Offender health profile for Norfolk by Josh Robotham 7 Dr Kadhim Alabady Judy Lomas Ellie Phillips

Offender Health Profile for Norfolk Final Report – November 2014

By:

Josh Robotham Dr Kadhim Alabady Judy Lomas Ellie Phillips

Norfolk Public Health Improving health and wellbeing, Protecting the population Preventing ill health

www.norfolk.gov.uk

Offender Health Profile for Norfolk

Acknowledgements •

Colin Back, Veterans in the Criminal Justice System Specialist Employment Consultant Regular Forces Employment Association.

•

Steve Baker, Procurement, Contracts and Partnerships Manager – Norfolk & Suffolk Community Rehabilitation Company.

•

John Beamish, Norfolk and Suffolk NHS Foundation Trust analyst.

•

Dr Julian Beezhold, Consultant Psychiatrist – specialist in acute/crisis mental health services; Chair of Trust’s Medical Advisory Committee (MAC).

•

David Britcher, Performance Researcher – Norfolk Constabulary.

•

Stephanie Butcher, Interim Norfolk Drug and Alcohol Strategy Manager – Public Health, Norfolk County Council.

•

Alison Campbell, Rehabilitation consultant.

•

Karen Clements, Secure Services Manager for the NHS Trust.

•

Barbara Cliff, Business Improvement Manager – Norfolk and Suffolk Community Rehabilitation Company Limited.

•

Stephen Curnow, Relapse Prevention Practitioner, Criminal Justice Mental Health Team.

•

Janet Dean, Development Manager for Mental Health within the criminal justice system.

•

Aktar Deelawar, ex Health Trainer service Manager – NHS Norfolk and Waveney Clinical (now Quality and Patient Safety Manager – NEL Commissioning Support Unit).

•

Owen Fry, Service Line Lead – Forensic and Norfolk HPFT.

•

Rowena Hagger-Utting, 4Women Senior Client Service Manager, Volunteer Ambassador – 4Women Resource Centre.

•

Kevin Hanner, Service Manager - City Reach, NCH&C NHS Trust.

•

Doreen Kelf, Lead Liver Specialist Nurse, Norfolk and Norwich University Hospitals (NNUH).

•

Dr Peter Langdon, Senior Lecturer in Clinical Psychology and Disability, Honorary Consultant Clinical and Forensic Psychologist – University of Kent and Canterbury.

•

Claire Leborgne, Offender Pathways Manager, Norfolk & Suffolk, Community Rehabilitation Company.

Page | 1

Offender Health Profile for Norfolk

•

Jenny McKibben, Deputy Police and Crime Commissioner – Office of the Police and Crime Commissioner for Norfolk.

•

Stuart Macdonald, Assistant Chief Executive, Norfolk & Suffolk, Community Rehabilitation Company.

•

Lucy Macleod, Interim Director of Public Health.

•

Glynis Murphy, Professor of Clinical Psychology & Disability, TheTizard Centre, University of Kent.

•

Wendy Narducci, Information, Advice and Advocacy Manager, Equal Lives.

•

Clive Rennie, Assistant Director of Commissioning – Community Services (Adult Care).

•

Lynsey Rodway, Research & Information Manager – Norfolk & Suffolk Constabularies.

•

Clare Scott, Mental Health Case Manager, Specialised Commissioning, East Anglia Area Team.

•

Joanne Spaull, Performance and Information Officer (Drug and Alcohol Action Team) – Public Health, Norfolk County Council.

•

Gemma Stannard, Head of Joint Performance and Analysis Department, Norfolk and Suffolk Constabularies.

•

Helen Taylor, Area Manager – Eastern Unit, Norfolk Youth Offending Team.

•

Ian Trenholm, Deputy Service Manager – Norfolk and Suffolk NHS Foundation Trust.

•

Claire Watson, Health and Justice Commissioning Manager – NHS England East Anglia Area Team.

•

Euan Williamson, Mental Health and Learning Disability Commissioning Manager – Community Services (adult care).

•

The Offender Health Needs Assessment Working Group and all those in partner organisations who provided data and information for this report.

Page | 2

Offender Health Profile for Norfolk

Contents ACKNOWLEDGEMENTS ................................................................................................................................................. 1 CONTENTS ....................................................................................................................................................................... 3 KEY FINDINGS ................................................................................................................................................................. 7 OTHER ANALYSIS NEEDED? ....................................................................................................................................... 14 RECOMMENDATIONS ................................................................................................................................................... 15 ABBREVIATIONS ........................................................................................................................................................... 16 1. BACKGROUND .......................................................................................................................................................... 18 1.1. PURPOSE OF THIS REPORT ...................................................................................................................................... 18 1.2. DEFINITION OF OFFENDERS ..................................................................................................................................... 18 1.3. THE NATIONAL CONTEXT .......................................................................................................................................... 18 1.4. THE NEW COMMISSIONING LANDSCAPE FOR HEALTH AND JUSTICE .............................................................................. 19 1.5. OFFENDER HEALTHCARE MANAGEMENT IN PRISONS AND IN THE COMMUNITY .............................................................. 21 1.5.1. Healthcare in prisons in England .................................................................................................................. 21 1.5.2. Healthcare for offenders in the community in England ................................................................................. 21 1.6. HEALTH AND OFFENDING ......................................................................................................................................... 22 1.7. OVERALL PICTURE OF OFFENDING AND OFFENDER POPULATION................................................................................. 23 1.7.1. Crimes in Norfolk........................................................................................................................................... 23 1.7.1.1. Overall picture of crime and disorder..................................................................................................... 23 1.7.1.2. Crime Survey for England and Wales (CSEW) ..................................................................................... 24 1.7.1.3. Crimes attributable to alcohol ................................................................................................................ 24 1.7.1.4. Violence Indicator Profiles (VIPER) ....................................................................................................... 27 1.7.1.5. Youth offending...................................................................................................................................... 28 1.7.2. Population relating to offenders .................................................................................................................... 28 1.7.2.1. Introduction ............................................................................................................................................ 28 1.7.2.2. Population .............................................................................................................................................. 30 1.7.2.3. Offender population ............................................................................................................................... 33 1.7.2.4. Deprivation ............................................................................................................................................. 35 1.7.2.5. Ethnicity ................................................................................................................................................. 38 1.8. OFFENDER PATHWAYS AND COMMISSIONING IN NORFOLK ......................................................................................... 39 2. OFFENDERS IN POLICE INVESTIGATION CENTRES ............................................................................................ 41 2.1. INTRODUCTION ....................................................................................................................................................... 41 2.2. PATHWAYS FOR THOSE WHO NEED MEDICAL INPUT ................................................................................................... 42 2.2.1. Introduction ................................................................................................................................................... 42 2.2.2. Forensic Medical Service .............................................................................................................................. 42 2.2.3. In-Reach services ......................................................................................................................................... 43 2.3. DATA FROM POLICE INVESTIGATION CENTRES IN NORFOLK ....................................................................................... 43 2.3.1. Number of detentions by centre and re-arrest .............................................................................................. 43 2.3.2. Time of arrivals.............................................................................................................................................. 45 2.3.3. Health risk assessment ................................................................................................................................. 47 2.3.4. Arrest offences .............................................................................................................................................. 49 2.3.5. Age of detainees ........................................................................................................................................... 53 2.3.6. Resident area ................................................................................................................................................ 54 2.3.7. Deprivation .................................................................................................................................................... 55 2.3.8. Mosaic profiles .............................................................................................................................................. 56 2.4. NORFOLK APPROPRIATE ADULT SERVICE................................................................................................................. 59 3. LIAISON AND DIVERSION......................................................................................................................................... 61 3.1. INTRODUCTION ....................................................................................................................................................... 61 3.2. EXISTING SERVICE AREAS ........................................................................................................................................ 62 3.3. PEOPLE WHO USE CJMHT LIAISON AND DIVERSION SERVICES IN NORFOLK ............................................................... 66 3.4. CHANGES TO THE CRIMINAL JUSTICE MENTAL HEALTH TEAM .................................................................................... 69 4. FORENSIC MENTAL HEALTH SERVICES ............................................................................................................... 70

Page | 3

Offender Health Profile for Norfolk

4.1. INTRODUCTION ....................................................................................................................................................... 70 4.2. THE COST OF SECURE MENTAL HEALTH SERVICES ..................................................................................................... 72 4.3. DIVERSION AND THE MENTAL HEALTH ACT ............................................................................................................... 73 4.4. FORENSIC SERVICES IN NORFOLK ............................................................................................................................ 73 4.4.1. High Secure Mental Health Services (Adults) ............................................................................................... 74 4.4.2. Medium Secure Services in Norfolk (Norvic Clinic) ...................................................................................... 75 4.4.2.1. Pathways into the Norvic Clinic ............................................................................................................. 78 4.4.2.2. Process on release in Norfolk ................................................................................................................ 78 4.4.2.3. Other issues ........................................................................................................................................... 79 4.4.2.4. Local data from the Norvic Clinic April 2010 to March 2013 ................................................................. 79 4.4.3. Low Secure Services in Norfolk (Hellesdon Hospital) .................................................................................. 81 4.4.4. Mental health needs at Low and Medium Secure Services .......................................................................... 81 4.5. TRANSFER FROM ONE OF THE THREE PRISONS IN NORFOLK TO A SECURE MENTAL HEALTH FACILITY............................ 83 4.5.1. The Mental Health Act .................................................................................................................................. 83 4.5.2. What is a mental disorder according to the Mental Health Act? ................................................................... 84 4.5.3. Offenders with any mental health disorder ................................................................................................... 84 4.5.4. Prisoners transferred to hospital ................................................................................................................... 84 4.5.5. Psychologically Informed Planned Environments (PIPEs) ........................................................................... 90 4.6. RELEASE INTO THE COMMUNITY ............................................................................................................................... 91 4.6.1. Secure Services Community Team .............................................................................................................. 91 4.6.2. Meeting with Deputy Service Manager for Norfolk and Suffolk NHS Foundation Trust ............................... 93 5. OFFENDERS WITH INTELLECTUAL DISABILITIES AND OTHER DEVELOPMENTAL DISABILITIES ............... 94 5.1. HOW DO WE CATEGORISE LEARNING DISABILITIES AND HOW ARE THESE GROUPS TREATED WITHIN THE CRIMINAL JUSTICE SYSTEM? ...................................................................................................................................................................... 95 5.1.1. The continuum of learning ability .................................................................................................................. 95 5.1.2. Developmental disabilities ............................................................................................................................ 96 5.1.2.1. Autism .................................................................................................................................................... 96 5.1.2.2. Asperger Syndrome ............................................................................................................................... 97 5.2. CRIMINAL JUSTICE SYSTEM AND OFFENDERS WITH LEARNING DISABILITIES – NORFOLK EXPERIENCE............................ 98 5.3. SECURE SERVICES FOR OFFENDERS WITH LEARNING DISABILITIES IN NORFOLK .......................................................... 99 5.4. THE BROADLAND CLINIC/MEDIUM SECURE ACCOMMODATION IN NORFOLK................................................................ 100 5.5. LOCAL FINDINGS AND NEEDS FOR OFFENDERS WITH LEARNING DIFFICULTIES ............................................................ 100 5.6. OFFENDERS & SOCIAL CARE - INTELLECTUAL DISABILITIES (OFFSCA-ID) .............................................................. 104 5.6.1. Background about OFFSCA-ID .................................................................................................................. 104 5.6.2. OFFSCA-ID summary ................................................................................................................................. 105 6. YOUNG OFFENDERS .............................................................................................................................................. 107 6.1. NATIONAL CONTEXT .............................................................................................................................................. 107 6.2. EXTENT OF YOUTH OFFENDING .............................................................................................................................. 108 6.3. RESPONSES TO OFFENDING................................................................................................................................... 109 6.4. SECURE ESTATE SETTINGS .................................................................................................................................... 110 6.5. HEALTH AND WELLBEING NEEDS OF YOUNG OFFENDERS.......................................................................................... 111 6.6. PHYSICAL HEALTH OF YOUNG OFFENDERS .............................................................................................................. 111 6.7. MENTAL HEALTH OF YOUNG OFFENDERS ................................................................................................................ 112 6.8. LOCAL EVIDENCE .................................................................................................................................................. 112 6.8.1. Extent of Out-of-Court Disposals ................................................................................................................ 112 6.8.2. NYOT Assessment 2008-09 ....................................................................................................................... 113 6.8.3. NYOT Health Needs Audit 2014: Comprehensive Health Assessment Tool (CHAT) ................................ 114 6.8.4. Emerging themes and latest developments ................................................................................................ 114 7. OFFENDERS IN MAINSTREAM PRISONS ............................................................................................................. 116 7.1. INTRODUCTION ..................................................................................................................................................... 116 7.2. PHYSICAL HEALTH ................................................................................................................................................. 117 7.3. MENTAL HEALTH ................................................................................................................................................... 119 7.4. SUBSTANCE MISUSE .............................................................................................................................................. 122 7.5. SELF-HARM .......................................................................................................................................................... 122 7.6. COMMUNICABLE DISEASE ...................................................................................................................................... 122 7.7. SERVICE PROVISION .............................................................................................................................................. 123 7.8. NHS HEALTH CHECKS .......................................................................................................................................... 127

Page | 4

Offender Health Profile for Norfolk

7.8.1. Background ................................................................................................................................................. 127 7.8.2. Health Checks in prison .............................................................................................................................. 128 7.8.3. The Norfolk prison programme ................................................................................................................... 128 7.8.4. Service delivery ........................................................................................................................................... 128 7.8.5. Patient invite................................................................................................................................................ 128 7.8.6. NHS Health Check delivery ........................................................................................................................ 128 7.8.7. Outcomes .................................................................................................................................................... 129 8. FEMALE OFFENDERS ............................................................................................................................................. 130 8.1. THE NATIONAL PICTURE ......................................................................................................................................... 130 8.1.1. Background: an overview of women offenders ........................................................................................... 130 8.1.2. Young female offenders .............................................................................................................................. 131 8.1.3. Pregnant women and new mothers ............................................................................................................ 132 8.2. LOCAL EVIDENCE .................................................................................................................................................. 134 8.2.1. Evidence from Police Investigation Centres (PICs): number of offenders.................................................. 134 8.2.1.1. Evidence from PICs: age and residence of offenders ......................................................................... 134 8.2.1.2. Evidence from PICs: type and extent of offence ................................................................................. 135 8.2.1.3. Evidence from PICs: health needs of female offenders ...................................................................... 136 8.2.2. Female prisoners ........................................................................................................................................ 136 8.2.3. Provision for women offenders with substance misuse problems .............................................................. 138 8.2.4. Community provision in Norfolk .................................................................................................................. 139 9. ROLE OF PROBATION IN SUPPORTING EX-OFFENDERS ................................................................................. 142 9.1. INTRODUCTION ..................................................................................................................................................... 142 9.2. THE NATIONAL OFFENDER MANAGEMENT SERVICE ................................................................................................ 144 9.3. SERVICE REFORMS ............................................................................................................................................... 144 9.3.1. Transforming Rehabilitation ........................................................................................................................ 144 9.3.2. Resettlement from prison ............................................................................................................................ 145 9.3.3. Management of offenders with community orders or release on licence ................................................... 147 9.3.4. Local implications ........................................................................................................................................ 148 9.4. FOCUS GROUP AMONG PROBATION OFFICERS ........................................................................................................ 149 9.4.1. Focus group results .................................................................................................................................... 149 9.4.2. Main health problems .................................................................................................................................. 149 9.4.3. Signposting ................................................................................................................................................. 150 9.4.4. Access to health services ........................................................................................................................... 150 9.4.5. Understanding their medical conditions ...................................................................................................... 151 9.4.6. Diet and home environment ........................................................................................................................ 151 9.4.7. Health/offender manager group sessions ................................................................................................... 151 9.4.8. Gaps ............................................................................................................................................................ 151 9.4.9. Access to health promotion leaflets and posters ........................................................................................ 151 9.5. PROBATION SURVEY.............................................................................................................................................. 152 9.5.1. Introduction ................................................................................................................................................. 152 9.5.2. Survey sample ............................................................................................................................................ 152 9.5.3. Survey methodology ................................................................................................................................... 152 9.5.4. Section A: characteristics of survey respondents ....................................................................................... 153 9.5.5. Medical access to local GP practitioner, accident and emergency (A&E), and outpatients and inpatients admissions ............................................................................................................................................................ 154 9.5.6. Medical conditions....................................................................................................................................... 154 9.5.7. Risk and protective factors .......................................................................................................................... 155 9.5.7.1. Alcohol ................................................................................................................................................. 155 9.5.7.2. Smoking ............................................................................................................................................... 155 9.5.7.3. Sexual behaviour ................................................................................................................................. 156 9.5.7.4. Healthy eating ...................................................................................................................................... 156 9.5.7.5. Physical activity ................................................................................................................................... 156 9.5.7.6. Vaccination .......................................................................................................................................... 156 9.5.7.7. Conclusion ........................................................................................................................................... 157 9.6. OFFENDER ASSESSMENT SYSTEM (OASYS) .......................................................................................................... 158 10. SUPPORT FOR PEOPLE WHO MISUSE SUBSTANCES .................................................................................... 161 10.1. THE PREVALENCE OF SUBSTANCE MISUSE IN NORFOLK ......................................................................................... 161

Page | 5

Offender Health Profile for Norfolk

10.2. TRENDS IN SUBSTANCE MISUSE ........................................................................................................................... 161 10.3. DRUG AND ALCOHOL SERVICES FOR OFFENDERS IN NORFOLK ............................................................................... 162 10.4. DRUG REHABILITATION AND ALCOHOL TREATMENT REQUIREMENTS ........................................................................ 163 11. OFFENDERS WHO ARE ARMED FORCES VETERANS - PROJECT NOVA ..................................................... 164 11.1. INTRODUCTION ................................................................................................................................................... 164 11.2. LOCAL INTEGRATED OFFENDER MANAGEMENT (IOM) ........................................................................................... 165 11.3. THROUGH THE GATE SUPPORT............................................................................................................................. 165 11.4. FINDINGS FROM DATA COLLECTED SO FAR ............................................................................................................ 165 12. SUPPORT TO EX-OFFENDERS IN THE COMMUNITY ........................................................................................ 167 13. CONCLUSIONS ...................................................................................................................................................... 169 APPENDICES................................................................................................................................................................ 170 APPENDIX 1: PATHWAYS FOR POLICE INVESTIGATION CENTRE DETAINEES WHO REQUIRE HEALTH INPUT ......................... 170 APPENDIX 2: FORENSIC SECTION DEFINITIONS ............................................................................................................... 171 APPENDIX 3: W HAT DOES HIGH, MEDIUM AND LOW SECURE MEAN IN RELATION TO HOSPITALS? ........................................ 174 APPENDIX 4: IQ TEST .................................................................................................................................................. 175 APPENDIX 5: W HAT ARE PERVASIVE DEVELOPMENTAL DISORDERS? .............................................................................. 176 What is Asperger Syndrome? ............................................................................................................................... 176 What is mild autism? ............................................................................................................................................. 176 What is high functioning autism? .......................................................................................................................... 176 What is PDD-NOS?............................................................................................................................................... 176 What is severe autism? ......................................................................................................................................... 176 APPENDIX 6: OFFENDERS & SOCIAL CARE - INTELLECTUAL DISABILITIES (OFFSCA- ID) STUDY ...................................... 177 APPENDIX 7: BRIEF REPORT: SCREENING PRISONERS FOR INTELLECTUAL DISABILITIES IN THREE ENGLISH PRISONS ......... 185 A 7.1 Abstract ........................................................................................................................................................ 185 A 7.2 Introduction .................................................................................................................................................. 186 A 7.3 Method ......................................................................................................................................................... 186 A 7.4 Results ......................................................................................................................................................... 187 A 7.5 Discussion ................................................................................................................................................... 188 A 7.6 Acknowledgements...................................................................................................................................... 189 A 7.7 References .................................................................................................................................................. 190 APPENDIX 8: PROBATION SURVEY ................................................................................................................................. 192 APPENDIX 9: OASYS TABLES........................................................................................................................................ 198 APPENDIX 10: INFORMATION FROM PROJECT NOVA SO FAR .......................................................................................... 200 Employment ...................................................................................................................................................... 200 Substance misuse ............................................................................................................................................ 200 Violence ............................................................................................................................................................ 200 Housing and debt .............................................................................................................................................. 200 Post-traumatic stress disorder (PTSD) ............................................................................................................. 200 Sex offenders .................................................................................................................................................... 200 Remount Charity ............................................................................................................................................... 200 Royal British Legion Industries (RBLI) Lifeworks programme .......................................................................... 200 Solicitor and court letters provided ................................................................................................................... 200 Referrals to the Royal British Legion and Support for Soldiers & Military Families (SSAFA) .......................... 201 CONTACT INFORMATION ........................................................................................................................................... 202

Page | 6

Offender Health Profile for Norfolk

Key findings General •

The system for commissioning health care for offenders is fragmented and contains gaps and duplications. There would therefore be health economic benefits in creating a jointly commissioned offender health pathway.

•

Mental health commissioning is crucial to the role and functioning of services for offenders in Norfolk. There are currently four bodies who are commissioning mental health services for offenders in Norfolk:  NHS England, who commission mental health services for three prisons  NHS England Specialised Commissioning who commission Medium and Low Secure Services.  The National Offender Management Service (NOMS) who commission some specialist probation services on behalf of the Secretary of State for Justice.  Clinical Commissioning Groups (CCGs) who jointly or individually commission the generic community mental health support team.

The different commissioning boards need to inform each other’s work and be aware of other services before making commissioning decisions.

•

There are some groups about whom there is limited knowledge, limited referral and limited provision such as offenders with learning disabilities (LD), with personality disorders, female offenders and short sentence foreign nationals.

•

There is clearly inadequate provision for offenders with learning disabilities and neurophysiological disorders at all points along the pathway. There is insufficient screening for LD leading to unquantified, poorly understood, unmet need. Planned developments in the system are expected to increase the level of screening and referrals taking place.

However, there is insufficient capacity in existing services to meet the potential significant increases in referrals. Furthermore very little is known about offenders with personality disorders.

Police custody •

2013 figures show that one quarter of people detained in police custody suites answered positively to the question ‘do you have any mental health problems’. According to agespecific rates this group of people were more likely to be aged between 20 and 29, and live in Great Yarmouth or Norwich.

•

Fifteen per cent of detainees answered positively to the question ‘are you dependent on drugs (prescribed or otherwise)?’ Rates were higher for this group of people in Norwich and Great Yarmouth and for the 30-39 age groups.

•

A comparatively small proportion of people detained answered positively to the question ‘are you dependent on alcohol?’ (5%). The rate of people who were detained and answered

Page | 7

Offender Health Profile for Norfolk

positively to this question was also higher in Norwich and Great Yarmouth and higher for people in Norfolk in the 30-39 age groups.

•

For people with drug or alcohol dependency or mental health problems the rate was highest for the most deprived quintile of areas within Norfolk.

•

Identification of people with learning disabilities and developmental disabilities at Police Investigation Centres (PICs) is patchy and still needs improvement. A method of assessment of learning disabilities is being piloted in some PICs but we have no feedback on its success.

Liaison and diversion team •

These services are the only healthcare services available for those who attend court; all other health needs are not assessed.

•

The current team focuses primarily on offenders with mental health problems but does pick up some cases with intellectual disabilities.

•

The service is not full-time so people with clear mental health illnesses are sometimes not identified in the PICs and end up in prison. The new service (see below) should improve the situation.

•

There are due to be more changes to the way Liaison and Diversion services are provided.

Following the changes brought in during 2010, services around the country developed separately according to local needs. A nationally consistent ‘standard service’ will be used to ensure quality services; this ‘standard service’ is expected to be rolled out fully by 2017/18. 1 This new service is expected to include a wider range of vulnerable offenders including those of all ages rather than just adults, those with intellectual disabilities and those with drug and alcohol problems.

Forensic offenders

1

•

The predominant mental illnesses among people admitted to the Medium and Low Secure Services in Norvic Clinic and Hellesdon Hospital include psychosis, personality disorder, mood disorder and depression (although this group of people are less likely to end up in prison system or be classified as offenders).

•

Within this group of offenders there is a higher prevalence of substance misuse and increased likelihood of being a smoker.

•

The Norvic Clinic pay for the GP consultations for patients, this arrangement varies across the country.

http://www.england.nhs.uk/ourwork/commissioning/health-just/liaison-and-diversion/ (Accessed 02.07.14).

Page | 8

Offender Health Profile for Norfolk

•

The majority of forensic offenders in the three main prisons were aged 15-34 (46%), 69% suffered from psychosis and 67% were transferred to medium secure services, of which 19 out of 61 (31%) offenders were admitted to Norvic Clinic.

•

The process of transferring people with improved mental health status to the standard (nonforensic) community team may be difficult in the future due to capacity issues.

•

Personality disorder was said to be more challenging as it is too expensive to treat. It was generally found that for all conditions the focus should only be on those who have reasonable prognosis such as:  Motivated people who want to change.  People who have support outside of the services (such as family support).  Educated people and those with better communication skills.

•

It was raised that the major challenge facing managers of offenders who are referred for treatment for mental health issues is the effective targeting of services. This is because there is a huge unmet need.

•

It was perceived that substance misuse treatment gives most benefit. Treatment of psychosis and mania was said to also be beneficial but to a lesser extent.

•

The concept of psychiatric liaison is not a new one and changes have recently been made in Norfolk to improve the level of capacity available. Psychiatric liaison is primarily geared towards supporting people in an acute general hospital environment who display signs of a mental illness and could benefit from an intervention. Often the patient has been admitted for a physical health problem but the mental illness becomes apparent during their hospital stay, or contributed to/exacerbated the physical issue. The psychiatric liaison service is designed to support general hospital staff in the treatment of the individual and where appropriate, direct the individual to suitable mental health support and raise awareness among hospital staff of mental health needs more generally.

Release into the community •

Improving Access to Psychological Therapies (IAPT) is a psychological therapies service designed for people with a mild/moderate common mental health disorders. The criteria for entry are broad but if a person has complex needs then the service is unlikely to be appropriate. Where this is the case an offender with complex needs should be referred via their GP to secondary care mental health services. If the person is appropriate for secondary care they will be offered treatment and potentially, if suitable, be directed to an assessment process regarding their social care eligibility. All mental health service entry criteria is clinically based and defined by whether a person would benefit from an intervention/treatment episode at that time.

• The generic mental health teams have been found not to have the capacity to take patients released to the community when there is no longer a forensic need, and as a result forensic mental health community teams are unable to offload these patients – in many cases the team keep these patients on until they are able to be discharged from mental health services completely. It is thought that currently there are around 20 people on the forensic mental Page | 9

Offender Health Profile for Norfolk

health community team caseload who are ready to be passed on to generic community mental health teams.

Offenders with intellectual disabilities and other developmental disabilities (Broadland Clinic) •

There is a considerable number of offenders in prisons with borderline learning disabilities (IQ score 70-80) or autism. As these groups are not routinely identified it has been suggested that screening on release may give them access to appropriate support services.

However, it is clear that community support services do not have sufficient capacity to deal with demand.

•

There is a need for dedicated specialists for people with intellectual disabilities and other developmental disabilities – professionals aligned or part of the Liaison and Diversion service to assist in identifying people with intellectual disabilities and other developmental disabilities.

•

There are no services for intellectual or developmental disabilities in the community.

•

It is a priority to have a local forensic mental health and learning disability service to meet the mental health, psychological, behavioural and social care needs of offenders in conjunction with other health and social care agencies. There is no agreed joint policy Care Programme Approach (CPA) for people with learning disability in Norfolk.

Youth offenders (These findings are mainly based on national research as the findings of the Youth Offending Health audit carried out summer 2014 have not yet been finalised. A report on the findings of the audit will be added into JSNA later in the year).

•

Children and young people in contact with the youth justice system (YJS) have more – and more severe – unmet health and wellbeing needs than other children of their age and are likely to have received less in the way of health promotion, screening and preventative services than their non-offending peers.

•

Young offenders frequently face a range of other difficulties including school exclusion, fragmented family relationships, bereavement, unstable living conditions, and poor or harmful parenting that might be linked to parental poverty, substance misuse and mental health problems.

•

Reviews of health services to young people in the YJS in the community found health problems were identified in around a tenth of the assessments carried out by Youth Offending Teams but considerable under-reporting existed because assessments were focused on offending behaviour rather than wider health issues.

•

Slightly more is known about the health needs of young people in custody: in a health needs assessment undertaken in 1999-2000 in Youth Offender Institutes, the main physical health problems identified were asthma, dental health, blood-borne viruses such as hepatitis B and C, sexually transmitted diseases and epilepsy.

Page | 10

Offender Health Profile for Norfolk

•

Young offenders are at least three times as likely to have mental health problems than their non-offending counterparts and being in custody can exacerbate mental health problems.

The most common disorders are conduct disorders, followed by anxiety and depression.

Prevalence rates for personality disorders, psychosis, attention disorders, post-traumatic stress disorders and self-harm are much higher than in the general population.

Offenders in mainstream prisons •

Offenders are often not identified as having a learning disability and it is thought that many offenders may fall into this group (having an IQ of below 70). The lack of identification of the offender as someone with a learning disability, means that they are often treated inappropriately in prison – the diagnosis means that they should receive ‘reasonable adjustments’ under the Disability Discrimination Act (DDA) 1995, and by not doing so, it can be argued that the CJS is complicit in discriminating by not giving fair access to appropriate opportunities both in prison and in the community. This is supported by much of the evidence reported by the No One Knows report (2008) – a major report by the Prison Reform Trust.

•

The development of the resettlement prisons may result in better support and preparation of offenders for release. HMP Norwich will be the main resettlement prison for Norfolk.

•

In the year 2013/14 there were 658 NHS Health Checks carried out in Norfolk prisons. The prison NHS Health Check profile is generally younger with over two thirds (67%) being carried out on the 40-49 year olds in prison compared with only 34% for the programme as a whole. This has enormous potential preventative health benefits, as unhealthy lifestyle behaviours can be picked up and managed, for example 65% of residents in prisons having an NHS Health Check are ‘current smokers’, compared to only 15% for the programme as a whole, all received smoking advice and 17% (71) took up Stop Smoking services.

Women offenders •

Women prisoners have, in general, poorer physical and mental health than the general public and pose particular public health challenges. A health needs assessment of women held in Young Offender Institutions showed that their physical and mental health was poorer than women in manual classes and adult female prisoners.

•

National research has shown that mental health problems for women in prison are greater than for men, with much higher levels of self-harming. The mental health needs of women offenders are high and are often not picked up in the community but are identified when the woman is imprisoned. The needs of women in prison need to be identified as different to men, and improvements will not be felt until this is acknowledged.

•

The 4women Centre in Norwich provides a generic support service for women with a range of problems, including those involved in the criminal justice system and provides a critical role in supporting women in Norfolk (focused on Norwich). The Centre has developed a deep understanding of local need but faces challenges in demonstrating to funders the wider health and social benefits it provides to offenders through community based services.

This issue needs to be addressed.

Page | 11

Offender Health Profile for Norfolk

•

With the existence of the 4women Centre and probation orders working well, diverting women from courts and prisons to receive support in the community has developed and started to work well in Norwich. As a key recommendation of the Corston Report, support and advice centres such as the 4women Centre appears to be approach that needs of further development, and can reduce the wider impacts of offending on families. There is a clear need for improving integrated support for female offenders in Norfolk.

•

Overall provision of services for adult female offenders in Norfolk with substance misuse problems is good, but there are areas where coordination could be improved and gaps covered.

People under probation •

Services are currently under review and the development of the changes as part of the ‘Transforming Rehabilitation’ agenda will lead to new approaches to provision of services to assist offenders.

•

It is not clear how this will develop ― the link between the CRCs and the resettlement prison services are likely to be key.

•

The research project showed similar patterns of health needs of those under probation with prisoners, but probation services are not able to always deal proactively with all health conditions.

•

People with learning disability such as ADHD often have some difficulties in interacting with the probation health team – the condition is difficult to handle and does not come under mental health.

Support for people who misuse substances •

Data collection relating to people who come into contact with the drug and alcohol services is currently being reviewed and improved due to changes in reporting mechanisms which gave rise to gaps in data availability.

•

Awareness of Drug Rehabilitation Programmes (DRP) and Alcohol Treatment Requirements (ATR) need to be increased amongst relevant professionals.

•

Clear pathways need to be established for offenders to access recovery support within their local communities.

•

Norfolk is an outlier in terms of the number of drug related deaths.

Page | 12

Offender Health Profile for Norfolk

Veterans Project Nova is an 18 month trial project which aims to support veterans who are arrested and taken into police custody in Norfolk and Suffolk. The project will focus especially on veterans who have late onset mental health issues, and it will ensure partnership working and supported business planning using all of the following established pathways. The final evaluation report for Project Nova is expected to be available in 2015.

•

Data from the project so far indicate that:  58% of the veterans were in employment at time of arrest.  47% have indicated that they are either currently misusing substances or have done so.  Over half of the veterans were arrested for violence (including domestic violence).  9% of the veteran referrals were homeless or NFA at time of arrest.  Post-traumatic stress disorder (PTSD) is common among veteran offenders.  There have been a few veterans arrested for Child Sexual abuse.

Support in the community •

On discharge from prison, ex-offenders should be given a statement of their medical needs/medication by the prison, but these are often lost or not collected. As a result, if an ex-offender arrives at City Reach for treatment they have their needs reassessed. Lack of data sharing between a range of agencies makes the situation more difficult – such as between City Reach, the prisons, the Community Mental Health Teams etc.

•

Primary care is not easily accessible for offenders. Offenders experience difficulty in being accepted onto and/or retained on a GP practice list. There is a need for clarity in terms of how health providers manage offenders who are difficult to support and in terms of how health providers communicate on this to one another.

•

From our discussion with City Reach, a main reason for ex-offenders not accessing a range of services is their lack of accommodation. This includes some specialist health services such as the Community Mental Health Team. It also has a major impact on their chances of being offered employment.

•

There is a need to ensure that there is a raised awareness and information available on IAPTs services.

Page | 13

Offender Health Profile for Norfolk

Other analysis needed?

This project has focused on pathways and health care provision for a range of offenders to help identify gaps and duplications in the system and to provide a ‘whole system’ profile. However, it has been clear from our investigations that there are gaps in the information collected that are important to the criminal justice system as it works in Norfolk - and therefore need more work. The following list has been collated by the project team as some of the key issues to explore further.

•

Further work should be undertaken in collaboration with commissioners, for example:  To assess community care services for offenders, to identify the gaps, and to ensure that these teams are working in collaboration with each other in the community and other partners.  To consolidate latest evidence of best practice for offender health pathways, including a review of literature.  To assess and describe the needs of certain groups ― mainly those with learning disability and medium IQ, autism, personality disorders and challenging behaviors. It is important to know their needs and how these people are identified during their involvement with the justice system locally.  To investigate more fully the ‘environmental social’ issues which are closely related to offending and re-offending in particular housing and employment.  To look at the needs and support for sex offenders.  To re-visit the sharing of data between different partners / improve data sharing agreements.  Commission specific local data collection projects, ie surveys and focus groups among service users and providers – initially to focus this on offenders in the community and those with intellectual disabilities or other developmental disabilities.  To investigate how the new reforms to the system, particularly affecting prisons and probation services, impact on this picture.  To investigate health needs of short sentence foreign national offenders from Norfolk.

•

We have also identified ongoing research which would inform the project, but that has not yet been reported. This includes:  Youth Offending Health survey of service users – this survey will report shortly and a summary of the findings will be added into JSNA.  Costs and benefits of social care support for ex-offenders with learning disabilities – a study by the Tizall Centre at Kent University – partly being conducted at Norwich Prison.

Page | 14

Offender Health Profile for Norfolk

Recommendations General • • • •

To create an integrated offender health and social care commissioning board who would report to the Health and Wellbeing Board and the Rehabilitation of Offenders Board.

To map the offender health pathway, including provision for specific groups.

To develop an effective means of integrated offender health commissioning.

Promote awareness of the IAPT service among agencies in the criminal justice system.

Specific recommendations Liaison and Diversion services • To engage with the national liaison and diversion Steering Group and NHS England to highlight capacity issues regarding liaison and diversion.

Offenders in mainstream prisons • Ensure the IAPT service in Norfolk’s prisons is promoted to agencies in the criminal justice system and work closely with the IAPT provider to improve continuity on release for Norfolk offenders returning to the community.

Offenders in secure hospitals • To ensure county wide provision of psychiatric liaison services.

Offenders with learning disabilities • To improve screening for learning disabilities by frontline staff including police officers • To explore opportunities for a joint strategic approach to training.

Support in the community • To map the primary care pathway for offenders including services for specific groups such as female offenders, forensic offenders, offenders with learning disabilities and offenders who are difficult to support.

• Improve community mental health, learning disability and dual diagnosis provision.

Substance misuse findings • To map the offender health pathway including provision of substance misuse services.

Page | 15

Offender Health Profile for Norfolk

Abbreviations A&E

Accident and Emergency

MAPPA

Multi Agency Public Protection Arrangements

MBU

Mother and Baby Units

MH

Mental Health

MHA MHRT

Mental Health Act Mental Health Review Tribunal Mental Health Treatment Requirement Measles, Mumps and Rubella vaccine

ATR BBV

Attention deficit hyperactivity disorder Association of Public Health Observatories Alcohol Treatment Requirement Blood Borne Virus

BME

Black and minority ethnic

MHTR

BMI

Body Mass Index

MMR

ADHD APHO

CCG CG

Community Alcohol and Drug Services Counselling, Assessment, Referral, Advice and Through care Clinical Commissioning Group Clinical Guideline

CI

Confidence Interval

NACRO

CJMHT

Criminal Justice Mental Health Team

NCHOD

CJS

criminal justice system

N-DAP

CMHT

Community Mental Health Team Chronic Obstructive Pulmonary Disease

NFA

Medium Secure Unit Norfolk and Waveney National Association for the Care and Resettlement of Offenders National Centre for Health Outcomes Development Norfolk Drug and Alcohol Partnership No Fixed Abode (homeless)

NHS

National Health Service

CPA

Care Programme Approach

NICE

CPN

Community Psychiatric Nurse

NOMS

CPS

Crown Prosecution Service Community Rehabilitation Companies Crime Survey for England and Wales

NRP

Drug and Alcohol Action Team

NSFT

CADs CARATs

COPD

CRCs CSEW DAAT

MoJ

Ministry of Justice

MSOA

Middle layer Super Output Area

MSU N&W

NSCRC NSF

FACS FME

Defence Analytical Services and Advice Department of Health Detention Officer Drug rehabilitation requirement East of England East Region Public Health Observatory Fair access to care services Forensic Medical Examiner

FMS

Forensic Medical Service

PBMA

GMS GP GY HEA HepatitisB HIV

General Medical Services General Practice Great Yarmouth Health Equity Audit Hepatitis B Human Immunodeficiency Virus

PCC PCMD PCT PHE PHO PHOF

DASA DH DO DRR EoE ERPHO

Page | 16

NSPIS NSPT NYOT OASys OCD OFFSCAID ONS PBC

National Institute for Health and Clinical Excellence National Offender Management Service Norfolk Recovery Partnership Norfolk and Suffolk Community Rehabilitation Company National Service Framework Norfolk and Suffolk NHS Foundation Trust National Strategy for Police Information Systems Norfolk & Suffolk Probation Trust Norfolk Youth Offending team Offender Assessment System Obsessive-compulsive disorder Offenders & Social Care Intellectual Disabilities Office of National Statistics Practice Based Commissioning Programme Budgeting and Marginal Analysis Police and Crime Commissioner Primary Care Mortality Database Primary Care Trust Public Health England Public Health Observatory Public Health Outcome Framework

Offender Health Profile for Norfolk

HMPS HMYOI

Her Majesty's Prison Service Young Offender Institution

PIC PICU

HNA

Health Needs Assessment

PIPEs

Police Investigation Centre Psychiatric intensive care units Psychologically Informed Planned Environments

ID IDTS

Heartfordshire Partnership NHS Foundation Trust Health and Social Care Information Centre High security unit Improved Access to Psychological Therapies Information Centre International Classification of Disease Index of Deprivation Integrated Drug Treatment System

IMD

Index of Multiple Deprivation

SSAFA

IOM IQ IV

STD STI TADS TB

Tuberculosis

JSNA KL&WN L&D LA LAPE

Integrated Offender Management Intelligence Quotient Intravenous Joint Health and Wellbeing Strategies Joint Strategic Needs Assessment King's Lynn and West Norfolk Liaison and Diversion Local Authority Local Area Profiles for England

Standardised Mortality Ratio Super Output Area Soldiers, Sailors, Airmen and Families' Association Sexually transmitted diseases Sexually transmitted infection Trust Alcohol and Drug Service

TRBL UL VD VIPER WHO

LL

Lower Limit of confidence interval

YJB

LSOA

Lower layer Super Output Area

YOT

The Royal British Legion Upper limit of confidence interval Venereal Diseases Violence Indicator Profiles World Health Organisation Youth Justice Board for England and Wales Youth Offenders and Youth Offending Team

LSP LSU

Local Strategic Partnership Low Security Unit

HPFT HSCIC HSU IAPT IC ICD

JHWS

Page | 17

PSA

Public Service Agreements

RCP

Quality Management and Analysis System Quality and Outcomes Framework Rehabilitation for Addicted Prisoners Trust Royal College of Physicians

SHA

Strategic Health Authority

SMR SOA

QMAS QOF RAPt

Offender Health Profile for Norfolk

1. Background 1.1. Purpose of this report In Spring 2014, the Public Health Team were approached by a representative of the Strategic Board for the Rehabilitation of Offenders to ask for them to carry out a review of offender health services in Norfolk, providing a picture of how the services fit together and are developing following and during major structural change.

The report was timed to provide a baseline of offender health services and statistics to inform commissioning priorities for 2015/16. However, with tight timescales, the project team were unable to carry out primary research so used existing reports updated with new data where possible, plus an extensive programme of interviews to develop the report.

1.2. Definition of offenders The term offender within this report will refer to someone who has been convicted, cautioned, or recently arrested and has been linked to a crime as an offender. This definition covers those who have been charged with an offence but may not have been through custody (for example prison), people who have been in a custodial setting, those who have been released from custody on licence and young offenders. 2

1.3. The national context Provision of health services has always been complicated, with a mix of national and local services developed to ensure the health and wellbeing of those in custody, convicted of crimes and exoffenders. The aim of this project is to investigate and set out how these services and provisions work in Norfolk, and to make an assessment of their apparent effectiveness.

A formal National Partnership Agreement has existed for offender health services in public sector prisons in England since 2003. The original agreement, between the Home Office and the Department of Health, was developed to coincide with the Ministerial decision to transfer responsibility for policy and funding of healthcare in prisons from HM Prison Service to the Department of Health. A second revised National Partnership Agreement 3 was published in 2007 to coincide with the transfer of responsibility for escort and bedwatch services and the start of devolution of responsibility for prison health commissioning from the Department of Health to NHS Primary Care Trusts (PCTs), completed in 2009. 4 Since the publication of the last National Partnership Agreement in 2007, there has continued to be a number of transfers of further responsibility between the National Offender Management Service (NOMS) and the Department of Health. The previous National Partnership Agreement has formed the basis of many of the core instructions and service specifications within NOMS as well as providing the basis for historical local partnership agreements that underpinned local prison

2

University of East Anglia Surveying Hard to Reach Groups: Final Report (2009), http://www.norfolkinsight.org.uk/jsna/groupsatrisk#summary (Accessed 28.5.14).

3 http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publi cationsPolicyAndGuidance/DH_064096.

4 http://www.justice.gov.uk/downloads/about/noms/work-with-partners/national-partnership-agreementcommissioning-delivery-healthcare-prisons2013.pdf.

Page | 18

Offender Health Profile for Norfolk

partnership boards. These brought together senior leaders from establishments and healthcare providers across England.

In 2010 the coalition government announced proposals for significant reforms of the way in which Health is commissioned and supported in England – requiring a new approach and commitment to partnership working.

1.4. The new commissioning landscape for health and justice 5 In March 2012, the Health and Social Care Act received royal assent. The Act introduced significant restructuring of healthcare services in England from April 2013, including the abolition of Strategic Health Authorities and Primary Care Trusts. It created an independent NHS commissioning board – NHS England – with one of its new responsibilities being ‘the commissioning of services and facilities for people in prison and other places of detention’. Also the act resulted in the formation of Public Health England (PHE). The responsibilities of the new NHS England cover both public and contracted prisons and therefore effectively complete the transfer of responsibility for prison healthcare to the NHS. From April 1 2013, NHS England became responsible for commissioning all health services (with the exception of some emergency care, ambulance services, out of hours and 111 services) for people in prisons in England through ‘Health and Justice’ commissioning teams in 10 of NHS England’s 27 Area Teams, supported by a small national Health and Justice Team. This expanded the range of healthcare services directly commissioned for prisons, in particular with new responsibility for commissioning secondary care, community services and public health services, including substance misuse services (under a section 7a agreement with the Department of Health) in addition to continued commissioning of dentistry and optometry. 6 The Mandate between the Department of Health and NHS England published in November 2012 set out key expectations of the department in relation to working with people in prison, including improving the transition between custody and the community and developing Liaison and Diversion services, specifically: ‘Developing better healthcare services for offenders and people in the criminal justice systems which are integrated between custody and the community, including through development of Liaison and Diversion services’. 7 Health and justice services are interdependent and work together with the aim of delivering a system which is safe, legal and decent and which delivers both health and re-offending outcomes for the prisoner/patient. As independent organisations responsible for commissioning interdependent offender services, it is essential that NOMS and NHS England align their priorities and resources.

NHS England, Public Health England and NOMS have clear agreements to ensure

5

http://www.justice.gov.uk/downloads/about/noms/work-with-partners/national-partnership-agreementcommissioning-delivery-healthcare-prisons2013.pdf.

6 See www.wp.dh.gov.uk/publications/files/2012/11/29-People-in-prison-specification-121025.pdf.

7 The Mandate, A mandate from the Government to the NHS Commissioning Board: April 2013 to March 2015, Department of Health, November 2012, p25.

Page | 19

Offender Health Profile for Norfolk

Commissioning activity and delivery is co-ordinated at all levels within the organisations.

Commitments in this agreement mean that there is no need for arrangements to be re-negotiated in local partnerships as these are also covered by the national agreement.

The reforms to the health system in England have also abolished the National Treatment Agency and the Health Protection Agency, both of which have had a key role in services delivered to offenders and created a new body, Public Health England. Some of the former functions of these agencies will now be taken forward within Public Health England led by a Health and Justice Team matrix working with wider PHE functions such as alcohol and drugs advisors.

The PHE Health and Justice Team will work in partnership with NHS England commissioners in support of their responsibility for commissioning public health functions in prisons, at national and local level. In addition to the national team, ten Health and Justice Public Health Specialists will be located in PHE Centres, mapping to the ten NHS England Area Teams with specialist Health and Justice commissioning teams.

For the purposes of this agreement, the scope of commissioned services covers: •

All healthcare for remand and sentenced prisoners in establishment is commissioned by NOMS 8 (with the exception of emergency care, ambulance services, out of hours and 111 services) including:  Primary care (including pharmacy, optician & dentistry services).  Planned secondary care (including outpatient, diagnostic and inpatient services).  Community care services (including mental health services).  Public health (including health promotion, immunisation and infection control 9 and clinical and non-clinical substance misuse services).

•

Sentenced and remand prisoners over the age of 18 years of age in both public sector and contracted prisons in England. 10

•

Personality disorder services for offenders who are high risk of harm (men) and high risk of reoffending (women) which are jointly funded and commissioned by NOMS and NHS England. 11

8

This recognises that HMPS also provides custodial services to the Youth Justice Board and Home Office which will be subject to separate agreements with NHS England.

9 NHS England is supported in this function by Public Health England for prisoners and those on remand.

10 The agreement covers health services for offenders in prisons in England only, recognising that NOMS, unlike NHS England, is also responsible for commissioning prison and probation services in Wales. This agreement does however cover services for Welsh prisoners held in English prisons.

11 Personality Disorder Services including those for offenders, like Offender Health are a direct commissioning function of NHS England, but are commissioned as part of Specialised Commissioning as opposed to Offender Health Commissioning.

Page | 20

Offender Health Profile for Norfolk

1.5. Offender healthcare management in prisons and in the community 12 Helping offenders to recover from addiction and illness can significantly reduce reoffending and cut crime in local communities.

Health and justice services therefore work closely together to achieve these shared aims.

Arrangements for policy, commissioning and funding healthcare services for offenders differ between England and Wales and between custody and the community.

1.5.1. Healthcare in prisons in England From April 2013, responsibility for commissioning all healthcare services for prisoners (including drug and alcohol services but excluding emergency and our of hours services) rests with NHS England. 13 NOMS, NHS England and Public Health England have set out how we align, enable and support health and substance misuse services in prisons in a National Partnership Agreement.

1.5.2. Healthcare for offenders in the community in England Offenders in the community are generally expected to access the same healthcare services as the rest of the local population. From April 2013 Clinical Commissioning Groups (CCGs) are responsible for commissioning the majority of these healthcare services (including mental health services) with local authorities responsible for commissioning public health services, including drug and alcohol services. Health and Wellbeing Boards develop Joint Strategic Needs Assessments (JSNAs) to inform Health and Wellbeing Strategies which in turn inform local commissioning of services. It is important therefore that these include an understanding of the needs of those in contact with the criminal justice system. 14 Local data on the health and wellbeing of offenders is sparse and uncoordinated. Indeed it is hoped that this report will be the start of further work which will identify those healthcare interventions and commissioning priorities necessary to meet the wider health problems of offenders. However whilst the specific picture of the health needs of offenders is patchy, much can be gained by setting the problem in context and by considering what can be learned from the local picture based on the available information.

This will consider the overall pathways, focusing on those areas where little work has been done in identifying trends, characteristics and needs, and will identify gaps in services and resulting outcomes where possible.

Principles agreed: • Focusing on Offender pathways and identification of gaps. • Improvement of commissioning of Integrated Management Service and reduction of reoffending.

12

https://www.gov.uk/healthcare-for-offenders.

More information: Securing Excellence in Commissioning for Offender health (NHS England).

14 More information: Statutory Guidance on Joint Strategic Needs Assessments and Health and Wellbeing Strategies.

13

Page | 21

Offender Health Profile for Norfolk

1.6. Health and offending Offenders are more likely to smoke, misuse drugs and/or alcohol, suffer mental health problems, report having a disability, self-harm, attempt suicide and die prematurely compared to the general population. The links between poor health and reoffending have been long understood. 15 For example, evidence suggests: •

Drug users are estimated to be responsible for between a third and a half of acquisitive crime and treatment can cut the level of crime they commit by about half. 16 17

•

Alcohol is a factor in an estimated 47% of violent crime and A&E data sharing and targeted interventions have been shown to reduce overall A&E violence related attendances in one study by 40%. 18 19

The clear links between the wider determinants of health and factors affecting reoffending such as sustainable housing or employment create a potentially vicious circle. For example, offenders with addiction or mental health problems are more likely to need support with housing, education or employment to change their lives and prevent future victims, yet at the same time research shows these offenders will find it more difficult to access mainstream help than the general population.

Increased health inequalities are therefore compounded by greater barriers to accessing services to meet those needs.

There is a wealth of studies and information to support these facts, but we have not had time to investigate or summarise these in this report. An analysis of this sort would provide a useful context and would suggest initiatives that have been successful in reducing offending and reoffending and the Project Team suggest that this might be something worth carrying out in the near future.

15

http://www.justice.gov.uk/downloads/about/noms/work-with-partners/national-partnership-agreementcommissioning-delivery-healthcare-prisons2013.pdf.

16 MacDonald, Z., Tinsley, L., Collingwood, J., Jamieson, P. and Pudney, S. (2005). Measuring the harm from illegal drugs using the Drug Harm Index. Home Office Online Report 24/05. http://webarchive.nationalarchives.gov.uk/20110218135832/rds.homeoffice.gov.uk/rds/pdfs05/rdsolr2405.p df.

17 National Treatment Agency (2012) Estimating the crime reduction benefits of drug treatment and recovery www.nta.nhs.uk/uploads/vfm2012.pdf.

18 Crime Survey for England and Wales: Nature of Crime tables 2011/12 http://ons.gov.uk/ons/rel/crimestats/crime-statistics/nature-of-crime-tables--2011-12/index.html.

19 Effective NHS Contributions to Violence Prevention: the Cardiff Model www.vrg.cf.ac.uk/Files/vrg_violence_prevention.pdf.

Page | 22

Offender Health Profile for Norfolk

1.7. Overall picture of offending and offender population 1.7.1. Crimes in Norfolk 1.7.1.1. Overall picture of crime and disorder 20 For most people, Norfolk remains a very safe place. It has one of the lowest crime rates in England, with the level of crime and disorder in most places being well below the national average.

Overall, the total number of crimes recorded by police in Norfolk fell by around nine per cent over the 12 months to March 2013, with around 38,200 crimes being recorded. The rate of total recorded offences per 1,000 population for Norfolk is 44, compared with 53 for the East of England region and 64 for England. 21 There have been around 31,800 anti-social behaviour (ASB) incidents recorded by the police in Norfolk over the year, representing a fall of around 16% compared to the previous year 2011/12. 22 However, ASB suffers from under-reporting with national figures suggesting that 75% goes unreported. In Norfolk, Operational Partnership Teams have been set up in each district following a countywide review of how we tackle ASB. This provides partnership hubs to ensure that vulnerable victims of ASB are identified at the earliest opportunity and prevent repeat victimisation.

Over the 12 months to March 2013, the numbers of recorded crimes by offence group for Norfolk have fallen in terms of violence against the person (decrease of 1%); sexual offences (decrease of 16%); robbery (decrease of 19%); theft offences (decrease of 10%); criminal damage and arson (decrease of 20%); possession of weapons offences (decrease of 26%); public order offences (decrease of 7%); fraud (decrease of 3%); and offences categorised as ‘miscellaneous crimes against society’ (decrease of 11%). Increases in the numbers of recorded crimes for Norfolk for the same period include drug offences (increase of 9%); shoplifting (increase of 1%); and violence without injury (increase of 6%). 23 Table 1 shows crimes per 1,000 residents for each of Norfolk’s local authority areas for the year ended March 2013. Each of Norfolk’s local authority areas has experienced a fall in their rate of total crime per 1,000 residents from 2012 to 2013. Great Yarmouth has seen the greatest fall in crime rate, with North Norfolk and King’s Lynn & West Norfolk also having better than county average reductions over the year. Norwich continues to have the highest crime rate of all Norfolk’s local authority areas, remaining well above the Norfolk average (83.1 per 1,000 residents compared with 44.3 for Norfolk). Great Yarmouth also has a consistently higher crime rate compared with the Norfolk average (58.8 per 1,000 residents compared with 44.3 for Norfolk).

Crime rates for Breckland, Broadland, North Norfolk and South Norfolk remain well below the Norfolk average.

20

Norfolk’s Story – July 2013 Page 29&30. Available: http://www.norfolkinsight.org.uk/Custom/Resources/NorfolkStory.pdf (Accessed 4th June 2014).

21 ONS Statistical Bulletin. Data Tables available at: http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-314526 (Accessed: 19 July 2013) .

22 ONS Statistical Bulletin. Data Tables.

23 ONS Statistical Bulletin. Data Tables.

Page | 23

Offender Health Profile for Norfolk

Table 1: Crimes per 1,000 residents for Norfolk by local authority area, for years ended March 2012 and March 2013 % change to March 2012 March 2013 March 2013 Breckland 40.3 38.7 -4.0 Broadland 26.3 24.1 -8.1 Great Yarmouth 70.8 58.8 -16.9 King's Lynn & West Norfolk 46.2 41.4 -10.2 North Norfolk 31.7 27.9 -12.1 Norwich 89.8 83.1 -7.5 South Norfolk 33.1 30.5 -7.9 Norfolk 48.9 44.3 -9.5 Source: Norfolk Insight (Norfolk Constabulary), 2013

1.7.1.2. Crime Survey for England and Wales (CSEW) The Crime Survey for England and Wales is a nationwide crime survey conducted using face-toface interviews with household residents. In the survey people aged 16 or over are asked about their experiences of crime within the past 12 months. 24 Latest figures from the Crime Survey for England and Wales (CSEW) estimate that there were 8.6 million crimes in England and Wales, based on interviews with a representative sample of households and resident adults in the year ending March 2013. This represents a 9% decrease compared with the previous year’s survey. This latest estimate is the lowest since the survey began in 1981 and is now less than half its peak level in 1995. The CSEW also estimated that there were an additional 0.8 million crimes against children aged 10 to 15 resident in the household population.

The police recorded 3.7 million offences in the year ending March 2013, a decrease of 7% compared with the previous year. This is the lowest level since 2002/03 when the last major change in police recording practice was introduced.

Within victim-based crime there were decreases across all the main categories of recorded crime compared with the previous year, except for theft from the person (up 9%) and sexual offences (1% increase). The latter increase is thought to be partly a ‘Yewtree effect’, whereby greater numbers of victims of sexual offences have come forward to report historical offences to the police.

1.7.1.3. Crimes attributable to alcohol The North West Public Health Observatory has produced and published Local Alcohol Profiles for England (LAPE)25 on an annual basis since 2006. The latest update, Local Alcohol Profiles for England 2012, was released on August 16th 2012. The profiles contain 25 alcohol-related indicators for every local authority in England. The indicators measure the impact of alcohol on local communities and include a national indicator generated by the Department of Health – admission episodes for alcohol-attributable conditions (previously National Indicator 39). Indicators 24

Norfolk Insight: http://norfolkinsight.wordpress.com/2013/07/19/crime-in-england-and-wales-year-endingmarch-2013/.

25 Profiles are available online through the tool at Local Authority level via dynamic PDF: www.lape.org.uk.

Page | 24

Offender Health Profile for Norfolk

are available for the number and rate of violent crimes attributed to alcohol, sexual crimes attributable to alcohol and overall crimes attributable to alcohol.

In 2011/12 there were 4,355 crimes attributed to alcohol in Norfolk. Looking at the rates of crime attributed to alcohol in Norfolk per 100,000 people the county appears to perform well in many local authority areas: Breckland, Broadland, King’s Lynn and West Norfolk, North Norfolk and South Norfolk had rates lower than the East of England and the England average (Table 2). There were exceptions within Norfolk as both Great Yarmouth and Norwich had rates significantly higher than the England average – around one third of all alcohol attributable crimes in Norfolk occurred in Norwich, and around one fifth in Great Yarmouth.

Table 2: Recorded crime attributable to alcohol: Persons, all ages, crude rate per 1000 population (2011/12) Number of all recorded Rate per Lower Upper crime 100,000 people 95% CI 95% CI attributable to alcohol Breckland 4.26 3.92 4.63 558 Broadland 2.56 2.28 2.86 317 Great Yarmouth 8.35 7.79 8.95 812 King's Lynn and West Norfolk 4.64 4.29 5.01 666 North Norfolk 3.40 3.05 3.78 346 Norwich 8.99 8.51 9.50 1,290 South Norfolk 3.01 2.71 3.33 367 East of England 5.97 5.90 6.03 34,800 England 7.02 7.00 7.04 366,791 Source: LAPE, 2012 In the five years preceding 2011/12 the rate of crime attributed to alcohol has remained relatively similar across Norfolk with the exception of Norfolk and Great Yarmouth.

Although Norwich has seen a decline in the rate from 11.77 in 2007/8 to 8.99 in 2011/12 the local authority district has consistently performed significantly worse than the national and regional average (the rate in England was 9.14 per 100,000 people in 2007/8 which has declined to 7.02 in 2011/12). Great Yarmouth had a rate which was not significantly different to the England average in 2007/8 (9.36 compared with 9.14 in England) but failed to improve in line with national figures over the five year period, and has subsequently exceeded the national average rate significantly.

In Norfolk there were 3,589 violent crimes attributable to alcohol in 2011/12. Similar to the overall figure of crime attributed to alcohol – one third of these occurred in Norwich and one fifth of these occurred in Great Yarmouth.

The rate of violent crimes attributed to alcohol in Norfolk was significantly higher than the England and East of England average in Norwich and Great Yarmouth in 2011/12 (Table 3), and the trends over the previous five years have followed the same pattern as the overall alcohol attributable crime figure – the rate of these crimes in England has improved from 6.48 in 2007/8 to 5.03 in 2011/12. Compared to the national average there has been little improvement in Norwich or Great Yarmouth (which had rates of 8.95 and 7.90 per 100,000 people respectively).

Page | 25

Offender Health Profile for Norfolk

Table 3: Violent crimes attributable to alcohol: Persons, all ages, crude rate per 1000 population (2011/12) Number of all violent crimes Crude rate per Lower Upper attributable to 100,000 people 95% CI 95% CI alcohol (2011/2012) Breckland 3.51 3.20 3.85 460 Broadland 2.09 1.84 2.36 259 Great Yarmouth 7.16 6.64 7.71 696 King's Lynn and West Norfolk 3.64 3.33 3.96 522 North Norfolk 2.92 2.59 3.26 296 Norwich 7.50 7.05 7.96 1,076 South Norfolk 2.30 2.04 2.58 280 East of England 4.44 4.38 4.49 25,878 England 5.03 5.01 5.05 262,792 Source: LAPE, 2012 According to the LAPE there were 120 sexual crimes attributable to alcohol in Norfolk in 2011/12, which appear to share the same distribution across Norfolk as the overall crime rate and violent crime rate attributable to alcohol (with higher numbers in Norwich and Great Yarmouth).

The rates of sexual crimes attributable to alcohol per 100,000 people were highest in Norwich (0.23) and Great Yarmouth (0.21) which in turn was also higher than the England and East of England average (Table 4).

Trends over the preceding five years show that the rate per 100,000 people in Norwich has improved slightly compared with 2007/8 figures (from 0.25 to 0.23 in 2011/12) but the rate has increased in every other local authority district in the county over the same period (from 0.18 to 0.21 in Great Yarmouth, 0.06 to 0.13 in Breckland, 0.07 to 0.08 in Broadland, 0.07 to 0.11 in King’s Lynn and West Norfolk, 0.10 to 0.11 in North Norfolk and from 0.06 to 0.10 in South Norfolk.

Table 4: Sexual crimes attributable to alcohol: Persons, all ages, crude rate per 1000 population (2011/12) Number of all Rate per sexual crimes Lower Upper 100,000 attributable to 95% CI 95% CI people alcohol (2011/12) Breckland 0.13 0.07 0.20 16 Broadland 0.08 0.04 0.15 10 Great Yarmouth 0.21 0.13 0.32 21 King's Lynn and West Norfolk 0.11 0.07 0.19 17 North Norfolk 0.11 0.05 0.19 11 Norwich 0.23 0.16 0.32 33 South Norfolk 0.10 0.05 0.17 12 East of England 0.11 0.10 0.12 644 England 0.13 0.12 0.13 6,548 Source: LAPE, 2012 Page | 26

Offender Health Profile for Norfolk

1.7.1.4. Violence Indicator Profiles (VIPER) In 2011/12 the highest rates of sexual offences were seen in Norwich and Great Yarmouth (Table 5) these districts both had rates significantly worse than the national average rate (1.78 and 1.65 compared with 0.96 per 100,000 respectively). Both of these are considered the most deprived local authorities in Norfolk according to the Indices of Multiple Deprivation (2010). The average number of sexual offences for Norfolk as a whole was 1.07 per 100,000 - again higher than the national average of 0.96. 26 When comparing to other local authorities nationally Norwich and Great Yarmouth had the 8th and 16th worst rate of sexual assault in England (from 326 local authority rates recorded).

Table 5: Sexual offences: Crude rate per 1,000 population, (2011/12)

Breckland Broadland Great Yarmouth King's Lynn and West Norfolk North Norfolk Norwich South Norfolk East of England England

Crude rate per 100,000 people

Lower 95% CI

Upper 95% CI

0.96 0.62 1.65 0.88 0.86 1.78 0.74 0.85 0.96

0.80 0.49 1.40 0.74 0.69 1.57 0.59 0.83 0.96

1.15 0.78 1.92 1.05 1.06 2.01 0.91 0.87 0.97

Number of sexual offences (2011/12) 126 77 160 127 87 255 90 4,954 50,371

In terms of violent crime, districts in Norfolk generally performed better than the regional and national average of 11.99 and 13.60 per 100,000 people (Table 6), but also with the exception of Norwich (20.26) and Great Yarmouth (19.35) which both had significantly higher rates of violent crime.

Table 6: Violent crimes against the person: Crude rate per 1,000 population (2011/12) Number of violent Crude rate per Lower Upper crimes against the 100,000 people 95% CI 95% CI person (2011/12) Breckland 9.50 8.98 10.04 1,243 Broadland 5.65 5.24 6.09 699 Great Yarmouth 19.35 18.49 20.25 1,881 King's Lynn and West Norfolk 9.83 9.33 10.36 1,412 North Norfolk 7.88 7.34 8.44 801 Norwich 20.26 19.53 21.01 2,907 South Norfolk 6.22 5.79 6.68 758 East of England 11.99 11.90 12.08 69,940 England 13.60 13.57 13.63 710,249

26

Musgrave, S. Pickup, L. Maskrey, V. Blyth, A. Notley, C. Holland, R (2013) A Health Needs Assessment for Complainants of Sexual Assault in Norfolk and Suffolk.

Page | 27

Offender Health Profile for Norfolk

1.7.1.5. Youth offending There were 213 drug offences recorded as being committed by people aged 18 or under in 2010/11. Eighty-five percent of these related to possession of cannabis, 4% to possession of Class A drugs, 4% to possession with intent to supply (mostly of cannabis) and 3% for cultivating cannabis. The majority of these offenders were male (86%).

Only 116 were under the age of 18 at the time of the offence, numbers increased with age: 23% were 16 or under, 31% were 17 and 46% were 18 at the time of the offence.

In 2010-11 a further 363 crimes were linked to an offender or suspect who was 18 or under at the time of the arrest and the crime was also linked to alcohol or drugs.

The majority of these (82%) were violent offences linked to alcohol, 9% were violent crimes linked to drugs, and the remaining 9% were robberies and sexual offences (although these were very low numbers).

This represents an 11% decrease from the year before where there were 403 youth crimes linked to drugs and alcohol. For the 363 crimes there were 300 people detected as offenders, 74% of these were males. This shows that while there are far more male offenders, young females are more likely to be involved in alcohol related violence than drug offences. 27 Whenever someone is searched by the police a record is generated and the reasons for the search are recorded. It is worth remembering that these records only provide an indication of substance misuse related issues, as not all stop searches resulted in the police finding drugs or alcohol.

In 2010/11 there were 3,607 recorded ‘stop and search’ carried out on people aged 18 and under.

1,269 of these were searched on suspicion of being in possession of illegal drugs, 35% of all searches. Eighty three of these drug searches were also alcohol related and a further 113 nondrug searches were alcohol related (3% of all searches).

This totals 1,382 substance misuse related stops over 2010-11 representing 38% of all stops of young people. This is 179 more than the previous year, a 13% increase that is largely due to a small increase in alcohol related searches.

1.7.2. Population relating to offenders 1.7.2.1. Introduction This section summarises the characteristics and future trends of the population and levels of deprivation within Norfolk. Comparison with national and regional data is included where available and further breakdown by district is made.

27

N-DAP Young Person’s Substance Misuse Needs Assessment 2012, http://www.ndap.org.uk/files/6713/6673/2827/NDAP_Young_Persons_Substance_Misuse_Needs_Assessment_2012.pdf (Accessed 26.3.14) pp.36-38.

Page | 28

Offender Health Profile for Norfolk

Statistics for the county are broken down by area into smaller constituent sub-areas: local authority districts, wards, and super output areas 28 (listed from largest to smallest respectively) 29. This will be the basis for the presentation of statistics related to demographic indicators within the county.

Norfolk contains seven local authority districts: Breckland, Broadland, Great Yarmouth, King’s Lynn and West Norfolk, North Norfolk, Norwich, and South Norfolk (Figure 1). Norfolk is a large rural county (549,751 hectares) with one city classed as an ‘other urban area’, Norwich.

There are also three large market towns – Great Yarmouth, King’s Lynn and Thetford. Forty per cent of Norfolk’s population live in these four urban areas. The other significant urban areas in the county consist mainly of small market towns with typical populations of 6,000 to 12,000 people.

There are also many small and medium size villages scattered across the county. 30 Figure 1: Norfolk district boundaries

Source: Norfolk Insight, Norfolk County Council

28

Super Output Areas are grouped into two categories: Lower Super Output Areas (LSOA) which contain around 1,500 people; and Middle Layer Super Output Areas (MSOA); these consist of a mean population of 7,200.

29 More information on area classification is available at: http://www.neighbourhood.statistics.gov.uk/dissemination/Info.do?page=nessgeography/neighbourhoodstati sticsgeographyglossary/neighbourhood-statistics-geography-glossary.htm.

30 Norfolk’s Story June 2012, Norfolk Insight. Available: http://www.norfolkinsight.org.uk/Custom/Resources/NorfolkStory.pdf.

Page | 29

Offender Health Profile for Norfolk

1.7.2.2. Population According to 2011 mid-year estimates 859,400 people live in Norfolk (Table 7). King’s Lynn and West Norfolk and Norwich have the largest populations; King’s Lynn and West Norfolk has around 147,900 people and Norwich has an estimated 132,200 people (17.2% and 15.4% of the population respectively). The district with the lowest population is Great Yarmouth with around 97,500 people (11.3% of Norfolk population).

Table 7: Population estimates by gender and age group as a proportion of the total county population. Norfolk, 2011 Age Group Male 0-15 16-24 25-44 45-69 70+ Total Breckland 11,800 7,000 15,500 21,600 8,900 64,800 Broadland 10,700 5,800 13,900 21,700 8,800 60,900 Great Yarmouth 8,900 5,600 11,100 15,900 6,300 47,900 King's Lynn And West Norfolk 12,700 7,700 17,000 24,300 10,800 72,400 North Norfolk 7,500 4,500 9,500 18,600 9,200 49,200 Norwich 11,100 10,700 21,200 16,300 6,000 65,300 South Norfolk 11,500 5,600 13,800 21,300 8,500 60,700 Norfolk 74,100 47,000 101,900 139,700 58,500 421,200 % of Total County 8.6 5.5 11.9 16.3 6.8 49.0 Population Female

0-15 11,200 10,100 8,500 12,100 7,200 10,600 10,900 70,600

16-24 6,300 5,300 5,200 7,100 4,300 11,600 5,600 45,400

25-44 15,300 14,500 11,300 17,000 9,400 19,800 14,700 101,800

Breckland Broadland Great Yarmouth King's Lynn And West Norfolk North Norfolk Norwich South Norfolk Norfolk % of Total County 8.2 5.3 11.8 Population Source: Mid-year estimates 2011, Office for National Statistics.

45-69 22,200 22,700 16,500 25,900 19,800 16,600 22,400 146,200

70+ 11,200 11,200 8,100 13,400 11,800 8,300 10,200 74,200

Total 66,200 63,800 49,600 75,500 52,400 66,900 63,800 438,200

17.0

8.6

51.0

Table 8 and Figure 2 show gender specific population projections for the county through to 2020 by district and by age. Between 2011 and 2020 the population of Norfolk is projected to rise by 7.8%. The district with the largest estimated real population increase between 2011 and 2020 is Norwich (by 12,100 people). The district with the largest estimated proportional increase in population between 2011 and 2020 is South Norfolk (an increase of 9.4%).

There is set to be an estimated population increase from 859,400 people in 2011 to 926,700 in 2020. There are 4% more females than males in 2011, but the gap is projected to drop to a difference of 2.5% in 2020.

One of the reasons for the projected drop in the gap between the number of males and females in the population will be due to males living relatively longer in 2020, especially to over the age of 90, where it is predicted there will be an 82% increase.

Page | 30

Offender Health Profile for Norfolk

Table 8: Projected population by gender and local authority for Norfolk, 2011-2020 Year Male 2011 2012 2014 2016 2018 2020 Breckland 64,800 65,500 66,900 68,200 69,500 70,800 Broadland 60,900 61,300 62,200 63,100 64,100 65,100 Great Yarmouth 47,900 48,300 49,200 50,200 51,100 51,900 King's Lynn and West 72,400 73,000 74,300 75,500 76,800 78,200 Norfolk North Norfolk 49,200 49,600 50,300 51,100 51,900 52,800 Norwich 65,300 66,300 68,200 69,700 70,900 72,000 South Norfolk 60,700 61,400 62,800 64,100 65,500 66,800 Norfolk 421,200 425,400 433,800 442,000 449,800 457,500 Female

2011 66,200 63,800 49,600

2012 66,700 64,100 49,900

2014 67,800 64,800 50,600

2016 69,000 65,600 51,200

2018 70,100 66,400 51,900

Breckland Broadland Great Yarmouth King's Lynn and West 75,500 76,000 77,200 78,400 79,700 Norfolk North Norfolk 52,400 52,700 53,200 53,700 54,400 Norwich 66,900 67,900 69,500 70,700 71,600 South Norfolk 63,800 64,300 65,500 66,800 68,100 Norfolk 438,200 441,600 448,500 455,400 462,300 Source: Interim 2011-based population projections, Office for National Statistics.

Page | 31

2020 71,300 67,300 52,700 81,000 55,100 72,300 69,400 469,200

Offender Health Profile for Norfolk

The population is projected to rise in most age groups, and in particular the proportion of the population at or over 70 years of age is set to increase from 15.4% of the county population (132,600 people) in 2011, to 19% of the population (174,300 people) in 2020 (Figure 2).

Figure 2: Population distribution by gender, age, and population comparison with 2020.

Norfolk, 2011

Source: based on 2010 sub-national population projections, Office for National Statistics.

Page | 32

Offender Health Profile for Norfolk

1.7.2.3. Offender population Whilst routine data are collected for offenders who attend prisons in Norfolk it is possible that some in contact with the criminal justice system from Norfolk do not attend prisons within the county.

When given a detention/training order, young people are often transferred many miles from home, sometimes as far away as Milton Keynes, Kent, Bristol, Southampton or Rugby. There are also no prisons for women within Norfolk – women offenders are sent to Peterborough Prison as a matter of course, and in some cases prisons further away.

The population of offenders within the criminal justice system fluctuates and estimates at any one time are difficult to obtain. 31 Snapshot figures taken from previous health needs assessments show the age distribution of residents at the three prisons in Norfolk (Table 9).

Due to constantly changing inflows of prisoners these figures may not provide a reliable picture of typical populations within the prisons in the longer term. Segregation of prisoners by offending characteristics also means that it is not appropriate to compare prison resident populations to the overall population of Norfolk.

The classification of prison and the nature of crimes the offenders have committed may have an impact on the age distribution of offenders. HMP Bure accepts adult male sex offenders from areas nationally but priority is given to offenders from the East of England 32 and as a result the age profile of these residents may be skewed by the age profile of people who commit these crimes (for example people who commit sex offences may be older than typical offenders 33 which would explain older populations in HMP Bure). HMP Bure has a higher proportion of prisoners aged 50 and above (29.2%) compared with HMP Wayland (7.4%) and HMP and YOI Norwich (14.4%).

HMP Bure has been found to have a high proportion of older prisoners (aged 50 and above) even when compared with other sex offender establishments. 34 Table 9: Snapshot number of offenders in the three prisons in Norfolk HMP and YOI Norwich HMP Bure (July 2012) HMP Wayland (August 2011) (January 2013)* Age band No. % No. % No. % 21-29 107 20.5 425 42.8 227 33.7 30-39 123 23.5 316 31.9 166 24.6 40-49 140 26.8 177 17.8 139 20.6 50-59 84 16 58 5.8 61 9.1 60-69 45 8.6 16 1.6 23 3.4 70+ 24 4.6 0 0 13 1.9 Total 523 992 674 Source: NHS Norfolk and Waveney Public Health Information Team Health Needs Assessment HMP Wayland and HMP Bure (2012)

*HMP/YOI Norwich also has 45 people (6.8%) aged 18 to 20 31

University of East Anglia Surveying Hard to Reach Groups: Final Report (2009), http://www.norfolkinsight.org.uk/jsna/groupsatrisk#summary (Accessed 6.6.14).

32 http://www.justice.gov.uk/contacts/prison-finder/bure.

33 Office for National Statistics, Ministry of Justice and the Home Office An Overview of Sexual Offending in England and Wales (2013) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/214970/sexualoffending-overview-jan-2013.pdf.

34 NHS Norfolk and Waveney Health Needs Assessment: HMP Bure (2012).

Page | 33

Offender Health Profile for Norfolk

Previous Health Needs Assessments for HMP and YOI Norwich acknowledge that the prison population is constantly changing due to new receptions (offenders entering prison), transfers in (from other prisons), transfers out (to other prisons) and releases. Due to this there are many more who need health services than are captured in snapshot figures. Nearly a quarter of Norwich’s population was aged under 25 (156 prisoners – 23%), and less than 6% were aged over 60 (36 prisoners). 35 Comparison of age profiles for people who have been arrested with the general population in Norfolk may be more appropriate – these data include people who have been detained in police custody who have been arrested due to involvement, or suspected involvement, in a criminal offence. 36 Figure 3 compares the population distribution of people who were arrested and detained in police investigation centres (PICs) in Norfolk in 2013 with the distribution of the county resident population as a proportion of males/females aged 15-69.

Proportionally there were more people in their ‘20s’ detained in Norfolk. 19% of male and 17% of female PIC detainees were aged between 20-29 in 2013 – higher than the proportion of the local population aged between 15 and 69 in Norfolk. It is worth noting that although the proportional distribution of the PIC detainee population was similar for males and females, far fewer females were detained in Norfolk (1,616 females aged 15-69 compared with 7,378 males).

Figure 3: Norfolk Police Investigation Centre detainee age distribution compared with the general population (aged 15-69). Norfolk, 2013

Source: ONS Mid-year population estimates 2013 and Norfolk Constabulary

35

NHS Norfolk and Waveney Health Needs Assessment: HMP Norwich (2013), http://www.norfolkinsight.org.uk/resource/view?resourceId=308.

36 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/117583/pace-code-g2012.pdf.

Page | 34

Offender Health Profile for Norfolk

1.7.2.4. Deprivation People in contact with the criminal justice system are proportionally more at risk of socioeconomic deprivation than the general population. 37 Deprivation levels can be measured by comparing social, economic and housing issues between areas; more specifically, these can be grouped by a single score for each Lower Layer Super Output Area (LSOA) 38, using the Index of Multiple Deprivation (IMD) 2010. This Index is calculated by collecting data from each Lower layer Super Output Area for several domains of deprivation, which are grouped under one IMD score. Each domain is weighted by merit based on academic research and consultation (Table 10). 39 Table 10: Domains of multiple deprivation and their weights Domain 40 Income deprivation Employment deprivation Health deprivation and disability Education, skills and training deprivation Barriers to housing and services Living environment deprivation Crime

Domain Weight 22.5% 22.5% 13.5% 13.5% 9.3% 9.3% 9.3%

Source: Department for Communities and Local Government, Indices of Deprivation 2010 (IMD 2010).

The ‘living environment deprivation’ domain includes road accidents which account for a 1.5% weighting within the overall index and therefore do not have a significant impact on the overall deprivation score.

Each of the 32,482 SOAs in England have been assigned a score and a rank for the IMD 2010.

Summary measures can be combined and presented at local authority district, county, ward, and general practice population level by calculating the population-weighted average of LSOA scores within them. There are 354 local authority districts in England, seven of which are in Norfolk.

Wherever IMD scores are ranked, one represents the most deprived area. The index can compare relative levels of deprivation between districts and small areas. The scores and ranks of Norfolk (district and county level) can be observed in Table 11.

37

Revolving Door Agency Balancing Act: Addressing health inequalities among people in contact with the criminal justice system (2013), www.norfolkinsight.org.uk/news/item?itemId=612 (Accessed 09.06.14).

38 The Index of Multiple Deprivation (IMD) 2010 is an update of the Indices of Deprivation 2007 for England produced by the Department for Communities and Local Government. The new index is based on the same structure and methodology used to create the indices for 2010 but uses more up-to-date information. The IMD 2010 measures multiple deprivation for smaller area levels, namely ‘super output areas’ (LSOAs), these are geographical units of around 1,500 people and are sub divisions of current electoral wards.

There are 32,482 LSOAs in England, 530 are in Norfolk.

39 Information available at: http://www.communities.gov.uk/publications/corporate/statistics/indices2010.

40 There are also two supplementary indices: income deprivation affecting children and income deprivation affecting older people.

Page | 35

Offender Health Profile for Norfolk

From the Department for Communities and Local Government website, Norfolk is ranked as the 97th most deprived county of England (out of 149).

The IMD 2007 scores, whether at LSOA, local authority district, county, ward, or general practice level have been divided into five approximately equal-sized groups ranging from the 20% most deprived areas to the 20% least deprived areas. These groups could be referred to as local, regional, or national quintiles. This can give indication as to how an area performs compared with others in terms of deprivation. Occasionally this can be divided into ten approximately equal-sized groups ranging from the 10% most deprived areas to the 10% least deprived areas at the same mentioned levels.

Table 11 divides the LSOA of Norfolk by national quintile, to compare with collective country LSOA. The table observes the number of LSOA in each district which fall into each national quintile (one being most deprived, and five being least deprived).

There are 51 out of 530 LSOA in the most deprived 20% in England, of which are: 23 in Norwich, 16 in Great Yarmouth, 10 in King’s Lynn and West Norfolk, one in Breckland, and one in North Norfolk.

The 51 represent 9.6 % of Norfolk’s LSOA in the most deprived 20% in England which have the following characteristics on average: • • • •

Just over a third of people (35.4%) are income deprived.

One in five women aged 18-59 and men aged 18-64 (20.3%) are employment deprived.

Just under half of children (48.8%) live in families that are income deprived.

37.5% of older people are income deprived.

There are 80 that represent (15.1%) LSOA in the least deprived 20% in England of which 30 are in Broadland, 23 in South Norfolk, nine in Breckland, six in King’s Lynn and West Norfolk, nine in Norwich, and two in North Norfolk.

Table 11: Index of Multiple Deprivation score by number of LSOA by national quintile, score and rank by district National Quintile

IMD 2010 Score

District 1 2 3 4 5 Total Score Breckland 1 15 25 28 9 78 15.91 Broadland 0 0 21 33 30 84 10.41 Great Yarmouth 16 17 15 12 1 61 27.66 King's Lynn and West Norfolk 10 20 38 13 6 87 21.05 North Norfolk 1 22 30 7 2 62 19.28 Norwich 23 23 16 8 9 79 25.65 South Norfolk 0 3 20 33 23 79 11.31 Norfolk 51 100 165 134 80 530 Source: Department for Communities and Local Government, Indices of Deprivation 2010.

Note: 1 = most deprived, 5 = least deprived

Page | 36

Rank 187 279 54 123 146 70 259

Offender Health Profile for Norfolk

Figure 4 and Figure 5 provide IMD 2010 score and rank information for each district and ward.

Figure 4 shows the number of LSOAs in each national quintile, comparing all districts, while Figure 5 provides information on weighted IMD 2010 scores (local deprivation quintile) by ward for Norfolk.

Figure 4: Weighted IMD 2010 score by district for Norfolk

Figure 5: Weighted IMD 2010 score (local deprivation quintile) by ward for Norfolk

Page | 37

Offender Health Profile for Norfolk

1.7.2.5. Ethnicity41 Norfolk’s ethnic make-up is characterised by a predominantly White English, Welsh, Scottish, Northern Irish, British or Irish population (92.9% in the 2011 Census). A further 0.1% are Gypsy or Irish Travellers and 3.5% Other White. The proportion of people with an ethnic group other than White is 3.5%, and at local authority level this figure varies from 1.4% in North Norfolk to 9.2% in Norwich. In terms of national identity, the Census shows that 95% of people are associated in some way with a UK, British or English identity, and the remaining five per cent with other nationalities only. 22,900 (3.5% of passports held) were for EU countries (after the UK and Ireland are excluded). There were slightly more than 1,900 non-UK born short term residents of Norfolk recorded in the Census – these being people who intended to stay in the country for between three and twelve months.

There are a number of sources of information about migrant workers entering the county, though none gives complete coverage. The mechanism for capturing information relating to the numbers of migrant workers is limited – for instance, outflows are not fully captured. Data from the Department for Work and Pensions, however, show the number of National Insurance number registrations to overseas nationals entering the UK. For the year ending March 2011, the official statistics show around 50,300 registrations, the main nationalities being Polish, Lithuanian, Portuguese and Latvian. ‘Flag 4’ records within the NHS Patient Register Data Service indicate people who have registered with a GP in England and Wales who were previously living overseas.

There were some 6,900 new such registrations in Norfolk from mid-2009 to mid-2010.

People of Black and minority ethnic origin are overrepresented within the criminal justice system both nationally and locally. A report on the accommodation and related support needs of offenders in Norfolk (2004) found that: 42 • Offenders of Black and minority ethnic origin on the Norfolk Probation Area caseload had more accommodation problems than the general caseload and were the group most likely to have no fixed abode.

• More offenders of Black and minority ethnic origin on the Norfolk Probation Area caseload had drug misuse issues linked to their offending than White offenders.

• The Norfolk Youth Offenders Team assessments presented a slightly different picture: there were few significant differences between offenders of Black and minority ethnic origin and White offenders in relation to accommodation; but mental health and substance misuse associated with offending were both higher for offenders of Black and minority ethnic origin.

• There were a higher proportion of girls/young women and people of Black and minority ethnic origin amongst 16-18 year old offenders compared with adult offenders.

The health needs assessments for HMP Norwich (2009), HMP Bure (2012) and HMP Wayland (2012) found that the largest ethnic group other than White (who generally accounted for 65% to 76% of the prison population) was Black. This group accounted for 14% of the prison population in HMP Norwich, 15% in HMP Bure and in HMP Wayland and is overrepresented in prisons compared to both the overall population of Norfolk and Norwich (with ethnic groups other than White accounting for 3.5% and 9.2% of the population respectively).

41

Norfolk’s Story – July 2013 Page 11. Available: http://www.norfolkinsight.org.uk/Custom/Resources/NorfolkStory.pdf (Accessed 4th June 2014).

42 Research Plus: The Accommodation and Related Support Needs of Offenders in Norfolk (2004) http://www.broadland.gov.uk/PDF/Backdated_benefit.pdf (Accessed 9.6.14).

Page | 38

Offender Health Profile for Norfolk

1.8. Offender pathways and commissioning in Norfolk Healthcare for people in contact with the criminal justice system is sometimes seen as falling exclusively under the remit of NHS England, who assumed responsibility for commissioning healthcare for offenders within custodial settings in April 2013. In fact, NHS England Health and Justice Teams only have responsibility for commissioning services within police custody, prisons, Immigration Removal Centres (IRC) and the Secure Estate. 43 The proportion of offenders living in the community far outweighs those within the custodial estate.

While Clinical Commissioning Groups (CCGs) have responsibility for commissioning services for people in contact with the criminal justice system as members of the wider community, Directors of Public Health have specific duties to improve the health of this group as part of their remit to reduce health inequalities. 44 Public Health Outcome Framework (PHOF) indicators relating to the adult population in contact with the CJS include those relating to self-harm, suicide, smoking, under 75 mortality rate from liver disease, people entering prison with alcohol dependency previously unknown to the treatment community, successful completion of drug treatment and numerous others. In addition, some of the wider determinants of health such as domestic violence, violent crime, reoffending levels and older people’s perception of community safety are also relevant. 45 Whether in custody or under community supervision, offenders are much more likely than average to be subject to factors such as mental illnesses, personality disorders, learning disabilities, substance misuse, homelessness and poor educational achievement. People in the Criminal justice system (CJS) experience significant problems accessing adequate health and social care services (Department of Health, 2009, Improving Health: Supporting Justice the National Delivery Plan of the Health and Criminal Justice Board). 46 In general, the physical and mental health of people in the CJS is poorer than that of the general population. Forensic mental health services are provided through the Criminal Justice Mental Health Team and a range of rehabilitation wards and units are provided in Norwich and Great Yarmouth.

There is a need to work with offenders to improve their health and reduce their risk taking behaviour. Integrated offender management includes improving general health, mental health and substance misuse as well as self-worth, along with education, training and help with employment

43

NHS England Securing Excellence in Commissioning for Offender Health, http://www.england.nhs.uk/ourwork/commissioning/health-just/ (Accessed 26.3.14).

44 Revolving Door Agency Balancing Act: Addressing health inequalities among people in contact with the criminal justice system (2013) www.norfolkinsight.org.uk/news/item?itemId=612 (Accessed 7.3.14).

45

Public Health England Public Health Outcomes Framework http://www.phoutcomes.info/public-healthoutcomes-framework#gid/1000049/pat/6/ati/102/page/0/par/E12000004/are/E06000015 (Accessed 21.3.14).

46 A Health Needs Assessment of the Hertfordshire Probation Trust Caseload (2009) NHS Hertfordshire Probation Trust, http://www.ohrn.nhs.uk/resource/policy/NeedsassessmentHertfordshireProbation.pdf (Accessed 11.06.14).

Page | 39

Offender Health Profile for Norfolk

and housing – all of which should help to address offending behaviour and reduce incidence of reoffending. 47 A review of mental health needs in prisons found that in terms of diversion: 48 •

Police, court officials and magistrates should have regular training to understand mental illness and learning disabilities.

•

Local mental health and social care services should be required to provide full and current information to courts about the resources and services in their areas.

•

The ‘Appropriate Adult’ in police stations and courts must be fully resourced so that they can work with duty social workers to facilitate referrals to mental health services and social care.

47

Norfolk and Suffolk NHS Foundation Trust Forensic Services http://www.nsft.nhs.uk/OurServices/Forensic-Services/ (Accessed 26.3.14).

48 Prison Reform Trust: Too Little Too Late: an independent review of unmet mental health need in prison (2009), http://www.prisonreformtrust.org.uk/Portals/0/Documents/Too%20Little%20Too%20Late%20%20a%20review%20of%20unmet%20mental%20health%20need%20in%20prison%20.pdf (Accessed 13.06.14).

Page | 40

Offender Health Profile for Norfolk

2. Offenders in Police Investigation Centres 2.1. Introduction Police Investigation Centres (PICs) have been opened as part of a collaborative venture designed to improve the services offered by Norfolk and Suffolk constabularies. The custody suites host CCTV facilities, forensic and photographic facilities and interview rooms with modern interview recording equipment – allowing specialist police officers, staff and investigators to question suspects and hold them in custody under one roof. The PICs were completed towards the end of 2011, with the closure and replacement of all previous custody facilities. 49 There are six custody suites operated jointly by Norfolk and Suffolk Police, with four based in Norfolk. The number of custody suites and cell capacity in Norfolk are as follows: •

Aylsham (8).

•

Great Yarmouth (30).

•

King’s Lynn (24).

•

Wymondham (30).

Two additional PICs are based in Bury St Edmunds and Martlesham in Suffolk with a cell capacity of 24 and 30 respectively.

The King’s Lynn PIC also serves the Cambridgeshire Constabulary area.

The custody suites are staffed with permanent custody sergeants who are supported by civilian Detention Officers (DOs). DOs look after on-going care and welfare of detainees and assist custody officers by inputting arrest and detainee details onto the National Strategy for Police Information Systems (NSPIS) custody computer system.

Criminal Justice Liaison Services is an alternative to custody and available in the ‘custody suite’ – access is by telephone referral and an emergency team can be called out of hours.

Young people with suspected mental health problems are referred to the Youth Offending Team (YOT), who under usual circumstances offers a young person an appointment for assessment following release from custody.

49

Norfolk Constabulary. (2012). 50,000 through Police Investigation Centres. Available: http://www.norfolk.police.uk/newsandevents/newsstories/2012/november/50000throughpic.aspx. Last accessed 28.5.14.

Page | 41

Offender Health Profile for Norfolk

2.2. Pathways for those who need medical input 2.2.1. Introduction Health pathways for PICs in Norfolk have been well investigated. The Norfolk and Suffolk Custody Health Needs Assessment (2012) extensively maps out medical inputs for detainees at PICs (Appendix 1 page 170).

After arrest detainees are brought to PICs and are assessed by a custody officer prior to admission. The custody officer will undertake a detailed risk assessment which includes assessment of the detainees’ current physical state, pregnancy, physical health and mental health history (including chronic conditions), regular medications, drug and alcohol use (including requests for help with these issues), allergies, and history of self-harm. The custody officer will then make an informed decision on any health care input required based on the answers to these questions, along with the circumstances of the arrest and the officers’ observations of the detainee. Occasionally a detainee will need to attend A&E immediately to deal with a particular condition.

When a detainee has been accepted into custody the level of observation required, cell allocation and required healthcare input will be determined by the results of the risk assessment. A detainee can also request to see a health care professional if they wish.

Detainees are monitored by custody staff for the rest of the time that they are at the PIC and may call for health care input at any time if required.

If healthcare input is required, the Forensic Medical Service (FMS) is the primary contact for any medical input or advice if there is any doubt over a detainee’s fitness to be detained, interviewed or discharged.

Multiple services may operate in parallel simultaneously and depending on time of day and day of week detainees may be referred directly to mental health or drug and alcohol services by custody staff without any input from the FMS (Appendix 1).

2.2.2. Forensic Medical Service Health care is provided to PICs in Norfolk by G4S Forensic Medical Services (UK) Ltd (G4S) who provide nurses, paramedics and forensic medical examiners (FMEs).

G4S provides telephone triage/advice, forensic physicians, nurses and paramedics. G4S has a small number of permanent full time employees, but to a larger extent the service is reliant on casual bank staff, who are employed full–time elsewhere in the NHS. The registered nurses are required to have A&E but not mental health or substance misuse experience, and may be on any part of the Nurse and Midwifery Council register. The service provider has no affiliation to the NHS and permanent nursing staff are professionally isolated from the NHS, with no formal link for relevant continuing professional development or career progression opportunities.

Page | 42

Offender Health Profile for Norfolk

Healthcare professionals employed by G4S provide a service into the PICs with availability 24 hours a day, seven days a week and 365 days a year. There is no ‘resident’ 24 hour healthcare professional presence in any PIC. 50

2.2.3. In-Reach services In-Reach is provided to all PICs in Norfolk by the Criminal Justice Mental Health Team (CJMHT), which is provided by Norfolk and Suffolk NHS Foundation Trust (NSFT) (see Chapter 3). The Team does not provide an out of hours service – this is provided by the G4S doctor and the NSFT Crisis Resolution and Home Treatment Teams (CRHT).

The NRP through their Community Criminal Justice team, who attend PICs in Norfolk every day provide a service to detainees to give them an opportunity to engage with substance misuse services. The team receives referrals directly from custody staff that both pass on detainee requests to see a drug and alcohol worker or make suggestions of detainees who may benefit from being offered this service.

Drug and alcohol workers attempt to see all detainees in the PIC at the time of their visit to offer the opportunity of self-referral to the detainee (cell door visits). If they have missed seeing someone at the PIC they will follow on and see the person at the court.50 Support for people who misuse substances is discussed in Chapter 10 page 161.

2.3. Data from Police Investigation Centres in Norfolk 2.3.1. Number of detentions by centre and re-arrest Arrest and detainee details have been extracted from the National Strategy for Police Information Systems (NSPIS) custody computer system; these records provide information relating to PIC detainees in Norfolk during the 2012 and 2013 period. Detention records have been cross matched using detainee’s first and second name and date of birth in order to find the number of times each person has been arrested during the two years.

There were 31,913 detention cases in total during 2012 and 2013. Around 40.6% (12,948) were at the custody suite in Wymondham, 24.4% (7,791) were at the suite at King’s Lynn, 21% (6,696) were at Great Yarmouth PIC and 14% (4,478) were at Aylsham PIC (Table 12).

50

Holland, R, Maskrey, V, Musgrave, S, Kidd, A, Tamson, T, Blyth, A, Wagle, A & Notley, C (2012) Norfolk and Suffolk Police Custody Health Needs Assessment.

Page | 43

Offender Health Profile for Norfolk

Table 12: Total number of detentions in Norfolk by year and gender 2012 Police Investigation Centre (PIC) Male Female Total Male Aylsham 1,926 364 2,290 1,808 Great Yarmouth 2,795 584 3,379 2,779 King’s Lynn 3,270 633 3,903 3,263 Wymodham 5,414 966 6,380 5,572 Norfolk 13,405 2,547 15,952 13,422

2013 Female 380 538 625 996 2,539

Total 2,188 3,317 3,888 6,568 15,961

The total number of detentions in the two year period includes cases where people have been arrested multiple times. There were a total of 18,458 people detained in PICs in Norfolk in 2012 and 2013, an average of 9,229 per year.

The number of people who were arrested only once during this time period was 13,943. There were 2,436 people who were arrested twice during the two year period and 2,079 people were arrested three or more times.

Males were more likely than females to be arrested more than once. 25.7% of males were arrested twice or more during the two year period compared with 19.0% for females (Table 13).

Table 13: Number of arrests per person in 2012 and 2013 2012 Number of arrests per person Male Female One arrest 5,603 1,389 Two arrests 1,039 181 Three or more arrests 868 133 Number of people arrested in Norfolk 7,510 1,703

Page | 44

Total 6,992 1,220 1,001 9,213

Male 5,608 1,047 919 7,574

2013 Female 1,343 169 159 1,671

Total 6,951 1,216 1,078 9,245

Offender Health Profile for Norfolk

2.3.2. Time of arrivals The number of people arrested and taken to a PIC in Norfolk peaked in the summer months in 2013 (Figure 6). Most detentions were in August (1,545) and the fewest were in February (1,052) – this was similar to the previous needs assessment conducted in 2012 which found that there were more detentions in August in Norfolk than any other time of the year.

Figure 6: Number of people detained by month. Norfolk, 2013

The number of people detained increased on the weekends in 2013. There were 2,738 detentions on Saturday and 2,718 on Sunday, compared with 1,945 on Monday – this pattern was also the same as indicated within the previous needs assessment ( Figure 7).

Figure 7: Number of people detained by day of the week. Norfolk, 2013

Page | 45

Offender Health Profile for Norfolk

The time and day of arrivals to police custody suites have been analysed as an update to the previous health needs assessment for Norfolk and Suffolk carried out in 2012.

The distribution of arrivals for people who have been found to have a mental health problem is relatively similar to the distribution of arrests over time and day to the distribution for all arrivals (Table 14).

Table 14: Percentage of all detentions by day and time of arrivals. Norfolk, 2013 Hour of day 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Total

Mon 0.40 0.56 0.33 0.27 0.16 0.22 0.07 0.16 0.43 0.64 0.67 0.59 0.64 0.51 0.63 0.65 0.84 0.71 0.81 0.70 0.66 0.55 0.46 0.53 12.19

Colour key Low hourly rate Mid hourly rate High hourly rate

Page | 46

Tue 0.43 0.45 0.43 0.37 0.19 0.19 0.07 0.26 0.53 0.59 0.78 0.65 0.61 0.85 0.75 0.69 0.79 0.76 0.76 0.79 0.68 0.53 0.53 0.56 13.24

Wed 0.50 0.38 0.31 0.18 0.19 0.21 0.07 0.21 0.63 0.63 0.87 0.81 0.65 0.68 0.64 0.56 0.93 0.83 0.71 0.63 0.54 0.54 0.41 0.58 12.68

≤0.599 0.600% - 0.849% ≼0.850

Percentage (%) Thu Fri 0.48 0.56 0.31 0.55 0.33 0.48 0.24 0.38 0.23 0.28 0.16 0.19 0.08 0.08 0.23 0.13 0.51 0.45 0.75 0.75 0.93 0.64 0.58 0.70 0.70 0.66 0.64 0.57 0.70 0.85 0.82 0.73 0.83 0.88 0.73 0.60 0.81 0.64 0.62 0.70 0.70 0.75 0.67 0.69 0.44 0.88 0.78 1.29 13.28 14.43

Sat 1.25 1.25 1.37 1.07 0.55 0.26 0.11 0.13 0.19 0.35 0.52 0.48 0.55 0.58 0.65 0.67 0.95 0.78 0.66 0.83 0.72 0.81 1.00 1.43 17.15

Sun 1.70 1.93 1.38 1.38 0.92 0.27 0.12 0.13 0.31 0.47 0.41 0.37 0.45 0.55 0.71 0.54 0.49 0.88 0.65 0.62 0.68 0.61 0.85 0.61 17.03

Total 5.33 5.44 4.63 3.89 2.50 1.50 0.60 1.25 3.06 4.18 4.82 4.17 4.27 4.37 4.92 4.66 5.70 5.29 5.05 4.89 4.72 4.40 4.58 5.79 100.00

Offender Health Profile for Norfolk

2.3.3. Health risk assessment Five health assessment questions were selected to be extracted from the police custody data, these were based on alcohol or drug dependency or mental health issues: 1.

2.

3.

4.

5.

Are you dependent on alcohol?

Are you dependent on any other substance?

Are you dependent on drugs (prescribed or otherwise)?

Are you dependent on solvents?

Do you have any mental health problems?

The questions have been used to represent those who have drug or alcohol related problems, or mental health problems.

A data validation exercise found that in cases where people responded positively to ‘dependency on any other substance’ many of the responses involved tobacco. Where the detainee gave an answer involving: ‘smoking’, ‘smokes’, ‘cigarettes’, ‘tobacco’ or ‘fags’ cases were retained and grouped separately. Answers from this question involving dependency on any other substance has been grouped with people who answered positively to dependency on drugs and solvents.

Those which involved prescribed drugs or solvents were merged with those who answered positively to ‘dependency on drugs’.

The proportion of people who answered positively to each of the questions remained similar in 2012 and 2013.

In 2013 there were six people who attended PICs in Norfolk who indicated they were addicted to solvents and 162 people who indicated that they were dependent on tobacco.

1,403 people in 2013 supplied a positive response to ‘are you dependent on drugs’ and 477 people who gave a positive response to the question ‘are you dependent on alcohol’ (Table 15).

There were 283 people who provided a positive answer to both the alcohol dependency and mental health problems and 831 people who provided a positive answer to both questions about drug dependency and mental health problems.

Table 15: Risk assessment of detainees undertaken by the Police at arrival to custody suites in Norfolk Risk assessment question Are you dependent on alcohol?

Are you dependent on drugs (prescribed or otherwise)?

Do you have any mental health problems?

Positive answer to both alcohol dependency and mental health problems Positive answer to both drug dependency and mental health problems Positive answer to alcohol dependency and drug dependency No positive response to all/did not answer All detainees Page | 47

2012 Number 513 1,322 2,166

2013 % Number % 5.6 477 5.2 14.3 1,403 15.2 23.5 2,362 25.5

302

3.3

283

3.1

730

7.9

831

9.0

171 6,281 9,213

1.9 68.2 100

175 6,155 9,245

1.9 66.6 100

Offender Health Profile for Norfolk

A search of key words in free text responses to the questions ‘are you dependent on drugs?’ and ‘are you dependent on any other substance?’ has been carried out.

Although the search allowed for some common misspellings/associated terms the data must still be interpreted with caution because of lacking context. This form of free text analysis can be subjective due to misspellings/different terms. A random sample of 100 cases were taken from the analysed records and compared to the word identification from the free text response. Specified words were missed in 10% of cases due to typing errors. In another 8% of cases prescription drugs or medication were missed because the specific drug name was given in the response. The words ‘methadone’, ‘diazepam’ and ‘valium’ were added to the search criteria and were grouped separately from ‘medication’.

The search showed that from those who answered positively to questions in 2013, 75 contained the word ‘crack’ (0.5% of all custody cases), 50 contained the word ‘cocaine’ (0.3%), 403 contained the word ‘heroin’ (2.5%), 288 contained the word ‘cannabis’ or ‘weed’ (1.8%) and 21 contained the word ‘ketamine’ (0.1%) (Table 16).

1,580 responses contained the words ‘prescribed’, ‘prescription’, ‘medication’ or ‘meds’ (9.9%), 660 contained the word ‘methadone’ (4.1%), 61 contained the word ‘diazepam’ (0.4%) and 42 contained the word ‘valium’ (0.3%).

59% of people who responded positively to drug dependency in 2013 also responded positively to having mental health problems. In around 74.6% of detention cases where ‘prescribed’, ‘prescription’, ‘medication’ or ‘meds’ was mentioned in the free text answer to ‘are you dependent on drugs (prescribed or otherwise)?’ there was also a positive response given to the question ‘do you have any mental health problems?’, possibly because people with mental health problems may be more likely to take medication for their illness.

48.6% of those with the word ‘heroin’ within the question response also responded positively to the question about mental health problems, as did 48.4% of those with ‘cannabis’ in the free text response.

Table 16: Free text responses to the questions ‘are you dependent on drugs?’ and ‘are you dependent on any other substance?’ for detainees in 2013 Words contained in free % of which % of all % of positive answers text responses to Number of also indicated custody to drug/substance substance/drug related responses mental health cases dependency questions questions problem Crack 75 0.5 2.2 64.0 Cocaine 50 0.3 1.5 68.0 Heroin 403 2.5 11.9 48.6 Cannabis 288 1.8 8.5 48.4 Ketamine 21 0.1 0.6 42.9 Prescribed/prescription/ 1,580 9.9 46.7 74.6 medication/meds Methadone 660 4.1 19.5 53.2 Diazepam 61 0.4 1.8 68.9 Valium 42 0.3 1.2 71.4 Note: these responses relate to all detentions in 2013 and therefore people with these issues could be represented more than once in the case of multiple arrests.

Page | 48

Offender Health Profile for Norfolk

2.3.4. Arrest offences The top 15 types of arrest offences for people who have been taken to a PIC and have answered positively to questions about drug addiction, alcohol addiction or mental health problems are listed below. In 2013 theft from shops was either the first or second most common offence for these groups. Common assault and assault occasioning actual bodily harm (ABH) were also within the top five offences for each of these groups.

Drug related crime consists mainly of acquisitive crimes committed by problem drug users such as theft and burglary, to feed their drug habit. It has been reported that up to half of acquisitive crime, primarily burglary, theft and similar crimes, is drug related. Problem drugs were defined as opiates (mainly heroin) and crack cocaine, as most drug related crime was related to their use. 51 Taking this into account it is perhaps not surprising that in Norfolk the most common types of offence for those who have answered positively to the question ‘are you dependent drugs (prescribed or otherwise)?’ was theft from shops (14.6%) and theft (8.4%).

In Norfolk the most common offences for people who answered positively to the question ‘are you dependent on alcohol?’ were drunk and disorderly (11.6%), theft from shops (8.9%) or breach of bail (8.1%). To provide context the National Probation Service advises offenders that ‘alcohol is a factor related to a lot of crimes including many assaults, murder and rape cases (between 50 and 80%).’ Drinkaware, the industry body, publish lower figures – where alcohol is a factor in one in three (30%) sexual offences, one in three (33%) burglaries and one in two (50%) street crimes nationally. Additionally, previous studies have not been confident of any relation between acquisitive crime and drinking. The majority of offenders interviewed in national studies saw no causal connection between their alcohol use and their criminal behaviour. Patterns of pre-offence drinking and normal drinking were similar. Alcohol, however, has been found to be popular with shoplifters, especially well-known spirits. 52 Due to the wide range of mental health problems people can suffer from and the different effects these conditions have it may not be possible to comment on reasons for the types of crime these offenders commit. The most common type of arrest offences for those who answered positively to the question ‘do you have any mental health problems?’ were theft from shops (9.8%), common assault (8.9%) and theft (7.1%) (Table 17).

51

http://www.publications.parliament.uk/pa/cm200910/cmselect/cmpubacc/456/45605.htm#n9 (Accessed 15.08.14).

52 CIVITAS Crime Factsheets Alcohol and Crime:http://www.civitas.org.uk/crime/factsheet-alcoholcrime.pdf (Accessed 22.08.14).

Page | 49

Offender Health Profile for Norfolk

Table 17: Most common arrest offences for people who have answered positively when questioned about addiction to drugs, addiction to alcohol and mental health problems.

Norfolk PICs, 2013 Addicted to drugs Addicted to alcohol Mental health problems Offence No. % Offence No. % Offence No. % Theft from shops Theft Common assault Drug offences Assault ABH Criminal damage Breach of bail

457 263 246 184 155 152 141

14.6 8.4 7.9 5.9 5.0 4.9 4.5

Burglary

129

4.1

Drunk & disorderly Warrant - Failed to Appear Drug offences (Class A) S.5 Public Order Act 1986 Positive breath test S.4 Public Order Act 1986 Sexual offences All offences

110

3.5

99

3.2

76

Page | 50

156 120 108 106 78 78 70

11.6 8.9 8.1 7.9 5.8 5.8 5.2

Theft from shops Common assault Theft Criminal damage Assault ABH Drunk & disorderly Breach of bail

468 426 340 333 308 276 229

9.8 8.9 7.1 7.0 6.4 5.8 4.8

50

3.7

Drug offences

174

3.6

42

3.1

3.6

39

2.9

132

2.8

37

2.8

126

2.6

65

2.1

Affray

31

2.3

107

2.2

61

2.0

30

2.2

103

2.2

57

1.8

27

2.0

Sexual offences

99

2.1

53 3,125

1.7 100

Burglary S.4 Public Order Act 1986 Drug offences All offences

Burglary Warrant - Failed to Appear Positive breath test S.5 Public Order Act 1986 Affray

173

2.4

Drunk & Disorderly Theft from shops Breach of bail Common assault Assault ABH Criminal damage Theft Warrant - Failed to Appear Breach of the peace S.5 Public Order Act 1986 Positive breath test

23 1,341

1.7 100

Breach of the peace All offences

97 4,788

2.0 100

Offender Health Profile for Norfolk

The proportion of people who were detained for the 15 most common offences who answered positively to the question ‘are you dependent on drugs (prescribed or otherwise)?’ was much higher for people who had been arrested for theft from shops (29.2%), drug offences (24.5%) and warrant for failure to appear (22.1%) compared with all offences (15.2%) (Figure 8).

The proportion of people who were detained for the 15 most common offences who answered positively to the question ‘are you dependent on alcohol?’ was higher for people with arrest offences recorded as warrant for failure to appear (11%), theft from shops (7.2%) and drunk and disorderly (7.0%) (Figure 9).

The proportion of people who were detained for the 15 most common offences who answered positively to the question ‘do you have any mental health problems?’ was higher for people with a recorded arrest offence of warrant for failure to appear (33.1%), theft from shops (31.9%), section 5 of the Public Order Act 1986 (31.3%) and criminal damage (30.8%) (Figure 10).

Figure 8: Top 15 arrest offences in Norfolk by the proportion of people who have answered positively to the question 'are you dependent on drugs (prescribed or otherwise)?' 53

53

Error bars within the chart show confidence intervals. Confidence intervals (CIs) are a measure of whether a result that differs from the average is likely to be real or merely a chance fluctuation. In this case the error bars in the chart show 95% CIs – we can be 95% confident that the true value is likely to occur within this range.

Page | 51

Offender Health Profile for Norfolk

Figure 9: Top 15 arrest offences in Norfolk by the proportion of people who have answered positively to the question 'are you dependent on alcohol?'

Figure 10: Top 15 arrest offences in Norfolk by the proportion of people who have answered positively to the question 'do you have any mental health problems?'

Page | 52

Offender Health Profile for Norfolk

2.3.5. Age of detainees People aged 20-24 had the highest age-specific rate of people who attended a PIC in Norfolk per 1,000 people (35.7) followed by people aged 25-29 (29.6), people aged 15-19 (24.5), those aged 30-34 (23.9), 35-39 year olds (18.7) and 40-44 year olds (13.9). These age groups were all above the Norfolk rate for people aged 15 and above (Figure 11).

Figure 11: Age-specific rate of people detained in a PIC per 1,000. Norfolk, 2013

The age-specific rate per 1,000 people in Norfolk who had been taken to a PIC and answered positively to the question ‘do you have any mental health problems?’ was higher for the 20-24 age group than any other (6.8). This declined with age; the rate for the 65+ age group was 0.2 per 1,000.

The age-specific rate per 1,000 people in Norfolk who had been taken to a PIC and answered positively to the question ‘Are you dependent on drugs (prescribed or otherwise)?’ was higher for the 30-34 and 35-39 age groups (4.2 and 4.0 respectively) than any other.

The age-specific rate was lower for positive answers to the question ‘are you dependent on alcohol?’ across all age groups. The rate was also higher the 30-34 and 35-39 age groups than any other, which had a rate of 1.6 and 1.5 per 1,000 respectively (Figure 12).

Page | 53

Offender Health Profile for Norfolk

Figure 12: Age-specific rate of people who answered positively to questions about drug dependency, alcohol dependency or mental health problems at least once when attending a PIC in Norfolk in 2013

2.3.6. Resident area Great Yarmouth has the highest rate of people who have been taken to a PIC and answered positively when questioned about mental health problems per 1,000 population followed by Norwich and King’s Lynn and West Norfolk. The same pattern applies to those who supplied positive responses when questioned about alcohol dependency or drug dependency (Figure 13).

Figure 13: Rate of people who answered positively to questions about drug dependency, alcohol dependency or mental health problems at least once when attending a PIC by home address. Norfolk, 2013

Page | 54

Offender Health Profile for Norfolk

2.3.7. Deprivation The rate of people who answered positively to questions about drug dependency, alcohol dependency or mental health problems at least once when attending a PIC was highest for those from areas within the most deprived national quintile in all cases (Figure 14).

Figure 14: Rate of people who answered positively to questions about drug dependency, alcohol dependency or mental health problems at least once when attending a PIC by deprivation quintile. Norfolk, 2013

Page | 55

Offender Health Profile for Norfolk

2.3.8. Mosaic profiles Mosaic is a geo-demographic segmentation system developed by Experian. The basic premise of geo-demographic segmentation is that people tend to gravitate towards communities with other people of similar backgrounds, interests, and means.

Mosaic Public Sector classifies all consumers in the United Kingdom by allocating them to one of seven super groups, 15 groups and 69 types. These paint a rich picture of UK citizens in terms of their socio-economic and socio-cultural behaviour.

The super groups have been created to provide a high level overview of an area and are constructed by combining together the relevant groups. 54 These groups have been matched with the residential postcode of each person who has been detained in a PIC during 2013.

Table 18 and Table 19 show the social backgrounds for people who have been detained in Police Investigation Centres in Norfolk during 2013. From the 9,245 people detained in 2013 Mosaic can recognise 8,341 postcodes supplied.

Within the super groups there was an overrepresentation of ‘social housing tenants’ in the police custody population compared with the Norfolk general population. 18.1% of people detained in PICs were from areas assigned to this geo-demographic group, whereas these people only account for 5.7% of the population. The number of PIC detainees who were from areas associated with ‘young people starting out’ and ‘lower income tenants’ was higher than expected – people from these areas accounted for 14.3% and 27.8% of PIC detainees respectively, but only 8.6% and 17.6% of the population of Norfolk are classified as living within these areas (Table 18).

There were seven geo-demographic sub-groups overrepresented within the PIC population in Norfolk (Table 19). According to resident postcodes supplied by PIC detainees: 2.2% of people from the group ‘young people renting flats in high density social housing’ in Norfolk were detained in a PIC in 2013, 3.29% of people from the ‘families in low-rise social housing with high levels of benefit need’ group, 3.3% from the ‘lower income workers in urban terraces in often diverse areas’ group, 2.2% from the ‘young, well-educated city dwellers’ group, 2% from the ‘residents with sufficient incomes in right-to-buy social housing’ group, 1.7% from the ‘couples and young singles in small modern starter homes’ group and 1.2% from the ‘elderly people reliant on state support’ group.

54

Segmentation information available in further detail at: http://guides.businessstrategies.co.uk/mosaicpublicsector2009/html/visualisation.htm?010121.

Page | 56

Offender Health Profile for Norfolk

Table 18: Mosaic Public Sector super groups of Police Investigation Centre detainees.

Norfolk, 2013

Mosaic Public Sector super groups

%

Norfolk population (18+)

%

Detainees as proportion of population %

1,772

21.2

247,059

35.3

0.7

60

PIC detainees

Index

A

Rural and small town inhabitants

B

Affluent households

250

3.0

49,436

7.06

0.5

42

C

Middle income families

504

6.0

57,853

8.26

0.9

73

D

Young people starting out

1,189

14.3

60,079

8.6

2.0

166

E

Lower income residents

2,317

27.8

123,410

17.6

1.9

158

F

Elderly occupants

803

9.6

122,373

17.5

0.7

55

G

Social housing tenants

1,506

18.1

39,969

5.7

3.8

316

8,341

100

700,179

100

1.19

100

Total

Page | 57

Offender Health Profile for Norfolk

Table 19: Mosaic Public Sector groups of Police Investigation Centre detainees. Norfolk, 2013

Mosaic Public sector Groups A

Residents of isolated rural communities

PIC detainees

%

Norfolk population (18+)

%

Detainees as proportion of population %

Index

496

6.0

81,292

11.6

0.6

51

B

Residents of small and mid-sized towns with strong local roots

1,276

15.3

165,767

23.7

0.8

65

C

Wealthy people living in the most sought after neighbourhoods

13

0.2

3,999

0.6

0.3

27

D

Successful professionals living in suburban or semi-rural homes

237

2.8

45,437

6.5

0.5

44

E

Middle income families living in moderate suburban semis

290

3.5

34,540

4.9

0.8

70

F

Couples with young children in comfortable modern housing

214

2.6

23,313

3.3

0.9

77

G

Young, well-educated city dwellers

745

8.9

34,300

4.9

2.2

182

H

Couples and young singles in small modern starter homes

444

5.3

25,779

3.7

1.7

145

Lower income workers in urban terraces in often diverse areas

944

11.3

29,032

4.2

3.3

273

J

Owner occupiers in older-style housing in ex-industrial areas

486

5.8

49,536

7.1

1.0

82

K

Residents with sufficient incomes in right-to-buy social housing

887

10.6

44,842

6.4

1.98

166

L

Active elderly people living in pleasant retirement locations

313

3.8

81,875

11.7

0.38

32

M

Elderly people reliant on state support

490

5.9

40,498

5.8

1.21

102

N

Young people renting flats in high density social housing

701

8.4

15,469

2.2

4.53

380

O

Families in low-rise social housing with high levels of benefit need

805

9.7

24,500

3.5

3.29

276

8,341

100

700,179

100

1.19

100

I

Total

Page | 58

Offender Health Profile for Norfolk

2.4. Norfolk Appropriate Adult Service The Norfolk Appropriate Adult Service was developed in 1996, and is currently provided by Equal Lives: a user-led organisation formerly known as the Norfolk Coalition of Disabled People. The service is jointly commissioned by the Norfolk Youth Offending Service and Clinical Commissioning Groups (CCGs). This is a combined service, meaning that Appropriate Adults will support children and young people as well as vulnerable adults, who are detained in police custody. Norfolk Appropriate Adults Service also provides support to vulnerable people interviewed under caution in other settings (eg local mental health units and the Department of Work and Pensions), as well as supporting vulnerable people who are victims or potential witnesses.

All of the Appropriate Adults provided by this service are volunteers, and there are currently 89 active volunteers on the rota. As each Police Investigation Centre (PIC) is provided with a weekly rota, custody staff contact the volunteer ‘on duty’ whenever a vulnerable detainee has been identified. This service is available between 8.30am and 23.00pm only, and Appropriate Adults aim to attend the PIC within one hour of receiving a request. This is a busy service: •

Between April 2013 and March 2014, Norfolk Appropriate Adult Service attended on 2,526 occasions: 1,472 (58.3%) for vulnerable adults and 1,054 (41.7%) for juveniles.

•

Between April and the end of August this year, Appropriate Adults have already attended on 1,351 occasions: 723 (53.5%) for vulnerable adults and 628 (46.5%) for juveniles.

Figure 15: Number and proportion of Norfolk Appropriate Adult Service provided at PICs group (vulnerable adults and juveniles) from April 2013 to March 2014, and April 2014 to the end of August 2014.

Page | 59

Offender Health Profile for Norfolk

The Appropriate Adult role was created with the introduction of the Police and Criminal Evidence Act (PACE) 1984. Appropriate Adults are independent of the police, and they have an important role to play in safeguarding the rights and entitlements of vulnerable detainees. This can include advising detainees to exercise their right to free and independent legal advice (and requesting this on their behalf if they feel it is the detainee’s best interests to do so), as well as facilitating communication between the police and detainees and ensuring that any access needs are taken into consideration.

All juveniles (anyone under the age of 18) should have an Appropriate Adult present when they are interviewed by the police. If their parents or carers are unavailable, or they are deemed to be unsuitable (for example, if they are involved in the alleged offence), the Youth Offending Service has a statutory duty to arrange an Appropriate Adult in their absence.

PACE defines vulnerable adults as people who have a ‘mental disorder’ or are ‘otherwise mentally vulnerable’. Generally the Custody Officer will make this judgement during the risk assessment process, as well as in consultation with other professionals within the custody setting (eg solicitor, Criminal Justice Mental Health Team). PACE is quite clear that if the Custody Officer has ‘any doubt about the mental state or capacity of a detainee, that detainee should be treated as mentally vulnerable and an Appropriate Adult called’.

The Norfolk Appropriate Adult Service is a member of the National Appropriate Adult Network (NAAN), and has always had a presence on its Board of Trustees. NAAN defines what it considers to be ‘best practice’ in terms of Appropriate Adult provision, as well as aiming to influence national policy development.

In line with national standards, all volunteers are required to undertake DBS checks and provide satisfactory references upon application. They are not accepted on to the rota until they have successfully completed their training, which includes a period of shadowing and assessment by their peers. The NAAN training programme is followed (which is accredited), and this is supplemented by training delivered by external agencies where specific expertise is required.

In addition to safeguarding people’s rights during interview, Appropriate Adults have a role to play in identifying and sharing concerns about the welfare of detainees in police custody. If detainees disclose relevant information about their physical or mental wellbeing which has not been recorded, Appropriate Adults will share this with custody staff to inform the on-going risk assessment process. Equally if the Appropriate Adult has any concerns about a detainee’s mental wellbeing, and the impact of this in terms of their ‘fitness’ for interview, this will also be raised with custody staff; and if necessary, the interview postponed pending a further professional assessment.

The service has always had a positive working relationship with the Criminal Justice Mental Health Team, and Appropriate Adults can make a direct referral to this team via the Custody Officer. A similar referral pathway exists with the Norfolk Recovery Partnership, where detainees have identified that they would like to access support around substance misuse. These referral routes are currently in line with local protocols and the service specification as opposed to legislation.

Page | 60

Offender Health Profile for Norfolk

3. Liaison and diversion 3.1. Introduction When people with mental health problems or learning disabilities come into contact with the criminal justice system their first engagement with forensic mental health services will typically be through the Criminal Justice Mental Health Team for Norfolk (CJMHT). This chapter describes Liaison and Diversion services in Norfolk and following chapters will discuss the routes that people with mental health problems/learning disabilities take when they have been diverted from the criminal justice system (Chapter 4) as well as what happens to them once they have been released (Chapter 12).

The Norfolk and Suffolk NHS Foundation Trust (NSFT) provide mental health and learning disability services across Norfolk and Suffolk as well as being a partner within the NRP for substance misuse. 55 The Norfolk CJMHT (Liaison and Diversion) is one of the services provided by the Trust. The team provides specialist mental health services to agencies working within the criminal justice system. The team do not undertake any prolonged casework with individuals but refer them on to appropriate services.

The team provides an initial mental needs assessment and risk screening, provision of reports or advice at any stage between the arrest of an offender and conviction, provides a liaison and training role to ensure access to appropriate services and an understanding of mental disorder and the function of the CJMHT within partner agencies. 56 The client definition according to the operational policy of the local CJMHT is ‘an adult who has – or may have – a mental health difficulty or learning disability (which implies the existence of clinically recognisable signs, symptoms or behaviour) and who has – or is suspected to have – committed an offence, and requires an assessment of their health/social care needs in order to consider whether temporary or permanent diversion from the Criminal Justice System (CJS) is appropriate’.

The CJMHT liaison team consists of five nurses commissioned by NHS England and one probation nurse (Relapse Prevention Practitioner) commissioned jointly by Clinical Commissioning Group (CCG), Norfolk County Council, and Norfolk and Suffolk Probation Trust and operates from 9-5pm on week days.

The aim of the Relapse Prevention Practitioner is to provide assessment and Liaison and Diversion services to offenders with mental health needs within the Probation Service in Norfolk.

The practitioners mainly supervise those under community order, people released from prison on licence or people resident at probation approved premises at John Boag House in Norwich.

Sometimes the practitioners will be required to assess the mental health needs of prisoners prior to their release, especially in the case of high-risk offenders who are subject to Multi Agency Public Protection Arrangements (MAPPA). Appropriate referrals on to other mental health services will be made if required. The number of referrals through Relapse Prevention Practitioners fluctuates; in

55 56

http://www.nsft.nhs.uk/About-us/Pages/default.aspx (Accessed 02.07.14). http://www.nsft.nhs.uk/Our-services/Pages/Norfolk-CJMHT.aspx.

Page | 61

Offender Health Profile for Norfolk

the past year 198 referrals have been received from probation. In total, there were 775 referrals from June 2010 to June 2014 (an average of 193 referrals per year).

3.2. Existing service areas The team provides a proactive service to all Police Investigation Centres (PIC), Her Majesty’s Courts Service (Youth, Magistrates’, and Crown), probation offices and approved premises that fall within the NSFT geographical boundary. The team structure and distribution of staffing in Norfolk can be summarised as follows:

Deputy Service Manager (Hosted by the Secure Services operating to provide a Trust wide service)

Western Cluster

Central Cluster

Eastern Cluster

(Kings Lynn area)

(Norwich area)

(Gt. Yarmouth/Waveney)

Servicing:

Servicing:

Servicing:

Kings Lynn

Police Investigation Centre

Kings Lynn Magistrate Court

Wymondham

Gorleston

Police Investigation Centre

Police Investigation Centre

Aylsham

Gt. Yarmouth

Norwich

Lowestoft

Police Investigation Centre Magistrate Crown Court

Magistrate Court Magistrate Court

Norfolk Area Probation Servicing:

Norwich

Probation office & Approved Premises

Gt. Yarmouth Probation office

Kings Lynn Probation office

The Norfolk Criminal Justice Mental Health Team provide a service to PICs at Wymondham, King’s Lynn, Aylsham and Great Yarmouth (see Chapter 1). The team also provide services to four magistrates’ courts at King’s Lynn, Norwich, Great Yarmouth and Lowestoft; plus Norwich Crown Court (processes shown in (Figure 16) and the Norfolk and Suffolk Probation Trust (processes shown in Figure 17).

Norwich Crown court is the busiest magistrates’ court in Norfolk, and there is a practitioner from the Criminal Justice Mental Health Team permanently based there. Referral process can be one or more of the following: •

Being alerted about detainees arriving from Police Investigation Centres and who have already been assessed by the team.

•

Solicitors requesting an assessment.

•

Crown Prosecution Service (CPS) or magistrates requesting an assessment.

•

Court custody staff requesting an assessment.

Page | 62

Offender Health Profile for Norfolk

•

Health or social care colleagues making a referral for service users who will be attending court.

The team also operate the Service Level Agreement for Norwich Crown Court, whereby any request for a psychiatric report at the point of conviction or prior to sentence will be triaged by a practitioner to ensure that the request is appropriate, in which case a psychiatric report should be obtained.

King’s Lynn Magistrates’ Court is covered by another dedicated practitioner who also covers police custody at Great Yarmouth (the process for receiving referrals are as above).

The CJMHT does not currently operate a strict written referral process, as their experience suggests that CJS prefers to verbally refer on the day of court appearance due to the nature of the working practices in the CJS (this is because of the rapid daily turnover of court cases, the need to process cases and the inability to plan who would be making the first appearance on the day).

There are no other commissioned health services within the courts. Any emergency health problems are dealt with in the same way as those for the general public. The only health practitioners who are based in the courts are those of the Liaison and Diversion services – these practitioners deal primarily with mental health problems.

Page | 63

Offender Health Profile for Norfolk

Figure 16: Magistrates’ / Crown Court liaison and diversion assessment process Charged mental health / learning difficulty individual identified at the Court stage

No mental health or learning difficulty issue identified

Assessment conducted

(or continued if known to CJMHT)

at earliest available

Mental health or learning difficulty issues identified

Written/oral report prepared with recommendations to assist courts, solicitor or probation service

Continue through Criminal Justice Process

CJMHT recommendation accepted Diversion not appropriate. Individual continues through Court process.

Informal Diversion

Formal Diversion

Liaison/referral to partner agency/service as appropriate:

Hospital admission (under Part 3 of

(inc receiving prison or MH in-reach team etc)

Community disposal: Health/social care referral, CRHT or Mental Health Treatment Requirement (s207 CJA 2003)

Adjournment for full psychiatric court report to inform disposal

MHA) or other recommendation…

Hospital admission

(under civil section of MHA) # NB: If ‘temporarily’ Diverted client bailed to hospital by court

Deemed fit to plead

Continue with due process

Pre-conviction phase notes: I. The CJMHT have developed sound links with HMP In-Reach Teams and will work collaboratively with this allied service to facilitate, where appropriate, the diversion of those individuals on remand who subsequently require psychiatric hospital transfer (eg under s48.

MHA 1983, as amended)

Page | 64

Offender Health Profile for Norfolk

Figure 17: Probation – Relapse Prevention liaison and diversion assessment process

Individual residing at local probation approved premises

Individual subject to any Community Order (CJA, 2003)

Individual released under licence from HM Prison

Convicted individual with suspected mental health / learning difficulty referred by Offender Manager

No mental health or learning difficulty issues identified

Assessment conducted at earliest available opportunity

Continue with current Offender Management

Mental health or learning difficulty issues identified

Written/oral report prepared to assist Offender Manager Further period of brief intervention/monitoring (Maximum 3 months)

Referral concern resolved. No further intervention required by CJMHT. Continue with Offender Management arrangements

Referral to appropriate health/social care/ other community provision etc.

Acute MH/LD need identified: CRHT or informal / formal (under MHA) hospital admission

Post-conviction phase notes: I. The Practitioner also provides a key liaison role between the Offender Manager/Probation Service and the team responsible for delivering the health and social care packages of those individuals subject to a Mental Health Treatment Requirement (MHTR).

Page | 65

Offender Health Profile for Norfolk

3.3. People who use CJMHT Liaison and Diversion services in Norfolk Data from Liaison and Diversion (L&D) services have been collected both locally and nationally by the Offender Health Research Network. These data were collected to capture the key aspects of the activity and outcomes of the work undertaken by L&D services. 57 The three main areas of the data collected concentrate on which L&D services see, what L&D services do, and outcomes for their clients.

Over the 12 month period from August 2012 to July 2013 data from CJMHT L&D services in Norfolk showed that a total of 479 cases (an average of 40 cases per month) were submitted by CJMHT services, which accounted for 3% of the total number of cases submitted nationally over the same time period. The data show that from those in contact with the CJMHT services: •

The mean age was 37 years, which was higher than the national average of 32.

•

Most of the people (96%) were White and 4% from Black and minority ethnic (BME) groups, compared with 88% and 12% nationally.

•

Most commonly people in contact with the services were single (77%).

•

48% were unemployed, 30% were not at work because of a long term sickness or disability and only 13% were in paid employment or self-employed, which was the same proportion as those employed nationally who were in contact with the services.

•

There were a larger proportion of people with a long term sickness/disability who came into contact with the services in Norfolk (30% compared with 9% nationally).

•

67% either rent or own a house or flat which is higher than nationally (60%).

•

84% of people were registered with a GP which is slightly lower than the national average (89%).

•

23% of people had previous convictions which is nearly equivalent to the national rate (22%) (Table 20).

•

The majority were referred from the police (Table 21).

•

Of those offenders who used CJMHT liaison services in Norfolk the majority had either had previous contact with mental health services or were currently engaged with these services (70%):  41% had previous contact with mental health services.  29% were currently engaged with these services.

57

Offender Health Research Network: Liaison and Diversion Minimum Dataset Collection conducted on behalf of the Department of Health: August 2012-July 2013 (2013).

Page | 66

Offender Health Profile for Norfolk

ďƒ˜ 13% had been informally hospitalised for mental health problems. ďƒ˜ 22% had been detained under the mental health act previously.

Nearly one quarter (23%) had a chronic physical health problem but no treatment was required in custody, 6% had a chronic physical health problem with treatment required in custody, and 6% had an acute physical health problem which required medical attention while in custody (Table 22).

87% of those seen had primary diagnosis of a mental health problem and 46% had a secondary diagnosis of a mental health problem. This figure is much lower than the national average where the comparative figures were 73% and 30% respectively.

The CJMHT services also assess hazardous or risky behaviours undertaken by offenders. The service looks for people with drug or alcohol problems, as well as those at risk of suicide or selfharm. It was found that 42% had an alcohol use problem, 26% had a drug use problem, 21% had a cannabis use problem, 16% had a class A drug use problem and 31% were at risk of suicide or deliberate self-harm.

Table 20: Previous convictions of those in contact with CJMHT liaison services as a proportion of total referrals Previous convictions Norfolk (%) All Sites (%) Violence against the person 33 24 Public nuisance/order, including alcohol related behaviour 15 19 Criminal damage 12 7

Table 21: Source of referral to CJMHT liaison services as a proportion of total referrals Source of referral Norfolk (%) All sites (%) Police 68 46 Police custody health services 6 6 Probation service 6 5 Court staff 6 2 Solicitor 6 3 Community mental health services * * Judiciary/magistracy * * Third sector services * * Other * * Note: Due to small numbers it is not possible to present the information for all sources (asterisks in table).

Page | 67

Offender Health Profile for Norfolk

Table 22: Identification of need, problem or risk from CJMHT liaison cases Identification of need, problem or risk Norfolk All sites (%) studied (%) Learning disability 7 5 Accommodation 20 17 Financial 8 7 Physical None 61 70 health Not assessed 5 12 problem Chronic: no treatment required in custody 23 11 Chronic: treatment required in custody 6 3 Acute: requires medical attention while in 6 3 custody Mental health None 13 27 problem Depressive illness 25 22 (primary) Schizophrenia or other delusional 18 14 disorder Personality disorder 13 9 Anxiety/phobia panic disorder/OCD2/ 9 7 PTSD Other 8 6 Unknown 1 4 Bipolar affective disorder 6 4 Adjustment disorder/reaction 5 3 Attention deficit disorder 1 2 Organic disorder 1 1 Dementia 0 0 Eating disorder 0 0 Mental health None 54 70 problem (secondary Anxiety/phobia panic disorder/OCD2/ 10 6 PTSD Depressive illness 8 6 Unknown 2 6 Personality disorder 11 3 Other 7 3 Adjustment disorder/reaction 4 2 Schizophrenia or other delusional 3 2 disorder Bipolar affective disorder 2 1 Attention deficit disorder 1 1 Organic disorder 1 0 Eating disorder 0 0 Dementia 0 0 Alcohol use No problem 54 51 problem Yes, hazardous 17 16 Yes, harmful 12 13 Page | 68

Range (%) (2-14) (5-36) (2-29) (40-88) (0-38) (0-26) (0-9) (0-10) (2-61) (5-35) (4-36) (3-27) (2-16) (1-24) (0-15) (0-8) (0-30) (0-6) (0-5) (0-2) (0-1) (53-91) (0-16) (2-11) (0-11) (0-11) (0-24) (0-8) (0-4) (0-2) (0-2) (0-1) (0-1) (0-1) (32-69) (5-24) (6-30)

Offender Health Profile for Norfolk

Drug use problem

Cannabis use problem

Class A drug use problem

Yes, dependence Unknown No problem Yes, problematic Yes, dependence Unknown No problem Yes, problematic Unknown Yes, dependence No problem Yes, problematic Unknown Yes, dependence Current suicide or DSH risk

13 3 69 19 7 4 73 18 6 3 79 11 5 5 31

13 8 63 18 11 8 70 15 10 4 72 10 10 9 21

(2-24) (0-33) (42-80) (7-30) (2-29) (0-30) (49-81) (6-31) (0-35) (1-8) (48-81) (4-24) (0-33) (0-25) (4-63)

3.4. Changes to the Criminal Justice Mental Health Team There are due to be changes to the way CJMHT liaison services are provided in Norfolk. The Liaison and Diversion (L&D) programme was created in 2010 following recommendations from the Bradley Report. 58 L&D services around the country have developed separately according to local need since their inception in the 1990s, and following recommendations from the Bradley Report a nationally consistent ‘standard service’ will be used to ensure quality services; this ‘standard service’ is expected to be rolled out across the country fully by 2017/18 . Liaison and Diversion services are going to be used both at PICs and courts in order to identify, screen and refer people with mental health, learning disability, substance misuse and social vulnerabilities.

From 1 April 2014, the new programme transitioned from Department of Health to NHS England to reflect the move into its implementation phase. The programme will now work significantly with L&D service providers to ensure that roll out of the programme is delivering as scheduled. 59 From 1 April 2015 the CJMHT liaison will provide services for vulnerable people of all ages with all mental health conditions and other problems such as learning disability, alcohol dependency and drug dependency and the team will be assessed by results and outcomes such as attendance of appointments or further reoffending.

Locally the new programme is expected to bring about increased coverage (access will be all hours and for all ages – as opposed to only 9-5pm on weekdays). There will also be increased screening assessment, signposting and identified pathways. The impact of the changes to services in Norfolk is not currently known. However, concerns have been expressed by service managers over the ability of services to cope with increased referrals from the CJMHT. 58

https://www.gov.uk/government/news/extra-funding-for-mental-health-nurses-to-be-based-at-policestations-and-courts-across-the-country (Accessed 02.07.14).

59 http://www.england.nhs.uk/ourwork/commissioning/health-just/ (Accessed 02.07.14).

Page | 69

Offender Health Profile for Norfolk

4. Forensic mental health services 4.1. Introduction An offender can become a restricted patient by one of two main routes. An offender convicted for a serious offence may be ordered to receive hospital treatment instead of a prison sentence. When making the hospital order, the court has the option of adding a restriction order for offenders posing a risk of serious harm to others. ‘Restricted patients’ are subject to risk management by the Secretary of State for Justice. Alternatively, if the court passes a prison sentence, it can simultaneously direct the offender's admission to hospital, or the offender can subsequently be transferred to hospital by the Secretary of State. These prisoners are usually made subject to restrictions. In addition, there are other groups of restricted patients, such as offenders transferred from prison service establishment while un-sentenced or untried, or offenders who are unfit to plead.

The core objectives for secure services are to assess and treat mental disorder, reduce the risk of harm that the individual exhibits to others and to support recovery. Secure services provide a comprehensive range of evidence based care and treatment. Care and treatment is provided by practitioners in the field of forensic mental health including consultants in forensic expert psychiatry. A range of specialist offence related treatment programmes delivered either individually or within groups will be available. These will typically include sex offender treatment programmes, aggression management programmes and programmes to address fire setting. The aim is for the individual to safely return to the community or prison or transfer out of secure services.

This chapter provides information about mentally disordered offenders (forensic offenders).

Forensic mental health services are specialist services for people who have a mental health problem who have been arrested, who are on remand or who have been to court and found guilty of a crime. ‘Forensic’ means ‘pertaining to the law’.

These services are an alternative to prison for people who have a mental health problem and offer specialist treatment and care. They are ‘secure’ units, which mean that people who are referred there are not free to come and go. Most people are detained in secure forensic services under mental health legislation.

Professionals who work in forensic mental health services take decisions about length of stay in collaboration with the professionals who will be responsible for an individual's support and care following discharge. If someone has been found guilty of a violent offence, or has been considered to be dangerous, the Ministry of Justice and Parole Board are involved in decisions about discharge.

Secure hospitals or units are categorised by three different levels of security – high, medium and low. There are three high secure hospitals nationally which are each part of an NHS trust – Ashworth, Broadmoor and Rampton. People referred to one of these hospitals are detained under mental health legislation because they are thought to pose a ‘grave and immediate danger to the public.’

Low and Medium Secure Services provide a therapeutic psychiatry services for individuals with a mental disorder – mental illness, personality disorder, neuro-developmental disorder – who present a significant risk of harm to others.

Page | 70

Offender Health Profile for Norfolk

Medium secure hospitals/units are for people who are detained under mental health legislation and pose a serious danger to the public. They are run by either the NHS or by private healthcare organisations.

Most people transferred from court or prisons are initially sent to medium or high secure units.

Low secure units are run by either the NHS or by private healthcare organisations. People who have already spent some time in a medium secure unit may be transferred onto a low secure unit before they are discharged back into the community. Sometimes, people who have never been involved with the criminal justice system are admitted to one of these units when they are detained under the Mental Health Act as an involuntary patient.

People who have been detained under Section 37/41 of the Mental Health Act are placed under social supervision on release. This supervision and regular assessment is required by the Ministry of Justice (MoJ). Three-monthly reports are carried out by either a social supervisor or a social nurse which will be submitted to the MoJ. Not everyone who has a mental health problem and comes into contact with the police or the courts will be referred to forensic services. Many people who have offended do get sent to prison.

However, the government recognises that prisons do not offer the best treatment and care to people who have mental health problems, and is introducing services and training to make sure people are ‘diverted’ from the criminal justice system to forensic services as early as possible.

Diversion and liaison schemes (described in Chapter 3) are used in police stations, courts and prisons to identify mental health problems of offenders early and ensure appropriate treatment, help or diversion from the criminal justice system to an appropriate NHS mental health service.

The maintenance of security is crucial to the provision of effective therapeutic interventions in secure services. A key principle underpinning the provision of secure services is that individuals should be managed in the least restrictive environment possible in order to facilitate their safe recovery. Least restrictive refers to the therapeutic use of the minimum levels of physical, procedural and relational measures necessary to provide a safe and recovery focused environment.

Page | 71

Offender Health Profile for Norfolk

4.2. The cost of secure mental health services The total average spending on secure services amounted to £1.2 billion in 2009/10, corresponding to 18.9% of all public expenditure on adult mental health care (Mental Health Strategies, 2010).

Secure care is a high cost, low volume form of service provision. The cost of accommodating a person for a year in a low security hospital is an average of £152,000, and £176,000 in a medium secure hospital. 60 The equivalent for a high security hospital costs in the region of £273,000 (see Table 23).

Average lengths of stay are very long, when compared to acute mental health admissions, implying limited turnover and relatively small numbers of people using these services over the course of a year. For example, only a third of people in high and medium secure units stay for less than two years and nearly half stay for more than five years. In sharp contrast, among all people in ordinary (non-secure) psychiatric hospitals, over 50% stay for less than one month and only 4% stay for more than one year. Of all those in high and medium secure hospitals at any one time, over 70% will still be there a year later.

In addition to the generally high cost of secure care, it is important to note that there are also significant differences in cost by level of security. For example, one year spent in a high secure hospital costs nearly £100,000 more than the same period of time spent in a medium secure unit.

Such differences highlight the importance of appropriate placement, as detaining a patient at a higher level of security than necessary carries a substantial cost penalty. The difference is less marked between medium and low secure, at around £24,000 a year.

This cost differential applies not just within the secure hospital sector but also between secure hospitals and other settings, such as prison, which may form part of the pathway that offenders with severe mental health problems follow from initial arrest through detention to eventual release back into the community. At every point on this pathway there are cost differences between settings.

Table 23: Cost data published by the Department of Health show the following unit costs for secure services in 2008/09 Patient cost per day Patient cost per year Low secure £416 £152,000 Medium secure £482 £176,000 High secure £749 £273,000

60

Pathways to unlocking secure mental health care, Centre for Mental Health 2011, www.centreformentalhealth.org.uk.

Page | 72

Offender Health Profile for Norfolk

4.3. Diversion and the Mental Health Act The Mental Health Act can be used to admit someone to hospital for assessment and/or treatment for mental illness. This is carried out in the interests of the person’s own safety or the safety of others.

Criminal courts are able to use Section 37 of the Mental Health Act if they think that an offender should be in hospital instead of prison, and the Crown Court can add a Section 41 restriction order if they have concerns about public safety or personal risk. The hospital is able to treat patients held under these laws without their permission.

People who are detained under Section 37/41 of the Mental Health Act can appeal to the courts, hospital managers and the Mental Health Review Tribunal (MHRT) but the decision to allow them to leave lies with the Secretary of State for Justice (the Ministry of Justice).

After discharge, people who have been detained are entitled to free aftercare services under Section 117 of the Mental Health Act (which includes supported housing and other services). 61 These people will be risk assessed on release and will be given information and help to make sure that they can use community services.

4.4. Forensic services in Norfolk There are a number of centres in Norfolk designed to accommodate offenders who are or have been detained under Section 37/41 of the Mental Health Act. The police are able to use Section 136 of the Mental Health Act to take someone to a place of safety when they are in a public place and they suspect that person has a mental illness and is in need of care.

A place of safety can be a hospital or a police station. The police can keep people under this section for up to 72 hours. While in the place of safety an Approved Mental Health Professional (AMPH) and two doctors will carry out a Mental Health Assessment on the person being detained. 62 The outcomes of being taken to a place of safety can include further detention under the Mental Health Act, informal hospital admission, home treatment and discharge with no further action (where the person will return to supervision of their GP).

Police Investigation Centres are designated as places of safety but the constabulary will avoid taking people to these in favour of Section 136 suites where they can be assessed properly. There is a Section 136 suite based in central Norwich, King’s Lynn and Great Yarmouth.

In cases where people are being violent or are intoxicated but need to be taken to a place of safety they will be taken to the Police Investigation Centre initially.

61

http://www.rethink.org/living-with-mental-illness/police-courts-prison/section-37-41-hospital-order-givenby-crown-court (Accessed 18.07.14).

62 http://www.rethink.org/living-with-mental-illness/police-courts-prison/section-136-police-taking-you-to-aplace-of-safety-from-a-public-place (Accessed 18.07.14).

Page | 73

Offender Health Profile for Norfolk

4.4.1. High Secure Mental Health Services (Adults) 63 All individuals admitted to High Secure Services will be detained under the Mental Health Act (1983 amended in 2007) and fulfil the criteria as defined by the NHS Act 2006, for people who “require treatment under conditions of high security on account of their dangerous, violent or criminal propensities.� High Secure Services are provided in hospitals that have physical security arrangements equivalent to a Category B prison. They can, however, treat individuals who in a prison setting would be in a Category A environment.

The decision to admit to a secure service will be based on a comprehensive risk assessment and detailed consideration of how the risks identified can be safely managed whilst in hospital. Many, but not all of those admitted to High Secure Services, will have been in contact with the criminal justice system and will have either been charged with or convicted of a violent criminal offence.

High Secure Services play a key role in assessing an individual’s ability to participate in court proceedings and in providing advice to courts regarding disposal following sentencing.

High Secure Services comprise of three hospitals which provide services for the populations of England and Wales. NHS England (NHSE) commissions 100% of the capacity. Rampton Hospital also provides a national service for those diagnosed with a learning disability and those who are D/deaf. 64 Each of the high secure hospitals serves a defined catchment population for men diagnosed with a mental illness or personality disorder.

This service specification relates to all High Secure Services provided for adult men and women (aged 18 and above) with mental illness, personality disorder and neuro-developmental disorders including learning disabilities.

The three hospitals (Ashworth, Broadmoor and Rampton) are expected to work collaboratively to achieve consistency in applications of policies and practice to ensure there are equitable High Secure Services for patients regardless of which hospital the patient is placed.

63

http://www.england.nhs.uk/wp-content/uploads/2013/06/c02-high-sec-mh.pdf.

The term D/deaf is used throughout higher education and research to describe people who are Deaf (sign language users) and deaf (who are hard of hearing but who have English as their first language and may lip-read and/or use hearing aids). D/deaf is often used as a short cut to describe both groups who are similar but not exactly the same when it comes to communication, http://www.gre.ac.uk/study/support/needs/disabled/aap/ddeaf.

64

Page | 74

Offender Health Profile for Norfolk

4.4.2. Medium Secure Services in Norfolk (Norvic Clinic) Individuals with mental disorder or neuro-development disorder who are liable to be detained under the Mental Health Act (1983) and whose risk of harm to others and risk of escape from hospital cannot be managed safely within other mental health settings require care and treatment within a secure mental health service.

Individuals will typically have complex mental disorders, with co-morbid difficulties of substance misuse and/or personality disorder, which are linked to offending or seriously irresponsible behaviour. Consequently most individuals are involved with the criminal justice system, the courts and prison system and many have Ministry of Justice restrictions imposed.

In order to manage the risks involved the therapeutic environment is carefully managed through the delivery of a range of security measures.

A number of levels of security currently exist to manage increasing levels of risk to others.

Presently these consist of High, Medium and Low Secure Services, each of which provides a range of physical, procedural and relational security measures to ensure effective treatment and care whilst providing for the safety of the individual and others including other patients, staff and the general public. In addition community forensic mental health services provide for the transition back to the community for individuals who no longer require secure care.

The decision to admit to a secure service will be based on a comprehensive risk assessment and detailed consideration of how the risks identified can be safely managed.

Medium secure hospitals are not as secure as High Secure Services. However, they still have to meet a certain level of security. They can provide different levels of secure care as the patients there will have different needs. For example, as you are working towards leaving, the hospital could build up your unescorted leave. 65 Medium secure units must meet Department of Health standards as well as extra standards identified by members of the Quality Network for Medium Secure Units. 66 Commissioners in England currently purchase approximately 6,000 inpatient beds in secure mental health services. 67 • • •

Approximately 680 in high security (commissioned for England and Wales).

Approximately 2,800 in medium security.

Approximately 2,500 in low security.

A transfer from a prison to a secure hospital is often a very slow process. The government has instigated a pilot project to bring waiting times down to 14 days, but often it takes several months for a transfer to take place. We have received numerous reports that prison transfer times are rising but the available statistics do not provide sufficient information to give a clear picture of what is happening on the ground.

65

Joint Commissioning Panel for Mental Health. Guidance for commissioners of forensic mental health services. May 2013. Available from www.jcpmh.info/wp-content/uploads/jcpmh-forensic-guide.pdf (Page 8, accessed September 2013).

66 http://www.rcpsych.ac.uk/pdf/final%20standards%20for%20medium%20secure%20units%20pdf.pdf.

67 http://www.england.nhs.uk/wp-content/uploads/2013/06/c03-med-low-sec-mh.pdf.

Page | 75

Offender Health Profile for Norfolk

This section provides information about mentally disordered offenders admitted to, detained in or discharged under mental health legislation from the Norvic Clinic in Norfolk during 2014 (See Mental Health Act definitions in Appendix 2 on page 171). The Public Health Team conducted an in-depth interview with the Secure Services Manager for the NHS Trust to determine the needs of forensic offenders in the Norvic Clinic.

The Norvic Clinic is a specialist commissioned service (commissioned by NHS England Specialised Commissioning, East Anglia Area Team) that includes regional forensic secure psychiatric care (medium secure) for patients living in Norfolk, Suffolk, Cambridgeshire and occasionally from other areas (mainly Essex) detained under the Mental Health Act. The Norvic Clinic has 51 medium secure beds, admitting patients from a predominantly rural catchment area. The service admits men and women with both mental illness and primary personality disorder but does not have a learning disability service 68 (For further details see Table 24).

In Medium Secure Services in Norfolk there are: • • •

Eight assessment and rehabilitation beds for females at the Acle Ward.

Ten admission and assessment beds for males at the Catton Ward.

Sixteen male rehabilitation beds at Drayton Ward, nine at Eaton Ward and eight at Thorpe Ward.

Table 24: Profile of Low and Medium Secure Services. Norfolk, July 2014 Profile of Secure Services in July 2014 Unit No. of No. No. Description beds females males Medium Secure Service Norfolk (MSU) Acle Ward 8 8 Female medium secure Catton Ward 10 10 Admission/assessment Drayton Ward 16 16 Rehabilitation Eaton Ward 9 9 Rehabilitation Thorpe Ward 8 8 Rehabilitation Total MSU beds: 51 8 43 Low Secure Service Norfolk (LSU) Whitlingham

12

Yare Ward

15

15

Rehabilitation

4

4

Non – secure hostel

Highlands (Non secure) Total LSU beds: Total Secure Services beds

68

12

Female low secure

31

12

19

82

20

62

http://www.cppconsortium.nhs.uk/admin/files/1323338342Appendix%206%20%20Forensic%20Pathway%20Report.pdf.

Page | 76

Location

Norvic Clinic Norvic Clinic Norvic Clinic Norvic Clinic Norvic Clinic

Hellesdon Hospital Hellesdon Hospital Yarmouth Road Norwich

Offender Health Profile for Norfolk

Routes into the regional medium secure unit can be directly from prisons (more often for forensic offenders requiring medium secure care), from courts, from more secure mental health provision as part of the process towards discharge, from psychiatric hospital, transfer from a prison, from community and from other NHS organisations.

The main pathway to Low Secure Services is through the medium secure route (patients who go through the Norvic Clinic will be discharged to a low security ward in the county such as the Yare Ward or Whitlingham Ward at Hellesdon before they are taken on by community teams for subsequent discharge into the community).

Small percentages of forensic offenders admitted to the Norvic Clinic referred from a high secure hospital (when high security care is no longer required).

Rarely people detained under Civil Section (Section 3 of the Mental Health Act) will be referred to the Norvic Clinic.

Once they are released into the community they may still be bound by Section 37/41 of the Mental Health Act and will be obliged to carry on complying with treatment.

These facilities are part of the NHS not the prison service. Previous research has revealed that some people sentenced to prison have been subsequently diagnosed with severe enough mental health problems to be transferred to the Norvic Clinic. The need to identify the most appropriate type of facility for offenders with mental health problems at the earliest opportunity was therefore emphasised. 69 The predominant mental illnesses among people admitted to the Medium Secure Services (Norvic Clinic) were severe. The most common mental disorders were schizophrenia and personality disorder. The vast majority have a history of violence towards other people. Forensic offenders admitted to Medium Secure Services were more likely to smoke, misuse drugs and or consume alcohol.

Health and wellbeing needs among patients in the Medium Secure Services are worse than the general population ie the prevalence of long term conditions such as diabetes is higher than the average rate.

Patients in Low Secure Services generally use their own local GP and dental practices. Patients in Medium Secure Services receive dental care provided at the Norvic Clinic by the Norfolk Community Health and Care NHS Trust (NCH&C) and the Norvic Clinic commissions a GP services from Thorpewood Medical Group (this service is available once a week). In general the demand for dental services in prisons is high. It is not known if these dental needs are met.

The Norvic Clinic also funds GP consultations for patients in the medium secure service. 70 Offenders often face discrimination and a double disadvantage of both health inequality and difficulty of access to health services generally, particularly primary care. 71

69

Research Plus: The Accommodation and Related Support Needs of Offenders in Norfolk (2004).

This varies nationally, some services got for free while others pay for GP consultations.

71 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/118088/healthcommissioning-changes.pdf.

70

Page | 77

Offender Health Profile for Norfolk

Psychotherapy, an invaluable service, is provided solely by the Norvic Clinic in a range of settings to help patients overcome their difficulties.

There is a clear link between the wider social determinants of poor health and reoffending.

Sustainable housing is an example of this, and patients who have been through Medium Secure Services, specifically those who are labelled as high risk, are not able to get appropriate housing.

This concern has long been identified but no action has yet been taken.

4.4.2.1. Pathways into the Norvic Clinic Transfers from prison to secure services should ensure offenders with severe mental health problems have access to the right treatment and care. Such transfers, however, have been especially problematic, subject to excessively long delays even for very acutely unwell prisoners.

The Bradley Report called for a mandatory 14-day maximum transfer time for prisoners to be admitted to hospital and for a review of security at low and medium secure units.

Locally the mental health teams at three prisons make referrals to Medium Secure Services – the vast majority of referrals are accepted.

If someone is referred from the prisons (ie from the prison mental health teams) then staff from the Norvic Clinic will go to the prison and make an assessment. If appropriate they will be transferred to the Medium Secure Services under the Mental Health Act. The security level of mental health services for people who have been transferred from prison under the Mental Health Act will be determined by the offence that they had committed. In some cases it is not appropriate to refer these patients to Medium Secure Services if they committed a low-level offence. This decision can also be based on the risk that the patient poses to the public.

Occasionally patients who have been transferred from medium to low security services are transferred back to Medium Security Services if Low Security Services are unable to manage the patient.

In general, each patient has their own pathway based on need and patients could be referred to Low Secure Services or to the community or the prison. People can also be re-admitted to Medium Secure Services if their mental health deteriorates, but if these patients pose no risk to the public they can be referred to acute mental health services (non-forensic services).

For more details about low, medium or high secure hospitals see Appendix 3 on page 174.

4.4.2.2. Process on release in Norfolk Each patient has their own pathway out of the system; however, generally, patients who are discharged from Medium Secure Services will be moved to Low Secure Services, and following that moved onto the community mental health teams.

Sometimes patients can be discharged straight to community mental health teams (either forensic or generic) or discharged straight to prison in cases where they have been referred to the service from prison and are well enough to return.

Page | 78

Offender Health Profile for Norfolk

The planned pathway of release from medium and low security mental health services is through forensic community mental health teams (managed by the Deputy Manager of the Norfolk and Suffolk NHS Foundation Trust) who will subsequently refer these people on to the generic community mental health teams. Historically, the transfer of care to generic community teams has been difficult due to issues that include a lack of understanding about team functions, as well as apparent lack of capacity within adult generic teams. This has also been complicated by a lack of clarity from commissioning bodies.

It is thought that currently there are around 20 people on the forensic mental health community team caseload who are ready to be referred on to generic community mental health teams.

4.4.2.3. Other issues People will enter the Norvic Clinic with a mental health problem as their primary diagnosis but a high proportion of patients will also have drug or alcohol problems. It is thought that 90% of patients have had drug or alcohol problems. These patients are treated for this within the Norvic Clinic.

People with a primary diagnosis of mental health illness could also have learning disability. People with mental health and learning disability co-morbidity will go to either the Norvic Clinic or will be referred to secure services for people with learning disability in Norfolk (these facilities are at Little Plumstead Hospital) depending on which condition is predominant.

4.4.2.4. Local data from the Norvic Clinic April 2010 to March 2013 This section shows the data for Medium Secure Services in Norfolk from the Norvic Clinic over the three year period 2010/11 to 2012/13. It is not possible to present the figures in detail due to few admissions each year – there were 81 admissions in the three year period (an average of 27 per year).

Table 25 shows that over the three financial years there were 44 (54.3%) people from Norfolk admitted to the Norvic Clinic and 37(45.6%) from East of England. These figures do not mean the rate for Norfolk is high, as the Norvic Clinic is not the only medium secure unit provider for the East of England. It is the policy of Norfolk and Suffolk NHS Foundation Trust (NSFT) to keep people local as there may be risks associated with transporting patients’ long distances.

There are seven independent sectors that provide Medium and Low Secure Services in the East of England (See Table 26).

Table 27 provides information on admissions to the Norvic Clinic for medical or health related conditions during the same period of time. It can be seen that slightly over half of admissions were due to form of schizophrenia, 21% were due to bipolar disorder or depression, 16% due to personality disorder and 6.2% due to mental and behavioural disorders.

Page | 79

Offender Health Profile for Norfolk

Table 25: Medium Secure Services data in Norfolk from the Norvic Clinic in the three financial years April 2010 to March 2013 Persons Restricted 37/41 From Not sectioned Yes No Total Norfolk * * 34 44 East of England * * 29 37 Total 10 8 63 81 Note: Due to small numbers it is not possible to present the information for all areas (asterisks in table).

Table 26: East of England independent sector Medium and Low Secure Service providers Sector Type of service Town County MSU & LSU MI & Neuro 1 Kneesworth House Royston Hertfordshire Development Disorder Burston, 2 Burston House LSU Neuro Development Disorder Norfolk Diss 3 Suttons Manor LSU, MI Romford Essex Cygnet Hospital 4 MSU & LSU, MI Stevenage Hertfordshire Stevenage North 5 St Andrew's Healthcare LSU MI Clare House Essex Benfleet LSU, Neuro Development 6 Oaktree Manor Tendring Essex Disorder 7 Huntercombe Hospital LSU Neuro Development Disorder Newmarket Suffolk

Table 27: Medium Secure Services data in Norfolk from the Norvic Clinic by medical or health related condition in the three financial years April 2010 to March 2013 Registered by GP in Norfolk Total Disorder Yes No Number % Form of schizophrenia 21 23 44 54.3 Personality disorders 7 6 13 16.0 Bipolar disorder or depression * * 17 21.0 Mental and behavioural disorders, due to alcohol or drug use or without * * * * Other conditions * * * * Total 44 37 81 100 Note: Due to small numbers it is not possible to present the information for all disorders (asterisks in table).

Page | 80

Offender Health Profile for Norfolk

4.4.3. Low Secure Services in Norfolk (Hellesdon Hospital) 72 Low security care for people living in Norfolk, Suffolk and Cambridge is managed within their local area, with the exception of females from Suffolk, where care is managed in Norfolk.

Hellesdon Hospital Trust provides a range of specialist mental health services to nearly 800,000 people from all age ranges across central and east Norfolk and north Suffolk. The Trust also provides secure services to the whole of Norfolk, Suffolk and Cambridgeshire. Hellesdon Hospital is a significant employer within the local community employing approximately 2,200 staff.

Many of the services, especially in-patient services, are centred on Norwich, Great Yarmouth and Lowestoft. The staff also provide a range of services in a variety of settings and community locations throughout the catchment area.

The Trust works in partnership with other statutory and non-statutory bodies that provide services to people suffering mental ill health and are currently working with social services to bring about a Partnership Trust.

Low Secure Services are monitored by the performance indicators described within the Best Practice Guidance for Low Secure Services, and are subject to an annual peer review undertaken by the Centre for Continuous Quality Improvement CCQI. In total there are 31 beds available as following: • • •

Yare Ward provides inpatient support in a low secure setting for males over 18. 73 Yare Ward has 15 beds for males. It is mainly designed for rehabilitation services.

Whitlingham Ward provides inpatient support for females over 18 who require the relational, procedural or environmental security that the low secure service provides. 74 Whitlingham Ward has 12 beds for females (low secure).

Highlands is a non-secure hostel75 and provides inpatient support in an open setting for males over 18. Highlands Hostel accept referrals from medium secure units, Ministry of Justice, National Offender Management Service, other wards within the Trust and sometimes further afield. It has four beds.

4.4.4. Mental health needs at Low and Medium Secure Services Qualitative evidence also has an important role to play in understanding the needs of patients in Low Secure Services in Norfolk. These exploratory interviews are used to gain further information about the health characteristics of offenders in Low Secure Services in Norfolk.

Local health needs and services available for people with mental health problems who have been in contact with the criminal justice system were discussed in a meeting with Consultant Psychiatrist Dr Julian Beezhold, a specialist in acute/crisis mental health services based at Hellesdon Hospital in Norwich. 76

72

http://www.nursingnetuk.com/employerdetails/24. http://www.nsft.nhs.uk/Our-services/Pages/Yare-Ward.aspx.

74 http://www.nsft.nhs.uk/Our-services/Pages/Whitlingham-Ward.aspx.

75 http://www.nsft.nhs.uk/Our-services/Pages/Highlands.aspx.

76 A meeting was held with Dr Julian Beezhold at Hellesdon Hospital in Norwich on the 13 of June 2014.

73

Page | 81

Offender Health Profile for Norfolk

Within the meeting it was established that there are generally three groups of patients with mental health issues who come into contact with the criminal justice system: •

Those who have been given community sentences and have to comply with treatment as part of their sentence (for example attending therapy).

•

Those who have been diverted from either a PIC, court or prison and have not been convicted of a criminal offence – in this case their healthcare is the responsibility of the NHS.

•

Those who are in the criminal justice system and have not been detected – health care (especially mental health care) was perceived to be generally poor for this group of people.

People may fall into the latter group because their mental health problems can be missed at assessment stages and they are subsequently convicted and taken to prison. This could occur when a custody officer has not recognised a mental health issue and/or diversion services have not picked up on the need.

The majority of those who are referred to Hellesdon Hospital have a substance misuse disorder but some have a personality disorder.

People with mental health problems can be detained with a court order. These court orders can vary depending on how serious the offence was and how serious a mental health issue is: •

The most common court order in Norfolk is to detain someone under Section 37 of the Mental Health Act. Under this Act, someone with a mental health issue can be detained for up to six months. A doctor can make the decision to renew this detention order if needed.

•

People with mental health issues who have committed more serious crimes and are possibly more of a risk to the public can be detained under Section 41 of the Mental Health Act. In this case a court will decide when an offender will be released.

The most common health issues of those referred to the Norvic Clinic and Hellesdon include: • • • • • •

Substance misuse Psychosis Personality disorder Mood disorders Depression (however these are less likely to end up in prison system or be classified as offenders) Increased likelihood of being a smoker.

Personality disorder was said to be more challenging as it is too expensive to treat. It was generally found that for all conditions the focus should only be on those who have reasonable prognosis such as: a. Motivated people who want to change. b. People who have support outside of the services (such as family support). c. Educated people and those with better communication skills.

Page | 82

Offender Health Profile for Norfolk

It was felt that the major challenge facing managers of offenders who are referred for treatment for mental health issues is the effective targeting of services as there is a huge unmet need. It was perceived that substance misuse treatment gives most benefit. Treatment of psychosis and mania was said to also be beneficial but to a lesser extent.

There are regular cases where people will be admitted if they have a court case coming up. One percent of offenders in court (mainly anti-social offenders) may abuse mental health services to avoid prison.

4.5. Transfer from one of the three prisons in Norfolk to a secure mental health facility Individuals with mental disorder or neuro-development disorder who are liable to be detained under the Mental Health Act (1983) and whose risk of harm to others and risk of escape from hospital cannot be managed safely within other mental health settings, require care and treatment within a secure mental health service.

These individuals will typically have complex mental disorders, with co-morbid difficulties of substance misuse and/or personality disorder, which are linked to offending or seriously irresponsible behaviour. Consequently most of these people are involved with the criminal justice system, the courts and prison system and many have Ministry of Justice restrictions imposed.

In order to manage the risks involved, the therapeutic environment is carefully managed through the delivery of a range of security measures. A number of levels of security currently exist to manage increasing levels of risk to others. Presently these consist of High, Medium and Low Secure Services, each of which provides a range of physical, procedural and relational security measures to ensure effective treatment and care whilst providing for the safety of the individual and others including other patients, staff and the general public.

All individuals admitted to Secure Services will be detained under the Mental Health Act (1983 amended in 2007) and fulfil the criteria as defined by the NHS Act 2006.

4.5.1. The Mental Health Act This section looks at sections of the Mental Health Act. The Mental Health Act is the law which can be used to admit offenders to hospital for assessment and/or treatment for a mental illness. To be detained or ‘sectioned’, offenders must have a mental disorder which needs assessment or treatment. A person must need assessment or treatment in hospital in the interests of their own health or safety or to protect other people.

Table 28: Mental Health Act sections prisoners detained in Norfolk have been transferred under Section Description Section 35 Offenders sent to hospital by criminal court for a medical report Section 36 Offenders sent to hospital by a Crown Court for treatment Section 37/41 Hospital order given by Crown Court Section 38 Interim hospital order given by a criminal court Section 47/49 Transfer of a sentenced prisoner to hospital Section 48/49 Transfer of a prisoner on remand to hospital For a detailed description of each of these sections see Appendix 2.

Page | 83

Offender Health Profile for Norfolk

4.5.2. What is a mental disorder according to the Mental Health Act? The Mental Health Act defines the term ’mental disorder’ as ‘any disorder or disability of mind'. It includes mental health conditions such as: • • • • • • •

Schizophrenia Depression Bipolar disorder Anxiety disorder Obsessive-compulsive disorder (OCD) Eating disorders Personality disorders

It also includes other conditions such as dementia, changes in behaviour due to brain injury, mental disorders due to drug use and autistic spectrum disorders. The definition includes learning disability only where it is associated with abnormally aggressive or seriously irresponsible behaviour. 77 If offenders have problems with alcohol or drug use, they can only be sectioned if they have a mental disorder as well as a drug or alcohol problem. 78

4.5.3. Offenders with any mental health disorder A completed review of existing evidence by the Ministry of Justice (MoJ) helpfully summarises key findings in relation to experiences of adults with mental health problems: 79 •

Adults with mental health problems are over-represented in populations of offenders.

•

Adults with mental health problems are more at risk of crime victimisation than the general population.

•

There is inconsistent but mainly supportive evidence about the effectiveness of so-called criminal justice 'diversion' schemes in terms of preventing offending or improving mental health, however, more research is required.

•

There is evidence that prejudicial attitudes within the criminal justice system may result in negative justice outcomes for adults with mental health problems and decisions being based on an incorrect understanding of mental health problems.

Research has also identified the difficulties people with learning disabilities encounter upon entry to the Criminal Justice System (CJS). People with learning disabilities are, for example, unlikely to be identified; suffer from poorer general health, particularly with regard to mental health; and, finally, likely to struggle with police questioning and cautions.

4.5.4. Prisoners transferred to hospital This section includes people who have been transferred from one of the three prisons in Norfolk to a secure mental health facility following a medical recommendation. These people have been 77

s1(2A) Mental Health Act 1983 (MHA). s1(3) MHA. 79 http://www.cps.gov.uk/publications/research/offenders_with_mental_health_problems.html.

78

Page | 84

Offender Health Profile for Norfolk

transferred to a facility for treatment for either a mental disorder or a neuro-development disorder between the 1 January 2011 and 30 June 2014.

During this period, there were 61 offenders who had been transferred out of prisons in Norfolk under Sections 35 to 49 of the Mental Health Act. The (61) people who have been transferred to services will not necessarily have all come from the county. NHS England commissions the secure beds across the country and historically funding has come from the prisoner’s home area, which has resulted in prisoners having to travel to access secure services in their home area. If a prisoner requires access to services under the Mental Health Act (MHA) and he/she is from another area (for example London) that person will go back to their resident area for care in a secure mental health facility. This rule does not apply to those who are referred to High Secure Services provided by the Ashworth, Broadmoor, and Rampton Hospitals. Such services are only available nationally.

Research demonstrates that resilience to mental illness can be gained through education and employment. Within this report it is not possible to examine the characteristics of forensic offenders such as their gender, ethnicity, medical history, employment history, where they live, deprivation status, or marital status. These factors are essential in determining the association between offending, mental health conditions and re-offending.

The ages of all 61 offenders transferred to mental health services were collected. The minimum age was 19 years as there are no places for juveniles in Norfolk, and the maximum was 69 years.

The data set shows that 36.1% of the offenders transferred under the Mental Health Act (MHA) were aged 25-34, 19.7% aged 15-24 and 26.2% aged 35-44. There were few older offenders: people aged 45-69 only made up 18% of offenders with health disorders admitted to other national secure services in Norfolk (see Table 29).

Table 29: Offenders with mental health disorders in Norfolk or those admitted to other national secure services from 1 January 2011 to 30 June 2014 Age band Number % 15-24 12 19.7 25-34 22 36.1 35-44 16 26.2 45-69 11 18.0 Total 61 100

With regards to type of mental disorder, there were a total of 42 out of 61 (68.9%) offenders transferred under the MHA who suffered from a psychosis disorder. Of these, 33 (54.1%) suffered from psychosis, seven (11.5%) suffered from schizophrenia, one had combined schizophrenia and personality disorder, and one suffered from personality disorder.

There were a total of five (8.2%) people transferred with Learning disability (LD), 10 (16.4%) with Personality disorder and one further offender with ADHD, Personality disorder and Post Traumatic Stress Disorder (PTSD). There were two (3.3%) offenders without diagnosis ( Table 30).

Page | 85

Offender Health Profile for Norfolk

Table 30: Primary mental disorder – offenders with any mental health disorder in Norfolk or those admitted to other national secure services from 1 January 2011 to 30 June 2014 Mental disorder Number % Learning disability (LD) * * Personality disorder 10 16.4 Psychosis 33 54.1 Psychosis (schizophrenia) 7 11.5 Psychosis (schizophrenia & personality disorder) * * * Psychosis (Personality disorder) * * ADHD/Personality disorder/PTSD * * No formal diagnosis or missing * Total 61 100 Note: Due to small numbers it is not possible to present the information for all disorders (asterisks in table).

The decision to admit a patient to a secure service will be based on a comprehensive risk assessment and detailed consideration of how the risks identified can be safely managed whilst in hospital. Many, but not all of those admitted to secure services, will have been in contact with the criminal justice system and will have either been charged with or convicted of a violent criminal offence. Low and Medium Secure Services play a key role in assessing an individual’s ability to participate in court proceedings and in providing advice to courts regarding disposal following sentencing.

This specification relates specifically to medium and low secure mental health services provided for men and women (aged 18 and above) with mental illness, personality disorder and neurodevelopmental disorders including learning disabilities.

A specification for medium and low secure mental health services for young people under the age of 18 have certain criteria fully described.

It is expected that individuals will be treated and managed within a whole care pathway approach, with services working collaboratively with each other in order to ensure that the admission and any transfer within the secure care pathway is achieved seamlessly and efficiently. The pathway through care should be identified early in admission though may be subject to change depending on changing needs or circumstances.

Multi-disciplinary working and the Care Programme Approach (CPA) process will underpin service delivery. The multidisciplinary team will include appropriately trained medical staff including consultant forensic psychiatrists, or a consultant with extensive forensic experience, clinical psychologists, mental health nursing staff, social workers and allied health professionals such as occupational therapists; art therapists: specialist clinical pharmacist; forensic psychologist; speech and language therapist.

Page | 86

Offender Health Profile for Norfolk

It is expected that each individual will be treated and managed in accordance with a ‘care pathway’. The care pathway will be planned in consultation with the individual. The care pathway, whilst not prescriptive, describes the individual’s anticipated journey of transition into, through and out of the secure care. In general it can be described in five phases: • • • • •

Referral Assessment and pre-admission Admission, care, and treatment Forensic care pathway Transition

All individuals admitted to High Secure Services will be detained under the Mental Health Act (1983 amended in 2007) and fulfil the criteria as defined by the NHS Act 2006, for people who “require treatment under conditions of high security on account of their dangerous, violent or criminal propensities.” High Secure Services are provided in hospitals that have physical security arrangements equivalent to a Category B prison. They can, however, treat individuals who in a prison setting would be in a Category A environment. 80 Commissioners in England currently purchase approximately 7,719 inpatient beds in secure mental health services. 81 The frequency of offenders in contact with the criminal justice system in Norfolk in secure care is as follows: • • • •

Approximately 10 (16.4%) in low secure Approximately 41 (67.2%) in medium secure Approximately five (8.2%) in high secure Approximately five (8.2%) in Psychiatric Intensive Care Units (PICU)

Thirty three out of 61 (54.1%) people from prisons in Norfolk were transferred to local Medium and Low Secure Services. 15 (24.6%) transferred to London, and 13 (21.3%) to other areas, of which five (8.2%) went to a High Secure Hospitals HS unit and eight (13.1%) went to other low and medium care secure services other than Norfolk or London (Table 31).

Table 31: Location of transferred place – offenders with any mental health disorder in Norfolk or those admitted to other national secure services from 1 January 2011 to the 30 June 2014 Number % London 15 24.6 Norfolk 33 54.1 Other areas 13 21.3 Total 61 100 Note: The other areas figure divided as follows: five (8.2%) in high secure care hospitals and eight (13.1%) in other low and medium care.

Table 32 shows the hospitals where mental health services are provided. In total, there were 24 types of mental health services which looked after forensic offenders from prisons in Norfolk, this varies between High, Medium and Low Secure Services spread nationally.

80

2014/15 NHS Standard Contract for High Secure Mental Health Services (Adults), NHS Commissioning Board, 2013 The NHS Commissioning Board is now known as NHS England.

81 http://www.england.nhs.uk/wp-content/uploads/2013/06/c02-high-sec-mh.pdf.

Page | 87

Offender Health Profile for Norfolk

In total, there were five people from the three prisons in Norfolk referred to high secure care of which two people were referred to Rampton.

Table 32: Service providing hospitals – offenders with any mental health disorder in Norfolk or those admitted to other national secure services from 1 January 2011 to 30 June 2014 Type Number (%) Alpha Hospital Arnold Lodge** Beechward Bracton Centre Broadland Clinic Broadmoor Hospital Brockfield House Easton Ward, Ipswich Edenfield, Manchester Edgware Hospital Foxhall House Fromeside Hospital Goodmayes Hellesdon Hospital John Howard Centre Kneesworth House Hospital Newham Centre MH

North London Clinic Norvic Clinic Rampton Hospital Reaside Clinic River House Stockton Hall Three Bridges Unit Total

Low and medium secure In-patient Forensic psychiatric service MH-low (if HPFT) Low and medium secure, and low secure unit for women with challenging behaviour Learning disability (LD) Medium High security Mental health – adults of all ages No longer a ward - changed to Foxhall House below Low and medium secure Community Hospital Low Inpatient 80 bed medium secure unit in Bristol Mental health Low security Medium

*

*

*

*

* *

* *

6

9.8

* * *

* * *

* * * * * * * *

* * * * * * * *

*

*

*

*

19

31.1

* *

* *

*

*

* *

* *

61

100

Medium and Low In-patient and community mental health services (people can be detained in hospital under the Mental Health Act).

Medium Medium security High security Male medium secure unit (MSU) for adult men offenders Male medium secure unit (MSU) for adult men.

Offenders Institution.

Medium Medium

Note: Due to small numbers it is not possible to present the information for all services (asterisks in table). ** The Unit provides an In-patient Forensic psychiatric service to adults aged 18 and above who are, or who are thought to be suffering from a mental disorder and due to their criminal offence and their seriously disturbed behaviour cannot be managed by a General Mental Health Service or Low Secure Service.

Page | 88

Offender Health Profile for Norfolk

Table 33 provides information on the number of offenders transferred under mental health sections. It can be seen that there are wide variations between different sections. The majority were under Section 47, where there were 29 (47.5%) transfers of sentenced prisoners to hospital.

There were 19 (31.1%) transfers of prisoners on remand to hospital (Section 48).

The number of offenders under Section 35 (When the criminal courts send offenders to hospital for a medical report) was five (8.2%).

The vast majority of offenders with mental disorder or neuro-development disorder who are liable to be detained under the Mental Health Act and transferred to secure services were either sentenced or on remand. This this would translate to over 78.7% (48 from 61) of all forensic offenders.

Table 33: Section of Mental Health Act – offenders with any mental health disorder in Norfolk or those admitted to other national secure services from 1 January 2011 to 30 June 2014 Sections Number % 35 * * * 36 * * 37 * * 38 * 47 29 47.5 48 19 31.1 * 37/41 * * 47/49 * * 48/49 * Total 61 100 Note: Due to small numbers it is not possible to present the information for all age groups (asterisks in table).

Page | 89

Offender Health Profile for Norfolk

4.5.5. Psychologically Informed Planned Environments (PIPEs) PIPEs are specifically designed environments where staff have additional training to develop an increased psychological understanding of their work. This enables them to create a supportive environment which can facilitate the development of those living there. PIPEs are not treatment, but are designed to enable offenders to maintain developments they have previously achieved. In prison, PIPEs are progression units for offenders who have completed high intensity treatment.

They are applied to existing offender populations in approved premises. 82 Psychologically Informed Planned Environments (PIPEs) in Norfolk are commissioned by the National Offender Management Service (NOMS) to explore the enabling features of Psychologically Informed Planned Environments (PIPEs) in two pilot sites – in Wayland HM Prison Service and with probation approved premises.

The Public Health Team has not assessed the development of PIPEs and their effectiveness locally.

82

http://www.natcen.ac.uk/our-research/research/enabling-features-of-psychologically-informed-plannedenvironments/.

Page | 90

Offender Health Profile for Norfolk

4.6. Release into the community 4.6.1. Secure Services Community Team 83 The Norvic Clinic provides a comprehensive, recovery-focused community model of care for patients who are in the process of being discharged from a medium secure unit.

Individuals with mental illnesses who have been through Secure Services (specifically the Norvic Clinic) are liable to be referred to the secure services community team. All other offenders will be the responsibility of generic mental health teams. The secure services community team have been commissioned to follow up those discharged from the Norvic Clinic.

The team currently consists of nurses and social workers, with a designated community responsible clinician. Their responsibilities include extensive liaison with the Ministry of Justice, provision of social supervision reports, risk assessments and Care Programme Approach (CPA) processes, administration and monitoring of medication, identifying suitable accommodation, identifying and accessing financial resources, personal budgets, contributing to the staffing approved mental health practitioner rotas and identifying referral pathways to facilitate their transfer to adult recovery teams.

The community service is aligned with forensic inpatient facilities, therefore it is part of a tertiary service and referrals are currently generated from within the Trust's Secure Services.

The team also consider external referrals from other inpatient specialist forensic hospitals, originating from Norfolk, Suffolk and the Cambridgeshire and Peterborough area.

If forensic offenders get support from a Community Mental Health Team (CMHT) they will usually be under the CPA. CPA means that they will have regular contact with a care coordinator. The care coordinator might be a social worker, community psychiatric nurse (CPN) or an occupational therapist. They will work with forensic offenders to write a 'care plan', which sets out how their needs will be met.

Community forensic mental health services ultimately aim to refer forensic offenders along to the standard (non-forensic) community mental health services. 84 The Secure Mental Health Community Team is provided by the Norfolk and Suffolk NHS Foundation Trust. The Team is based at Meadowlands and consists of 12 full-time practitioner posts (six nurses and six social workers), as well as one community support worker. In addition to this the team uses the services of a community consultant forensic psychiatrist from the Norvic Clinic.

The team currently deals with around 70 offenders (with a maximum capacity of 75). The majority of these offenders have been discharged following detention under Section 37/41 of the Mental Health Act.

83

http://www.nsft.nhs.uk/Our-services/Pages/Secure-services-community-team.aspx.

Thomson, L. The forensic mental health system in the UK. In Soothill, K., Rodgers, P. and Dolan, M. (eds) Handbook of Forensic Mental Health. Devon, UK: Willan Publishing; 2008. p19-63.

84

Page | 91

Offender Health Profile for Norfolk

The service provided by the team operates from 9-5pm on weekdays. Out of hours patients can be supported by on call clinicians or referral can be made to the Crisis Resolution and Home Treatment Team (CRHT) which is part of adult acute services.

The teams will also actively source housing. Housing is supplied by the third sector in Norfolk and will be provided once offenders are released into the community. Housing is supplied by organisations such as Julian Support who provide a range of supported housing schemes in the county. 85 The secure services community team are made aware of a patient as early as possible when they are admitted to the Norvic Clinic – a social worker from the team will then be informed. Best practice recommends that a social circumstances report is provided for the admission CPA meeting, which is usually within three months of admission date.

Planning for discharge should commence on admission, and community practitioners are involved in developing an effective discharge plan.

People who are released into the community may go into supported accommodation in Norwich, Great Yarmouth or King’s Lynn – most likely in social care complexes. It is possible for service users to be supported to live independently on discharge, but it is far more likely that some form of supported housing will be a requirement of discharge.

For different reasons many people remain on the caseload of the secure community team in cases such as when: •

A patient does not apply for absolute discharge from a Mental Health Review Tribunal.

•

There is limited capacity in the generic community mental health team.

•

Relapse occurs.

•

The service user’s risks are such that discharge is not supported by the team or MoJ.

There is a significant minority of offenders with mental health needs whose original place of residence were outside of Norfolk prior to admission, who remain in the Norfolk area following discharge as a result of factors such as available accommodation and personal choice.

85

Julian Support provides a number of different types of outreach service, and the aim is to help people gain or maintain their independence in the community. Julian Support works with clients in helping them recognise and build on the strengths they already have and to eliminate barriers that impact on their mental health. Social factors such as unaffordable housing, homelessness, living on a low income and feeling isolated from the community can all be major barriers to recovery, http://www.juliansupport.org/supportedhousing/index.asp (Accessed 11.07.14).

Page | 92

Offender Health Profile for Norfolk

4.6.2. Meeting with Deputy Service Manager for Norfolk and Suffolk NHS Foundation Trust Needs of forensic patients were discussed in a meeting with the Deputy Service Manager of Norfolk and Suffolk NHS Foundation Trust. Pressures on limited resources were seen as the biggest concern with regards to community services. An additional view expressed was that an enhanced Liaison and Diversion service will lead to more potential referrals to teams that are already under pressure due to capacity issues.

It was felt that there is evidence that referrals to recovery teams are not being accepted in many cases, or there has been considerable delay before acceptance, which must be due to capacity issues in those teams.

It was raised that once forensic offenders move into the community they no longer have access to psychological therapies (for example treatment for personality disorder) or other specialist treatment. Therapists at the Norvic Clinic only deal with inpatients and the Improving Access to Psychological Therapies (IAPT) 86 programme only deals with those who pose low to moderate risk (people who have been released from the Norvic Clinic are generally higher risk patients). There is no dedicated personality disorder service.

There is a large unmet need for people with learning difficulties – there is no resource at all for those with borderline learning disabilities. Referral action will be taken with people who have a low IQ but people who have borderline medium/low IQ (in the range of 70-80) may receive custodial sentences which are thought to be ineffective in relation to addressing this vulnerability. These people are thought to have much more complex problems than can be dealt with in such institutions.

There are some areas of mental health service provision which were thought to be much better than those provided in other areas of the country. Norfolk has good provision for places of safety87 compared with other local authorities and the probation service has strong links with prison inreach services (which are provided by private companies).

86

The IAPT Health Needs Assessment for Norfolk is available here: http://www.norfolkinsight.org.uk/resource/view?resourceId=912.

87 The police are able to use Section 136 of the Mental Health Act to take someone to a place of safety when they are in a public place and they suspect that person has a mental illness and is in need of care. A place of safety can be a hospital or a police station. The police can keep people under this section for up to 72 hours. While in the place of safety an Approved Mental Health Professional (AMPH) and two doctors will carry out a Mental Health Assessment on the person being detained . The outcomes of being taken to a place of safety can include further detention under the Mental Health Act, informal hospital admission, home treatment and discharge with no further action (where the person will return to supervision of their GP). Police Investigation Centres are designated as places of safety but the constabulary will avoid taking people to these in favour of Section 136 suites where they can be assessed properly. There is a Section 136 suite based in central Norwich, King’s Lynn and Great Yarmouth. In cases where people are being violent or are intoxicated but need to be taken to a place of safety they will be taken to the Police Investigation Centre initially.

Page | 93

Offender Health Profile for Norfolk

5. Offenders with intellectual disabilities and other developmental disabilities Intellectual disability is a disability characterised by significant limitations in both intellectual functioning and in adaptive behaviour, which covers many everyday social and practical skills.

Therefore the term intellectual disability covers those with Intelligence Quotient test (IQ) score as 70 or under, and people with a diagnosis of having an autistic spectrum disorder which is not necessarily to have IQ 70 or under 88. See Appendix 4 on page 175 for more details on the Intelligence Quotient test (IQ).

Using this terminology allows us to include those with a learning disability (assessed as those with an IQ of 70 or under) and those in the autistic spectrum.

Offenders with learning difficulties are not routinely identified. Adequate provision is, consequently, not always made by the agencies involved to cater for their specific needs which often appear to go unnoticed. Given the recent changes in the commissioning of health services, it is now increasingly important that the specific needs of this group of offenders are both recognised and addressed.

The Care for offenders with learning disabilities report which was published recently (30 January 2014) 89 concluded that the needs of offenders with learning disabilities are not being met by police, probation, and prosecution services. Although 30 per cent of those going through the criminal justice system have learning disabilities, staff often lacks the appropriate training to handle their conditions. 90 The report highlighted that people with learning disabilities receive poorer health care than the rest of the population. When they enter the criminal justice system, it is important they have a nurse or a health care professional with specialised skills and knowledge to help assess their needs and provide suitable care.

People with learning disabilities have contact with criminal justice services at every point of the criminal justice system – police, prosecution, courts, probation and prison. This section primarily deals with the first phase of contact, focusing specifically on those that have been transferred to local secure hospital (Broadland Clinic, medium learning disability secured hospital).

The real question for us is: do criminal justice agencies in Norfolk meet the specific needs for people with learning disabilities who find themselves in the criminal justice system. To answer this, the Public Health Team have undertaken in depth interviews with the service manager and the clinical psychologist consultant at Little Plumstead Hospital (managed by Hertfordshire Partnership Foundation Trust provision of Integrated service for the East of England), along with findings from a range of national and local research to assess local needs.

88

http://www.learningdisabilities.org.uk/help-information/about-learning-disabilities/definition-learningdisability/.

89 http://www.rcn.org.uk/newsevents/news/article/uk/care_for_offenders_with_learning_disabilities.

90 Dr Peter Carter, Chief Executive & General Secretary of the RCN, said: "Everyone who comes into contact with the police or the criminal justice system has the right to be treated fairly. This report clearly shows that this is not always the case for people with learning disabilities. This is discrimination and needs to be addressed.�

Page | 94

Offender Health Profile for Norfolk

5.1. How do we categorise learning disabilities and how are these groups treated within the Criminal Justice System?

5.1.1. The continuum of learning ability In an attempt to explain the wide range of different abilities the idea of a continuum of learning has been used for some time. The terms currently used are shown on the continuum below and are then described in more detail. 91

Profound People with profound intellectual and multiple disabilities, or profound and multiple learning disabilities (PMLD), can be some of the most disabled individuals in our communities. They have a profound intellectual disability, which means that their intelligence quotient (IQ) is estimated to be under 20 and therefore they have severely limited understanding. In addition, they may have multiple disabilities, which can include impairments of vision, hearing and movement as well as other challenges such as epilepsy and autism.

Most people in this group need support with mobility and many have complex health needs requiring extensive support. People with profound intellectual and multiple disabilities may have considerable difficulty communicating and characteristically have very limited understanding. Many people express themselves through non-verbal means, or at most through using a few words or symbols. In addition some people need support with behaviour that is seen as challenging, such as self-injury. There are about 16,000 adults with profound and multiple learning disabilities (PMLD) in England. 92

91

Further information about definitions can be found at www.improvinghealthandlives.org.uk, www.bild.org.uk and www.bris.ac.uk/cipold.

92 This definition is taken from the Raising Our Sights report (2010) by Professor Jim Mansell.

Page | 95

Offender Health Profile for Norfolk

Severe People with a severe learning disability often use basic words and gestures to communicate their needs. Many need a high level of support with everyday activities such as cooking, budgeting, cleaning and shopping.

Moderate People with a moderate learning disability are likely to have some language skills that mean they can communicate about their day to day needs and wishes. People may need some support with caring for themselves, but many will be able to carry out day to day tasks with support.

Mild A person who is said to have a mild learning disability is usually able to hold a conversation, and communicate most of their needs and wishes. They may need some support to understand abstract or complex ideas. People are often independent in caring for themselves. They usually have some basic reading and writing skills. People with a mild learning disability quite often go undiagnosed, and may not come to the attention of services until something happens (eg the death of informal carers). Most people still need appropriate support with tasks such as budgeting and completing forms.

5.1.2. Developmental disabilities Developmental disability is a diverse group of severe chronic conditions that are due to mental and/or physical impairments. Developmental disabilities cause individuals living with them many difficulties in certain areas of life, especially in "language, mobility, learning, self-help, and independent living". 93 Developmental disabilities can be detected early on, and do persist throughout an individual's lifespan.

5.1.2.1. Autism Autism is a lifelong developmental disability which affects one in 100 people in the UK. It affects the way a person communicates and how they experience the world around them. 94 Autism is described as a spectrum condition. This means that while people with autism, including Asperger Syndrome, share certain characteristics, they will be highly individual in their needs and preferences. Some people with autism are able to live relatively independent lives but others may face additional challenges, including learning disabilities, which affect them so profoundly that they need support in many areas. The full categorisation of autism fall within ‘autism spectrum disorder’ (ASD). Autism types and definitions are given in Appendix 5 on page 176.

Forms of autisms and link to offending: Mild autism The term ‘mild autism’ is not an official diagnosis. It's simply a more descriptive term than ‘Asperger Syndrome’ or ‘autism’. Generally speaking, when people use the term mild autism they are referring to individuals whose symptoms fit an autism spectrum diagnosis, but who have strong verbal skills and few behavioural issues. Those individuals may, however, have significant problems with social communication. They may also have problems coping with too much sensory input (loud noise, bright lights, etc).

93

Canters for Disease Control and Prevention. (2013). Developmental disabilities. Retrieved October 18, 2013.

94 http://www.ambitiousaboutautism.org.uk/page/about_autism/what_is_autism.cfm.

Page | 96

Offender Health Profile for Norfolk

Atypical autism Is the term used when the person’s behaviour pattern fits most but not all the criteria for typical autism. Atypical autism usually differs from autism in terms either of age of onset or of failure to fulfil all three sets of autism diagnostic criteria. Atypical autism is likely to become manifest only after three years of age and it is a type of autism that may go undiagnosed for years. 95 Severe Autism This is sometimes called autistic disorder, low-functioning autism, classic autism, ‘Kanner’ autism or profound autism. Simply, it is the most severe of the autism spectrum disorders. 96 While everyone with an autism spectrum disorder has a difficult time with social skills and communication, people with severe autism are most likely to be entirely unable to use spoken language. They may also appear to take no notice of the people around them. It's important to know, however, that appearances can be deceiving: some people with severe autism have learned to communicate using sign, spelling boards or other tools, and they make it clear that people with severe autism may well be much more aware than they appear to be.

People diagnosed with severe autism are less likely to commit crime but more likely to display challenging behaviour. 97

5.1.2.2. Asperger Syndrome Asperger Syndrome is an autism spectrum disorder (ASD) considered to be on the ‘high functioning’ end of the spectrum. Affected children and adults have difficulty with social interactions and exhibit a restricted range of interests and/or repetitive behaviours. Motor development may be delayed, leading to clumsiness or uncoordinated motor movements. Compared with those affected by other forms of ASD, however, those with Asperger Syndrome do not have significant delays or difficulties in language or cognitive development. Some even demonstrate precocious vocabulary – often in a highly specialized field of interest. 98 Table 34: Autism links with aggression and crime Forms of autism Offences Asperger Syndrome Similar offending rate to general population Severe Very low rates for crime, show challenging behaviours.

A number of people with autism spectrum disorders (ASDs) are involved in the Criminal Justice System (CJS) as victims, witnesses or offenders. 99 There is no evidence of an association between ASD and criminal offending. In fact, due to the rigid way many people with ASD keep to rules and regulations, they may be more law-abiding than the general population. People with an ASD are more at risk as victims of crime rather than as offenders.

95

http://www.specialeducationalneeds.co.uk/atypical-autism.html. http://autism.about.com/od/autismterms/g/What-Is-Severe-Autism.htm.

97 The term ‘challenging behaviour’ has been used to refer to the ‘difficult’ or ‘problem’ behaviours which may be shown by children or adults with a learning disability including: Aggression (eg hitting), Self injury (eg head banging), Destruction (eg throwing objects), other behaviours (eg running away).

98 http://www.autismspeaks.org/what-autism/asperger-syndrome.

99 http://www.autism.org.uk/working-with/criminal-justice/criminal-justice-system-and-asds.aspx.

96

Page | 97

Offender Health Profile for Norfolk

A study in Broadmoor Hospital, one of England’s three high-security psychiatric hospitals, estimated that 1.5–2.3% of the hospital’s male population had Asperger Syndrome or autismspectrum disorder (if equivocal cases were included) (Scragg 1994). This significantly exceeds the 0.36% prevalence estimated for the general population using the same criteria (Allen 2007). This overrepresentation of Asperger Syndrome (at least 1.68%, n = 22) was subsequently confirmed in all three English high secure units (Hare 1999). In a sample of 72 men referred to the dangerous severe personality disorder unit of Her Majesty’s Prison Whitemoor, two prisoners were given a definite diagnosis of Asperger Syndrome and four a provisional diagnosis (in the absence of parental accounts), suggesting a prevalence of 2.7–8.3%. A further four men showed autistic traits (Hawes 2003). Interestingly, much lower prevalence, of 0.46% in secure psychiatric units and 0.93% in the prison service, have been reported in Scotland (Myers 2004). 100 In contrast to these UK estimates, in a group of Swedish young offenders referred for forensic assessments in Stockholm, 15% were diagnosed with a definite autism-spectrum disorder and a further 12% with a probable disorder of this type (Siponmaa 2001).

All of these findings are surprising, given that a Danish study found that the rate of conviction of people with Asperger Syndrome was similar to that for people without (P = 0.89), and that the conviction rate of people with atypical autism was lower than that of people without (P = 0.14) (Mouridsen 2008). Similarly, a low rate of law-breaking behaviour (using both self-report and official data) was found in a UK community sample of people with Asperger Syndrome (WoodburySmith 2006).

Thus, the literature is difficult to interpret, but it seems reasonable to conclude that, even though the prevalence of the syndrome is higher than expected in forensic psychiatric populations, this does not reflect a raised rate of convictions, or indeed a raised rate of offending, in the community as this sample requires specialist care and are therefore likely to attract the attention of specialist psychiatric services. Nevertheless, it is important for clinicians to be aware of autism-spectrum disorders in offenders. An early diagnosis and intervention may reduce the risk of future offending.

5.2. Criminal justice system and offenders with learning disabilities – Norfolk experience Offenders are often not identified as having a learning disability and it is thought that many offenders may fall into this group (having an IQ of below 70). The lack of identification of the offender as someone with a learning disability, means that they are often treated inappropriately in prison – the diagnosis means that they should receive ‘reasonable adjustments’ under the Disability Discrimination Act (DDA) 1995, and by not doing so, it can be argued that the CJS is complicit in discriminating by not giving fair access to appropriate opportunities both in prison and in the community.

This is supported by much of the evidence reported by No One Knows report (2008) – a major report by the Prison Reform Trust.

100

http://apt.rcpsych.org/content/16/1/37.full.

Page | 98

Offender Health Profile for Norfolk

They found many instances of disability discrimination and possible human rights abuses in the treatment of people with learning disabilities in prison. Four areas of their greatest concern are listed below: •

Maltreatment of people with learning disabilities and learning difficulties by the police and by prison officers.

•

The lack of an Appropriate Adult for vulnerable suspects during police interview.

•

Defendants with learning disabilities and learning difficulties being unaware of what is happening to them during their trial and an inability to understand decisions of the court.

•

Prison information and regimes that are inaccessible to prisoners with learning disabilities and difficulties.

At the moment, unidentified learning disabilities are indicated by: 1. In the custody suite – screening questionnaire (Learning Disability Screening Questionnaire) is being introduced to help the police identify someone who is likely to have a learning or developmental disability which can then prompt a proper test/diagnosis. This has not yet been fully implemented but is hoped to have a major impact.

2. Solicitors may ask for an assessment before someone appears in court – then likely to lead to an ‘expert witness’ who can give the results of a psychiatric test and a diagnosis.

Once a diagnosis is made, they will then be referred to the local assessment centre for assessment of needs and risk.

5.3. Secure services for offenders with learning disabilities in Norfolk Facilities at Little Plumstead Hospital, Norfolk This provides an integrated service for the East of England – Norfolk is part of the Hertfordshire Partnership Foundation Trust provision. This includes: •

Inpatient Medium Secure Services and step down facilities are provided for men with a learning disability at the Broadland Clinic, Little Plumstead, near Norwich. The Trust also provides Learning Disability Psychiatry which works alongside the Community Teams run

by Norfolk Learning Difficulties Service.

•

Assessment and Treatment Services are provided for adults with learning disabilities at Astley Court, Little Plumstead, near Norwich.

Page | 99

Offender Health Profile for Norfolk

5.4. The Broadland Clinic/medium secure accommodation in Norfolk 101 Broadland Clinic provides specialist intervention to offenders with mild, borderline, and medium learning disabilities who may also suffer from mental health problems or personality disorder.

To facilitate this, the service maintains close links with local health and adult services as well as the criminal justice system. The service maintains the principles of valuing people, promoting patient choice and inclusion in the planning of their own care, working towards achieving timely discharge and allowing people to live in an environment that is the least restrictive to meet their individual needs.

The Broadland Clinic is a 25 bedded service which offers assessment, treatment and rehabilitation to persons with mild/borderline/medium learning disabilities and forensic histories within a medium secure environment.

The Clinic currently offers a medium secure service. It has a number of recreational facilities mainly at the Wherries eg a gymnasium, 5-a-side football pitch, a craft and education areas.

The most common developmental disabilities seen at the Broadland Clinic are: •

Intellectual disability as defined by an IQ below 70 along with limitations in adaptive functioning and onset before the age of 18 years.

•

People diagnosed with autism and intellectual disability.

5.5. Local findings and needs for offenders with learning difficulties A meeting was held with experts from Little Plumstead Hospital/the Broadland Clinic with the main objective of finding out the needs of offenders in the form of health, social life, quality of life, interventions, and identifying the gaps.

The Public Health Team undertake a planned qualitative research by interviewing the experts. The resulting information will be used to build up a baseline assessment.

The main findings from this in-depth interview:

101

•

Annual turnover is a good way to inspect the average capacity and work volume. The overall estimated number of admissions to the Broadland Clinic for adult offenders with learning disability is (7) and the number of discharge is (7) per annum.

•

One in every seven (14.3%) referrals for medium secure accommodation will be admitted to the Broadland Clinic.

•

The Broadland Clinic learning disability team receive referrals from courts, prisons, police service, probation service, and high secure hospitals.

http://www.hpft.nhs.uk/our-services/ld-and-forensic-services/norfolk/services/medium-secure-in-norfolk/.

Page | 100

Offender Health Profile for Norfolk

•

All offenders that were admitted to the Broadland Clinic were men. Women with learning disabilities more likely to be classified as low risk rather than medium or high (Occasionally there are a few cases classified as medium risk.)

•

The majority of offenders with learning/developmental disability are in their late twenties or early thirties, but are often known to other services during childhood and adolescence.

•

All high risk learning/developmental disability offenders are transferred to Rampton Hospital.

•

Most of those offenders were suffering either from learning disability or autism. These figures are divided equally between the two conditions.

•

Some of the more serious types of offence committed by people with learning disability or autism were: murder, sexual offences, fire setting. They advised that some people with a history of sexual offending could be managed in the community jointly with probation should an appropriate service exist.

•

In emergency situations such as when there are no places at the Broadland Clinic the additional cases are transferred to other private sector facilities, mainly at St John’s House 102 which provide’s care (Medium Secure Services for men and Low Secure Services for women, just outside Diss) and Burston Hospital103 (mainly men, low secure hospital, located to the east of Diss).

•

The diagnosis of learning disability can be confirmed by applying two standard procedures (general and specific methods):  Not formally: Using the Learning Disability Screening Questionnaire (LDSQ) – developed to help those who work with adults who are suspected of having an intellectual disability. It is valid and reliable and can be completed quickly with minimum demands on the individual, carer or professional completing it. 104 The assessment is designed to be of use to a wide range of professionals, families and carers in a range of settings, including health, social care and criminal justice services.  IQ test (formal test): a psychometric test of intelligence 105 along with a formal assessment of adaptive behaviour. It is designed to measure a variety of mental

102

St. John's House provides quality, specialised treatment and care of adults with learning disabilities where their needs challenge mainstream service provision.

103 Burston House provides quality, specialised treatment and care for men who have learning disability and other conditions and who can not be adequately managed and supported in mainstream services.

Men with a primary diagnosis of learning disability who may also have secondary diagnoses of conditions including Asperger Syndrome, other autistic spectrum disorders, personality disorders, major mental illnesses and substance misuse. All patients are detained under the Mental Health Act. http://www.partnershipsincare.co.uk/hospitals/burston-house.

104 The LDSQ can discriminate with high levels of accuracy between those who have an intellectual disability and those who do not (identifying those people who have an intellectual disability with 91% accuracy) and it does not require intensive and time-consuming assessment. http://gcmrecords.wordpress.com/about/the-learning-disability-screening-questionnaire-ldsq/ 105 http://dictionary.reference.com/browse/iq+test.

Page | 101

Offender Health Profile for Norfolk

functions, such as reasoning, comprehension, and judgement. It is conducted by psychologist to confirm the diagnostic.  The measure of IQ has been used to define the severity of learning disability: a person with an IQ of less than 20 would be described as having a profound learning disability, an IQ of 20-34 a severe learning disability, 35-49 moderate, and 50-70 mild learning disability. 106 107 •

The most frequent health or health related problems seen with learning disability offenders are: social problems, including social exclusion, poor diets, elevated rates of smoking and alcoholism and drug dependence.

•

There are a number of interventions available in place to raise awareness of identifying offenders with low IQ such as training new police officers, leaflets to increase awareness of autism and mental illness, sign posting, learning disability first aid etc However, no evaluation has been conducted to measure how effective these interventions are.

•

It is the responsibility of police and courts to identify offenders with a learning disability disorder among adult offenders. Solicitors are better at using the available diagnosis methods and know who to approach. However, some offenders may resist being labelled as having a learning disability, especially those with 50-70 IQ score.

•

The main gap identified for Norfolk is the lack of a forensic learning disability service in the community. It is a priority to have a local forensic mental health and learning disability service to meet the mental health, psychological, behavioural and social care needs of offenders in conjunction with other health and social care agencies. 108 109 There is also no agreed joint Care Programme Approach (CPA) for people with learning disability in Norfolk.

•

All offenders with learning/developmental disability have, as part of their care, allocated professionals involved in supporting them. There is a primary healthcare team including general practice nurses, GPs, a dental clinic/once a week (at Bowthorpe Health Centre – The Trinity & Bowthorpe Medical Practice), and dieticians. Patients can be transferred to General hospital if they require certain interventions or treatments.

106

http://www.patient.co.uk/doctor/general-learning-disability.

Some people might not be picked (mainly those borderline score).

108 Bristol successfully managed to create a forensic team that have a small specialist team providing a tertiary service, based in the community at the Withywood Centre, to people with a learning disability who are at risk of offending and are normally resident and are registered with a GP within Avon (Bristol, Bath, South Gloucestershire and North Somerset). The team consists of clinical psychologists, team leader, learning disabilities nurse practitioner and team secretary. All team members work on a part-time basis. http://www.awp.nhs.uk/services/community/community-learning-disabilities/.

109 Another example is the: East Kent Community Forensic Psychology Service The East Kent Community Forensic Psychology Service (EKCFPS) is part of the Kent Forensic Psychiatry Service and provides a specialist service for adults with a learning disability who live in the community in East Kent.

The service is intended to provide input to the existing community teams for people with learning disabilities and does not replace the need for continuing local involvement with people referred to the East Kent Community Forensic Psychology Service, http://www.kmpt.nhs.uk/ekcfps.

107

Page | 102

Offender Health Profile for Norfolk

•

Inpatients at the Broadland Clinic can use other facilities such as education and training eg gym, clinical psychologist and occupational therapy.

•

The Broadland Clinic has an outreach team providing support for discharged offenders in the community and provides support for up to a year. They work alongside Area Mental Health Teams. However there are no community treatment orders (as with mental health) and this support is only provided for those discharged from secure accommodation.

The total number of referrals to the Norvic Clinic over five year period 2009 to 2013 was 181 referrals (an average of 36 referrals per year). The total number of admissions to the Norvic Clinic during the same period was 32 admissions out of 181 referrals (18%). 11 out of 32 (34.4%) were from Norfolk, for further details and sources of referrals see Table 35.

Table 35: Number and percentage of referrals to the Norvic Clinic by source of referral during 2009 to 2013 Number referred

Number admitted

Percentages (%) admitted

*

*

*

Cambridge

16

*

*

Suffolk

18

*

*

Hertfordshire

24

*

*

Essex

38

8

21

Norfolk

80

11

14

Other Total

* 181

* 32

* 18

Bedfordshire

Note: Due to small numbers it is not possible to present the information for all areas (asterisks in table).

Page | 103

Offender Health Profile for Norfolk

5.6. Offenders & Social Care - Intellectual Disabilities (OFFSCA-ID) 110 5.6.1. Background about OFFSCA-ID Offenders & Social Care - Intellectual Disabilities (OFFSCA- ID) is a research project looking at the cost and benefits of social care, and its effectiveness in preventing people with intellectual disabilities from re-offending. 111 The research is on-going and men with learning disabilities from HMP Norwich have been selected in this study. There were three participants from Norfolk–all from HMP Norwich, of these only one has been interviewed so far, October 2014.

People with learning disabilities are thought to be represented in not insignificant numbers in the prison population in the UK: recent studies have suggested about 7% of people in prison have a learning disability. 112 Yet on leaving prison they often receive remarkably little support as Community Learning Disability Teams often deem them too able for support and social services argue that they do not meet FACS (Fair Access to Care Services) criteria. However, anecdotal evidence suggests that small amounts of support can make a big difference to outcomes, such as re-offending.

The project aims to select people (who have already screened positive for learning disabilities), as they are leaving prison, and will follow them up for one year. Measures of their health, well-being, re-offending and service utilisation will be made at two time points: T1- within one month of leaving prison, T2- in nine months’ time. People screened positive for learning disability who are due to leave prison will be invited to take part in the study. Their care manager or offender manager will also be invited to take part.

Statistical tests will be carried out to document outcomes such as the extent of social care support and services that are associated with rates of re-offending and quality of life as well as the effects and costs of social care input. 113

110

http://www.kent.ac.uk/tizard/research/research_projects/OFFSCA_ID.html.

The project is funded by SSCR (School for Social Care) and it will run for two years. The project has also been approved by NHS ethics and NOMS (National Offender Management Service).

111

112

http://www.kent.ac.uk/tizard/research/research_projects/Centre%20study%20posters%202013/OFFSCAID_%2010.6.13_pc.pdf.

113 The researchers will be working for two years alongside adults with learning disabilities who have just left prison, to find out: • Does social care input, on leaving prison, affect mood, behaviour and quality of life of people with ID? • What are the costs of social care support for these ex-offenders with ID? • How do the social care costs relates to the outcome for the ex-offenders with ID? Page | 104

Offender Health Profile for Norfolk

5.6.2. OFFSCA-ID summary Prisoners with intellectual disabilities are known to be disadvantaged in prisons and to be more susceptible to bullying, segregation, depression and anxiety than other prisoners.

It has been suggested that 7% of the current prison population have learning disabilities 114.

The Bradley Report, 2009 review examined diversion policy for people with learning disabilities/mental health needs. Amongst the recommendations: •

There should be a national strategy for rehabilitation of offenders with mental health needs and/or LD because of the inconsistency of support when people leave prison.

OFFSCA-ID: AIMS • Does social care input, after leaving prison, affect the mood, behaviour and quality of life of ex-offenders with LD? • What are the costs of social care support for these ex-offenders with LD? • How does the social care input alter the outcome in terms of re-offending for the exoffenders with LD? Design and Participants • Planned to work with three prisons and associated Trusts. Actually working across 14 NHS Trusts and 19 prison establishments.

• Men screened positive for LD are recruited when they are due to leave prison (we planned for n=130 but recruitment was very difficult).

• Care manager and offender manager are also invited to take part (if participants have them).

• Interviews are held at two time points: T1- within one month of leaving prison, T2- in nine months’ time.

Interim findings • 28 consented participants.

• 17 participants have been released from prison.

• 12 Time 1 (T1) interviews have been completed.

• 6 men out of 12 interviewed have been re-arrested within one month of their release (50%).

• 3 out of 12 interviewed have returned to prison within one month of their release (25%).

• 1 participant has not received any support services at T1.

• Only 1 participant was receiving support from social services.

114

Mottram, 2007; Hayes et al, 2007.

Page | 105

Offender Health Profile for Norfolk

What other support was on offer?

For more details see Appendix 6 Page 177 – screening prisoners for intellectual disabilities in three English prisons see brief report Appendix 7 Page 185.

Page | 106

Offender Health Profile for Norfolk

6. Young offenders 6.1. National context The 2009 Department of Health document Healthy Children, Safer Communities, a strategy to improve the health and well-being of children and young people at risk of offending and re-offending, describes the youth justice system (YJS) as “responses to children who have offended … or have been charged to appear at court. The system includes the police, Youth Offending Teams, the Crown Prosecution Service, the courts, sentences, community and custodian sentences and resettlement.” 115 It includes those in the formal YJS and those at risk of offending who are involved with services such as the Youth Justice Board or other agencies to prevent them from entering the YJS. Figure 18 below shows the range of agencies involved.

Figure 18: Agencies and partners in the youth justice continuum

Key CJS: Criminal Justice System, CPS: Crown Prosecution Service, YJS: Youth Justice System, YJLD: Youth Justice Liaison and Diversion, YOT: Youth Offending Team, YPSE: Young People's Secure Estate.

Source: DoH and the Youth Justice Board The health and well-being needs assessment model template (2012) http://www.chimat.org.uk/yj/na/template (Accessed 24.7.14)

115

DoH Healthy Children, Safer Communities: a strategy to promote the health and well-being of children and young people in contact with the youth justice system (2009) p.9. http://dera.ioe.ac.uk/11034/1/dh_109772.pdf (Accessed 24.7.14).

Page | 107

Offender Health Profile for Norfolk

6.2. Extent of youth offending Figure 19 below shows the number of young people who entered the youth justice system in 201213 in England and Wales but does not give the number diverted through Triage or a restorative justice programme.

Figure 19: Flows through the Youth Justice System 2012-13

Source: Ministry of Justice/Youth Justice Board Youth Justice Statistics 2012-13 England and Wales (2014) p.13 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/278549/youthjustice-stats-2013.pdf (Accessed 24.7.14).

Page | 108

Offender Health Profile for Norfolk

6.3. Responses to offending Outcomes for young offenders depend on the nature of the crime and previous offending behaviour. Figure 20 below shows the youth justice system and ‘hierarchy’ of disposal options (but note that reprimands and final warnings are no longer an option, the ‘Local evidence’ section which follows gives more detail).

Figure 20: Case disposal options

Source: DoH Healthy Children, Safer Communities p.93.

Page | 109

Offender Health Profile for Norfolk

6.4. Secure estate settings The overwhelming majority of children and young people in contact with the YJS remain in the community throughout that contact, but a small number are remanded or sentenced to custody.

There are no secure estate settings in Norfolk (see Figure 21 below) and Warren Hill, a young offender institution in the East, is now closed.

Figure 21: Secure estate settings in England and Wales (2012)

Source: CHIMAT Youth Justice Health and Wellbeing Needs Assessment Toolkit http://www.chimat.org.uk/yj/na/ayjs/map (Accessed 25.7.14).

Page | 110

Offender Health Profile for Norfolk

The children and young people’s secure estate is made up of three types of setting: Young Offender Institutions (YOIs) – There are currently 11 YOIs in England and Wales, eight male and three small female units which accommodate 15-17 year old boys and some 17-year-old girls. Nine are run by HM Prison Service and two by private contractors. There are also six YOIs that hold young people from the ages of 18-21 years, these are Cookham Wood, Feltham, Hindley, Werrington, Parc and Wetherby.

Secure Training Centres (STCs). STCs are purpose-built custodial facilities for 12-17 year olds.

There are currently four STCs, all run by private contractors.

Secure Children’s Homes (SCHs). SCHs are smaller facilities run by local authorities and provide facilities for 10-17 year olds, including some of the youngest and most vulnerable. SCHs can also accommodate children looked after by local authorities where courts have authorised that they may be detained for welfare reasons. 116

6.5. Health and wellbeing needs of young offenders Children and young people in contact with the youth justice system (YJS) have more – and more severe – unmet health and wellbeing needs than other children of their age. They have often missed out on early attention to health needs. They frequently face a range of other, often entrenched, difficulties, including school exclusion, fragmented family relationships, bereavement, unstable living conditions, and poor or harmful parenting that might be linked to parental poverty, substance misuse and mental health problems. Information about the physical health needs of children and young people in custody indicates that they have significantly more physical health problems than the general population of young people, and that they have received less in the way of health promotion, screening and preventive services than their non-offending peers.

The Child and Maternal Health Intelligence Network offers two templates for health needs assessment: one for the secure estate and one for community settings as the health needs of offenders in each setting are different. However for both groups, the vulnerabilities which arise from social factors such as homelessness or being NEET (Not in Education or Training) are similar and are described in the templates. 117

6.6. Physical health of young offenders Reviews of the provision of health services to children and young people in the YJS in the community found health problems were identified in around a tenth of the assessments carried out

by Youth Offending Teams but considerable under-reporting existed because assessments were focused on offending behaviour rather than wider health issues.

A systematic audit of the first 70 cases referred to a YOT in one London borough during one year found more than a third of the young people (36%) had a chronic health condition. Slightly more is known about the health needs of young people in custody, for example, a review of 16-20 year olds showed that a quarter of males and a third of female young offenders reported a longstanding 116

Public Health England Health and Justice Health Needs Assessment Toolkit for Prescribed Places of Detention (July 2014) p.14.

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/331622/Health_Needs_Asse ssment_Toolkit_for_Prescribed_Places_of_Detention_Part_1.pdf (Accessed 23.7.14).

117

CHIMAT Youth Justice Health and Wellbeing Needs Assessment Toolkit: HWBNA Model Template (Community)and HWBNA Model Template: Community) p4 http://www.chimat.org.uk/yj/na/template (Accessed 24.7.14).

Page | 111

Offender Health Profile for Norfolk

physical complaint of which respiratory problems were the most common. 118 In a health needs assessment undertaken in 1999-2000 in YOIs, the main physical health problems identified were asthma, dental health, blood-borne viruses such as hepatitis B and C, sexually transmitted diseases and epilepsy. 119

6.7. Mental health of young offenders A review of evidence about the health of young offenders showed that: “mental health problems in children do not manifest themselves as clearly as they do in adults. They can emerge in ways that are less easily defined, for example, through behaviour problems and emotional difficulties, substance misuse and self-harm. This can lead to under-estimates of mental health problems among groups of children and young people”. 120 A literature review of studies into the mental health of young offenders concluded they are at least three times more likely to have mental health problems than their non-offending counterparts and being in custody can exacerbate mental health problems. The most common disorders are conduct disorders, followed by anxiety and depression.

Prevalence rates for personality disorders, psychosis, attention disorders, post-traumatic stress disorders and self-harm are much higher than in the general population. Young offenders frequently experience one or more disorders at the same time and there is also evidence of the cooccurrence of mental health problems with learning disability and/or with substance misuse.

6.8. Local evidence 6.8.1. Extent of Out-of-Court Disposals Between 1 January and 31 December 2013 the Norfolk Youth Offending Team (NYOT) recorded: •

Youth cautions – 111

•

Youth caution + conditions – 14

•

Youth conditional caution – 48

•

Final warnings - 77 121

A youth caution is a statutory out-of-court disposal which replaced Final Warnings and Reprimands in April 2013. It can be given for any offence when the young person admits the offence and there is sufficient evidence for a realistic prospect of conviction but it is not in the public interest to prosecute.

The police must inform the YOT when a youth caution is given. The youth condition caution is also a statutory out-of-court disposal offered when the young person admits an offence, there is 118

M Ryan and J Tunnard Evidence about the health and well-being needs of children and young people in contact with the youth justice system (2012) http://www.chimat.org.uk/resource/view.aspx?RID=111768 pp.56.

119 Ryan and Tunnard Evidence about the health and well-being needs of children and young people p.6.

120 Ryan and Tunnard Evidence about the health and well-being needs of children and young people p.7.

121 Figures kindly supplied by Samantha Hookham, Performance and Information Officer, NYOT. Page | 112

Offender Health Profile for Norfolk

sufficient evidence of a realistic prospect of conviction, and the public interest can best be served by the young person complying with suitable conditions rather than a prosecution.

The police officers must have the authority of the Crown Prosecution Service to use a youth conditional caution as an out-of-court disposal for an 'indictable only offence'. 122 Young offenders are screened using the Youth Justice Board ONSET/ASSET tool which covers physical and mental health but also a wide range of factors which indicate existing or potential vulnerabilities. 123 A score of two or greater would mean that a health assessment of the young person would be undertaken. In 2013, 142 young people scored two or more when tested by NYOT (131 in the mental health section of ONSET/ASSET and 11 in the physical health section). 124

6.8.2. NYOT Assessment 2008-09 Between 1 April 2008 and 31 March 2009, NYOT carried out assessments on 1,357 children and young people. Although there were problems with the data collection (including a possibility of underestimating the scale of the problem) and some of the questions about physical health were poorly completed, the section relating to emotional and mental health showed that: •

Approximately one third of people in the sample were believed to be coming to terms with significant past events.

•

YOT assessors believed the emotional health of around one quarter (24%) of the sample to be at risk due to their current circumstance.

•

A quarter of the sample had been in contact with mental health services.

•

70% of the sample admitted to smoking. The mean age of onset was 12 and the average number of cigarettes smoked each day was 11 (with 23% smoking over 20 cigarettes each day).

•

High levels of depression were reported, with 22% of the young people scoring in the top end of the screening scale.

•

Potential need linked to ADHD was extremely high, for both diagnosed and undiagnosed young people.

•

The evidence showed that NYOT are sometimes frustrated in their attempts to get children and young people the help they need at a time when they are being actively engaged. 125

122

Youth Justice Board Disposals https://www.justice.gov.uk/youth-justice/courts-and-orders/disposals (Accessed 25.7.14).

123 Youth Justice Board ONSET https://www.justice.gov.uk/youth-justice/assessment/onset (Accessed 25.7.14).

124 Figures kindly supplied by Samantha Hookham, Performance and Information Officer, NYOT 125 Norfolk Youth Offending Team Health Needs Assessment (2009). www.chimat.org.uk/resource/view.aspx?RID=126149 (Accessed 7.3.14).

Page | 113

Offender Health Profile for Norfolk

6.8.3. NYOT Health Needs Audit 2014: Comprehensive Health Assessment Tool (CHAT) The CHAT was developed by the Department of Health and the Youth Justice Board to identify the unmet health needs of all young people in contact with youth offending services. The tool includes Reception Screening (an initial assessment of immediate risk in physical health, substance misuse, mental health, and immediate safety risks) followed by a comprehensive review of physical health, substance misuse, mental health and neurodevelopmental disorders. It is completed by qualified medical staff such as Registered General Nurses or CAHMS practitioners within a set time period. 126 Of the 80+ assessments taken during the three month period for the 2014 NYOT Health Needs Audit, preliminary findings seem to indicate that there is improved communications between General Practitioners and the Health Co-ordinators employed into Norfolk's Youth Offending Teams across the county. The sharing of medical information relating to immunisation status, medication, ADHD and on-going treatments has much improved.

The findings also indicate that a high proportion of the young people seem to present with ADHD type behaviours. As expected the audit has also evidenced the well-developed CAMHS pathways when a young person needs to be referred. It also appears evident that the young people interviewed did not regard their physical or mental health as particularly important. This is not unusual as some young people do characteristically view themselves as ‘invincible’. More detailed analysis is under way and so additional findings may emerge. 127

6.8.4. Emerging themes and latest developments There are closer links developing between YOT and LAC nurses and this is expected to deliver a more aligned service for young people as they will no longer have to repeat their history to different nurses and information will be shared more efficiently.

The YOT and LAC nurses have met to ensure a clear understanding of their respective roles and identify where duplication may occur. Sharing information will ensure swift responses (where necessary) to changes in a young person's medical history: this is particularly relevant for YOT when vulnerabilities are increased as this may affect the young person’s emotional and mental health.

Potential vulnerability is greater when there is a risk of remand or being detained in a young offenders institution. Joint working will also provide opportunities to pick up health related issues that are being investigated or discussed with young people as a LAC issue whilst they are on a YOT intervention and vice versa.

The issue of young people transferring at the age of 18 years to adult services (both in the health and criminal justice arena) can be problematic. This is an area of on-going development where mental health issues are present and there needs to be further discussion to ensure that the transition for young offenders is effective. This service has however significantly improved since the age parameters were increased to 25 years.

126

Offender Health Research Network Manual for CHAT (January 2014), http://www.ohrn.nhs.uk/OHRNResearch/CHATManualYOS.pdf (Accessed 28.7.14).

127 Assessments led by Helen Taylor, Area Manager, Eastern Unit, Norfolk Youth Offending Team.

Page | 114

Offender Health Profile for Norfolk

Research suggests there is an increased number of a young persons within the criminal justice setting who have speech and language problems. The current health assessment, CHAT, does address speech and language and training to identify those specific issues is currently being identified for NYOT staff to enable a speedy signposting to the relevant health providers when a problem is identified.

Page | 115

Offender Health Profile for Norfolk

7. Offenders in mainstream prisons 7.1. Introduction There are three male prisons in Norfolk: HMPs Bure, Norwich and Wayland. There are no prisons for females in Norfolk. The type and occupational capacity details of each prison from the HM Prison Service website are given below.

Operational Capacity (OC) is the maximum safe capacity of the prison population which is higher than the Certified Normal Accommodation (CNA). There is a statutory programme of needs assessment required in collaboration with the prisons and commissioners, where further detail on health services for prisoners are assessed – the latest health needs assessments were undertaken for HMPs Wayland and Bure in 2012 and for HMP Norwich in 2013. 128 HMP Bure is a Category C prison for adult sex offenders built on part of the former RAF Coltishall site, seven miles north of Norwich. The prison was constructed throughout 2009 and is a mix of new buildings and those converted from their previous uses as airmen's accommodation and service buildings. Opened in two phases, HMP Bure accepted its first offenders at the end of November 2009, with the remainder of the accommodation coming on line in April 2010. 129 The operational capacity is for 523 prisoners.

HMP Wayland is a Category C adult male training prison. It opened in 1985 with the site buildings being added to, on four occasions. It now comprises thirteen residential units 130. The operational capacity is for 1,017 prisoners.

HMP Norwich is a Category B local prison which serves the courts of Norfolk and Suffolk for men aged over 18 years. The prison holds remanded, newly sentenced, newly remanded and Category C prisoners for local release. The prison has occupied its current site overlooking the city of Norwich since 1887. It is a split site prison and consists of ten wings and a Special Care Unit. 131 The operational capacity is for 767 prisoners.

Due to differing population structures there may be differing levels of need within each of the prisons in Norfolk, although it is acknowledged that the populations of each of these prisons have greater health needs compared with the general population of Norfolk. Table 36 shows the rate of hospital admissions, outpatient attendances and A&E attendances per 1,000 population taken from the health needs assessment carried out for HMP Bure in 2012 (HMP Bure may be overrepresented in these statistics due to older populations of offenders).

Table 36: Hospital episode rates per 1000 prisoners for Norfolk prisons 2011/12 HMP HMP HMP Indicator Bure Norwich Wayland Hospital admissions per 1,000 population 157 163 92 Outpatient attendances per 1,000 population 677 563 494 A&E attendances per 1,000 population 117 193 128 128

Norfolk Insight http://www.norfolkinsight.org.uk/jsna/groupsatrisk (Accessed 6.6.14). http://www.justice.gov.uk/contacts/prison-finder/bure (Accessed 6.6.14).

130 http://www.justice.gov.uk/contacts/prison-finder/wayland (Accessed 6.6.14).

131 http://www.justice.gov.uk/contacts/prison-finder/norwich (Accessed 6.6.14).

129

Page | 116

Offender Health Profile for Norfolk

Prisons for women operate under the same rules and policies as prisons for men. However, women’s prisons are also required to comply with gender specific standards for working with women prisoners so that staff are made aware of the gender specific issues that affect women prisoners and are able to respond appropriately.

There are 13 women’s prisons in England and women from Norfolk who are serving sentences will typically go to Peterborough which is a privately operated establishment. 132 HMP Peterborough is a Category B prison for men and a closed prison for women and female young offenders which are operated by Sodexo Justice Services. The prison was opened in March 2005 and is the country’s only dual purpose-built prison for men and women, who are kept separate at all times. The prison has a 12 place Mother and Baby Unit.

The occupational capacity of HMP Peterborough is 840 (480 male and 360 female) as of 4 August 2008. Peterborough accepts adult male prisoners from Cambridgeshire and females from Nottinghamshire, Lincolnshire, Leicestershire, Cambridgeshire, Northamptonshire, Norfolk and Suffolk.

The majority of the accommodation is single occupancy and the wings hold an average 34 women.

There is a Separation and Care unit and a 15-bed healthcare facility which incorporates a first night centre for women who are new to custody. 133

7.2. Physical health Recent health needs assessments have taken prevalence data from QOF registers for conditions of prisoners in HMP Bure, HMP Wayland and HMP Norwich and compared these to the equivalent figures for the general population in Norfolk and epidemiological prevalence estimates for prison populations using the Birmingham toolkit. 134 According to the Health Needs Assessment of HMP Bure carried out in 2012 there is a high prevalence of Chronic Obstructive Pulmonary Disease (COPD) and a high prevalence of cancer within the prison population – which could be due to the older population within this prison. It was also found that a high number of residents had diabetes and that the rate of obesity was higher than would be expected (Table 37).

The QOF register for HMP Wayland indicated that compared to the population of Norfolk there was a slightly higher prevalence of asthma, epilepsy and obesity. There was a much lower prevalence of hypertension compared with the general population.

The prevalence of diabetes among prisoners is more than four times higher in HMP Wayland than the resident population (estimated level from the Birmingham toolkit). This is however, similar to the prevalence in Norfolk. Diabetes is closely linked with obesity which also has a similar prevalence to Norfolk (Table 38). The prevalence of epilepsy is three times that expected (and three times the community prevalence). There is a high prevalence of cardiovascular disease 132

http://www.justice.gov.uk/offenders/types-of-offender/women (Accessed 27.6.14). http://www.justice.gov.uk/contacts/prison-finder/peterborough (Accessed 27.6.14).

134 Marshall, T. Simpson, S. Stevens, A. (2000) Toolkit for health care needs assessments in prisons.

Department of Public Health and Epidemiology, University of Birmingham.

133

Page | 117

Offender Health Profile for Norfolk

conditions (CHD, hypertension) which could be indicative of case finding via the Health Check Programme. 135 Table 37: Prevalence of long term conditions at HMP Bure and HMP Wayland according to QOF registers HMP HMP Bure Wayland NHS QOF HMP Bure HMP QOF Norfolk Register QOF Wayland Condition Register % QOF numbers Register QOF numbers (October (October % Register % (October 2011) 2011) 2011) Asthma 71 13.6 88 8.9 7.1 COPD 24 4.6 11 1.1 1.7 Cancer 18 3.4 * * 1.7 Coronary heart disease 32 6.1 * * 4 Diabetes 35 6.7 19 1.9 5.5 Epilepsy 10 1.9 25 2.5 0.9 Hypertension 74 14.2 43 4.3 15.4 Obesity 96 18.4 114 11.5 10.6 Source: NHS Norfolk and Waveney Public Health Information Team Health Needs Assessment HMP Wayland and HMP Bure (2012) and HMP Norwich (2013).

Note: Due to small numbers it is not possible to present the information for all conditions (asterisks in table).

Table 38: Prevalence of long term conditions at HMP Norwich according to QOF registers NHS HMP Norwich HMP Norfolk % QOF Register Condition Norwich QOF QOF Numbers Register % (March (March 2013) 2013) Asthma 60 8.5 7.1 COPD 11 1.6 1.7 Coronary heart disease 19 2.7 4 Diabetes 28 4.0 5.5 Epilepsy 21 3.0 0.9 Hypertension 42 5.9 15.4 Obesity 84 11.8 10.6 Source: NHS Norfolk and Waveney Public Health Information Team Health Needs Assessment HMP Norwich (2013).

135

NHS Norfolk and Waveney Public Health Information Team Health Needs Assessment HMP Norwich (2013).

Page | 118

Offender Health Profile for Norfolk

7.3. Mental health The Bradley Report (2009) found that there is a need for better mental health screening when offenders arrive at prison and urgent consideration should also be given to the identification of learning disabilities within the screening process. 136 Fazel and Danesh conducted research in 2002: a review of 22,790 prisoners (18,530 men, 4,260 women) from 62 surveys across 12 countries found that prisoners were several times more likely to have psychosis and major depression, and about ten times more likely to have antisocial disorder than the general population. The prevalence of psychotic illness was 3.7% for men and 4% for women, major depression 10% for men and 12% for women, and personality disorder 65% for men and 42% for women. Nearly three quarters (47% of the 65%) of men and half (21% of the 42%) of women with personality disorders had antisocial personality disorder.

Singleton et al137 conducted a small scale national survey in the UK in 1997 – published in 1998 involving 1,633 remand (1,415 males, 218 females), and 1,930 sentenced (1,254 males, and 676 females). The study showed that prisoners were particularly vulnerable to developing mental health problems. Histories of abuse, deprivation, homelessness, unemployment, and substance misuse were common. Many prisoners had numeracy and literacy problems and most prisoners had a lower than average IQ. 138 The study found a higher prevalence of personality disorder and psychosis, the prevalence of personality disorder in men was 78% in remand prisoners and 64% in sentenced prisoners and in women the prevalence was 50%. The rates for psychosis were 7% for male sentenced, 10% for male remand, and 14% for female prisoners. The study found that women prisoners were significantly more likely than men to suffer from a neurotic disorder, whereas 59% of remand and 40% of sentenced male prisoners in England and Wales had a neurotic disorder, the corresponding figures for women were 76% and 63%.

In the Fazel and Danesh 139 report of 22,790 prisoners from 12 countries discussed above, UK prisoners contributed the second highest percentage (5,545 prisoners) 25% of all prisoners.

Taking this into account along with findings by Singleton et al, and other evidence it is likely that these findings apply to local prisons. However, if the prevalence of mental illness in local prisoners is different from those reported in these studies, it will still mean that there are a high number of local prisoners in need of mental health care.

A recent independent national review of unmet mental and health needs in prison has recommended that:

136

The Bradley Report: Lord Bradley’s review of people with mental health problems or learning disabilities in the criminal justice system 2009, http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/ dh_digitalassets/documents/digitalasset/dh_098698.pdf (Accessed 11.06.14).

137 http://www.bis.gov.uk/assets/foresight/docs/mental-capital/sr-b5_mcw.pdf.

138 Her Majesty’s Inspectorate of Prisons, 1997b, 2000a; Singleton et al, 1998.

139 Studies were from Australia (598 prisoners), Canada (3,196 prisoners), Denmark (583 prisoners), Finland (1,317 prisoners), Ireland (280 prisoners), Netherlands (450 prisoners), New Zealand (1,431 prisoners), Norway (41 prisoners), Spain (99 prisoners), Sweden (103 prisoners), UK (5,548 prisoners), and USA (9,144 prisoners).

Page | 119

Offender Health Profile for Norfolk

•

Police, court officials, and magistrates should have regular training in understanding mental illness and learning disabilities.

•

Local mental health and social care services should be required to provide full and current information to courts about the resource and services in their areas.

•

The ‘Appropriate Adult’ in police stations and courts must be fully resourced so that they can work with duty social workers to facilitate referrals to mental health services and social care. 140

Due to the high prevalence of mental health conditions among prisoners, the policy of moving out the acute mentally ill prisoners within 14 days to specialist mental health services should be assessed formally as there is no nationally available published information. It is noted that the three prisons for Norfolk only hold male prisoners; we have no data on female residents of Norfolk who become remand and sentenced prisoners elsewhere.

Table 39 gives the estimated numbers of male prisoners with psychotic illness, major depression, and personality disorder after applying the obtained prevalence from the international studies review (Fazel and Danesh, 2002) to the three prisons, and assuming that the local prisons are full to capacity.

Table 39: Estimated number of local male prisoners with psychotic illness, major depression and personality disorder Estimated number of male prisoners with conditions assuming prison full to operational Condition capacity Bure Wayland Norwich Total Psychotic illnesses 19 38 28 85 Major depression 52 102 77 231 Personality disorder 340 661 499 1500 Antisocial personality disorder 160 311 234 705 University of Birmingham, Department of Public Health & Epidemiology in 2000 produced a toolkit for health care needs assessment in prisons. 141 The toolkit provided estimated figures for mental health disorders for remand and sentenced prisoners, the estimated mental health disorders prevalence is given in Table 40.

Local data from QOF registers relating to mental health problems were presented within the latest needs assessment for HMP Bure (2012) where it was found that there were 72 people with depression, one person with dementia, seven people with learning disability and 28 people on the 140

Prison Reform Trust: Too Little Too Late: an independent review of unmet mental health need in prison (2009) http://www.prisonreformtrust.org.uk/Portals/0/Documents/Too%20Little%20Too%20Late%20%20a%20review%20of%20unmet%20mental%20health%20need%20in%20prison%20.pdf (Accessed 13.06.14).

141

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4034 355.pdf.

Page | 120

Offender Health Profile for Norfolk

MH register with psychosis (equivalent figures for HMP Wayland and HMP Norwich were not made available).

Data were not available for the health needs assessment carried out for HMP Norwich in 2009 for the numbers of mental health patients who were identified at reception screening.

According to inpatient bed records from HMP Norwich around 45% of bed days occupied were due to a prisoner’s mental health problem, 38% due to a physical health problem, 6% due to detox, 6% due to supervised medication and 5% due to constant watch (this could also be because of a mental health problem and the location of one of the constant watch cells).

Table 40: Prevalence of mental health disorders among prisoners, using national toolkit Males Remand Sentenced Personality disorders 78% 64% Functional psychosis (In the past year) 10% 7% Common neurotic symptoms Sleep disorders 67% 54% Somatic symptoms 24% 16% Worry about physical health 22% 16% Neurotic disorders (in the past week) Post-traumatic stress disorder 5% 3% Mixed anxiety & depression 26% 19% Generalised anxiety disorder 11% 8% Depressive episode 17% 8% Phobias 10% 6% Obsessive-compulsive disorder 10% 7% Panic disorder 6% 3% Any neurotic disorder 59% 40% Self-harm and suicide Suicide attempts (past week) 2% 0% Suicidal thoughts (past week) 12% 4% Non-suicidal self-harm 5% 7% Alcohol misuse AUDIT score >32 (severe problem) 7% 4% Drug dependence Cannabis only 9% 8% Stimulants only 17% 16% Opiates and stimulants 15% 10% Opiates only 11% 8%

Page | 121

Offender Health Profile for Norfolk

7.4. Substance misuse The substance misuse needs assessment undertaken by N-DAP in 2013 showed that around a third of the 87 people undergoing drug treatment in HMP Bure cited crack as the main problem (followed by cannabis and alcohol) and of the 1,260 new receptions to HMP Wayland in 2010-11 almost two-thirds (774 or 61%) were identified as requiring treatment: heroin was the primary problem cited, followed by cannabis, powder cocaine and crack. The needs assessment also showed that of the 2,858 new receptions to HMP Norwich in 2010-11, 573 were identified as needing treatment for their substance misuse and 413 started treatments: the primary issue cited was heroin. 142

7.5. Self-harm Within all three prisons in Norfolk detainees are monitored when they are thought to be a risk to their own safety.

According to data from the NOMS incidents recording system there were 14 self-harm incidents in HMP Bure during 2013, 70 self-harm incidents in HMP Wayland and 232 self-harm incidents in HMP Norwich.

It has been suggested in previous needs assessments that HMP Norwich has a higher rate of A&E attendances than other prisons in Norfolk due to self-harm. In 2013 HMP Norwich was the only prison where self-inflicted deaths occurred, there were three self-inflicted deaths during the calendar year.

7.6. Communicable disease The prevalence of blood borne viruses (BBVs) is known to be higher among prison populations. 143 This is partly because there is a high proportion of injecting drug users among prisoners and partly because prisons are locations of practices which increase the risk of BBV transmission, such as injecting equipment and unprotected sex. 144 Specific prevalence figures for HIV are not obtainable from recent health needs assessments for HMP Norwich and HMP Wayland although it has been acknowledged that prevalence of long-term conditions is under-reported within these prisons.

HMP Bure has been found to have a significantly lower number of prisoners with Hepatitis B, Hepatitis C and HIV than expected in a prison population; this may be because there are significantly less drug users in the population compared with other mainstream prisons.

A specialist nurse from Norfolk and Norwich Hospital provides an outreach clinic once a month to support treatment for Hepatitis B and C positive residents in HMP Wayland and on an ad-hoc basis to those in HMP Bure.

142

N-DAP Adult Substance Misuse Related Needs Assessment (2012). www.norfolkinsight.org.uk/resource/view?resourceId=507 p.66, 70, 74 (Accessed 24.3.14).

143 Prison Reform Trust and NAT (2005), HIV and Hepatitis in UK Prisons: Assessing Prisoners’ Healthcare Needs.

144 Department of Health and NAT (2011). Tackling Blood-Borne Viruses in Prisons: A framework for best practice.

Page | 122

Offender Health Profile for Norfolk

Tests for Hepatitis B, Hepatitis C and HIV are carried out for prisoners of HMP Wayland, although the latest health needs assessment (carried out in 2012) does not provide information on the frequency of testing for each of these diseases. The report does recommend improvements to data collection on BBVs and also that Hepatitis B vaccinations and Hepatitis C testing should be available to all residents who require them in a timely manner. In Q3 2011/12 around 94% of eligible prisoners received Hepatitis B vaccinations within 31 days of reception into HMP Wayland.

HIV tests are given to prisoners on request in HMP Norwich, and these are carried out by the Hepatitis C specialist nurse. Pre and post-test counselling is offered to patients. HMP Norwich operates a routine Hepatitis B vaccinations programme, for which the uptake was 66% as of December 2008 (screening is undertaken by the prison’s primary care nurses); although we have no figures to confirm that this level has been maintained. The prison provides residents with information and materials on Hepatitis C and a screening programme is conducted by a specialist nurse from Norfolk and Norwich University Hospitals Foundation Trust (NNUHFT).

In HMP Norwich prisoners who are found to be Hepatitis C positive are referred to the gastroenterology department at NNUHFT, and those who are found to be HIV positive are referred to a GUM consultant at NNUHFT where they are given access to a full range of treatments. A specialist HIV nurse from the NNUHFT GUM clinic also provides a HIV in-reach service.

The latest health needs assessment carried out for HMP Norwich found that prisoners in high risk groups are not routinely screened for TB and the number of prisoners with a diagnosis of TB is unknown.

Screening for TB is carried out at HMP Bure and HMP Wayland and a specialist nurse from the Community TB team attends when required to perform Manteaux tests, to plan treatments and to provide other TB related services. In the year 2011/12 there was no clinical need for the TB service at the prison.

A flu vaccination programme is in place and offered to all prisoners in ‘high risk’ groups in prisons in Norfolk. It has been indicated within the most recent health needs assessments for prisons in Norfolk that seasonal flu vaccinations are offered to all eligible prisoners within the three prisons in Norfolk on a routine basis and access to these is generally good.

In winter 2011 there were 160 administered vaccinations in HMP Wayland and 349 administered vaccinations in HMP Bure. There were no take up data collected for HMP Norwich.

It was found that during 2011/12 there were no outbreaks of gastrointestinal diseases reported in HMP Bure and HMP Wayland, and there was no mention of gastrointestinal diseases as an issue within the 2009 HNA of HMP Norwich.

7.7. Service provision The most recent health needs assessment of HMP Bure (October 2012) showed that: • •

There is a good overall standard of care though lack of adequate accommodation is problematic.

The population is ageing and a large proportion of prisoners are serving life (or lengthy) sentences: this will result in an increase in numbers of elderly, disabled and infirm prisoners and additional need for end of life care and social care needs.

Page | 123

Offender Health Profile for Norfolk

•

There is good evidence of health promotion activities. 145

An unannounced inspection of HMP Bure in April and May 2013 concluded that outcomes in health care were reasonable, but the arrangements for ordering and collection of medications were a concern. Some prisoners waited for days before getting their medications, often being turned away without treatment for what were sometimes serious conditions. 146 The most recent Care Quality Commission assessment of health provision provided by independent health service provider, Horizon Health, in HMP Bure (May and June 2013) was generally good. The report summary reads: “We observed some effective and respectful interactions between staff and patients, and received a lot of compliments from prisoners about clinical staff. In a survey conducted as part of the inspection process, 65% of prisoners said that the quality of healthcare services was good, or very good. This percentage was significantly better than the 44% of prisoners at comparable prisons. One patient stated that the healthcare service was ‘The best one I have been to.” Another said “You cannot beat the healthcare service.” The team of five prescribing nurses offered good continuity of care and treatment. Staff had appropriate qualifications and experience, which enabled them to meet the needs of the prison population.

Horizon Health worked collaboratively with other healthcare staff within HMP Bure. Patients benefitted from this cooperation between healthcare providers by receiving appropriate care, treatment and advice in a timely way. Patients with whom we spoke were universally complimentary about the service’ 147.

The Care Quality Commission follow up report into psychiatric care provided by Partnerships in Care Ltd at HMP Bure in August 2013 was positive. The report notes: “there were effective policies and arrangements in place to ensure that people who received care, treatment and support from the secondary mental health in-reach team in a timely way. This included an integrated pathway that was regularly reviewed. This pathway clearly set out the roles and responsibilities of all healthcare partners in ensuring that people were referred and assessed in a timely way.

Adherence to the integrated pathway was monitored. The provider submitted evidence that showed that the way in which people were referred to, and assessed by the secondary mental health team was timely and effective. The evidence also showed that the effectiveness of these arrangements, and staff’s compliance with the integrated mental health pathway was monitored and discussed on a regular basis. Records showed that people’s experience of care and treatment that involved more than one healthcare provider was kept under review.” 148 The most recent health needs assessment of HMP Wayland (April 2012) found that: •

Prevalence (or recording) of long-term conditions is less than expected based on predictions from national populations, which could mean many prisoners are living with conditions that could have serious implications if left untreated (eg diabetes).

145

Norfolk Insight www.norfolkinsight.org.uk/resource/view?resourceId=312, (Accessed 7.3.14).

Her Majesty’s Inspector of Prisons Report on an Unannounced Inspection of HMP Bure. http://www.justice.gov.uk/downloads/publications/inspectorate-reports/hmipris/prison-and-yoiinspections/bure/bure-2013.pdf (Accessed 7.3.14).

147 Care Quality Commission http://www.cqc.org.uk/directory/1-153586433 (Accessed 7.3.14), archived on 10/7/14.

148 Care Quality Commission http://www.cqc.org.uk/directory/1-341872185 (Accessed 7.3.14), archived on 10/4/14.

146

Page | 124

Offender Health Profile for Norfolk

• • • • • •

Healthcare provision is good but could be improved by increasing the skill-mix to include nurse prescribing and provision of minor procedures; the Nurse Practitioner service provides effective triage and treatment.

Although prison healthcare staff have expertise in prison specific health issues, this should extend to expertise in health issues affecting the ethnic and cultural population which is a different profile to Norfolk as a whole.

Undertaking an Equity Impact Audit would ensure that access to healthcare is equitable irrespective of age, ethnicity, prisoner status or health status.

There is a good Health Trainer service within the prison.

The prison management at Wayland appears to be supportive of healthcare but there is room for improved communication and closer working to co-ordinate resource allocation to healthcare in the form of escorts for hospital appointments.

There is provision of mental health awareness training for prison staff and this has been recently revised in an attempt to improve uptake. 149

An unannounced inspection of HMP Wayland in the summer of 2013 concluded that health care had improved, clinical governance was good, and good care and treatment was observed. Access to clinics varied: the nurse practitioner service was “impressive” but the waiting list for dental treatment was still too long. Pharmacy services and the administration of medicines had improved since the last inspection, but better governance was needed of the management of safe medicines. Primary care and secondary care mental health services were well integrated. Access to counselling services was good. Substance misuse pre-discharge planning was organised and effective, supported by good links with community drug services. Health care discharge arrangements were good for prisoners with physical and mental health conditions. 150 The most recent Care Quality Commission assessment of health provision provided by independent health service provider, Horizon Health, in HMP Wayland (September 2013) was generally positive: nurse practitioners offered people consultations, a range of health checks, treatment and advice according to their needs. Records confirmed that consultations were consistently structured and that people were prescribed appropriate treatments. The service was not required to provide care to people in a medical emergency but nurse practitioners provided support and advice to other healthcare staff on such occasions. Staff received support to enable them to undertake their role and to develop their skills and knowledge. There were arrangements in place to ensure that staff received the training, supervision and development opportunities that they required. 151 The latest health needs assessment of HMP Norwich (June 2013) provided the following general health recommendations: • •

An audit of the caseload diagnosed with epilepsy should be conducted to ensure accuracy of diagnosis and appropriate treatment.

All staff should be aware of signs of genuine epileptic seizures.

149

Norfolk Insight www.norfolkinsight.org.uk/resource/view?resourceId=676, (Accessed 7.3.14).

Her Majesty’s Inspectorate of Prisons Report on an Unannounced Inspection of HMP Wayland (2014), http://www.justice.gov.uk/downloads/publications/inspectorate-reports/hmipris/prison-and-yoiinspections/wayland/wayland-2014.pdf, (Accessed 7.3.14).

150 Care Quality Commission http://www.cqc.org.uk/node/302122 (Accessed 7.3.14).

150

Page | 125

Offender Health Profile for Norfolk

• • • • • • • • •

Measures should be put in place for improved case finding of respiratory conditions. This could link with Health Promotion activity.

Vaccinations should be offered for all infectious diseases as per community availability, including MMR. Seasonal flu vaccinations should be offered and uptake encouraged amongst all of the eligible population.

A specialist Health Needs Assessment should be commissioned to investigate Blood Borne Viruses (BBVs – Hepatitis B, Hepatitis C and HIV) to ensure optimum case finding and appropriate pathways for vaccinations/treatment.

If not already in place, a Steering Group should be implemented for BBVs to oversee education (including all staff), testing and treatment pathways and data monitoring.

The Stop Smoking Service should be expanded and supported to ensure that it is embedded effectively. Links need to be formalised for specialised external support to be accessed as required.

Appropriate clinical space and facilities should be made available to allow healthcare services to function effectively Formal links with specialist infection control support in the community should be reestablished.

Communication with prisoners needs to be improved across the pathway (whilst adhering to security procedures). This includes:  Ensuring that written healthcare information is available in different languages to staff conducting reception screening.  Written confirmation is available to prisoners when a secondary care referral has been made.

• •

• • •

Careful monitoring and audit should investigate the rising trend in A&E attendances to assess whether this reflects clinical need or is a training issue.

A skills audit should be undertaken (with appropriate training to follow) to ensure that healthcare staff are proficient in dealing with medical emergencies. This is to enable more incidents to be managed within the prison and ensure that ambulance call-outs and A&E attendances are clinically appropriate. Prison staff also need to be proficient in dealing with emergencies.

The new system of re-referring rather than re-booking as a result of prisoner refusals to attend hospital should be monitored for evidence of effectiveness of service improvement.

Clinics for specified long-term conditions should be available to provide condition monitoring, self-management advice, medication reviews and general advice. These clinics should be multi-disciplinary.

An audit should be conducted to examine the use of the inpatient unit to determine the most efficient and effective use.

An unannounced inspection of HMP Norwich in July and August 2013 made numerous recommendations to improve health services: • • •

There should be a clear strategy for the development of health services.

All nursing and medical staff should have access to clinical supervision/protected learning time.

All health care areas should comply with infection control requirements.

Page | 126

Offender Health Profile for Norfolk

• • • • • • • • •

All health care complaints should be managed confidentially by the health services department.

There should be a full range of long-term condition clinics for prisoners.

The high numbers of 'did not attends' at health appointments should be reduced.

Discipline officers should be available during medicine administration times to minimise potential bullying and diversion of supplies.

There should be pharmacy led clinics.

The prescribing of co-codamol, gabapentin, pregabalin and tramadol should be reviewed and there should be consistency in decisions made by prescribers.

The timing of medication rounds should ensure the best treatment for patients.

There should be action to reduce the waiting list for routine dental appointments Group support, group therapy or therapeutic day services should be available to prisoners who need additional support for emotional, behavioural and common mental health problems, and the day care centre should be fully used for therapeutic purposes. 152

There is no Care Quality Commission inspection available for HMP Norwich at the moment. 153

7.8. NHS Health Checks 7.8.1. Background The NHS Health Check programme is a national cardiovascular risk screening programme that aims to prevent heart disease, stroke, diabetes, kidney disease and certain types of dementia. It is delivered locally to 40-74 year olds without existing cardio vascular disease (CVD). It is a five year rolling programme that aims to prevent CVD and keep people living healthier and longer through healthier lifestyle information and support services.

In Norfolk the programme is delivered by multiple providers; 80% of NHS Health Checks are delivered in GP practice, 16% in pharmacy and 4% in workplace and prison. The inclusion of prison as a setting for the delivery of NHS Health Checks is unusual but not unique across the country, however the Norfolk programme is one of the largest.

NHS Health Checks in Norfolk prisons were originally commissioned by Public Health through the PCT NHS Norfolk, as part of the wider NHS Health Check programme. In April 2013 as part of the changes in the NHS, Public Health function moved to Norfolk County Council and offender health became the responsibility of NHS England. In order for continuity of service and owing to the uncertainly of the location of offender health until late in the commissioning process, Public Health continued to fund the existing provider Horizon Health. From April 2014 Public Health Norfolk no longer commissions the service, which is now the responsibility of NHS England, the provider Horizon Health has been taken over by Virgin Health. NHS Health Checks continue as a requirement of the healthcare contract.

152

Her Majesty’s Inspectorate of Prisons Report on an Unannounced Inspection of HMP Norwich (2013) http://www.justice.gov.uk/downloads/publications/inspectorate-reports/hmipris/prison-and-yoiinspections/norwich/norwich-2013.pdf (Accessed 7.3.14).

153 Care Quality Commission http://www.cqc.org.uk/directory/1-153586391 (Accessed 7.3.14), archived 10/7/14.

Page | 127

Offender Health Profile for Norfolk

A Well Man clinic operates in HMP Norwich as a result of a collaborative health project between public health staff, gym staff at HMP prison, and Virgin Health in all three prisons; it offers around 600 NHS Health Checks each year. 154

7.8.2. Health Checks in prison Prison provides a valuable opportunity to access what may be called ‘hard to reach’ groups in the community ie men from deprived areas, who are unemployed or in manual and manufacturing employment and with low literacy levels. A number of the men in custody in Norfolk’s three prisons will return to live in Norfolk and may not access the NHS Health Check service when they return to the community. A prison NHS Health Check – with access to healthy lifestyle services – can help prevent CVD and also identify conditions that may not have been picked up. It is also an opportunity to develop healthier patterns of behaviour such as Stop Smoking, reduced alcohol and healthier eating.

7.8.3. The Norfolk prison programme NHS Health Checks have been carried out in Norfolk prisons since January 2012. A total of 1,024 NHS Health Check were delivered between January 2012 and March 2014.

The project started in HMP Norwich in January 2012. The project then expanded to HMP Wayland in August 2012 and finally to HMP Bure in January 2013.

7.8.4. Service delivery The service was carried out by Horizon Health, a small social enterprise, which was recently taken over by Virgin Health in April 2014. A nurse practitioner and a Health Care Assistant (HCA) carried out the programme with support by prison staff and health trainers.

7.8.5. Patient invite A System One report is run to identify eligible patients. All eligible patients are invited at reception for new arrivals. Patients already in prison are invited routinely with a standard invite letter and leaflet with an appointment time. In 2013 /14 the prison uptake rate (those offered to delivery) was 74% compared to 49% for the whole Norfolk programme and 49% nationally for the whole programme.

7.8.6. NHS Health Check delivery NHS Health Checks are carried out by HCA’s in 20-30 minute appointments, using Near Patient Testing (NPT). The NHS Health Check includes standard measurements such as; blood pressure, cholesterol and BMI and well as questions about healthy lifestyle behaviours including smoking, physical activity, alcohol intake and a family medical history. This produces a CVD risk factor.

In addition to the standard NHS Health Check the mental health WHO-5 Wellbeing assessment is included with the check. Those identified as high risk are referred to the nurse practitioner and given an appointment for further investigation and follow up if required. Everyone is given healthy lifestyle advice and access to Stop Smoking, and links to Well Man clinics and Peer Health Trainers (HMP Norwich). The use of appropriate pictorial NHS literature for people with low literacy and numeracy levels is used.

154

NHS Health Check programme provision in Norfolk prisons, www.healthcheck.nhs.uk/document.php?o=526 (Accessed 7.3.14).

Page | 128

Offender Health Profile for Norfolk

7.8.7. Outcomes In the year 2013/14 658 NHS Health Checks were carried out in Norfolk prisons (this is greater than the total of health checks carried out in other English prisons over this period). The prison NHS Health Check profile is generally younger with over two thirds (67%) being carried out on the 40-49 year olds in prison compared with only 34% for the programme as a whole. This has enormous potential preventative health benefits, as unhealthy lifestyle behaviours can be picked up and managed. For example, 65% of prisons residents having a NHS Health Check are ‘current smokers’. compared to only 15% for the programme as a whole; all received smoking advice and 17% (71) took up Stop Smoking services.

The prison programme also supports the reduction of healthy inequality as 26% of those having an NHS Health Check are from a non-white ethnicity compared to 10% for the whole programme.

In 2013/14 there were 1,347 pieces of healthy lifestyle advice logged including; general healthy lifestyle, weight management, physical activity and Stop Smoking. 118 referrals were made to a collection of healthy lifestyle services including weight management, physical activity programmes, health Trainer service and Stop Smoking services. There were 79 high risk referrals for further investigation.

Page | 129

Offender Health Profile for Norfolk

8. Female offenders 8.1. The national picture 8.1.1. Background: an overview of women offenders Female and male offenders have different health needs and different experiences of the criminal justice system: these differences were acknowledged by the 2007 Corston Report (‘A review of women with particular vulnerabilities in the criminal justice system’) commissioned by the House of Commons Justice Committee and the later review Women Offenders: after the Corston Report (2013). 155 The report noted that women, who make up less than 5% of the prison population in England, generally commit crimes of less seriousness than men, have different motivations for their offending behaviour, and are less likely to have previous convictions. Female prisoners are more likely than male prisoners to suffer from anxiety (49% v 23%), report symptoms indicative of psychosis (25% v 15%) or to have suffered domestic violence or emotional, physical or sexual abuse as a child. 156 Indeed, The Ministry of Justice recognises women affected by violence and those who self-harm as two groups in need of additional support. 157 The Corston Report review (hereafter called ‘the review’) examined what could be done to divert women with particular vulnerabilities from prison, particularly given that most are non-violent, petty, persistent offenders and many have primary care responsibility for children. The vulnerabilities identified by the review as affecting the health of women and as potential causes behind offending behaviour are: •

Domestic issues (domestic abuse, childcare issues, single parenthood).

•

Socio-economic issues (poverty, isolation and employment).

•

Personal issues (mental illness, low self-esteem, eating disorders, substance misuse).

Evidence submitted by witnesses to the Committee described the types of health and social care issues experienced by female offenders. One community-based organisation described its service users as: “Women already at the margins of criminal behaviour who have not yet been arrested: bingedrinking, antisocial behaviour, sex working, abusive relationships, crack and heroin use, rough sleeping, personality disorders and unaddressed mental health problems all correlate highly with a drift towards offending behaviours even though none of these, except drug possession, are offences themselves.” 158 155

House of Commons Justice Committee Women offenders; after the Corston report (2013), http://www.parliament.uk/documents/commons-committees/Justice/Women-offenders.pdf (Accessed 14.7.14).

In May 2013 there were 3,893 women in prison in England and Wales.

156 Prison Reform Trust Prison: the Facts, Bromley Briefings (Summer 2013), http://www.prisonreformtrust.org.uk/Portals/0/Documents/Prisonthefacts.pdf (Accessed 14.7.14).

157 Ministry of Justice A Distinct Approach: a guide to working with female offenders (2012), http://www.justice.gov.uk/downloads/publications/noms/2012/guide-working-with-women-offenders.pdf (Accessed 18.7.14).

158 After the Corston report p.8.

Page | 130

Offender Health Profile for Norfolk

The disproportionately harmful effect of prison on women and their children and the need to divert women with, for example mental health problems, into appropriate treatment instead of custodial sentences were discussed in the review and it concluded that the majority of women who receive custodial sentences could be dealt with more effectively in the community.

The review recognised that a mother being imprisoned (as opposed to a father) has potentially more serious consequences for the child and in fact only 9% of children whose mothers are in prison are cared for by their fathers. 159 However, the courts’ ability to divert offenders to community based provision including women’s centres is limited by availability of local programmes and having sufficient information on which to base decisions. For example, health assessments may not be provided in time or the offender may not wish to divulge personal information in a public setting.

The review found that women’s mental health needs are high and are often not picked up in the community but are identified when the woman is imprisoned. It concluded that community mental health services were failing to address the mental health needs of women particularly in the absence of mechanisms to divert women into suitable healthcare on arrest or from court. It also noted a shortage of clinicians to assess mental health needs and a lack of women only community day care which reduced the opportunity for increased diversion from court and custody. 160 The Corston Report provided the legislative background for the subsequent National Service Framework for Women Offenders and the Gender Specific Standards for Women Prisoners. In 2012 the Secretary of State for Justice decided to separate responsibility for women in the criminal justice system from that for men in recognition that there are different issues to address.

The review six years after the report was published found that progress in many areas was slow.

High levels of unmet mental health need among female offenders still existed and community mental health services were failing to address need. Appropriate and accessible housing was identified as key to preventing reoffending but is rarely available. 161

8.1.2. Young female offenders Young female prisoners aged between 18 and 21 reside in designated accommodation within women’s prisons and those under 18 are held in one of three Young Women’s Units at Downview, Eastwood Park and New Hall women’s prisons. 162 A health needs assessment of 17- year old women held in Young Offender Institutions (YOI) in England and Wales, commissioned by Youth Justice Board for England and Wales (YJB) in 2005 showed that the physical and mental health of these young women was poorer than women in manual classes and adult female prisoners.

Although the study is now dated it has not been refreshed and no other female specific study has been undertaken so is referenced here.

159

Prison: the Facts p.4.

After the Corston report p.38.

161 Prisoners who reported being homeless before custody were more likely to be reconvicted than those who did not report being homeless (79% compared to 47% in the first year). Prison: the Facts p.9.

162 Ministry of Justice Women Prisoners, https://www.justice.gov.uk/offenders/types-of-offender/women (Accessed 14.7.14).

160

Page | 131

Offender Health Profile for Norfolk

Access to health care professionals (including dentists, mental health professionals and specialist sexual health workers) was limited and there were no occupational therapist, speech and language therapists or physiotherapists. The findings showed that of the 73 respondents: Physical and mental health

Alcohol and substance misuse

• 71% had some level of psychiatric disturbance

• 81% smoked, average start age was 12

• 36% had self harmed in the last month

• 86% drank and 82% used illegal drugs before entering YOI

Sexual health

• 23% had been diagnosed with a sexually transmitted disease • 10% had been paid for sex

The report highlighted the extreme vulnerability of this group of young women and observed that “social exclusion, deficient health education and lack of self-care skills are manifested in poor mental health and sexual health and extensive substance misuse … young women in YOIs fared less favourably on health indicators than adult female or young male prisoners”. 163 There are no YOIs for females in Norfolk: the nearest one is at Peterborough Prison.

8.1.3. Pregnant women and new mothers The review of the Corston report found that pregnant women and those who have recently given birth are generally treated the same as non-pregnant women and recommended that regimes should be adapted for pregnant women through the provision of additional food and opportunities to eat frequently; appropriate clothing; comfortable bedding; and longer ‘maternity leave’ from work placements, as women are currently expected to return to the normal regime after eight weeks.

Several witnesses referred to the need for better ante-natal care and sensitive support when women are handing the care of their child to someone outside the prison. 164 The report noted that some custodial units in Europe take an integrated approach to imprisonment and welfare from a family perspective: women are given curfews to return in the evening, children can live there, so they are able to attend school, and this helps to reduce the harmful effects of a parental prison sentence on children’s lives. 165 No such units exist in England.

There are 13 women’s prisons in England and seven Mother and Baby Units (MBU) catering for up to 77 mothers within these prisons, including Peterborough. Female prisoners from Norfolk are most likely to be accommodated at Peterborough although some may go to London prisons. A mother is only admitted to an MBU following an admission board chaired by an Independent Chair who is a certified social worker.

163

Youth Justice Board Female health needs in young offender institutions (2006), http://yjbpublications.justice.gov.uk/en-gb/Scripts/prodView.asp?idproduct=322&eP= (Accessed 18.7.14).

164 After the Corston report p.63.

165 After the Corston report p.73.

Page | 132

Offender Health Profile for Norfolk

There should be links to the local Safeguarding Board where the prison is located and the decision to admit a mother and her child takes into account: whether it is in the best interests of their child; the necessity to maintain good order and discipline within the MBU; and the health and safety of other babies and mothers within the unit. 166 At Peterborough Prison, mothers and children are accepted into the Unit from birth up to the age of 18 months. The mothers are assessed prior to entry onto the unit and registered with the Bretton Health Centre GP practice. The Mother and Baby Unit team comprises a manager, three nursery nurses and two dedicated prison officers.

There is also a visiting health visitor and the service works closely with the local midwife. 167 During 2013 there were 183 appointments to see the midwife. The service provides support for mothers, provides advice on contraception and immunisations and vaccinations as well as advice for prison officers and nursery nurses with the Unit. 168 The Select Committee for the Corston Report leading the review heard evidence from a charity, Babies in Prison, who felt that staff training for mother and baby units was being detrimentally impacted by funding cuts and the report authors expressed surprise that “mother and baby units, which enable babies to remain in prison with their mothers for up to 18 months, are frequently under-occupied”. 169 The Mother and Baby Unit in Peterborough Prison housed one mother and baby in January 2013 and five in December 2013 which is under-capacity. 170 The Chief Inspector of Prisons Report 2011 announced in the inspection notes that women in the unit “spoke highly of the support they received”. 171

166

Public Health England Health and Justice Health Needs Assessment Template: Adult Prisons (July 2014) p.38, https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/331628/Health_Needs_Asse ssment_Toolkit_for_Prescribed_Places_of_Detention_Part_2.pdf (Accessed 21.7.14).

167 Community Innovations Enterprise HMP Peterborough Health and Social Care Needs Assessment (April 2014) p.64.

168 HMP Peterborough Health and Social Care NA (2014) p.65.

169 After the Corston report p.63.

170 HMP Peterborough Health and Social Care NA (2014) p.31.

171 HM Chief Inspector of Prisons Report on an announced inspection of HMP Peterborough (Women) 4-8 April 2011 p.13 http://www.insidetime.org/resources/HMCIP/peterborough_Female_April_2011_AFI.pdf (Accessed 18.7.14).

Page | 133

Offender Health Profile for Norfolk

8.2. Local evidence 8.2.1. Evidence from Police Investigation Centres (PICs): number of offenders In 2013, 1,974 female offenders and 9,678 male offenders were arrested and taken to a PIC in Norfolk and Bury St Edmunds. These figures are roughly in line with the 2012 figures which were 1,996 female offenders and 9,960 male offenders. Figure 22 below shows that most offenders were taken to Wymondham PIC. Figure 22: Number of offenders arrested and taken to PICs in 2013 5,000 4,500 Female Male

4,000 3,500 3,000 2,500 2,000 1,500 1,000 500 0 Female Male

Aylsham 258 1110

Bury 88 531

Gt Yarmouth 408 1960

King's Lynn 482 2275

Wymondham 738 3802

8.2.1.1. Evidence from PICs: age and residence of offenders Figure 23 below show that both female and male offenders tend to be under 50 and around half are under 30. The majority are resident in Norwich, King’s Lynn and Great Yarmouth areas.

Figure 23: Average age of females (left) and males (right) arrested and taken to PICs in Norfolk, 2013-14 48 163

223

10-19

336

622

1416

20-29 1460

365

30-39 40-49 656 404

Page | 134

50-59 2129

60-69

3749

Offender Health Profile for Norfolk

Figure 24 below shows that the greatest proportion of offenders arrested and taken to a PIC during 2013-14 gave a home address in Norwich City Council area, followed by King’s Lynn, and Great Yarmouth.

Figure 24: Offender’s home address by District Council, 2013-14 2,000 1,800

Female

1,600

Male

1,400 1,200 1,000 800 600 400 200 0 Breckland Broadland Female Male

199 995

133 552

Gt Yarm 333 1401

King's Lynn 334 1449

North Nfk

Norwich

South Nfk

133 583

394 1842

132 579

8.2.1.2. Evidence from PICs: type and extent of offence The most common crime committed by women arrested and taken to Norfolk PICs is assault followed by common assault (see Table 41 below). Similarly, the most common crime committed by male offenders is common assault followed by assault. Theft, criminal damage, positive breath test, and drunk and disorderly are also frequently committed offences by both female and male offenders.

Table 41: Ten most commonly committed crimes Offence Female Offence Assault 240 Common assault Common assault 232 Assault Theft from shops 175 Theft Theft 148 Criminal damage Positive breath test 134 Drunk and disorderly Drunk and disorderly 128 Positive breath test Criminal damage 106 Theft from shops Drug offences 64 Drug offences S5 Public Order Act 1986 48 Burglary Breach of the peace 47 Sexual offences

Page | 135

Male 955 869 679 630 624 569 444 377 335 241

Offender Health Profile for Norfolk

8.2.1.3. Evidence from PICs: health needs of female offenders In 2013 1,748 females arrested and taken to the Norfolk PICs were asked the following risk assessment questions (the figure next to it shows the number who answered positively): • • • • • •

Are you dependent on alcohol? (109) Are you dependent on drugs (prescribed or other)? (353) Do you have any mental health problems? (732) Positive answer to both alcohol dependency and mental health problems (80) Positive answer to both drug dependency and mental health problems (260) Positive answer to both alcohol dependency and drug dependency (49)

Between and a third and a half (41.9%) of those who experienced problems had mental health issues. The Bradley Report, Lord Bradley’s review of people with mental health problems or learning disabilities in the criminal justice system (2009) identified high levels of unmet mental health need in the criminal justice system. 172 However a criticism of the report was that it failed to tease out the differences between male and female offenders which would have revealed much higher levels in the female offender population. 173

8.2.2. Female prisoners Most female prisoners from Norfolk are accommodated at Peterborough Prison which is the only dual prison for male and female prisoners in the country. Peterborough Prison is a Category B prison with capacity for 624 male and 384 female prisoners. A health assessment of female prisoners’ health (2009) showed that around a third of prisoners came from the Eastern region (mainly Norwich, Peterborough and Ipswich), a third from the East Midlands, and a third from elsewhere. 174 It is not known what proportion of the current prison population originate from Norfolk.

Although prisoners aged over 60 are the fastest growing group in prisons (which has implications for how health and social care services are provided) this is not true of Peterborough prison where two-thirds of the female population are aged 21-39 and the majority (approximately 83%) are aged 49 or younger. 175 The prison contains a Young Offenders Unit for female prisoners aged between 18-25 years, a small Mother and Baby Unit for 12 mothers, and two adapted cells for prisoners for disabilities.

Accommodation for female residents comprises two house blocks containing five wings. House block one holds women on remand and sentences YOIs, detox induction and Voluntary Drug 172

The Bradley Report, Lord Bradley’s review of people with mental health problems or learning disabilities in the criminal justice system (2009), http://www.mac-uk.org/wped/wp-content/uploads/2013/03/Dept-ofHealth-Bradley-Report-Exec-Summary.pdf (Accessed 4.8.14).

173 Women in Prison Bradley Review Disappoints, http://www.womeninprison.org.uk/news_show.php?id=20 (Accessed 4.8.14).

174 1B + 2B HMP Peterborough Female Health Needs Assessment (2009) p.25. http://www.peterborough.gov.uk/pdf/Prison%20-%20health%20needs%20assessment%20female.pdf (Accessed 18.7.14).

175 Prison Reform Trust Doing Time: the experiences and needs of older people in prison (2008) p.34, http://www.prisonreformtrust.org.uk/Portals/0/Documents/Doing%20Time%20the%20experiences%20and%20nee ds%20of%20older%20people%20in%20prison.pdf (Accessed 18.7.14) and HMP Peterborough Health and Social Care NA (2014).

Page | 136

Offender Health Profile for Norfolk

Testing; house block two holds Lifers and IPPs (Indeterminate Public Protection sentence), Voluntary Drug Testing and all sentenced women. The majority of accommodation is single occupancy. Primary health care is provided by Sodexo and secondary health care by the NHS. 176 Prisoners have, in general, poorer physical and mental health (see Table 42 below) than the general public and pose particular public health challenges. For example, a large proportion of the prison population (both male and female) have engaged in high-risk behaviour (unprotected sex, multiple partners, injecting drugs). Levels of smoking and obesity are high; significant co-morbidity exists and prisoners are likely to have led chaotic lives characterised by low levels of engagement with health services.

The prevalence of risk factors for non-communicable diseases in female prisoners nationally is: • • • • • •

Smoking – 85% at reception.

Physical inactivity - 87% did not meet government guidelines.

Alcohol excess - 45% at reception.

Illegal drugs - 75% six weeks prior to imprisonment.

Poor nutrition - 87% did not meet government guidelines.

Weight - 27% BMI <25 and 29% BMI >30. 177

Table 42: Prevalence of mental health problems in female prisons Prevalence of disorder and how many Mental health disorder times more likely in prison population (ratio of prison to national) Remand prisoners Sentenced prisoners Mixed anxiety and depression 36% 3.2 31% 2.8 Depressive episode 21% 7.5 15% 5.3 Phobia (unspecified nature) 18% 9.0 11% 5.5 Obsessive compulsive disorder 12% 9.2 7% 5.4 Suicidal thoughts (past week) 23% 23.0 8% 8.0 Source: Public Health England Health Needs Assessment Template: Adult Prisons (July 2014) pp.49-50 Other health inequalities exist: male and female prisoners experience different health and social needs. HM Inspectorate of Prisons reported to the Corston Committee carrying out the review, and summarised its assessment of the impact of inequalities in health and social care provision for men and women as: “The level of need in women’s prisons is visibly greater than in the male estate. Despite improvement, the women’s prison estate is still not configured to best manage the women it holds. For example, the smaller number of women’s prisons means that women are often held further away from their homes than men: on average 55 miles away. This is exacerbated for women from Wales where there is no prison, and who have to serve their sentences in England. A prison’s catchment area is now so large as to make visiting difficult for families and to pose challenges when trying to make links with community resettlement services. For example, HMP Eastwood Park works with eight probation trusts, 72 local authority areas, 52 176 177

HMP Peterborough Health and Social Care NA (2014) p.29.

Public Health England Health NA Template: Adult Prisons p.37.

Page | 137

Offender Health Profile for Norfolk

drug and alcohol teams, and a complex network of healthcare trusts, social services departments, and third sector organisations.” 178 In addition, female prisoners are more likely than male prisoners to self-harm but male prisoners are at greater risk of suicide. During 2013 the number of recorded incidents of self-harm among females in Peterborough prison was 850 of which there were two near misses/suicide attempts but there were no deaths. 179 Some female-specific health services (cervical screening and mammograms) are unavailable on-site which limits the number of women able to receive this service. 180 The last announced inspection of Peterborough Prison (2011) included an examination of health provision for women and concluded: “Overall primary care services were good and the range was adequate for the needs of the population, with substantial improvements since 2006. Pharmacy services and medicines management were satisfactory, although some issues required attention. Dental services provided a good level of care. Mental health services were good and primary mental health and in-reach services had recently integrated. Women complained about delays in obtaining appointments to see a doctor or dentist but provision of services was good, with only short waiting lists. It was unsatisfactory that there was no woman GP. Some problems with the organisation of appointments were indicated by the high rate of non-attendance at some clinics. Health care facilities were good and the department was fully staffed, with a satisfactory skills mix. Nurses held lead speciality roles and there were good links with the wider prison.” 181

8.2.3. Provision for women offenders with substance misuse problems An analysis of the provision of services for adult female offenders with substance misuse problems in Norfolk was commissioned by the Norfolk Drug and Alcohol Partnership (N-DAP) in 2009. 182 The research found high levels of drug and alcohol misuse among female offenders. During the year April 2008-09 the number on orders to probation was 595 and, of the 374 which had completed assessments by Probation, 296 were identified as having drug or alcohol issues. One hundred and twenty-six of these had specific drug problems, 170 had alcohol problems and 58 had both drug and alcohol problems. 183 The research also found that differences in drug use among ethnic groups emerged: 77% of white women surveyed had used drugs in the twelve months prior to imprisonment which fell to 63% for black or mixed race women. Around a third of the whole sample reported ‘harmful or hazardous’ levels of alcohol in the twelve months prior to imprisonment. 184 The N-DAP report concluded that overall provision of services for adult female offenders with substance misuse problems is good, but there are areas where coordination could be improved and gaps plugged: 178

After the Corston report p.70.

HMP Peterborough Health and Social Care NA (2014) p.52.

180 HMP Peterborough Health and Social Care NA (2014) p.17.

181 HM Chief Inspector of Prisons Report on an announced inspection of HMP Peterborough (Women) p.45.

182 S Moore and A Collis, Anglia Ruskin University, Cambridge An analysis of the provision of services for adult female offenders with substance misuse problems in Norfolk (June 2009), http://www.ndap.org.uk/files/5413/7000/0858/ARU_Female_Offenders_research_2009.pdf (Accessed 18.7.14).

183 Moore and Collis Provision of services pp.16-17.

184 Moore and Collis Provision of services pp.18-19.

179

Page | 138

Offender Health Profile for Norfolk

• • • • • • •

The importance of prisoners’ partners needs to be recognised and support given, if appropriate, to members of the extended family.

Greater use could be made of peer group support (an example at The Junction, in Cromer, was cited as a successful model) which minimises stigma attached to problematic drug or alcohol use.

Travel to centres where services are available can be problematic or prohibitively expensive.

Services need to be flexible particularly around transition points such as release from custody.

Housing providers need to take into account some women’s experience of violent victimisation and their continued vulnerability: supported housing is key to achieving this.

Increased support may be needed for mothers given the centrality of the family to the resettlement process, particularly around opportunities for substance misuse services and child protection agencies to work more closely together.

Women only provision of services should be given priority where possible. 185

8.2.4. Community provision in Norfolk Although the review of the Corston Report did not suggest separate sentencing frameworks for men and women, it acknowledged that women and men face different challenges and proposed a fundamental rethink in the way vulnerable women are treated in the criminal justice system. The review considered that the majority of women who receive custodial sentences could be dealt with more effectively in the community through a network of women’s centres in accordance with a nationally coordinated strategic plan. 186 The women’s centres would also provide greater diversion from the courts and custody.

The National Offender Management Service (NOMS) identified 53 centres nationally in its Stocktake of Women’s Services for Offenders in the Community including one in Norfolk and one in Suffolk. 187 The centres act as referral centres for women who offend or who are at risk of offending behaviour and act as a means of diverting women from court and police stations and for the delivery of probation and other programmes to provide an alternative to prison. In particular, such centres could (and in some cases, already do) provide vital support for women in the first 48 hours after leaving prison when women are most at risk. The review noted that existing centres: “seek to provide constructive and humane responses to many women who need a whole range of support from community-based services including both psychological therapy to aid personal development and practical assistance to help them develop economic prospects”. 188 In Norfolk, '4women Resource Centre is part of Stonham Care & Support Home Group Ltd’ (known hereafter as 4women) and provides the type of ‘wraparound’ and ‘one stop shop’ support advocated by the Corston Review. 189 Referrals come from a wide range of statutory and voluntary bodies and women can also self-refer; the centre’s services are available to everyone. In addition 185

Moore and Collis Provision of services pp.48-49.

After the Corston report pp.24-30.

187 NOMS Stocktake of Women’s Services for Offenders in the Community (October 2013) p.10 and p.30, http://www.womensbreakout.org.uk/wp-content/uploads/downloads/2013/10/stocktake-wcs.pdf (Accessed 23.7.14).

188 After the Corston report p.27.

189 4women 2nd Year Report (2013) and Consultation Report (2013): both documents kindly provided by Amanda Payne at the 4women Centre, Norwich.

186

Page | 139

Offender Health Profile for Norfolk

to services for women in contact with the criminal justice system, clients are assessed for one-toone support, counselling and direct access to the wide range of services available at the 4women Centre. These services, which not only have a positive impact upon the women themselves, but also their families and communities, encourage women to: • • • •

Increase social inclusion and make positive life choices.

Reduce risk of victimisation.

Reduce levels of crime, and ultimately.

Divert (women) from the criminal justice system.

Between April 2011 and January 2013, approximately 170 probation referrals were received.

Referrals are received from the magistrates’ and Crown Courts, from solicitors, and from Offender Managers when preparing pre-sentence reports. Where the Norfolk and Suffolk Probation Trust are involved, staff at 4women may provide a report to the Offender Manager preparing the presentence report which can influence the woman’s engagement and commitment to change (see case study below). 190 A room is set aside at the centre for Norfolk and Suffolk Probation Trust to undertake pre-sentence reports to divert women away from probation centres and minimise attendant risks of attending such centres. A support coordinator provides assistance to individuals during criminal and family court hearings across Norfolk for as long as it is required.

Case Study: Carol Carol is now 32 but she left school when she was 13 and has numeracy and literacy needs. She has been a victim of domestic abuse and has a history of poly substance abuse together with long term mental and physical health needs. Carol has three children and was prosecuted for her first offence of £40k of benefit fraud.

Her case was referred from magistrates court to Crown Court: the pre-sentence Report was undertaken by 4women and identified a vulnerable woman.

Between the two court appearances 4women provided Carol with 1:1 support, anger management, debt management, attendance at a confidence building group and the Freedom programme (for victims of domestic abuse). 4women also provided support in court to Carol. The Crown Court judge could see that Carol was addressing the issues behind her offending behaviour and gave her an 18 month suspended prison sentence and 200 hours unpaid community work.

Carol undertook her community work within the 4women centre which started as cleaning but soon progressed to manning the reception desk. She is now housed safely with her children and has a healthy relationship with a new partner. Her mother is also now accessing services at 4women as a survivor of domestic abuse.

190

Women’s Breakout Stonham Women Resource Centre: Case Studies, http://www.womensbreakout.org.uk/wp-content/uploads/downloads/2013/06/4women-Case-Studies.pdf (Accessed 23.7.14).

Page | 140

Offender Health Profile for Norfolk

Both the review of the Corston Report and a 2011 inspection report into the use of alternatives to custody for women offenders highlighted some of the problems faced by community and women’s centres which offer services for women with offending behaviour. 191 The review pointed to possible future ‘payment-by-results’ style funding in which reduction of reoffending rates is the primary measure of success and ‘upstream’ diversion from offending or reducing frequency and seriousness of offending is of lower priority. 192 Moreover, future evidence-based commissioning may pose problems for women’s community centres which tend to generate qualitative data including case studies.

The review notes that there is no system to capture and disseminate the experience of women’s community projects (even for those centres in receipt of Ministry of Justice funding) and this point is reiterated in the NOMS review of Women’s Services. 193 The lack of systematic data collection methods which allows comparisons to be made between centres and for outcomes to be measured could make community and women’s centres vulnerable. These issues mean that women’s centres (such as 4women in Norwich) which have a deep understanding of local need and awareness of ‘what works’ may find it difficult to demonstrate the wider health, wellbeing and social benefits of their services to funders.

191

HMI Probation and HMI Prisons Joint Inspection Thematic Report Different but Equal? An inspection of the use of alternatives to custody for women offenders pp.28-31, http://www.justiceinspectorates.gov.uk/hmiprisons/wp-content/uploads/sites/4/2014/04/womens-thematicalternatives-to-custody-2011.pdf (Accessed 18.7.14).

192 193

After the Corston report pp.52-53.

NOMS Stocktake of Women’s Services for Offenders in the Community pp.23-25.

Page | 141

Offender Health Profile for Norfolk

9. Role of probation in supporting ex-offenders 9.1. Introduction The health status of offenders being managed in the community is generally underreported (Brooker et al, 2008). Yet offending has a wide personal, social and economic impact on individuals, their families and local communities. Evidence suggests that lifestyle factors (such as smoking, diet, physical activity and alcohol use) which are generally key contributors to morbidity and premature mortality have a more significant impact, especially as offenders are disproportionately from more deprived socio-economic groups. Many offenders experience higher levels of poor health; do not have a GP or dentist and a far higher percentage of offenders smoke and are unfit. Male offenders are four times more likely to die early than the general male population, drugs and alcohol are related to approximately 46% of the deaths of offenders (Sattar, 2001).

Alongside the need for ‘strong’ pathways within the criminal justice system there must be robust pathways between custody and community. According to a report by the Revolving Doors Agency one of the most critical transition points is the release from custody, where men and women are 29 and 69 times more likely to die than the general population respectively within the first week. This emphasises the importance of whole pathway approaches to improve health outcomes among offenders who have been released from custody – most of whom are on probation. The report also highlights the need for well-developed pathways to improve health outcomes for offenders who have not been taken into custody but have been in contact with the criminal justice system and have not been given custodial sentences (such as those who have been given community orders). 194 For those on probation it is acknowledged that there are often a number of competing priorities which prevent a healthy lifestyle. Coping with release, readjusting to society and dealing with their underlying mental health or family problems are often seen to be more important than worrying about eating well, smoking or exercising. 195 The Bradley report (2009) found that there needs to be greater continuity of care for people who have left prison and have been released back into the community, and that help is needed for petty offenders with mental health problems or learning disabilities to ensure that they are helped to stay out of trouble. 196 This chapter explores information available locally, based on health needs of offenders who come into contact with the probation service, focus groups with managers discussing previous service provision, and changes to the services which are to take place from autumn 2014. It is emphasised that the focus groups with probation managers and questionnaire study of people under probation 194

Revolving Door Agency Balancing Act: Addressing health inequalities among people in contact with the criminal justice system (2013), www.norfolkinsight.org.uk/news/item?itemId=612 (Accessed 28.5.14).

195 Ipsos MORI Social Research Institute East of England Lifestyles Final Report: Research into attitudes towards health and health-related behaviours of people within the Criminal Justice System (2009), http://www.norfolkinsight.org.uk/jsna/groupsatrisk.

196 The Bradley Report: Lord Bradley’s review of people with mental health problems or learning disabilities in the criminal justice system 2009, http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/ dh_digitalassets/documents/digitalasset/dh_098698.pdf (Accessed 11.06.14).

Page | 142

Offender Health Profile for Norfolk

was carried out in 2012, well before the proposed restructuring of the probation service, and as a result some of the findings have either been addressed or will no longer be relevant.

For the purposes of this report we are using the term probation to relate to those offenders who are supervised by the Probation Service on either a community sentence or on post custody licence (including parole). During probation an offender is supervised and has to comply with a number of requirements or conditions. Offenders who do not comply with their community sentence are returned to court for further action whilst those who fail to comply with their post custody licence can be recalled directly to prison.

While on probation, the offenders may have to: • • • •

Do unpaid work (ie Community Payback).

Complete an education or training courses.

Get treatment for addictions, like drugs or alcohol.

Have regular meetings with an ‘offender manager’ who will create an agreed ‘sentence plan’ which will indicate rules and responsibilities of probation.

Offenders may be required to take part in Community Payback schemes. Community Payback is a court-ordered punishment available as part of a Community Order or a condition of a Suspended Sentence Supervision Order. It can stand as a punishment in its own right or be combined with other community order requirements, such as supervision by a Probation officer or an offending behaviour programme. It is available to all offenders whose crimes are serious enough to warrant a community-based penalty but are not so serious as to merit immediate imprisonment. Typically, offenders undertaking Community Payback will have been convicted of offences of dishonesty, lesser violent offences, driving offences and criminal damage.

All offenders being considered for Community Payback are assessed for their suitability and the risk they may pose to others and themselves. The aim is to ensure that all offenders undertaking Community Payback can be safely managed and are physically able to undertake the work required of them.

Members of the public can nominate projects to be completed by offenders. The work should be of benefit to the community and also enable offenders to learn useful skills which could help them in future paid employment. Any project undertaken must not take away work from businesses.

Beneficiaries typically include charities and community organisations.

When an offender is ‘recalled’ to prison they may return for either: • • •

197

A fixed-term recall - offender goes back to prison and is released on probation after 28 days and go on licence until the end of the sentence.

A standard recall - offender will stay in prison until the end of the sentence, unless a Parole Board decides otherwise.

An extended sentence - offender’s case will be sent to a Parole Board on return to prison and they will either be released straight away or within a set date timescale of one year when they can be released on licence. 197

https://www.gov.uk/guide-to-probation/overview.

Page | 143

Offender Health Profile for Norfolk

9.2. The National Offender Management Service Norfolk & Suffolk Probation Trust (NSPT) is responsible for overseeing offenders released from prison on licence and those on community sentences made by the courts. 198 Probation prepares pre-sentence reports for judges and magistrates in the courts to enable them to consider the most appropriate sentence. Probation also works with victims of crimes where the offender has committed a sexual or violent offence and has been given a prison sentence of 12 months or longer.

The aim is to make Norfolk and Suffolk safer by protecting the public, reducing re-offending and preventing future victims. The staff work in the courts, the community and in prisons to rehabilitate offenders and liaise with the victims of serious crime.

At any one time staff are supervising more than 3,000 offenders on community sentences.

Norfolk & Suffolk Probation Trust prepares more than 5,000 reports for the magistrates, and Crown Courts every year, and supervises the completion more than 300,000 hours of Community Payback hours in local neighbourhoods in Norfolk and Suffolk. This work equates to more than £1.8 million of free labour for local communities in our area.

The vision is that the communities NSPT serve will feel and be safer through the work of NSPT, which is delivered both directly and through a variety of other collaborative and contractual arrangements.

The NSPT mission is to protect the public and local communities by reducing and preventing re-offending and its impact on victims. NSPT currently do this by commissioning or providing competitive, cost effective and high quality services to courts, offenders, victims and other stakeholders.

9.3. Service reforms 9.3.1. Transforming Rehabilitation ‘Transforming Rehabilitation’ describes the changes to the delivery of offender services in the community to reduce reoffending rates whilst delivering improved value for money. From autumn 2014 the Government will change the way that offenders are managed by reforming the current probation services in England and Wales and outsourcing some of the services to Community Rehabilitation Companies (CRCs).

The 35 former probation trusts will be replaced by a single National Probation Service (NPS) which will generally deal with higher risk offenders. Local Community Rehabilitation Companies will deal with medium to low risk offenders.

CRC services will be commissioned across 21 ‘contract package areas’ in England and Wales – the local Community Rehabilitation Company will cover Norfolk and Suffolk and is estimated to serve around 5,000 low and medium risk of harm offenders starting in the system annually. 199

198

http://www.nsprobation.org.uk/.

Page | 144

Offender Health Profile for Norfolk

Overall, the proposals set out by the Government include: • • • • • • • •

200 201

Creating a new public sector National Probation Service to work with the most high-risk offenders.

Opening the majority of probation services to competition, with contracts to be awarded to providers who can deliver efficient, high quality services and improve value for money.

Forming 21 new Community Rehabilitation Companies (CRCs) to turn round the lives of medium and low-risk offenders.

Commissioning to be managed centrally, with specifications informed by local delivery requirements within the 21 regional contract package areas, to generate economies of scale and deliver efficiencies, whilst responding to local needs.

Giving statutory supervision and rehabilitation in the community to every offender released from custody, including 50,000 of the most prolific group of offenders (those sentenced to less than 12 months in custody).

Only paying providers in full for real reductions in reoffending.

More scope for providers to innovate, with payment by results as an incentive to focus on rehabilitating offenders – it is expected that there will be increased use of mentors and an emphasis on addressing offenders’ ‘life management’ issues.

Establishing a nationwide ‘through the prison gate’ resettlement service to give most offenders continuity of support from custody into the community; a network of resettlement prisons will ensure that offenders continue to be managed by the same provider as they move from custody into the community.

9.3.2. Resettlement from prison Along with reforms to the probation services there will be changes to the way offenders receive inprison rehabilitation services before release. New commissioned services from the CRCs will not only provide for offenders who are have been released into the community or are serving incommunity sentences but will have a role in providing services for those in custody prior to release from prison.

Under the new ‘Transforming Rehabilitation’ proposals there will be changes to the way the prison estate is organised in order to fill service gaps between custody and community. Resettlement prisons will be designated within each CRC contract area and will release the vast majority of offenders to that area. This will allow the same provider to work with offenders in custody and continue their rehabilitation work in the community in most cases. 202 Resettlement prisons will be expected to allow multiple organisations to work together more effectively to rehabilitate prisoners and provide ‘through the gate’ transitions from custody back into the community. For example agreements are in place with the Department of Health to 199

Ministry of Justice Transforming Rehabilitation: A Strategy for Reform (2013). Available: https://consult.justice.gov.uk/digital-communications/transforming-rehabilitation/results/transformingrehabilitation-response.pdf (Accessed 19.06.14).

200 https://consult.justice.gov.uk/digital-communications/transforming-rehabilitation (Accessed 19.6.14).

201 http://www.justice.gov.uk/transforming-rehabilitation (Accessed 19.6.14).

202 Ministry of Justice Transforming Rehabilitation: A Strategy for Reform (2013). Available: https://consult.justice.gov.uk/digital-communications/transforming-rehabilitation/results/transformingrehabilitation-response.pdf (Accessed 19.06.14).

Page | 145

Offender Health Profile for Norfolk

develop a comprehensive ‘end-to-end’ approach to tackling addiction during the transfer from custody to community using the new prisons.

According to the Government proposals, prisoners who are serving short term sentences will serve the whole of their sentence in resettlement prisons, which will improve family links and community engagement. Offenders who serve longer sentences are expected to spend a minimum of three months in resettlement prisons before release.

Offenders who enter custody will initially enter a designated resettlement prison (Figure 25) where they will have an assessment of their resettlement needs. Offenders who are serving longer sentences will be transferred to longer term prisons but will subsequently return to a resettlement prison before release.

In August 2014 the MoJ published a revised list of resettlement prisons in each CRC contract area.

The lead providers for males in Norfolk and Suffolk will be HMP Hollesley Bay (an open prison based in Suffolk), HMP Norwich and HMP Wayland (based in Norfolk). Females resident in the CRC contract area will be hosted by HMP Peterborough in Cambridgeshire.

Figure 25: ‘Through the Gate’ service delivery Model

Source: Ministry of Justice Transforming Rehabilitation: A Strategy for Reform (2013)

Page | 146

Offender Health Profile for Norfolk

9.3.3. Management of offenders with community orders or release on licence Under the government proposals the Public Sector Probation Service will work together with contracted service providers to provide effective offender management. The diagrams below show how people who serve a community order, suspended sentence order or custodial sentence will be managed.

Offenders who enter the prison system will be risk assessed and those who are not considered to pose a high risk of serious harm will be allocated to a provider, who will provide day to day management. If there is a change in circumstances and a prisoner may again be at risk of causing serious harm then they will be referred back to the Public Sector Probation Service (Figure 26 and Figure 27).

The Public Sector Probation Service will also manage offenders who require management under Multi Agency Public Protection Arrangements (MAPPA). 203 Figure 26: Community Order Offender Management Model

Source: Ministry of Justice Transforming Rehabilitation: A Strategy for Reform (2013)

203

Ministry of Justice Transforming Rehabilitation: A Strategy for Reform (2013). Available: https://consult.justice.gov.uk/digital-communications/transforming-rehabilitation/results/transformingrehabilitation-response.pdf (Accessed 19.06.14).

Page | 147

Offender Health Profile for Norfolk

Figure 27: Licence case process Offender Management Model

Source: Ministry of Justice Transforming Rehabilitation: A Strategy for Reform (2013).

9.3.4. Local implications In a meeting with probation managers held in Norwich in June 2014 the proposed changes to services were discussed. It was found that currently offenders who have sentences which last for less than 12 months have previously had no rehabilitation/support engagement with the probation service in Norfolk. It was perceived that the proposed service changes that will come in from April 2015 will be very effective ie offenders receiving a prison sentence of less than 12 months will now become liable to a period of post custody supervision.

Page | 148

Offender Health Profile for Norfolk

9.4. Focus group among Probation officers 9.4.1. Focus group results Focus group sessions were organised to gather information from those responsible for Probation officers. The sessions were conducted by the Health Trainer service in collaboration with Public Health in Norwich and King’s Lynn (2012) and involved offender managers in probation. 204 Staff representatives from Probation who oversee and work with offenders either released from prison on licence or serving community sentences were invited and informed about this project.

The aim was to assess the risk an offender may pose to the community and how that risk may be limited. Supervising sentences in the community were also assessed, as well as main health needs and issues for offenders.

Probation officers tend to work with offenders who are at higher risk of harm and reoffending than those Probation service officers work with. Both roles require in-service training and qualification 205 and therefore they can provide useful information on offenders needs.

9.4.2. Main health problems There was agreement between Probation officers that drug and alcohol use is associated with mental illness for people under probation, and remains high among those under supervision. They highlighted that mental health illnesses have physical health related consequences. The Probation officers identified the following risk factors and diseases as key issues: • • • • • • • • • •

Smoking Drugs (majority) and alcohol Cannabis (high prevalence among younger age group) Mental illnesses - mainly depression, anxiety Insomnia (sleeping pills) Not eating properly ADHD (which is a massive area for probation health team as it is difficult to handle and does not come under mental health) Learning difficulties HIV Hepatitis

The Probation service officers highlighted that people under probation may find it difficult to discuss sexual health and neglect to discuss the topic. It was mentioned that some of the people under probation have been affected by sexually transmitted infection.

Substance misuse is a key problem for offenders and treatment for substance misuse improves outcomes and reoffending behaviour, as well as possibly their health.

204

Qualitative research (two sessions, focus group) with offenders’ managers in the probation service in Norwich and King’s Lynn. Aktar Deelawar, Dr Kadhim Alabady, and Linda Hillman, 2012.

205 http://www.justice.gov.uk/jobs/probation.

Page | 149

Offender Health Profile for Norfolk

9.4.3. Signposting The Probation officers highlighted the value of the signposting service for people under probation which can help them to access health and social care services. Probation officers mentioned that they are sometimes not aware of the options available to them ie if problems are identified they struggle to get the right help for people. They recommended having a health team to provide information and support to offenders. 206 Initially people don't want to open up about their health issues. Even if they do, some officers don't feel they have the experience or the qualifications to deal with these problems.

9.4.4. Access to health services The Probation officers who work in prisons advised improvements in the oral health of prisoners as a priority for dental services. They mentioned that the first health priority of a prisoner was referral to a prison dentist.

Most offenders receive advice and medication from professionals for their illness, but they do not get complete support when looking at other factors such as smoking, employment and isolation.

The Probation officers identified that there is a gap in the Community Alcohol and Drug Services (CADs) in engaging and linking people who suffer cannabis addiction and are under probation.

206

A probation officer provided an example of this: â&#x20AC;&#x153;She was dealing with a woman who was released out of prison recently, and this woman probably was sleeping around, had alcohol addiction and other issues. She doesnâ&#x20AC;&#x2122;t feel qualified to deal with this person and is not sure where to beginâ&#x20AC;?.

Page | 150

Offender Health Profile for Norfolk

9.4.5. Understanding their medical conditions Many people under probation are not fully aware of their medical condition(s) or support needs.

They do not feel sufficiently comfortable to discuss or share private details about their health with their GPs and they are not able to build stronger relationships with their doctors either due to lack of confidence or the fact that they see different physicians every time they visit.

On occasions conflict exists - if an offender feels sick on the day of an appointment with a Probation officer they have no choice but to attend the appointment and neglect seeing their GP as it is difficult to obtain a sick report from their GP.

9.4.6. Diet and home environment There was agreement that many people under probation have never had healthy eating support as a child. Diet and home environment are also not a priority for clients.

9.4.7. Health/offender manager group sessions There was some suggestion of situations where people under probation could benefit from joint health manager/offender group sessions. This type of arrangement could be a successful approach to increase health knowledge on a continuous basis.

9.4.8. Gaps People with learning disability such as ADHD often have some difficulties in interacting with the probation health team – the condition is difficult to handle and does not come under mental health.

There is a national policy to provide a service for adults with ADHD. This could be helpful to improve care for people who suffer from ADHD. The focus groups suggested that people with Asperger’s syndrome and autism are not always supported unless they have other mental health problems, e.g. depression.

9.4.9. Access to health promotion leaflets and posters It was suggested that leaflets can empower offenders. Someone in the probation management team or a health trainer should be identified to take ownership of the leaflets – they need to identify those most useful and display them in a proper way to make them accessible, and make sure most up to date versions are available. The leaflet should be worded in the right way to suit offenders rather than the general public.

All health promotion teams who work with offenders should work as a collaborative team. The prevention team who provide the Stop Smoking training cannot work by itself without considering other risk factors, as somebody who smokes might have other problems such as drug addiction or mental illness. The team can assist and support people who require further health input from other areas.

Page | 151

Offender Health Profile for Norfolk

9.5. Probation survey The Norfolk Health Trainer service in collaboration with Public Health in Norfolk conducted a quantitative research (cross sectional survey) among people under probation (2012). 207

9.5.1. Introduction The purpose of the 2012 Local Probation Survey is to assess the views of offenders and provide accurate data on health behaviours and protective factors among this group. The survey was designed to: •

Help local policy makers develop priorities, establish programmes, and advocate for resources for offenders’ health and health programmes.

•

Allow researchers and others to make comparisons across counties regarding the prevalence of health behaviours and protective factors.

•

Establish trends in the prevalence of health behaviours and risk factors by offender sub-groups for use in evaluation of offender’s health and offender’s health promotion.

This survey is intended to inform evaluation of the health needs among offenders under probation and is the first baseline of a series of annual assessments, which would allow longitudinal trends in data to be identified and analysed over a number of years to assess local intervention.

Any differences between participating groups of people can be examined and quantified. The results can then be used to help improve/redefine the needs and the intervention for these target groups in order to reduce the impact of any inequalities and improve services.

It was agreed that the survey questionnaire should be completed by all participants anonymously.

Surveys were collected by each organisation involved in service provision and then forwarded to NCC Public Health where the data was collated and analysed.

9.5.2. Survey sample The survey targeted all offenders under probation, each being a Norfolk resident. The questionnaire was developed by the Public Health Intelligence Team and reviewed and agreed by the Probation Health Trainer service.

9.5.3. Survey methodology The survey was a cross sectional probation-based survey conducted primarily among people under probation aged 15 and above. The survey uses a standardised random sample selection process. All people under probation were targeted for the survey. This was to achieve the most complete picture of health needs.

The questionnaires were completed either by the participant themselves or by the Health Trainer in their presence if assistance was required and included quantitative and qualitative questions to determine demographic information about the participants. Information gathered included age, gender and place of residence.

207

This piece of work was led by Aktar Deelawar, Dr Kadhim Alabady, and Linda Hillman, 2012.

Page | 152

Offender Health Profile for Norfolk

The survey was designed to achieve and address ten health issues. It covered the following: • Alcohol use • Dietary behaviours • Drug use • Hygiene • Mental health • Physical activity • Protective factors • Sexual behaviours • Tobacco use • Violence and unintentional injury

9.5.4. Section A: characteristics of survey respondents There were 83 people who responded to the survey, of which 70 (84%) were males and 12 (14%) were females. One person did not provide information.

The survey collected information on the age of the participants. Approximately 39% of respondents (32 people) reported their age as 20-29 years. The breakdown of all survey respondents by age band is given in Table 43. It can be seen that the largest group were those aged 20-44 years.

Table 43: Number and percentage of participants by age band and gender Number Age band Males Females Missing Persons 15-19 * * * 20-24 15 * * 18 25-29 11 * * 14 30-34 10 * * 10 35-39 6 * * 7 * * 40-44 9 10 * * 45-49 6 6 * * * 50-54 * * * * 50-55 * * * * 50-56 * * * * 55-59 * * * * 65-69 * * * * Missing *

% Persons 21.7 16.9 12 8.4 12 7.2 * * * * * *

Total 83 Note: Due to small numbers it is not possible to present the information for age groups (asterisks in table).

88% of survey respondents were White and 2.4% were Asian or Asian British. The survey results showed that 21% of people under probation had a belief or religion status while 65% had no belief or religion status.

The data available show that 70% of respondents were without disability, 19% with disability, and 10% preferred not to mention their disability status.

Page | 153

Offender Health Profile for Norfolk

9.5.5. Medical access to local GP practitioner, accident and emergency (A&E), and outpatients and inpatients admissions This section of the survey provides important information relating to people under probation and their medical access to local GP practitioners, accident and emergency (A&E) departments and outpatient and inpatient admissions.

Of the survey respondents, 56% people under probation have been able to see their family doctor (GP) in the last 12 months. It is known that this group of people are at considerably higher risk of having medical conditions than others.

There were 23 people (27%) who have been at local Accident and Emergency (A&E) departments in the last 12 months.

A large percentage of survey respondents (68.7% or 57) did not visit the local hospital as an outpatient in the last 12 months; only 26.5% (22) had been seen as outpatients during the same time period.

Only 13% of respondents were admitted as inpatient in the last 12 months. The survey was not able to determine whether this was through elective or emergency routes.

9.5.6. Medical conditions This part of the survey evaluates how people under probation think and feel about their medical conditions. It provides valuable information on mobility, self-care, anxiety or depression, disease prevalence, and chronic diseases.

The majority of the respondents (80.7%) had no problem with walking and only 15.7% had some difficulties with mobility. 86% of respondents had no difficulties with self-care compared to 3.6% who did.

Less than 45% of participants in the survey were suffering from anxiety or depression in comparison to 40% who were free from anxiety or depression.

3.6% of people under probation had diabetes, which was lower than local GP practice QOF disease registry prevalence (6.17%). 4.8% had epilepsy which was around five times higher than the rate among the local population (0.87%). Almost 12% of people under probation had asthma which was considerably higher than the prevalence seen within Norfolk local population (7%) and around 2.4% of respondents were diagnosed with COPD which was almost equivalent to the local rate (2.04%).

The survey sample is very small, therefore these results could not reflect the true prevalence and we cannot perform meaningful tests to assess if there are significant differences. A larger sample size is needed to lead to more accurate estimates. This can be done either by combining data from locations in the country or collecting data over time.

The survey showed that the prevalence of chronic long-standing physical or mental health problems was around 31% among this group of individuals, and of these 16.9% had a mental illness and 7.2% had only a physical health problem.

Page | 154

Offender Health Profile for Norfolk

More than a quarter of those who had chronic long-standing physical or mental health illnesses stated that their medical condition had a massive impact in limiting their daily activities.

9.5.7. Risk and protective factors This section reviews the evidence of risk factors that have a big impact on health behaviours and outcomes of people under probation.

Several behaviours that exert a strong influence on health were summarised in this section: tobacco use, alcohol consumption, physical activity and diet, sexual practices, and vaccinations.

9.5.7.1. Alcohol Alcohol misuse is a major cause of illness, injury and death. The World Health Organisation has identified alcohol as the third largest risk factor to health in developed countries. 208 48% of the people under probation reported drinking alcohol regularly; the rate could be higher than this as 8.4% of the respondents refused to provide an answer. We cannot accurately estimate the percentages of consuming alcohol among those who do not respond. Around 37.3% started drinking alcohol under the age of 15.

The frequency of alcohol drinking per week over the last 12 months prior to the interview varies considerably: 10.8% of respondents had a drink on a daily basis and 2.4% consumed alcohol five or six days a week. The figures could be under reported.

The survey evaluated the willingness of people under probation to quit drinking alcohol so that they could be effectively targeted in the future. It was estimated that 27.7% of respondents were willing to cut drinking levels - this group of people should be identified and referred to the Norfolk Recovery Partnership (NRP), who are the providers of drug and alcohol treatment for adults in Norfolk. NRP is open to all Norfolk residents.

51.8% of respondents refused to cut down alcohol consumption - this group should be aware of the potential side effects of drinking.

Drinking first thing in the morning (to avoid withdrawal symptoms) is a measure of alcohol dependence for people, those that do it have a strong desire for alcohol and have great difficulty in controlling consumption.

The survey identified that around 10% of respondents had an alcoholic drink first thing in the morning. Again, the rate could be much higher if people who had alcoholic drinks first thing in the morning were less likely to provide an answer (14.5% refused to respond).

9.5.7.2. Smoking Rates of smoking in prisons are extremely high. Approximately 80% of prisoners smoke, compared with 22% of the UK population as a whole. 209 The smoking prevalence among people under probation was 77%, which was slightly lower than the national rate among prisoners.

208 209

http://www.alcoholconcern.org.uk/publications/factsheets/factsheet-the-impact-of-alcohol-on-health. http://www.ohrn.nhs.uk/resource/policy/NoSmokingPrisonGuide.pdf.

Page | 155

Offender Health Profile for Norfolk

Although smoking and substance abuse rates amongst people under probation are extremely high, this could present a unique opportunity for support from Stop Smoking services.

There are different types of smoking cessation intervention. 21% of people under probation prefer the Nicotine Replacement Therapy (NRT), 19.2% prefer visiting a Stop Smoking clinic and 13.5% prefer to Stop Smoking without intervention. Almost 27% refuse to quit smoking.

9.5.7.3. Sexual behaviour Sexually transmitted diseases (STD), also referred to as sexually transmitted infections (STI) and venereal diseases (VD), are illnesses that have a significant probability of transmission between humans by means of sexual behaviour, including vaginal intercourse, anal sex and oral sex. Some STIs can also be contracted by using IV drug needles after their use by an infected person, as well as through any incident involving the contact of a wound with contaminated blood or through child birth or breast feeding.

Detained and incarcerated adolescent offenders, in particular, have high rates of STDs which makes them a potentially important core subgroup of STD transmitters. 210 Around 18% of the respondents rated their sexual practice as unsafe while 54% rated their practice safe. Almost 28% of the participants did not provide an answer – this could have been either due to refusal or lack of safe sex knowledge.

9.5.7.4. Healthy eating A healthy diet can help reduce the risk of developing coronary heart disease and prevent weight gain - reducing the risk of diabetes and high blood pressure. It can also help lower cholesterol levels and reduce the risk of some cancers. 211 A well-balanced diet should include at least five portions of fruit and veg a day.

In the area of healthy eating, the survey found that the majority of respondents (74%) ate 1-4 portions of vegetables each day, and 70% of respondents ate 1-3 portions of fruit each day (only 7% ate four portions of fruit).

Almost one in ten and about third of respondents said they never eaten a portion of vegetables or fruit each day respectively. (More details are given in.

9.5.7.5. Physical activity The national recommended minimum level of exercise is 30 minutes or more of moderate or vigorous exercise at least five times per week. Just over one quarter of people under probation who responded achieved this. Almost 31% of respondents exercised once or twice a week. 18% of the group never took part in at least 30 minutes of daily exercise.

9.5.7.6. Vaccination The survey was designed to give an overview on the status of the Polio, Tetanus, Hepatitis B, Diphtheria, MMR, TB vaccinations however the information provided by people under probation was not relevant due to the fact that more that 50% of the responses were either ‘do not remember’ or ‘missing’.

210 211

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2679796/. http://www.bhf.org.uk/heart-health/prevention/healthy-eating.aspx.

Page | 156

Offender Health Profile for Norfolk

9.5.7.7. Conclusion The survey provides snap-shot estimates of the health or health-related issues focusing on people under probation. The sample size was small, therefore, it could not provide the most precise measurement and could not help in identifying trends among groups ie black minorities ethnic communities, age band, and gender. If we want to generalize the result the sample should at least be of a size that could be sufficient enough to make the significance level.

The survey has other limitations: it did not cover housing issues or employment status.

See Appendix 8 for more details on the survey questionnaire on page 192.

Page | 157

Offender Health Profile for Norfolk

9.6. Offender Assessment System (OASys) The Offender Assessment System (OASys) is a structured clinical assessment tool used by Her Majesty's Prison Service and the National Probation Service. 212 It has been developed to assess offending-related needs, likelihood of reconviction and risk of serious harm. Offenders are assessed at the pre-sentence stage, at the start of most community and custodial sentences and at regular intervals during the sentences. 213 OASys comprises a series of computer-based forms on which clinical evaluations are made by staff of offenders. Supervision and sentence plans for the forthcoming period of supervision are recorded typically every 16 weeks for offenders in the community, and less frequently for imprisoned offenders.

OASys is designed to enable a properly trained and qualified individual, often a Probation officer, to: • Assess how likely an offender is to be re-convicted • Identify and classify offending-related needs, including basic personality characteristics and cognitive behavioural problems • Assess risk of serious harm, risks to the individual and other risks • Assist with management of risk of harm • Link the assessment to the supervision or sentence plan • Indicate the need for further specialist assessments • Measure change during the period of supervision/sentence Usually offenders are assessed by probation staff before they are sentenced. Offenders who are thought to pose the lowest risk of re-offending are typically given a standalone requirement to do unpaid work and are given a short paper-based assessment which does not appear in the OASys dataset. 214 The parameters assessed include a number associated with health needs, such as: • • •

Personal factors - emotional, thinking and behaviour, attitudes.

Links to risk of harm or associated lifestyle ie drug misuse, alcohol misuse.

Unfortunately we were not able to look at social and economic factors such as accommodation, education/employability, financial management, relationships, associates due to limited access to QASys dataset.

This section has been undertaken with the full collaboration of the Norfolk and Suffolk Probation Trust and will provide a brief summary of OASys data in order to examine a range of health related issues and risk factors of offenders in the community.

212

http://en.wikipedia.org/wiki/Offender_Assessment_System.

Home Office the Offender Assessment System: an evaluation of the second pilot (2006) Available: http://www.internetjournalofcriminology.com/newbold_an_evaluation_of_the_offender_assessment_system _ijc_august_2011.pdf (Accessed 20.6.14).

213

214

http://webarchive.nationalarchives.gov.uk/20110201125714/http://www.justice.gov.uk/publications/docs/res earch-summary-oasys-10-09.pdf (Accessed 19.6.14).

Page | 158

Offender Health Profile for Norfolk

During July 2014, there were 1,146 offenders under probation who had completed an OASys health assessment with the Norfolk and Suffolk Community Rehabilitation Company (NSCRC). Of these, 164 (14.3%) were female and 982 (85.7%) were male (Table 44). The majority were in Norwich 398 (34.7%).

Table 44: Offenders with a completed OASys assessment Team Male % Female Bury St Edmunds 177 91.2 17 Ipswich 194 89.8 22 King's Lynn 140 82.8 29 Norwich 326 81.9 72 Waveney & Yare 145 85.8 24 NSCRC 982 85.7 164

% 8.8 10.2 17.2 18.1 14.2 14.3

Total 194 216 169 398 169 1146

Offenders and ex-offenders generally experience greater health inequalities and social exclusion.

62% of the females and 49.2% of males stated that they had general health difficulties or concerns (Table 45).

Table 45: Offenders with general health issues (OASys) Team Male % Female Bury St Edmunds 80 45.2 10 Ipswich 88 45.4 14 King's Lynn 79 56.4 23 Norwich 155 47.5 46 Waveney & Yare 81 55.9 9 NSCRC 483 49.2 102

% 58.8 63.6 79.3 63.9 37.5 62.2

Total 90 102 102 201 90 585

% 46.4 47.2 60.4 50.5 53.3 51

Alcohol misuse contributes significantly to crime. Alcohol can also act as a disinhibitor or be used as an excuse, or result in crime because the individual has a drinking problem. It features prominently in violent offences, including domestic violence, and is often associated with antisocial behaviour.

Research also shows that those who frequently drink to excess are more likely to offend than those who donâ&#x20AC;&#x2122;t. 215 Table 48 and Table 49 provide figures for people under probation with alcohol use problems at the time of assessment. It can be seen that 26% of males and 21% of females have some alcohol related problems while 11.9% of males and 14.8% of females stated that they have significant problems related to alcohol.

It is common for prisoners who have alcohol problems to also have drug problems. Just over a quarter of male prisoners and around a fifth of female prisoners who are hazardous drinkers are dependent on at least one type of illicit drug. 216 It can be seen that 55.9% of males and 52.3% of females who have completed an assessment under probation said that their offending was mainly due to their drug dependence (Table 50 and Table 51).

215

http://www.alcohollearningcentre.org.uk/_library/Working_with_Alcohol_Misusing_Offenders_a_Strategy_fo r_Delivery.pdf.

216 http://www.prisonreformtrust.org.uk/Portals/0/Documents/Alcohol%20briefing.pdf.

Page | 159

Offender Health Profile for Norfolk

Evidence of the condition of mental health and wellbeing in the prison population is well documented by statutory organisations. 217 Of the data that is available in OASys 15.6% of males and 22.5% of females mentioned that they suffer from some sort of psychiatric problem, while 3.1% of males and 5.1% of females stated that they have significant psychiatric problems (Table 52 and Table 53).

Depression is higher among offenders than in the general population. 218 From the OASys dataset given in Table 54 and Table 55 it can be seen that 37.8% of males and 66.7% of females had some form of depression, and 9.1% of males and 17.4% of females had significant depression.

See page 198 in Appendix 9 for more information on OASys results.

217 218

Singleton et al, 1998. Psychiatric Morbidity in the Prison Population London, HMSO. http://www.divisiononaddiction.org/html/handouts/Mysell_Depression_Poster_2014.pdf.

Page | 160

Offender Health Profile for Norfolk

10. Support for people who misuse substances From April 2013 the new Police and Crime Commissioner will be directly accountable to the public for reducing drug and alcohol related crime. This section aims to outline the links between substance misuse and crime, and the impact substance misuse services can have on offending in Norfolk. This will demonstrate why an effective treatment system is a key element in any strategy to reduce offending and to ensure the Norfolk continues to be one of the safest counties in the country.

10.1. The prevalence of substance misuse in Norfolk Findings from the British Crime Survey (BCS) suggest that cannabis is the most commonly used drug by adults in the UK (6.9% of adults used in the last year), followed by powder cocaine (2.2%).

Overall 3% of the adult population admit to using class A drugs in the last year, and this rate is not statistically significantly different from rates recorded 15 years ago in 1996. 219 Not all people who use drugs and alcohol will become dependent on them but it is estimated that in Norfolk: • • •

5.4% of people have some dependence on alcohol (approximately 29,000 people in Norfolk) 3.4% have some dependence on a drug (approximately 18,000 people in Norfolk) 0.8% of people use opiates or crack cocaine (approximately 4,400 people in Norfolk)220

Most adults drink alcohol at least occasionally, 87% of people in the Eastern region reported drinking in the past year. 221 The government recommends certain safe levels of drinking which many adults exceed. It is estimated that in Norfolk 12.5% of those aged over 16 are engaged in ‘increasing risk drinking’, 222 and 3.1% in ‘higher risk drinking’. 223 This equates to 16% of over 16s in Norfolk being involved in harmful drinking (around 108,000 people), which is slightly below the regional average.

10.2. Trends in substance misuse There are a number of nationally recognised trends in substance misuse that are also being seen in Norfolk. The opiate using population appears to be getting older with heroin becoming less and less popular among younger age groups. People aged under 25 are more likely to seek support for problems with ‘party drugs’ such as cocaine, amphetamine, ecstasy, cannabis and alcohol. A significant proportion (41%) of people receiving specialist substance misuse services in Norfolk state that alcohol is their primary problem substance, generally this group tends to be older than those with primarily drug problems. Ketamine (a powerful hallucinogenic anaesthetic), has been the biggest riser in the UK drug market in recent years. Another trend in drug use is the rise of new psychoactive substances or ‘legal highs’. 224 219

Home Office (2012) Drug Misuse Declared: Findings From the 2011-12 Crime Survey for England and Wales HM Government.

220 National Centre for Social Research (2007) Adult psychiatric morbidity in England.

221 Beynon, C et al. (2011) Topography of drinking behaviours in England.

222 Increasing risk drinking is defined as consumption of between 22 and 50 units of alcohol per week for males, and between 15 and 35 units of alcohol per week for females.

223 Higher risk drinking is defined as consumption of more than 50 units of alcohol per week for males, and more than 35 units of alcohol per week for females.

224 Daly, M. and Simpson, P (2011) The Ketamine Zone, Druglink Vol. 26, Issue 6.

Page | 161

Offender Health Profile for Norfolk

A recent study described an increase in alcohol consumption among women, an increase in consumption among middle and older age groups and rising consumption among very young adolescent drinkers. 225

10.3. Drug and alcohol services for offenders in Norfolk In April 2013 the Norfolk Drug and Alcohol Adult Treatment System was re-commissioned and changed to a whole system approach. This service is delivered on behalf of Public Health by the Norfolk Recovery Partnership (NRP). The service is accessible to all Norfolk residents aged 18 years and over, their families and significant others who are experiencing issues with drug and/or alcohol use. It is also delivered to those within Norfolk prisons (covering the former CARAT service), Police Investigation Centres (PIC) and courts who are not Norfolk residents. The system is outcome and recovery focused, where the expectations for recovery and reintegration are explicit, characterised by the ability to motivate and support clients to achieve short and longer term goals and move through the system and into mainstream provision free from dependency.

NRP offers a menu of services including group work, talking therapies, non-structured activities, substitute prescribing and development of life skills. It also facilitates access to inpatient detoxification services and residential rehabilitation. NRP Criminal Justice team works closely with the criminal justice system at a number of levels, including: • Providing open access support for anyone experiencing problems with drugs and/or alcohol (and prioritising offenders within this system) • Active in-reach into Norfolk custody suites and courts • Working closely with National Probation Service to manage offenders • Works with the Integrated Offender Management Scheme (IOM) • Providing treatment and support to those on drug rehabilitation Requirements • Providing drug and alcohol treatment and recovery services in prisons

225

Smith, L. and Foxcroft, D (2009) Drinking in the UK: An exploration of trends. Joseph Rowntree Foundation.

Page | 162

Offender Health Profile for Norfolk

10.4. Drug rehabilitation and alcohol treatment requirements Offenders can be given a Drug Rehabilitation Requirement (DRR) or an Alcohol Treatment Requirement (ATR) as part of their probation agreement.

DRR is targeted mainly at drug users committing acquisitive crime. It combines clinical and non-clinical structured treatment. Three â&#x20AC;&#x2DC;levelsâ&#x20AC;&#x2122; are available that determine intensity per week.

ATR is targeted at offenders with serious alcohol problems who agree to treatment. The duration of these orders can be six months to three years, and people are encouraged to continue their treatment on a voluntary basis if necessary, once completing their requirement.

The DAAT is currently working on a new strategy to ensure accurate and timely sharing of information around DRR & ATR numbers. This will be a requirement for the new CJITDET data submitted nationally by the Criminal Justice Team within NRP on a monthly basis. This should be taking effect from 18th November (first submission for October).

A snapshot of people who could easily be identified within caseloads on care-notes in July 2014 show that in total, there were 70 adults in treatment who are under a DRR (Table 46).

Table 46: Snapshot of the number and percentage of adults under a DRR in July 2014 as seen from caseloads on care notes (treat as estimate) CCG Number % Central (Norwich and north Norfolk) 31 44.3 West 24 34.3 South 3 4.3 East 12 17.1 Total 70 100.0 The DAAT are currently working on a new strategy to ensure accurate and timely sharing of information around DRR & ATR numbers as this will be a requirement for the new CJITDET submission that will be submitted nationally by the Criminal Justice Team within NRP on a monthly basis. This should be taking effect from 18th November 2014 (first submission for October).

The NRP also operates in prisons across Norfolk (HMP Norwich, HMP Bure, and HMP Wayland) and provides services to any other source of referrals.

In November 2012, the DAAT team produced a report on Drugs and Alcohol in Norfolk and the Criminal Justice System. 226

226

The report was conducted by Claire Gummerson, previous Research and Information Officer for Norfolk Drug and Alcohol Action Team DAAT. For further details the report can be found here: http://www.ndap.org.uk/files/8313/7121/9626/Substance_Misuse_and_Crime_PCC_Report_Final.pdf.

Page | 163

Offender Health Profile for Norfolk

11. Offenders who are armed forces veterans - Project Nova 11.1. Introduction Veterans may become involved in the criminal justice system due to mental health problems, drugs or alcohol misuse or difficulties adjusting to civilian life; the latter reason being a concern of those who are involved in improving pathways for offenders, especially access to community services and support. 227 228 From October 2013 any person who has been detained in a Police Investigation Centre (PIC) in Norfolk or Suffolk will be asked by a custody sergeant at the pre-release risk assessment stage if they have ever served in HM Forces. Once a person has intimated “Yes” they will be given a leaflet making them aware of support services available to veterans and they will be referred to Project Nova which will collect service level and demographic data from them whilst providing a support programme based on their level of need.

Project Nova is an 18 month trial project which aims to support veterans who are arrested and taken into police custody in Norfolk and Suffolk. The project will focus especially on veterans who have late onset mental health issues and it will ensure partnership working and supported business planning using all of the following established pathways: • • • • • • • • •

Accommodation Education, training and employment Health Drugs and alcohol Finance, benefits and debt Children and families Attitudes, thinking and behaviour Prostitution Abuse

The purpose of the project is to reduce re-offending by the ex-military community with early intervention and subsequent diversion through engagement and appropriate signposting for bespoke support, followed by a constant tracking method to ensure re-offending is reduced.

Post-trial, Project Nova has the aim of attracting funding from the government and the charitable sector for the roll out of a national programme to assist veterans in police custody.

The data that is being collected by the project will be used to find any links between working in the armed forces and offending, with the potential to help veterans in police custody integrate back into society using a coordinated response from a number of different services.

227

Southampton City NHS: Veterans’ Health Needs Assessment. Southampton (2012).

Defence Analytical Services and Advice: Estimating the proportion of offenders supervised by Probation Trusts in England and Wales who are ex-Armed Forces. Ministry of Defence (2010). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/280539/16-march-2011.pdf (Accessed 16.07.14).

228

Page | 164

Offender Health Profile for Norfolk

11.2. Local Integrated Offender Management (IOM) Project Nova has embedded itself with the 180 Project being delivered across Norfolk and Suffolk as part of the IOM. The IOM is an overarching framework for bringing together agencies in local areas to prioritise interventions with offenders who cause crime in their locality. IOM arrangements will work best if they are not restricted to statutory or local criminal justice agencies, but involve a wide range of social agencies, including the voluntary sector, which has a role to play in tackling risk factors associated with crime and offending.

Project Nova is in the process of setting up an IOM model in the counties of Norfolk and Suffolk purely for the support of veterans in the community working in conjunction with other support agencies.

The Police and Crime Commissioner’s office in Norfolk has been extremely supportive of this whole initiative providing office space, telephony and IT and when necessary, intervention at the highest level if providers seem to be slow over delivery.

11.3. Through the gate support Project Nova has engaged with HMPs on three occasions when a veteran has been remanded in custody. A wheelchair was provided for a disabled veteran and accommodation arranged with a housing provider and NACRO prior to release. Another veteran was provided with a court letter including the offer of employment should he be released back into the community. The final veteran is currently still on remand and engaging with the veterans forum group linked to the prison to arrange bespoke support prior to release.

11.4. Findings from data collected so far The final evaluation report for Project Nova is expected to be available in 2015. Data collection for the project began in October 2013 and the data have been made available for those who have been engaged in the project from eight month period up to July 2014.

Data collected so far show that: •

There have been 101 veterans referred from PICs - two of which turned out not to be military referrals. 79 veterans have been engaged with the project and the other 22 have failed to engage after receiving phone calls or letters.

•

75 of the veterans engaged with the project are male and four are female. The average age of arrested veterans is 34.9.

•

All engaged were White British.

•

Since October 2013 there have only been two re-arrests.

The joined up approach shown by the Norfolk Police and Crime Commissioners office and the 180 Project working with Project Nova is the way forward. It is a simple template that can be rolled out nationally with realistic and minimal buy-in financially as it can bolt onto existing frameworks.

Page | 165

Offender Health Profile for Norfolk

As can be seen from the reoffending figures (two veterans in seven months) this indicates a potentially enormous saving to the tax payer, as well as a great improvement to the quality of life of the veteran and their family and improvement in crime rates in the community in which they reside.

Many veterans are too proud to ask for post-release support. Due to the 'Be the Best' military training process, asking for help is seen by many as a sign of failure. Veterans are generally too proud to seek help. This can be overcome by the â&#x20AC;&#x2DC;veteran 2 veteransâ&#x20AC;&#x2122; approach used by Project Nova. There is a bond that can easily be picked up again and by reinforcing the military family ethos, results can be achieved fairly quickly. Lord Ashcroft highlighted improving the transition process to make the veteran more aware of support available and recognising the veteran in society.

See page 200 in Appendix 10 for more information and results for on Project Nova.

Page | 166

Offender Health Profile for Norfolk

12. Support to ex-offenders in the community On release from custody, accessing support and services is key to individuals making a successful transition back into society. Some offenders will be helped in this process by contact with Probation, although those being released from custody after shorter sentences have, in recent years, not had as much of this sort of support.

Under the new â&#x20AC;&#x2DC;Transforming Rehabilitationâ&#x20AC;&#x2122; proposals there will be changes to the way the prison estate is organised in order to fill service gaps between custody and community. Resettlement prisons will be designated within each CRC contract area and will release the vast majority of offenders to that area. This will allow the same provider to work with offenders in custody and continue their rehabilitation work in the community in most cases. 229 It is hoped these new arrangements, due to start implementation from 2015, will lead to much better support for offenders when they are released from custody.

City Reach is a Specialist Primary Care Service, funded by NHS England. City Reach provides healthcare services for people who find it difficult to visit mainstream GP services. The service is provided for people who are homeless, or those at risk of being homeless, sex workers, prisoners and ex-offenders, substance mis-users, travellers and asylum seekers. 230 The service provides care at the City Reach Clinic or at outreach clinics, and also helps clients get appointments at a hospital or other clinics in Norwich.

The services provided include: treatment for minor illness or injuries, immunisations, sexual health or blood borne virus screening, advice on mental health or substance misuse, needle exchange and referrals to specialist services.

The City Reach Service Manager estimates that a quarter to a third of those who come to the practice are ex-offenders. There are no direct referrals to the service but people are signposted by a range of agencies.

On discharge from prison, ex-offenders should be given a statement of their medical needs/ medication by the prison, but these are often lost or not collected. As a result an ex-offender arrives at City Reach for treatment, they have to have their needs reassessed. Improved data sharing would assist the service in ensuring that those ex-offenders who seek medical support receive it in a more timely and managed way.

The City Reach practice building also provides a place to make available general guidance and support for other services.

Women offenders â&#x20AC;&#x201C; women offenders can use City Reach health services, but they also can obtain more generic support and advice, in Norwich, from the 4women Centre. The chapter on women offenders provides more detail on the centre and other support.

229

Ministry of Justice Transforming Rehabilitation: A Strategy for Reform (2013). Available: https://consult.justice.gov.uk/digital-communications/transforming-rehabilitation/results/transformingrehabilitation-response.pdf (Accessed 19.06.14).

230 http://www.norfolkcommunityhealthandcare.nhs.uk/The-care-we-offer/Service-search/city-reach.htm.

Page | 167

Offender Health Profile for Norfolk

Other support for ex-offenders This study has primarily focused on â&#x20AC;&#x2DC;health needs and provisionâ&#x20AC;&#x2122; but there are clearly a range of wider determinants of health, the most important and probably key to reducing re-offending being housing and employment.

From our discussion with City Reach, they believe a main reason for ex-offenders not accessing a range of services is their lack of accommodation. This includes some specialist health services such as the Community Mental Health team. It also has a major impact of their chances of being offered employment.

The Project Team has not been able to cover this area in detail, and it has been identified as one of the areas where further research is required. There has been considerable work done in the past of housing for offenders and this can provide a basis of future work.

Page | 168

Offender Health Profile for Norfolk

13. Conclusions The Project Team presented the findings and early recommendations to the Offender Health Project Advisory Group in early September, - a group of key officers who were either members of the Strategic Board for the Rehabilitation of Offenders or who the Project Team had seen as key in developing the Report. This meeting was used both as a sense check and a start to the development of the recommendations to the Board. In general terms, the report was well received and the findings seen as accurate and appropriate.

Acknowledging that the Project Team had not been able to include all issues and specialist areas in the development of the report, the introduction of the main report includes a list of topics that need further research and analysis to supplement the picture presented here.

A sub-group of the advisory group further developed the findings and recommendations for presentation at the Strategic Board and for sharing with the Health and Wellbeing Board. These were further discussed at a final meeting of the Advisory Group at the end of September, and it was agreed to share them with the Health and Wellbeing Board at their October meeting.

The report was then finalised for publication in Norfolk’s JSNA – it is published in the section ‘Groups at risk of disadvantage: http://www.norfolkinsight.org.uk/jsna/groupsatrisk.

Page | 169

Needs Assessment of those in Contact with the Criminal Justice System

Appendices Appendix 1: Pathways for Police Investigation Centre Detainees who require health input

170

Needs Assessment of those in Contact with the Criminal Justice System

Appendix 2: Forensic section definitions Section 35: 231 When the criminal courts send offenders to hospital for a medical report •

The criminal courts can send offenders to hospital using Section 35 of the Mental Health Act if they want more information about their mental health.

•

They can use this section at any point during court case.

•

A psychiatrist will write a medical report about their mental health. This will give information to the court and recommend what the court should do.

•

If the court feels that they do not need to be in hospital for a medical report to be written, they could send offenders to prison on remand instead.

•

Offenders have to give their permission to be treated if they are on section 35. Hospital staff cannot treat them against their will.

•

After offenders have been on a Section 35, a number of things could happen. The court can use other sections of the Mental Health Act.

Section 36: 232 Crown Court sending offenders to hospital for treatment •

The Crown Court can use Section 36 if they think the offenders should be in hospital for treatment.

•

They can use this section at any point during their court case.

•

The hospital can treat offenders without their permission.

•

After offenders have been on a Section 36, a number of things could happen. The court can use other sections of the Mental Health Act.

Section 37 and 41: 233 Hospital order given by Crown Court •

The criminal courts can use Section 37 if they think offenders should be in hospital instead of prison. Section 41 is a restriction order. The Crown Court can add this order to a Section 37 if they have concerns about public safety and offender’s level of risk.

231

http://www.rethink.org/living-with-mental-illness/police-courts-prison/section-35-court-sending-you-tohospital-for-a-report.

232 http://www.rethink.org/living-with-mental-illness/police-courts-prison/section-36-crown-court-sendingyou-to-hospital-for-treatment.

233 https://www.rethink.org/living-with-mental-illness/police-courts-prison/section-37-41-hospital-order-givenby-crown-court.

171

Offender Health Profile for Norfolk

•

Offenders can appeal to the courts if they do not agree with this sentence. There are strict timescales if they want to do this.

•

Offenders can appeal to the hospital managers and the Mental Health Review Tribunal (MHRT). However, the Secretary of State for Justice (the Ministry of Justice) decides when they can leave.

•

The hospital can treat offenders without their permission.

•

When offenders are discharged, they are entitled to free aftercare services under Section 117 of the Mental Health Act. This can include things such as supported housing.

Section 38: 234 Criminal courts giving an interim hospital order •

The criminal courts can use Section 38 when offenders have been found guilty of an offence that they could go to prison for.

•

This is an ‘interim’ order as it is temporary while the court decides what sentence to give offenders.

•

The hospital can treat offenders without their permission.

•

The Responsible Clinician (the doctor responsible for their care) will see how they respond to treatment and update the court.

•

The court will decide what sentence to give them. This could be staying in hospital on a hospital order (Section 37 or 37/41). The court could decide on another sentence, which could be prison.

Section 47 and 49: 235 Transfer of a sentenced prisoner to hospital •

If offenders are a sentenced prisoner and have a mental illness, the prison may not be able to manage their mental illness.

•

If so, the prison can ask the Secretary of State for Justice (Ministry of Justice) to transfer them to hospital using Section 47/49 of the Mental Health Act.

•

Offenders could be moved back to prison if their condition improves.

•

If offenders reach the end of their prison sentence and they are still in hospital, they could be discharged from hospital. If they still need treatment in hospital, they could be moved to a different section (known as Section 37 “notional”).

234

http://www.rethink.org/living-with-mental-illness/police-courts-prison/section-38-criminal-courts-giving-aninterim-hospital-order.

235 http://www.rethink.org/living-with-mental-illness/police-courts-prison/section-47-49-transfer-of-asentenced-prisoner-to-hospital.

Page | 172

Offender Health Profile for Norfolk

•

Offenders can appeal to the hospital managers and the Mental Health Review Tribunal (MHRT) if they do not agree with being on this section.

•

The hospital can treat offenders without their permission.

•

When they are discharged, they are entitled to free aftercare services under Section 117 of the Mental Health Act. This can include things such as supported housing.

Section 48 and 49: 236 Transfer of a prisoner on remand to hospital •

Offenders are a prisoner on remand if their court case is still happening or they are waiting to be sentenced.

•

If they are a prisoner on remand and have a mental illness, the prison may not be able to manage their mental illness.

•

If so, the prison can ask the Secretary of State for Justice (Ministry of Justice) to transfer them to hospital using Section 48/49.

•

Offenders could be moved back to prison if their condition improves.

•

They can appeal to the hospital managers and the Mental Health Review Tribunal (MHRT) if they do not agree with being on this section.

•

The hospital can treat them without their permission.

•

When they are discharged, they are entitled to free aftercare services under Section 117 of the Mental Health Act. This can include things such as supported housing.

236

http://www.rethink.org/living-with-mental-illness/police-courts-prison/section-48-49-transfer-of-a-prisoneron-remand-to-hospital.

Page | 173

Offender Health Profile for Norfolk

Appendix 3: What does high, medium and low secure mean in relation to hospitals?

Secure hospitals can be low, medium or high secure.

High secure High secure hospitals treat people who need high levels of security because they could be dangerous, violent or are a high risk to other people.

Prisons in England and Wales are called Category A, B, C or D prisons, depending on how secure they are. Category A prisons are the most secure. High secure hospitals are as physically secure as a Category B prison at least. If someone would be in a Category A prison, a high secure hospital can set up the same level of security. 237 There are three high secure hospitals in England and Wales â&#x20AC;&#x201C; Ashworth (in Merseyside), Broadmoor (in Berkshire) and Rampton (in Nottinghamshire).

Medium secure Medium secure hospitals are not as secure as High Secure Services. However, they still have to meet a certain level of security. They can provide different levels of secure care as the patients there will have different needs. For example, as forensic offenders are working towards leaving, the hospital could build up un-escorted leave.

Low secure The definition of low secure is not as clear as medium and high secure. Low secure units have less physical security than medium secure units but are more secure than standard mental health wards.

Forensic offenders may be in a low secure hospital if they are detained under the Mental Health Act and other mental health services cannot treat them because of their risk to other people or because of challenging behaviour.

Forensic offenders can move up and down between the different levels depending on the level of risk. They may be moved down the levels of security before they discharged back into the community.

The Department of Health has written guidance for secure hospitals. They set out what standards low 238, medium 239 and high secure hospitals 240 241 should meet.

237

Joint Commissioning Panel for Mental Health. Guidance for commissioners of forensic mental health services. May 2013. Available from www.jcpmh.info/wp-content/uploads/jcpmh-forensic-guide.pdf (Page 8, accessed September 2013).

238 Department of Health. Mental Health Policy Implementation Guide, National Minimum Standards for General Adult Services in Psychiatric Intensive Care Units (PICU) and Low Secure Environments. London: The Stationery Office; 2002.

239 Department of Health. Best Practice Guidance, Specification for adult medium secure services. London: The Stationery Office; 2007.

240 Department of Health. The High Security Psychiatric Services (Arrangements for Safety and Security.

London: The Stationery Office; 2011.

Page | 174

Offender Health Profile for Norfolk

Appendix 4: IQ Test 242 An IQ test is a psychological measure of a person’s “intelligence quotient” (IQ).

Intelligence Quotient, or IQ, is a theoretical construct used by psychologists within standardized tests as a means of describing one’s intelligence level. In the most commonly-administered IQ test — the Wechsler Adult Intelligence Scale (WAIS) - an average score is 100; about 95% of IQ scores fall between 70 and 130. It is important to note that IQ is not real - is simply a philosophical construct psychologists have created to describe a subset of human functioning they believe to be subjectively important in modern society. (Because of this, unless an IQ test has been specifically adopted for a different culture or country - and the most popular one has - IQ tests are very culturally specific and may be invalid when used in other cultures.)

IQ tests involve the measure of two primary components — verbal and performance. Because the performance portion of the IQ test requires physical manipulation of objects in front of the testing psychologist, a legitimate IQ test cannot be taken online. All of the so-called “IQ tests” you see online are invalid - none have been validated against real-world IQ tests with peer-reviewed journal publications.

When an IQ test is scored, three primary scores are obtained - verbal IQ, performance IQ, and the full scale IQ. The full scale IQ is what is commonly referred to as one’s IQ score by laypeople.

Most people perform better in one component over the other in IQ testing (one either has a strength in verbal or performance).

241

Department of Health. National Standards for the provision of Social Care Services in the High Security Hospitals. London: The Stationery Office; 2001.

242

By John M. Grohol, Psy.D. http://psychcentral.com/encyclopedia/2010/what-is-an-iq-test/.

Page | 175

Offender Health Profile for Norfolk

Appendix 5: What are Pervasive Developmental Disorders? 243 Pervasive Developmental Disorder is a formal term that means exactly the same thing as autism spectrum disorder.

What is Asperger Syndrome?

Asperger Syndrome describes individuals at the highest-functioning end of the autism spectrum.

The term - and the diagnosis - was removed from the diagnostic manual in 2013, but virtually everyone in the autism community continues to use it because of its usefulness in describing a very specific group of people. People with Asperger Syndrome generally develop spoken language in the same way as typically developing children, but have difficulties with social communication.

These difficulties that become more obvious as they get older and social expectations rise.

Because people with Asperger Syndrome are often very intelligent but "quirky", the disorder is sometimes nicknamed "geek syndrome" or "little professor syndrome".

What is mild autism?

The term mild autism is not an official diagnosis. It's simply a more descriptive term than Asperger Syndrome or autism. Generally speaking, when people use the term mild autism they are referring to individuals whose symptoms fit an autism spectrum diagnosis, but who has strong verbal skills and few behavioral issues. Those individuals may, however, have significant problems with social communication. They may also have problems coping with too much sensory input (loud noise, bright lights, etc).

What is high functioning autism?

Like mild autism, high functioning autism (sometimes shortened to HFA) is a made-up term that has become more and more commonly used. It can be hard to distinguish a person with HFA from a person with Asperger Syndrome. The official distinction is that people with HFA had or have speech delays, while people with Asperger Syndrome have normal speech development. But there may also be very real differences in terms of social awareness, personality characteristics, and other traits.

What is PDD-NOS? Pervasive Developmental Disorder Not Otherwise Specified describes individuals who don't fully fit the criteria for other specific diagnoses, but are nevertheless autistic. Because there is no easy way to define the symptoms of PDD-NOS, which may range from very mild to very severe, the diagnostic category no longer exists, though a new diagnosis, Social Communication Disorder, may become a similar catchall category. The term PDD-NOS is rarely used outside of practitioners' offices: most parents, therapists and teachers prefer to use more descriptive (though less official) terms to describe their children, students and patients with most but not all symptoms of autism.

What is severe autism?

Severe autism is not an official diagnosis; instead, it is a descriptive term along with profound autism, low functioning autism, and classic autism. People with autistic disorder are often non-verbal and intellectually disabled, and may have very challenging behaviours.

243

http://autism.about.com/od/whatisautism/tp/ASDs.htm.

Page | 176

Offender Health Profile for Norfolk

Appendix 6: Offenders & Social Care - Intellectual Disabilities (OFFSCA- ID) study

Page | 177

Offender Health Profile for Norfolk

Page | 178

Offender Health Profile for Norfolk

Page | 179

Offender Health Profile for Norfolk

Page | 180

Offender Health Profile for Norfolk

Page | 181

Offender Health Profile for Norfolk

Page | 182

Offender Health Profile for Norfolk

Page | 183

Offender Health Profile for Norfolk

Page | 184

Offender Health Profile for Norfolk

Appendix 7: Brief report: Screening prisoners for intellectual disabilities in three English prisons A 7.1 Abstract Background Prisoners with intellectual disabilities are known to be disadvantaged in prisons and to be more susceptible to bullying, segregation, depression and anxiety than other prisoners.

Method In this study, nearly 3000 new prisoners entering three English prisons were offered screening for intellectual disabilities, using the LDSQ. Results Only 14% refused screening and overall just under 7% were screened positive on the LDSQ. Conclusions It is argued that it is time for screening for intellectual disabilities to be rolled out to all prisons.

Page | 185

Offender Health Profile for Norfolk

A 7.2 Introduction There have been frequent claims that there is an over-representation of people with intellectual disabilities (ie those with an IQ below 70 and deficits in adaptive behaviour, present in the developmental period) in courts and prisons in many countries (Hayes et al, 2007; Crocker et al, 2007; Sondenaa et al 2008), though some researchers have disputed this in relation to the UK (see Murphy & Mason, 2014, for a review of this issue).

What is certainly not disputed, is that there are many people in prison with specific learning disabilities, such as dyslexia (Talbot, 2008), and many with borderline learning disabilities (Murphy, Harnett & Holland, 1995), so that it is often difficult for prison staff to be sure who has and who has not got intellectual disabilities (ID), especially as they do not routinely screen for this (Talbot, 2008).

Yet people with ID in prisons are disadvantaged by, for example, difficulties in understanding written information, filling in forms (to order meals, book visitor or doctor appointments), accessing work or offending behaviour programmes, and they are more likely to be depressed, anxious and segregated than other prisoners (Talbot, 2008). As a result, one of the recommendations of the Bradley Report (2009) was that prisons should routinely screen for ID.

A 7.3 Method This study examined the feasibility of screening for ID in three English (male) prisons.

Ethical approval The study was approved by the National Research Committee of the National Offender Management Service (NOMS) and by the governor of each prison. Every prisoner gave informed consent, using an accessible information sheet and consent form, before being assessed, and it was made clear to prisoners that declining to take part in the research would not adversely affect their time in prison.

Participants Three prisons took part in the project (prisons A, B, C). Each prison agreed to screen every new prisoner in a three month period, provided they gave informed consent. Prisoners who were non-English speaking were not included, in order to avoid over-identification (false positives) due to unfamiliarity with the English language.

Measure The screening tool used was the Learning Disability Screening Questionnaire (LDSQ) 244 originally developed to screen people for ID when they were referred to Community Learning 244

‘Learning Disabilities’ is the phrase used in the UK for intellectual disabilities (ID). The term used throughout this paper is intellectual disabilities, so as not to confuse the international readership. ‘Learning Disabilities’ is only retained where necessary (in the names of community teams and in the name of the screening tool, although it has the same meaning as ID).

Page | 186

Offender Health Profile for Norfolk

Disability Teams (McKenzie & Paxton, 2006a). This tool was chosen over other possible tools, such as the HASI (Hayes, 2002) and the LIPS (Mason & Murphy, 2002) because it was brief (7 items), required no special equipment and could be used by prison staff with minimal training (ie training of about 2 hours; it did not require the assessor to have particular qualifications, such as a psychology degree). In community services, the LDSQ had a sensitivity of 91% and a specificity of 87% for detecting those with ID (McKenzie & Paxton, 2006b), while in prisons and forensic in-patient units it has a sensitivity of 82% and specificity of 87.5% for detecting those with ID McKenzie, Michie, Murray & Hales, 2012).

Procedure The staff responsible for assessing prisoners were trained in intellectual disability awareness and in how to administer the LDSQ questionnaire. Prison A chose to ask the Disability Liaison Officer to undertake the assessments; prison B chose the Intellectual Disability nurse who worked in the prison; prison C chose prison staff in their education and skills department.

A 7.4 Results Prisons were asked to screen the new prisoners in the first 72 hours but not all prisons managed this. Prison A screened on day 2 of induction, prison B screened on days 3-5 of induction and prison C screened on day 7. In several prisons one person was responsible for screening which had the advantage of consistency but the disadvantage of gaps, if the person was away from the prison or otherwise engaged.

Table 47: Numbers of prisoners offered screening, numbers screened, numbers refused and numbers identified as having ID in the three prisons Total number of Total number Total number Number new prisoners offered refused to be identified with screening (% of screened (% of intellectual all new those offered disabilities (% of prisoners) screening) those screened) Prison A 1600 1364 (85.3%) 195 (14.3%) 59 (5.0%) Prison B 1546 1099 (71.1%) 58 (5.3%) 89 (8.5%) Prison C 632 362 (57.3%) 143 (39.5%) 21 (9.6%) Overall 3778 2825 (74.8%) 396 (14.0%) 169 (6.9%) Table 47 shows the total numbers of new prisoners in the three month trial period, the total number offered screening in each prison, the number who refused to be screened and the number identified as having intellectual disabilities on the LDSQ. The two prisons screening earlier (by day 5) included over 70% of new prisoners, with low refusal rates (below 15%). However, the third prison, which screened prisoners later included proportionately fewer prisoners and had more refusals. Overall, prisons screened 7% of new prisoners as positive on the LDSQ. It should be noted also that 216 prisoners were not asked to complete the questionnaire because they were classified as non-English speaking.

Page | 187

Offender Health Profile for Norfolk

The three prisons were not asked to do anything specific following screening, since there were no new resources available for prisons. Nevertheless, different prisons took different actions when someone was screened positive.

In prison A, identified prisoners were referred, if they consented, to a third sector organisation that offered a variety of learning programmes in the prison and prepared prisoners for release into the community (signposting them onto appropriate community courses). In addition, again only with consent, all wing governors were advised who had been identified.

In prison B, prisoners identified were referred to the prison-based intellectual disabilities service, which had strong contacts with intellectual disabilities services outside the prison. Typically in this prison, with consent, contact was made with the prisoner’s local Community Learning Disability Team, who were invited into the prison to make contact with ‘their’ prisoner, allowing post-release planning.

In prison C, those identified were referred to Education and reports were also sent to prison Psychology for consideration of a more detailed assessment. Prison C said it was developing a care pathway for prisoners with ID whilst in prison, including healthcare.

A 7.5 Discussion Prisoners with ID are significantly disadvantaged in prisons in a variety of ways and are more likely to be depressed and anxious, and less likely (for example) to see the doctor or have visitors, making their time in prison particularly difficult (Talbot, 2008). Moreover, prisoner Dennis Gill (who was thought to have ID) recently took the English Government to court via judicial review for breach of the Disability Discrimination Act, on the grounds that he needed to complete a treatment programme in order to earn parole, but at the same time he was excluded from the programme on the grounds of his ID. As a result he had actually served twice his tariff. Gill won his case (Straw & Lomri, 2010).

In order to mitigate against the disadvantages that people with ID suffer in prison, prisons obviously need to identify which of their prisoners has ID. The gold standard assessment for determining ID entails a full assessment for IQ and adaptive behaviour, but such IQ assessments can be very lengthy (over an hour per person) and have to be done by psychologists, who are in short supply in prisons. Moreover, assessments of adaptive behaviour are problematic in prisons given that they normally rely on third party report, by someone who knows the prisoner well, about their skills in a ‘normal’ environment.

Given the numbers of new prisoners entering the three prisons in this study, such a gold standard assessment would not have been practicable. Nevertheless, it appeared that the LDSQ was a feasible substitute, requiring little training, no specialist professional qualifications, and taking little time (about 10 minutes). Nevertheless the LDSQ was only a method of screening. It was possible that the LDSQ, if anything, overestimated the number of prisoners with ID, since it did not entail an assessment of adaptive behaviour (see also other screening methods such as Mason & Murphy’s

Page | 188

Offender Health Profile for Norfolk

(2002) tool, the LIPS). Adaptive behaviour is extremely hard to evaluate in prisons due to the restrictive environments.

In conclusion, it seemed that it was feasible to use the LDSQ in prisons, that few prisoners refused it and that the three prisons involved in the study had begun to try to implement improvements in their services for those screened positive.

In the short term, the National Offender Management Service (NOMS) needs to roll out ID screening to all prisons, as a first step to ensuring that people with ID are not disadvantaged during their time in prison.

Currently NOMS is in breach of the Disability Discrimination Act in not making reasonable adjustments for people with ID (and, for example, in not having a set of offender behaviour programmes that they can access in prison). Moreover, in the longer term, it would seem sensible to screen people at an earlier stage such as on arrest at the police station, so that the difficulties that the person may have could be taken into account throughout their journey through the CJS, given that it has been well-established for years that people with ID are disadvantaged in the police station (Clare & Gudjonsson, 1995; Medford et al, 2000; Kassin et al, 2010) and in courts (Kebbell & Hatton, 1999; Talbot, 2008), both in this country and elsewhere (Murphy & Clare, 2009; Perske, 2011).

A 7.6 Acknowledgements The authors are grateful for the help of the staff in all three prisons and for all prisoners who volunteered, without whom this study could not have been completed. This study was funded by the Department of Health.

Page | 189

Offender Health Profile for Norfolk

A 7.7 References Bradley K. Lord Bradleyâ&#x20AC;&#x2122;s review of people with mental health problems or learning disabilities in the criminal justice system (2009). http://www.centreformentalhealth.org.uk/pdfs/Bradley_report_five_years_on.pdf Clare, I.C.H. & Gudjonsson, G.H. (1995) The vulnerability of suspects with intellectual disabilities during police interviews: a review and experimental study of decision-making.

Mental Handicap Research, 8, 110-128.

Crocker, A.G., Cote, G., Toupin, J. St-Onge, B. (2007). Rate and characteristics of men with an intellectual disability in pre-trial detention. Journal of Intellectual & Developmental Disability, 32, 143-152.

Hayes, S. C. (2002). Early intervention or early incarceration? Using a screening test for intellectual disability in the Criminal Justice System. Journal of Applied Research in Intellectual Disabilities, 15: 120-128.

Hayes, S., Shackell, P., Mottram, P. & Lancaster, R. (2007). The prevalence of intellectual disability in a major UK prison. British Journal of Learning Disability, 35, 162-167.

Kassin, S.M., Drizin, S.A., Grisso, T., Gudjonsson, G.H., Leo, R.A. & Redlich, A.D. (2010).

Police-induced confessions: Risk factors and recommendations. Law & Human Behavior, 34, 3-38.

Kebbell, M.R. & Hatton, C. (1999) People with mental retardation as witnesses in court: a review. Mental Retardation, 37, 179-187.

Mason, J. & Murphy, G.H. (2006). People with an intellectual disability in the criminal justice system: developing an assessment tool for measuring prevalence. British Journal of Clinical Psychology, 41: 315-320.

McKenzie K, Michie A, Murray A, Hales C. (2012). Screening for offenders with an intellectual disability: the validity of the Learning Disability Screening Questionnaire.

Research in Developmental Disabilities, 33: 791-795.

McKenzie K, Paxton D. Learning Disability Screening Questionnaire. Edinburgh: GCM Records, 2005 McKenzie K, Paxton D. (2006b) Promoting access to services: the development of a new screening tool. Learning Disability Practice, 9: 17-21.

Medford, S., Gudjonsson, G. & Pearse, J. (2000) The Identification of Persons at Risk in Police Custody: The Use of Appropriate Adults by the Metropolitan Police. Jointly published

by Institute of Psychiatry and New Scotland Yard Murphy, G. & Clare, I.C.H. (2009). Intellectual disabilities. In S. Young, M. Kopelman, & G.H. Gudjonsson (Eds) Forensic Neuropsychology in Practice. Oxford University Press. Pp 53- 79.

Page | 190

Offender Health Profile for Norfolk

Murphy, G.H., Harnett, H., Holland A.J. (1995) A survey of intellectual disabilities amongst men on remand in prison. Mental Handicap Research 1995; 8: 81-98 Murphy, G.H. & Mason, J. (2014) Forensic and offending behaviours. In Handbook of Psychopathology in Intellectual Disability (Eds E. Tsakanikos and J. McCarthy). New York: Springer Science.

Perske, R. (2011). Perskeâ&#x20AC;&#x2122;s list: False confessions from 75 persons with intellectual disability. Intellectual and Developmental Disabilities, 49, 365-373.

Sondenaa, E., Rasmussen, K., Palmstierna, T. & Nottesstad, J. (2008). The prevalence and nature of intellectual disability in Norwegian prisons. Journal of Intellectual Disability Research, 52, 1129-1137.

Straw A, Lomri S. Public Law Update: Failing prisoners with learning disabilities. Criminal Law and Justice Weekly 2010; 174: 292-293.

Talbot J. (2008) Prisonersâ&#x20AC;&#x2122; Voices: Experiences of the criminal justice system by Prisoners with learning disabilities and Difficulties. London: Prison Reform Trust.

Page | 191

Offender Health Profile for Norfolk

Appendix 8: Probation survey

Health and Wellbeing Questionnaire

For each of the following questions, please mark X in the box that best describes your answer. Please ignore the numbers after the boxes.

About yourself So that we understand your needs, it is important that we ask you a few questions about yourself. As with all the questions elsewhere in this survey, your answers will be completely confidential.

1. Are you: 1. Male 1 2. Female 2 3. Transgender

3

2. What year where you born?

3. Do you consider yourself to have a disability, include diagnosed aspergers/LD/etc?

1. Y 1 2. N 2 3. Prefer not to say 3 Any comments ______________________________________________________________________________________________ ______________________________________________________ 4. Which of these activities best describes what you are doing at present?

1. Employee in full-time job (30 hours plus per week) 1 2. Employee in part-time job (under 30 hours per week) 2 3. Self-employed full or part-time 3 4. On a government supported training programme 4 (eg modern apprenticeship / training for work) 5. Full-time education at school, college or university 5 6. Unemployed and available for work 6 7. Permanently sick / disabled 7 8. Wholly retired from work 8 9. Looking after the home 9 10. NEET (not in employment education or training) 11. Doing something else 10 (please state below)_____________________________________________________________________________________ ___________________________________________________________________________________________ ________________________________ 5.

1.

2.

3.

Which of these groups do you consider you belong to?

White: British 1 White: Irish 2 White: Other 3

Page | 192

Offender Health Profile for Norfolk

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

Mixed: White & Black Caribbean 4 Mixed: White & Black African 5 Mixed: White & Asian 6 Mixed: Other 7 Asian or Asian British: Indian 8 Asian or Asian British: Pakistani 9 Asian or Asian British: Bangladeshi 10 Asian or Asian British: Other 11 Black or Black British: Caribbean 12 Black or Black British: African 13 Black or Black British: Other 14 Chinese 15 Other ethnic group 16 Decline to declare 17

6. Do you have a belief or religion?

1. Y 2. N 3. Prefer not to say Any comments ______________________________________________________________________________________________ ______________________________________________________ Your Health and Wellbeing 1. Have you been to see your family doctor (GP) in the last 12 months?

1. No 1 2. Yes, in the last 4 months 2 3. Yes, between 5 and 8 months ago 3 4. Yes, between 9 and 12 months ago 4 5. yes, but can’t remember when 5 Any comments ______________________________________________________________________________________________ ______________________________ 2. Have you been to your local Accident and Emergency Department in the last 12 months?

1. No 1 2. Yes, in the last 4 months 2 3. Yes, between 5 and 8 months ago 3 4. Yes, between 9 and 12 months ago 4 5. Don’t know 5 6. Yes, I can’t remember 6 3. Have you visited your local hospital as an outpatient in the last 12 months?

1. No 1 2. Yes, in the last 4 months 2 3. Yes, between 5 and 8 months ago 3 4. Yes, between 9 and 12 months ago 4 5. Don’t know 5 4. Have you visited your local hospital as an inpatient in the last 12 months?

1. No 1 2. Yes, in the last 4 months 2 3. Yes, between 5 and 8 months ago 3 4. Yes, between 9 and 12 months ago 4 5. Don’t know 5 5. Was this by elective or emergency proceedings?

1. Elective 1 2. Emergency 2

Page | 193

Offender Health Profile for Norfolk

6. By placing a tick in one box in each group below, please indicate which statements best describe your own health state today: a) Mobility 1. I have no problems in walking about 1 2. I have some problems in walking about 2 3. I am confined to bed 3 b) Self Care 1. I have no problems with self-care 1 2. I have some problems washing or dressing myself 2 3. I am unable to wash or dress myself 3 c) Anxiety / Depression 1. I am not anxious or depressed 1 2. I am moderately anxious or depressed 2 3. I am extremely anxious or depressed 3 d) Medical Health Problems 1. None 1 2. Diabetes Type 1 or 2 2 3. Epilepsy 3 4. Asthma 4 5. CHD 5 6. COPD 6 7. Other please state_________________________________ 5 7. Do you have a chronic long-standing physical or mental health problem? (Long-standing means anything that has troubled you over a period of 3 months).

1. Yes, both a physical and a mental health problem 1 2. Yes, a physical health problem only 2 3. Yes, a mental health problem only 3 4. No 4 5. Donâ&#x20AC;&#x2122;t know / not sure 5 8. Does this illness or disability limit your activities in any way?

1. Yes 1 2. No 2 Drinking Experiences For each of the following questions, please mark X in the box that best describes your answer.

1. Do you drink alcohol nowadays, including drinks you brew or make at home? (If answer yes go to next question) 1. Yes 1 2. No 2 2. How old were you the first time you ever had a proper alcoholic drink? Write in how old you were then (eg 16).

1. Under 15 2. 16 -20 1 3. 20 - 29 2 4. 30 - 39 3 5. 40 - 49 4 6. 50 - 59 5 7. 60 â&#x20AC;&#x201C; 69 6 8. 70 or over 3. Thinking now about all kinds of drinks, how often have you had an alcoholic drink of any kind during the last 12 months? Please place X in one box.

1. Almost every day 1 2. Once or twice a week 7 3. Three or four days a week 5 4. Five or six days a week 3

Page | 194

Offender Health Profile for Norfolk

5.

6.

7.

8.

Once or twice a month 2 Once every couple of months 4 Once or twice a year 6 I have not had an alcoholic drink in the last year

8

Comments ___________________________________________________________________ 4. On how many days out of the last seven did you have an alcoholic drink?

1. One 1 2. Two 2 3. Three 3 4. Four 4 5. Five 5 6. Six 6 7. Seven 7 8. None 8 Office use only, circle criteria. Regular/occasional/binge/non drinker 5. Have you felt that I ought to cut down on your drinking?

1. Yes 1 2. No 2 3. Don’t know 3 6. Have you felt ashamed or guilty about your drinking?

1. Yes 1 2. No 2 3. Don’t know 3 7. Have people annoyed me by criticising your drinking?

1. Yes 1 2. No 2 3. Don’t know 3 8. Do you have an alcoholic drink first thing in the morning?

1. Yes 1 2. No 2 3. Don’t know 3 Sexual Health and Vaccinations 1. Do you practice safe sex?

1. Yes 1 2. No 2 3. Don’t know 3 4. Prefer not to say 4 2.

1.

2.

3.

4.

5.

6.

7.

Are you vaccinated against the following?

Polio Y 1 N 2 Can’t remember 3 Tetanus Y 4 N 5 Can’t remember 6 Heb B Y 7 N 8 Can’t remember 9 Diphtheria Y 10 N 11 Can’t remember 12 MMR Y 13 N 14 Can’t remember 15 TB Y 16 N 17 Can’t remember 18 Other ___________________________________________________________________________________________ ___________________________________________________

3. Have you been screened for the followings?

1. Chlamydia Y 1 N 2 Can’t remember 2. Heb B Y 4 N 5 Can’t remember

Page | 195

3 6

Offender Health Profile for Norfolk

3. HIV

Y

7

N

8

Canâ&#x20AC;&#x2122;t remember

9

Healthy Eating 1. On average, how many portions of vegetables do you eat each day?

(1 portion of vegetables is, for example, 3 heaped tablespoons of cooked vegetables such as carrots, cabbage, peas or sweet corn, or one cereal bowl of mixed salad. Beans and other pulse vegetables, such as kidney beans, lentils and chick peas can count, but only once a day, however much you eat. You can include raw, cooked, frozen or tinned vegetables, but do not include potatoes.) Please put X in one box.

1. One 1 2. Two 2 3. Three 3 4. Four 4 5. Five 5 6. Six 6 7. Seven or more 7 8. None 8 2. On average, how many portions of fruit do you eat each day?

(1 portion of fruit is a medium apple, banana or orange; a handful of grapes, cherries or berries; a large slice of pineapple; 2 plums, apricots etc; 1 tablespoon of dried fruit; 1 medium glass of fruit juice.) Please put X in one box.

1. One 1 2. Two 2 3. Three 3 4. Four 4 5. Five 5 6. Six 6 7. Seven or more 7 8. None Smoking 1. Have you ever smoked?

1. No (go to Q1 leisure)1 2. Yes 2 Please state 3. Tobacco 3 4. Cigarettes 4 5. Cannabis 5 6. Water pipe 6 7. other 7 _____________________________ 2. If YES, do you smoke now?

1. Yes 1 2. No (go to Q1 leisure)2 3. Would you like help in trying to give up smoking?

1. Yes 1 2. No (go to Q1 leisure)2 4. If YES, how would you like to give up smoking?

From the list below, please put X by all that apply: 1. Using nicotine patches / gum (N.R.T) * 1 2. Visiting Stop Smoking clinic 2 3. Talk to GP / Practice Nurse 3 4. Talk to Pharmacist 4 5. Give up on my own 5 6. Other (please state)_______________________6 *NRT is Nicotine Replacement Therapy, available on prescription from a health professional.

Page | 196

Offender Health Profile for Norfolk

Leisure 1. On average, how many times do you take part in physical activity each day for at least 30 minutes?

(This can be made up of 2 periods of 15 minutes or 3 of 10 minutes & include activities that are of light to moderate intensity brisk walking, strenuous gardening and vigorous housework) 1. Never 1 2. Once a week 2 3. Twice a week 3 4. Three times a week 4 5. Four times a week 5 6. Five times a week 6 Exercise is a specific form of physical activity â&#x20AC;&#x201D; planned, purposeful physical activity performed with the intention of acquiring fitness or other health benefits, 2. On average, how many times do you take part in exercise each day for at least 30 minutes?

(This can be made up of 2 periods of 15 minutes or 3 of 10 minutes & include activities that are of moderate to vigorous intensity like jogging, swimming, cycling and weight training etc) 1. Never 1 2. Once a week 2 3. Twice a week 3 4. Three times a week 4 5. Four times a week 5 6. Five times a week 6 Is there anything else you would like to add?

(PLEASE WRITE IN THE BOX BELOW)

THANK YOU for taking part in this survey Please ensure that you have marked all of the relevant boxes.

Page | 197

Offender Health Profile for Norfolk

Appendix 9: OASys tables Table 48: Alcohol - Current use a problem male Team Bury St Edmunds Ipswich King's Lynn Norwich Waveney & Yare NSCRC

No problems 101 116 80 217 88 602

% 57.4 60.4 57.1 66.8 61.1 61.6

Some problems 45 56 45 82 31 259

% 25.6 29.2 32.1 25.2 21.5 26.5

Significant problems 30 20 15 26 25 116

%

Total

17.0 10.4 10.7 8.0 17.4 11.9

176 192 140 325 144 977

%

Total

* * * 15.3 * 14.8

* * * 72 * 162

Table 49: Alcohol - Current use a problem female Team Bury St Edmunds Ipswich King's Lynn Norwich Waveney & Yare NSCRC

No problems 10 12 16 49 17 104

% 58.8 54.5 57.1 68.1 73.9 64.2

Some problems * * * 12 * 34

% * * * 16.7 * 21.0

Significant problems * * * 11 * 24

Note: Due to small numbers it is not possible to present the information for all areas (asterisks in table).

Table 50: Drugs linked to offending male Team Bury St Edmunds Ipswich King's Lynn Norwich Waveney & Yare NSCRC

No 62 72 47 113 43 337

% 50.8 46.8 44.8 42.8 35.8 44.1

Yes 60 82 58 151 77 428

% 49.2 53.2 55.2 57.2 64.2 55.9

Total 122 154 105 264 120 765

% 54.5 50.0 35.3 47.9 52.6 47.7

Yes * * 11 25 9 57

% * * 64.7 52.1 47.4 52.3

Total * * 17 48 19 109

Table 51: Drugs linked to offending female Team Bury St Edmunds Ipswich King's Lynn Norwich Waveney & Yare NSCRC

No 6 7 6 23 10 52

Note: Due to small numbers it is not possible to present the information for all areas (asterisks in table).

Page | 198

Offender Health Profile for Norfolk

Table 52: Psychiatric problems male Team Bury St Edmunds Ipswich King's Lynn Norwich Waveney & Yare NSCRC

No problems 110 145 112 259 100 726

% 76.4 84.3 87.5 81.4 76.3 81.3

Some problems 27 21 11 51 29 139

% 18.8 12.2 8.6 16.0 22.1 15.6

Significant problems 7 6 * 8 * 28

%

Total

4.9 3.5 * 2.5 * 3.1

144 172 * 318 * 893

Note: Due to small numbers it is not possible to present the information for all areas (asterisks in table).

Table 53: Psychiatric problems female Team Bury St Edmunds Ipswich King's Lynn Norwich Waveney & Yare NSCRC

No problems 11 9 14 55 11 100

% 84.6 50.0 82.4 77.5 57.9 72.5

Some problems * 8 * 12 7 31

%

44.4 16.9 36.8 22.5

Significant problems * * * * * 7

%

Total

* * * * * 5.1

13 18 17 71 19 138

Note: Due to small numbers it is not possible to present the information for all areas (asterisks in table).

Table 54: Psychological problems / depression for males Team Bury St Edmunds Ipswich King's Lynn Norwich Waveney & Yare NSCRC

No problems 67 99 81 164 63 474

% 46.5 57.6 63.3 51.6 48.1 53.1

Some problems 66 57 35 119 61 338

% 45.8 33.1 27.3 37.4 46.6 37.8

Significant problems 11 16 12 35 7 81

%

Total

7.6 9.3 9.4 11.0 5.3 9.1

144 172 128 318 131 893

%

Total

* * * 19.7 * 17.4

13 18 17 71 19 138

Table 55: Psychological problems / depression for females Team Bury St Edmunds Ipswich King's Lynn Norwich Waveney & Yare NSCRC

No problems * * * 12 * 22

% * * * 16.9 * 15.9

Some problems * * * 45 * 92

% * * * 63.4 * 66.7

Significant problems * * * 14 * 24

Note: Due to small numbers it is not possible to present the information for all areas (asterisks in table).

Page | 199

Offender Health Profile for Norfolk

Appendix 10: Information from Project Nova so far Employment 58% of the veterans were in employment at time of arrest; of these, almost half would prefer a new job.

42% of the veterans were unemployed, of which 25% could not work due to ill health or substance misuse and 3% were over the retirement age. Of the approximate 30 people referred who were unemployed, nine are now in employment and eight are still awaiting the outcome of applications after receiving support from Project Nova and Welfare to Work providers known to Project Nova.

Substance misuse 47% have indicated that they are either currently misusing substances or have done so.

6 referrals have been made to Outside the Wire and nine to the NHS. Other veterans have intimated that they are currently engaged with NHS via their GP or with other community groups.

Violence Over half of the veterans were arrested for violence (including domestic violence). There were nine referrals to anger management courses locally and nationally.

Housing and debt 7 (8.9%) of the veteran referrals were homeless or NFA at time of arrest and have been supported

by Project Nova by referring into Genesis Stars project, Stonham Housing, St Martins Housing Trust and Waveney district council. All are now in accommodation.

62% indicated that they are in some form of financial debt ranging from housing arrears to loans or credit cards. Referrals to Money Advice Service/Citizens Advice Bureau and the Royal British Legion offered to all candidates.

Post-traumatic stress disorder (PTSD) 11 veterans have intimated that they have been diagnosed with PTSD (although project workers are unable to corroborate this at present). Project Nova has made seven referrals to Combat Stress.

Sex offenders There have been two arrests for child sexual abuse (allegations), two for indecent assault and one for voyeurism. One veteran has asked for specialist support for his offending behaviour and has been linked with that bespoke support.

Remount Charity 3 Project Nova candidates have been referred and attended the Remount Charity course.

Royal British Legion Industries (RBLI) Lifeworks programme One Project Nova candidate has been referred to Lifeworks.

Solicitor and court letters provided The Project Nova VIC-SEC has been in contact with eight solicitors, providing a letter for the court giving an overview of what Project Nova has organised for the veteran and how the veteran has engaged. Current talks are in place to give formal presentations to all practitioners engaged in the criminal justice system in the counties of Norfolk and Suffolk.

Page | 200

Offender Health Profile for Norfolk

Referrals to the Royal British Legion and Support for Soldiers & Military Families (SSAFA) 29 referrals have been made for support in the forms of housing grants, employment support grants, debt advice and clothing grants.

Walking with the Wounded has provided financial assistance to two veteran referrals in the form of course fees and transport costs.

Page | 201

Offender Health Profile for Norfolk

Contact Information For more information please contact: Josh Robotham – Researcher Norfolk County Council, Carrow House, 301 King Street, Norwich, Norfolk, NR1 2TN. Telephone: 01603 638030.

Email: joshua.robotham@norfolk.gov.uk Dr Kadhim Alabady – Technical / clinical lead Norfolk County Council, County Hall, Martineau Lane, Norwich, Norfolk, NR1 2DH. Telephone: 01603 638362 Email: kadhim.alabady@norfolk.gov.uk Ellie Phillips – Research analyst Norfolk County Council, County Hall, Martineau Lane, Norwich, Norfolk, NR1 2DH. Email: ellie.phillips@norfolk.gov.uk Judy Lomas – Project Manager Norfolk County Council, County Hall, Martineau Lane, Norwich, Norfolk, NR1 2DH. Telephone: 01603 223442 Email: judy.lomas@norfolk.gov.uk

Page | 202