Offenders With Complex Needs - Analysis Report

Version number: 0.
3
Date: 21st July 2014
Author: M. Scott & S. Senker
Status: Draft
Rebalancing Rehabilitation
Making the case for change to ensure a level playing-field for Offenders
with Complex Needs across Essex
CONTENTS
Executive Summary
1. Literature Review
2. Local Data Analysis
3. Qualitative Interviews
4. Recommendations
5. Next Steps
Annex: Data workbook
TONIC: Discussion Paper
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
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 offending
These individual vulnerabilities include substance misuse (drugs & alcohol), mental
health problems, learning difficulties and disability
These are often co-occuring leading to further complexity
The 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 outcomes
There are optimum moments in CJS to ask questions about complexity which are
being missed
The lack of clear pathways, experienced staff and dedicated services means that
many OCN remain unsupported leading to a cycle of re-offending
Summary of Recommendations
Quick Wins
1. Clear pathways (inc. agreed
Medium
4. Engender a climate that promotes
Longer-Term
8. System-level change including
terminology and criteria), a Concordat,

an Idiots guide & service directory for
OCN
shared responsibility - looking at the

offender holistically not modularly
5. Uniform, yet flexible and responsive
(but not only) the introduction of

an integrated service throughout
CJS and unified across MH, LD, SM
training for statutory & non-statutory
agencies:
& co-location of key individuals,
service providers so practitioners
Flexible (out of hours)
services to help break down barriers &

unlock existing expertise to offer case
across CJS feel skilled, confident and

competent at identification of need
Tiered by level of need

Recovery focused (integrated
consultation
and ensuing adaptation & referral
2. Networking events, Joint training
with society, leading sustainable
3. Clear information sharing protocols 6. Tools chosen to aid identification

to reflect fast movement through
should be validated, comprehensive
custody chain: portable risk and

need file that mimics or extends the
& used at earliest opportunity

throughout CJS
personal escort record form (PERF)
7. 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
lives through employment & housing
Skilled link workers filling gaps (e.g.

through the gate)
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
10
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
11
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 reoffending 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 reoffending:
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
12
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
13
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
14
Chapter 2
Local Data Analysis
15
LOCAL PREVALENCE ESTIMATES

Offenders with
Complex Needs
Drugs
Alcohol
Substance Misuse
POLICE
CUSTODY
PRISON
PROBATION
12%
10%
24%
5%
42%
29%
COMMUNITY
19%
Drug treatment
clients are CJS
4%
Alcohol
treatment
clients are CJS
13%
12 - 17%
42 - 71%
39 58%
25%
10 - 11%
9 12%
awaiting
8%
(proxy)
2 30%
16 - 23%
2.4%+
7%
8%
6%
15%
Learning Disability &

Mental Health
awaiting
4%
3 4%
n/a
Substance Misuse &

Learning Disability
awaiting
23%
11 15%
awaiting
3%
2 3%
Essex Police data

based on
Basildon, Grays &
Southend
Essex Probation
data on those with
prison sentences
(SM)
Mental Health
(MH)
Learning Disability
(LD)
Dual Diagnosis:
Mental Health &
Substance Misuse
TOXIC TRIO:
Substance Misuse,
Mental Health &
Learning Disability
Data Source
TONIC Consultants Ltd
HMP Chelmsford
Needs Assessment
Essex Probation
data
Treatment
clients are CJS
n/a
n/a
NDTMS data
LOCAL DEMAND ESTIMATES

Offenders with
Complex Needs
POLICE
CUSTODY
Drugs
4,800
Alcohol
2,000
PRISON
PROBATION
COMMUNITY
1,339
554 in DIP
1,628
111
587
220 Inside
Out
97 IDTS
59
57 Treatment
814
1,534
Substance Misuse
4,800
(SM)
10,000
Mental Health
85 Appropriate
Adult call outs
(March 2014)
247
59
2,207
Estimate of
those with SM
treatment
need in CJS
155 on CPA
8 Transferred to
MH hospital
492
644
13 Appropriate
Adult call outs
(March 2014)
176
887
37
2,800
47
334
1,092

Mental Health
awaiting
23
163
n/a
Substance Misuse &

Learning Disability
awaiting
135
620
n/a
awaiting
18
124
n/a
(MH)
3,200
Learning Disability
(LD)
Dual Diagnosis:
Mental Health &
Substance Misuse
TOXIC TRIO:
Substance Misuse,
Mental Health &
Learning Disability
Data Source
Key: Actual Estimate
Essex Police data

Essex Probation
Essex Probation
based on Basildon, data & HMP
data
Grays & Southend Chelmsford Needs
Assessment
Population: 40,000 Population: 587
Population: 5,593
NOTE: This only

shows drug and
alcohol treatment
data
Population: 6,864
Are these numbers are potentially manageable

through a specialist case management approach?
PREVALANCE ESTIMATES
From literature review
Offenders with
Complex Needs
POLICE
CUSTODY
PROBATION
COMMUNITY
27%
25 40%
64%
Drugs
Alcohol
PRISON
(MoJ, 2013)
66%
(Sloshed &
Sentenced)
Substance Misuse
32 73%
(MoJ, 2013
Scottish Prisoners
Needs
Assessment)
32%
(Singleton,
2003)
(SM)
23% Male, severe

(Senior, 2013)
Mental Health
33% Male,
depression
(MH)
49% Female (MoJ,
(Brooker, 2012)
2013)
Learning Disability
(LD)
Dual Diagnosis:
Mental Health &
Substance Misuse
Mental Health
Substance Misuse &
Learning Disability
TOXIC TRIO:
Substance Misuse,
Mental Health &
Learning Disability
20-30%
(Louckes, 2007)
7%
25% Borderline LD
40%
women (No
one Knows, 2007)
75%
(Prison Reform
Trust, 2011)
60%
reading age
of 5 or
under
2%
(DH, 1998)
74 85% of SM
clients have MH
44% of MH
clients have SM
36%
60%
of LD service
users have SM
SERVICE AVAILABILITY
Balanced Scorecard
Offenders with
Complex Needs
POLICE
CUSTODY
PRISON
PROBATION
COMMUNITY
Inside Out
Atrium
DIP
Treatment
System
DIP
Treatment
System
Emerging
growth in
alcohol
treatment
DIP
Treatment
System
Drugs
Arrest
Referral,
DIP, FME
Alcohol
FME &
Treatment
system
Atrium
Low referral
rates into
treatment
FME, DIP &

Treatment
system
IDTS
Inside Out
Atrium
DIP
Substance Misuse
(SM)
Barriers to 3rd
sector support
Appropriate
Adult service,
FME, Liaison
& Diversion
pilot, CJMHT
Prison
Inreach
Atrium
Appropriate
Adult service,
Liaison &
Diversion pilot
Nowhere
to refer to
Nowhere
to refer to
Siloed
approach
Good
prison DD
provision
Siloed
approach
Gaps & Too

many links in
the chain

Mental Health
No
identification
No
identification
1 lead in
CJMHT,
but not
specialist
Data gaps
Service gaps
Substance Misuse &

Learning Disability
No
identification
No
identification
High
prevalence
in frequent
offenders
No
dedicated
services
No
identification
Highest
prevalence
in frequent
& severe
offenders
No
dedicated
services
Mental Health
(MH)
Learning Disability
(LD)
TOXIC TRIO:
Substance Misuse,
Mental Health &
Learning Disability
Out of hours gap
No
identification
CJMHT, but no
NHS Trust
engagement
Training &
service gaps
Choice &
Control
Thurrock
NO#SPECIFIC#RESPONSE#FOR#COMPLEX#OFFENDERS#
Dual Diagnosis:
Mental Health &
Substance Misuse
[to add ?]
Section 2.1
PROBATION DATA
16
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
Age & Individual Vulnerability of Essex Probation Clients
(n= 5,072)
45%#
40%#
35%#
30%#
Alcohol#
25%#
Drugs#
SM#
20%#
MH#
LD#
15%#
10%#
5%#
0%#
17*25#
26*34#
35*44#
45*54#
55+#
17
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
Age & Complexity of Essex Probation Clients (n= 5,072)
14%#
12%#
Axis Title
10%#
DD##
8%#
LD#&#MH#
SM#&#LD#
6%#
TRIO#(all#3)#
4%#
2%#
0%#
17*25#
26*34#
35*44#
45*54#
55+#
18
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
Gender & Individual Vulnerability of Essex Probation Clients
(Male = 4,986; Female = 607)
40%#
35%#
30%#
25%#
Male#
20%#
Female#
15%#
10%#
5%#
0%#
Alcohol#
Drugs#
SM#
MH#
LD#
19
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
Gender & Complexity of Essex Probation Clients
(Male = 4,986; Female = 607)
12%#
10%#
8%#
Male#
6%#
Female#
4%#
2%#
0%#
DD##
LD#&#MH#
SM#&#LD#
TRIO#(all#3)#
20
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
Re-offending frequency & Individual Vulnerability of Essex Probation
Clients (n= 5,584)
70%#
60%#
50%#
Prevalence
Alcohol#
40%#
Drugs#
SM#
30%#
MH#
LD#
20%#
10%#
0%#
1#only#
2#to#10#
11#to#20#
21+#
21
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
Re-offending frequency & Complexity of Essex Probation Clients
(n= 5,584)
30%#
25%#
Prevalence
20%#
DD##
LD#&#MH#
15%#
SM#&#LD#
TRIO#(all#3)#
10%#
5%#
0%#
1#only#
2#to#10#
11#to#20#
21+#
22
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
Probation Clients - "Events" by vulnerabilities
70%#
60%#
50%#
40%#
Oenders#with#no#vulnerabiliPes#
Oenders#with#only#1#vulnerability#
30%#
Oenders#with#2+#vulnerabiliPes#
20%#
10%#
0%#
ALL#
1#oence#
2*5#oences#
6+#oences#
23
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
Probation clients by Community or Prison sentence (n=3,636)
70%#
60%#
50%#
40%#
ProbaPon#
Prison#
30%#
20%#
10%#
0%#
SM#
MH#
LD#
LD#&#MH#
LD#&#SM#
DD#
Trio#
24
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
25
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+
Vulnerability,Factors,for,under,50s,&,those,aged,50+,
<50#
50+#
60%#
43%#
34%#
22%#
23%#
20%#
15%#
17%#
21%#
16%#
8%#
9%#
12%#
4%#
ProbaPon#Events#2+#
Prison#sentence#
Drugs#
Alcohol#
LD#
MH#
Perpetrator#of#DV#
26
Section 2.2
SUBSTANCE MISUSE
TREATMENT DATA
27
Commentary: There is some variation across the area amongst

recorded levels of offenders engaged in drug or alcohol treatment
Prevalence of Offenders amongst treatment population
25%#
20%#
15%#
10%#
5%#
0%#
Essex#
Southend#
Thurrock#
ALL#
28
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)
Prevalence of Dual Diagnosis amongst treatment population
(MH & SM)
20%#
18%#
16%#
14%#
12%#
10%#
8%#
6%#
4%#
2%#
0%#
Essex#
Southend#
Thurrock#
ALL#
29
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
Treatment outcomes for All CJS clients v DIP clients
50%#
45%#
40%#
35%#
30%#
ComplePons#(CJS)#
25%#
ComplePons#(DIP)#
20%#
15%#
10%#
5%#
0%#
Essex#
Thurrock#
Southend#
TOTAL#
30
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

31
Section 2.3
POLICE CUSTODY DATA
32
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
Prevalence of vulnerabilities amongst those in Police custody

(n= 4,088 from Basildon, Grays & Southend)
40%#
35%#
30%#
25%#
Female#
20%#
Male#
TOTAL#
15%#
10%#
5%#
0%#
Alcohol#
Other#drugs#
Drugs#
Mental#Health#
Need#help#with# Self#harm#(indicaPons)#Self#harm#(self#report)#
reading#&#wriPng#
33
Section 2.4
CJMHT DATA
34
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
CJMHT referrals (estimate of 963 in 12 months)
Probation
5%
Police#
39%#
Court#
56%#
35
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
% take up of CJMHT assessment (based on 562 referrals over 7 months)
100%#
90%#
80%#
70%#
60%#
50%#
40%#
30%#
20%#
10%#
0%#
Court#
Police#
ProbaPon#
36
Section 2.5
HMP CHELMSFORD
PRISON DATA
37
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
38
71% have
personality
disorder
8% have
functional
psychoses
22% have
anxiety/
depression
49% have a
neurotic
disorder
39
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
40
HMP Chelmsford staff do

not feel trained in LD, SM
or MH issues
41
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
42
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.
43
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%)
44
Section 2.6
HMP HOLLOWAY
45
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
46
Section 2.7
LEARNING DISABILITY
SERVICES
47
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
Estimated cases of adults with learning disabilities
4,000#
3,500#
3,000#
2,500#
2,000#
1,500#
1,000#
500#
0#
48
Moderate & Severe LD peaks in the 35-54 age ranges with 42% of all
cases being found in this age range
LD population estimates (Essex)
7,000#
6,000#
5,000#
Low#
4,000#
Moderate#
Severe#
3,000#
Total#
2,000#
1,000#
0#
18*24#
25*34#
35*44#
45*54#
55*64#
65+#
49
1,524 (5%) of the LD population in Essex is estimated to have severe

learning disability
Severe
5%
LD estimates by severity (Essex)
Moderate#
32%#
Low#
63%#
50
Chapter 3
Qualitative Interviews
51
Total: 20 interviews
Overview
1#general#oender#manager#
1#Housing#Ocer#
1#EducaPon,#training#and#
employment#ocer#
2#Custody#Sergeants#
Forensic#Medical#Examiner#
Safer#Custody#&#Violence#
ReducPon#Manager##HM#P#
Chelmsford#
Deputy#Custody#Commander,
##Essex#Police#
CRC#
Custody:#
Police#&#
Prison#
MH#
SM#
Informal Interviews:
AMP Practice Lead
Nurse Consultant
Director of Secure
Services
G4S Regional Manager
1#Appropriate#Adult#
2#CJMHT#(pracPPoner#and#
service#manager)#
1#Criminal#jusPce#lead;#third#
sector#organisaPon#
######1#DRR#pracPPoner#
1#service#manager;#3rd##sector#
organisaPon#
2#Access#&#Engagement#sta;##
3rd#sector#organisaPon#
52
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
53
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!
54
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 deskilled workforce there will also need to be links with
National Probation Service
55
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 cannot 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
56
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/pacecode-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
57
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.
58
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
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
60
Chapter 4
Recommendations
61
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)
62
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
63
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 reoffending
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)
64
Chapter 5
Next Steps
65
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.
2.
3.
4.
5.
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
Present the key findings to the Reducing Reoffending Board overseeing this piece of work
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
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
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
66
High
Joint work
ing with
other age
ncies
Train othe
rs
Programm
e design
Consultati
on & Advic
Medium
Full case
managem
ent
Therapeu
tic
Interventi
on
e service
Identifica
tion
Signpost
& Refer
Adapt CJS
Programm
es
Info shari
ng
Tailor CJS
response
Staff Train
ing
Low
Tiered Response
Delivery Options
MH
LD
Team Lead
MH
SM
Trainer
Admin
New Co-located
specialist team or
One Stop Shop
LD
Prison
DIP
SM
CRC
Police
New Virtual Team
DD
L&D
FME
Prison
CJMHT
Pool existing teams

& functions
Annexes
Annex A: Literature Review
Annex B: Data Workbook
67

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Glossary of Key Terms & Abbreviations

TONIC: Discussion Paper

We have to acknowledge the prevalence and impact of individuals with overlapping

terminology and criteria), a Concordat,

shared responsibility - looking at the

(but not only) the introduction of

training for statutory & non-statutory

& co-location of key individuals,

service providers so practitioners

Flexible (out of hours)

services to help break down barriers &

across CJS feel skilled, confident and

Tiered by level of need

and ensuing adaptation & referral

2. Networking events, Joint training

with society, leading sustainable

3. Clear information sharing protocols 6. Tools chosen to aid identification

should be validated, comprehensive

custody chain: portable risk and

& used at earliest opportunity

personal escort record form (PERF)

7. A focus on need not just risk, e.g.

Consult & involve service users

lives through employment & housing

Skilled link workers filling gaps (e.g.

Learning Disabilities (LD)

There are some significant gaps in local provision, especially for LD

TONIC: Discussion Paper

Gaps In Capacity & Capability

What Works: Adapting Rehabilitation

R & R programme findings suggest that cognitive-behavioural,

LOCAL PREVALENCE ESTIMATES

Learning Disability &

Substance Misuse &

Essex Police data

TONIC Consultants Ltd

LOCAL DEMAND ESTIMATES

Learning Disability &

Substance Misuse &

Essex Police data

NOTE: This only

Are these numbers are potentially manageable

23% Male, severe

49% Female (MoJ,

TONIC Consultants Ltd

FME, DIP &

Gaps & Too

Learning Disability &

Substance Misuse &

TONIC Consultants Ltd

Out of hours gap

TONIC: Discussion Paper

Commentary: The general trend is for individual vulnerabilities to occur with

TONIC: Discussion Paper

Commentary: The general trend is for complexity (multiple vulnerabilities) to

TONIC: Discussion Paper

Commentary: In nearly all individual vulnerabilities, they are found in slightly

TONIC: Discussion Paper

Commentary: The reverse is true when considering complexity (where

TONIC: Discussion Paper

Commentary: In general, the prevalence of individual vulnerabilities rises with

TONIC: Discussion Paper