Healthcare in Secure Environments encompasses the delivery of primary health care services in prisons, young offenders institutions, immigration removal centres, secure children’s homes, secure training centres and primary care in medium and high secure hospitals. By virtue of a patient’s detention in a secure environment they are not able to access the wider NHS primary care services and therefore GPs and other primary care team members are commissioned to deliver services in these settings.

The over-riding principle of care delivery is the aim to deliver care equivalent to that available in the wider community.

This specific objective requires attention to the particular practical, ethical and medical issues affecting the appropriate delivery of care in these settings. It is frequently thought that working with offenders and detainees could be considered more ‘risky’ or hostile but it is our collective experience that these settings are extremely safe.

Being a compassionate and caring doctor very much sits at the heart of treating patients in secure environments. In many cases you are addressing the needs of some of the most vulnerable and under-served members of our society. Treatment needs to be non-judgemental and delivered to the highest possible level irrespective of the nature of offence, convicted or remand status. There is no one set of defining features for a GP working in secure setting. The skills required are many and varied and range from having knowledge of ‘the system’ and how it will impact on the your ability to deliver care; having the relevant consultation skills when addressing drug-seeking behaviour; safer-prescribing in the secure setting, substance misuse treatment and addressing a high prevalence of mental health issues. 

The high levels of health needs of patients who are detained are well-documented and range from significant levels of substance misuse, alcohol misuse, mental health issues and an increased prevalence of infectious diseases as well as unaddressed chronic disease and lifestyle management. Within the prison setting the healthcare services have been adapted to serve the increased needs of the patient group although detailed epidemiological data remains an area of need for further development. GPs working in prisons benefit from having an additional set of skills in order to properly address these needs, however at this time there is no requirement for additional training. The RCGP Certificates of the Management of Drug Misuse Parts I and II continue to be an important basic additional qualification.

It must be acknowledged that this aspect of healthcare is a continually evolving and developing area. We have only had clinical IT systems in prisons since c. 2010. The improved use of this system is central to improving the level of care being provided as it will provide the data necessary for a better understanding the health needs of our population and thereby help us to determine our aims for defining the health outcomes and objectives required to provide ‘equivalence’ to this community. Future developments within the prison IT system will see connection to the NHS Spine and this will bring much of the functionality available in the wider community - such as electronic referrals, timely transfer of electronic records, access to national screening programmes and a range of other enhancements - to this group.

Dr Jake Hard

More reading: Medicine in Secure Environments