The size of the prison population has doubled in the last 20 years and many people in the criminal justice system have complex mental health needs which are poorly recognised and inadequately managed. Large numbers end up in prison: a high-cost intervention which is inappropriate as a setting for mental health care and ineffective in reducing subsequent offending.
One prisoner in ten has a severe mental illness such as schizophrenia. Nearly half have depression or anxiety. A similar proportion are dependent upon alcohol or illegal drugs, while two-thirds meet the criteria for a diagnosis of personality disorder. Overall, 90% of prisoners have some kind of diagnosable mental health problem and 70% have two or more such problems.
In many cases the use of prison can be avoided if people are diverted at an early stage of their contact with the justice system (although people can be diverted at ANY stage). Liaison and diversion services identify people who have mental health problems and learning disabilities when they come into contact with the police and courts. They assess the person's needs, advise on their case management and ensure that those in need receive the treatment and support they require.
We have shown that successful diversion can improve health, it may reduce the risk of re-offending and it can cut the costs of crime. But often opportunities for diversion are missed and too little is being done to ensure that offenders with mental health problems make continuing use of community mental health services.
We have developed a model of diversion for children and young people and have tested it out in practice. And we are supporting the national expansion of diversion services throughout England as part of the Offender Health Collaborative.
Key components of successful diversion
From our research into liaison and diversion services across the country, we know that these are the key components of successful services:
- having a comprehensive knowledge of local social and health economies and good relationships with agencies across it.
- making engagement a key activity as many of those it will want to target will have had previous poor experience of services.
- assessing for a broad range of psycho-social needs.
- having immediate access (within team) to housing and benefits advice.
- keeping the service user’s view of their needs at the core of their assessment.
- focusing on meeting basic needs first.
- being sufficiently resourced to connect people to a range of services (this might include accompanying people to appointments).
- being pro-active and assertive (services that are active and not just reactive to a clients needs and where possible offer not just a formal appointment based service).
- providing some indefinite support with a focus on crises and educating service users on averting these.
- providing a drop-in service after the initial intervention.
- being interested in outcomes and following up on referrals and sign-posting.
- understanding the needs of police, probation and sentencers.
- improving mental health awareness among criminal justice agencies and staff.
What you can do - Policy
- The Government should commission a programme of research to improve our knowledge of effectiveness and cost-effectiveness.
- The Government should collect and publish much more information on unit costs in the criminal justice system.
- The Government should consider the scope for improving the identification of mental illness by police officers, court officials and other criminal justice staff.
- The Government and CCGs should develop new methods of primary care support for offenders with complex needs and other similar groups.
- More use should be made of the Mental Health Treatment Requirement as a sentencing option.
What you can do - Commissioning
- Clinical commissioning groups should identify a lead commissioner with a specific remit to coordinate care across agencies for those identified with multiple and complex needs. Such commissioners would have charge of a specific set of pathways for individuals meeting appropriate criteria. Within this remit would be the identification and long-term monitoring of those at higher risk or most persistent vulnerability.
- A Diversion and Liaison Team for people with mental health problems who come into contact with the criminal justice system should be established in every CCG area in England. These teams should be supported by a national statement of policy and associated implementation guidance.
- Diversion and liaison services should always be commissioned on the basis of joint funding from mental health and criminal justice budgets.
- Commissioners of diversion and liaison services should wherever possible consider the scope for using voluntary sector agencies.
- Liaison and diversion services should be commissioned to provide an element of indefinite support, in the form of drop-in support focused on averting crises and reconnecting service users with mainstream services where required.
- Local NHS commissioners need to ensure that offenders have timely access to psychological therapy services with clear referral routes from liaison and diversion services and from probation.
What you can do - In practice
As well as implementing the key components of successful diversion above, there are other things you can do:
- Every diversion and liaison team should be overseen by a cross-agency management group.
- The services to be provided by diversion and liaison teams to criminal justice agencies should always be specified in contracts or service-level agreements.
- Commissioners and managers of all community-based mental health services should ensure that a potential client’s offending history does not act as a barrier to receipt of these services.
- Teams should be organised to support offenders with mental health problems at all stages of the criminal justice pathway.
- Strengthening positive social networks in the service user’s community is a vital part of the diversion infrastructure. This should include a capacity to intervene with and support families and the provision of alternatives such as volunteer mentoring to fill gaps in the support available.
- Extend the use of pro-active methods of identifying potential clients, including 100% screening of selected groups of offenders.
- Develop and agree plans for the provision of training in mental health issues for criminal justice staff.
- In appropriate circumstances, criminal justice agencies should make greater use of conditionality in decisions relating to charging, remand and sentencing as a means of promoting engagement with mental health services by offenders.