On 30th of June 2018 there were 261,196 people on probation in England and Wales1 (Ministry of Justice 2018). Not all people in contact with probation2 are the same. For example, some will have been to prison for serious offences, whilst others will have been convicted of minor offences and will not have been to prison. However, people in this group are often deprived, marginalised, or vulnerable and are more likely to have certain health needs (e.g. mental health, drug and alcohol problems) when compared to the general population.

Many people in contact with probation will experience more than one health problem at any given time and often experience other negative social determinants of health such as unemployment and homelessness. Very little research has been done on this population and their voice is seldom heard by those commissioning healthcare or those providing oversight and scrutiny of healthcare services.

Despite the high level and complexity of health needs in this group, people in contact with probation face both system-level and personal-level barriers to accessing healthcare. Many people in contact with probation are not registered with a GP, and/or only access healthcare during crises (Revolving Doors Agency 2013). Sometimes services simply do not exist to meet their needs, and sometimes services are difficult to access due to things like their location, opening hours, restrictive referral criteria and poorly understood access routes. Moreover, the health needs of people in contact with probation and how best to structure service provision to make healthcare accessible to and appropriate for this group are not always considered by healthcare commissioners.

There are a number of reasons why we need to address the healthcare needs of people in contact with probation. These include:

* This group of people are often marginalised, deprived and in poor health, so improving the health of this population is essential if we are serious about reducing health inequalities in society and achieving equivalence of care. There is a need to reduce the high rates of morbidity and mortality in this group

* Good health is a recognised pathway out of reoffending (NOMS 2004), so by addressing people’s health problems, we will also be contributing to reducing offending behaviour, and thereby reducing the number of victims of crime, improving safety in society, and saving costs for criminal justice and health services

* Ensuring that people in contact with probation engage with healthcare at an early stage rather than when they reach crisis point can potentially produce cost-savings for the NHS from less unnecessary use of urgent and emergency services and missed appointments (Revolving Doors Agency 2013)

* Being in good health can help people to complete probation and to do other things that reduce their chances of re-offending, such as finding and keeping employment

* Improving the health of an individual in contact with probation may also lead to positive changes for people around them like their family

* Thus improving health produces a ‘community dividend’ in numerous ways including the potential to reduce communicable diseases in the community and a wider impact on others due to cost savings from reduced re-offending and use of crisis services

Producing this toolkit was the ultimate aim of a two-year research project funded by the National Institute for Health Research (NIHR) Research for Patient Benefit Programme which investigated:

* How healthcare can best be provided to achieve good health outcomes for people in contact with probation

* The current ways that healthcare is delivered to people in contact with probation in England

* The data that are already available that could be used to measure and improve the health of people in contact with probation and the quality of the healthcare that they receive

The toolkit was produced by a team of academics from the University of Lincoln (Dr Coral Sirdifield (lead), Dr Rebecca Marples, Professor Niro Siriwardena) and Royal Holloway, University of London (Professor Charlie Brooker, Professor David Denney) together with service user and probation representatives (Mr Dean Maxwell-Harrison, Ms Sophie Strachan, Mr Tony Connell).

Advice and feedback on the content was received from an external advisory group made up of key stakeholders including the following individuals and organisations:

* Dr Linda Harris FRCGP, Chair, Health and Justice Clinical Reference Group

* NHS England Joint HMPPS/NHS OPD Programme

* Probation Institute

* Public Health (Lincolnshire)

* Lord David Ramsbotham

* Russell Webster

* HM Inspectorate of Probation

* Together Women


* Public Health England

We hope that this toolkit will assist those working in health and criminal justice environments in England, and in particular commissioners to improve the way in which healthcare is provided for people in contact with probation by providing an overview of:

* The responsibilities of different organisations and how they can work together to contribute to improving both the health of people in contact with probation and their access to health services

* The likely health needs of people in contact with probation so that these can be considered in Joint Strategic Needs Assessments, Joint Health and Wellbeing Strategies and commissioning decisions

* What research tells us about the best ways of providing healthcare to people in contact with probation and where there are gaps in the evidence base

* How healthcare is currently provided to this group, including models of good practice that could be spread

* What barriers people in contact with probation currently encounter to accessing healthcare, and barriers that criminal justice staff encounter when trying to facilitate access to healthcare for people on their caseloads, so that we can think about how these can be overcome

* How the quality of healthcare that people in contact with probation receive can be measured and improved