Dimension IV - STEREOTYPES, PREGUDICES AND RACISM
9.4.2. We all have stereotypes and prejudices
The roles and responsibilities of the National Treatment Agency, HMP Nottingham and the CDP have been unsure. As of July 2008 the CDP assumed commissioning responsibility for the IDTS programme. Therefore, any areas of development will be identified during Stage Two of the Treatment System Review.
6.2 Consultation Findings
New and pre-existing consultation findings utilised for the treatment system review presented some key issues for consideration under the criminal justice element of the treatment system.
In summary these consultation findings included:
2. Service user consultation identified that access to the Fit 4 Work programme was very beneficial as it addressed several areas of needs for clients. The Fit 4 Work programme addressed the life skills of offenders through nutrition, exercise and education.
3. A range of positive feedback on the effectiveness of CJIT from services users and other professionals involved with CJIT.
4. There is some duplication between the CJIT role and the role of some access and engagement provision, in particular where a pre-existing or disengaged CJIT client is picked up by another drug treatment access and engagement service.
5. Consultation from the first stakeholder event indicated that the treatment system should cater for many substance misuse needs not just opiates and crack cocaine use. As DIP primarily focuses on opiate and crack cocaine
1 National Offender Management Service (2006) Drug Strategy Unit DIP Prisons Guidance Delivery of the Drug Intervention Programme in Prisons – Guidance for Prisons
users. This could be seen as a gap for drug using offenders who do not use these substances.
6. As stated in other sections, consultation consistently highlighted the need for suitable out of hours provision and ideally some 24/7 access for clients in times of crisis. Building on the 0800 number that CJIT currently provide.
7. Rapid access to structured treatment is desirable across the treatment system not just limited to those clients coming through the criminal justice route.
8. The criminal justice system needs to recognise alcohol as part of offending behaviour and provide appropriate interventions to address this particular type of offending behaviour through appropriate support and interventions.
6.3 Criminal Justice Drug Treatment Provision in Nottingham
Drug treatment through the criminal justice system is currently provided by the following services in Nottingham
Criminal Justice Intervention Team (CJIT)
CJIT hosted by Nottinghamshire Probation Service provide ‘end to end’
management of drug using offenders coming through the criminal justice system, including through custody suites, courts and prison release. The service provides assessment and brief interventions at Test on Arrest, care co-ordination and unstructured interventions as well as support and referral into treatment. CJIT also provides a throughcare and aftercare provision for clients who are completing treatment or orders. CJIT also work with prison releases as part of the Integrated Drug Treatment System (IDTS) to support them to re-engage with treatment. The conurbation element is commissioned by Nottinghamshire County DAAT.
Rapid Access
Hosted by the Nottinghamshire Mental Healthcare Trust as part of the Nottingham Alcohol and Drug Team, Rapid Access provide the first phase of structured drug treatment for drug using offenders coming through the criminal justice route.
Probation Substance Misuse Team (SMT)
A jointly funded service between Nottingham CDP and Nottinghamshire Probation Service with the conurbation element commissioned by Nottinghamshire County DAAT. This treatment team delivers structured treatment interventions to probation clients with offender management as integral to the service’s delivery model. SMT provide case management, offender management and, psychosocial and prescribing based interventions.
6.4 Good Practice
The review of the drug treatment system has highlighted a range of good practice across the criminal justice element. Some of the good practice identified around integration and care co-ordination provides a useful framework for the wider drug treatment journey where there is limited similar provision.
Good practice within the criminal justice drug treatment system includes:
Integration
The Adult Offender Team is the co-location of local services involved in delivering offender management and treatment for drug using offenders at Castlegate House.
The co-location of teams within the Adult Offender Team model is having positive gains in enabling more integrated working between services and workers providing discreet elements of a client’s holistic package of care.
Such integration is also improving care pathways for clients, in particular in transition from engagement via CJIT into treatment with Rapid Access.
Feedback from consultation indicates that the co-location of offender managers and drug workers is beneficial, as is being able to have a wide range of interventions accessible from one place.
SMT make effective use of mentor services, particularly when clients are difficult to engage, demonstrating further integration with the wider drug treatment system.
Care co-ordination
There is strong evidence of good care co-ordination across the criminal justice system through CJIT and SMT workers who co-ordinate treatment, offender management and wraparound/continuing care for clients in a holistic package of care. Such care co-ordination acts as an anchor for the client as they move through their treatment and offender management journey.
However, there is also evidence that there could be increased care co-ordination to enable those drug using offenders already successfully engaged in a treatment programme to remain in that treatment programme if placed on a DRR or order. This would require improved care co-ordination across the criminal justice system and offender management through to mainstream drug treatment.
The CJIT model of care ordination is noted as good practice with a single care co-ordinator allocated for while the client is engaged in treatment and care co-ordination handing over to the aftercare element of the service one the client is no longer in treatment.
Consultation feedback suggested that improved care co-ordination functions throughout the treatment system would support clients to access appropriate treatment interventions, as well as providing clearer and easier to navigate care pathways and facilitating more integrated care.
Rapid access
National guidance on DIP stipulates that clients accessing through the criminal justice route should have rapid access to structured drug treatment provision. As stated above this is provided by the NADT Rapid Access team based within the Adult Offender Team at Castlegate House, where clients are seen for assessment and start of treatment within 48 hours.
At present the majority of the work provided by the Rapid Access team is focused primarily on prescribing based interventions although there is some psychosocial structured treatment also available.
At present there is no equivalent level of rapid access provision for non-criminal justice clients. As stated earlier, consultation identified that all drug users should have rapid access to structured treatment inline with that provided to clients coming through the criminal justice route by Rapid Access at the Adult Offender Team.
Wraparound
Analysis within the criminal justice drug treatment system indicates that there is availability of strong wraparound provision with both CJIT and SMT addressing client’s holistic needs. SMT in particular provide education, training and employment opportunities and the Fit 4 Work programme referenced in the consultation findings above.
Out of hours support
CJIT provide a 24/7 service to support clients and provide crisis support. Such provision was identified as needed across the treatment system through consultation mechanisms.
CJIT also cover the custody suites for extended hours from 8am to 10pm enabling those drug using offenders identified through Test on Arrest to be engaged and referred to treatment.
Needle Exchange in Custody Suite
In early 2008/9, a new scheme for provision of needle exchange within custody suites was launched to reduce the health risk created when injecting drug users have clean injecting equipment disposed of at custody suites.
This fits with the Nottingham Harm Reduction Strategy aim to implement a range of interventions to keep drug users as healthy as possible while they choose to continue using drugs.
The ‘Safe Works Scheme’ sees the Police and CJIT work together to ensure injecting drug users are identified within custody suites and clean injecting equipment provided upon release wherever possible.
The scheme is due for evaluation later in the year.
6.5 Weaknesses
While there is a range of good practice within the criminal justice drug treatment system, analysis and consultation has also identified some challenges facing effective delivery.
Pathways
There is evidence that some care pathways for criminal justice clients would benefit from strengthening, in particular:
• Pathways between the criminal justice system (CJS) and treatment providers
• Pathways from CJS into continuous care
• Pathways and the exchange of information between prison and the community
• Pathways into alcohol specific services
Although there have been a considerable amount of developments around care pathways into access and engagement there is minimal evidence that this is consistent.
Structured versus brief interventions
As with access and engagement provision (section 3), much of the work done by CJIT once a client is allocated to the CJIT caseload should be considered structured treatment. CJIT clients are often provided with a fairly high level of support which is care planned, often structured and provided by a single keyworker/case co-ordinator.
This is supported through self assessment by CJIT who felt they delivered ‘other structured interventions’ in line with the National Treatment Agency definition while this work is not included in the Service Level Agreement.
Such work is not being counted as structured treatment in reports to the Home Office and NTA which provides the information for monitoring performance against targets for the partnership.
As with the main drug treatment system, it is possible that CJIT are plugging the gap of structured psychosocial interventions within the criminal justice system, particularly for those clients who are not suitable for prescribing based interventions. This is supported by the fact that there are a high proportion of crack and cocaine users being case managed by CJIT.
Duplication
There appears to be some duplication across services within the criminal justice system with duplication noted between SMT and Rapid Access evidenced within pathways and audits.
There also appears to be duplication between criminal justice services and the wider drug treatment system. In particular CJIT duplicates at some level with structured treatment provision, access and engagement services and mentoring provision.
The duplication with access and engagement services is strengthened by the review of access and engagement provision. Analysis shows that it can evidently be difficult to identify who should work with disengaged CJIT clients identified by wider access and engagement services. This still appears to be problematic despite joint working protocols being established across these services.
This is supported by the fact that CJIT have experienced difficulty in understanding their remit, often moving into other areas of work. This is not unique to CJIT and is evidenced throughout the treatment system adding to the likelihood of duplication.
Referral into structured treatment and DRR’s
A fairly consistent area of concern that has been identified over recent years is the number of individuals referred via CJIT through into structured treatment. All systems are currently being reviewed to improve the referral process from CJIT to Rapid Access and through into NADT.
While it is hoped that co-location of CJIT and treatment elements through the Adult Offender Team will improve referrals into structured treatment, it is also possible that some CJIT clients (particularly non-opiate users) are having their needs met by CJIT as there is a common perception that there is no structured treatment provision
available other than prescribing (see above). This is a gap consistently highlighted through consultation and analysis of both the wider drug and alcohol treatment systems. In part this is likely to be due to the fact that CJIT is providing structured interventions and so onward referral may not required.
It has also been identified that there are no systems in place for the early identification of individuals appropriate for a Drug Rehabilitation Requirement through CJIT.
6.6 Effectiveness
As explained in Models of Care the main aim of DIP is to break the cycle of drug misuse and offending behaviour by intervening at every stage of the criminal justice system to engage offenders into drug treatment.
In order to be considered effective, the criminal justice treatment system must:
• Identify and engage drug using offenders
• Refer drug using offenders into structured drug treatment
• Provide effective offender management
Identify and engage drug using offenders
CJIT work within the custody suites is the main route to identify and engage drug using offenders into the treatment system.
The access and engagement element of CJIT provision through Test on Arrest has improved dramatically over the last six months highlighting the services ability to adapt to change.
The establishment of the DIP/PPO Performance Meeting has enabled detailed performance monitoring of the DIP process. The monthly meetings has provided a forum on which to problem solve issues in partnership with all the agencies involved.
There is however considerable amount of improvement required in engaging those drug using offenders leaving prison which could benefit from improvement through the Integrated Drug Treatment System.
Refer drug using offenders into structured drug treatment
As covered in more detail above, referral into structured drug treatment via CJIT has its areas for improvement. Work underway to review systems will go someway to improve this as will the recommendations to review and expand the availability of structured psychosocial interventions and to consider whether the work provided by CJIT is ‘other structured interventions’.
6.7 Care Pathways
As well as pathways into treatment through the custody suites via CJIT drug using offenders are also referred into SMT through the courts, as well as general offender managers being able to identify someone with a drug problem who may be suitable for a DRR.
However, the pathways out of SMT into the wider drug treatment system and general offender management appear to be more effective than the pathways into the service. Routes into SMT and onto DRR’s would benefit from improvement and further embedding within practice.
Information taken from the 2006/7 and 2007/8 DIP Compact performance reports suggests that many clients in contact with CJIT are receiving Tier 2 interventions with them. National performance data and local information suggests that the proportion accessing structured drug treatment is relatively low in comparison. A waiting times audit undertaken in 2006/7, which sought to establish the number of clients accessing structured treatment within 3 weeks of contact with DIP, suggested very low numbers moving into structured drug treatment. Likewise, local performance and monitoring reports produced for the partnership’s DIP Operational group suggest that onward movement is low. On average, the attrition rate for clients attending their treatment appointment following an assessment and referral by CJIT was 50%.
22% of referrals into structured treatment were via DIP or Criminal Justice System (CJS). This is consistent with last year, but is less than in the region (30%) and nationally (25%).
The interventions put in place to date 2007/8 have included a focus on Follow Up Assessments, which were introduced to the DIP system in April 2007. This second appointment is a legal requirement, and was implemented to combat the attrition of clients moving into treatment following their initial CJIT appointment. From April 07, clients were legally required to begin their assessment in the custody suite and complete the remainder at another appointment. In Nottingham, this second appointment takes place within a treatment centre, to provide opportunity for clients to complete a Comprehensive Treatment Assessment or arrange a treatment appointment at the same locality. In the first 6 months of 2007/8, the attrition rate for treatment appointments at Rapid Access has reduced to approximately 30% on average, with 70% of clients attending their appointment.
The number of referrals is currently averaging at 39 a month. This remains relatively low in comparison to the number of treatment naïve clients estimated to be in contact with CJIT, and suggests further work is required.
Alcohol Arrest Referral
The Nottinghamshire Healthcare Trust’s review of alcohol treatment services
comments that the Alcohol Arrest Referral Scheme in the Nottingham police custody suites is transferred into CJIT. This is supported in principle but is dependant on appropriate funding.
Alcohol Treatment Requirements (ATRs)
The Nottinghamshire Probation Service have been pro-active in establishing ATRs within the offender management. It is recommended that there are further developments in determining the referral pathways into alcohol treatment services in line with the new proposed treatment system model.
6.8 Client Group
It may be that the Tier 2 interventions provided to the clients in contact with CJIT are adequate to meet their treatment needs. Nonetheless, the proportion of DIP referrals into structured drug treatment is less than expected looking at the 2006/7 data. This is particularly pertinent as the problem drug users in contact with CJIT are more likely to be under 25, male, using cocaine or crack and / or of BME ethnicity than seen in the in treatment population. This clearly reflects the treatment naïve population, and suggests there are blockages to this group accessing treatment via DIP.
Considerable work has been undertaken in the previous treatment year (2006/7) and is ongoing in 2007/8 around improving the pathway into treatment for clients in the criminal justice system. The Rapid Access service, a structured treatment provider specifically in place to meet the needs of problem drug users coming through the criminal justice route, has expanded to provide stimulant interventions alongside rapid prescribing. The period a client is held in Rapid Access has also been extended to support them in stabilizing in treatment before moving into mainstream services.
Pathway process maps have also been developed to maximise the impact of DIP on supporting problem drug users coming through the Criminal Justice System into treatment. (See Process Map in appendices). The flow of clients into structured treatment from DIP has continued to be a focus for 2007/8, with low compact performance prompting further in depth investigation into the DIP pathway (see Performance Exception Paper in appendices).
Looking at the profile of DIP referrals into structured treatment against the profile of clients referred from other sources, it is evident that clients referred by DIP are more likely to be:
• Males – by a significant margin (87% are males)
• White (81%)
• More likely to be aged between 25 and 34 (56%)
• Much more likely to be opiate users (94%)
• Current (35%) injectors – or never have injected (30%)
6.9 RECOMMENDATIONS
Recommendations relevant to the criminal justice treatment system:
1. That SMT and Rapid Access become one service working across the Adult Offender Team.
2. Should structured interventions be identified within CJIT work should be done to capture this formally in contracting arrangements and reporting.
3. Dependent on positive evaluation of the needle exchange scheme in custody suites this provision should be continued.
4. Further work should be undertaken to identify the level of structured interventions being provided by CJIT.
5. Further work to clarify roles and responsibilities with clear eligibility criteria requirements should be developed within the new model in order to reduce duplication between criminal justice treatment and drug treatment providers.
5. Further work to clarify roles and responsibilities with clear eligibility criteria requirements should be developed within the new model in order to reduce duplication between criminal justice treatment and drug treatment providers.