Examination of Witnesses (Questions 305
- 319)
TUESDAY 28 OCTOBER 2008
SAVAS HADJIPAVLOU
Chairman: Mr Hadjipavlou, welcome, we
are very glad to have you in our justice reinvestment inquiry,
and sorry to have kept you waiting. I am going to invite Mr Heath
to begin.
Q305 Mr Heath:
I am going to start with a fairly basic question which is: I read
that you are Head of Health Strategy in the Ministry of Justice
and my belief was that the health of prisoners had been transferred
to the Department for Health and was mediated through the PCTs
and the other partnerships so what are you doing in the Department
of Justice?
Savas Hadjipavlou: Why have I
got a job! The role sits in the context of the Criminal Justice
Group in the Ministry of Justice which has as part of its remit
strategic direction-setting and regulation for the National Offender
Management Service. I would say that the Ministry of Justice is
a major stakeholder in terms of access to health services for
offenders. In 2006 there were over 200,000 people who received
sentences by the court. The evidence that we have suggests that
substantial proportions of those offenders have various mental
health needs, for example, which need to be addressed either in
the context of custody if they receive custodial sentences or
in the context of the community if they are on community orders.
Some are high-risk individuals where the risk is connected with
or sometimes co-occurring with mental illness and so both from
the perspective of attending to those public protection risks
in terms of a secure environment and addressing their needs. Overall
I would say that the Ministry of Justice has a very legitimate
purpose in terms of looking at the strategic direction of its
offender management services and how they connect with health.
My specific role is to make sure that we have an opportunity to
shape and influence those events, those services, those strategies
from the health side.
Q306 Mr Heath: But one of the reasons
that the transfer of responsibilities took place was because the
predecessor departments and the Prison Service were perceived
as perhaps not providing an adequate level of health care for
prisoners. Under the new arrangements, under your strategic leadership
has new money actually reached the health care provision in prisons?
Do we actually see improvements?
Savas Hadjipavlou: I think we
have come a long way from a few years ago when asking a then health
authority to help with a needs assessment of a particular prison
required payment. The transformation that is taken within the
context of future organisation of prison health care and the injection
of new resources in terms of mental health inreach has made a
difference. I think we have moved substantially forward in terms
of access to services.
Q307 Mr Heath: Sorry to stop you
but is that actually quantified? Do we know that there is extra
money reaching the prisoners?
Savas Hadjipavlou: I can give
you that. In 2002-03 there were some £118 million spent on
prison health, if I could just be specific about prison health
for the moment. That is now of the order of £200 million,
so over five or six years that has risen very substantially.
Q308 Mr Heath: Is that on the same
base?
Savas Hadjipavlou: It is largely
on the same base. You have to make allowance for the fact that
the prison population has risen but that includes, for example,
£20 million for mental health inreach. It is a start but
I do not think we can claim what has been provided is enough in
the context of the scale of need.
Q309 Mr Heath: So you can quantify
an increase in input. Can you quantify an improvement in outcome
as well? Has there been any sort of assessment of a cohort of
prisoners to see whether their general state of health is now
better than it was before these changes were put in place?
Savas Hadjipavlou: Nothing specific.
I think one of the things we have yet to measure well enough is
access to services. We have quantified the problem very well but
we have not done enough in terms of access to services. There
has been some research for example on mental health inreach which
shows that although it has an impact, the scale of need far exceeds
that, so I think in the negative one can say yes, we made a start
but we do know that it is not enough.
Q310 Alun Michael: Could I follow
up on a couple of specific points. Obviously we are concerned
about the treatment of prisoners but we are also concerned about
treatment which could prevent the likelihood of offending. One
of the issues that comes up repeatedly for Members of Parliament
is people who are identified as having psychiatric problems but
identified as "untreatable" and therefore told that
there will be no treatment. In some ways it goes beyond offending;
I think one sees cases where you see great frustration because
people are not being helped to manage a condition and sometimes
that leads to offending as a result. Is it part of your remit
to deal with those sorts of issues a) within the system and b)
in terms of the wider implications?
Savas Hadjipavlou: I think the
answer is yes it is within the strategic remit which I have. The
question which you address is most often in the context of personality
disorders. I think five or six years ago there was a good deal
of what I might describe as therapeutic pessimism. I am not sure
that that is the case now. I think there has been substantial
investment in terms of looking at for example the Dangerous People
with Severe Personality Disorders (DSPD) programme which has been
looking at the extent to which you could put together services
that could deliver for this group and indeed what impact that
might have. Some of the therapeutic pessimism was connected to
the fact that there were no services in relation to personality
disorder offenders and I think that is largely still true. If
you look at the scale of need in terms of personality disorders
in prisons for example, it is of the order of 50%, 60% or 70%,
depending on where you draw the threshold. If you look at the
more severe end obviously the proportions would be less. If you
ask the question "what services are available for this group?"
the answer is "not very much". The Department of Health
published a document around 2002 called Personality disorder:
no longer a diagnosis of exclusion in the context of the then
investments in health, but I think it is fair to say that the
capability within health services to address personality disorder
conditions is not there, it needs to grow.
Q311 Alun Michael: I think the pessimism
still exists and clinical pessimism is a good description. I am
not entirely convinced it has been eradicated. Does your reply
refer to the relationship between the justice system and the Health
Service in both England and Wales?
Savas Hadjipavlou: In the context
of personality disorders?
Q312 Alun Michael: Yes.
Savas Hadjipavlou: I think it
does, yes. My contacts with Wales for example in relation to,
being specific, the DSPD programme were very interested in access
to services and I think for the pilot services they were able
to access those services particularly for individuals from Wales.
Alun Michael: I think it would be helpful
if there could be some expansion on those points in writing because
it is an important area.
Chairman: If you could clarify the Welsh
situation.
Q313 Alun Michael: The other thing
that I would like to know is in terms of funding for these services,
very often there is a feeling that he who holds the budget calls
the tune. Certainly back in 1998 there was an initiative following
that Comprehensive Spending Review to put money for crime reduction
into a pot which was actually parked then in the Home Office but
was actually shared in terms of ownership across the Home Office,
Lord Chancellor's Department, the Department for Health and whatever
the Department for Communities was called at that stage because
of the recognition of cross-border issues, and that gave joint
ownership of trying to solve the problem rather than simply spending
money in the cells. Is there a need and a scope for more of that
in relation to Health Service spending not just in prison but
in terms of the preventative rehabilitative elements?
Savas Hadjipavlou: We have had
a lot of injections of money but one of the major challenges which
we do face is joining up services, and if there is a frustration
between services at the moment it is linked to the way that partnerships
work and the weaker governance arrangements generally. There is
good practice and there is poor practice. I think there is inevitably
some frustration about the pace of progress. I think it is a key
issue for us collectively how to achieve better joined-up aligned
services. Harking back to the earlier question what is there left
to be done, I think this must be one of the priority areas for
us. We know a fair amount about the content and nature of interventions.
I think we are less confident about how you organise services
across the whole pathway. If we could think in terms of pathways
I think that would be very helpful for us because the final outcome
of the system, is more than the sum of what you do at each stage,
so we do need to connect them up. I would agree that one of the
emphases that we have got to look at is the extent to which we
can join up services and certainly pooling the budgets of one
sort or another are a way of gaining engagement. However, I would
say having the right kind of commissioning unit is important,
and a PCT, for example, at one level, is perhaps too small an
area to be able to capture the entirety of a prison's catchment,
so we have got to get that kind of thing right as well.
Q314 Mr Turner: I think you said
it was £118 million last year and £200 million this
year.
Savas Hadjipavlou: That was 2002.
Q315 Mr Turner: We are paying something
like four times as much money with health than we did with justice
this year. This is the Isle of Wight which has three prisons within
half a mile of the hospital and they are paying three or four
times as much as was paid delivering it last year. That obviously
hits the ordinary people who are on the island all year round
by choice not by pressure. There are 130,000 people on the island
and yet you are taking this disproportionate amount of money from
the Health Service and spending it on prisoners. What is your
reaction to that?
Savas Hadjipavlou: I do not think
prisons are a separate part of the community.
Q316 Mr Turner: They are.
Savas Hadjipavlou: People in prisons
spend some of their time in prison and some of their time in the
community. Around 70% of the people who are sentenced to imprisonment
receive a sentence that is less than 12 months so there is a continuity
of flow between the community and people in prisons. I do not
have specific information about the share for example in relation
to the Isle of Wight prisons. I do know that over that period
in terms of the new money there was an effort made to even out
the then historical allocations as between prisons. When new money
was becoming available it was preferentially directed at those
institutions that had on an historical basis not received, if
I can put it crudely, their fair share. I think the motivation
for including or putting a responsibility for health services
within the NHS was in part to be able to do the thing that I was
mentioning earlier—to connect up services to be able to
say that somebody who is in the community receiving mental health
care where there is a chance they end up in prison that that should
not break that link and that treatment should continue insofar
as possible in return. I am not sure that I accept the point that
prisons are completely separate from the community. I think they
are part of the community and we ought to be treating them as
part of the community in that context.
Mr Turner: You talk about perchance as
if it was an accident that somebody ends up in prison and that
is not case, is it?
Chairman: Is there a question in that?
Mr Turner: Yes there is. The problem
is that the Isle of Wight has 130,000 by way of population. That
is the only way in which money for health comes into the island.
It is the smallest unit compared with Hampshire for example which
has large national hospitals. The Isle of Wight has a single body
unlike Hampshire and everywhere else—
Chairman: I am going to have to ask you
to be brief because we have only got another five minutes or so
with our present witness.
Q317 Mr Turner: I will be brief.
We only have one unit whereas much larger units can spread the
needs out. Could you correct that?
Savas Hadjipavlou: I think that
must go to the point of commissioning and the extent to which
the prison in your area is properly included in the commissioning
plans of the strategic health authority in that area. I am not
quite sure how you would want that corrected. With extra resources
the allocations did allow for the fact that prisons would bring
an extra burden to them, including at the time as I recall £20
million that was within the health system that was preferentially
directed towards those PCTs that had prisons allocated to them
because they took that responsibility.
Q318 Mrs Riordan: In terms of evaluating
the costs and benefits of interventions to meet the mental health
and substance misuse needs of offenders, what gaps exist, in your
opinion?
Savas Hadjipavlou: One of the
difficulties with the offending population is that a substantial
section of it has a wide range of problems. They do not bring
with them just mental health problems, they have alcohol and drug
addiction problems, and I think that is an area that we do need
to look at in more detail simply because services that look at
just one dimension and ignore the other two are almost from the
start bound to be less effective. I think that would be an area
which requires attention. I think there are two areas which I
would focus on in the transition between the criminal justice
system. One is the court stage and the other one is for people
who are released back into the community. You can do good work
in prison which you subsequently completely dissipate because
it is unconnected or disconnected through care in the community.
If you take somebody on a drug programme who has completed that
programme and then has to wait or is lost to the system outside
you can easily undo whatever benefits you might have had. I think
we do need to come back to the point about connecting services
as a way of maximising impact.
Q319 Mrs Riordan: So following on
from that is there much information about the agencies working
together to serve needs both in prison and in the community of
offenders with mental health problems and substance misuse problems?
Savas Hadjipavlou: The outcome
of the consultation Improving health, supporting justice
was published a couple of months ago which had over 100 examples
of what might be described as individual initiatives. There were
one or two in there, specifically I think Lincoln, which sought
to integrate those services, so I think there are people who are
being innovative who do see the connection and do try and do that.
I think what we have got to do just in terms of gaps is make sure
they are evaluated, and where they are generalisable and replicable
we should roll them out. There is no point in reinventing the
wheel.
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