Offenders with complex needs - analysis report

Rebalancing Rehabilitation

Making the case for change to ensure a level playing-field for Offenders with Complex Needs across Essex

Version number: 0.3

Date: 21st July 2014

Author: M. Scott & S. Senker

Status: Draft

CONTENTS

Executive Summary 1. Literature Review 2. Local Data Analysis 3. Qualitative Interviews 4. Recommendations 5. Next Steps Annex: Data workbook

TONIC: Discussion Paper 1

Glossary of Key Terms & Abbreviations

LD = Learning Disability / Difficulties SM = Substance Misuse (drugs &/or alcohol) MH = Mental Health problems DD = Dual Diagnosis (mental health & substance misuse) DIP = Drug Intervention Programme (also known as CJIT Criminal Justice

Intervention Team) CJMHT = Criminal Justice Mental Health Team CRC = Community Rehabilitation Company (formerly known as Essex Probation) L & D = Liaison & Diversion service (for MH & LD) NDTMS = National Drug Treatment Monitoring System HMP = Her Majestys Prison CJS = Criminal Justice System DRR = Drug Rehabilitation Requirement ATR = Alcohol Treatment Requirement MHTR = Mental Health Treatment Requirement Older Prisoner = those aged 50+ Vulnerable = Any individual who is, or maybe, in need of community care services by reason of mental, physical or

learning disability, age or illness and who is or may be unable to take care of himself or herself, or unable to protect himself or herself against significant harm or serious exploitation which maybe occasioned by actions or inactions of other people. [Law Commission, 1995]


Executive Summary


We have to acknowledge the prevalence and impact of individuals with overlapping needs which are linked to the frequency and severity of their offendingThese individual vulnerabilities include substance misuse (drugs & alcohol), mental health problems, learning difficulties and disabilityThese are often co-occuring leading to further complexityThe prevalence of the offenders with complex needs (OCN) are often under reported in CJS, where these issues are not identified/recorded, nor treated (service gaps)The current fragmented system disadvantages these people further, leading to inequality of access to rehabilitation opportunities and increased risk of re-offending and other poor outcomesThere are optimum moments in CJS to ask questions about complexity which are being missedThe lack of clear pathways, experienced staff and dedicated services means that many OCN remain unsupported leading to a cycle of re-offending

Executive summary

Quick Wins1. Clear pathways (inc. agreed terminology and criteria), a Concordat, an Idiots guide & service directory for OCN2. Networking events, Joint training & co-location of key individuals, services to help break down barriers & unlock existing expertise to offer case consultation 3. Clear information sharing protocols to reflect fast movement through custody chain: portable risk and need file that mimics or extends the personal escort record form (PERF)

Medium4. Engender a climate that promotes shared responsibility - looking at the offender holistically not modularly5. Uniform, yet flexible and responsive training for statutory & non-statutory service providers so practitioners across CJS feel skilled, confident and competent at identification of need and ensuing adaptation & referral6. Tools chosen to aid identification should be validated, comprehensive & used at earliest opportunity throughout CJS7. A focus on need not just risk, e.g. Consult & involve service users in future service design & development Importance of women-specific services not to be underestimated LD may not be seen as treatable in the way SM & MH are, but there is still a vital place for management and adaptation to improve outcomes/reduce re-offending

Longer-Term8. System-level change including (but not only) the introduction of an integrated service throughout CJS and unified across MH, LD, SM agencies: Flexible (out of hours) Tiered by level of need Recovery focused (integrated with society, leading sustainable lives through employment & housing Skilled link workers filling gaps (e.g. through the gate)

Summary of Recommendations

The Challenge The Reducing Re-offending Board wanted to explore pathways and systems for

offenders with complex needs (OCN) The OCN group across Essex, Southend & Thurrock want to improve services for

individuals with: Learning Disabilities (LD) Mental Health (MH) Substance Misuse (SM) which includes drugs and alcohol That are in contact with the Criminal Justice System (CJS) As a result of the Care Act coming into force from April 2015 and its renewed clarity

over adult safeguarding, there is also a need for local authorities to consider the needs of

Older offenders Vulnerable adults That are in contact with the CJS

There are some significant gaps in local provision, especially for LD There are knowledge gaps about vulnerability, LD & MH demand, e.g: how frequently they

enter custody & what happens to them when they are there There is a view that an integrated offender recovery management service is needed to

reduce re-offending and improve the care of OCNs: With touch points at police, probation, courts and prison To identify, screen, refer and manage OCNs Access community services and planned resettlement wing at HMP Chelmsford

TONIC was commissioned to help the group better understand the scale and scope of OCN needs


Our Approach

We conducted a number of lines of inquiry, across the CJS, including:

Reviewing UK literature on OCN including prevalence & priority needs/issues

Collating & analysing relevant local data from a range of partners throughout the different stages of CJS

Conducting qualitative interviews with key stakeholders

Producing an options paper on potential ways to address the needs identified in this project


Chapter 1 Literature Review


Interlinked Relationships There is a strong and recognised relationship between Substance Misuse (SM), Mental

Health problems (MH), Learning Disability (LD) and offending in terms of: An increased likelihood of committing a range of crimes from acquisitive offences (drug

misuse); violent crime (alcohol & MH; sex offences and arson (LD); & re- offending (drug users are 3-4 times more likely to commit crime than non-users)

Their prevalence in offending populations (an estimated 25% - 65% of offenders have MH; 50% SM; 30% LD needs)

Their overlapping, co-occurring nature (dual diagnosis is the norm not the exception; & 60% of individuals with LD will also have an SM problem)

These issues, therefore, have a high cost to the CJS (est. 13.9 billion for drug related crime) OCN are often more vulnerable in CJS being more likely to experience restraint in custody

(LD & MH), violence (alcohol), being frightened and confused (MH/LD) with higher rates of attempted suicide and self harm (LD). They are also more vulnerable on exit from the Criminal Justice System, experiencing higher rates of housing difficulty and unemployment

Research and campaigning organisations have made strong and enduring calls for dual diagnosis services (SM/MH) & MH/LD services to be delivered jointly for offenders

OCN have unequal access to support options available to other offenders, and as a result are further disadvantaged

NOTE: The full Literature Review is available as a separate document


Older Offenders Prisoners over 60 are the fastest growing group in the prison estate. The number of women

prisoners aged over 50 has more than trebled (Prison Reform Trust, 2008) Older prisoners now represent around 12% of the total prison population and have a high

prevalence of physical and mental disability (Ministry of Justice, 2014) Much research on older offenders in the criminal justice system comes from the prison estate. The national minimum standards for the care of older people in the community or in care

homes do not apply in prison (HMIP, 2008) The Prison Reform Trust (Doing Time; The needs and experiences of Older Prisoners, 2008) has

indicated poor regimes and lack of engagement with older people are leading to isolation in prison and a lack of planning for resettlement means that older people do not get the services they need on return to their community and experience anxiety about the future

Thematic work from the Inspectorate of Prisons (No Problems, Old and Quiet, 2004) found that none of their sampled prisons had a separate regime for older prisoners. Retired prisoners had not been asked about what they wanted to do during the working day. Where activities are not accessible, alternatives should be provided to avoid discriminatory practice

Older offenders needs are not restricted to their time in custody but also require specific resettlement plans, especially where they have served life sentences. The Inspectorate found that over a quarter (28%) of the prisoners sampled would be at least 70 years old on release. They would be unlikely to be seeking employment. Many will require health and social services support in addition to having to adjust to the outside world.

Of course, not all older offenders are ill or infirm but there is a strong encouragement to view age as a potential vulnerability


Vulnerable Offenders Vulnerability in the prison estate and specifically the term

vulnerable prisoner is unique to this environment and is not the same as in the community this presents various difficulties in communication between settings and presents challenges in identification

The Inspectorate of Prisons states: Prisoners, particularly adults at risk, should be provided with a safe and secure environment which protects them from harm and neglect. They should receive safe and effective care and support.

The Care Act 2015 seeks to improve and clarify local authority safeguarding procedures for vulnerable adults including those in prison and across the criminal justice system being able to identify such adults is clearly crucial in order to ensure their safety


Identification Is Vital Identification of these needs for offenders should be at the earliest

possible point in the CJS, and also repeated on entry to prison & probation This is crucial when rehabilitating people / reducing re-offending, not least

with regard to making appropriate referrals and recommendations for adapting sentences or facilitating access to suitable treatment

There is chronic underreporting of these issues for offenders, influenced by: There is great variation in the criteria and terminology used to identify

these needs across agencies and across the country The data not regularly or uniformally captured (e.g. sometimes only a

primary factor can be recorded) Individuals fear being stigmatised and do not divulge information,

meaning that identification must be sensitively handled There is a lack of consistent, validated tools many tools in circulation

require specialist skills or training &/or significant time to complete Practitioners do not feel skilled or empowered to identify these needs


Gaps In Capacity & Capability The literature identifies a number of key gaps in capacity and

capability to identify and respond to these issues: Staff skills & awareness: training needs have been highlighted

around: identification how to adapt and deliver programmes delivery of specific interventions treating multiple overlapping needs

Service provision is often disparate & siloed some unmet need divisions between services no unified services across these issues contributing to a confusing support landscape and gaps


What Works: Adapting Rehabilitation

Some adapted programmes, use of appropriate sentencing & ensuring access to specific support or treatment based on OCN needs can improve efficacy of rehabilitation and preventing re-offending among offenders with complex needs E.g. Drug treatment can decrease reconviction rates by 47%, and early

treatment of mental health problems is preventative for violent crime R & R programme findings suggest that cognitive-behavioural,

cognitive skills programmes should work with this group Government guidance and calls from campaigning organisations

agree that a Care not Custody approach may be more effective in rehabilitating OCN

Specific issue treatment programmes have an impact on reducing re-offending: The best evidence is for drug treatment (2.50 savings from criminal &

health economies for every 1 invested in treatment) However, more research is required to evidence impact of specialised

interventions on recidivism rates for those experiencing problems with alcohol, MH or LD


Recommendations To Consider The literature points to a number of recommendations that have

been regularly made to deal with these issues more effectively: Introduce an integrated service throughout the CJS process and

unified across MH, LD, SM agencies Terminology and criteria used to identify these needs should be

specific and consistently applied Tools used to aid identification should be validated,

comprehensive and used at the earliest opportunity and throughout the CJS

Practitioners should feel skilled, confident and competent at identification of these needs and ensuing adaptation & referral

Agencies and policy makers should consult CJS service users in improving the response to these needs


Qualitative Interviews

Map which relevant services are available locally Where the service provision gaps lie The identification process - tools, training,

requirements, recording data Response & Referral processes when needs are

identified barriers, strengths, adapted programmes, addressing stigma

Joint working arrangements & practices - information sharing

Views on how to better meet needs & an integrated OCN service inc. best practice examples


Chapter 2 Local Data Analysis


LOCAL PREVALENCE ESTIMATES

Offenders with Complex Needs PRISON PROBATION POLICE

CUSTODY

TONIC Consultants Ltd

n/a 2 3% 3% awaiting

TOXIC TRIO: Substance Misuse, Mental Health & Learning Disability


Substance Misuse & Learning Disability


Learning Disability & Mental Health

15% 6% 8% 7%

Dual Diagnosis: Mental Health & Substance Misuse

2.4%+ 16 - 23% 2 30% 8% (proxy) Learning Disability

(LD)

awaiting 9 12% 10 - 11% 25%

Mental Health

(MH)

13% Treatment

clients are CJS 39 58% 42 - 71% 12 - 17%

Substance Misuse

(SM)

4% Alcohol

treatment clients are CJS

29% 42% 5%

Alcohol

19% Drug treatment clients are CJS

24% 10% 12%

Drugs

COMMUNITY

Data Source Essex Police data based on Basildon, Grays & Southend

Essex Probation data on those with prison sentences HMP Chelmsford Needs Assessment

Essex Probation data

NDTMS data

LOCAL DEMAND ESTIMATES


CUSTODY


n/a 124 18 awaiting


n/a 620 135 awaiting


n/a 163 23 awaiting


1,092 334 47 2,800


37 887 176 3,200

13 Appropriate Adult call outs (March 2014)

Learning Disability

(LD)

644 492 59

155 on CPA 8 Transferred to

MH hospital

10,000 85 Appropriate Adult call outs (March 2014)

Mental Health

(MH)

1,534 Estimate of

those with SM treatment

need in CJS

2,207 247 4,800 Substance Misuse

(SM)

111 1,628 59 57 Treatment 2,000

Alcohol

814 554 in DIP 1,339

587

220 Inside Out

97 IDTS

4,800

Drugs

COMMUNITY

Data Source Key: Actual Estimate

Essex Police data based on Basildon, Grays & Southend Population: 40,000

Essex Probation data & HMP Chelmsford Needs Assessment Population: 587

Essex Probation data Population: 5,593

NOTE: This only shows drug and alcohol treatment data Population: 6,864

tonic

tonicAre these numbers are potentially manageablethrough a specialist case management approach?

tonic

PREVALANCE ESTIMATES From literature review


CUSTODY



60%

of LD service users have SM


36%


74 85% of SM clients have MH

44% of MH clients have SM

75% (Prison Reform

Trust, 2011)


2% (DH, 1998)

60% reading age

of 5 or under

7% 25% Borderline LD

40% women (No one Knows, 2007)

20-30% (Louckes, 2007)

Learning Disability

(LD)

25 40%

27% (Brooker, 2012)

23% Male, severe (Senior, 2013)

33% Male, depression

49% Female (MoJ,

2013)

Mental Health

(MH)

32% (Singleton,

2003)

Substance Misuse

(SM)

32 73%

(MoJ, 2013 Scottish Prisoners

Needs Assessment)

66%

(Sloshed & Sentenced)

Alcohol

64% (MoJ, 2013)

Drugs

COMMUNITY

Inside Out Atrium

Atrium

DIP Treatment

System

SERVICE AVAILABILITY Balanced Scorecard


CUSTODY


No dedicated services

Highest prevalence in frequent & severe offenders

No identification

No identification


No dedicated services

High prevalence in frequent offenders

No identification

No identification


Data gaps Service gaps

1 lead in CJMHT, but not

specialist

No identification

No identification


Gaps & Too many links in the chain

Good prison DD provision

Siloed approach


Training & service gaps

Choice & Control Thurrock

Nowhere to refer to

Nowhere to refer to

Appropriate Adult service,

Liaison & Diversion pilot

Learning Disability

(LD)

Barriers to 3rd sector support

CJMHT, but no

NHS Trust engagement

[to add ?] Prison Inreach Atrium

Appropriate Adult service, FME, Liaison & Diversion

pilot, CJMHT Out of hours gap

Mental Health

(MH)

DIP Treatment

System DIP

IDTS Inside Out

Atrium

FME, DIP & Treatment

system

Substance Misuse

(SM)

Emerging growth in alcohol

treatment

Low referral rates into treatment

FME & Treatment

system

Alcohol

DIP Treatment

System

Arrest Referral, DIP, FME

Drugs

COMMUNITY

Siloed approach

NO#SPECIFIC#RESPO

NSE#FO

R#COMPLEX#O

FFENDERS#

PROBATION DATA Section 2.1


Commentary: The general trend is for individual vulnerabilities to occur with greater frequency as age increases, up to the 35-44 age range when they generally decrease with age Exceptions: However, MH continues to increase up to the 45-54 age range Whilst LD becomes less prevalent with age from the 17-25 year olds

0%#

5%#

10%#

15%#

20%#

25%#

30%#

35%#

40%#

45%#

17*25# 26*34# 35*44# 45*54# 55+#

Age & Individual Vulnerability of Essex Probation Clients (n= 5,072)

Alcohol#

Drugs#

SM#

MH#

LD#


Commentary: The general trend is for complexity (multiple vulnerabilities) to decline with age in prevalence among the cohort of probation clients Exceptions: However, MH issues are higher in the 35-44 & 45-54 age groups

0%#

2%#

4%#

6%#

8%#

10%#

12%#

14%#

17*25# 26*34# 35*44# 45*54# 55+#

Axi

s T

itle

Age & Complexity of Essex Probation Clients (n= 5,072)

DD##

LD#MH#

SM#LD#

TRIO#(all#3)#


Commentary: In nearly all individual vulnerabilities, they are found in slightly greater prevalence with men Exceptions: However, MH issues are twice as likely to be found with women than men

0%#

5%#

10%#

15%#

20%#

25%#

30%#

35%#

40%#

Alcohol# Drugs# SM# MH# LD#

Gender & Individual Vulnerability of Essex Probation Clients (Male = 4,986; Female = 607)

Male#

Female#


Commentary: The reverse is true when considering complexity (where offenders have multiple vulnerabilities co-existing), with women more likely to experience nearly all combinations of vulnerabilities especially Dual Diagnosis (SM & MH) where they are twice as likely as male offenders to experience this Exceptions: However, male probation clients are more likely to experience SM & LD in combination

0%#

2%#

4%#

6%#

8%#

10%#

12%#

DD## LD#MH# SM#LD# TRIO#(all#3)#

Gender & Complexity of Essex Probation Clients (Male = 4,986; Female = 607)

Male#

Female#


Commentary: In general, the prevalence of individual vulnerabilities rises with the number of times an individual has entered Probation (i.e. re-offending frequency) Exceptions: There is a leveling off of alcohol misuse at the 21+ re-offending group

0%#

10%#

20%#

30%#

40%#

50%#

60%#

70%#

1#only# 2#to#10# 11#to#20# 21+#

Pre

vale

nce

Re-offending frequency & Individual Vulnerability of Essex Probation Clients (n= 5,584)

Alcohol#

Drugs#

SM#

MH#

LD#


Commentary: There is an increase in the rate of complexity experienced by probation clients as the frequency of their re-offending rises. This generally sees a tailing off from the 11-20 re-offending group to the 21+ group Exceptions: However, the prevalence continues to rise in the SM & LD cohort

0%#

5%#

10%#

15%#

20%#

25%#

30%#

1#only# 2#to#10# 11#to#20# 21+#

Pre

vale

nce

Re-offending frequency & Complexity of Essex Probation Clients (n= 5,584)

DD##

LD#MH#

SM#LD#

TRIO#(all#3)#


Commentary: The distribution of offenders by their complexity (i.e. number of vulnerabilities they experience) becomes more even as the frequency of their offending becomes higher

0%#

10%#

20%#

30%#

40%#

50%#

60%#

70%#

ALL# 1#oence# 2*5#oences# 6+#oences#

Probation Clients - "Events" by vulnerabilities

Oenders#with#no#vulnerabiliPes#

Oenders#with#only#1#vulnerability#

Oenders#with#2+#vulnerabiliPes#


Commentary: Probations own analysis shows that most vulnerabilities and complexities are more common in the prison population than those who receive community sentences. This adds more weight to the evidence that multiple vulnerability is linked to increased frequency or severity of offending

0%#

10%#

20%#

30%#

40%#

50%#

60%#

70%#

SM# MH# LD# LD#MH# LD#SM# DD# Trio#

Probation clients by Community or Prison sentence (n=3,636)

ProbaPon#

Prison#


Older & Vulnerable Offenders

Currently 451 prisoners (11%) over the age of 50 these are across the criminal justice system and may be incarcerated or in the community

Probation does not have a distinct protocol for older offenders they dont normally distinguish offenders on this basis.

Safeguarding with regards to vulnerability Probation would make referrals to partner agencies and social care if necessary


Commentary: Older offenders are categorised by the Prison Service as those aged 50+. When comparing this group with those aged under 50 in the Essex Probation cohort, we found older offenders were less likely to experience many vulnerabilities, with the exception of alcohol misuse and mental health problems

11% of Essex Probation clients are aged 50+ 1% of the total are aged 65+, 2% aged 60+

TONIC: Discussion Paper

60%#

22%#20%#

15%#16%#

9%#

23%#

43%#

34%#

4%#

17%#

8%#

12%#

21%#

ProbaPon#Events#2+# Prison#sentence# Drugs# Alcohol# LD# MH# Perpetrator#of#DV#

Vulnerability,Factors,for,under,50s,&,those,aged,50+,

SUBSTANCE MISUSE TREATMENT DATA

Section 2.2


Commentary: There is some variation across the area amongst recorded levels of offenders engaged in drug or alcohol treatment

0%#

5%#

10%#

15%#

20%#

25%#

Essex# Southend# Thurrock# ALL#

Prevalence of Offenders amongst treatment population


Commentary: There is greater variation in the prevalence of Dual Diagnosis (MH & SM) problems amongst the treatment populations across the area (from 2% in Thurrock to 19% in Essex)

0%#

2%#

4%#

6%#

8%#

10%#

12%#

14%#

16%#

18%#

20%#

Essex# Southend# Thurrock# ALL#

Prevalence of Dual Diagnosis amongst treatment population (MH & SM)


Commentary: CJS clients do better in treatment when in a specialised programme - DIP clients average a 16% successful treatment completion rate, compared to 13% for all CJS clients in treatment

0%#

5%#

10%#

15%#

20%#

25%#

30%#

35%#

40%#

45%#

50%#

Essex# Thurrock# Southend# TOTAL#

Treatment outcomes for All CJS clients v DIP clients

ComplePons#(CJS)#

ComplePons#(DIP)#


Observations from the Substance Misuse Treatment Data

DUAL DIAGNOSIS Differences in DD recorded rate across areas Variation in CJS involvement for clients in treatment

OCU around 20% Low for alcohol Higher for non-OCU

Estimate there are over 1,000 people with dual diagnosis (excl. out of treatment alcohol & non-OCU) 644 (59%) are currently in treatment

DD rates average 14% (drugs) and 24% (alcohol) across the area however there is great variation in recorded DD levels from 4% to 29%

OFFENDERS IN TREATMENT Estimate there are (conservatively) 1,534 offenders in CJS with drug or alcohol misuse problems

925 (60%) of whom are in treatment 554 (60%) of these are DIP clients

CJS clients do better in treatment when in a specialised programme: DIP clients average 16% successful treatment completion rate, compared to 13% for all CJS clients

CJS clients make up only 4% of those in alcohol treatment, compared to 19% of drug treatment population

REFERRAL SOURCE Relatively few (5%) referrals to alcohol treatment come from CJS agencies Less than 1% of referrals appear to come from Mental Health services Whilst LD services are not recorded as a referral source so no data is available


POLICE CUSTODY DATA Section 2.3


Commentary: of those arrested have MH issues identified and nearly 1/5 have self harm issues. However, there is relatively low levels of drug/alcohol use identified (12%) Gender differences Women are more likely to be identified with MH, self-harm and drug issues , whilst men were more likely to be identified as needing help with reading or writing Note: Need help reading or writing is used as a proxy for LD

0%#

5%#

10%#

15%#

20%#

25%#

30%#

35%#

40%#

Alcohol# Other#drugs# Drugs# Mental#Health# Need#help#with#reading#wriPng#

Self#harm#(indicaPons)#Self#harm#(self#report)#

Prevalence of vulnerabilities amongst those in Police custody (n= 4,088 from Basildon, Grays & Southend)

Female#

Male#

TOTAL#


CJMHT DATA Section 2.4


Commentary: We estimate that there are 963 referrals to CJMHT (North Essex only) in 12 months. These referrals predominately come from Court and Police, with only a small number coming from probation

Court#56%#

Police#39%#

Probation 5%

CJMHT referrals (estimate of 963 in 12 months)


Commentary: The average assessment take-up rate from referral is 75%. There is variation in take-up rates from different referral sources It is worth noting that only 5% of referrals come from Probation which has the lowest rate of service take-up

0%#

10%#

20%#

30%#

40%#

50%#

60%#

70%#

80%#

90%#

100%#

Court# Police# ProbaPon#

% take up of CJMHT assessment (based on 562 referrals over 7 months)


HMP CHELMSFORD PRISON DATA

Section 2.5


Prisoners view SM & MH services more favourably than the general picture

Prison Staff feel that SM & MH needs are met in HMP Chelmsford, but do not feel trained in these issues


71% have personality disorder 8% have functional psychoses 22% have anxiety/depression 49% have a neurotic disorder


Staff think it is easy to access SM & MH services in their prison

Prisoners agree that access to SM services is good, but it is more mixed re access to MH provision


HMP Chelmsford staff do not feel trained in LD, SM or MH issues


Access to specialist drug services from prison is reasonably good, but under half started treatment within 3 weeks of release. Waiting for access to DIP after prison release can increase the risk of overdose or re-offending Note: This data should be checked against NDTMS data at local authority level


HMP Chelmsford: Older Offenders

Prison Health Needs Analysis: 53 prisoners said they have problems with mobility (of those surveyed) 54 prisoners said they were unable to wash or dress themselves 9% of prisoners are over 50 yet there is no lead healthcare professional to older

prisoners and there is little social care outside of healthcare to support with issues such as incontinence and personal hygiene

Prisoners over 50 might be located on a specific wing determined by space or availability but there is no dedicated older prisoner wing

Support at present is provided either through primary care or a prisoner trained as a carer, is not commissioned to include nursing support and help with personal care.

An older persons assessment is carried out for every prisoner over 55 this covers next of kin, housing, mobility and hygiene needs appropriate referrals can be made of the back of this.

Can make links in to Essex County Council for prisoners who might need a social care assessment for release planning.

Disabilities officer dedicated to making sure disabled prisoners have access to services they need.

There does not seem to be a specific protocol for supporting older prisoners nor distinct referral pathways or resettlement plans.


HMP Chelmsford: Vulnerable Offenders At present there are 30 prisoners on the vulnerable prisoner wing they

are there based due to the nature of their offences (which makes them at risk of harm from other prisoners) rather than vulnerabilities as defined by the Law Commission and adult social care [see glossary]

Healthcare and services such as Atrium support mental health problems but there are significant challenges in identifying and assessing mental health and learning disabilities/difficulties.

Prison Health Needs Analysis indicates: 3.2% of prisoners in HMP Chelmsford have epilepsy 4.8% are obese 1.9% estimated to have a Learning disability with more (approximately 147

prisoners) suspected of having a borderline LD, based on national prevalence rates

9.9% estimated to have any neurotic disorder Currently waiting to get some data on number of vulnerable prisoners

using the induction pack introduced a few months ago. Currently waiting to ascertain the number of prisoners in HMP Chelmsford

over 50 although we approximate this to be 10% (9 11%)


HMP HOLLOWAY Section 2.6


HMP Holloway: Older & Vulnerable Offenders

Currently have 50 prisoners (10%) aged over 50 ranging from 51-66

Holloway does not have a separate Vulnerable Prisoners Wing and considers all prisoners to be vulnerable by the fact they are imprisoned

There are however 49 women on an ACCT (Assessment, Care in Custody and Teamwork document) to manage risk of self harm and suicide

Those deemed particularly vulnerable are supported by mental health services and are discussed in a weekly complex prisoners meeting

The adult safeguarding policy is currently being drafted


LEARNING DISABILITY SERVICES

Section 2.7


There are 32,724 adults (estimate) living with LD in Essex this is expected to increase by 7.75% over the next 6 years. 6,007 (18%) people with LD are aged 45-54, the largest age group cohort

0#

500#

1,000#

1,500#

2,000#

2,500#

3,000#

3,500#

4,000#

Estimated cases of adults with learning disabilities


Moderate & Severe LD peaks in the 35-54 age ranges with 42% of all cases being found in this age range

0#

1,000#

2,000#

3,000#

4,000#

5,000#

6,000#

7,000#

18*24# 25*34# 35*44# 45*54# 55*64# 65+#

LD population estimates (Essex)

Low#

Moderate#

Severe#

Total#


1,524 (5%) of the LD population in Essex is estimated to have severe learning disability

Low#63%#

Moderate#32%#

Severe 5%

LD estimates by severity (Essex)


Chapter 3 Qualitative Interviews


Overview

######1#DRR#pracPPoner#1#service#manager;#3rd##sector#organisaPon#

2#Access#Engagement#sta;##3rd#sector#organisaPon#

1#Appropriate#Adult#2#CJMHT#(pracPPoner#and#service#manager)#1#Criminal#jusPce#lead;#third#sector#organisaPon#

2#Custody#Sergeants#Forensic#Medical#Examiner#Safer#Custody#Violence#ReducPon#Manager##HM#P#Chelmsford#Deputy#Custody#Commander,

##Essex#Police#

1#general#oender#manager#1#Housing#Ocer#1#EducaPon,#training#and#employment#ocer#

CRC#Custody:#Police#Prison#

SM#MH#

Informal Interviews: AMP Practice Lead Nurse Consultant Director of Secure Services G4S Regional Manager

Total: 20 interviews


Key Findings ! Lack of validated or uniform tools across the system; identification is mainly through clinical judgement and therefore the skills/expertise of the

practitioner ! Use of reading and writing/statemented school as an indication of LD, or no

specific questions asked ! There are problems with self-report but raw scores generated by validated

tools may not be easily communicable to other agencies/professionals ! Services are largely left to their own devices to ascertain and identify further

needs (e.g. substance misuse workers need to identify LD or MH themselves rather than the information following the client) there are no systems for information sharing allowing need to be passported through the CJS journey

! Referrals from one agency to another are not felt to be heard or taken seriously Inc. into social care

Substance misuse workers are seen as the poor profession by mental health workers and prescribing

clinicians even though they have much contact with offenders their concerns & information get ignored

! Time constraints in police custody and court place pressure on the identification and assessment process


Key Findings (2) ! Training was limited but better around mental health awareness

than learning disability ! New training for custody sergeants seems to be comprehensive

and attends to LD, MH and ASD ! Where an individual is identified as having a complex need; this

information tends to remain within the organisation. Information sharing was highlighted as problematic

Information from prison is not shared when someone leaves and enters the community

! The ability to make onwards referrals for offenders with learning disability was consistently identified as lacking especially for those who are not severely disabled and below the threshold for adult social care. There was a general lack of knowledge about where to refer to for LD clients

If someone cant read or write there are not many places that will support this

There are no referral pathways for offenders with learning disabilities. If we do have that information, we dont know what to do with it!


Key Findings (3) ! Generally there was dissatisfaction with organisations

ability to identify and work with LD offenders The criminal justice system is not the right place

for people with learning disabilities, it is not geared up for them

Learning Disability is an unknown territory especially for group work

! Probation stated some services (esp. 3rd sector & GPs) may exclude offenders with complex offence histories

! There are no specific programme/service adaptations for individuals with complex needs; this comes down to the skills of the practitioner and the resources of the organisation

! E.g. Custody Sergeants have access to simplified rights and entitlements ! There are concerns over the impact of CRCs and a de-

skilled workforce there will also need to be links with National Probation Service


Key Findings (4)

LD in prison In Reach are commissioned to care for LD clients There is no LD nurse within the team, so they can-

not carry out LD assessments Social care do come in and assess prisoners

occasionally If the In Reach team need advice on Learning

Disability clients, there is a Learning Disability specialist in the trust, who can be reached by phone

The LD specialist can check electronic records and case details of the particular prisoner


Key Findings (5): Older & Vulnerable Offenders

HMP Chelmsford is piloting a new induction pack on their reception wing in order to identify prisoners who are vulnerable as per the law commission definition. The current prison definition in the male estate of vulnerability is based on offence type. HMP Holloway (the main womens prison for Essex residents) does not use the traditional definition, using the premise that all female prisoners are vulnerable

Prison is the only CJS environment that uses any older age threshold, as it defines an offender as older when they are 50 or over. HMP Chelmsford has a separate, but not exclusive, wing for older offenders

In Police Custody age is considered a vulnerability automatically if the offender is a juvenile (e.g. with specific pathways and protocols around their care, and checking/observation mandated to be occur at a minimum of every 30 minutes)

This is not replicated at the other end of the age spectrum. If an offender is older no specific pathways exist.

Police use PACE to consider the appropriateness of arrest on an individual basis [https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/117583/pace-code-g-2012.pdf]

All offenders in police custody are assessed on a range of vulnerabilities rather than age alone using visual assessment, previous risk assessment, information from PNC and the g4s medical provision - this determines the level of care provided for the individual

Those in Police Custody have a pre-release risk assessment. Police look to social services and 3rd sector for help placing and supporting a vulnerable person on release if needs are identified


Anecdotal Evidence: Case Studies

CASE STUDY A: An individual with Aspergers presents at Custody Suite and Sergeant says to him write your name there, pointing at a piece of paper. The individual proceeds to write his name as there. Due to the custody sergeant having an interest in learning disability, educating himself outside of work, he understands the instruction has confused or misled the individual because of the nature of his disorder. Prior to this awareness, the custody sergeant may have thought the individual was being obstructive or difficult with implications for his treatment. CASE STUDY B: A young woman with learning disability is housed in Chelmsford despite this being the place she was abused for most of her life. She runs away regularly, is confrontational on arrest and becomes embroiled in the CJS spending time in Holloway. The CJMHT argue her housing is the root of the problem but adult social care will not re-house her due to lack of alternative provisions.


What did services suggest? ! Awareness needs to be increased throughout the custody chain -

An Introductory Guide on Offenders with Complex Needs for all working in the CJS & with clients on exit from CJS

! Improved information sharing negotiated and agreed from the top Services across substance misuse, mental health and learning

disability need to sign up and commit to information sharing and collaborative working

! Improved working relationships between services so referrals are seen as credible avoid unnecessary links in the chain (e.g. delays while a doctor confirms a suspected diagnosis)

Greater understanding, respect and partnership working between mental health, substance misuse and adult social care

! Improved out of hours services; Appropriate Adults and CJMHT not available 24 hours a day

The AA provision is failing, there are individuals sitting waiting overnight

! Link workers for prison/hospital and re-entry to community Having a link worker feeding in to the prison is

an invaluable link and improves continuity of care TONIC: Discussion Paper 59

What did services suggest? (2)

! Social enterprise or employers willing to take on ex-offenders. Making job searching sociable to avoid periods of isolation (e.g. job club)

! Service provision maps for informed referrals offenders being given lists of relevant service providers before released from prison

! Clear pathways and improved relationships with learning disability teams ! Multiple seconded staff in each service e.g. mental health nurse in probation

and/or substance misuse teams CJMHT are in the station at Chelmsford, this is a really useful new addition

! A unified, integrated service to overcome siloed models of care and fragmented systems

A one stop shop would be really beneficial, staff from a number of professions in one building, not phoning from place to place, just one port of call to streamline the process and speed up service access

! A system that represents shared care to avoid to-ing and fro-ing and duplicating information

Individuals get bounced around services If an individual has a substance misuse problem they get rejected from mental health services


Chapter 4 Recommendations


Our Recommendations for future provision & practice: Short Term

1. Produce clear pathways, Concordat, beginners guide & directory resources. This will clarify Terminology and criteria used to identify complex needs, which should be specific and consistently applied. Consider adopting a non-stigmatising term, such as offenders with additional needs. Review current use of specialist court orders (DRR, ATR & MHTR)

2. Encourage the consideration of the impact of age of offenders on individual rehabilitative efforts and engagement ability

3. Encourage the consideration of vulnerability beyond the prison definition currently based on offence type to include a broad range of needs (MH, LD, physical health, and age)

4. Networking events, Joint training & co-location that bring together a range of services across sectors and disciplines; breaking down barriers. Explore how expert services can offer case consultation. This will capacity build the ability to identify and respond to these needs

Regular open days are always a useful way forward to improve joined up working

3. Clear information sharing protocols to reflect fast movement through custody chain:

portable risk and need file that mimics or extends the personal escort record form (PERF)


Recommendations: Medium Term 4. A climate that promotes shared responsibility. Looking at the offender holistically not modularly 5. Resettlement officers need training to recognise appropriate agencies to refer older prisoners to prior to release. Prisons should link with voluntary agencies in their area so that isolated older people have a support network on release 6. Uniform, yet flexible and responsive training for statutory and non statutory service providers; on range of needs education and awareness. CJS professionals are crucial in identifying offender needs. So that practitioners across CJS feel skilled, confident and competent at identification of these needs and ensuing adaptation & referral

When the second voice came in, I couldnt concentrate

on anything else, it really made me think about what its like to be schizophrenic

7. Tools used to aid identification should be validated, comprehensive and used at the earliest opportunity and throughout the CJS this must take account of limited time, training, & be meaningful for onward referrals


Recommendations: Longer Term

8. A focus on need not just risk e.g. Consult and involve service users on future service design &

development Importance of gender specific services not to be underestimated Issues to consider: LD may not be seen as treatable in the way SM,

physical health & MH are, but there is still a vital place for management and adaptation to improve outcomes/reduce re-offending

9. System-level change including (but not only) introduce an integrated service throughout the CJS process and unified across MH, LD, SM agencies flexible (out of hours), tiered, recovery focus (integrated with society, leading sustainable lives through employment & housing), link workers (e.g. through the gate)


Chapter 5 Next Steps


Next Steps This is a complex policy area, and one that in spite of wide recognition of the issues, little significant reform of service commissioning, design and delivery has taken place. With this in mind, we recommend consideration of the following points when determining a set of next steps to take forward the learning from this report: 1. Disseminate this discussion paper to a wider set of stakeholders across the criminal justice system in

Essex, Thurrock and Southend, and to those support services focusing on the needs of those with MH, SM or LD issues

2. Present the key findings to the Reducing Reoffending Board overseeing this piece of work 3. Conduct a strategic investment mapping exercise to capture the current and planned investment into

support services, interventions and pilots that address the issues raised in this report from across local authority, public health, CCG, NHS England, CRC, NOMS, Police, 3rd sector, courts & other partners

4. Review the findings of the investment map against the issues raised in this report to identify key service gaps, examine opportunities for pooling the investment to maximise impact

5. Bring service users, commissioners, service providers and partners together to consider this landscape and work collaboratively in a co-design environment to assist in identifying innovation to maximise impact


High

Medium

LowTailor CJS responseStaff Training

IdentificationSignpost & Refer

Adapt CJS ProgrammesInfo sharing

Consultation & Advice service

Full case managementTherapeutic

Intervention

Joint working with other agenciesTrain othersProgramme design

Tiered Response

Pool existing teams & functions

MH

LD SM

Team Lead AdminTrainer

DIP

DD FME

L&D CJMHTPrison

MH

LD SM

Prison PoliceCRC

Delivery Options

New Co-located specialist team or One Stop Shop

New Virtual Team

Annexes

Annex A: Literature Review Annex B: Data Workbook


Documents

Offenders with complex needs - analysis report