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Bethan Roberts is a salaried GP at HMP Cardiff and a representative for GPC UK and GPC Wales and chair of the BMA forensic and secure environments committee.
I work as a GP at Her Majesty’s Prison, Cardiff. Prior to GP training, I worked as a locum in forensic psychiatry at HMP Wandsworth and knew I wanted to work behind bars again once I qualified as a GP.
I started planning for working as a prison GP during my GPST2 year after making a chance connection with a GP working in prison. I used one of my self-directed learning sessions to visit the prison and used my study leave to attend relevant courses and events.
Daily life behind bars
My day-to-day work is structured in the same way as a regular GP day – I have a session for face-to-face appointments, then I catch up with prescribing, blood results and paperwork. I see the patients in my consulting room on my own – for equivalence of care – with an officer available outside if I have any concerns. I have not had any direct risk to my personal safety and, in general, I feel safer working in the prison than I have at times working in the community.
Security and operational issues do not dictate the kind of healthcare we provide but I always have to be mindful of the possibility that patients may be feigning symptoms to secure a hospital transfer for reasons other than illness (such as escape or planned drug pick-ups) but decisions about prescribing, investigating and referring are generally made in the same way as they would be in the community.
We also have the old fashioned but statutory ‘seg round’, where a doctor has to attend the CSU (care and separation unit, previously known as the segregation wing) three times a week to see anyone who has been detained there. Home visits take on a very different flavour; I visit very unwell patients in their cells with another member of staff for safety purposes.
Challenges for a prison GP
A lot of my work has to be done without having seen patients, such as prescribing for new arrivals from the community, so it’s important to be up to speed with guidelines on safe prescribing. My duty is to prescribe safely and appropriately – no different to my role in the community – and communicating this message to patients is vital. I write to my patients explaining why I’ve had to reduce or stop certain medications and it always helps when I can tell them that the treatment I give in prison is the same as in the community.
The work is challenging, mainly due to the prevalence of substance misuse issues; almost everything we prescribe has abuse potential. The plastic holders of metered dose inhalers can be used as a drug delivery device and certain topical treatments for acne can be used as accelerants to start fires.
Prison GPs often experience more conflict with patients around medication issues, as we are often asked to prescribe medications that the patient wants rather than needs. Consultations about pregabalin, gabapentin, quetiapine and mirtazapine are the ones that attract most conflict.
There are also physical obstacles in our way, with multiple locked doors and gates to get through. Prisoners have a much-reduced life expectancy compared with the general population and will often have significant physical and mental health issues – it’s sobering to note that the average life expectancy of someone in prison is 56.
Gaining the skills
A prison GP is not a separate specialty and no specific extra training is required – all you need are a certificate of completion of training and to be on a performers list as a GP. My background in psychiatry has been useful, as was an A&E job during GP training, which has left me confident in managing acute trauma, deciding when to manage in-house and when to transfer to hospital. Further learning on substance misuse issues was useful for me as I did not have much experience of this during my GP training.
While we have a population with challenging health problems, I enjoy my prison work immensely and would recommend it to anyone who has an interest in working with vulnerable patients.
Such a fantastic insight Bethan! Thanks for this.