A healthy criminal justice system? The changing character of offender health provision Nick de Viggiani Senior Lecturer

1. A healthy criminal justice system? The changing character of offender health provision Nick de Viggiani Senior Lecturer, Faculty of Health & Life Sciences Project Lead, South West Offender Health Research Network www.offender-health-sw.org.uk

2. Core Argument To deliver effective measures to improve the health of offenders, there must to be a concerted shift towards health improvement measures throughout the offender journey or “pathway” (the social system), with particular attention to social inequalities. Context NOMS (the National Offender Management Service) has adopted an ‘end-to-end offender management approach’. NOMS acknowledges the significance of inequalities and social exclusion to offending behaviour. The NHS is moving towards a justice system focus for the management of offender health services (police custody, the courts service, prisons, probation). Overview [1] summary of relevant epidemiological and criminological data that underpin this broad approach. [2] links between criminality and poor health; comparison of pre-CJS determinants of offending and of poor health. [3] consideration of priorities for health commissioning and public health

3. Offender Health Offenders have poorer levels of health relative to the general population (physical and psychiatric morbidity). >25% of new prisoners report a long-standing physical disorder or disability, commonly musculo-skeletal or respiratory. Offenders have, on average, less healthy, more “risky lifestyles. Offenders commonly reside in poorer communities / areas of relative deprivation. 63% of prisoners rented from LAs or Housing Associations before prison sources Stewart, D. (2008), The problems and needs of newly sentenced prisoners: results from a national survey, London: Ministry of Justice Prison Reform Trust (2009) Prison populations reveal strong evidence of health inequalities and social exclusion. This is a valuable opportunity to identify and tackle the broad health needs of a vulnerable and socially excluded population. (Department of Health 2005)

4. WHO, 2003 - international trends Most offenders come from marginalised &/or vulnerable social groups. Most come from populations with poorest health (esp. given cross-over with drug misuse and sex work). Prison populations have the highest rates of TB, HIV and Hep B. Constant movement of people through prisons may further the transmission of communicable diseases. Prisons are ‘sinks’ of poor health with their tendencies for overcrowding, violence, lack of light, fresh air and clean water, poor nutrition, and high risk behaviours.

5. LEARNING & SKILLS DEFICITS 20-30% prevalence of learning disability (based on IQ measures) (Loucks 2007) 25% have IQs of <80 (7% at <70) (Mottram 2007) 23% of under 18s with IQs at <70 (Harrington et al 2005) 48% at or below reading age of 11yrs 65% at or below numeracy age of 11yrs 82% at or belowwriting age of 11 yrs (Hansard 2007) 41% of men, 30% of women, 52% of under 16s permanently excluded from school (Stewart 2008) 15% of YOs have special educational needs (YJB 2005)

7. Determinants of poor health commonly mirror precursors of offending … • offending (family) histories • custody environments • access to health services • broken / dysfunctional family relationships • overcrowded custody environments • cultures of violence • emotional deprivation / neglect • (HM Prisons Inspectorate 2000) Contributory Factors to Offending low maternal bonding poor parenting skills abusive home relationships truancy / exclusion from school looked after child status conduct disorders socioeconomic background childhood experiences stressful life events adverse prison experiences experience of victimisation (Marshall et al 2000) Risk factors can be similar for different outcomes, including violent and non-violent offending, mental health problems, alcohol and drug problems, school failure and unemployment …Cumulative, interactive and sequential effects of risk factors may increase the risk of becoming a persistent offender. Farrington, D.P. (2006). Saving Children from a Life of Crime. Oxford: OUP.

8. LIFECOURSE Early onset factors that may contribute to future risk of offending moor maternal health victim of child abuse learning difficulty looked after child being a male in poverty poor familial environment ADHD, conduct disorders, disruptive behaviour substance, alcohol, drug misuse anti-social behaviour school exclusion offending behaviour Engagement with Criminal Justice System increased risk of further abuse /victimisation, alcohol and drug misuse, physical and psychiatric morbidity Ex-Offenders increased prevalence of homelessness and unemployment Adapted from Nurse J (2006) ‘Preventing Violence and Abuse: Creating Safe and Respectful Lives’ South East Regional Public Health Group Information Series 1.

9. “IMPORTATION” theory (re: prisons) “presenting culture” of the offender wider context of social exclusion and deprivation “The seeds of poor health are sewn for the majority long before they entered an institution.” (Spencer 2001) Prisons as repositories for the failures of society (Short 1979) Spencer A (2001) Removing bars to good treatment. Short R (1979) The care of long-term prisoners.

10. criminogenic criminogenic environment criminogenic factors criminogenic social conditions … variables thought to bring about criminal behaviour in persons (e.g. imprisonment with other criminals is believed to be a criminogenic atmosphere). “If an agent lacks protective predispositions and is exposed to a criminogenic environment, the agent will find it considerably more difficult, all else being equal, to avoid offending than a person who is more fortunately endowed and exposed to a more benign environment.” (Morse, 2000, ch.5)

11. ‘Criminogenic Environments’ [< crimin- (in CRIMINALa.) + -O- + -GENIC.] Tending to cause or foster criminal behaviour “… the significant or determining criminogenic factors in a given case.” (Proceedings of National Conference on Social Work 1919) “… the interrelation of different criminogenic factors, both social and psycho-physical.” (Brasol 1927) “Where there is a high overall crime rate in the communities to which the prisoners are released, there is high prospect of the releasee coming from and going to highly criminogenic circumstances.” (Glaser 1964) ”The police should be more interactive to the community, and they should be friendly. The kind of government in place makes Nigeria a criminogenic society.”   (African News 2003)   “New-build developments provide the opportunity to evaluate empirically certain designs and contribute towards a broadening of our understanding of the criminogenic capacity of residential housing design.” (Cozens et al, 1999, The sustainable and the criminogenic: the case of new-build housing projects in Britain)

12. WHO 1986 – Ottawa Charter • - health is created and livedwithin settings of everyday life • - supportive environments for health • criminal justice setting • - Health in Prisons: a guide to the essentials in prison health (WHO 2007) • - 2003 Moscow Declaration: offender health as part of public health

13. "To a man with a hammer, everything looks like a nail" Mark Twain street drinker personality disordered patient rough sleeper chaotic adult substance misuser ex-offender mentally disordered individual arrestee prolific offender dual diagnosed anti-social neighbour defendant homeless person socially excluded adult prisoner sex worker

14. Challenge for Public Health & Health Service Commissioning Smith 2000 - collective and structural (systems) approach (vs. a purely individualistic one) Unhealthy/risky lifestyles are consequences rather than root causes Dooris 2004 - joined-up, congruent action across settings is essential to maximise the public health contribution

15. A public health approach Action at the social & cultural level A [criminal justice] systems approach – the ‘offender pathway’ Interdisciplinary working – criminology, law, health, social policy, planning, etc. Joint commissioning across sectors Reorientated institutional, political and professional goals New training, education & workforce development priorities Advocacy for offenders as ‘citizens’ (resettlement, rehabilitation, empowerment, inclusion)

16. COMMISSIONING PARTNERSHIPS 54% of annual total spending on offender rehabilitation and resettlement is commissioned by organisations other than the National Offender Management Service PCTs, Mental Health Trusts, Learning and Skills Councils, the National Treatment Agency, Local Authorities. PCTs play an increasingly pivotal role in commissioning health services for offenders prisons, police custody, the courts service, probation.

17. Public Service Agreements & Local Area Agreements Required to focus on reducing re-offending, address health needs of offenders and tackle social exclusion, via partnerships (public, third & independent sectors) Joint Strategic Needs Assessments (JSNAs) PCTs and LAs jointly identify the needs of their population though consultation with communities and other stakeholders.

18. World Class Commissioning (DH 2007) PCTs are required to invest in achieving the greatest possible health gains (= reductions in health inequalities) Priority must be given to those with greatest need “Strategic priorities should include investment plans to address areas of greatest health inequality.” The Challenge for Commissioners … demonstrate leadership on offender health (as a priority area) show commitment to addressing inequalities effectively partnership working (new partners) care vs. custody dilemmas represent the voices of service users (offenders, victims, the public) NE Public Health Observatory currently developing an offender health observatory “… to collect data that will support the commissioning and provision of offender health services in prisons and in the community, and research and development initiatives.”

19. A note of caution … an increasingly evangelistic public health? Durkheim – deviance, a normal feature of social life ↓crime ↑repression > “unhealthy society” Crime & Disorder Act 1998 – antisocial behaviour / respect agenda ‘Pathologisation’ of Body / Society – e.g. “obesity epidemic” ‘Criminalisation’ of Body / Society – e.g. “antisocial behaviour” Gillian Bowditch (2006) Sunday Times: “the Enforcers” “a-socials” – “people who demonstrate through their behaviour, which is alien to the community but not necessarily criminal, that they will not adapt themselves to the community …beggars, vagrants, work-shy, prostitutes, drunkards, people with contagious diseases … who evade the measures taken by the public health authorities …” (Reinke 2005:57) Core business of the Kriminalpolizei in 1930s Nazi Germany