In the early 2000s, the government started the move to transfer responsibility for healthcare services in prisons from the Home Office to the National Health Services. Since these changes, doctors working in prisons are required to have completed GP training rather than having been employed by the body responsible for incarceration.

In England, healthcare services in prisons are commissioned by NHS England, and in Wales by local health boards. In Northern Ireland, the Health and Social Care Board (HSCB) works in conjunction with the six healthcare trusts to deliver services, while in Scotland healthcare services in prisons are delivered by territorial boards, following the transfer of responsibility from the Scottish Prison Service in 2011 to the NHS.

The term 'secure environments' covers a range of settings; prisons and young offenders institutes, medium and high secure hospitals, immigration removal centres (IRCs), secure children's homes and secure training centres. IRCs are different on the basis that the people in these establishments are not being held as a result of a punishment or criminal activity.

Broadly speaking, once a person has been detained within a secure environment and deprived of their liberty, they no longer have independent choice about who and where they receive their healthcare. The secure setting becomes their place of residence. This subtle but important shift effectively places greater responsibility on both the healthcare and security staff to ensure the required level of care and to work in collaboration.

Medicine in secure environments is an emerging specialism within general practice which requires a sound knowledge of how the healthcare you provide interacts with the establishment where the patient resides.

Where someone is punitively detained or incarcerated, their punishment is by definition the deprivation of liberty. It is not about restricting access to healthcare services.

In general terms within secure settings, we see a greater prevalence of substance and alcohol misuse and mental health issues. Practitioners need to be suitably competent and skilled in these areas to address and manage issues such as 'detoxification', opioid substitution therapy and complex needs. High levels of polypharmacy, drug-seeking behaviour, misuse and diversion of prescribed medications all create a challenging landscape in which prescribers must tread very carefully. The RCGP's Safer Prescribing in Prisons has been updated specifically to help support clinicians navigate this terrain.

Equivalence

In 1996, Her Majesty's Chief Inspector of Prisons Sir David Ramsbotham published his paper 'Patient or Prisoner?' in which his terms of reference were, 'to consider health care arrangements in Prison Service establishments in England and Wales with a view to ensuring that prisoners are given access to the same quality and range of health care services as the general public receives from the National Health Service'. This paper brought to the UK the concept of 'equivalence' of care and set the scene for what continues to be an evolving area of prison and secure environment medicine.

The principle of 'equivalence' is essentially set out within a number of United Nations resolutions and European Prison Rules which seek to ensure that the treatment of prisoners is humane, but it was not formerly defined and was left open to interpretation by the various accountable organisations. The RCGP Secure Environments Group Position Statement published in July 2018 sets out a working definition with the aim of providing a foundation on which commissioners, providers and inspectors can design and implement 'equivalent' care.

Our next steps must be to accurately benchmark and define the health needs of our population. Ultimately, by accepting the principle of providing 'equivalent' care, we are striving to improve the health outcomes of detained patients and are also committing to the benefit it will bring for society as a whole.

The model for service delivery in secure environments is different from that used in the community in that it is primarily nurse-led. GPs are often engaged on a sessional basis, and as a result their involvement is more detached when compared to the model seen within primary care partnerships, clusters and federations in the community. My own view is that GPs need to be more actively involved in the leadership of the healthcare teams in secure environments in order to help bring about the necessary improvements to the quality and consistency of healthcare.

Patients in secure settings are clearly unable to take themselves to A&E after injury and incidents and this needs careful consideration by practitioners. Seemingly simple injuries can be overlooked and not investigated or treated in a timely manner, which can result in delayed diagnosis and poor outcomes for patients. For example, routine radiology requests from a secure setting are frequently not timely enough to ensure that a diagnosis of a fracture is made swiftly - bearing in mind the additional complexities of having to arrange for timely follow-up in fracture clinic if a fracture is found.

Ensuring that people in secure establishments reach their secondary care appointments can be disrupted by the lack of availability of resources and staff within the establishment, leading to a detrimental effect on delivering safe clinical care that must be considered by practitioners. While it is the responsibility of the healthcare provider to refer and arrange the hospital appointments with the outside hospital and inform the security staff, it is the responsibility of the security staff to arrange secure transport of the patient to their appointment/admission and back again.

Good record keeping

Frequently, clinicians are asked to 'prioritise' their patients being transported on a given day because of resource issues like those described above.

In Razumas v Ministry of Justice [2018] EHWC 215 a prisoner who had made a claim for clinical negligence against the Ministry of Justice, rather than against the specific health care provider, had his claim dismissed. The conclusion reached was that the Ministry of Justice is not subject to a non-delegable duty in respect of providing healthcare to prisoners because it has no statutory duty to do so, and therefore is not liable for alleged failures on the part of the healthcare provider.

This means that a considerable onus falls on healthcare providers to ensure they have systems in place to check that appointments are made and followed through - and also to clearly record the reasons for any delays.

With this agreed definition, we should now be able to work with stakeholder colleagues and the Inspectorates to ensure a more measured, fair and consistent approach to evaluating the difficult and complex healthcare we provide in these settings.

Medico-legal issues: common themes

Why does the principle of equivalence matter from a medico-legal perspective? Any death in custody is subject to an investigation and a coroner's inquest. This is an important test of the 'health' of our justice system - one that ensures the deaths of those in the care of the state are investigated transparently, and which also serves to gain a valuable insight into the level of care being provided.

Of course, the inquisitorial approach of the investigation (undertaken by the prison and probation ombudsman in England, and by a fatal accident inquiry in Scotland) and subsequent inquest is intended to establish the cause of death, not to seek blame. However, the experience of many fellow practitioners who have been the subject of this intense scrutiny can focus on how critical it can be, which can feel unjust: 'Why are the deaths of patients in the community not looked at in this way?'

The clinical IT systems within the secure estate do not currently fully connect with wider NHS services within any of the four nations. This creates a digital divide and limits the timely flow of information both into and out of secure settings. The Health and Justice Information System in NHS England will see the connection of the secure estate clinical IT system with the NHS 'Spine', enabling the flow of the community GP lifelong clinical record into the prison setting. Patients will shortly be able to register with the prison GP and pre-register on release. These advances should provide welcome continuity for practitioners working both inside and outside the secure estate.

Guidance

Recognition of acute and deteriorating illness remains a particularly challenging area in prison medicine. The adoption of MEWS and NEWS (Modified/National Early Warning Scores) have seen improvements in the measurement and reporting of baseline observations, but this is set against a backdrop of the complex health needs of a patient group with (occasionally psychoactive) substance misuse and withdrawal issues.

Patients coming into prison have a very high prevalence of opioid, benzodiazepine and alcohol misuse, which needs appropriate yet cautious treatment. The interpretation of symptoms as being related to an assumed substance abuse can therefore lead to false reassurances and a clinician missing out on diagnosis of 'genuine' illness.

A good understanding of the relevant guidance (Drug misuse and dependence: UK guidelines on clinical management 2017 – The Orange Book), as well as careful consideration of the objective and subjective clinical signs of alcohol and opioid withdrawal, so as to avoid misinterpretation and over medication in the early days of custody, is key to avoiding deaths caused by prescribing. This is especially true for the use of opioid substitution in conjunction with polypharmacy of other hypnosedative medications.

In summary

The very essence of being a GP is about respect and advocacy - addressing an individual's needs on a case by case basis and without judgement. Caring for patients in secure environments requires working with some of society's most underserved and vulnerable people and the opportunity to do so is a privilege, but it is a complex and challenging area.

MDU case analysis from Dr Caroline Fryar, MDU head of advisory services

The MDU has opened an increasing number of cases relating to prison medicine over recent years. In a review of MDU files over the last five years, we found that the most common reason for cases to be opened was members seeking advice about providing statements for, or attendance at coroner's inquests. This is unsurprising given that, as Dr Hard mentions, all deaths in custody are scrutinised in this way. The breakdown of case types is as follows:

Our claims experience echoes the concerns expressed by Dr Hard. A number of these cases involved allegations of delayed referral or diagnosis, leading to more extensive treatment being required. Orthopaedic injuries featured particularly highly (for example, missed fractures and tendon ruptures), and a couple of cases related to delayed diagnosis of retinal detachment. Several involved presentation with diabetic ketoacidosis, so it is encouraging to see Dr Hard's reference to MEWS/NEWS scores, which might enable earlier identification of this life-threatening condition.

The breakdown of case themes is shown below:

Sadly there are a number of suicides included in these figures, and those practising in this area need to make sure their knowledge of mental health matters is sound and to ensure careful safety netting and excellent record keeping. Medication issues were common, and Dr Hard talks of the issues of poly-pharmacy and drug misuse amongst the prison population. Many cases involved concerns about continuity of medications when moving from prison healthcare to general practice and vice-versa. A number of cases referred to unexpected side effects of prescribed medications.

As might be expected, prison doctors are regularly asked for witness statements in a variety of guises, so the ability to write clear reports is a must. Likewise, many queries regarding confidentiality arose, each often with a novel theme. The MDU is happy to advise on such issues to ensure that prison doctors feel well supported in this challenging but rewarding area of practice.