The next item of business is a one-off round-table evidence session on brain injury and the criminal justice system. I welcome participants to the meeting. This might be the first time that some of you have given evidence to a committee. The method is that you are the people who will be speaking and for once—you will love this—the politicians will be restrained and will, as far as they can, be silent. I really want the witnesses to interact with one another, but please indicate to me if you want to speak and I will call your name. I will let you know that I have got your name and I will let you know when you are to be the next person to speak. I hope that your microphone will come on automatically—the microphone operator will be on their toes—just as mine has. A red light will appear when it comes on—you do not need to press any buttons.
I am so glad that you have given up your time to be here. There are so many professors here that I am a bit inhibited—and it takes a bit to inhibit me. We have copies of the written submissions; thank you very much for those. They have been circulated, complete with an amended figure from Professor Williams.
I know that you will have been introduced to the people sitting next to you, but the best way to start is to invite each member and each participant to introduce themselves. It says in my brief that I should start with me. Well, I know who I am; the clerk does not need to keep reminding me. I am all right so far. I am Christine Grahame and I convene the committee.
I am the deputy convener of the committee.
I am from the Brain Injury Rehabilitation Trust.
I am a member of the Justice Committee.
I am from the Howard League society for penal reform in Scotland.
I am the MSP for North East Fife and a member of the Justice Committee.
I am a clinical neuropsychologist working in the national health service and am part of the division of neuropsychology.
Good morning. I am a member of the committee.
Good morning. I am an MSP for Highlands and Islands.
I knew that you would say, “Highlands and Islands”, John. Great—you never let me down. Next please.
I am from Police Scotland’s criminal justice division.
I am a consultant in neurorehabilitation in NHS Tayside.
I am MSP for Glasgow Kelvin and a member of the committee.
I am a consultant in neuropsychiatry in Edinburgh at the national brain injury unit. I am here as the lead clinician of the Scottish Acquired Brain Injury Network.
I am assistant director for health and care for the Scottish Prison Service.
I am an MSP for North East Scotland and member of the Justice Committee.
I am a clinical neuropsychologist and deputy chair of the policy unit of the division of neuropsychology.
I am MSP for Motherwell and Wishaw and a member of the Justice Committee.
I am professor of clinical neuropsychology at the University of Glasgow.
Thank you. As I said, the committee asks you to bring issues to our attention. We have an hour and a bit for the case to be made to the committee about the importance of the connections between brain injury and the criminal justice system, and how the system is letting people down, as we have seen.
So the first questions are: why are you here and why should we listen to you? Who wants to start?
I would be happy to go first.
Thank you, Professor Williams. You go for it.
The main point to be made is that there are a lot of neurodisabilities, or general brain injuries of various kinds, in people who end up in the prison system. Traumatic brain injuries that have been caused by falls, assaults or accidents tend to be a big factor, and there seems to be a high prevalence of brain injury in the numbers of people in prison systems. The trends in studies that we have conducted internationally indicate that the presence of brain injury is associated with problems in rehabilitation, so it tends to be associated with greater degrees of reoffending, greater problems in mental health, and more difficulties in engaging with treatments around mental health and resettlement. It is likely that addressing brain injury issues as a chronic health condition in that population might be beneficial in terms of reducing long-term costs by reducing crime and by reducing the number of victims of crime.
Does anyone else want to come in? I do not see anyone indicating that they do. Is the system letting people down?
My main clinical experience is in addictions medicine. I work in a court-mandated community-based drug treatment programme. In that context, I see a number of people and in that population, the statistics show that if you ask our clients, “Have you ever been hit hard enough on the head to be knocked out?” about 70-odd per cent will give a positive response.
However, there is a subset of those people who, when we quiz them further, turn out to have had significant levels of head injury. Some of them have had neurosurgical treatment. Some started off with some level of follow-up treatment and then dropped out, and some have never had any follow-up at all. Those folk do not seem to have been identified in the criminal justice system, but their injuries seem to impact on their ability to engage with rehabilitation and so on.
It is very difficult to get such people to a point at which they can be treated. For a start, one has to stabilise their drug use, which one can usually do to a fairly significant extent. However, even when we try to set up a referral pathway into a rehabilitation service to get people to that first appointment, and even if we get them to the first appointment where they can be assessed as needing further work, they tend not to go back. We see the same thing with blood-borne virus treatment. People present to the service, but as soon as we have to refer them outside that service, attendance rates plummet. We get people into blood-borne virus treatment by bringing that treatment into the clinic.
There is a pool of unmet need in people who have very significant head injuries whom we could serve better if we could use an outreach service that goes into criminal justice facilities.
I also highlight the link between brain injury, mental health and suicide rates. Although this is a discussion about criminal justice, the police often come into contact with suicidal individuals earlier than some of the other services. The point has been made about subsequent referral to services that can help individuals and thereby reduce the considerable longer-term cost to society.
If the committee members want to ask something, they can come in. Obviously the witnesses have priority, but if there is a silence, the politicians can step in. They know that.
I have a point to make in response to Dr Aldridge and Superintendent Allan. The big issue is that people who have the significant brain injuries that might be present in two or three in 10 will have cognitive problems. They do not remember things, they are impulsive, they lack foresight and so on, so they do not plan ahead well. They also lack insight into their problems and are not very aware of them. That is why, as Superintendent Allan pointed out, brain injury in the mix is a big risk factor when it comes to suicidality. We know that suicide is, unfortunately, a common occurrence after a brain injury.
We carried out a preliminary audit study in three prisons in the Glasgow area, linking medical records to the current prison population, and found that 23 per cent of the prisoners had at some point in their lives been admitted to hospital with a head injury. We looked at records going back to the 1980s and carried out the study in April. What was interesting was that a significant proportion had intracranial injuries, which suggests that they had had a severe head injury. About 50 per cent of those who had had a head injury had had a severe head injury. Normally, the epidemiology of head injuries is that 90 per cent would have been mild head injury and 10 per cent would have been severe. So, it looked at first sight as though a significant number of prisoners had had a severe head injury.
The other finding of note is that the epidemiology of head injury shows that there are peaks in children and young adults. In the group of older adults who were prisoners, a very high proportion of those with a severe head injury had their head injury before the age of 15; they had received the injury when their brain was continuing to form. The social brain continues to develop until about the age of 25, so they had a head injury relatively early in life.
I want to pick up on the point that Professor McMillan just made. In the papers that were helpfully circulated in advance, there was a lot of reference to childhood injuries. I wonder whether, given the philosophy of getting it right for every child, there is an issue about how that information is shared early on. Clearly, if a high percentage of people with criminal behaviour have had childhood head injuries, there is a percentage who have not. There is also a stigmatisation issue about a person’s having sustained an injury. I wonder whether there are opportunities to head the problem off in childhood before Superintendent Allan’s colleagues in the criminal justice system come to be involved.
If I can speak to that—
Before you do that, I say to Sandra White that she should not fret, because she is on my list after Elaine Murray. However, I also have Mr Gentleman on it and I will take him next, then let in the members on my list. You are on my pink list, Sandra, and you are on my yellow list, Professor Williams, just so you know that you are not being missed. Please just go ahead, Mr Gentleman.
I want to make two points that may not necessarily be obvious to everyone round the table. The first is that delivering services for brain-injured people, whether they are anything to do with the criminal justice system or not, requires quite a lot of individuals and agencies. Ideally, it should be done in a seamless way, but the reality is that it is very often not done in a seamless way, which is a challenge.
There is also a challenge when something happens—it might be another illness or admission to the prison system—that cuts the thread of continuity. It is then very often difficult for the individual to re-access services.
The other thing that is not particularly, or necessarily, obvious is that nine tenths of people who have had a significant brain injury—as Huw Williams said, it could affect their ability to think, reason, judge and so on—look entirely normal on the outside. They do not have a plaster on, use a wheelchair or have a badge of disability. At one level that is a very good thing for them, but at another level it is not. Often, the information that would allow professionals and other people who are involved in their care to deal with them in a different and perhaps better way does not flow with them. It is important to put that problem on the table, because head injury is an invisible disabling condition.
Does any other witness wish to come in on the continuity issue and how we might resolve it?
I definitely second what Douglas Gentleman said. Where assessments have been done, it has been seen that there is a problem with the flow of information. Even within the criminal justice system, we do not get information from any prison health assessments. We pass on the information that we gather to people’s general practitioners, but people frequently move around from one practice to another. Continuity of care is definitely an issue but it is not something that people tend to flag up unless we ask them specifically about their history; they often do not see the significance of it until we start to question them.
10:15
One issue is that young people who are admitted to hospital are often keen to return home, so even if services are offered, they do not always take them up. It can sometimes therefore be difficult to identify people and it can be difficult for them to take up services, even if they are available. There is also an issue about preventing people from developing an offending profile. There is a population in prisons who have not had support or intervention, and one of the biggest risk factors for having a head injury is already having had a head injury, which means that that population is potentially at risk of making the situation worse when they leave prison, including by further head injury.
My interest is similar to that which was expressed by John Finnie. I have the impression that head injury among children and young people might result in problems further down the line. I wonder whether more could be done on recording when young people have had a head injury and to raise awareness among teachers and others so that, when behaviours start to show later on, the link can be made before the behaviour gets as serious as offending or suicide, or before more severe mental health issues arise. Is there a problem regarding general awareness that could, if it were addressed, lead to problems for young people being picked up earlier?
That is an excellent point. Studies in New Zealand have shown that children who have a head injury around age five or six, even a relatively mild injury, tend to start to have problems in school within two or three years, because their attention and concentration are not so good. Within four or five years, they start to get excluded from schools for misbehaviour. They are twice as likely to end up drifting out of school and into crime. By the time they are 14 or 15, they start to get involved in impulsive kinds of crimes. We can track the problems and show that brain injuries in the young tend to lead to their falling out of school and into bad company. Such people are often used by gangs because they are suggestible.
The critical issue is to ensure that there are links between accident and emergency departments, general practitioners, schools and the people who have oversight of the management of kids going back into schools, in order to ensure that those kids get support to stay there and to enable them to learn in that environment rather than end up in the criminal justice system. One of our prison studies showed that adults with head injuries tended to be in prison from, on average, age 16, compared to age 21 among non-head-injured people. People who have a brain injury tend to be in prison from a much younger age, for longer and, increasingly, for more violent crimes.
I take on board John Finnie’s point that we want to stay away from stigmatising people because they have a brain injury. If people start to associate brain injury too much with necessarily ending up being involved in crime, the problem might be that people would not report it. We want people to be able to report a head injury and get help and support, which can lead to positive changes and allow people to reclaim their lives. We need to steer clearly away from stigmatising people, but the problem is that historically in society we have tended not to see head injury. As Mr Gentleman said, it is very often an invisible disability. The problem is that, in that darkness, people have not really seen the true issue.
I will touch on an issue that John Finnie and Elaine Murray mentioned, but I want to go back to an earlier stage. Some of the submissions talk about pre-birth and birth trauma. Can forceps birth and breech birth lead to brain injury? Have any studies been done on that and can it have an effect on people’s actions as they go through life?
There is the general idea of neurodisabilities, which can come from various sources—any form of impairment to the brain—and there is some work that refers to a markedly increased chance of pretty much every form of neurodisability among the offending population, particularly brain injury. The incidence of foetal alcohol syndrome, attention deficit hyperactivity disorder and other conditions would also be higher, so it is not just traumatic brain injury. Typically, there are comorbidities—other issues—but brain injury seems to have the biggest prevalence.
There is monitoring of newborns and in the early years of life so, if the injury happened before or around birth, there would normally be at least some safeguards to ensure that a neurodevelopmental problem is discovered. I suspect that the danger is more with children who are a bit older, where the follow-up is brief and the difficulty is more likely to go undetected.
The picture that is emerging of birth injury—as we have tended to call it down the years—is that a difficult labour is often a marker of some form of developmental problem even before birth. There has been a tendency to identify the birth itself as the initiating event in explaining why there is disability in the child subsequently, but the picture seems to be more complex than that.
That is a very important point. One of the issues that I want to highlight from an epidemiological point of view is what is called reverse causality.
The example was given of the New Zealand school study. Brain injury does not happen randomly in the population; it often happens to people who have risk factors. Therefore, if a child has behavioural problems, they are more likely to have a brain injury.
In the New Zealand cohorts that were worked up, the strong likelihood was that the brain injuries were not necessarily relevant but the other factors in the lives of the children that led to the brain injuries also led to the other problems.
Brain injury may be a marker of a problem, but examination of the vast majority of mild brain injuries has found that they do not necessarily cause adverse consequences for the brain but happen to people who already have things going wrong with them, such as substance misuse, alcohol misuse, behavioural problems and risk-taking behaviours, all of which strongly associate with criminality. We must be cautious that, among the mild injury cases, which are the vast majority, we do not attribute everything to brain injury but realise that there is a much more complex social problem.
Separately, in the much smaller number of severe injuries, I would fully agree with all that has been said, but we need to separate those two aspects of the discussion out. To think of them all as one group is highly misleading in respect of where the problems come from.
I understand that. Thank you for that distinction.
I will let Sandra White finish her questioning—same line, though, Sandra; keep on the same issues.
Yes, it is on the same line. Dr Carson touched on my next question, which is about the severity of the injury. If the prisons have medical records and are working in partnership with the NHS, would screening of prisoners for head injuries come into force?
I will take Ms Parker on that one because it is linked to her remit.
HMP Grampian is working in partnership with NHS Grampian staff to test a model of care to identify and diagnose traumatic brain injury on admission. A clinical neuropsychologist will provide inreach support and transition into the community. The information that is gathered through the health assessment will further inform any offending behaviour programmes, and healthcare records will be shared.
We will look at the feasibility of delivering either one-to-one or group support to address offending behaviour, and the results of the pilot will further inform the agenda. I understand that there has been difficulty with recruiting, but it looks as if that model of care will be tested in September in an environment in which people are coming into prison and being diagnosed or assessed.
Where are the police in this? People who come out may just go out and reoffend. Is any connection made between the SPS and Police Scotland?
Yes, but there is also a good connection between the police and NHS records in our custody environment. You will now see NHS nurses working in police custody facilities, and many of them now have access to the NHS computer records within the police custody suite. When a person is asked a series of medical questions about their physical and mental health on arrival or they present in a way that gives us concerns, we can raise that with the nurses. They can then check what information is on the health system and their care can be looked at. That information is then introduced to the system either for assessment prior to release or for use by the court systems.
I will let Dr Aldridge come in if his comments are on this topic. Otherwise, I will take Dr Carson on the business of continuity from prison to police. Are your comments on this topic, Dr Aldridge?
They are more about causation.
We will leave that for now.
My comments are specifically on records.
Yes—I want to hear about that.
We know from a lot of research—particularly stuff from Professor McMillan’s group—that in NHS Scotland, and indeed in the UK in general, medical records on whether somebody has had a brain injury are poor. Although the information is there, which is certainly better than our not having it, we know that, for a large proportion of people who have had a significant brain injury, it is not well recorded in their medical records. We also know about the reverse—for a large group of people who have not had a significant brain injury, what started out as a mild bump in the head, over the years gets inflated in the medical records to be a severe, traumatic brain injury.
The Scottish acquired brain injury network is putting together a set of proposals, which will go to NHS National Services Scotland, on making a dramatic change to how we record brain injuries and starting to have a national programme for the proper recording of such injuries from the point of diagnosis in A and E onwards. When we see someone 10 years down the line, making a diagnosis is not a facile process. Doing it in retrospect is complex, so SABIN is excited about promoting the programme. It is in its infancy, but it might be of benefit.
Dr O’Neill and Dr McFarlane want to come in. I want to stay on the subject of recording and sharing information. Are your comments on that?
I was going to speak about screening.
My comments are also on screening.
That is fine. We will stay on that, and we will come back to Professor Williams on records.
Dr Aldridge, you wanted to speak about causation. Does it relate to the current theme? I do not want to park you if it does.
There is an element of that. I was going to say that a useful concept is a web of causation, where we look at a large number of factors that, among the group that we are discussing, tend to be rooted in deprivation, trauma and a lack of social resilience. For some people, the consequences of a head injury start to become a predominant theme in their presentation. The difficulty is that, when we look at it from a clinical perspective, some people have had obvious, severe head injuries and have had treatment, while other people, unfortunately, have been victims of physical abuse and there were active attempts at concealment when they were children. It is difficult to piece records together, so continuity of information is definitely an issue.
I have a list of others who want to come in: Dr O’Neill, followed by Dr McFarlane, followed by you, Professor Williams. I will then take Roddy Campbell, who has been waiting for a while.
10:30
In line with the idea of a web of causation, health services in prisons are becoming increasingly good at identifying mental health problems, substance misuse and potential learning disabilities. We propose that screening for brain injury is added to that mix, so that we have a fuller understanding of the needs of the prison population. Screening is the first step. There are reliable measures to identify the problem, such as the comprehensive health assessment tool. That would lead us to be able to look more closely at the kinds of difficulties that this group have, such as whether they have behavioural discontrol problems or emotional disregulation problems, which would predispose them to further offending.
I just wanted to add a little bit more about screening. I know that my colleagues in Grampian are bringing in a pilot programme. That will be about prisoners who obviously have a brain injury; there will still be a hidden population that the prison is serving well, given the routine and structure within it. As Dr O’Neill said, screening for all prisoners would be of use.
Dr O’Neill and Dr McFarlane mentioned CHAT—the comprehensive health assessment tool screening measure, which is now in use across the youth secure estate in England. It consists of just a few questions. We do not want to end up with too many screening tools, but we need to know what the relevant factors in offending are, so brain injury and other neurodevelopmental problems are now being screened for.
It is really important to link records up, as Dr Carson said. Unfortunately, often medical records are not full and have been written up in a hurry, so they are often not a reliable resource—although they are at least a resource. When people come into the criminal justice system is a good opportunity to screen for common neurodevelopmental disabilities, particularly brain injury.
I am thinking especially about young people. To return to a point that was made earlier about the developing brain, the critical issue that people need to understand is that, given the plasticity of developing brains, we will not know the consequences of an injury to a developing brain until years down the line. Very often, that brain will not develop in a normal way. A bang on the head when someone is young can have much more devastating effects on the brain than a bang on the head when someone is older. We need to bear that in mind.
I will take Ms Parker and then Roddy Campbell, because this is on the whole issue of records and screening.
The Justice Committee is aware that health boards are now responsible for the provision of healthcare services in Scottish prisons. A memorandum of understanding and an information-sharing agreement are in place. The new director for health and justice at the Scottish Government, Andreana Adamson, in her capacity as chair of the national prison health network, is currently in discussion about setting up a workstream on brain injury among prisoners. I know that she is interested and that she has invited some of the people who are here today giving evidence to participate in that workstream. That would be an opportunity to look at some of the issues that have been raised today, such as information sharing, records and the transfer of information. Andreana was unable to come today because she is on annual leave—
She is allowed that. People are allowed it. Sometimes people say, “Why?”, but we support her being on annual leave.
She has proposed setting up a workstream in the autumn, on her return. That would be an opportunity to take forward work in some of these areas, looking particularly at Scottish prisons. Andreana also chairs a group on the transfer of healthcare into police custody suites. There is an opportunity to join some of that up.
If people do not want to do it this way, I am happy, but Roddy Campbell, Margaret Mitchell and Alison McInnes have been waiting for a while. If they want to put their questions out there, that will let them be dealt with. Roddy, what do you want to ask about?
I was initially going to raise the issue of the comprehensive health assessment tool in England, but Professor Williams touched on that and said that it did not amount to more than a few questions.
What I am really interested in from the justice point of view is what we could learn from other justice systems. In what way are other justice systems more advanced in this area than we are? Bearing in mind what Ruth Parker said, we could take account of all that in moving forward.
I am going to leave that question out there.
There has been a lot of concentration on people with brain injuries in prison, but how do we identify such people if an alternative disposal to custody is given? There is some progress with those on remand. Would the comprehensive health assessment tool help with those people, or what else could be done?
There has been lots of discussion about early intervention. Professor Williams talked about help and support, and Ms Parker spoke about offender programmes. How successful would cognitive rehabilitation be and where is it at the moment? If we did all the screening, would it be possible to make a significant difference?
Thank you. Let us start with what we can learn from other justice systems.
The comprehensive health assessment tool has different parts, from the risk assessment of suicidality and so on early on through to the assessment of neurodisabilities, and it is used in England in the youth offending institutions. It is going to be moved into the community side as well over the next year or so. It has been quite helpful so far, as it has been shown to be very sensitive in picking up the issues and—incredibly importantly—assessing whether an issue is relatively mild and does not require too much in the way of intensive intervention or whether some education is needed around when someone’s thinking has been affected to some extent or when their memory might be affected but not to a severe degree. There is a sort of triage system to identify the ones who really do need more intensive interventions.
In pilot projects that I am involved in through the Disabilities Trust, we have put brain injury link workers into two major young offender institutions, one in Leeds and one in Manchester. We are finding it incredibly helpful to have those brain injury link workers there to help the prison staff to identify and manage young people with brain injury. In the past, there may have been an indication that there was a problem but the staff were not aware of the true extent and effect of the problem, and the CHAT is a useful system for identification.
In terms of intervention, the link worker projects seem to be—
Let us leave that just now. I want to keep to the one topic, and there are other justice systems to discuss. We will then move on to the other members’ questions. Dr Carson wants to talk about what we can learn from other justice systems.
I want to make a small point about screening tools such as the CHAT and other measures. They tend to be very sensitive—the chances are that they will pick up all people who have had a brain injury—but they tend not to be very specific. In other words, they also pick up a lot of other people who have not had a brain injury.
We accept that. What about other justice systems? Can you narrow your comments?
I just wanted to make that point about screening. Proper diagnosis is quite labour intensive and if, as your colleague mentioned, you are thinking about custodial diversion as opposed to programmes within a custodial setting, that becomes quite a big issue.
We understand the complexity. One size does not fit all, and there is no one reason for a person’s behaviour—there are complex environmental and family reasons and it depends on what has happened to them.
Can we go back to other justice systems? We heard from Professor Williams. Does anyone else have any examples? Is Scotland lagging behind? From what you say, Professor Williams, it sounds as though it is.
We have been involved in recent submissions to the Welsh Assembly along the same lines. In the United States, in New York, a recent initiative in which all the young people who entered the criminal justice system were screened indicated that half of them—male and female—had knockout histories. There are similar programmes in Canada, Australia and New Zealand, where there is an interest in trying to screen more effectively. People seem to be picking up on the screening side of things as something that can be done.
Other justice systems have found ways of identifying particular problems that are associated with reoffending. For example, attentional dysfunction is likely after brain injury. One study found that if the population who have attention deficit hyperactivity disorder, which is associated with impulsive behaviours, are identified and appropriately medicated, their chances of offending are reduced by one third. Just by identifying a cognitive domain that is impaired and medicating the person to prevent their engaging in impulsive behaviour, we can reduce the reoffending rate by one third.
We also have to give the Scottish justice system some credit for how it deals with people with brain injuries as victims and witnesses. The police have the vulnerable persons database and there is the legislation on vulnerable witnesses and victims, so a considerable amount of work is being done across the justice system that puts us in a strong position compared with many countries.
We know about that—we did the Victims and Witnesses (Scotland) Bill. However, the issue might be that people conceal—or may not be aware that they have consequences from—some injury that they received at some point in their lives. Perhaps another issue is that people may not be aware that they have had a brain injury and that it is part of the problem. It might not be in their medical records.
That relates to the range of causes that are described—the legislation and the database enable us to record vulnerability for a variety of reasons and then handle the individual without a label, other than vulnerability. That is an important strength.
I move on to alternatives to custody. I ask Margaret Mitchell to remind me of her question.
It seems that we are talking about routine screening in prison: there is a pilot, which will give some good practice. It would be interesting to see how much that is followed up by NHS boards—and, indeed, how much they have the issue on their radar at all. However, particularly with a non-custodial sentence, where do we start to identify the issue, let alone do something to intervene and treat it?
Again, in terms of the severity of the injury, we have to distinguish. If the injury is severe and is essentially disabling in terms of the person’s daily life, it is very likely that a period of in-patient rehabilitation would be required to effect a change. If the disability is largely cognitive and emotional, the best evidence base for creating a change points to holistic forms of neurobehavioural rehabilitation. If it is a severe injury, that is the route that one would think of going down.
If the injury has had a less disabling effect on the person’s lifestyle, we may then be looking at more of an education-based intervention programme. We are looking at piloting a feasibility study in Polmont of more of a generic system that is based on a cognitive behavioural therapy model developed by Professor Chris Williams at the University of Glasgow. The system focuses on changing people’s attitudes to their lifestyle but it has a theoretical basis for doing that. It is a group-based programme that, potentially, many people could access, and it does not require clinically trained staff to provide it. We are hoping to do a feasibility study on that.
Can you give us any dates or a timeline for that?
I have been to meet the governor, and Professor Williams is going back to Polmont in a couple of weeks to discuss further initiating a feasibility study.
Again, that is in a prison setting. I wonder whether the pilot might concentrate on remand prisoners. When their cases come up, they might be released—they might be given a non-custodial sentence. Could the pilot identify those people? How do you identify people with non-custodial sentences? At what point are they screened?
Identifying them is an issue. That type of programme has not been developed specifically for prison so, potentially, it would work for people who are not given a custodial sentence. It would be a matter of having a screening system that could identify people who potentially had a brain injury.
That type of intervention would be suitable not just for people who had a brain injury—as we have said, the picture is complicated—but for people who may abuse drugs or have other issues.
Are we moving to routine testing for traumatic brain injury in the criminal justice system as a matter of course, to identify those people whenever they come in contact with the criminal justice system?
I think that that would be a good step.
10:45
It is very possible and desirable for people on community sentences who have such a condition to be managed. We talk a lot about rehabilitation, but we must not forget that people’s functioning is often affected on a global level, and they can become fairly vulnerable. Some of the interventions that we might be looking at are about helping to support people to access and maintain housing and tenancies, benefits and so on. It is not all focused directly on rehabilitation.
The committee is quite good at that. We understand. We have looked at all these issues, particularly in relation to women offenders. It can be about simple and practical things such as having a roof over your head and your benefits arriving on time. It is about stability.
Absolutely. You are right to point that out. A lot of good work is being done in Scotland, and a lot of that work can be done well with a community sentence. We certainly identify people who are on a court-mandated community-based drug treatment programme and who have head injuries. There is absolutely no reason why such screening cannot take place.
I have Professor Williams and Dr O’Neill. Is it on the same topic?
That is right.
We will then go back to Alison McInnes’s question.
As Superintendent Allan mentioned, the police have a way of understanding when someone is vulnerable. That is excellent. They can flag up across the system that there is an issue when someone comes into the criminal justice system.
We are trying to enable probation staff, magistrates and judges—although it is rather tricky—to pick up on the issue so that they can make decisions about the best placement for somebody and about that person’s ability to change their behaviour. If we had screening tools that were associated with identifying vulnerability and brain injury, they would be able to inform the judicial process about whether someone could really participate in that process and understand what was happening around them and the consequences of the sentence that they had been given, whether it was a community-based sentence or a custodial sentence. It is of paramount importance to put in screening early on and link it with police systems.
We could have done with hearing from someone from the social work system, as that view is missing from this discussion. They are often on the front line and meet people whose behaviour is challenging for various reasons. [Interruption.] The clerk tells me that we asked.
If someone’s behaviour is identified as problematic and causes an offence, and if a brain injury is associated with it, it is referred to as a neurobehavioural disability. We can identify vulnerable offenders who might have that kind of neurobehavioural disability, and thankfully the provision of the holistic neurobehavioural rehab that Professor McMillan referred to is increasing in Scotland. For many years, we have had Dr Carson’s service at the Robert Fergusson unit, and the Brain Injury Rehabilitation Trust also runs a unit in Glasgow that provides holistic, evidence-based intervention.
There have been various studies of the cost effectiveness of such interventions that show that the functional gains in life skills that those people get can mean a lifetime saving of between £1.3 million and £1.8 million in care costs. It is about re-equipping people with the skills that they might have lost as a result of their injury or which they never really developed because of adverse social experiences in early life.
What does that £1.8 million relate to? Is it per individual? It is a lot of money; I just want to know what it is.
The care costs for someone with neurobehavioural disability are very high because they have to be kept safe and the people around them need to be kept safe from their behaviour. If the people who are admitted to those services have their behaviour ameliorated, their lifetime care costs are not so high. We are talking about people who might not have ended up in the criminal justice system and people who might have a previous history of criminal justice service use. Two studies have been carried out: one was by Oddy and Ramos, which I can supply to the committee if you are interested, and the other was by Worthington et al.
As always, Governments have to consider money. If we spend more to prevent people from going into the criminal justice system or from reoffending and so on, we will save the public purse—that should not be the basic reason for doing that, but it is very helpful. You introduced the figure of £1.8 million, and you can imagine the public’s perception that that is a lot of money to save one person. Of course, that is not what you are saying.
No. I am saying that those are the likely savings on the lifetime care costs of someone with neurobehavioural disability.
I want to expand on that point.
I agree with Dr O’Neill. There has been a wealth of evidence for around 30 years—a lot of it has come from the United States, admittedly, but increasingly it has come from other countries—that says that if you invest money in rehabilitation services, however those are defined, which would include the social and housing rehabilitation that has been mentioned, you recoup the money within three to five years, because you convert somebody who is dependent into someone who is independent. In the best-case scenario, you convert someone back into a wage-earning taxpayer. The difficulty sometimes is that different pots of money are involved: someone has to spend the money for someone else to recoup the benefit later on. Joined-up thinking would help a good deal to make the economic argument for rehabilitation.
I think that Government is moving in that direction and looking at the holistic spend rather than the spend in various silos.
I agree.
Professor Williams is next—I am getting to Alison McInnes’s question.
I just wanted to make a point about preventative economics. It seems that reoffending costs about £10 billion a year—
Which country are you talking about?
I am talking about the UK Government.
We need the Scottish figures.
I wonder what the Scottish figures are. The figure that came from the Rt Hon Chris Grayling last year was between £7 billion and £13 billion. We then start to think about what a reoffending person looks like, and they look like the people we have been talking about. Although alcohol and drugs issues—the web of risk factors—will be big factors, brain injury seems to be the keystone condition. That is why some preventative spending on identifying and managing brain injury, particularly early on, may bring some economic benefit down the line.
If I go back to my clinic this afternoon and identify someone with that level of problem and I make a referral, it can be several months before they are offered an appointment. If the person happens to miss that appointment, it may be another four months or so before they get an offer of an out-patient assessment. In between, we need to try to stabilise their drug use. The area feels underresourced. If I sit in my clinic this afternoon with someone in that position, it will probably be a year or so before I can get them to their first appointment with neurorehabilitation services, even for their assessment. It just takes that long. It feels underresourced.
I was just going to make that point, with some Scottish figures. As part of its general programme for trying to improve head injury care in Scotland, SABIN is putting forward a comprehensive proposal. On the rehabilitation aspect of that, we estimate that Scotland, which has 120 rehabilitation beds, should have about 400 rehabilitation beds with associated outside services. Some areas are severely underresourced in terms of community service, let alone having an adequate service. There is a huge gap.
However, if one then talks about custodial diversion, there is a separate issue about containment, depending on the severity of the crime. There are currently very few forensic beds in Scotland for brain-injured offenders. My unit is probably the only brain injury unit in Scotland that occasionally takes brain-injured offenders. However, we come across security problems because we are not a secure unit; we are a rehab unit.
The majority of the medium-secure forensic psychiatry facilities do not take people with brain injury as a matter of policy. The state hospital does, but there is a massive gap in provision.
There is also a problem with the compulsory aspect of treatment. Most of the studies that are quoted have been of people who volunteer for treatment and are at least willing to engage, although I fully agree that all the cognitive difficulties can get in the way. However, that is before anyone looks at using the Mental Health (Care and Treatment) (Scotland) Act 2003 or its criminal provisions to divert people. That is complicated; the position is not straightforward.
I will take Ms Parker, then Alison McInnes can repeat her question. After that, we will wind up the session.
The SPS’s experience of making referrals to health boards for the assessment of prisoners who are identified as having had a traumatic brain injury shows evidence of waits of up to 12 months. There are huge resource implications across health boards.
I ask Alison McInnes to remind us of her question, mainly because I cannot read my handwriting any more.
I was keen to find out how successful cognitive rehabilitation is. Dr Brian O’Neill, Professor Williams and Mr Gentleman have touched on that, but it is clearer that such treatment is seriously underresourced and that we are just talking about cranking it up. That is the main message; I am not sure that more can be added to my initial question.
The question for us is where the resources would come from—that relates to spending to save.
I will wind up the session. This is not a parlour game, but I would like each person to give us one key point—and I mean one—that they would wish us to consider if we make a recommendation to be taken forward. I know that asking for one thing is unfair, but I am not sitting here to be fair. As the witnesses know, we have a gap—a short time for the discussion. Do they have one thing that they want us to take home? I think that we have begun to get to such things, after the broad discussion.
I will not go round the witnesses in order; they can nominate themselves. They will get only one bite at the cherry.
I am confident that my colleagues will add other things that would be on my list, but one place where we need to start is with a comprehensive epidemiological study, which would give us good information about head injuries throughout prisons in Scotland and the relationship to offending.
An epidemiological study would be key, but teaching and training to increase staff awareness would also help to improve prisoner wellbeing.
The identification of brain injury in offenders and the provision of training have been undertaken by the Disabilities Trust, which uses link workers who go into prisons to train and help people to identify vulnerable offenders.
So you recommend more link workers.
Yes—more link workers.
When we are focusing on prisoners, screening and rehabilitation, I wish for continuity of care, to ensure that we get the community reintegration package right and that we get consistency across Scotland on rehabilitation centres.
Many years of running a brain injury rehabilitation unit as a doctor have taught me that, if only the medical or clinical issues are looked at, a lot of the picture will be missed. I make a plea for more resourcing of the resettlement of offenders in the community, to reduce the risk of reoffending and provide a better quality of life, if possible.
Mr Gentleman’s answer was better than the one that I was going to give.
I will let you think of another answer; I am sure that you can pluck something else out.
I would like us to look at what we can do about secure beds for patients with known severe brain injuries who have committed significant crimes and who are in the criminal justice system. They are currently impossible to place in Scotland.
All these points are good.
My point links very much to the lack of available services. This week’s publication by Her Majesty’s inspectorate of constabulary for Scotland of a review of police custody highlighted the challenges of providing appropriate mental health service access once people are identified as needing it. As for the potential beneficiary of any increased spend, we—as well as the overall public purse—would probably reap the savings, but I would have to support the need of mental health services to have additional funding.
I am sure that the point has been made about screening—that is incredibly important—so I will not make that point. I would wish for preventative action on childhood brain injuries to pick up on those injuries more effectively by having links between A and E departments, GP practices and schools that would enable better reintegration into school of children who are at risk. That would ensure that, down the line, they were in school rather than prison.
Has anybody not given me something yet? Has Dr McFarlane contributed?
I have.
On prevention, what we are talking about feeds into the minimum alcohol pricing agenda, for instance, which tries to reduce availability. Alcohol feeds into the risk factors that are associated with getting a head injury. More resource and awareness should be directed at that.
11:00
That relates to causation.
Yes.
The witnesses have written our little report for us—we will not need to discuss it afterwards—as we have got all the points. I thought that I would save members time.
I thank the witnesses very much for giving their valuable time. It is always extremely interesting to have round-table discussions and to hear views across the spectrum. The witnesses will find out in due course what we will do, but I do not think that we will stop here.
11:01 Meeting suspended.