Health and wellbeing are probably not the first things that would come to most people’s minds when considering prisons and their role in society.

With a prison population of 81,000, England, Wales and Scotland have the highest incarceration rates of inmates per 100,000 of population in western Europe, while the total number of inmates in UK prisons is predicted to rise to 97,000 by 2025.

Despite its large and growing population, those imprisoned in the UK should receive equivalent standards in healthcare to those in society.

This ambition is further complicated by the fact that those in the prison population often tend to be in poorer health than those in society.

A report published by the Nuffield Trust in October last year examining the challenges around healthcare access in prison, found many people entering prison have complex health issues concerning mental health and addiction.

GP Mark Pickering has spent the past 13 years of his career working in prisons and secure psychiatric hospitals. He is one of a relatively small number of doctors responsible for assessing, referring and providing care to inmates in the closely controlled yet often challenging environment of the prison estate.

‘One of the things that often strikes you is that every prison is sort of very different and set in its ways and yet there are these common themes across them,’ he says.

‘There’s so many logistical barriers to good care [in prison] so while we talk about equivalence of care, that you’re meant to be trying to give [inmates] the same range and standard of care that you would give in the community, it’s often very difficult to do that.’

With UK prisons spanning a broad range, from maximum security to open facilities, experiences of the doctors working in them, and the resources available to them, can vary, thus making a ‘typical day’ hard to define.

Dr Pickering says as well as running clinics similar to what might be expected in a community GP setting, another critical responsibility of doctors working in a prison is monitoring and assessing those inmates confined to a segregation unit.

‘If the prisoners are in segregation for fighting or trading drugs or something like that, then they have to be seen by a doctor every 72 hours, regardless of whether there’s anything wrong,’ he explains.

‘There’s always a challenge as the doctor because often you’re traipsing around with a prison officer and in some places, they don’t want to open the [cell] doors, so you might just be looking through the door flap and asking the inmate if they’re OK. The rules say you’re meant to assess their physical and emotional and mental state, but how can you do that through a closed door?’

Personal safety is a consideration likely to preoccupy anyone entering a prison for the first time and may be a factor deterring some doctors from even entertaining the idea of working in a secure environment.

In his experience, however, Dr Pickering says there are misconceptions as to the safety risk of his job. ‘You’re generally much safer working in a prison than you are walking through the town centre on a Saturday night,’ he says.

‘There are things you’ve got to be alert to, you’re meant to put the patient further away from the door than you so that if they do get aggressive you can exit quickly, and you’ve got panic buttons in the room.

‘It’s a much more controlled environment and there are always prison officers around and risk assessments being done.’

One of the most significant challenges facing doctors working in prisons is the almost constant requirement to balance the health needs of inmates with the limitations imposed by shortages in prison officer staffing.

This balancing act is often most acutely felt when doctors believe that an inmate might or indeed should be referred to secondary-care services outside the prison. Using the example of an inmate attending a clinic with an injured hand after punching a wall, Dr Pickering outlines the number of factors that might need to be considered before reaching a clinical decision.

‘[In the community] you’d just say, “Pop down to A&E and go and get it checked out”, but in prison you first have to consider things like, has the inmate done this deliberately so that they can try to get out of the prison as part of an escape attempt?,’ he says.

‘You may say to someone that they should probably go to A&E for the chest pain that they’re suffering, but it’s not a simple case of them just going to A&E. They have to get handcuffed, strip searched, and then get taken out handcuffed to a couple of officers and perhaps wait around like that for hours.

‘Sometimes you really do have to think quite laterally, and you’re having to make some of these prioritisation decisions that you just wouldn’t have to make normally [in the community].’ This difficult balancing act is one that prison doctor Amanda Brown knows only too well.

Having started out in a traditional community-based general practice role, Dr Brown has spent the past 18 years working in a variety of men’s and women’s prisons in England.

She says that on more than one occasion during her career as a prison doctor she has found herself being ‘cross-examined’ by a prison governor and essentially asked to justify her request that a particular inmate be transferred to hospital for treatment.

‘Probably the most frustrating thing for me is referring patients to outside appointments,’ she says. ‘Certainly [at] Wormwood Scrubs it could be so tricky to get patients out to important outpatient appointments. And I can remember for example, there was a man in there for quite a long time with renal failure and three times a week he had to go for dialysis.

So that took a precious resource, at least two prison officers to escort him. ‘Depending on the risk of the prisoner, it could take two or three officers to escort someone to hospital, which obviously cuts out the staff for the running of the prison.’

Responsibility for the commissioning of primary and public healthcare services in prisons was transferred from the Home Office to the NHS in 2006, although from this year services could also be commissioned by ICS (integrated care systems).

The range of health services available to inmates can vary hugely from prison to prison, with some prisons possessing on-site secondary care facilities such as dialysis or sonography.

Dr Brown’s place of work, HMP Bronzefield, offers a range of healthcare services including physiotherapy, podiatry, dentistry, mental health and an optician. As a remand prison, however, the patient population at Bronzefield can often prove to be a fairly transient one, with inmates only staying for a few weeks before being released or transferred.

Dr Brown says that delivering continuity of care to patients under such circumstances can be extremely challenging. ‘A woman might, for example, have just got to the point where she’s going to have a hip replacement. She then comes to prison for maybe six weeks or two months, so she’s lost that slot [for the operation].

‘If she’s going to be in prison for a long time, we’d have to re-refer them to a local hospital which means they then go to the back of the queue. [Alternatively] we might refer a patient and get an appointment through the day after they’ve been released.’

Addiction and the use of drugs by those in custody is a health issue that even those who have never set foot inside a prison are likely to be well aware of.

In its most recent report into prison health, the Commons health and social care committee notes that 28 per cent of men and 42 per cent of women prisoners report having a drug problem upon arrival in prison with 13 and 8 per cent developing issues with substances while incarcerated.

Jake Hard has spent 16 years working as a GP in prisons in England and Wales. Now clinical director at HMP Cardiff he also serves as an expert witness on healthcare in prisons and is the former chair of the Royal College of GPs’ secure environments group, a multidisciplinary UK-wide network promoting access to high standards of care for those detained by the justice system.

Having a long-standing clinical interest in treating substance misuse, he gave evidence to the Health and Social Care committee’s inquiry into prison health in 2018 and has seen at first hand the significant harm drugs can have in prisons, on inmates and the health professionals there to care for them.

‘I’ve seen over the years, the implementation of opioid substitution therapies, methadone and buprenorphine and I’ve subsequently seen, with buprenorphine, the considerable illicit trade of buprenorphine in the prison estate which had a significant impact,’ he says.

‘Then we had a substantial issue with the arrival of psychoactive substances within secure settings which was devastating for lots of reasons.’

Dr Hard says he witnessed some of the harrowing consequences from psychoactive substances often known as spice.

‘I’ve seen some of the destructive effects on patients of psychoactive substances. I have seen incidences of people suffering self-inflicted injuries as a consequence of using these drugs.

‘Groups of people under the influence and severely intoxicated and cases such as these have a profound impact on healthcare staff and prison staff.

‘One example I can think of was, there was a time when we had about eight people under the influence [of spice] and some were on the floor vomiting and hallucinating or fitting. You can imagine the effect that has on your nursing team resources and your GPs at that point in time.’

As with every other part of society, COVID-19 presented huge challenges to prisons, with the day-to-day lives of inmates and in the delivery of healthcare. A modelling exercise conducted by HMPPS (HM Prison and Probation Service) and Public Health England in April 2020 concluded that measures were required to avoid excessive prisoner deaths, which would have been the case if no actions were taken to avoid outbreaks in the prison estate.

In response, the prison service took the step of implementing a series of restrictions to protect the vulnerable patients. This included inmates being locked in their cells for up to 23 hours a day to reduce transmission of the virus.

A study published last year by the HM Inspectorate of Prisons What Happens to Prisoners in a Pandemic? concludes that, while the measures had been effective in reducing cases and deaths, it was unclear what the effect of the strict and extensive period of lockdown may have been on many individuals’ mental health.

Indeed, in its report, the Nuffield Trust reveals a mixed picture as to the pandemic’s effect on mental health in prisons, with the report noting that, while the rate of self-harm per 1,000 men in prison fell by 13 per cent in 2020, it increased by the same percentage in the women’s prison estate.

‘From an infection prevention control point of view, the measures that were put in place were completely understandable and helped to avoid what could have been a significant number of deaths,’ says Dr Hard.

‘The measures put in place in the prison estate endured for longer than the measures that were seen in the wider community, and this included being locked in their cells for 23 hours a day, but were ultimately intended to minimise the impact of further outbreaks.’

The BMA forensic and secure environments committee is responsible for supporting and improving the conditions of doctors working in prison settings, with the committee planning on holding a special conference next year to this end.

FSEC chair Marcus Bicknell says the pandemic and prevailing challenges mean healthcare standards are still not at the level staff and inmates deserve. He says: ‘Prison remains a challenging place for healthcare workers to deliver care.

'NHS England Health and Justice has adopted a helpful, inclusive partnership approach to improving services, but workforce pressures are extreme, which adversely affects the delivery of safe GP and psychiatric care, and we are a distance away from being able to deliver the quality of health service which we aspire to.’