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Research and Projects

Care for Offenders: Continuity Of Access (COCOA)

Who is involved?

Theme: CLAHRC - Mental Health & Dementia
Status: Complete

Read a BITE sized summary of this project.


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.


A mixed methods synthesis led to the development of a causal model for access to and continuity of care for offenders and other marginalised or vulnerable groups.  Past experience and varied coping styles are significant inhibitors of access for mental health problems, and require powerful healthcare mechanisms to be overcome.  These can be interpersonal or organisational.

Continuity of access included on-going care with the same practitioner (longitudinal continuity), within the same teams or on to a different team.  Continuity of information is critical.  A range of interpersonal and organisational mechanisms can deliver on-going access.  At the practitioner level, respectful interactions, flexibility and an integrated approach (holistic, bio-psycho-social) were important in their own right and also contribute to access and continuity.

Organisationally, service configuration contributed to initial access and on-going continuity. Access could be enhanced by having flexible opening times, non-stigmatising services, co-location with criminal justice services, and tolerant policies.

Organisational mechanisms for integrated care and continuity include: good communication (particularly to the offender but also between services to ensure continuity of assessment); liaison between services; clear pathways to and from services; collaborative arrangements for sharing responsibility between services.

Collaborative care beyond health can be seen as the institutionalisation of holistic individual care.

Each of the criminal justice settings has the potential to contribute to ensuring access and continuity, and current health services will need to work together more closely, particularly mental health, primary care and substance misuse teams. We suggest that the liaison and diversion teams proposed in the Bradley Report will not be effective unless they either take on some case management responsibilities or ensure that specialist mental health services have the skills, pathways and capacity to work with offenders.  Such a service may have long term financial benefits beyond health which will require incentives. Training of health and criminal justice practitioners, both about how to work together and for specific skills, will be required to ensure these ambitions are met.

In summary this project has i) described the current status of continuity of healthcare for offenders and identified areas of best practice, ii) identified some clear mechanisms for ensuring initial access and continuity of care throughout the health and criminal justice systems and iii) produced some conjectured hypotheses of the essential elements of effective models of healthcare service delivery for offenders. The relative absence of both clinical and health service research for offenders with common health problems suggests the need for focused clinical studies and on-going service evaluation to test these theories and determine best models of care.

Further information

For more information, please read the final COCOA project report.

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Others Involved

Professor John Campbell, Dr William Henley, Dr Andy Gibson


  • COCOA Participant Summary - PDF