Download LCJB Health sub group - Needs Assessment Report 2014

Thames Valley Criminal Justice Board
Improving = Reducing
Health Crime
A Needs Assessment
Report by the TVCJB
Health Sub-Group
Published 2014
TVCJB Health Sub-Group Improving Health – Reducing Crime
Contents
Note from the chair of Thames Valley LCJB Health Sub-Group ......................
4
Executive Summary ................................................................................................
5
1. Introduction .........................................................................................................
6
2. The National Strategic Context .........................................................................
7-8
3. Criminal Justice Agencies in Thames Valley ...................................................
9
4. Criminal Justice Facts and Figures ...................................................................
10-13
5. Learning Disability and Autism .......................................................................
14-15
6. Thames Valley Police ...........................................................................................
15-18
7. Court Liaison and Diversion Service ................................................................
18-20
8. Offenders supervised by Probation .................................................................
21-23
9. Thames Valley Probation – Offender Profiles .................................................
24-29
10. Offenders at Highest Risk of Re-offending ..................................................
30
11. Critical areas to secure improvement in offender health ..........................
30-33
12. Conclusion and Recommendations...............................................................
33-34
13. Case studies........................................................................................................
35-37
14. References ..........................................................................................................
38-39
3
Improving Health – Reducing Crime TVCJB Health Sub-Group
Note from the Chair of Thames Valley LCJB Health Sub-Group
T
his assessment has been written for a wide audience, bringing
together the different bodies responsible for commissioning
clinical and health & well-being services in Thames Valley and
Criminal Justice agencies.
The goal of the Thames Valley Local Criminal Justice Board – Health SubGroup is to encourage agencies to work together to provide seamless
commissioning and service provision to attain their organisation’s individual
and shared goals, including the improvement of the health of people
socially excluded and reduction in the risk of re-offending, by ensuring
access to effective health and well-being provision.
Kilvinder Vigurs
The conclusion of
this assessment
is to repeat
the need for
commissioners,
providers and
stakeholders
to support the
development and
management of
health and social
care services to
support people
who are often at
the margins of
society.
There are well rehearsed elements to this assessment and it is
acknowledged that some areas in Thames Valley have made significant
strides to co-ordinate health commissioning, but due to the disparate
nature of the area such advances are variable.
The information provided is from a moment in time and very likely that
some elements of joint working and commissioning will have moved on by
the time of publication.
On behalf of the group, I ask that you take this opportunity to use this
assessment to review your commissioning process to ensure that it includes
the needs of those subject to the Criminal Justice System including the
accessibility of services.
Kilvinder Vigurs
Chair of the Health Sub-Group
Thames Valley Local Criminal Justice Board
Acknowledgements:
Courtney Hougham, Open University
Andrew Bates, Forensic Psychologist, Thames Valley Probation
Julie Grimes, Information Officer, Thames Valley Probation
Jan Penny, Thames Valley Police Inspector, Lead for Mental Health
Sunita Sturup-Toft, Public Health England (NHS)
David Colchester, Programme Manager for Thames Valey Local Criminal
Justice Board
Partnership Managers in Thames Valley Probation
Fiona Tarrant, Thames Valley Probation, report design/layout
4
TVCJB Health Sub-Group Improving Health – Reducing Crime
Executive Summary
In order to support the co-ordination of criminal
justice activities, Thames Valley has a Local Criminal
Justice Board which brings together the criminal
justice agencies to support joint working and shared
outcomes.
The Health Sub-Group was created to provide a
forum to link criminal justice with offender health
commissioners and some of the specialist providers.
Through its review of the criminal justice and health
pathway, the sub-group recognised disconnection
between differing commissioning groups, service
users and key stakeholders.
The geographic and political landscape in
Thames Valley conspires to create complexities in
commissioning and providing consistent services
across the area.
There are sixteen local authorities with commissioning
groups for health and well-being initiatives, ten clinical
commissioning groups and national commissioning
for specific offender health interventions normally
linked to police custody, courts and prisons.
The lack of connectivity across the area between
community provision and centrally commissioned
interventions is problematic for criminal justice
agencies working across Thames Valley including the
Police, Courts and Probation.
The problems facing the agencies include the need to
engage with every commissioning group to influence
commissioning and link the services together.
There is also the additional dimension of the
inequalities experienced by offenders. Many
offenders have challenging lifestyles linked with poor
health outcomes. A number of national and local
studies demonstrate the disparity between offender
groups and the national population.
A study by Berkshire West Primary Care Trust*
illustrates a number health and social welfare
concerns impacting on adult offenders supervised
by Probation and compares this with the general
population. In addition to health concerns, learning
disabilities are also known to be more prevalent in
offender groups.
A recent study of adults on Probation supervision in
Milton Keynes** suggested that the offenders were
five times more likely to have autism than the general
population. A number of case studies set out in this
report provide real examples of the problems offender
face in accessing health and social care and the
benefits of receiving the right support.
Tackling inequalities of health has traditionally been
the responsibility of the National Health Service.
However this assessment will confirm that to tackle
the social determinants of health, a partnership
response is required.
The link between determinants of health and
likelihood of re-offending is strong. In the same vein,
access to health and social care is an essential part of
reducing re-offending.
Improving health, reducing re-offending improves
communities and lessens the number of victims. This
needs to be recognised in commissioning and service
specification in order to provide effective health and
social care services. The same is true across the whole
range of health services, but particular attention
has to be paid by commissioners for mental health,
learning disabilities and addictions services for young
and adult offenders.
Thames Valley Probation has provided a snapshot of
its caseload highlighting the many personal and social
circumstances contributing to offending behaviour.
There is also a wider issue for Thames Valley Police
who are often called to support vulnerable adults
in the community. Due to the lack of available and
consistent resources to help people exhibiting mental
health problems, the police are faced with using
custody suites as a place of safety until appropriate
accommodation is secured. Vulnerable adults in
serious distress and mental health problems should
have access to community resources.
The conclusion of this assessment is to repeat
the need for commissioners, providers and
stakeholders to engage in meaningful discussion to
share information and experiences to support the
development and management of health and social
care services to support people who are often at the
margins of society.
* See Page 21 ** See Page 14
5
Improving Health – Reducing Crime TVCJB Health Sub-Group
1. Introduction
The Thames Valley Criminal Justice Board – Health
Sub-Group is made up of senior representatives
from criminal justice agencies including the Courts,
Police and Probation, along with colleagues from
the two Offender Health Commissioning Groups
covering Thames Valley and specialist service
providers.
The group was initially set up to review the individual’s
journey in the Criminal Justice System and the impact
of the new health commissioning arrangements.
Whilst there have been developments in offender
health commissioning including Court Liaison and
Diversion schemes, the group recognised a significant
gap between offender health commissioning, which
focuses criminal justice processes (police custody,
courts, prisons etc.) and general clinical health and
well-being commissioning for community provision.
Consequently, it became very clear for the group’s
need to work closely with the new clinical health and
wellbeing commissioning arrangements in order
to inform the development of service provision,
including mental health, learning disabilities,
substance abuse treatments and health screening.
To this end, the group commissioned this assessment
to set out the complexities of commissioning health
and social care provision across Thames Valley and
provide an evidence-based approach supporting
the need to improve the health and well-being of
those people subject to the Criminal Justice System
and their families, who often face health and social
inequalities compared to the general population.
The principles set out in the assessment are:
A. Improving efficiency and effectiveness of systems
B. Working in partnership
C Equity of access to services
D. Raising awareness of offender health needs
E. Strengthening referral pathways and continuity of
care
F. Improving health
G. Reducing re-offending
6
The assessment provides a framework for
commissioners together with a range of partners
including statutory agencies, private and voluntary
sector to work collaboratively to recognise and
respond to the complex needs of offenders.
It is only when the agencies work together that health
can be improved for this often hard to reach group,
which in turn supports a reduction in re-offending.
It is envisaged that action arising from this assessment
will be owned and implemented by a range of
organisations within a local commissioning context.
Local priorities to improve the health of the offender
population have been identified as:
A. Assessment and treatment for substance misuse
among adults and young people
B. Assessment and treatment for mental health of
adults and young people
C. Dual diagnosis and treatment of mental ill-health
and substance misuse
D. Assessment and services for adult and young
people with learning disabilities
E. Support for long term conditions
F. Access to general health provision.
Lochner and
Moretti ‘s study1 found
the rate of 52.3% school
leavers before the age of
16 in the probation sample
was different to 32%
observed in the general
population.
In Chappell’s
sample2 49.5%
of men and 66.7% of
women had left school
before or at the age of 16 in
contrast to 89% of men
and 84% of women in
prison.
75% of all
prisoners have a
dual diagnosis (mental
health and alcohol or drug
misuse) yet HM Prisons
Inspectorate found dual
diagnosis services
remain patchy3
TVCJB Health Sub-Group Improving Health – Reducing Crime
2. National Strategic Context
Health Commissioning from April 2013
– National Health Service Commissioning Board
Structural changes to commissioning arrangements were introduced in
2012 as required by the Health and Social Care Act 2012 which created the
NHS Commissioning Board and abolished Primary Care Trusts.
Prior to April 2013, The National Offender Management Service (NOMS) was
responsible for commissioning and delivering services in 120 prisons and
Young Offender Institutions in England, (both through the public sector prison
service and contracted providers) including enabling provision of healthcare
in such establishments.
The NHS was responsible for all health services in public sector prisons as
well as some or all health services in contracted prisons, the scope of which
varied by the type of contracts held with prison operators for individual
establishments by NOMS.
NHS England is now responsible for the commissioning the health care in
to the prisons, supporting the police in commissioning police health care in
custody suites and providing Liaison and Diversion mental health and learning
disability services into police custody suites and courts.
There are nine Area Teams (AT) and one regional team (London) which are
responsible for the commissioning of services including contract negotiation
and management for all service activity with all providers within the defined
area.
In order to reduce the risk involved in moving towards consistent contracting
and service specifications and avoid destabilising any services during
the period of transition, the NHSCB agreed to set time limited transition
arrangements and work closely with providers ready for the 2014/15
contracting round.
The NHSCB has to be satisfied that it is meeting its duty under the Health and
Social Act by arranging medical services for prisoners, irrespective of custodial
providers and putting arrangements in place to affect this assurance for all
prisons.
The Secretary of State for Health’s mandate to the NHS Commissioning Board
sets a clear priority for services in terms of developing better healthcare
services for offenders and people in the criminal justice system which are:
■ Integrated health care services between custody and the community,
■ Development of liaison and diversion services, pre and post court bearing
in mind that the majority of offender’s time is spent in the community
rather than custody,
NHS England is
now responsible
for the
commissioning
the health care
in to the prisons,
supporting
the police in
commissioning
police health
care in custody
suites and
providing Liaison
and Diversion
mental health
and learning
disability services
in to Police
custody suites
and courts.
■ Close working between providers and co-commissioning partners to ensure
Continued overleaf
7
Improving Health – Reducing Crime TVCJB Health Sub-Group
2. National Strategic Context
Health Commissioning from April 2013
– National Health Service Commissioning Board
continued from previous page
that services are designed with clear pathways both
between prison and other places of detention and
between places of detention and the community,
(Woodhill) and Milton Keynes police custody suite and
Thames Valley Area Team covers the remaining five
prisons, all other police custody suites and courts.
■ Shared assessments of need including contributing
to the work of Health and Well-Being Boards
and other ‘through the gate’ services e.g. lead
commissioners in area teams might make best use
of existing joint commission substance misuse
services in custody to secure delivery of identified
outcomes in the community where they can be
assured this will deliver their outcomes.
The role of Clinical Commissioning Groups
The NHSCB is designed to improve outcomes for
patients while reducing inconsistency and duplication
in the system, by commissioning directly health
services or facilities for persons who are detained in
prison or in other secure accommodation, and for
victims of sexual assault in England.
CCGs are also responsible for commissioning health
services for adults and young offenders serving
community sentences or released under supervision
on licence by Probation and health services for initial
accommodation for asylum seekers.
In addition to prisons and young offender institutions,
it will include ‘other secure accommodation’ i.e. secure
children’s homes, secure training centres, immigration
removal centres, police custody suites and courts
which previously have been provided by the UK
Borders Agency (UKBA) for Immigration Removal
Centres; the Youth Justice Board (YJB) for Secure
Children’s Homes and Secure Training Centres and
youth offending places in YOIs; and Police Authorities
for Police Custody Suites and Sexual Assault Referral
Centres.
A central pillar of the NHSCB’s vision for the future of
commissioning is achieving equity of access to and
excellence in care and treatment. Having a consistent
approach to central planning, with delivery at a local
level will help to tackle variations and will be a positive
step forward in raising the standard of care, using the
same minimum standards and quality of care that can
be expected in the community.
Thames Valley Offender Health Commissioners
Two NHS England Area Teams (AT) cover the Thames
Valley area. East Midlands AT covers one prison
8
Clinical Commissioning Groups (CCG) are now
responsible for commissioning emergency care,
including Accident & Emergency and ambulance
services as well as out-of-hours primary medical
services, for prisoners and detainees present in their
geographical area.
There are ten CCGs in Thames Valley, they are
responsible for the commissioning of health care
for those people in the community, including those
subject to a Community Order or resident at a
Approved Premise.
Health & Wellbeing Boards
It is a requirement of the Health and Social Care Act
that a Health and Wellbeing Board is established for
every single and upper tier local authority. There
are sixteen local authorities in Thames Valley with
representatives who sit on the Health and Wellbeing
Boards.
These boards are responsible for drawing together
a Joint Strategic Health Needs Assessment for their
areas.
The boards also bring together representatives from
local authorities and National Health Service. Central
guidance from Department of Health and Local
Government have encouraged the Boards to build
effective engagement with Criminal Justice Partners
to support the improved commissioning to achieve
better health, justice and community safety.
TVCJB Health Sub-Group Improving Health – Reducing Crime
3. Criminal Justice Agencies in Thames Valley
In Thames Valley, the police, probation and courts are co-terminus. There are six prisons in Thames Valley,
5 probation approved premises and one (voluntary) female approved premise. The Crown Prosecution
Service work across Thames Valley, Bedfordshire and Hertfordshire.
The Thames Valley Local Criminal Justice Board brings together the criminal justices agencies. More locally,
the Board has local performance groups focusing primarily on shared prosecution and court performance
measures. More strategically, the police and probation services in particular are statutory members of
community safety partnerships alongside their health partners, local authority and fire service.
The criminal justice agencies and health and social care need to work together to ensure that services are
available to offenders to support them out of crime and improve their life chances.
The diagram below illustrates the partnership landscape. Evidence is drawn from the different stages of the
criminal justice journey.
Clusters
COMMISSIONING
Clinical Commissioning
Group
Secondary care incl. MH
Milton Keynes
&
Northants
Oxon
&
Bucks
Public Health (local
authority) – (influence CCG/
ratify decisions)
Health & Wellbeing Boards
incl. teenage pregnancy,
smoking cessation etc.
Substance Abuse (reduction
in the community)
Berks
National Commissioning
Board – Regional offices/Sub
Groups/Local Area Teams
Primary Care/Military Health/
Offender Health
(prison, police custody,
court liaison & diversion,
Immigration Centres, SARCs,
Children Secure Training Units,
CARATs)
Criminal Justice
Community
Safety
Partnerships –
IOM/MAPPA/
MARAC
OFFENDER
HEALTH
Mental Health and
Learning Disability
Interventions –
Substance Abuse
Treatment
Inequalities in
health
Local sub groups
of Criminal Justice
Board – Courts, CPS,
Police, Probation,
Witness/Victims
9
Improving Health – Reducing Crime TVCJB Health Sub-Group
4. Criminal Justice Health Facts and Figures
The majority of offenders enter prison and
probation with a range of health and social
problems, including poor mental health, drug
and alcohol misuse and low levels of literacy and
numeracy.
These problems and deficits are known to be
associated with offending behaviour.
Seven key areas or ‘pathways’ are identified
to support the rehabilitation of offenders:
Accommodation, education, training and
employment, health, drugs and alcohol, finance,
benefit and debt, children and families and
attitudes, thinking and behaviour.
Despite huge strides in each of these pathways,
there is still a long way to go, especially in the area
of health.
This report looks at health in the criminal justice
system. To reinforce the recommendations
being made, we have sourced facts and figures
associated with all aspects of offenders’ health and
their correlation with offending, re-offending and
lifestyle choices.
This section is broken down into key groups
where specific health needs have been
identified.
AGE
Young people
A cross government strategy to improve the health
and well-being of children and young people at risk of
offending and re-offending entitled Healthy Children,
Safer Communities was released on 8 December 20094.
The strategy was borne out of the development of The
Improving Health and Criminal Justice Programme
Board, which identified the need for a specific,
discrete strategy involving relevant agencies involved
in youth crime and recognising that children have
separate health needs and that the legal and service
frameworks are also different5.
Research has demonstrated an inextricable
10
association between levels of education attainment
and crime6. There is a significant negative correlation
between higher education and re-offending rates.
Overall the rate of 52.3% school leavers before
16 years in the probation sample was different to
32% observed in the general
population. Further, lower
In Chappell’s
6
education is related to
sample 49.5%
poorer health outcomes7
of men and 66.7% of
with a conservative
women had left school
before or at the age of 16 in estimate of 25% of
service users without any
contrast to 89% of men
qualification.
and 84% of women
in prison.
This cross government
strategy builds on the Youth
Crime Action Plan8 and on the agenda
set out in Healthy Lives, Brighter Futures9. It responds
to the Healthcare Commission and HMI Probation
findings on the inadequate provision for those in
contact with the Youth Justice Service. It reflects the
vision to improve outcomes for children set out in the
Children’s Plan10 and Every Child Matters Programme11.
Young people in prison – some facts
■ Mental health problems, drug and alcohol abuse are
common amongst young people in prison. They are more
likely than adults to suffer from mental health problems
and are more likely to take, or try to take, their own life
than both younger and older prisoners. 12
■ 27% of young adults reported arriving into prison with
an alcohol problem and 23% believe they will leave
with an alcohol problem. These figures almost certainly
underestimate the scale of the problem, as many of
those with alcohol problems will fail to recognise or
acknowledge them. 13
■ A quarter of the young adult population surveyed by HM
Prisons Inspectorate thought they would leave prison with
a drug problem. 14
■ Young adults account for 20% of individuals in prison who
self-harm although they represent 12% of the population
in custody. 15
TVCJB Health Sub-Group Improving Health – Reducing Crime
4. Criminal Justice Health Facts and Figures
Age
AGE
Older people
Within the prison population, the over 60s are the
fastest growing age group, with 6661 male and 316
female prisoners over 50 in prison nationally, of which
454 are over 70. The over 60 population is three times
that of 1996 (now 2242), some 100% more than the
rise in the under 60s offender population. 16
Of this group, over 50% have mental illness, most
commonly depression. 17
■ On 31 March 2011, there were 8,804 prisoners aged 50
and over in England and Wales, including 2,975 aged 60
and over. This group makes up 10% of the total prison
population. 18
■ Some older prisoners will have a physical health status
of 10 years older than their contemporaries in the
community. 19
WOMEN
In March 2006, Baroness Jean Corston was
commissioned to conduct a review of women in
the Criminal justice System who had particular
vulnerabilities. 20
The review examined women’s pathways through
the CJS process and the interventions and services
available at each stage, to identify what more could be
done to tackle the problems at an earlier point.
Baroness Corston considered these women in terms of
their “vulnerabilities”, identifying three categories:
1. Domestic circumstances
issues such as domestic violence, childcare issues,
being a single parent
2. Personal circumstances
Issues such as mental illness, low self-esteem, eating
disorders, substance misuse
3. Socio-economic circumstances
issues such as poverty, isolation and unemployment.
When women are experiencing a combination
of factors from each of these three types of
vulnerabilities, it is likely to lead to a crisis point that
ultimately results in prison.
It is these underlying issues that must be addressed
by helping women develop
resilience, life skills and
emotional literacy.
In terms of specific
needs the Corston
Report found:
■ Up to 50% of women
in prison report
having experienced
violence at home
compared with a quarter
of men.
The 2011 rate of 2,104 self
harm incidents per 1,000
female prisoners was over TEN
TIMES higher than that for men
(194 incidents per 1,000 male
prisoners) 21
■ One in three women in prison have suffered sexual abuse
compared with <1:10 men.
■ One in 20 women (all women not just prisoners for
whom the chart may be higher) have been raped at least
once since the age of 16.
■ 85% of women received had a substance misuse problem
prior to arrest
■ Up to 80% of women in prison have diagnosable mental
health problems compared with a chart of 15% for the
general adult female population
■ 66% of women in prison are assessed as having
symptoms of neurotic disorders (depression, anxiety or
phobias) compared with 20% in the general population.
■ About 50% display features of personality disorder
(mood swings, poor emotional control, and problems
with relationships, poor impulse control).
■ In 2003 women represented only 6% of the prison
population but accounted for 15% of suicides.
■ In 2005, notwithstanding the small number of women
in prison compared with men,
56% of all recorded incidents
There
of self-harm occurred in the
is
only
ONE
female estate. In the first nine
purpose-built
months of 2006 self-harm
incidents in the female
women’s centre in
estate accounted for 51% of
Thames Valley – Alana
all incidents (compare this to
House, based in
the 2011 figures in the blue
Reading.
circle above right).
11
Improving Health – Reducing Crime TVCJB Health Sub-Group
4. Criminal Justice Health Facts and Figures
PHYSICAL HEALTH
A survey by the Ministry of Justice found that over
a quarter of newly sentenced prisoners reported a
long-standing physical disorder or disability.22
■ Musculoskeletal and respiratory complaints were
most commonly reported
■ 31% of newly sentenced women prisoners report
a long-standing physical disorder or disability
compared to 26% for men
■ Newly sentenced male prisoners were more likely
to report good or very good health than newly
sentenced women prisoners (69% compared to
61%)
■ In 2010, there were a total of 26,983 incidents
of self-harm in prisons, with 6,639 prisoners
recorded as having injured themselves. Women
accounted for 47% of all incidents of self harm
despite representing just 5% of the total prison
population.23
■ Homelessness can also prevent former prisoners
from accessing support services such as benefits or
registering with a GP.24
■ 13% of newly sentenced prisoners reported being
unable to work because of long-term sickness or
disability. A greater proportion of women reported
being unable to work owing to long-term sickness/
disability than men (17% compared to 13%)25
MENTAL HEALTH
■ 13.6 % of the total probation
population were in contact with
Black and
the local mental health trust
minority ethnic
with the proportion higher
groups are 40% more
amongst female offenders
likely to access mental
(19.6%)26
health services via a
criminal justice system
gateway27
12
■ Mentally ill offenders
receiving community
supervision are frequently
failed by services that are
not geared towards the needs of this population28
■ Mentally ill offenders were disenchanted with
mental health services and were unlikely to seek
help themselves29
■ Offenders with serious mental illness are twice as
likely to fail in community supervision30
■ 49% of offenders had a previous
psychiatric diagnosis and 19%
Half of all
had multiple diagnoses. A
those sentenced
mental health need was
to custody are not
identified in 92% and 71%
registered with a GP
had a history of substance
prior to being sent
misuse31
to prison.32
■ The Chief Inspector of Prisons
has estimated, based on visits to
local prisons that 41% of prisoners being held in
health care centres should have been in secure NHS
accommodation. Research found that there are up
to 500 patients in prison health care centres with
mental health problems sufficiently ill to require
immediate NHS admission33
■ 75% of all prisoners have a dual diagnosis (mental
health problems combined with alcohol or drug
misuse)34. Yet HM Prisons Inspectorate found that
dual diagnosis services remain patchy35
■ A fifth (21%) of newly sentenced prisoners reported
wanting help with a mental health problem. Adults
were more likely to request help than young
offenders (22% compared to 14%) and women
more than men (49% compared to 18%)36
■ The Revolving Doors Agency found that 49% of
prisoners with mental health problems had no
fixed address on leaving prison. Of those who had
a secure tenancy before going to prison, 40% lost it
on release. 37
SUBSTANCE MISUSE
The misuse of drugs and alcohol has serious
consequences for individuals and communities
in terms of physical and mental health problems
alongside related crime to fund on-going use,
TVCJB Health Sub-Group Improving Health – Reducing Crime
4. Criminal Justice Health Facts and Figures
domestic abuse, harm to children and family
breakdown, homelessness and loss of employment.
Drugs facts and figures
■ In 2010, 15% of men and 24% of women in prison
were serving sentences for drug offences.38
■ There is a much wider group of prisoners whose
offence is in some way drug related. Shoplifting,
burglary, vehicle crime and theft can be linked to
drug misuse.39
two-fifths of sentenced
Offenders who
women (39%) admit to
receive residential
hazardous drinking
drug
treatment are 45%
which carries the
less likely to reoffend than
risk of physical or
comparable offenders
mental harm. Of
receiving prison
these, about half
sentences47
have a severe alcohol
dependency.46
■ 22% of prisoners surveyed by
HM Inspectorate of Prisons reported having an alcohol
■ Between a third and a half of new receptions into
problem when they entered their prison. It was even
prison are estimated to be problem drug users
higher among young adults (27%) and women (29%).
(equivalent to between 45,000 and
These figures almost certainly underestimate
65,000 prisoners in England and
the scale of the problem, as many with
In 20% of violent
Wales).40
alcohol problems will fail to recognise or
crimes reported to the
acknowledge them.48
■ A report by the Cabinet Office
2010-11 British Crime Survey,
Social Exclusion Task Force
the victim believed that the
■ 26% of the local and 23% of the
found that around 70% of
offender was under the influence
young adult prison populations
women coming into custody
of drugs. 20% of robbery victims
believed they would leave with an
require clinical detoxification
believed their attacker to be
alcohol problem.49
and that 65% had used a drug
under the influence of
■ 54% of the surveyed prisoners with
during the year before custody.
drugs42
alcohol problems also reported a problem
However, practitioners report
with
drugs, and 44% said they had emotional
that women may hide or underplay
or mental health issues in addition to their alcohol
substance misuse through fear of losing their
41
problems. The correlation with emotional or mental
children
health problems was especially pronounced among
■ Drug use on release from prison is
the women surveyed.50
very high. Relative to the general
In 44% of
population, male prisoners are 29
MORBIDITY
violent crimes
times more likely to die during
the victim believed
the week following release, while
the offender or
■ Offenders in the community are four times more
female prisoners are 69 times
offenders to be under
likely to die than the general male population and
more likely to die during this
the influence of
twice the rate as that of imprisoned offenders51
period.
The
same
study
found
that
43
alcohol
59% of deaths following release
■ Males aged 35-54 years on probation have 35 times
were drug related.44
the rate of suicide than others of the same age52
■ Nearly a third (29%) of newly sentenced prisoners
reported wanting help with a drug problem. Adults ■ Drugs and alcohol were related 53to around 46% of
deaths of community offenders
were far more likely to request help than young
offenders (32% compared to 15%) and women
■ Half of offender deaths occurred within 12 weeks
more than men (44% compared to 28%)45
of release54 and women are 36 times more likely
Alcohol facts and figures
■ Nearly two-thirds of sentenced men (63%) and
to commit suicide or die from an accidental drugs
related overdose in the first two weeks after release
than the general population.55
13
Improving Health – Reducing Crime TVCJB Health Sub-Group
5. Learning Disability and Autism
In April 2009 Lord Bradley published his report56 into
the needs of people with mental health and learning
disability issues in the criminal justice system.
tool (the AQ-10) applied to 336 offenders. It resulted
in 4.5% screening positive for autism. This is five times
higher than the population average.
There were three key objectives in the report:
An Autism Project Officer can take referrals from
Milton Keynes officers if there is substantial evidence
that an offender has autism/Asperger’s and they can
provide a full FACS assessment in such cases.
1. Harnessing mainstream services to reduce
offending and re-offending
2. Addressing health and well-being throughout the
criminal justice system
3. Implementing change via co-ordinated approaches
and clear outcomes.
Good links have been established with the Autism
Society with Thames Valley Probation sitting as a
member of the Berkshire Autism Partnership Board.
Berkshire Autistic Society and Autism Oxford launched
an Autism Alert Card in conjunction with Thames
At the end of 2009 the Government published its
response to the Lord Bradley Report, Improving Health, Valley Police. According to Berkshire Autistic Society,
35% of anti-Social Behaviour
Supporting Justice, the
LEARNING DISABILITIES AND Orders (ASBO) are issued to
National Delivery Plan57
young people with mental
DIFFICULTIES – FACTS
and Healthy Children,
health problems.
Safer Communities58.
Both these documents
provided a strategy
and action plan to
promote the health
and well-being of
those in contact with
the criminal justice
system.
The needs of people
with learning
disabilities are
highlighted in:
■ 20 – 30% of offenders have learning disabilities or
difficulties that interfere with their ability to cope with
the criminal justice system.59
■ 7% of prisoners have an IQ of less than 70 and a further
25% have an IQ between 70-79.60
■ Offending behaviour programmes are not generally
accessible for offenders with an IQ below 80. There is a
mismatch between the literacy demands of programmes
and the skill level of offenders, which is particularly
significant with regard to speaking and listening skills.61
■ Health Care for All 2008 – report of the Independent
Inquiry into Access to People with Learning Disabilities
by Sir Jonathan Michael
■ Valuing People Now: A new three-year strategy for
people with learning disabilities. “Making it happen
for everyone” (2009).
Thames Valley Probation is partnering with Oxford
University and a doctoral researcher conducting
qualitative research on the governance of defendants
with autism in English criminal justice, police and
criminal court practice.
Part of this local research was at the Milton Keynes
Probation office, using a clinically reliable screening
14
Thames Valley Probation has
now agreed an informationsharing protocol with Oxford
University, similar to the one it
already has in place with Bucks
New and Bedford Universities,
to allow access to information
systems for reference for
research.
Oxfordshire courts teams
also agreed to run the AQ-10
screening tool on all defendants processed by court
duty offices for a pilot period of November 2013 –
February 2014.
Positive screens will be referred for a full Autism
Diagnosis Observation Schedule (ADOS) assessment
by the Thames Valley Probation forensic psychologist,
who will then make recommendations to be included
in the pre-sentence report. It is intended that this
pilot study will inform commissioning practice for
offenders with autism across Thames Valley.
A Senior Practitioner in Higher Functioning Autism/
Asperger’s Syndrome for Oxfordshire Social and
Community Services will take referrals from probation
staff in Oxfordshire if there is substantial evidence that
Continued on next page
TVCJB Health Sub-Group Improving Health – Reducing Crime
continued from previous page
an offender has autism/Asperger’s. They can access a
full Fair Access to Care Services (FACS) assessment.
screening for learning disabilities, using the Learning
Disability Screening Questionnaires (LDSQ), in police
custody suites.
The Thames Valley Probation forensic psychologist
has links with clinical psychologists based in Oxford
Health and Southern Health Learning Disability
Service who have assisted in the development of his
clinical skills in the assessment of autism using the
Adult Asperger’s Assessment and the ADOS.
Thames Valley Probation was praised in a recent
HMIP inspection report62 for its one-day training
programme and staff intranet resource pack on
learning disability issues. The inspection found that
these were seen by Thames Valley Probation staff
as vital tools and gave them more confidence when
assessing offenders with learning disabilities.
The Police Custody Intervention Programme (CIP) is
6. Thames Valley Police
Section 136 detentions – places of safety
S136 Mental Health Act states:
demand. Due to this, police custody suites are still the
default second choice place of safety as there are no
other health based contingencies available.
“If a Constable finds in a place to which the public
have access, a person who appears to him to
be suffering from mental disorder and to be in
immediate need of care or control, the Constable
may, if he thinks it necessary to do so in the interests
of that person or for the protection of other persons,
remove that person to a place of safety”.
There is a perception that the issue is about the
overuse of S136 rather than a lack of provision. Even
if this were the case, there are still no contingencies in
place when more than one person is detained within
the Health Trust area at a time. Equally there is an
issue around a lack of an alternative to the use of S136
provided by health services.
The Mental Health Act code of Practice states and
documents such as The Bradley Report along with
considerable national research recommends that
police stations should not be used as places of safety
unless in exceptional circumstances and that more
suitable, health based facilities should be available.
The chart below demonstrates where the subjects are
detained by county area over the previous 12 months
and then more recently within the last 3 months to
Nov 2013 and detained in police custody suites rather
than the health based place of safety.
In Thames Valley there are health based places of
safety in each Mental Health Trust area however
the facilities provided are not sufficient to meet the
It shows that across the Thames Valley 303 persons
were detained in this way (roughly 76 per quarter) and
Continued overleaf
MH S136 Custody Utilisation by LPA + Hub 12M to Nov13
100.00%
46.8%
69.7%
92.5%
53.2%
30.3%
7.5%
25.4%
Custody Not Utilised
45.2%
6.2%
Custody Utilised
74.6%
93.8%
7.4%
60.3%
92.6%
32.1%
13.9%
7.5%
23.1%
40.2%
42.2%
59.1%
0.00%
20.6%
10.00%
35.33%
20.00%
54.8%
63.9%
40.00%
30.00%
39.7%
36.1%
63.0%
67.9%
86.1%
50.00%
76.9%
59.8%
92.5%
79.4%
60.00%
64.67%
70.00%
57.8%
40.9%
80.00%
37.0%
90.00%
15
Improving Health – Reducing Crime TVCJB Health Sub-Group
6. Thames Valley Police
MH Custody reasons last 12M + last 3M by Hub to Nov-13
100%
5.88%
8.64%
90%
8.64%
23.53%
80%
70%
28.40%
4.08%
12.26%
5.88%
16.67%
27.78%
9.43%
12.50%
27.78%
50%
7.92%
8.05%
10.56%
6.90%
50.00%
31.13%
60%
4.76%
2.38%
10.20%
41.25%
71.43%
65.31%
54.02%
50.00%
40%
25.00%
64.71%
30%
51.85%
20%
47.17%
44.44%
10%
39.60%
25.00%
20.83%
0%
Berks last
12M
Berks last 3M
Bucks last
12M
Bucks last 3M MK last 12M
29.89%
21.43%
20.41%
MK last 3M Oxon last 12M Oxon last 3M TVP last 12M TVP last 3M
Alcohol/ Behaviour
Already absconded f rom MH POS
Complaint About POS
No capacity/ ref used in commissioned POS
Other of f ence
Unknown
MH136 cases to Custody by HUB + reason
Berks
Berks
Bucks
Bucks
to Nov-13
last 12M last 3M last 12M last 3M
MK last MK last Oxon last Oxon
12M
3M
12M
last 3M
TVP last TVP last
12M
3M
Behaviour
Already absconded from MH POS
Complaint About POS
42
1
1
11
1
50
5
8
1
20
9
120
1
1
26
1
0
No capacity/ refused in commissioned POS
23
4
33
12
5
1
64
30
125
47
Other offence
7
0
10
3
5
2
10
1
32
6
Unknown
All Reasons
7
81
1
17
13
106
4
24
4
4
98
2
42
24
303
7
87
18
continued from previous page
Across Thames Valley for the period to Nov 2013
custody was still utilised as the place of safety in
30.3% of cases. This ranged from less than 7.5% in
Milton Keynes to over 60% in several parts of the force
area. Alongside these figures has to be considered
the amount of time taken for the police officers to be
released and allowed to continue with their duties. In
Milton Keynes where, although so many are accepted
into the health based place of safety, for over 50%
of occasions officers were required to remain at the
Continued on next page
Reasons for Custody Detention by LPA/Hub 12M to Nov-13
100%
90%
4
1
1
1
1
2
80%
70%
2
10
5
2
1
7
9
2
60%
1
1
2
2
3
6
5
27
50%
2
7
7
6
3
12
8
9
5
22
28
20
5
1
1
26
5
3
32
15
2
11
2
5
116
59
40%
30%
20
4
4
14
8
20%
10%
6
9
4
5
10
3
23
40
47
8
114
19
8
0%
Behaviour
16
Already absconded from MH POS
Complaint About POS
No capacity/ refused in commissioned POS
Other offence
Unknown
TVCJB Health Sub-Group Improving Health – Reducing Crime
6. Thames Valley Police
Place of safety utilised by Hub 12M to Nov-13
100%
Wexham Park then Heatherwood, 5
Wexham Park, 28
90%
MK General then Campbell Centre, 27
Oxford Custody, 40
Royal Berks then Prospect Park, 9
80%
Royal Berks, 5
Tindal Centre, 152
70%
60%
Warneford, 5
Tindal Centre, 4
Oxford Custody then Littlemore, 5
MK General , 54
Prospect Park, 92
MK Custody then Campbell Centre, 4
MK Custody then Campbell Centre, 8
MK Custody, 10
50%
Littlemore, 183
Stoke Mandeville then Tindal Centre, 14
40%
Newbury Custody, 16
30%
Loddon Valley Custody, 27
Stoke Mandeville, 21
Littlemore, 4
High Wycombe Custody, 38
20%
10%
Campbell Centre, 97
John Radclif f e then Littlemore, 13
Banbury Custody then Warneford, 3
Heatherwood, 62
Banbury Custody, 20
Aylesbury Custody, 44
Abingdon Custody, 19
0%
Berks
Bucks
MK
Oxon
continued from previous page
health based place of safety for over 4 hours and
sometimes considerably longer. In Oxfordshire in the
vast majority of cases officers resumed patrol within
an hour.
What the data does not show is that the flow of
detainees is not regular. There is, on average, 3 x
S136 detained persons across Thames Valley per day.
However there can often be 2 or 3 detained at the
same time in any one Trust area which will mean one
going into the health based place of safety and the
others going into custody.
Health based places of safety are also unable to
accommodate those subjects who are abusive or
violent and so those individuals will come into police
custody as well.
The latter is of importance, since recently published
is HMIC joint report about ‘The Criminal Use of Police
Cells’ and the ‘Department of Health commissioned
concordat’ which will ultimately preclude S136
subjects from going to police custody and will require
the current places of safety to have more robust
arrangements, especially for those who are abusive or
potentially violent.
The chart above reflects the location of those detained
and demonstrates still the high number of subjects
being held in police custody.
It is therefore considered that an end to end review of
the use of S136 detention covering these very issues
is of clear importance and to include the following
points:
■ What led to the individual’s crisis and what
proactive work had occurred?
■ What alternatives are available to reduce the need
for deprivation of liberty?
■ What contingencies are in place to ensure that
police stations are used only in exceptional
circumstances?
■ What follow up work or care plans exist where a
person is detained on a S136 more than once in a
specified time?
A police representative recently stated that there are
approximately 3 S136 detentions across the force area
each day, which is approximately 1095 people per
year, of whom approximately 30% are still taken into
police custody.
Continued on next page
17
Improving Health – Reducing Crime TVCJB Health Sub-Group
6. Thames Valley Police
continued from previous page
However, of the 70% who are accepted into a health
based place of safety a large number of these
remained supervised by police officers for significant
lengths of time (2 plus hours) (data taken for 12
month period to Nov 2013).
Case Study:
An 85 year old male presented with
serious mental health issues and was put
on a Sect 136 detention. There were no
Mental Health professionals or clinicians
available, so he was in a police cell for 16
hours waiting for an assessment.
Custody Intervention Project
The police currently commission SMART Custody
Referral Workers to complete screening on people
suspected to have mental health or learning
disabilities, in addition to screening for drugs and
alcohol. A SMART worker can try to help in terms of
referral pathways; however, if someone from SMART
(or another service) is not available when the person is
released, the police default to providing a leaflet with
service information.
It has been assessed that there is an increased chance
that they will be picked up again on a S 136 or that
they will revert to criminal activity.
Street Triage
A police representative said that a gold standard
would be if the police on the street dealing with
someone presenting as a S136 could ring a number
and a health services representative would arrive on
the scene and do an assessment there and then.
A Street Triage model similar to this will be piloted in
Oxfordshire from 31st December 2013 for 12 months.
This initiative will help evaluate whether this type of
approach supports the subject in a more effective
way by reducing their need for detention and better
still appropriately signposts them into a more suitable
service.
7. Thames Valley Court Liaison & Diversion Schemes
Berkshire (East and West), Buckinghamshire and Oxfordshire
The Berkshire Liaison and Diversion bi-monthly
steering group has been overseeing the expansion
of the Court Liaison and Diversion (previously
known as ‘Divert’) scheme, replicating the existing
scheme already active in Reading in East Berks and
Newbury.
This has resulted in more meetings between Berks
Community Mental Health Managers and the Liaison
& Diversion Team to improve communications
and increase access to Mental Health Treatment
Requirements (MHTRs).
As part of the team, there is a part time psychiatrist
(0.5 of a post) who is able to provide psychiatric
assessments for courts across Thames Valley when
requested. They are to be joined by a learning
disability nurse.
18
In March 2013, a similar service was commissioned for
Bucks and Oxon from Berkshire NHS Trust to deliver a
Liaison and Diversion service to those at the point of
arrest and appearing before the courts.
Additional staff recruitment means that 4 more
mental health workers (CPNs or social workers)
will join the existing 3 in place, (2 at Slough and 1
at Newbury) along with admin staff. The service
went live in Oxfordshire in November 2013 and in
Buckinghamshire in early 2014. It includes the service
in custody suites, as well as at court.
All these services provided by the Liaison and
Diversion Team focus on mental health and are
developing formal links to services providing learning
disability resources.
The Berkshire Liaison and Diversion Team gathered
Continued on next page
TVCJB Health Sub-Group Improving Health – Reducing Crime
7. Court Liaison and Diversion Schemes
Berkshire (East and West),
Buckinghamshire and Oxfordshire
continued from previous page
referrals and assessment data from April to June
2013 as part of the national pathfinder. This is a
new data set and is difficult to compare with other
data collected from the teams at this stage, but the
findings are as follows:
In Berkshire during Q1 2013:
40 individuals were assessed (27 men, 13 women)
■ The majority of the cases were in Reading (32)
■ 3 assessments in Newbury
■ 5 assessments in Slough.
■ 32 were identified as having previous or current
contact with mental health services.
■ Advice was given in 11 of the cases
■ For 12 there was no action required,
■ 15 were recorded as N/A
■ 1 case was referred to another agency and
■ 1 was recorded as ‘other’.
■ The primary mental health issues identified for
the 40 cases assessed identify None as the most
common (12),
■ Personality Disorder 8 cases,
■ Schizophrenia or other delusion 4 cases,
■ Anxiety/OCD/Phobia 4 cases,
■ Depression 3 cases,
■ Bi-polar 2 cases,
■ Other 4 cases and
■ 4 cases where this information is unknown.
Milton Keynes – a different
approach
TV Probation and P3 (a link worker scheme) were
successful in bidding for funding for a Court Liaison
and Diversion service in Milton Keynes.
This built on the work of the link worker service, which
had been developed with Probation over the previous
year. P3’s Link Worker Project successfully undertook
significant work in supporting vulnerable offenders in
court and probation settings.
The principle of the Link Worker scheme is based on
vulnerabilities exhibited by individuals rather than
formal diagnosis. The worker targets the appropriate
assessments and treatment for each individual. Their
work follows the principles outlined in writings about
Desistance Theory63.
Link Workers aim to work very closely with service
users in order to build up a detailed knowledge of
their circumstances and difficulties. They work across
service boundaries in order to provide an inclusive
and holistic approach to support. They carry out a
comprehensive assessment of needs with the service
user and build up a personalised service user centred
action plan, then work to resolve identified issues.
The intention is to build up trust and confidence in
the worker which will enhance the results obtained. It
is an advantage in this situation to be operating from
a Third Sector platform as many of the service users
have an inherent mistrust of statutory services.
P3 Referrals (1st April to 30th September
2013): 105
Caseload as of 30th September, 2013:
Involved in Court Proceedings :
Plus 10 on waiting list
34 Active
Not involved in Court Proceedings:
PLus 4 on waiting list
12 Active
Average age of caseload:
30.9 years
SEE chart on next page for visual display of these service
users’ most prominent needs
19
Improving Health – Reducing Crime TVCJB Health Sub-Group
7. Court Liaison and Diversion Schemes
Health (inc mental health)
The chart represents the most
The chartneed
represents
the by
prominent
presented
most prominent need
the service users on assessment.
presented by the clients on
They
usually present
with
assessment.
They usually
multiple
but this
presentissues
with multiple
issues but this
demonstrates
the area which is
demonstrates
the area
causing
most concern.
Accommodation
Drugs and Alcohol
Finance
which is causing most
concern.
Attitude
Learning Disabilities
0
20
The chart above represents the percentage of service
users who report that their situation has improved in
each of the identified categories.
20
40
60
TVCJB Health Sub-Group Improving Health – Reducing Crime
8. Offenders Supervised by Probation
Berkshire West Primary Care Trust (Dr A A Pari, Dr E
Plugge and Dr J Maxwell) undertook a Health Needs
Assessment of offenders on Probation in 2012.64
The demographic structure of the sample of
participating offenders from the Berkshire West
Probation caseload was broadly similar to the overall
Berkshire West caseload.
■ The research suggested that 60% of male
Probationers reported having children, 78%
of female offenders reported having children,
comparable with the national
average.
33.6% of male
It is important that due
Probationers were in
consideration is given
employment, while only 23.8%
to the children’s wellof female Probationers were
being, as research has
in any kind of employment. The
demonstrated that
proportion of overall employment
children who have
was far below the general
a parent in prison or
population figures and was
on Probation have a
statistically significant.
greater likelihood of
suffering from mental
health problems, and poor
psycho-social outcomes (Phillips,
Venema et al. 2010).
■ In comparison to the general population, both
men (67.6 and women 78.3%)in the sample who
smoked, showed between 2.5 and 3.8 times the
number of smokers than expected from the general
population of a similar age distribution. This is
in concordance with the findings of Singleton et
al (1998) who studied sentenced prisoners who
smoked.
■ By using the Alcohol Use Disorders Identification
Test (AUDIT) screening instrument 26 males (23.6%)
and 10 females (43.5%) were non-drinkers, 16.4%
of men and 17.4% of women were identified
as alcohol dependent, with 44% of women
service users found to be “hazardous drinkers” in
comparison to 43% male service users, with women
service users having higher average AUDIT scores
than male service users.
Overall 43.2% of the women
The prevalence
participants screened
of hazardous
positive for hazardous
drinking was highest in
drinking which is
the 25-39 age group (35%).
significantly higher than
High rate of dependence
women in the general
was observed in the most
population (15%).
economic productive age
groups of 25 -39 and
40 -49.
■ In respect of problematic
substance abuse in the
sample 37.6% reported having
a problem, with a high prevalence
in males of 39.09% against 30.43% in females.
■ The greatest proportion of offenders with
problematic drug use was observed in the age
group 25-39 (44%) followed by those in the 18-24
age group (43%).
■ 45.5% of male offenders and 30.4% of female
offenders reported a significantly larger usage of
illegal drugs in the past year in contrast to 13% of
men and 8% of women in the general population.
■ In the prison setting, 66% of sentenced male
prisoners and 55% of sentenced female inmates
reported using illegal drugs in the last year, which
was significantly higher than those identified in our
sample. In addition offenders, who had high risk
sexual behaviour, were more likely to abuse alcohol
or drugs and offend.
■ Offenders in the sample
questioned about
One third of male service
engaging in sexual
users undertook treatment
activity with casual or
for sexually transmitted
regular partners were
infections in the last 12
asked if they used
months.
condoms or any other
protective methods
with their respect sexual partners in the past 12
months. One third of male and female Probationers
did not use any means of protection. Only 35% of
women and 23% of men reported using protective
methods.
■ Physical activity and quality of health is a wellknown correlate. There is well established
Continued overleaf
21
Improving Health – Reducing Crime TVCJB Health Sub-Group
8. Offenders Supervised by Probation
continued from previous page
epidemiological evidence indicating that regular
physical activity reduces rates of chronic ailments
including coronary heart disease, diabetes,
hypertension, osteoporosis and
depression (Pate, Pratt et al.
1995).
From the sample
39.4% of men and 27.3%
The sample also showed
of females engaged in
that a higher proportion
strenuous physical activity and of older individuals
showed that 37% of the sample were engaged in
engaged in recommended
strenuous exercise
physical activity compared
unlike the general
with only 12% of the
population.
general population.
Many of the sample were
physically active as part of
their community order i.e. unpaid
work requirement rather than scheduled fitness. In
addition, in interview, exercise was endorsed as a
coping measure to deal with stress and to boost selfesteem.
■ 65% of women and 43% of men screened positive
for depression, and of them, around half of women
and 83% of male offenders had not accessed any
kind of mental health services in the past year.
■ Secondary care costs outstripped primary care
and mental health costs. Inpatient care costs
due to hospitalisation, other than mental illness,
accounted for around 50% of total cost of female
offenders, and 36% of total cost of male offenders.
Female offenders had worse mental health
than male offenders, prisoners, and the general
population, their access to mental health was poor
with subsequent expenditure on mental health
only 6% of the overall expense.
■ Health was not a high priority due to more pressing
concerns i.e. employment, appropriate housing, or
for those with alcohol and drug problems, meeting
the needs of their addiction.
■ Mental health was poorest in ages 25 – 29 years,
followed closely by age group 40 – 49 years.
■ There is a significant co-morbidity observed
between those who abuse drugs and who have
22
poor mental health. Offenders who abuse both
alcohol and drugs are around 3 times more likely to
be screened positive for clinical depression.
■ The overall prevalence of blood borne viruses was
found to be higher in the Probation sample than
the general population.
Personality Disorder
Thames Valley Probation has successfully bid for
funding to deliver a Personality Disorder Pathways
Service in partnership with Oxford Health, which has
been resubmitted with a view to identifying in Oxon
and West Berks those offenders with a personality
disorder and to then provide offender managers with
consultation, case formulation and clinical support in
working with those cases.
Further workforce development is planned to build on
the Knowledge Understanding Framework Awareness
Level Personality Disorder training, delivered to 96
Probation staff by May 2013. The project also provides
psychological input into certain Approved Premises
with a view to reducing recalls and increasing
workforce skills with this service user group.
Alongside this Oxford Health Forensic Mental Health
Service, in association with Oxfordshire Complex
Needs Service, is running a Mentalisation Based
Therapy (MBT) Group for men with anti-social
personality disorder in Oxford on a weekly basis which
includes offenders on court orders or licences.
Offenders who have
poor mental health
and wellbeing incurred
significantly higher health costs
- £2,636 per head of population
compared with a cost of £729
for non-offenders.
TVCJB Health Sub-Group Improving Health – Reducing Crime
8. Offenders Supervised by Probation
Demographic characteristics of the study participants, the Berkshire West Probation
caseload (2009/2010 case management system, and the national Probation data:
Probation sample
Berkshire West caseload
National Probation data*
Males
110 (82.8%)
548 (88.1%)
143148 (84.3%)
Females
23 (17.2%)
74 (11.9%)
26545 (15.6%)
Total
133
622
169693
18-24
37 (28.0%)
241 (38.7%)
61069 (36.0%)
25-39
48 (36.4%)
246 (39.5%)
73496 (43.3%)
40 – 49
21 (15.9%)
96 (15.4%)
25538 (15.0%)
50+
26 (19.7%)
39 (6.30%)
9590 (5.70%)
Total
132
622
169693
Probation sample
Berkshire West caseload
National Probation data*
109 (82.0%)
478 (76.8%)
139961 (82.5%)
10 (7.52%)
55 (8.84%)
10097 (5.95%)
Asian British
5 (3.76%)
28 (4.50%)
7919 (4.67%)
Other
2 (1.50%)
25 (4.02%)
2071 (1.22%)
Mixed
6 (4.51%)
29 (4.66%)
4532 (2.67%)
Missing
1 (0.75%)
6 (0.96%)
2718 (1.60%)
Not stated
0
1 (0.16%)
2395 (1.41%)
Total
133
622
169693
Gender
Age Group
Ethnicity
White
Black or
Black Asian
Asian or
* persons starting Community Orders and Suspended Sentence Orders under supervision by the England & Wales Probation 2009.
Continued overleaf
23
Improving Health – Reducing Crime TVCJB Health Sub-Group
9. Thames Valley Probation – Profiles
Thames Valley Probation is split into five operational
Local Delivery Units (LDUs), which generally
correspond with Local Authority Area (LAA) borders
and police areas:
TV LDU
Local Authority Areas
Buckinghamshire
Aylesbury Vale, Chiltern, South Buckinghamshire, Wycombe
Milton Keynes
Milton Keynes
Oxfordshire
South Oxfordshire, West Oxfordshire, Cherwell, Oxford, Vale of White Horse
West Berkshire
Reading, West Berkshire, Wokingham (part)
East Berkshire
Slough, Windsor & Maidenhead, Bracknell Forest, Wokingham (part).
Thames Valley Probation works closely with
partnership agencies to provide and deliver
appropriate interventions in the community to reduce
the risk and address identified needs of offenders in
the community.
risk management plans, matching needs to effective
interventions.
Thames Valley Probation has a number of multiagency teams located in its offices, including
Integrated Offender Management Units and Court
Liaison & Diversion Schemes.
OASys data provides information on health and
wellbeing predictors. Data has been extracted from
a total of 5648 offenders who had a valid OASys
assessment completed on them between 1 January
2012 and 30 September 2012.
Data Sources for offender profiling in Thames
Valley
Thames Valley Probation provided two sources of
data for this assessment: Offender Assessment System
(OASys) – a national IT system used by both Probation
and prison services to undertake analysis of the
offences, risks and needs of individuals. It comprises
actuarial calculation of the likelihood of re-conviction
and supports structured professional assessment on
risk, and also ICMS (Integrated Case Management
System) which has now been superseded by a new
system, nDelius.
OASys records offending related social and individual
needs, including basic personality characteristics and
cognitive behaviour problems, incorporating further
specialist assessments and also measures change over
time.
All offenders, except those who are assessed as low
risk and/or subject to a Stand Alone Unpaid Work
Requirement, have an OASys prepared. Importantly,
OASys also provides a template for supervision and
24
Data sources identify needs of offenders through selfreporting and corroborating evidence.
Integrated Case Management System (ICMS)
containing contact logs recording work undertaken
with each offender. It included details of court orders
and requirements, content of interviews, breaches and
communication with partnership agencies.
ICMS was used to provide the demographic profile
figures and the disability data for this report. The data
contained in this report was 6,472 offenders recorded
as current on the 30 September 2012, of which 5,863
(91%) were males and 605 (9%) females.
Overall the caseload by age-band is 646 (10%) aged
18-20; 1,396 (22%) 21-25; 3,879 (60%) 26-49; 457 (7%)
50 – 64; and 90 (1%) 65+.
Offender tiering and profiles in Thames Valley
Probation
Thames Valley Probation currently uses a tier system
based on the threats posed by the offender, the
complexity of their situation and the needs they
present. It follows the principle of risk – needs –
responsivity.
TVCJB Health Sub-Group Improving Health – Reducing Crime
9. Thames Valley Probation – Profiles
A Tier 1 offender is someone considered as low risk
with low level of needs. The increase in tiers signifies
increasing risk, complexity and required resources.
Offenders are regularly re-assessed and can move up
and down tiers during the period of their supervision,
although changes are mainly infrequent.
A recent snapshot in Thames Valley Probation:
■ 16% of offenders are Tier 4
■ 41% Tier 3
■ 19% Tier 2
■ 23% Tier 1.
Across Thames Valley Probation:
■ 33% of all offenders are recorded as Black and
Minority Ethnic Groups,
■ 65% as Non BME and
■ 2% are recorded as “not known”.
Across Thames Valley Probation:
■ 5% of offenders are assessed as posing High Risk of
Serious Harm
■ 64% Medium Risk of Harm and
■ 17% are recorded as Low Risk of Serious Harm.
■ Across TV Probation there are 4 offenders recorded
as Very High Risk of Serious Harm, 3 in Bucks LDU
and 1 in West Berks.
Across TV Probation male offenders are far more likely
to receive a custodial sentence than females; of the
current caseload 52% of all males received a custodial
sentence compared to 26% of all females.
Females are recorded as receiving more Community
Orders (CO) and Suspended Sentence Orders (SSOs)
than males, 54% and 20% respectively, compared to
35% of all males receiving a CO and 14% a SSO.
There is often a lack of joined up provision in health
care services for those leaving prison, particularly
offenders who serve short prison sentences, in
accessing continued health care services on release,
including medication, due to delays in accessing
prison medical records.
In addition common problems are:
■ Offenders are not registered with a GP practice or
■ Feelings of mistrust and inadequacy regarding
visiting a GP.
This can leave GPs with the dilemma of having
to make decisions on prescribing medication for
offenders with little or no information, exacerbating
the problem of the hard to reach, often complex,
sector of society.
Ideally, people leave prisons on a Care Programme
Approach should have after care plans developed by
the mental health in-reach team which include the
prisoner, the prisoner’s family and probation to ensure
continuity of care upon release.
Provision should be made to ensure prisoners are
registered with a GP practice before release to secure
the timely release of medical records without delay.
Disability
There are 2 distinct figures; the number of current
offenders with disability and the number of disabilities
recorded for all current offenders.
Of the total number of Thames Valley Probation
offenders recorded as current 19% (1,220) were
recorded with at least one disability.
■ Against the 1,220 offenders with a disability there
were 1,643 disabilities recorded.
■ Of the total number of disability cases recorded
in Thames Valley Probation (not the number of
offenders) mental illness accounted for over 25%
(418)
■ 298 cases of dyslexia were recorded and 178
recorded for learning difficulties, with 154 cases
recorded with reduced mobility
■ Reduced physical capacity 69 cases recorded
■ Hearing impairment 64
■ Visual impairment 41
■ Progressive condition 34 cases
■ Speech impairment recorded 19
■ 9 cases of severe disfigurement.
Charts overleaf show disability by LDU and
across Thames Valley
Continued overleaf
25
100
80
60
40
20
0
26
Speech
Impairment
Progressive
Condition
Visual
Impairment
Hearing
Impairment
Reduced
Physical
Capacity
Reduced
Mobility
Learning
Difficulties
Other
100
80
60
40
20
0
Dyslexia
Severe
Disfigurement
Speech
Impairment
Progressive
Condition
Visual
Impairment
Hearing
Impairment
Reduced
Physical
Capacity
Reduced
Mobility
Learning
Difficulties
Other
Dyslexia
100
80
60
40
20
0
Severe
Disfigurement
Speech
Impairment
Progressive
Condition
Visual
Impairment
Hearing
Impairment
Reduced
Physical
Capacity
Reduced
Mobility
Learning
Difficulties
Other
Dyslexia
Mental Illness
Severe
Disfigurement
Speech
Impairment
Progressive
Condition
Visual
Impairment
Hearing
Impairment
Reduced
Physical
Capacity
Reduced
Mobility
Learning
Difficulties
Other
Dyslexia
Mental Illness
100
80
60
40
20
0
Mental Illness
Severe
Disfigurement
Speech
Impairment
Progressive
Condition
Visual
Impairment
Hearing
Impairment
Reduced
Physical
Capacity
Reduced
Mobility
Learning
Difficulties
Other
Dyslexia
Mental Illness
100
80
60
40
20
0
Mental
Illness
Improving Health – Reducing Crime TVCJB Health Sub-Group
9. Thames Valley Probation – Profiles
continued from previous page
Disability shown by LDU (below) and across the Thames Valley (on next page)
The number of disabilities recorded in Oxon LDU
The number of disabilities recorded in West Berks LDU
The number of disabilities recorded in Bucks LDU
The number of disabilities recorded in East Berks LDU
The number of disabilities recorded in Milton Keynes LDU
TVCJB Health Sub-Group Improving Health – Reducing Crime
9. Thames Valley Probation – Profiles
Disability shown as a percentage of the total number of disability instances recorded in ICMs
Severe Disf igurement
Speech Impairment
Progressive Condition
Visual Impairment
Ref usal To Disclose
Hearing Impairment
Reduced Physical Capacity
Reduced Mobility
Learning Dif f iculties
Dyslexia
Other
Mental Illness
0%
5%
10%
Substance Abuse
Alcohol
■ Of the total number of Thames Valley Probation
offenders with a valid OASys assessment completed
between Jan – Sept 2012, 33% were assessed to
have a current alcohol problem. Interestingly, this
third is equally distributed across the LDUs, each
showing approximately a third of the caseload
with people recorded as having a current alcohol
problem.
Drugs
■ Of the total number of Thames Valley Probation
offenders with a valid OASys assessment completed
between Jan – Sept 2012, 72% were recorded as
having used drugs, of which 17% were recorded as
using a Class A drug.
■ 77% of all West Berks offenders were assessed as
having used drugs of which, 22% were recorded as
using a Class A drug.
■ In Milton Keynes it was 76%, of which 11% were
recorded as using a Class A drug.
15%
20%
25%
30%
■ 68% of all Bucks LDU offenders were recorded as
having used drugs, of which 15% were recorded as
using a Class A drug.
General Health
Offenders’ general health issues are recorded in
OASys Section 13. This section records any physical
or mental health concerns, or any chronic conditions
from which the offender is suffering or recovering,
which would need to be taken into account if a referral
to unpaid work, curfew, or a programme is being
considered as part of a sentencing proposal.
General health issues recorded in this section of OASys
could include pregnancy, epilepsy, vertigo, asthma
or any disability or access considerations. Of all the
offenders with a valid OASys assessment completed
between Jan – Sept 2012:
■ 41% (2307) were recorded as having some general
health concerns, of which 61% of males/66% of
females, were in the 26 - 49 age group and
■ 74% of offenders with general health concerns
recorded were Non BME, 15% (349) BME.
Mental Health
■ In Oxon 70% of the LDU total had used drugs of
which 20% have used a Class A drug.
Three questions in the Emotional Well-being section
aid the identification of mental health needs.
■ 69% of offenders were recorded as having used
drugs in East Berks, of which 17% were recorded as
having used a Class A drug.
Are there current psychological problems/depression?
This question captures information about any current
psychological problems the offender is experiencing,
Continued overleaf
27
Improving Health – Reducing Crime TVCJB Health Sub-Group
9. Thames Valley Probation – Profiles
continued from previous page
of which the most commonly reported conditions are
diagnosed depression, anxiety, obsessive/compulsive
disorders, and phobias such as agoraphobia,
sociophobia and hypochondria.
Is there a history of self-harm, attempted suicide, suicidal
thoughts or feelings? This question records if at any
time the offender has attempted suicide or selfharmed in some way, for example, self- mutilation,
pharmaceutical overdoses, ‘cutting-up’, or any other
potentially lethal behaviour. This question also
includes those who report having suicidal thoughts or
feelings but have not acted upon them.
Any current psychiatric problems? This question
captures information about any current psychiatric
problems that the offender may be experiencing
including illnesses or symptoms diagnosed by a
GP or a psychiatrist, such as schizophrenia, manic
depression, or obsessive compulsive behaviours.
The profile of offenders with a valid OASys assessment
completed between Jan – Sept 2012 and a score in
any of these three questions in section 10 of OASys is
displayed in the charts on pages 27 and 28.
Across Thames Valley Probation 37% (2070) of
offenders were recorded with a score in at least one of
the three questions in Section 10. These offenders are
profiled in the charts below.
TVP offenders recorded in
OASys as having general
health concerns - by
gender
TVP of f enders w ith a score
in any of the mental health
sections of OASys - by
gender
100%
80%
100%
60%
50%
40%
20%
0%
Female
Male
0%
Female
TVP offenders recorded in OASys as having
general health concerns - by age band
80%
80%
60%
40%
20%
0%
18 - 20
21 - 25
26 - 49
50 - 64
65 +
Emotional Well-being
Current psychological problems
Thames Valley Probation offenders who had a valid
OASys assessment completed between Jan – Sept
2012:
■ 27% reported as having current psychological
problems.
■ Milton Keynes offenders recorded the highest
percentage of offenders as having current
psychological problems/depression with 30%,
■ West Berks recorded 29%
■ Bucks 27%,
■ East Berks 26%
■ Oxon 25%
Self-harm, attempted suicide, suicidal thoughts or
feelings
■ 24% of TV Probation offenders were recorded as
having a history of self-harm, attempted suicide,
suicidal thoughts or feelings,
■ Likewise, the percentages across the LDUs of
offenders recorded with having a history of selfharm, attempted suicide, suicidal thoughts or
feelings are similar.
■ Bucks recorded the highest proportion of 27%,
■ Oxon and Milton Keynes 25%,
60%
40%
■ West Berks 23% and
20%
0%
18 - 20
28
Male
TVP offenders w ith a score in any of the mental
health sections of OASys - by age band
21 - 25
26 - 49
50 - 64
65 +
■ East Berks 21%.
Continued on next page
TVCJB Health Sub-Group Improving Health – Reducing Crime
9. Thames Valley Probation – Profiles
Current psychiatric problems
Of the total number of TV Probation offenders 11%
were recorded on OASys as having current psychiatric
problems.
■ 13% of Milton Keynes offenders recorded current
psychiatric problems
■ East Berks and Bucks 11%
■ West Berks 10%
■ Oxon 9%.
General Health Provision in Probation
East Berkshire – offenders sentenced to a community
order/licence can see a work health trainer whose
services are paid for by Thames Valley Probation. They
are based part time at Slough and Bracknell probation
offices.
They undertake a health questionnaire, assist
offenders to register with a GP and/or dentist, link
them to courses within their community i.e. parenting
classes, provide information on specific health
complaints from the intranet, assist with eating plans
and increasing fitness, make mental health referrals,
help offenders to budget for healthy eating, and,
with the offender’s consent ,speak to GPs to assist
communication where offenders find this difficult.
The questionnaire is also very useful in not only
spotting health problems which need to be overcome
before they go to the Bridge to Employment Unit
within Probation regarding literacy, numeracy, writing
a CV, job searching, but is also an opportunity to test
the offender’s motivation to engage.
West Berkshire – Health Outreach Liaison Team
(HOLT) - This is a Reading-based service and provides
an outreach nurse led health service for homeless and
hard to reach individuals. This service has recently
co-located at the Reading probation office and will
start providing a clinic in the probation office from
December 2013.
The service has two nurse clinicians specialising in
wound/trauma treatment and mental health. They
will be screening all offenders at the start of their
Community Order or post custody Licence to ascertain
their health needs. They will support individuals to
access appropriate health care either through direct
treatment or within the local community depending
on the individual’s support needs.
Milton Keynes – Negotiations are currently under way
to commission a nurse part time to provide health
screening and support to offenders released from
prison or on Community Orders.
10. Offenders at highest risk of re-offending
Open Justice, 201265 states that nationally 58% of
offenders sentenced to less than 12 months custody
will re-offend compared to:
■ 36% sentenced to 1 – 4 years
■ 31% sentenced to 4 – 10 years
■ 15% sentenced to 10+ years
There is disparity between different prisons’
reconvictions rates. To illustrate this point, 72% of
those sentenced to less than 12 months released from
Reading Prison* will re-offend an average of 5 times,
whilst by comparison 44% who are sentenced to over
12 months will re-offend an average of 4.4 times66
(*Reading Prison closed in 2013).
At present adult offenders who are sentenced to less
than 12 months’ custody are currently not subject to
supervision by probation upon release.
However, impending changes in legislation and the
commissioning of community rehabilitation services
will ensure that those serving any time in custody will
be subject to licence conditions on release.
The experience of probation staff working with this
short term prisoner group on a voluntary basis has
indicated reluctance by offenders to engage without
the requirement of a statutory licence period. Where
Continued overleaf
29
Improving Health – Reducing Crime TVCJB Health Sub-Group
10. Offenders at highest risk of re-offending
there are links between custody and community
providers, there is evidence of high levels of attrition
from point of release to service access.
The group of offenders representing the largest
group likely to re-offend are those with minimum
opportunity to access resources in prison because of
their short sentences and chaotic lifestyles.
The lack of stability creates a revolving door
into prison. Screening this group at the point of
imprisonment and linking them to community
provision at the point of release may impact on both
improving health inequalities and reduce re-offending
rates.
11. Critical areas to secure improvement in
offender health
I – Early Health Care Screening
The Bradley Report67 estimates that up to 90%
of prisoners have one or more of five psychiatric
disorders (psychosis, neurosis, personality disorder,
and hazardous drinking or drug dependence).
The inclusion of alcohol and drugs in this list is one
of the issues raised by the Criminal Justice Joint
Inspection 200968. The Report claimed that there is
no universally accepted definition of “offender with
mental disorder” (p.7) with some, including Lord
Bradley, including substance problems while others
take a narrow approach.
Offenders should not be left to be identified as
having health or mental health problems etc. while
in custody. This is far too late but instead should be
screened at either pre-charging stage while in police
custody suites, before they are sentenced so they can
be diverted away from the Criminal Justice system or
at worst at the beginning of their intervention with
the probation service.
Ideally all offenders should be screened for:
■ Depression using a brief screening tool
■ Alcohol using “AUDIT” alcohol screening tool
■ Substance misuse disorder using “DAST” or any
other appropriate screening tool
■ Mental health where required including autism and
learning disabilities.
II – Commissioning targeted
health services for offenders
The risk of someone becoming an offender starts
early in life. This risk increases with a range of
contributory factors that begin in childhood such as:
continued from previous page
■ Low maternal bonding
■ Poor parenting skills
■ Abusive home relationships
■ Truancy and exclusion from school
■ Looked after child status
■ Conduct disorders
Children in or close to the youth justice system (YJS)
have far more unmet health needs than other children
of their age, face a range of other difficulties including
school exclusion, substance misuse, fragmented
family relationships and unstable living conditions.
If these problems then continue into adulthood they
can not only become exacerbated but may continue
to go undetected unless the appropriate services are
put into place for this “hard to reach” sector of the
community.
Offenders who form a section of the “hard to
reach” members of society evidence a poor take
up of the full range of health care provisions,
Continued overleaf
30
TVCJB Health Sub-Group Improving Health – Reducing Crime
11. Critical areas to secure improvement in
offender health
continued from previous page
therefore consideration should be given towards
commissioning targeted health services for offenders
with easier access and more innovative and effective
ways of raising offenders’ awareness of health and
health care services.
This could include, but should not be limited to,
strengthening and enhancing the capacity of existing
health trainers scheme as in East Berkshire to provide
an initial health screening or alternatively a nurse
operating out of probation offices, as is planned for
the Milton Keynes probation office.
This role would provide a health screening for all,
liaison with Approved Premises, probation staff and
offenders to establish links between offenders under
statutory supervision and an appropriate local primary
care service, including referrals to mental health,
specifically addressing the physical and mental health
needs of female offenders or access to counsellors
who raise awareness and promote mental health and
well-being.
III – Access to health records at
pre-charging stage
The Bradley Report stated that the police stage
is the least developed in the offender pathway69,
however, it is often at this stage that an offender
with a mental health problem is first seen, and
whilst regular screening for drug and alcohol
problems exist, mental health is still not given the
same priority.
By 2015 police will hand over commissioning to the
NHS who will provide a trained medical person to
assist them but until then there is unlikely to be any
significant improvement and unless screening is
introduced quickly, offenders’ mental health needs will
be undetected.
inputting and may not be up-to-date. In respect
of healthcare, this often involves resorting to
telephoning local hospitals, doctors, etc. to establish
whether an offender is known to them.
IV – Appropriate Adults
The Bradley Report recommended that the role of
appropriate adults in police stations needed to be
reviewed on the basis of increasing consistency,
availability and expertise70.
In Thames Valley, as in other areas, there is still a
significant gap in provision with no national legislative
authority being given to any organisation to provide
this service, and to date the AA Network has been
unsuccessful in obtaining funding to set up force-wide
cover.
As a result the limited number of full trained
appropriate adults available is unlikely to increase
and custody suites will continue to rely on goodwill
links with various partnerships i.e. Liaison & Diversion
Schemes.
V – Court diversion and
sentencing
Checking the court list two days in advance as to
whether offenders are already known to probation
and/or mental health services, are delayed due to
the Liaison and Diversion Schemes staff not having
access to their own NHS health records.
They are therefore required to pay daily visits to the
nearest hospital or health care centre to access this
information to check custody lists.
There also needs to be a link with police custody and
community provision.
Police on the street have access to the Police National
Computer records to check on previous offending
and cautions but the information relies on accurate
Continued overleaf
31
Improving Health – Reducing Crime TVCJB Health Sub-Group
11. Critical Areas to secure improvement in
offender health
continued from previous page
VI – Mental health and
learning disability services
It is important that Court Liaison & Diversion
Schemes are linked to community mental health
teams, however there is no consistency across the
Thames Valley, making it more difficult for statutory
and non-statutory agencies to access services in
a timely manner either to assist in sentencing or
treatment.
Despite the high prevalence of poor mental health in
the offender population, the mental health treatment
requirement (MHTR), one of 12 Requirements which
can be attached to a Community Order is rarely used.
While an MHTR is used 1% of the time when choosing
a Community Order71 and the use of MHTRs in Thames
Valley is consistent with this national figure at 1.1%,
the evidence of MHTRs in Thames Valley is decreasing
despite the existence of Court Liaison & Diversion
Schemes. MHTRs have halved from 47 in 2010 to 27 in
2013.
The report on MHTRs discussed the following barriers
to use72:
■ Uncertainty over who should receive an MHTR
■ Low awareness and confidence amongst
professionals
■ No specific guidance on how an offender can
breach an MHTR
■ Need for a formal psychiatric report, which can be
time consuming and costly if no offer of treatment,
then the MHTR cannot be issued.
While the initial assessment by Court Liaison &
Diversion Schemes ensures appropriate targeting and
result in few full psychiatric reports being undertaken
across the Thames Valley area, it remains a good use
of time and resources with offenders being sentenced
correctly at the earliest opportunity.
Those offenders who do have full psychiatric reports
32
completed are rarely made the subject of an MHTR
attached to a Community Order.
Under the new LASPO Act a shorter format report can
be completed by a community psychiatric nurse or
other qualified medical practitioner e.g. psychologist.
However, there is still a need to define a clear pathway,
a responsible agreed clinician and a plan into
treatment for each Court.
This will require Liaison and Diversion officers to
liaise with their colleagues within Community Mental
Health Teams to ensure the relevant mental health
practitioners are on board for the future and are able
to supervise MHTRs.
VII –Drug and alcohol services
The misuse of drugs and alcohol has serious
consequences for individuals and communities
in terms of physical and mental health problems
alongside related crime to fund on-going use,
domestic abuse, harm to children and family
breakdown, homelessness and loss of employment.
The National Drug Strategy 201073 signalled a move
away from focusing primarily on reducing the harms
caused by substance misuse towards a focus on
supporting individuals to choose recovery as a way
out of dependency.
It also recognised that the issues underlying
substance misuse are complex and personal and that
services need to be holistic and centred around each
individual and consequently there has been a shift in
power to local design and service commissioning.
Thames Valley Probation uniquely collects a wide
range of data in relation to offenders substance
misuse in the Thames Valley area and this information
is used to inform and support local and regional
commissioning decisions relating to substance misuse
services and offender health.
These data sets are used by probation partnership
managers in the public health arenas such as the
Continued on next page
TVCJB Health Sub-Group Improving Health – Reducing Crime
11. Critical areas to secure improvement in
offender health
continued from previous page
Health and Well Being Boards and Drug and Alcohol
Strategic Groups to highlight the importance of
an integrated approach to the commissioning and
delivery of substance misuse treatment services and
community health provision.
Research is clear in identifying that individuals coming
through the criminal justice system have a higher
incidence of substance
misuse, poor physical
and mental health
compared to
The Coalition Government
the rest of the
published its Drug Strategy:
population.
Reducing Demand, Restricting Supply,
Building Recovery, Supporting People
to Live a Drug Free Life in 2010, with a
strong focus on abstinence based
treatment and recovery.
The relevance
of health
screening as
a mechanism
to initiate
signposting
and treatment
referral has been put to
local commissioners alongside the need for rapid
assessment and access to treatment for substance
misusers.
Probation staff continue to work with drug and
alcohol services to monitor and provide feedback in
relation to offenders responsiveness to treatment e.g.
ability and willingness to manage titration without
recourse to use of illicit substances and further
associated offending.
Tensions and gaps in provision between mental health
and substance misuse services for offenders with dual
diagnosis alongside issues concerning the accessibility
of treatment and barriers to engagement continue to
effect the likelihood positive outcomes for this group.
However, learning from the outcomes for those
subject to DRR and ATR and projects such as the
developing Court Liaison and Diversion Schemes,
is used by Thames Valley Probation to continue to
inform and support local commissioning to secure
effective service provision to reduce the health and
social risks associated with continued substance
misuse.
12. Conclusion
Consultations with key stakeholders, interviews with
offenders, literature review and results of surveys
have revealed that improvements in quality of
primary, social and mental health care access could
bring substantial long term improvements in health
and well-being for offenders.
This, in turn reduces the number of victims and
improves communities, as well as significant financial
savings for the public purse.
The aim of this assessment is to form the basis
of further discussion with commissioners and
stakeholders in order to reduce health inequalities
and the rates of re-offending, fully realising positive
health outcomes will be dependent on integrating
and aligning the design and delivery of services.
Treating people with decency and appreciating
differences that lead to inequalities can improve
access to services.
It is important to continue to build on effective
partnership structures and practices that exist in
Thames Valley, while at the same time recognising
and reacting to the challenges of the changes to
organisations, particularly at a time of austerity.
The information provided in this assessment,
especially details of organisations, is true at the time
of writing.
Given that services are on commissioning and
contract cycles, these are likely to change at some
point, although the issues highlighted remain.
Continued overleaf
33
Improving Health – Reducing Crime TVCJB Health Sub-Group
12. Conclusion
RECOMMENDATIONS:
1. This Needs Assessment is adopted by the Local Criminal Justice Board and its Health SubGroup.
2. This document is used as the beginning of a process of dialogue and as an aid to
communication in relation to the integration of services for offenders within the general
community requirements of each area.
3. The information provided is used to inform commissioning at all levels, particularly
community provision.
4. The information specifically supports a review of the capacity and capability of local
services to support the S136 MHA police detention processes and, in particular, the
requirement to adequately accommodate detainees.
Improving Health = Reducing Crime
A checklist of critical areas:
Availability of early screening for:
❒ Drugs
Access to, timely and purposeful
provision for:
❒ Alcohol
❒ Drugs
❒ Learning Disabilities
❒ Alcohol
❒ Mental Health
❒ Learning Disabilities
❒ Access to health records
❒ Mental Health
❒ General health – GP
❒ S136 Places of Safety
❒ Criminal Justice membership at CCG
❒ Appropriate adult provision
❒ Criminal Justice membership at H&W Board
❒ Court Liaison and Diversion provision
❒ Strategic Needs Assessment involvement
34
– dentist
Joint commissioning and performance
management:
TVCJB Health Sub-Group Improving Health – Reducing Crime
13. Case Studies
Case Study 1
A is a 34 year old man who was convicted, aged 32,
for sexual assault of a 15 year old boy, a friend of his
then partner. A received a 4 year custodial sentence.
During his sentence he had considerable problems.
He was considered by prison staff to be rude because
he refused to make eye-contact when speaking to
others, often mumbled and was pedantic in the way
he wanted things done. For the same reasons he had
problems in relationships with other prisoners.
He experienced severe migraines in his prison cell but
did not know why this was happening. A undertook
an Enhanced Thinking Skills programme in custody
but he found the group work very difficult and felt
distinctly uneasy in a group.
On release from prison A went to live in an approved
premise (a hostel). He also experienced problems with
staff there as he was seen as surly, uncommunicative
and pedantic.
On one occasion he appeared to be seeking to
befriend a younger resident but did so by getting up
at 6am to sit in the garden with this young man when
he went into the garden for a cigarette. The young
person found this unnerving and threatening.
A spent most of his time in the hostel garden tending
the plants – something which he was very good at,
having previously worked as a gardener. One day A
had an argument with another resident about how
he tended the garden. He became angry after this
and told other residents that he had poisoned all the
plants in the garden as he thought others did not
appreciate what he had done.
A’s Probation officer thought that there was
something unusual about A. He ran an AQ-10
Autism screening tool on A which came out with a
score of 9/10, indicating likely autism. The Probation
psychologist ran a more detailed questionnaire on
A and interviewed him and confirmed that he did
indeed exhibit clear signs of Asperger’s syndrome.
The main features of this are:
■ Difficulty in making or maintaining eye contact
■ General problems with recognition of social ‘norms’
and interactive social behaviour
■ Great sensitivity to light or sound especially
fluorescent lighting
■ Rigid application to certain rules and great
discomfort if these are not adhere to.
Once this condition had been recognised much
of A’s difficulties in prison and the Approved
Premises were explained e.g. his problems with
staff (eye contact, apparent surliness), his difficulty
in undertaking group work, his migraines resulting
from harsh fluorescent lighting in his prison cell (a
significant and unacceptable discomfort), his unusual
and problematic social approaches to the fellow
resident, preferring his own company in the garden
and tending the plants and his extreme response to
criticism about his gardening.
Greater understanding of and a capacity to assess
for Autistic Spectrum Disorders such as Asperger’s is
essential if problems for both the individual, other
offenders and staff alike are to be avoided or at least
minimised.
Correct identification of ASD can result in a much
better understanding of how an individual is likely to
behave and to take account of this in a constructive an
fair manner.
In A’s case once the ASD had been identified his
management at the AP, while still somewhat
challenging, became more stable as the manager and
staff were better able to understand and predict his
behaviour.
He was excused group activities that were not
essential, as they were highly problematic with him,
and allowed more time in the garden where he
continued to work successfully. Due to his condition
further group work was not deemed viable by the
psychologist however his probation officer undertook
some individual work with him using specially
adapted materials. A is shortly about to move out of
the AP into his own rented accommodation which has
a small garden.
35
Improving Health – Reducing Crime TVCJB Health Sub-Group
13. Case Studies
Case Study 2
PM was referred by a Crown Court in February 2013
due to concerns about her presentation and fitness
to plea. She had previously received counselling
and the judge was requesting support for this
lady prior to her court appearance. She had been
charged with seven counts of fraud.
At the time of both referral and assessment he was
not engaged with any other support agencies. He
presented with significant mental health needs
associated with bereavement, was self medicating low
mood with alcohol, illegally bought diazepam and
heroin and had a history of deliberate overdose.
She was assessed and presented as a withdrawn
lady with a long history of anxiety and depression.
Following a further assessment with a Liaison and
Diversion Scheme Psychiatrist she was diagnosed with
post-traumatic stress disorder and depression, for
which she was already undergoing treatment.
B was not registered with a GP. He said he had a
negative experience of services 4 years ago and this
had caused him to isolate himself and disengage from
support networks.
The opinion of her doctor was that the court
proceedings were one of the main causes of her
current mental state. The plan was for her to receive
regular counselling sessions to support her up to her
court date and then further therapeutic work. Her
doctor sent a report to the Crown Court outlining the
assessment and plan.
PM attended eleven sessions, including assessment
with Liaison and Diversion Scheme, and during that
time was helped with a range of anxiety management
techniques and coping strategies. The plan was
to attend with her at the Court on 10 June but
unfortunately this date was changed at short notice
and the Liaison and Diversion Scheme worker was
unable to attend on the new date. A lot of time was
spent in preparing PM for the court date which has
been beneficial and will help her to feel less anxious.
(Liaison and Diversion Scheme CPM, 11 June 2013).
Case Study 3
B is a 32-year-old male on the Short Term Prisoners
Scheme. He has 42 previous convictions (first
offence age 18) including drunk and disorderly,
attempted robbery, shoplifting criminal damage,
assault on a police officer and fraud.
B was sofa surfing at his brother’s address on and off
at the time of the referral, spending the occasional
night rough sleeping. He wanted help to access
accommodation outside the Milton Keynes area. He
was not in employment or education and asked for
help to apply for a college course in catering.
36
B was helped to register with a GP surgery. A link
worker attended the surgery with him to discuss
previous experiences, offer reassurance and improve
his confidence in seeking advice and help from GP. He
was prescribed anti-depressant medication and began
to attend the surgery regularly.
We then referred him to a specialist bereavement
counselling services and he began to attend regular
sessions. Link worker appointments were used to
reflect on the progress made in counselling sessions.
Significant improvements were seen in B’s mood,
motivation and feelings about his future.
Link workers referred him to CRI drug and alcohol
service and supported him through initial assessment,
key worker allocation and the development of a
support plan to reduce his drug and alcohol use and
work towards abstinence.
He was supported in his application for a catering
course in Manchester, applying for student finance
and finding affordable accommodation near to the
college.
Link workers liaised with the college to assist with the
risk assessment process. B moved to Manchester in
September 2013, with all support service transferred
to Manchester. Telephone contact was maintained
with B by the Thames Valley-based team for his first
two weeks in Manchester.
B was in contact with our short term prisoners’ scheme
for 14 weeks and had 10 contacts with us during that
time. He has not committed any offences since his
initial referral.
TVCJB Health Sub-Group Improving Health – Reducing Crime
13. Case Studies
Case Study 4
SY was referred to the service by the SMART team
following arrest for affray whilst on a suspended
sentence for criminal damage.
At the point of referral SY was reporting problematic
alcohol use, excessive cannabis use, no secure housing
and concerns around his mental health.
Through the needs assessment it was identified that
SY’s offending behaviour was linked to his alcohol and
drug use and problems with family relationships.
The support plan was agreed to cover improving
engagement with his GP in order to address mental
health concerns, referral to CRI drug and alcohol
service, support to access appropriate education
or employment and support with housing to help
improve family situation as SY could no longer remain
at his mother’s home.
A GP appointment was arranged and SY was
prescribed anti-depressants in order to manage his
symptoms of low mood. SY reported that he felt more
able to cope with what was going on as a result of this.
A referral was made to CRI, SY engaged well and has
reduced his drinking dramatically. He no longer feels
dependent on cannabis use.
Advice and information was given in regards to
housing options, support provided to attend Milton
Keynes Council and provide the necessary information
required to access social housing.
SY now holds his own tenancy. Support was provided
by link workers with early tenancy set up and to
manage the initial anxieties in living independently.
SY is now settled in his home and has an improved
relationship with his family as a result of this.
With SY’s drinking and cannabis use at a manageable
level and stable accommodation in place, support was
given to apply for the Prince’s Trust team programme
at Milton Keynes College, which SY has now started.
He is enjoying it and reports on his participation were
positive.
Link workers were also able to provide positive
feedback to inform SY’s pre sentence report and
support was offered to SY throughout the court
process.
SY was sentenced to a Community Order. His
Suspended Sentence Order was not activated and
no further offences have been committed since his
referral to the link worker service.
37
Improving Health – Reducing Crime TVCJB Health Sub-Group
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39