Monday, January 24, 2011

"What, with these feet?!"

Norman Stanley Fletcher, that perpetual con, trying to blag the prison Doctor into giving him decent shoes in the first episode of Porridge, while simultaneously disavowing homosexuality.
Many a truth is woven within the fabric of comedy, and Fletcher's exchange with the Medical Officer is a classic. Not only as a comedy sketch, but as a reflection of the essentials that form part of our dealings with the MO.
The Medical Officer - nowadays a contracted GP - is one of the few gateways that prisoners can try to exploit in order to gain some small advantage or benefit above the herd.
A new mattress? Wide-fitting shoes? A proper chair? An unusual diet? An excuse from work? All lay within the domain of the MO. And the wordly-wise con will try to blag his way from the first moment. Hence Fletcher's complaints about flat feet as soon as he lands at HMP Slade. His previous experience shows!
Of course, there are those whose complaints and maladies are quite genuine. But any medical condition which leads to some perceived benefit, such as comfier shoes, will doubtless be faked by some chancer.
This places the MO in a difficult position. Is he dealing with a genuine complaint or a faker? The historical method of weeding out the later is to treat every con as if he was lying through his teeth, and see who gives up and who ends up at deaths door.
With the dismemberment of the Prison Medical Service in favour of NHS treatment, we had hoped that this malign and mistrustful view of prisoner-patients would wither. To some extent it has, but not completely.
When you go to see your GP, does she assume you are lying? If you require pain relief, is it prescribed? Because these are pretty fundamental to any medical service worth its name. But despite our healthcare now being provided by the NHS, nurses who are based within prisons find it difficult to avoid being contaminated with the attitudes of the screws - that is, anti-con.
This sometimes shows up in small ways. I recently overheard a nurse phoning a hospital outside regarding two appointments. Both times, she referred to the men as 'prisoners'. Not patients, prisoners. As that's an irrelevant consideration for arranging appointments, that merely reflected how that nurse perceives us -prisoners first, patients second. And prisoners come with baggage - such as an assumption that we are invariably lying.
At the grand age of 45, I have had prescription strength painkillers (i.e., anything above Ibuprofen) issued to me by the MO a total of four times in my adult life. Four. Either I am a medical marvel, obscenely healthy, or prison medics really don't like issuing painkillers. I lean - heavily - towards the latter.

This is one of the difficulties facing the MO. Even if they completely avoid being contaminated by the prisons attitudes of prisoners, they then have two other hurdles to negotiate. Firstly, the attitudes of nurses, the permanent staff in the healthcare wing. It is a regular event that some prescription or other is questioned by nurses, mostly prescriptions for the more effective drugs. "Oh, I don't think the Doctor should have prescribed these...". Cynical as I may be about the Medical Officer, they do have the benefit of 8 years medical school and the letters MD; it's not for nurses to question.
The second hurdle for the GP to navigate around is the Formulary. In brief, there is an official presumption against giving strong medications - especially painkillers - to prisoners. Ibuprofen is King in prison healthcare, and it's a cynical truism that Paracetamol can be used to cure anything up to and including cancer.
Fletcher didn't manage to get his shoes from the MO. And he'd have had as much chance as the rest of us as getting decent painkillers.


  1. A minor pedantic point (and not central to the thrust of your article) but I believe comparatively few of the medical practitioners who we address as "Doctor" are actually MDs.

  2. I'm 56 and I've had prescription painkillers twice, for back trouble. People do differ a lot.

  3. I hated the medical staff when I was doing bird. The so called Doctor asked about my drinking habits and I told him I would drink perhaps four cans of lager a night. He diagnosed me as an Alcoholic.

    I got that little matter sorted on release.

    Also from I understand prisons didn't used to release medical notes to an ex prisoner's doctor resulting in several suicides that may not have happened had their own doctors had access to these vital pieces of information.

  4. Three very pedantic points which I mention only in case you're interested.

    1, it's five years of medical school in the UK, and the vast majority of doctors in the UK are not MDs.

    2, we don't like prescribing anything stronger than paracetamol to *anyone* if we can possibly avoid it. I'd imagine most people at forty five have never had strong painkillers, because mostly there is no need for them. I don't know your details obviously so I don't know how reasonable your medication requests have been, but I'm pretty sure it's not unusual for 45 year old men not to be given strong stuff.

    3, there's a certain type of nurse that does that thing about prescriptions whether they're in the prison infirmary or an NHS ward or a private hospital. Even if the person prescribing is the world expert on whatever it is the patient has, even if the nurse can't even pronounce whatever condition it is, a certain kind of nurse will always say "oh, I don't think the doctor meant to prescribe these, I'd better check with the charge nurse..." as if the doctor just wrote down the first thing that came into their head.

    I don't doubt you guys get it worse than your average patient, I just thought I'd add my twopence.

    Incidentally, paracetamol is good for *everything*.

  5. Further to prior pedanticness, Paracetamol when taken regularly is extremely effective. In the hospital people complaining of pain get dosed up on 1g four times a day first, to be augmented or replaced with the harder stuff later.

    It seems that the MO is in a tough place, esp. with prescribing anything which might have non-medicinal use. How to pick out those who really are ill, and those simply after the benefits (not a problem absent in primary care in general).

    I don't see any better solution than in cases where the 'treatment' is valuable whether you're ill or not: simply having a higher suspicion that the patient is 'faking it' if dealing with a prison population. The consequence is inevitably under-treatment. Is there a better way?

  6. It's easily solved, the majority of NHS records are available via computer database. It would take any Doctor/Nurse less than a few minutes to determine whether the patient has pre-existing conditions that may require a bit more than Paracetamol. I am facing a lengthy prison sentence later this year and I regularly take Co-Dydramol for existing problems so this is a concern to me.

  7. ' The historical method of weeding out the later is to treat every con as if he was lying through his teeth, and see who gives up and who ends up at deaths door'.

    Very much like the process involved in receiving disability benefits on the outside. The default tactic is humiliation.