1. www.phrn.nhs.uk IDTS Leads Perception of Implementing IDTS The First Stage of the Evaluation of IDTS Sharon McDonnell

2. www.phrn.nhs.uk Research Team Professor Jenny Shaw Dr. Jane Senior Dr. Sharon McDonnell Centre for Suicide Prevention University of Manchester Funded by the Department of Health, Offender Health The report will be available on the PHRN website.

3. www.phrn.nhs.uk What is IDTS?  IDTS is an acronym for Integrated Drug Treatment System.  A new initiative that aims to radically improve the clinical and psychosocial services offered to substance misusers within prisons.  Particular emphasis on early custody.

4. www.phrn.nhs.uk Background Prison clinical drug services have often been:  under-resourced.  unable to provide adequate clinical treatment practices. Specifically  substitute prescribing  incorporating maintenance.

5. www.phrn.nhs.uk Background Many prisons have had poor links between:  Prison clinical services.  CARATS (Counselling, Assessment, Referral Advice and Throughcare).  Substance misuse services within the community.

6. www.phrn.nhs.uk Aim of IDTS To expand the quantity and quality of drug treatment options within prison establishments.  Substitute prescribing. To provide more effective and needs based treat- ment within prisons.

7. www.phrn.nhs.uk Aim of IDTS Improve the continuity of care for substance misusers  within prison establishments  entering/moving between prisons and  on release. Best achieved  Integration of prison clinical and CARAT services.

8. www.phrn.nhs.uk What is IDTS? An integrated drug treatment system (IDTS).  Enhanced clinical treatment (Health care)  Psychosocial intervention (CARATS) Prisoners who arrive at reception who are substance dependent.

9. www.phrn.nhs.uk Main Aim: Enhanced Clinical Treatment  Improve clinical management of substance misuse within prisons – resulting in an increase in levels of methadone maintenance prescribing.  A broader range of clinical responses to drug dependence, such as extended opiate detoxification.

10. www.phrn.nhs.uk Main Aim: Psychosocial Intervention 28 day structured care package of psychosocial support  Complements enhanced clinical treatment.  Takes into account previous treatment in the community or custody. and  Provides a platform for longer-term drug treatment in prison and on release.

11. www.phrn.nhs.uk First wave of Prisons 46 prisons implementing IDTS.  29 enhanced clinical treatment  17 enhanced clinical treatment and psychosocial aspect of IDTS.

12. www.phrn.nhs.uk Aims of Study  Identify the key steps in the first wave of implementation of IDTS.  Inform the next implementation phase.  Identify the specification for full IDTS research evaluation.

13. www.phrn.nhs.uk Aim of the Presentation  Describe the IDTS leads experience of preparing to implement IDTS. Highlight  The difficulties experienced by prisons preparing to implement IDTS.  The perceived problems once IDTS is implemented.  Suggest how the next wave of prisons could implement IDTS more effectively.

14. www.phrn.nhs.uk Methodology Inclusion criteria  All prisons (n = 46) implementing IDTS enhanced clinical services n=29 clinical and psychosocial services n=17 Sample  n = 38 prisons (83% of first wave prisons) enhanced clinical services n=24 clinical and psychosocial services n=14

15. www.phrn.nhs.uk Methodology  IDTS leads from each prison participated in a semi- structured telephone interviews.  Interviews conducted June - Oct 2007 (proposed date they would go live 1 st Oct).  To ensure anonymity none of the prisons are identifiable in the study.  Mixed methods - Thematic analysis and descriptive statistics.

16. www.phrn.nhs.uk Interview Schedule  The leads perception of IDTS.  The perceived level of support/guidance received.  Key obstacles that have delayed implementation and how they have been overcome.  The extent to which IDTS has been/will be implemented.

17. www.phrn.nhs.uk Interview Schedule  Their perceived difficulties when IDTS is implemented.  Identify how the second wave of prisons could implement IDTS more effectively.

18. www.phrn.nhs.uk Placing the time frame into context Interviews were conducted  Transitional process (Prison healthcare services being devolved to PCTs).  The merging of Trusts.  Contractual issues (e.g. ‘Agenda for change’).

19. www.phrn.nhs.uk Positive Perception of IDTS ‘It’s brilliant.’ participant 32

20. www.phrn.nhs.uk Positive Perception of IDTS Missing link in treatment. Clinical solution to drug dependency. National standardised drug treatment within establishments. Enable prisoners to move around the prison estate more successfully. Reduce self harm, suicide and drug related fatalities during early release. First serious attempt to integrate services – beneficial for prisoners and staff.

21. www.phrn.nhs.uk Negative Perception of IDTS ‘They (0ffender Health) fail to realise 80,000 are in custody and the majority are substance misusers.’ participant 29

22. www.phrn.nhs.uk Negative Perception of IDTS  Bulldozed into implementing IDTS with little concern for the possible implications. Specifically  The clinical risk if not implemented correctly.  The unmet need of the current prison population.  The legal implications if these issues are not addressed.

23. www.phrn.nhs.uk IDTS Leads  The majority of IDTS leads are enthusiastic and highly motivated individuals.  Various backgrounds and disciplines. Prison healthcare n = 22 Discipline staff n = 10 External agencies n = 4 PCT IDTS lead n = 2  Knowledge about substance misuse varied dramatically.

24. www.phrn.nhs.uk IDTS Lead Huge variation in protected time to implement IDTS  14 (37%) employed full time IDTS Leads.  24 (63%) had additional responsibilities. Extreme cases  6 were expected to implement IDTS, in addition to their normal workload.

25. www.phrn.nhs.uk IDTS Leads  20 (53%) leads felt they had not been given enough time to implement IDTS.  29 (76%) leads encountered major obstacles.  Many felt that they lacked authority/seniority to deal with some of these problems.

26. www.phrn.nhs.uk IDTS leads Specific Tasks Required to oversee and manage all aspects of implementation  Structural work to implement IDTS.  Implementing a major policy which encroaches on many aspects of a prison regime.  Apply for additional funding.  Managing budgets.

27. www.phrn.nhs.uk IDTS leads Specific Tasks  Write protocols.  Communicating/liaising with senior prison staff and outside agencies (e.g. PCTs, steering committees).  Encourage integration between CARATS and healthcare staff.  Recruitment of staff.

28. www.phrn.nhs.uk Findings Suggest IDTS Leads not only need an understanding of substance misuse but also require effective  Management  Leadership  Problem solving  Communication skills To deal with the multi-faceted problems they might encounter.

29. www.phrn.nhs.uk Interviews conducted in the following prisons Male Female Young offenders Contracted out Public Local Training Open prisons

30. www.phrn.nhs.uk Type of Prison

31. www.phrn.nhs.uk Local Prisons Main Concerns  Training prisons will not be ready – creating a bottle neck.  Unable to receive prisoners from court due to this bottleneck.  Overwhelmed by demand.

32. www.phrn.nhs.uk Training Prisons Main Concerns  They might receive unstable prisoners from the local prison.  Safety issues – working with heavy machinery.  An increase in bullying.  Healthcare staff lack of knowledge about substance misuse.

33. www.phrn.nhs.uk Contracted out Prisons Main Concerns  Difficulties acquiring funding from the Home Office.  Risk of overspend as money not released – unable to recruit or send staff on training.

34. www.phrn.nhs.uk Young Offenders Main Concern  Question whether IDTS is suitable for young offenders.  Suggest that focus should be on abstinence not methadone maintenance.

35. www.phrn.nhs.uk 6 Themes Associated With Implementing IDTS MAIN THEMES SUB-THEMES Fundamental Problems Lack of/or no space. And/or Buildings not fit for purpose Lack of funding to provide appropriate facilities. Combined Difficulties managing the prison population. Operational Issues Finances Estates Regime

36. www.phrn.nhs.uk Themes Associated With Implementing IDTS MAIN THEMES SUB-THEMES Communication Guidance on implementing IDTS Support Lack of communication. Staff-Related Issues Recruitment Training Negative attitudes

37. www.phrn.nhs.uk Themes Associated With Implementing IDTS MAIN THEMES SUB-THEMES Major Concerns Protocols Capping Legal implications PCTs Risk factors Ethical Issues Confidentiality Standard of care

38. www.phrn.nhs.uk Theme 1 Fundamental Problems Physical Environment Lack of/or no space. And/or Buildings not fit for purpose. Lack of funding to provide appropriate facilities. Combined Difficulties managing the prison population.

39. www.phrn.nhs.uk Theme 2 Operational Issues Finances  Inaccurate costing for IDTS.  PCTs/Home Office Regime  Movement of prisoners  Key performance targets

40. www.phrn.nhs.uk Theme 3 Communication Support  The majority of leads felt inadequately supported. ● Regional steering committee ● Local implementation groups ● PCTs

41. www.phrn.nhs.uk Theme 3 Communication Guidance on implementing IDTS  Felt bombarded with paperwork. Lack of Communication  Between healthcare and discipline staff.

42. www.phrn.nhs.uk Theme 4 Staff-Related Issues Recruitment  Difficulties accessing IDTS funds (e.g. PCTs).  Difficulties recruiting staff. Training  Unable to train staff if they have not been recruited!  Locality of IDTS courses an issue.

43. www.phrn.nhs.uk Theme 4: Staff-Related Issues Negative attitudes towards IDTS  Two leads didn’t agree with IDTS, didn’t want to go on training or implement it.  Some CARAT staff believed that IDTS compromises them professionally.  Two nurses wanted to be conscientious objectors and refused to go on IDTS courses.

44. www.phrn.nhs.uk Theme 4 Staff-Related Issues Negative attitudes towards substance misusers  Some healthcare staff disliked caring for substance misusers.  Use negative terminology when referring to them such as ‘dickheads.’

45. www.phrn.nhs.uk Theme 5 Major Concerns 76% leads encountered major obstacles. The following issues created the most anxieties. ● IDTS Protocols ● Transfer of IDTS prisoners ● PCTs ● Capping of IDTS prisoners ● Legal implications

46. www.phrn.nhs.uk Theme 5 Major Concerns IDTS Protocols ‘It’s like keep re-inventing the wheel.’ Participant 5  Wanted standardised protocols whenever possible.  Some had no experience of writing protocols.  Difficult for those who have no knowledge of substance misuse.  Concerned about the legal implications if scrutinised.  Delays (3mths) waiting for outside agencies to sign protocols.

47. www.phrn.nhs.uk Theme 5 Major Concerns Capping of IDTS Prisoners ‘We (prison) don’t know what’s coming (demand for IDTS)’. Participant 18  71% (n=27) believe they will be overwhelmed by demand.  The majority leads feel every prison should be capped, especially when they first go live.  Question whether Offender Health’s refusal to cap all prisons is safe practice.

48. www.phrn.nhs.uk Theme 5 Major Concerns Transfer of IDTS Prisoners ‘It’s a joke, we need transfer policies.’ participant 30  Problematic for prisons that cover a large area or feed to, or received prisoners from several other prisons.  Believe Offender Health should pay more attention to transfer issues as it could have serious implications if ignored.

49. www.phrn.nhs.uk Theme 5 Major Concerns Leads argued that transfers are necessary  To ensure establishments do not become over- whelmed by demand.  To prevent a bottle neck occurring.  To manage the numbers of IDTS prisoners transferred to establishments that are currently capped.  To ensure safe practice.

50. www.phrn.nhs.uk Theme 5 Major Concerns Legal Implications  Possible lack of consistency and continuity of IDTS care across establishments.  Little attention to substance misusers who are already detained.

51. www.phrn.nhs.uk Theme 5 Major Concerns Primary Care Trusts (PCTs)  Leads difficulties accessing IDTS funding.  Created delays in recruiting and training staff.  Strained relationship between PCTs and IDTS leads.  Lack of understanding of prison establishments.

52. www.phrn.nhs.uk Theme 6 Ethical Issues  Confidentiality  The standard of care some substance misusers might receive in some establishments.  Lack of guidance for those already detained.

53. www.phrn.nhs.uk Limitations and Strengths of the Study Limitations  8 (17%) prisons did not participate in the study.  Their specific problems and needs might not be identified in study. Strengths  Provides a unique insight into how many PCTs currently relate with prison establishments whilst preparing to implement a major health policy.

54. www.phrn.nhs.uk Recommendations IDTS leads play a pivotal role in the implement- ation process. To ensure effective implementation it is necessary to: ● identify, ● acknowledge ● address their specific needs.

55. www.phrn.nhs.uk Recommendations IDTS Leads  Must be receptive to IDTS and its implementation.  They need protected time to implement IDTS.  They need appropriate authority or seniority to deal with senior staff and outside agencies.  They must have effective management, communication and leadership skills.  They should be given a realistic time-frame to implement it.

56. www.phrn.nhs.uk Recommendations Support  Steering committees and local implementation groups should provide the conditions whereby leads feel supported throughout the implementation process. Communication  Discipline staff should be informed about IDTS in an appropriate manner and at the earliest opportunity.

57. www.phrn.nhs.uk Recommendations Access to IDTS funding  The Home Office and PCTs should ensure that IDTS funding is more accessible to IDTS Leads. Recruitment and Training of Staff  Should commence at an earlier stage in the next wave of implementation.

58. www.phrn.nhs.uk Recommendations The need for Offender Health  To develop standardised protocols whenever possible.  To reconsider issues surrounding the capping of prisons.  To consider issues surrounding transfer of IDTS prisoners.

59. www.phrn.nhs.uk Putting the findings into context  The interviews were conducted prior to IDTS being implemented. Possible  Some of the leads concerns and anxieties might be unfounded. Emphasises the need to evaluate  The specific experiences and needs once IDTS has been implemented.

60. www.phrn.nhs.uk Conclusion Findings suggest  Prison establishments are embracing IDTS and the vision Offender Health has for the future development of prison healthcare.

61. www.phrn.nhs.uk Conclusion Ensuring that the vision becomes reality requires:  Effective communication between IDTS leads, PCTs and Offender Health.  Critically evaluate all aspects of the implementation process.  The ability to learn from mistakes (i.e. prisons, PCTs Offender Health).  A sense of openness to amendments throughout whole process of implementation.