What Health Care?

Here's an interesting LSE blog that contains information long known to all probation staff, but that may come as news to the privateers now running 70% of probation:- 

Healthcare policy for those on probation operates on a wing and a prayer.

Over 200,000 offenders on are probation in the UK. Recently, probation has been extended to all those released from prison. Offenders are often socially excluded, deprived and highly vulnerable, with a high prevalence of physical and mental health problems compared to the general population. Here, Charlie Brooker outlines how this vulnerable population can fall through gaps in healthcare policy.

Comin’ in on a wing and a prayer
Comin’ in on a wing and a prayer
Though there’s one motor gone
We can still carry on
Comin’ in on a wing and a prayer
(Adamson and McHugh [1943] – songwriters)

Previous research estimates that 39 per cent of offenders experience a mental illness whilst on probation. Suicide rates in prison rightly receive much media attention, yet suicide rates in probation are also much elevated in comparison to the general population but receive little consideration. Mental health treatment requirements exist as a sentencing option for the courts when considering prison or probation for an offence, but they’re rarely used. Nationally, they constitute 0.1 per cent of all requirements.

The health of probationers compares highly unfavourably with the general population, and even with the more unhealthy of the population (the lower social classes). This is the case for both physical and mental health.

Many offenders have (co-occurring) substance misuse problems. In the first two weeks following release, mortality rates are 12 times higher than for the general population. In a nested case control study, Bingswanger and colleagues established some of the clinical risk factors involved. These included: injecting drug use; tobacco use; cirrhosis; panic disorder and use of psychiatric medications. Probationers also experience elevated levels of long-term illness and disability.

The need for continuing and integrated healthcare is clear.

However, issues like mistrust of healthcare professionals, transient lifestyles, negative attitudes amongst healthcare staff towards offenders, problems with inter-agency communication, and inflexible/insufficient service provision mean that offenders’ access to healthcare is less than their needs. Many offenders are not registered with a GP and only access healthcare during crises.

To improve the health of this population and reduce health inequalities it is essential that they have access to health services which meet their needs. This would also enable us to uphold the principle of equivalence and reduce both re-offending and the use of crisis services (and the costs associated with this).

Probation services and arrangements for commissioning healthcare for offenders have both been the subject of recent reforms. Probation provision is now split into the National Probation Service – a public-sector service managing high-risk offenders; and Community Rehabilitation Companies – a mix of private and voluntary sector agencies managing medium and low-risk offenders.

Clinical commissioning groups should now commission healthcare for offenders on probation, but previous research suggests that many of them are unaware of this responsibility. The most recent study found that in 2013, 7 per cent of these groups directly funded healthcare in probation, a figure that declined to 1 per cent in 2014. Such commissioning should be informed by Joint Strategic Health Needs Assessments overseen by Directors of Public Health. It is iniquitous that all 136 prisons in England and Wales have been subject to local health needs assessments by either NHS England Area Teams or local public health groups whereas the same is true of only 25 per cent of probation services.

Some Mental Health Trusts do fund ‘own account’ mental health services into probation from their block contracts, but again this proportion has declined from 70 per cent in 2013 to 61 per cent in 2014. The two most likely services provided were clinics in probation offices and support for multi-agency public protection arrangements – the latter being a statutory responsibility. Clinic services vary but often consist of two hours per week where a mental health professional is available to give advice. There has also been a recent national initiative to provide professional support in probation for those with personality disorder. However, the impact of this scheme has yet to be reported.

Previously, government has outlined a role for the probation service in England and Wales in offender health involving advising the courts on alternatives to prison, and working in partnership with other agencies to ensure that offenders’ health and social care needs are addressed. There are links between health and offending, and health interventions can reduce crime. Improved health has been cited as a pathway out of re-offending, and considering offenders’ physical and mental health needs in sentence planning using the Offender Assessment System screening tool is an established part of probation staff’s role. However, there are concerns that local-level partnerships between probation and health services may break down following the restructure of probation and (for the reasons stated above), improving offenders’ health and access to healthcare remains a challenge.

Due to this high level of health needs and disproportionately low level of service access, the NHS, through clinical commissioning groups, should be commissioning healthcare locally for probationers with an in-depth understanding of needs and with a view to removing current barriers to service access for this population. Until then ‘we’re comin’ in on a wing and a prayer’.