CSP Wales Office

1 Cathedral Road

Cardiff CF11 9SD

029 2038 2429


Chair and Committee Members

Health, Social Care and Sport Committee

National Assembly for Wales

Cardiff Bay

Cardiff CF99 1NA


14th May 2019


Dear Chair & Committee Members


Provision of Health and Social Care in the Adult Prison Estate


The Chartered Society of Physiotherapy (CSP) in Wales is pleased to provide a written contribution to this enquiry.


1.      Physiotherapy ‘offer’ to the adult prison population


1.1 Physiotherapy services should be available to the prison population (adult and children/young people) for the range of services that the profession offers, in particular addressing musculoskeletal (MSK) problems.  Rehabilitation skills and consideration of issues relating to frailty will also be applicable and specific requirements for older prisoners, some of whom may have long-term conditions such as Parkinson’s disease, will be relevant.


1.2 The prison population can benefit from physiotherapy services, which promote activity and exercise, particularly in preventing injury and treating conditions caused by reduced physical activity. 


1.3 Physiotherapists are autonomous practitioners, able to assess, diagnose, treat (and in some instances prescribe) and discharge patients.  Ideally, physiotherapists should be a key member of the prison healthcare staff.  However, this is not the case in most situations in Wales and prisoners therefore need to access physiotherapy services outside the prison setting.  This may be via the NHS in Wales or possibly via a private physiotherapy practitioner.


2.      Feedback from CSP Members in Wales on Current Provision in Welsh Prisons for the Adult Population


2.1 Feedback from CSP members indicates a variation in physiotherapy service provision.


2.2  Most respondents indicated that physiotherapists no longer provide services inside prisons.  Instead, primarily for MSK, prisoners attend community physiotherapy clinics, usually accompanied by two prison officers.


2.3  By contrast, Betsi Cadwaladr University Health Board has two physiotherapists (a Band 7 and Band 6) who work in the recently opened Berwyn Prison.  All their services are provided within the prison environment.  Services involve running clinics in a health and wellbeing building, within clinic settings on the communities (houses) and they use the prison gym and sports hall in collaboration with the prison physical activity department.


2.4  The Berwyn physiotherapists report that they mainly deal with MSK presentations, with a priority focussed on managing referrals to orthopaedics.  This has involved developing a pathway with the GPs within the prison to ensure that, wherever possible, any patients potentially requiring surgical opinion are referred first to physiotherapy to ensure that all conservative options have been fully explored and it is possible to appropriately manage patient expectations.  This model is based on the NHS Clinical Musculoskeletal Assessment and Treatment Service (CMATS) orthopaedic triage service model and there are good links and collaboration with services in Betsi Cadwaladr as required.


2.5  The Berwyn physiotherapists also link with other areas of speciality within the wider physiotherapy team as and when required, eg respiratory and neurology teams and others such as hand specialists in order to ensure that patients receive appropriate input.


2.6  The Berwyn team note they were in a fortunate position in that on opening the prison in 2017 they were able to design the service to, as far as possible, not only replicate good practice already in place in the wider health board, but also to tailor it to meet the needs of the prison population.  A service pathway and service outline are included in the appendix (with thanks to Betsi Cadwaladr UHB and Berwyn Prison physiotherapy service for their inclusion).


2.7  Other member feedback highlights a similar theme that physical activity is overseen by exercise professionals employed at the prisons.


2.8  A concern is raised by one member in relation to the prescription and use of analgesics.  This is an area where it might be helpful to have greater physiotherapy presence for assessment and treatment/advice to manage understanding of medications.  An example was cited that officers were excluding prisoners from using fitness/gym equipment if they were taking particular medications.  The physiotherapy service could see no contra-indication to prisoners exercising.


2.9  A further issue flagged by a member is the resource required by prisons to escort a prisoner to the physiotherapy department.  Staffing issues can lead to prisoners failing to attend and therefore receiving physiotherapy treatment.


2.10      It is reported by the Berwyn team that future plans include the development of a pain management programme to meet the chronic pain issues within the prison population.  It is evident, they note, that this would need a multi-disciplinary approach to address the associated biopsychosocial factors.  There is also a high prevalence of both illicit and prescription drugs misuse related to chronic pain which would need to be explored and addressed through this service and may differentiate it from equivalent services in the general population.


3.      Notable Practice from Outside Wales


3.1  Physiotherapy Frontline featured two physiotherapists who have revamped the MSK care provided for male prisoners at The Mount, a men’s prison close to the village of Bovingdon, on the edge of the Chilterns[1].


3.2  The local NHS Trust, Hertfordshire Community, won the tender to provide services to the prison and added physiotherapy to the team – which already included doctors, dentists, specialist nurses and other visiting health professionals.


3.3  As well as providing physiotherapy clinics, physiotherapists work on chronic pain services with the gym staff and have developed a pathway for the whole service.  Since taking up their posts, the physiotherapists have radically reduced waiting times and their input was recognised by them winning a 2016 NHS England award for ‘Best Healthcare Professional’ in the Anglia region.


4.      Considerations from the Chartered Society of Physiotherapy


4.1  It is clear from member feedback that, apart from Berwyn Prison, most physiotherapy for prisoners is provided outside of the prison setting.  Note – The CSP does not have details of the physiotherapy provision in PARC Prison.


4.2  There are limitations and practical difficulties in attending NHS premises for assessment and treatment.


4.3  Lack of physiotherapy services in prisons may mean that the older prisoners’ needs are not being met.  This is highlighted similarly by physiotherapists commenting on a report by the Justice Committee in Westminster in 2013.[2]


4.4  The Westminster report pointed out, in 2013, that the older prisoners are the fastest growing group in the prison population, with those aged over 60 growing by 120% from 2002 to 2013.


4.5  The MPs report also notes it is broadly recognised that many prisoners have the biological characteristics of those who are 10 years older; they may have chronic health and mental health disorders, as well as disabilities that, in the community, would be typical among those who are significantly older[3].


4.6  The CSP considers there is a need to address the particular needs of older prisoners and suggests that physiotherapists are key professionals who should be involved in the prison health care team.


4.7  The CSP considers there is much that can be learned from the Berwyn model and the profession is pleased to see ‘in house’ service provision in the prison.


4.8  The CSP suggests that generally there is a lack of physiotherapy provision to the Welsh adult prison population which has not been addressed.


The Chartered Society of Physiotherapy is pleased to have played an active part in this enquiry and we look forward to its outcome and recommendations.


Yours sincerely




CSP Public Affairs and Policy Officer for Wales


In association with:

CSP Welsh Board

Welsh Physiotherapy Advisory Group Leaders


About the CSP and Physiotherapy


The Chartered Society of Physiotherapy is the professional, educational and trade union body for the UK’s 58,000 chartered physiotherapists, physiotherapy students and support workers.  The CSP represents 2,400 members in Wales.


Physiotherapists use manual therapy, therapeutic exercise and rehabilitative approaches to restore, maintain and improve movement and activity.  Physiotherapists and their teams work with a wide range of population groups (including children, those of working age and older people); across sectors; and in hospital, community and workplace settings.  Physiotherapists facilitate early intervention, support self-management and promote independence, helping to prevent episodes of ill health and disability developing into chronic conditions.


Physiotherapy delivers high quality, innovative services in accessible, responsive and timely ways.  It is founded on an increasingly strong evidence base, an evolving scope of practice, clinical leadership and person centred professionalism.  As an adaptable, engaged workforce, physiotherapy teams have the skills to address healthcare priorities, meet individual needs and to develop and deliver services in clinically and cost effective ways.  With a focus on quality and productivity, physiotherapy puts meeting patient and population needs, optimising clinical outcomes and the patient experience at the centre of all it does.


Appendix 1.  Betsi Cadwaladr UHB and Berwyn Prison


Physiotherapy Service Outline


See Physiotherapy pathway for an overview of the service which is detailed below.


Accessing the service

·         Men can be self refer into Physio via a unilink message to healthcare.  This is picked up by admin who forward on to us as a task and also request a Self-referral form to be sent out the man for him to fill in and return.  This allows us to gather required information and prioritise his referral appropriately. The form is sent out by the Service User Engagement Officer via the Heath & Well being peer mentors who can offer support to men in completing the form if this is needed.

·         Healthcare staff can refer men via the Therapies referral template on S1.  This is usually done by the GP or Clinical Nurses who are running nurse triage clinics.  We would always recommend that other Healthcare staff that are not in a position to provide any supporting information with the referral signpost men to the self -referral process.  This is especially encouraged if they are approached by a man on the community outside of a clinical setting.  Again this enables us to gather sufficient information to prioritise their care appropriately but also puts some responsibility on the individual to arrange this which we are trying to encourage.

·         Any prison staff calling requesting that a man be seen by a Physiotherapist should be asked to signpost the man to the self-referral process, for the reasons outlined above.  



·         Once referred, a man will be placed on a waiting list for a face-to-face triage clinic appointment.  This will be prioritised as routine or urgent, based on the information provided with the referral.

·         We currently run weekly triage clinics on each of the houses as follows:

o   Tuesday pm               Bala

o   Wednesday pm        Ceiriog

o   Thursday pm              Alwen


·         We always aim to triage a man on their own house to reduce the barriers to men not attending appointments.

·         There may be occasions when a man is asked to attend a triage appointment on another house.  This might be if he is deemed a high priority and needs to be seen as soon as possible or if there is increased demand on one house which may otherwise delay their appointment.



·         During their triage appointment the man will be assessed and an treatment plan developed

·         This will usually be one of the following:

o   Physiotherapy intervention at Health & Well being building or the gym

o   Allocation to a Rehabilitation Exercise group (further details below)

o   Discharge with education and advice regarding ongoing management



Rehabilitation Groups

·           An integral part of Physiotherapy is exercise and physical activity.  We currently run weekly exercise/education based rehabilitation groups at the Owain Glyndwr Sport Hall (Next to Football pitch) which cater for a maximum of 12 men per session.  These are currently as follows

o   Monday am                9.30-10.30 & 10.30-11.30               Lower limb Rehabilitation group (Hip, knee ankle injuries)

o   Tuesday am                9.30-10.30 & 10.30-11.30               Spines Rehabilitation group (Back, neck injuries)

o   Wednesday am       9.30-10.30 & 10.30-11.30              Upper limb Rehabilitation group (Shoulder, elbow & hand injuries)


·         The men will attend the group for 6-8 weeks (on average) however this will be determined by clinical need.  Our aim is to provide the men with an understanding of their condition and the tools to manage it independently in the future.

·         Prior to starting the group, the men are sent a letter outlining some details about the group and any expectations.  This is sent via admin.


Onward Referrals

·         There may be occasions where, following assessment, men need referral to other services within Berwyn for additional support (GP, Primary Care, Occupational Therapy, Podiatry).

·         Some men may also need to be referred for specialist opinion to services outside of Berwyn with the local Health Board such as Orthopaedics, Orthotics, Pain Management.

·         We currently have a pathway in place that requires all men being referred to the local Orthopaedic to be assessed screened by Physiotherapy prior to referral.  This ensures that men are receiving the most appropriate care in a timely manner and that all appropriate conservative treatment options have been considered prior to them having a surgical opinion.


Waiting Times

·         There is currently an average wait of 14 days to be seen face to face in triage clinic following receipt of referral.  This will fluctuate depending on time of year and staffing resources.

·         Referrals deemed as being urgent will be seen sooner than this depending on clinical need and staffing resources.


Appendix 2 – Physiotherapy Service Pathway











[1] https://www.csp.org.uk/frontline/article/physio-prison-inside-story

[2] https://www.csp.org.uk/frontline/article/older-prisoners-may-be-missing-out-physiotherapy-assessments

[3] https://publications.parliament.uk/pa/cm201314/cmselect/cmjust/89/89.pdf