Speaking ahead of a BMA conference for prison GPs last week, the GPC lead on prison services describes an increasingly challenging environment: GPs buffeted on all sides by NHS resource pressure, the GP workforce crisis, a prison service staffing crisis, and increasing tensions, violence and drug use in jails.
‘At the same time,' Dr Sanford-Wood maintains, ‘it is an incredibly rewarding job.’
He talks about his incarcerated patients with a compassion much of society fails to afford them. They are ‘incredibly vulnerable’, says the portfolio GP, who began working in HMP Exeter three years ago.
‘It is very easy to look in from outside and think that prisoners are young, fit males with issues perhaps of their their own making.
‘Actually, they by-and-large are a very vulnerable group of people.’
His patients have an ‘incredible prevalence’ of mental health problems as well as issues of social exclusion. Many are on a ‘revolving door’ between prison and the outside, without the personal resources to break the cycle.
‘Trying to provide good quality medical care in that environment is really very difficult,' says Dr Sanford-Wood.
Prison health services are commissioned by NHS England from a patchwork of providers which are mostly either NHS partnerships of the type which run community services on the outside, or private providers such as Care UK. GPs work either as employees, contractors or locums for the services.
This fragmented provision means prison GPs can lack the kind of peer support and learning other doctors have, says Dr Sanford-Wood, making Friday’s conference all the more important.
In many ways, though, many of the challenges facing the prison GP service are the same as those all GPs are struggling with: resources and the workforce crisis.
"We are getting increasing numbers of people [in prison] who perhaps ought to be in secure psychiatric settings."
Dr Mark Sanford-Wood
In the intensely pressurised prison environment, though, unfilled GP sessions create serious strains on the system as workload backs up.
And as well as the GP workforce crisis, prison doctors are forced to contend with prison officer shortages as well. The government has announced funding for an extra 2,500 officers in England and Wales to help tackle a shortage that the Prison Officers Association fears will cause ‘bloodbaths’ in jails as prison numbers continue to rise.
The staff shortage and tensions mean doctors are having to make more careful judgments about when to send patients in need of urgent care to hospital, says Dr Sanford-Wood, because of the requirement for two officer escorts.
While no one is being denied the care they need, he says, GPs may have to decide to send someone for an emergency x-ray later or tomorrow. ‘You are aware that if the prison officer levels drop to certain amounts the prisoners are simply then locked in their cells’, he says. ‘And that then creates further tensions.’
Official figures published last week revealed record levels of suicides in jails, and increases in self harm. Dr Sanford-Wood believes that while the causes of this increase are ‘multifactorial’, resource pressures on prison services ‘inevitably’ will ‘make things more difficult, and you may get more suicides’.
Mental ill health
Over the last year, he says, he has seen an increase in numbers of prisoners sent from the courts who are already significantly mentally ill and who perhaps would be better off in hospital.
‘You see someone coming in from court and they are accused of a minor assault but they are acutely psychotically paranoid. It is difficult not to draw the conclusion that they might be in the wrong institution,' he says.
‘And if we are getting increasing numbers of people who perhaps ought to be in secure psychiatric settings, then inevitably the prison system is going to be more challenged in providing them the care they need.’
Meanwhile the difficulty in accessing specialist psychiatric services from hospitals means prison GPs are having to care for increasing numbers of more seriously unwell patients who would previously have been under the care of a consultant.
‘That may be a funding issue, or it may be shortages in the psychiatric workforce,' he says. But he adds: ‘There has been an increase in the number of psychiatric cases we are having to deal with ourselves.
‘I'm not not saying those cases are being unsafely dealt with, but there is certainly a more challenging environment.’
There is ‘no doubt’, the GP says, that ‘underfunding of the prison service is leading to quite serious tensions’ in jails. Dr Sanford-Wood’s HMP Exeter has received prisoners dispersed from four different riots in other jails in the last three months. GPs, he says, feel the increased tension.
‘You have to be more careful.' Two years ago, he didn't think much more about safety than following the procedures. But these days, he says: ‘Now and again, there is sixth sense: there is something brewing over there...go a different way around.'
The ‘perennial’ problem for prison doctors is ensuring continuity of care for patients in a system where inmates, including many with long-term conditions, are often moved around. And when prisoners are released, GPs then struggle to hand over to community and primary care services on the outside. ‘The vagaries of the prison service and probation service, which are underfunded, often make it very, very difficult to know where they are going, who their GP is going to be when they get out,' he says.
‘It makes liaison extremely difficult. And that has serious implications for the management of drugs misuse and so on.’
Discussions with NHS England and NHS Employers are ongoing and making progress towards improving the prison medical services, Dr Sanford-Wood says. But, the service’s needs are similar to the needs of general practice as a whole: ‘We need a lot more funding, a lot more resources, we need a lot more staff.’
‘We need doctors who have the time to give to patients that need it. We need doctors who have the time to do in-service training.’
And because they work in small teams, isolated from each other, prison doctors struggle to share learning, so need structures for career development, training and education.
Dr Sanford-Wood, admits that the ‘forgotten service’ is probably not many people’s top priority for public resources. ‘That may reflect a wider societal attitude towards offender management,' he says. ‘My personal view is that it is a false economy. Because if we properly rehabilitated these people - and that includes treating their mental illness and so on properly - then society may be the biggest beneficiary of that.’