RECONNECT – Care After Custody

LTP Priority: Wider social impact: Health and justice interventions

Population Intervention Triangle: Segments (link to Section 1 PHE PBA): Service

Type of Interventions: RECONNECT – Care After Custody

Major driver of health inequalities in your area of work

For many people, release from prison is a crisis point. They are leaving a secure environment where their needs (health, housing etc) are met, and moving to an environment where, not only are they responsible for themselves, however they may have interrupted care pathways and are often without accommodation. They move from a supported and regimented environment to one with little or no support and uncertainties. As described in Revolving Doors publication The Rebalancing Act 2017 , prisoners display “Low levels of help seeking behaviour: distrust of services, linked to previous negative experiences of contact with statutory services, such as being taken into care, was identified as a barrier in accessing healthcare services in interviews with recently released prisoners.”

As long ago as the 2009 Bradley Report ,it was recognised that where people have been accessing treatment in prison, it is important to ensure that we continue to engage with them once they leave the prison. Bradley stated “If prisoners get the support they need inside prisons they are more likely to engage with services outside prison….so extra effort will be necessary to ensure that they engage with services on release”.

This finding has been repeated numerous times since 2009, however, The National Audit Office (NAO) report into Prison Mental Health Services, published in June 2017, noted: “Prisoners do not routinely receive continuity of care on release, making successful rehabilitation more challenging. It is important that prisoners have good continuity of care between prison and the community. Over half (57%) of prisoners sentenced in 2016 were sentenced to less than one year, and most will serve half their sentence in prison, and half in the community. It can be challenging for prison healthcare and Community Rehabilitation Companies to establish links with community health teams, particularly when a prisoner is released far from their home or at short notice”.

In February 2016, the Mental Health Taskforce in their Five Year Forward View for Mental Health concluded that “… many people living with mental health problems struggle to get the right help at the right time, and evidence-based care is significantly underfunded”. This makes it difficult for people who have left prison to access the services that they need, especially when they have other vulnerabilities.

A recently commissioned deep dive by the Cabinet Office Implementation Unit (IU) in to Continuity of Mental Health Care from Prison to Community also identified a gap in continuity of service provision for those leaving prison. The IU concluded: “there are not yet any clear national pathways to help plan ongoing care when offenders leave prison, there is no organisation with a clear statutory duty to ensure continuity of care for those leaving prison”.

The Drug Strategy 2015 also recognises the need for better continuity of treatment for offenders on release into the community stating “We are working with local commissioners to develop community-based health treatment pathways. These mean that offenders can access appropriate treatment at any point of their journey in the criminal justice system – from the police station through community sentences and after release from prison”.

The Government, in August 2018 published their Rough Sleepers Strategy, which builds upon the Rough Sleeping Initiative that was announced in March 2018. It brings all of government together to deliver a new system built around three core pillars: Prevention, Intervention and Recovery. This is a system that has prevention at its heart: it identifies timely support to tackle mental health and substance misuse issue as key to reducing homelessness.

The Governments Female Offender Strategy aims to make custody as effective and decent as possible for those women who require custodial sentences. Women are more likely to reoffend after short prison sentences (70.7% of adult women and 62.9% of adult men released from custody between April to June 2016 following a short custodial sentence of less than 12 months reoffended within a year) therefore they require a special focus to make custody and the health gains made in custody effective. Any Care After Custody provision should ensure that the health needs of women are addressed.

Female offenders can be amongst the most vulnerable of all, in both the prevalence and complexity of their needs. Many experience chaotic lifestyles involving substance misuse, mental health problems, homelessness, and offending behaviour – these are often the product of a life of abuse and trauma. It is unlikely that these issues will be completely addressed whilst in custody on short sentences.

Target groups

Deprivation, Inclusion health group (Inclusion Health has been used to define a number of groups of people who are not usually well provided for by healthcare services, and have poorer access, experiences and health outcomes. The definition covers people who are homeless and rough sleepers, vulnerable migrants (refugees and asylum seekers), sex workers, and those from the Gypsy, Roma and Traveller communities.).

Intervention

RECONNECT – Care After Custody

Description

By providing a navigator service upon release, we are seeking to prevent a return to ill health as well as a reduction in reoffending. By preventing this decline in health through robust reconnection with health services in the community we will reduce health inequalities in this vulnerable patient group and encourage them to take personal responsibility for their own healthcare needs.

Evidence

Commissioning of health services for offenders are divided between CCGs, local authorities and NHS England. NHS England are responsible for the mental health, substance misuse and physical health needs of offenders whilst in the prison, whilst CCG’s are responsible for the MH and physical health needs of those within the community. Additionally, the Local Authorities are responsible for the substance misuse needs within the community. Increasingly services within the community are coming together to work in Sustainability and Transformation Partnerships (STP), and Integrated Care Systems (ICS).

NHS England recently published a new service specification for MH in prisons which places a responsibility on the prison MH provider to undertake routine follow-up to assess whether people who have received mental healthcare in prison continue to receive care on release, however this is not a service, and is just good practice.

Typically, the planning for support for a prisoner with mental health issues as they move into the community will involve a minimum of five different organisations – the prison mental health care provider; the Offender Management Unit (OMU); the Community Rehabilitation Company (CRC) or probation; the community mental health provider, which is often different to that in prison; and the offenders GP. Many will also receive substance misuse and housing support. The sheer number of organisations with a responsibility for planning support through the gate and transfer of mental health care creates barriers to effective care coordination. Each handoff is an opportunity for information to be lost, trust to break down between prisoner and provider, and create a delay in care planning.

In their paper From Prison to Work (2018) The Centre for Mental Health recommended that “…{there}should be a tailored, wrap-around approach that supports a person through the prison gate and into the community.”

The Cabinet Office IU clearly note “…for many people, release from prison is both a crisis point for mental health and the precise point where mental health support is at its weakest. For prisoners with severe and enduring mental illness who are on a Care Programme Approach, their appointed care coordinator has responsibility for continuity of care as they leave prison. This only covers ~30% of prisoners with severe and enduring Mental Health conditions.

For the rest, there is no one organisation that is responsible for care through the gate. Prison MH providers have no duty, and no capacity, to provide outreach to patients leaving prison. GPs in principle have the responsibility of receiving referrals from prison MH and referring on to MH support in the community, but many prisoners are not registered with GPs, and for those that are, they need to get a GP appointment to begin the referral process.

Probation and CRCs are the only organisations that do have a duty of care through the gate, but they have no contractual responsibilities around health care, and no levers to influence health providers except discretionary support they might offer people in terms of setting up appointments.

The Public Health Outcome Framework (PHOF) indicator 2.16 is a national indicator that measures continuity of care for people with a substance misuse treatment need who are released from prison and are referred to, and subsequently engage with, a community treatment provider.

Continuity of care of substance misusing offenders between prisons and community treatment is also a key service outcome in Service Specification 29 (Public Health Services for Children and Adults in Secure and Detained Settings in England) and is therefore one of the performance indicators in the public health functions agreement (Section 7A) to which NHS England is held to account.

Current PHOF indicator 2.16 and section 7A data provides evidence that successful transfer of offenders to substance misuse treatment in the community is low (30%).

The current picture for those with ongoing health needs leaving prison, continuity of care means little more than being told to register with their GP and receiving a referral letter in hand to present to their new GP when they get an appointment. Whilst this is changing with  the roll out of the new HJIS system (Offenders will be allocated a GP prior to release) there is still a gap in continuity of care for those who are unable or do not have the capacity to make and attend appointments without support.