The term ‘offender’ refers to an individual who has come into contact with the criminal justice system by committing a crime or violating a law.

The link between offending, re-offending and the impact on health is well known.

Offenders and ex-offenders are far more likely to be more socially isolated and marginalised than the general population and to have a broader range of health concerns. As the number of people who come into contact with the criminal justice sector increases, there will be an increasing number of ex-offenders in communities.

There is a real need to divert offenders who have serious mental health problems away from prison and into the appropriate health service facilities. The needs of those suffering from physical health problems and from substance misuse and abuse must also be addressed.

This topic links with the following JSNA topics:

Last updated: 2014-01-20 15:50:38
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1. What are the key issues?


  • 90% of prisoners have substance misuse problems, mental health problems or both;
  • 72% of male prisoners and 70% of female prisoners suffer from two or more mental health disorders;
  • 20% of prisoners have four or five major mental health disorders;
  • 83% of prisoners smoke (averaging 16 cigarettes per day);
  • 9% of prisoners suffer from severe and enduring mental health illness;
  • 10% of prisoners have a learning disability;
  • up to 50% of new prisoners are estimated to be problem drug users;
  • 40% of prisoners declare no contact with primary care prior to detention;
  • People who have been in prison are up to 30 times more likely to commit suicide (in the first month after discharge from prison) than the general population;
  • 20% of male and 37% of female sentenced prisoners have previously attempted suicide;
  • There is often poor continuity of health care information on admission to prison, on movement between prisons and on release;
  • 49% of male, sentenced prisoners were excluded from school (2% in general population).


  • Many offenders in Middlesbrough are not accessing the support they require.
  • Local needs analysis (specifically the health needs assessment) is unco-ordinated between organisations.
Last updated: 20/01/14

2. What commissioning priorities are recommended?


Consider offender health in the context of broader health & social care and public health issues with much closer working relationships strategically and operationally, especially in primary care.


Reflect the public health outcomes framework in local strategies to reduce re-offending.


Emphasise family/social isolation issues in local care planning processes.


Improve the co-ordination of the assessment of offender health needs and the action plans between organisations.


Emphasise that offenders are seen as a priority group within health commissioning processes, with appropriate resources targeted at them. Full use of access to this socially isolated group should be made through the criminal justice and drug & alcohol treatment services.


Reflect the needs of offenders in local housing and employment strategies/action plans.


Develop local services and approaches so that they are more closely aligned with the ‘Big Diversion’ project and with commissioning processes within the ‘The North East Offender Health Commissioning Unit’.


Include recommendations from the prison and probation health needs assessments in local partnership action plans.

Last updated: 20/01/14

3. Who is at risk and why?

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4. What is the level of need in the population?

Content currently being revised.

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5. What services are currently provided?

Big Diversion Project

A comprehensive mapping of services related to offender health will be taking place in 2012 as part of the Big Diversion Project.

Early intervention, arrest and prosecution

Services are co-ordinated through joint working between the Safer Middlesbrough Partnership, childrens, families & learning departments in the local authority and appropriate organisations and include:

  • Family-related work;
  • Neighbourhood policing; and
  • Youth offending team.

The court process

There are different support systems available within the courts. These are primarily delivered by mental health services and via the Drugs Intervention Program.

Prison, community sentences and resettlement

HMP Holme House

Clinical provision is provided by CareUK and includes a full range of healthcare interventions including substitute prescribing for substance misusers.

There are currently four non-clinical, drug treatment-specific services:

  • CARAT service (Counselling, Advice, Referral, and Throughcare) is the primary method used to address the non-clinical treatment needs of the majority of prisoners with substance misuse problems;
  • Short Duration Programme (SDP) is an intensive 4-week programme focused on harm reduction goals and based on cognitive behavioural goals;
  • Therapeutic Community (TC) is a residential, 10 to 12 month programme, focused on abstinence goals and based on pro-social modelling, cognitive behavioural and peer support techniques;
  • Drug Recovery Wing (DRW) is a residential programme and requires a commitment to reduce medication.

HMP Kirklevington Grange

Kirklevington has a CARATS service and clinical healthcare provision similar to that of Holme House.

National Screening Programmes

Work continues to include prisoners in the bowel screening programme.  A regional solution is being developed and supported by the regional cancer screening hub.

Prisoners have access to retinal screening in Holme House and Kirklevington Grange via a visiting service and abdominal aortic aneurysm (AAA) screening is currently being introduced.

NHS Health checks have been commenced within both prisons via CareUK.


DTV Probation Trust

  • Health Trainers have been in post since May 2011.
  • Offender Managers work with offenders on a one-to-one basis and in conjunction with community resources and partner agencies to address individually identified criminogenic needs as outlined in the offender’s sentence plan.
  • Alcohol treatment and drug rehabilitation requirements are available as a statutory requirement of a community/suspended sentence order. However, the continuing provision of such interventions is dependent upon local authority area/PCT funding allocations/priorities.

The Middlesbrough Integrated Offender Management (MIOM) scheme

The MIOM is a multi-agency service that works with the most prolific offenders in Middlesbrough.

Last updated: 20/01/14

6. What is the projected level of need?

The DTV Probation health needs assessment identifies several trends that are getting worse, especially those related to mental health and to smoking.

Early indications are that alcohol and drug misuse continue to have a significant impact on offender health with alcohol misuse a particular concern. The Local Alcohol Profile (LAPE) shows that there are more alcohol-related admissions locally each year and that alcohol-related mortality is increasing for males.

The evidence base from national data sets and research would indicate that mental health continues to be a key area of concern and that overarching issues such as accommodation and employment affect offender health.

Last updated: 20/01/14

7. What needs might be unmet?

Mental health

There is clearly a high level of need amongst offenders in respect of mental health. It has already been identified in local and national needs assessments that this is an issue.

Learning difficulties/disabilities

It is unknown how many offenders have learning difficulties/disabilities that are undiagnosed and therefore have unmet support needs.

Substance misuse

Alcohol misuse remains a major problem with the long-term consequences for healthcare. Access to support via primary, secondary and specialist care is available, but this needs to be extended (especially in relation to early interventions). The type of drug(s) an offender uses dictates the intervention/s offered to them. This process needs to be further developed to meet the changing profile in substances used.


Smoking remains a major risk to health. There are some processes in place for dealing with smoking and other lifestyle risks (staff working within the criminal justice system or via referral to community services) but this does not meet all the needs of the client group.

Housing & employment

Access to appropriate housing and to employment is a key priority. This has a major impact on reducing offending and improving health.

Female offenders

There are difficulties associated with engaging females into support and/or treatment and there is the possibility that vulnerable women will not use services.

Young offenders

If youth offending service officers do not have access to the relevant training and associated support then it increases the possibility that young offenders health needs will be unmet.

Children of offenders

The level of need is not currently known for children of offenders. Investigation, effective interventions and integrated working is required.

Needs analysis

There is a need to improve processes for identifying unmet needs. There is an under-reporting of mental illness, learning disabilities and blood borne viruses.

Last updated: 20/01/14

8. What evidence is there for effective intervention?

Content currently being revised.

Last updated: 20/01/14

9. What do people say?

The 2012 Health Needs Assessment for both local prisons details the findings of focus groups and surveys of offenders, including the perception of the quality and accessibility of the different healthcare services.

Holme House

The highest rated services for quality at HMP Holme House were:

  • Nurse led clinics (46%);
  • Sexual health (40%);
  • Immunisations and vaccinations (38%).

The lowest rated services for quality at HMP Holme House were:

  • Physiotherapy (28%);
  • Dentist (27%).

The highest rated services for accessibility at HMP Holme House were:

  • Nurse led clinics (39%);
  • Sexual health (37%);
  • Immunisations and vaccinations (38%).

The lowest rated services for accessibility at HMP Holme House were:

  • Dentist (18%);
  • Podiatry (15%).

Kirklevington Grange

The highest rated services for quality at HMP Kirklevington Grange were:

  • Mental health services (89%);
  • Nurse led clinics (84%);
  • Immunisations and vaccinations (82%).

The lowest rated services for quality at HMP Kirklevington Grange were:

  • Physiotherapy (43%);
  • Dentist (43%);
  • Physical disabilities (33%).

The highest rated services for accessibility at HMP Kirklevington Grange were:

  • Mental health services (100%);
  • Learning disabilities (100%)
  • Immunisations and vaccinations (92%).

The lowest rated services for accessibility at HMP Kirklevington Grange were:

  • Dentist (50%);
  • Physiotherapy (50%);
  • Podiatry (50%).

The perception of quality and accessibility scores tended to be higher at HMP Kirklevington Grange than HMP Holme House.

Durham Tees-Valley (DTV) Probation Trust

Stopping smoking was identified as a main need by 24% of respondents to the 2011 DTV Probation Trust HNA questionnaire.

The DTV Probation Trust caseloads for mental health have increased in 2011 and this is clearly an area where signposting, support and further investment will be required. 

DTV Probation HNA 2011 report states than 20% of respondents are currently misusing illegal or prescription drugs. 26% of respondents felt they wanted or needed to cut down on their drug use.

The DTV Probation HNA 2011 showed a considerable rise in the number of respondents who felt they should cut down their drinking; from 35% in 2008 to 47%.  Nationally, just under 5% of adults disclose drinking at harmful levels and 17.5% disclose being binge drinkers (Source: Local Alcohol Profiles England

In 2011, there were a higher number of offenders (47%) who felt guilty about their drinking, than 39% in 2008.

In 2011, there was an increase in the number of offenders who had had a drink first thing in the morning from 24% in 2008 to 29% in 2011.

The DTV Probation Trust caseload has had an increase in the number of respondents who identify themselves as smokers (from 72.8% in 2008 to 77% in 2011).

The Safer Middlesbrough Partnership Client Satisfaction Survey (CSS)

This is an annual survey of clients who are currently accessing drug and alcohol treatment services in Middlesbrough. Although not all clients have entered treatment via the criminal justice system (45% have been arrested in the last 12 months) it is still a good indicator of offender health.

Mental health

Over one-third of the respondents (36.84%) say they have poor or very poor mental health.

There is no significant correlation between age and mental health, although the proportion of 18 to 24-year-olds is slightly higher than for the general sample.  It does appear that women are more likely than men to suffer from poor or very poor mental health.


Over one-half of respondents have either attempted suicide or ‘prefer not to say’. 

One-third of those saying they have attempted suicide describe their mental health as good and another 7.3% as very good.  However, the proportion of respondents who rate their mental health as poor/very poor who have attempted suicide is 52.3%. 

Respondents who report having either none or just one or two close relationships appear to have worse mental health than those with a higher number:

  • 62.1% have poor/very poor mental health as opposed to 36.8% of general respondents.
  • 60.6% have attempted suicide. This is much higher than general respondents at 38.3%.  This would suggest that not having many significant others impacts on mental health and likelihood to attempt suicide.

Lifestyle issues

The CSS questionnaire did not ask about specific health needs, only about general physical health. There appears to be a correlation between accommodation status and poor physical health especially those who have experienced rough sleeping. 

Similarly and unsurprisingly, those with very poor physical health are more likely to be unemployed and unfit or unready for work and only one respondent reported employment and one reported volunteering.  However, although less than the proportion of the general sample, 20% still say they are unemployed and ready for work.  What is of some surprise is that those who rate themselves as having poor (rather than very poor) physical health seem to be even less likely to feel they are fit or ready for work than both those with very poor health and the general sample. 

For those with good/very good health, a much higher percentage are occupied constructively including 8.7% volunteering and 11.1% in employment. A high proportion (36.6%) say they are unemployed and ready for work. 

The DTV Health Needs Assessment

A health needs assessment was carried out across all offender management units (OMU) in Teesside in 2008. This was repeated across the merged Durham Tees Valley Probation Trust in 2011.The Health Needs Assessment questionnaire was made available to all offenders over a 1-month period and aimed to gather information regarding the health requirements of offenders on probation in the area, Middlesbrough achieved a 3.4% return (27 offenders).

The overall picture of health needs across the probation area is shown in the chart below. The chart illustrates that the needs of the offenders questioned have remained relatively consistent between 2008 and 2011. 

Whilst there is a decrease in the number of respondents identifying smoking as a health need, it is a concern that the 2011 HNA identified a 4.2% increase in the number of respondents who smoke. 

Whilst it is positive that there has been a reduction in the need for help with dental issues, this remains a key concern for the offenders questioned.

Healthy eating, weight management, safe/sensible drinking, drug misuse and healthy lifestyle/exercise are needs that have been identified as moderate health needs and are all issues that could be addressed via the core functions of the health trainer or via established referral pathways into treatment services.

Last updated: 20/01/14

10. What additional needs assessment is required?

  • A more co-ordinated approach is required to gather information in relation to the health needs of offenders in adult and young person’s services.
  • Health needs assessments (HNAs) should be very closely linked with public health information processes.
  • The “Big Diversion Project” needs to be used to gather information for future needs analysis.
  • Within prisons, there is an under reporting of mental health, learning disabilities and blood borne virus issues.
  • Within prisons, issues such as housing and employment need to be addressed in the HNAs as these impact heavily on health outcomes. 
  • The numbers completing the HNA with regards to probation need to increase for the process to be comprehensive.
  • There is currently no specific health needs analysis of young offenders locally.

The Safer Middlesbrough Partnership CSS could be improved to ask more specific questions on health issues. The CSS needs to identify offenders so that this data can be extrapolated from the overall picture across substance misuse services.

Last updated: 20/01/14

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