Examination of Witnesses (Questions 329
- 339)
TUESDAY 28 OCTOBER 2008
ANGELA GREATLEY
AND PROFESSOR
JONATHAN SHEPHERD
CBE
Q329 Chairman: Ms Greatley, Professor
Shepherd, welcome. We decided that we would try to draw on your
expertise in a rather different way and instead of going through
a formal question process we have asked you each to give us a
short introduction, and we told you in advance some of the key
things we are trying to assess or find out, and then we may have
some points we want to raise when you have done so. Can I invite
you to do that and who would like to start?
Angela Greatley: Thank you very
much for the opportunity to speak with the Committee. The thing
that we were asked to look at from the Sainsbury Centre for Mental
Health, which of course is a research and development organisation,
was the top five priorities that we might come up with for reinvesting
money in and around the criminal justice system, given our particular
interest in mental health problems. I think the first one is to
make it possible for people to be diverted to mental health treatment
at all stages of the criminal justice pathway. If I use the "pathway"
word is that okay with everyone? You know we are talking about
the various stages that people might go through. And not just
that but to do it as early as possible. There is a great deal
of discussion about the meaning of the term "diversion".
If I use it here I am thinking principally of two things. Firstly,
people with severe mental health problems should be diverted away
from the criminal justice system as early as possible, and that
means at the police stage as well as the court stage and of course
later on if they become unwell in prison they need to be transferred
for health care. It is also in a sense diverting people particularly
from short sentences of custody to more appropriate community
sentences with mental health treatment that might avoid the dislocations
that occur in people's lives and in their mental health and other
health treatments from short sentences. We would advocate investing
significantly in the evidence-based early years work. I know it
is not particularly the remit of this group but if people are
interested in the Committee we could write more about the considerable
evidence that exists for investing very early on with children
and families.
Q330 Chairman: That is children for
whom a mental health problem has been identified?
Angela Greatley: No, that would
be with families who might well be identified as having problems
that we could sum up as dislocation from society, multiple difficulties,
poverty, social exclusion, and the children who are brought up
in those families will often require some extra support, so there
is some considerable evidence where we might intervene. The third
point I would make is about young people where problems have been
identified.
Q331 Mrs James: Would we identify
them through crime mapping, through established methods? How would
we identify those young people? I think we understand how but
it might be worth putting it down on the record.
Angela Greatley: Where we are
talking about very early interventions with children we would
be looking for families in schools, we would be looking at the
very early services that mean that if we identify families are
not coping well with what people will call parenting that we very
quickly intervene with those families because the evidence we
have of things like developing conduct disorders during early
life are that they have quite poor outcomes for young people in
later life. For young people we would be particularly concerned,
if we are talking about the teenagers through to the later teens,
to have youth justice services and youth teams where the police
are beginning to identify difficulties in the community so that
very early on those young people are identified, particularly
at the point where they have been identified in the youth justice
system and come to the notice of the police. If they come into
a police station, there should be positive screening for their
various mental health difficulties that might be underlying, and
then there could be an assertive engagement with them. "Assertive"
is a very polite word for making sure that people who do not want
to engage and do not want to use services necessarily are made
aware that there are real opportunities and those services are
offered in a very positive way.
Q332 Mr Heath: Could I just pick
up this interaction with the police because I think it is a very
interesting thing that we have not discussed previously. One of
my observations from working with the police for many years is
that since the institutions no longer exist, the mental hospitals
no longer exist that what a PC on the beat used to do with someone
he felt probably had mental health problems, which was to simply
drop them at the door effectively of the hospital and ask them,
"Would you look after this person and assess them?"
is now not available, there is nothing in the community. Should
we be thinking beyond screening in custody to providing places
of safety in communities that the police could interact with to
provide help for those who may have a mental health problem which
is at the root of any anti-social or other behaviour?
Angela Greatley: One of the areas
of success that has happened in investment in mental health services
is the growth of quite a variety of community-based teams. There
was a National Service Framework in mental health. It did have
targets about criminal justice but they have not been well observed.
What there is in the community is quite an array of different
kinds of community mental health teams, assertive outreach terms,
home treatment teams and crisis teams. The Committee was asking
earlier about the partnerships, and if the inter-agency partnerships
are flourishing then there should be very clear protocols and
guidelines by which the police (who should not be dealing with
these matters, you are quite right, it is not their business in
that sense) are able to identify and know exactly where they can
both signpost but in more serious cases make sure that somebody
arrives at the door of services. There are more services there
than perhaps there were some many years ago. Psychiatric hospitals
of course do exist now but they are in general dealing with people
with much more severe problems, particularly crises, and of course
they are covered by the Mental Health Act that was brought in
not too long ago.
Q333 Chairman: We rather stopped
you.
Angela Greatley: Those were the
first three of our priorities. The fourth speaks very much to
the conversation we have just had which is for the Health Service
to invest (we are not looking for Justice's money here, I think
it is the job of the Health Service) more in assertive teams and
particularly we are concerned that if people are sentenced to
community orders there is the option of a mental health treatment
requirement. It is almost never used, and we think this is partly
because courts and sentencers are not confident of what will actually
be provided by the mental health services and the mental health
services themselves have probably not been alerted properly to
the responsibilities and actions they could take. My own organisation
is currently doing a great deal of work on the mental health treatment
requirement which is not working well now, not as well as for
instance the drug treatment requirement which is also available.
We would hope for instance that we could write to you as that
develops. We have had a great deal of co-operation from probation
and from others but clearly that is an option with good assertive
working. With primary care that becomes interested in offenders
one would be able to divert more people perhaps from short custodial
sentences to community orders with some real teeth to the kind
of mental health support that they would get. I guess our fifth
point from a mental health perspective is that although we are
interested in effective treatment and care for mental health problems
we also know that the biggest contribution is that someone has
somewhere to live and something to do in the day, preferably work,
and therefore the whole re-settlement area is one where we think
we can effectively spend money better by avoiding that revolving
door of people with a complex mix of drug and alcohol and mental
health problems, poor housing, just revolving back through the
prison system because they are not being treated and supported
effectively. Those would be our five priorities.
Q334 Chairman: Thank you very much
indeed. I would invite Professor Shepherd to do something similar
and then we will open the field.
Professor Shepherd: Thank you
very much, Chairman. I have four priorities that I would like
to draw the Committee's attention to. The first one is to develop
offender management schools and institutes in research-intensive
universities. I know the Committee has heard evidence with regard
to research and I think this is important. These institutes and
schools would work to provide and carry out high-quality research
and they would also integrate their activities with the training
of offender management staff. I was privileged to hear a talk
by Jonathan Allen from the Research Directorate in the Home Office
about the quality of the evidence which is relevant to "what
works" in offender management. It is clear that the studies
are limited, the interventions are limited, the research standards
are not high and there is little applied research in this area.
This proposal would increase the number and the quality of offender
interventions. It would result in disinvestment in things that
do not work, as has happened in the Health Service in a number
of areas. It would increase service reliance on what works and
it would provide local research hubs with which practitioners
could work. There are models for this in our medical schools,
in town planning schools, in our best universities. They are all
power houses for innovation and driving up efficiency and effectiveness.
Clearly there is a cost issue but to reassure the Committee that
in a related field, in police science, we developed in South Wales
a university police school which is entirely cost neutral and
it is already resulting in local economic benefits and less crime
locally as well as contributing internationally with regard to
the products of its work. That is the first point. It would require
the training of a cadre of practitioner academics. Just as I am
a Professor of Surgery who practised in the clinic this morning
and runs a research team, in the same way we need to train offender
management staff as academics. That is the first point. The second
point relates to victims. I think it is very important that we
look at how we can increase the quality of victim services. There
is one particular proposal I would like to bring to the Committee
and that is that we acknowledge that alcohol intoxication increases
the chances of victimisation (without of course blaming victims
for what has happened to them) and by acknowledging that, which
is strongly supported by the research, we deliver motivational
interviews (which are known to work across a range of settings)
in the violent crime units across the country. The delivery of
that kind of intervention to reduce alcohol misuse is known to
be cost-effective. Thirdly, we need to use Crime and Disorder
Reduction Partnership (Community Safety Partnership in Wales)
resources to ensure high-quality data analysis for crime reduction.
I would even go as far as saying that we might develop a new crime
reduction specialty with analysts who are high-quality and trained
in statistics but also have an eye on the research evidence on
what works. Targeted police work and local authority work is effective
but deployment of their precious resources depends on the identification
of targets and crime hot spots. Without that identification continuously
we cannot target our resources properly because, for that, policing
needs to respond to continuously updated information. My team
has been around the country recently and it is clear that even
with police data this is not used to target hot spots for violence,
for example, in some areas. The model I bring, and which you have
had information about prior to the Committee today, relates to
the combination of accident and emergency data and police data,
but data analysis is crucial to that. Fourthly and lastly, a point
that relates to the role of the media, which I know the Committee
is interested in. Developing offender management schools and institutes
will increase very substantially the amount of research which
is published on what works, and so the media would then pick that
up and we would be in a position where the media would be diverted
perhaps from reporting opinion to reporting the results of high-quality
experiments about what works, as happens almost every week when
a new medical advance is published in the British Medical Journal
or The Lancet. Secondly with regard to the media, we need
to contextualise crime risk. With every story about the death
of Jimmy Mizen or Damilola Taylor for example,we need always to
contextualise that in terms of risk and how much violence we are
really dealing with. We need much less focus on police records
for violence and disorder. They are a poor measure of minor violence
and even of moderately serious violence and disorder. I would
suggest—and it is something we have done in our publications—that
we need to switch from a focus on police records to harm-based
injury public health approaches which really do quantify violent
crime, in particular, in a straightforward way and avoid the archaic
language of "grievous bodily harm", which may not even
involve bodily harm at all, so this approach would bring simplicity
to this work. Those are my proposals, Chairman.
Q335 Alun Michael: When I suggested
we heard from you, Jon, because we have known each other for long
time, it was really with a sense not so much of the specifics
as understanding the methodology. The work that you did in Cardiff
resulted in the city moving from being high in terms of violent
crime to being comparatively safe. What you did was to bring your
medical analysis to bear, I think I am right in saying, comparing
for instance the methodology that resulted in a drop in the actual
injuries that you were seeing in terms of car accidents to that
of an inner city. Could you say a little bit about the methodology
and how that might be applied to other areas of crime reduction?
Professor Shepherd: The basis
of that approach was the finding from my research team and the
finding also of the British Crime Survey which is that there is
a lot of violence that is not reported and recorded for a number
of well-known reasons. So the conclusion was that, to understand
violence in a city, whether Cardiff or Birmingham or Northampton,
it means that we need to access accident and emergency information
particularly about the locations and the weapons and the times
and the dates when the violence occurs and then share that anonymised
information (it is not personal data of course; it is all anonymised
data) with a crime analyst, hence the centrality of the crime
analyst, who then combines those data with police intelligence
and then summarises the hot spots on a weekly or monthly basis
so they are continuously updated. It is a simple concept but it
requires a data delivery chain if you will forgive the jargon.
It needs the capacity to collect the data electronically in A&E.
It needs the capacity to anonymise that, share it with the crime
analyst, for the crime analyst to put the information together,
for there to be a violent crime task group in the partnership
which combines that information and most importantly acts on it
and holds the practitioners to account, especially those in the
police and local government, who can make the biggest difference.
I would say in terms of methodology it is the unique data that
the Health Service can provide in a cost-neutral way. This has
happened without any further funding. The first thing is the use
of those unique data and the second thing that is emerging from
the evaluations is the dynamic between police officer and accident
and emergency consultant. "We have seen 17 admissions from
that night club in the past quarter; what are we going to do about
it?" There is something about that dynamic that is very powerful
because it is senior practitioners holding each other to account.
Q336 Alun Michael: That requires
a relationship and communication that is a two-way process.
Professor Shepherd: Yes, and that
is very important. I think that we need to move away from the
situation where police officers usually go to A&E seeking
evidence about a particular case, but in the context of the CDRP/CSP,
for the police officers at the appropriate level to make friends
with their A&E colleagues.
Q337 Julie Morgan: I have questions
for both of you. First of all for Professor Shepherd—and
I must declare an interest here as a constituent of mine, and
I am also well aware of his work—I was very interested in
what you were saying about victims and how if you abuse alcohol
you are more likely to be a victim. I think that is something
that is not thought about widely, because we usually think about
those using alcohol being the offenders. I wondered if you could
say a bit more about these interviews that you are referring to,
because I think that sounds a very fascinating way of reducing
the risk of being a victim.
Professor Shepherd: The research
team found that alcohol intoxication increases the chances of
victimisation because it makes people less physically competent
to get away—to put it simply—and it erodes decision-making
ability. Heavy drinking means that people are going home alone
at night through risky environments, and being intoxicated means
that the victim is far less able to identify the person who hit
them. So there are four reasons, really, why intoxication increases
the risk of victimisation. Motivational interviews have a very
good record and they are very effective, and they take 15 to 20
minutes. They have been used very widely in a range of health
care settings but not yet in victim services—
Q338 Chairman: You are talking about
victims who might become victims again. Is that how you have identified
who to have these interviews with?
Professor Shepherd: Yes, exactly;
a victim coming into an Accident & Emergency department or
identified by Victim Support, in order to reduce their risk of
re-victimisation—which, of course, we must consider alongside
re-offending—so that the risk of further victimisation can
be reduced by that process.
Q339 Julie Morgan: That sounds a
very positive step and I am also very much in support of your
proposal for the offender management school. I think that is very
interesting. If I could ask you, the comments you are making,
are they made in an England and Wales setting, or is your knowledge
based on the English health service?
Angela Greatley: They are based
on England and Wales. Indeed, some of the comments about diversion
are based on the evidence we have been able to gather from a number
of countries internationally. However, we do work with Wales as
well as England.
Julie Morgan: I wanted to know how available
you felt that help in the community was, generally. Obviously,
with what you are proposing, it is key that those facilities are
there to help.
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