Experience of prison psychiatry: a gap in psychiatrists' basic professional training

Abstract

Aims and Method

To survey the forensic psychiatry training and experience received by a sample of successful MRCPsych candidates. A questionnaire was sent to all 208 candidates who passed the Spring 2001 MRCPsych Part II examination.

Results

A total of 99 candidates replied. Of the 42 who had not trained in forensic psychiatry posts, two-thirds had never visited a prison.

Clinical Implications

More supervised visits to prisons should be provided for basic specialist trainees.

The National Health Service (NHS) is taking over prison medical services (Smith, 1999; Birmingham, 2002). The Department of Health began to fund prison health services from April 2003 and, over the next 5 years, primary care trusts are expected to take on the responsibility for their commissioning and provision (Gulland, 2002). The Government recognises that, to provide a high standard of care, continuity with community services when a prisoner is released is vital. Local general psychiatrists will therefore be asked to carry out a large proportion of this work. Given the high prevalence of psychiatric disorder in prisons, there is likely to be a high level of demand for their services (Singleton et al, 1998). It is crucial that they receive appropriate training for this new role.

The Royal College of Psychiatrists recommends that during basic specialist training ‘experience in forensic aspects of psychiatry should be gained, wherever possible, by direct involvement in the clinical care of patients referred to consultants with a special interest or responsibility in forensic psychiatry’ (Royal College of Psychiatrists, 1999). College guidelines state that ‘it is also valuable for trainees to accompany consultants when patients are seen for medico-legal purposes at prisons’… ‘and other establishments’. However, such clinical experience, perhaps surprisingly, is not mandatory (Reiss & Meux, 2000). In this light, we decided to survey forensic psychiatry training and experience in candidates successful in passing the Royal College of Psychiatrists Membership Examination (MRCPsych Part II). Such candidates were chosen because they had completed sufficient basic specialist training to be eligible to sit the examination, had attained an adequate level of competence to be able to move on into higher training, and many may not receive any further experience of psychiatry in prisons or other forensic settings.

Method and results

A questionnaire was enclosed within the results envelope sent from the Royal College of Psychiatrists to all 208 successful candidates (49% of the 429 candidates) in the Spring 2001 MRCPsych Part II examination. The respondents were asked to report details of their clinical experience in forensic psychiatry, as well as to give professional background information.

A total of 99 replies were received - a response rate of 48%. The doctors had been medically qualified for a mean of 7.7 years (s.d.=4.4, range=3.6-26.0 years, mode=5 years). The overwhelming majority (79; 80%) were senior house officers (SHOs) and nine were staff grades. They had been working in psychiatric posts for a mean of 4.4 years (s.d.=2.2, range=1.9-17.2 years, mode=3 years). Almost all (91; 92%) had been trained in psychiatry in the UK, four in Hong Kong, two in the Indian subcontinent, one in Australia and one in Ireland.

Most (57; 58%) had trained under the clinical supervision of a consultant forensic psychiatrist or consultant with a special interest or responsibility in forensic psychiatry. Of these, 29 (51%) had worked in a medium secure unit, 11 (19%) in a high security hospital, 16 (28%) in a forensic locked ward, 7 (2%) in a forensic open ward, 3 (6%) in a forensic community/outreach service, 6 (11%) in a forensic out-patient service, 13 (23%) in a general psychiatry locked ward with a forensic special interest and 8 trainees (14%) had experience of other types of unit (some trainees worked in more than one setting).

Table 1 shows the number of forensic psychiatry settings visited at least once for those trainees who had trained under the clinical supervision of a consultant forensic psychiatrist or consultant with a special interest or responsibility in forensic psychiatry and for those who had not.

Table 1. Settings visited at least once for those with forensic training (n=57) and those without (n=42)

	Forensic training		No forensic training
Setting	No.	%	No.	%	Odds ratio	95% Cl	P
Prison and/or remand centre	50	88	14	33	14.3	4.7-45.9	<0.0000002
Medium secure unit	57	100	15	36	Undefined	Undefined	<0.0000001
High-security hospital	37	65	6	14	11.1	3.7-36.9	<0.000002
Forensic locked ward	29	51	12	29	2.6	1.0-6.7	<0.05
Forensic open ward	12	21	4	10			NS

Comment

The most striking finding of this survey is that two-thirds of the trainees who have not done a placement in a forensic psychiatry post have never, as part of their training, even been inside a prison. There are slightly over 2000 psychiatric basic specialist trainees in the United Kingdom, and only approximately one in eight of these will have the opportunity to train in a specialist forensic psychiatry position (Royal College of Psychiatrists, 2002). Although this does not include those who work under the supervision of psychiatrists in other subspecialities who have a special forensic interest, it is still probable that, at a conservative estimate, in the region of half of these trainees will finish their basic training having had no prison experience whatsoever.

If prison medical services are going to be able to attract psychiatrists to work within custodial environments, it is important that trainees have at least some experience of psychiatry within prisons at an early stage of their training. This survey shows that at the moment not enough trainees are receiving even a minimal taste of prison psychiatry. Perhaps a mandatory objective of basic specialist training should be to provide trainees with a basic understanding of the factors relevant to the practice of psychiatry within prisons, as well as knowledge of the relevant general and forensic psychiatry services that can care for mentally disordered offenders.