Unlocking the health of those behind locked doors

If you ask most people to conjure up a physiotherapist in their minds, what will they see? Someone working in sports? A person working with older generations supporting their rehabilitation after a fall or a hip replacement? Perhaps.

How about helping prisoners or those on remand with their rehabilitation? Unlikely, and yet where there’s a population, there’s a physiotherapy service. Today I’m talking with four inspiring physiotherapists doing just that. 

Reflecting on one of the CSP’s strategy aims (2023-27) ‘to improve the health of communities through high quality physiotherapy’, in particular by promoting cultures, policies and practice in physiotherapy services which address health inequity, it will come as no surprise that there are physiotherapists already doing their bit to meet this aim, as they work in partnership with other healthcare practitioners and those within the justice system to meet the needs of patients either on remand or serving a sentence. 

Let me introduce team lead Graham* and his two colleagues Taylor* and Shakti*, as well as Paul New who works for Practice Plus Group’s Health in Justice team.

Graham, Taylor and Shakti work as part of a team of six who support those on remand in prison. The team operates on a rotational basis and head into prison once a week. The remainder of the time Graham, Taylor and Shakti work within the NHS offering MSK services for the general population. Paul, on the other hand, works for a private provider which is contracted to supply health provision to more than 60 prison services operating across England.

Workforce supply

For those of you interested in workforce supply, commissioning still happens through the NHS and as Graham notes they stipulate that services need to provide as similar a physiotherapy service in the prison as outside, so that it is as equal as it can be.

The ‘Big picture’ box below provides greater detail on how services are commissioned across all four countries but while there are different agencies involved, the goal everywhere across the UK is to provide integrated healthcare that addresses health inequalities. 

So what does healthcare in prisons look like?

Graham explains that healthcare is multidisciplinary – with GPs, optometrists, nurses, occupational therapists and physios working closely together. Taylor shares that the multidisciplinary and team-working nature of the role appealed to her. 

She says: ‘Often in MSK, you tend to see the patients one-on-one, but here we tend to go to prison in pairs, so it’s always working closely with other colleagues.’ 

Shakti notes that this is in part what drew her to the role - a curiosity to see how services were delivered. She reflects that her experiences so far have been positive – seeing prisoners with access to 24-7 multidisciplinary healthcare including mental health services, a difference she notes to what is provided within prisons in India, where, as of three years ago, she feels healthcare and rehabilitation services for prisoners were not so well-developed or widespread. 

While the services are set up to be as similar to outside healthcare services as possible, all four physios note that there are significant differences that make the role challenging and rewarding in equal measure. This includes: 
 

• Patient population: Paul explains: ‘We’ve got lots of homeless people, lots of people with substance misuse, loads of childhood trauma, and low educational attainment. Mostly all unemployed, so it’s very much this difficult cohort of people that will keep coming in and out, especially in a remand prison. Integration with mental health and substance abuse services is vital given the level of trauma faced by this population. Over 90 per cent of prisoners over 50 have moderate to severe physical and mental health conditions.’
• Case histories: Because of the transient nature of the population, Taylor says that another challenge is that often these individuals have moved around a lot creating difficulties gaining access to medical records. She adds that this can be compounded when a patient ‘sometimes doesn’t know what different treatments or surgeries they’ve had, or maybe they don’t want to tell us’. Graham also adds that in a setting where prisoners don’t want to be seen as weak, patients may not present at the earliest opportunity and may be reluctant to tell you their case history.
• Clinical caseload: All four physios talk about the clinical aspect of their work. While it is MSK in nature, the MSK health of the patients is poor and the types of injuries and conditions they see are more varied. Unsurprisingly their caseload also consists of respiratory and neurological referrals, as well as conditions that will be familiar to any physiotherapist working within frail elderly, or orthopaedic settings. And they all note that sometimes a patient is there to get a break from their routine – perhaps just because they want to talk, meaning that they may have little desire to get better.
• The nature of injuries: Paul says there’s a prevalence of hand injuries from fights or stabbings. Taylor adds: ‘Our community MSK service doesn’t currently accept any referrals six months post-fracture, but in prison, I get the opportunity to work with patients who might have a bilateral calcaneal fracture after they’ve jumped out of a building trying to run away, for example.’
• The setting: All the interviewees describe the setting using similar adjectives but can be summarised best in Shakti’s words - ‘grim’. Personal items, such as phones, are left behind at the start of the day and delivery of their service is at the mercy of the needs of the prison as a whole. Graham notes that ‘some days there aren’t clinic rooms available, and you’ll have to see the patient on the wings’. He adds : ‘You may only have a short window to see patients in because at 11:15am they will get locked away again because it’s the start of lunch, and they won’t be out until 2pm for another short period before getting locked away again.’
• Health inequalities: The connection between the social determinants of health and the clinical cases prompted Paul to embark on a PhD while Graham and his team are undertaking service evaluations to better understand the MSK health starting point for working with patients within the prison population. Unsurprising to any of them, their findings have shown that those within prisons have higher levels of poor health than the general population. Paul et al’s research into persistent pain highlights the difficulty managing pain for the prison patient population who are likely to be entering the prison service with substance misuse issues, which then become compounded within the system itself. With patients entering the system with higher levels of persistent pain, but the knowledge that pain medication is a currency within the prison system, the complexities around patient care are amplified. 
• Risk of harm: While all four physios acknowledge that they are working with patients who are criminals, none talk of fear of being at risk of harm themselves. All however talk pragmatically about being alert and aware of their surroundings, but rather when considering risk, their focus switches to other prisoners. Graham, Taylor and Shakti all mention that equipment that they routinely give out in other settings, such as crutches and resistance bands, within the prison system can can be used to endanger themselves or other prisoners.

Given these challenges, I’m curious to know whether you need a particular mindset to work within the justice sector. But the interviewees mention qualities at the core of any physiotherapeutic relationship – those of empathy and building trust. 

They also talk of the rewards of problem-solving and finding solutions. In Shakti’s words: ‘That’s my job. I need to be able to provide a proper solution to their problems and I’m enjoying being able to do that for them.’

The four physios also talk about resilience and making use of similar mechanisms to decompress, as those who worked on the frontline during the Covid pandemic or in the military. All four are keen for the CSP to support a network for those that work within this sector – not just to have a space to decompress and share experiences but also to unpick the issues at the heart of care within the prison service – those of addressing the health inequalities that their patients face. 

Paul notes: 

You are dealing with society’s biggest problems. What initially shocked me was how much the social determinants of health lay almost exactly over the top of the social determinants of crime.

He adds: ‘My view of prison before to now is 100 per cent changed. You end up with a lot of empathy for people from disadvantaged backgrounds in struggling lives, and you start to see that their lives could have gone one way or another at one point in time. And this could have been any one of us. Once you see that, you develop empathy.’  

Taylor agrees saying this role has made her think more about society generally. For Graham, he wants to dig deeper into these determinants to make the services the best they can possibly be for patients. 

And when I ask all four whether they would recommend this role to others, it’s a resounding yes. 

I’ll leave you with Shakti’s words: ‘The more you put yourself outside of your comfort zone, the more you evolve, the better a clinician you’ll be. It’s as simple as that.

‘If you get a chance to work within a service like this, I encourage you to go for it’.

Big picture: how it all comes together throughout the UK

Those featured in this article all work in England, however the principles for commissioning health services within the justice sector, as well as their focus, is similar in all four UK countries. Services are tailored to the needs of individuals within the prison system, with an emphasis on integration and tackling health inequalities. All four countries aim to provide rehab and injury management, improving mobility and overall health with the aim of supporting reintegration into society.

In England, health services are commissioned through NHS England, with its framework focused on providing integrated care across prisons, probation services, and community healthcare.

Wales follows a similar model, with NHS Wales and local health boards responsible for commissioning healthcare services in the justice system. 

In Northern Ireland, the Health and Social Care Board oversees healthcare services within the criminal justice system working in partnership with the Prison Service.

In Scotland, health services within the criminal justice system are governed by NHS Scotland and the Scottish Government. Again, the focus is on holistic care and reducing health inequalities, and all new entrants receive comprehensive health assessments.