Rampton

I may have mentioned that during my placement in GNT I was offered the opportunity to visit the dietitians at Rampton, which is one of only four high-security hospitals in the UK. Patients there have personality disorders, learning difficulties or mental health issues that mean that they present a serious risk to themselves or others. It is also a national centre for treating women and deaf people. As I understand it, the main aim of treatment is to reduce this risk and enable patients to be transferred to a lower security facility. Despite this, the average stay is around 6 years, with some staying much longer.

I spent the day with two of the three dietitians who work there, and it was a fascinating and challenging experience. The environment is pleasant for both patients and staff - light, clean, airy rooms with plenty of windows - but large, thick, heavy, locked doors. Many, many locked doors, and high fences. The majority of work for dietitians is around healthy eating and obesity, but there are a few other chronic conditions. I was particularly interested in how people who have insulin-dependent diabetes are looked after. Obviously they are not freely given insulin and hypodermic syringes, but after a long process of risk assessment and care planning there is one patient who is using an insulin pump. There isn't anyone needing dialysis at the moment, but there was a recent case of possible coeliac disease.

The main difficulty in dietetic treatment seems to be that you can't be sure that the patient is telling the truth, either because of learning disability or because patients can be highly manipulative, especially if they can see an advantage to behaving in a particular way, for example. Claiming to need a 'special' diet would probably relieve the monotony of the normal food, and a hunger strike was described as 'typical attention-seeking behaviour'. The other difficulty is motivation - is losing weight or any other aspect of physical health going to be a priority when there are many other pressing mental health issues (this is a hospital, after all), and a prolonged period of incarceration lies ahead?

Having said that, I observed two consultations, both concerning surgery for weight management, one before surgery and one after. What struck me, apart from the unusual setting and heightened security awareness, is that both consultations and both patients were nothing out of the ordinary, just the same as any other patients that I had seen in GNT. In fact, if there had been anything out of the ordinary, the nurses caring for the patients would have advised that it wasn't appropriate for the consultations to have gone ahead.

Setting aside the one-to-one aspect of the dietitians' job, there are some good examples of work that has been done within the hospital to address aspects of food service and the 'obesogenic environment' that research has shown to be a factor in the obesity epidemic in society at large. As well as indicating the 'healthy' choices on the menu that are low in calories, they have produced photographic menus and labelled those as well. There is a limited daily allocation of milk, bread and butter, and the dietitians also work with the shop to try to discourage unhealthy food purchases.

As I found during my previous visit to a secure mental health hospital, the dietary handicaps for patients are the level of inactivity particularly in the evenings, the relatively large amount of disposable income that patients have, and the availability of the high fat, high sugar snacks that cannot be prevented. And because it's a hospital and access to the grounds is restricted, none of the patients is allowed to smoke, which must be quite a challenge for them and those around them when they are first admitted. Inevitably this leads to weight gain, especially when the health condition and medications used to treat it may also contribute to the effect.

Such a small exposure to such a complex setting often raises more questions than answers. But in terms of dietetic input, it is very little different from treating patients in any other hospital setting, and there are a number of advantages - the nurses are much more inclined to talk to you, the patients and their notes are always available and notes are legible, and there is much less doubt and vagueness about the patients' care or their dietary intake. I think I would prefer to work there than in an ordinary acute hospital.