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Chapter 4: Engaging with Transitional Care

Introduction

The previous chapter provided an overview and professionals' perspectives on the organisational and operational arrangements for Transitional Care. This chapter examines the extent to which ex-prisoners engaged with Transitional Care by taking up the offer of up to three appointments following their release and considers the perceived barriers to accessing Transitional Care. First, however, an overview of the characteristics of ex-prisoners referred to Transitional Care is presented.

The characteristics of prisoners referred to Transitional Care

Sex and age

Monitoring data were available in respect of 4794 ex-prisoners for whom a Transitional Care monitoring log had been completed ¹³. This included 4231 men (90%) and 478 women (10%). The sample varied in age from 16 to 79 years, with a mean of 28.4 years. The proportions of ex-prisoners in different age groups within this range is illustrated in Figure 1.

Figure 1: Age of Those Referred to Transitional Care

Ethnicity

The ethnicity of ex-prisoners was recorded in 4091 cases. Preliminary analysis suggested that 86% of the sample was white, which appears low in relation to the known ethnic composition of the Scottish prison population. For example, in 2003 ethnic minority groups represented only 2% of the total prison population (including persons awaiting deportation who would not be eligible for Transitional Care) (Scottish Executive, 2004). Further inspection of the data indicated that only 11 ex-prisoners were identified as being black, Asian or Chinese while 559 cases had their ethnicity recorded as 'other'. It is assumed that the 'other' category was being used when the ethnicity of the ex-prisoner was unknown. With these cases removed, almost 100% of ex-prisoners were identified as being white. Clearly, the very small number of ex-prisoners of known ethnic minority status prevents any further analysis of take-up of Transitional Care and ex-prisoners' needs by ethnicity.

Employment

The employment status of ex-prisoners prior to imprisonment was recorded in 1998 cases. As Table 5 indicates, the majority of prisoners (95%) were unemployed when they received their custodial sentence and in most cases had been unemployed for more than one year.

Living situation

Information about who the ex-prisoner was living with before being imprisoned was recorded in 2252 cases. Around two-thirds of the sample were living alone or with parents (Table 6). The percentage of ex-prisoners who were living with children appears very low. It is assumed that this reflects the categories included on the monitoring form, the design of which did not enable ex-prisoners to be recorded as living both with dependant children and with other adults and that those recorded as living with dependent children were living with children alone.

The type of accommodation to which ex-prisoners expected to return was known in 2968 cases. The relevant data are summarised in Table7. More than one third were recorded as being of no fixed abode. However, others - for example those living in hostels or with friends - were also likely to be returning to temporary living arrangements. As shall be seen, this high level of housing insecurity is reflected in the high level of identified housing needs among those who took up the offer of Transitional Care. This is also evident from other studies ( e.g. Reid-Howie Associates Ltd, 2004).

Women were slightly, though not significantly, more likely than men to be returning to local authority housing (45% compared with 38% of men) but the percentages of men and women who were described as being of no fixed abode were similar (35% and 31%). Accommodation status appeared to be unrelated to age: for example the percentages recorded as being of no fixed abode were similar for those under 25 years of age and those aged 25 year or older (34% and 35% respectively).

Region to which returning

Details of the regions of Scotland to which ex-prisoners were returning were available in 2868 cases (Table 8). The most common destinations on release were Glasgow City, Tayside, Lanarkshire and Ayrshire. Despite Edinburgh being the second largest city in Scotland, a relatively low percentage of ex-prisoners were planning to return there on release.

Transitional Care service provider

The agency responsible for providing Transitional Care in the area to which ex-prisoners were returning was recorded in 2897 cases (Table 9). Transitional Care was being provided in just under one half of all cases by two agencies - SACRO and Cranstoun.

Take-up of Transitional Care

Interviews with Transitional Care staff and scrutiny of the Cranstoun audit of Transitional Care conducted in 2003 suggested that the take-up of the service was relatively low. Further information about the take-up of Transitional Care was provided through the monitoring data collected by Cranstoun and through the survey interviews conducted by TNS. The latter additionally explored the reasons for not taking up the offer of Transitional Care, as did the in-depth interviews conducted with 37 ex-prisoners.

Contact with prisoners prior to release

The Transitional Care worker who would be working with the client in the community was expected to attend at least one pre-release case conference with the client. It was believed that this face-to-face contact would increase the likelihood of the client attending appointments post-release. In practice, these meetings did not always happen. In some cases, remand prisoners had been released before a meeting could be arranged. In other cases, Transitional Care agencies sent just one member of their team to attend case conferences in prisons at some geographical distance - so the client may not have met the worker to whom they were assigned upon release.

Of the respondents interviewed at the four-month stage, 64% said they had met their Transitional Care worker while they were still in prison, 23% said they had not and 13% did not know/could not remember. There is clearly a possibility that some respondents may forget having seen a Transitional Care worker, or be confused about who works for which agency. Of the 47 individuals who claimed to have seen a Transitional Care worker post-release, nine are shown in the Cranstoun monitoring data as not having attended any appointments. Of the 123 who said they did not see a Transitional Care worker post-release, the monitoring data indicates that 10 did attend at least one appointment. ¹⁴

Nine of the 37 respondents who participated in the qualitative interviews could not recall having received any publicity about Transitional Care whilst in prison, although the majority remembered either seeing leaflets or posters or receiving a talk about the service as part of their induction process on admission. This publicity was seen as helpful at the time, but on reflection several suggested that it could be improved. Some respondents said they also talked about Transitional Care with other prisoners - indeed a couple of respondents said they strongly recommended it to other prisoners, whilst one mentioned discussing the possibility of Transitional Care with the prison social worker.

On the basis of the qualitative interviews, Polmont and Dumfries seemed to fare the best on the number of visits to prisoners by Transitional Care staff whilst Barlinnie prisoners recorded less visits overall. However, the number of visits obviously depended on the length of sentence, whether or not the visits were requested by prisoners or automatically initiated by caseworkers and whether the prisoner required or requested ongoing support. Furthermore different regimes were reported to operate in different prisons in relation to visits and access to prison-based services. For example, one man on remand recollected waiting two weeks for a caseworker to visit him after filling in a 'request form', whereas others could request such a visit at very short notice. Several respondents also suggested that the culture within particular prisons might not always have been conducive to visits from outside agencies.

The only qualitative interview respondents who thought they did not receive an assessment while in custody were two in Barlinnie and one in Low Moss. Otherwise, there did not seem to be any apparent differences in the type or frequency of contact between prisoners and Cranstoun caseworkers depending on which prison they were held in prior to release. Nor were there differences in respondents' perceptions of the quality of service provided according to where they were held.

There was, however, a lot of confusion amongst respondents about who exactly visited them in prison or who referred them to which agencies on release, as illustrated by the following quote:

"… the Straight Out Project, they helped me because they came to see me in prison and when I got out [Researcher: Was it Transitional Care that referred you to Straight Out?] No, I think they just visit any 16-25 year old that's getting out of prison in Renfrewshire area… I was supposed to be with SACRO as well but they just mostly do the same thing as the Straight Out Project. I couldn't be bothered going to all these places if I was just going to sit and say the same thing. Because that's what they were doing every week before I [was released], they were all coming down and telling me the same and asking me the same thing, I was like 'no!'."

A few respondents felt that their one-off visit from a caseworker did not constitute an assessment as such, but was seen more as a 'courtesy call'. For example, one respondent indicated that he was told to phone Cranstoun if he needed assistance on release; another told the caseworker that he did not need any help; a third implied that he was only seen to agree to participate in the research ("Just got to sign a bit of paper saying I would do this for a tenner and I said 'aye, no bother"); and a fourth was told by the caseworker that he would return to assess his needs nearer to the date of his release but failed to do so:

"[The Cranstoun worker] didn't say much, no. Just asked if I had alcohol problems… He said he'd be back in touch but never got back in touch… He was gonna see me before I was released, but never."

It was a common view amongst the qualitative interview respondents that Cranstoun caseworkers did not fulfil their promises.

There seemed also to be a lot of confusion amongst prisoners about who was providing which service. Some suggested they were 'assessed' by several visitors. That said, the vast majority thought that their assessment was realistic and helpful, not only in identifying their needs, but also in enabling them to talk through problems with somebody who seemed genuinely keen to help.

Complaints about assessment included the timing (too soon after admission to have got over initial withdrawal) and the fact that it was sometimes perceived to be service- rather than needs-led. For example:

"[Cranstoun] said they could try and do this and that [in relation to housing], but I was trying to explain to them I'm no interested in the housing. It's the drugs I need, I need help with the drugs… when I got the answer that I wasnae getting help with drugs, it kinda, I wasnae bothering… I told him about the drugs, eh, he was asking me about reading and writing and that's what was annoying me, I said I'm no here for reading and writing, I want help with drugs. I need help with drugs and that's what I thought it was all about. He was asking me stupid questions that I'm not interested in."

One respondent who had not had the opportunity to see a Transitional Care worker in prison expressed reluctance at having to provide information as part of the assessment for Transitional Care, only to have to repeat this again with another worker when released. Another respondent in an area where the Transitional Care workers were based in the prison, indicated that he found it beneficial to have met the worker in prison, and to have the opportunity to maintain that contact following his release. A third respondent who was in contact with a separate service (the Straight Out Project) had decided to maintain contact with this service on release rather than taking up Transitional Care. The importance of continuity appeared to be important for some respondents. As one respondent commented

"I put in to see them (Transitional Care) when I first came in and saw somebody two days before I got out, that was the first time I saw somebody".

Attendance at Transitional Care appointments

Despite practical difficulties in collating accurate information on the percentage of clients attending first appointments from the monitoring data, when all the data files were merged it was found that 28% of ex-prisoners had attended their first Transitional Care appointment following release from custody. Attendance at subsequent appointments declined steeply, though more one half of those who attended a previous appointment attended the subsequent one (Table 10). These data were consistent with the survey finding that 27% of respondents said they had seen their Transitional Care worker at least once after release while 70% said they had not and 2% did not know/could not remember. While the take-up rate may not appear high, it is widely recognised that voluntary take-up rates of services by this client group are low. Whilst it is difficult to make a direct comparison with other studies, Burrows et al. (2001) found that only a third of prisoners had sought help from a drug service following release, with many of them making contact with a service they had been in contact with before being imprisoned, while Hickman at al (2004) estimated that between 16 and 22% of intravenous drug users in three English cities were receiving structured treatment.

The reasons for non-attendance at Transitional Care appointments recorded in the monitoring log are summarised in Table 11. In the majority of cases the reasons for non-attendance was not known, but this is not surprising given that the majority of clients referred to Transitional Care had no post-release contact. A return to custody and/or being arrested accounted for the majority of known reasons for non-attendance. Indeed, in total, being returned to custody or arrested accounted for 10%, 15%, 18% and 17% respectively of known non attendance over the four appointments included in the monitoring data. Being arrested or being returned to custody becomes particularly prominent after the first appointment. This finding would seem to support staff concerns that outstanding offences appeared to be a motivational barrier preventing some clients from engaging with the Transitional Care service.

Many offenders who were offered Transitional Care had outstanding charges. This, it was suggested by staff, could influence their motivation to engage with services or could result in work undertaken by Transitional Care staff being 'undone' as a result of the client receiving a further custodial remand or prison sentence. There were reports of clients being liberated, engaging with services and making progress and then finding themselves in court some time later for an 'old' offence. Many staff therefore suggested that if a mechanism could be established for outstanding offences to be 'rolled up' and dealt with all at once, this could improve the motivation of some clients to engage with Transitional Care and the community-based services into which ex-prisoners were linked.

Further data on reasons for non-attendance were provided by the ex-prisoner survey. Of respondents in the quantitative survey sample, just over half (n=26 out of 48) of those who saw their worker post-release said they had attended all of the appointments made with them. The most common reasons for not attending appointments are shown in Table 12. The responses are from respondents who had not attended any appointments and those who had attended at least one, but not all appointments.

Base: 149 (Those who did not attend any appointments and those who attended at least one but not all appointments)
Source: 4 month data

Although there was no difference in attendance between those who had met their worker pre-release and those who had not, those who had not met their Transitional Care worker prior to release were more likely to say their reason for not attending was that they had not received an appointment (n=21 out of 33 who had not met their worker compared with 34 out of 94 who had).

Some respondents indicated that despite having an appointment made for them to attend on release, continued drug use had deterred them from attending. For example, from the in-depth interviews, it was clear that in some cases, respondents left prison and were engaged in drug use immediately or very shortly after release. As a result, if appointments had been arranged to put them in contact with Transitional Care agencies or related services, the respondent considered there was little point attending if they had resumed their drug use.

However most of the 15 qualitative interview respondents who said that they heard nothing from Transitional Care after they were released said that they had been told while in prison that that a Transitional Care worker would ring them to arrange an appointment but that this had not happened. As one ex-prisoner commented ,

"the last thing they said [was] they would contact me, but I'm still waitin".

The fact that the single most common reason for non-attendance was simply not receiving an appointment (regardless of meeting the worker pre-release), suggests that the process for engaging the client at the outset needed to be improved.

For those who declined to attend Transitional Care on release, the main reason given was that they felt at the time of release that they no longer needed any help. Several qualitative interview respondents cited this as a reason for not pursuing the service:

"She [Transitional Care worker] was gonna help us get a job and that, but I ended up getting a job straight away when I got out… So I didnae get time to go in and see her… I just phoned her up and said 'well, I've got such and such a job'… They are quite willing to help if you're… it would be very useful for somebody that definitely need it. I just didnae happen to need it when I came oot but if somebody needed it, she's good."

Attendance and age

There was found from the monitoring data to be an association between age and likelihood of attending an initial Transitional Care appointment. The mean age of those who attended appointments was higher than that of those who did not (29.3 compared with 28.0 years) ¹⁶. Similarly, the percentage of those under 25 years of age who attended appointments was significantly lower than the percentage of those aged 25 years or more who did so (25% compared with 30%) ¹⁷. The lowest attendance rate was found among those under 21 years of age (23%). The attendance rate increased with age, with 37% of those over 40 years of age attending their initial Transitional Care appointment. In line with the analysis of the monitoring data, the survey findings suggested that older respondents were more likely to attend. However, the number of older respondents was too small to allow any robust analysis of this issue.

These finding supports staff perceptions that young people appeared less inclined to engage with the service and attend post release. Many staff felt that the 'model' of intervention was not the most appropriate for young people with substance misuse problems, for whom a more proactive and supportive approach might be required.

Attendance and gender

From the monitoring data, attendance rates at first appointment amongst men and women were not significantly different at 28% and 31% respectively. This is contrary to the perception of Transitional Care staff that women were more reluctant to engage with the service.

Attendance and housing

The relationship between anticipated accommodation status on release and attendance at initial Transitional Care appointments was examined using the monitoring data. It was found that those who were recorded as being of No Fixed Abode were significantly less likely to attend appointments (24%) than those who had local authority housing (43%) or who had other living arrangements (46%). This is consistent with the view expressed by staff that it was particularly difficult to engage those who had no fixed address with Transitional Care on release.

Attendance and participation in pre-release case conferences

There was a perception on the part of staff that clients who received a pre-release meeting with an identified Transitional Care worker and who participated in a pre-release case conference were more likely to attend appointments in the community when released. In practice, however, this contact appeared to have little effect upon actual attendance rates. Examining the relationship between case conference and attendance at Transitional Care appointments was not, however, straightforward. First, the relevant information was not recorded on the monitoring log for much of the period under consideration, only being introduced in October 2003. Second, attendance at a case conference was not recorded as a discrete variable but rather was linked to identified needs. For example, it was possible to identify, from October 2003 onwards, whether ex-prisoners who were assessed as having particular needs had had a case conference in relation to each of these needs.

Comprising attendance rates according to whether or not a pre-release case conference had been convened produces somewhat different findings across different domains of need. In most domains (see Chapter Five) there was no apparent association between case conferences and subsequent attendance. However, a significant difference was found in the attendance rates of those with an identified health need who did and did not have case conferences. Contrary to the perceptions of staff, 45% who were recorded as having had a case conference attended their initial appointment compared with 54% of those who had not ¹⁸. On the other hand, attendance was more likely among those with an assessed financial need/benefits need who had a case conference than among those who did not (51% compared with 45%) ¹⁹.

These data would appear to suggest that the pre-release case conference has a less important role in encouraging the take-up of Transitional Care in the community than had previously been assumed. Indeed, an absence of association between participation in a case conference and engagement with Transitional Care was also found in the survey of ex-prisoners: those who had seen their worker in prison were no more likely to attend after release than those who had not seen their worker in prison. Yet, as we shall see, there was also evidence that the Transitional Care scheme that provided the greatest degree of continuity in terms of staff support in prison and in the community (Cranstoun in Dumfries and Galloway) also achieved the highest post-prison attendance rates. More generally, workers who had made themselves known to respondents while they were in prison and following release were viewed positively and proactive intervention was generally appreciated, particularly in relation to arranging appointments with welfare agencies. In one case, the support provided by the Transitional Care worker was viewed as the 'best thing' about Transitional Care:

"to me he is a very helpful person and he'll go out of his way to help you".

Attendance and local authority area

Table 13 summarises the attendance rate for first appointment by local authority area, the percentage of clients from each area and the Transitional Care partner operating in that area. As Table 13 illustrates, there were considerable differences between attendance rates across local authorities and Transitional Care providers. Six local authority areas had an attendance rate of over 40%. Dumfries & Galloway (Cranstoun) had the highest attendance rate, followed by West Dumbartonshire ( SACRO), Inverclyde ( SACRO), Dundee city (Cyrenians), North Ayrshire ( SACRO) and Highland ( SACRO).

All other local authority areas account for 1% or less of the total client numbers.

There would appear to have been some association between attendance rates and the geographical accessibility of the Transitional Care service. Many agencies which covered rural and semi-rural areas reported difficulties in finding suitable meeting places for client appointments. It was often the case that their office base was some distance away from potential clients. For example, SACRO had an office in Edinburgh but covered the East, Mid and West Lothian local authority area. This meant clients had to travel into Edinburgh or SACRO had to find a suitable meeting area nearer to the clients' home. Similarly, CLCS covered North Lanarkshire, Falkirk, Stirling and Clackmannanshire. CLCS had a low percentage of total clients and low attendance figures, however their figures for North Lanarkshire, where their office was based, were higher than for the other areas they covered. The Cyrenians, based in Dundee, also covered Angus and Perth and Kinross. Their attendance rates were higher in Dundee city than either of the other two areas.

Cranstoun workers covering Dumfries and Galloway and Borders also reported experiencing difficulty in finding suitable accessible meeting venues. However, while attendance rates for the Borders were very low, attendance rates for Dumfries and Galloway were high. Some areas, notably Glasgow, were also affected by a change of office accommodation for Transitional Care staff, which was thought to have affected the level of contact with prisoners on release. As one respondent explained:

"She said somebody would get in touch with you after a few months of coming out of prison… Cos they were starting up a [new] office somewhere… I never had any information. There was no phone number or anything like that. I didnae know where they were… All she told me was that they were starting an office down from [street name]. I went away doon there a few weeks ago. I went into the social work department… They said they're no in here."

Both pre-release and post-release accessibility of Transitional Care may impact on the uptake of service. In terms of pre-release accessibility, the level of informal contact with potential clients may be a relevant factor. Some penal establishments were able to allow caseworkers and Transitional Care staff greater access than others. Staff reported better access to prisoners in Dumfries, Greenock, Cornton Vale, Low Moss and Perth. Conversely, staff felt that in some penal establishments, for various reasons, formal or informal access to prisoners was more difficult to achieve: Aberdeen, Barlinnie and Edinburgh were all viewed in this way by caseworkers. For example, although the Throughcare Centre in Edinburgh was perceived to be advantageous for co-ordinating a prisoner's pre- and post- release care, it was also thought to have brought about a reduction in opportunities for informal access to prisoners in workshops or halls.

Attendance and penal establishment

Table 14 shows the percentages of clients coming from different penal establishments and the attendance rate for first appointments. Attendance at first appointment varied considerably between establishments with some - such as Dumfries (61%), Kilmarnock (43%), Perth (42%), Greenock (37%) Inverness (37%) - all having higher than average rates of attendance at first appointment.

All other penal establishments account for 1% or less of the total client numbers.

Some prisons held prisoners from across Scotland (for example, Polmont, Cornton Vale) while others catered for a much more local population. It was suggested by staff that geographical distance impacted on the ability of Transitional Care staff to meet with prisoners prior to release and that this in turn could adversely affect attendance rates when prisoners were released. However, there was no evidence that attendance rates were lower among prisoners in establishments with a wider geographical catchment area. This, along with the case conference data, suggests that pre-release contact may be less important for engaging prisoners with Transitional Care than had previously been supposed.

Edinburgh is worthy of special mention as it is the second largest city and it appears to have had one of the lowest uptakes of Transitional Care. HM Prison Edinburgh has a largely local population, with the vast majority of prisoners coming from Edinburgh City followed by West Lothian, Mid Lothian, Fife and East Lothian. The staff working across Edinburgh and the Lothians reported difficulties in accessing clients both prior to and following release - possibly because many prisoners accessed pre-release services via the well-established Throughcare Centre - and this may have impacted on attendance at Transitional Care.

Summary

Monitoring data were available in respect of 4794 prisoners who 'signed up' to Transitional Care while in prison. The mean age of ex-prisoners on release was 28.4 years and 90% of the sample was male. Most prisoners (95%) were unemployed when they received their prison sentence and many (35%) were recorded as being of no fixed abode. Ex-prisoners were most commonly returning to Glasgow City (24%), Tayside (10%), Lanarkshire (10%), Ayrshire (9%) and Grampian (9%).

Twenty-eight per cent of prisoners were recorded as having attended their first Transitional Care appointment on release, 15% attended a second appointment and 8% attended a third appointment. Survey and interview responses indicated that those who attended Transitional Care appointments were positive about the service they received.

Attendance rates at first appointment were similar for men and women, but ex-prisoners under 21 years of age were least likely to attend and, consistent with staff perceptions that they were more difficult to engage with Transitional Care, attendance rates were lower among those who were of no fixed abode.

Sixty-four per cent of those interviewed at 4 months said they had met their Transitional Care worker while they were still in prison. There was, however, no evidence - either from monitoring data or the survey - that attendance at a pre-release case conference increased the take-up of Transitional Care. However, geographically, the highest attendance rate at first appointment was in Dumfries and Galloway, where the same Transitional Care workers provided a service in the prison and in the community.

Arrest or return to custody accounted for most instances of non-attendance where the reason was recorded in the monitoring database. Those surveyed indicated that the single most common reason given for non-attendance was not receiving an appointment while in custody or following release. Ex-prisoners who had not seen their worker prior to release were more likely to give 'not receiving an appointment' as a reason for non-attendance, suggesting that mechanisms for engaging clients could be improved.

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