Appleby's editorial ^{Reference Appleby1} on how best to tackle offender health, particularly mental ill health and substance misuse, was a stimulating read. However, it contained no reference to the estimated 5800 prisoners with an intellectual disability. This group of offenders are effectively excluded from interventions within prisons aimed at reducing re-offending. Moreover, research from the Prison Reform Trust indicates that individuals with an intellectual disability in prison are subject to routine human rights abuses, are five times more likely to be restrained and three times more likely to be segregated compared with prisoners without intellectual disability. ² These are harrowing statistics.

Appleby highlighted three essential service provision aims for offenders with mental ill health - early intervention, alternatives to prison and multi-agency packages when leaving prison. Any services and interventions established to meet these aims for individuals with mental illness would not necessarily meet the needs of offenders with an intellectual disability. It is essential that thought is given to the means of providing appropriate support for them.

Throughout British psychiatric and mental health history - from the closing of the Victorian asylums to community care and revisions to the Mental Health Act - policy has always been weighted more towards people with mental health problems than those with an intellectual disability. We should redress this imbalance.

Since Lord Bradley's report, ³ important steps have been taken to try to improve away-from-prison diversion schemes for offenders with an intellectual disability. These include piloting a screening questionnaire for intellectual disability, due to be available in prisons next year. It is vital that the government continues to support the development of strategies for offenders with an intellectual disability as well as those with mental health problems. Budgetary restrictions should not be allowed to impede this work.

Many people appear unaware of the role of the independent sector in providing care and treatment for an increasing proportion of this patient group. In 1998, 15% of individuals with an intellectual disability were detained within hospitals in the independent sector, but in 2008 this had grown to 46%. ⁴ Moreover, in 2007/2008 a total of 67 Section 37 Hospital Orders were made (restricted and unrestricted), of which 42 individuals were placed within the independent sector. ⁴

Collectively, the independent sector has immense expertise in how best to provide tailor-made and specialist care to this patient group. However, at a strategic level it is only consulted at a superficial level regarding the future development of services to meet the needs of this patient group. This may reflect a guardedness in relation to the commercial foundations of the independent sector, which may be linked to a misunderstanding of its funding basis. In regard to the provision of services to patients with an intellectual disability, all care is funded by the National Health Service (NHS) or Social Services, not by the individual receiving care. In effect, the independent sector works in clinical partnership with the NHS as its agency to develop and provide such care. Given this level of cooperation and the expertise of the independent sector, it seems surprising that the input from this sector is missing from the strategic development of services for this very vulnerable group of individuals.