Multi-agency action learning: Challenging institutional barriers in policing and mental health services

Abstract

The police have underdeveloped links with mental health and social care services despite daily contact with mentally ill individuals. They struggle with identifying and managing the mentally ill in custody, and consistently express a lack of support from partner agencies. In 2010, our research team developed a mental health screening tool and pathway for use by police custody officers, The Police Mental Health Screening Questionnaire (PolQuest). However, due to the large number of agencies with different organisational goals and responsibilities that deal with mentally disordered offenders, the introduction of a screening tool alone was considered insufficient. Thus, an action learning group comprising key professionals from relevant services in one geographical area was tasked with developing a manual and training materials to support the implementation of PolQuest by frontline staff. This paper reflects upon the key themes that emerged from the experience of action learning as a method for engaging multi-agency staff, operating under different occupational goals and cultures, to develop shared practice-oriented outcomes. Data analysed include the facilitator’s reflective notes, meeting minutes and emails. The action learning process was considered a useful method for engaging multi-agency stakeholders in developing materials to support PolQuest’s implementation in vivo.

Keywords

Multi-agency partnership action learning policing mental health

Introduction

Since 2009, a priority in England and Wales has been to identify and provide services to individuals with mental ill health at the earliest point of entry into the criminal justice system (Bradley, 2009; Department of Health, 2009; Ministry of Justice, 2010). In 2010, the research team began a project to develop a mental health screening tool and referral pathway for use by police custody sergeants, designed to identify and improve the targeted referral of detainees with mental health problems to clinical specialists operating within police custody. The resultant tool, The Police Mental Health Screening Questionnaire (PolQuest), is a 14 item screen that is quick and easy to administer, covering a range of mental health issues including psychosis, depression and risks of suicide and self-harm (Noga, Walsh, Shaw, & Senior, 2014). PolQuest was designed to bridge the gap between the police and mental health services within police custody in regard to the identification and on-referral of mentally disordered offenders. However, it quickly became apparent that this process involved a complex network of multi-agency professionals with opposing institutional goals who traditionally worked independently. In order to successfully implement PolQuest, collaborative practices and joint decision making would be necessary.

The current paper focuses on the use of the action learning method for engaging multi-agency staff in the development of a manual and training materials to accompany PolQuest and support its implementation. We identify the themes that emerged from the analysis of the group facilitator’s reflective notes, meeting minutes and email exchanges, critically reflecting upon the use of action learning to bring together diverse stakeholders from a range of agencies. By doing so, we contribute to the growing literature base on the utility of action learning techniques within criminal justice settings.

Background

In 2010/2011 an estimated 1.3 million people were arrested and booked into police custody in England and Wales (Home Office, 2012). It is widely known that individuals involved with the criminal justice system have high rates of psychiatric morbidity (Bradley, 2009; McKinnon, Srivastava, Kaler, & Grubin, 2013; Singleton, Meltzer, & Gatward, 1998) and present with a complex range of health and social care needs (Social Exclusion Unit, 2004). With regard to police custody, small scale prevalence studies have found that between one-third and one-half of detainees may be experiencing mental health problems (McKinnon et al., 2013; Payne-James et al., 2010). McKinnon, Srivastava, Kaler, and Grubin (2013) reported that 39% of detainees in a sample drawn from those in police custody in London presented with some form of mental disorder. Of these, 38% presented with low mood or depression and over a quarter (29%) were determined to be mentally vulnerable enough to require an Appropriate Adult.¹ A 2007 review of police custody records in one London police station found that 46% of detainees had a recorded mental health problem (Payne-James et al., 2010). Additionally, evidence shows that many of those with mental ill health in custody also have co-existing substance misuse problems (Payne-James, Wall, & Bailey, 2005; Treloar & Holt, 2008), as well as poor physical health and a wide range of social care needs such as housing, finances, registration with a general practitioner and unemployment (McKinnon & Grubin, 2010; Payne-James, et al., 2010; Treloar & Holt, 2008). High rates of co-morbidity not only reveal a potentially vulnerable and needy group but also show the practical and administrative complexities of caring for these individuals, as each need often falls under the remit of a different professional agency.

Despite daily involvement with mentally ill individuals police officers are provided with little to no training in the identification and management of mental ill health, making them largely dependent on the support of partner agencies (Adebowale, 2013; Borum, Deane, Steadman, Morrissey, & Williams Deane, 1998; Cummings & Jones, 2010; Mind & Victim Support, 2013; Moore, 2010; The Police Federation of England and Wales, 2013). Despite this, 81% of custody sergeants reported having experienced difficulties in securing support from mental health partner agencies on multiple occasions (The Police Federation of England and Wales, 2013), potentially leading to significant consequences for the safety of both officers and vulnerable detainees (Adebowale, 2013; Krameddine, Demarco, Hassel, & Silverstone, 2013).

Some police custody suites in England and Wales have on-site access to a criminal justice mental health liaison and diversion service (CJMHL&D) which can assist in screening detainees for mental ill health, provide detailed assessments and facilitate onward referral to community services. However, such services have developed in localised, ad hoc ways, leading to inadequate staffing; operating hours which frequently exclude evenings and weekends and confusion over which client group should be targeted (Pakes & Winstone, 2010; Senior, Lennox, Noga, & Shaw, 2011). Due to the limitations of current screening processes, CJMHL&D services see only a minority of those in custody and may be missing a large proportion of people who could benefit from their service (Senior, et al., 2011). At the heart of these issues is a long established culture of competing organisational interests and goals hindering multi-agency partnership working. At its core, the police service is focused on law enforcement whilst often being drawn into the role of health and social care advisor for vulnerable people. Healthcare agencies, whilst operating with the welfare of the patient as core, often struggle with a lack of resources, narrow inclusion criteria and fragmented community service provision.

Thus, currently, the ability to use police custody as an opportunity to effectively signpost a person with mental health needs into appropriate services is hampered by a number of factors, including police officers’ limited training, health models which are routinely incomplete, patchy service provision and inadequate multi-agency cooperation. Structural and organisational barriers, combined with the complex needs of the target population, demonstrate that the creation of a new screening tool alone maybe insufficient on its own; rather, what is required is the tool, accompanied by guidance for both training in its administration and practical implementation, designed and supported in cooperation with a full range of partner agencies. These issues led to our choice of action learning as the method with which to challenge institutional barriers, resulting in joint decision making and the creation of a manual and training materials that would accompany the new custody mental health screening tool.

Action learning

Action learning can be used as a tool for improving and understanding professional practice in organisations where users and workers are directly involved in creating or adapting a new development (Dixon, 1998; East & Robinson, 1994; Sandars & Waterman, 2005; Williamson & Prosser, 2002). The method is underpinned by the principles of Action Research where cycles of planning, observing, acting and reflecting are used to conceptualise a problem and provide solutions (Zuber-Skerritt, 2001, 2002). The action learning methodology was orginally conceived with multi-agency participation in mind (Revans, 1998), and has been cited as a useful tool for encouraging multi-agency staff to critically reflect on their own service and how they work with partner agencies (Ball, 2013; Dixon, 1998). In theory, multi-agency action learning groups should enable individuals and organisations to learn from each other and develop more effective solutions to challenging situations (Revans, 1998). In our case, the challenge was to engage multi-agency staff in the development of an intervention that, when implemented, would require the co-operation of a complex network of partner agencies who traditionally work in isolation.

This paper describes the use of action learning as the methodology guiding the development of staff resources to create mutually beneficial and acceptable ways of working at the interface of health and criminal justice systems. In recent literature, unique issues have been identified when utilising action learning methodology within criminal justice settings, including the relatively inaccessible and closed nature of many criminal justice organisations and the imbalance of power between criminal justice staff and detainees (Walsh, Forsyth, Senior, O’Hara, & Shaw, 2014). As well as the power disparity experienced between custodial staff and detainees, other professional stakeholders, notably health providers, frequently find working in the criminal justice system challenging as they seek to deliver patient-centred care within institutional structures which hold punishment and deprivation of liberty and autonomy as core aims and values. However, there are limited examples of action learning research in criminal justice settings where criminal justice staff, professionals from other agencies and detainees have worked together and achieved promising positive outcomes. Action learning has been successfully used in prison settings, incorporating participation from both healthcare and security professionals as well as prisoners themselves to improve healthcare practices (Fieldhouse & Onyett, 2012; Giblin, Kelly, Kelly, Kennedy, & Mohan, 2012; Walsh & Freshwater, 2009; Walsh et al., 2014). Having been widely implemented within healthcare settings and supported by emerging evidence of its utility within prison settings, our current use of action learning at the interface between health services and police custody is a valuable step forward in increasing its currently limited use in such settings.

The aim of this paper is to add to the limited literature on the use of action learning within the criminal justice system and discuss the utility of action learning as an approach to engaging multi-agency staff operating under opposing occupational goals and cultures, in the development of shared practice-oriented service improvement outcomes.

Approach

In our study, the action learning process began by ensuring that every potentially relevant agency from one local area was introduced to the research project’s aims and objectives and invited to take part in the action learning group. The participating locality was chosen due to a keen interest in improving the identification of mental ill health and demonstrated engagement throughout previous stages of the project. Additionally, the local constabulary did not use a custody based mental health screening tool and the NHS trust concerned had a well-staffed CJMHL&D team. Choosing a site with an existing CJMHL&D team was considered by the research team as essential for developing a best practice model that could then be modified via subsequent trials for areas without service provision.

The main research objective was to create a manual and training materials for custody sergeants to accompany the PolQuest screening tool. Group members formulated and agreed a set of ground-rules, including committing to active participation during meetings; completing assigned tasks between meetings; engaging their wider colleague group in assignments; contributing respectful, constructive criticism; and the freedom to steer each meeting within the parameters of the research objectives.

The group met monthly between November 2012 and July 2013 at a regional police training centre in England. This location was chosen due to ease of access for multi-agency staff, ample parking, and to emphasise the relevance of the project to police practice and training. Thirteen people attended the first action learning meeting. Attendees had very different professional backgrounds including police, private providers of custody-based healthcare, NHS CJMHL&D staff, crisis resolution home treatment, adult community mental health, substance misuse, social care, Appropriate Adult service providers and a service user involvement organisation. Participants’ professional experience ranged between 13 and 30 years. Members were generally at managerial level, as recommended for effective action learning by Dixon (1998); however, some managers preferred to attend meetings accompanied by a frontline practitioner. Twelve people participated throughout, with 4 to 8 people attending each meeting. Members who were unable to attend a particular session would contribute by commenting on materials via email. There was consistent representation throughout from the police, the private custody healthcare provider, NHS CJMHL&D and the Appropriate Adult service provider.

The meetings were facilitated by a first time action learning facilitator who is a social sciences academic with a background in quantitative and qualitative research methods. The facilitator had no professional affiliations with any of the participant agencies or stakeholders beyond the key project objectives. This meant that the facilitator was impartial, adding an aspect of neutrality to the decision making process throughout the sessions. The facilitator’s purpose was to promote adherence to, and ensure progress toward the overarching group objectives, facilitate communication, encourage engagement and ultimately ensure completion of the project through multual agreement. The facilitator was supervised by a senior clinical researcher experienced in the use of action learning who was based in another geographical region, thus neutral to the environment. Accompanying the facilitator to all meetings was a CJMHL&D clinician who supported the facilitator with organisational and administrative tasks and was professionallly known to many of the participants. This was a purposeful decision as it assisted in gaining access to local resources, enchancing the legitimacy of the project for participants, as well as providing a friendly and familiar platform for encouraging participant engagement in between meetings.

Meetings generally consisted of open, but focussed, discussions, leading to decision making or the identification of specific actions. Actions undertaken by members between meetings centred around holding discussions with extended team members, followed by drafting revised working practices to be included in the manual and obtaining frontline feedback on revisions. Any points raised by extended teams, especially any perceived barriers, were then discussed and reflected upon in subsequent meetings until an agreed solution was achieved and incorporated into the implementation manual (Figure 1).

Figure 1.

Action learning group approach.

Over the nine month period the facilitator kept a reflective research diary, through which new learning was identified and the progression of the group toward the research objectives was monitored. The reflective diary followed a template which included a summary of what the group achieved in each meeting; the facilitator’s reactions to events; observations of group dynamics; specific items to be carried forward to be incorporated into final group outcomes; and any additional notes or agreed actions.

Data from meeting minutes, the facilitator’s reflective diary and email correspondence with participants were analysed using qualitative content analysis, the systematic classification process of coding and identifying corresponding themes or patterns that emerged throughout the action learning group meetings (Hsieh & Shannon, 2005; White & Marsh, 2006). Initial guiding questions included how group members responded to the action learning group setting; how members interacted with each other; and in what ways the action learning process resulted in, or contributed to, any outcomes outside those required for the research project.

Discussion of key themes

Five key themes emerged from the data: engagement and motivation; relinquishing control; overcoming the defeatist mindset; group dynamics; and strengthening partnerships. These themes are a reflection on the utility of the action learning process itself, rather than the actual project outputs.

Engagement and motivation

In the first meeting careful attention was given to ensure the presence of at least one representative from every organisation that the research team considered could, in some way, be affected by the introduction of PolQuest. The group began positively with 13 people attending. There was consensus that the group objectives addressed an important multi-agency issue and members spoke with enthusiasm about potential developments and opportunities to work collaboratively.

‘The group as a whole seems to have immediately signed up to the idea and I expect most of them will continue to attend. Two people approached me to discuss options for staying involved for the dates they would have to miss.’ (Facilitator notes, November 2012)

However, this observation may have been too optimistic. After the first meeting, some organisations that focused on community based services or did not specialise in mental health felt they were less directly affected by what happened in police custody and should not continue to attend group meetings. Interestingly, though they wanted to be included in group communications, and some were willing to comment on materials in absentia or attend specific meetings where their service would be the focus of the discussion. Upon reflection, it may have been beneficial in the first meeting to have spent more time discussing the wider impact of PolQuest on partner agencies and how they could benefit from being involved in the action learning sets.

‘Some people saw themselves as less directly linked to police custody operations and thought they were not going to be useful or were unsure why they should be part of the group. I don’t think enough time was spent on exploring how people with “indirect” services may be affected by the study.’ (Facilitator notes, November 2012)

Regular in-person participation came from those who saw their organisations as most directly affected by PolQuest, for example the police, CJMHL&D, private custody healthcare and the Appropriate Adult service. Initially the group facilitator was concerned that a lack of wider participation would be a disadvantage, as some decision-making may be hampered due to the absence of certain agencies. Whilst it was acknowledged that it might have been beneficial for those agencies who had, early in the process, judged their role as indirect to have had a more prominent presence, the group overall appeared to understand why they had chosen to remain at arms-length and ultimately felt the right people and agencies were in regular attendance.

‘I think the right people were around the table – I agree that for some agencies there was no direct or immediate benefit but there was for everyone else that was here, yes they were the right people’. (Action Learning Group Staff Member)

The purpose of inviting a wide range of multi-agency representatives reflected the potential ripple effect of PolQuest, as judged by the research team. We felt that the introduction of PolQuest may reveal an unknown level of mental healthcare need by, for the first time, systematically screening each adult detainee individually for mental ill health. This could not only increase the number of people requiring an assessment by the CJMHL&D service, but also impact upon wider service provision if, as a result, more detainees were referred into community health and social care services. Perhaps importantly, some participants from community agencies, expressing that their services were already overstretched, displayed a defeatist attitude to a potential increase in rates of referral. Thus, holding on to traditional patterns of ‘silo working’ may have been a factor which deterred some services from engaging fully in the action learning process.

Relinquishing control

Throughout the meetings, the group began to show a dependence on the facilitator. Although encouraged to ‘make the group their own’, initially this was not fully taken on board. This may be because the action learning groups were expected to contribute to a research project which, by the time of their involvement, had been running for over a year. Group members may therefore have felt reluctant to ‘take charge’, as they had not set the over-arching agenda themselves. The role of facilitator is meant to support the group focus and challenge assumptions (Dixon, 1998); however, in this particular case, the facilitator had a significant professional interest in achieving specific outcomes for the success of the research project overall, a conflict which contributed to a struggle in handing over responsibility to the group.

‘In this meeting I learned that I need to be more assertive with delegating tasks and more trusting to let members contribute in their own ways. I need to make more of an effort to pass responsibility onto others in the group.’ (Facilitator notes, April 2013)

As running the action learning sets was part of her role as a member of the research team, the facilitator felt ultimate responsibility for the production of outputs which would be regarded by the extended research team as fit for purpose. It is possible that, since group members were aware of this, that it impacted upon the group’s dynamics. Whilst members would participate actively during the meetings, they often looked to the facilitator to confirm final decisions and assign actions. When asked to provide feedback on drafted materials, the group gave constructive and creative input; however many members were resistant to independently taking the lead to draft materials from scratch.

An obstacle of action learning is that, whilst members view the group as their own, the consequences linked to failure often rest solely on the facilitator. In our work, this feeling of responsibility experienced by the facilitator was mitigated over time by an acknowledgement and confidence that group members had diverse expertise and skills which were perfectly suited to achieving successful project outcomes, thus it was both possible and important to explore and exploit these to their full extent. The inability of a facilitator to relinquish control has been widely discussed within the action learning literature (Rothwell, 1999; Stark, 2006; Weinstein, 1999). Reflecting on the action learning process with other facilitators can assist in discovering behaviour and thought patterns, addressing doubts and finding appropriate solutions (Weinstein, 1999). In this case, the group facilitator was supported by a senior action learning facilitator who provided initial training, reviewed and commented on the facilitator’s reflective diary and observed occasional group meetings, providing immediate feedback. This resulted in the facilitator’s increased awareness of her behaviour, its impact on group dynamics, leading to a more assured style of facilitation.

Careful consideration was required as to the level of work members were given between meetings. We chose not to require individual reflective diaries, aware that the project would require substantial action in between meetings and thus mindful not to overload members with ongoing tasks. It became apparent that the setting of ‘excessive’ homework resulted in noticeably low attendance at the following meeting thus, over time, the facilitator worked hard to ensure a balance. As meetings progressed and deadlines approached, those with the highest stake in the success of the project, for example the police and custody-based healthcare clinicians took the lead, making useful contributions which had been discussed within, and were clearly supported by, their own teams. Upon reflection, this was perhaps due to an unintended lack of clear communication on the part of the group facilitator. Initially, six action learning meetings were scheduled but, part way through the process, two further meetings were scheduled to allow more time to complete the project objectives, so perhaps this action led to group members being unable to identify a clear project end point, impacting upon their contributions.

Overcoming the defeatist mindset

A recurring challenge at the start of the action learning group meetings was to manage the tendency of some members to focus on examples of worst case scenarios in which it was suggested that the usage of PolQuest could ‘grind the police custody process to a halt’, resulting in pandemonium.

‘The further need for mental health assessments could slow down the custody process dramatically … it is likely to lead to more Appropriate Adults being required … could open the floodgates to lots of legal challenges on past cases … opportunists could use it to slow down the custody process and get pointed down an alternative pathway than the criminal justice system’. (Action Learning Group Staff Member)

Police custody can be a high stress and volatile environment where things can, and sometimes do, go wrong. However, it is equally true that it is very controlled, bound by strict rules and predominated by a set of routines which have developed over time. For the facilitator, it became increasingly important to focus members on the bigger picture, concentrating on what usually happens, rather than allowing them to extrapolate a small number of discrete, particularly challenging cases and thus falling prey to defeatist attitudes. Williamson and Prosser (2002) stated that, since action research is aimed at change, it can be perceived as threatening for individuals and organisations and the question ‘how could things be done differently’ can be extremely daunting.

Group members routinely positioned their working lives within a context of harsh and repeated budget cuts; loss of services through commercial competition; high turnover of staff through recruitment and retention issues; and unmanageable workloads for which they believed they would not receive appropriate levels of support from within their own organisations.

‘People were very focused on the details such as staffing and resource implications … some representatives from community services were dismissive, stating they were already overworked and had a backlog of referrals so what would it matter if they got more’. (Facilitator notes, November 2012)

Discussions that were intended to be taken to extended staff groups were initially met with a ‘can’t do’ attitude, constantly stating ‘lack of capacity’ as an insurmountable barrier. Instead of challenging this situation, group members tended to sympathise with each other, accepting this as a viable reaction. One technique that worked particularly well for our group was the use of a grid where members were asked to identify individual problems or areas of concern, but were discouraged from listing additional barriers until a solution to the first barrier was written on the board.

‘Creating a chart that mapped each issue raised and corresponding solutions was invaluable. The group responded well to this and were able to cover a lot in a short period of time. We made excellent progress. This is a strategy we should continue in other meetings.’ (Facilitator notes, December 2012)

This method quickly created an enlightening list of barriers, all accompanied by potential solutions, thus maintaining focus on the positives, rather than the negatives.

Group dynamics

Many of those who attended the meetings already knew each other from other areas of their working lives as some, such as the police, CJMHL&D and the private healthcare provider, routinely worked together. As a result, group members were generally comfortable with each other from the outset. Initially, this was considered to be positive.

‘What is good is that most people already know each other or have working relationships outside the group. They felt comfortable around each other and were discussing how to support each other with group actions’. (Facilitator notes, January 2013)

Unsurprisingly, those with the greatest stake in the success of PolQuest, and those who were well known by other group members, tended to dominate conversations. Noticeably, the pre-established amiability and familiarity amongst some members could prove challenging when asking the group to consider new solutions and changes to current practices. Group members were generally diplomatic and professional, however, sometimes to the detriment of challenging each other critically and objectively.

‘Participants wanted to speak truthfully about how things were in practice but often seemed to bite their tongues in favour of diplomacy. Manageability of workload and “covering their backs” when something had the potential to go wrong appeared to be the priority.’ (Meeting minutes, April 2013)

Upon reflection, it may have been beneficial to have more people present without pre-existing relationships to other group members, to assist members in seeing their issues in a new light, thus encouraging optimism for change. In the absence of this, it was often the facilitator who challenged the group in an attempt to assist them in being open to new ways of thinking.

Securing the regular attendance of a service user at meetings was a struggle. Although in the earlier stages of the study a number of service users were willing to take part, reasons for not attending included feeling uncomfortable with the group setting, periods of mental ill health and an inability to arrange escorted leave to attend from the secure mental health facility in which one service user was formally detained.

Involving service users with mental health problems and a past history of offending in a research project over time can present unique challenges. Such individuals may lead complex lives and may still experience regular periods of ill health. Additionally, many ex-offenders with mental health issues have not had particularly positive experiences with the police or mainstream mental health services and therefore attending a meeting with such professionals can be daunting. When absent from the actual group meetings, service user input was continued by arranging separate meetings between the facilitator and individual service users, as well as engaging the professional lead for a local service user involvement group. When a service user did attend the meetings, there was a tangible, and positive, change in group dynamics. Staff noticeably became more optimistic and enthusiastic about creatively exploring service improvements above and beyond the project objectives. The service user was also best placed to pose the difficult questions that challenged staff to consider innovative solutions.

‘What went really well was having a service user attend. It offered invaluable insight, everyone seemed to appreciate that he was there and enjoyed talking to him. It was clear that staff were also interested in asking him a variety of questions that could help them improve their services in general outside of the meeting objectives. He was incredible. I was reminded of the importance of having a service user present in staff meetings and I think the other staff were reminded of the value of service user insight as well.’ (Facilitator notes, July 2013)

This change in group dynamics demonstrated the benefit of having service users and staff work closely together to identify barriers and solutions. The thrill of having a service user with lived experience, willing to share his story, reflect on the challenges facing staff and propose well thought out solutions became an asset for engaging staff participants. Staff were occasionally inspired to ‘sneak in’ questions and conversation topics that reflected a specific challenge they faced, outside the remit of the group agenda. The professionals experienced first-hand the value of service user input in their work. Additionally, the service user gained confidence in his ability to speak to, and be heard by, professionals in positions of power. When the project was completed, the service user who had attended the group spoke at a national conference about mental health and policing, confidently sharing the speakers’ platform with two members of the House of Lords, senior police officers from the United States of America and the UK, as well as a range of highly respected clinicians and academics (Noga, McKinnon, Sansbury, & Booth, 2013).

Strengthening partnerships

A benefit to the action learning method is that participants tend to strengthen their working relationships outside of the group as a result of the discussions that take place throughout the action learning process itself (Walsh et.al., 2014). One of the most practical unintended outcomes came from a discussion on the Appropriate Adult policy between the police and the local county council. Throughout the discussion it was apparent that some confusion around the current protocol existed between the agencies that had not previously been investigated.

‘This is a significant gap in services [regarding Appropriate Adults] which needs addressing … This discussion has actually resulted in changes to the county council Appropriate Adult protocol to provide clarity in the service they offer and make it easier for officers to contact them.’ (Meeting minutes, January 2013)

Through their own initiative, the representatives from the police and the county council subsequently revised the Appropriate Adult protocol and changed the wording to provide clarity and improve procedures, thus strengthening their partnership more broadly as a result of participation in the group.

Group members generally felt that the process had strengthened the working relationships they currently shared and had facilitated additional dialogue between themselves and other agencies. Some group members noted areas where their services could further develop partnerships, intending to explore these options with their newly strengthened contacts.

‘Two group members stated that even though they did know each other prior to the group, they hadn’t really sat down and discussed specific improvements to agency practices and reflected on how to implement them but, as a result of the meetings, they were now working together better.’ (Facilitators notes, July 2013)

Participation in the group also resulted in increased levels of confidence and self-esteem as they now felt their concerns were understood and shared by others, reducing feelings of professional isolation. One member stated that she

‘was given the courage to bring forward some concerns and challenges she had in her everyday working practices and as a result, relevant managers were now in an on-going discussion regarding this issue.’ (Meeting minutes, July 2013)

Group members commented on how quickly the action learning meetings were able to achieve outputs. Their previous experiences in developing multi-agency protocols had taken much longer, attributed to the absence of a clearly identified group of individuals meeting regularly to complete defined tasks.

‘Appreciating how long things take when done as multi-agency – this project has been achieved relatively quickly’. (Action Learning Group Staff Member)

Action learning was judged by participants to be an effective method for focusing group members on the task at hand, ensuring that dedicated time was set aside. Additionally, those with the questions were sitting across from those with the answers, allowing clarifications in professional roles and institutional practices to be provided quickly.

Participation in the action learning group also resulted in new partnerships. Most interestingly, emboldened by the experience of working with the police as an equal partner, rather than against them as an offender, the service user representative invited the police representative to speak to the ex-offending members of a local services user involvement group. They have since begun to work alongside the police by attending meetings and providing consultancy services on the police custody and detention process (personal communication, September 2013). Additionally, the service user involved and the CJMHL&D representative have set up a local community forum to involve the public in improving custody healthcare services (personal communication, May 2014). This is a significant step for ex-offending service users who have spent a significant amount of their lives in conflict with the police and society; prior to involvement, some service users could barely mention their experiences without becoming distressed. One service user commented;

‘For me, this [project] has been life changing’. (Action Learning Group Service User Member)

This illustrates the impact involvement in an action learning set can have on individual members and agencies outside of the group, resulting in the achievement of more than the main group objectives. Unfortunately, the action learning group was not successful in strengthening partnerships between all agencies as some, described in previous sections, were resistant to engaging meaningfully in the process. However, the action learning groups may have assisted in revealing gaps in service provision, the defeatism of silo working and, in doing so, identify where future attempts to improve partnership working should be targeted.

Conclusions

This paper has explored the themes that emerged from the use of action learning to engage multi-agency staff operating under different occupational goals and cultures in the development of a manual and training package for PolQuest, a new police custody mental health questionnaire. As a research team, we found the use of the action learning methodology to be instrumental in ensuring that our key research objectives were met and rooted into new practice developments by creating materials directly relevant to their intended end-users. By consensus, we created a health and justice pathway for mentally disordered offenders in police custody which informed both officers and health professionals on the safer management of this vulnerable group. When implemented, the materials developed through our action learning groups are expected to address a number of the key service delivery problems described earlier in this paper, including ensuring adequate screening for mental health problems in a vulnerable population, enhanced awareness and training in mental health for police and timely access to services around the clock.

Upon reflection, our findings have also revealed the utility of action learning for encouraging dialogue between multi-agency stakeholders resulting in wider benefits for collaborative working outside of the primary project objectives. Five key themes emerged from reflecting on the action learning process, all were considered to be important considerations for undertaking action learning groups with multi-agency membership. There were a number of challenges that arose, notably difficulties in securing regular engagement from some agencies; addressing the fear that introducing PolQuest into the custody system would be catastrophic in terms of the time required and potential hold-ups to justice processes; and encouraging individuals to take ownership in the development of meeting outcomes. However, once immersed in the process, those who attended regularly proved themselves to be committed and willing to share solutions to jointly held problems.

When attempting to engage multi-agency staff in a project, consideration must be given to how best to communicate the mutually beneficial value of participation. Our experience demonstrates the need to appreciate fully both how a single intervention operates within, and impacts upon, the system as a whole, and also the importance of remaining solution-focused to achieve progress. Strategies to avoid getting stuck on a single issue were invaluable to the process. However, as a limitation, some issues were found to require more lengthy discussion than was available within the research time frame and impacted upon matters that went above and beyond the group’s key objectives, such as issues surrounding information sharing protocols and adequate access to Appropriate Adult services. Reflection of the group’s dynamics revealed how the presence or absence of a single individual could completely change the tone of individual meetings. Regular members were able to strengthen their partnerships more generally, resulting in wider personal and professional benefits and a sense of pride in the outcomes they achieved. The action learning method proved valuable for encouraging multi-agency collaboration and achieving quick and relevant outcomes. In the area of policing and mental health provision, where multi-agency collaboration is essential, it may be beneficial for services to consider integrating the principles of action learning into standard practice in an effort to break down the barriers that obstruct and slow down partnership working.

The action learning group members successfully produced an implementation manual for PolQuest, along with training materials, however, the piloting of PolQuest was not an objective of the action learning group. A future study will pilot PolQuest, along with the implementation manual and training package, with an aim to evaluate the impact on service development, the health outcomes of service users and adaptability for areas with different service models.

Footnotes

Acknowledgements

The authors wish to thank the members of the action learning group for their dedication and contributions to the overall project. Additionally, we are grateful to Dr. Svante Lifvergren and the anonymous reviewers for their constructive comments, which greatly contributed to improving the overall quality of this paper. Should there be any comments/reactions you wish to share, please bring them to the interactive portion (Reader Responses column) of the website: .

Ethics

Ethical approval was granted by the NHS National Research Ethics Committee North West (11/NW/0120) and governance approvals obtained from the police service and NHS Trust involved.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0808-17154). The views expressed in this paper are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Note

Author biographies

Heather Noga is a Research Assistant and PhD Student at Simon Fraser University in the School of Criminology. She was previously a Research Assistant for the Offender Health Research Network, University of Manchester.

Alison Foreman is a Registered Nurse in mental health with a BSC Hons in mental health. She has worked in a local remand prison In Reach team and is currently the deputy manager for the Lancashire Mental Health Criminal Justice and Diversion Team.

Elizabeth Walsh is an Associate Professor in the School of Health Care at the University of Leeds. She is a qualified nurse with clinical, academic and practice development experience in prison healthcare settings. She is the Chair of the Royal College of Nursing, Nursing in Criminal Justice Services Forum and an Adjunct Professor at the School of Nursing, University of Ottawa, Canada.

Jenny Shaw is a Professor of Forensic Psychiatry and Academic Lead for the Offender Health Research Network at the University of Manchester. She is also Clinical Director for the Specialised Services Network and a Consultant Forensic Psychiatrist at Lancashire Care NHS Foundation Trust.

Jane Senior is manager of the Offender Health Research Network, based at the University of Manchester. She is a qualified mental health nurse with clinical and academic experience in prisons, secure, acute and community mental health settings.

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