There are more than 11,000 people under 25 years of age in young offender institutions and prisons in England and Wales, representing 14% of the total population in custody. While the number of children (under 18s) in secure settings has fallen sharply over the past 15 years, very serious challenges remain over the use of force in the children’s secure estate, with ongoing concern over children being held in solitary confinement, some for extended periods. Population pressures in the adult estate of late have led to an increase in the number of young people aged 18 or over in the children’s secure estate, which drastically alters the age profile of the children’s secure estate population.
This analysis uses routinely collected hospital data to look at the service-use patterns of children and young adults aged 25 and under in young offender institutions and prisons in England. We engaged with experts and looked at the literature to consider this in the context of the key health care needs of young people. Looking across the children’s secure estate as well as the adult estate provides a novel perspective on the key health care issues for young people, allowing us to compare experiences more easily.
Our research finds that some of the biggest problems affecting the adult prison estate – violence and self-harm – have a disproportionate impact on young adults. We consider how the prison service can meet the needs of young people in custodial settings, and the benefits of providing tailored support for young adults in particular.
42% of hospital admissions by young adult males in custody had a primary diagnosis of injury or poisoning.
This was significantly higher than among the adult prisoner population, where injury or poisoning accounted for just 16% of hospital admissions. Violence and self-harm were much more prevalent in younger age groups than older age groups. While mental health care needs partially drove this, age group in itself was a significant predictor. This supports the need for tailored support and interventions for young adults to reduce violence and self-harm in prison, which are long-standing issues facing the prison estate, and impact on living and working conditions for everyone, regardless of age.
Some 60% (n=55) of hospital admissions for young adult males in prison where a diagnosis of attention deficit hyperactivity disorder (ADHD) was flagged had a primary diagnosis of injury or poisoning.
This was significantly higher than for young adult males without ADHD, where it accounted for 41% of admissions. 6% (n=92) of hospital admissions by young adult males in prison had ADHD recorded as a diagnosis, compared with just 2% of admissions by young adult males in the general population, which may reflect a higher prevalence of ADHD among those in custody. Staff need to be trained in neurodiversity and providing appropriate support, management and access to care. This is particularly important in relation to ADHD as it may be linked to challenging behaviour.
Boys detained in young offender institutions had a higher proportion of outpatient appointments cancelled on their behalf (18%) than both young adult males (14%) and other adult males (13%) in prison.1
Access to hospital care for children in custody is a significant cause for concern. Children in young offender institutions have a higher proportion of hospital appointments cancelled on their behalf than both young adult males and other adult males in prison. Appointments may have to be cancelled for a number of reasons (people being transferred to another location, reaching the end of their sentence, or hospital appointments clashing with court appointments, for example). Similar pressures exist within the adult estate, but these issues may be more significant within the children and young people secure estate and it is unclear why this is.
The children and young people secure estate has much higher staff–child ratios than is the case with prisoners in the adult estate, which affects the culture in each and makes the transition between the two more complex.
Staffing is integral to all aspects of day-to-day life in secure settings, and the children and young people's secure estate makes the case for better resourcing in the adult estate. The higher staff–child ratio in the children's estate means that day-to-day activities in these institutions are less likely to be cancelled due to a lack of staff, and staff are more familiar with those under their care and can potentially develop better relationships with them. At the most basic level, staff need to be in place to provide the tailored support for young adults that is so clearly needed.
But it’s not just about staffing ratios, as a recent Urgent Notification invoked in relation to HMYOI Cookham Wood demonstrates (the centre reportedly has around 360 staff (including 24 senior leaders) managing a population of 77 boys). It is vital that staff with the right skills are employed and that they receive appropriate training and support to develop trusted relationships with young people.
We now set out our recommendations for signatories of the Children and Young People Secure Estate National Partnership Agreement,2 signatories of the National Partnership Agreement for Health and Social Care for England3 and for HM Prison and Probation Service specifically.
For Children and Young People Secure Estate National Partnership signatory organisations
Understand and address the reasons why outpatient appointments for children and young people in young offender institutions are cancelled much more often than is the case for people in prisons. Make data on reasons why hospital appointments are missed publicly available. This is important so that action can be taken, and national partnership members can be held accountable.
For National Partnership Agreement for Health and Social Care for England signatory organisations
Develop specific national guidance or standards relating to health care for young adults in secure settings. We support the need to address the key health care issues for young people as part of any future national strategy for young adults in the secure estate.
For HM Prison and Probation Service
Ensure all staff have sufficient understanding of, and training in, neurodiversity. This should be considered as part of staff recruitment, initial training, ongoing training and awareness-raising activities within secure settings.
This is the third and final report from an ongoing programme of work funded by The Health Foundation exploring access to health care services by prisoners. The first, focused on women in prison, was published in July 2022 and second report on the older prisoner population followed in April 2023.
Davies M, Hutchings R and Keeble E (2023) Growing up inside: Understanding the key health care issues for young people in young offender institutions and prisons. Research report, Nuffield Trust