The next patient, Tony, tentatively knocked on the reinforced-glass paned consulting room and the SHO nodded to him to enter. He loped in, head bowed, obviously a new prisoner with his prison issue purple tracksuit and black shoes, presently without laces until his suicide risk had been assessed. He reported feeling 'low'.

At 23, this young man's past history was full of rejection, emotional poverty and violence. Tony's mother had been an alcoholic and his father was involved in the drug trade. If Tony refused to deliver drugs to users, his father would beat him. Tony started using cannabis and alcohol at the age of seven and left home at the age of 14. Since then he had had a number of short term casual jobs and been in prison three times previously on short sentences for petty crime. Recently life had been more settled, living with his girlfriend with whom he has two small children. He was still in contact with his ex-girlfriend and the daughter they had together.

Two days previously he was off to do a building job with his best friend. As he came up to road works Tony lost control of the van, skidded through bollards and crashed. He remembered nothing until he was taken out of the van by the police and driven to the police station. He was informed that his friend hadn't made it, and charged with death by dangerous driving.

He was horrified and didn't know what his friend's family would say to him. He was worried about what would happen to his family if he had to spend a long time in prison, and broke down when asked about his children. He hadn't been able to contact his family yet since his PIN for the prison phones hadn't come through by then.

This short case history of a fictional character is not unrepresentative of many that I encountered during my elective placement in HMP (Her Majesty's Prison) Belmarsh, a London prison holding some of the country's most high risk male prisoners.

Why a prison elective?

Around 80,000 people are currently held in prisons at any one time in Britain. These people primarily come from populations with poor health and poor access to healthcare; prison sentences could be an opportunity to impact populations that are usually difficult to reach. The challenge of providing this care in the prison environment is considerable. I was keen to see what care was currently on offer and what plans there were for the future.

What did I do?

During my three week placement I gained an overview of prison medicine by spending time with some of the many medical teams including the GPs and the detox group. My concept of 'care' extended to the spiritual and so I also joined the chaplaincy team.

Jesus inside

The chaplaincy team spend time with prisoners during services, small group Bible studies and in the accommodation blocks. Most prisoners have little previous contact with church but are keen to attend chapel if only to socialise with friends from other accommodation blocks or to trade goods.

I found that the most rewarding aspect of the week was working directly with the prisoners. At first I felt conspicuous and ill at ease, not sure how to approach them and what their response would be to me. Once I got chatting I found that most were pleased to see someone from the 'outside' but rather curious as to why I had bothered to come to prison!

I felt particularly privileged to have the opportunity to pray with prisoners. We prayed through situations that the prisoners were finding it difficult to deal with. One was feeling angry after the prison officers (POs) had 'spun' (searched) his cell and confiscated his soap supply so that he could not wash properly. Another had lost his council house whilst in prison and now had nowhere to go on release.

I remember one prisoner very clearly; a charismatic, intelligent, black east Londoner who used to have a reputation for violence against POs. He became a regular attender at chapel and people began to notice that he was no longer always in trouble. On his release he wrote a letter to one of the chaplains, acknowledging that the beginnings of faith had made a difference to him and although he wasn't quite ready to make a commitment he would like to encourage his mates to give the 'Jesus stuff' a chance.

Clinics in the clink

My first visit to the general ward block was a great shock. I found it difficult to get used to the fact that the main priority in prison healthcare is not so much patient care but security, and the environment reflected that. There is no doubt that the type of patient also poses significant problems to healthcare staff. Most are very needy, some are violent and others are malingering since they are frightened of going onto the main prison accommodation blocks.

A further challenge to medical practice in prison is that the therapeutic options are limited. For example, one of the most common complaints in prison is sleep problems. This is not surprising in the noisy, crowded prison environment where many prisoners are anxious (especially about court cases) and isolated from family and friends. Usual strategies are almost impossible to implement in prison, such as getting plenty of exercise each day, reading quietly rather than watching television before bed, perhaps taking a shower and making sure that the bedroom is quiet and dark. Many prisoners demand benzodiazepines. This may be understandable in the circumstances but doctors have a duty to remember that benzodiazepines have trade value in prison and can be sold on for profit. Prisoners can be highly persistent and adept at manipulating doctors into prescribing more than they initially intended.

I spent most of my time during the three weeks with the psychiatry team. The vast majority of patients will have some psychiatric pathology, with the incidence of psychotic disorders and severe personality disorders being greatly increased in prison. The forensic psychiatrists deal with the more severe end of disorders and many grey cases where court reports have to be prepared to assess whether a psychiatric condition is present and if it contributed to the index offence. It is fascinating and demanding work with very few clear-cut answers.

What are you waiting for?

A placement in prison medicine is a unique type of adventure, taking you to a different world without leaving Britain. You will be stretched, forced to re-evaluate your attitudes, have a chance to share your faith in situations you never imagined and leave from there being humbled. You will see and hear some heartbreaking stories but also witness true friendship between prisoners and laugh with them, as many prisoners and staff alike are great company!