Brooker, Charlie

Denney, David

Marples, Rebecca

Sirdifield, Coral

University of Lincoln Institutional Repository

PROBATION QUARTERLY  ISSUE 14Improving the Health and Quality ofHealthcare for People on ProbationCoral Sirdifield, Rebecca Marples, Charlie Brooker, and David Denney present their recent research11IMPROVING THE HEALTH AND QUALITY OF HEALTHCARE FOR PEOPLE ON PROBATION Probation Healthcare and complexity of needOn 30th June 2018 there were 261,196 people in contact with probation in England and Wales1 (Ministry of Justice, 2018). Whilst not everyone in this group is the same, people on probation are often socially excluded, and the limited research available suggests that they have a high prevalence and complexity of health problems when compared to the general population (Brooker el al 2012). Many people in contact with probation will experience negative social determinants of health such as unemployment and homelessness. In addition, their voice is seldom heard by commissioners or those providing oversight and scrutiny of healthcare services.Despite the high level and complexity of health needs in this group, people in contact with probation face both system-level and personal-level barriers to accessing healthcare. If we wish to reduce health inequalities by improving the health of this population it is essential that they have access to health services which meet their needs. This could also potentially reduce the use of crisis services and the costs associated with this. Moreover, improved health is cited as a pathway out of re-offending. Clinical Commissioning Groups (CCGs) are responsible for commissioning the majority of healthcare for the probation population but previous research suggests that many of them are unaware of this responsibility (Department of Health, 2013; Brooker et al., 2017). This article describes a study which asks whether people in contact with probation are receiving the care that they need, and how we can best ensure that their needs are met. The study funded by the National Institute of Health Research investigated the range and quality of healthcare for people that are in contact with probation (defined as those living in the community, including in probation Approved Premises and in contact with the National Probation Service (NPS) or a Community Rehabilitation Company (CRC)) in England. The research sought to establish the most effective ways of providing healthcare for people on probation to achieve good health outcomes by investigating current systems, policies and existing procedures within each probation provider to deliver healthcare to people in contact with probation.   We adopted a multi-methods approach combining a narrative systematic review with a survey of key stakeholders in England, analysis of policies and procedures, and telephone interviews to inform case studies in a purposive sample of six geographical areas. A systematic search was undertaken of the published literature and the grey literature, including hand searching of key journals from 2000 to September 2017. Survey participants were also asked to provide examples of evaluations or research undertaken in relation to any aspect(s) of their work in offender healthcare.  Barriers to health careThe review identified numerous barriers to service access that are encountered by people in contact with probation including: low levels of literacy and health literacy; financial barriers; some staff having an uncaring professional demeanour and stigmatising people; people not being registered with GPs; competing priorities making it hard for people to focus on their health; inadequate service provision; and commissioning not being informed by the health needs of people in contact with probation (Sirdifield et al., 2019). 1 This figure includes those on community sentences, suspended sentences, pre-release supervision and post-release supervision that are in contact with either the National Probation Service (NPS) or a Community Rehabilitation Company (CRC)12IMPROVING THE HEALTH AND QUALITY OF HEALTHCARE FOR PEOPLE ON PROBATION PROBATION QUARTERLY  ISSUE 14The research revealed a significant paucity of research on the effectiveness of interventions to improve the health of people in contact with probation. In relation to mental health, a high prevalence and complexity of mental illness amongst this group including high levels of co-morbidity and dual diagnosis was noted. Research papers highlighted the value of specialist mental health probation Approved Premises for improving residents’ engagement with mental health services and of implementing psychologically informed and planned environments to improve probation staff’s confidence in working with people with personality disorder. Findings also showed that the rate of suicide amongst people in contact with probation is higher than amongst the general population. Some studies suggested that increased risk of suicide may be linked to mental illness and substance abuse, with risk being particularly high during the time immediately after release from prison (Phillips et al., 2018). Studies also pointed to high levels of drug and alcohol use amongst people in contact with probation (Brooker et al., 2012).We also conducted six national surveys – sending invitations to participate to all probation Approved Premises, National Probation Service areas, Community Rehabilitation Companies, Public Health Departments, Mental Health Trusts and Clinical Commissioning Groups in England (n=591). A total of 141 organisations responded to the surveys. We later sent freedom of information (FOI) requests to the non-participating CCGs, Mental Health Trusts and Public Health Departments to acquire key data. This resulted in an additional 325 responses, bringing our total to 466 (78.8%). Many respondents reported gaps in service provision and/or a lack of clear and understood pathways into services. Other themes included difficulties for those who were temporarily housed in probation Approved Premises and organisational changes resulting in people falling through the gaps in service provision. Respondents also reported an absence of services to meet the needs of groups whilst negative perceptions of people in contact with probation could lead to them being denied access to services. Individuals on probation were also perceived as lacking motivation or ability to attend appointments. Poor information sharing often made it difficult to achieve continuity of care. Staff training in relation to health needs could also be inadequate whilst crucially Probation lacked a voice in the commissioning process.In order to respond to these identified problems respondents suggested increased investment in service provision, improved speed of access, clear information about the services available and how to access them, specific services and/or access routes for probation.We also conducted semi-structured interviews with staff from Mental Health Trusts, Public Health Departments, Community Rehabilitation Companies, the National Probation Service and probation Approved Premises in six areas of the country. The existence of many barriers to healthcare were reported including problematic (restrictive and unclear) referral pathways which can be diffuse and opaque, difficulties in accessing GPs, and problems with the continuity of care. Likewise, probation staff also struggle to navigate an increasingly complex and ever-changing health landscape.13PROBATION QUARTERLY  ISSUE 14IMPROVING THE HEALTH AND QUALITY OF HEALTHCARE FOR PEOPLE ON PROBATION Conclusions and Recommendations Crucially CCGs need to recognise that healthcare commissioning for people in contact with probation is their responsibility not NHS England’s. CCGs in association with Public Health Departments should be undertaking ‘gap’ analyses to examine the complex healthcare needs of people in contact with probation in their areas and the extent to which current service provision meets those needs. The new National Probation Service Health and Social Care Strategy 2019-2022 outlines ways in which routinely collected data in probation might be able to enable such gap analyses. Data from the research literature about health needs is also set out in our toolkit (see below) and could be used to inform commissioning. The research revealed generally that there is a need to improve understanding of the health needs of the probation population, and for improved partnership working between health and justice agencies, particularly with respect to developing mechanisms to support routine sharing of health data at transition points throughout the criminal justice pathway.Those in contact with probation have high levels of mental health and substance misuse needs. CCGs and Public Health Departments should examine the extent to which services are currently configured to meet these needs. The research also shows that working with criminal justice agencies to address other obstacles to health service access such as GP registration needs to be urgently addressed. Criminal Justice agencies also need to be included in commissioning processes to help improve understanding of the complex needs of people in contact with probation and ensure that services can meet them.The research also revealed the need for cross-agency training, with respect to supporting people with mental health and substance misuse needs. Mechanisms to support routine sharing of health data at transition points throughout the criminal justice pathway should also be improved. The announcement made in May 2019 that the responsibility for delivery of all offender management services will in future rest with the NPS will remove some of the organisational complexities created by part privatisation that have exacerbated and in some cases created barriers to information sharing. This reversal of policy could impact positively on the possibility of this recommendation being adopted (see https://www.parliament.uk/business/news/2019/may/the-system-isnt-working-statement-on-renationalisation-of-probation/).We also recommend involvement of criminal justice agencies in Health and Wellbeing boards and other commissioning forums and the co-location of criminal justice and health staff to ensure clear pathways into services for those in contact with probation.Implementation of these recommendations can be supported by our toolkit for commissioners and practitioners. This toolkit seeks to raise awareness of probationers’ likely health needs, what is known about the most effective ways of providing healthcare to this group (to produce good health outcomes), models of good practice, and how barriers to providing good quality and accessible healthcare for probationers can be overcome. It is available for free from: https://probhct.blogs.lincoln.ac.ukDr Coral Sirdifield, University of Lincoln, Rebecca Marples, University of Lincoln, Professor Charlie Brooker, Royal Holloway, University of London, Professor David Denney, Royal Holloway, University of London14IMPROVING THE HEALTH AND QUALITY OF HEALTHCARE FOR PEOPLE ON PROBATION PROBATION QUARTERLY  ISSUE 14This article presents independent research funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0815-20012). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.ReferencesBrooker, C., Sirdifield, C., Blizard, R., Denney, D. & Pluck, G. (2012) Probation and mental illness. The Journal of Forensic Psychiatry and Psychology, 23, 522-537, https://doi.org/10.1080/14789949.2012.704640 Brooker, C., Sirdifield, C., Ramsbotham, D. & Denney, D. (2017) NHS commissioning in probation in England - on a wing and a prayer. Health and Social Care in the Community, 25, 137-144, 10.1111/hsc.12283.Department of Health (2013) Statutory Guidance on Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies.  Department of Health, London.Ministry of Justice (2018) Offender Management Statistics Bulletin, England and Wales. Quarterly April to June 2018.  Ministry of Justice, London.Phillips, J., Padfield, N. & Gelsthorpe, L. (2018) Suicide and community justice. Health and Justice, 6.Sirdifield, C., Marples, R., Brooker, C., et al. (2019) Probation Healthcare Commissioning Toolkit, A resource for commissioners and practitioners in health and criminal justice.  University of Lincoln, Lincoln. https://probhct.blogs.lincoln.ac.uk15PROBATION QUARTERLY  ISSUE 14IMPROVING THE HEALTH AND QUALITY OF HEALTHCARE FOR PEOPLE ON PROBATION 

Improving the Health and Quality of Healthcare for People on Probation

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Improving the Health and Quality of Healthcare for People on Probation

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