to ensure good communication with others who may also be providing care, and is invaluable in the event of an adverse incident or complaint. Good communication with the patient’s GP in the community, on discharge, is equally important and patients may need assistance with registering with a GP on release.
Doctors should seek to develop specific communication skills so they are equipped to de-escalate any conflict which may arise, and should not be afraid to seek support themselves to help deal with the challenging environment in which they work.
Complaints and criticism
Inquests are held for all deaths that occur in prison, usually with a jury. In the event of an inquest, complaint or an investigation by the Prison Ombudsman or NHS England doctors can seek advice and assistance from their medical defence organisation. It is also important that doctors ensure their medical defence organisation is aware of any changes to the scope of their practice so the indemnity arrangements they have in place remain adequate.
- Dr Marika Davies is medico-legal adviser at Medical Protection.
1. The health of prisoners: summary of NICE guidance. BMJ 2017;356:j1378