Rethink Mental Illness were appointed to deliver psychological therapies (IAPT step 1 and 2 interventions) and resettlement services across 7 prisons within the North East of England as a subcontract from Tees, Esk and Wear Valley NHS Foundation Trust. The service was a brand new initiative in the North-East Prisons, who prior to 2015 did not have any IAPT provision, which is indicated in the NICE guidelines for common mental health problems as the treatment model of choice. The service has now been mobilised for 3 years and we have become an integrated part of the existing secondary care model throughout the prisons.
Highly Commended - Improving Access to IAPT Category - #MHAwards18
From start: No
During process: Yes
In evaluation: No
PP Collaborative: Yes
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Jonathan Munro - Head of Prisons and Criminal Justice
Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.
Rethink Mental Illness were appointed to deliver psychological therapies (IAPT step 1 and 2 interventions) and resettlement services across 7 prisons within the North East of England as a subcontract from Tees, Esk and Wear Valley NHS Foundation Trust. The service was a brand new initiative in the North-East Prisons, who prior to 2015 did not have any IAPT provision, which is indicated in the NICE guidelines for common mental health problems as the treatment model of choice. The service has now been mobilised for 3 years and we have become an integrated part of the existing secondary care model throughout the prisons. This integrated approach is key, allowing effective, safe care to be provided within IAPT principles, to those who may be excluded from community services due to risk, medication, or comorbidities.
Co-production is used routinely with Tees, Esk and Wear Valley NHS Foundation Trust, with the wider mental health team all adhering to standard processes, agreed at management level between the 2 organisations, to ensure a positive patient journey, focussing on the patients needs and presentation. Our resettlement service, provides intensive support to those individuals with mental health difficulties who are sentenced to 12 months or less, providing comprehensive through the gate support for 10 days post release, to make release as successful as possible and maintain their mental health throughout this process.
What makes your service stand out from others? Please provide an example of this.
Our service exemplifies accessibility to mental health support. The service is overseen by a National Manager who has extensive prison background, both in uniform roles, substance misuse roles and psychological training. This knowledge is complemented by frontline managers who have a strong background in IAPT provision and delivery within community setting, ensuring that the compliance of the model with guidelines remains true and effective whilst appropriate and engaging for a complex prison environment. Secondly the integration with an acclaimed secondary care provider, who already had strong reputations and working relationships within the prisons identified meant the safe systems of work were easily identifiable. This integration has also allowed both providers to excel in their area and focus on providing the service within their remit to the best of their ability, whilst allowing joint work to engage the service users who typically may not reach service thresholds for access in the community.
The introduction of this IAPT provision has meant that those individuals who were not acutely unwell but still required mental health support and skills development, have been able to access an evidence based service to address this. The role of the PWP specifically looks at empowerment and self-management of difficulties, which is invaluable in an environment where autonomy is often lacking. The service has been very well received, evidenced by excellent Patient Experience Questionnaires, and feedback from the Royal College of Psychiatry CCQI scheme and recent CQC visits.
How do you ensure an effective, safe, compassionate and sustainable workforce?
All new staff receive a comprehensive induction, agreed in conjunction with Tees, Esk and Wear Valley NHS Foundation Trust, which covers all area of clinical activity, prison skill set and company specific criteria. This includes attendance at a prison managed induction training session. All staff received supervision on a clinical basis as per the IAPT guidelines, which allows for safe, effective clinical delivery: 1 hour per week case management supervision (review of relevant cases on caseload to ensure compliance with guidelines, safety and effective patient journey) 2 hours per month group clinical skills and reflective supervision (skill development and refinement, complex case management, update on clinical guidelines and consideration of relevant research and training) In addition, as a service all staff receive 1 hour per month of line management supervision, which allows dedicated space for reflection, development, progression with a restorative function.
Furthermore, there is a 1 hour per month Rethink Mental Illness team meeting, hosted by the Head of Prisons and Criminal Justice which provides service updates, feedback on lessons learnt, policy changes, service development opportunities and changes to service delivery/working practices. Rethink Mental Illness have an open-door policy for supervision, meaning that supervision can be requested at any stage if a staff member feels necessary. Staff utilise a range of CPD options, with internal and external training courses attended, which are identified in yearly staff appraisals and mid-year developments review. All staff are also encouraged to complete a Wellness Recovery Action Plan (WRAP) as part of their employment with Rethink Mental Illness and each base attends an annual team building away day, organised by Tees, Esk and Wear Valley NHS Foundation trust. We are also currently introducing a peer mentor scheme within the North-East prisons.
Who is in your team?
1 FTE Head of Prisons and Criminal Justice 2 FTE Senior Psychological Wellbeing Practitioner / Service Managers 11 FTE Psychological Wellbeing Practitioners 4 FTE Trainee Psychological Wellbeing Practitioners 3 FTE Mental Health Care Navigators (Resettlement Support)
How do you work with the wider system?
We are one of 4 providers of mental health services in the North-East Prisons. Tees, Esk and Wear Valley NHS Foundation trust, oversee the contract, with counselling support from Middlesbrough and Stockton MIND and specialist Psychiatry input from Northumberland, Tyne and Wear NHS Foundation Trust. We have a daily Integrated Management Panel meeting, which all mental health staff on duty attend in each prison – during this meeting all new assessments are discussed, along with any who require an multi-disciplinary approach, to ensure an appropriate patient journey can be identified and the best possible care provided, using joint working between mental health providers. As an integrated service, we run awareness days in each of the 7 prisons about our service provision and access routes, whilst also providing mental health awareness to prison staff. As part of the induction process, our staff shadow different agencies such as non-clinical substance misuse, who we often joint work patients with. Our Mental Health Care Navigators oversee our Resettlement Service and they work closely with Through The Gate, community providers of housing, employment, benefits, mental health care and volunteering schemes. These are both statutory and voluntary organisations.
Do you use co-production approaches?
Patient Experience Questionnaires help to shape our service delivery, which allows us to consider the viewpoints of service users at the forefront. In addition we run regular service user forums, which allow mental health patients to feed into service provision and development. For example, in one forum it was identified that due to the throughput of individuals in a remand only jail, consecutive group sessions were unhelpful, so we redeveloped the group to be standalone sessions on relevant mental health topics. Furthermore, we have also introduced mental health helpdesks in some of the prisons, based on service user feedback, to allow a drop-in advice service for Step 1 information and referral queries.
Do you share your work with others?
We routinely share our work with the Royal College of Psychiatry CCQI programme and have had a number of articles published over the last 3 years highlighting good practice. In addition, we are currently undertaking research into the recovery rates of IAPT within the North-East Prisons. Our staff are encouraged to attend conferences as a speaker and present our way of working, and we have been invited to speak at a number of IAPT and criminal justice conferences to date. From an IAPT perspective, we link in with community IAPT providers by regular attendance at the regional Senior Psychological Wellbeing Practitioner Forum, to ensure we share good practice and stay aware of current developments in practice. Our service is also promoted through the prisons we work in, where we often use mental health events to promote our service and presence to prisoners and staff alike.
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
Within the North-East prisons we use the IAPT minimum data set of the PHQ9 and GAD7 measures. As these scores can be inflated due to environmental factors within a jail, we also record a narrative account of their difficulties to ensure they receive the best possible care. Due to this inflation, we have begun research into these figures to look at how best to evidence recovery in a prison setting, as currently we are using community standards which have limited applicability within a prison setting. These measures are carried out at every session and recorded on System One, which is the recording system for healthcare professionals within the North-East prisons. In addition we use the Patient Experience Questionnaires to monitor satisfaction levels, and these are given to every patient at the point of discharge (regardless of whether treatment has been completed or not). These look at progress, recovery, perception of service success and identifying areas of dissatisfaction or improvement.
Has your service been evaluated (by peer or academic review)?
All 7 of the North-East prisons are involved in the Royal College of Psychiatrists CCQI programme and are reviewed annually as part of this. On numerous occasions good working practices from Rethink Mental Illness have been identified and acknowledged. In addition, all of our services in the North-East prisons are subject to CQC and HMIP inspections, none of which have identified concerns specific to Rethink Mental Illness to date. In 2017, Rethink Mental Illness was successful in receiving funding from the Ministry of Justice for a Pets as Therapy evaluation, which looked at the role of therapeutic dogs in the Assessment Care in Custody and Teamwork (ACCT) process. This process has now finished and the data is being evaluated by the Centre for Mental Health and is due for publication this summer.
How will you ensure that your service continues to deliver good mental health care?
We continually look for innovative and progressive ways to develop our service, in conjunction with IAPT updates and innovations led by both the prison service and Tees, Esk and Wear Valley Foundation NHS Trust. For example, HMP Holme House is currently part of the Drug Recovery Programme, aiming to be a substance free environment with a focus on recovery and rehabilitation, which has seen new ways of working developed and proposed. Tees, Esk and Wear Valley NHS Foundation Trust are also a forward-thinking trust, who hold service improvement events based on Kaizen principles, to make rapid improvements to services, which has allowed us to identify issues with service delivery and work with them, using this process to address them quickly and effectively. These ideas can come from commissioners or senior managers, but also come from monthly management meetings, which is attended regionally by all the mental health team managers from the providers in the North-East prisons, allowing us to identify areas for improvement and proactively address challenges. Rethink Mental Illness actively seek out further funding to explore new ways of working. For example, we have currently secured funding to work with a local housing provider to give support and a step-down service to vulnerable women being released from custody. This is a 12 month project based on a need identified by the team in HMP and YOI Low Newton.
What aspects of your service would you share with people who want to learn from you?
Our biggest message is that IAPT can be extremely successful and effective within a prison setting, engaging those hard to reach individuals typically excluded from traditional Step 1 and 2 services. This can be achieved through a solution focussed, flexible and adaptable approach, with a key emphasis on joined up working and patient centred care. Our service implementation has led to reduced waiting times to access the wider mental health team, service users accessing the appropriate level of care at the appropriate time and allowing for a holistic assessment of needs to take place at an earlier stage. One of our successes in relation to staff satisfaction is the high level of supervision and support they receive from management and other staff, combined with tangible evidence of making a difference with incredibly complex cases, whilst staying safely within a Step 1 and 2 IAPT remit. The service allows for innovation and creative practice, with staff being encouraged to suggest pilots and lead on all aspects of service improvement projects. As a result, staff are able to adapt their practice to further their own passions and interest, utilising CPD and training to maximise the skillset they can offer. Finally, the passion and commitment of the integrated management team, means that the service continues to combine best practice guidelines, with the realism of working within a challenging setting, whilst ensuring that staff feel supported, encouraged and empowered. All of this ultimately leads to a more effective and safe patient journey, which is key in the IAPT Five Year Forward publication.
How many people do you see?
We have a combined population of approximately 5800 prisoners who can access our service if required and across the region we carried out assessments on 290 referrals last month, which is fairly typical. Staff have a 50/50 work split of assessments and caseload clients. In terms of caseload these are both group and 1:1 – groups tend to have 10-15 attendees and at any stage, the average caseload of our staff sits between 20-30 individuals. Whilst this is lower than the community, this is often down to the restrictiveness of the prison regime and availability of prisoners.
How do people access the service?
Referrals are accepted from all other staff, concerned family members, self-referrals or referrals from some of the enhanced prisoners or peer mentors who support individuals on the wing.
How long do people wait to start receiving care?
We aim to assess all referrals within 4 days and then they are placed on a waiting list for further support if necessary. Basic self-help is provided at assessment and on average across the region currently patients wait 7 weeks to begin treatment, with our shortest wait being 6 days and our longest wait being 13 weeks.
How do you ensure you provide timely access?
We have streamlined our assessment process in 2017 to make the initial assessment more efficient and effective. This allows more assessments to be completed within a time frame. Prior to assessment all referrals are triaged jointly by a PWP and Band 6 CPN to make a judgement based on all the information available to them, to ascertain any urgency or risk factors. In addition, staff within the prison have the ability to request a crisis referral for any individual they are concerned about and this would be carried out by a Band 6 CPN the same working day. If staff sickness occurs, the Senior PWP’s will often try to support clinically and then we have contingency policies to ensure that caseloads are not left unmanaged due to sickness. The Senior PWP’s also monitor waiting lists and if an influx occurs, overtime is offered or staff from bases with no waiting lists are utilised to provide clinical support.
What is your service doing to identify mental health inequalities that exist in your local area?
We work with all individuals within the prison estate. We have a presence at prisoner induction to give an overview of the service and referral routes. In addition they all receive a printed information pack on the mental health team upon arrival at the North East prisons. Furthermore, we utilise our service user forums to identify ways to increase accessibility and work with the prison to identify those with vulnerabilities.
What inequalities have you identified regarding access to, and receipt and experience of, mental health care?
Prison populations have a population compromised of those who often experience inequality. They have a diverse range of needs and demographics and we pride ourselves on making our service accessible to all. This includes many different races, religions, intellectual functioning, sexuality, gender identity, age and disabilities.
What is your service doing to address and advance equality?
All staff are trained in equality and diversity, both from a Rethink Mental Illness perspective and through attendance at the prison led Equality and Diversity modules – this training ensures all staff are aware of legislation and this is updated via team meetings as changes occur. We utilise national events such as Mental Health Awareness Week and Time to Talk to promote mental health with all prisoners and have recently introduced drop in Recovery Cafes and helpdesks to further support these initiatives. Events are carried out within the prisons to reduce stigma and increase awareness, and referral routes have been adapted to allow self-referrals (including an easy read version of the form) to overcome some of the stigma in accessing services. We also have access to specialist Speech and Language Therapists and Learning Disability nurses to improve access and communication needs.
How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?
Our assessment is based on national IAPT frameworks, using a standardised assessment, considering situation, thoughts, behaviour, emotions and physical manifestations. This is carried out alongside a risk assessment which considers risk to self, to others, from others, self-neglect and substance misuse considering protective factors and future focus. In addition we utilise the PHQ9 and GAD7 as directed by the IAPT MDS.
How do you meet the needs of people using the service and how could you improve on this?
The Seniors PWP’s ensure that all new ways of working are compliant with NICE guidelines and IAPT best practice guides, which includes closely linking with the local university who provide IAPT training to ensure we have the most up to date guidance. We also utilise complex case panels within the integrated mental health team and all staff, including supervisors attend the relevant training for their role, to ensure qualifications remain accredited and up to date. Finally, we use patient experience questionnaires and service user feedback to shape our service and meet the needs of our patient group appropriately.
What support do you offer families and carers? (where family/carers are not the service users)
This is not directly applicable in the prison, however we do communicate with the prison staff and offer training to them in how best to support those suffering with mental health conditions. Training is also offered to other agencies such as substance misuse and education within the prison service so that a consistent, informed approach can be utilised across the prison estate. In addition, our resettlement service provides support and signposting on an individualised basis for those upon release, who may require support.
Hours the service operates *
8-4 Monday to Friday
Brief description of population (e.g. urban, age, socioeconomic status):
We work with prisoners, including youth offenders, females, older adults and high profile individuals. We work with males and females, both on remand and sentenced.
Size of population and localities covered:
We cover: HMP Northumberland (privatised Cat C sentenced male), HMP Durham (Cat B, local male remand), HMP and YOI Low Newton (remand and sentenced, adult and youth female with some restricted status), HMP Frankland (Cat A, high secure sentenced, adult male), HMP Holme House (Cat C, sentenced adult male), HMP Kirklevington Grange (open, Cat D adult male) and HMYOI Deerbolt (sentenced youth male). The combined population is approximately 5800 individuals.
Commissioner and providers
Commissioned by (e.g. name of local authority, CCG, NHS England): *
We are subcontracted by Tees, Esk and Wear Valley NHS Foundation Trust, who are commissioned by NHS England Health and Justice (North)
Provided by (e.g. name of NHS trust) or your organisation: *
Rethink Mental Illness (subcontracted by Tees, Esk and Wear Valley NHS Foundation Trust)
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