Healthcare and probation

Introduction: Health in probation

Commissioning for healthcare generally follows an assessment of health need through the conduct of a health needs assessment. In the NHS, before the recent reforms, this was the responsibility of Public Health Departments that sat in the Primary Care Trusts. Now healthcare for offenders is split between the NHS Area Teams who assess and commission health for those who are detained (prisons and police custody for example) and Clinical Commissioning Groups (CCGS) who are responsible for those serving community sentences. In the last two years or so, practically every prison, secure children’s home and police force in England has been subject to a health needs assessment (HNA), i.e. health needs of these groups have been assessed. For the current probation trusts there have been six such HNAs undertaken out of the 35 Trusts in existence. In those Trusts where HNAs have been undertaken both physical and mental health needs have been determined to be significantly higher than the general population.

This is not surprising; in 2012 we published research showing that the prevalence of mental health disorders in probation was high (Brooker et al., 2012). For example, the prevalence of psychosis was 11 per cent, at least ten times higher than the general population (and as high as the prevalence in prisons). In addition, substance misuse was common as was personality disorder. Levels of suicidality were also high and actual suicides in probation were rising as the levels in prison declined. The two rates of suicide − in probation and prison − will converge if current trends continue.

The completion of an HNA is an important task because shortfalls in services can be detected, and if resources allow, shortfalls in service provision can be rectified. For example, following the completion of the HNA in Hertfordshire Probation Service, a voluntary agency has been employed to work with the probation service on clients with complex mental health needs and a consultant clinical forensic psychologist has been newly appointed in the drug and alcohol service to work with offenders.

NHS reform and the impact on probation

These findings have been of concern, and in the flurry of the recent NHS reforms, healthcare in probation has yet to be embedded. The most recent offender healthcare commissioning guidance makes it clear that GP-led CCGs are responsible for the provision of healthcare to probation whilst NHS England (and the NHS Area Teams) are responsible for detainees (whether this is in prison or police custody it is worrying that − six months after the healthcare reforms began to be implemented − most CCGs are unaware that this is even in their remit. In order to examine the extent to which the NHS reforms were working the author sent out Freedom of Information (FOI) requests to all 213 CCGs and a common response has been to refer the request to a local NHS Area Team as ‘they deal with offender health’. The CCGs were asked if they directly funded healthcare for probationers in their patch and if so what services were commissioned. In Table 1 the answers to these questions are shown and aggregated to the four main regional teams that commission primary care. As Table 1 shows a minority (5%) of CCGs directly fund general healthcare in probation. Whilst this minority continue to fund innovative services (for example, health trainers in Leicestershire), clearly most CCGs have yet to grasp the nettle. However, rather than criticize CCGs, maybe the wisdom of the architects of NHS reform should be questioned as they were responsible for the disconnect between those on probation and those being detained.

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Table 1.

The extent to which Clinical Commissioning Groups (CCGs) commission healthcare in probation

	Yes	No		Response
		CCG thinks it to be Area Team responsibility	CCG does not commission anything
North of England	3	19	21	63% (43/68)
Midlands and East of England	3	9	34	74% (46/62)
London	0	3	27	94% (30/32)
South of England	2	8	27	74% (37/50)
TOTAL	8 (5%)	39 (25%)	109 (70%)	74% (156/212)

Note: FOI Replies were received throughout October and November 2013.

CCGs often also stated that they were unable to say whether or not mental health services were funded directly to probation as their mental health services were subject to a block contract. In other words, this was at the discretion of the mental health service provider. So FOI requests were sent to the 53 Mental Health Trusts to ask them what mental health services they provided. 40 per cent of Mental Health Trusts did not provide a specific service into probation. The majority did but often this was at a minimum level − that is, attendance at MAPPA meetings and a half day clinic for advice, once a week in the local probation service. Only three teams provided an assessment and treatment service into approved premises.

Transforming Rehabilitation: Reform of probation

NHS reform has also been accompanied by plans to reform probation services themselves under the Transforming Rehabilitation (TR) project. TR has split the probation service into two parts: a new National Probation Service (NPS) which works directly with the Courts and victims and manage high risk offenders and 21 new Community Rehabilitation Companies (CRCs) who manage and deliver rehabilitation interventions to all low and medium risk offenders, both on community sentences and on licence after release from prison. Additionally, the number of NPS teams have reduce by a third from the previous 35 Probation Trusts, leading to challenges with the co-terminosity of NHS commissioning teams in CCGs.

There is a high risk that mental health services for offenders will deteriorate since CCGs, in addition to not understanding their responsibilities for offender health, will now have to negotiate and agree services with two different probation structures – the National Probation Service and the CRCs. This will complicate both commissioning and referral structures for those who will themselves be trying to establish a new working relationship in rather difficult circumstances.

Why does the healthcare of probationers matter?

In the grand scheme of things, why is the mental health of those on probation of any importance? Although there have been some learned commentaries on the relationship between mental illness and offending (see Peay, 2010 for one such analysis) it seems moot to ask whether mental illness is the consequence of offending or vice versa. What is unquestionable is that the NHS should strive to provide an equivalent service for the whole population irrespective of class, colour, creed or offending status. Our research showed that not only was the prevalence of mental health disorders high in probation but that probation staff themselves often failed to notice it. For example, for those with a psychotic illness, reference was only made to this condition in 33 per cent of cases. Add to this the likelihood that such individuals will also be experiencing an alcohol or drug problem and very probably a personality disorder and one should be left with the strong impression that more should be done. More is done in the United States where it has been established that whilst under probation supervision, those with a serious mental illness were more likely to violate their supervision order than those without a serious mental illness. In many states across the US specialist mental health probation staff have been trained to offer a case management service to those with a serious mental illness. These specialists work with lower caseloads than generic probation staff, manage integrated budgets, and look after the client’s range of needs including housing. The development of such workers followed a seminal publication by Vesey in 1994 which described a parole system where clients with serious mental illness were not identified and did not identify the needs of those with a serious mental illness when they did. Sound familiar? The assumption underpinning such services was that ‘the purpose of correctional services for offenders with a mental illness should always be to maximize their potential for living and functioning effectively in the community’ (Clear, 1996: 9). By contrast in the UK, there has been very little use of Mental Health Treatment Requirements (MHTRs) – the only dedicated sentence aimed at offenders with mental health problems. They represented less than 1 per cent community sentences in 2011 with just 567 made in the year to March 2013 (MoJ, 2013). Various reasons have been given for the underuse of MHTRs: MHTRS are more costly than other community orders (National Audit Office, 2008); the stigma of being branded an offender leads to problems with engagement in mental health services (Seymour and Rutherford, 2008); many people in the criminal justice system do not have their mental health problem recognized (McKinnon and Grubin, 2010); there can be lengthy delays in obtaining psychiatric reports on which to base an MHTR (Seymour and Rutherford, 2008).

So what changes would we advocate here? At a national level, the Ministry of Justice and the Department of Health should be designing a national strategy for the healthcare of offenders. Such a programme of work was being actively considered in the Autumn of 2012 before the planning for the NHS reforms paralysed the system. The strategy should look keenly at development in the United States which have now been well evaluated over the past 20 years. The evidence base is there.

At a local level, and given it is their responsibility, CCGs should be undertaking a systematic health needs assessment of their probationer population. This should not only include mental health but physical health too. We would be highly surprised if both physical and mental health needs were not high and largely unmet. Discussions should then take place between CCGs and NHS Area Teams about what interventions should be prioritized. It is highly likely that new healthcare pathways need to be designed. Whatever the outcome, probation training itself should be equipping staff to at least recognize mental health disorders and to take some action in attempting to connect probationers to existing services. Yes, the resource environment is poor, yes, offenders are not attractive to most healthcare professionals but offenders deserve equivalence of healthcare and if it makes it far less likely that they will revoke their orders, such an approach makes sense.