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Blurring the boundaries: the convergence of mental health and criminal justice


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A presentation about how mental health and criminal justice policies and services are converging in the UK. The report on the subject is available from:

Originally uploaded 15 March 2010.

Published in: Health & Medicine
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Blurring the boundaries: the convergence of mental health and criminal justice

  1. 1. Blurring the Boundaries: The convergence of mental health and criminal justice policy, legislation, systems and practice Max Rutherford, Prisons and Criminal Justice Programme
  2. 2. Policy development: 1990-2009 <ul><li>1990 – Home Office Circular 66/90 </li></ul><ul><li>1994 – Completion of the Reed Reports </li></ul><ul><li>1996 – HMIP ‘Patient or Prisoner?’ </li></ul><ul><li>1999 – HMPS/NHS ‘The future organisation of prison health care’ </li></ul><ul><li>1999 – DH ‘National Service Framework for Mental Health </li></ul><ul><li>2001 – DH/HMPS ‘Changing the Outlook: A Strategy for Developing and Modernising Mental Health Services in Prisons’ </li></ul><ul><li>2005 – DH/NIMHE ‘Offender Mental Health Care Pathway’ </li></ul><ul><li>2007 – ‘Improving Health, Supporting Justice’ </li></ul><ul><li>2007 – ‘The Corston Report’ </li></ul><ul><li>2007 – HMIP ‘Mental health of prisoners thematic’ </li></ul><ul><li>2009 – ‘The Bradley Report: A review of diversion of offenders with mental health problems and learning disabilities away from prison’ </li></ul><ul><li>2009 – DH/MoJ ‘Delivery Plan’ (expected November 2009) </li></ul>
  3. 3. Convergence project <ul><li>i. Analysis of legislation and policy </li></ul><ul><li>ii. Written submissions from experts </li></ul><ul><ul><ul><li>Government departments </li></ul></ul></ul><ul><ul><ul><li>Clinicians </li></ul></ul></ul><ul><ul><ul><li>Academics </li></ul></ul></ul><ul><ul><ul><li>Professionals </li></ul></ul></ul><ul><ul><ul><li>Non-statutory organisations </li></ul></ul></ul><ul><li>iii. Expert event – conclusions and recommendations </li></ul>
  4. 4. Convergence project (2) <ul><li>Analysis of legislation and policy: </li></ul><ul><ul><li>Criminal Justice Mental Health teams </li></ul></ul><ul><ul><li>Mental health courts </li></ul></ul><ul><ul><li>Mental Health Treatment Requirement </li></ul></ul><ul><ul><li>IPP sentences </li></ul></ul><ul><ul><li>DSPD Programme </li></ul></ul><ul><ul><li>Hospital and Limitation Direction </li></ul></ul>
  5. 5. 1. CJMH teams <ul><li>Diversion schemes have developed since 1990s </li></ul><ul><ul><li>150 by 2000s </li></ul></ul><ul><li>Limitations of current arrangements: </li></ul><ul><ul><li>No central strategy </li></ul></ul><ul><ul><li>Patchy coverage </li></ul></ul><ul><ul><li>Piecemeal impact </li></ul></ul><ul><ul><li>Modest </li></ul></ul><ul><ul><li>Not influential or assertive </li></ul></ul>
  6. 6. CJMH teams (2) <ul><li>Bradley specifications: </li></ul><ul><ul><li>Core minimum standards for each team </li></ul></ul><ul><ul><li>National network </li></ul></ul><ul><ul><li>Reporting structure </li></ul></ul><ul><ul><li>National minimum dataset </li></ul></ul><ul><ul><li>Performance monitoring </li></ul></ul><ul><ul><li>Local development plans </li></ul></ul><ul><ul><li>Key personnel </li></ul></ul><ul><ul><li>Mandated in the NHS operating framework </li></ul></ul>
  7. 7. CJMH teams (3) <ul><li>Potential benefits: </li></ul><ul><ul><li>Cost and efficiency savings within the criminal justice system; </li></ul></ul><ul><ul><li>Reductions in re-offending; </li></ul></ul><ul><ul><li>Improvements in mental health </li></ul></ul><ul><li>£20,000 savings per diversion </li></ul><ul><ul><li>£8,000 to CJS </li></ul></ul><ul><ul><li>£16,000 from reducing reoffending </li></ul></ul>
  8. 8. 2. Mental health courts (1) <ul><li>Benefits: </li></ul><ul><li>Early identification </li></ul><ul><li>Increased efficiency </li></ul><ul><li>Specialism </li></ul><ul><li>MH options for sentencing </li></ul><ul><li>Review function </li></ul><ul><li>“ On the face of it this seems a way of successfully dealing with offenders with mental health problems” (Bradley 2009, p. 78) </li></ul><ul><li>Concerns: </li></ul><ul><li>Limited places </li></ul><ul><li>Complexity needs </li></ul><ul><li>Not integrated </li></ul><ul><li>Time-limited funding </li></ul><ul><li>Redundant function? </li></ul><ul><li>“ I would also question the value of such courts if the role of liaison and diversion services is to be developed as recommended” (Bradley 2009, p. 78) </li></ul>
  9. 9. Mental health courts (2) <ul><li>Two mental health court pilots </li></ul><ul><ul><li>Brighton </li></ul></ul><ul><ul><li>Stratford </li></ul></ul><ul><ul><li>One year funding </li></ul></ul><ul><ul><li>350 offenders per year </li></ul></ul>
  10. 10. 3. Mental Health Treatment Requirements <ul><li>Implemented in 2005 (CJA 2003) </li></ul><ul><ul><li>One of twelve </li></ul></ul><ul><ul><li>Less than 1% of all requirements </li></ul></ul><ul><ul><li>918 issued in 2008 </li></ul></ul><ul><li>A missed opportunity’ due to: </li></ul><ul><ul><li>Lack of knowledge and understanding </li></ul></ul><ul><ul><li>Lack of unified purpose </li></ul></ul><ul><ul><li>Unclear criteria </li></ul></ul><ul><ul><li>Poor identification </li></ul></ul><ul><ul><li>Unclear breach process </li></ul></ul><ul><ul><li>Poor inter-agency communication </li></ul></ul>
  11. 11. Mental Health Treatment Requirements (2) <ul><li>Potential benefits: </li></ul><ul><ul><li>Flexible sentencing provision </li></ul></ul><ul><ul><li>Diversion option </li></ul></ul><ul><ul><li>Robust supervision </li></ul></ul><ul><ul><li>Engagement with services </li></ul></ul><ul><ul><li>Reduce reoffending </li></ul></ul><ul><ul><li>Cost-benefit </li></ul></ul><ul><li>Bradley 2009, p. 96: </li></ul><ul><ul><li>“ Further research into the use of MHTRs” </li></ul></ul><ul><ul><li>“ Development of clear guidance regarding the use of MHTRs” </li></ul></ul><ul><ul><li>“ SLA to ensure that MHTRs can be provided to offenders when requested by courts” </li></ul></ul>
  12. 12. 4. Imprisonment for Public Protection <ul><li>Introduced in April 2005 (CJA 2003) </li></ul><ul><li>5,800 IPP prisoners by December 2009 </li></ul><ul><li>140 new IPP sentences each month </li></ul><ul><li>2,130 are beyond tariff </li></ul><ul><li>94 released </li></ul><ul><li>Amended in summer 2008; abolition attempt in House of Lords </li></ul>
  13. 13. Imprisonment for Public Protection (2) <ul><li>General problems: </li></ul><ul><ul><li>Volume </li></ul></ul><ul><ul><li>Lack of information </li></ul></ul><ul><ul><li>Shortage of courses </li></ul></ul><ul><ul><li>Volatile tensions </li></ul></ul><ul><li>“ A study should be commissioned to consider the relationship between imprisonment for public protection sentences and mental health or learning disability issues&quot; </li></ul><ul><li>Bradley 2009, p. 100 </li></ul><ul><li>Mental health impact: </li></ul><ul><ul><li>Diagnosing dangerousness </li></ul></ul><ul><ul><li>Indeterminacy </li></ul></ul><ul><ul><li>Impact on families </li></ul></ul><ul><ul><li>Avoidance of mental health services </li></ul></ul><ul><ul><li>Exclusion from courses </li></ul></ul>
  14. 14. Imprisonment for Public Protection (3) <ul><li>OASys data (2,204 IPP prisoners, 3,368 Life prisoners and 54,785 general prison population) </li></ul><ul><ul><li>55% ‘emotional wellbeing’ </li></ul></ul><ul><ul><li>18% have received psychiatric treatment in the past </li></ul></ul><ul><ul><li>10% continue to receive psychiatric treatment in prison </li></ul></ul><ul><ul><li>21% receiving medication for a mental health problem </li></ul></ul><ul><ul><li>6% classified as ‘currently or ever been a patient in special hospital or regional secure unit’ </li></ul></ul><ul><ul><li>37% have a history of self-harm or suicidal behaviour </li></ul></ul><ul><ul><li>106 transferred to High/Medium secure forensic hospitals </li></ul></ul><ul><ul><li>8 suicides </li></ul></ul>
  15. 15. 5. DSPD Programme <ul><li>Pilot project since 2001 – MoJ/NOMS/DH/NHS </li></ul><ul><li>300 high secure places for men </li></ul><ul><li>75 medium secure and community places with community teams </li></ul><ul><li>12 bed service for women </li></ul><ul><li>Research and Development programme </li></ul>
  16. 16. DSPD Programme (2) <ul><li>Two high-security prisons </li></ul><ul><ul><li>HMP Whitemoor and HMP Frankland </li></ul></ul><ul><li>Two high-security hospitals </li></ul><ul><ul><li>Broadmoor and Rampton </li></ul></ul><ul><li>12-bed ‘Primrose’ unit for women </li></ul><ul><ul><li>HMP/YOI Low Newton </li></ul></ul><ul><li>Treats an average of 234 people each year (2008-9) </li></ul><ul><li>Average length of stay varies considerably between units </li></ul><ul><ul><li>1.6 to 4.2 years ( HC Hansard , 15 Jun 2009 : Column 66W) </li></ul></ul>
  17. 17. DSPD Programme (3) <ul><li>One of the longest running and most expensive pilots in UK history </li></ul><ul><li>In its ninth year </li></ul><ul><ul><li>Treated around 450 people </li></ul></ul><ul><li>DSPD has cost £488 million since 2001 </li></ul><ul><ul><li>Capital expenditure </li></ul></ul><ul><ul><ul><li>£128m (2001-3) </li></ul></ul></ul><ul><ul><li>Annual spending since: </li></ul></ul><ul><ul><ul><li>£40 million pa 2003-4 to 2005-6 </li></ul></ul></ul><ul><ul><ul><li>£60 million pa 2006-07 onwards </li></ul></ul></ul>
  18. 18. DSPD Programme (4) <ul><li>Not in statute </li></ul><ul><ul><li>Several attempts since 2000 </li></ul></ul><ul><li>In June 2009, the government stated that: </li></ul><ul><li>“ There are no plans to change the statutory basis of the Dangerous and Severe Personality Disorder programme” ( HC Hansard , 15 Jun 2009 : Column 65W) </li></ul>
  19. 19. DSPD Programme (5) <ul><li>DSPD intended to address: </li></ul><ul><ul><li>“ The challenge to public safety presented by the minority of people with severe personality disorder, who because of their disorder pose a risk of serious offending” </li></ul></ul><ul><li>For persons who: </li></ul><ul><ul><li>Are more likely than not to commit an offence that might be expected to lead to serious physical or psychological harm from which the victim would find it difficult or impossible to recover; and </li></ul></ul><ul><ul><li>Have a severe disorder of personality; and </li></ul></ul><ul><ul><li>There is a link between their disorder and the risk of offending </li></ul></ul>
  20. 20. DSPD Programme (6) <ul><li>Reaction in 1999-2000: </li></ul><ul><ul><li>War of words between psychiatrists and Home Secretary </li></ul></ul><ul><ul><li>Opposition from parliamentarians (debates; Health Select Committee) </li></ul></ul><ul><ul><li>Widespread lobbyist, academic and clinical opposition </li></ul></ul>
  21. 21. DSPD Programme (7) <ul><li>Main concerns of critics: </li></ul><ul><ul><li>Ethical </li></ul></ul><ul><ul><li>Non-medical </li></ul></ul><ul><ul><li>Limitations of risk-based interventions </li></ul></ul><ul><li>Some research findings: </li></ul><ul><ul><li>DSPD requires the detention of six people to prevent one crime </li></ul></ul><ul><ul><li>DSPD started badly, but may have a use </li></ul></ul><ul><ul><li>DSPD needs to be cost-effective </li></ul></ul>
  22. 22. DSPD Programme (8) <ul><li>“ An evaluation of the DSPD programme to ensure it is able to address the level of need” (Bradley 2009, p. 109) </li></ul><ul><li>The government accepted this: </li></ul><ul><ul><li>“ A Personality Disorder strategy will be developed by February 2010 that will address this recommendation” (Ministry of Justice, 30 April 2009) </li></ul></ul><ul><li>One alternative approach: </li></ul><ul><ul><li>Decommission and reinvest in a comprehensive tiered prison-based PD service </li></ul></ul><ul><ul><li>£60 million per year would have a substantial impact on the current level of need in mainstream prisons (up to 70% of prisoners have a diagnosable PD) </li></ul></ul>
  23. 23. 6. Hospital and Limitation Direction <ul><li>Section 45a of the Mental Health Act (‘Hybrid Order’) </li></ul><ul><li>Issued at the point of sentencing by a judge </li></ul><ul><ul><li>Transfer to secure hospital for indeterminate length </li></ul></ul><ul><ul><li>AND a prison sentence (potentially of indeterminate length) </li></ul></ul><ul><li>For what psychiatric conditions? </li></ul><ul><ul><li>Any mental disorder (since November 2008) </li></ul></ul><ul><ul><li>No need for psychiatrists’ recommendation, just the diagnosis </li></ul></ul>
  24. 24. Hospital and Limitation Direction (2) <ul><li>Origins: </li></ul><ul><ul><li>DH/HO (1985): ‘psychopathic disorder’ </li></ul></ul><ul><ul><li>Reed Report (1994): ‘psychopathic disorder’ </li></ul></ul><ul><ul><li>Conservative (White Paper 1996, pictured): all mental disorders </li></ul></ul><ul><ul><li>Labour ‘Crime (Sentences) Act 1997: ‘psychopathic disorder’ </li></ul></ul><ul><li>Rarely used since 1999 </li></ul><ul><ul><li>34 uses </li></ul></ul><ul><ul><li>16 patients detained in forensic mental health services under a HLD (31 st December 2007) </li></ul></ul>
  25. 25. Hospital and Limitation Direction (3) <ul><li>Mental Health Act 2007 </li></ul><ul><ul><li>All mental disorders </li></ul></ul><ul><ul><li>Implemented November 2008 </li></ul></ul><ul><li>Proposed benefits: </li></ul><ul><ul><li>Flexibility in sentencing </li></ul></ul><ul><ul><li>Clinical treatment and aftercare </li></ul></ul><ul><ul><li>Societal justice </li></ul></ul><ul><ul><li>Public protection </li></ul></ul>
  26. 26. Hospital and Limitation Direction (4) <ul><li>Potential risks: </li></ul><ul><ul><li>Clinicians as agents of the state </li></ul></ul><ul><ul><li>Pressure on sentencers </li></ul></ul><ul><ul><li>Fundamentally un-therapeutic </li></ul></ul><ul><ul><li>Doctor as gaoler </li></ul></ul><ul><ul><li>Discontinuity of care </li></ul></ul><ul><li>‘ Avalanche effect’ * </li></ul><ul><ul><li>Punitiveness </li></ul></ul><ul><ul><li>‘ Double indeterminacy’ </li></ul></ul><ul><ul><li>Alternative defences </li></ul></ul><ul><ul><li>Resources pressure (NHS, CJS) </li></ul></ul><ul><ul><li>‘ Reverse diversion’ </li></ul></ul>*Eastman, N (1996), Hybrid Orders: An analysis of their likely effects on sentencing practice and on forensic psychiatric practice and services’, Journal of Forensic Psychiatry , Vol. 7, No 3. 481-494, p. 481
  27. 27. Convergence: Our initial conclusions <ul><li>Convergence describes a complex interaction and overlap between mental health and criminal justice </li></ul><ul><li>Instances of convergence have been limited but increasing over the last 10 years </li></ul><ul><li>Convergence looks likely to increase in the short and medium term </li></ul><ul><li>‘ Hybrid sentencing’ could become more common for offenders with mental health problems </li></ul><ul><li>There are potential benefits and concerns </li></ul><ul><li>Cost may determine future developments </li></ul>
  28. 28. <ul><li> </li></ul><ul><li>[email_address] </li></ul>