INTEGRATED HEALTH AND JUSTICE STRATEGY 2020-2024
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INTEGRATED HEALTH AND JUSTICE STRATEGY 2020-2024
2 3
CONTENTS
Health and justice in Greater Manchester 6
Executive summary 8
Our priorities 10
1. Why focus on health and justice? 12
Our opportunity in Greater Manchester 12
Defining the case for change 13
isk factors associated with contact with the
R
criminal justice system 17
National and international policy and evidence 19
Greater Manchester evidence and insight 24
enefits of violence reduction in human and
B
system costs 26
2. Whole-system leadership for health
and justice 27
A whole-system approach to Family Justice 28
3. O
verview of specialist health and justice
provision in Greater Manchester 30
4. Rationale for strategic focus
on particular groups 33
5. Health and justice strategic framework
and priorities 36
Existing health and justice work programmes 36
New strategic priorities 37
6. Delivery and resource planning 38
Delivery 38
Resource planning 38
4 5
In Greater Manchester, justice devolution has provided us with a unique opportunity to address The development of this integrated health and justice strategy is a first for Greater Manchester
the typically very poor physical and mental health of people, both victims and offenders, and potentially also the first placed-based strategy in England developed specifically to
who come through our criminal justice system. This includes a focus on earlier identification address the health and social inequalities experienced by vulnerable children, young people
of health and support needs, more responsive interventions, and providing health and care and adults seen across our criminal justice systems. Like justice devolution, health and social
services, which are equal to those available to people living in the wider community. care devolution in Greater Manchester creates new opportunities to address the ongoing social
This strategy describes in detail the broad range of risk The values and priorities represented in this strategy challenge of health inequalities. This strategy is a significant part of that effort, focusing on
factors and the complexity of individual, family and closely reflect our public service reform principles perhaps the most vulnerable members of our communities.
social circumstances that contribute to victimhood for the city-region and our model of public service The health inequalities experienced by children and One of these risk factors is mental health. The strong
and offending behaviour. These complexities only delivery – preventative, proactive and person-centred. adults seen in the criminal justice system are broad association of poor mental wellbeing, low to moderate
serve to emphasise the value of closer integration We believe that this approach will support the most and deep, and in some cases, contact with the criminal mental health issues and clinical mental health
and collaboration between our public services. From vulnerable members of our community, including justice system will be the first time that they have had conditions, with health and justice has been widely
services providing health and social care, education victims and offenders, to recover from their experiences, their health needs assessed or have had any consistent referenced by colleagues, partners and the public
and accommodation to the police, Crown Prosecution build their physical and emotional resilience, and contact with a health or social care professional. This during the development of and consultation for the
Service, courts, prisons and probation services – each eventually enable them to succeed and thrive. is why the strategy places high value on the early strategy. For the purposes of this health and justice
has collective responsibility to address the issues identification of health care and support needs, to strategy, a broad definition of ‘mental health’ has been
Whilst individuals and families benefit most directly
outlined in this strategy. Justice devolution will help ensure that they are recognised on first contact with adopted, which crucially recognises the psychological
from this approach, there is also a ‘community
to consolidate and strengthen the way services work the criminal justice system and that effective action is and emotional impact of adverse childhood
dividend’ for society as a whole, including safer
together around the needs of people seen in the taken to prevent issues from getting worse. experiences on lifetime mental health and wellbeing.
communities, less children in care, fewer people at risk
criminal justice system in Greater Manchester. This is why the strategy recommends a trauma-based
of homelessness, lower rates of violent crime, more The strategy also adds to our appreciation that being
vulnerable children and young people participating in model of intervention and support, which is also more
either a victim of serious violent crime, or an offender,
likely to prevent youth offending and effectively support
"We believe this approach will education, and better health for all. is often an indicator of past or current vulnerability. The
victims of sexual violence and abuse. This signifies an
priority groups that are a focus for our early strategic
support the most vulnerable work reflect this understanding – children and young
important change in the way public services will work
people to recover from their people; vulnerable and marginalised women; people
with victims and offenders in Greater Manchester.
with learning disabilities, autism or communication
experiences, build their physical disorders; and people who are rough-sleeping. However,
and emotional resilience, and Beverley Hughes
Deputy Mayor for Policing, Crime, Criminal Justice
the choice of these priority groups has been made
eventually enable to them thrive." and Fire
with an awareness that the risk factors that lead to
victimhood and offending are broad, complex and Lord Peter Smith
overlap with each other and this is highlighted in Chair Greater Manchester Health and Social Care
the strategy. Partnership Board
6 7
Health and justice in Greater Manchester
These Greater Manchester specific research and insight exercises tell us that:
Physical Health 55%
Mental Health 48%
23–51% 76–83%
Self-harm or suicide risk 41%
28–25% 25%
More than one in four victims of crime will
0% 10% 20% 30% 40% 50% 60%
develop symptoms of post-traumatic stress
disorder as a result. People who have experienced
One third of young people in the Greater Between 76-83% of women who have been crime can often be surprised by how much Screening of individuals in police custody shows
Manchester youth justice system have assessed by a Greater Manchester Women’s distress they experience. Experiencing crime can that members of the public who are arrested
substance misuse issues. 28-35% of young Centre have mental health issues, often linked lead to the development of long-term problems on suspicion of committing a crime are far
people on the youth justice caseload have to their experiences of domestic abuse. 25% of such as depression or anxiety, which in turn can more likely to have a health problem. 55% of
special educational needs, whilst 23-51% women who have accessed Greater Manchester manifest as physical problems. Many victims of individuals in police custody had a physical
have recognised speech, language and Women’s Alliance Partnership services have a crime experienced harm – often severe – as a health issue, while 48% had an underlying
communication needs. physical health issue. 55% of women who use direct result of the crime that was committed. mental health issue. 41% of these individuals
these centres have a child under the age of 18. The experience of each victim will vary. were at risk of suicide or deliberate self-harm.
33%
Cardiovascular Disease 34%
16% Muskuloskeletal Problems 24%
MEN
Asthma/respiratory conditions 20%
16%
50% 44% Epilepsy 5%
Diabetes 5%
34%
WOMEN
0% 10% 20% 30% 40%
In HM Prison Manchester, 16% of prisoners Mental and physical health needs are highly
were reported as being homeless during the Mental and physical health problems are often common in prisons. High levels of severe and
year before imprisonment. A review of the enduring and can be a cause of re-offending. enduring mental health problems are matched
Over 50% of the women who go to the Greater Cheshire and Greater Manchester Community 16% of men and 24% of women who are on by very high instances of physical illness,
Manchester Sexual Assault and Referral Centre Rehabilitation Company (CRC) caseload in 2018 probation self-identify as having a mental health including 34% with cardiovascular disease (like
(SARC) have a history of domestic abuse. Repeat found that 33.1% of people had an issue with problem. Suicide is the most common cause of angina), 24% with musculoskeletal problems
attenders at the SARC are typically female and accommodation. This proportion was higher for death among offenders. It is the cause of 44% (like arthritis), and 20% with respiratory problems
have a background mental health problem, a those who had an identified mental health or of deaths for those open to the National (like asthma). Many of these conditions go
learning disability, or are a child. suicide/self-harm need. Probation Service. unidentified and untreated.
8 Integrated Health and Justice Strategy 9
Executive summary However, there is broad acknowledgement that
the application of trauma-led practice is especially
The purpose of this first Integrated Health and Justice Strategy for Greater Manchester important in supporting this population of children,
is to inform and enhance the way in which we understand and address the health, social young people and adults, as many victims and
care and criminal justice factors that can lead to life-long poor physical and emotional offenders have a history of challenging life experiences
including abuse, which can in some cases lead to poor,
health, and reduced life-expectancy, for people who are seen in the criminal justice system,
ongoing psychological and emotional health.
as offenders or victims.
Building on our assets
The devolution opportunity Targeting our efforts
It is important to recognise that there are already a
The benefits of focusing on addressing the social and The engagement work that has fed into the number of well-established public and VCSE sector
health inequalities experienced by this group of often development of the strategy has pointed towards an services across Greater Manchester whose purpose it
vulnerable people will be seen at an individual level – in initial strategic focus on four particularly vulnerable is to improve the health and wellbeing of people seen in
the form of improved physical and mental resilience, groups; the criminal justice system, such as the Sexual Assault
healthy relationships, reintegration in community and Referral Centre (SARC), the Women’s Support
• c
hildren and young people
life and the avoidance of first or repeat offending or Alliance services and wider victim support services.
victimisation – and at a community level, reduced • v ulnerable and marginalised female victims of
domestic abuse or sexual violence Whilst Greater Manchester is leading the way nationally
health inequalities, lower crime rates, and safer and with new, jointly commissioned service models, i.e.
more cohesive communities. • p
eople with a learning disability, autism or
Integrated Healthcare in Custody and wider Liaison
communication disorder
Increasing national focus on effective healthcare for and Diversion, there is scope for greater alignment and
the victims of abuse and sexual violence, and offenders • and people who are rough sleeping. collaboration across Greater Manchester around the
in the prison estate, provides a backdrop for the needs of this population group, not only across health
Doing things differently and justice provision, but across mainstream services
development of this Greater Manchester city-region
approach, alongside local needs assessments and The strategy introduces two key concepts that offer and professional domains.
strategic review work. the potential to transform the way that public services This strategy and the delivery plan in particular reflects
across all sectors in Greater Manchester identify, this combination of existing development work and
Greater Manchester’s long-standing ambition as a
engage with and support some of the most vulnerable new health and justice ambitions and priorities, with
city-region has been to take greater control of its own
people living in our communities. a view to bringing greater strategic coherence to both
destiny. Our devolution deals, including health and
social care and now justice devolution, are enablers The first is the idea of adopting a public health programmes of work, and eventually bringing them
to achieving that. Integrating and reforming public informed approach to health and justice strategy, together as one. As well as seeing the emergence of a
services is the key to breaking down service silos policy and delivery. This is intended to stimulate a more consistent, whole system approach to health and
and moving towards a preventative approach which more preventative model of identification and support justice in Greater Manchester within the first 5 years of
serves residents and communities better. This strategy for victims and offenders, with an explicit aim of the strategy, a further success factor will be tangible
emphasises and embraces this vision of public intervening earlier to reduce the likelihood of offending evidence of health, social care, Voluntary, Community
service reform. or being victimised. In practice, this means using data and Social Enterprise (VCSE) sector and criminal
and intelligence to understand this typically vulnerable justice services providing more trauma-informed,
population of children, young people and adults and collaborative care and support to this population group,
the complex often interdependent factors that have led with a stronger emphasis on prevention and earlier
them to be in contact with the criminal justice system. intervention. In due course, this should manifest in
The second concept introduced through the strategy better health and wellbeing and reduced offending
is the development of trauma-informed approaches and reoffending.
that involve moving to a position where public This first Integrated Health and Justice Strategy
services in Greater Manchester regularly and for Greater Manchester therefore provides both a
consistently use more therapeutic practices, which case for change and a platform for improvement
recognise the impact of previous trauma or difficult and development in health and justice intelligence,
life experiences. What works to support and address commissioning and service provision through
the health, care and wider social needs of people in its delivery plan.
contact with the criminal justice system is currently an
evolving field, and the delivery programmes identified
in the strategy will no doubt add to this relatively narrow
evidence base.
10 Integrated Health and Justice Strategy 11
Our priorities
Prevention
1. 2. 3.
I ntroduce a public health Work with schools, youth Building on the work with
approach to violence reduction justice and children and the Women’s Alliance
across public service young people’s services to Partnership, extend provision
provision, with a focus on develop upstream, targeted to reach a wider cohort of
children and young people at interventions that reduce the vulnerable women who are
increased risk of committing risk of first-time entry to the at risk of victimisation or
anti-social or criminal activity criminal justice system committing criminal activity,
and, strengthen health care
pathways between existing
services
Intervention
4. 5. 6.
Develop best practice Agree a standardised health Work with partner
approaches and pathways improvement model with the organisations to promote
that appropriately identify and NHS and youth justice teams and embed the principles
support offenders and victims that targets and addresses of Family Justice within
of violence or exploitation health vulnerability in this the strategic direction and
who have a learning, autistic group of young adults operational delivery of unified
spectrum or communication/ public services in Greater
speech and language issue Manchester
Enablers/Systems
7. 8. 9.
Develop a long-term, Collaboratively develop Establish more consistent
sustainable approach to workforce training and approaches to service user
commissioning services that development programmes engagement in the design and
deliver specialist healthcare that promote insight into delivery of specialist health
and therapeutic support to trauma, abuse, learning and justice services
offenders and the victims disability and communication
of crime, agreeing common disorder presentation and how
quality standards for Greater to identify and support these
Manchester issues effectively12 Integrated Health and Justice Strategy 13
1. Why focus on health and justice?
Our opportunity in Greater Manchester
The 2016 devolution of responsibilities for health and Focusing our collective efforts specifically on the
social care brought to life through ‘Taking Charge’ Plan, health needs of people in contact with the criminal
and the 2019-2021 justice devolution agreement, create justice system, or at risk of entering it, is a relatively
an opportunity for Greater Manchester to innovate and new approach for the city region, and it presents a
integrate public policy and services in the field of health chance to deliver high-impact change in the medium
and justice. to long-term for some of our most marginalised and
vulnerable children, young people and adults.
Devolution has created a framework to do this,
enhanced by a new Greater Manchester integrated The emphasis throughout this strategy is to integrate
public services model and reform principles which policy and services relating to health and justice,
emphasise prevention, people and place. Together including the development of innovative approaches
these act as enablers for change, but they are also to support people who can often become stuck in a
helping to stimulate a shared understanding of the cycle of exclusion, vulnerability, offending, victimhood Defining the case for change
health needs and health inequalities of a population or exploitation. In line with a shared ambition in Greater
The founding premise of this strategy is that health However, poor physical and mental health amongst
group who have traditionally been ‘seen’ separately by Manchester to invest in preventative approaches, the
and wellbeing of people in contact with the criminal victims and offenders is also attributed in part to the
public services. strategy focuses on the need for earlier identification of
justice system, as a victim or an offender, is a priority and value that individuals place on their own
risk factors and health and social care needs, as well as
shared responsibility of local authorities, CCGs, NHS health, with vulnerable people often not accessing
appropriate interventions and support.
healthcare providers, the Greater Manchester Health health and care support in proportion with their needs,
and Social Care Partnership (GMHSC), the Greater leading to pronounced differences in life course health
Manchester Combined Authority (GMCA), the Voluntary and life expectancy. Whilst health inequalities are often
A Focus on Prevention and Intervention Community and Social Enterprise (VCSE) sector and driven by socio-economic disadvantage and poorer
criminal justice services. opportunities and life chances, amongst children,
young people and adults who come into contact with
This is because the majority of people that have been
the criminal justice system, it is common to see a
a victim of crime, or a perpetrator, live in and are part
further layer of complexity which increases the risk
of our local communities and it is in a community
of exposure to criminality or victimhood. These risk
setting that health, wellbeing and resilience can be
factors include:
best supported and improved.
• c
omplex and traumatic personal histories and
In fact, many more offenders are supervised in the
relationships, which may also include abuse and
community than in secure custody, and the majority of
exploitation;
custodial sentences are relatively short at 12 months
Address ‘upstream’ determinants • e
nduring mental health and/or substance misuse
or less.1 This means most custodial sentences allow
e.g. ACE, Troubled Families issues;
for a relatively limited opportunity for the health and
Programme, Truancy, Youth
wider care and support needs of offenders to be • learning disabilities, autistic spectrum disorders and
Offending, Liaison & Diversion,
identified and addressed, before they return to their communication disorders;
Drug & Alcohol dependence, Address ‘downstream’ determinants
communities. • g
ender, in particular women and girls; and
unemployment etc. e.g. support recovery from drug/alcohol
dependence, address mental health problems, In addition, the transitional period of returning to the • r ace, particularly Black and mixed ethnic minority
REDUCE OFFENDING /
ensure access to primary care, support through community after a prison sentence is known to carry men in terms of offending.3
VICTIMHOOD
training, education, employment, housing etc. significantly increased risks to physical and mental
This combination of risk factors can lead to entrenched
health, including premature death – suicide, accidental
SUPPORT REHABILITATION, RECOVERY health inequalities, which then negatively impact
death and homicide – and reoffending.2 Identifying and
& REDUCE REOFFENDING upon personal resilience and reinforce vulnerability,
supporting the health, care and wider social needs of
meaning that people in contact with the criminal
offenders, as well as victims of crime, whose multiple
justice system are some of the most marginalised,
and complex needs may not always be recognised, is
vulnerable and health-deprived population groups in
regarded to be a major factor in rehabilitation
any community.
and recovery.
1
Balancing Act, published by Revolving Doors Agency 2013
2
As 1
3
he Lammy Review: An independent review into the treatment of, and outcomes for, Black, Asian and Minority Ethnic individuals in the Criminal Justice System,
T
September 201714 Integrated Health and Justice Strategy 15
The Public Health Engand CAPRICORN framework, showing the interaction between risk and protective
factors for children and young people
Addressing the root causes
Strengthen
Promote good communities
mental health – building on
community
Upstream Prevention Prevent drug assets Prioritise looked
to prevent youth violence and alcohol after children
and offending problems
unities and soci
mm ety
Prevent violence
Co Early indentification
and exploritation and support for
neurodisability
• Give the best start in life
• Promote stable environments
• Support nurturing and responsive
attachment relationships
Promote inclusive • Reduce sources of stress Reduce povety,
schools and • Strengthen core life skills and build deprivation and
System wide approach
ensure exclusion aspiration and resillience address wider
is used as a last determinants of
resort health
Individuals and families
Trauma
Access to
informed
• Peer mentoring housing
services
• Family level interventions
• Building life skills
CASE STUDY:
Nurturing Support for Victims of Violence
environments Employment
y Co support An individual was referred to the Women’s Centre by her Offender Manager after receiving a community
et mm
unities and soci sentence for assault. At this point, her children had been taken into care. In addition to managing her
probation, the Centre identified that she needed support with several areas, including substance misuse,
Downstream prevention Identify and Liason and financial problems and relationship issues. Together, these factors had given her the unstable lifestyle that
to reduce youth support children diversion
re-offending at risk Support to
had led to the assault.
Support
access the right
identified health
education and The Women’s Centre worked with her to address her most immediate needs. This included:
needs
training
• Working to help her maintain her tenancy, avoiding potential homelessness
• P
roviding her with advice, support and advocacy regarding how social services were working with
Transforming lives
her children
• Supporting her to access donations from a local food bank
• L
iaising with probation staff to help her understand how to avoid breaching her Community Order (which
The following graphic showing the Public Health more likely to be seen in a healthcare or social care may have resulted in prison)
England CAPRICORN framework4 demonstrates the context, so for many victims the route to accessing • Supporting her into drug and alcohol services to help her stop misusing substances
interaction between risk and protective factors for help and support is typically outside of the criminal • Providing her with support to stop self-harming.
offending in children and young people. justice system. Existing examples of this in Greater
Manchester include the independent domestic and It took some time to build a trusting relationship with the woman. After a period of disengagement, she
In the case of victims of interpersonal violence or returned to the service, disclosing that she was suffering domestic violence, and was traumatised by
sexual violence advocates and the GP-based IRIS
harm, there is an opportunity to improve identification an abusive childhood. Her disclosure became possible because her lifestyle had become more settled,
domestic abuse referral programme. Further details of
and specialist support, initially through mainstream including having suitable accommodation. She also stopped abusing substances, and her drug and alcohol
existing health and justice programmes are set out
health and care provision. Victims of violence, including worker agreed that she seemed to have given up for good. She also became more aware of the coercive
on p36.
domestic abuse and sexual abuse or exploitation, are nature of some of her relationships.
Through ongoing work with health and justice professionals over several months, and in particular with the
support of her key worker, the woman was able to have more positive discussions with social care regarding
her children, increasing her access to them with a view to them returning to her full-time care.
4
Public Health England (PHE) Collaborative approaches to preventing offending and re-offending in children (CAPRICORN): A resource for local health & justice
system leaders to support collaborative working for children and young people with complex needs, published July 201916 Integrated Health and Justice Strategy 17
A focus on health and social care needs in a criminal justice context justice therefore has the potential to: Risk factors associated with contact
with the criminal justice system
The risk factors associated with offending behaviour
and victimhood range from individual, relationship and
situational factors – such as race, gender, relationship/
parenting styles, exposure to substance misuse, being
a refugee or asylum seeker – to wider social norms,
Increase identification of people Improve the health, wellbeing and resilience of people seen in
inequalities and determinants, including access to
affected by interpersonal violence the health and justice context, including their sense of safety
education, secure housing and work.
or abuse and security
However, the evidence suggests that some risk factors
may have a more pronounced effect by inherently
increasing vulnerability to violent crime, offending and
being a victim of abuse.
These risk factors include CASE STUDY:
• a
dverse childhood experiences Adverse Childhood Experiences
• m
ental health issues and psychological trauma A vulnerable 8-year-old child, who was living in a
• h
aving a learning disability, autism or a household where there was frequent domestic
Create an awareness that offending and victimhood
Reduce health inequalities in abuse, arrived at a new school. It wasn’t long
can be markers of poor psychological and physical health communication disorder.5
a locality before he began displaying some extremely
and wellbeing Whilst multiple factors combined may increase the violent and disturbing behaviour towards
risk of entering the criminal justice system, including other pupils and staff. The school is a trauma
factors commonly associated with socio-economic informed school. Trauma informed practice
disadvantage and social exclusion e.g. homelessness, is a cornerstone of the approach set out in
unemployment, some factors may also create a context this strategy. Instead of approaching the child
in which the risk of violence or harm is normalised e.g. with traditional sanctions for disruptive and
trans-generational family violence or abuse. threatening behaviour, the child was supported
These risk factors apply to children and young people with interventions that recognise the effects of
Reduce the risks associated with offending or becoming a Reduce offending and as well as adults, but in the case of children and young adverse childhood experiences (ACEs). The child
victim of violence or harm reoffending rates people, exposure to multiple adverse childhood events was allocated a 1-1 worker and also given access
can significantly impact upon child development – to a ‘calm room’.
neurologically, psychologically and in terms of health- Accompanied by some 1-1 therapeutic support
related behaviours – and increases vulnerability to both this meant that the child’s disruptive and often
victimhood and offending.6 violent episodes at school reduced from around
The associated opportunity is to
use this strategy to reinforce and 6 per month to nil, over the course of 6 months.
Responding to the risks This didn’t just support the child, but also
enhance a shared understanding of
the interaction of complex risk factors Many of the strategic interventions recommended by prevented the disruption of other pupils at the
that can lead to acts of crime and the World Health Organisation (WHO) (see page 22) school, allowing the focus to remain on learning
exploitation or becoming a victim of focus on protective factors or provision which evidence and education. Without these intensive trauma-
it, and, develop a more attuned and suggests may mitigate some of these risk factors. informed interventions, it is likely that the child
integrated public service and VCSE would have been permanently excluded, at
Public Health England7 (see page 14) also emphasises
response to addressing and mitigating significant cost to both the child and the school.
the value of individual, family and social protective
the effects of those risk factors. factors for vulnerable children and young people.
The following case studies from existing services in
Greater Manchester, and further examples throughout
the strategy, exemplify effective responses to various
presenting risk factors.
5
Mental health and learning disabilities are both highlighted in the 2009 Bradley Report: Lord Bradley’s review of people with mental health problems or learning
disabilities in the criminal justice system
6
As 4 – Public Health England (PHE) Collaborative approaches to preventing offending and re-offending in children (CAPRICORN): A resource for local health &
justice system leaders to support collaborative working for children and young people with complex needs, published July 2019
7
As 618 Integrated Health and Justice Strategy 19
National and international policy and evidence
The national context for health and justice
In the UK over the period 2013-14, a series of structural and mental health, who commonly engage in
and policy changes took effect in the delivery of local high-risk behaviours and whose needs are often
and national public health provision, the rehabilitation multiple and complex.
of offenders and the National Probation Service.
In the intervening period since the publication of
Public Health England (PHE), The Probation Chiefs Balancing Act, the Revolving Doors Agency has
Association (PCA) and the Revolving Doors Agency (a published Rebalancing Act in January 2017. The
specialist national charity) responded to these changes primary message of Rebalancing Act is that a whole-
by collaborating to produce a briefing paper called system, integrated response is the only solution to
Balancing Act: addressing health inequalities among supporting people with multiple, complex health and
people in contact with the criminal justice system. social needs and circumstances, and that addressing
people’s needs in this way will give rise to wider social
The briefing highlighted that male and female
and community benefit – what they refer to as a
offenders and ex-offenders are an often-overlooked
‘community dividend’.8
group who disproportionately experience poor physical
Benefits of the Community Dividend
Improved health Reduced offending
= reduced costs = reduced cost to
to NHS law enforcement
Community
Dividend
Supporting
Lower crime rates rehabilitation =
= improved increasing levels
community safety of productive activity
and social cohesion
One example of this is breaking the pattern of often include coercive and/or physically abusive
offending, abuse or psychological trauma that can relationships.
sometimes be ‘passed’ between generations of
However, Rebalancing Act acknowledges that working
the same family e.g. domestic abuse reducing the
in the arena of health inequalities with people who
likelihood of poor mental health amongst wider family
often have complex and multiple health, care and
members, supporting effective parenting and caring,
social needs is challenging. Whilst our understanding
meaning that children are less likely to become ‘looked
of the characteristics and needs of this population
after’ by the state due to concerns about safeguarding.
group is improving, our understanding of what works
An example of this in Greater Manchester is the
to reduce the health and social inequalities they
success of the Women’s Support Alliance in reducing
experience is less well-developed.
offending rates amongst women offenders, by tackling
the issues that have contributed to offending which
8
Diagram courtesy of PHE20 Integrated Health and Justice Strategy 21
Health care in the criminal justice system
NHS England also published its Strategic direction Following on from this, NHS England then published
for health services in the justice system: 2016-2020, its Strategic direction for sexual assault and abuse
covering the provision of care for men and women in all services – Lifelong care for victims and survivors:
custodial settings (pre-, during and post-custody). The 2018-2023, which highlights:
strategic priorities include:
• S
trengthening the approach to prevention
• A radical upgrade in early intervention • P
romoting safeguarding and the safety, protection
• A
decisive shift towards person-centred care that and welfare of victims and survivors
provides the right treatment and support • I nvolving victims and survivors in the development
• S
trengthening the voice and involvement of those and improvement of services
with lived experience • I ntroducing consistent quality standards
• S
upporting rehabilitation and the move to a pathway • D
riving collaboration and reducing fragmentation
of recovery
• E
nsuring an appropriately trained workforce
• E
nsuring continuity of care, on reception and post
release, by bridging the divide between healthcare Most recently, the NHS Long Term Plan published in
services provided in justice, detained and community January 2019 reinforces the importance of access
settings to health and social care for the vulnerable young
• G
reater integration of services driven by better people and adults seen in the criminal justice system.
partnerships, collaboration and delivery It also makes specific references to national pilot
schemes including the Community Service Treatment Violence reduction as a public service and population health goal
Requirement (CSTR) programme and RECONNECT. The
CSTR enables courts to require people to participate The World Health Organisation has been advocating It has developed an ‘ecological framework’ as a way
in community treatment, instead of a custodial for better awareness about violence as a public health of understanding the factors that influence violence,
sentence, whilst RECONNECT is a care after custody issue, and the multiple effects of violence on health showing the interaction of multiple factors that can
service which works with people before they leave and wellbeing, since the publication of its first World lead to violent behaviour and it is regarded to be a
prison to assist the transition to health and social care report on violence and health in 2002. sound basis for understanding the issue.
community-based services.
These national strategies set out expectations for the
Factors that Influence Violence – World Health Organisation
way healthcare needs to evolve for offenders in custody
and victims and survivors. Similarly, this Greater
Societal Community Relationship Individual
Manchester Health and Justice Strategy creates a set
of priorities for improving access to health and care Rapid social change Poverty Poor parenting practices Victim of child
maltreatment
provision for offenders, ex-offenders and the victims Gender, social and economic High crime levels Marital discord
of abuse and sexual violence living in our Greater inequalities Psychological/personality
High residential mobility Violent parental conflict disorder
Manchester communities. As the work to develop the Poverty
strategy has progressed, it is clear that many of the High unemployment Low socioeconomic Alcohol/substance abuse
Weak economic safety nets household status
principles expressed in the national strategies are Local illicit drug trade History of violent behaviour
equally relevant to offenders, and victims of violence Poor rule of law Friends that engage in
and abuse, living in the city region. Situational factors violence
Cultural norms that support
violence22 Integrated Health and Justice Strategy 23
In 2010, WHO published a series of evidence briefings Strategy) that is characterised by a multi-agency The evidence-base for what works to support evidence and insight indicates that the style, aims and
on violence prevention, in which it advocated 7 main system response that is place-based, and which vulnerable and marginalised people whose needs responsiveness of support may be as important as the
strategic interventions, based on a review of the draws on public health thinking. It recommends five cut across health, care and the criminal justice focus of the intervention.
available international evidence. They are listed below components to successful serious violence prevention: system is still an emerging field in the UK, but current
with some examples.
• c
ollaboration
Some characteristics of positive support include10:
Public Health England has also developed a resource • c
o-production
to support the local system response to violent crime,
• c
o-operation in data and intelligence sharing, Non-judgemental and
which advocates a balance between prevention and
• c
ounter-narrative development person-centred
enforcement, and aligns with the evidence above.9
The resource outlines an approach to serious violence • c
ommunity consensus.
prevention (defined by the national Serious Violence
WHO strategic interventions Examples of practical support / services that show emerging Services need
Approaches that build
evidence of effectiveness to be dynamic and
self-confidence and
responsive to mirror the
agency
nature of recovery
Increasing safe, stable and nurturing Programmes that provide parental support and family
relationships between children and approaches / therapies which focus on attachment, family bonds
their parents and caregivers and healthy relationships often in the Early Years e.g. Family
Nurse Partnership, Triple P, Incredible Years Pre-school.
Multi-component approaches e.g. Multi-systemic therapy
(an intensive family therapy which addresses multiple issues)
Build in and expert
and Sure Start programmes are also thought to have a
‘relapse’ as part of the Eliminating stigma and
positive effect.
service delivery model as focusing on inclusion in
this is an integral part of society
Developing life skills in children Programmes that address life, social and emotional skills and the recovery process
and adolescents competencies e.g. Incredible Years Child / teacher programmes,
Training Promoting Alternative Thinking Strategies (PATHS).
Reducing availability and harmful Programmes that offer brief interventions and longer-term
Valuing the positive input of friends and also family,
use of alcohol treatment for problem drinking, including psychotherapeutic
supporting people to reconnect with social networks
interventions such as CBT. Reducing alcohol sales has also been
and form healthy relationships
linked to reducing violence.
Reducing access to guns, knives Programmes that directly target young people in gangs e.g. as in
Reducing serious violence (SVRU), which has been operating since 2006. Other
and pesticides USA and Glasgow.
UK regions, including the West Midlands Violence
Greater Manchester is one of several regions to have
Prevention Alliance and the Cardiff Model for Violence
Promoting gender equality School-based programmes that address gender norms and adopted a public health informed approach to violence
Prevention, have adopted approaches designed to
attitudes and issues of gender-based power and control. reduction and has recently established a Violence
understand and predict the prevalence, types and
Reduction Unit (VRU). This VRU is a dedicated, co-
causes of violence within a community and take steps
located, multi-agency team including representation
Changing cultural norms that Programmes that address dating violence and sexual violence to address those issues through co-ordinated multi-
from across policing, health, local authorities, schools
support violence amongst young people by challenging social and cultural norms. agency action.
and the voluntary sector. These partners will work
together to tackle violent crime and its underlying In developing its approach to violence reduction, the
Victim identification, care and Programmes that aim to identify victims e.g. through screening causes, by identifying the drivers of serious violence new Greater Manchester Serious Violence Action
support and referral, alongside interventions such as advocacy for locally and developing a coordinated response to Plan will be informed by the most up to date evidence
victims of violence e.g. IRIS domestic violence intervention, and tackle them. in the field and expertise in criminology, through a
psychosocial interventions which address psychological trauma. collaboration with Manchester Metropolitan University
Greater Manchester has modelled elements of its
(MMU) academics.
approach on the Scottish Violence Reduction Unit
9
Public Health England. A whole-system multi-agency approach to serious violence prevention: A resource for local system leaders in England, published October
2019 10
Based on Greater Manchester analysis of common themes drawn from multiple evidence sources used to develop the strategy24 Integrated Health and Justice Strategy 25
Additional insight from health and justice focused workshops
Several workshops were hosted as part of the Other service user feedback highlighted the following
stakeholder engagement for the development of the themes and issues:
strategy. Some of these were general, whilst others
• t he long lasting and devastating impact of domestic
focused on specific issues and groups, including
violence and abuse within families and a reluctance
children and young people, vulnerable and
to disclose it because of fear both of the perpetrator
marginalised women, and people with learning
and of children being taken into care
disabilities and autism.
• t he impact of domestic violence and abuse on
The feedback at the workshops reinforced many of the children and the need for services supporting
messages from the evidence above. Discussions at children to be trauma-informed
the children and young people’s engagement event in
• s
ervices in the right place, at the right time, for as
particular drew attention to the additional vulnerability
long as people need support
associated with having a learning disability, having
autism, and/or having difficulties communicating, and • t ransition points and their impact on individuals are
their presentation among young people in contact with often particularly difficult and require additional and
youth justice services. consistent support – including from primary to high
school, from children’s to adult social care, from
prison to community, from a home environment to
being looked after
Greater Manchester evidence and insight Acting on what we know
Based on this Greater Manchester-specific evidence,
Local research and reinforced by wider national and international
Understanding the health and social care needs of the They are: sources, this first integrated health and justice strategy
offender population and the victims of violence and for Greater Manchester has a strong focus on the
• A
Health Needs Assessment of the population served groups of people in our communities who appear to be
abuse in depth is a relatively new arena of public policy
by the St Mary’s Sexual Advice and Referral Centre at an increased risk of violent crime and abuse.
and service delivery for public health and criminal
(SARC), which summarises the characteristics and
justice teams, but the same principles apply as for This might be because of characteristics or
needs of the people who have used the service, in
other population health work: circumstances which seem to increase vulnerability to
particular multiple attendances
• understand the needs of the population of interest; criminality or victimhood, such as race, gender, having
• T
he Voice of Survivors Research: Hearing Women for
a learning disability/autism/communication issue, and
• identify health-related risk factors and their causes; Change – conducted by MMU, MASH and Manchester
rough-sleeping.
and Rape Crisis
• intervene in ways that reduce the exposure to or Alternately, it could be because evidence and insight
All four documents are available separately and a
offer protection from the detrimental effects of suggests that intervening earlier to reduce the risks
collated summary of their main insights has fed into
those risk factors. associated with offending behaviour is the most
the development of this strategy.
effective approach e.g. focusing on identifying and
Work has already been completed that will support Overall, local insight and research is consistent supporting potentially vulnerable children and young
the development of this strategy and advance our with national and international findings. These people and addressing underlying problems as early
understanding of the needs and characteristics of point towards a range of complex often interrelated as possible, such as trauma or hidden mental health
people in contact with the criminal justice system in factors that increase an individual’s vulnerability to issues.
Greater Manchester. These include: contact with the criminal justice system, including
• A
Greater Manchester Criminal Justice System poor physical and mental health, and lifestyle factors
Health Needs Assessment (CJS HNA) (2018) including smoking, drug and alcohol use, alongside
previous life experiences which may have been
• A
n independent Health and Criminal Justice
traumatic or challenging.
Strategic Commissioning Review (2018)
There are also a number of pieces of victim-focused
research and insight which have been undertaken
by Greater Manchester partners working to support
victims of domestic and sexual violence which inform
this strategy.26 Integrated Health and Justice Strategy 27
Benefits of violence reduction in human and system costs 2. Whole-system leadership for health and justice
The World Health Organisation reports that although In Rebalancing Act, The Revolving Doors Agency Our one system approach Our strategy aims
the economic case for a focus on interpersonal also put forward the concept of a ‘community
This strategy will be delivered by a wide variety of In considering what is needed to create an environment
violence prevention isn’t currently well-developed11, dividend’ which points to the wider societal benefits
public service partners in the statutory and VCSE in which colleagues are informed, equipped and
“the provision of treatment, mental health services, of addressing the health inequalities associated with
sectors and the implementation of the strategy supported to improve practice, the aims of the strategy
emergency care and criminal justice responses are crime, violence and offending, because of the extended
will reinforce and complement a series of existing are to:
some of the direct costs associated with violence.” impact on the families and communities who surround
Greater Manchester-wide programmes, including
and support offenders and victims. • H
ighlight the risk factors, health vulnerabilities and
The need for additional and sometimes intensive programmes in support of:
health inequalities experienced by offenders,
support from public and voluntary services including “The community dividend model suggests that by
• Gender based abuse and domestic violence ex-offenders and the victims of personal violence
health, social care and criminal justice services, for addressing the health needs of those in contact with
both victims of violence and offenders, is self-evident the criminal justice system there can be positive • Serious Violence Action Plan • P
rovide clarity on the existing evidence base (and its
but largely unquantifiable. effects on the wider population. People in prison or • Learning disability limitations)
those in their friendship, family and social networks • Autism • A
dvocate for the introduction of trauma-informed
Individuals, and their families, bear the most serious
also disproportionately experience wider societal health practices proportionately across the workforce which
consequences of interpersonal violence including • Mental health, including suicide prevention
and social inequalities – they often come from under- emphasise the strong association between adverse
sometimes life-long effects on behaviour and health, • Substance misuse
served populations and return to those communities childhood and life experiences and victimhood/
including:12 • Homelessness
when their immediate involvement in the criminal offending – and collaboratively identify the resources
• A
cute physical injury or disability: Lacerations, justice system has ended. Therefore, meeting the to deliver high-quality workforce development
Alignment and integration with other Greater
fractures, brain or major organ injury, burn and scalds. health needs of people in contact with the criminal • I nform integrated, whole system public health
Manchester-wide strategies will be essential to
• M
ental health and behavioural effects Alcohol and justice system can help to achieve reductions in crime, approaches to violence reduction with an emphasis
achieving improvements in the field of health and
drug abuse, depression and anxiety, post-traumatic reduce offending and improve the individual’s health.”13 on early help, early in life and stimulate Greater
justice. These programmes of work include:
stress disorder, suicidal thoughts or behaviour, eating Manchester partners to work towards delivering
• The Greater Manchester Children’s Plan
and sleep disorders, smoking, unsafe sex this collaboratively
• T
he Children and Young People’s Health and
• C
reate a clear account of ‘health and justice’ for
• S
exual and reproductive effects: Unintended Wellbeing Framework
mainstream health, care and criminal justice
pregnancy, pregnancy complications, gynaecological • T
he Greater Manchester Mental Health in Education services, using and sharing data and intelligence, so
disorders, chronic pelvic pain, HIV and other sexually (MHiE) programme that vulnerable and marginalised people are better
transmitted infections
• T
he ‘A Bed Every Night’ scheme and the Housing identified and appropriately supported
• C
hronic disease: Arthritis and asthma, cancer, First Greater Manchester regional pilot • A
cknowledge the complexity of working where
cardiovascular diseases, diabetes, kidney problems, • T
he Justice and Rehabilitation Devolution health and justice issues intersect and explore with
liver disease memorandum of understanding localities and partners how to develop and share best
• T
he White Paper on Unified Public Services for the practice across Greater Manchester and learn from
People of Greater Manchester each other, in the short and medium term
• S
tanding Together – The Police and Crime Plan • U
nderstand how current organisational practices
and processes may need to change to facilitate
• O
ur People, Our Place – the Greater Manchester
more effective early identification and intervention of
Strategy
vulnerable children, young people and adults, within
Along with identifying what we plan to do differently organisations and between them e.g. assessment
in Greater Manchester to reduce health inequalities and referral practices
and improve life chances for victims and offenders, • E
mphasise collaboration amongst commissioners
the strategy also sets out how the conditions will be and providers in order to improve the accessibility
created for professionals and practitioners to improve and quality of support for this population group.
what they currently do and the way they do it.
11
WHO Global Status Report on Violence Prevention (2014)
12
Based on findings of WHO Global Status Report on Violence Prevention (2014)
13
Rebalancing Act 2017, p. 1228 Integrated Health and Justice Strategy 29
A whole-system approach In Greater Manchester, the principles of Family Justice – and in some instances this is already the case.
are well-aligned with the broader ambitions set out in Colleagues from the Centre for Mental Health were
to Family Justice our approach to unify public services within a single, asked to review emergent place-based initiatives
coherent and effective model.15 More specifically, already being delivered in Greater Manchester and
Family Justice is a branch of the Health and Justice integrated, place-based teams working within some found that they demonstrated “the ready capacity to
agenda which pursues the provision of integrated of Greater Manchester’s neighbourhoods present an deliver” on the principles of Family Justice.
support for vulnerable families engaged in the criminal opportunity to deliver a Family Justice approach
justice system. Its purpose is to ensure that services
make decisions together which promote the holistic
Unified Public Services in GM
wellbeing of the whole family.
The internationally recognised principles of Family
Justice are: Information is shared between agencies safely
Directed by one public service leadership team. to support effective delivery and identifying those
• S
afety focused: Increase safety, promote healing, most at risk.
and foster empowerment through services for
victims and their children
• V
ictim-centred: Provide victim-centred services that Working as one public service workforce, with
promote victim autonomy A single commissioning function for the locality. redesigned roles and shared Job Descriptions
across organisations.
• S
urvivor-driven: Shape services to clients by asking
them what they need
CASE STUDY: • R
elationship-based: Maintain close working Universal services, like schools and GPs,
A Place-Based Approach to relationships among all collaborators/agencies
are cornerstones of public services in their The VCSE sector are part of the fabric of public
communities and are connected with other services. Public services are delivered with local
Supporting Families public services through integrated citizens, communities businesses.
• O
ffender-accountability: Increase offender
neighbourhood functions.
A place-based team in Holts and Lees draw on accountability through evidence-based prosecution
support from probation services. This provides an strategies and/or evidence-based treatment One integrated neighbourhood function for
enhanced way of working with ex-offenders and programs each geographic footprint (30-50k). Frontline
their families in a local setting. In one particular • T
ransformative: Evaluate and adjust services by
practitioners, pulling on specialist support.
example, the probation worker was aware that it including survivor input and evidence based best • Care coordinators/navigators
was highly likely one of her clients would receive practices • Community safety advisors
a custodial sentence of up to 6 months. • CRC workers
• C
ulturally competent: Commitment to the utilisation • District nurses
This offender expressed concern about the of culturally competent services • Early years workers
impact his time in prison would have on his • E
mpowered: Offer survivors a place to belong even A single function
• Environmental health officers
Integrated specialist • Family support workers
family and home, as he was the sole tenant for after crisis intervention services are no longer /acute services
for triage, assessment,
tasking and • Focused care workers
his two-bedroom property, as well as the main necessary for the most
coordination across
complex and costly • Health visitors
claimant for all their benefits. The probation all cohorts • Housing officers
• K
ind-hearted: Develop an approach that values,
worker brokered a relationship with the place- • Key workers/early help workers
affirms, recognises and supports staff, volunteers,
based team who supported the offender to • Mental health practitioners
and clients.14 • Neighbourhood beat officers
complete a deed of assignment to put the
• Neighbourhood/community safety officers
tenancy in joint names and, once sentenced, a
• Pharmacists
local support worker was immediately available • Police community support officers
to support his girlfriend to apply for welfare • Social workers
benefits in her own right. The team also offered • Substance misuse workers
ongoing support to the family whilst the offender • VCSE sector workers and volunteers
completed his five-month sentence.
When released from prison, the offender stated
to the probation worker that for the first time he
felt he was being released into a more stable
environment where historically his life would
have been much more chaotic. He wanted to
stop offending, and he stated that a more stable
home life would help him to do this.
14
EFJCA, ‘About the Family Justice Centers’, https://www.efjca.eu/centers 15
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