Criminal justice liaison and diversion schemes - Offender Health ...

Mental health briefing September 2008Criminal justice liaison anddiversion schemes: A focuson women offendersIntroductionAgainst the backdrop of a rapidly increasing female prison population andconcern at the significant number of women with mental health problems heldin custody, criminal justice liaison and diversion (CJLD) schemes have beentasked with diverting offenders* with mental health needs away from thecriminal justice system into the care of health and social services. Thisbriefing paper presents key findings from an evaluation conducted betweenJanuary 2006 and March 2007 of 10 CJLD schemes. The evaluation aimed toprovide a qualitative and quantitative description of the schemes and theextent and nature of the service they provided for women offenders withmental health needs.Contents Introduction page 1 The schemes page 3 CJLD schemes’ datafindings page 8 Recommendationspage 10Written by:Gillian Hunter Institutefor Criminal PolicyResearchIsabella Boyce Institutefor Criminal PolicyResearchLucy Smith NacroThree areas were addressed by the evaluation:The extent to which CJLD schemes were able to contact women offenderswith mental health needs.The extent to which schemes provided access to support and treatment toenable women to remain in the community rather than receive a custodialsentence.The factors that helped or hindered CJLD schemes in their task ofidentifying and supporting women offenders with mental health needs.The schemes included in the evaluation reflect different types of liaison anddiversion services. They were located in police stations and magistrates’courts, rural and urban locations, include schemes with and withoutpsychiatric input and those which used proactive and reactive methods ofworking (checking for evidence of mental health problems or relying oncustody staff and other criminal justice practitioners to make referrals).For each scheme the evaluation:reviewed operational policies and protocols, where availablewww.nacromentalhealth.org.ukwww.nacro.org.ukNacro 2008compiled socio-demographic and an assessment outcome data profile foroffenders assessed by the scheme (based on routine monitoring and casefile data for 2005)collated information about multi-agency involvement to map local serviceprovision and examine the links between the scheme and other agenciesconducted interviews with key professionals (scheme staff and others frompolice, courts, probation and receiving services) and women service usersNacroPark Place, 10-12 Lawn Lane,London SW8 1UDTelephone 020 7840 1209Fax 020 7840 1213Email mentalhealth@nacro.org.ukNacro is a registered charity no. 226171placed scheme activity in context through examination of local arrest andsentencing data.* This briefing paper has used the term ‘offenders’, but includes those who come into contact with the criminal justice systembecause they are suspected of committing an offence.1

Criminal justice liaison and diversion schemes: A focus on women offendersPolicy contextDiverting offenders with mental health needsaway from the criminal justice system into thecare of health and social services has been apolicy aim for some time. 1-3 As far back as 1992,the Reed Review of Health and Social Services forMentally Disordered Offenders (the Reed report)recommended that there should be nationwideprovision of properly resourced court assessmentand diversion schemes to achieve this goal.Prison exacerbates mental ill health, heightensvulnerability and increases the risk of self-harmand suicide. In addition, mental health serviceswithin prison are unsuitable and inadequate fordealing with prisoners with chronic and severemental health conditions. 4-7 Recent developmentsin this area include a government review ofservices for offenders with mental health needsconducted by Lord Keith Bradley, and theforthcoming publication in 2009 of the firstoffender healthcare strategy. 8 There are alsoefforts afoot to improve and standardise theprovision of court assessment, liaison anddiversion services through the introduction ofservice level agreements (SLA) betweenmagistrates’ courts and mental health services.Pilot projects using SLAs are currently beingundertaken in the south-west of England andnorth-west London.*Baroness Corston conducted a review of vulnerablewomen in the criminal justice system. 9 Thishighlighted the failure of the NHS to properlyresource schemes to divert women with mentalhealth needs away from prison and intocommunity-based healthcare. The Women’sOffending Reduction Programme (WORP) sought todevelop more appropriate communityinterventions for women to encourage theirdiversion at pre-court and pre-sentence stages ofthe criminal process and the greater use ofcommunity disposals. 10 In addition, the GenderEquality Duty (April 2007) placed a legal obligationon public bodies to show that they werepromoting equality of opportunity between menand women through the Equality Act 2006. Theimplications for criminal justice agencies includedrecognising and catering for the potentiallydifferent needs of male and female offenders. 11,12What we know about the femaleoffending populationMost female prisoners are serving short sentencesfor non-violent crimes and over a third have noprevious convictions. 13 The majority (66%) are* For more details contact Offender Health at the Department of Health.mothers, 14 yet the small size of the female prisonestate means that many are held far from homemaking it difficult to maintain regular family ties,which can have damaging consequences for theirchildren and for the women’s mental health.Ensuring that community-based disposals areavailable wherever possible for women withmental health issues could help to reduce thenumber serving these short prison sentences. 9Mental ill health is high among women offenders.Female prisoners are twice as likely as males tohave had contact with mental health servicesprior to their imprisonment. They are also morelikely than male prisoners to suffer fromfunctional psychosis and neurotic disorders suchas depression, anxiety and phobias. Two-thirds ofwomen prisoners have been assessed as having aneurotic disorder. 15 Approximately 50% of womenprisoners were receiving prescribed medicationsuch as anti-depressants and anti-psychoticmedicine. 15 A more recent study has reported thatwomen in custody were five times more likely tohave a mental health problem than women in thegeneral population. 9Nearly a third of women prisoners self-harmed in2003 compared to only 6% of men, and whilewomen comprise a minority (6%) in the prisonpopulation, they accounted for 46% of all selfharmincidents. 16 Furthermore, nearly half offemale remand prisoners had attempted suicidein their lifetime compared to a quarter of maleremand prisoners. 17 There were 54 self-inflicteddeaths of women prisoners between 2000 and2005 and the majority of prisoners who commitor attempt suicide have a history of mental13, 18disorder.Substance misuse is common, with femaleprisoners more likely than men to be dependenton opiates. 15 In a sample of 301 women from 10prisons, 34% reported hazardous levels ofdrinking in the year before prison and 43%reported use of crack cocaine and 44% use ofheroin in that time frame. Over a quarter (27%)had used heroin and 9% had used crack cocainewhile in prison. 19 Unsurprisingly, there is also ahigh degree of comorbidity: one study found that83% of female remand prisoners and 70% offemale sentenced prisoners had two or moremental disorders. 15 Other issues includeexperience of violence: 50% of women prisonershave experienced domestic violence and about athird have been sexually abused. 132

Mental health briefing 2008Linking with women’s prisonsA common problem was the relatively poor linksschemes had with women’s prisons. Two relatedissues were noted: the geographic dispersal of thewomen’s estate meant it was often impractical toarrange visits and the infrequency of contactmade it difficult to build up workingrelationships with prison health teams. This hasimplications for transferring mental healthassessment information from the scheme to theprison and vice versa on release. Although thereare standard procedures for the notification of aprisoner’s risk of suicide and self-harm, otherinformation about mental health may be lost.Scheme 9 had appointed a prison link worker forwomen. Her role was to ensure continuity of careand access to services on leaving prison. She alsotried to help women stay in contact with familiesand carers through practical help such asarranging transport for visits.Guidance and trainingDespite the emphasis on guidance and trainingfor those working with women offenders withmental health needs, 10, 21 only two schemesreported receiving any gender-specific trainingand this was focused on self-harm. None of theschemes had received guidance on dealing witheating disorders or sexual abuse.User involvementThere is an increasing emphasis on the centralityof the service user in mental health policy 21 andregular consultation with service users isrecommended as a routine factor in serviceplanning. 23 None of the schemes in our samplehad any routine procedures for collating feedbackfrom their service users or any recent findingsfrom user consultations. Our own limitedendeavours show that it was difficult for thewomen to differentiate the service input they hadfrom different health and criminal justiceagencies, which has implications for any futuremethods schemes may use to collect serviceusers’ opinions. The interviews we undertookwith service users (11 in all) did however showthat women were generally positive about theservice provided by the schemes and gainedvaluable help and support from the receivingagencies. The following interview extracts showthe importance the women placed on havingsomeone at court or in the police station who hadtime to listen to their concerns and who hadsome understanding of what they were goingthrough:‘I thought it helped me more, because thenother people get to understand from mypoint of view, rather than just going inthere and they don’t understand everything,I mean, at least people then have, youknow, realise reasons why you get yourselfinto trouble… if I could kiss that man, Iwould, from the [CJLD scheme], you know, Iwould, he done wonders for me… and heactually sat down and he listened to me,you don’t get many people like that.’Wilma, 23 years old‘Just being able to go in and speak aboutanything really and knowing that it ain’tgoing to go any further. It’s private andconfidential. Nobody else needs to knowabout it. He’s always saying, it stays in theroom that we’re in. It’s just nice to knowthat he’s not in judgement.’Emily, 24 years oldBelow, Gale, 25 years old, describes her situationbefore and after intervention by the CJLD schemewhich led to a transfer to a mental health facility:‘I feel better here [in the secure unit]because in jail I had the voices really badand I was trying to pretend to everybody Iam all right. I was making a joke with itbecause me voices kept saying ‘out thewindow’ and I said ‘you’re telling me to goout the window’ and I was making a joke ofit. And I was making out I was all right toeveryone because I didn’t want anyonetaking the piss out of me… And I had neverbeen to jail before so I was trying to makeout I was all right when I wasn’t. Where hereI have been able to get better and tell thetruth.’ResourcesAs a general point, all the schemes talked aboutoperating with very limited resources. Thefollowing extract from an interview with asteering group chair and commissioner offorensic services is used to illustrate the issuesfaced by many schemes:‘It’s way under capacity… it’s very difficultto keep it on the commissioning agendabecause you are going through this tieringon the commissioning side. You are in there7

Criminal justice liaison and diversion schemes: A focus on women offenderswith all the other service programmes, likecancer, like heart diseases, all the other bitsand pieces… They all get dealt with first.Mental health comes way down thecommissioning list and within mentalhealth you have all those targets that youare performance-managed… Court diversionhas not appeared in that. It barely got amention in the criminal justice carepathway… never mind a target.’CJLD schemes’ datafindingsData qualityWe collated local police arrest and sentencingdata and scheme monitoring data from 2005 toprovide an indication of the need for CJLDschemes for women offenders in different areas.From the outset it was clear that the extent andquality of routine monitoring data would vary. Anearlier Nacro survey 22 found that one in fiveschemes did not collect service level activity data,while two-fifths did not record details of clients’gender. As anticipated, much of this activity datawas paper-based.The quality and consistency of activity data wasgenerally poor and monitoring systems wereinadequate. The minimum data set proposed forthis study (see Box 2, page 11) representedcommon core data that were available across theschemes, according to screening and assessmenttools. However, only four schemes routinelytransferred these data onto an electronicdatabase, three had no electronic data at all, twogave us partial electronic data and one schemecould provide no activity data. As a result, theproportion of missing data was high, particularlyon items such as primary diagnosis and referralrecommendations. Criminal justice outcomeswere not easily available at eight of the schemes.Likewise, the outcome of referrals to communityservices were not recorded routinely.This meant that we were unable to draw anyconclusions about the recommendations made tothe court by CJLD schemes for women offendersand the proportion of recommendations taken upby courts, or the proportion of successfulreferrals from CJLD of women to hospital andcommunity-based mental health services andcriminal justice system interventions. Thesekinds of outcome data were not recordedroutinely by most schemes, making it very hardto judge the effectiveness of the schemes. Whatwe can say about the CJLD contacts and referralsources is limited. This dearth of monitoring datais an important finding in its own right.Nature and extent of contact byCJLD schemesWe can say that the schemes were seeing onaverage 2% to 3% of the total number of offenderspassing through the police station and courts.This suggests a considerable level of unmet need.Surveys of the offender population haveconsistently found a high proportion with mentalhealth problems. 15There were 2,155 adult referrals to the nine CJLDschemes between January and December 2005,ranging from 16 to 688 referrals per scheme (themean was 239). Around three-quarters of referralsduring this period were made via police custody(n=1,123; 52%), probation (n=289; 13%) or thecourts (n=192; 9%).Four schemes operated at the police station. *Between January and December 2005 these policeforce areas came into contact with a total of49,666 arrestees. During the same period theCJLD schemes received 1,492 referrals, but notsolely from custody suites – equivalent to 3% ofthe arrestee population at these sites. The rate ofcontact was similar for female suspects (3.5%).The level of contact with the arrestee populationvaried by area from 4.7% in Scheme 9 to 1.4% inScheme 10.At all nine CJLD sites it was possible to gathercomparable data on court activity (though onlysix operated as court-based schemes). During2005, 85,893 defendants were sentenced by thecourts. The schemes in these areas received 2,155referrals – equivalent to 2.5% of the populationprocessed by the courts. As with the arresteedata, the rate of contact was almost identical forfemale defendants (2.6%), but with the level ofcontact varying considerably between areas, from0.8% in Scheme 1 to 4.9% in Scheme 7, thisscheme also engaged the highest proportion offemale defendants (7.7%).The most common reasons for making a referralwere unspecified mental health concerns (n=500),* Two schemes operated both at the police station and at the court stage.8

Mental health briefing 2008Table 2 Primary diagnosis for CJLD referrals requiring furtherintervention (%) (n=1146)35 32%16%3025201513%11% 11%1056%5%3%2% 2%1%0Substance useSerious and enduringmental illnessDepressionOtherPersonality disorderNo diagnosisLow level mentalhealth needsDual diagnosisLearning disabilityMissingSelf-harmself-harming (n=355), substance use (n=28) orother reasons (n=184). * The available activitydata from the nine sites suggests that less thanone-third (n=648) of those referred to CJLDschemes during 2005 had previous contact withpsychiatric services. ** In some cases CJLDworkers completed a full assessment with thereferrals they saw (n=820; 38%); however, wecannot be certain of the extent to which thishappened, as details on the type of assessmentundertaken were often missing.Over half the adults referred to the CJLD schemeswere assessed as requiring further intervention(n=1146; 53%). *** Table 2 illustrates how substanceuse (n=362), SEMI (serious and enduring mentalillness, such as schizophrenia and bipolar/manicdepressive psychosis) (n=187) and depression(n=142) were the most common forms of primary* The reason for referral was not recorded in 51% of cases (n=1089).** Data on previous contact with psychiatric services was not recorded in 44%of cases (n=956).*** Data on referral recommendations were missing (including not known andnot assessed) in 25% of cases (n=545).diagnosis made by CJLD workers followingassessment of need. The high rate of CJLDreferrals being identified with substance misuseproblems indicates some duplication of effort orthe potential for dual diagnosis of substancemisuse and mental health problems. Thisreinforces the need to establish links betweenCJLD schemes and DARS.How did the women seen by theCJLD schemes differ from the men?It is important to consider whether women’sexperiences of the CJLD schemes differed frommen’s and to understand what factors wereimportant in shaping these experiences. Therewere a limited number of variables, for which wehad reasonable data, which we could hypothesiseas being potentially important factors (see Table 3overleaf).The women seen by the schemes were more likelythan men to be white; to have beenarrested/charged with a public order or violentoffence (but not section 136 detainees); and, to9

Criminal justice liaison and diversion schemes: A focus on women offendersTable 3 Female and male contactsseen by the CJLD schemesFemaleEthnicity (white) 96%(361/377)Marital status(single)74%(218/293)Homeless 14%(24/167)Has previousconvictions65%(107/166)Violent offender 17%(55/325)Male91%(1481/1637)79%(1132/1436)17%(133/766)80%(544/681)14%(193/1369)RecommendationsBelow we outline some recommendations, basedon our research, for how schemes might improvetheir service for women offenders with mentalhealth problems.ResourcesThe schemes are clearly under-resourced andthe entire criminal justice system wouldbenefit from greater investment in them. Theirprofile might be raised if schemes weredirectly commissioned by primary care trustsand had clear performance targets from theDepartment of Health. For this to happen thereneeds to be good evidence about throughputsand impact, and this information will only beavailable if there is investment in theadministrative infrastructure of CJLD schemes.Public orderoffenderSection 136detaineeHas previouscontact withmental healthservicesMental healthneed (SEMI)Substancemisuse problem15%(50/325)9%(116/1369)1% (3/325) 1%(10/1369)94%(149/159)8%(25/325)38%(125/325)93%(498/537)14%(194/1371)29%(394/1371)Providing services for a higher proportion ofthose in need is in part a question ofresources. The schemes simply do not havethe capacity to provide sufficient coverage.However, a higher proportion of thepopulation in need could be located ifschemes’ times of operation were more closelysynchronised with the times of peak demand,such as evenings and weekends.If more resources were made available, CJLDschemes should aim for a more proactiveworking style by, for example, checkingcustody records and prisoner escort recordforms for evidence of mental health issuesand/or previous contact with mental healthservices, rather than relying on referrals fromcustody staff.have been diagnosed with a substance use issue.They were less likely to have previous convictionsor have been diagnosed with SEMI than their malecounterparts. This is in contrast to researchshowing a higher prevalence of mental illness(including psychosis) among female prisonerscompared to male prisoners, 15 and suggests somedegree of unmet need and missed opportunities forthe mental health screening of women in contactwith the criminal justice system.Informed gender practiceProactive screening may be particularlyimportant for identifying women with mentalhealth problems because they may be lessobvious to the non-specialist. However, womenwho appear challenging can also be extremelyvulnerable.Wherever possible, the service user shouldhave the choice of speaking with a femalemember of staff. Schemes could encouragethe recruitment of female staff by offering,for example, job shares and part-timeappointments.10

Mental health briefing 2008Box 2Recommended minimumdata setDate of referral and assessmentAge, sex and ethnicity of clientSource of referral (eg, police, court, probation)Improving working relationships andcommunication between the schemes andprison inreach teams in female prisons is alsoa priority. Initially, this may simply be a matterof establishing links with other CJLD schemesto ensure a local (to the prison) team canprovide support to the offender until they arereleased and move back to their area ofresidence.Housing, employment and relationship status ofclientCJLD scheme staff should also be aware of anygender equality strategy produced by theiragencies under the Gender Equality Duty (April2007).If more resources are made available, thenthese should be deployed in a way thatpermits more gender-specific workingpractices. This should include training forscheme staff on women’s mental health andother needs and the profile of womenoffenders.Partnership workingCurrent offence and previous convictionsReason for referralPrevious contact with mental health servicesPrimary diagnosisReferral recommendationsCriminal justice outcomeThere is clearly a need to improve andformalise links between the CJLD schemes andDARS and these links could be developed tobetter cater for those offenders with mentalhealth and substance misuse problems. Links with community-based services couldalso be improved. Signposting is limited andthus developing more formal referral linkswith appropriate local agencies (including thevoluntary sector) could result in betterattendance at follow-up services in thecommunity among CJLD clients. Schemesshould map out women’s organisations thatoffer counselling, women’s centres, womenonlyhostels, supported accommodation anddrug projects, crisis centres and services thatengage with sex workers. The Griffin Society *has a resources database which may be useful.Any gaps that exist in provision, for example alack of women-only inpatient facilities, shouldbe raised with commissioners.Performance monitoring The minimum data set defined for this studyto monitor scheme activity (set out in Box 2above) could be achieved easily (all theschemes collected these data as part of routinescreening and assessment procedures) ifresources were available for administrativesupport, including database construction andmanagement.User engagement Strategies for user engagement are at arudimentary level and should be developed.Publicity The work of the CJLD schemes needs to bepublicised via leaflets and posters at policestations and in courts and given to defencesolicitors to ensure that all criminal justiceprofessionals, offenders and detainees areaware of the services they provide.* www.thegriffinsociety.org11

Criminal justice liaison and diversion schemes: A focus on women offendersReferences1 Reed J (1992) Review of Health and Social Services for Mentally DisorderedOffenders and Others Requiring Similar Services London: HMSO.2 Home Office (1990) Circular 66/90 Provision for Mentally DisorderedOffenders London: Home Office.3 Home Office (1995) Circular 12/95 Mentally Disordered Offenders: Interagencyworking London: HMSO.4 Edgar K (2004) Lacking Conviction: The rise of the women’s remandpopulation London: Prison Reform Trust.5 Department of Health (2005) Offender Mental Healthcare Pathway London:Department of Health.6 Sainsbury Centre (2006) London’s Prison Mental Health Services: A reviewLondon: The Sainsbury Centre.7 Care Services Improvement Partnership (2006) Women at Risk: The mentalhealth of women in contact with the judicial system London: Department ofHealth.8 Department of Health (2007) Improving Health, Supporting Justice: Aconsultation London: Department of Health.9 Baroness Jean Corston (2007) The Corston Report London: Home Office.10 Home Office (2004) Women’s Offending Reduction Programme Action PlanLondon: Home Office.11 Fawcett Society (2006) Doing Your Duty: Guide to the Gender Equality Duty,London: Fawcett Society.12 Fawcett Society (2006) Understanding Your Duty: Report on the GenderEquality Duty and the criminal justice system London: Fawcett Society.13 Howard League for Penal Reform (2006) Prison Information Bulletin 2:Women and girls in the penal system London: Prison Reform Trust.14 Women’s Estate Policy Unit (2003) Working with Women Prisoners London:Prison Service.15 Singleton N, Meltzer H, Gatward R, Coid J and Deasy D (1998) PsychiatricMorbidity Among Prisoners in England and Wales London: The StationeryOffice.16 Rickford D (2003) Troubled Inside: Responding to the mental health needs ofwomen in prison London: Prison Reform Trust.17 Meltzer H, Jenkins R, Singleton N, Charlton J and Yar M (2003) ‘Non-fatalsuicide behaviour among prisoners’ International Review of Psychiatry, 15,pp. 148-149.18 Shaw J, Appleby L and Baker D (2003) A National Study of Prison Suicides1999-2000 London: Department of Health.19 Borrill J, Maden A, Martin A, Weaver T, Stimson G, Farrell M and Barnes T(2001) Differential Substance Misuse Treatment Needs of Women, EthnicMinorities and Young Offenders in Prison: Prevalence of substance misusetreatment needs London: Home Office.20 Centre for Public Innovation (2005) Court Diversion and Liaison Schemes:Recommendations for models of care London: Centre for Public Innovation.21 Department of Health (2003) Mainstreaming Gender and Women’s MentalHealth: Implementation Guide London: Department of Health.22 Nacro (2005) Findings of the 2004 Survey of Court Diversion/CriminalJustice Mental Health Liaison Scheme for Mentally Disordered Offenders inEngland and Wales London: Nacro.23 Nacro (2006) Liaison and Diversion Schemes for Mentally DisorderedOffenders: A mental health good practice guide London: Nacro.24 Birmingham L (2001) ‘Diversion from custody’ Advances in PsychiatricTreatment, 7, pp. 198-207.Do you need this leafletin another format?Ring 020 7840 7220.Nacro’s Mental Health UnitNacro believes that responses to offenders withmental health needs should focus on their care andtreatment rather than on punishment. To help bringabout this change, Nacro campaigns for: more effective working partnerships betweenagencies the development of specialist skills in the criminaljustice system better information sharing the education and training of staff so that theyhave the skills and encouragement they need towork with a group who can be difficult andunrewarding.Nacro’s Mental Health Unit has been working to tackleproblems faced by offenders with mental healthneeds since 1990. We work with government agenciesat a national and local level to develop more effectiveways to deal with offenders with mental health needs.We provide a range of services: information andadvice; policy development and other consultancyservices; and training. We also run a major annualconference on mental health and crime.Nacro has a specialist mental health websitewhich offers information and support for practitionersand policy makers working in the field of criminaljustice and mental health. To find out more, visit thewebsite or contact the Mental Health Unit on 020 78401209 or email mentalhealth@nacro.org.uk.www.nacromentalhealth.org.ukICPRThe Institute for Criminal Policy Research (ICPR)carries out multi-disciplinary research into crime andthe criminal justice system. We produce work whichis independent and objective. Our key audiences aremanagers and practitioners within the criminal justicesystem, other professionals working with offenders,and politicians and their advisors. Our researchapproaches incorporate both quantitative andqualitative methods. Our main areas of researchinclude:the quality and effectiveness of public servicesand resources (including police, probation andservices for offenders and drug users)the causes, consequences and prevention ofoffendingpublic attitudes towards crime and sentencing,the police and community safety.www.umds.ac.uk/schools/law/research/icpr/12