Strong partnerships with community teams are just one of the elements needed for successful continuity of care after prison, say Jim Barnard and Avril Culley.
A seamless transition from prison to community is important for those prisoners being supported in their recovery from substance misuse. Evidence suggests that prisoners who relapse on release from custody are more likely to reoffend, resulting in a return to custody. It’s also important as people being released from prisoners are – in the first six weeks – four times more likely to overdose on opiates, resulting in high drug related deaths in this group. This is something that was recognised by Dame Carol Black’s review, which stated the importance of ‘keeping prisoners engaged in treatment after release – improved engagement of people before they leave prison and better continuity of care into the community.’ Furthermore, it’s one of the performance indicators in the public health functions agreement to which NHS England monitor compliance.
At Inclusion we are a provider of both community and prison drug and alcohol services, so we see the issues of continuity of care from both sides of the fence. We always thought we were doing this quite well until the national figures came out, suggesting that the number of people successfully continuing their treatment in the community after leaving prison was only in the mid-30 per cent range. We felt that it was a high priority to improve this, so we tasked our prison and community services with concentrating on this area. This focus was increased when the national target of 75 per cent successful transitions was announced.
Psychosocial interventions
The psychosocial intervention (PSI) pathway no longer ends when an individual leaves the prison gates – our health in justice (HIJ) psychosocial substance misuse teams are committed to ensuring their journey continues into the community when the need is identified. Our teams embraced the wider drug strategy agenda and began monitoring continuity of care, having a keen focus to support success for release – once individuals were released, we started contacting community drug and alcohol teams to follow up attendance. This gave us real-time information, which allowed us to be responsive to themes and respond to barriers affecting continuity of support and treatment.
The continuous demand on the prison population has also meant that the majority of sites have seen an increase in the number of prison releases. Given individuals are most at risk of overdose following periods of abstinence while in custody, the need for the psychosocial teams to commence effective release planning and coordination of continuity of care is crucial, and there has been an increase in the numbers of naloxone kits, training and harm reduction advice disseminated to patients prior to release.
Patient feedback
Patient feedback has been paramount to determining the next steps on this journey – our teams tried to further understand the barriers to continuity of care upon release, enabling them to respond accordingly. For example, patients feedback typically suggested they would like to meet their community worker prior to release, and our teams where possible were able to support community prison link workers accessing the prisons to meet people as part of their release planning process.
Supporting and coordinating specialist community staff to access the prison to provide a collaborative seamless approach to care has seen an increase in the number of patients attending their community appointments following release.
Alongside this, since the pandemic the prison substance misuse teams are seeing an increase in the demand for support with alcohol and non-opiate substances, mirroring drug trends in the community. We’ve implemented collaborative non-opiate patient release pathways, which include obtaining an appointment upon release and a stringent transfer of care for this population.
Another example relates to feedback around the length of time elapsing between release and a community appointment – it was recognised that an increased period of time until the appointment corresponded to lower attendance rates.
Community teams
Our teams made a conscious effort to strengthen our excellent connections with community teams, which has supported joint working and outreach for those individuals who do not attend. Prison leads met with community leads to review the continuity of care process, sharing ideas, innovation, and physically cross referencing each individual release each month to provide assurance regarding the accuracy of the NDTMS data.
They have been collectively working with teams in the community to strengthen this pathway, and working alongside OHID to complete data exercises to improve accuracy and overall support for the people in our care. Consideration was given to how our services can replicate the community model – providing assurance that the people in our care in custody had access to the same quality of care, as well as accessibility to a varying range of interventions. Staff feedback was also compiled, and further training and guidance provided to teams to support the transitional NDTMS data metrics compilation.
Service user pathway
Another area of development included the service user pathway for remand prisoners. Our teams linked with communities to ensure continuity of care for court releases, which included educating remand patients on this pathway and creating discharge packs for those attending court. These responded to service user feedback and positively promoted patient choice, identifying treatment/support options available following release from custody.
The standardised PSI pathways have also strengthened how our services respond to need and how our services engage individuals at different stages of their recovery. These pathways embed evidence-based interventions that provide structure and guidance, and strengthen recovery capital in preparation for release. We recognised that our patients at different stages of their recovery require varying levels of support and intervention. We developed needs-led, strengths-based interventions within flexible service user pathways. Our HIJ teams recognised that preparation for release must begin as soon as a prisoner arrives in custody, with treatment plans focused on long-term recovery and continuity in the community.
Collaborative approach
Within our Yorkshire and West Midlands HIJ sites we saw an impressive increase in the number of individuals attending their community appointments. Last quarter, the cumulative average from local data of individuals engaging with the community treatment providers and continuing on their recovery journey following release increased to 72 per cent for Yorkshire prisons and 69 per cent for HMP Hewell, West Midlands – given the current national average is approximately 37 per cent, these results highlight the effectiveness of a collaborative approach to recovery.
However these statistics are not always being replicated by the national figures, which we think is a problem for many services nationally. For instance, from following up all service users who left HMP Hewell it was found that 83 per cent had attended their appointment in Telford, while the national statistics put Telford at around 41 per cent in terms of successful transition. We think this may be partly the result of people being discharged to a different locality initially and so not showing up on our data or theirs. We are also aware that this is an issue that affects many services where the actual successful transition rate is much higher than the national data would suggest.
We feel that the target of 75 per cent successful transitions as achievable, but that the problems with how the data is collected will need to be resolved first. We are shortly meeting with NDTMS to try to begin resolving this.
Jim Barnard is deputy head of operations for community drug and alcohol services and Avril Culley is deputy head of operations for health in justice services at Inclusion.