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									Exploring Effective Practice in MDO
 Schemes: Towards a 21st Century

                 Dr. Francis Pakes
                 Ms. Jane Winstone
       Making Changes for the 21st

     “most court diversion services are currently
    inadequately planned, organized or resourced,
    and are therefore of limited effect….A central
    strategy is required, and properly designed and
    adequately supported court services should be
    incorporated into….mainstream local
    psychiatric provision. Without such action, the
    future of court diversion lies in doubt.”
                                          (James, 1999; pg. 507)

2               Pakes and Winstone 2007
         Our Research (OCJS/MoJ/DoH)

       To identify provision of support for individuals
        in the criminal justice system with mental
        health difficulties

       To improve that provision by supporting

3                    Pakes and Winstone 2007
         Aims of the Mental Health Effective
        Practice Audit Checklist (MHEP-ACE)

       To use areas and elements identified through
        literature review and test sensitivity of tool to:
        –   Identify effective practice
        –   Identify sustainability
        –   Identify ways to measure value for money
        –   Identify a range of operational strategies

4                      Pakes and Winstone 2007

       6 Areas of Effective Practice
        –   Screening, Assessment, Facilitating Access; Other
            Liaison; Multi-Agency Arrangements; Information
            Sharing; Data Collection and Analysis
       Each Area tested against 6 Elements of
        Effective Practice
        –   Statement of Purpose; Policy; Management;
            Resourcing; Practice; Continuous Professional

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                        Pilot Study

       9 schemes
       Selected for diversity of delivery and
        geographical spread
       Newly established and long running schemes
       Based in Magistrates‟ Courts, Hospitals, Local
        Government Offices

6                   Pakes and Winstone 2007
        A Brief Word on Provisional Findings

       A single bastion of best practice does not exist

       All schemes were driven by committed, hard
        working individuals often providing a first-class
        service in the face of numerous hurdles

       Variety and ingenuity

7                    Pakes and Winstone 2007
             Assessment and Screening

       Not all schemes undertake both activities (pro-active screening is
        rare) but all schemes seek to be a low threshold, easily accessible
        “even if they call me and there turns out to be no mental health issues
        that is still good. Manager; I want him (CPN) down there (Custody Suite)
        so that people know who he is and what he does”

       Practices are, however, developing non-strategically which can
        lead to feelings of being asked to “be all things to all people” and
        to unrealistic expectations and perceptions of failure to deliver

       Recommendation: Having an identification strategy and
        development plan is important

8                          Pakes and Winstone 2007
    Facilitating Access to Mental Health
       A core task undertaken by many, but not all, schemes
       The differences in practice ranged between:

           “once referred on then there is no control over what happens or
           whether the referral agency will provide what is needed for the client –
           aggravated by massive cultural differences”
          “we do not just refer – we physically take them to their first

       Recommendation: To achieve a „seamless‟ multi-agency delivery
        there is merit in overlapping boundaries in service provision and
        admission criteria that are not exclusive
9                          Pakes and Winstone 2007

        Included constructive contact with statutory, community
         and voluntary providers
        Main issues are availability of and access to scarce
              “a grief ridden process”
              “nothing is easy”
        The importance skills of “persuasion and manipulation” to
              “Being able to offer something – not just going
              through the motions”
        Recommendation: Protocols and Service Level
         Agreements would validate fragile personality/networking
         based arrangements
10                      Pakes and Winstone 2007
             Multi-Agency Arrangements

        Overall agreed as an essential part of delivery, however:
         – Role Boundaries
         “The real problem is that nurses become police officers and
           police officers become nurses”
         – Leadership and Management
         “You work via negotiation; who should take the lead in
           someone’s care planning?”

        Therefore clearer agreements for multi-agency work
         along MAPPA lines is likely to enhance multi-agency
         arrangements in mental health delivery for those who
         do not qualify for MAPPA

11                      Pakes and Winstone 2007
                   Information Sharing

        Information sharing often reliant upon personal
         contacts and networking skills
            “when I pick up the phone they will recognise my
            name and voice and tell me everything I need to
            know – but if it was you (researcher) they might not
            tell you anything”
        Recommendation: Sustainability of information sharing
         arrangements is achieved through protocols
           “ Policy formalises informal arrangements and gives
            them some validity”

12                     Pakes and Winstone 2007
            Data Collection and Analysis

        All schemes collected some form of data
        All schemes acknowledged the importance of data collection
         and analysis
        Schemes used a variety of systems for data collection; most
         schemes felt that the resources available were insufficient,
         failed to capture the full range of activities and failed to
         measure „success‟
        Data analysis was, for most part, very limited
        Evaluation which might lead to bidding for resources was not
         strongly evidenced
        Recommendation: Provision of compatible IT packages
         measuring data over comparable values would significantly
         enhance the establishment of value for money practices

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            Establishing Value for Money

        Value for money at a lowest threshold
         demonstrates service costs versus service
         outputs – a budget
         “We don’t have a budget!”
         “Whenever we need stationary or such, I have to beg, steal or
         “We don’t know the cost of our service. No one has ever asked”
        Recommendation: To establish operational
         budgets linked to aims that identify core and
         ancillary activity to create a baseline measure
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         Working Towards a Unified Costing

        Need for a comparable framework for activity
         costing across Schemes (including IT
         packages and Data Collection variables)

        Need to specify operating costs
         - fixed costs (staff, office space, etc)
         - variable costs (stationary, travel, training etc)

15                     Pakes and Winstone 2007
     Measuring Value For Money Outcomes:
              Possible Indicators

           Addressing The Revolving Door Syndrome
        Criminal Justice Outcomes
               Reduced involvement in CJ (reduction in frequency of offending)
               Reduction of use of custody
               Reduction in delays (for Psychiatric Reports etc)
               Enhanced public safety (reduction in seriousness of offence)
        Health Outcomes
               Reduced use of future services (effective assessment etc)
               Reduction in individual risk of harm factors (self-harm etc)
        Other Outcomes
               Increased social inclusion
               Reduce social exclusion through welfare provision
               Promote health and well being
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        Several best practices identified

        Not a case of „one size fits all‟

        Successful and sustainable models can be

        Disseminating best practice is the next
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         The Fall (and Rise?) of Diversion?

        Lord Bradley Review:
         "To examine the extent to which offenders with mental
         health problems or learning disabilities could, in
         appropriate cases:
          –   be diverted from prison to other services
          –   the barriers to such diversion; and
          –   to make recommendations to government, in particular on the
              organisation of effective court liaison and diversion
              arrangements and the services needed to support them."

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