• health policy
• health system
• patient-centred care
• multi-disciplinary

‘As long as poverty, injustice and gross inequality persist in our world, none of us can truly rest’1 said Nelson Mandela in his address to Johannesburg’s Live 8 concert in 2005.

One of the most disadvantaged groups in our society can be defined by their contact with the criminal justice system, including people in prison and other prescribed places of detention and those engaged with probation services living in the community. All of these people are patients of National Health Service (NHS) services. They are some of the poorest and most vulnerable, experiencing high levels of disadvantage, deprivation and adversity. As of 26 May 2023, the population in English prisons was reported to be 80 090 with 96% in the male estate and 3.9% in the female estate.2 However, the number of people in contact with the criminal justice system is far larger than the prison population. At any one time, the number of people using probation services in the community outnumber those serving a custodial sentence by around 3 to 1 ratio. Most recent data shows there were 226 078 offenders on probation in England.3 The average life expectancy of people detained in prison in England is reported to be 56 years compared with 81 years in the general population and the standardised mortality rate of prisoners is 50% higher than the general population.4 Higher rates of substance misuse including tobacco smoking and a higher burden of epilepsy, asthma, coronary heart disease, musculoskeletal problems, dental decay and oral diseases, poorer mental health including depression, anxiety and psychosis define some of their significantly higher burden of diseases.5 6 Over a quarter of children and young people in the youth justice system have a learning disability with rates of suicide in boys aged 15–17 years (who have been sentenced and remanded in custody) being 18 times higher than their counterparts in the general population.7 8 Contact with the justice system especially imprisonment has a profound impact on families, in particular on the children of imprisoned parents, who are at least twice as likely to experience mental health problems, be affected by poverty and become isolated and stigmatised.9 Irrespective of age, this group experiences complex, comorbid physical and mental health difficulties which are maintained and exacerbated by a history of poorer access to health and care support proportionate to their needs. They face significant barriers to healthcare and experience higher rates of poverty, social exclusion, socioeconomic deprivation, homelessness, unemployment and lack of basic level education as well as adverse childhood experiences with 24% of adults who were looked after as children and had experience of the care system.10 Reducing these health inequalities and improving health equity for this disadvantaged group should, therefore, be a key priority for the leadership across the health landscape.

Health inequalities are defined as the ‘avoidable differences in health outcomes between groups or populations—such as differences in how long we live, or the age at which we get preventable diseases or health conditions’.11 Similarly, health disparities are described as ‘a particular type of health difference that is closely linked with social, economic and/or environmental disadvantage’.12 13 Health equity, on the other hand means ‘the absence of unfair, avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically or by other dimensions of inequality (eg, sex, gender, ethnicity, disability or sexual orientation)’.14 The NHS has a central contribution to make in addressing the healthcare inequalities of its patients explained in terms of the differences in patient access, experience and outcomes. It was, therefore, a common thread in the NHS Long Term Plan 2019,15 the organisational 10-year plan setting out priorities for healthcare that highlighted the importance of preventative initiatives to tackle ill health and to reduce the gap in outcomes between the richest and the poorest.15 It is equally important to make note of another umbrella term ‘inclusion health’ that describes ‘people who are socially excluded, who typically experience multiple overlapping risk factors for poor health, such as poverty, violence and complex trauma. This includes people who experience homelessness, drug and alcohol dependence, vulnerable migrants, Gypsy, Roma and Traveller communities, sex workers, victims of modern slavery as well as people in contact with the justice system who are known to experience many of these intersectional disadvantages’.16 On the 75th year of the inception of the NHS, inequities in the quality of healthcare experienced by patients from this population group remain a great concern, and therefore, Nelson Mandela’s words in 2005 (quoted above) should resonate strongly with all of us throughout the health system.

NHS England has developed and deployed Core20PLUS5 (national NHS England approach to support reduction of healthcare inequalities) as the vehicle for translating the Long Term Plan’s ambitions into reality.17 18 Three years since its introduction, this approach has been providing an evidence-based lens with data and research, giving national steer and direction while recognising that regional and local healthcare systems know their populations the best. Those in contact with the criminal justice system experience profound health inequities as shown above and therefore are one of the focused groups for support through the Core20PLUS5 approach identified as a key ‘PLUS’ group.

The Core20PLUS5 approach aligns with the NHS England Health and Justice framework for Integration built on the National Partnership Agreement for Health and Social Care for England, which commits to improving the quality of services for people in prison and those subject to statutory supervision by the probation service in the community.19 20 These important documents provide leaders across the health and justice system a blueprint for a focused approach, enabling us to gain traction, thus demonstrating impact in reducing healthcare inequities for this population group. They collectively provide a great opportunity for us to have oversight of what communities have a right to expect as the NHS seeks to address health inequities. While our focus is on healthcare inequalities, it is important to remember the role of the NHS as an anchor institution21 in supporting partnerships with social care, education, youth, housing, family support and other services to provide coordinated person-centred care to address the wider determinants of health of this population.

International standards such as the ‘United Nation’s standard minimum rules for the treatment of prisoners’ known as the ‘Mandela Rules’22 and the ‘United Nations rules for the treatment of women prisoners and non-custodial measures for women offenders’ called the ‘Bangkok Rules’23 encourage the responsibility of a country to ensure that this vulnerable group are provided healthcare, that is, at a minimum, equivalent to that available in the community, an affirmation known as the principle of equivalence. Established in 1995, the WHO Regional Office for Europe Health in Prisons Programme is committed to addressing the health needs of people in prisons, with the aim of integrating the commitment into the overall public health agenda.24 A review of prison healthcare systems in a few Western European countries highlighted that there is no ideal governance or leadership model.25 Therefore, whole system collaborative agreements and intersectoral cooperation should find efficient solutions around the key principles of equivalence of care, respect for human rights and continuity of care.

For the health and justice system to be socially equitable, fair and just, whole system leadership has a central role to ensure all those in contact with prison and probation have an equitable opportunity to thrive, regardless of their age, race, sex, religion or any other protected characteristic. In addition, and in order to tackle the life expectancy gap, there is an urgent need for whole system collaboration to bring about sustainable change. The pandemic highlighted the importance of digital innovation for improved healthcare access, better care quality and cost savings which we need to carry on building. Equally important is data and evidence to drive interventions to bring about health improvement thus generating the intelligence about what works. Focusing on the greatest risk of poor health outcomes, it is vital we work together to accelerate preventative programmes across prisons and probation settings that proactively engage this population group which could also prevent harm. Incorporating public health approaches to our current work programmes will help to promote improved health and well-being, enable and encourage healthy lifestyle choices for this population, their families and staff, subsequently reducing health inequalities and driving down offending and reoffending behaviours. Key to this ambition is our strengthened systems leadership and accountability for supporting this population across the whole health and justice landscape that will ensure delivery of wider societal goals. There has been ongoing work across NHS England and HM Prison and Probation Service joining up system-wide conversations to develop a co-ordinated, efficient and effective approach to help achieve these healthcare goals. Active collaboration at national and system levels is now needed to understand the current situation and assess equitable access, quality of experience and optimal outcomes. This is particularly important given the significant number of people in the prisons who have poor access to NHS services, despite having a range of complex health problems. Being within this setting, therefore, presents an opportunity to diagnose and manage any health conditions, along with supporting the safe and effective handover of care as individuals are released from custody and enter back into the community. By maintaining this continuity of care, we can improve the management of long-term health conditions and minimise the risk of people going into crisis and reoffending, as well as the subsequent pressure placed on the NHS. This is only achievable, however, by working together across the system to support individuals pre, during and post custody, recognising that we all have a part to play with ensuring the safe and effective care of this vulnerable patient group thus reducing the likelihood of reoffending and with resulting wider societal benefits.

The Leadership Framework for Healthcare Inequalities Improvement programme is an NHS England programme to ensure that the NHS effectively prevents and responds to the health inequalities which many communities experience.26 It allows Chairs and Non-Executives of the recently created 42 Integrated Care Systems (ICSs) across England to be creative and innovative in delivering the national vision of ‘exceptional quality healthcare for all through equitable access, excellent experience and optimal outcomes’. The framework also provides a legacy for the future as well as tools for immediate application, supporting the system senior leadership to investigate the specific challenges of their communities and to take effective leadership action on behalf of the most marginalised and disadvantaged populations. It is, therefore, a call to action as everyone has a role to play if we are to succeed in reducing health inequalities that impact the most vulnerable in our societies like those in contact with the justice system.

As the Marmot Review 10 Years On Report27 highlights, being a perpetrator or victim of crime is closely associated with deprivation and exclusion, resulting in lifelong impacts on health. Although the relationship between health and social influences on offending and reoffending behaviours is complex, attention to these issues will help to bring about reduction in reoffending, generate health improvement and increase in healthy life expectancy. We have an opportunity to tackle the healthcare gap in this vulnerable group, and therefore, need to champion learning and insight across the system, building an inclusive leadership around quality improvement principles and reflect on our own evidence-based practice. This is our best opportunity to narrow the stark healthy life expectancy and overall life expectancy gap in this vulnerable group through our shared vision, priorities and collective action embedded throughout the system. This can be achieved by considering the health needs of this patient group in ICS 5-year strategies and Integrated Care Board Joint Forward Plans and commissioning arrangements, as well as working collaboratively with health and justice commissioners and providers, and justice partners. This is our call to action for health leaders to address the stark inequities faced by people in contact with justice systems across the country. There are lessons to be learnt and actions to be taken to support people experiencing these harsh inequalities all over the world to improve outcomes and reduce the detrimental impacts of crime.