Broad statements do not tell whole story of prison medicine

Editor—I work in custodial medicine and would find abhorrent the idea of referring to my patients, albeit incarcerated, as anything other than my patients. However, the news article by Gulland describing how the NHS is to take over responsibility for prison health services does not tell quite the whole story.¹

Obviously differences exist across the service. In my experience a prison doctor sees urgent cases during the same day and around three days routinely. A consultant psychiatrist can be accessed the same week or within two weeks. Nurses are available immediately. Well man clinics, bloodborne virus clinics, etc, are provided. Locally, general practitioner waiting lists are around 14 days, and the time to see a consultant psychiatrist is five months. It seems to me that prisoners don't fare badly—in a medical sense.

The average prisoner (particularly drug misusers) can expect to see a police surgeon when arrested, a nurse on reaching the prison, and another nurse with a doctor the next day. Consultations in prison can be fairly spurious—often reflecting drug seeking behaviour—not seeking help—as I believe Gulland's article implies.

Legislation, not prisons, generates inappropriate medical tasks,²,³ a remnant of the days when prison regimes truly were draconian. Custodial medicine is a complex skill, sorting out the genuine disease (of which there is a great deal) in a population that may try to manipulate medical services for other than a desire to get well.

If anything, problems with access to health care seem to exist after prisoners are freed. Often a prisoner has lost his or her general practitioner and cannot quickly access addiction services, or support services if he or she is drug free.

Often housing has been lost and families split up. Having no fixed abode can affect the ability to be followed up by a mental health team. There can be little doubt that, for some health professionals, prisoners are a group with which they wish little contact. I have witnessed the unconscious prejudice of colleagues when confronted by a handcuffed person.

Many prison healthcare staff are highly trained individuals working in difficult circumstances. I question whether most mainstream NHS staff have the skills to deal with prisoners or could operate well in such a restrictive environment. Staff turnover in new prison health centres is well above the average. Not all prisoners are a danger, as some suggest, but clearly all are patients—the two are not necessarily mutually exclusive.