Slide 1A causal model of access and continuity for marginalised
groups
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COCOA study group
CARES Liverpool 2014
COCOA Study Group
Richard Byng 1, Cath Weyer Brown 1, Rod Sheaff 3 , Chiara Samele 2,
Claire Warrington2 , Dean Harrison 4, Chris Brown 5, Christabel
Owens 1, Christine Wright 1, Jill Annison 3, Sean Duggan 2, John
Campbell 1
1 Peninsula Medical School, Plymouth and Exeter, England
2 Sainsbury Centre for Mental Health, London, England
3 University of Plymouth, Plymouth, England
4 Peer Researcher Consultant, England
5 University of Swansea, England
This project is funded by the National Institute for Health
Research Service Delivery and Organisation Programme (NIHR
SDO).
The views and opinions expressed herein are those of the author(s)
and do not necessarily reflect those of the Department of Health or
the NHS.
Prison
Probation
3
We conducted a literature review of policy documents for health and
criminal justice examining what they said should be happening in
each of the above fields; focusing particularly on where health
policies talked about criminal justice and where criminal justice
polices talked about health.
The study is about access and continuity of healthcare for
offenders, so we were particularly interested in transition points
between different parts of the criminal justice system.
The project started with some overarching questions about offenders
access to, and continuity of, healthcare. We then used the policy
literature review to generate further sub-questions.
This presentation focuses on ‘accessing and receiving continuity of
care in and beyond the prison gates’ and so addresses the two
following research sub-questions:
Problem
Objective
complex system, ill-defined concepts
access and continuity
5
Define elements of continuity and access - the outcome of
interest
Identify potential mechanisms for achieving continuity –
Collation of all evidence of cause and effect
Examine by domains
200 offender pathways
28% with opiate misuse (40% all contacts), 64% mental health
problems, 96% physical
Discontinuity was predominant experience except substance use
Poor access to mental health care (3/per annum)
25 times as many gain specialised substance use care….
7
Attending initially and ongoing is objective outcome of
interest
Experience of access and ongoing care are subjective but important
– in own right and as causes
INITIAL / RENEWED ACCESS
CONTINUITY OF ACCESS: Right person, right time, right place, right
information:
Same practitioner
Abdicators
Vocally dismissive of medical/health care
Practitioners – view from offenders
Feeling cared for
Walk in
shared training
integrated assessment
integrated plan
Organisational integration
CONTINUITY OF ACCESS
Problem 2 – too banal
TRUST, COPING STYLE, BELIEFS.
CONTINUITY OF ACCESS
Identify themes
Eg Concerns about non-effectiveness of treatment lead to some
participants turning down, or not desiring, mental health
treatments (1014a, 1026a, 1036a, 1117a, 1158a).
Analytic process (cont)
Examine data in detail
Eg “D’you know what I mean so, I’m not (laughs) I don’t mind
speaking to a psychiatrist d’you know what I mean, I mean but, at
the end of the day I know, that talking ain’t gonna do nothing”
(1036a)
Identify possible causal processes in each and group to write one
positive contingent statement
If the way treatment is presented matches existing beliefs or
overcomes previous negative beliefs offenders will believe that the
treatment they will be offered might be effective and they are more
likely to access healthcare
Link to other generic mid range theories: candidacy
Underlying mechanisms
A range of practitioner actions (showing cares, understands,
values,) generate trust in practitioner which through
branding/associations etc can be generalised to wider service or
other practitioners
Words, signs, letters, conversations can generate belief in
care/treatment– that its available and effective (both offenders
AND practitioners from other team/sectors)
Getting seen - somehow – “any time, any place, any person” –and
then either trust or belief triggers disclosure, or practitioner
elicits further problems - means access can lead to treatment for
one problem and can lead to more
Practitioners supported to stay calm clear when medication requests
are not permissible by professional standards
Services that ‘work with’ rather than exclude because of
multi-morbidity, through a range of components of integration,
release constraints from practitioner to act flexibly and
holistically
Matching assessment/protocols/individualised goals across a health
system trigger practitioners to work collaboratively across
teams
Reliable and flexible arrangements for accessing another
team/service – rather than loose ‘signposting’ – ensure onward
transition to care that is required
The phone’s always engaged
Wouldn’t work for me anyway
Surely there’s a better way than this
Don’t trust them anyway
We need more disease pathways
She’s here so perhaps I’ll go in
She seems to care – and didn’t get cross
Valium works for me may be she’ll give me some
Ok so lets try those techniques in mentalisation – stay calm sit
back, acknowledge his distress, be firm
Guess I can see her point ….. I need to stop buying them off the
street too
And she does seem to understand me….
Phew – that was tough
I can see this might even work for me
May be I’ll try referral to the counsellors who say they wont
exclude due to substance use any more
He’s ok too – really values what I think
Great the counsellor has sent an update – may be we could all meet
together and work up one of those new shared plans
And they don’t seem to disagree
Applying the model
Continuity and access (being seen) need to be seen as a continuum
with objective criteria
Relationships, flexibility, integration mechanisms (liaison, case
management, shared protocols) – can be seen as part of the
experience AND contributing to objective criteria for continuity of
access
A practical framework for those developing services for offenders
and other excluded groups
Application to other groups – older people, children in care, as
well as those with long term conditions
Thank you
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