Inside job

AT first glance, Dr Iain Brew’s first job as a GP in the Shetland Islands couldn’t be further removed from his current role. His base off the north east of Scotland was remote, extraordinary, wild at times and involved a broad spectrum of clinical practice.

Now working as a full-time GP at a sprawling urban prison, Iain still finds his job can be remote, extraordinary and wild at times with a varied and busy clinical case load. And while the Victorian-built prison in which he practises doesn’t boast quite the same scenic beauty as the Shetlands, Iain wouldn’t have it any other way.

He began prison work in 2001 when a friend asked him to help with evening work at HM Prison Lincoln. “I thought it would be something a bit different,” he says, “but I really liked it.” He never looked back, working part-time at Lincoln before eventually becoming a full-time GP at HMP Leeds in 2006.

“My first impressions of prison work proved to be right. The patients – and to me they are always patients first and prisoners second – are medically very needy. There is a great deal of advanced pathology going on – psychiatric as well as physical – as this is a population who do not normally engage well with the health service. You would not encounter such textbook pathology in a local surgery.

“I also felt this was a needy group who traditionally have not received good care within the prison service. Only since 2004, when prison health started to be commissioned by the NHS, has it been a requirement to have qualified GPs in prisons.”

HMP Leeds is a Category B men’s prison with a population of 1,150. It’s a local prison taking both remand and short-stay prisoners but also accommodates a number of ‘lifers’ awaiting a placement elsewhere.

Iain is part of a team comprising two part-time GPs and a clinical director – the equivalent of 1.6 full-time equivalents. That may seem sufficient considering the population, but research shows prisoners consult four to five times more than average. Iain confirms this: “We have an annual turnover of about 6,000 [consultations] – that’s 500 per cent of our patients.”

Proactive

One of Iain’s interests is chronic disease management and he is clinical lead for a city-wide team of nurses covering three prisons. They take a proactive approach, actively seeking out new prisoners identified in reception screening as having a medical diagnosis.

Iain’s real passion though is for hepatitis C work and he runs a successful in-house treatment service in conjunction with the local hepatology department. The service has earned widespread praise with interest in rolling out the model UK-wide. He has also helped develop an online training course in hep B and C treatment with the RCGP.

Over the past five years, the service has treated 75 patients – people who, Iain says, probably won’t have accessed sustained help before. He explains: “We give them antiviral treatments and have excellent completion and SVR (sustained viral response) rates – in other words ‘cure’.”

Encouraged by clinical director, Nat Wright, also a member of the RCGP’s 15-strong Secure Environments Group, Iain has completed a literature review of hep C treatment in primary care globally (currently in publication), and is evaluating research involving the first 50 patients through hep B treatment. Having a captive audience means research ethics are high on the agenda.

His overall clinical remit at Leeds is wide. “We try to treat as much as we can within the prison as it costs the NHS to send patients to hospital escorted by prison officers. With the support of specialists, we manage everything from sexual health, joint injections and IV antibiotics to palliative care.”

Safeguards

A key element of Iain’s job is the importance of safe prescribing. About a quarter of the prison is on methadone and another five per cent are on buprenorphine as an opiate substitute. The substance misuse group accounts for 70 per cent of patients and, consequently, drugseeking behaviour is common.

As a result, the GPs have to be consistent in explaining why a drug may not be suitable. For example pregabalin, prescribed for pain management, has opiate and benzodiazepine type effects and causes euphoria. Consequently it is highly valued. Iain outlines the size of the problem: “Out of 25 patients I saw yesterday, six had prolonged discussions with me about their need for pregabalin.”

Security and prescription considerations are manifold: no glass bottles or aerosols as they could be weapons, no gum-based nicotine to make impressions of keys or block locks. No injectables. Iain also has to assess a genuine need for hospitalisation, as most escapes happen in court or in hospital.

Despite his work environment, Iain says he rarely feels threatened and there is seldom the need to have prison officers sit in on consultations.

“Very occasionally prisoners try to threaten, especially about their desires for medication. The highest risk comes from the mentally unwell.”

On occasion, it does get “wild at times”. Says Iain: “Things got hairy recently during an evening reception clinic when a long-term prisoner opened his dialysis fistula with a biro, refused to go to hospital with paramedics and allowed himself to bleed out until losing consciousness.

“There was no DNAR in place due to his mental fluctuations and IV access was impossible due to previous drug use. We were only able to deliver first aid to him and thought we were going to lose him at one point. At the same time, another prisoner was withdrawing very badly from alcohol and had a series of seizures requiring diazepam followed by a detox script.”

While this may sound alarming, Iain adds: “When thinking about safety, I have been in more danger in GP practices than in prison due to the uniformed staff and alarm bell system.”

Alongside drug abuse, mental health issues are also common with half of patients diagnosed with personality disorders. Iain says: “We have to be alive to psychiatric diagnosis. I ask patients about suicide directly several times a day.”

What has surprised him most about his patients? Iain is unequivocal in his response: “Their humanity. When I started out I had a ‘Daily Mail reader’ attitude but prisoners are just people like you and me. They have often been excluded socially from a very young age.

“There are some really intelligent people here. If they had applied themselves within the law they would have been brilliant. So I feel compassion and some sadness for how things could have been different.”

Downsides are pressure and intense scrutiny. While GPs have to deal with endless requests for drugs they also have to ensure patients feel they are properly treated.

“For me, examining people well is part of that,” says Iain, “but any death in custody, even natural-causes deaths, is extremely involved.” First there’s a 48-hour review of clinical care; a police investigation; prison and probation ombudsman statements; a clinical reviewer who will scrutinise records of care; and eventually a coroner’s inquest (with jury) often up to three years after the death.

Iain believes the job is challenging but rewarding and is keen for trainee doctors to find out more. He stresses that prison doctors need to be confident in their assessment and be able to switch off at the end of the day.

He would encourage trainees to get involved. “We have foundation doctors in one day a week as GP attachments, and medical students doing their intercalated BSc,” he says. “Anyone interested should try to contact their local prison. I know prison GPs are keen to encourage that; I certainly am.”

Alison Bird is a freelance writer