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The level of need in the population

Adults :: Offenders :: The level of need in the population

Contact with the criminal justice system may provide the first point of contact with healthcare services for an individual offender. In 2011, 125 individuals who came into contact with the criminal justice system, aged between 40 and 74 years, agreed to undergo an NHS Health Check. Fifty of these were referred back to their GP for advice or treatment. The results showed that 57% were smokers and the same proportion were drinking alcohol at unsafe levels. Five were serious drinkers requiring referral to the alcohol treatment service and 13% were found to have a BMI which indicated obesity.

The data obtained from the probation systems demonstrated that 922 offenders have a need related to alcohol; of those 35% have an alcohol treatment order. Alcohol misuse is linked to offending behaviour and risk of harm. There are also high needs for accommodation amongst those people accessing the probation service which may influence their health needs. Only 2.6% of offenders have a GP address recorded in the system.

Nationally, there is a high prevalence of mental health conditions amongst offenders under the probation service. Twenty seven per cent of offenders currently have a mental health condition. Many young offenders are fathers; their health worker is able to liaise with the local family nurse practitioner, health visitors and safeguarding nurses to consider any child protection measures. As well as pre-existing health needs, offenders are also at risk of health problems created as a consequence of imprisonment: through overcrowding, isolation and exposure to violence and access to illicit drugs.[1]

Mental Health

A Mental Health Needs Assessment[2] carried out in both Medway prisons between June 2005 and November 2006 identified:
• 17.9% of participants reported contact with the Mental Health Services whilst in custody
• 15.4% reported prior contact with Mental Health Services
• Of those interviewed, the majority left school under 16 years old
• 35.9% had previously attended a special school
• 38.2% were found to have an IQ score which suggested learning difficulties
• 38.5% scored within the 'low IQ' range
• The most common needs being reported as unmet needs were 'safety to others' (46.2%) and 'psychological distress' (28.2%)
• The Psychiatric Diagnostic Screening Questionnaire indicated a range of features where participants scored on or above the threshold
• Drug abuse/dependence was found to be 64.1%

• Alcohol abuse/dependence was reported to be 51.3%

• Obsessive Compulsive Disorder was also reported as 51.3% Therefore it is likely that prisoners will have high mental health needs

Learning Disability

Learning disability is not adequately screened at reception and is grossly under reported in prisons in the UK. There is an estimation that 23% of offenders under 18 years of age have an IQ of less than 70 and a further 25% have an IQ of less than 80. Below 80 is thought to be borderline intellectual functioning.[3]

A reception screen for learning disability has been piloted by Offender Health. This screen is based on a simple seven question screen and will identify in a crude way any young man who may have a learning disability, although further assessment would be required to assess the disability fully.

Having a learning disability whilst being in prison comes with many difficulties for the individual, from not being able to cope with the prison regime to bullying from other offenders. Therefore it is essential that offenders with a learning disability are identified at reception via screening and then adequately assessed as to the degree of their disability and an appropriate care/support plan drawn up.

It should be noted that this does not include learning difficulties, which is a much wider issue that needs to be addressed. As the prisons do not currently have a measure of learning difficulties it has been challenging to quantify the scale of the issue.

Substance misuse needs

In the young offender population alcohol misuse is often of greater significance than drug misuse.

In November 2011, the assessment data from HMP Rochester indicates
• Opiates used in 10% of prisoners
• Hazardous levels of alcohol used in 14%
• Cocaine was used by 12%
• Crack was used by 9%
• Cannabis was used by 8%

In November 2011, the assessment data from HMYOI Cookham Wood indicates
• Opiates used in less than 5% of prisoners
• Alcohol used in more than 75% of prisoners, with binge drinking being a key feature
• Club drugs (Ecstasy, amphetamines and cocaine) were used by 25–30%
• Benzodiazepine and Ketamine use was found to be very rare
• Cannabis was used by 80–90% of prisoners

Smoking Cessation

Offenders display high levels of smoking prevalence as identified in the police cells, YOT and the prison service. In September 2011, there were 659 smokers across the two prisons, which represent 79% of the prison population (source: HMP Cookham Wood and HMP Rochester); the young age groups have the highest number of smokers however they represent the biggest proportion of the prison population. Stop Smoking Support in HM Prisons offers a best practice checklist for smoking cessation in prisons which should be incorporated in any future health promotion strategy.

Immunisations and Blood Borne Viruses

Many of the young people in the prison had irregular attendance at school and have often missed standard vaccinations and health interventions. There were three patients who tested positive for hepatitis C and as yet no patients have been diagnosed with Hepatitis B or HIV. Both hepatitis B and C are reported each quarter to the Health Protection Agency.

Sexual Health

Sexual health needs are relatively high with a disproportionate number requiring the services of an external Genito-Urinary Medicine Clinic.

Chronic Diseases

The incidence of chronic diseases is lower among young offenders, however early recognition and prevention of smoking is essential to reduce the future burden of disease and reduce inequalities. Information from both prisons indicates that the proportion and number of prisoners suffering from long term conditions is small, but good management is vital in preventing deterioration in conditions such as asthma, epilepsy and diabetes.

Heart Disease

There were 12 patients with heart disease at the time of this report (source: HMP Rochester, November 2011), but the population at this time was mostly young offenders under 21. It is expected that this number will increase with the population becoming older. In the UK prison population, chronic diseases such as heart disease and diabetes form a high percentage of the health care needs. The Prison and Probation Ombudsmen produced a report in 2010[4] which looked at 115 deaths from circulatory disease, and they found:
• The average age at death from all circulatory diseases was 53 years. Thirty per cent of these deaths were of prisoners aged less than 45 years (34 of 115).
• Of those who died as a result of ischemic heart diseases (82 cases), 35% had been diagnosed with ischemic heart diseases (most commonly angina) prior to death.
• A further 19 were receiving medication for high blood pressure and/or high cholesterol (23%). Thirty-four were neither diagnosed with nor receiving treatment to prevent development of heart disease (41 per cent).


The expected prevalence for diabetes for Rochester Prison will change compared to historic prevalence. This is because the prison population will include a greater proportion of older people. It is estimated that 5.1% of the population of England has diabetes of either type. In September 2011, there were four people at HMP Rochester who were diabetic (0.6%). Therefore further work needs to be carried out to identify whether there are true differences in the populations or whether identification needs to be improved.

Asthma and Respiratory Disorders

The number of people receiving treatment for asthma in the UK is reported to be 5.4 million people of which 4.3 million are adults; this is almost 10% of the UK population. It has previously been reported that the prevalence of asthma amongst prisons is 13%, of which 5% will require treatment.[5] The local prison data indicates that 78 patients had a diagnosis of asthma which is 12% of the September 2011 population. In HMP Rochester, three patients were identified with COPD who are all aged between 35 and 50. The prevalence generally increases with age and long term smoking.


The expected prevalence of epilepsy in the prison population is approximately 1% of the population.[5] According to NICE guidance, the age-standardised prevalence of epilepsy in the UK is estimated to be 7.5 per 1,000 population. This would suggest that at least seven patients at Rochester will have epilepsy. Local data indicates that seven prisoners had a diagnosis of epilepsy, although there is no chronic disease register for this disorder.


The populations of both prisons are at risk from minor illness and injuries related to fights. Injuries are common reasons that necessitate external hospital appointments.

Parenting Skills

As with the experience in the YOT, many of the prisoners are young fathers, with poor experience of parenting and for whom parenting skills training would be potentially reduce the generational cycle of criminogenic activity.


[1]   De Viggiani N. Unhealthy prisons: exploring structural determinants of prison health Sociology of Health & Illness 2007; 29:1: 115-135.
[2]   Harding C, Wildgoose E, Sheeran A, et al. A Mental Health Needs Assessment 2007; Kent and Medway Health and Social Care Partnership Trust (KMPT).
[3]   Talbot J. No ones knows: identifying and supporting prisoners with learning difficulties 2006; Prison Reform Trust London.
[4]   RyanMills D. Learning from PPO investigations: Deaths from circulatory diseases 2010; Prisons and Probation Obudsman for England and Wales.
[5]   Marshall DT, Simpson DS, Stevens PA. Health care in prisons: A health care needs assessment 2000; University of Birmingham. .