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Download the Liaison and Diversion Bulletin: April 2014
Contents:
Welcome to the monthly Liaison and Diversion (L&D) Bulletin, bringing all news and L&D updates together in one place. This month we are running a special edition to coincide with the ten trial schemes going live and the Programmes transition to NHS England. Other highlights for this month include:
News roundup
Trial schemes go live and Programme transition to NHS England!
National Conference 2014 – a summary of the day
Highlights from the 2nd Thematic Day on case identification, screening, assessment and supporting people with learning disabilities
Highlights from the 3rd Thematic Day on the data set and data flow
L&D web pages
L&D voice
Call for contributions
Next month’s bulletin
News roundup:
Trial schemes go live!
We are delighted to announce that the 10 trial schemes, as listed in January’s bulletin, have this month begun delivering the new national L&D Standard Service Specification. The schemes aim to provide a national and consistent L&D service across the country. They will look to achieve quality and accessibility for all service users regardless of location in England. The 10 trial schemes have been actively preparing for this moment during the last three months and it is exciting to see their hard work and planning being transformed into reality. This milestone marks an achievement in providing better healthcare and support for those vulnerable people who need it the most. In the next few months we expect to witness the development of these services that aim to provide coherent and better support to service users. This will also include service user case studies which will provide a picture of what is really making a difference to people’s lives. We also expect to see a growing awareness of L&D as it reaches new stakeholders and providers as well as developing existing relationships. For those wanting further information on the service specification and operating model you can find these documents on our website. These are a valuable resource, especially for schemes delivering existing L&D services, as it will enable them to begin embedding the new model for the future.
As mentioned in last month’s bulletin we can now confirm that the L&D Programme has transferred from the Department of Health to NHS England from 1 April 2014. This marks a major milestone as we move into implementation with the 10 trial schemes and work towards the full business case for further roll out.
National Conference 2014: Building on Firm Foundations – a summary of the day
The Liaison and Diversion National Conference, Building on Firm Foundations, organised by the Offender Health Collaborative (OHC) on behalf of NHS England, took place in Leeds last month. It aimed to share and promote good practice between all L&D schemes and discuss operational successes, challenges and possibilities in planning and implementing the new service model. The conference was hailed a great success and brought lots of discussion, networking and ways of implementing the new model. It also sought to provide an opportunity for trial and non-trial schemes to learn from each other and build on the previous Policy into Practice events. The conference was opened by the keynote speaker Norman Lamb MP, Minister of State, Care and Support at the Department of Health. Other speakers included Graham Beech and Dave Spurgeon from the OHC, Kate Davies OBE, Head of Public Health, Armed Forces and their Families and Health & Justice, NHS England and Dave Burton, Programme Director, NHS England.
“The fact this person may be autistic, schizophrenic, or have any mental condition which may have caused them to be arrested in the first place, usually isn’t spotted until they’re in prison.” Normal Lamb, MP
Over 140 professionals attended the conference which included L&D schemes and practitioners, commissioners, policy officials and key stakeholders. The Minister opened the conference by describing why L&D services are needed. Delegates heard the Minister declare that it was an enduring scandal that so many people with a mental health problem or a learning disability are not spotted until they are in prison.
“The ability to work with our counterparts, to create a homogenous service, is the key to getting the best out of our liaison and diversion teams.” Normal Lamb, MP
He talked about by working together, individuals will be offered treatment, support or care a lot sooner than they are now, thus aiming to help break the cycle of re-offending. L&D services will help to bring this change and a positive difference to people’s lives, The Minister emphasised his continued support for the development of L&D and how this programme remains one of his top priorities.
The Minister emphasised that the conference was not just about the 10 trial schemes but reflected the learning and experience of all who worked in the field of liaison and diversion. He paid tribute to those practitioners who understood the challenges posed by people with complex needs, carrying out vital and, often unrecognised, work and cited the initial work of Lord Bradley.
During his speech and the Q&A that followed, Norman Lamb stressed the importance of building an evidence-based platform which integrated commissioning and joined up services as key building blocks to ensure effective delivery.
Additional points from the Q&A included:
How to ensure that the Full Business case for L&D is successful. The Minister stressed there is always a risk of mental health losing out when budgets are squeezed but the momentum of the programme plus the demonstrable effect on people’s lives are its best hope of ensuring continuation.
The lack of resources – including beds – following assessment. Norman Lamb said teams should look to use the Mental Health Crisis Care Concordat as a starting point to argue for more local resources and that issues arising from the Francis inquiry should apply to mental health services as much as physical health.
Additionally, the Minister noted the concerns raised about the lack of funding for appropriate adults and that this may need joint funding and better use of resources locally to ensure that they are available.
Kate Davies and David Burton then set out the roll-out and implementation of the L&D programme. Kate emphasised that the £25m announced for L&D services reflected the ambition to build upon what had already been achieved. As such, this was a national programme that went beyond just the 10 Trial Schemes. She took delegates through the current commissioning landscape and how integrated commissioning has improved since NHS England came into being in 2013. The key goal is to achieve a sustainable reduction of health inequalities as well as wraparound care and support for vulnerable people.
David Burton provided the context for the L&D programme and the relationships with a range of stakeholders. The 10 Trial Schemes currently provide a service to 22% of the population and the vision is that by 2017, 100% of the population would be covered by the new standard service specification, if the full business case is approved by HM Treasury. It is important to trial the service specification as a new way of working that will test how the model operates in practice. It will then be possible to review and amend it if necessary and to develop innovative practice.
Dave Spurgeon, OHC, took delegates through the new standard specification highlighting its key elements, including:
an all-age response;
a 24/7 services with core hours and out of hours arrangements;
availability at all points of intervention in the youth and criminal justice pathway;
addressing a wide range of health issues and vulnerabilities;
intervention at the earliest point along the justice pathway – i.e. as soon as someone comes into contact with the police under suspicion of having committed an offence.
The service specification is predicated on a core team responsible for L&D supported by an extended team that helps access services. The presentations were supplemented by video contributions from Lord Bradley on progress since his 2009 report and service users, Jeff and Pat, on how L&D has helped them. The videos showed how effective L&D services could impact positively on a service user’s life:
Lord Bradley speech: Making effective Liaison and Diversion services a reality
Jeff and Pat: This video features powerful stories from two service users on how L&D services have impacted on their lives.
During late morning and afternoon, delegates attended two of four workshops focused on elements of the operating model:
developing an all-age response;
service user engagement;
integration with substance misuse services; and
learning disabilities – effective engagement with justice processes.
The purpose of holding the four workshops was to explore with delegates those elements that are most likely to be the most difficult to implement.
Developing an all-age response
Delegates discussed how at the moment the range of agencies involved and the services available to children and young people differs significantly to that of adults, hence the need for an all age response. Providing an all-age response would ensure that the transition for a service user from the youth to the adult services is smooth one. It is important to ensure that whoever comes into contact with the justice system at any point gets a service, whether that would be a young or adult user.
Discussion centred on the differences between children, young people and adults in terms of presentation, legislation, the different pathways available, the risk factors and the possible responses. They also looked at what at an all-age response would look like.
Service user engagement
We were grateful to have with us a service user involved in this workshop, who gave his perspective of what service users experience from an L&D service. The workshop initially discussed the importance of involving service users into the development and feedback of the services operation. Service users can inform improvement on delivery and development of a service and using their experience they can take an active part in reviewing and assisting in any future changes. The workshop focused on the following challenges and how to overcome them:
How timing is essential i.e. if service user engagement was undertaken too quickly there was a concern that users could still be in crisis and requesting feedback would place strain and unnecessary burden on them while they are focusing on their treatment
How you could request feedback information safely, quickly and effectively. For example using ‘scratch card feedback form’ with pre-paid postage
How to engage users in the feedback process and rectify the low response rates to surveys.
The need to make it count; a number of delegates suggested there was a risk of tokenism where clients undertake services because they are asked to and not getting meaningful results.
Substance misuse
In terms of substance misuse, it is critical to ensure that governance of both health and justice commissioning is aligned. Delegates felt there was a need for a holistic delivery in complex cases involving the join up of specialist services and integrated pathways.
Workshop delegates discussed some key areas that each service needs to think about. Some of the non-trial Schemes are integrating police healthcare and street triage in their areas, the key issue being that national L&D should not fall behind what is happening locally. Locally, it is therefore critical that governance of both health and justice commissioning is aligned and there are areas where this happens and where it is clearly not happening. So the key questions from participants are how to impose a national programme within a wider localism agenda? Who can provide this leadership, local or national or preferably from the workshop participants view, both? How do you achieve holistic delivery in complex cases? How do the various specialist services join up and ensure there is an integrated pathway into the right services.
Learning disabilities
The learning disabilities workshop heard from an L&D scheme in the north-west (The 5 Boroughs Partnership NHS Trust) with a project specifically for meeting the needs of clients with known or suspected learning disabilities.
They explained how:
They had established close working relationships with local criminal justice agencies, local health services and learning disabilities services; training several hundred criminal justice staff on learning disability awareness and encouraging local learning disability services to work more with the offender population.
They take a holistic approach and are not using strict learning disability eligibility criteria for accessing their service. This means they can also offer some support to borderline cases.
They have developed a care pathway to their service and various options for supporting a client with learning disabilities. In addition, various resources such as Easy Read materials have been produced to promote their services and these have been placed in police stations and courts.
The day concluded with a panel session featuring Kate Davies, David Burton, Andy Hunt, Pauline Fisher and Sinead Dervin, chaired by Graham Beech, which discussed various issues, including:
Overcoming problems with information not being shared is to obtain strategic buy in from all agencies via local governance structures and develop effective protocols.
Developing local infrastructure involves taking an evidence-based approach learnt through implementing the service specification; being aware of quality standards that reflect parity of esteem between mental and physical health, and; developing clinical governance around temporary detention.
Linking up with the transforming rehabilitation agenda involves looking at who is doing what and establishing contact with them with a view to sharing information and developing common aims
To best meet the needs of victims teams must show L&D works by reducing the risk of reoffending thus reducing the chances of becoming further victimized;
Reducing demand on already overstretched services requires dealing more effectively and appropriately with individuals and wrap-around services can improve engagement and thus reduce re-offending. L&D is in a good place to provide information to both CCGs and health and wellbeing boards.
Panel members summed up the conference with five key points.
Andy Hunt stressed integrating L&D with street triage and police custody health care is vital and to provide wider join-up throughout the health and justice agenda
Pauline Fisher spoke of the value of bringing people together to both problem solve and reduce barriers, not just from the trial schemes but from other schemes as well;
David Burton highlighted the importance of relationships and the flow of information, plus how it is vital to learn from one another;
Sinead Dervin emphasized the need to achieve parity of esteem between mental and physical health and integrated commissioning;
Kate Davies spoke of a noticeable change in momentum and how there is a real opportunity to demonstrate positive health and justice outcomes. She encouraged delegates to ‘go for it’ by embracing our wide range of innovation and local flexibility.
Delegate feedback
Feedback from conference delegates was generally very positive with 63 per cent saying it was excellent and 36 per cent giving it a ‘good’ rating. Please see below:
Comments from delegates included the following:
“Thank you for a well-organised and informative event”.
“First conference I’ve been to for a long time where I’ve actually learnt a fair bit. I just hope that after going to conferences about L&D for 20 years that changes will now happen.”
“Need a similar event part-way through the year to share the L&D journey so far and encourage dissemination of best practice.”
“Useful conference in relation to gathering information, understanding of progress in other Schemes and networking. Particularly enjoyed Norman Lamb’s presentation regarding political commitment and support.”
2nd Thematic Day – 5 March 2014
The second of four thematic days for the 10 Trial Schemes took place at Nacro’s Head Office in London. During each of these days, participants identify and address key themes relevant to the implementation of the service specification. This day focused on:
the inter-related process of case identification, secondary screening/triage, assessment; and
Supporting people with learning disabilities in the Justice System.
Case identification, screening/triage, assessment
Identifying and assessing individuals with mental health problems and/or other vulnerabilities within the justice system consists of three distinct areas of operation, as illustrated in the pyramid below: case identification, screening, and assessment.
Case identification aims to identify an individual with a mental health issue or vulnerability. This is the first step in the L&D pathway
Screening is carried out by an L&D practitioner using standardised tools.
A more detailed assessment is then undertaken
Participants discussed each of these areas in detail. It was agreed that, where an assessment was completed, it should be an assessment of both their mental health, learning disability and social needs as opposed to just one or the other and include a person’s:
mental health state – including learning disability, personality disorder, conduct disorder and ADHD);
cognitive functioning and developmental maturity;
Key vulnerabilities such as communication needs, family and social circumstances, drug and alcohol needs, cultural, religious spiritual and/or gender needs.
Participants were then taken through what desirable outcomes would look like, which includes:
Having a clear and agreed process at each stage underpinned by protocols and SLAs. Each stage represents the point of intervention in the justice pathway, e.g. at police custody, court, pre-police custody;
being able to evidence and evaluate the various stages;
using validated assessment and screening tools;
having a clear and agreed referral pathways at each stage ( a pathway into services at each point of intervention);
having an agreed process to obtain specialist assessments; and,
feeding back on the outcome of the screening/assessment to criminal justice partners who either identified the individual in the first place or made the referral.
From this session, participants developed their understanding of the different processes as well as tips on how things should be implemented and what an ideal outcome would look like for them. There is no universal, ‘one size fits all’ solution.
Supporting people with learning disabilities in the Justice System
This session was presented by Neisha Betts, (Criminal Justice Project Manager, KeyRing Living Support Networks and organiser for the National Learning Disabled Offender steering group), and Wayne from the service user group, ‘Working for Justice’.
Wayne provided an account of his experience of the criminal justice system. This was supported by exerts from a DVD of service user voices highlighting the difficulties many service users with a learning disability face in navigating their way through the justice system. Neisha outlined recommendations from Positive Practice Positive Outcomes, a best practice handbook for criminal justice professionals working with offenders with learning disabilities and learning difficulties, published by Department of Health, 2011) and identified some of the resources available to assist L&D practitioners to identify and support people with learning disabilities in contact with the criminal justice system. This included screening tools such as the LDSQ (Learning Disability Screening Questionnaire), training, pathways into services, and information sharing. She also highlighted necessary safeguards such as Appropriate Adults, registered intermediaries and special measures, to help protect the interests of the individual and ensure a fair and just process. Easy Read materials have been developed to assist people with learning disabilities to understand the justice process.
The outcomes from this session concentrated on the need to properly identify and assess individuals, what services and pathways are available, so they can develop their own responses.
3rd Thematic Day – 25 March 2014
The third of four thematic days for the 10 trial schemes took place at Challenge House in Birmingham. This third day looked at:
The new data set (based upon evidence from the Offender Health Research Network among others, see below) and the collection of data; and
Data flow along the justice pathway and between justice and healthcare.
Karen Ambrose, Analyst, at the Department of Health (DH), highlighted how data collection was important for:
informing the evaluation and business case for full roll-out
monitoring performance of schemes
identifying gaps in service provision
informing future investment/commissioning decisions
The new minimum data set is based on the previous ‘Pathfinder data set’ developed by the Offender Health Research Network (OHRN) and collected by 20 adult and 15 youth justice schemes in the year to July 2013. The new set incorporates input from L&D schemes, NHS England area teams, analysts and policy colleagues at DH, Ministry of Justice (MoJ), Home Office (HO), and Her Majesty’s Courts and Tribunal Service (HMCTS).
Returns will be submitted at the end of each month and a report will be produced for schemes and area teams. Cases will remain ‘live’ until a final criminal justice outcome is achieved and recorded and the data record completed and closed.
Mat Jordan, Programme Manager, National Systems and Applications Transition, Health and Social Care Information Centre (HSCIC) whose profile featured in the bulletin last month, facilitated participant discussion of the information strategy. Mat took the participants through his initial thoughts, testing the assumptions gleaned through his own analysis.
Mat outlined four types of information needing to be managed:
Information for the operation of L&D services
Management/performance information for L&D services
Outcomes information from treatment/intervention services
Outcomes information from the justice system
Using flow diagrams, he tested the assertions he had made and identified key challenges. It was a consultation exercise undertaken by Mat Jordan and participants’ feedback will help inform his final report and any recommendations the HSCIC makes to the programme team.
Liaison and Diversion web pages
We are excited to share with you the new L&D web pages which are hosted on the NHS England website: www.england.nhs.uk/ourwork/commissioning/health-just/liaison-and-diversion/.
Here you can find information on what L&D is, how the programme works, more information on the standard service specification, where you can submit case studies and watch videos from L&D service users.
Liaison and Diversion voice
Each month we look to feature an example of good L&D practice from around the country. This month we are very grateful to the L&D team in London who have kindly provided us with the case study (below). The programme team is very keen to hear from services that are creating case studies to illustrate how their practice delivers in accordance with the Standard Service Specification.
Mrs S is a 43 year old woman with a history of Borderline Personality disorder and depression. Mrs S was homeless and sleeping on the streets at the time of contact with the Liaison and Diversion service at court. She was socially isolated, without a support network of friends or family in place, and had been involved in street prostitution. She had been the victim of a sexual assault that the police were investigating at the time she was arrested. Her alcohol use and lack of an appropriate and stable accommodation increased her vulnerability and made her susceptible to exploitation by others.
She presented as very anxious and was withdrawing from alcohol. Mrs S had previously experienced auditory hallucinations and had been prescribed olanzapine in the past. At the time of her arrest she was not on any medication and had disengaged from mental health services. Mr S has a history of self-harm but there has been no evidence of suicidal intentions – although she confessed that some time ago she had tried to throw herself in front of a car while under the influence of alcohol. Mrs S also has a history of cocaine use but denied any use at time of contact.
Mrs S was arrested for a public order offence, following heavy alcohol use. She first came into contact with the criminal justice system in 2007 and has a history of offences, including theft, common assault and criminal damage. The Women’s Forensic Mental Health practitioner met Mrs S in the court custody suite and provided a report to the court to highlight her distinct needs and to make recommendations on the assistance required.
As Mrs S was already known to a number of services, it was important for all the agencies to work together to assist with housing:
Police were investigating the rape case and were seeking stable accommodation for her;
Outreach and street rescue service were trying to assist her with housing;
the Drug Intervention Programme were also involved as Mrs S had a keyworker.
The L&D practitioner initiated communication between all these different agencies in order to effectively support Mrs S and found suitable accommodation in a hostel in the neighbouring borough. Mrs S was also referred to the local women-only one stop-shop which provided further support through providing outreach to engage her with services.
Matina Marougka, a Women’s Forensic Mental Health worker in the L&D scheme who is project managing the implementation of the service specification for the London trial Scheme, added:
“As a result of my intervention, the magistrates had all the relevant information they needed to make an informed decision on the day. Mrs S received a conditional discharge for the offence before the court and was moved to safe accommodation. With a stable address she was now able to engage with the drug and alcohol service and then with her GP, who was monitoring her mental health.”
Call for contributions to the bulletin
As always, we are keen to include contributions from schemes implementing the new service specification. If you would like to send us a service user case study, please complete the form on our website and email it to england.liaisonanddiversion@nhs.net.
The programme is also particularly keen to hear about examples of good L&D practice in order that we may share these among stakeholders and build up a bank of useful knowledge. Please can examples of successful policies and procedures be sent to Dave Spurgeon at dave.spurgeon@nacro.org.uk.
Correction
February’s bulletin contained a write up of the first thematic day for Trial Schemes which looked at developing an all-age response. The article referenced three resources that were circulated to participants and made available afterwards via the bulletin. We wish to apologise for and correct any confusion there may have been and point out that the Comprehensive Health Assessment Tool (CHAT) was developed by the Offender Health Research Network (OHRN).
Next month’s bulletin…
We will provide readers with an overview of the NHS England commissioning process now that the programme resides with NHS England. There will also be an outline of the fourth thematic day and information on the second cohort of trial schemes. The thematic day will take place on 14 May and will be an opportunity for schemes to reflect on their experiences of implementing the service specification.
We are hoping to be able to include a case study written from a commissioner’s perspective and a recent update of our twitter feed, including some of the tweets!
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