The London Pathways Partnership (LPP) is a unique collaboration between four London NHS Trusts, led by Oxleas in partnership with East London, South London & Maudsley and Barnet, Enfield & Haringey. We came together in 2013 as four mental health Trusts who had already demonstrated a commitment to working with offenders who pose a high risk of violence to others, and who struggle with pervasive psychological difficulties that underpin both their offending and their non-offending lives.
What We Did
The London Pathways Partnership (LPP) is a unique collaboration between four London NHS Trusts, led by Oxleas in partnership with East London, South London & Maudsley and Barnet, Enfield & Haringey. We came together in 2013 as four mental health Trusts who had already demonstrated a commitment to working with offenders who pose a high risk of violence to others, and who struggle with pervasive psychological difficulties that underpin both their offending and their non-offending lives. We now deliver innovative services to individual offenders who have complex psychological difficulties (with or without a formal diagnosis of personality disorder) across all of London and in three prisons (Swaleside, Brixton and Aylesbury).
Personality disorder – despite changes to policy guidance – has remained a controversial area for mental health services. Many teams lack the confidence and competence to work with this group, who as a result experience very restricted access to mainstream mental health services, and are often dismissed as attention-seeking or untreatable. This is often even more the case for those whose difficulties have contributed to serious offending and involvement in the criminal justice system, as organisations prefer to avoid the risk associated with these individuals. In addition, stringent risk management approaches, which focus on imposing restrictions, often lead to their being excluded from opportunities for relationships, training and work as well as psychological support.
The key to the success of this project has been LPP’s partnership with the probation service in London and with the prison staff in the three prisons. We also have a number of partnership arrangements with third sector organisations, and our service users are increasingly becoming partners in our projects and their development. We have succeeded in improving outcomes for individuals who would otherwise be excluded from mainstream mental health services and who are often marginalised and disenfranchised members of society.
Wider Active Support
In 2013 there were opportunities to tender for funding to develop services to personality disordered offenders and LPP was formed, as the Trusts decided that collaboration was more productive than competition. Despite the inflexible and cumbersome mechanisms that are normally associated with health service delivery, the small group of LPP clinicians overcame financial and human resource barriers to develop a highly effective Steering Group. Over the past 3 years LPP has developed and expanded rapidly as Commissioners from both the NHS and the National Offender Management Service (NOMS) have seen us mobilise and deliver effective, value-for-money services against a background of austerity and structural change, particularly in probation and the prison service.
The LPP Steering Group now oversees delivery of a range of services providing support and interventions for individual offenders, and the professionals working with them, along a pathway through the criminal justice system. These include a 36-bed service at HMP Brixton (recently relocated from HMP Belmarsh); a 60-bed unit at HMP Swaleside, and another of the same size which is about to open; a 30 place enhanced support service for violent prisoners who regularly require healthcare admissions and segregation at HMP Swaleside; a treatment service at HMPYOI Aylesbury; and an outreach and support service at Standford Hill to help prisoners make the transition through open prison and back into the community. In the community we have worked in close partnership with probation to deliver training, consultation and support to the entire probation workforce across London and to deliver a co-working model of intervention to service users.
Our ethos from the start has been to strive for accessibility and efficiency. We have aimed to develop lean services, to maximize added value, and to embed expertise within probation and prison staff and services, rather than developing dependency on health services. We aim to facilitate high quality service provision that is delivered efficiently, so that the right support is equally available and accessible to high risk service users with personality disorder across London and the prisons.
Tangible outcomes include the following:
1) Implementing a single model of care for all high risk London offenders with personality disorder, based on an understanding of attachment and research into desistance from offending
2) A system for tracking an individual from the point of sentencing, through relevant prison interventions – some of them co-delivered by LPP – providing advice to the Parole Board, and supporting individuals back into the community, with access to community treatment and support through and beyond the period of statutory supervision.
3) Training around 1,000 probation and prison staff in four core themes related to personality disordered offenders, and demonstrating a significant improvement in their confidence and competence
4) Forming a partnership with First Step Trust in order to provide real work-related opportunities (driving, mechanics, catering, painting/decorating and gardening) for those who, because of their offending and personality difficulties, are excluded from training for the general public.
5) Forming a partnership with Sova to recruit volunteers from the general public to provide psychosocial support to 60 high risk offenders struggling to resettle back into the community.
6) Running effective and well-evaluated group work programmes for personality disordered violent and sexual offenders, which are accessible to all across the whole of London.
7) Combatting loneliness, isolation and poor self-care with the development of a weekly café evening for our known service users, promoting social support, creative activity and life skills.
8) Taking 200 offenders into our residential prison services, including many who had previously refused or been excluded from prison mental health and criminal justice interventions, and successfully progressing 50% along pathways back to the community
9) Attracting over 30 psychological therapists, 25 specialist probation officers and 40 prison officers into our services, and developing a specialist workforce with the capacity and ability to be the leaders of tomorrow.
10) Developing continuity across services, including reducing physical barriers between prison and the community by: prison teams following up men after release to aid resettlement; community-based volunteers and third sector services working with service users both before and after release; ‘graduate’ service users coming back to share their experience of release with their peers who are still in prison; and holding open days for professionals and stakeholders to help them learn and understand more about service users and the work we do.
11) Involving experienced users of our services to co-deliver interventions and training for professionals.
12) Developing the first pan-London service user forum for high risk personality disordered offenders, to develop and oversee user-led initiatives that assist service users to develop a new identity as contributing citizens, build a social support network, and gain skills to help them re-integrate into the community.
13) Developing a peer mentoring training programme with a group of service users, and then training two cohorts of service user ‘graduates’ to support vulnerable peers during the difficult transitional period after leaving custody, thus helping them to establish a stable lifestyle in the community and avoid a return to custody.
14) Establishing a website for both professionals and service users, which includes information and guidance to enhance professionals’ ability to deal sensitively and effectively with difficult interpersonal situations and behaviour, and information for service users to help them obtain relevant support in the community.
We have sought to involve service users from the start, consulting them about the original design of services, regularly obtaining feedback, and working in partnership with them wherever possible. Our overarching model is underpinned by an understanding of the centrality of relationships, and we work collaboratively with service users, supporting them to be actively involved in the direction of their own care pathway. As our and their experience has grown, we have been strengthening the role of service users in the development and delivery of services. We believe that service users have an essential and unique role to play in making services useful and accessible, and that peer support and input can make the crucial difference in helping someone make a successful return to the community from prison. We believe we are one of very few organisations to have enabled the development of a service user forum for high risk personality disordered offenders living in the community, which has real responsibility and influence in enhancing opportunities for service and self-development. So far the Forum has been involved in developing our website, developing and implementing the peer mentoring programme and carrying out service evaluations; service users are also involved in co-delivering training and therapeutic interventions, in recruitment and in promoting our services. The testimonials below also provide evidence for the importance of our services in enabling individuals, otherwise excluded from services and facing a bleak future, to feel listened to and hopeful about progress.
Many service users have difficult relationships with family and friends (where they have any) and we facilitate family meetings with clinical support when the service user wishes to try and repair or resolve past and present difficulties and start building better relationships for the future.
Looking Back/ Challenges Faced
There is nothing major we would have done differently. It might have been easier to roll out services in a more staggered way, but the Commissioners were concerned to ensure that available money was budgeted and spent in line with the proposed models. This led to some strain on organisations, trying to recruit, fill beds, and reach hundreds of staff across London, but these outcomes were achieved, not only in a reasonably timely manner, but also against a background of dramatic structural change in probation and the prison service.
When we started our partnership working, we had no idea that the probation service would be subject to Transforming Rehabilitation and effectively cut in half as a service; nor did we anticipate the most radical reorganization of the prison service – in New Ways of Working – which severely challenged recruitment to our prison services. Both these challenges have been overcome by working together, demonstrating flexibility, keeping up transparent communication among partners and with Commissioners, and always holding in mind the overriding aim of providing an effective and efficient service to a challenged and easily neglected and excluded group of service users.
Challenges internal to LPP included the inflexibility of health systems – particularly finance and HR – which meant that we needed to encourage HR managers to communicate across Trusts, and to be flexible in the use of fixed term contracts, secondments and pan-Trust working.
The services we provide are for high risk offenders with complex psychological difficulties, and inevitably there are anxieties across the multi-agency professional network about involving users in the development and delivery of services. This is an ongoing challenge which we manage through open communication, partnerships between a range of health, criminal justice and third sector agencies, robust governance procedures overseen by the LPP Quality Board, high levels of support and supervision for involved service users, and evaluation of all new initiatives.
The services have provided opportunities for a range of psychological therapists to develop their leadership skills in the field of personality disordered offenders. These senior staff have now worked across the community, into prisons, and with our public sector and third sector partners; the service is not reliant on a single person, but on a group of leaders, with emerging leaders coming up behind them.
Working as four Trusts together, rather than one on its own, has also helped us to deliver flexibly while constantly and explicitly referring back to the core principles and aims of our services. We have invested in the training of our prison and probation partners, and this is also paying dividends, as they are empowered to deliver psychologically-informed services without undue reliance on psychological therapists.
The pilot phase of the service was evaluated and the findings published in Personality and Mental Health (2011): Shaw, J., Minoudis, P., Craissati, J. & Bannerman, A. ‘Developing probation staff competency: An evaluation of the Pathways Project’. :Wiley Online Library (wileyonlinelibrary.com) DOI 10.1.1002/pmh.192. This concluded that the pilot project provided evidence for the effectiveness of the project model that supported its implementation on a broader scale.
In 2013 LPP commissioned an independent evaluation of the services it was providing through the probation and prison partnerships, to be carried out by the Universities of Nottingham, Greenwich, Cambridge and Leicester and GetTheData Ltd. The final report is about to be completed and published, and the findings include the following:
Services are appropriately targeting the most high risk offenders; The most high risk offenders are achieving a reduction in their risk; Users of our prison services have a good understanding of their risk and of what is needed to help them build safer lives; Prisoners changed their attitude to authority, improved their understanding of themselves, and gained a greater sense of self-worth and optimism through good relationships forged with staff; New coping skills were learned, both through courses and by facing up to difficulties on the Unit; Staff valued prisoners and took an interest in them as people; having a psychological perspective on understanding prisoners’ issues and modelling pro-social behavior, were seen as paramount.
An Approved Premises supported by LPP practitioners has become the first in London to obtain an ‘Enabling Environment’ Award (awarded by the Royal College of Psychiatrists) and our service in HMPYOI Aylesbury has also achieved an Enabling Environment Award; our other services are in the process of submitting their portfolios or awaiting the result.
We also regularly get feedback, written and oral, from service users and staff in our prison services, and some examples are given below:
“It’s very helpful to me to be part of the Unit and to share each different side of emotions that I don’t really know anything about, and experiences that we all have and takes impact on our lives, and now I can get the help I really need to deal with my life on the outside thanks to psychology. The Unit is helpful in ways that the rest of the prison establishment isn’t”.
“I’ve been a prison officer for 9 years and during this time I’ve witnessed the service change dramatically. I remember feeling safe and thankful for certain colleagues and prisoners who had the time to guide me through those early years and impress on me the value of patience, fairness and decency within the prison environment. The ever changing political climate and cutbacks don’t allow people to give their time so freely now, so these values are sadly declining. Pathways has brought that feeling back for me. Communication and guidance through difficult decisions and challenging situations is commonplace now and a more positive atmosphere can be physically felt on the Unit”.
“I know there is progress, I can see it in front of my face, and so that for myself has made my confidence and my self-esteem and my hope, it’s restored, it’s rejuvenated my hope that there’s going to be a future”.
[From a prisoner, now successfully released after many years of being ‘stuck’ in prison] “The Unit’s seen a lot of behaviour from me, picking chairs up and throwing them across the landing, and a lot of verbal aggression, you know, so my main sort of voice that I’m saying to the lads back there is that it isn’t too late, it can still change, you just need to work on what you’re doing, and when you’re given the opportunity to come somewhere like here you need to grab it with both hands, make the most of it you know because the main thing is we all want to get out to be with the people we love and it’s only ourselves that are going to hold us back”.
And finally, the following data demonstrates our effectiveness in assisting individuals to progress despite their pervasive difficulties:
Between April 2013 and April 2016: - Identification of 5,588 offenders with significant personality difficulties linked to sexual/ violent offending with a high risk of causing a high level of harm to others - Work with probation and the prison to identify a more appropriate pathway for 1,881 of them who had reached an impasse, resulting in many hundreds of offenders accessing specialist services - Prison services at Belmarsh and Swaleside admitted 198 people, of whom 29 have made progressive custodial moves and 33 have been released into the community, most of them after prolonged periods of being ‘stuck’ in prison - Significant reductions in self-harm and aggression among offenders accessing our prison services
We have a programme of in-house research and evaluation which we publish; we present at national conferences (e.g.the British & Irish Group for the Study of Personality Disorder; Division of Forensic Psychology conference); we always contribute to relevant consultations, and are closely involved with Pathway developments nationally; we share our service model documents; and we host open days in our services. Transparency and openness are part of our ethos, and this applies to all the work we do, as our primary aim is to support the delivery of improved, compassionate and effective services to our service users.
Please also see our website www.lpp-pd.co.uk for more information, publications, and evidence of our open access approach.
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People with complex difficulties don’t follow a straight line as they try to move forward in their lives, and we’ve now been involved with many service users who have moved between hospital, prison and the community at different times depending on their needs, achievements and struggles. Whatever direction an offender is moving in, we strive to provide continuity of understanding, relationships and informed decision-making across both health and criminal justice settings, to maximize consistent, safe and effective management and support towards a stable life in the community.