Outcome Evaluation of the National Model for Liaison and Diversion [book]

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more » ... prohibited. Permission is given to duplicate this document for personal use only, as long as it is unaltered and complete. Permission is required from RAND to reproduce, or reuse in another form, any of its research documents for commercial use. For information on reprint and linking permissions, please visit www.rand.org/pubs/permissions. Support RAND Make a tax-deductible charitable contribution at www.rand.org/giving/contribute www.rand.org www.rand.org/randeurope For more information on this publication, visit www.rand.org/t/RRA1271-1 Published by the RAND Corporation, Santa Monica, Calif., and Cambridge, UK © Copyright 2021 RAND Corporation R® is a registered trademark. iii RAND Europe Preface This document is the final report of an independent evaluation of the National Model for Liaison and Diversion (L&D). L&D schemes operate primarily in police custody suites and courts. They aim to identify and assess people with vulnerabilities as they pass through the criminal justice system, to ensure their health and other needs are known about and that they are referred to appropriate services for treatment or support. The Liaison and Diversion Programme was created in 2010 to facilitate development of a model for commissioning L&D services, and to support existing L&D service providers. From 2011 to 2013, the Programme developed a national model for L&D services, with an initial focus on the diversion of people who are brought into police custody. In 2014 the Liaison and Diversion Operating Model was published by the Programme and NHS England launched a new National Model for L&D services. Liaison and Diversion (L&D) services aim to identify those in the criminal justice system (CJS) who have mental health needs and other vulnerabilities, refer them to appropriate support services, and ensure that information about those needs is available to decision-makers in the CJS. L&D services have operated in some form for over 25 years, but their nature and quality varied between locations and there are many areas of the country where no L&D services were available. Between 2011 and 2013, the Department of Health was supported by an external partner, the Offender Health Collaborative, to develop a national L&D model. In 2014, NHS England launched the national Liaison and Diversion Operating Model for L&D services (NHS England Liaison and Diversion Programme 2014). Following the launch of the National Model in 2014, it was implemented at ten trial sites in England, followed by a further 13 sites in 2015. In July 2016, funding was announced to expand implementation of the National Model further, with the goal of providing services to 75% of the country by April 2018. 1 The National Model for L&D provides 24-hour, seven days per week services for people of all ages in the adult and youth justice pathways, covering a range of health issues and 'vulnerabilities' 2 including mental health, physical health and learning disabilities. 3 The intended outcomes of L&D services are fourfold:  Improve access to healthcare and support services for vulnerable individuals and a reduction in health inequalities.  Reduce reoffending or escalation of offending behaviours.  Divert individuals, where appropriate, out of the youth and criminal justice systems into health, social care or other supportive services.  Deliver efficiencies within the youth and criminal justice systems. 1 https://www.england.nhs.uk/commissioning/health-just/liaison-and-diversion/news/programme-updates/ [accessed March 2020]. 2 'Vulnerabilities' is the term used in the operating model and service specification. 3 The National Model for L&D is contained in two documents: an operating model (NHS England Liaison and Diversion Programme 2014) and a service specification (Liaison and Diversion Programme 2014). The service specification is based on the operating model. The service specification has since been updated, most recently in 2019. Summary of key findings from the evaluation L&D services following the National Model have succeeded in engaging with people who have a broad range of vulnerabilities Overall, 88% of people referred to Liaison & Diversion services had at least one vulnerability identified. Almost three-quarters (71%) of those referred had a mental health need, and half (52%) experienced drug or alcohol misuse. Other vulnerabilities identified included risk of suicide or self-harm, unstable accommodation, being an abuse victim, financial needs, and needs relating to physical health, communication difficulties, or learning disabilities. Some service users had more than one vulnerability; for example, almost 20% were recorded as having more than one mental health need. This may present a challenge for L&D staff if multiple vulnerabilities are present, but none of these meet the criteria for referral. A quarter (26%), however, of people referred to L&D services had no prior service contacts recorded, indicating L&D services were potentially providing their first contact with health and social care services. This demonstrates that L&D services have accomplished the aim of engaging people with multiple vulnerabilities to facilitate access to support services. L&D services appear to intervene at a point of crisis Using the novel cross-sector linked data set we identified increased use of multiple healthcare services in the months leading up to the arrest that precipitated referral to an L&D service. The 6-12-month prior period to L&D referral is often characterised by a steep increase in contact with Accident & Emergency (A&E) services, specialist mental health services, and declining self-reported health in those attending drug ix RAND Europe treatment services. However, L&D service users with and without previous criminal justice system contact were as likely to go to A&E after involvement with the L&D service. This suggests that for L&D service users it is acute health vulnerabilities that lead to contacts with the CJS, rather than the other way around. We also observed an increase in detentions under the Mental Health Act (MHA) (1983, amended 2007) in the six months prior to referral to an L&D service, suggesting that referral to L&D was not their first crisis-related contact with police for some service users. We did not observe such a marked increase in offending behaviour, except in the one to two months immediately prior to the arrest leading to L&D referral. This pattern of repeated health service contacts over an extended period suggests there may be a window of opportunity for intervention prior to L&D referral. The interventions offered by L&D services vary by individual and by L&D site Interventions provided by L&D services, and their uptake by service users, varies widely. Reported interventions spanned a wide spectrum, from advice and brief interventions, to primary care referral, to detention under the MHA for psychiatric assessment. Referral to health care services varied significantly between sites, particularly for the national Improving Access to Psychological Therapies (IAPT) service. Variability between sites is a planned aspect of the National Model as it is intended that referrals and other interventions are tailored to individual needs. Yet, insofar as this suggests variation in the delivery of the National Model, this represents an unplanned aspect of its implementation. Intervention uptake also varied, with people with substance use vulnerabilities in particular being more likely to decline L&D referral and interventions overall, despite being more likely to have multiple vulnerabilities. Results from the qualitative interviews indicated that timeliness of accessing onward referral services may contribute to variation in both provision and uptake; lengthy delays decrease the likelihood that service users engage with services, but interviewees reported that in some instances waiting times could be up to six months. Following L&D referral, there is a short-term increase in referral to mental health services Referral to L&D services appears to be followed by an increase in referral to IAPT services and non-L&D specialist mental health services. We did not, however, find evidence that these referrals translated into a substantial increase in face-to-face attendances in the post-L&D referral period. For IAPT services, there was no evidence for an increase in attendances. There may have been some increase in attendances at specialist mental health services, but due to how information was recorded in the data source, we could not differentiate between specialist mental health services, so this may just represent contact with L&D services. Drug and alcohol treatment referral and attendance may increase following L&D referral After L&D referral, drug and alcohol treatment service referrals appear to increase. A substantial minority of the drug and alcohol treatment service referrals were for individuals without previous recorded contact with these services. Additionally, referrals to drug and alcohol treatment services appear to translate into increased attendance at appointments, although this increase was not statistically significant. Referral to L&D services does not appear to reduce offending Overall, we did not find any evidence for an impact of referral to L&D services on offending behaviour in the post-L&D referral period. This lack of effect was at odds with the perceptions of L&D service staff x RAND Europe regarding the impact of the National Model. Our interview participants consistently identified that L&D services aimed to reduce offending by addressing the unmet needs of offenders through appropriate assessment and referral. This discrepancy between the information from the interviews and the overall data linkage analyses may partially be due to heterogeneity in the population targeted by L&D services, and the wide variation in interventions offered both within and between services. We also found, however, that (after accounting for other vulnerabilities) contact with the criminal justice system is not a predictor of healthcare utilisation after L&D referral, which suggests that offending behaviour in this cohort is a symptom of a wider health and/or social problem that a single contact with a L&D service may not be sufficient to address. L&D services appear to increase diversion from custodial sentences L&D services may reduce the proportion of offences resulting in custodial sentences and thus increase diversion from the criminal justice system. Considering changes in the proportion of offences resulting in a custodial sentence over time, the likelihood of service users receiving a custodial sentence after involvement with L&D services was almost half that of the historic control group. This estimate of impact of the National Model was statistically significant (p = 0.05). There was, however, no evidence for an impact of the National Model on the length of custodial sentences. Court processes are not significantly affected by L&D services The duration of court proceedings was reduced for offences committed at or just after referral to L&D services, but the available data do not provide sufficient statistical support to conclusively demonstrate an impact of the National Model on this outcome. There was no evidence for a statistically significant impact on number of hearings per court case. Following L&D referral, the time from first hearing to completion was almost 7 days shorter in the evaluation cohort compared to the historic control, but this difference was not statistically significant. The qualitative interviews, however, did provide additional support for the role L&D staff play in expediting court decisions via drafting on-the-day reports for presentencing. The L&D programme contributes to savings in the criminal justice system, but not in the healthcare system L&D services appear to directly contribute savings of between £13.1 million and £41.5 million in the criminal justice system through diversion from custody and consequent increases in productivity. The economic analysis (see Box S1 for approach and limitations) hinges on custodial sentence length; when considering the diversion from custody based on average sentence length, L&D is associated with a total saving of £38.1 million, or £858 per L&D referral not declined. If we also consider increases in productivity due to avoidance of custody, then the savings increase to £933 per L&D referral (average sentence length) or £294 per L&D referral (median sentence length). We estimate the National Model of L&D costs £659 per L&D referral not declined. Based on the average sentence length, the cost of L&D referral is thus more than offset by the £933 of savings due to diversion from custody. These analyses do not incorporate costs or savings related to healthcare utilisation outcomes as the national L&D programme was xi RAND Europe not found to have any statistically significant effect on attendance at A&E, (non-L&D) mental health specialist services, IAPT, or drug and alcohol treatments services. Box S1 Approach and limitations of the economic evaluation Evaluation conclusions This evaluation used a novel, large-scale linked data set combining nationally-collected administrative data from both the healthcare sector and the criminal justice sector. This unique data set provided insights into contact with a range of services both before and after referral to a L&D service which could not have been reliably obtained in other ways. Analyses conducted across these data sources consistently showed that L&D services are successfully engaging with a group of service users with a broad range of vulnerabilities, often at a time of acute crisis when they are most in need to support. There was, however, substantial variation between L&D services in the types of interventions offered, and referrals to healthcare services often did not translate into face-to-face contact with health service providers. This is likely to be due to a combination of factors including differences in service user needs at each site, variation in availability of services to which L&D staff can refer people, and length of waiting time for face-to-face appointments. The impact of the National Model for L&D on healthcare and criminal justice system outcomes appears to be focused on increasing referrals to mental health and drug and alcohol treatment services and diversion from custodial sentences. It may also lead to an increase in attendances at drug and alcohol treatment services, and in the number of hearings per court case, but there was no evidence for a statistically significant impact on these outcomes in this study. The evaluation identified only limited improvement in some outcomes after L&D referral, but there was no evidence that outcomes became worse due to L&D referral, and we did not identify any unintended Approach  Comparison of NHS England and NHS Improvement commission costs of the national L&D programme with the impacts on costs more widely and on benefits achieved.  Cost-consequences analysis examining the effects on the health service and criminal justice system, as well as impacts in terms of service users' net contribution to the economy.  Considers costs and benefits over a one-year period resulting from the national L&D scheme against the historic 'control' cohort identified from based on those charged with an offence three to four years prior to referral to L&D. Limitations  A cost-effectiveness analysis, where an overall measure of efficiency would be provided, was not possible given the available data.  A lack of data meant that many potential costs and benefits could not be quantified in the economics analysis (see Chapter 11).  As per the main evaluation analyses, these results are based on data from the first two waves of L&D implementation; findings may not generalise to all L&D services in England. xii RAND Europe consequences of referral. Evaluating the programme is challenging due to heterogeneity in the implementation of the intervention and the population targeted. There are, however, some limiting factors that could be addressed to improve the overall impact of L&D services; most notably increasing capacity for onward referrals and developing approaches to support people who have multiple vulnerabilities but are not currently eligible for referral because no single vulnerability meets a required therapeutic threshold.
doi:10.7249/rra1271-1 fatcat:dzoewdd25zerzk62ld3mx2e6ky