10 • Profile


INSIDE


Prison GP Dr Iain Brew talks about the challenges and rewards of working behind bars


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T 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, drug- seeking 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


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