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Institute of Psychiatry, King’s College London
University Department of Child and Adolescent Psychiatry, Manchester, UK
Correspondence: Barbara Barrett, Centre for the Economics of Mental Health, Box PO24, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK. E-mail: b.barrett{at}iop.kcl.ac.uk
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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Aims To estimate the full cost of supporting young people in the criminal justice system in England and Wales and to examine the relationship between needs, service use and cost.
Method Cross-sectional survey of 301 young offenders, 151 in custody and 150 in the community, conducted in six geographically representative areas of England and Wales.
Results Mental health service use was low despite high levels of need, particularly in the community. Monthly costs were significantly higher among young people interviewed in secure facilities than in the community (£4645 v. £1863; P<0.001). Younger age and a depressed mood were associated with greater costs.
Conclusions Young people in the criminal justice system are a significant financial burden not only on that system but also on social services, health and education. The relationship between cost and depressed mood indicates a role for mental health services in supporting young offenders, particularly those in the community.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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The costing study presented here was part of a larger review commissioned by the Young Justice Board. Chitsabesan et al (2006) report the needs of the cohort; this paper examines detailed service use information and estimates the full range of costs needed to support young people in the youth justice system in England and Wales, both in secure facilities and in the community. Predictors of service use and cost are explored to determine the impact of client characteristics and needs on the total cost of accommodating and supporting young people in the youth justice system.
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METHOD |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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Outcome measures
The primary outcome measure was the Salford Needs Assessment for Children
and Adolescents (SNASA; Kroll et
al, 1999), a semi-structured interview for assessing mental
health needs and other potential needs in the spheres of education, risky
behaviour, violence and social relationships. A full explanation of the SNASA
and the secondary outcome measures is given by Chitsabesan et al
(2006).
Resource use and cost
We assessed service use with a questionnaire developed through previous
research in young people by the authors and adapted for the purpose of this
study (Byford et al,
1999; Harrington et
al, 2000). The questionnaire collected information on the
young person’s accommodation, use of all health, social, education and
voluntary sector services, psychotropic medication, contacts with the police,
lawyers and courts, and time spent in secure facilities. At baseline, cost
data were collected for the 6 months preceding the interview. At follow-up,
cost data covered the period from baseline to final interview, which was
approximately 9 months.
Total costs were calculated by multiplying the number of contacts with each service by an appropriate unit cost. All unit costs were for the financial year 2001–2002. For time spent in secure facilities, the cost per day of the young offenders institutions was obtained from the Prison Service Annual Report and Accounts (HM Prison Service, 2001). The costs of local authority secure children’s homes were obtained directly from the Youth Justice Board. Some young people spent time in secure training centres, which are centres for young offenders up to the age of 17 years, and relevant unit costs were obtained from the Youth Justice Board. Costs of health and education services in secure facilities are included in the overall facility costs, rather than itemised separately. For time spent in the community, total costs were calculated as the sum of all service use. As far as possible local unit costs were used (Chartered Institute of Public Finance and Accountancy, 2002; Statistics for Wales, 2003), otherwise national unit costs were applied (Harries, 1999; Metropolitan Police, 2000; British Medical Association & Royal Pharmaceutical Society of Great Britain, 2002; Netten & Curtis, 2002). The costs per day of education for those under 16 years old were taken from the relevant Office for Standards in Education reports for each establishment. Costs of accommodation provided by social services were taken from a number of sources (Finn et al, 2000; Netten & Curtis, 2002). We included the cost of domestic accommodation (living at home with families or living alone) and living expenses to avoid biasing costs in favour of the community sample. National estimates of the cost of housing and family expenditure were used to estimate the cost of domestic accommodation (Building Cost Information Service, 2002; National Statistics, 2003).
Self-reported information on the number of crimes committed by the young people in the cohort was also collected in interview. The financial impact of their crimes was not included in the main analysis because emphasis was on the cost of supporting young people in the youth justice system, not the cost of their offences. However, we included the societal cost of crime in an additional analysis. The unit costs applied included the cost of property stolen or damaged, emotional and physical impact on victims, lost output, victim services and victim health services (Brand & Price, 2000).
Statistical analysis
All analyses were performed using the Statistical Package for the Social
Sciences version 11 for Windows. Average total costs per month are reported.
Total costs at baseline were compared between offenders interviewed in secure
facilities and in the community using the standard t-test. Despite
the cost data being skewed, analyses compared differences in mean costs using
parametric tests, with the results confirmed using non-parametric bootstrap
techniques (Barber & Thompson,
2000). The advantage of this approach, as opposed to logarithmic
transformation or non-parametric tests, is the ability to make inferences
about the mean cost (Thompson &
Barber, 2000).
Using data from the subsample of young people interviewed in secure facilities and followed up an average of 9 months later, a cost–function analysis was undertaken to explore and quantify the impact of individual baseline characteristics and needs on total costs at follow-up. The literature on factors that influence resource use and cost in young people was reviewed in order to identify potential predictors of total cost (Byford et al, 2002). To explore the relationship between cost and needs, one variable from each section of the SNASA (mental health, education, risky behaviour, violence and social relationships) was included. Univariate associations between each of the specified predictors and total monthly costs were explored in linear regression. For continuous variables, although analyses were carried out on continuous data, results are presented in two groups split at the median. Multiple regression was used to reduce the variable set to those factors independently associated with costs, using a process outlined by Byford et al (2002). The multiple regression initially included all variables that had important univariate associations with cost, discarding from the model all variables that were no longer found to be important. Variables that did not have a univariate association with cost were added and retained if they added significantly to the model, or were otherwise discarded. The model finally arrived at was checked to ensure that no variable excluded would add significantly to it. A significance level of around 10% was used although not strictly applied.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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Mental health need
Almost a third (31%) of young people interviewed at baseline had a mental
health need and within that, almost one in five had significant depressive
symptoms One in ten reported anxiety or post-traumatic stress symptoms, and
hyperactivity and psychotic symptoms were found in 7% and 5% of the cohort
respectively. There was no significant difference in the number of mental
health needs between the community and secure facilities samples.
Service use and cost at baseline
Economic data were available for 299 offenders at baseline. Service use
over 6 months is detailed in Table
1 and reflects interview location. Young people in the secure
facilities sample spent more days in young offenders institutions, local
authority secure children’s homes and secure training centres over the
previous 6 months compared with the community sample. There remained, however,
substantial movement between secure facilities and the community in both
samples, which reflects sentence length, and perhaps a tendency for repeat
offenders to be given a custodial sentence. Considering the sample as a whole,
contact with general medical services was high: 88% of the secure facilities
sample had contact with a general practitioner, although contacts among those
interviewed in the community were lower (48%). Differences may reflect more
easily accessible medical services in secure facilities. In total, around 40%
of the sample had some contact with mental health services, including
community services, hospital services and drug and alcohol services, either in
secure facilities or in the community. However, there was considerable
variation between the secure facilities and community samples: mental health
services were accessed by 60% of the secure facilities sample but by only 20%
of the community sample.
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Average total cost per month was £3260, or almost £40 000 per year. Costs were significantly higher among the secure facilities sample compared with the community sample (£4645 v. £1863; P<0.001). This was primarily the result of the high costs of secure facilities. Table 2 breaks down the cost by service-providing sector and demonstrates that costs were not confined to the criminal justice sector. Costs to social services were also high, constituting 43% of total costs in the community sample. In general, the cost burden was greatest on the sector providing accommodation and residential care. Thus, for the secure facilities sample the criminal justice system bore the greatest burden owing to the high cost of secure placements, and for the community sample, after domestic accommodation, social services bore the greatest burden owing to foster placements, residential care and placements in hostels. Costs to health services were relatively low because they tended to be contacts with professionals rather than in-patient stays.
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Service use and cost at follow-up
Service-use data were available for 72 young people at follow-up. Service
use and costs for the subsample of young people initially interviewed in
secure facilities display a broadly similar pattern to that shown at baseline.
Total cost per month was £2729 or just under £33 000 per year. The
greatest financial burden fell on the criminal justice sector, which bore 86%
of total costs as a result of the large number of young people in the cohort
who had not been released or who had returned to secure facilities.
Cost–function analysis
Variables examined in the cost–function analysis are given in
Table 3. Univariate analysis
revealed that higher monthly total costs at follow-up were significantly
associated with younger age, a history of social services care, and needs
related to depressive symptoms, violence to people and problems with family
relationships. Costs did not vary with gender or ethnicity.
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Factors significantly and independently related to cost in multiple regression analysis (Table 4) included age and needs related to depressive symptoms. The results demonstrate that for every yearly reduction in age, total cost per month increased by £627, and individuals with depressed mood cost £5444 more per month than those without depression. The regression model was able to account for around a quarter of the variation in total costs (adjusted R2=0.24).
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Societal costs of crime
The average cost per month of the cohort including the cost of criminal
activity was £4777, or around £57 000 per year. The difference in
cost between the secure facilities and community samples was no longer
statistically significant (£5927 v. £3519;
P=0.11), perhaps reflecting the greater opportunity for criminal
activity in the community sample.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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The average annual cost of a young person in the youth justice system was around £40 000, excluding the wider societal costs of crime. The costs incurred by young offenders interviewed in secure facilities were significantly higher than those of the young offenders interviewed in the community. However, these differences should not lead to conclusions that community sentences are somehow better or more cost-effective than custodial sentences because they are less expensive. This can only be determined by comparison of two groups similar in all respects apart from location of interview, and assessment of both the costs and outcomes of the two groups in an economic evaluation. Indeed, the finding that young offenders’ needs are perhaps better met in secure facilities may have a greater positive influence on outcomes and thus on cost-effectiveness.
Use of mental health services
Mental health service use was substantially lower in the community sample
(20% v. 60% in secure facilities), even though mental health needs
were similar to those found in the secure facilities sample. In secure
facilities it is likely that mental health services are more readily available
on site and that routine assessment is able to identify those likely to
benefit from mental health care. Conversely, the results raise concerns that
young offenders in the community sample do not appear to be accessing mental
health services in the community. With a greater emphasis on community
sentences (Audit Commission,
2004), improving access to and provision of mental health services
for young offenders in the community is a particularly pertinent concern. The
National Service Framework for children and young people emphasises the
importance of child and adolescent mental health services in young offenders
institutions but pays less attention to the role of such services for young
offenders in the community, aside from a recommendation that youth offending
teams should include a mental health professional
(Department of Health,
2004).
Comparisons with previous studies
Costs estimated here are greater than estimates made in similar research as
a result of the broader cost perspective taken, with this study including
costs to all service-providing sectors. For example, Liddle
(1998) estimated the lifetime
costs of services used by young people in custody to be only £7000, but
this figure excluded health service and voluntary sector costs as well as many
additional costs borne by social services and the education sector. Such
differences in estimates of total costs highlight the importance of collecting
and measuring costs broadly. In particular, in comparative analyses, narrow
cost perspectives may make one intervention or one group of young people
appear less costly than another simply because relevant costs have been
excluded.
Associations with cost
Characteristics that were found to be associated with higher costs included
younger age and depressed mood. Costs were perhaps greater in younger age
groups because younger people require more intensive support if in the
community (a foster placement rather than supported accommodation, for
example) or are more likely to serve their custodial sentence in a secure
training centre or local authority secure children’s home, which have
significantly higher unit costs than young offenders institutions. The
findings add credence to the arguments that support and crime prevention
should be aimed at younger age groups and that such schemes may lead to cost
savings (Audit Commission,
2004). The highly significant relationship between depressed mood
and high cost is less obvious, but it is unlikely to be a direct one since the
cost of health services for depression makes only a small contribution to the
total costs reported here. Instead, depression may be a marker for people who
have experienced significant life events
(Rutter et al, 1981).
For example, depression is common in young people who have had difficult lives
as a result of abuse, multiple local authority accommodation placements or
time spent in institutions (Harrington,
1995). Thus, depression may be an indicator of other problems that
will lead to high use of health, social and youth justice services and perhaps
to an increased likelihood of these young people being in supported
accommodation rather than living with their family, or of being given a
custodial rather than a community sentence.
Despite findings in this sample of relatively large needs in the areas of peer and family relationships (48% of the sample; Chitsabesan et al, 2006), needs in areas other than mental health were not found to be significant predictors of cost in multivariate regression, perhaps reflecting the lack of tangible services to meet these needs. This finding highlights the need for investment into support for young people with relationship difficulties.
Limitations and strengths
Our study was limited by the lack of a comparison group of young people
with no history of offending. Thus, no real inference can be made about the
additional cost of services for young people in the youth justice system
beyond comparisons with previous research. In addition, the total cost of care
packages may be an underestimate of the true societal cost of supporting young
offenders, as a result of the exclusion of private costs to families in terms
of out-of-pocket expenses and employment losses. However, the relative
difference in cost between those interviewed in secure facilities and those
interviewed in the community is significant and unlikely to be greatly
influenced by the inclusion of such costs. Finally, we did not have
information on the original sentence for which the young person was in either
a secure facility or the community. Therefore, the cost estimates should not
be considered estimates of different sentences. Rather, by interviewing in
both the community and secure facilities, a good estimate of the range of
costs of dealing with young people in the youth justice system has been
achieved.
The study cohort was taken from a wide geographical area and included people in the youth justice system with custodial and community sentences, so the results are generalisable to young people in England and Wales in the youth justice system as a whole. These results demonstrate the significant financial burden of young people in the youth justice system not only to the criminal justice sector but also to social services departments, the National Health Service and the education sector. Of particular concern is the finding that young offenders in the community are less likely to access mental health services than those in secure facilities, despite relatively high levels of mental health need in the cohort. The significant relationship between cost and depressed mood also indicates a role for mental health services in the support of young people in the youth justice system.
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Clinical Implications and Limitations |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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Received for publication February 15, 2005. Revision received September 22, 2005. Accepted for publication October 27, 2005.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| Psychiatric Bulletin | Advances in Psychiatric Treatment | All RCPsych Journals |
