Together with Nacro, Clinks is writing a blog series on the Community Sentence Treatment Requirements (CSTR) programme as part of our health and justice work funded by the Department for Health and Social Care’s Voluntary, Community and Social Enterprise (VCSE) Health and Wellbeing Alliance. The CSTR programme is jointly overseen by NHS England and NHS Improvement, Public Health England, the Department for Health and Social Care, Her Majesty’s Prison and Probation Service, and the Ministry of Justice. The programme aims to reduce reoffending and divert people from short-term custodial sentences by addressing the mental health, substance and alcohol misuse issues of the person in contact with the criminal justice system through treatment requirements that are undertaken in the community. In addition to funding from the NHS Long Term Plan, the CSTR programme has been given an additional £2.5million from the recently announced Mental Health Recovery Programme, with investment coming from the Department for Health and Social Care. Find out more about what CSTRs are in our report here.
For this blog series, Clinks and Nacro have met with different sites to discuss their journey to becoming a CSTR site, how the site interacts with the voluntary sector, how the site functions, the benefits it offers to clients, and how they have been functioning during Covid-19. As all sites have voluntary sector partners who deliver treatment requirements, we have been keen to understand the experiences of organisations delivering these requirements, how they engage with statutory agencies, and what advice they would give to other organisations who may deliver treatment requirements as the programme rolls out in the future. We previously published our findings from the Essex CSTR site, which we conducted in December 2020.
For our second site visit in January 2021, we met with Hazel Roberts, Clinical Team Manager at Livewell Southwest, and her team at the Plymouth CSTR site. Here’s what we found out:
How do you set up as a CSTR site?
Plymouth was one of the five original test-bed sites that piloted the CSTR programme, and has been live since November 2017. Plymouth was selected for the pilot as there was already an existing integrated complex needs team made up of Livewell Southwest and Harbour staff delivering substance misuse and alcohol support services. Livewell Southwest is a recognised provider of integrated health and social care services operating across South Hams, West Devon and Plymouth, with additional responsibilities for delivering specialist services to people living in certain parts of Cornwall and Devon. Harbour provides substance and alcohol misuse support.
The challenge for Plymouth was to establish a mental health treatment requirement (MHTR) programme from scratch in 2017, which was achieved over a 5-week period. In such a short space of time, it was not possible to recruit into the team, so they had to adapt their existing staff resources. This was only possible because of the level of experience in their existing staff team, and because they already had relationships with the courts, police and probation.
Plymouth has a long history of delivering treatment requirements within the criminal justice system through voluntary sector organisations, and the team has strong connections with other local agencies, literally sitting in the same building as police and probation staff. This helped to get the site up and running, forging strong partnerships between the statutory and voluntary sector agencies.
How have services changed?
The introduction of MHTRs means that Plymouth is now able to offer a comprehensive service to its clients – becoming a CSTR site has brought all the treatment requirements together in a way that wasn’t happening before. Prior to becoming a CSTR site, they knew that there were groups of people that were falling through gaps in existing mental health services. This is not just an issue in Plymouth, it is nationwide – many people in contact with the criminal justice system have mental health needs that are too complex for primary care due to intersecting issues and multiple disadvantage, but not severe enough to qualify for secondary care services. This therefore results in a lot of people having contact with the criminal justice system without treatment options to address the root causes of offending, or to meet their needs. With this in mind, Plymouth siezed the opportunity to undertake MHTRs because they saw people in contact with the criminal justice system who would clearly benefit from mental health treatment in the community.
Delivering combined requirements to service users
The team reflected the benefit of combined orders is that they get planned in a way that ensures the timing of different orders works with needs of the service user.
In Plymouth, there is a ‘phased’ combination order, which means they wait until a service user is benefiting from the alcohol treatment requirement (ATR) or drug rehabilitation requirements (DRR) before beginning the MHTR. This is to try to ensure that the MHTR has value, and the service user is able to fully engage with and participate in the treatment order.
Adapting to Covid-19
It was reflected by the Plymouth team that initially, delivering treatment requirements in a pandemic was challenging. It was difficult to work with people over the phone, as it was hard for service users to not get distracted when in their home environment, and difficult for staff to assess how engaged a service user was without seeing them. In response to this issue, they developed a Facebook page and a YouTube channel with a number of video resources specifically related to acceptance and commitment therapy, mindfulness, and emotional wellbeing. Service users can go through these videos and then engage with the team via Zoom as part of their treatment requirements.
To facilitate strong engagement with treatment requirements during Covid-19, service users get a number of reminder texts in the lead up to their appointment, and they have online sessions where they can share screens and show videos, so that everything they previously did face-to-face can now be delivered online. This has been very successful, and engagement rates have improved significantly. Only two people were unable to engage with online sessions, and so for them telephone contact has been continued. For many people who are anxious about meeting face-to-face initially or can find environments such as waiting rooms stressful, having the option to work together online first has been a real game changer at Plymouth.
Collaborative and partnership working between learning and development, probation, CSTR providers and the courts is vital to ensure CSTR suitability and appropriate client health and social support.
Are there any downsides?
The Plymouth team didn’t express any major downsides, but noted that whilst working with other agencies is key to success of a site, it will always present challenges, as there can be competing pressures, priorities and objectives between stakeholders. The most important thing is to keep lines of communication open and keep talking with partners. This is particularly true during the pandemic, when different agencies may have different internal rules about things such as remote working and recovery planning.
Room for improvement
In Plymouth, they are looking at implementing a number of things to improve on their current offer, including:
- Developing a group offer - ATR/DRRs are traditionally delivered one to one, but they want to look at a group offer, as this could be really beneficial for some clients. They are looking to develop this once the pandemic is over.
- They want to ensure same day assessments can be done at court and have an assessor in the court for all CSTRs. This would be a significant development, and was planned before the pandemic, but has currently stalled due to a shortage of space at court.
- A number of staff are currently on a two-year dialectical behavioural therapy course (DBT), which means they will be able to offer an evidence-based psychologically informed intervention for a range of people on CSTRs.
Words of advice
The Plymouth team would definitely recommend setting up a CSTR site. Their key advice:
- Service agreements between agencies about data exchange are crucial
- Establish and maintain forums which are both operational and strategic so that you have the main players in the room, otherwise drift from your shared purpose is inevitable
- All agencies involved in the site working collaboratively together is vital.
Zahra Wynne was Clinks' Health and Justice Policy and Development Officer until June 2021.