Wendy Dyer

Prison Health Discharge Planning – Evidence of an Integrated Care Pathway or the End of the Road?

This article is based on research conducted in several prisons in North East England. It explores the effectiveness of prisons, and the wider criminal justice system, at meeting the healthcare needs of inmates as they leave prison, or transfer between prisons. In doing so, the article details policy context, areas of good practice and issues that still need to be addressed in relation to the creation of an integrated care pathway.

Assessing the risk of self-harm in an adult offender population: an incidence cohort study.

BACKGROUND Self-harm is common among prisoners, particularly female prisoners. In 2007, concerned about the rising incidence, the prison service introduced a care-planning system called Assessment, Care in Custody, and Teamwork (ACCT). To date, it does not incorporate a standardised diagnostic test to estimate the risk of future self-harm. OBJECTIVE To identify potential screening instruments, or items from those instruments, to predict the risk of self-harm among prisoners. PARTICIPANTS Prisoners who had been assigned to an ACCT during the recruitment period. DESIGN A multistage prospective cohort study. Following a pilot study, instruments were administered to prisoners by interview at baseline, and followed up for 6 months (or until point of release if this was sooner) to ascertain self-harm status. Instruments were assessed for unidimensionality, scalability (Mokken) and quantitative structure (Rasch). Area under the curve (AUC) analysis was used to examine the ability of instruments and/or their items to predict future self-harm. Cox proportional hazards regression models were used to examine the multivariate predictive ability of the scales and various sociodemographic and sentencing factors. SETTING Three prisons (including one womens prison) in northern England. MAIN OUTCOME MEASURES A set of standardised questionnaires, including the Prison Screening Questionnaire (PriSnQuest), Revised Borderline Symptom List-23 (frequency-based responses) (BSL-23-F), Self-Harm Inventory (SHI), Patient Health Questionnaire (PHQ-9) and the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM), together with sociodemographic and sentencing data. RESULTS In total, 450 prisoners consented to participate in the study, of whom 26% were female. The mean age of participants was 31.2 years. Over half of male prisoners recruited were on remand, compared with just over one-fifth (22.6%) of female prisoners. The average tariff of those sentenced was 41 months, of which 14.7 months, on average, had been served. Just over one-third of ACCTs had been initiated because of a known self-harm event, and over one-quarter (27.8%) of participants self-harmed during the follow-up period. Thus, almost half (46.7%) of those entered into the study were reported to have self-harmed, either from their index ACCT, or subsequently, or both. Cutting was the most frequent behaviour (51%). All screening instruments showed some evidence of unidimensionality, and four out of five showed scaling criteria consistent with ordinal scaling, so verifying the validity of the cut points. However, many showed gender bias and failure to fit the Rasch measurement model. While a resolution was made in most cases, both ordinal raw scores and latent interval scale estimates failed to show predictive value when applied within AUC analysis (0.491-0.566) or adjusted Cox proportional hazards models. However, good predictive values were shown for gender-specific sets of items, thus providing easily applied screening indexes. CONCLUSIONS While four out of five potential screening instruments were found to have acceptable psychometric properties within this setting, their predictive validity of all instruments was poor under AUC analysis. Gender-specific item sets were put together to form two screening indexes with formative indicators which gave reasonable AUC values, particularly so for females. The indexes provide identification of low-medium-high risk of self-harm, and so may help to inform potential care pathways and decisions to sign prisoners off from the ACCT. Future work should concentrate on refining a set of predictive screening items among different offender populations and investigating the time point at which this set of items should be administered. Future work may also look at the different magnitudes of risk as indicators for care pathways. FUNDING The National Institute for Health Research Health Technology Assessment programme.

Criminal Justice Diversion and Liaison Services: A Path to Success?

Diversion services for adult mentally disordered offenders are back in the limelight twenty years after their original development. This article argues there are a number of important lessons to be learnt. Services of this kind ‘process’ different people in different ways with different outcomes. Current developments therefore need to provide an holistic, patient-centred approach across the whole offender pathway, which meets the needs of different groups of people. What works for some might not work for others, but patterns can be mapped and good and bad pathways identified and used to inform good practice and service improvement.

The Psychiatric and Criminal Careers of Mentally Disordered Offenders Referred to a Custody Diversion Team in the United Kingdom

Custody diversion teams were introduced in England in order to divert mentally disordered offenders away from the criminal justice system and custody because of concerns about the growing prevalence of psychiatric disorder in prison populations. This research explored the impact of one such team on the psychiatric and criminal careers of people referred to it. Time ordered cluster analysis was used to identify and map the different institutional careers experienced by people referred to the team and the different paths their careers took as a consequence of the teams actions. Five different types of career were identified. Careers One and Two describe experiences of offenders – violent offenders with no psychiatric history who were referred, assessed and diagnosed but had no health or social care needs identified and were not referred again. Careers Three and Four describe experiences of mentally disordered offenders – violent offenders with a psychiatric history half of whom (Career Three) were referred, assessed and diagnosed, had health or social care needs identified and were not referred again; the remainder (Career Four) were not assessed or diagnosed, nor did they have needs identified and consequently all were re-referred repeatedly. Career Five represents neither – individuals referred for information and for whom little else is known.

Complex realism in social research

In recent years, both realism and complexity have begun to have methodological influence in social research. Yet for the most part, these have existed separately and have had limited impact on empirical research. In this article, we develop a theoretical argument for complex realism, grounded in an ontology of probability, that may be operationalised to demonstrate the reality of social change at a micro- and meso-level. We apply our conception of complex realism to an example using the method of longitudinal case–based cluster analysis to analyse the trajectories over time of male and female prisoners aged 18 and above who were at risk of self-harm.

‘Enhanced Support for High Intensity Users of the Criminal Justice System’: An Evaluation of Mental Health Nurse Input into Integrated Offender Management Services in the North East of England

The current UK Government’s focus on the development of services to manage and support offenders with mental health problems has resulted in a number of innovative project developments. This research examines a service development in the North East of England which co-located Mental Health nurses with two Integrated Offender Management teams. While not solving all problems, the benefits of co-location were clear – although such innovations are now at risk from government changes which will make Integrated Offender Management the responsibility of new providers without compelling them to co-operate with health services.