The justice system and public health: promoting the health of people with criminal backgrounds

Health policies that improve the health of all people, with a particular focus on the most vulnerable in communities, are instrumental to unlocking meaningful change – change that goes far beyond individual health and wellbeing.

The health of patients with criminal backgrounds is a matter of public health. The Lancet report that more than 10 million people are currently held in penal institutions around the world; the majority of them will be released at some point, with many cycling in and out of prison repeatedly. The health of this population is, in every sense, largely a matter kept behind closed doors. 

Events such as the Covid-19 pandemic – where prison populations suffered from the virus at disproportionate rates – remind the world of the health challenges and outcomes routinely faced by this section of society.

Why is supporting patients with a criminal background important?

Those with a criminal history, or even those detained in immigration and detention facilities, are disproportionately more prone than the overall population to suffer from poor health outcomes.. This includes:

• Smoking
• Mental health problems
• Substance abuse issues, such as drugs and alcohol
• Reporting a disability
• Chronic health conditions
• Self-harm
• Suicide attempts
• Premature death

Evidence shows that this section of society tends to receive inadequate healthcare before, during, and after incarceration or detention, further exacerbating health and other disadvantages.

Aside from promoting health equality for all – and offering better quality of life – providing treatment and support for illness and addiction recovery can significantly reduce reoffending. It also, therefore, helps to minimise crime within local communities. It tackles some of the most significant and harmful healthcare inequalities, and helps to minimise government and state spending on health and social care.

Reoffending and mental health

Research published in The Journal of the American Academy of Psychiatry and the Law (JAAPL) estimates that 68% of persons released from prison will be rearrested within the first three years of release, and 83% will be returned to the criminal justice system within nine.

While former offenders with mental illness recidivate at a rate similar to others, the numbers are higher for individuals with substance abuse issues. Those with both mental illness and substance disorders recidivate at even higher rates. Evidence suggests that the nature of the mental health disorder may also affect outcomes; schizophrenia and bipolar disorder account for higher rates than other psychiatric disorders.

It’s a complex issue, with contributing factors reaching far beyond mental health. However, better engagement with mental health support services and health systems has been shown to reduce the risk of committing serious and more violent crimes. For individuals with severe mental illness, providing routine outpatient treatment – including medication – reduces the likelihood of subsequent arrests.

Collaboration between healthcare providers and justice services

Policy arrangements, commissioning and funding health services for offenders varies enormously – locally, regionally, nationally and globally. For example, inmates under the U.S. Department of Justice’s jurisdiction are the only U.S residents with a constitutional guarantee of medical care – a situation that changes abruptly upon release.

Close working between healthcare services and criminal justice systems is fundamental to achieving shared aims. Staff members across all services – from doctors to probation officers to caregivers – need to take collective responsibility for delivering improved care services in correctional facilities. This responsibility cannot end upon release; protecting and prioritising healthcare must move from custody to community.

The American Academy of Family Physicians (AAFP) state that as incarceration and detention are, of themselves, detrimental to health, preventing those convicted of minor offences from entering the prison system is beneficial. Governments need to acknowledge that complex health and social needs are not the sole purview of prison services. Medical intervention can occur at multiple points while a prisoner is in custody – underscoring the requirement for communication and collaboration between health and justice systems. Only by acknowledging the challenges, and developing long-term strategies to address them, can there be a hope of improving both the health and lives of prisoners and the wider public.

An ever-widening socio-economic gap

Patients with criminal records are already at a significant disadvantage compared to the general population.

Re-entry to society is multifaceted and complex. Social structures of families and friends – which so many of us rely on – are often fractured or non-existent. A lack of support and means upon release often makes it difficult to secure appropriate accommodation. Mental illness – even when managed – can be a cause of stigma and misunderstanding, making it harder to engage with independent responsibilities. Entering gainful employment is considerably more complicated. As well as screening – including DBS checks and other criminal background checks often used to ‘filter out’ ex-offenders – potential employers and their prejudices and misconceptions may also negatively influence hiring decisions. Fortunately, policies such as the Rehabilitation of Offenders Act work to offer fair access to employment.

Societies that help offenders and ex-offenders to access quality healthcare play a pivotal role in providing them with an all-important second chance. This access has the potential to remove, or reduce, one of the many significant barriers to a stable life and livelihood.

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