Impact case study database

for Dyfed-Powys, from April 2018, the screening tool was further adopted for use with all referrals to the Youth Justice Service (YJS) across the Dyfed-Powys force area - Pembrokeshire, Carmarthen, Powys and Ceredigion [5.1; 5.2] - to ensure: a) a valid screening process for referrals as identified through HM Probation Youth Offending Team (YOT) inspections, and b) a standardised force-wide process to facilitate data sharing and research. The risk-assessment tool informs decision making on the most appropriate level of involvement following referrals to the YJS and is able to screen out approximately 35% of the entire case load referred to CYJPS, depending on whether an individual is identified as either a low-risk, or high-risk young offender [5.3; 3.2].

The key beneficiaries are threefold. Firstly, adopting a ‘Child First’ approach has been applied towards Young People in Ceredigion and Dyfed-Powys reducing the stigmatisation/ labelling of the young people referred to the service; this further reduces the chances of later offending for these low-risk offenders. The number of referrals in Ceredigion was reduced by approximately 30% in terms of total case load. The Head of CYJPS confirms:

The development of the Ceredigion Youth Screening Tool (CYSTEM) has been a major driver of change in the way in which we assess and process young people referred to the service. CYSTEM has allowed us to focus resources on the most critical individuals and avoid stigmatizing the very low risk cases; figures show that this has had an impact on the number of young people re-entering the system over the past two years. [5.1]

Secondly, staff working in Youth Justice saved time and financial resources , which enabled more efficient allocation of intervention work such as group work, sports-based interventions, one-to-one supervision, and substance misuse programmes. Using CYSTEM for a third of cases saves between three and five hours per referral and between approximately 150 and 200 hours per year, per caseworker. Not having to formally assess very low risk young offenders has significantly reduced demand for resources and freed up case workers’ time to provide intervention work with the high-risk category. The Head of CYJPS confirms:

The tool has changed the practices of referrals by screening out low risk individuals and has since been adopted across the four Dyfed-Powys force areas. Beyond the benefits realized by the young people, CYSTEM has saved hundreds of hours in staff time and released vital resources for important work in the community. [5.1]

Thirdly, the wider public benefited through crime reduction, by enabling resources to be targeted at medium to high risk offenders, the group which have been demonstrated in showing the greatest improvement from high quality intervention work, as identified by a Home Office SOC Policy Advisor in relation to the SOC Evaluation reports [3.4; 3.5]: ‘[t]he evaluations demonstrate a positive impact on the lives of these young people…that demonstrate how to change the life trajectories of many very vulnerable young people’ [5.4].

The UK Minister for National Security and Economic Crime referred to the Ceredigion SOC-2 project at a briefing for the Association of Police and Crime Commissioners (APCC), 9 May 2019 [5.4]. The briefing, interventions project, and Dr Norris’ evaluation work were also cited in a Home Office press release, 13 May 2019:

A project that the Home Office and Ceredigion Youth Justice and Prevention Service funds is helping around 30 young people by giving them an opportunity to recognise the consequences of becoming involved in serious and organised crime, and to learn to recognise high risk situations and practice ways of responding. [5.5]

The work also featured in the Home Office SOC Local Partnerships Bulletin in August 2019 [5.6]. The SOC project was nominated for a Howard League Community Award in 2018 and 2019 [5.7].

For the Head of CYJPS: ‘Dr Norris' evaluations for the two Home Office projects have been pivotal in furthering our understanding of the way in which Serious and Organized Crime (SOC) manifests itself amongst the most vulnerable young people in Ceredigion’ [5.1]. As such, the Dyfed-Powys PCC has awarded funding for the CJYPS to continue using the intervention work utilised within these projects [5.2]. Dr Norris has an on-going role in the design and evaluation of this continuation of the SOC project though funding secured from the Serious Youth Violence fund, delivering targeted interventions based on CYSTEM profiles [5.1; 5.2]. Approximately 100 young people have been provided opportunities through these targeted interventions. (Project on-hold due to Covid-19).

The approach advocated by Ceredigion Prevention Services is being formalised as a model for Welsh Government providing a template for youth justice practice across Wales [5.8.a]. Following the success of the Ceredigion model, the Youth Justice Board (YJB) awarded GBP30,000 in funding to formalise the approach into a proposed model for Youth Justice across Wales. Dr Norris will be a consultant in this project and deliver a revised version of CYSTEM [5.8.b; 5.8.c)]. (Delayed due to Covid-19).

As a continuation of Dr Norris’ work within Youth Justice, he has also informed the Home Office’s development and testing of a UK Prevent Intervention Toolkit aimed at practitioners working with people at risk of, or involved in, SOC [5.9]. A Home Office Policy Officer confirms, ‘Dr Norris provided expert input in relation to delivering programmes with young people, vulnerability and assessment of risk. We are grateful for his time, case studies and documents he provided on the CYSTEM screening tool and the SOC checklist used in the Ceredigion interventions, elements of which were cited in the toolkit ’ [5.9]. Dr Norris also contributed to South Wales Police Violence and Vulnerability Unit’s work, developing a strategic framework for tackling serious violence in Wales [5.10].

A “SOC Workbook” was developed for use by YOT’s and ancillary organisations for SOC intervention work [5.11]. The workbook includes material on risk-assessment, including CYSTEM and a SOC Checklist developed by Norris, and is used in the on-going SOC preventions work funded by the PCC. A dedicated ‘Preventions’ web-portal hosts the workbook, project details and information on local and national preventions work [5.11].

Dr Norris was also invited to work as a consultant with the Home Office ‘Prevent’ programme to design and deliver educational programmes for young people as part of a three-year intervention on SOC in Albania [5.12]. A Home Office Policy Advisor confirms: `The work has provided the Home Office with a valuable insight into the nature of SOC vulnerability…which will be used further afield as part of the Prevent programme in the UK as well as for our work on Prevent upstream programme internationally’ [5.4].

Aberystwyth University informed the set-up and evaluation of a novel telehealth service offering psychosocial support to rural palliative care and cancer patients that was otherwise unavailable. Hywel Dda UHB services an estimated population of 384,000, it covers a quarter of the landmass of Wales and is the second most sparsely populated Welsh health board. There has been a steady rise in the number of patients recorded on its’ Primary Care Palliative Care Register with figures more than trebling between 2009 and 2019, from 517 to 1726 [5.1]. The telehealth service was provided in collaboration with the Palliative Care Team at Bronglais Hospital who delivered the psychosocial support.

The research demonstrates impact in three key ways:

The research influenced the Health Board’s telemedicine manager to recommend incorporating telehealth into the Health Board’s palliative care service. In 2015, this proposal was presented to, and supported by, Hywel Dda’s palliative care strategy group [5.2] and subsequently supported by the Committee who agreed to include telehealth as part of the Health Board’s strategy for service delivery [5.2]. The service continued with laptops provided by the project on long-term loan. In 2017, Hywel Dda UHB applied to and transferred some of its Integrated Care Fund allocation (GBP13,560) to purchase i-pads enabling the service to continue in a flexible way, and to commission AU to develop promotional films to market the service more widely to patients and staff [3.4; 5.3]. Subsequently, the use of telehealth was extended to other multidisciplinary team staff including, consultant services, nursing, occupational therapy, and to allied services (e.g., mental health services) with common patient cases [5.4]. The commissioned films are embedded on the Hywel Dda UHB website and were sent to Palliative Care Teams across the Health Board and health professionals involved in oncology and palliative care across Wales. They have been used by the Health Board to highlight as an example of an innovative community care treatment pathway with a view to encouraging wider patient and staff uptake during the Covid-19 pandemic [3.4].

Improving patients’ access to psychosocial support and supporting access to care closer to home

The telehealth service provided vital psychosocial support for palliative care and cancer patients and enabled convenient access to multidisciplinary staff; including, consultant led services, nursing, and occupational therapy. The Health Board’s General Manager for Primary and Community Care reports the telehealth project was ‘of great of benefit to patients, families, carers and staff working in rural Communities ’ [5.5]. Frontline staff highlighted how telehealth can ‘enable patients … [to] … see each other […] and still feel part of a supportive group’ [5.6]. Patients reported how the service improved their ability to manage their daily lives and adapt to a terminal diagnosis, and minimised the need to miss appointments. The ability to access support from a familiar home environment supported good quality professional interactions and freedom of discussion through which patients felt their health professionals developed a holistic understanding of their needs [5.7; 5.8].

This service has been a vital part of my treatment… The introduction of the face time service has been amazing… This service… has enabled me to keep appointments that may have been missed due to my physical mobility problems and inability to travel. [5.7]

[S]ince the surgery I've obviously felt a lot more tired and physically as well initially I couldn't drive… So to do a session yesterday was good because … I sort of got up, had breakfast, did a few things and then did that… [telehealth consultation] … And then as soon as you sign off the rest of the day is your own. But if I'd gone to Aber it's pretty much the whole day really... [5.8]

Well, it's just nice to have somebody to talk to. I think the most important thing is it's nice to have someone that cares, what you think and how you're feeling which because obviously my family are all away, I don't have anyone to ask how I am or what you're feeling. Everybody is too busy. [5.8].

Well she might even know me more from doing it like that [telehealth] from face to face really… [S]o probably I've just disclosed or talked about more than I would have done in real life, really. [5.8]

Benefitting the working practices of healthcare staff

Research findings were presented and disseminated to the Welsh Gerontology Society in 2016 where 80% of attendees agreed that information about the telehealth research was of use to their clinical work [5.9]. Health board staff who used the telehealth service also saved travel-time which increased the efficiency of their clinical work [5.4; 5.10]. The service also improved staff access to patients, who were otherwise hard to reach either because of geography or psychological barriers [5.4; 5.10]. Additionally, the technology supported the inclusion and supervision of other psychotherapists working separately in other rural hospitals, enabling increased professional support, and inclusion within the multidisciplinary team [5.11]. Specialist Health Board staff using the service report explain:

This lady lives so far away that I might have been able to see her only once a month in person, now we are using the ipad I am able to contact her weekly, or more often if there is a need. [5.4]

This patient is a highly anxious lady … she’s very cautious about letting people into her own home and she can’t come to me, so to be able to communicate in this way it’s meant that I am available to her in ways that I wouldn’t have been able to because she sometimes doesn’t allow me into her home because of her anxiety levels.… [I]t’s made a big difference to her care [5.10].

Over the last six months I’ve been able to save just in terms of travel just over a thousand miles, and in hours something like five days. [5.4]

Because of geography in rural wales sometimes I’ve got to drive over an hour to see a patient and that isn’t always achievable by using the ipad it can mean I don’t have to travel 2-3 hours just to see one patient so I can make better use of my clinical time. [5.10]

Since Covid-19, the Palliative Care teams’ experience of, and ready access to telehealth equipment, meant that despite initial delays in setting up remote working for health board staff, the transition away from face-to-face clinics to remote support was able to happen seamlessly and rapidly for the Palliative Care team. The online service was able to facilitate pain management advice from consultants supporting specialist nurses in the community. It enabled therapies to continue with a non-verbal patient with multisystem atrophy where telephone consultation was not viable. It also supported staff wellbeing by enabling supervision and practical solutions during the transition [5.11].

Similarly, in response to the Covid-19 pandemic, a hospice charity, Hospice at Home Aberystwyth Volunteers, used the research findings to develop a new virtual strategy, securing National Lottery funding to develop ‘a virtual hospice at home service ’ for use during and beyond the pandemic [5.12]. This service will dovetail with the palliative care telehealth service to deliver an online suite of supportive therapies such as, counselling, art therapy, and relaxation sessions, whilst enabling befriending volunteers to maintain contact with their clients [5.12].