This Position Paper addresses the health needs of offenders under supervision in the community and presents principles for improving these services and the take up and use of services

Brooker, Charlie

Sirdifield, Coral

University of Lincoln Institutional Repository

   OFFENDER HEALTH PI Position Paper 2/17 November 2017 Probation Institute: admin@probation-institute.org       Abstract This Position Paper addresses the health needs of offenders under supervision in the community and presents principles for improving these services and the take up and use of services.   Published by the Probation Institute/ this paper may be reproduced without prior approval as long as source is acknowledged /PP2/17     2 Offender Health  Introduction 1.1 This Position Paper addresses the health needs of offenders under supervision in the community and presents principles for improving these services and the take up and use of services. The paper recognises that the severe health issues manifest by individuals in prison is a significant but structurally separate challenge, which is addressed here briefly, because the health of prisoners impacts significantly on the supervision of these individuals on release into the community.  1.2 Everyone in the criminal justice system is an individual with his or her own needs. However, research shows that, often, offenders are:   From deprived backgrounds  Vulnerable  Likely to have more, and more complex physical and mental health needs than the general population, and   Do not access healthcare, or only access it at crisis point 1.3 Researchers have estimated that around 39% of offenders experience a mental illness whilst on probation [1, 2], and the rate of serious mental illness such as psychotic disorders is very high in this population (11% are estimated to have a current psychotic disorder compared to 0.4% of the general population) [2, 3].  1.4 In 2016 there were 40,161 incidents of self-harm in prisons, the equivalent of one incident for every two prisoners. In the same year there were 120 self-inflicted deaths in prison, almost twice the number in 2012, the highest year on record but likely to be exceeded in 2017. In 2016, the Prisons and Probation Ombudsman found that 70% of prisoners who had committed suicide between 2012 and 2014 had mental health needs. 1.5 Government needs to address the rising rates of suicide and self-harm in prisons as a matter of urgency and to recognise the challenging impact on probation and wider justice agencies of the health needs of offenders on release from prison. 1.6 Many offenders also have substance misuse problems, and they are more likely to report a long-term illness or disability than the general population [4]. In the first two weeks following release from prison, mortality rates are 12 times higher than for the general population due to issues such as injecting drug use, tobacco use, cirrhosis, panic disorder and use of psychiatric medications [5].  1.7 However, despite often experiencing complex health issues, many offenders do not access healthcare, or only access it when they reach crisis point. This is due to barriers such as:  Mistrust of healthcare professionals  Transient lifestyles  Not being registered with a GP  Negative attitudes of healthcare staff towards offenders  Inter-agency communication problems  Inflexible and insufficient service provision [6-13]  Published by the Probation Institute/ this paper may be reproduced without prior approval as long as source is acknowledged /PP2/17     3 1.8 Staff working in criminal justice and health settings (including public health) are well placed to overcome some of the above barriers. It is important that all criminal justice and health staff work together to monitor and improve the health of offenders both as an end in itself, and because improved health may also increase compliance with community sentences, is potentially a way of reducing reoffending [12, 14], and is likely to lower the current high use of crisis services [12] which could result in much needed cost-savings to the NHS. There is an important role for ex-service users in supporting offenders in engaging effectively with health services; this work is promoted by voluntary organisations including Revolving Doors and User Voice. 1.9 Whilst NHS England commissions healthcare in secure environments, Clinical Commissioning Groups (CCGs) are responsible for commissioning healthcare for offenders in the community [15-17], with Public Health Departments in Local Authorities commissioning drug, alcohol and public health services. Commissioning should be informed by Joint Strategic Health Needs Assessments prepared through Health and Wellbeing Boards [18]. However, research has shown that many CCGs are unaware of their responsibility [19, 20], and many Joint Strategic Health Needs Assessments do not contain specific sections considering the health needs of offenders in the community. As steps towards improving offenders’ health and thereby reducing health inequalities, there are a number of principles that criminal justice and health agencies should adhere to:  Principle 1: There should be a national strategy for healthcare for those in contact with probation Both probation provision and the commissioning of healthcare for people in contact with probation have been subject to reforms. Agencies appear to be unclear about their roles and responsibilities. If we are serious about reducing health inequalities in our society and having rehabilitation as a central focus of criminal justice agencies, then there is an urgent need to develop a national strategy for healthcare for those in contact with probation. Such a strategy would focus attention on this area, enable sharing of knowledge around best practice, including appropriate provision for diverse groups, and ensure that there is a strategy for measuring and monitoring progress in this area in the future. Principle 2: High quality healthcare should be provided to all based on clinical need Everyone has a right to good quality, evidence-based healthcare regardless of their background, personal characteristics or financial resources. The services that are commissioned and how they are provided should be based on an assessment of the population’s health needs and models of good practice Principle 3:  All service users should at all times be treated with respect, dignity and compassion Service users should not encounter discrimination, stigma or negative attitudes when seeking and accessing healthcare Principle 4: Women may require a carefully tailored approach to take account of their particular health needs Women who come into contact with the criminal justice system may often have experienced issues such as trauma, domestic abuse, trafficking and sex working. Nearly half of women in prison have suffered domestic abuse, and over half have experienced childhood abuse.     Published by the Probation Institute/ this paper may be reproduced without prior approval as long as source is acknowledged /PP2/17     4 Principle 5: People from BAME backgrounds may require a carefully tailored approach to take account of their particular health needs Research also highlights that different ethnic groups have different rates and experiences of mental and physical health problems. A tailored approach to healthcare provision is needed which reflects different cultural and socio-economic contexts and enables access to culturally appropriate services.  Principle 6: Criminal justice and health agencies should work in partnership to monitor and improve the health of offenders in their area Probation agencies, Clinical Commissioning Groups, Public Health Departments and voluntary agencies should work in partnership to ensure that offenders’ health needs are recognised and addressed Principle 7: Cross-agency training should be provided to enable criminal justice staff to identify health, including mental health, issues and refer into appropriate agencies Given the high level and complexity of physical and mental health problems experienced by many offenders in contact with probation, it is important that staff receive adequate training to identify offenders’ health needs, and refer them into appropriate services. Providing cross-agency training enables all agencies to increase their understanding of each other’s roles, remits and responsibilities Principle 7: Agencies should engage the support of ex-service users in encouraging better and more effective take up of heath care by offenders Organisations such as User Voice and Revolving Doors can offer advice and point towards resources to enable support by ex-service users as peer mentors and supporters. Principle 9: Health should be considered in all routine HM Inspectorate of Prison and Probation visits Having good health is important in terms of potentially assisting compliance with probation, reducing re-offending and helping individuals to maintain employment. Ensuring that agencies are assessing and addressing offenders’ health needs should be a core part of all routine HM Inspectorate of Probation visits (as currently happens in HM Inspectorate of Prison visits). Principle 10: Health and Wellbeing Boards should consider the needs of offenders in contact with probation in their Joint Strategic Needs Assessments Commissioners need to recognise that people in contact with the probation service are a vulnerable and marginalised group within their local community. These individuals often have a high level and complexity of health need and face many barriers to service access. One way of beginning to overcome these barriers and improve the health of this population is to ensure that their needs are fully considered as part of local Joint Strategic Needs Assessments. Presently, there are 152 Departments of Public Health but only 15 of these have published Health Needs Assessments for probation.        Published by the Probation Institute/ this paper may be reproduced without prior approval as long as source is acknowledged /PP2/17     5 Conclusion The Criminal Justice pathway is complex following reform in 2015.  The commissioning and the provision of healthcare are similarly multi-faceted. There is a basic lack of understanding on the part of Clinical Commissioning Groups that healthcare for offenders sits firmly in their bailiwick. National research, funded by the National Institute for Health Research, led by Dr C Sirdifield, aims to produce a commissioning toolkit for CCGs hopefully improving their performance in this area (see http://cahru.org.uk/2017/02/28/improving-healthcare-commissioning-for-probation-mapping-the-landscape/ ). Public Health Departments have responded poorly to identifying the health needs of this population. The challenges are immense when set against the backcloth of austerity. We believe there is now the need for a national strategy for healthcare in probation.   Annex 1.  References 1. Brooker, C., et al., Probation and mental illness. Journal of Forensic Psychiatry and Psychology, 2012. 23(4): p. 522-537. 2. Brooker, C., et al., An Investigation into the Prevalence of Mental Health Disorder and Patterns of Health Service Access in a Probation Population. 2011, University of Lincoln: Lincoln. 3. Singleton, N., et al., Psychiatric Morbidity among Adults living in Private Households, 2000: Summary Report. 2001, Office for National Statistics: London. 4. Mair, G. and C. May, Offenders on Probation, Home Office Research Study 167. 1997, Home Office: London. 5. Binswanger, I.A., et al., Clinical risk factors for death after release from prison in Washington State: A nested case control study. Addiction, 2015. 6. Abdul Pari, A.A., et al., Health and wellbeing of offenders on probation in England: an exploratory study. The Lancet, 2012. 380(S21): p. 21. 7. Brooker, C., et al., Community managed offenders' access to healthcare services: Report of a pilot study. Probation Journal, 2009. 56(1): p. 45-59. 8. Clinks, Good person-centred care for offenders in the community. Evidence to support Care Quality  Commission inspections. 2014, Clinks: London. 9. Durcan, G., et al., The Bradley Report five years on. An independent review of progress to date and priorities for further development. 2014, Centre for Mental Health: London. 10. HMIP, An Effective Supervision Inspection Programme Thematic Report. 'Half Full and Half Empty'. An Inspection of the National Probation Service's Substance Misuse Work with Offenders. 2006, HMIP. 11. Howerton, A., et al., Understanding help seeking behaviour among male offenders: qualitative interview study. BMJ, 2007. 334: p. 303-307. 12. Revolving Doors Agency, Balancing Act. Addressing health inequalities among people in contact with the criminal justice system. A briefing for Directors of Public Health. 2013, Revolving Doors Agency, Probation Chiefs Association, Public Health England: London.  Published by the Probation Institute/ this paper may be reproduced without prior approval as long as source is acknowledged /PP2/17     6 13. Social Exclusion Unit, Reducing re-offending by ex-prisoners - Report by the Social Exclusion Unit. 2002, Office of the Deputy Prime Minister: London. 14. Home Office, Reducing Re-offending National Action Plan. 2004, Home Office Communication Directorate. 15. NHS Commissioning Board, Securing Excellence in Commissioning for Offender Health. Frequently asked questions. 2013, NHS Commissioning Board: London. 16. NHS England, Commissioning fact sheet for clinical commissioning groups. 2012, NHS England: London. 17. NHS England, Securing Excellence in Commissioning for Offender Health 2013, Crown Copyright: London. 18. Department of Health, Statutory guidance on joint strategic needs assessments and joint health and wellbeing strategies. 2013, Department of Health: London. 19. Brooker, C. and D. Ramsbotham, Probation and mental health: who cares? British Journal of General Practice, 2014. 64(621): p. 170–171. 20. Brooker, C., et al., NHS commissioning in probation in England: on a wing and a prayer. Health and Social Care in the Community, 2015.  With thanks to Dr Coral Sirdifield and Professor Charlie Brooker  Acknowledgements: Thanks to Lord David Ramsbotham for his helpful comments on this paper  

Offender health [PI Position Paper 2/17]

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Offender health [PI Position Paper 2/17]

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