Past Medical History

It’s Friday night on the assessment suite in the Royal Victoria Infirmary. Patients swell through the doors, and line the corridors. Sent in by their GP, who agonised over whether to send them in, but did so in their best interests. They have suspected disease which needs further attention within the hospital. It could be serious. A stroke or a heart attack.

My job, as the junior doctor, is to clerk them. They’ve already been seen by a nurse, who is equipped to triage them on to me. I take them to a side room, to ensure confidentiality despite the place being full to capacity.

I try and ascertain why they are here, what medications they take, and what treatment they now need. They bring with them bags of medications, and a prescription if I’m lucky. But it’s important that I go through them. Prescribing certain drugs incorrectly is a never event, meaning it should never happen under any circumstances. I could be referred to the regulator, that patient would have every right. I would tell them my GMC number. The standards are that high even for such a routine task as this. 

Another patient, in a bay down the corridor, starts getting irate. His shouts and yells echo down the corridor. But the nurse looking after that bay knows how to diffuse the situation. The anger comes from the uncertainty, the long waits, and the pathology that put him here. She knows this, from experience. She speaks with him calmly, and offers clear instructions and a plan of action. No alarm is pressed. The security guards by the entrance relax.

It only gets busier, as I do this for the next twelve hours. It is routine. Unremarkable. I refer people who make attempts on their own life to liaison psychiatry, and they are seen promptly. I explain things as best I can to those on new medications, and where they’ll go next on their journey through the hospital. I force through requests for scans and consults, time is of the essence, and early treatment can save lives. I send some home, with a discharge summary immediately written, so their GP knows what to do next.

It doesn’t strike me that there is any other way to practise medicine, but to do it to the best of my abilities. Patients come to us in their most vulnerable state, and trust in us that we will treat them as we would a close family member.

Unfortunately, I broke this trust. My professionalism didn’t extend beyond the hospital doors. I sold drugs to fund and fuel my addiction to cocaine and alcohol. I was arrested, in that same hospital trust, and sent to prison a year later.

Withdrawal

I was naïve to think I could live the double life of a doctor and drug dealer. I entered prison equally naive about the situation that awaited me within. I assumed that the prison service. A big, state-run organisation with bureaucracy and lanyards and badges, would function just like the NHS. That prisoner’s healthcare needs would be looked after in the same way. To the same standards I was taught at medical school were universal. This naivety didn’t last long.

I arrive in reception, hungry but inquisitive of my new home. The local category B, specifically designed for accepting people fresh from court. I go through various questionnaires, with some attempts to screen me for mental health issues by prison officers. Like many who enter here, I have psychiatric disease in depression, and am stable on medication. So important to me is my newfound mental stability, that I brought three months’ worth of Venlafaxine with me. Sealed in pharmacy bags, prescription alongside.

But it’s Friday, I’m told, as I eat a cheese baguette. There is no pharmacy cover over the weekend. I won’t receive my medication until at least Monday. I don’t believe them when they say this. There will be systems in place.

Not for the first time, I am wrong. I sit in my cell all weekend, withdrawing from this medication. The last remnants of it leaving my body into the toilet situated a metre away from my cellmate. He offers me weed, and I briefly consider taking it, if only to relieve me from the insomnia, headaches, and brain zaps I’m now experiencing.

Monday comes, and I work out that I am supposed to go to a medication hatch to get my drug. I queue up, in a tiny corridor. I can hear everything said to others at the hatch, the drug names spoken aloud for all to hear. My turn arrives, but I am told it’s not been prescribed. They’ll put a note on, they say, but there is nothing they can do. Another day without.

An idea starts to form through the fog, that this may not be a one-off error. That this sort of negligence is inherent to the running of this place. At lunch, I talk to others of my plight. My hope diminishes as one man tells me he didn’t get his anti-epileptic medication for six weeks. Not even a seizure was enough to prompt them.

Eventually, I do get my medication, so long as I am able to go to the hatch each morning, which is by no means guaranteed.

I’m summoned to healthcare one afternoon, unexpectedly. So I sit in the healthcare waiting room with many others, avoiding eye contact. Another prisoner walks in. He is slightly agitated, in contrast to the rest of us waiting here. He asks loudly, of the nurse behind toughened glass, when his appointment will be. The nurse tells him to shut up, that he missed his earlier appointment, and he’ll have to wait his turn. His eyebrows furl. He says it wasn’t his fault that he missed the appointment. That the wing staff failed to release him. She calls him a liar, and baits him, telling him he’ll be thrown out if he doesn’t shut up. Of course, he rises to this taunt, as she knew he would. He punches the glass, she doesn’t flinch, as his slender fist rebounds off. He is smothered by two officers nearby, and bundled away. The nurse smiles, as though pleased she’s reduced the waiting list. 

I should have said something. But I was too meek. Already it seemed like this was just the way things were done round here, and who was I to complain. Instead I look around the walls of this room, for any posters from the regulators, suggesting how I might complain about this issue. But I can’t see the NMCs details. Nor those of the GMC and CQC. The only thing I see, is a paper stuck to the toughened glass, with the number of missed appointments this month written on it. Apparently, this is our fault.

Eventually I go through, and they say I need an electrocardiogram, ECG, to check my heart. But they put the leads in the wrong places. I let them know at the time, pointing at the diagram on the machine. But I’m mistaken, the healthcare assistant says. I do complain, in writing this time. But I receive my complaint back, weeks later, to state that they were correct, and that in fact I was in the wrong. There is no appeal process. Not with G4S health, who have their own separate healthcare complaints system.

Over the following months I start to see the dark side of this place. The end result of a healthcare provider insisting it is always right, yet with standards far below what is required. The effects of the inability to get the care one needs. I see people slash their skin with blades at the slightest anguish. I see people when they attempt to take their own life, but I can’t refer them on to anyone here. And there are those I don’t see, trapped behind their cell door by their own fear of what’s outside.

Stuck

Christmas comes, and I’m comparing a quiz on my wing. But half the page I am reading from suddenly goes blank. I look up, and half the room is missing. I know it’s one of two diagnoses – migraine or a transient ischaemic attack, a precursor to stroke. The blood supply to my visual cortex interrupted by a clot.

I know what I would do, were I in the community. But here, I can’t just go to A+E. There’ll be no GP in today. There’s now an intermediary, between me and healthcare, in the shape of a prison officer. It’s unfair on them to be placed in this position. They aren’t medically trained. They know it will drain resources if I am sent to hospital in an ambulance. And so, I don’t want to bother the staff, who will likely tell me to wait until a normal day. So, I just continue the quiz, and hope it passes. My mind flitting between debate about whether Boris Johnson had said letterbox or post-box, and the idea that my visual cortex is slowly dying.

I think back to an incident which occurred only weeks ago. The man who had a heart attack, locked in his cell overnight. His pressing the buzzer with crushing chest pain, and it not being answered for quite some time. He had to be resuscitated by a gym officer at one point. They shook hands, but the prisoner died weeks later.

I see the GP when I can. But it’s not a transient ischaemic attack, he says, confidently. And I believe him. Maybe I’m misremembering the NICE guidelines. I believe him until the moment it happens again, and again. And I start to wonder if it was the four different scans, and four separate hospital trips, required to rule out this disease, that put him off this diagnosis. The only scanners in here are those to detect drugs.

Fortuitously, I am moved prisons. To a category C as my sentence progresses. I can try my luck with a different healthcare provider. Perhaps the shoddy healthcare in the last place was just a one off.

My new cellmate here has ADHD. On our first night together, upon discovering that I am a doctor, he stops flicking through the nine TV channels for a moment, to show me a blister of the pills they gave him – Atomoxetine. He’s usually on Concerta (Ritalin or Methylphenidate to many), but they switched him, and didn’t explain why. The leaflet in the drug packet only worries him with an enormous list of side effects. So has stopped taking it. I tell him that they switch it as Concerta has a resale value, and guidelines prohibit its use in prisons. He looks at me, face scrunched. “Ritalin’s shit”, he says, perplexed. “Why would anyone here want to snort that?”

He lies back on his bunk, above me. Now he just sucks on a vape all evening, or he would, but keeps running out of cartridges. It’s still far cheaper than Nicorette. Then I pick up a feint burning smell, as small embers float downwards past me and onto the floor. The TV channels stop switching, and I realise he has knocked himself out with spice. He doesn’t even need to pay for it. There is so much of it here that it is given out for free.

One day, I arrive back at the cell, and my cellmate tells me that I have to see the doctor about my vision. This isn’t something I’ve told him between spice comas. Instead, a slip of paper from healthcare arrived under our door, informing me of my appointment. And he read it, and now knows I’m maybe not well.

When I go to see the doctor here, I’m pleased to see the healthcare is run by an NHS trust. My hopes are raised by the big NHS logo, that I’ll receive healthcare akin to what I practised, within that same NHS.

But here too, in an all to brief appointment, the GP insists it’s not TIA or stroke. Even me dropping in phrases like Amaurosis Fugax and Hemianopia aren’t enough to sway him, as he ushers me out the door.

It’s here that I really start to worry. That this place will delay my treatment so much that I end up having a full-blown stroke. That part of my brain will not leave prison with me. All because I’m stuck in here, with a single healthcare option, and not out there. Those NHS logos not signalling the standards they should espouse.

Open

Fortunately for me, I arrive at open prison early in my sentence. This is because of who I am, and my ability to navigate prison bureaucracy with relative ease. My literacy standard, backed with years of form filling as a doctor, have paid dividends in this strange world. Those less fortunate remain stuck in higher category prisons, health suffering as a result.

And finally, the GP here admits it might be stroke. He puts me on anticoagulants, which I am able to pick up that same day. I am able to go to external healthcare appointments alone, unsupervised, on temporary licence. That not so subtle reluctance of prisons to send people to external appointments no longer influencing healthcare staff to alter their practise. They can now address the needs of the prisoner, rather than the prison.

In the local hospital, the stroke consultant I finally get to see, says what I am experiencing is typical of stroke, and I must be investigated. He is concerned, and asks why it took so long. He shares that naivety that I once had, in a similar position. I shrug, and say “That’s prison”.

Final Year

In my last year inside, now adequately treated and without the worry that had previously gripped me, I start to really reflect on the differences in healthcare, between that in prison and outside. It’s still hard to get hold of information, even in here, an open prison. But I do learn of this standard of equivalence that healthcare is supposedly held to in prisons. The idea that the healthcare received in here, should be the same as that received in the community. The same healthcare I used to practise. 

Like many in here, I think back to where it all started to go wrong for me. The heavy drinking and drug use in medical school. But I think then of those sleepy afternoon medical ethics lectures, in first and second year. The standards that medical practise should be held to. Things that seemed obvious at the time. Beneficence; to offer the best treatment. Non-Malfeasance; not to allow patients to come to harm. Autonomy; to respect patient’s wishes. And Justice; that access to healthcare was a right for all.

These principles were imprinted on me, and guided my practice, back in the Royal Victoria Infirmary.

But these principles, if applied to prison, show up its grotesque flaws.

Here, in prison, people necessarily come to harm, and are not offered the best treatments. It is baked in, that successful treatment is stopped, not for medical reasons, but for operational reasons. The prison dictates what can be done, be it through changes to medications for security reasons, or not being referred to specialists the guidelines stipulate you should see, because they aren’t available, or because the prison isn’t equipped to do so. 

Autonomy is obviously rescinded, but it is not adequately replaced. You can’t choose your doctor in here. Choices of treatment are limited to what the prison can offer. Requests for treatment must now go through an intermediary, a prison officer, with obvious, tragic results, as you lie behind the door suffering.

Further, you have little to no information to make decisions with what little autonomy remains. Few public health measures designed to better one’s life make it through the walls. Smoking cessation costs the prisoner money. The nutritional content of meals is lacking. But you are welcome to eat all the ultra-processed, obesogenic junk you wish, and use all lung traumatising tobacco products you like. The prison service will happily profit at your expense.

And finally, ironically, justice. Despite housing a population with such high burdens of psychiatric and physical disease, this high level of need is not met. Access to medical care is instead prefaced on the lottery of who you are, and what prison you are in. It is jarringly unjust, in a place existing to preserve and promote justice.

Release

I wonder, in my last few weeks of prison, as I think more about the outside world, where the public and professional concern is. Why this longstanding inadequacy in prison healthcare persists.

Ignorance will play its part. My GP won’t have had any idea that my Venlafaxine prescription wasn’t being acted upon. My stroke physician seemed shocked at the difficulties in being referred. And I certainly had little idea how bad it was in prisons, all those years ago when I was practicing.

But perhaps it is more sinister. That there is a societal acceptance that prisoners should be treated less well than their community peers. It’s prison, after all. A punishment. That the public are just like I was, when I sat in my chair in the waiting room two years ago, as the nurse baited the impulsive prisoner. Seeing this practise as wrong, and yet, not quite bad enough to want to do anything about it.

Pessimistically, I begin to think it would just be easier if we all admitted that it is not possible to have equivalence of healthcare between prisons and society. For sentencing remarks to henceforth state that included as part of the punishment, will be a deterioration of health. That you might even die, because of this sentence.

I leave prison in October 2020. It’s an experience that has shaped me. I cannot leave it behind. Unlike my medical records, which of course were not forwarded to my GP upon release.

Pleasingly, since release, my pessimism has turned to hope. I have discovered that there are in fact pockets of healthcare professionals dedicated to improving the state of healthcare within prisons. That there is a growing movement within the NHS, and other healthcare bodies, setting about to fundamentally change the way healthcare is practised in prisons. To finally change the way healthcare sits within prisons. Not as an adjunct to a static Victorian prison model. But inherent to the functioning of the prison. 

Crucially, they will use the lived experience of those like me and the many others who have traversed prison, to fuel this movement. Removing that veil of ignorance surrounding prisons, that has hamstrung previous efforts to do the same. We can offer unparalleled insights into the failings of prison healthcare, and offer novel solutions.

I’m unlikely to practice medicine again. I will only ever be entering hospitals as a patient. Gone are the days of directly improving people’s health. But the memory of those places, and the standards they upheld, inspire me to work now to instil the same standards into prisons. To take prison healthcare off the critical list, and into a new, compassionate era.