Care for Offenders: Continuity Of Access (COCOA)

Offenders have a high prevalence of many health problems, particularly mental illness and substance misuse. Passage through the many elements of the criminal justice system (CJS) provides both the potential for initial access to healthcare and also the disruption of existing care.

The Care for Offenders: Continuity of Access (COCOA) project aimed to examine how, and in what situations, the health and criminal justice systems can best work together to improve health and resettlement.

The objectives, as articulated in the original proposal were to determine;

• The current status of continuity of care for offenders
• The essential elements of, and facilitators for, continuity of care for offenders
• Potentially effective models of healthcare service delivery for offenders

This multi-method investigation of continuity of healthcare for offenders used the Realistic Evaluation framework and included: a provisional programme theory based on policy guidance; a longitudinal interview (n=200) and health records study (n=50) of offenders’ healthcare incorporating qualitative and quantitative analyses; two system wide, and six mini organisational case studies.

The final synthesis of qualitative and quantitative data at organisational and offender levels yielded: development of theory about access and continuity of care for offenders, potentially of relevance to other marginalised groups; and a revised programme theory detailing how the health and criminal justice systems could work together to improve access and continuity of care.

Fifty three percent reported drug misuse, 36% alcohol misuse, 15% severe and 59% moderate mental health problems. Only 4% believed they had no physical problems. Co-morbidity was typical.

There were significantly more healthcare contacts in probation than in other CJS settings; predominantly for heroin, dependence forming 40% of all health contacts.  Overall contact rates for mental health problems were low, particularly for those without heroin misuse.

Although offenders saw health problems as causing them difficulties, healthcare was not always perceived as being part of the solution. Offenders prioritised other needs and ambitions over healthcare, including employment, accommodation, family and relationships. The whole system case studies and mini-case studies of best practice demonstrated a number of facilitators of, and barriers to continuity and good healthcare particularly at the organisational level.
 

COCOA Participant Summary.