- Email: [email protected]
Adapting needs assessment methodologies to build integrated health pathways for people in the criminal justice system
p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 7 6 3 e7 6 9
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Adapting needs assessment methodologies to build integrated health pathways for people in the criminal justice system N. de Viggiani* Department of Health and Applied Social Sciences, Faculty of Health and Life Sciences, University of the West of England, Bristol BS16 1DD, UK
article info
summary
Article history:
Criminal justice health services should be underpinned with good public health evidence
Received 29 March 2011
about the population’s health needs. Health needs assessment methodologies can provide
Received in revised form
valuable intelligence for commissioners to evaluate the quality of services and innovate
23 March 2012
according to need. However, health needs assessment can be limited if it takes a conven-
Accepted 30 May 2012
tional epidemiological approach, focussing on individuals’ healthcare needs in criminal
Available online 6 July 2012
justice settings. Techniques used to measure health and social need could be more widely applied and appropriately employed in the planning of health and social care services,
Keywords:
especially if the intention is to be effective in reducing social exclusion and tackling health
Health needs
inequalities. Assessment tools are available that capture individual, social and
Health impact
environmental risk factors and determinants predisposing people to health and crimino-
Criminal justice health
genic risks. Good evidence gathering can mean that public health practitioners not only
Prison health
improve health, reduce inequalities and tackle social exclusion, but contribute to reducing
Offender health
re-offending. This paper suggests a new approach to assessment that integrates the full
Assessment
range of assessment methodologies available to practitioners. An integrated approach may be the way to enhance and enrich the public health function in providing evidence to improve the quality of local public services. ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Since 2005, the UK National Health Service (NHS) has been tasked with delivering health services for prisoners in England and Wales,1 and the former Labour Government planned to extend NHS commissioning across the criminal justice system to include the police and courts services.2 Effective health service commissioning and provision should be underpinned with good public health intelligence about the population’s health needs. Health needs
assessment (HNA) methodologies can provide valuable evidence to enable commissioners to evaluate current provision, maintain the quality of existing services, and innovate according to need. In the light of recent political change e particularly the strong shift towards a mixed economy ‘Big Society’ future for public services3 e this paper argues that approaches to measuring health and social need should be more widely focused and appropriate for the planning of criminal justice health and social care services, in order to effectively reduce social exclusion and tackle
* Tel.: þ44 (0) 1173 288547. E-mail address: [email protected]. 0033-3506/$ e see front matter ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2012.05.030
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health inequalities. A broad public health approach should embrace systemic structural, organizational and social factors, as well as epidemiological characteristics of criminal justice populations. Assessment tools should therefore capture individual, social and environmental risk factors (or determinants) that predispose people to criminogenic and health problems. Conventional epidemiological approaches used to measure prisoners’ health are essentially individualistic and healthcare focused; indeed, important overlapping criminogenic, pathogenic and salutogenic factors may not be recognized if the focus is primarily on healthcare outcomes for the purposes of healthcare delivery. If evidence is gathered intelligently, there is great potential for public health to not only improve health and reduce inequalities, but also to contribute to reducing re-offending.
The shifting policy context The 1992 Reed Review of Health and Social Services for Mentally Disordered Offenders4 recommended positive, responsive approaches towards meeting complex needs of people in the criminal justice system. The Social Exclusion Unit5 has since argued that cross-sector partnership working would be key to achieving meaningful health, social care and rehabilitation outcomes for prisoners. Offending behaviour has been strongly correlated with social exclusion, socioeconomic disadvantage, low educational attainment, poor employment prospects and poor health, particularly in relation to youth offending.5e11 This general pattern of disadvantage has been acknowledged in the Coalition Government’s Health and Social Care Bill,12 which states that offenders show significant co-morbidity in terms of mental health, alcohol, drug and physical health problems, and typically lead chaotic lives prior to prison exacerbated by minimal, if any, formal contact with NHS services. Under the former Labour Government, transfer of public sector prison healthcare services in England and Wales, from the prison service to the NHS, was completed in 2006, with primary care trusts (PCTs) taking on commissioning responsibility in England.1 Under the Coalition Government, responsibility for prison healthcare is likely to remain with the NHS, while commissioned by the national NHS Commissioning Board, in collaboration with local general practitioner consortia, local health and well-being boards, directors of public health and NHS provider organizations.12 Under this arrangement, the independent and third sectors are potential candidates as healthcare providers, a model that exists in Scotland, where primary care and forensic psychiatry are contracted to private providers.13 PCTs in England with public sector prisons in their locality were formerly responsible for commissioning prison health services according to ‘need’, and were expected to work collaboratively with social care, welfare and criminal justice commissioning and provider organizations. Commissioned services could be contracted to NHS, third sector, independent sector and statutory sector providers,2 a ‘hub-andspoke’ approach based upon a quality strategic framework of service monitoring (via Department of Health performance indicators), clinical governance and needs assessment.14 It
could enable efficient and effective liaison, referral and diversion to take place, for example via integrated drug treatment services and procedures for managing people requiring access to mental health services.15e17 With the reorganization of NHS commissioning under the Coalition Government, it is likely that the national NHS Commissioning Board will be expected to continue this function in collaboration with local commissioning groups.12 An additional former function of PCTs was to work with providers and public health teams to publish annual prison health delivery plans (PHDPs),18 informed by HNAs.19 Prison healthcare was then performance tested annually against criteria published in the PHDPs,14 with the goal of delivering prison healthcare to an equivalent standard to that provided for the general population.19 In line with this, the 2006 Health and Social Care White Paper20 and the Darzi review of NHS services21 established a quality framework for health and social care services based on local need and user involvement, planned and commissioned at local level, and orientated towards those perceived to have greatest need. Thus, commissioners were expected to ‘take into account the wider determinants of health when considering how to improve the health and well-being of their local community’,22 and encouraged to collaborate with partners inside and outside the NHS to innovate and continuously improve services. Furthermore, it was acknowledged that: Those who offend often have a significant profile of other needs, including health needs [.] Joint work between the health and criminal justice systems offers real potential to reduce health inequalities and crime, as does integrated working between health, education, social care and youth justice in youth offending teams.2 An important goal of commissioning was to tackle inequalities through effective local partnership working. As a consequence, prison health service objectives have included measures to address unmet healthcare needs, promote health and well-being, maintain dignity and respect of human rights, attempt to reduce future ill-health costs, and improve offender health across public services.2 The 2010 Commissioning Best Practice Guide for tackling social exclusion moreover emphasized the importance of robust local needs assessments.23 Bradley’s review of criminal justice mental health services24 strongly recommended effective partnership working through joint commissioning, local accountability and strategic needs assessment. Bradley argued that regional strategic partnerships and local partnership boards should jointly commission needs-led services, using joint strategic needs assessments, but emphasized that this would require a substantive shift of values and priorities for commissioning organizations that had not previously managed prison healthcare services.24
Assessing need Healthcare need essentially relates to an individual’s or community’s requirement for a healthcare service. Health
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need, on the other hand, is a contested and internally complex concept that involves personal, social and environmental determinants of health, which apply as much to criminal justice populations as to any other. Definitions and interpretations of need depend upon values, beliefs, loyalties, standpoints and predispositions of different ‘players’ e profiled populations, service commissioners and providers, and organizations or institutions with their political drivers. Offenders’ rehabilitation needs are, likewise, varied and contextual, linked to individual, social, structural and environmental determinants. Offender management commonly involves ‘criminogenic’ needs assessment, which conventionally distinguishes dynamic (or changeable) from static (or unchangeable) risk factors; the response to the former is usually to target offending behaviour via individually tailored offender management programmes.25 However, Ward and Stewart26 suggested that an enriched conceptualization of criminogenic need is required, akin to the notion of salutogenic need,27 with the focus less on lifestyle and behaviour goals and more on health improvement, human potential and tackling the root causes of criminality; this could offer a more realistic and effective basis for rehabilitation. Several methodologies are currently available for measuring the health needs of local populations that often form a basis for service development. These include HNA, health impact assessment (HIA), health equity audit (HEA) and joint strategic needs assessment. Needs assessment methodologies are routinely used by criminal justice organizations to determine offending risk, and rehabilitation and resettlement needs. Those most relevant to this discussion are described briefly below.
Health needs assessment HNA uses a range of methods to systematically measure health needs, assets and differences across a discrete population. The objective is to inform planning, commissioning and delivery of healthcare services,28 including prison healthcare. Under NHS commissioning, commissioning organizations would liaise with directors of public health to prepare health improvement plans for the local population or, for prisons, PHDPs.
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services towards those with greatest need.31 HEA is useful for building evidence on inequalities into mainstream service delivery; to date, NHS commissioners have had mandatory responsibility for ensuring that annual HEA is performed routinely for all NHS services. An HEA is successful when it leads to a significant reduction in inequality.
Joint strategic needs assessment NHS organizations and local authorities in England are required to collectively publish annual joint strategic needs assessments of their local populations in accordance with the Local Government and Public Involvement in Health Act 2007.22 A joint strategic needs assessment is used to identify current and future health needs in light of existing services and drive service planning. It provides ‘the big picture’ on local health need and inequality28 via aggregated assessments of need, enabling identification of groups whose needs are not met or who experience poor health outcomes. Essentially, this means services can then begin to engage with ‘. particularly vulnerable and hard to reach groups, those with complex medical and social care needs and those experiencing exclusion [.] since they are more likely to suffer from poor health, well-being and inequalities .’.28
Offender assessment system The National Offender Management Service uses the offender assessment system (OASys) standardized assessment tool to score an individual offender’s risk of re-offending and to identify factors that may have contributed to their offending behaviour.32,33 It is the first stage of the offender management ASPIRE process (Assess e Sentence Plan e Implement e Review e Evaluate),33 but is not used with individuals serving short prison sentences because of the time required to work through a sentence plan. An arguably more effective approach is that used in Canada, the offender intake assessment (OIS),34 which evaluates prisoners’ offending histories, personal characteristics, relationships, situational determinants and environmental conditions.
Prison health needs assessment Health impact assessment HIA is primarily orientated towards assessing a policy, programme or project to attempt to predict its impact on the health of the population.29,30 It seeks to identity potential health inequalities through predicting differential distributions of effects across the population. It may therefore require profiling of vulnerable subgroups and engagement with stakeholders or key informants to build evidence-based recommendations that reflect local needs, yet which potentially improve the health of the least healthy.
Health equity audit HEA takes a defined population, and involves local partners systematically identifying how fairly resources are distributed in relation to health needs; action is then taken to orientate
HNA is commonly undertaken annually in English public sector prisons to inform PHDPs,19 and to enable performance testing so that commissioners can evaluate a prison’s ability to meet the healthcare needs of prisoners.14 HNA tends to be undertaken by local public health teams or by prison healthcare providers. The Prison Healthcare Needs Assessment Toolkit, produced by Marshall et al. in 2000 and adopted by the Department of Health as the recognized methodology for conducting prison HNAs,35 is still commonly used to inform commissioning and service planning. It focuses on healthcare need, primarily employing epidemiological indicators; in this regard, it does not provide scope for measuring health and social need in the broadest sense e in terms of health and illness determinants, health impact or inequality. It takes a three-tiered approach: a corporate assessment to
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canvass stakeholders’ views of service needs; a comparative assessment comparing services for equivalence (by geography, population or provider type); and an epidemiological assessment using morbidity, mortality, service usage and treatment outcomes data. The tool is useful for developing healthcare performance targets but is limited as a strategy for addressing health need and health impact, and measuring inequality. Thornton-Jones et al.36 suggested that conventional HNA may even obscure more salient systemic factors that have a detrimental impact on health. However, as prison-based HNAs have evolved, there has been a shift towards using mixed research and evaluation methodologies, with greater use of qualitative interviewing to inform corporate needs assessment. Douglas and Plugge’s37 healthcare needs analysis of the female young offender estate in England used an adapted version of the Department of Health’s toolkit, which included Short Form-36 (SF-36; to measure physical and mental health) and the General Health Questionnaire-12 (to measure mental and emotional health). Similarly, Brooker et al.’s38 HNA of ex-prisoners on probation took a mixed methods approach, using an adapted SF-36, CAGE (a screening tool for alcohol dependence), UNCOPE (a screening tool for detecting substance dependence) and qualitative interviews with offender managers. However, despite these modifications to the original toolkit, approaches have tended to remain limited in focus, with the primary goal of improved healthcare services rather than health improvement per se. Local public health teams still commonly use the toolkit to conduct annual prison HNAs, but there is a pressing need to evolve the approach from what is essentially an individualistic, epidemiological healthcare audit towards a model of intelligence gathering that builds year-on-year, taking an integrated public health approach.
An integrated system of assessment The former Labour Government acknowledged that needs assessment of the most disadvantaged should go beyond gathering routinely available local data, and involve partner organizations working collectively to source the most relevant and appropriate data.23 Individuals serving custodial or community-based sentences, or those on remand (non-sentenced) encounter different organizations and professional cultures on their journey though the criminal justice system. This makes it difficult for services that are not ‘joined up’, coterminous or working collaboratively to take a needs-led approach to service planning and delivery, whether this be to address unmet health or social need, provide health or social care, provide education and skills, or reduce re-offending. Services are not routinely assessed for their health impact, nor do they undergo HEA. For services to be effective across the offender management system, it is essential that they are seamless and, to some extent, ‘bespoke’ to clients’ individual health, welfare and criminogenic needs. Furthermore, the system itself must not impede an individual’s progress. Conventional epidemiology is commonly used to systematically gather and analyse evidence of health variations within prison populations. As has been argued for many years
from within public health, epidemiology, as the ‘basic science’ of public health, has traditionally adopted a biomedical, clinical science model,39e41 taking a somewhat reductionist, individualistic approach towards health and illness, while treating health determinants as mere background phenomena. This has been described as the prevailing, hegemonic disease model of epidemiology that locates health problems as decontextualized exposures to risk factors or as isolated behaviours of individuals.42 Alternatives to conventional epidemiology include social, critical, alternative and feminist epidemiologies,41 which support a more robust relationship with the social sciences and engagement with micro, meso and macro health determinants. Such approaches acknowledge that the system has a much greater impact on the individual than the individual has on the system, which tips the balance of responsibility for health, well-being, social welfare and criminality towards the social system. Social or critical epidemiology thus lends itself better to health assessment approaches that include measurement of health impact, inequality and health need. An integrated approach towards HNA should then measure health, social and criminogenic factors at multiple levels of the social system, consistent with the World Health Organization’s prison public health approach.43 This approach is underpinned by core values of equity, social justice, public service, collective responsibility, partnership working, human rights and dignity; it seeks to ensure that criminal justice public health acts on the determinants or root causes of ill health, which are often synonymous with those of offending. A systemic approach would therefore require assessment and planning that consider multiple and sometimes overlapping health and criminogenic determinants. As such, a singular approach using HNA or OASys alone is likely to miss or obscure key contextual factors. An integrated approach would combine a mix of available methodologies to enable more comprehensive evaluation of the health/justice system, where the principal goal is equity through health improvement and reduced offending. This could arguably be better achieved through a combination of HNA, HEA and HIA methodologies e termed a ‘health system assessment’ (HSA) in this paper e that more effectively empowers decision makers to reach informed judgements about the efficacy of services for people in the criminal justice system. This approach would enable HNA approaches to be applied with stakeholders (including ‘users’), and HEA and HIA approaches to be used to evaluate the impact of the system. An integrated HSA approach would cover four domains, as outlined below.
Personal development domain This domain focuses on individual and group development. Objectives could be aligned with existing National Offender Management Service pathways to reduce re-offending and health promotion goals, based on empowerment and participation, health education and health improvement, prevention, learning and skills development, attitude and behaviour change, life skills development, healthcare, treatment, and management of longstanding illness and disability. This
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domain could be evaluated using HNA, OASys, OIS and programme evaluation methodologies.
Health communication domain This domain focuses on human agency and service development and improvement. Objectives would centre around communications within the institution or service to enable participants (professionals and clients) to function more effectively as a ‘community’ via mechanisms geared towards mediation, advocacy, involvement, partnership working, equal opportunities, decency and rights, positive relationships and roles, and collective responsibility. This domain could be evaluated using HEA and programme evaluation methodologies.
Supportive environment domain This domain focuses on developing the physical environment and infrastructure of the custody setting, whether it be police custody, the courts, prisons or other institutional contexts. Objectives would be geared towards adapting the physical and/or built environment and use of space to ensure it is fit for purpose and function, via spatial planning and organization. This domain could be evaluated using HIA.
Social justice domain This domain focuses on re-orientating organizational and institutional processes and norms, via appropriate policies and procedures, robust and equitable political decision making, intersector/interprofessional relations, and human resource management (e.g. workforce development, management of change, professional identities and values). This domain could be evaluated using HIA, HEA and programme evaluation methodologies. Conventionally, needs assessments are undertaken with offenders on arrest, during sentencing, on reception to prison and during sentence management by a range of different professionals with their respective objectives. This proposed scheme of integrated assessment is not exhaustive in terms of the range of objectives and methodologies that could be employed. It shows, however, that the focus can be pulled away from a purely client-centred, epidemiological focus that problematizes the offender to multiple system-wide goals (or determinants) that impact on health and propensity for offending. A broad approach could arm commissioners with valuable evidence upon which to develop policy and practice innovations. It could also provide the impetus for developing new service objectives, standards and performance indicators that address collective public health and criminal justice goals, essentially as a justice public health strategy.
Public health stewardship The challenge for the justice system, with its respective institutions and processes, is to build public health into its core business. This is consistent with the World Health Organization’s Healthy Prisons approach that involves an
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‘upstream’, systemic approach towards health improvement across prisons and wider justice systems.43 This approach shares the broad objective of world class commissioning e to tackle inequalities and reduce social exclusion. A justice system public health strategy thus requires a shift in perception and focus from purely healthcare-need-focused delivery towards systemic action across justice regimes, where measures are aimed at improving health, reducing inequalities, respecting human rights and reducing re-offending. For public health, this is consistent with a stewardship role where the public health function is to work alongside commissioners and service providers to support, inform and facilitate innovation. Local public health teams can provide strategic leadership and intelligence relating to the needs of criminal justice populations and of the impact, efficacy and consequential effects of the system. Such cross-cutting, system-wide measures, using robust health assessment methodologies, could help to engineer a justice system that serves its purpose as a public enterprise. A more ideal scenario might be for this to be conducted collectively, with broader public health and public service goals that essentially impact more effectively to serve society’s needs. Lord MacPherson44 emphasized that public services should take proactive measures to ensure that socially marginalized or disadvantaged groups have fair and ethical access to services that meet their needs; this was based on the premise that as inequalities prevail in society, equal provision does not guarantee equity. Hence, disadvantage and discrimination can become embedded within social, institutional, political and economic systems where the same rules of access or opportunity apply to unequal status groups e via ‘open door’ policies e and which thereby generate further inequality; this is a key characteristic of the criminal justice system. A socially just approach requires proactive measures that recognize the culpability and responsibility of the individual and of the system. A justice public health approach infers a synergistic system of public health where action is focused on social determinants of health, of inequality and of offending. Public health is strongly positioned to support the justice system, to help it to innovate and thereby reconfigure to meet its challenges.
Conclusion This paper has sought to explain and contextualize the role of needs analysis methodologies within the context of criminal justice health commissioning. The policy arena surrounding commissioning and public service organization has become ever more complex, especially with a recent change of government and shifting political ideology. However, there is enormous potential to create equitable, ethical and responsive services geared towards tackling social exclusion, health inequality and root causes of ill-health and criminality. The objectives of public health and criminal justice intersect, and using a systemic approach, it may be feasible to innovate and develop public services that are more fit for purpose, responsive and ethical. Integration of existing assessment methodologies is a logical way to provide intelligence for commissioners in the planning and delivery of services across
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the criminal justice sector, where public health can play an important function in providing the evidence base for improving services.
Acknowledgements Ethical approval None sought.
Funding None declared.
Competing interests None declared.
references
1. Department of Health and Home Office. National partnership agreement between the Department of Health and the Home Office for the accountability and commissioning of health services for prisoners in public sector prisons in England. London: Department of Health; 2007. 2. Department of Health. Improving health, supporting justice. London: Department of Health; 2008. 3. Cabinet Office. Building a stronger civil society: a strategy for voluntary and community groups, charities and social enterprises. London: Cabinet Office; 2010. 4. Department of Health, Home Office. Review of mental health and social services for mentally disordered offenders and others requiring similar services. Cm. 2088. London: HMSO; 1992. 5. Social Exclusion Unit. Reducing re-offending by ex-prisoners. London: Social Exclusion Unit; 2002. 6. Lader D, Singleton N, Meltzer H. Psychiatric morbidity among young offenders in England and Wales. London: Office for National Statistics; 2000. 7. Kroll L, Rothwell J, Bradley D, Shah P, Bailey S, Harrington R. Mental health needs of boys in secure care for serious or persistent offending: a prospective, longitudinal study. Lancet 2002;359:1975e9. 8. Anderson L, Vostanis P, Spencer N. Health needs of young offenders. J Child Health Care 2004;8:149e64. 9. Farrington DP. Saving children from a life of crime. Oxford: Oxford University Press; 2006. 10. Nurse J. Preventing violence and abuse: creating safe and respectful lives. South East Regional Public Health Group Information Series 1. London: Home Office & Department of Health. Available at: http://www.sepho.org.uk/viewResource.aspx? id=11415; 2006 [accessed 18.06.12]. 11. Walker JS, Bright JA. False inflated self-esteem and violence: a systematic review and cognitive model. J Forens Psychiatr Psychol 2009;20:1e32. 12. Department of Health. Health and social care bill 2011: combined impact assessments. London: Department of Health; 2011. 13. NHS Scotland, Scottish Prison Service. Potential transfer of enhanced primary healthcare services to the NHS: report of the Prison Healthcare Advisory Board. Edinburgh: NHS Scotland; 2007. 14. Department of Health. Guidance notes: prison health performance and quality indicators. London: Department of Health; 2009.
15. Centre for Public Innovation. Court diversion and liaison schemes: recommendations for models of care. London: Centre for Public Innovation; 2005. 16. NACRO. Findings of the 2004 survey of court diversion/criminal justice mental health liaison scheme for mentally disordered offenders in England and Wales. London: NACRO; 2005. 17. NACRO. Liaison and diversion schemes for mentally disordered offenders: a mental health good practice guide. London: NACRO; 2006. 18. Department of Health. Guidance on developing local prison health delivery plans. London: Department of Health; 2003. 19. Department of Health, HM Prison Service. Guidance on developing prison health needs assessments and health improvement plans. London: Department of Health; 2002. 20. Department of Health. Our health, our care, our say: a new direction for community Services. London: Department of Health; 2006. 21. Darzi, Rt Hon Lord. High quality care for all: NHS next stage review e final report. London: Department of Health. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/DH_085825; 2010 [accessed 29.03.11]. 22. Department of Health. Commissioning framework for health and well-being. London: Department of Health; 2007. 23. Department of Health. Inclusion health: improving primary care for socially excluded people. a commissioning best practice guide. London: Department of Health; 2010. 24. Bradley, Rt Hon Lord. The Bradley report: Lord Bradley’s review of people with mental health problems or learning disabilities in the criminal justice system. London: Department of Health; 2009. 25. Hollin CR, Palmer EJ. Criminogenic need and women offenders: a critique of the literature. Leg Criminol Psychol 2006;11:179e95. 26. Ward T, Stewart C. Criminogenic needs and human needs: a theoretical model. Psychol Crime Law 2003;9:125e43. 27. Antonovsky A. The salutogenic model as a theory to guide health promotion. Health Promot Int 1996;11:11e8. 28. Department of Health. Guidance on joint strategic needs assessment. London: Department of Health. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/dh_081097; 2007 [accessed 29.03.11]. 29. EPHIA Project Group. European policy health impact assessment e a guide. Brussels: European Commission; 2004. 30. Quigley R, Cavanagh S, Harrison D, Taylor L, Pottle M. Clarifying approaches to HNA, HIA, IIA, HEA and REIA. London: Health Development Agency; 2005. 31. Department of Health. Health equity audit: a guide for the NHS. London: Department of Health; 2003. 32. Andrews D, Bonta J. LSI-R the level of service inventory revised users’ manual. Toronto: Multi Health Systems; 2002. 33. National Offender Management Service. The NOMS offender management model. London: Home Office. Available at: http:// www.swmprobation.gov.uk/wp-content/uploads/2010/05/ offender_management_model_1.pdf; 2006 [accessed 29.03.09]. 34. Correctional Service of Canada. OIA e offender intake assessment e users’ manual. Ottawa: Correctional Service of Canada; 1994. 35. Marshall T, Simpson S, Stevens A. Health care needs assessment in prisons: a toolkit. J Public Health 2001;23:198e204. 36. Thornton-Jones H, Hampshaw S, England P. Health needs assessment in prisons. Br J Healthc Manag 2005;11:105e10. 37. Douglas N, Plugge E. A health needs assessment for young women in young offender institutions. Oxford: University of Oxford/ Youth Justice Board; 2006. 38. Brooker C, Fox C, Barrett P, Syson-Nibbs L. Assessment of offenders on probation caseloads in Nottinghamshire and Derbyshire: report of a pilot study. Lincoln: University of Lincoln; 2008.
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39. Charlton B. Epidemiology as a toolkit for clinical scientists. Epidemiology 1997;8:461e3. 40. Krieger N. Epidemiology and social sciences: towards a critical reengagement in the 21st Century. Epidemiol Rev 2000;22:155e63. 41. Marcia C, Inhorn K, Whittle L. Feminism meets the ‘‘new’’ epidemiologies: toward an appraisal of antifeminist biases in
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epidemiological research on women’s health. Soc Sci Med 2001;53:553e67. 42. Wing S. Limits of epidemiology. Med Glob Surviv 1994;1:74e86. 43. WHO Regional Office for Europe. Health in prisons: a WHO guide to the essentials in prison health. Copenhagen: WHO; 2007. 44. MacPherson W. The Stephen Lawrence inquiry. London: Stationery Office; 1999.
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Adapting needs assessment methodologies to build integrated health pathways for people in the criminal justice system N. de Viggiani* Department of Health and Applied Social Sciences, Faculty of Health and Life Sciences, University of the West of England, Bristol BS16 1DD, UK
article info
summary
Article history:
Criminal justice health services should be underpinned with good public health evidence
Received 29 March 2011
about the population’s health needs. Health needs assessment methodologies can provide
Received in revised form
valuable intelligence for commissioners to evaluate the quality of services and innovate
23 March 2012
according to need. However, health needs assessment can be limited if it takes a conven-
Accepted 30 May 2012
tional epidemiological approach, focussing on individuals’ healthcare needs in criminal
Available online 6 July 2012
justice settings. Techniques used to measure health and social need could be more widely applied and appropriately employed in the planning of health and social care services,
Keywords:
especially if the intention is to be effective in reducing social exclusion and tackling health
Health needs
inequalities. Assessment tools are available that capture individual, social and
Health impact
environmental risk factors and determinants predisposing people to health and crimino-
Criminal justice health
genic risks. Good evidence gathering can mean that public health practitioners not only
Prison health
improve health, reduce inequalities and tackle social exclusion, but contribute to reducing
Offender health
re-offending. This paper suggests a new approach to assessment that integrates the full
Assessment
range of assessment methodologies available to practitioners. An integrated approach may be the way to enhance and enrich the public health function in providing evidence to improve the quality of local public services. ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Since 2005, the UK National Health Service (NHS) has been tasked with delivering health services for prisoners in England and Wales,1 and the former Labour Government planned to extend NHS commissioning across the criminal justice system to include the police and courts services.2 Effective health service commissioning and provision should be underpinned with good public health intelligence about the population’s health needs. Health needs
assessment (HNA) methodologies can provide valuable evidence to enable commissioners to evaluate current provision, maintain the quality of existing services, and innovate according to need. In the light of recent political change e particularly the strong shift towards a mixed economy ‘Big Society’ future for public services3 e this paper argues that approaches to measuring health and social need should be more widely focused and appropriate for the planning of criminal justice health and social care services, in order to effectively reduce social exclusion and tackle
* Tel.: þ44 (0) 1173 288547. E-mail address: [email protected]. 0033-3506/$ e see front matter ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2012.05.030
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health inequalities. A broad public health approach should embrace systemic structural, organizational and social factors, as well as epidemiological characteristics of criminal justice populations. Assessment tools should therefore capture individual, social and environmental risk factors (or determinants) that predispose people to criminogenic and health problems. Conventional epidemiological approaches used to measure prisoners’ health are essentially individualistic and healthcare focused; indeed, important overlapping criminogenic, pathogenic and salutogenic factors may not be recognized if the focus is primarily on healthcare outcomes for the purposes of healthcare delivery. If evidence is gathered intelligently, there is great potential for public health to not only improve health and reduce inequalities, but also to contribute to reducing re-offending.
The shifting policy context The 1992 Reed Review of Health and Social Services for Mentally Disordered Offenders4 recommended positive, responsive approaches towards meeting complex needs of people in the criminal justice system. The Social Exclusion Unit5 has since argued that cross-sector partnership working would be key to achieving meaningful health, social care and rehabilitation outcomes for prisoners. Offending behaviour has been strongly correlated with social exclusion, socioeconomic disadvantage, low educational attainment, poor employment prospects and poor health, particularly in relation to youth offending.5e11 This general pattern of disadvantage has been acknowledged in the Coalition Government’s Health and Social Care Bill,12 which states that offenders show significant co-morbidity in terms of mental health, alcohol, drug and physical health problems, and typically lead chaotic lives prior to prison exacerbated by minimal, if any, formal contact with NHS services. Under the former Labour Government, transfer of public sector prison healthcare services in England and Wales, from the prison service to the NHS, was completed in 2006, with primary care trusts (PCTs) taking on commissioning responsibility in England.1 Under the Coalition Government, responsibility for prison healthcare is likely to remain with the NHS, while commissioned by the national NHS Commissioning Board, in collaboration with local general practitioner consortia, local health and well-being boards, directors of public health and NHS provider organizations.12 Under this arrangement, the independent and third sectors are potential candidates as healthcare providers, a model that exists in Scotland, where primary care and forensic psychiatry are contracted to private providers.13 PCTs in England with public sector prisons in their locality were formerly responsible for commissioning prison health services according to ‘need’, and were expected to work collaboratively with social care, welfare and criminal justice commissioning and provider organizations. Commissioned services could be contracted to NHS, third sector, independent sector and statutory sector providers,2 a ‘hub-andspoke’ approach based upon a quality strategic framework of service monitoring (via Department of Health performance indicators), clinical governance and needs assessment.14 It
could enable efficient and effective liaison, referral and diversion to take place, for example via integrated drug treatment services and procedures for managing people requiring access to mental health services.15e17 With the reorganization of NHS commissioning under the Coalition Government, it is likely that the national NHS Commissioning Board will be expected to continue this function in collaboration with local commissioning groups.12 An additional former function of PCTs was to work with providers and public health teams to publish annual prison health delivery plans (PHDPs),18 informed by HNAs.19 Prison healthcare was then performance tested annually against criteria published in the PHDPs,14 with the goal of delivering prison healthcare to an equivalent standard to that provided for the general population.19 In line with this, the 2006 Health and Social Care White Paper20 and the Darzi review of NHS services21 established a quality framework for health and social care services based on local need and user involvement, planned and commissioned at local level, and orientated towards those perceived to have greatest need. Thus, commissioners were expected to ‘take into account the wider determinants of health when considering how to improve the health and well-being of their local community’,22 and encouraged to collaborate with partners inside and outside the NHS to innovate and continuously improve services. Furthermore, it was acknowledged that: Those who offend often have a significant profile of other needs, including health needs [.] Joint work between the health and criminal justice systems offers real potential to reduce health inequalities and crime, as does integrated working between health, education, social care and youth justice in youth offending teams.2 An important goal of commissioning was to tackle inequalities through effective local partnership working. As a consequence, prison health service objectives have included measures to address unmet healthcare needs, promote health and well-being, maintain dignity and respect of human rights, attempt to reduce future ill-health costs, and improve offender health across public services.2 The 2010 Commissioning Best Practice Guide for tackling social exclusion moreover emphasized the importance of robust local needs assessments.23 Bradley’s review of criminal justice mental health services24 strongly recommended effective partnership working through joint commissioning, local accountability and strategic needs assessment. Bradley argued that regional strategic partnerships and local partnership boards should jointly commission needs-led services, using joint strategic needs assessments, but emphasized that this would require a substantive shift of values and priorities for commissioning organizations that had not previously managed prison healthcare services.24
Assessing need Healthcare need essentially relates to an individual’s or community’s requirement for a healthcare service. Health
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need, on the other hand, is a contested and internally complex concept that involves personal, social and environmental determinants of health, which apply as much to criminal justice populations as to any other. Definitions and interpretations of need depend upon values, beliefs, loyalties, standpoints and predispositions of different ‘players’ e profiled populations, service commissioners and providers, and organizations or institutions with their political drivers. Offenders’ rehabilitation needs are, likewise, varied and contextual, linked to individual, social, structural and environmental determinants. Offender management commonly involves ‘criminogenic’ needs assessment, which conventionally distinguishes dynamic (or changeable) from static (or unchangeable) risk factors; the response to the former is usually to target offending behaviour via individually tailored offender management programmes.25 However, Ward and Stewart26 suggested that an enriched conceptualization of criminogenic need is required, akin to the notion of salutogenic need,27 with the focus less on lifestyle and behaviour goals and more on health improvement, human potential and tackling the root causes of criminality; this could offer a more realistic and effective basis for rehabilitation. Several methodologies are currently available for measuring the health needs of local populations that often form a basis for service development. These include HNA, health impact assessment (HIA), health equity audit (HEA) and joint strategic needs assessment. Needs assessment methodologies are routinely used by criminal justice organizations to determine offending risk, and rehabilitation and resettlement needs. Those most relevant to this discussion are described briefly below.
Health needs assessment HNA uses a range of methods to systematically measure health needs, assets and differences across a discrete population. The objective is to inform planning, commissioning and delivery of healthcare services,28 including prison healthcare. Under NHS commissioning, commissioning organizations would liaise with directors of public health to prepare health improvement plans for the local population or, for prisons, PHDPs.
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services towards those with greatest need.31 HEA is useful for building evidence on inequalities into mainstream service delivery; to date, NHS commissioners have had mandatory responsibility for ensuring that annual HEA is performed routinely for all NHS services. An HEA is successful when it leads to a significant reduction in inequality.
Joint strategic needs assessment NHS organizations and local authorities in England are required to collectively publish annual joint strategic needs assessments of their local populations in accordance with the Local Government and Public Involvement in Health Act 2007.22 A joint strategic needs assessment is used to identify current and future health needs in light of existing services and drive service planning. It provides ‘the big picture’ on local health need and inequality28 via aggregated assessments of need, enabling identification of groups whose needs are not met or who experience poor health outcomes. Essentially, this means services can then begin to engage with ‘. particularly vulnerable and hard to reach groups, those with complex medical and social care needs and those experiencing exclusion [.] since they are more likely to suffer from poor health, well-being and inequalities .’.28
Offender assessment system The National Offender Management Service uses the offender assessment system (OASys) standardized assessment tool to score an individual offender’s risk of re-offending and to identify factors that may have contributed to their offending behaviour.32,33 It is the first stage of the offender management ASPIRE process (Assess e Sentence Plan e Implement e Review e Evaluate),33 but is not used with individuals serving short prison sentences because of the time required to work through a sentence plan. An arguably more effective approach is that used in Canada, the offender intake assessment (OIS),34 which evaluates prisoners’ offending histories, personal characteristics, relationships, situational determinants and environmental conditions.
Prison health needs assessment Health impact assessment HIA is primarily orientated towards assessing a policy, programme or project to attempt to predict its impact on the health of the population.29,30 It seeks to identity potential health inequalities through predicting differential distributions of effects across the population. It may therefore require profiling of vulnerable subgroups and engagement with stakeholders or key informants to build evidence-based recommendations that reflect local needs, yet which potentially improve the health of the least healthy.
Health equity audit HEA takes a defined population, and involves local partners systematically identifying how fairly resources are distributed in relation to health needs; action is then taken to orientate
HNA is commonly undertaken annually in English public sector prisons to inform PHDPs,19 and to enable performance testing so that commissioners can evaluate a prison’s ability to meet the healthcare needs of prisoners.14 HNA tends to be undertaken by local public health teams or by prison healthcare providers. The Prison Healthcare Needs Assessment Toolkit, produced by Marshall et al. in 2000 and adopted by the Department of Health as the recognized methodology for conducting prison HNAs,35 is still commonly used to inform commissioning and service planning. It focuses on healthcare need, primarily employing epidemiological indicators; in this regard, it does not provide scope for measuring health and social need in the broadest sense e in terms of health and illness determinants, health impact or inequality. It takes a three-tiered approach: a corporate assessment to
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canvass stakeholders’ views of service needs; a comparative assessment comparing services for equivalence (by geography, population or provider type); and an epidemiological assessment using morbidity, mortality, service usage and treatment outcomes data. The tool is useful for developing healthcare performance targets but is limited as a strategy for addressing health need and health impact, and measuring inequality. Thornton-Jones et al.36 suggested that conventional HNA may even obscure more salient systemic factors that have a detrimental impact on health. However, as prison-based HNAs have evolved, there has been a shift towards using mixed research and evaluation methodologies, with greater use of qualitative interviewing to inform corporate needs assessment. Douglas and Plugge’s37 healthcare needs analysis of the female young offender estate in England used an adapted version of the Department of Health’s toolkit, which included Short Form-36 (SF-36; to measure physical and mental health) and the General Health Questionnaire-12 (to measure mental and emotional health). Similarly, Brooker et al.’s38 HNA of ex-prisoners on probation took a mixed methods approach, using an adapted SF-36, CAGE (a screening tool for alcohol dependence), UNCOPE (a screening tool for detecting substance dependence) and qualitative interviews with offender managers. However, despite these modifications to the original toolkit, approaches have tended to remain limited in focus, with the primary goal of improved healthcare services rather than health improvement per se. Local public health teams still commonly use the toolkit to conduct annual prison HNAs, but there is a pressing need to evolve the approach from what is essentially an individualistic, epidemiological healthcare audit towards a model of intelligence gathering that builds year-on-year, taking an integrated public health approach.
An integrated system of assessment The former Labour Government acknowledged that needs assessment of the most disadvantaged should go beyond gathering routinely available local data, and involve partner organizations working collectively to source the most relevant and appropriate data.23 Individuals serving custodial or community-based sentences, or those on remand (non-sentenced) encounter different organizations and professional cultures on their journey though the criminal justice system. This makes it difficult for services that are not ‘joined up’, coterminous or working collaboratively to take a needs-led approach to service planning and delivery, whether this be to address unmet health or social need, provide health or social care, provide education and skills, or reduce re-offending. Services are not routinely assessed for their health impact, nor do they undergo HEA. For services to be effective across the offender management system, it is essential that they are seamless and, to some extent, ‘bespoke’ to clients’ individual health, welfare and criminogenic needs. Furthermore, the system itself must not impede an individual’s progress. Conventional epidemiology is commonly used to systematically gather and analyse evidence of health variations within prison populations. As has been argued for many years
from within public health, epidemiology, as the ‘basic science’ of public health, has traditionally adopted a biomedical, clinical science model,39e41 taking a somewhat reductionist, individualistic approach towards health and illness, while treating health determinants as mere background phenomena. This has been described as the prevailing, hegemonic disease model of epidemiology that locates health problems as decontextualized exposures to risk factors or as isolated behaviours of individuals.42 Alternatives to conventional epidemiology include social, critical, alternative and feminist epidemiologies,41 which support a more robust relationship with the social sciences and engagement with micro, meso and macro health determinants. Such approaches acknowledge that the system has a much greater impact on the individual than the individual has on the system, which tips the balance of responsibility for health, well-being, social welfare and criminality towards the social system. Social or critical epidemiology thus lends itself better to health assessment approaches that include measurement of health impact, inequality and health need. An integrated approach towards HNA should then measure health, social and criminogenic factors at multiple levels of the social system, consistent with the World Health Organization’s prison public health approach.43 This approach is underpinned by core values of equity, social justice, public service, collective responsibility, partnership working, human rights and dignity; it seeks to ensure that criminal justice public health acts on the determinants or root causes of ill health, which are often synonymous with those of offending. A systemic approach would therefore require assessment and planning that consider multiple and sometimes overlapping health and criminogenic determinants. As such, a singular approach using HNA or OASys alone is likely to miss or obscure key contextual factors. An integrated approach would combine a mix of available methodologies to enable more comprehensive evaluation of the health/justice system, where the principal goal is equity through health improvement and reduced offending. This could arguably be better achieved through a combination of HNA, HEA and HIA methodologies e termed a ‘health system assessment’ (HSA) in this paper e that more effectively empowers decision makers to reach informed judgements about the efficacy of services for people in the criminal justice system. This approach would enable HNA approaches to be applied with stakeholders (including ‘users’), and HEA and HIA approaches to be used to evaluate the impact of the system. An integrated HSA approach would cover four domains, as outlined below.
Personal development domain This domain focuses on individual and group development. Objectives could be aligned with existing National Offender Management Service pathways to reduce re-offending and health promotion goals, based on empowerment and participation, health education and health improvement, prevention, learning and skills development, attitude and behaviour change, life skills development, healthcare, treatment, and management of longstanding illness and disability. This
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domain could be evaluated using HNA, OASys, OIS and programme evaluation methodologies.
Health communication domain This domain focuses on human agency and service development and improvement. Objectives would centre around communications within the institution or service to enable participants (professionals and clients) to function more effectively as a ‘community’ via mechanisms geared towards mediation, advocacy, involvement, partnership working, equal opportunities, decency and rights, positive relationships and roles, and collective responsibility. This domain could be evaluated using HEA and programme evaluation methodologies.
Supportive environment domain This domain focuses on developing the physical environment and infrastructure of the custody setting, whether it be police custody, the courts, prisons or other institutional contexts. Objectives would be geared towards adapting the physical and/or built environment and use of space to ensure it is fit for purpose and function, via spatial planning and organization. This domain could be evaluated using HIA.
Social justice domain This domain focuses on re-orientating organizational and institutional processes and norms, via appropriate policies and procedures, robust and equitable political decision making, intersector/interprofessional relations, and human resource management (e.g. workforce development, management of change, professional identities and values). This domain could be evaluated using HIA, HEA and programme evaluation methodologies. Conventionally, needs assessments are undertaken with offenders on arrest, during sentencing, on reception to prison and during sentence management by a range of different professionals with their respective objectives. This proposed scheme of integrated assessment is not exhaustive in terms of the range of objectives and methodologies that could be employed. It shows, however, that the focus can be pulled away from a purely client-centred, epidemiological focus that problematizes the offender to multiple system-wide goals (or determinants) that impact on health and propensity for offending. A broad approach could arm commissioners with valuable evidence upon which to develop policy and practice innovations. It could also provide the impetus for developing new service objectives, standards and performance indicators that address collective public health and criminal justice goals, essentially as a justice public health strategy.
Public health stewardship The challenge for the justice system, with its respective institutions and processes, is to build public health into its core business. This is consistent with the World Health Organization’s Healthy Prisons approach that involves an
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‘upstream’, systemic approach towards health improvement across prisons and wider justice systems.43 This approach shares the broad objective of world class commissioning e to tackle inequalities and reduce social exclusion. A justice system public health strategy thus requires a shift in perception and focus from purely healthcare-need-focused delivery towards systemic action across justice regimes, where measures are aimed at improving health, reducing inequalities, respecting human rights and reducing re-offending. For public health, this is consistent with a stewardship role where the public health function is to work alongside commissioners and service providers to support, inform and facilitate innovation. Local public health teams can provide strategic leadership and intelligence relating to the needs of criminal justice populations and of the impact, efficacy and consequential effects of the system. Such cross-cutting, system-wide measures, using robust health assessment methodologies, could help to engineer a justice system that serves its purpose as a public enterprise. A more ideal scenario might be for this to be conducted collectively, with broader public health and public service goals that essentially impact more effectively to serve society’s needs. Lord MacPherson44 emphasized that public services should take proactive measures to ensure that socially marginalized or disadvantaged groups have fair and ethical access to services that meet their needs; this was based on the premise that as inequalities prevail in society, equal provision does not guarantee equity. Hence, disadvantage and discrimination can become embedded within social, institutional, political and economic systems where the same rules of access or opportunity apply to unequal status groups e via ‘open door’ policies e and which thereby generate further inequality; this is a key characteristic of the criminal justice system. A socially just approach requires proactive measures that recognize the culpability and responsibility of the individual and of the system. A justice public health approach infers a synergistic system of public health where action is focused on social determinants of health, of inequality and of offending. Public health is strongly positioned to support the justice system, to help it to innovate and thereby reconfigure to meet its challenges.
Conclusion This paper has sought to explain and contextualize the role of needs analysis methodologies within the context of criminal justice health commissioning. The policy arena surrounding commissioning and public service organization has become ever more complex, especially with a recent change of government and shifting political ideology. However, there is enormous potential to create equitable, ethical and responsive services geared towards tackling social exclusion, health inequality and root causes of ill-health and criminality. The objectives of public health and criminal justice intersect, and using a systemic approach, it may be feasible to innovate and develop public services that are more fit for purpose, responsive and ethical. Integration of existing assessment methodologies is a logical way to provide intelligence for commissioners in the planning and delivery of services across
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the criminal justice sector, where public health can play an important function in providing the evidence base for improving services.
Acknowledgements Ethical approval None sought.
Funding None declared.
Competing interests None declared.
references
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