A Liaison and Diversion (L&D) service:
- identifies people with mental health, learning disability, substance misuse or other vulnerabilities coming into contact with the justice system
- assesses and refers the identified individual to an appropriate treatment or support service
- shares, with consent, information gained from assessments with criminal justice agencies and the judiciary, so that they can make more informed and timely decisions about out of court disposals, case management and sentencing
- is commissioned by NHS England
Past, present and future L&D services
- L&D services have developed in a variety of forms. Services grew organically with a local structure and where delivery was based on a local need.
- The L&D programme has agreed a standard service specification to be used to commission L&D services in order to deliver a consistent L&D service.
- NHS England are rolling-out L&D services across the country, by April 2018 delivering the new specification to 82% population coverage in England and then 100% by March 2021.
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- What is Liaison and Diversion?
- Why are L&D services needed?
- What benefits do you expect to see from L&D services?
- How are L&D services going to be rolled out in the future?
L&D Partners – Working Together
- How will L&D services help police officers?
- How will L&D services help the courts’ system?
- Do L&D services support people in Crown Courts also?
- How will L&D help offender management?
- Will L&D services just let offenders off the hook?
- How can this work if there are not the treatment services to refer people into?
- How can a referral service really make a difference?
- What is the difference between L&D services and street triage?
- How will L&D services fit with section 136 responsibilities?
About the Liaison and Diversion Programme
- What is the background and role of the L&D Programme?
- What has the L&D programme achieved?
- What is in the standard service specification?
- Why is it necessary to have a standard L&D service specification?
- How was the standard service specification developed?
- What about localism?
- How are service users involved in the delivery of the standard service specification?
- How are L&D services funded?
- What about those parts of England that are not covered by L&D services?
- Why is the programme only covering England?
- The Bradley report came out in 2009, why is it taking so long to roll-out L&D services?
- How will you know that L&D services are effective?
- Where can I find out more about L&D services and the L&D programme?
About Liaison and Diversion Services
Liaison and Diversion (L&D) services operate in the following ways:
- Identify, assess and refer people of all ages with a wide range of mental health, learning disability, substance misuse and/or social vulnerabilities when they first come into contact with the youth and adult criminal justice systems on suspicion of having committed a crime.
- When a person is assessed as having single or multiple vulnerabilities, they will be referred to the appropriate treatment or support service and an appropriate package of care and/or support will be instigated.
- Accurate, timely information on the person will be shared with police and the courts (with an individual’s consent where necessary) to ensure that any charging, sentencing or disposal decisions are based upon an authoritative assessment of their mental health, any learning disability and whether they have a substance misuse issue.
- L&D services support the most appropriate outcome for those individuals. For many this contact with criminal justice agencies will be the first time they will have been assessed and diagnosed.
L&D is not itself a treatment service, but it is an identification, assessment and referral service. It uses assessments to make appropriate referrals for treatment and support, and ensures criminal justice practitioners are notified of specific health requirements and vulnerabilities of an individual which can be taken into account when decisions about charging and sentencing are made.
Services will aim to identify individuals as early as possible after they come into contact with the police and criminal justice system. They offer a service to the police for those individuals who are not arrested but dealt with by voluntary attendance and will provide coverage at police custody suites, and at criminal courts. They will link up to other parts of the justice process, such as probation, youth offending teams, prisons and the young people’s secure estate.
There are well-documented high levels of health and care needs within youth and adult offender populations, with the prevalence higher than in the general population:
- 31% of young people (aged 13-18) who offended (including young people in custody and in the community) were identified as having a mental health nee
- The prevalence rates for personality disorder, psychosis, attention disorders, post-traumatic stress disorder and self-harm are notably higher than in the general population.
- Learning disability is more common in young people in custody; a prevalence of 23-32%, compared to 2-4% of the general population. A study by Harrington & Bailey (2005), Chitsabesan et al. (2006) found that 20% of young offenders had a learning disability, with a further 31% assessed as ‘borderline’ regarding intellectual functioning as measured via the Wechsler Abbreviated Scale of Intelligence.
- Almost 50% of adult prisoners suffer from anxiety and/or depression compared with 15% of the general population
- An analysis of data drawn from over 120,000 Offender Assessment System (‘OASys’) Assessments found that nearly half (47%) had misused alcohol in the past, 32% had violent behaviour related to their alcohol use and 38% were found to have a criminogenic need relating to alcohol misuse, potentially linked to their risk of reconviction
- Evidence from an Office of National Statistics survey (1997) of psychiatric morbidity among prisoners found that the prevalence of any personality disorder was 78% for male remand prisoners, 64% for male sentenced and 50% for all female sentenced prisoners.
- People in contact with the criminal justice system are also known to be one of the groups of people known to be at higher risk of suicide than the general population
- Certain groups that have protected characteristics under the Equalities Act (2010) are over-represented in within the criminal justice system. For example, over one-quarter of the prison population whose ethnicity was recorded were from a minority ethnic group. Among British nationals 21% of the population were from a minority ethnic group, 62% of foreign national prisoners were from a minority ethnic group. (2012)
- The offender population also experience higher socio-economic disadvantage and related health inequalities (generally and those health needs that relate to certain protected characteristics).
By addressing people’s mental health, learning disability and/or substance misuse vulnerabilities when they first come into contact with the youth and adult justice systems, it is expected that offending behaviours will be addressed, contributing to reductions in future arrests and in the use of police and court time.
The following benefits are anticipated, for which evidence will be gathered from the evaluation of services:
For children, young people and adults entering the youth and adult justice systems:
- Improved access to treatment and support services
- Decreasing health inequalities
- Improving health outcomes
- Improved experience of the health service (including through active participation in the treatment they receive)
- Improved experience of the youth and adult justice systems (including the opportunity to be actively involved in justice processes, through the provision of appropriate support)
For the youth and adult justice systems:
- Reductions in the time it takes to process vulnerable individuals though police custody, by the provision of timely information to the charging / disposal process
- Reductions in court time and unnecessary adjournments, by the provision of timely assessment information
- Reductions in repeat arrests, because vulnerable people will receive appropriate treatment in the community, thus tackling the underlying issues that may cause them to offend
- Assurance that vulnerable people have been able to understand, and participate appropriately in the justice system
For the health and social care systems:
- Improved efficiency as vulnerable people are identified earlier, thus reducing the likelihood that they will reach crisis-point
- Improved information on vulnerable people and their conditions. These vulnerable people may be “frequent flyers” at Accident and Emergency services, in crisis mental health facilities, and may call on emergency accommodation services.
- Improved information will facilitate better planning of services across health, social care and the justice systems.
Further development of L&D services is underway:
- By 2017/18, 82% of the population of England will be served by an L&D service conforming to the new standard service specification.
- New providers will extend services to areas of the country not already served by L&D.
- Existing L&D service providers not already delivering the standard service will be supported to do so.
- The programme is due to end in March 2021, when the rollout is expected to be complete, and L&D services will be part of mainstream NHS service provision.
All services will be encouraged to continue awareness of their local population and other relevant equalities and health inequalities issues, to ensure that their service meets the diverse needs of those communities they serve.
L&D Partners – Working Together
Better integration of L&D services into police custody will improve the efficiency of custody suites, particularly when dealing with offenders with health needs related to their offending. Early intervention with vulnerable individuals should also reduce the frequency of arrest, assuming that they are referred to and engage with effective treatment services. If these unmet health needs are appropriately addressed, this should then lead to a reduction in arrests and time spent in police custody. In addition to this L&D services, commissioned by the NHS, will provide better links to community health and mental health services that should free up police officer time that is spent dealing with these people.
The provision of timely specifically focussed L&D assessments in supporting magistrates and judges in consideration of their remand and sentencing decisions can limit the number of court hearings, avoiding costly adjournments and periods on remand.
NHS England are investing to deliver enhanced L&D services across Crown Court Centres. We have been working in partnership with colleagues from the Ministry of Justice and HM Courts and Tribunals Service to identify the level of demand for L&D services at individual Crown Court centres, in order to target resources effectively, enabling L&D service staff to be based within the busiest Crown Court centres. NHS England have identified four pathfinder services to implement the delivery of enhanced services at located at Crown Court centres in Birmingham, Bristol, Liverpool and Nottingham throughout 2017-18. The Senior Presiding Judge has indicated his support for this initiative.
With regular and efficient information sharing and exchange between L&D and probation provider and prison staff, improvements to offender management, caseloads, appropriate sentencing and potentially reduction in re-offending benefits may be realised. Early identification in the police custody suites has benefits in signposting towards Drug Rehabilitation Requirements, Alcohol Treatment Requirements and Mental Health Treatment Requirements at the earliest possible stage. Assessment for drug, alcohol and mental health in the L&D service, if shared through to probation providers, can be cost saving if accepted at court. These can speed the process of sentence to community order by cutting the pre-sentence report stage back.
This has benefits for offender management through scaling back on reports processes and to the offender through affording appropriate support and treatment early in the offender journey and helping to avoid the problems associated with delays in sentencing. In regards to ‘Integrated Offender Management’ and ‘Through the Gate’ support (especially where sentences are less than 12 months) these early L&D assessments can be used on release for onward referral to treatments. They can also be used for as information for broader social care support.
Identification of problems such as mental health, learning difficulties and/or other vulnerabilities by the L&D service may facilitate relevant support to these offenders rather than a CJS intervention. This has potential to reduce caseload numbers and effectively divert away from custody or community sentences.
Definitely not. L&D services are about providing better, more timely information to the youth and criminal justice system so that police, CPS, Probation, YOTs, magistrates and Judges, can make informed decisions about case management, sentencing and disposal. The judiciary make appropriate decisions, based on the evidence and information presented to them, L&D services will not provide a softer option. L&D services will also provide a route into treatment for people whose offending behaviour is linked to their illness / vulnerability, addressing these health needs will contribute to longer term reductions in offending behaviour. It is therefore also about the prevention of crime and reductions in offending.
It’s true that L&D services will not be effective on their own. That is why this is a commissioning-led model of development. NHS England’s Health and Justice Regional Teams will work with the youth and criminal justice systems, health and local authority partners to ensure that L&D services are integrated into a framework of mental health, drug and alcohol rehabilitation, learning disability, youth offending, school nurse partnerships and physical health services to make the most of the services available at a local level. L&D services will provide crucial intelligence of key areas of unmet need and how services can be reconfigured to best support vulnerable individuals passing through the justice system.
By making sure that vulnerable individuals are supported to attend their initial appointments, and by following up with service providers to ensure they keep on attending. Commissioners will require service providers to give evidence that individuals are being supported to attend appointments as part of the contract performance management process.
Street triage is an identification approach being piloted with adults in a number of areas in England. It takes the form of mental health professionals supporting police officers when responding to emergency calls to cases which involve a person who may be suffering from a mental illness. These members of the public often come into contact with the police despite not necessarily having committed an offence. The L&D approach is more typically concerned with helping people when they are suspected of having committed an offence (and therefore encompasses work at police stations and courts); but street triage could be one of the ways in which L&D service providers, in agreement with local police forces and health commissioners, might deliver a wider L&D service in future.
Section 136 of the Mental Health Act allows the police to remove an individual from a public place to a “place of safety” if they appear to have a mental disorder and are in need of care or control. Each force area should have local protocols on how partners manage the response to such events. In the vast majority of cases, the individual should be taken to a health based place of safety, but there will be circumstances where this may not happen and the individual is taken to a police custody suite. In such circumstances, it will still be the responsibility of the Approved Mental Health Professional to co-ordinate an assessment under the Mental Health Act.
There will be other occasions where a detainee is arrested for a criminal offence and whilst in the police custody environment it is identified that there may be a requirement for an assessment under the Mental Health Act. The existence of a skilled mental health practitioner as part of an L&D service in the custody suite, may help inform the custody officer and other relevant authorities as to the need for an assessment, based upon their ability to better identify such issues. The pattern of such referrals will also help to inform local health needs analyses, and potentially help to fill gaps in mental health provision.
About the Liaison and Diversion Programme
The L&D Programme was created in 2010 to help the Government meet its commitment to develop the best model for commissioning L&D services. It came about as a consequence of the Bradley Report of the previous year. The Government is committed to the rollout of L&D services across England. Since 2010, the programme has worked extensively with L&D service providers to build an active network as well as the new standard service specification.
The programme is a cross-Government initiative, with partners from:
- Department of Health
- NHS England
- Home Office
- Ministry of Justice
- Youth Justice Board
- HM Courts and Tribunals Service
- Public Health England
- Offender Health Collaborative
- Bradley Review Group
- Her Majesty’s Prison and Probation Service (HMPPS), formerly NOMS (National Offender Management Service)
NHS England holds the Senior Responsible Officer responsibility for the programme; NHS England is also responsible for commissioning L&D services under its Mandate from Government. The Department of Health will hold NHS England to account for the rollout of L&D services, and for ensuring that they are of high quality. The development of L&D services is an objective in the business plans of the Department of Health, Ministry of Justice and the Home Office.
Since its inception in 2010, the L&D programme has taken a phased approach to the development of L&D services. So far, it has:
- Created a network of existing L&D service providers to understand existing service models.
- Funded 36 L&D pathfinder schemes, and collected data to help define good practice.
- Produced a model of good practice for L&D services.
- Agreed the standard service specification, to be used to commission L&D services.
- Agreed a rollout plan, to implement L&D services to the new service specification.
- Delivered a full business case to Her Majesty’s Treasury, to obtain approval for the rollout strategy, and secure funding for future services.
- With the support of Department of Health Research and Development Directorate, formally commissioned the evaluation of the new model of L&D services operating in the first 10 pathfinder schemes in 2014/15 and a further longitudinal evaluation of schemes, due to report in 2019.
The specification reflects the need for services to be available at all relevant points of the youth and adult justice systems. L&D service providers will focus on identification, screening and assessment of individuals, advice, referral, short-term interventions, data-collection, monitoring and safeguarding, to achieve:
- All-age services (children, young people and adults).
- Identification and referral of a wide range of mental health, disability, substance misuse and social vulnerabilities.
- Coverage of the justice pathway, including police custody and court settings, with hours of operation to reflect service need.
L&D services have been around in a variety of different forms for many years. A standard service specification is needed for the following reasons:
- To provide assurance to service users of consistency in the quality of services, nationally.
- To allow comparison between different providers, and assess value for money and to allow for meaningful evaluation of the services as a whole.
- To allow commissioners to investigate new sources of provision.
- To focus attention on the outcomes expected from L&D services.
The programme, and its partner the Offender Health Collaborative, reviewed existing L&D services. It considered what worked well in the existing services, in particular it focused on:
- When services are needed (hours of operation)
- The different needs of the youth and adult justice systems
- The range of vulnerabilities identified by L&D services
- How vulnerable people are treated and how they access treatment services
- Feedback from service users and service providers
- The workforce requirements of L&D services
All of this was brought together and developed in collaboration with NHS England Regional Health and Justice Leads to create a service model and standard service commissioning specification.
The standard service specification will focus on the outcomes to be achieved from L&D services. Locally:
- NHS England commissioners will work with service providers and other local health and justice commissioners to ensure that L&D services fit in to the local service landscape, to avoid duplication / gaps in provision.
- Commissioners will encourage local innovation by asking providers to propose the best way to deliver L&D services in their area.
- Commissioners will review how services are actually delivered, which may lead to the service specification being refined over time, as further evidence of good practice emerges.
A service user voice can impact and inform improvement on delivery and development of a service and using their experience they can take an active part in reviewing and assisting in any future changes. Service user involvement is embedded within various levels of the programme. On a national level we engage with a lived experience team facilitated by the Revolving Doors Agency, who provide a user voice at the national L&D programme board and in assurance forums.
On a local and commissioning level, NHS England Commissioners and L&D services are working together to include service user voice within the service itself and its forward planning to ensure service users are adequately represented in the L&D agenda. The Programme is integrating service user voice via case studies and other communication channels.
The national lived experience team have also co-designed with NHS England a ‘Peer Support model’ specifically for L&D services – this consists of a paid peer support worker with a pool of peer support volunteers. Both the paid peer support worker and the volunteers will have had experience of being in contact with criminal justice; arrest, being charged and being processed through the courts and being sentenced, as well as experience of a vulnerability.
Two services have also agreed to be Pathfinder sites for the ‘Peer Support model’ to test out the effectiveness of the model with the aim that peer support will become an integral part of the national L&D service specification. Avon and Wiltshire Mental Health NHS Partnership Trust, providers of the L&D services in Wiltshire, will be trialling the Peer Support model in their area. Birmingham and Solihull Mental Health NHS Foundation Trust, providers of the L&D services in Birmingham, have asked Shelter (the Homelessness Charity) to deliver the Peer Support Model on their behalf given Shelter’s experience of delivering Peer Support in Birmingham. Both are starting in early 2017.
L&D services are directly commissioned by NHS England. Funding for L&D services will flow directly from NHS England, which receives funding for its Mandate commitments from the Department of Health.
Currently, some long-standing L&D services are funded by Clinical Commissioning Groups, under arrangements inherited from the old Primary Care Trusts and Strategic Health Authorities. This will change over time as NHS England takes over responsibility for these services, in consultation with the Clinical Commissioning Groups.
NHS England will work with existing L&D service providers to see how existing, high quality services could be extended to cover parts of the country not currently served. At the same time, NHS England will investigate new providers as part of its normal commissioning processes. New providers may include existing NHS mental health and community trusts, other public-sector providers, as well as independent providers from the private and third sectors.
Health is a devolved matter, and therefore falls to the health commissioning arrangements in each of the four countries (England, Scotland, Wales, and Northern Ireland). Other countries are taking an active interest in the development of L&D services, for example: there is a single criminal justice system for Wales and England, and the programme shares materials and findings with colleagues in Wales.
This is for a number of reasons:
- When the programme started, there was no “register” of L&D services, because services had grown up through sporadic, local innovation. It took time to identify where the services existed.
- Existing L&D services (those previously developed before the programme started) operated in a variety of different ways. In order to rollout effectively, and crucially in order to evaluate services, there needed to be a standard model of service.
- It took time to build a network of L&D service providers who were willing to share good practice, and contribute to the development of the standard service specification.
- Only since the inception of NHS England as a national commissioner, has it been possible to bring the learning from the programme into a single place to allow services to be formally commissioned.
- NHS England is only able to release funding for L&D services annually in accordance with the terms of the comprehensive spending review. Therefore, the programme is taking a phased approach to rollout.
The evaluation of the first ten pathfinder schemes reported the following findings in 2015:
- Qualitative findings were positive and provided an insight into the way that services work.
- The evaluation highlighted much that is very good. In particular, relevant and timely information being shared with custody and court staff is enabling better informed decision making and is perceived to be leading to efficiency savings. The expertise and knowledge of L&D staff was appreciated by colleagues in the police and courts, and they were perceived to be part of the routine functioning of the system.
- The introduction of the support worker function was seen as a major strength, as was widening the scope of needs addressed (e.g. to covering learning disability) and to addressing practical and urgent needs, such as lack of housing or financial difficulties, which can precipitate a crisis and trigger offending behaviour.
- In just 18 months L&D services ad become fully embedded in the fabric of the local health and justice landscape. The evaluators found that L&D services have become intertwined with existing services and partnerships, particularly for the youth justice pathway.
In addition, the programme team works via its partners to gain user and service provider feedback on the extent to which L&D improves access to treatment services for vulnerable people in the youth and adult justice systems.
The Department of Health has commissioned ‘RAND Europe’ to conduct a second phase of research, to determine the outcomes of L&D services in relation to the impact on re-offending, diversion from the justice system, the impact on healthcare utilisation, and a full economic analysis of the services.
This will involve conducting comparative research to measure the ‘before and after’ effect of the introduction of L&D services. This research is due to conclude in 2019.
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