Effective Practice in Mental HealthDiversion and Liaison

FRANCIS PAKES and JANE WINSTONEFrancis Pakes is Reader in Comparative Criminology and

Jane Winstone is Principal Lecturer, Institute for Criminal Justice Studies,University of Portsmouth

Abstract: Many criminal justice mental health diversion and liaison teams are underthreat of extinction. Nacro (2005) notes a steady decline in their number, despite the factthat these schemes in principle provide a valuable service and can fit any social inclusionor crime preventative agenda. In order for such teams and schemes to thrive they need tobe strengthened urgently, a point concurred with by Jack Straw when he asked LordBradley to undertake a review into mental health diversion as a means of reducing theprison population. But before these schemes can thrive they must survive. We, therefore,argue that research into their sustainability is required and here we introduce a tool wedeveloped (MHEP-AC) that is now in use for that purpose.

Keywords: mental health; diversion; sustainability; effective practice

Introduction: The Demise of Diversion

The provision of mental health services to individuals passing through thecriminal justice system is a matter that drifts in and out of politicalconsciousness. Despite a steady stream of Home Office circulars andreports provision remains patchy and piecemeal (Nacro 2005). There is,and there has been for some time, support for diversion, that is, to takeindividuals with mental health issues, where appropriate, out of criminaljustice contexts and link them up with mental health and social carefacilities. The Home Office Circular 66/90 Provision for Mentally DisorderedOffenders (Home Office 1990) provided guidance on diversion, and soonafter that the often quoted Reed Report (1992) strongly favoured diversionas a means of disposal for many disordered offenders who commit minoroffences and exhibit a multitude of mental health and other needs (Reed1992). Further to this, a 1995 Home Office Circular emphasised theimportance of multi-agency working in this area (Home Office 1995).Diversion arrangements are usually given shape by dedicated schemes andteams that undertake assessments, provide advice to police or courts andsupport to the individuals concerned. These are commonly referred to as

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court diversion or criminal justice diversion and liaison teams (CJLTs)although they operate under various names.

Court diversion and CJLTs are the hub of diversion. The activity of mostschemes, however, is not characterised by the single-minded pursuit of adiversionary outcome. Many mental health diversion schemes do not somuch divert but rather offer information to the courts and support to thementally disordered individual without diversion being the main objective.Instead, their operations might be thought of as a mixture of assessment,referral, liaison and on occasion, advocacy. Although it is generally agreedthat prisons are unsuitable places for those suffering from severe andenduring mental illness (for example, Reed 2003), many others who passthrough the criminal justice system will benefit from in-reach orcommunity mental health interventions alongside a prosecution.

According to Nacro (2005), which keeps a comprehensive database,there are some 143 such schemes in England and Wales. Nacro, however,notes a decline in their number from the 190 identified in 1997 (Nacro2005). Carpenter and Dyer (2007) identified 112 criminal justice liaison ordiversion schemes and similarly a slight reduction in their number (from120 in 2002). The lack of certainty with regard to how many schemes areactually operating exemplifies their obscurity: there is no nationalframework to support or even identify such schemes and teams.

Nacro constructed four broad categories to describe the aims andfunctions of the schemes it surveyed. First, there are diversion schemes, whichaim to identify mental illness and facilitate admission to psychiatrichospital. This is diversion as referred to by James et al. (2002) and James(2006), in that it targets severe or acute mental health conditions. Second,assessment schemes. Their role is to provide advice to the court on theindividual’s mental state, mental health problems, and the necessity andsuitability of remand or other disposals. Liaison schemes mainly providesupport to mentally disordered individuals in the criminal justice system.These focus upon social welfare concerns which can be contributory factorsto the commission of an offence, such as problems around accommodation,employment etc. Finally, through panel schemes, criminal justice, health andsocial care agencies strive to agree on a co-ordinated care and treatmentplan for an individual. In practice, however, most schemes are difficult toplace into distinct categories. Their activities are wide-ranging and may besubstantially removed from their original or stated purpose, as Nacro’sDave Spurgeon (2005) explains: ‘the reality is that many schemes are, orhave become, eclectic’ (p.25).

Two issues raise concern. The first is the decline in the number of suchschemes. However, it is even more puzzling that most of the 360 or somagistrates’ courts in England and Wales do not benefit from the servicesof such schemes at all. In most places, they simply do not exist. This iscurious because it fails the national aim to deliver a coherent experience ofjustice for individuals passing through the criminal justice system, andbecause diversion and securing appropriate care for individuals passingthrough the criminal justice system has been on the agenda since the1990s. Furthermore, where such individuals may also be experiencing

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mental disturbance it would appear to be equally, if not more, important toensure that they receive equal access to resources, in whichever court theyappear.

In order to get to grips with this situation it is necessary to addresspertinent questions regarding diversion schemes. If, since the 1990s it isgenerally agreed that such schemes should exist across the country, thenwhy has that not been achieved? In order to respond to this, we examinetwo further questions: Is the effectiveness of diversion, in terms of health,criminal justice and social inclusion insufficiently demonstrated?; and: Dodiversion schemes fail to demonstrate that they provide value for money?Subsequently we will look at the factors frequently mentioned asobstructions to effective practice and present our work which addressesexactly these.

Can Diversion Secure Favourable Health, Criminal Justice andSocial Inclusion Outcomes?

There is little doubt that diversion schemes can divert individuals awayfrom criminal justice settings and into health, social and community caresettings. This is demonstrated across the stages at which pre-trial diversioncan occur. At the police stage, a comprehensive study by James (2000)looked at a scheme that operated at three police stations in London, over31 months. Further to a targeted screening process, 1.1% of all detaineeswere formally assessed, which amounted to 710 cases. Of these, 34% werereferred to hospital and 91% of these referrals were admitted the same day.Another 32% of those assessed were successfully referred to health or socialcare providers. In the period covered, the total number of referralsincreased fourfold, suggesting that such schemes do not duplicate work byothers, but are responsible for diverting substantial numbers of detainees.James suggests that such a mental health service at police stations should bestandard.

A similar study was carried out more recently in Belfast (McGillowayand Donnelly 2004). Community psychiatric nurses engaged in so-calledpaper-based screening by examining the custody forms of 4,917 detaineesin police cells. Of these, 16% met the criteria set for a formal assessment. Ofthose assessed, 48% were referred onwards but mostly to educationalservices or a general practitioner. No more than 4% were compulsoryadmitted to hospital. This pattern of onward referrals carries an importantpoint. Most individuals are not admitted to hospital, voluntarily orotherwise. Instead, the common course of action is for such individualsto be referred onwards to community health, social and educationalservices.

The Belfast research included a follow-up study. Unfortunately, only39% of those referred onwards had actually made contact with the agenciesto which they were referred, although 19 interviewed service usersinvariably expressed positive views on the scheme. McGilloway andDonnelly (2004) noted that: ‘many initiatives set up in isolation frommainstream services often fail to achieve their long term aims’ (p.274).

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That is a pertinent point. The prowess of diversion and liaison schemes isdependent on the take-up of onward referrals.

Most liaison and diversion schemes operate at magistrates’ courts. Keyaims of court diversion schemes are to reduce the number of mentallydisordered individuals on remand awaiting a psychiatric report and toreduce the time spent on remand; this has clear cost and sentencingbenefits to the criminal justice system but also health benefits for theindividual. James et al. (1997) argued that remand is an unsuitable andunnecessary option for mentally disordered individuals. Mental healthassessments can be carried out at court whereas a psychiatric report can beundertaken in health settings as long as beds with an appropriate level ofsecurity are available. James et al. (1997) did find that time spent onremand is substantially reduced by such court liaison schemes. Availabilityof beds at an appropriate level of security is crucial. In the 2004 Nacrosurvey, 72% of schemes identified lack of beds as a barrier to their schemeoperating successfully. Kingham and Corfe (2005) reported on the EastSussex Court Diversion Scheme and also note that an increasing shortageof secure psychiatric provisions is a significant barrier to its success. Arelated finding is the lack of professional staffing; half of the schemes hadno sessional input from either a psychiatrist or a psychologist, and theimpact of this cannot be divorced from the finding that 41% of schemesreported difficulties in obtaining psychiatric reports (Nacro 2005).

It is self-evident that whatever diversion schemes might achieve in termsof unlocking services, what happens further to their involvement mightwell hold the key to success of any intervention. Chung et al. (1999)established the quality of life for a group of diverted individuals betweensix months and one year after their diversion. Most had a transient lifestylewith little success in either education or employment. Chung et al.’sfindings highlight the need for a comprehensive outreach programmetailored to such individuals. More recently, Green, Smith and South (2005)concluded that assessment by criminal justice mental health teams broughtfew discernable advantages for the majority of clients.

The seriousness of this type of shortcoming was alluded to by James(1999) when he wrote that: ‘most court diversion services are currentlyinadequately planned, organized or resourced, and are therefore oflimited effect . . . A central strategy is required, and properly designed andadequately supported court services should be incorporated into . . .mainstream local psychiatric provision. Without such action, the future ofcourt diversion lies in doubt’ (p.507).

Soon after writing this, James et al. (2002) undertook what is probablythe most convincing court diversion to hospital study to date. Their resultswere highly positive. The study compared outcomes over two years of agroup of 214 individuals who were admitted to hospital through the courtswith a matched group of 214 compulsory admissions through thecommunity. They found that most court-admitted patients achieved apositive clinical outcome. Their reoffending rate was as low as 28%. Inaddition, the scheme operating at the court increased the detection ofmental illness and significantly reduced the time between arrest and

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admission, therefore reducing the length of time spent on remand. Jameset al., therefore, argue that rather than diversion to hospital being a ‘softoption’, it would appear to be an effective crime reduction strategy. Thus,court diversion can be highly successful, at least for the group for whomdiversion into hospital is suitable.

It must, at the same time, be borne in mind that most of the individualsdealt with by such schemes will not meet the threshold of suffering from asevere and enduring mental illness. The majority of the clientele can belabelled as disordered rather than as seriously ill. The latter group isfrequently in need of mental health and social care as well as drugs misusesupport but does not require psychiatric in-patient services. For this group,the results might not be as positive, as they are more likely to fall in betweenservices and more likely to disappear off the radar. Findings by Green,Smith and South (2005) indeed support this. This population ischaracterised by a chaotic lifestyle with issues of accommodation andemployment so that diary keeping and regular attendance cannot be takenfor granted. Shaw et al. (2001) found that loss of contact with services washighly common and argued for a more comprehensive outreachprogramme to secure higher levels of engagement.

Do Diversion and Liaison Schemes Provide Value for Money?

Trying to define and establish value for money in justice and health settingsis a treacherous undertaking. Value for money may be influenced by anynumber of factors, not least whether it is in terms of actual costs to eitherthe criminal justice or health organisations, whether value is perceived interms of health outcomes and/or criminal justice outcomes and, of course,how health or criminal justice outcomes are themselves to be measured.Nevertheless, just because an issue is fraught with definitional andmeasurement difficulties does not mean that any attempt to explore itshould be avoided.

The work of James et al. (2002) shows that by speeding up admissioninto hospital, valuable time can be saved and that can easily be translatedinto financial savings. Thus, part of the answer to the question posed lies inthe reduction of criminal justice expenditure for those on remand. Moregenerally, cost can be measured by establishing the cost of a scheme and byoff-setting that against the service that it provides. The cost of the schemesseems to vary between d30,000 and d40,000 for a scheme operated by asingle worker, to about d250,000 for a dedicated multi-agency team. Manyschemes deal with between 100 and 250 clients on an annual basis (Nacro2005; Centre for Public Innovation (CPI) 2005; Winstone and Pakes inpress). From that, a measure of cost-per-client, or activity costings might bederived. However, in practice, the vast majority of schemes seem unable todo that. Current practice in data collection and analysis simply does notprovide a basis upon which to do such sums (Centre for Public Innovation(CPI) 2005; Winstone and Pakes 2008).

Research that establishes cost-effectiveness is scarce but there is anotable study from the US (Cowell, Broner and Dupont 2004), which

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looked at four diversion schemes for people with serious mental illnessoperating at sites at Lane County in Oregon, Memphis in Tennessee, NewYork City and Tucson in Arizona. Cowell, Broner and Dupont set out toestablish the cost of diversion as compared with non-diversion over twelvemonths. The schemes were varied: three were so-called post-bookingprogrammes (roughly comparable to court schemes) and one was a schemethat operated earlier in the process (pre-booking, at the police stage). Theschemes also differed in the populations that they served. The generalfinding was that diversion reduces criminal justice costs. However, thatsaving has to be off-set against an increase in treatment costs. A key factor intreatment costs is, not unexpectedly, the destination of the diverted. In onesite, Memphis, diversion occurred mainly into residential care settings.The result of that was an overall increase in cost to the care setting. Othersites showed different patterns of results. Savings in New York City, wheremany diverted avoided jail and entered community care, were the mostsubstantial (in the order of $6,000 per individual) whereas for both LaneCounty and Tucson, the differences were less stark, but diversion was stillfound to be cost-effective in the first twelve months, when compared withnon-diversion. Simply put, the savings in criminal justice were larger thanthe extra costs in the treatment domain. Therefore, with cost savings acrossdomains, some form of redistributing costs or budgets will be required(Winstone and Pakes 2007).

In addition, the Cowell, Broner and Dupont study included a twelve-month outcome assessment. It showed that although most expensive interms of treatment costs, the Memphis diversion scheme reported goodclinical outcomes which may well serve to reduce cost in terms of bothhealth care and criminal justice interventions in the longer term. Therelatively brief twelve-month follow-up period (half that of the James et al.(2002) study and shorter than the typical 24-month reconviction studies inthe UK) was justified by explaining that any effect obtained can be ascribedto the diversion scheme rather than to the efforts at the onwarddestination. It can, on the other hand, be argued that such diversionschemes have the potential to be the catalyst for lasting change. Shouldsuch schemes be instrumental in breaking the vicious ‘revolving door’cycle, the cost savings for both criminal justice and health care in the longterm could be significant. If it were the case that investing in mental healthschemes would yield long-term health benefits and reduce involvement incriminal justice, then value for money would have been established.

At present, however, comparisons between schemes on cost-effective-ness variables are virtually impossible to establish by reason of the lack ofcomparability in their activities. In addition, a lack of clarity and a sense ofisolation permeates all areas of practice. Support for these claims comesfrom the report published by the Centre for Public Innovation (CPI)(2005) based on an analysis of the working of ten diversion and liaisonschemes. This suggests that lack of organisation and funding strategies,development plans, vision (both locally and from the funding body) andthe absence of an overarching national framework conspire against boththeir efficacy and longevity. These are also common complaints voiced by

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scheme workers. Nacro (2005) found that a third of schemes cite staffing asa major problem and almost a quarter felt that mentally disorderedoffenders were a low priority for agencies in their area. A third of schemessurveyed by Nacro are run by a single individual and as individuals mightmove on at any time, such schemes are invariably in a precarious position.Nacro (2005) also demonstrated that monitoring was inconsistent and datacollection patchy without an agreed minimum dataset or shared ITsystems.

In addition, performance monitoring was ad hoc, without set targets orreference to a vision within either local mental health contexts or thecriminal justice system. The Centre for Public Innovation (CPI) (2005)noted that most schemes were focused on outputs, in particular, numbersof clients seen; many scheme workers found it difficult to articulate theintended outcomes of their schemes. Where discussed, it was mainlyconceptualised in terms of improving the lives of individuals with mentalhealth needs. Schemes did not seem to be (or feel) part of a larger contextof either improving health or reducing reoffending.

This disparate state of affairs inevitably has repercussions for any debateon cost-effectiveness or value for money. ‘In the current state, it is notpossible to state clearly whether a scheme is effective or not, or to describewhat causes a scheme to be effective, or to say that a scheme is providing‘‘value for money’’’ was the sobering conclusion drawn by the Centre forPublic Innovation (CPI) (2005, p.45). Thus, despite the fact that studies oncost-effectiveness and health and criminal justice outcomes (low in numberas they are) exist, their findings cannot be extrapolated to diversion andliaison schemes as they currently operate. In fact, given such a bleak state ofaffairs, even to seek to establish their cost-effectiveness at all at this stageseems premature.

The Mental Health Effective Practice Audit Checklist (MHEP-AC)

There is no doubt that mental health schemes can divert, are suited to playa role in strategic frameworks for reducing reoffending and can offer valuefor money. But their existence is frequently precarious due to theshortcomings identified above. We would, therefore, argue that researchinto such schemes should adopt a focus on sustainability.

In 2006, Winstone and Pakes were asked by the Office for CriminalJustice Reform (OCJR, now residing under both the Home Office and theMinistry of Justice) to develop a tool to identify best practice in diversionand liaison schemes. This tool took the shape of a checklist, the MentalHealth Effective Practice Audit Checklist (MHEP-AC). It has the followingaims: to identify a range of operational strategies; to identify effectivepractice; to identify sustainability, and to identify and develop ways ofmeasuring value for money. It was not intended to capture the personaland professional qualities of those who make schemes ‘tick’, often in theabsence of secure and sustainable arrangements. Rather, Winstone andPakes set out to tap into the factors frequently mentioned as obstacles tosuccess, despite the best efforts of individual scheme workers. Rather than

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measuring value for money directly, MHEP-AC sets out to identify ways inwhich funding, organisation and data analysis can be audited in order tomake robust cost-effectiveness and value-for-money assessments a possi-bility.

MHEP-AC assesses six areas of effective practice identified throughtwo qualitative literature reviews commissioned from Winstone and Pakesby OCJR. These six areas are ‘assessment and screening’, ‘facilitatingaccess to mental health support’, ‘liaison’, ‘information sharing’, ‘multi-agency arrangements’ and ‘data collection and analysis’. The literaturereviews (peer reviewed, and summarised in Winstone and Pakes (in press))demonstrated wide agreement that these areas are key to effectivepractice. To assess to what extent these activities are carried out in asustainable and cost-effective way, the absence or presence of six elementsof effective practice are tested. These are: ‘statement of purpose’, ‘policy’,‘management’, ‘resourcing’, ‘practice’, and ‘continuous professionaldevelopment’. The evidence suggests that such elements are fundamentalto each of the areas and to the sustainable success of schemes, as discussedbelow.

Assessment and Screening

When considering proactively operating schemes, screening is a vitalcomponent. It allows the scheme to service not only those who are referredto them but also to proactively identify their clientele. This enhances ascheme’s accessibility and makes it more likely that existing needs areproperly addressed, two key factors in quality health care as identified byMaxwell (1984).

James et al. (2002) noted that whether screening forms part of the workof any scheme has repercussions for both the size of its caseload and thetype of cases involved. ‘In a screening system, all cases passing through agiven location (police station custody suite, or magistrates’ court cell area)are examined in order to establish whether they have evidence of disorderor healthcare need. The ability of the screening procedure to identify caseswill depend in part upon the intensity of the screening procedure adopted’(p.100).

Assessment usually takes place further to screening. Research (Single-ton, Meltzer and Gatward 1998; Birmingham et al. 2000; Harrington et al.2005; Langley 2005) strongly suggests that training is of vital importance tosecuring accurate screening and assessment, so the training arrangementsto support screening and assessment are an important area to test.

The extent to which assessment is supported by multi-agency arrange-ments, by clear policy and practical protocol is important, as is the overallethos and philosophy of such arrangements. In addition there must beclear protocols, for instance in the form of decision trees, to determinewhat happens on the basis of the result of screening and assessmentprocedures. Furthermore, it is crucial that information is collected andcollated regarding these activities and what happens next. We echo thestatement of James et al. (2002) who argue that:

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The stated aims of each scheme must be audited in order to establish effectiveness,and to enable adaptation and change. There is no purpose in running schemeswhich are inefficiently audited. For instance, some current schemes record thenumber of assessments that are made, but not whether anything was achieved bythe assessment. Others record the recommendations that resulted from theassessment, without recording whether these were put into effect. There is nopurpose in a diversion scheme that does not know whether or not it diverts. (p.102)

Facilitating Access to Mental Health Support

Both police and court schemes can facilitate access to the appropriate levelsand settings of mental health support. Magistrates often follow the advicegiven by scheme workers, and James et al. (2002) in particular demonstratea stark increase in hospital admissions as a result. As it is clear that suchschemes have the capacity to work well and we have identified thecomponents that make them do so, we are testing these components in theMHEP-AC. They include the establishment of a clear philosophy that isshared throughout the team; specific funding that is long term, strategicmanagement overseeing this, psychiatric input, training and reflectivepractice and data collection and analysis.

Multi-agency Arrangements

The term multi-agency is in vogue and probably because of that, itsmeaning has both been widened and diluted. There are formalarrangements in criminal justice such as multi-agency public protectionarrangements (MAPPA) that recognise that multi-agency work is the onlyappropriate strategy in which to work towards public protection in dealingwith at-risk and high-risk individuals (Wood and Kemshall 2007). Workingwith mentally disordered offenders requires multi-agency input because ofthe complexity of their needs and risk management. Thus, where criminaljustice and health concerns meet, multi-agency involvement is both logicaland inevitable (Stone 2003).

Effective schemes should facilitate multi-agency working. Strategicmanagement should equally reflect the importance of multi-agencyinvolvement. Protocol on how to facilitate this should be in place withmulti-agency involvement subject to regular review and follow up. Thissection of MHEP-AC therefore seeks to test whether arrangements are inplace to secure long-term, effective, multi-agency involvement.

Information Exchange

Information sharing is critical to a range of activities that support theprovision of services to individuals with mental health needs. Most notably,referral, assessment and all aspects of multi-agency work rely uponinformation sharing which is accurate, timely and serves the purpose forwhich it is intended (Nacro 2004). Information exchange can thereforeserve as the glue that holds effective provision together but needs to becovered by policy, not least regarding confidentiality, data protection,human rights, risk and child protection (Nacro 2004).

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Effective information exchange refers to the protocols and procedureswhich facilitate the flow of information between the various agencies.Weaknesses in information exchange (Offender Health Care Strategies2005) appear to be at the point of an individual moving from one service orsetting to another, for example, between prison and the community. Goodinformation exchange processes to overcome this are characterised bybeing linked to a shared and coherent multi-agency ethos, sharedagreements around confidentiality, joint training arrangements withmulti-agency partners, clear roles and responsibilities with protocols foractivities linked to memorandum and/or service level agreements withspecified resource and funding arrangements. MHEP-AC therefore seeksto test out the extent to which these aspects can be identified as beingintegral to the ‘modus operandi’ of a scheme.

Liaison

Liaison is often used in tandem with diversion. We use the term ‘liaison’ todenote the process that concerns the ‘linking of people into appropriatecommunity agencies and services’ (James et al. 2002, p.99). Liaisongenerally focuses on those who do not need admission to hospital. Thesepeople will often present with a range of mental health problems,substance misuse, and chronic/acute personal and social issues (Robertson,Pearson and Gibb 1995). This is a situation frequently encountered withsuspects in police stations or at magistrates’ courts (James et al. 2002;Robertson et al. 1994).

Liaison, accessing mental health services and multi-agency work oftenintermingle (Stone 2003). For our purposes, however, it is important totreat them as conceptually separate, although not discrete categories, andassess to what extent they work well at present and the extent to which thearrangements are secured to last, via protocol, strategic management andsecure long-term funding. To achieve this we need to establish whetherthere is strategic input in identifying gaps and maintaining links. Thepresence of a link worker would be evidence of specific funding andstrategic support. Their work would be enhanced via, for example,protocols, service level agreements and specific resources, and a goodworking knowledge of the agencies involved, their nature and importancefor the benefit of service to mentally disordered individuals in the criminaljustice system. In support of this, the Royal College of Psychiatrists (RCP)(2005) found that effective liaison can easily deteriorate due to differingvalues and lingering disputes regarding resource allocation which havebeen shown to undermine such arrangements.

Data Collection and Analysis

Various researchers have emphasised the importance of both recordingand collating information. In addition, it is vital that the throughput of anyscheme is analysed to assess its success both in terms of qualitative andquantitative outcomes and to determine whether it is responsive to, and

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meets, local needs (Centre for Public Innovation (CPI) 2005). Nacro (2004)argues that information monitored should include:

� date and time of initial assessment;� personal details, including ethnicity;� site of intervention;� referring agency and details of referral;� mental health state, status and diagnosis;� subsequent assessment details;� criminal justice history;� risk factors (to others and suicide and self-harm);� drug and alcohol concerns;� recommendations; and� outcome.

James et al. (2002, p.102) argue that data analysis should enable answers tothe following questions:

� Is the scheme accessing people?� Is the scheme achieving its aims?� Are recommendations being accepted?� Are arrangements followed up?

MHEP-AC seeks to assess the extent to which these arrangements are inplace and supported by a sustainable framework. We are asking about theethos/philosophy underlying the data collection and analysis, and lookingfor protocols (procedures, standardised forms), strategic management andresourcing. In addition, we assess the extent to which the arrangementswork in practice and whether there is systematic review of thesearrangements.

With reference to outcome measures, ideally the scheme should begathering information across three parameters to demonstrate value formoney. These are: community justice outcomes (reduction in frequencyand seriousness of offending behaviour); health outcomes (improvementin physical and emotional well-being); and, social inclusion outcomes(securing accommodation, employment, and participation in communityactivities).

Conclusion: The Sustainability Challenge

In December 2007, Jack Straw, Lord Chancellor and Secretary of State forJustice, announced the Lord Bradley review. Its remit is as follows: ‘toexamine the extent to which offenders with mental health problems orlearning disabilities could, in appropriate cases: be diverted from prison toother services; the barriers to such diversion; and to make recommenda-tions to government, in particular on the organisation of effective courtliaison and diversion arrangements and the services needed to supportthem’ (Bradley 2008, p.1). Lord Bradley is due to report early in 2009.

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The Bradley review has led to a renewed interest in the working ofcriminal justice diversion and liaison schemes. This time, the interestcomes from the top and is part of a wider agenda: a reduction of the prisonpopulation. As it is beyond doubt that mental health problems in prison arerife and that prison, despite a plethora of pledges and initiatives remainsill-equipped to provide quality mental health care, this is a welcomedevelopment.

It is to be hoped that the Bradley Review will serve as a catalyst for thefurther development of the schemes in existence. All schemes in Englandwill be subjected to a version of the MHEP-AC in order to establish currentpractice and highlight best practice. That should lead to the strengtheningof already existing schemes which often, it is fair to say, lead a fragileexistence. In addition, it is hoped that the Bradley Review will seek toestablish a national framework for support including a quality assuranceagency. Rather than pump-priming as occurred in the 1990s, such schemesneed sustained investment, with the confidence that when established onproven tenets of effectiveness, diversion is likely to be achieved, rates ofimprisonment and use of remand can be reduced and care, health andcriminal justice outcomes can improve as a result. As a final note, it is ironicthat where mentally disordered offenders have frequently been argued tobe marginalised and disenfranchised (Winstone and Pakes 2005) anddescribed by Prins (1980) to be the people nobody owns, in a way, the sameis true for the schemes dedicated to look after them. This is a state of affairsthat needs addressing urgently.

References

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Bradley, K. (2008) Letter to London Development Centre, 31 January.Carpenter, J. and Dyer, W. (2007) Outcomes of Custody Diversion for Mentally Disordered

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Cowell, A.J., Broner, N. and Dupont, R. (2004) ‘The cost-effectiveness of criminaljustice diversion programs for people with serious mental illness co-occurring withsubstance abuse: four case studies’, Journal of Contemporary Criminal Justice, 20, 292–314.

Green, G., Smith, R. and South, N. (2005) ‘Court-based psychiatric assessment: casefor an integrated diversionary and public health role’, Journal of Forensic Psychiatryand Psychology, 16, 577–91.

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Date submitted: April 2008Date accepted: September 2008

171r 2009 The Authors

Journal compilation r 2009 The Howard League and Blackwell Publishing Ltd

The Howard Journal Vol 48 No 2. May 2009ISSN 0265-5527, pp. 158–171