There were 11,494 people under 25 years of age in young offender institutions and prisons in England and Wales as of 31 December 2022, representing 14% of the total population in custody. While the number of children (under 18) 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. From a legal perspective, young people are treated as adults from the age of 18 within the criminal justice system, but there is recognition of the needs of 18- to 25-year-olds as ‘young adults’ (see the work of t2a.org.uk), distinct from the needs of children or other adults.

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 in the so-called ‘children and young people secure estate’, which caters for those aged 18 and under and is run as a distinct part of the custodial estate, with those in the adult estate, which manages young adults alongside prisoners in older age groups. Understanding how health care access and needs differ is important, because the distinction between the two parts of the system is becoming increasingly blurred. Recently, population pressures in the adult estate have led to an increase in the number of young people aged 18 or over in the children’s secure estate, which will drastically alter the age profile of the children’s secure estate population. 

Key findings:

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. We found that violence and self-harm were much more prevalent in younger age groups than older age groups. While mental health care needs partially drove this, we found that 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. We found that 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. (Girls are not routinely sent to Young Offender Institutions and instead should be placed in Secure Children's Homes or Secure Training Centres.) 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. There are various reasons why appointments may have to be cancelled (for example, people being transferred to another location or reaching the end of their sentence, or hospital appointments clashing with court appointments). 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. The children and young people secure estate makes the case for better resourcing in the adult estate, particularly in terms of staffing, which is integral to all aspects of day-to-day life in secure settings. Young offender institutions have a higher staff–child ratio than the ratio of staff to prisoners in the adult estate, which 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.