As far back as 1992, the Reed Report into the care of mentally disordered offenders identified the need for close working between the Police, Health and Social Services and set out some clear principles for offenders with learning disabilities which called for a individually tailored approach with care and treatment provided in the community, close to home and existing support networks.
These principles were underlined in the work of the Bradley committee whose 2009 report made a number of recommendations for early identification, clear referral protocols, better training and community-based treatment for those at risk.
Last month, the Royal College of Psychiatrists published a faculty report which set out to describe the way in which people with learning disabilities interact with the criminal justice system and to make recommendations about developing skills and improving pathways.
Interestingly, the report spends some time on the potential confusion of terminology. The term ‘intellectual disabilities’ has become the term used in academic and clinical research and is recognised internationally (see for example IASSID), but is used interchangeably at service level with the term ‘learning disabilities’. These terms are defined very clearly as a significant impairment of intellectual functioning, a significant impairment of social functioning and that these impairments have been present from childhood. They draw a very clear distinction between this and the term ‘learning difficulties’, which is used by the Department for Education in the UK, and is used to cover issues like dyslexia, dyspraxia, speech, language and communication problems etc. There is further confusion caused by the fact that in the USA, the term ‘learning disabilities’ is used for this rather than ‘learning difficulties’.
This terminological confusion is relevant here because it impacts on research into prevalence and also means that there can be confusion for criminal justice system workers and adds one more layer of difficulty to the already complex joint working arrangements.
The authors also explore the problematic nature of the term ‘offending behaviour’ as English law defines a crime as both the act and the intent to commit, and it is this intent which is most contentious when considering people with learning disabilities. This can mean difference of perception between what might be seen as challenging behaviour or criminal behaviour and may also influence decisions by police over whether caution or to arrest and convict.
The authors point out that a person with moderate to severe learning disability may be unlikely to be dealt with through the criminal justice system, but that this becomes much less clear for people with mild learning disability, decisions related to reporting and police involvement, it is then for the Crown Prosecution Service to decide whether or not to prosecute, based on a perceived likelihood of conviction and the public interest of pursuing the case.
The authors describe the potential pathways through the criminal justice system from index offence, pointing out the number of points at which decisions by professionals will send a person on one branch of the pathway or another. This shows quite clearly the number of points at which a clear understanding of mental health legislation is required as well as understanding of the roles of everybody concerned in both the health and criminal justice system.
The authors suggest that there have been a number of improvements in joint working between health and criminal justice professionals in recent years, but that at present, there is no clear joined-up approach between the criminal justice system and health and social care systems supporting people with learning disabilities. They bemoan the lack of comprehensive training programmes for staff around, awareness, identification and liaison work when compared to arrangements in the mental health sector.
The authors point out that few programmes designed to address recidivism within prison or probation services are accessible for people with a learning disability, and that offenders with learning disability admitted to mainstream forensic units may be excluded from treatment programmes because the content is not delivered at an appropriate developmental and intellectual level.
Joint working They argue for a much closer joint working relationship, suggesting that learning disability services have as yet, not been party to collaborative arrangements that have begun to be set up between mental health and criminal justice services. Whilst there are some examples of diversion from courts, it is described as an exception rather than a rule, and not always for constructive and positive reasons.
The report makes 29 recommendations, which cover a range of issues, including:
- The development of national standards on health and social care provision for offenders with learning disability and a greater clarity of terminology
- The development of multi-agency strategic planning groups leading to better access for courts, probation services etc. to community forensic learning disability teams and/or specialist support.
- Learning disability awareness training for police officers and custody suite staff, members of the judiciary and probation service
- Access for all courts to a diversion scheme
- The role and training for learning disability psychiatry in terms of court reporting, support to courts around disposal options and recommendations to the court on necessary adaptations to the court process.
- Adaptation to approaches to substances misuse, sex offender treatment, fire-setting and violent offending in collaboration with mainstream services
- Reception screening in prisons for learning disability and links developed between prison healthcare providers and local community learning disability teams
- Support for the commissioning of a range of in-patient and community services to support care in the least restrictive setting, as near as possible to the home area of the person concerned.
- Continuation of the active collection of data on the number of offenders with learning disability in order to support service planning and commissioning.
- Support to the research agenda by creating clear descriptions of the nature of treatments with the development of a common data-set of short-term and long-term outcomes to be collected through a nationwide audit.
- Better information on costs of placements to be used to identify predictors of length of hospital stay and successful treatment outcomes.
Conclusion and comment
The report is a major contribution to the thinking around support for offenders with learning disabilities. The authors contribute to the clarification of the debate around terminology and set out very clearly the pathways and potential points of contact between health and social care and the criminal justice service agencies.
In the foreword, the faculty chair points out that this report may be of use to commissioners of forensic learning disability services, particularly if they need to be briefed in a short period of time and this report does contain a good deal of relevant and useful information for that purpose. It may have been interesting however to have reflected in the report on any consultation with commissioners about what information they may feel would be useful in supporting their task.
Department of Health, Home Office (1992) Review of Health and Social Services for Mentally Disordered Offenders and Others Requiring Similar Services. HMSO. (Reed Report)
Department of Health (2009a) Lord Bradley’s Review of People with Mental Health Problems or Learning Disabilities in the Criminal Justice System. Department of Health.
Forensic care pathways for adults with intellectual disability involved with the criminal justice system, Faculty Report FR/ID/04, Royal College of Psychiatrists’ Faculty of Psychiatry of Intellectual Disability and Faculty of Forensic Psychiatry London