Strategy development, assurance and commissioning

The strategic direction for health and justice and sexual assault services is set at a national level.

Responsibility for commissioning these services is discharged at a regional level. Assurance is provided via reporting from the Health and Justice Oversight group over quality, performance, and value for money.

The Health and Justice Governance group, Health and Justice Clinical Reference group, Children and Young People Governance group, Non-custodial Partnership Advisory group and Sexual Assault and Abuse Advisory group also make formal recommendations on the commissioning of services.

Foreword

In 2016, NHS England published its first ever strategy for health and justice (the Strategic direction for health services in the justice system, 2016-2020), providing a framework for NHS commissioners, providers, those with lived experience and criminal justice and cross-departmental partners to work collaboratively to improve health and wellbeing outcomes for those in secure and detained settings. This well received document paved the way for working in partnership to support greater inclusion of our patient group and facilitate opportunities to improve the health of and reduce health inequalities for adults and children in the criminal justice system. These opportunities included a radical upgrade to early intervention, a shift towards person centred care, strengthening the voice and involvement of those with lived experience, supporting rehabilitation and ensuring continuity of care by bridging the divide between healthcare services in justice, detained and community settings.

Six years on, I am delighted to present the ‘Health and justice framework for integration: improving lives and reducing inequalities’, which cements this important partnership, ensuring our work in this area is at the very core of integrated care systems (ICSs). This is fundamental in effectively tackling, at a local level, the health inequalities this vulnerable patient group face, along with improving their life chances as individuals move through the criminal justice system.

I am grateful for the ongoing commitment of our providers and partners to drive positive change in this area. None of this, however, would have been possible without the hard work and involvement of those with lived experience. By working closely together and embedding co-production in all that we do, we are able to deliver more authentic programmes of work that effectively reduce inequalities, prioritise continuity of care, drive up the quality of care and reduce early avoidable deaths.

Despite the healthcare challenges presented by the Covid-19 pandemic, health and justice teams have continued to improve service delivery and accelerate mobilisation of our digital plans; the use of portable IT equipment created greater service flexibility and connectivity across the secure and detained estate, and our RECONNECT pilots continued to effectively support people leaving prison during this challenging time. The hard work of health and justice commissioners, providers, partners and lived experience representatives during this difficult period has been unwavering and a testament to their professionalism and dedication to ensuring the provision of high quality health and wellbeing interventions for those in secure and detained settings, as well as for those moving back into the community.

As we extend our important partnership to formally include ICSs, we are in a much stronger place to progress service transformation to facilitate an equitable population health-based approach for our patients. The 12 commitments in this document are intended to enable the local delivery of robust plans to support health improvements, the development of individual care pathways, the reduction of offending behaviour and ultimately equivalence of care provision and outcomes.

By following this framework and delivering its commitments, we are well placed to drive real change to patient care, ensuring health gains achieved in secure and detained settings are maintained and supported as part of an individual’s long term rehabilitation. This is particularly the case for supporting delivery of the equality, diversity and inclusion duty on integrated care boards to improve health delivery and greater staff and patient experience of the NHS. Through local delivery of the work programmes set  out in this document, associated outputs will provide an evidence base for meeting these duties, by supporting an inclusive and diverse workforce, adopting a whole system view of the health needs of our patients and tackling inequalities in outcomes, experience and access. This approach will be front and centre of health care commissioning across the secure and detained estate, helping to support fair and equal access for one of the most vulnerable patient groups within the NHS.

Kate Davies CBE, National Director of Health and Justice, Armed Forces and Sexual Assault Services Commissioning.

Introduction

This framework sets out the direction of travel and national priorities which will inform the development of integrated health and justice services across England (excluding sexual assault and abuse services, which will have a separate framework for integration). It has been informed by the views and experiences of people with lived experience, partner organisations, providers and our own team. It also forms a companion document to existing strategies and programmes of work identified as beneficial to service improvement.

The Health and Care Act 2022 introduced significant reforms, putting ICSs on a statutory footing. This will support continued evolution of local partnerships and collaborative ways of working set out in the NHS Five Year Forward View and the NHS Long Term Plan (LTP).

This framework sets out our ambitions to work with the 42 integrated care boards (ICBs) and integrated care partnerships (ICPs) across England, as well as with our justice and police partners to further develop integrated pathways of care between the community and custodial environments. It links with and complements youth and criminal justice strategies, including the Prisons Strategy white paper. The Framework highlights the complex relationship between health influences on offending (the focus on offending is not inclusive of children in secure settings for welfare reasons) and reoffending behaviour, alongside wider social influences, such as poverty, housing, social exclusion and adverse childhood experiences (ACE).

We know that many people within the justice system experience greater health problems than the rest of the population but do not regularly access care. This framework sets out ambitions to improve healthcare for everyone (the term ‘everyone’ is used to ensure inclusivity and equality and includes all adults and children) across secure settings and spread good practice. It seeks to reduce health inequalities, particularly those highlighted during the pandemic and improve the wellbeing of people in secure and detained settings by addressing health-related drivers of offending behaviours.

We will focus on specific and measurable actions that reduce the health gap between people in the criminal justice system and the wider population, with the aim of achieving equivalence of care. Resolution of these health issues offers not only the prospect of reducing offending and reoffending rates, but significant societal benefits and a reduction in costs for the health service, social care, police, and criminal justice systems.

In support of the above, this framework aligns with Core20PLUS5, NHS England’s national approach to inform action to reduce healthcare inequalities at national and system levels. The approach defines a target population – the ‘Core20PLUS’ (NHS England » Core20PLUS5 (adults) – an approach to reducing healthcare inequalities) and identifies ‘5’ focus clinical areas requiring accelerated improvement. The approach, which initially focussed on healthcare inequalities experienced by adults, has been adapted to apply to children and young people. People involved in the criminal justice system, because of their offending behaviours, are one of the target groups of the Core20PLUS5 approach that may be identified by ICSs. Therefore, this framework and Core20PLUS5 provide a focus for partnership working and interventions to reduce health inequalities experienced by people involved in the criminal justice system.

We believe the work priorities in this plan reflect the needs of people accessing health and justice services and that the associated actions supporting work in progress are tangible and deliverable.

Commitment 1 – Putting the patient voice at the centre of everything we do

Our strategic decision-making processes and operational plans recognise that involving people with lived experience is central to commissioning services that reduce inequalities and meet the health and wellbeing needs of service users in, or at risk of contact with, the criminal justice our lived experience network chair and lived experience advisor support central and regional teams, creating opportunities for involvement across all programmes and work streams.

Our work will be underpinned by the following principles:

• Introducing consistent support and personal development for people with lived experience, through our Lived Experience Charter and competence frameworks, developed in partnership with Revolving Doors (The Revolving Doors Agency, also known as Revolving Doors, is a charitable organisation which works across England and Wales. Through research, policy and campaigning work, the organisation aims to improve services for people with multiple needs who are in repeat contact with the criminal justice system)..
• Supporting involvement of people with lived experience across all our programmes and work streams.
• Ensuring equity and equality for all service users in line with the principle that everyone matters.
• Confronting inequality head-on.
• Improving our understanding of those from different communities and reducing unconscious bias.
• Recognising people as individuals and strengthening our approach to personalised care.
• Valuing health, care and support equality.

Our programmes of work

• Developing an ‘independent’ patient and public voice (PPV) function which embeds representation across all programmes and functions and throughout the commissioning cycle (patient and public voice should draw from national and regional inclusion groups to support strategic planning and operational delivery).
• Developing lived experience leadership across the services we commission.
• Creating opportunities for apprenticeships and paid employment for people with lived experience.
• Identifying and implementing actions to improve access and health outcomes for people experiencing health inequalities (this will involve close working with the UK Health Security Agency, Office for Health Improvement and Disparities (OHID) and partner organisations).
• Implementing the recommendations of Beyond the data: understanding the impact of Covid-19 on BAME groups.
• Implementing the findings of the David Lammy report to create fresh thinking about how health might work differently within these settings.
• Engaging with the NHS Race and Health Observatory to undertake a study on race and health in health and justice and identify areas for improvements.
• Improving the collection and recording of ethnicity data to help identify inequalities; developing metrics to capture social value and improve our work in this area.

Key considerations for ICSs

• Commissioning trauma informed services that support the early identification of vulnerable men, women and children and deliver early interventions to help prevent offending and reoffending.
• Educating staff in partner organisations on all aspects of exploitation and radicalisation, including the modern slavery agenda and county lines, to ensure they are equipped to identify and support individuals who have been victimised and abused through criminal exploitation.
• Agreeing and monitoring metrics within local systems to improve the recruitment and retention of people with lived experience, maximising opportunities with local public sector organisations as anchor institutions.

Commitment 2 – Working in partnership to commission high quality care

We believe that the most effective services are co-designed in partnership with key stakeholders. We will further develop this approach by enhancing our existing partnership agreements and expanding our work with voluntary sector organisations and systems.

Partnership agreements

Our partnership agreements help us to collaborate and align our priorities, recognising our respective statutory responsibilities and independence. These agreements support a fully integrated approach

for the commissioning and delivery of excellent health services within these settings. We are committed to work together to ensure safe, legal, decent and effective care that improves health outcomes for prisoners, reduces health inequalities, protects the public and reduces reoffending. Our plans support collaboration and co-operation at all levels within our organisations to achieve our three core objectives. These objectives will be delivered through detailed annual work plans that outline activities and projects, their associated deliverables, measures and timelines.

The Ministry of Justice reforms to probation services will help to strengthen and build confidence in the rehabilitation and resettlement of offenders. This revised service will deliver unpaid work and behavioural change programmes in England and Wales. It will be supported by specialist organisations delivering resettlement and rehabilitative services, such as education, training, employment and accommodation. Our RECONNECT services will ensure they are closely linked to the 12 probation areas across England and Wales to ensure alignment of work programmes to meet individual needs when people are released from custody.

Our three core objectives

1. To improve the health and wellbeing of people in prison and reduce health inequalities.
2. To reduce re-offending and support rehabilitation by addressing health-related drivers of offending behaviour.
3. To support access to and continuity of care through the prison estate, pre-custody and post-custody into the community.

Working with ICSs

The Health and Care Act 2022 introduced significant reforms, putting ICSs on a statutory footing. This will support the continued evolution of local partnerships and collaborative ways of working set out in the NHS Five Year Forward View and the NHS Long Term Plan.

One of the real strengths of ICSs will be the emphasis on shared purpose and real ambitions, such as tackling health inequalities for colleagues and communities from ethnic minority groups, for people with learning disabilities and enduring mental health illness. Integrating care will make a huge difference to our populations as we work together to seize the opportunities this brings.

ICBs and ICPs, which bring together the ICB and their partner local authorities and other organisations (for example, health, social care, public health; and potentially others such as criminal justice organisations), will create a forum for partnership working and have a role in improving health outcomes and reducing the incidence and impact of offending and inequalities individuals may face.

With the benefits of this integrated approach highlighted throughout this framework, we will continue to support our regions to progress existing programmes of work with systems and local authorities in support of improved health outcomes for the populations we serve.

Our programmes of work

• Addressing health-related drivers of offending behaviour and supporting rehabilitation by working with partners across housing, homelessness, mental health and addiction to provide holistic care and support.
• Supporting His Majesty’s Prison and Probation Service (HMPPS) to bridge the gap on homelessness, adapting models for homeless discharge from community hospitals to prison settings.                 
• Ensuring the alignment of health service strategies to support the shared delivery of current and future changes across the custodial estate.
• Reviewing and improving commissioning between health and justice partners (including private sector prisons), to ensure the provision of high-quality health and social care services before, during and after custody.
• Continuing our partnership work with Health Education England, HMPPS and colleagues across government to support the development of career opportunities in health and justice.

Key considerations for ICSs

• National partnership agreements are usually set out on a five-year basis and will continue to be refreshed and renewed to ensure this approach continues. ICSs and health and care partnerships can support this partnership approach and are encouraged to include criminal justice partners (HMPPS, the Office of the Police and Crime Commissioner and probation and youth justice services) and health and justice commissioners in their committees. In addition, they are encouraged to engage with regional NHS England health and justice teams to support the deliverables of this Framework.
• Recognising the benefits of co-commissioning and co-design of services with probation services and youth offending teams to enhance the case management support for those released from prison and the children and young people secure estate (CYPSE).
• Fulfilling the ICB statutory duty (conferred from the clinical commissioning groups (CCGs)) to provide youth justice services in each local authority area, which includes commissioning healthcare services to form part of each local youth justice service and form part of their management Board.

Commitment 3 – Supporting people with neurodiversity and complex health needs

People with neurodiversity are statistically more prevalent in criminal justice Many of them may be disadvantaged when encountering the criminal justice system13 and find it particularly difficult to engage with health services. Furthermore, their needs may be undiagnosed or untreated. In addition, vulnerable children may not have been supported to access healthcare or been encouraged to maintain links due to a chaotic family lifestyle or parental health issues. There is huge potential to integrate our work programmes with ICSs and co-design services which deliver improved outcomes for these vulnerable people.

Liaison and diversion services now cover 100% of police custody suites and magistrates’ courts in Teams work with them to identify people with poor mental health, learning disabilities, substance misuse issues or other vulnerabilities when they are first in contact with the criminal or youth justice systems. This first point of contact is a key opportunity to jointly assess and identify health needs and link individuals with appropriate support.

Services use a validated screening tool to identify and respond to neurodiversity and share information to support sentencing A nationally agreed screening tool and communication protocol across health and social care (including shared IT) would improve understanding and early implementation of supportive measures.

Planning needs to consider that many people with these vulnerabilities may receive a community service order, be released without charge or be Without support, these individuals, some of whom will be below the threshold for community mental health support, may continue to commit offences of increasing gravity. The RECONNECT service is an important intervention for these individuals, alongside HMPPS probation services and youth justice services that will work with ICSs to support people with community sentences, out of court disposals and other prevention initiatives.

Our programmes of work

• Continuing to support and adapt services to meet the needs of people with poor mental health, learning disabilities, substance misuse issues or other vulnerabilities, through the consented sharing of health information, thus improving decision-making by the police and judiciary.
• Establishing a nationally agreed screening process and communication protocol with ICSs (including shared IT) to ensure people with neurodiversity are identified and properly supported across all services.
• Embedding the use of screening tools into every service to ensure masking behaviours used by neurodiverse people to fit in with society, are identified to ensure correct support can be provided to them.
• Developing tailored workshops, which support commissioners and ICS to understand and address needs identified in surveys, data analysis and feedback.
• Extending liaison and diversion services to civil courts, to support sentencing options for domestic cases, such as for anti-social behaviour (responsibility for hearing domestic incidents, eg anti-social behaviour, has transferred from criminal courts to civil courts).
• Supporting people attending Voluntary Interviews to ensure they receive the same access to services as people interviewed in police custody suites.
• Working with youth justice services and ICSs to improve liaison and diversion services for children and support prevention and Out of Court Disposals.

Key considerations for ICSs

• Developing locally integrated pathways of care with an emphasis on prevention for those identified at risk of entering the criminal justice system and to support the seamless transfer of care between the criminal justice system and community services.
• Working with local authority children’s and adult services to identify people in need of proactive support to reduce their risk of offending and reoffending.
• Implementing mitigations to reduce the health impact of separating mothers and fathers from their children where custodial sentences are given.
• Expanding community ‘at risk’ registers to include children in custody.
• Linking with criminal and youth justice partners to support alternatives to short custodial sentences and working with criminal and youth justice partners to co-design and commission services which directly enhance community alternatives.

Commitment 4 – Providing evidence-based treatment as alternatives to custodial sentences

Introduced in the Criminal Justice Act 2003, community sentence treatment requirements (CSTRs) provide the judiciary with treatment and evidence-based sentencing options, which may include alternatives to custodial sentences for some offences and some people. They are excellent examples of integration, demonstrating how health and care providers have worked in partnership with the criminal justice system. The three treatment types covering drug, alcohol and mental health issues, together with
a range of services, such as social care, housing, education and employment, provide holistic care and support and help to ensure improved life outcomes for people.

Individuals who may be suitable for a CSTR typically have complex health and wellbeing needs and are generally high users of out-of-hours, emergency health and social services, with many not registered with GPs.

The provision of dedicated mental health treatment requirements (MHTRs) for people with a mental health condition who are not engaged in treatment, ensures effective individualised treatment and support. MHTR services work in partnership with substance misuse, social care, and probation services to address underlying issues to help prevent further reoffending and support continuity of care.

The independent evaluation Community sentence treatment requirements protocol process evaluation report of the scaled up new primary care MHTR is showing a clear benefit, through improved use of MHTRs in sentencing.

The increased use of all three CSTRs has been driven through a national partnership that formed in 2017 between the Ministry of Justice, Public Health England, Department of Health and Social Care, HMPPS and NHS England. This is underpinned by a coordinated programme approach, which enables the use of combined orders for those with drug, alcohol and mental health issues.

In support of CSTRs, the Female Offender Strategy (2018) committed to piloting at least five residential women’s centres across England, offering sentencers a community option of intensive residential support packages, to decrease the number of women in custody.

Our programmes of work

• Accelerating increased availability of CSTRs to meeting recommendations of the NHS Long Term Plan and Justice committee report mental health in prison, Sept 2021.
• Achieving 100% coverage of MHTRs in England by 2024.
• Working with ICSs and criminal justice partners to identify funding and co-commissioning opportunities to expand CSTR coverage to 100%.
• Supporting the residential women’s centre pilots.
• Working with the youth justice system to develop and support the delivery of community sentences as alternatives to custody, eg treatment requirements attached to a youth rehabilitation order.

Key considerations for ICSs

• Establishing a shared vision and model for service delivery, which supports continuity of care for those with complex health and social care issues.
• Ensuring early identification and screening pre or at first point of arrest and creating individualised support packages to address the underlying issues of offending. Integral to this is ensuring access to GP registration in primary care, as well as access to wrap around social services, housing, education/employment and benefit advice.
• Developing effective working with probation and youth justice services at a local system level to improve targeted support, such as tackling homelessness and providing accommodation, to help minimise the risk of reoffending.
• Providing cross sector training on understanding the health and social care drivers of offending behaviour to aid the early identification and support of individuals at risk of entering the criminal justice system. This should include specific training on adverse childhood experiences (ACE) and the consequences, such as trauma, exploitation and school exclusion.

Commitment 5 – Improving the health and wellbeing of vulnerable children

At the end of 2021, the children and young people secure estate (CYPSE) in England had capacity for circa 1,100 children remanded or sentenced to custody or detained under the Children Act 1989 for welfare reasons.

These children, who are some of the most vulnerable in society, have significantly greater, and often previously unidentified and unmet health needs, than other children their age. Many have been victims of crime or abuse and they are twice as likely as the general population to have been subject to serious maltreatment (Healthy children, safer communities programme, A strategy to promote the health and wellbeing of children and young people in contact with the youth justice system). Time spent in a secure setting provides an opportunity to attend to their physical, mental and emotional health and wellbeing needs and plan for their continuing care on transition to the community or into the adult secure estate.

Our commitments for this cohort have been developed to help ensure services reflect their needs and support accessibility in ways that work for them, whether they are at risk of entering, in or leaving the youth justice and welfare system.

Girls form a small minority of the CYSPE population. They are more likely than boys to have been exposed to childhood adversity, trauma and victimisation, which may remain hidden, thus preventing important opportunities for early intervention and diversion. Their markers for self-harm are also different to that of boys and they are at greater risk of sexual exploitation (Out of sight, Centre for Mental Health).

Joining up healthcare, education and social care for these children, will provide us with the best opportunity to improve their life outcomes. These children are our future. Our 13 vanguard schemes, working as integrated units, have already prevented 10 children from being excluded from school. These teams use specialised mental health services, which look not just at the diagnosis, but the wider determinants of behaviours and ensure adequate support and advocacy (the domestic circumstances of children sometimes means there is no parent to act as their champion and the vanguards have implemented advocacy support in situations where the severity of the offence is not significant enough to warrant local
authority involvement and there is no parent to do this) is available.

Our programmes of work

• Continuing the roll out and sustainability of the Framework for Integrated Care (Secure Stairs) in the CYPSE with our partners and systems.
• Including vulnerable children, their families, parents and carers in the commissioning of services to ensure they are at the heart of everything we do.
• Continuing our work with partners and the secure school provider, to design an integrated framework for the first secure school in Kent, ensuring education and health at its centre.
• Moving to a population-based delivery approach to develop fully integrated services with systems.
• Focussing on elements which promote change and reduce the issues relating to reasons for detention.
• Reducing health inequalities by delivering integrated, trauma-informed services that help to prevent the progression of some children to high end mental health, justice and welfare systems.
• Working with the Youth Custody Service on initiatives focused around transition and resettlement, including adequate and timely information sharing to support the Child Protection Information Sharing project, improve health and life outcomes and prevent them ‘falling through the gaps’.
• Building strong links with the Complex needs pathway work described in the LTP through the delivery of the Framework for integrated care (community).
• Working with the Youth Custody Service to develop a Girls care strategy, ensuring girls in the CYPSE receive bespoke, gender-responsive care.

Key considerations for ICSs

• Refresh of Intercollegiate Healthcare Standards and Children Health Outcome specifications for CYPSE.
• Supporting a move to a population-based commissioning model which includes health and justice populations.
• Ensuring full integration of CYSPE health services with community pathways and sustainability of the Framework for Integrated Care (SECURE STAIRS).
• Creating a facilitative model of care that provides consultation, assessment and pathways for transition to specific services as and when required.
• Implementing the complex needs pathway work in the LTP via the Framework for Integrated Care (Community) vanguards (The Framework for Integrated Care (Community) is used by each vanguard as the principles and outcomes to deliver integrated care. The principles define how services come together to support children in a formulation and trauma informed way of working. Vanguards used this to develop their model for delivery of these care pathways) supporting children with complex needs through an integrated pathway.
• Fulfilling the ICB statutory duty (Crime and Disorder Act 1998) to provide youth justice services in each local authority area, which includes commissioning healthcare services to form part of each local youth justice service, and form part of their management Board.
• Ensuring all decisions made about children are cognisant of the potential impact on their life outcomes.

Commitment 6 – Improving the health and wellbeing of people in custody

For some people, prison can be the first time they have the opportunity to access care and improve their health and wellbeing. These people often have more complex health problems and a higher burden of illness than the rest of the population. Across the prison estate, there is a higher prevalence
of blood borne virus and infectious diseases (Hepatitis C and tuberculosis (TB)), alongside substance misuse and mental health conditions. These illnesses can be linked to lifestyle, increased vulnerabilities through homelessness, injecting behaviours and immigration (three out of four cases of TB in the UK affect people born outside of the UK). Our providers have made great improvements to reduce these diseases by supporting the TB screening and National Hepatitis C Micro Elimination programmes.

Changes to sentencing and higher numbers of elderly prisoners following prosecutions for historic sexual offences has led to greater demand for the management of chronic conditions, frailty and dementia, as well as increased demand for social care. We have introduced elderly care units in two prisons (prisons with elderly care units include HMP The Verne and HMP Whatton), but they are not able to support all the identified elderly healthcare needs and so we are working with HMPPS to resolve this.

Some people arrive in prison with significant health and social care needs, which cannot always be immediately met or delivered in custodial settings. We are supporting local authorities to provide care to disabled people with varying severity, up to and including quadriplegia, working with them and HMPPS to identify and adapt accommodation to meet their needs.

Our commissioning has been further influenced by the findings in Dame Carol Black’s Review of drugs part two: prevention, treatment, and recovery. We are moving to a lifecycle approach that reflects local populations and priorities and closer working with ICSs. This approach aligns with the zero- tolerance approach to drugs adopted by prisons and From harm to hope: a 10-year drugs plan to cut crime and save lives.

Our programmes of work

• Developing a whole prison approach to health and wellbeing, to support equitable access to care for all.
• Working with HMPPS to address restricted regimes, curbs on association and visiting to facilitate an environment which promotes health and wellbeing.
• Establishing a shared estates programme to commission a whole environment review of prisons which:
  • considers the role the environment plays in infection prevention and control and improving health outcomes
  • identifies ways to improve the environment so that it can be cleaned and ventilated and make a positive contribution to health and wellbeing
  • reviews the accommodation needs of increasingly elderly and vulnerable populations and identifies areas for improvement.
• Taking a lifecycle approach to commissioning, ensuring the right help is available at the right time during and after custody.
• Improving access to preventive, diagnostic and screening programmes for non-communicable diseases.
• Ensuring proactive detection, surveillance and management of infectious diseases in prisons; improving our joint capability to respond to outbreaks.
• Delivering the Covid-19 vaccination programme across the secure and detained estate, in line with the Joint Committee for Vaccination and Immunisation (JCVI) guidelines and aligned with community programmes.                  
• Continuing support to local authorities in the commissioning and management of social care provision in custodial settings.

Key considerations for ICSs

• Embedding a whole system approach to care by developing consistent pathways of care and rehabilitation that tackle health inequalities relating to addiction, mental illness, homelessness and infectious diseases across organisational and prison establishment boundaries.
• Supporting creation of a single data set which provides a system overview of the needs of populations, incorporating custodial data sets with community data sets.
• Developing shared care records and interoperability for patient care to address health inequalities via a population health management approach which is supported by data sharing.

Commitment 7 – Ensuring good mental health for adults in custody

Many adults in prison have mental health problems. These range from anxiety and depression, to serious mental illness, including psychosis and personality disorders, all of which are more prevalent than in the community. Some people have a dual diagnosis, which includes substance misuse (drug, alcohol and tobacco) issues.

The environmental factors of prison and life circumstance can lead to people experiencing low mood and anxiety that is proportionate to circumstance (reactive) and not a long-term condition. Considerate of this, we will work with ICSs and partner agencies to develop approaches for the management of mental distress across offender pathways in the community and prisons, avoiding the consequence of long-term psychiatric labelling of these people.

We are developing a multi-layered approach to mental healthcare provision for adults in prison to better support their needs, including improved support for women with children through our enhanced perinatal mental health services. These services take account of women who are pregnant when they enter prison or who may have given birth in the year before sentencing.

Midwives employed in local services visit the prison to provide care for women who are pregnant. These women are escorted to hospital to give birth and may return to one of two mother and baby units within the women’s estate (where they can look after their baby up to 18 months of age). Support is available for these mothers, as well as for mothers who are separated from their children when remanded to custody or following birth.

The mental health strategy for health and justice services sets out the three priority pillars for improvement – data information and analysis; integrated mental health services; and continuity of care. A toolkit supporting implementation of these priorities has been developed by the national health
and justice team and shared with regions for utilisation (copies of the mental health strategy toolkit can be obtained from hjaf.corpgovn@nhs.net). Learning from this will help to support the development of revised service specifications for mental health to be implemented across our services.

Our programmes of work

• Improving integrated working with our partner and mental health provider collaboratives, to reduce mental illness and improve the mental health and wellbeing of those in prison.
• Developing personalised and integrated mental health care pathways with community services, ensuring the smooth transition of patients between services on entry/release from prison.
• Applying a ‘no threshold’ access to psychological support and a psychologically informed approach to care.
• Ensuring the implementation of the Mental Health Transfer and Remission Guidance.
• Continuing development of maternity service provision across the estate.
• Improving perinatal mental health services to enhance women’s experience of pregnancy.
• Expanding perinatal care for women who are separated from their babies or young children (within 18 months post-birth).

Key considerations for ICSs

• Systems should ensure that pathway and capacity planning takes account of people in prison who may require transfer to community mental health services on release.
• Systems with prisons in their geography should have processes in place to take on a ‘temporary responsible commissioner’ role for any prisoners requiring transfer to secure mental health facilities
  to reduce delays where there are delays establishing the responsible commissioner.
• Ensuring access to community mental health services (such as eating disorders) for the prison population, including options for in reach services where appropriate.
• Supporting the interface with provider collaboratives for high secure/offender personality disorder services.

Commitment 8 – Reducing early and avoidable deaths

The number of natural cause deaths (defined by HMPPS as including “any death of a person as a
result of a naturally occurring disease process”) in prison is increasing, with heart disease and cancer being the two most common causes. We are embedding learning from our Section 7a Public Health Screening programme and working with providers to identify ways to increase uptake to ensure promotion of a preventative approach to care.

Some of these early deaths are preventable, and we are working with our partners to identify and address health inequalities and improve access and confidence in health services. For example, adults from Black, Asian and minority ethnic populations are less likely to report ill health and access support (The Lammy Review: An independent review into the treatment of and outcomes for Black, Asian and minority ethnic individuals in the criminal justice system). This can be due to a range of reasons, such as a distrust of services stemming from generational trauma and/or racism.

More people identified as being close to end of life, die in custody than in a hospice. Whilst this is a choice for some, for others, this may be due to a lack of hospice care or compassionate release being delayed or refused.

Prison healthcare is commissioned to provide care equivalent to that available in the community, but this can be challenging in older Victorian prisons which were not built to meet modern infection control requirements and support prisoners with greater acuity of healthcare needs. Our joint estates review seeks to find solutions to these issues.

Recognising that some individuals die by suicide each year, while in prison, or in the community post release, we are committed to working collaboratively with ICSs and partners, to support continuity of care on entry to and release from prison.

Our plans include reducing the number and frequency of self-inflicted deaths, by ensuring full involvement of health services in the assessment, care in custody and teamwork (ACCT) process in prisons, and ensuring individuals are supported following their release.

We are committed to reviewing each death to inform learning to achieve our aim of zero suicide and prevent early or avoidable deaths.

Our programmes of work

• Commissioning a joint independent review of existing escort arrangements to maximise access to services for the prison population.
• Implementing evidence-based practice to provide personalised care specific to individuals’ needs and improve health and social care outcomes for older people and those with serious illnesses.
• Supporting a joint review of processes for compassionate release to streamline processes and shorten timeframes to decisions.
• Strengthening our zero-suicide approach by adopting a multi-agency approach that includes risk assessments pre- custody and on release for prisoners at serious risk of harm.
• Ensuring ACCT is fully embedded and actioned at all levels by creating partnerships at national, regional and local establishments.
• Developing the custody deaths learning and assurance system to provide real time, automated national reporting on deaths in custody.
• Working with Integrated Care Boards and Partnerships to co-ordinate the approach to reducing suicide and self- harm of people in contact with the criminal justice system.

Key considerations for ICSs

• Developing a shared understanding of the needs of adults in the criminal justice system.
• Ensuring locally commissioned services have protocols for sharing healthcare information with court escort services and prison healthcare providers, including use of the electronic person escort record (EPER) to enable the transfer of key health information, risks and vulnerabilities for people moving between custodial settings.

Commitment 9 – Connecting people leaving custody to health services on release

41. Release from prison or other secure setting can be a crisis point for many people. They are leaving a secure environment where their needs (such as health and housing) are met and moving to an environment where they are responsible for themselves. These adults and children may wish to conceal their imprisonment, making it difficult to share healthcare information, which allows healthcare professionals to meet their ongoing needs. This can be further compounded by a reluctance to engage with services in the community due to previous negative experiences.

Providing support for these individuals at the point of transition is imperative. The 2009 Bradley Report recognised the importance of ensuring we continue engagement with people who have accessed treatment in prison following their release. Integrated working will help to improve support available and life outcomes for these people.

The RECONNECT service was launched in 2019 and established 11 pathfinder sites across England in 2020. These sites link with prison resettlement services and offer an early intervention service to empower individuals to take responsibility for themselves and their health care. RECONNECT starts working with vulnerable adults up to twelve weeks prior to release, offering support into prisons to help them make the transition to community-based services. This includes meeting people at the gate and helping them to access the services that will provide the health and care support they need.

An Enhanced RECONNECT programme has been developed for the most complex prison leavers. This is a psychologically led clinical service, which supports them to access and engage with community health care services, thereby reducing the risk that health vulnerabilities will heighten the possibility of repeat offending. The service provides clinical assessment and person-centred formulation of support plans, including engagement plans with clear step up and step down of service provision to manage risk.

Our vision for Enhanced RECONNECT supports the prison service ambition to put proper plans in place for people on their release and includes being closely connected with other services and agencies for offenders with complex health vulnerabilities. This includes the prison service, National Probation Service Multi-Agency Public Protection Panels and local health systems.

Our programmes of work

• Ensuring health gains achieved in prison are maintained in the community through extended support provision.
• Increasing the number of adults the RECONNECT service engages with year on year, extending services to cover 100% geographical coverage across England.
• Undertaking a review of RECONNECT to identify best practice, share learning and inform future service provision.
• Expanding delivery of Enhanced Reconnect programme across all prisons.
• Ensuring probation services and youth offending teams are key partners in supporting people leaving custody to reconnect and maintain engagement with health services.

Key considerations for ICSs

• Systems should ensure arrangements for registration and transfer of care to
  local health and social care services are in place to support continuity of care.
• Systems should ensure that locally commissioned services have protocols for sharing healthcare information with courts and secure and detained healthcare providers and are trained in the use, and have access to, the Electronic Person Escort Record (EPER) and child health summary.
• Local authorities should ensure effective plans are in place to improve health screening services for people with no access to public funds.

Commitment 10 – Improving the health of people detained in immigration removal centres

Adults held in immigration removal centres (IRCs) are those who have no legal right to be in the UK or who have not been able to prove their right to remain. Some may be foreign national prisoners who have completed prison terms and are awaiting deportation or determination of right to remain.

Some detainees are released into the community with the temporary right to remain and the opportunity to make an application for permanent right to remain, whilst others are deported to their country of origin. All detainees can leave at any time to return to their home country.

The population of the IRC estate is subject to change, in line with current or anticipated immigration issues. Detainees have a range of ethnicities (and nationalities) and are mainly men under the age of 40.

Children are not held in IRCs however when children are leaving the country with their family, they may be hosted in pre-departure accommodation immediately prior to leaving.

Adults in IRCs may not have had access to healthcare facilities in their home country or in the UK. Whilst some may have been detained directly after their arrival from their ‘home country’, many have been living in the UK for a while, without accessing NHS services because they are frightened of being detected. As a result, disease and long- term conditions may be undiagnosed.

A high percentage have some form of mental health problem and may have experienced significant trauma before or during their journey to the UK. They tend to be wary of any service with ‘mental health’ in the title and may be more likely to present with other conditions, including stress related conditions.

IRCs are more likely to be susceptible to outbreaks of infectious diseases due to lack of immunisation of the resident population.

The complexities of the health and wellbeing needs of detainees can only be supported through integrated working between IRCs and local community services. Joined up working will help to support these vulnerable people and improve their life outcomes.

Our programmes of work

• Working with the Home Office and cross Government partners, to ensure that potential impacts on a detainee’s health needs are properly considered in policy making and that shared objectives include a commitment to fairness, diversity and equality of opportunity.
• Improving system leadership and support for wider immigration issues that have health consequences, such as the 2021 Afghanistan crisis.
• Improving the mental health of detainees providing assessment, care and support commensurate with that of the wider community.
• Developing a menu of mental health and wellbeing care provision which includes trauma informed interventions to improve patient outcomes.
• Increasing pro-active detection, surveillance and management of infectious and non-communicable diseases in IRCs to ensure outbreaks and incidents are managed effectively.
• Ensuring detainees released into the community understand how they can access healthcare including GP or emergency services through a collaborative approach to discharge between detention and healthcare staff.

Key considerations for ICSs

• Systems should ensure that pathways are in place to support continuity of care for people released from IRCs, particularly primary care and mental health services which offer trauma informed therapy.
• Commissioning healthcare assessments for newly arrived refugee children, some of whom will be alone and without any family.
• Agreeing protocols between health and social care for the care and management of the unpredictable numbers of individuals arriving cross channel via boat.

Commitment 11 – Improving quality through learning and technology

The commitments in this Framework are underpinned by our ambition to commission high quality services, which meet the needs of adults and children in the youth and criminal justice systems.

Regional teams are responsible for commissioning services and monitoring service delivery, through contractual reporting requirements, such as the quality assurance improvement framework (QAIF) and alignment with the published healthcare standards for children in secure settings. This is supported by reviews of services and analysis to understand what they are doing well and where we need to implement improvements.

We are developing mental health indicators to understand how services support the mental health needs of our patients. We are also utilising data to demonstrate unmet needs and inform ongoing improvements as part of our commitment to review and improvement.

To support children to move seamlessly between settings, we are working with ICSs to integrate the Health and justice information systems (the HJIS Programme) and Youth justice application framework (YJAF) SystmOne for the CYPSE. This will ensure the sharing of medical records in a timely, accurate and appropriate way and support improvements to service provision and communication.

YJAF is the CYPSE record system.

This will be further enhanced through the new Visionable clinical system in secure settings that will integrate with community systems.

Health and justice services are delivered within other organisations’ estates, such as courts and prisons. The operational and security requirements, as well as the condition and environment of these settings, can impact on how, when and where care is delivered. We are working with our partners to identify solutions to this issue, particularly where estate conditions are likely to impact on the quality of care to patients.

All of our work is supported by the inclusion of people with lived experience, recognising that the voice of patients, service users and their families and carers families and carers is a vital component of driving quality and improving health and wellbeing outcomes.

Our programmes of work

• Developing a strong governance, accountability and assurance framework, underpinned by quality standards and outcomes to ensure high quality services.
• Defining future commissioning arrangements.
• Improving the digital interface between custodial and community healthcare services to facilitate the sharing of clinical information before custody, in custody and on release, eg acute and community use of Visionable.
• Developing interfaces which ensure all available information sources can be interrogated, including non-health systems, such as the Prison National Offender Management Information System (PNOMIS).
• Improving the quality of data recording and reporting, and reducing manual data collection, through the
  implementation of a national health and justice quality reporting portal.
• Improving our evidence base for best practice, by building capacity across services to participate in research and evaluation activities.
• Providing training and guidance which empowers staff to share data for safeguarding purposes.
• Utilising data to inform service design and delivery with a focus on trend analysis, interventions, and thematic studies in key areas areas, eg substance misuse, respiratory, heart conditions and cancer.

Key considerations for ICSs

• Developing protocols for sharing health information (in particular, substance misuse) to ensure the smooth transfer of care where custodial sentences are given.
• Ensuring all community staff (including call handlers) are properly trained to understand and support the needs of patients in the custodial environment.
• Ensuring care for people in custody is delivered safely. Minimising security risks and disruption to other custodial services. ICS commissioned services include ambulance services, A&E and out of hours GP/111.

Commitment 12 – Ensuring an inclusive and representative workforce

Recruitment and retention of suitably qualified and skilled healthcare professionals is a challenge across the NHS, but particularly in health and justice where daily operational issues and Covid-19 have created an intense working environment. Many healthcare professionals are unaware of services provided within the criminal justice system and those who are, can be hesitant of working with this cohort. As a result, health and justice providers have been struggling for many years to recruit and retain staff across all elements of service delivery.

Careers in health and justice can be both challenging and rewarding, with an opportunity to create new life chances for adults and children in the criminal and youth justice systems support them to address health issues and turn their lives around. Improving the health and wellbeing of these individuals also brings benefits to society, reducing the burden on community services and reducing health related offending.

The Inclusive Workforce Programme, established in 2020, in response to the NHS People Plan, sets out ways of working closely with regional colleagues, providers and people with lived experience, to identify the barriers to recruitment and consider support measures which will encourage people to consider health and justice as a career pathway. These measures will ensure that we support, motivate and develop staff to remain in post. This is particularly important when recruiting individuals with lived experience of the criminal justice system, where security and vetting clearance processes can result in a lengthy recruitment time.

The Inclusive Workforce Programme supports new ways of working with ICSs, including opportunities for shared staff, rotational working across different environments and improved training and career development opportunities.

Our programmes of work

• Ensuring health and justice is perceived as a leading-edge, inclusive area for a career by:
  • developing health and justice training modules with universities as part of nurse and healthcare professional training and providing opportunities for student placements.
  • creating rotational roles between prisons and community services to support continued professional development and integrated working with providers.
  • developing a national workforce competency framework with career opportunities and progression, which embeds equality and equity.
  • promoting Professional Nurse Advocate roles to facilitate restorative supervision to their colleagues and teams.
  • expanding work with third sector organisations to develop our workforce.
  • reducing the complexity of job descriptions and application forms to create a level playing field for all applicants.
  • ensuring all contracts and procurements embed the principle of ‘growing our own for the future’.
  • monitoring and improving provider performance against the Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES).
• Ensuring people with lived experience are provided with opportunities to work in health and justice roles, underpinned by:
  • a Lived Experience charter, which supports the involvement of those with lived experience in
    commissioning and service delivery.
  • recruitment guidance to support organisations develop a lived experience workforce.
  • designing and piloting workforce opportunities in NHS England/ICS teams as well as commissioned services.

Key considerations for ICSs

• Developing an integrated approach with health and justice commissioners and providers (including the independent sector) to implement new ways of working which include:
  • creating a flexible workforce with transferable skills.
  • facilitating system-wide working with partners in health and justice.
  • creating opportunities for rotational working across services, with a focus on improving the health and wellbeing of staff working with patients and service users with complex needs and behaviours where recruitment and retention is most challenging.
• Developing aligned recruitment and retention strategies which provide opportunities for career development across organisational boundaries.

Conclusion

This Framework is for our patients and those who support them. It sets out our commitments to reduce health inequalities and health related offending behaviours and improve life outcomes of people in, or at risk of entering, the criminal and youth justice systems.

This Framework is also for the NHS, as well as our partners within the youth and criminal justice systems and across voluntary sector organisations.

The pandemic has shown that there is benefit in joint working, which will continue into the future as we work towards our common goal of health and wellbeing improvements for those in contact, or at risk of contact with the criminal justice system.

We cannot deliver this in isolation and need the support of our ICSs and criminal justice colleagues to achieve our ambitions. Developing improved partnership working with ICSs will help us to ensure an integrated and informed approach.

The twelve commitments provide a framework for discussions and offer flexibility for implementation reflective of system maturity. In support of this, we have set out some considerations for ICSs.

The Health and Care Act 2022 sets out the roles we can play in supporting the physical, mental, social and economic needs of our populations. Building on this work, health and justice teams look forward to working with you to improve life outcomes and reduce health related offending behaviours by delivering the ambitions of this Framework for care not custody, care in custody and care after custody.

Publishing Approval Reference: PR630