Custody Health Care Screening Pilot Evaluation Final Report

Transcription

1 Custdy Health Care Screening Pilt Evaluatin Final Reprt 2014 Institute f Health & Wellbeing The University f Nrthamptn Bughtn Green Rad Nrthamptn NN2 7AL (01604) i

2 Institute f Health and Wellbeing The Institute f Health and Wellbeing (frmerly the Centre fr Health and Wellbeing Research) is an inter-disciplinary and inter prfessinal centre f excellence in Health and Wellbeing wrking with health and scial care prviders, cmmissiners and ther partners t supprt research, enterprise and innvatin relevant t the health and wellbeing f the ppulatin. The Institute is fully resurced t undertake evidence review and primary data cllectin using bth quantitative and qualitative evaluatin methds (e.g. large questinnaire surveys, scial surveys, ne-t-ne interviews, SPSS analysis, fcus grups, in-depth discussin grups, semi-structured and pen interviews, and tape transcriptins). All members f prject teams have extensive experience f research and evaluatin prjects. During members f this prject team have successfully cntributed t the fllwing research and evaluatin prjects: Persnal Health Budgets fr Carers in Nrthamptnshire: An Evaluatin (prject cmmissined by NHS Nrthamptnshire). An evaluatin f the Pilt Healthchecks scheme in Nrthamptnshire (prject cmmissined by NHS Nrthamptnshire). An evaluatin f the General Practitiner Referral Tl, Pathfinder (prject cmmissined by Nene Cmmissining). An evaluatin f the Zned Asthma Actin Plan card (prject cmmissined by Nene Cmmissining). A Cmmunity Cardivascular Unit Cnsultatin (prject cmmissined by Bedfrdshire Clinical Cmmissining Grup). Supprting Successful Transitins: Hw d patients in medium secure units react t envirnmental change? (prject cmmissined by St. Andrews Healthcare). This evaluatin was cmpleted by Dr. Jackie Parkes, Alisn Ward and Jane Yuell frm the Institute f Health and Wellbeing. 2

3 Executive summary Intrductin & Aims The Institute f Health and Wellbeing was cmmissined by the Offender Health Cmmissining Grup t undertake an evaluatin f the Custdy Health Care Screening Pilt service which is managed by the Criminal Justice Team. The pilt was set up t intrduce an electrnic screening prgramme fr everyne wh is brught int the Custdy Unit in Nrthamptn, with the aim f identifying whether an individual has r has previusly been identified as having a mental health issue, and prviding additinal supprt, referral services and infrmatin fr thse wh are highlighted t the team. This pilt started n 1 st July 2013 and initially ran fr fur mnths, with the initial phase finishing n 31 st Octber The pilt has received additinal funding t supprt an extensin t this initial timeframe; hwever, these evaluatin findings cver the initial pilt timeframe. The pilt perated frm Mnday t Friday, frm 9-5pm initially but was eventually extended frm 10am t 10pm. A team f five nurses with a mental health backgrund wrked n the pilt scheme, which was run alngside the existing frensic custdy assessment led by frensic physicians. The aim f this pilt was t intrduce a triage t identify and prvide supprt and referral services fr peple, specifically juveniles, with a mental health cnditin entering the custdy units in Nrthamptn. The Offender Health Cmmissining Grup wished t develp an evidence base t supprt the business case t cmmissin a lng term service aimed at reducing ffending thrugh interventin. The aims f the evaluatin were therefre t: 1. Identify the effectiveness f the custdy health care pilt; 2. Understand the links with the pilt and the existing frensic physician service prvisin; 3. Identify the key strengths f the pilt scheme and the frensic physician service prvisin; 4. Understand the impact n ffending rates fr thse identified thrugh the pilt; 5. Understand the health utcmes fr thse identified thrugh the pilt. Several utcme measures were als identified by the cmmissiners, which were t identify: 3

4 Type f ffences cmmitted; Numbers representing t custdy; Numbers representing t A&E; Referrals f liaisn and diversin/cri/dual Diagnsis; Numbers diverted frm Criminal Justice System; Numbers engaging with ther services; Numbers with learning difficulties/mental health/persnality Disrder/Autism; Numbers with a medical need; Numbers registered with a GP; Demand and nature fr safe guarding/scial care links; Identificatin f pathways and any issues that need t be reslved; Age grups presenting; Apprpriate identificatin and attentin t the needs f thse frm prtected grups; Numbers refusing assessment/an interventin; Numbers refusing GP r ther service (including schl exclusins). Methds A multi-methd qualitative, apprach was emplyed t ascertain a mre in-depth understanding f the nature f pilt s service prvisin. Face t face interviews were undertaken with pilt staff (n=3) and stakehlders (n=6) and telephne interviews were cnducted with service prviders wrking with pilt (n=6). In additin, tw bservatin sessins were undertaken f the pilt prcesses and prcedures in the custdy unit and an nline survey was distributed t frensic physicians (n=7). Discussin guides were designed, in cnsultatin with cmmissiner, (see Appendix 1 t 6), t btain qualitative infrmatin t explre the views n the pilt s delivery, engagement with ther services, ptential imprvements which culd be 4

5 made, any ptential benefits received frm the running f the pilt and any prblems which may have been experienced. Interviews were run at a time and place t suite the participants. In additin, analysis was carried ut n annymus rutinely cllected data which was gathered during the curse f the pilt. This data was cllated by the Criminal Justice team and prvided quantitative data n referral pathways, numbers accessing the service, and health details abut detainees. The evaluatin team als tried t ascertain the views f thse detainees wh had used the service, hwever, n respnses were btained during this evaluatin. Key findings The pilt was set up t prvide a cllabrative apprach t the transfer f healthcare cmmissining fr custdy. The key aims f the pilt were t intrduce a nursing service int the custdy unit in Nrthamptn t screen all individuals entering custdy fr mental health and physical health needs. Unlike ther trials in the cuntry, the Nrthamptnshire pilt emplyed mental health nurses, wh had additinal skills in addressing sme physical health needs. Overall, thse wh tk part in the evaluatin had a gd understanding f the aims f the pilt, which were seen as being in fur key areas: 1. Prviding health data abut thse ging thrugh the custdy unit; 2. Identifying thse individuals with a physical health r mental health need and prviding signpsting and referrals t agencies wh culd prvide n-ging supprt; 3. Operatinal factrs wuld be identified t prvide a better understanding fr cmmissining f a lnger term service; 4. Prvisin f a triage f health supprt t deal with minr illnesses/ailments. In additin, there were expectatins that the lnger term utcmes f the service wuld be in reducing crime rates fr thse peple with a mental health cnditin. The pilt had riginally aimed t screen all individuals ging thrugh custdy, hwever, given the timescales t undertake a screening and the number f staff wrking n the pilt, this was nt pssible. A fcus n screening juveniles and thse with an identified mental health cnditin were therefre given pririty. In practice, this was nt always pssible as the practicalities f wrking in the custdy unit did nt always enable the pilt t screen these individuals, with waiting times fr apprpriate adults r 5

6 interpreters, detainees being interviewed r released and access t rms and equipment ften impacting n the way the pilt was guided. Health data was recrded fr 505 individuals, this represents 10.8% f all thse ging thrugh the custdy unit during the initial pilt phase. The pilt experienced difficulties in accessing the full IT systems t access data prir t and after undertaking a health screening. This has impacted, t a degree, n the final utcme f the pilt as staff reprted t have been unable t access health systems, the internet and EPEXS and as such this has resulted in sme missing data n individuals, which made it harder t identify pririty individuals fr screenings. It shuld als be nted, that the prblems encuntered are a natinal issue and therefre nt specific t Nrthamptnshire. One stakehlder recmmended that a tw mnth lead in time was required t set up the necessary systems and access cdes fr new members f staff, and that this shuld be a cnsideratin fr taking n new staff shuld the pilt be taken frward r fr a newly cmmissined service. Further t this, an inductin t the wrking envirnment and the prcesses f the custdy unit wuld als be helpful fr new staff t enhance their understanding f wrking in the custdy unit. This shuld als supprt custdy staff wh can be mre cnfident that thse wrking within that envirnment knw the crrect prcedures t fllw. The rle and remit f the pilt was nt always reprted t have been clearly defined. Prblems were thught t have arisen thrugh incrrect expectatins f what the staff wuld be prviding and hw their rles related t ther teams. This may have had an impact n expectatins fr the pilt, with staff expected t be undertaking rles beynd that f the remit f the pilt. It was reprted that a psitive wrking relatinship was develping between the custdy staff and the pilt staff, with an understanding f each ther s rle within the custdy unit being central t the develpment f this relatinship. Operatinally, a number f issues were discussed in regard t peratinal hurs and use f the equipment and space fr cnducting screenings. The peratinal hurs were thught t be wrking well, especially as these had been revised during the curse f the pilt. Hwever, ne respndent thught these shuld be in line with ther teams shift patterns and hand ver perids, while thers thught that a 24/7 service was needed. Hwever, given the peaks and flws f wrk within the custdy unit, it was als thught that service prvisin may nt be needed at all times. The mst effective times t have staff in the custdy unit were thught t be during the custdy s busiest times, hwever, it has been reprted that busy times within custdy vary and can be difficult t 6

7 determine, as ften a weekday mrning can be busier than a weekend evening, which was nt expected. Identificatin f wh t screen as a pririty was nt always clearly reprted. Althugh there was a fcus n juveniles and thse with an identified mental health need, it was fund that screenings n these individuals was nt always pssible. A number f reasns had a pssible impact n the way screenings tk place, primarily these were: Access t rms r equipment; Waiting fr r missing an apprpriate adult/interpreter; Nt wanting t impede custdy prcesses; Time in undertaking a screening, als impacted by staffing levels and administrative prcesses; Detainees declining a screening. A mre frmal apprach t identifying wh shuld be screened may help the effectiveness f the pilt in the future and prvide a ratinale fr screening detainees wh may nt have an identified mental health issue r be a juvenile. In additin, the screening prcess culd be supprted thrugh agreement f when screenings can take place in terms f the custdy prcess. Links between the pilt and the frensic physician service As part f the evaluatin, the team cnsidered the impact f the pilt n the rle f the frensic physicians. Firstly, it shuld be nted that very psitive feedback was reprted frm thse taking part in the evaluatin f the frensic physician service, particularly in relatin t their prfessinalism, cmmitment and knwledge (bth in terms f medical matters but als the lcal area/services). It was als reprted t be a service which shuld be maintained within Nrthamptnshire, with sme respndents calling it essential and key. Althugh it was reprted that waiting times culd smetimes be quite lng and the number f female physicians n staff was lw. Mst f thse respnding t the evaluatin, reprted that gd relatinships were develping between the frensic physicians and the pilt team and that staff were liaising n cases and supprting each ther in the care f detainees. This supprt was seen thrugh the ffering f advice t the pilt staff, in persn and ver the telephne, and by the pilt staff being able t carry ut bservatins n r mnitr a detainee fr a 7

8 frensic physician. One respndent thught that a shared language was develping between the tw services which enabled greater sharing f infrmatin abut patients. Despite what is perceived t be an verall psitive and cllabrative relatinship develping between the frensic physicians and the pilt team, sme prblems had been experienced. There was sme misunderstanding r lack f knwledge abut the remit f the pilt and what the pilt staff were expected t d. Sme f the frensic physicians reprted that pilt staff did nt carry ut tasks at a level which they had expected in terms f physical care fr detainees and that there had been a negative impact in terms f unnecessary call uts (althugh this was nt universally reprted) as a result f the pilt. Initial tensins were als nted, as the pilt was ptentially seen as threatening t the rle f the frensic physicians, with thughts that it wuld reduce their wrking hurs and rle, althugh feedback frm the frensic physician questinnaire fund that, f thse respnding, 71% had nt experienced a change t their rle. In additin, there was a mixed respnse frm the frensic physicians as t the pilt s impact n their wrklad, with sme reprting n change and ne that there had been an increase. An analysis f the number f call uts made by frensic physicians shws that there was an -11% drp in the number f call uts made when cmparing data frm Nvember 2012 and Nvember Figures prvided fr December 2013 and January 214 (utside f the riginal pilt evaluatin phase) als shw that half f all call uts made by the frensic physicians t the Nrthamptn CJC were ver the weekend perid f Friday t Sunday (which is an interesting cmparisn t the qualitative feedback which suggests that weekday mrnings culd be busy perids, althugh this was mre a reflectin by pilt staff than the frensic physicians). During these tw mnths frensic physicians als attended the CJC fr 56% f call uts (December) and 47% f call uts (January) during the cre wrking hurs f the pilt service. A greater clarity in terms f what the pilt had aimed t achieve and what the pilt staff s rle entailed may have helped ease sme f the tensins experienced between these tw services. A clearly defined rle fr bth the frensic physicians and the pilt staff may have helped the transitin int the pilt and alleviated sme cncerns abut jb rles and areas f respnsibility. The develpment f mnitring systems t better understand the type f call uts, hurs per call ut, actin taken by the frensic physician and wh made the call (custdy staff r pilt staff), may als add clarificatin f the services rles, thrugh a greater understanding f the interactin between the tw services and the nature f their rles within the CJC and in understanding the skills mix between the pilt service and frensic physicians. 8

9 Cncern fr the health and wellbeing fr detainees was evident amngst thse wh tk part in the evaluatin and ensuring that the service prvided wuld best supprt their needs was essential. Therefre ensuring that pilt staff have been trained t an apprpriate level t manage and treat physical health needs was an imprtant theme which emerged frm the findings. A psitive develpment in the relatinship between the frensic physicians and the pilt has been that training has been prvided t the pilt staff by the frensic physicians where there has been an identified lack f knwledge. This shws a cmmitment t the pilt and the develpment f a cllabrative apprach t the care f detainees. The rle f the pilt staff was described as evlving ver the curse f the fur mnth trial, with staff taking n mre health care needs and dealing with the minr cases, while a fcus n ensuring call uts fr the frensic physicians was fr the mre serius cases. There was a perceptin that the pilt staff culd take n a greater rle in supprting the minr health needs f detainees, therefre minimising the pressures n the frensic physicians. Hwever, there needs t be greater clarificatin f what cnstitutes a minr case and where the bundaries f the nurses rle shuld lie t ensure that care is prvided at the apprpriate level and all staff are aware f when a frensic physician shuld be called ut. Cncerns were als expressed that an adequate service frm the frensic physicians shuld be maintained within the custdy unit t ensure that mre cmplex needs r unexpected changes t a persn s health culd be managed t ensure the best utcme fr the individual. Therefre a cntinued service prvisin frm the frensic physicians was seen as imprtant. Key strengths f the pilt The knwledge f the lcal area and lcal services was reprted t be ne f the key strengths f the pilt (this was als nted as a strength f the frensic physicians and frm the pilt stakehlders), with staff having a gd knwledge f lcal services, knwledge f narctics and medical matters. This knwledge was seen as adding value t the pilt. Hwever, nt all thse taking part reflected this view and it was thught that the identificatin f clear pathways fr making referrals and a prcess map f wh and when t cntact wuld be helpful fr the pilt staff. In additin t this, a database f rganisatins with telephne numbers and cntact names wuld ensure that staff had access t a cmprehensive range f supprt rganisatins and nt just thse persnally knwn t the pilt staff. The sharing f infrmatin abut the health and wellbeing f detainees between the pilt staff and custdy staff was als seen as a strength f the pilt. It was thught that the 9

10 pilt had been able t prvide greater knwledge t custdy staff in rder t help them prvide the best care fr individuals t ensure their safety and wellbeing. It was als reprted that custdy staff were being supprted by having a persn with medical knwledge n site and that the pilt staff had been able t help supprt decisin making n health matters and help t prcess peple thrugh the custdy unit mre apprpriately. The cllabrative apprach f the pilt was viewed psitively by a number f thse taking part in the evaluatin. Frm the utset f the prject, with the range f stakehlders wh helped t establish the pilt, thrugh t the develping wrking relatinships the pilt staff have with the different rganisatins within the custdy unit. Hwever, nt everyne reflected psitively n the jint wrking f teams, with reprts f teams wrking in islatin and the envisaged integrated wrking f the pilt nt having materialised. The presence f the pilt staff was als reprted as a strength as they were thught t prvide a different perspective and quality within the custdy unit. It was suggested that the hlistic apprach f the pilt supprted detainees t discuss issues abut their health and being an external bdy t the plice was seen as a psitive. The terminlgy used t describe their rle t detainees was imprtant as initially staff called themselves mental health nurses, which was nt well received, and a change t the use f just nurse saw greater engagement with the pilt by detainees. As well as a number f strengths f the pilt being reprted, there were als sme prblems experienced. The key issues were related t: Access t apprpriate equipment and space within which t carry ut assessments; Access t IT equipment and databases; Knwledge f the custdy prcesses, fr example accessing detainees, understanding IT systems; Clearly identified and knwn rles and remit f the pilt; The impact n external services and cncerns that the pilt had increased the wrklad fr these services, this was discussed in particular reference t the apprpriate adult service. 10

11 Impact n ffending rates identified thrugh the pilt One f the riginal aims f the pilt had been t understand the impact n re-ffending rates. The evaluatin identified that within the time perid f the pilt, it has been difficult t determine whether there has been an impact n ffending rates. Several f thse interviewed cmmented that such an impact culd take a lng time t becme evident and that this shuld perhaps be a cnsideratin fr the future cmmissining f a similar service within the custdy unit and part f a lnger term study. The cllectin f data by the pilt team, in terms f ffender histry, was als nt pssible due t access issues t the apprpriate plice systems. It has therefre nt been pssible t include an analysis f data n ffender histry at this stage f the evaluatin. The fcus f the pilt n reducing re-ffending rates was nt universally reprted t be apprpriate, by sme f thse interviewed. One respndent thught that the fcus f the pilt shuld be firmly with health and that any bi-prduct in terms f ffending rates wuld be a benefit, but shuld nt be the fcus. Health utcmes identified thrugh the pilt A physical health check was carried ut n 96% f thse screened. The pilt reprted t have identified a physical health cnditin (bth current and histrical) fr 51% f thse screened. Only 4%, f all thse screened, reprted t have been admitted t A&E and 17% were reprted t have a physical health cnditin utside f the nrmal range fllwing an assessment f their bld pressure, temperature, bld sugar level and respiratry rate. A number f health issues have been identified thrugh the pilt where pilt staff were able t supprt a detainee s physical needs fr example identificatin f a dislcated shulder and resuscitatin. A wide range f health issues were identified by the screening tls, these included asthma, arthritis, back prblems, allergies, infectins and varius physical pains. Alngside the physical issues identified, the pilt als reprted 55% f all detainees screened had a current drug r substance issue. Cannabis was the mst cmmnly used drug with 32% f current users reprting t use this, alchl was als reprted by 22% f current users. Often drugs were taken in a cmbinatin f drugs and alchl, fr example a mixture f cannabis and ccaine r amphetamines. The mental health f detainees was mnitred in fur ways, thrugh histric cntact with services, current cntact with services, reprted cnditins by the detainee, and bserved presentatins f an issue by the pilt staff. The number f detainees wh 11

12 reprted t have a mental health issue was greater than bth the number f histrically nted cases and current cases, with 54% f detainees screened. There was a range f cnditins reprted which als varied in severity, frm thse wh required cunselling t individuals diagnsed with either a bi-plar disrder r schizphrenia. Of thse wh were reprted t be presenting with a mental health cnditin (38% f detainees screened), 21% were assessed t have a cmbinatin f symptms frm being tearful, depressed, anxius t hearing vices and being paranid. The ther mst cmmn presentatin f symptms were depressin (11%), lw md (10%), tearfulness (8%) and anxiety (7%). A number f referrals fr n-ging supprt were made t a range f different service prviders, fr example: the traumatic brain injury team, CRI, GPs, Serenity, child prtectin services, the safeguarding team, adult mentrs, the drug and alchl team and cunselling services. A referral was made fr 34% f thse detainees screened. While a range f referral agencies were nted thrugh the interviews and the rutinely cllected data, the mst cmmn referrals were made t frensic physicians (43% f referrals), CRI (16% f referrals) and t the cmmunity psychiatric nurse (13% f referrals). With regard t actin taken in the fllw up f detainees, the mst cmmn frm f actin recrded was t recmmend a visit t the GP r referrals t ther rganisatins. Fr individuals wh were reprted t have an issue utside f the nrmal health range, 40 detainees were prvided with n-ging actin, in terms f referrals this meant a recmmended visit t their GP r being referred t the frensic physician. Additinally, safeguarding issues were recrded fr 38% f thse screened and these ranged, frm having been adpted, had a child adpted r being in fster care, children living with relatives, being knwn fr drug use/criminal behaviur, physical/sexual abuse within the family r scial services wrking with the family. It was discussed during the evaluatin that ften advice was given t detainees, but that the nus t act upn this advice was up t the individual. While staff culd write t GPs and ther service prviders, the individual was respnsible fr acting upn the advice. It was suggested that the pilt culd prvide a fuller service thrugh fllw up supprt and additinal treatment services. This wuld be a change in the current remit f the pilt, and wuld need t be cnsidered by the stakehlders as t the value f such additinal services. Hwever, there may be a benefit in ensuring that advice r referrals are fllwed up, currently this pilt phase was nly able t recrd a lnger term fllw up with 28% f thse screened, and ften this was advice t see a GP r infrmatin that a 12

13 new referral had been made, nt necessarily whether the individual had fllwed up n the referral r what the utcme f that referral had been. Outcme measures As part f the evaluatin the cmmissiners requested infrmatin n key utcme measures frm the pilt, these measures were identified at the utset f the evaluatin and frmed part f the aims and bjectives. The fllwing is a list f these utcme measures with the data nted alngside. The data has been identified frm analysis f the rutinely cllected data. Type f ffences cmmitted; 113 different ffences were recrded verall, with theft f all types being the mst cmmnly recrded and assault, breach, drug ffences and criminal damage; Numbers representing t custdy; 4,646 detainees presented in custdy (426 were juveniles); 505 detainees screened (24 were juveniles); Numbers representing t A&E; 19, f all thse screened, self-reprted presentatins t A&E; 4 referrals t A&E; Referrals f liaisn and diversin/cri/dual Diagnsis; 174 individuals were referred t anther agency; 77 t a frensic physician, 32 were t CRI, 22 t a CPN; Of thse referred t anther service, 20 were already knwn t that service; Numbers diverted frm Criminal Justice System; Numbers f diversins frm the criminal justice system were nt recrded, this culd be due t access issues t apprpriate IT systems and utcmes f the referrals being unrecrded; 13

14 Numbers engaging with ther services; 71 detainees were knwn t be currently engaged with mental health services; 7 detainees were knwn t be seeking supprt fr their drug/substance misuse; 129 detainees with current r histrical safeguarding issues are knwn t be r have been engaged with ther services; Numbers with learning difficulties/mental health/persnality Disrder/Autism; 201 detainees had histrical cntact with mental health services; 71 detainees were currently in cntact with mental health services; 276 detainees reprted t have r had an issue with their mental health; 194 detainees were reprted t be presenting in custdy with a mental health issue; 6 detainees were identified with a learning disability; 13 detainees were reprted t have a persnality disrder (histrical and current); 3 detainees were reprted t have autism (histrical and current); Numbers with a medical need; 259 detainees had a reprted physical health issue (84 had indicatins utside f the nrmal health range when mnitred); Numbers with registered with a GP; 448 detainees screened were registered with a GP; Demand and nature fr safe guarding/scial care links; 192 safeguarding issues were reprted (histrical and current); 14

15 These related t: having been adpted r had a child adpted r in fster care, children living with relatives, being knwn fr drug use/criminal behaviur, physical/sexual abuse within the family r scial services wrking with the family; Agencies wrking with detainees were reprted t be: Natinal Fstering Agency, scial services, child and family services, the curts, health visitrs, mental health services, Alchlics Annymus, Victim Supprt, NSPCC and a wmen s refuge; Identificatin f pathways and any issues that need t be reslved; Tw clear pathways have been identified thrughut this evaluatin. Firstly, thse referral pathways used t prvide detainees, with an identified need, supprt, secndly, pathways which detainees are already engaged (e.g. thrugh drug r substance misuse, mental health needs r safeguarding issues). These referrals are being made by bth the pilt team and frensic physicians. The range f different rganisatins identified are: Frensic physicians, CRI, cmmunity psychiatric nurses, Children and Adlescent Mental Health Services, GPs, Serenity, child prtectin services, Safeguarding team, adult mentrs, cunselling services, Natinal Fstering Agency, scial services, child and family services, the curts, health visitrs, mental health services, Alchlics Annymus, Victim Supprt, NSPCC and a wmen s refuge, Citizen s Advice Bureau, Husing, MASH, ADHD services, Changing Minds, Yuth Offending team, Dedicated Substance Interventin Prgramme, Hspital/A&E, Wellbeing team, Bridge, Campbell Huse, Berrywd, CAB, custdy team, Crisis Hme Treatment Team, Nstep, Shrt term team and Single Pint f Access this list may nt be exhaustive, but represents the range f rganisatins identified thrugh the evaluatin. One main issue has been identified, which impacts n the referral pathways made. The nus fr acting n the referral lies with the detainee; and while it is nt pssible t enfrce actin is taken, there are pssible measures which culd be put in place t assist, fr example thrugh the prvisin f a fllw up service t identify 15

16 whether the detainee and/r the referral agency has taken any actin. In additin, a small number f detainees refused the advice prvided by the pilt team, this will always be an issue the service will face, but culd be mitigated by the prvisin f apprpriate advice given in cnjunctin with infrmatin and cntact details shuld the detainee recnsider. Age grups presenting; Age grup N. Under Over 75 1 Apprpriate identificatin and attentin t the needs f thse frm thse prtected grups; 24 juveniles were screened during the pilt, this grup were perhaps under represented verall within the pilt, hwever sme difficulties in access were faced by the pilt team. Clser wrking ties with the apprpriate adult service may be required t ensure access is imprved. Identificatin f thse with mental health issues (including ADHD and autism) and/r learning disability were made thrugh the pilt and apprpriate referrals were reprted t have been made. Numbers refusing assessment/an interventin; 71 individuals were recrded as refusing an assessment; 8 refused aspects f the health assessment e.g. bld sugar test; 10 declined referral recmmendatins; 16

17 Numbers refusing GP r ther service (including schl exclusins). 11 detainees (self) reprted t have been expelled frm schl, a further 6 reprted t have left schl at an early age (aged 11-15); 87 f thse screened reprted t have n frmal qualificatins, 3 stated that they had nt cllected their GCSE results s these were unknwn; 3 detainees were attending a special schl and 1 had supprted learning needs; 3 detainees reprted t have difficulties reading r writing; Thse wh refused t access services fllwing recmmendatins frm the team declined supprt frm: Children and Adlescent Mental Health Service, Mental Health services (n=2), Campbell Huse, Talking Therapies, a drug interventin, bereavement cunselling, review by the frensic physician, Crisis Team and CRI. The findings frm this evaluatin wuld suggest that the pilt has prvided sme valuable data n the physical and mental health f detainees, what services they are accessing and hw best t supprt their needs. While sme prblems have been experienced with regards t data access, clarity ver the rles f the pilt staff and cmmunicatin between teams, the develping links between the frensic physicians and custdy staff is prmising. Recmmendatins The fllwing recmmendatins are made t supprt the develpment f the healthcare screening pilt and/r a newly cmmissined service and are based n the findings frm the evaluatin. Rles and remit f the pilt: Ascertain the remit f health care prvisin within the custdy unit, with clearly identified rles fr staff and agreed levels fr attending t minr illnesses and ailments f detainees. In additin, cnsideratin shuld be given t the level f supprt prvided t the frensic physicians in mnitring the health f a detainee and fr staff t be clear when a frensic physician shuld be invlved in the care f a detainee. Cntinued fllw up: Develp the ptential fr greater fllw up n detainees and understanding hw better t ensure that referrals r advice is acted upn. 17

18 Cmmunicatin f the pilt: Develp cmmunicatin acrss teams abut the wrk f the pilt, i.e. what it has achieved, wh the team are, their key rles and future plans fr the service culd be cnsidered. This culd be shared with all service prviders, frensic physicians and teams within the custdy unit t develp imprved knwledge f the pilt and cllabrative wrking. Audit f teams within the custdy unit: An audit culd be cnducted t identify the different teams wrking within the custdy unit and their rles and bjectives. This culd help t identify crssvers in wrking practice and develp a greater integrated service, while reducing the ptential t duplicate wrk. Access: Timely access t the apprpriate IT systems and building access will help t ensure accurate and cmplete assessments are undertaken. Cnsideratin culd als be given t the inclusin f an apprpriate lead in time fr new staff, t ensure systems are set up. Training: Identificatin f current and future training needs f the current pilt staff t develp health care skills and legal knwledge fr example fr fitness t detain/interview. Cnsideratin shuld als be given t prviding an rientatin prgramme fr new members f staff abut wrking practices within the custdy unit. Envirnment and equipment: Identificatin f an apprpriate, dedicated space within which t carry ut assessments. In additin, a review f the equipment required by the frensic physicians and the pilt staff shuld be undertaken t identify which resurces are required fr each team and t determine respnsibility fr maintaining and restcking this equipment. Screening prtcl: The develpment f frmal screening criteria t identify pririty detainees fr screening and prvide staff with clear ratinal fr requesting a screening with an individual may prvide greater cnsistency and clarity t the screening prcess. Service database: Develpment f a database f services, with cntact details and service infrmatin wuld supprt staff in identifying the mst apprpriate service t supprt an individual. This may help t ensure a cnsistent apprach is adpted in prviding advice and/r referrals and supprt any new members f staff/agencies wrking within the custdy unit. Prcess mapping: The develpment f a prcess map, identifying an apprpriate curse f actin (e.g. cnducting a mental health assessment r cntacting 18

19 anther service), when a service shuld be cntacted, hw t identify an apprpriate service and when and hw t fllw up n this actin shuld be cnsidered. This may help supprt staff in their decisin making and prvide clarity fr services wrking with the pilt/new health care service. Rutinely cllected data: Develpment f the rutinely cllected data t ensure greater cnsistency, fr example identify set phrases r cnsistent wrding fr each categry. This will ensure greater accuracy in interpreting the data as the service develps and ensures all staff fllw a cnsistent frmat fr recrding data. In additin, infrmatin abut whether the detainee has previusly been screened wuld help t identify the effectiveness f the pilt and prvide additinal backgrund infrmatin which may supprt decisin making. Additinal fields culd als be inserted t add clarity t the data: Drug r substance abuse issue type f drug, length f time using, level f usage, engagement with additinal services; Mental health issues current r histrical, services engaged/engaging with; NEWS health mnitring scre; Safeguarding - current r histrical, services engaged/engaging with; Mnitring f frensic physician call uts: nature f call ut, wh made the request, time taken at site, utcme f frensic physician attendance; Service user feedback: Develpment f a regular detainee feedback prcess which is incrprated within the service t ensure that this hard t reach grup are given an pprtunity t give their views n their experiences f having been screened. This culd be develped thrugh pst service questinnaires r feedback slips which can be sent t detainees nce released frm custdy r thrugh a shrt telephne interview f a representative sample agreement wuld need t be given fr this cntact t be made and culd be incrprated int the current data cllectin prcess. 19

20 Cntents Institute f Health and Wellbeing... 2 Executive summary... 3 Intrductin & Aims... 3 Methds... 4 Key findings... 5 Outcme measures Recmmendatins Intrductin Aims Methds Service User Questinnaire and Interviews Staff Interviews Service Prvider Interviews Stakehlder Interviews Frensic Physician Questinnaire Service Observatins Rutinely Cllected Data Analysis Data Analysis Ethical issues Evaluatin Findings Interviews and Observatins Pilt Aims and Expected Outcmes Rle f the Frensic Physician and Links with the Pilt Develping relatinships Changing rles Other impacting factrs Referrals frm frensic physicians Perceived Benefits and Strengths f the Pilt Knwledge f staff Imprved knwledge f custdy staff Identificatin f health needs Cllabrative wrking Perceived Weaknesses f the Pilt Access t IT Knwledge f custdy prcesses and apprpriate adult access Rle and remit f the pilt Impact n external services Awareness f pilt Operatinal Hurs Identifying and Undertaking Screenings

21 5.6.1 On-ging supprt Practicalities f Wrking in Custdy Physical space Equipment Training Needs Re-ffending Rates Imprvements fr the Future Rle and Remit Cmmunicatin abut the pilt its aims and remit Develping cllabratin acrss services Physical space and equipment Prvisin f n-ging supprt The Future Prvisin f Healthcare in Custdy Rutinely Cllected Data Findings Demgraphic Infrmatin Type f Offence Cmmitted Physical Health Mental Health Scial Factrs Referrals Juvenile Detainees Type f Offence Cmmitted Physical Health Mental Health and Referrals Scial Factrs Csts/Call ut analysis Cnclusins Effectiveness f the Pilt Links between the Pilt and the Frensic Physician Service Key Strengths f the Pilt Impact n Offending Rates Identified thrugh the Pilt Health Outcmes Identified thrugh the Pilt Outcme Measures Recmmendatins Limitatins f the Research Appendices Appendix 1: Further Data Analysis Appendix 2: Service User Questinnaire Appendix 3: Service User Interview Schedule Appendix 4: Staff Interview Schedule

22 9.5 Appendix 5: Service Prvider Interview Schedule Appendix 6: Stakehlder Interview Schedule Appendix 7: Frensic Physician Questinnaire List f Figures Figure 1: Percentage f individuals screened registered with a GP surgery Figure 2: Emplyment Status Figure 3: Percentage f Frensic Physician Call Outs by Weekday (December 2013 and January 2014) List f Tables Table 1: Frensic physician referrals Table 2: Age range Table 3: Ethnicity Table 4: Arrest details Table 5: Offenses fr thse with an identified safeguarding issue Table 6: Actin taken utside f nrmal range Table 7: Number f detainees with a current reprted substance misuse issue Table 8: Presenting mental health symptms Table 9: Type f accmmdatin Table 10: Educatinal level Table 11: Marital status Table 12: Referral Agencies Table 13: Call ut and cst cmparisn fr Frensic Physician service Table 14: Call uts by Time f Day (December 2013) Table 15: Call uts by Time f Day (January 2014) Table 16: Age, Gender, Mental Health, Type f Offence and Safeguarding

23 1 Intrductin The Institute f Health and Wellbeing was cmmissined by the Offender Health Cmmissining Grup t undertake an evaluatin f the Custdy Health Care Screening Pilt service which is managed by the Criminal Justice Team. The Criminal Justice Team (CJT), part f Nrthamptnshire Health Care NHS Fundatin Trust, wrks fr the best clinical utcmes fr service users with ffending behaviur by prviding best practice treatment ptins, adhering t NICE guidance and preventing unnecessary and cstly use f the prisn service and secure mental health beds. A stakehlder grup was established f criminal justice agencies and health cmmissiners t cllabrate n the transfer f healthcare cmmissining fr custdy. A review f plice custdy pathways was undertaken and Nrthamptnshire Healthcare NHS Fundatin Trust was cmmissined t run a pilt scheme t intrduce a nursing service int custdy in Nrthamptn. Similar pilts are being undertaken acrss the cuntry, trailing nurses in custdy, hwever, this pilt uses cmmunity psychiatric nurses (CPNs) wh have been up skilled in relatin t physical health and whse fcus is t prvide supprt and signpsting fr peple entering custdy with a mental health r substance misuse issue. The pilt was set up t intrduce an electrnic screening prgramme fr everyne wh is brught int the Custdy Unit in Nrthamptn, with the aim f identifying whether an individual has r has previusly been identified as having a mental health issue, and prviding additinal supprt, referral services and infrmatin fr thse wh are highlighted t the team. This pilt started n 1 st July 2013 and initially ran fr fur mnths, with the initial phase finishing n 31 st Octber The pilt has received additinal funding t supprt an extensin t this initial timeframe; hwever, these evaluatin findings cver the initial pilt timeframe. The pilt perated frm Mnday t Friday, frm 9-5pm initially but was eventually extended frm 10am t 10pm. A team f five nurses with a mental health backgrund wrked n the pilt scheme, which was run alngside the existing frensic custdy assessment led by frensic physicians. This reprt prvides the findings frm the interviews with stakehlders, service prvider rganisatins, staff members, questinnaire feedback frm frensic physicians, rutinely cllected data and bservatins carried ut within the custdy unit f the pilt prcesses. 23

24 2 Aims The aim f this pilt was t intrduce a triage t identify and prvide supprt and referral services fr peple, specifically juveniles, with a mental health cnditin entering the custdy units in Nrthamptn. The Offender Health Cmmissining Grup wished t develp an evidence base t supprt the business case t cmmissin a lng term service aimed at reducing ffending thrugh interventin. The aims f the evaluatin were therefre t: 1. Identify the effectiveness f the custdy health care pilt; 2. Understand the links with the pilt and the existing frensic physician service prvisin; 3. Identify the key strengths f the pilt scheme and the frensic physician service prvisin; 4. Understand the impact n ffending rates fr thse identified thrugh the pilt; 5. Understand the health utcmes fr thse identified thrugh the pilt. In additin, Nrthamptnshire Plice identified the fllwing utcmes and measures t be identified thrugh the evaluatin f the pilt: Type f ffences cmmitted; Numbers representing t custdy; Numbers representing t A&E; Referrals f liaisn and diversin/cri/dual Diagnsis; Numbers diverted frm Criminal Justice System; Numbers engaging with ther services; Numbers with learning difficulties/mental health/persnality Disrder/Autism; Numbers with a medical need; Numbers registered with a GP; Demand and nature fr safe guarding/scial care links; 24

25 Identificatin f pathways and any issues that need t be reslved; Age grups presenting; Apprpriate identificatin and attentin t the needs f thse frm prtected grups; Numbers refusing assessment/an interventin; Numbers refusing GP r ther service (including schl exclusins). 25

26 3 Methds This sectin utlines the apprach adpted in undertaking this evaluatin. A mixed methd apprach was chsen t achieve a cmprehensive understanding f the health care screening service and gain the views f thse wrking with, fr and using the service. 3.1 Service User Questinnaire and Interviews A paper questinnaire was designed, in cnjunctin with the cmmissining lead (see Appendix 1), t be handed t thse wh had received a healthcare screening assessment. Unfrtunately the pilt team were nt able t distribute the questinnaire and due t cnfidentiality agreements the questinnaires culd nt be distributed t service users retrspectively. N cmpleted questinnaires were returned t the evaluatin team. Accrding t the evaluatin prpsal design, participants fr fllw-up face-t-face interviews were t be recruited via the questinnaires. Given the challenges in recruiting via the paper questinnaire, it was agreed with the cmmissiners that a revised methdlgy was required t gain the views f this grup. Initially it was advised that interviews culd be cnducted with detainees, wh had cmpleted a health screening, while within the custdy unit. Tw sessins were bked t cnduct these interviews, ne was cancelled due t lw vlume f detainees and ne was cancelled due t safety cncerns expressed fr the interviewee s welfare in cnducting the interviews in custdy. A final data cllectin methd was adpted. Three full days, agreed in advance with the pilt team, were identified in which the evaluatin team wuld be available t cnduct face-t-face interviews/cmplete questinnaires with detainees after being screened and n release frm custdy. The pilt team agreed t cntact the evaluatin team when individuals were due fr release t enable the evaluatin team t be present when detainees were released. It was nt pssible t recruit any detainees via this rute as n subjects were identified during the timeframe r detainees were released withut the knwledge f the pilt staff. A discussin guide was designed, in cnsultatin with the cmmissiners, (see Appendix 2), t btain qualitative infrmatin explring the views n the service received, ptential imprvements which culd be made, any ptential benefits received frm accessing the service, and any prblems which may have been experienced. 26

27 3.2 Staff Interviews Three face-t-face interviews were undertaken with staff wrking n the pilt. A discussin guide was designed, in cnsultatin with the cmmissining lead (see Appendix 3), t btain qualitative infrmatin t explre the views n the running f the service, experiences f the staff members and views n the ptential benefits f the pilt. The interviews als included discussins n ptential prblems which may have been experienced and recmmendatins fr the future delivery f the service. Interviews were run at a time and place t suit the staff members and were 30 minutes t 50 minutes in duratin. 3.3 Service Prvider Interviews Six telephne interviews were undertaken with representatives frm service prvider rganisatins wh wrk with and supprt service users ging thrugh the custdy unit and help supprt their n-ging needs. Twelve service prvider rganisatins were apprached t undertake an interview, f which six agreed t take part in this evaluatin. Mst f the services declining t take part did nt prvide a ratinale fr their decisin. Hwever, tw rganisatins suggested that they did nt have enugh direct cntact with the pilt t prvide an apprpriate respnse, and ne respndent admitted t limited knwledge f the pilt having received little infrmatin abut it frm the plice. They believed the pilt had nly been running fr a very shrt perid. The list f rganisatins cntacted were discussed and agreed with the cmmissining lead. A discussin guide was designed, in cnsultatin with the cmmissining lead (see Appendix 4) t btain qualitative infrmatin n the pilt s delivery, wrking within the pilt, and the pssible benefit the pilt might add t current service delivery. The interviews als included discussins n ptential prblems which may have been experienced and recmmendatins fr the future delivery f services within custdy. Interviews were run at a time t suit the prfessinal service prviders and were minutes in duratin. A number f the service prvider rganisatins wh did take part in the evaluatin did nt wrk directly with the pilt staff and therefre were unable t engage fully n the questins relating t wrking practices within the pilt. This was either due t difficulties accessing the level f staff wh engage with the service n a day t day basis r as a result f sme service prviders declining t take part in an interview. 27

28 3.4 Stakehlder Interviews Six face-t-face interviews were undertaken with representatives frm stakehlder rganisatins wh were invlved in the develpment f the pilt. Seven stakehlder representatives were apprached t undertake an interview, f which six agreed t take part in this evaluatin. The stakehlder cntacts and a discussin guide was designed, in cnsultatin with the cmmissining lead (see Appendix 5), t btain qualitative infrmatin explring views n the aims and bjectives f the pilt, and the ptential benefits and prblems experienced in the running f the pilt. The interviews als asked participants t ffer recmmendatins fr the future delivery f services in custdy. Interviews were run at a time and place t suit the stakehlder representatives and were minutes in duratin. 3.5 Frensic Physician Questinnaire A paper/nline questinnaire was develped, in cnjunctin with the cmmissining lead, t gather the views f the frensic physicians (see Appendix 6). The questinnaire was distributed thrugh the Frensic Physician lead via , with ne reminder fllw-up. Seven respnses were received, representing a respnse rate f 30% f all frensic physicians in Nrthamptnshire. Questins explred views n the running f the pilt, ptential prblems and benefits experienced and als explred the relatinship between the pilt and the current frensic physician service. The questinnaire included a cmbinatin f pen ended and tick bx questins. 3.6 Service Observatins Tw 2 hur bservatin sessins were undertaken by the evaluatin team in rder t understand the prcesses emplyed in the custdy unit while the pilt service was being delivered. A member f the evaluatin team shadwed a member f the pilt staff n tw separate ccasins, bserving the prcesses fr screening identificatin, carrying ut a screening, and the subsequent write-up f the assessment. Detailed bservatin ntes were taken and these were written int an bservatin reprt. 3.7 Rutinely Cllected Data Analysis At the utset f the prject, the evaluatin team wrked with the Criminal Justice Team t identify the data which culd be included within their rutinely cllected data. This 28

29 data was linked t the data requirements f the cmmissiners as clsely as pssible t ensure the crrect level f data was btained. The pilt team experienced difficulties in accessing plice systems in rder t gain sme f this data, particularly infrmatin n previus criminal activity. Hwever, the data cllected includes infrmatin n the detainees demgraphic details, physical and mental health, current criminal activity, scial status and referral activity. 3.8 Data Analysis Interviews were recrded and fully transcribed fr interpretatin and clarificatin, and thematic analysis undertaken. Annymus verbatim qutes are included thrughut this evaluatin reprt t further infrm the discussin and maximise the vices f the practitiners themselves. Quantitative data was input int SPSS and Excel fr descriptive statistical analysis. 29

30 4 Ethical issues This evaluatin was vetted by a University f Nrthamptn Schl f Health Research Ethics Cmmittee t ensure adherence t best practice ethical guidelines. The Institute s participatin in supprting this prject was underpinned by the fllwing: Participants (service users, staff members, stakehlders and service prviders) tk part in the prject f their wn free will after being fully infrmed f where and hw the infrmatin was t be used; Cnfidentiality was assured at all times during the cllectin f data; All analysis dne by the Institute used annymised data and participants are nt persnally recgnisable in resultant reprts r disseminatin materials, hwever due t the number f interviews being undertaken participants were made aware that their views may be identified and were advised t discuss issues which they were cmfrtable sharing; Participants were fully infrmed f the ways in which the data cllected will be used by the cmmissiners f the prject and their partners; All research active staff in the Institute are trained t fllw strict cdes f practice and are CRB cleared; All data cllected as part f the prject is stred and transferred securely. Strage f data fllws the guidelines set by the Data Prtectin Act and the Freedm f Infrmatin Act. 30

31 5 Evaluatin Findings Interviews and Observatins This sectin presents the findings frm the staff, stakehlder and service prvider interviews, alngside the findings frm the frensic physician questinnaire and the pilt bservatins. Specific discussin surrunding the service prvided thrugh the pilt is presented, incrprating bth the benefits and issues which have emerged while delivering the pilt and suggested imprvements fr the future prvisin f services in custdy. The findings are presented via key themes identified frm the analysed data. 5.1 Pilt Aims and Expected Outcmes Thrugh the interviews, with stakehlders, service prviders and members f staff, the key aims f the pilt were discussed. While there was a varied respnse t this questin, it was apparent that mst peple interviewed were clear abut the cre aims f the pilt. These centred n the need t assess peple s physical and mental health n entering custdy, gathering data abut peple s health needs, and supprting peple wh may have health prblems thrugh apprpriate referrals and/r advice. This was ccasinally discussed in relatin t an understanding that ften peple with substance misuse r mental health issues can be missed when entering custdy, and it was hped that the identificatin and supprt f such cncerns at an earlier stage in the pathway culd nt nly benefit the individual, but culd als have a psitive impact n re-ffending rates. One interviewee als cmmented that the service prvided shuld be equal fr all, regardless f circumstances. it s t cllect data frm that with regards t what the health issues are f ffenders and hw thse can be addressed and whether there are services existing that can address thse needs r whether there s gaps in services in rder that we can ensure that ffenders still receive thse health interventins. picking up any utcmes t, passing them t the crrect pathways, especially I suppse because mental health, drug and alchl related issues, t try and reduce incidents that s kind f the primary driver isn t it, t make sure peple have gd access t healthcare, have that infrmatin and have an equitable service fr whatever diverse backgrund they re frm 31

32 t be able t then divert them apprpriately frm a punitive, custdial pathway t ne that actually gives them a chance f at least having their prblems specially evaluated and then having a diagnsis as t whether r nt the utcmes can be imprved r nt t actually pick thse peple up with the aim f reducing reffending But als engaging them in effective and the health and equalities agenda because we see the same peple ging rund and rund and rund and rund the system. S it s recgnising if yu can get the apprpriate medical interventin at the pint f arrest, at the pint f custdy that actually they dn t need t cme int the prisn system and that culd significantly reduce the prisn ppulatin but als ensure that peple are given the right level f care The Bradley reprt was mentined in a number f interviews and its influence in terms f the pilt s develpment and aims. Fllwing frm this, the prvisin f a cntinuity f care thrughut the criminal justice system and the way in which peple s health within custdy culd be better supprted was discussed. One f the ways that better supprt culd be prvided was thught t be thrugh imprved infrmatin being given t thse within the criminal justice system abut the specific needs f peple with a mental health prblem. Just the knwledge that a persn has a health need was thught t be very useful and culd help supprt the way the individual is managed thrugh the criminal justice system. S I saw this pilt as an attempt t actually identify thse individuals, get them n the right pathways and actually infrm the rest f us t actually then als prvide that infrmatin int the curt as well, s the curt has that infrmatin. As well as infrmatin supprting the wider criminal justice netwrk, it was suggested, by ne interviewee, that there was a benefit in GPs being made aware f their patients entering custdy and receiving health checks and referrals. Imprving the links t ther agencies was therefre seen as an imprtant aspect f the pilt. 32

33 I think imprving that link between what we d in the custdy suite and hw yu can then link them int services in the cmmunity and health services as well It was als expected that thrugh the pilt peratinal issues, including barriers t successful implementatin and hw these culd be vercme, wuld be identified, which culd ensure the effective delivery f the pilt in the future. This was als assciated with the lnger term visin f supprt within custdy, as well as future cmmissining requirements. the pilts wuld kind f tease ut what the actual peratinal challenges were, lcally, and then bviusly infrm cmmissin in the lng term s that a cmmissiner will take accunt f any challenges, any barriers and bstacles and kind f dismantle them t enable the service t run prperly nce it was given the g ahead I think it has given us a much clearer idea f what s needed in custdy I think the main benefit will be first f all t identify whether r nt there is a need fr that particular service in custdy Sme f thse interviewed fcused n the mental health pririties fr the pilt (with particular mentin f persnality disrders), while thers saw this assessment in mre general terms as an MOT n each detainee. It was als cmmented that the pilt shuld ensure that everyne ging thrugh custdy shuld have their health needs met and t prvide an enhanced view f their health, t ensure that they are prvided with care during the custdy prcess and beynd. Because they ve been taken t a place where they re cntained, r cmpulsry detentin really, s it s t make sure their needs are met but als t screen them fr any mental health r physical health prblems that may adversely affect the prcess f custdy and may impact n their wellbeing. And yu knw, suggesting where they culd maybe take that further thrugh their GP 33

34 redirecting, r directing them thrugh a pathway t access care shuld we pick up any difficulties and a lt f peple have cme in wh need, they might be n medicatin that they re having, kind f side effects t that they haven t addressed s it s giving them a little bit f educatin, nt t much because it s a quick screening Further t this, it was nted, that a distinctin shuld be made and understd between the needs f thse with different types f mental illness and learning disabilities and as a result gain a better understanding f the impact n a persn s criminal behaviur. I expect them t be able t actually be much mre discerning and much mre better equipped t separate ut thse wh have persnality prblems, learning disabled prblems, frm thse wh actually genuinely are criminals The riginal aim f the pilt was als understd t have been t screen everyne wh came thrugh custdy, regardless f their identified health needs, therefre at the start f the pilt; peple were being screened wh did nt have physical r mental health needs. Given the number f peple, pilt staff culd assess during a shift and the duratin f health screenings, the pilt develped int identifying nly thse with a specific health need and juveniles. One f the key expected utcmes, fr sme f thse interviewed, was this pririty fcus n under 18s and ensuring their health needs are nt missed. tw key parts f the pilt are t reduce ffenders and ffending behaviur and specifically t liaise r, and talk t every juvenile ffender. the under 18s, because that s ne f the peple we really wanted t target, t see if they were captured, we knew they were being missed s I wuld like t think that s an imprvement there and that they re seen The wrk f the frensic physicians was als discussed in relatin t the aims f the pilt. While thse interviewed, wh knew f the wrk f the frensic physicians, spke psitively f the service prvided, referring frequently t the psitive needs assessment review carried ut n the service prvided by the frensic medical examiner (FME), there was als recgnitin f the limitatins f the service, (discussed mre in sectin 5.2). The aim f the pilt was therefre als seen as supprting the rle f the frensic physicians and reducing their wrklad thrugh nsite supprt. 34

35 Other expected r anticipated utcmes included ptential reductin in A&E admissins and reduced health care csts thrugh early interventin and supprting peple t register with GPs. 5.2 Rle f the Frensic Physician and Links with the Pilt The rle f the frensic physicians (FPs) was discussed by mst f thse interviewed during the evaluatin. There was, verall, a very psitive respnse t the service prvided by the FPs particularly with regard t their prfessinalism and level f service prvisin. Thse interviewed discussed the FPs service in terms f it being excellent, essential, key and rbust. One interviewee thught the training and supprt prvided was very gd and spke particularly favurably abut the benefits f the duble rta system s that they knew there was always smene t call, while anther praised their lcal knwledge and cmmitment. The frensic physicians were asked t cmment n the way in which the frensic physician service currently perates frm within their wn perspective. They reprted n a frensic medical service which prvides a 24/7, all year rund, cver in the custdy unit. They undertake mental health assessments, investigate sudden deaths in the cmmunity, and respnd t calls t the Serenity Suite. The frensic physicians, respnding t the survey, spke psitively abut the wrk and the level f cver currently prvided by the service, as well as perceiving it t have a high level f standard in meeting mst f the Faculty f Frensic and Legal Medicine Quality Standards and having effective and experienced dctrs as part f the service. All f thse respnding reprted t be satisfied with the way the service is run, with 71% reprted t be very satisfied and 29% satisfied. Frensic physicians reprted the key benefits f the service, verall and fr service users, t be the level f cver prvided and the level f experience within the team, bth in terms f medical knwledge and als lcal knwledge. Further t this, the cmmitment f the team was nted by ne physician, while anther cmmented n the gd rapprt with the custdy team and the pr-active and respnsive nature f the service. Finally, ne respndent cmmented n the value f the service prvisin t the service user, cmmenting that delivery f the FP service is essential fr their safety and t prevent deaths in custdy. Cnsistently highly qualified individuals prviding the service which result in cnsistently high quality f care, advice, decisin making and referrals. 35

36 The frensic physicians were als asked t cmment n the perceived benefits f the service fr themselves. The key benefits frm a prfessinal perspective was reprted t be the enjyment f the jb, the flexible wrking hurs, the high standards and variety f the wrk, level f supprt, and the challenging nature f the rle, which can result in a need t act quickly and apply my medical training t deal with situatins which culd escalate. The wrk is different, interesting and interfaces between health and the law. Many f the detainees have challenging prblems. Alngside these benefits, frensic physicians als cnsidered sme f the prblems f the service, fr them as a prfessinal. The main issues raised were: Recruitment f new physicians may be hindered by increased call n their time and little re-numeratin in line with this increase. Stress f the wrk, particularly the wrklad and the pressure f cmpeting demands n physician s time t different call uts Develping relatinships Alngside discussin f the wrk carried ut by the FPs, the interviews als discussed links with the pilt service. An initial settling in perid was nted, by sme interviewed, between the pilt staff and FPs, where bundaries and rles were established. The general feeling was that gd relatinships were develping between the pilt staff and FPs, ne interviewee described it as quite an easy relatinship, while anther described it as very gd. Anther interviewee discussed hw the tw teams were able t liaise well, while pilt staff felt able t cntact the FPs fr advice and t check whether a call ut was necessary. There was an awareness f the value f an FPs time frm the pilt staff and they seemed t be cnscius f ensuring they did nt unnecessarily impact n this time. Additinally, there was a perceptin that FPs felt cnfident that they culd ask pilt staff t assist with their wrk and that pilt staff culd ask FPs fr advice. The knwledge f the FPs and their expertise were nted as being f real benefit t the pilt team. we liaise with the FPs a fair amunt I find if they are ut the ther side f the cunty, yu knw, Gt this, what d yu want me t d with it, what s the pririty? And smetimes that might be saying, we liaise with A&E and then send peple ff if they need t. S yeah, I mean we, everybdy has been pretty accmmdating in that respect. 36

37 And I think they see, because if they re busy in ne side f the cunty, knwing we re there and they can talk us thrugh ding bs r mnitring this s that they can kind f feel that they re ding bth And yu can phne them fr advice and they ll say, OK, yu need t d this, this and this, and it s quite reassuring fr us I think fr me it s abut them having the knwledge and expertise in things that I necessarily dn t have and being able t call n them fr advice and guidance if I m ding smething I m nt very sure abut. One interviewee als thught that the pilt was a gd way t supprt the rle f the FPs, prviding them with backup and thught that having the mral supprt f anther health wrker was imprtant. As such, the pilt was seen as a prcess f learning fr all invlved. Sme f them up here really keen t have actually that backup because they can't always get anywhere as quickly as they wuld wish and I m sure that s quite frustrating fr them and als I think it was quite a relief t have smebdy else there cause hwever skilled yu are actually being n yur wn is nt very nice S I think it s prbably been as enlightening fr them in different ways as it has been fr the plice. In additin t this, there is a shared language and knwledge develping between the pilt staff and FPs s that a telephne cnversatin abut a detainee culd prvide mre knwledge abut that detainee s health than if it had taken place between the plice and an FP. they ll have that cnversatin which is, has mre infrmatin in it fr them abut making a decisin because they ve, yu knw, gt the bservatins, they ve assessed them and etc. s This psitive relatinship is als evident thrugh the prvisin f training delivered by the FPs t the pilt staff. I als understand there has been sme feedback in relatin t sme training that the FMEs are prepared t give t the nurses t actually assist them in sme f the rles that they ve been ding. 37

38 Hwever, despite this develping wrking relatinship, it was als nted that nt all the frensic physicians were aware f the rle f the pilt. Further t this, it was suggested, the relatinship between pilt staff and frensic physicians culd smetimes depend n which dctr was n call. The perceptin was that nt all the FPs were fully supprtive f the pilt. Initial tensins were als nted as the pilt was ptentially seen as threatening t the rle f the FPs, with thughts that it wuld reduce their wrking hurs and rle. An additinal cmplexity nted was that mre than ne FP culd be called ut t visit a patient during the curse f a shift fr the pilt staff. This was reprted t be a difficult situatin t manage as decisins n the patient s cnditin culd differ frm physician t physician. Sme initial tensins may als have resulted frm the mental health backgrund f the pilt staff. It may have been expected initially that pilt staff wuld be physically health trained nurses, as is ccurring in ther regins in the cuntry. Despite training t up skill staff in physical health issues, early expectatins were that the pilt staff wuld be able t address a brader range f health issues. S [ther teams] I think have had reticence that we re nt perhaps able t reslve physical health issues in quite the way that they were expecting but then that s understandable t. In additin, ne frensic physician shared cncerns that service users health culd be put at risk thrugh the extended use f registered nurses t treat detainees. This individual expressed cncern that prblems can escalate quickly and withut adequate cver frm the frensic physician service, there culd be a ptentially negative impact n peple s health. This view was eched by anther frensic physician, wh reprted that under qualified and prly trained staff emplyed by external cmpanies culd have disastrus cnsequences t patient health and the criminal justice system. I feel wrried that there will be a mve t try and prvide the service cheaply with nurse cver I believe dctrs need t be the first line as very ften cases are mre cmplex then appear at face value I wrry there will be a delay r less dctr cver delaying the respnse we are able t prvide service users Changing rles There was a sense frm sme f thse interviewed that the pilt had evlved s that the pilt wrker s rle started t incrprate sme f the mre basic health care services, previusly referred t the FPs. This was driven by a number f areas: the presence f the pilt staff being in custdy, the plice asking fr pilt staff s assistance, 38

39 the develping rle f the pilt staff, identificatin f n-ging training needs in physical health, and a fcus fr the FPs n the mre serius cases. The increasingly mre active rle in treatment f detainees identified health needs cntinues t evlve as the pilt prgresses, and sme stakehlders have suggested that they see the ptential fr this t cntinue t grw. But it was mre abut can nurses d a lt f what the dctrs d S it seemed t mve frm what are the needs T here are sme peple s needs, d smething. Refer r treat r d, t mre f a, culd the nurse d that rather than the dctr? And I think we culd prvide a really quite well resurced nursing service that did supprt the fficers in risk assessment in sme acute management f cases and tk sme f the pressure ff the FPs t manage the mre high prfile areas that they have t be invlved in The prcess f change was described as being quite rganic, with thse participating in the interviews describing the natural evlutin f the prject as a result f trust between partners, and imprved knwledge f the skills each partner cntributes t the pilt. I think it s just hw it s evlved. I think initially the plice were reluctant because it was change and it was smebdy new and yu, I fund that they didn t really cme t yu as a medical prfessinal and say, Can we have yur pinin n this? it wuld g straight t the dctr. And then I think as we ve been there mre and they ve gt t knw us, they re, Oh culd yu just have a lk at r, We re nt t sure abut this, we re nt sure if it needs t g thrugh t the dctr, s I think it s just the way it s evlved, I dn t think it s anybdy saying, This is what yu shuld d, And exciting t be part f smething cmpletely new and t see it evlves, it s evlved in the fur mnths that I ve been there and I m sure it will cntinue t s The perceptin frm the interviews was that the pilt staff culd take n a greater rle in supprting the minr health needs f detainees and the serius r mre cmplex cases wuld then be the respnsibility f the FPs. This culd help t minimise the pressures n FPs time, which was recgnised as being very busy and valuable. Hwever, it was als recgnised that pilt staff needed t be aware f their wn limits in knwledge and skills and when it was apprpriate t refer t the FP. 39

40 I think if smebdy s, r yu re wrried abut smene s physical health, if yu re picking up there s physical health prblems then I d ask them t get the FP t see them One interviewee suggested that the hpe was that the pilt wuld reduce sme f the minr cases being dealt with by the FPs, and that this had already been taken n bard by the pilt. Hwever, frustratins had been expressed by sme FPs wh felt that pilt staff had been unable t deal with perceived minr cases due t lack f perceived knwledge and skills r because it fell utside their scpe f practice. They may ask the nurse t see them first which is what we were kind f hping s that we culd skim ff the lw level stuff and leave them with the mre urgent stuff, knwing that they ve als gt t respnd t the SARC, they ve gt t respnd t Mental Health Act assessments and all variety f things. S they either get called in by the plice and interestingly a lt f FPs will say, Can yu get the nurse t d it? S they re starting t, and I think there s smetimes sme frustratin that they can't d mre One interviewee saw the rle f the pilt staff and FPs as being distinctive, seeing benefits fr bth parties. When asked whether there had been any changes t their rle as frensic physicians as a result f the pilt, 71%, f FPs respnding, reprted that there had been n change and 29% were nt sure. When asked why they felt this way, the respnse fcused n the lack f perceived impact frm the pilt, with frensic physicians reprting t have nt seen any changes t my rle, nt having seen any f the pilt staff when n duty, and feeling that their wrklad [was] unchanged. Hwever, ne respndent als stated that they had seen an increase in their wrklads since the start f the pilt. Finally ne interviewee discussed the need fr service audits t be carried ut, by frensic physicians r an alternative future prvider, in ensuring that what is being delivered is still aligned t the prtcl Other impacting factrs During the discussins a cuple f ptential areas f cncern were raised abut the service prvisin by the frensic physicians. Firstly the number f female GPs engaged in the service was raised by several f thse interviewed, particularly when a female GP 40

41 was specifically requested by a detainee. Hwever, ne spke f the prfessinalism f the FPs and their flexibility in being able t attend when there was a necessity. we ve nw gt three female GPs which still desn t give us 24/7. And it s nt a huge prblem but, and it tends t relate purely t the SARC because victims can ask fr a female dctr Again generally we phne up ne f the three wh are arund and they just agree t cme ut, s it s very, very flexible and very gd but if there was, if I was t say there was a weakness, that is the weakness. There was acknwledgement, thrugh the interviews and the feedback frm the frensic physicians, that waiting times fr an FP culd be quite lng. Given that they cver the whle f the cunty it was suggested that this is nt unexpected, but culd cause delays in treatment r the prcessing f a detainee. Hwever, ne interviewee als thught that they did get a gd respnse frm the FPs and anther reprted that this culd be managed with adequate telephne triage. that whilst the FPs give a really excellent service, specialist service within custdy, it is ne FP acrss tw ptentially quite big sites and that s quite stretched and that puts huge pressures n the plice. Finally, it was reprted thrugh the frensic physicians questinnaire that there was a lack f prvisin fr referral t drug services and alchl services als that mental health prvisin is slw as a result f understaffing Referrals frm frensic physicians The frensic physicians were asked abut the type f referrals they make with detainees. The fllwing table shws the services t which detainees are referred and the number f frensic physicians wh make thse referrals, frm thse respnding t the questinnaire. Referrals t A&E, mental health services, the drug and alchl teams and scial wrkers were thse which the frensic physicians referred t mst ften. 41

42 Table 1: Frensic physician referrals Referral Organisatins N f FPs referring % f FPs referring A&E 6 86% Mental health supprt 5 71% Drug and alchl supprt 4 57% Scial wrker 3 43% General practitiner 2 29% Citizen's Advice Bureau 1 14% Family supprt services 1 14% Husing 1 14% Emplyment r training 0 0% (Base n=7) 5.3 Perceived Benefits and Strengths f the Pilt A number f benefits f the pilt were identified thrugh the interviews. These range frm imprved health infrmatin being available abut peple within the custdy unit, increased supprt fr custdy staff, increased referrals t external agencies, and supprt prvided fr detainee s mental and physical health Knwledge f staff One f the key strengths f the pilt was nted by ne interviewee as the knwledge base and skills mix f the pilt staff. It was felt that staff had a gd knwledge f the supprt/referral services available in the cunty. I mean this has been the advantage f having lts f nurses that knw the services s we ve gt lts f nurses that have lts f understanding f what s happening in the cmmunity in the lcal area, that can link in really well with lcal resurces because we all wrk within lcal teams that understand the drug and alchl services This was als identified, thrugh the bservatin sessins, that staff were able t prvide advice relating t benefits and jb seekers agencies, evidencing a brader knwledge f services ver and abve mental health services. This was als evident during an bservatin f ne assessment where the staff member shwed a gd street 42

43 knwledge f narctics, which helped their discussin with the detainee, and in their medical knwledge. The need fr this wide skills mix and knwledge f the lcality was eched by ne f the stakehlder interviews wh saw its benefit in being able t better supprt thse within custdy. This stakehlder discussed the added value f this knwledge in understanding the range f different rganisatins wh culd ffer supprt t staff and detainees, particularly where prblems may arise r smething desn t g quite t plan. This knwledge f lcal systems and peple was discussed in terms f nt nly the pilt staff, but als stakehlders and frensic physicians. I think that the service shuld be delivered by stakehlders wh are well rted in the lcal health ecnmy s that they have gt gd access and gd knwledge f the services available but that is n a daily basis knwing the peple that yu wrk with, knwing the services that are available, that just makes a very, very big difference And I think if yu have thse clse wrking relatinships then that is the added value because that can imprve the utcme fr peple that we re lking after. my understanding that this is nw being dne by healthcare prfessinals and that they, apart frm just ging thrugh a list they can add added value by having knwledge skills, etc. nt nly abut mental and physical health issues but als knw pathways, what s available fr peple, etc. because they are ur lcal GPs they knw the systems, they knw the services, they knw hw t access fllw up, they knw a lt f the peple that are cming thrugh and they knw a lt f the wrkers. One staff member did reprt that there had been sme early prblems in identifying the crrect referral pathways and that this had been a prcess f finding ur feet. A number f telephne calls and discussins with ther peple had taken place in rder t gain a better understanding fr making referrals, demnstrating the develpment f the staff s knwledge and cmmitment in supprting detainees. This was assciated with understanding the prcess t actin wrk/cntact teams within the custdy unit envirnment specifically, fr example mental health assessments r child prtectin rders. 43

44 I was like, Well, I really dn t think he s very well, and I thught he needed a Mental Health Act assessment s, but then hw that, hw that s implemented is hw I fund ut thrugh phning lads f different peple Because I wasn t sure what the prcess wuld be. If that was t happen again I nw knw the prcess and wuld be able t d that. It was suggested that a prcess map wuld be helpful in such instances s that staff knew wh t cntact. this is wh yu cntact, this is then what yu d, kind f flashcards, infrmatin cards, because it is slightly different Imprved knwledge f custdy staff As well as the knwledge and skills f the pilt and frensic physicians being a key benefit f the pilt, the sharing f knwledge abut the detainees t thse within the custdy unit has als been imprtant. One f the service prviders interviewed felt that the level f infrmatin abut peple in the custdy unit had been useful, prviding custdy staff with greater knwledge abut the best way t care fr individuals in rder t ensure their wellbeing and safety. we get the feedback we need that just imprves ur knwledge f the detainees s that their regime f care can be treated accrdingly In additin, the plice were thught t have gained a better understanding f the rle f different health prfessinals and that the supprt prvided by the pilt staff had assisted the custdy staff t fcus n their rles. there s benefits fr the plice t be able t think abut the safety f custdy and their prcesses and being able t cncentrate n that rather than healthcare Ultimately there s the welfare f the persn detained is the plice respnsibility and nbdy else, but by having a better understanding f what is ging n and what their needs are they can bviusly mitigate against any risk that there may be, etc. in a mre apprpriate fashin. 44

45 Alngside this imprved knwledge f the health and wellbeing f detainees, it was reprted, by several f thse taking part in the evaluatin, that there was an element f reassurance fr the plice that smene with medical knwledge was n site t assist with decisin making r t help in times f crisis, fr example when a persn has cllapsed. An example f this situatin was prvided and the relief fr the plice in having extra supprt was nted als this has helped t dispel sme early reservatins abut the rle f the pilt staff. what s becme apparent is we ve had a few physical, mre emergency type situatins and the nurse has been able t wrk smetimes n their wn but, and als alngside the FP, and the relief t the plice t knw that there s mre input at thse stages is quite visible and I think that really, ging thrugh an experience like that has changed their perceptins f the peple wh are wrking, f what might be the benefits f having nurses in custdy. If I ve gt a nurse that s actually wrking in custdy and I m nt very happy abut the presentatin f this individual, it s a real cmfrt t me as a custdy sergeant t have smebdy there that s gt sme health knwledge and health skills t be able t srt f fire that ff, s that s a real cmfrt blanket fr the plice Identificatin f health needs A number f health issues have been identified thrugh the pilt where pilt staff have been able t supprt peple s physical and mental health needs; fr example, the identificatin f a dislcated shulder, a resuscitatin, and screening individuals with a range f mental health issues. Fllwing n frm the screenings, a number f referrals fr n-ging supprt have been made t a range f different service prviders, fr example: the traumatic brain injury team, CRI, GPs, Serenity, child prtectin services, the safeguarding team, adult mentrs, the drug and alchl team and cunselling services. There was als a sense that these issues may nt have been identified had the pilt nt been taking place. 45

46 sme f the peple that have been diverted, sme f the things they ve picked up, a cuple f really serius safeguarding issues that wuldn t have been picked up therwise, an incident r an issue arund a chap wh had a serius head injury frm an accident many years ag that yu culd see that was directly attributable t his criminal behaviur frm that pint n because he didn t get referred t the serius head injury unit that he s nw receiving that supprt, there s been sme really gd stuff, yu knw, sme significant things that will definitely make a difference t these peple which is great. pririties, this is a health need, but actually there are peple wh dn t knw they ve gt a health need r, it wuld never have been picked up s I think that s really gd. The pilt has increased the number f health screenings being undertaken. While the plice cnduct their wn screening, the perceptin was that this may nt capture the underlying issues a persn may have. In additin, where a persn experiences chest pains, fr example, the plice may nt have the knwledge (and indeed are nt expected t) t knw whether the persn requires emergency attentin r is experiencing a panic attack. The rle f the pilt staff has been t supprt the plice in undertaking fuller screenings and t supprt their clleagues in addressing and understanding hw best t treat and supprt detainees. fr example, smebdy with chest pains is waiting t see a dctr when actually they re having an anxiety attack, it s things like that that the plice aren t trained t lk at and it s that mix f physical, mental health that I think is the key. It was als thught that sme minr issues were being identified, which previusly wuld have gne under the radar, such as lw level mental health prblems. An example was given f ne detainee wh had a lw level mental health prblem and thught that this was just the way life was, nt realising that they culd get help and supprt t deal with the issue. we ve picked peple up and bviusly the earlier we pick peple up the better prgnsis fr the future s I think the strengths are we re identifying peple that have gt mental health needs 46

47 Safeguarding issues have als been identified thrugh the pilt, with referrals being made t the Multi-Agency Safeguarding Hub (MASH), wh were reprted, by ne stakehlder, t have said that sme cases were being identified t the MASH wh may have previusly been missed. Fr staff, the recgnitin that they culd have a ptentially psitive impact in imprving a persn s life, via prblem identificatin, and thrugh ffering advice, was an imprtant aspect f the rle. that was really rewarding and a real strength fr me t see that actually she d have just gne unnticed, she d have gne hme, carried n as nrmal and prbably gt wrse and s that s really gd. In additin t this, the pilt staff were reprted t be wrking clsely with custdy staff, ffering advice n care needs fr service users r simply prviding supprt in making decisins t call the frensic physician r attend A&E. This has the ptential t nt nly reduce the number f unnecessary call uts but als reduces the need fr them t take that persn ut f custdy and then that persn can be prcessed accrdingly. Perhaps a less tangible strength f the prject has been the presence f the pilt staff within the custdy unit fr detainees. One stakehlder perceived the staff t bring a calming influence and anther dimensin. This view was supprted by anther interviewee wh thught that the pilt brught a hlistic apprach which was different t that f the plice and wuld encurage detainees t discuss issues with staff. I think the message has been very psitive abut the fact that this is a different type f persn ding a different type f thing, they just happen t be standing in that building s it s been very useful like that. This is perhaps due t their rle being external frm that f the plice and that they are seen as health wrkers. Interestingly, at the start f the pilt, the staff referred t themselves as mental health nurses, but this was nt always received favurably by the detainees, wh did nt wish t speak with a mental health nurse; but this changed as the pilt prgressed. Staff began referring t themselves slely as nurses, and the number f detainees wh engaged with them increased. It s very clear that their healthcare wrker is nt t d with the plice and what s been really fascinating is that they re much keener t speak t a nurse rather than a mental health nurse. 47

48 My presumptins, that is that we als are knwn r thught t lck peple up as are the plice s, yeah, peple are much happier t see a nurse and, Oh, yu re ging t d my bld pressure and take my pulse, and that feels cmfrtable and s, and peple, and they talk a whle lt mre s the nurses have srt f develped in that rle and gained their wn cnfidence, there s almst a srt f submissin [inaudible] t sme extent f peple cming in and saying, Oh well, yu knw, this, that and the ther, while yu re here can I tell yu abut this as well? Cllabrative wrking The cllabrative apprach adpted frm the utset f the pilt was thught t be ne f the key strengths f the prject. Particularly thrugh the invlvement f the varius rganisatins at the develpment/stakehlder level, frm prbatin, Cunty Cuncil, Health, Plice and referral agencies right thrugh t thse wrking cllabratively n the grund. This is assciated with the earlier pint made abut staff having a gd knwledge f services within the cunty and is supprted by the cllabrative way that the pilt was set up. what is the main strength, I srt f have t say it s the partnership wrking This cllabrative apprach was nted n the grund, within the custdy unit, as well as amngst stakehlders. A gd wrking relatinship was reprted between rganisatins within custdy whereby clleagues culd supprt each ther in making decisins which were best fr the health f the detainee. This culd be in relatin t custdy staff, CRI staff and pilt staff and was thught t have develped ver the curse f the pilt, with a shared knwledge and trust develping within relatinships. And having CRI there t clarify that and be able t just run with, yu knw, This is my decisin, that s my prcess, are yu happy with that, is that what yu yu knw, is really useful. Ultimately there s the welfare f the persn detained is the plice respnsibility and nbdy else, but by having a better understanding f what is ging n and what their needs are they can bviusly mitigate against any risk that there may be, etc. in a mre apprpriate fashin. 48

49 When they first started, sme f the staff in custdy were a little bit cautius in relatin t staff, and as they ve grwn with it and the staff within custdy have grwn with it, there s a much strnger bnd between them and the understanding f the language and hw they wrk with individuals cming in, have develped cntinually, s I think at the end f it all they wuld be able t give excellent feedback in relatin t what they ve fund and what the best way then frm there is t take it frward. Hwever, nt everyne cmmented psitively n the jint wrking practices within the teams, with ne interviewee talking abut the different teams in the custdy unit wrking in sil[s] and that the pilt had nt develped hw we visualised it wuld be. Initial prblems adjusting t the pilt and the numbers f peple in the custdy unit als caused sme early tensins between teams. Finally, the research team did nte specifically that there was real genuine cncern t ensure the health and wellbeing f the detainees, and that the pilt has benefitted frm being fully supprted by Nrthamptnshire Plice. S I think that ne f the benefits that Nrthamptn has certainly had is that the individuals that s been invlved in it have had a real willingness t make it wrk, bth frm a plice pint f view and frm the nurse s pint f view and hpefully that will be reflected in the utcme. One nte t cnsider, hwever, is the ptential fr duplicatin f rle within the custdy unit. A number f teams are wrking under very similar remits and it may be that this prcess needs t be rigrusly mapped, with the scpe f each rle and remit being carefully identified. This culd be cnsidered fr example with regard t the Dedicated Substance Interventin Prgramme team, CPNs and the health assessments cmpleted by the Detentin Officers. 5.4 Perceived Weaknesses f the Pilt While a number f strengths have been nted and bserved, there are als a number f issues identified during delivery f the pilt t date. These have ranged frm prblems with access t cmputer systems, understanding the rles and scpe f practice f pilt staff, awareness f the pilt evaluatin, and knwledge f the custdy unit prcesses. 49

50 5.4.1 Access t IT One f the main prblems faced by the pilt was access t the plice and cmputer systems. These prblems were experienced fr the majrity f the pilt with access t the internet, health systems and EPEXS (the plice database) being challenging. Prblems were als experienced as a result f nt having apprpriate access cdes fr the building and in becming familiar with new systems. This made it difficult fr the pilt team t cllect the full data required fr their recrds and t fully assess an individual. We still dn t have full access t the health systems in custdy which was ne f the things we wanted t have because we culd screen everybdy n the cmputer system. It s access really, the prblems initially were we didn t have access t the cmputer systems fr quite a lng, fr abut three mnths and we didn t have access cards t get in. S bviusly when yu see peple it s always gd t lk at the risk assessment the plice have dne, if they ve highlighted anything, if they ve been in custdy befre, any f the medical frms that they ve been seen befre s we ve nt been able t access that, that was quite difficult. These views were true at time f interview. The evaluatin team have since been made aware that access t systems has been imprved. It shuld als be nted that the prblems encuntered are als a natinal issue, with the sharing f infrmatin systems acrss the NHS and Plice being prblematic acrss the bard, nt specifically t Nrthamptnshire. This includes nt nly the access t IT systems but als challenges are faced in setting up apprpriate data sharing agreements with cnsideratin needed t ensure patient cnfidentiality and in understanding the terminlgy used by the different rganisatins. The plice were reprted t have been very helpful in prviding access t the systems and in supprting the pilt staff: als been great is letting us input n their plice cmputer systems because fr ages we didn t have any internet access at all. In additin, access t NHS recrds was discussed and it was thught that this wuld be f help t the pilt staff, and frensic physicians, and wuld enable them t have a 50

51 greater understanding f the needs f the peple being assessed prir t the assessment, fr example, histry f treatment fr mental health cnditin. One stakehlder acknwledged the delays experienced in prviding access t the IT and the building, and that sme f this had resulted frm delays in getting the names f the pilt staff early enugh t set the systems up. It was thught that a tw mnth perid was required t ensure all the CRB checks, HR systems, access cards and access rights were in place fr an individual Knwledge f custdy prcesses and apprpriate adult access Staff wrking n the pilt felt that they had quickly adapted and learnt abut the prcesses and systems used in the custdy unit. It was felt that little rientatin had been prvided t supprt staff in getting t knw their way arund and that this shuld be an area fr future cnsideratin. One interviewee reprted there had been difficulties with pilt staff nt being aware f the prcesses fr interviewing detainees and as a result nt always reprting when they were talking with detainees. Such missins had the ptential t trigger panic amngst custdy staff n realising a persn was nt in their cell. I think it wuld help greatly if they get their wn access, custdy system access s that they culd put the marker nt it straight away and then g and cllect the bdy and g ff t d the assessment. That way we re OK with where everyne is because we tend t panic. The need fr an apprpriate adult (and n ccasin an interpreter) t cnduct a health care screening was als thught t have had an impact n the duratin f sme health screenings and n ccasin, the apprpriate adults/interpreters may have already left the custdy unit befre the pilt staff had been able t see them. It was suggested that infrmatin abut the pilt may nt have been fully cascaded t peple n the grund and that these services wuld als be required by the pilt team. the infrmatin hadn t filtered dwn t their frnt end that they need t hang arund t have a discussin with the CPN which again isn t surprising because they ve gt an awful lt f apprpriate adults and yu need t tell them all and they all need t read that bit f cmmunicatin and understand it Althugh it was thught, by ne stakehlder, that this infrmatin had started t be filtered dwn and there was an expectatin that apprpriate adults shuld als be asking 51

52 whether the pilt staff needed their help. It is unclear frm the interviews and bservatins whether this expectatin is nw being met. Accessing detainees fr screenings was reprted t be quite time cnsuming n ccasins, and particularly frustrating when detainees had decided nt t participate in the prcess. One staff member discussed the prcess f asking custdy staff t help get s and s ut nly t discver that the detainee had been returned t their cell as they had declined t be screened. This interviewee described hw they had learned t adapt their apprach by speaking t them thrugh the hatch first s where I d get smebdy it s nt then a wasted jurney but it s the business f custdy. Therefre getting used t the prcess f gaining access t a detainee was thught t be really difficult, but it seems that staff adapted their wrking practice t fit in with these prcesses Rle and remit f the pilt The rle and remit f the pilt was nt always reprted t have been clearly defined by sme participants. Prblems arse thrugh incrrect expectatins f the service that pilt staff wuld be prviding. One interviewee, external t the pilt, talked abut the need fr clarificatin at the start f the prject t present clearly defined rles and clear referral pathways, s that staff wuld knw wh wuld deal effectively with the queries and cncerns raised. shuld the peple there, the custdy pilt, yu knw, assess them, and we ve said n, they shuld stay within their pilt rle, which is, yu knw, flag up, yu knw, any pints as they wuld abut physical health r anything in terms f filling ut the assessments, s there was that srt f query abut, and my staff were querying, well what s the rle f the pilt peple? S we had what I wuld call just nrmal teething prblems f any jb let alne a pilt, just sme clarity arund whse rle is what really One f the frensic physicians als expressed sme cnfusin as t the rle f the pilt staff, as their expectatin had been that staff wuld be triaging minr physical cnditins and assessing mental health, hwever, their view f the pilt was that staff nly seemed t be cllecting data. The expectatin fr this individual had been that they were t d everything except the frensic related jbs, therefre suggesting that clear cmmunicatin abut the pilt s rle and aims may be needed if this service is t be develped further. 52

53 In additin, the bundaries f the pilt were tested n ccasins when staff were asked t undertake tasks utside f their designated rles. This seemed t be partly in respnse t needing mre clarity cncerning the remit f the pilt wrkers; their visibility in the custdy unit (they are in the building s it is easy t ask fr their help), and their ability t supprt thers in their rle. sme will push the bunds f that pilt mre than thers, s sme will say, Well yu re a healthcare prfessinal, yu re [inaudible] I d like yu t d all these bservatins and X, Y and Z, which desn t fall within the bunds f the study There was a sense frm sme f thse interviewed that these bundaries were nt always adhered t and that pilt staff had t be accmmdating at times but als be quite strict in saying, yu knw, This can t hld us up in what we, yu knw, in what ur rles are. This tensin f adhering t the pilt remit may have resulted in ne respndent s cmment that the medical persnnel within the custdy unit were nt functining in a medical capacity and that their fcus was t much n data cllectin. There was a general feeling that the relatinships between the custdy staff and the pilt staff was wrking well; and that the custdy staff clearly understd the rle f the pilt staff. It was thught that there was a respect between the tw partners and pilt staff felt able t say n when asked t d smething utside f their remit/experience. but the plice have always been really pen t discussing thse and kind f wrking with us and respectful if we ve said, N, can t d, then we can t d A few ther cncerns abut the pilt s remit were als raised. Firstly, with regard t the cnfidentiality f data and where this data was stred. This was assciated with the use f shared systems and hw a detainee s infrmatin culd be shared, apprpriately, acrss prviders t ensure a synergy f wrk. Hwever, it was nt clear fr ne service prvider, whether this crss wrking wuld be pssible within the pilt. Secndly, ne interviewee talked abut the lack f cllabratin between their team and that f the pilt staff, thinking there wuld be a crss ver in discussins, but that this had nt taken place. This was thught t be a result f the fcus fr the pilt staff n yung peple, while this individual s team wrked with lder adults. 53

54 I feel like when we started my understanding wuld have been there wuld have been quite a lt f, perhaps, cmmunicatin between my team and that team. My understanding frm feedback I ve received it s nt really, they seem t wrk n very different individuals and I wndered if that was mre because the fcus has gne t the yuth wrld and we actually dn t fcus n the yuth wrld s Finally, cncern was expressed abut the cmmissining f a future service thrugh the NHS. The wrry was that the fcus wuld be t much n health and that the distributin f staff acrss different agencies may becme blurred, s that staff wrking in ne department may be expected t cver acrss different teams and pririties may be given t ne area ver anther. It s always a risk isn t it where resurces are becming mre finite that, yu knw, it might just be that my psychiatric nurse is cvering the plice statin it s all cmmissined thrugh the same service, s, that s a risk. Therefre, it was thught that any future service prvisin shuld ensure adequate staffing and resurces are in place Impact n external services It was suggested that the develpment f the mental health pilt culd have a direct impact n increasing the number f referrals t ther external agencies. And when yu ve gt a service that s quite busy, if yu then start ringing peple up and saying, We ve fund lts f peple with prblems, they just start thinking Oh ww s I guess we have referred nt them but they re, that s prbably swamped them t sme extent smetimes because we ve cme at it frm a different angle. We ve referred in quite regularly t the single pint f access fr cmmunity mental health services I think the ne place we refer int have been a little bit unclear abut ur rle and where we fit in and why we re generating mre wrk fr them 54

55 This was discussed in relatin t the frensic physicians, sme f whm reprted thrugh the questinnaire, that an increase in the number f calls had already been nted. One respndent was cncerned abut the explanatins fr sme f the calls and thught that many were unnecessary, resulting in time wasting and extra cst fr the plice. Examples were prvided f sleeping pills being requested fr detainees, cncerns ver high bld pressure, and an incident where a detainee had been kept in custdy lnger than the frensic physician n call thught was necessary. One respndent als thught that their rle had been made mre difficult as detainees, wh had already spken with a nurse, did nt want t speak with an FP. I think I have had mre requests t see detainees when therwise I have nt felt it necessary t see them nr have the plice. Cmments were als made n the increased rle f the apprpriate adult service, which cntained a number f vlunteers, wh had previusly been requested fr juveniles, but wuld nw in additin be required fr health screenings. they ve been very reluctant t stay, because they re there fr the rights and the interview Screenings with yunger peple were discussed as being difficult t carry ut, requiring the presence f an apprpriate adult. When this was nt a family member, the apprpriate adult service has been called, which can frequently delay screenings due t the length f time it can take t arrive, r they can leave the building while the pilt staff are attending anther persn. Because the prblem we were having was yu identify a child, carry n ding the screens, yu d cme ut f a screen and the apprpriate adult had been and gne s yu missed them. What usually happens with the apprpriate adults is they re called fr the interview prcess and they, by the time they arrive the interviewing fficer is ready t crack n with the prcess, yu dn t want t jump in befre that This is perhaps an issue related t ensuring that infrmatin cncerning the remit f the pilt is given t external agencies; and that they may be infrmed abut the ptential increase n referrals they receive. 55

56 5.4.5 Awareness f pilt On the whle, awareness f the pilt and its aims and remits was extensively knwn and reprted thrughut this evaluatin; hwever, sme individuals did admit t being unaware. Sme service prviders made cnnectins t it with ther prjects r admitted that they were nt aware that the prject was taking place. A number f ther factrs such as peratinal hurs, equipment and examinatin rm issues are discussed in the fllwing sectins and these issues (bth psitive and negative) are explred in detail. 5.5 Operatinal Hurs The peratinal hurs f the pilt changed during the initial few mnths. Originally designed t run frm 9am-5pm Mnday t Friday, these hurs were increased s that the pilt ran frm 10am-10pm. Fr sme, the hurs were viewed as very suitable as this cvered an adequate part f the day and ran in parallel with the shift patterns f custdy staff. Practically it was als suggested that thse peple brught in during the early hurs f the mrning were given time t recver frm any alchl excesses and t have been prcessed by the custdy staff befre a screening was carried ut. As fr the ten t ten, it s a gd time t start because, particularly n the weekend, if yu ve gt smene that s cme in at fur in the mrning, drunk, there s n pint trying t d anything with them befre ten r eleven anyway Hwever, ne persn interviewed raised a cncern that the pilt team were nt n duty at the time when shifts hand ver and infrmatin is shared between shift staff. It was thught this was a valuable transitin and the pilt team may benefit frm this. S starting at seven, everybdy gets that infrmatin first thing. Wh came in vernight, wh is still here, wh s ging ut f the dr in the next half an hur? S yu get t understand that mrning clarity and I dn t think that they start at seven, frm my understanding S they miss that, if yu like, that first what I think is really relevant The perceptin was very much that weekends and Friday night wuld be busiest, hwever, in practice this has nt necessarily been the experience. Busy times in custdy 56

57 seem t be very difficult t gauge, with week day mrnings smetimes prving t be busier than weekends. there was n pattern, it culd be busy n a Tuesday mrning as it culd be n a Saturday night, they were tld that it was, yu knw, all hell breaking lse all weekend but actually that s [nt what] they were finding The level f cverage was discussed by a number f thse invlved in the evaluatin, with sme suggesting a 24/7 service wuld be beneficial. One individual spke f the current prvisin being very spradic, while anther expressed cncern if 24/7 cverage in custdy was nt prvided lnger term. Their cncern centred n the need fr supprt cuntered against the use f resurces and funding. This discussin was tied in with understanding when the busy times are in custdy and needing mre than ne persn n duty during thse busy times. But als recgnising that there are ther times in custdy when ne r n staff may be needed. part f the prblem fr the mdel that we are pilting at the mment as well, is that smetimes yu need mre than ne persn and smetimes yu nly need half r a quarter and that is very, very difficult, s I dn t have the answer t that 5.6 Identifying and Undertaking Screenings The riginal remit f the pilt had been t screen all detainees entering the custdy unit in Nrthamptn. Hwever, given the level f staffing and the number f hurs f the pilt this was nt pssible. The team were therefre required t select r priritise peple fr screenings. Frm the interviews and bservatins, there did nt seem t be a prescribed prcess fr deciding wh t screen r wh nt, hwever staff tried t priritise juveniles and thse with a knwn mental health issue, as had been identified by the pilt aims and bjectives. Hwever, screenings culd be led by practical factrs such as wh was available t be seen r by discussins with the custdy staff t try t identify needs, and as such it has nt always been pssible t screen all pririty cases. Given the number f staff wrking n the pilt, ne per shift, and the time taken t undertake a screening (this can take several hurs with write-ups), it became clear that it wuld nt be pssible t screen everyne ging thrugh the custdy unit. One member f staff talked abut the pressures t see as many detainees as pssible and that this was difficult t d given the extensive paperwrk and dcumentatin which accmpanies 57

58 each screening. Other issues which culd prlng a screening included access t detainees at mealtimes and waiting fr apprpriate adults and interpreters And then a cuple f days I d nly d like five in a 12 hur shift and I d be like that s like ne every tw hurs, what have I been ding? But then when yu take int accunt the writing up f the health screening and then if yu are typing letters and fllwing up t GPs, it s all abut time if smebdy cmes in wh s under 18, that is seen as a pririty But then that invlves a lt f waiting s we have t like phne an apprpriate adult. The pririties fr screening fr ne interviewee were juveniles and thse with a mental health issue. Hwever, when neither f these pririty cases were present in the custdy unit n a given day, this participant described being questined abut why they were screening individuals with n immediate pririty cncern. It was felt that this cnfusin ccurred due t lack f clarity abut the aims f the pilt and their rle he said, Why are yu screening peple if we ve dne the risk assessment and said there s nthing, there s n issue? What s the utcme? Nthing because there isn t anything and he was saying, Well why are yu ding that? and I m like, Well, because that s the pilt we re screening. Prcesses within the custdy unit culd als interfere with screening prcedures, ne staff member described hw sme had had t be finished quickly as the detainee was ready fr release. There was an acknwledgement that this may have resulted in a lss f data, but there was als a feeling that the custdy prcess shuld be adhered t and nt subject t delay. it s quality f data in that respect, we ve prbably nt dne as well but that s brne ut frm nt wanting t stp peple frm being, ging thrugh that prcess they need t g thrugh. It shuld als be nted that detainees were given the pprtunity t take part in r decline being screened. S even if staff were available t screen every persn within the custdy unit, this may nt have always been pssible. While this was generally thught t be a psitive aspect enabling freedm f chice in an envirnment where this rarely ccurs - and is ethically crrect, there was als the cunter view psed that thse in an unstable mental cnditin culd refuse t be screened. This raised cncerns that sme 58

59 vulnerable individuals may nt be screened raising cncerns abut their fitness t be interviewed r detained. I think because we ve gt the clear cnsent bit at the beginning, they can say, N, nt interested, r, Yes, s they ve gt a chice which yu dn t really have much in custdy Thse that are mentally very unstable, prbably wn t cnsent t, s yu knw, actually prbably the weight f peple that are chrnically unwell might nt sit within the bunds f the study necessarily all the time because f hw yu deal with them. The cmplexity evident in determining the suitability f an individual t be health screened was als highlighted when ne participant talked abut having screened apparently healthy individuals. Cmments were made cncerning the ptential drain n resurces, but the cunter argument that was raised indicated that even apparently healthy individual can have unfreseen issues. there s certainly a cuple that I ve seen that cme in with n mental health prblems, n physical health and I ve seen them because there was nthing else, pririty-wise t see and actually they ve been really, really quite unwell but just kept a lid n it. I think that was gd in the idea f screening every, we say everybdy but as many peple as we culd On-ging supprt An aspect f the pilt which was raised by a number f thse interviewed was the prcess f fllw up r n-ging supprt ffered t thse wh had been screened and identified with a health need. It was thught that ensuring gd links with rganisatins was key t the success f the pilt and in ensuring that services a) knew that a detainee required their supprt and b) that detainees fllwed up n the advice prvided t them. And then saying, This persn prbably needs t see the psychiatrist in there r needs sme input frm the mental health team, and linking it in, yeah, s peple aren t left and slipping thrugh the net 59

60 It was discussed that ften advice was given t detainees but that the nus t act upn this advice was up t the individual. While staff culd write t GPs and ther service prviders, the individual was respnsible fr acting upn the advice. The pilt is nly in a psitin t invite detainees t engage with services, they cannt insist n it. In additin, ne persn interviewed discussed that ften at the time f screening, the detainee and the pilt staff can be unaware that they have been struck ff by their GP. This nly cmes t light when the pilt staff make cntact with the GP. Therefre, it was thught t be imprtant t have a way t fllw these cases t ensure they receive the treatment/services required. I m saying t peple, G back t yur GP and ask fr a referral t Changing Minds r get yur medicatin reviewed r ask t be seen, yur GP might want t refer yu int secndary services, s there s a lt f that ges n and I say t them, yu knw, We ll write t yur GP whilst yu can t have a cpy f this we can certainly send that infrmatin t yur GP, s just fllw that thrugh, and, yeah. because we bviusly get a respnse back frm the GP saying, This persn is n lnger n ur lists, We re nt clear that that detainee knws that s, because they ve nt engaged, s I think it s picking up thse srt f things. 5.7 Practicalities f Wrking in Custdy The pilt staff encuntered sme early difficulties in getting t knw the systems and prcesses f wrking within a custdy unit. It was thught that this knwledge was develped quite quickly and that staff went thrugh a rapid prcess f learning t understand the prtcls f the custdy unit. The custdy staff were reprted t be very helpful in supprting the pilt staff t access detainees, helping t get peple frm the cells t the screening rm and enabling access t cmputer systems while technical difficulties were experienced by the pilt team. the detentin fficers have been great in getting peple ut fr us and als been great is letting us input n their plice cmputer systems because fr ages we didn t have any internet. 60

61 Hwever, as has already been discussed, the practicalities f accessing cmputer systems and knwing when and hw t mark a detainee ut f their cell were part f the pilt staff s learning. In additin, sme f the practicalities f wrking in the envirnment were als difficult t manage, in particular the access t a suitable space t carry ut screenings and the use f equipment Physical space The physical wrk envirnment within the custdy unit was discussed by a number f thse interviewed, primarily relating t the space in which screenings take place. Fr the first few mnths f the pilt, staff were nt sure f all the rms available t them and where they culd carry ut screenings. we fund ut there were tw clinics, we didn t knw that fr a gd few mnths In additin t this, issues have arisen ver the use f the clinical rms, ne space is dedicated fr the use f the frensic physicians and this is given pririty fr their use. A sterile examinatin rm has als been used, but this has caused cncerns as it n lnger remains a sterile envirnment if screenings are taking place. Other rms have been identified as ptential rms t carry ut screenings, hwever, due t safety issues r practical issues such as nt having a sink r apprpriate safety measures, these have nt been suitable fr use. As well as the pilt staff and frensic physicians using interview rms, CRI and ther teams were als accessing space, smetimes having an impact n when screenings culd take place. Therefre, it seems t have been difficult fr the pilt staff t create a space in which t undertake their screenings. There s nt actually much rm t d these things s I think that s smething that s prbably the mst stressful between the nurse and the dctr, it s nt thrugh persnal issues but just wh des what when. S ccasinally there was times I just culdn t see anybdy because there was n rm Equipment As well as sme issues arising frm the sharing f spaces within the custdy unit, similar issues have been experienced frm the sharing f equipment. When the same piece f equipment has been required fr bth pilt staff and frensic physicians at the same 61

62 time r where a piece f equipment has been mved t a different area, difficulties have arisen. This has resulted in the level f screenings being undertaken, n ccasin, r frensic physicians finding it difficult t access equipment. Prblems were als experienced by pilt staff in mving frm rm t rm with equipment, as well as nt having apprpriate facilities in screening rms, such as wash basins. that can be an issue because they, the frensic dctrs lk fr it and then we ve gt it and then if they have it we then can t screen peple fully because we dn t have the equipment And the equipment issue I think is frustrating, frm bth parts because they g, they see smebdy and g t d smething and the equipment s nt there and bviusly if yu ve gt a detainee in the rm with yu then can t just walk ut t g and get smething, yu have t then take them back t a member f staff And then cme back, find the equipment and then get them back if yu d use a different rm, carrying equipment, sharps bxes, needles, then g int a rm where there s n facility t wash yur hands after yu ve taken smebdy s bld sugar Anther issue, which was raised by ne f thse interviewed, was that f respnsibility t check and recalibrate/restck equipment. With bth teams using the same equipment the respnsibility f wnership may have been blurred and n ccasin items had run ut, were nt available when needed r waste was nt rutinely cllected. As part f the discussins the need fr duplicate equipment was discussed and it was thught this culd alleviate sme f the issues experienced during the pilt. S just simple things like my general medicine isn t that gd s smetimes I need t check the spelling but the BNF s in the dctrs rm and if the dctr s there yu can t access it. A medical dictinary because everything s gt a medical name and just having tw sets f things I suppse fr me the nly difficulty such as, yu knw, lack f clinical waste dispsal and rms and things Fr bth the use f rm and equipment, and perhaps mre generally with regard t psitins, there was a feeling frm ne interviewee f hierarchy between the pilt staff 62

63 and frensic physicians: the real issue is there s still the srt f hierarchy f that s the dctr s the rm and I m the dctr and yu are just the nurse, s Finally, ne interviewee raised cncerns that sme f the equipment was nt in a gd wrking rder and errrs were encuntered when using sme equipment. 5.8 Training Needs A number f training needs were identified during the curse f the evaluatin, bth in relatin t training undertaken and training needs fr the future. One f the training issues discussed during the interviews was f the training which had been prvided t pilt staff t ensure their skills were suited t the tasks they were being asked t perfrm. As the pilt staff were mental health nurses the fcus was n develping their physical health skills. It was felt by ne stakehlder that it was ptentially mre feasible t develp these physical health skills than t develp mental health skills in a nnmental health nurse. yes, putting CPNs up, maybe it s cause I m mental health trained, I dn t knw, but I think it s harder t up skill in mental health than it is in physical but there s mre cntainable specific training that rather than a way f wrking, it s hard t up skill n a whle way f wrking whereas yu can say, OK, identify these particular healthcare needs and, yes, yu ve dne that, we can see yu re cmpetent in that and yu can then g and practice that. My wn pinin abut that is I dn t see any mre physical health patients than I see mental health patients r vice versa, withut mental health knwledge wuld yu have the backgrund and expertise t g fishing fr things that perhaps are undisclsed r undiagnsed? I guess likewise with the physical health knwledge and cntinue up skilling either prfessinally in bth and there s n denying that there are skill mix areas that we need t lk at if we were t mve frward Future training needs were identified thrughut the running f the pilt in a number f areas. Sme were practical in relatin t health skills and sme mre ethical in relatin t fitness t detain training/interview and discharge risk assessments. 63

64 Is he fit t be interviewed, is he fit t be detained? and that s, frm a mental health perspective I m happy t make that decisin but frm a legal perspective I m nt because I dn t understand the legal framewrk that ges with that Training in physical health issues were identified in the areas f treating minr injuries, further infrmatin n cnducting physical assessments, assisting in prescribing medicatins and suture training. These are the key areas which have been identified as requiring further training. Further t this the ptential t supprt individuals in the management f alchl/narctics and their withdrawal were als thught t be an area in which the pilt staff culd be supprted t develp. One f the psitive aspects t have been identified, and shws the cllabrative apprach f the pilt, is that the frensic physicians have agreed t supprt the pilt staff in develping sme f these physical health training needs and will be undertaking that training with them. I als understand there has been sme feedback in relatin t sme training that the FMEs are prepared t give t the nurses t actually assist them in sme f the rles that they ve been ding. In additin t the training needs f the pilt staff, the training needs were als discussed with regard t the frensic physicians and it was nted that they need t maintain their skills and ensure they are appraised in line with [General Medical Cuncil] requirements. One interviewee als discussed the need fr training t be prvided n the cmputer systems, the legal issues and the prcesses f wrking in the custdy unit. As has been discussed, n frmal inductin prgramme r training was prvided t staff and it was thught that such an inductin prgramme wuld be very helpful t put in place if the service cntinues and if new staff jin the team. Yeah, I think if, depending where the pilt ges and if it ever develps t be a service, I think I wuld be wanting a clear, defined inductin prgramme abut the plice prcesses, the legality side f it, yeah, because it was verwhelming 64

65 5.9 Re-ffending Rates One f the riginal aims f the pilt had been t understand its ptential impact n the re-ffending rates. Thrugh the identificatin f supprt needs and apprpriate referrals t external agencies, it was hped that individuals may be helped t nt re-ffend. One interviewee felt that this wuld be particularly pertinent t yung peple, wh thught that greater links with the care system, health system and the criminal justice system culd ptentially supprt the lwering f ffending rates fr juveniles. Hwever, the cmplexities f this were als nted, in particular the ften, large number f services, which are frequently invlved with lked after children. The evaluatin has indicated that within the time perid f the pilt it has been difficult t identify whether there has been an impact n ffending rates. Several interviewees cmmented that it wuld be difficult t determine its impact in the shrt term, but may be a cnsideratin fr the future cmmissining f a similar service within the custdy unit, which culd mnitr re-ffending rates lngitudinally. I think t reduce re-ffending, I think it s ging t take a lng time t evidence that because it s, it s nt even necessarily abut peple s severe and enduring mental health prblems but sme f the mre lw level self-esteem, anxiety, depressin, whereas they access wellbeing teams and have the apprpriate interventins, I think yu re lking at a mre lngitudinal study I dn t knw whether we re truly ging t see that re-ffending, I think that needs, I ve always said that needs t be in the cntract f whever has s that yu culd review after a cuple f years, yu can't really tell in mnths. Hwever, the fcus f the pilt n reducing re-ffending rates was nt universally felt t be apprpriate. One persn thught that the fcus shuld be firmly n the perceived health benefits and utcmes in the first instance, but they did acknwledge that a reductin in re-ffending culd be a useful bi-prduct. S urs is very much fcused n reducing ffending and I dn t think it s necessary fr all f us t always have such a strng, yu knw, fcus n reducing ffending Fr me this is health and, yu knw, if it des have a gd knck n effect, brilliant 65

66 5.10 Imprvements fr the Future The interviews discussed aspects f the pilt and healthcare in the custdy unit mre generally, which sme participants thught culd be imprved fr the future. The fllwing sectin suggested imprvements fr the pilt, and the fllwing sectin fcuses n the custdy unit Rle and Remit It was hped that thrugh this pilt, a clear picture f hw nurses culd supprt the custdy unit and the rle f the frensic physicians wuld emerge. In terms f the rle f the pilt staff, there was agreement frm thse interviewed, that the main aim was still t prvide a way f identifying thse entering the custdy unit wh have a mental health r physical health need and prviding apprpriate signpsting t supprt fr these individuals whether this is fr physical/mental health r scial services issues. my gal wuld be that ffender s needs, as they cme int custdy, are identified, be they mental r health r emtinal wellbeing needs, physical health needs, I include autism and things like that in there, r scial husing benefit r drugs r alchl are all identified and that persn is actually cnnected in. The rle f the pilt staff was als reprted t be imprtant fr further cnsideratin, with a clearly defined remit. Sme additinal elements t their current rle were suggested, fr example being able t administer medicatin and gaining a fuller understanding f the fit between the frensic physicians and the pilt team, i.e. identifying which lwer level tasks can becme the respnsibility f the pilt staff. One respndent reprted that this shuld be mre f a triage prcess within custdy, with staff treating minr illnesses r ailments. It was suggested, by ne stakehlder, that cnsideratin shuld be given t the level f staffing fr any future service. Wuld mre staff make it pssible t screen everyne entering custdy? Is this necessary fr a future service? These were sme f the cnsideratins psed by this interviewee Cmmunicatin abut the pilt its aims and remit The need fr a clear utline f the rle f the pilt and its remit was discussed by sme interviewed. This was the case as the pilt was initially launched and fllwing its extensin, when there was a further pprtunity t restate the aims. 66

67 the pilt in custdy s been really gd and it s still a learning curve fr all f us but I think clear definitin f what we d and we dn t d wuld be really helpful. The need fr imprved cmmunicatin was als discussed as a key fr the pilt shuld it develp further, in terms f presenting the service t a wider range f supprt services and prviding infrmatin abut its functin, aims and remit. As ne stakehlder stated, if yu want peple t cme n bard just t increase their understanding, yu knw, yu d achieve that even if just by sharing a bit f infrmatin. Cnsideratin shuld therefre be given t sharing the wrk f the pilt mre widely, specifically in relatin t wrking hurs, staff rles and backgrunds etc. In this way a better understanding f the purpse f the pilt can be disseminated and pprtunities fr team cllabratins identified. but key t that is that service wrks, is effective, is knwn by all partners because I think, I have t say that is a real challenge, magistrates and judges and getting all that infrmatin ut, but that infrmatin gets t them as well and everybdy s familiar with that The actual rle f the pilt needs t be cnfirmed s that staff clearly understand what supprt they can prvide t frensic physicians, and what health needs they can specifically supprt. I think what we d like t see is perhaps if smene s gt a bump n the head, yu knw, d they need a steristrip r d they need t g t hspital which takes the nus ff f the dctrs, wh as I say can be therwise cmmitted fr sme hurs Develping cllabratin acrss services As the pilt develps further, it was suggested that strnger cmmunicatin prcesses needed t be established t maintain and strengthen gd links with external services s that staff are aware f the full range f services which they can signpst fr detainees. One service prvider talked abut wanting t knw mre abut the pilt and f ensuring that they were nt frgtten as a service. It was suggested that a database f rganisatins with key cntacts culd be develped t ensure that all apprpriate services are linked int the pilt. 67

68 A cllabrative apprach was als seen as a key t the future success f this pilt, thrugh jint wrking between services. The use f a single database f infrmatin fr example was suggested as a way f supprting this sharing f infrmatin/knwledge. One interviewee was cncerned that the different teams shuld nt be wrking in islatin, but that there shuld be a cnnectin and crss wrking between teams. While anther suggested that inter-agency training wuld help t prvide a better crdinated apprach t patient care. A service that is integrated int the cre f the NHS enabling direct exchange f infrmatin between custdial medicine and mental health services, GP, hspitals etc Physical space and equipment The prvisin f a suitable envirnment fr health assessments and apprpriate equipment has already been discussed as areas fr cnsideratin in the future. Duplicatin f equipment fr pilt staff and frensic physicians was thught culd imprve the running f the pilt, as well as practical elements such as a clck in each rm, new equipment such as a pressure machine and a thermmeter, and clear respnsibility fr upkeep f equipment and supplies. Mental health wrker having a dedicated clinical rm and with access t apprpriate IT. One interviewee als spke abut the ptential t cmplete the screening frms electrnically t ease the pressures f writing up. It was suggested that an ipad r ther electrical devise wuld be valuable in supprting staff t undertake screenings mre effectively and in a mre timely manner Prvisin f n-ging supprt Anther area which was suggested where the pilt culd develp, was in supprting detainees t access supprt and in seeing that end result utside f the custdy unit, perhaps thrugh mre in-depth supprt r further advice. Primarily, it was thught that ensuring infrmatin abut peple s mental health issues is actually being picked up by ther agencies r thrugh the criminal justice system was thught t be a key area which the pilt culd take up and that detainees access the supprt suggested, thus prviding a greater cntinuity f care. 68

69 but it was ne f the things f the pilt, is getting the infrmatin dwn the system making sure peple get the apprpriate care and I mean we can all give peple scripts and give them an appintment t g t but a lt f these peple dn t s I think there needs t be much mre structured interventins fr peple n release with mental health prblems. While initial fllw up is being carried ut by the pilt team, it was thught there culd be scpe fr a mre invlved, lnger-term fllw up t ensure that nce identified as being at risk, individuals are nt lst in the system, but are prperly supprted. then they can be referred n because if yu let these peple g, especially substance misuse and, yu knw, repeat ffenders, if yu let these peple g, yu lse them again t services and they can t get the supprt. It was als suggested that a timeframe within which a persn is held in custdy and when supprt is accessed shuld be cnsidered s that peple are prcessed in a timely manner and t get things mving. it is, yu knw, have that pprtunity there and then within a set timeline, get rid f them int either custdy straight away r clinical assessment r scial care r family r smething, and get things mving. The prvisin f additinal services by the pilt staff was als discussed, with ne interviewee suggesting the team shuld be able t prvide cgnitive behaviural therapy (CBT) t detainees r shrt term interventins with peple, smetimes arund educatin (in relatin t medicatin fr example). It was als suggested that this lnger term interventin shuld be delivered utside f the custdy unit in a mre neutral envirnment. Hwever, this wuld be an extensin t the rle and remit f the pilt, but culd be cnsidered in the future. it might invlve us ding the mental health assessments as well, s getting a fuller assessment f peple, but it might als invlve us ding sme fllw-up with them as well s getting them t see peple utside f custdy and just lking at what they can d. I mean fr me, fr me there is rm t d srt f [inaudible] fcus there and there is rm t d a bit f CBT here and there, yu knw, medicatin advice, illness advice, there s rm t have peple back 69

70 It was als suggest that a mre in-depth assessment, fr thse individuals wh are presenting in custdy regularly, culd take place in rder t develp a mre hlistic understanding f the issues cntributing t the individual s criminal behaviur, rather than the snapsht currently being prvided by the pilt. smene saw yu week after week r mnth after mnth and yu had lnger cnversatins with them that were mre abut them as peple rather than what they d dne, I think yu d find that yu d get a lt mre than what we ve gt in this study, this kind f snapsht f, Have yu gt any mental health prblems? N. Yu knw, I think yu culd extend it quite a lt in that respect The Future Prvisin f Healthcare in Custdy As part f the discussins, interviewees were asked t cnsider the future f health care fr peple ging thrugh the custdy unit and this led t a number f recmmendatins r aspiratins fr the way custdy units culd be imprved. The key aims fr the future f the custdy unit were t: Encurage mre female frensic physicians and paediatricians encuraged t take n frensic wrk. Develp an understanding f the ratis f staff t victim with a view t benchmarking the cunty against ther areas via a gld standard. Include a wider remit f scial and educatinal partners t becme part f discussins n hw best t tackle issues f mental health and crime. It was suggested that including educatinal teams culd help t prvide supprt t juveniles at an earlier age and start t tackle the issues as early as pssible. Develp imprved links with and greater access t accmmdatin services. Prvide earlier interventins, befre peple enter the custdy unit fr example with nurses attending in plice vehicles. It was thught, by ne interviewee, that prviding supprt further dwn the line, at an early stage and fr thse peple wh d nt attend custdy and are dealt with n the street, in their hmes etc., was an imprtant way t take this service frward. Cnsider the facilities fr individuals under the Sectin 136 f the Mental Health Act, are there sufficient facilities and supprt available fr these individuals. 70

71 A cncern was als raised with the crisis team whse wrk was thught t be prblematic by ne respndent. I wuld like fr us t be able t refer t supprt and that wuld ideally include accmmdatin, yu knw, because that s s key. That wuld be, but t have, the ideal is t have it everywhere, s it desn t matter where yu pp up, it s there and therefre it s dealt with. having sufficient staff and sufficient facilities fr Sectin 136 s that they dn t end up in a plice statin The next sectin presents the findings frm the rutinely cllected data. The themes emerging frm each element f the reprt are then drawn tgether in the Cnclusins sectin. 71

72 6 Rutinely Cllected Data Findings This sectin prvides the findings frm the rutinely cllected data, with infrmatin prvided n detainees demgraphic details, physical and mental health, current criminal activity, scial status and referral activity. 6.1 Demgraphic Infrmatin Data was cllected n 505 individuals wh had received a screening during the initial pilt phase. This includes data n physical and mental health, scial circumstances, arrest details and demgraphics. The exact number f thse wh declined a screening is nt cnfirmed, hwever, 71 individuals were recrded as declining and the perceptin frm staff is that this figure is under recrded. During the pilt phase (1 st July 2013 t 31 st Octber 2013) a ttal f 4,646 detainees went thrugh the custdy unit, this represents a 10.8% rate fr thse being screened. Of thse detainees, 426 were juvenile detainees, representing a 5.6% rate f juveniles screened during the pilt. Of thse whse data was cllected as part f the pilt, 16% (n=79) were female and 84% (n=426) were male (83%, n=20, f thse aged under 18 were male and 17%, n=4, were female). A wide range f ages was reprted, with individuals screened frm 13 years f age t 81. Thse aged between 18 t 45 years f age represent the majrity f thse wh were screened. Only 24 (5%) f the individuals screened were under the age f 18 and a further 55 (11%) were aged years ld. Table 2: Age range Age range N. % Under % % % % % % % Over % (Base=505) 72

73 The majrity f thse wh were screened were White British (74%, n=373) and a further 7% (n=35) were frm anther white backgrund. Table 3: Ethnicity Ethnicity N. % White British % White Irish % Any ther White backgrund % White and Black Caribbean % White and Black African 6 1.0% White and Asian 1 0.2% Other mixed backgrund 2 0.4% Bangladeshi 5 0.9% Indian 6 1.0% Pakistani 3 0.6% Any ther Asian backgrund 2 0.4% Black African 16 3% Black Caribbean % Any ther Black backgrund 8 1.5% Chinese 1 0.2% Any ther Ethnic Grup 3 0.6% Nt knwn 1 0.2% (Base=505) 6.2 Type f Offence Cmmitted A large range f different ffenses were recrded as having been reprted fr individual s arrest details. These relate t 113 ffenses, with shplifting (9.5%, n=48), ABH (5.3%, n=27), ABH and anther crime (5%, n=25) and theft (4.6%, n=23) being the mst cmmn ffences reprted. Lking at the crimes in brader terms, the fllwing were identified as the mst prlific reasns fr arrest (Table 4 shws the full range f crimes reprted): Theft/rbbery (f all types) 35% (n=176) f all detainees; Assault (including ABH, GBH and cmmn assault) 21% (n=106); Breach/disturbance f peace 4% (n=22); Drugs ffenses 5% (n=26); 73

74 Criminal damage 4% (n=20); Driving ffenses 4% (n=18); Affray 3% (n=17); Fraud 3% (n=17); Sexual ffenses (including rape and indecent expsure) 3% (n=16). Table 4: Arrest details Offence N. % Shplifting % ABH % ABH and Criminal Damage/GBH/Arsn/Other wunding % Theft % Other ffences % Breach % Burglary % Cmmn assault % Burglary dwelling % Warrant % Affray % Assault % Fraud % GBH/wunding % Criminal damage ther % Criminal damage 9 1.8% Pssessin with intent t supply 9 1.8% Rbbery 9 1.8% Pssessing class A/A &B/ ther drugs 8 1.6% Drunk & disrderly 7 1.4% Theft (ther) 7 1.4% Drink drive/unfit (drugs) 6 1.2% Affray/Offences against State 5 1.0% Assault n plice 5 1.0% Drink driving 5 1.0% Theft f mtr vehicle 5 1.0% Threats t kill, and ther ffence 5 1.0% Threats/cnspiracy t murder 5 1.0% Other drug ffences 4 0.8% Recall 4 0.8% Sexual assault 4 0.8% Theft frm persn 4 0.8% Theft frm vehicle 4 0.8% Theft f pedal cycle 4 0.8% 74

75 Theft, and ther ffense 4 0.8% Attempted burglary 3 0.6% Attempted murder 3 0.6% Attempted rbbery 3 0.6% Burglary nt dwelling 3 0.6% Cmmn assault, ther ffences 3 0.6% Cnspiracy t cmmit rbbery 3 0.6% Harassment 3 0.6% Other fraud 3 0.6% Aggravated burglary 2 0.4% Arsn 2 0.4% Carrying a knife/ ffensive weapn 2 0.4% Cultivatin f Cannabis 2 0.4% Dangerus driving 2 0.4% Disqualified driving 2 0.4% Dmestic assault/vilence 2 0.4% Failing t appear 2 0.4% Firearms Acts ffences 2 0.4% Ging equipped fr theft 2 0.4% Immigratin ffences 2 0.4% Murder 2 0.4% Obstructing plice 2 0.4% Perverting curse f justice 2 0.4% Rape 2 0.4% Sexual ffences 2 0.4% Theft at wrk 2 0.4% Theft by an emplyee 2 0.4% Theft frm dwelling 2 0.4% Threats t kill 2 0.4% Unlawful disrder 2 0.4% 136 Place f safety 1 0.2% Abductin 1 0.2% Alleged assault/abh 1 0.2% Armed rbbery 1 0.2% Arsn / Cannabis 1 0.2% Assault/criminal damage 1 0.2% Attempted criminal damage 1 0.2% Attempted rape & kidnap 1 0.2% Cmputer misuse 1 0.2% Cnspiracy t supply class A drugs 1 0.2% Cunterfeit mney/fraud 1 0.2% Criminal Damage/ffensive weapn 1 0.2% Dangerus dg 1 0.2% Dmestic 1 0.2% Driving ffences 1 0.2% Drunk in charge f a child 1 0.2% 75

76 Equipped t steal 1 0.2% Fail t prvide 1 0.2% False imprisnment 1 0.2% Fly tipping (warrant nn-payment f fines) 1 0.2% Handling stlen gds 1 0.2% Harassment & pssessin Class B drugs 1 0.2% Indecent expsure 1 0.2% Indecent images n cmputer 1 0.2% Other drugs ffences/ther ffences 1 0.2% Pssessin weapns with intent 1 0.2% Public rder ffences 1 0.2% Racially abusive 1 0.2% Rape, abductin, sexual assault f minr 1 0.2% Reckless driving, driving withut a licence 1 0.2% Return fr bail 1 0.2% Rbbery S18 with intent 1 0.2% Sexual ffences breach 1 0.2% SS Firearms 1 0.2% Suspicin burglary 1 0.2% Suspicin f ABH 1 0.2% Suspicin f child prn images 1 0.2% Suspicin f rbbery 1 0.2% Suspicin f theft 1 0.2% Suspicin f theft f pedal cycle 1 0.2% Theft & breach f prbatin 1 0.2% Theft f jewellery 1 0.2% Theft f mbile phne 1 0.2% Theft f quad bike 1 0.2% Threats f arsn 1 0.2% TWOC (aggravated) 1 0.2% Vehicle interference 1 0.2% VTAS 1 0.2% Wasting plice time 1 0.2% (Base=505) Thse identified as having a current r previus safeguarding issue had been arrested fr a range f different ffenses, which are identified in the table belw. 76

77 Table 5: Offenses fr thse with an identified safeguarding issue. Type f ffense N. % Theft 68 35% Assault 38 20% Other 18 9% Breach and affray 15 8% Drugs 13 7% Fraud 9 5% Sexual crimes 8 4% Criminal damage 8 4% Threats 7 4% Driving ffenses 5 3% Alchl 3 2% (Base: 192) A further breakdwn f the type f ffence charges by age grup is presented in Appendices 1 and includes additinal figures n mental health and safeguarding. 6.3 Physical Health As part f the data cllected thrugh the screenings, participants were asked whether they were registered with a GP surgery, the majrity (89%, n=448) reprted that they were, the full number f registratins is represented in figure 1. 77

78 Figure 1: Percentage f individuals screened registered with a GP surgery Registered with a GP surgery Yes N Nt knwn 0.4% 11% 89% (Base=505) Only 20 individuals (39%) were reprted t have a knwn health cnditin, hwever, thrugh the screening it was identified that 259 (51%) had a reprted physical health issue. The range f cnditins was very varied and included asthma, arthritis, back prblems, allergies, infectins and pains t parts f the bdy sme were reprted as histrical and sme were current cnditins. Participants were asked whether they had been admitted t A&E befre entering the custdy unit, nly 19 (4% f all thse screened) were knwn t have been t A&E. The main reasn fr admittance was fr an X-ray (fr fur individuals), the ther reasns varied (fr example dislcatin/brken bne, infectin, injury r verdse). Admittance t A&E was self-reprted and the exact timeframe and persn accmpanying the individual fr these admissins varies. The recrds prvide the fllwing infrmatin abut A&E attendance: Attended A&E with plice r while in custdy n=7; Attended A&E within a week prir t custdy n=3; Attended A&E within last 6 mnths n=4; 78

79 Attended A&E within 6mnths t 1 year n=1; Timeframe nt knwn n=4. Of the seven wh were taken t A&E by the plice, tw were referred t see a frensic physician while in custdy, ne f whm als saw their GP as part f a lnger term fllw up. One individual was als referred t A&E as a lnger term fllw up and this persn was nt reprted t have previusly been admitted t A&E. A physical health check was carried ut n 96% (n=485) f thse screened. This health check included taking bld pressure, respiratry rate, temperature and heart rate. Of thse, 84 (17%) were reprted t have a reprted issue utside f the nrmal range. A full assessment was nt pssible fr seven peple wh refused t have ne r all f the tests cmpleted, with mst refusing t have their bld sugar level mnitred. Fr thse individuals wh had a reprted issue utside f the nrmal range, actin was taken n 40 detainees. This actin ranged frm advising peple t see r register with a GP (43%), repeated health checks r cntinued mnitring (28%) and referral t a frensic physician (15%). One persn wh did nt have any reprted issues utside f the nrmal range was als advised t seek an x-ray and ne persn wh did nt agree t a health check was checked by a frensic physician. Table 6: Actin taken utside f nrmal range Actin taken N % Referred t GP % Mnitr/recheck bld pressure etc % T see FP r spken t FP % Due fr release 1 2.5% Already under GP 1 2.5% FP t attend / discuss with CRI 1 2.5% Nt eaten tday 1 2.5% Feeling anxius 1 2.5% Advised t eat breakfast 1 2.5% (Base=40) As part f the health screening, all detainees were asked whether they had a histry f r current substance misuse issue, 65% (329 detainees) reprted t have sme experience f drug r alchl use bth histric and current. Thse wh were reprted t have a current issue (277, 84% f current users) reprted using a range f different drugs and different frequencies f use (fr example sme detainees reprted nly ccasinal r scial use while thers reprted having a dependency n a particular substance). 79

80 Seven detainees reprted t be seeking supprt frm CRI (n=4), ne frm AA, ne frm Spring Huse and ne frm Maple Access. Three reprted t want t give up (tw were cannabis users and ne was a herin user) and tw were n a regime r supervisin fr their drug habit. Tw f the three peple wh stated they wanted t give up were given a referral t CRI wh had already attended, and t the frensic physician. The individual wh did nt receive a referral had stated they were trying t quit and this may have impacted n the decisin nt t refer the ntes n the ther tw individuals stated that the detainee wants t give up/stp. Table 7: Number f detainees with a current reprted substance misuse issue Substance use N % Cannabis % Alchl % Cannabis and ther drug (e.g. ccaine) % Herin and ther drug (e.g. cannabis, subutex) % Cannabis and alchl % Ccaine 9 3.2% Methadne 9 3.2% Methadne and ther drug (e.g. cannabis, ccaine) 8 2.9% Herin 7 2.5% Alchl and drug (e.g. Herine, methadne, cannabis) 6 2.2% Methadne and alchl 5 1.8% Subutex 5 1.8% Amphetamine 4 1.4% Ccaine and ther drug (e.g. cannabis) 4 1.4% Subutex and ther drug (e.g. cannabis) 4 1.4% Cannabis, alchl and ther drug 3 1.1% Crack 3 1.1% Crack, alchl and ther drug 3 1.1% Legal/herbal highs 3 1.1% Amphetamines and ther drug (e.g. cannabis) 2 0.7% Ccaine and alchl 2 0.7% Herin, alchl and ther drug 2 0.7% Crack and ther drug (e.g. cannabis) 1 0.4% Diazepam and alchl 1 0.4% Herin and alchl 1 0.4% Methadne, alchl and ther drug 1 0.4% (Base=277) 80

81 6.4 Mental Health In additin t the physical health f detainees being mnitred, the pilt als screened individuals fr any mental health issues. Fur recrds f detainees mental health status were nted: 1. Whether the individual was knwn t have a histry f cntact with mental health services; 2. Whether the individual was currently being seen by mental health services; 3. Whether individuals reprted t have any mental health issues (histric r current); 4. Whether individuals presented with any mental health issues. Of thse screened, 201 (40%) were knwn t have a histry f cntact with mental health services and f thse, 48 (24%) had previusly been admitted as a result f their mental illness (the number f admissins ranged frm ne t 10). Furteen per cent (14%, n=71) f thse wh had been screened were currently being seen by mental health services (fr example, Cmmunity Mental Health Team, Criminal Justice Team, Learning Disability team, Crisis Reslutin Hme Treatment Team and the Nrthamptn Drug and Alchl Team). Of thse screened, 276 (54%) self-reprted t have r have had a mental health issue. The severity f the mental health issue varied greatly fr example frm having had cunselling t thse wh had paranid schizphrenia and were bi-plar. The number f thse wh reprted t have a mental health issue is higher than bth thse knwn histrically r currently t be engaging with a mental health supprt rganisatin. In additin, the pilt recrded the number f detainees wh presented with a mental health issue at the time f the screening, 194 (38%) were nted t have a presentatin f an issue during the screening prcess. The symptms nted varied frm mild symptms f distress, ptentially resulting frm their time in custdy, t mre significant symptms indicating schizphrenia and parania. A cmbinatin f several symptms were present in 21% f thse individuals reprted t be presenting with a mental health issue. The symptms varied but included a cmbinatin f being tearful, depressed, lw in md, anxius, hearing vices, being biplar, having ADHD r pst-traumatic stress disrder. Depressin and having a lw md were reprted fr 11% and 10% f individuals respectively. Tearfulness and 81

82 anxiety were als cmmn symptms (8% and 7% respectively). The ther symptms recrded included memry prblems, lack f understanding, lack f emtinal warmth and prblems with alchl withdrawal. Table 8: Presenting mental health symptms Symptms N. % Cmbinatin f symptms % Depressin % Lw md % Tearful % Anxiety % Other % Parania % Anger issues 9 4.6% ADHD 8 4.1% Flat md 7 3.6% Stress 6 3.1% Agitated 5 2.6% Schizphrenia 3 1.5% Persnality disrder 3 1.5% Bi-plar 2 1.0% Distressed/frustrated 2 1.0% Disinterested/distracted 2 1.0% Eccentric 2 1.0% Hearing vices 2 1.0% Panic symptms 2 1.0% Pst-traumatic stress disrder 2 1.0% Memry prblems 2 1.0% Restless 2 1.0% Self-harm 1 0.5% Psychsis 1 0.5% (Base=194) A learning disability and an ADHD screening tl was als available as part f the pilt screening tls. Six individuals were reprted t be presenting with a learning disability but nly ne screening fr a learning disability was undertaken. An assessment f ADHD was undertaken n 38 individuals (7.5% f all thse screened). 6.5 Scial Factrs Scial factrs relating t husing, emplyment, educatin and relatinships were als reprted as part f the screening prcess. 82

83 The majrity f detainees respnding t this questin were living with a family member r partner (28%), r in private r rented accmmdatin (16%). A further 14% were in cuncil accmmdatin and 9% were hme wners. A high prprtin f detainees als reprted t have n fixed abde r t be sfa surfing (8%) while a further 3% declared that they were hmeless with ne persn stating that they lived in a tent and anther in a htel. Thse under 18 years f age predminantly lived with family members and three reprted that they lived in care r in a children s hme. Table 9: Type f accmmdatin Type f Accmmdatin N. % Living with family/partner % Private/rented accmmdatin % Cuncil accmmdatin % Hme wner % Nt knwn % N fixed abde/ sfa surfing % Shared prperty % Husing assciatin accmmdatin % Living with friends % Hmeless % Supprted living 5 1.0% Evicted frm prperty 4 0.8% Caravan 3 0.6% In care 2 0.4% Student accmmdatin 2 0.4% Children's hme 1 0.2% Fster parents 1 0.2% In prisn 1 0.2% Oasis Huse 1 0.2% Bat 1 0.2% (Base=505) Nearly half (48%) f thse wh were screened reprted their current emplyment status t be that f unemplyed, while ver a third (37%) were in a frm f emplyment r were self-emplyed. The ther categries reprted were that f student (5%), carer (2%), retired (1%) and vlunteer (1%). A further 3% reprted anther status, fr example a full time mther and sme were reprted t be n sick leave. Finally, the emplyment status was nt knwn fr 2% f thse screened. 83

84 Figure 2: Emplyment Status Emplyment status 3% 2% 2% 1% 1% 1% 5% 48% 37% Unemplyed Student Nt knwn Retired Wrking/self emplyed Other Carer Vlunteer (Base=505) An educatinal status was nly recrded fr half (50%) f thse screened. Of these individuals, 87 (34%) reprted t have n qualificatins (three individuals reprted nt t have cllected their GCSE results s these were nt knwn), 69 (27%) t have GCSEs, 32 (13%) were currently still in schl r cllege, with a further 9 (4%) at university. 84

85 Table 10: Educatinal level Educatin level N. % N Qualificatins % GSCE % Schl/Cllege % HND/City and Guilds/NVQ % Prfessinal % Other % University 9 3.5% A Level 7 2.8% Degree 4 1.6% Special educatin schling 3 1.2% Unable t read and write 3 1.2% Supprted learning needs 1 0.4% Apprentice 1 0.4% (Base=254) When asked abut their marital status, the majrity f detainees reprted that they were single (32%) with 18% with a partner and a child/children, 17% with a partner, and 15% were single with a child/children. Table 11: Marital status Marital status N. % Single % With a partner and children % With a partner % Single with children % Married with children % Divrced/separated with children % Nt knwn % Divrced/Separated 8 1.6% Married 5 1.0% Other (e.g. lives alne/with family) 5 1.0% (Base=505) Detainees were als asked abut any safeguarding issues r actins which were knwn fr themselves r their families. Of thse screened, 38% (n=192) reprted t have a knwn safeguarding issue (current and histrical). These ranged greatly, frm having been adpted r had a child adpted r in fster care, children living with relatives, being knwn fr drug use/criminal behaviur, physical/sexual abuse within the family r scial services wrking with the family. A number f the incidents reprted were histrical, with detainees reprting t have been in care in childhd and ther cases related t a change f care f a child, fr example ne detainee reprted t have wn custdy f sn. 85

86 Of thse individuals with a safeguarding issue, 129 (67%) were knwn t be r have been engaged with a supprt rganisatin. A number f different agencies were reprted as having engaged with the detainees n these issues, these included: Scial Services, Natinal Fstering Agency, child and family services, the curts, health visitrs, mental health services, Alchlics Annymus, Victim Supprt, NSPCC and a wmen s refuge. Of thse detainees identified with a safeguarding issue, 76% (n=146) were male and 24% (n=46) were female. The ages ranged frm 13 t 81, with 7% (n=13) aged under 18 years f age, 30% (n=57) were aged between 18-25, 28% (n=53) were aged between 26-35, 23% (n=45) were aged between 36-45, 9% (n=17) were aged between 46-55, 3% (n=5) were aged between and 1% (n=2) f individuals were aged ver 66 years f age. When cnsidering their mental health status, 18% (n=34) were knwn t mental health services and 49% (n=95) had previusly been seen by mental health services. Additinally, 51% (n=98) reprted that their emplyment status was that f unemplyed r receiving benefits and 18% (n=34) reprted t have n qualificatins while a further 8% (n=15) reprted t nt knw their GCSE results r t have been expelled frm schl/were nt attending schl. 6.6 Referrals Alngside the referrals already discussed, i.e. the actin taken where physical cnditins were utside f the nrmal range, thse juveniles ffered a referral t supprt any learning difficulty issues and the supprt agencies invlved in the safeguarding. A recrd was made f the referral pathways ffered t all f thse detainees wh were screened. Just ver a third (34% n=174) f thse individuals screened were referred t anther rganisatin r ffered advice t seek supprt, either internal r external t the custdy unit. Of thse ffered advice r referral, 9 were already engaged with an apprpriate rganisatin and 10 peple were reprted t have declined referrals r treatment recmmendatins, fr example bereavement cunselling r talking therapies. The mst number f referrals, lking at the referrals made in custdy and external referrals, were made t the frensic physicians, with 41% (n=77) f referrals being made t them. CRI had 17% (n=32) f referrals, 11% (n=22) were made t the cmmunity psychiatric nurse and 10% (n=19) were made t GPs. 86

87 Table 12: Referral Agencies Referral agencies N. % Frensic Physicians % CRI % Cmmunity Psychiatric Nurse % GP % Mental Health Team 5 2.6% Child and Adlescent Mental Health Service 5 2.6% Single Pint f Access 3 1.6% Dedicated Substance Interventin Prgramme 2 1.0% Hspital/A&E 2 1.0% AA 2 1.0% Other 2 1.0% Wellbeing Team 2 1.0% Campbell Huse 2 1.0% Bridge 1 0.5% Carer supprt 1 0.5% ADHD service 1 0.5% Berrywd 1 0.5% CAN 1 0.5% CAB 1 0.5% Custdy staff 1 0.5% Crisis Hme Treatment Team 1 0.5% Nstep 1 0.5% Shrt Term Team 1 0.5% Scial Services 1 0.5% Yuth Offending Service 1 0.5% (Base=187 please nte that sme individuals were referred t multiple agencies and therefre the ttal number f referrals is greater than 174) Of thse wh were given a referral, 20 (11% f all referrals) were already knwn t r engaged with the recmmended service, r in the case f the frensic physicians had already been seen. The fllwing is the list f rganisatins and the number f individuals wh were already knwn t these teams: Frensic Physicians n=9; CRI n=7, plus ne individual wh was referred t A&E; Campbell Huse/Criminal Justice team n=2; CAMHS n=1; CPN n=1; DSIP n=1. (tw individuals were knwn t multiple rganisatins) 87

88 Additinally, seven individuals refused r declined the referral recmmendatin made by the pilt team r thrugh the external referral. A further tw individuals were reprted t have declined t fllw up with their referral when the pilt team fllwed up n the lnger term utcme f their interventin and ne individual had declined a previus drug interventin. An initial utcme and a lnger term utcme were reprted during this pilt phase. There was n further actin taken n 303 (60%) f the detainees screened and 100 (20%) were advised t visit r register with their GP. Other initial utcmes reprted n referrals made t ther rganisatins, as discussed in Table 11, and n-ging mnitring f peple s cnditin while in the custdy unit. Lnger term utcmes were knwn fr 140 (28%) individuals. A visit t r review by a GP was made fr 74 f these individuals (53% f thse with a knwn lnger term utcme r 15% f all thse screened), actin taken as a result was t make a referral t anther rganisatin, review the case r mnitred the patient s health (e.g. bld pressure) and five were recmmended t register with their GP. The fllwing utcmes were als nted: Assessments were made by ther rganisatins (e.g. an apprved mental health prfessinal, cmmunity psychiatric nurse); Anger management referral; Appintments made with ther rganisatins (e.g. alchl team, Citizen s Advice Bureau); Access t treatment/therapy (e.g. Bereavement cunselling, CBT r Talking Therapies, cunselling and anger management); Referrals made t ther rganisatins (e.g. Child Prtectin team, Assertive Outreach team, Wellbeing team, Single Pint f Access, Criminal Justice Team, Reablement, Children and adults mental health service, Changing Minds); Mental health assessments were carried ut; ADHD assessment carried ut; Review f health and medicatin. Alngside making referrals and prviding advice t the detainees, pilt staff als supprted the custdy staff in managing detainees health. This has been reprted thrugh the rutinely cllected data in the ntes taken n advice ffered t the plice. Advice was ffered t the plice fr 155 (31%) f thse screened. This advice ranged 88

89 frm supprting decisins n whether the individual was fit fr interview, advising n whether a frensic physician r apprpriate adult was required t see the detainee and prviding infrmatin abut the persn s health (in particular bserving fr signs f withdrawal). 6.7 Juvenile Detainees This sectin identifies the data which is specific t thse under 18 years f age. Only 24 individuals were aged under 18 and f thse, 83% (n=20) were male and 17% (n=4) were female, 79% (n=19) were White British, 8% (n=2) were Asian Bangladeshi, 4% (n=1) were Black African, 4% (n=1) were White Irish and the ethnicity f ne individual was nt knwn. The ages f these detainees ranged frm 13 t 17 with 71% (n=17) aged 17 years ld, 8% (n=2) were 16 years f age, 13% (n=3) were 15 years f age, 4% (n=1) was 14 years f age and 4% (n=1) was 13 years f age Type f Offence Cmmitted Thse wh were under the age f 18 had been arrested fr a number f reasns, with theft, burglary, rbbery and shplifting (54%, n=13) being the primary reasns. Additinal reasns fr their arrest were: assault and GBH (13%, n=3), causing an affray (13%, n=3), pssessin f cntrlled drugs/intent t supply (13%, n=3), criminal damage (4%, n=1) and breach (4%, n=1) Physical Health When cnsidering the health f thse juveniles screened during the pilt, 88% (n=21) were registered with a GP and nly ne had previusly been admitted t hspital fr treatment. Self-reprted incidents f a physical health issue were reprted by 29% (n=7) f thse screened and cnditins varied frm ADHD, anger management issues, anxiety t chest infectins and asthma. Five (21%) individuals presented with a medical issue during the screening, the cnditins were: a lw pulse, numbness in ne hand, a pssible chest infectin, previus head injury and a miscarriage and dizziness. A physical health check was cmpleted fr 92% (n=22) f the juveniles screened, f which three were identified with a health issue, frm lw bld pressure t having a panic attack and tw individuals refused t have an aspect f the health check cmpleted (their bld sugar levels). 89

90 When asked abut any substance abuse issues, 71% (n=17) reprted t have r had a substance issue. The use f cannabis was mst cmmn amngst these individuals with 82% (n=14) reprting its use (either n its wn r in cnjunctin with anther drug/alchl 35% (n=6) had used it in cnjunctin with anther substance), tw individuals were smkers and ne reprted t have tried ccaine nly Mental Health and Referrals Nne f thse under 18 years f age were screened fr a learning disability and nne were reprted t be presenting with a learning disability. Half (50%, n=12) were identified with a mental health cnditin, which ranged frm a lw md, ADHD, anger issues and panic symptms. Five (21%) individuals cmpleted an ADHD assessment. A referral was made fr nine juveniles t: see their GP (n=1), infrmatin passed n t the CPN (n=2), CAMHS (n=5), CRI (n=1), the Yuth Offending Team (n=1) and the ADHD team (n=1). Tw individuals received multiple agency referrals. Three where knwn t have had a lnger term fllw up, with referrals being made t their GP, Changing Minds, the Yuth Offending Team, CAMHS and the ADHD team. One juvenile was already engaged with CAMHS and ne refused the referral Scial Factrs When cnsidering the scial factrs such as educatin, emplyment and relatinship status fr this grup, 16 (67%) were living with family members, three (13%) were in care/children s hme and three (13%) were in private/rented accmmdatin. Details fr tw (8%) f the juvenile detainees were unknwn. Twelve (50%) juveniles reprted t be still at schl r cllege (ne persn reprted t be at a special schl, while anther had additinal learning needs), while five (21%) were unemplyed, fur (17%) were emplyed and ne (4%) was a carer fr a family member. Details fr tw (8%) f the juvenile detainees were unknwn. When discussing their educatinal attainment, six (25%) reprted t have n GCSEs, three (13%) had been expelled frm schl, ne (4%) individual reprted nt t attend schl and ne (4%) had a 68% attendance. Three (13%) juvenile detainees reprted t have attained GCSEs r t be currently taking these and tw (8%) stated they were at cllege, but the level is nt knwn. Details fr six (25%) f the juvenile detainees were unknwn. The majrity f thse juveniles screened were single (n=16, 67%), while six (25%) reprted t be with a partner (all 17 years f age). Details fr tw (8%) f the juvenile detainees were unknwn. 90

91 Thirteen (54%) f thse aged under 18 reprted t have a safeguarding issue, these were related t: Vulnerable, difficulties with family; Allegatin f rape - nt guilty; In fster care until 2011; Scial services invlved with partner; Scial services with nephews - case ended; New baby - appintment with Scial services; Scial services call fllwing reprt f rape; Adpted at age 3; Scial wrker invlved (n=2); Placed with family; Ran away frm hme previusly; Mther assessed 4 years ag. 6.8 Csts/Call ut analysis This sectin prvides a brief analysis f the assciated csts fr running the pilt and the frensic physician services. The cmmissiners identified a typical mnth t cmpare the number f call uts fr the frensic physicians and assciated csts during the pilt and the same mnth in the previus year. Due t cmplicatins f the intrductin f the new Criminal Justice Centre (CJC) in Nrthamptn, it was decided that Nvember 2012/13 wuld act as the cmparatr mnth (this is utside f the initial review perid fr this evaluatin but is within the extended time frame fr the pilt). Further t this, call ut figures and pilt staff wrking hurs are als included fr December 2013 and January 2014 t shw the number f call uts made by the frensic physicians during these mnths. All figures have been prvided by Nrthamptnshire Plice and the Criminal Justice Team, and unless stated are shwn fr the CJC in Nrthamptn. 91

92 The table belw shws the number f call uts and assciated csts fr the frensic physician service in Nvember 2012 and 2013 in bth Crby and Nrthamptn CJC (Crby prvides a cmparatr as the pilt service nly ran in Nrthamptn). Table 13: Call ut and cst cmparisn fr Frensic Physician service CJC N. Call Outs % difference Assciated Csts % difference Nv 2012 Nv 2013 Nv 2012 Nv 2013 Nrthamptn % 17, , % Crby % 7, , % A drp in the number f call uts and assciated csts has been recrded fr bth the Crby and Nrthamptn CJCs acrss the tw time perids. The percentage change fr Crby frm Nvember 2012 t 2013 shws a cnsistent drp bth in number f call uts and in the assciated csts at -5.7% and -5.6% respectively. Fr the Nrthamptn CJC an -11% drp in number f call uts has been recrded frm Nvember 2012 t Nvember 2013 and while there als has been a drp in assciated csts fr the frensic physician service, this is less than that reprted fr the number f call uts, at -3.1%. When taking an average f the unit csts per call ut fr each site, the csts fr Crby d nt vary greatly frm with an average call ut csting in 2012 and in Hwever, in Nrthamptn the average call ut cst increases in 2013, with an average call ut csting in 2012 and in These differences may be due t a change in the nature f call uts made, fr example mre ut f hurs calls, hwever, a further interrgatin f the data wuld be required t understand these figures. At present, the data captured by Nrthamptnshire Plice des nt enable this fuller examinatin t be undertaken. Figures have als been prvided fr the number f call uts made t the Nrthamptn CJC by the frensic physicians during December 2013 and January In December, 189 call uts were made t the CJC in Nrthamptn, while in January 169 call uts were made. The charts belw shws the percentage f these call uts by day f the week, with the mst number f call uts in December being made n Sundays (n=40, 21%), while Tuesdays and Wednesdays were the days with the fewest number f call uts, with 21 (11%) and 19 (10%) respectively. In January, the highest number f call uts were made n Saturdays and Sundays (n=34, 20%) and Wednesdays als shwed a high number f call uts (n=28, 17%). 92

93 While there is sme variatin in the call uts by weekday between December 2013 and January 2014, half the calls fr bth mnths fall ver the weekend perid f Friday, Saturday and Sunday (50% in December and 54% in January). Figure 3: Percentage f Frensic Physician Call Outs by Weekday (December 2013 and January 2014) % FP Call Outs by Day f the Week - December 2013 Sat 15% Sun 21% Fri 13% Mn 16% Thu 14% Tue 11% Wed 10% % FP Call Outs by Day f the Week - January 2014 Sun 20% Mn 10% Tue 8% Sat 20% Wed 17% Fri 14% Thu 11% When cnsidering the time f day in which the call uts were made, in December the highest prprtin ccur frm 9pm t 1am with 56 (30%) and 8am t 10am with 34 (18%) f call uts made during these hurs. During December 2013 the cre hurs the 93