Interview: Prison pharmacist Kaniksha Aggarwal on healthcare in prison

Kaniksha Aggarwal, a prison pharmacist and founder of Prison Pharmacy Connect, tells The Pharmacist’s Emily Warner what it’s like to be a female pharmacist in a male prison, what her typical day involves, and the most common misconceptions about her job.

Emily Warner (EW): What is your typical day as a prison pharmacist?

Kaniksha Aggarwal (KA): First thing in the morning, I go to a briefing with the prison governors, and I don’t just represent pharmacy but also healthcare on some occasions. We share a bit of intel about what’s happened and if there’s any insight I can provide, that’s what I do. Then I’ve got prescriptions to screen and repeats to manage – that is still a core part of my role, similar to community pharmacy.

There might be meetings during the day with the prison, and I might attend those meetings from a pharmacy perspective if we have a concern about a particular patient. I might also end up chairing some meetings, like a medicines optimisation group meeting to consider: Are we prescribing appropriately? Are there any problems with the clinics?

We also provide training for the nursing staff on something called a homely remedy. A homely remedy is like giving someone OTC medicines but only a select few – the quantity will be specific to the prison you’re in. You might only be able to give one or two tablets or a very small-sized tube of cream. My role now is very different to my previous prison job.

EW: Why is your job now so different to your previous role?

KA: It’s very dependent on where you work and who your manager is. I’ve got a clinical manager and a line manager who are two separate people. My clinical manager is a pharmacist, but my line manager is actually the head of healthcare, so she’s got things she wants me to do from more of a leadership point of view. In my previous role however, my clinical and line manager was a pharmacist, so I was solely managed by the pharmacy department, and my role was very heavily medicines related.

There is an opportunity to take your role beyond the traditional role of a pharmacy, and I think that is important. And it’s important people recognise that, just because you’re a pharmacist, it doesn’t mean you can’t do other roles.

EW: Are prison pharmacies impacted by medicine shortages differently to community pharmacies?

KA: It’s the same because the way we source our medicines is no different to the way a community pharmacist would. Whatever happens [outside the prison], we will also experience.

Of course, when there is a shortage, you can’t tell someone in prison to try the pharmacy down the road so you do what you would do in a hospital setting. You would have a conversation with them, explain that it’s a national issue, and that they might need to speak to a doctor to change it.

I’ll give you a fresh example: a guy came in on an inhaler which you can’t get in this country. I told him, if we can’t source this for you, we are going to have to change the inhaler, otherwise you won’t have anything – you would do that in community pharmacy too if there’s a shortage.

EW: Is there any additional training required to be a prison pharmacist?

KA: Not necessarily. There are courses you can do, like substance abuse training for example. The training is called Certificate in the management of Drug Misuse Part 1 and 2. This is provided by SLD training – I have done part one, but I can’t get funding for part two. I’d like to do it because I think it would benefit me but it’s not compulsory. There are so many people working in prison pharmacy who have not had any additional training. You can build up knowledge as you go.

EW: Have you ever felt threatened while doing your job, and how do you deescalate in that situation?

KA: One thing to remember when you're working in a prison is that the people there have control over nothing. They don't even know when they're going to shower. Healthcare is probably the last thing they've got control over so there are times when you have to say no to someone and they don't like it.

I have had situations like that. People have been aggressive, but you have to remember you can choose not to serve them just as you would in community pharmacy. In fact, in community pharmacy, there is nothing between you and the person in front of you. You don't have bars; you've just got a counter, so you're actually in a more threatening situation than in prison.

If [the aggression from the patient] is getting quite bad, you do have a panic alarm, or you can ask an officer to take them away. People think that prisoners are violent or aggressive, but you will always have help available to you and if your tone is calm, then you're more likely to get through to that person. And understanding that this is a place where people have no control, where they can't take their prescription elsewhere, goes a long way with people in prison.

EW: What kind of conditions do you see in prison?

KA: We see everything, and I mean absolutely everything – this is probably where it's similar to hospital pharmacy. If someone on a ward has a pre-existing healthcare condition, the hospital must ensure they are still receiving care while they are in hospital and if that means they have to get a specialist in, that's what they do. It's the same in prison. Sometimes specialists come to us in the prison, or we send the prisoners to the local hospital to have their reviews done.

In terms of conditions, we see absolutely everything. I've seen a really rare disease, which I've never even encountered in the community and that was quite a turning point for me, because I really understood the challenges of healthcare in prison. Someone can't just walk into A&E, as they can in the community – if it's a situation where the patient needs an ambulance, that responsibility lies with us.

I saw a guy who had a rare eye condition, and he needed eye drops to be administered every hour, but they also needed to be kept in the fridge. No one has a fridge in their cell, but his condition was so different that we had to get him a fridge. Then we were doing spot checks to make sure there wasn't anything being kept in the fridge besides his meds.

We organise palliative care; sometimes people are given compassionate leave to go home and spend their last few days there. We see your regular heart conditions, diabetes, depression. I would say the trauma and the mental health conditions that you see in prison are very different than what you see in a mental health setting and even in the community. That trauma really unfolds in a place like prison because time slows down – they're just waiting for time to go by so a lot of thoughts come back to them.

People sometimes think all you're dealing with are substance abuse patients, but if someone has got diabetes on the outside, they're going to have it inside prison too. It doesn't just vanish; they've not gone into another world.

EW: What is Prison Pharmacy Connect and what are you hoping to achieve with it?

KA: Prison Pharmacy Connect is an organization that raises awareness for prison pharmacy, because not many people you know what we actually do – particularly students who have a lot of apprehension about going into the setting. It's also about providing reassurance – I am an Asian female who is quite short and who has only ever worked in a men's prison as well, so I can provide some level of reassurance to other women who are considering working in prisons.

I also do podcasts with people who have been to prison where we discuss their healthcare needs, because there are lots of podcasts out there that talk about people's experiences in prison more generally, but there isn't anything that looks at their healthcare experience.

My aim is to have a network of pharmacy professionals who understand of what we do, the challenges we face, and how we can work better together. I’m also working closely with some organisations involved in the criminal justice setting, because the system needs to change.