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Chapter 5: Effectiveness of Transitional Care

Introduction

The key outcome by which the effectiveness of the Transitional Care initiative is to be evaluated is the extent to which it facilitates access to pre-existing community services, based on an individual's assessed needs. This chapter examines how successful the Transitional Care initiative was in this respect and whether this translated into more distal outcomes such as reduced drug use and offending and improved health. First, however, the needs of prisoners on release are discussed prior to considering the extent to which they had been met.

Ex-prisoners' identified needs

In order to assess whether or not Transitional Care was making a difference, respondents at the four-month stage were asked about their needs since leaving prison and respondents at the seven-month stage were asked about current needs. They were asked whether they needed help or advice in the following five areas:

• Housing.
• Education, training or employment.
• Benefits or money.
• Health, or drug or alcohol use.
• Issues to do with partners, children or other family members.

These specific areas were chosen because they fitted with the domains covered by the assessment tool used by caseworkers and Transitional Care workers to assess clients' needs. Where respondents indicated a need in a particular area, they were also asked what particular help or advice they thought they needed (mainly in terms of links with services).

Areas of need

The areas in which survey respondents most commonly said they needed help or advice are shown in Figure 2.

Figure 2: Areas in Which Respondents Said They Had Needed Help or Advice

Bases: 175 for 4-mth data (all respondents), 222 for 7-mth data (all respondents)
Source: 4mth and 7mth data

Not surprisingly, given that these individuals were all identified as substance misusers, the most frequently mentioned issue at the four-month stage was help in relation to health, drug or alcohol misuse (and, more specifically, "an appointment with a drugs agency or information on a drop in centre" and "an appointment with a GP"). Housing was mentioned by half the respondents at the four-month stage and was the most common need at the seven-month stage. The most common needs in this area were "an appointment with the housing officer" and "your name on the council waiting list". This backs up the perception of caseworkers and Transitional Care staff that housing and drug services were most in demand.

A relatively high proportion of respondents (38% at the four-month stage and 42% at seven months) said that they had needed help or advice in relation to education, training or employment. This contrasts somewhat with the perceptions of staff who suggested that (other than for young offenders) education, training and employment were longer-term aims. However, there are three points worth noting here. First, respondents were not asked to prioritise their needs - education, training or employment may have been a 'need' but a less pressing one than health or housing needs. Second, respondents were asked about needs 'since leaving prison' (at the four-month stage). They were interviewed around 16 weeks after release so 'longer term' needs may have been emerging by that stage. Third, it may be that caseworkers and Transitional Care workers have a different perception of clients' needs and of what the priorities might be. Previous research on community-based throughcare found, for example, that ex-prisoners more often identified employment and financial issues as being of concern on release from prison than did their supervising social workers (McIvor and Barry, 1998).

From the survey data there were few differences at the four-month stage between those who attended Transitional Care appointments and those who did not. The one significant difference was that those who attended were more likely to say that they had an education, training and employment need - 55% (n=27 out of 49) of those attending compared with 31% of those not. At the seven-month stage, there were no significant differences in the needs reported by those who had attended and those who had not.

Looking at those prisoners where we have data at both the four-month and seven-month stages, attenders were more likely to indicate a need in relation to education, training and employment at the seven-month stage than at the four-month stage. Those who had not attended were more likely to have needs in relation to health, drug or alcohol use and benefits or money at the seven-month stage than at the four-month stage.

The Cranstoun monitoring data were also examined in order to identify the needs of those clients who attended Transitional Care. Identified needs related to the six key domains of health (drugs and alcohol), housing, benefits and finance, education and training, employment and social issues. The design of the action plan and log did not allow for any differentiation of needs according to the first, second, third, or fourth appointments. The nature of needs and whether they changed over the course of appointments could not, therefore, be determined. It is possible, however, to report the identified needs of clients who attended at least one Transitional Care appointment following release and the proportion of clients who received notification of an appointment from a community agency within the 12 week post-release period.

In 1136 cases, the ex-prisoner was recorded as having attended at least one appointment post release. In the majority of these cases, information was also available with respect to the needs of prisoners that were identified following release by Transitional Care staff. The relevant data are summarised in Table 15.

Consistent with the perceptions of Transitional Care staff and ex-prisoners who had been referred to Transitional Care, health and housing needs were most common while needs relating to social issues and employment were least common. There were some significant differences identified in the needs of men and women on their return to the community (Table 16). More specifically, women were more likely than men to have an identified housing need, suggesting that a higher proportion of women were vulnerable in this respect when released from prison ( e.g. Scottish Office, 1998; Ministerial Group on Women's Offending, 2002). Men, on the other hand, were more likely than women to have a need identified in relation to employment, possibly because fewer women were in a position to take up employment as a result of commitments to children and other dependants.

The needs of ex-prisoners also differed according to their age (Table 17). Comparing those under 25 years of age with those aged 25 years or older, the former were significantly more likely to be identified as having needs related to education and employment.

The needs on release identified through the qualitative interviews were similar to those identified from the survey, with drugs and housing most prevalent followed by alcohol and benefits/finances. It appeared that clients who attended appointments were likely to do so if they had a pressing housing need and/or need for support in relation to drug use or health issues. However, several respondents commented that what they really wanted was to be put in contact with someone who could help them negotiate the bureaucracy of services they were likely to encounter on release ( e.g. benefit applications).

Whether needs were met

Health needs

As previously noted, a total of 654 ex-prisoners who attended at least one Transitional Care appointment were identified from the monitoring data as having a health need. Table 18 shows the number and percentage of prisoners who were assessed as having a range of specific health-related needs and the percentage of cases in which the action identified as being required had been achieved.

Table 18 indicates that the most commonly required needs among those identified as having health needs were referral to a drug agency, the provision of general information and a GP appointment in relation to their use of drugs. This suggests - consistent with the view expressed by staff - that clients' health needs at first appointment were very much related to their substance use.

Overall, 63 per cent of health-related needs were reported to having been addressed through an appointment having been made with the relevant community agency during the 12 week post-release period or through general information having been provided. Two-thirds of those who were deemed to require such a service had been referred to a drugs agency. However GP appointments had only been achieved in just over one half of the cases in which they were required.

Housing needs

Housing-related needs were, after health needs, most commonly identified among ex-prisoners. Overall, 58% of clients had a housing need identified at their first Transitional Care appointment. The specific housing needs most often identified included the provision of general information, an appointment with a housing officer and getting onto the local authority housing list (Table 19). Overall, action was reported to have been achieved in respect of two-thirds of housing-related needs identified by Transitional Care staff.

Financial needs

Thirty-one per cent of clients who attended at least one Transitional Care appointment had needs related to finances and/or benefits. The provision of general information and/or an appointment with a benefits officer were most often required (Table 20). The relevant action had been taken within 12 weeks in respect of 61% of financial needs.

It should be noted that, following changes to the Transitional Care service, this domain of need is no longer included in the Transitional Care action plan and log.. . However, the fact that almost one third of those attending an appointment had a need in this area would suggest that it is an area of concern for many ex-prisoners.

Education needs

Just over one quarter (26%) of ex-prisoners had education or training identified as an area of need. This most often involved the need for general information or referral to a training or education agency (Table 21), with action having been taken in respect of 63% of identified needs. Like finances/benefits, education/training is no longer included as a key Transitional Care domain.

Employment needs

Twenty-two per cent of clients who attended their first appointment had an employment-related need. Relevant actions included the provision of general information or an appointment with an employment agency, with these recorded as having been achieved in 59% of cases (Table 22).

Social needs

The category of 'social issues' relates to the identification of clients' needs in relation to mediation, family work, youth activity, diversionary activities and access to day and family centres. Eighteen per cent of clients who attended Transitional Care had identified needs in this area, these most often taking the form of general information and referral to diversionary activities (Table 23). Overall, specific needs identified within this wider domain were less likely than those in the other key domains to have been met.

Summary of client needs and action achieved

The 'top ten' needs identified from the Transitional Care monitoring data and the extent to which relevant actions had been taken in respect of these needs are summarised in Table 24.

Without doubt, the two most common needs of clients were an appointment with a drug agency followed by an appointment with a housing officer. In the key areas of need, appropriate action was typically reported as having been taken in around three-fifths to two-thirds of cases. The monitoring data largely bears out staff perceptions of clients' needs and data derived from survey and in-depth interviews with prisoners. It is also worth noting, however, that the third most common need - for referral to a benefits officer - was in an area that ceased from April 2004 to be within the remit of the Transitional Care initiative as the service evolved to avoid duplication with other service and to focus on the key issues that Transitional Care might appropriately address.

Further information about the effectiveness of Transitional Care in linking clients with services was provided by the survey data. Table 25 shows the numbers of survey respondents who attended Transitional Care appointments with a particular need and whether that need was met by the Transitional Care worker.

Base: 48 (All those who attended Transitional Care appointments) ²⁵
Source: 4mth data

Overall, it appears from the survey data that Transitional Care was reasonably effective in linking clients with services. The small sample means there are few significant differences in the proportions linked with different types of service. However, is does appear that Transitional Care was more effective at arranging appointments with Housing Officers and appointments for rehab assessments, than arranging appointments with GPs or with job centres, careers services and employment agencies.

What difference does Transitional Care make?

From the qualitative interviews it appeared that those having contact with Transitional Care reported reduced problems as a result of that contact. However there was also a corresponding reduction in the number of respondents citing reductions in problems since being released who had not had contact with Cranstoun in the community.

The more crucial test is whether Transitional Care is linking clients with services with which they would not otherwise be linked. If the Transitional Care worker is arranging an appointment that the client would otherwise have arranged themselves (or which their social worker, GP or mother would have arranged for them) then there is potentially no added value in the service.

In order to measure this, we looked separately at each domain in the quantitative interviews, and looked at the proportion of respondents who had any kind of "unmet need" in that domain. An "unmet need" was defined as being a case where the respondent said they had a particular need ( e.g. an appointment with a housing officer) but they had not had this need met either by their Transitional Care worker (if they had one) or by anyone else. We then compared the unmet needs of those who had been to Transitional Care appointments with those who had not. There were no significant differences between the two groups, although those who attended Transitional Care were slightly less likely to have one or more unmet needs. The results of this analysis are shown in Table 26.

Bases 49 (all those who attended Transitional Care appointments), 126 (those not attending any Transitional Care appointments)
Source: 4mth data

Uptake of appointments with other services and perceived helpfulness

There is, however, a distinction between referring clients on to other services and 'effectively linking' clients with existing services in the 12-week period following release. It is possible, for example, that Transitional Care workers were facilitating links with services but then clients were failing to turn up for appointments or to use those services. It was not possible to determine from the monitoring data whether or not community agencies were actively supporting clients within the 12-week timeframe since this information was not recorded. However, from the qualitative interviews it was apparent that most of those who had contact with Transitional Care following release also had contact with other agencies, including APEX, Turning Point and a drug project. Several of the qualitative respondents who declined to access Transitional Care services on release or who had had no contact from Transitional Care suggested that they had been in touch with no agencies since returning to their communities. Others had, however, initiated contact with agencies since being released, including drug services and social work, Realise, SACRO, APEX, Straight Out and drug and alcohol projects. Some indicated that although they had not attended Transitional Care appointments on release, they had, nevertheless made contact with other agencies with whom Cranstoun had put them in touch while they were in prison. Although there were mixed reactions to the quality of service offered by these various agencies, and a certain amount of ambivalence about their effectiveness in helping reduce problems in respondents' lives, they were generally viewed as worthwhile.

The survey also asked respondents who had indicated that they had received an appointment/link with a service (whether through Transitional Care or elsewhere) whether they had actually attended the appointment or used the service. In the vast majority of cases, the respondent indicated that they had attended or used the service.

It is also possible that the links were made, or information was provided, but the client did not find it helpful. For each item (whether appointment, or other link or information) that the respondent said they had received, we asked if they had found it "very helpful", "a bit helpful" or "not helpful". Again, in most cases, the majority of respondents did find the appointments or information they have received very helpful.

Other outcomes

The survey data collected at both the four-month and seven-month stages enabled some other outcomes to be examined, namely:

• Health symptoms.
• Drug use.
• Alcohol use.
• Offending.
• Stability/suitability of accommodation.
• Economic activity.

However, before discussing these, it is worth sounding a note of caution. Given the lack of contextual information - which would enable us to look at sub-groups of ex-prisoners with different characteristics - there is a limit to how much analysis can be undertaken and how much should be read into the results. Moreover, the primary aim of Transitional Care is to link clients with services. Ultimately, of course, the assumption is that facilitating better links with services will lead to an improvement in these outcomes - but the evaluation must be focused on the primary aim of facilitating links.

Health symptoms

A version of the MAP instrument was used to measure health outcomes. Respondents in the quantitative study were asked whether they had experienced a particular symptom and, if so, how often they had experienced it in the previous 30 days.

There were no differences at four-months or at seven months, between the mean number of physical symptoms reported by those who had attended Transitional Care appointments and those who had not. Similarly, there were no differences (at either stage) between the two groups overall in terms of the number of symptoms of anxiety or depression reported.

In terms of the difference for each individual between four and seven months, both those who had attended Transitional Care and those who had not, reported more physical symptoms at seven months than they had at four. There was no significant difference in the mean size of the change between attendees and non-attendees. In other words, attending Transitional Care appointments did not help prevent an increase in the number of physical symptoms reported at seven months. However, it should be noted that the base sizes here are very small (there were only 21 attendees for whom we had both four and seven month data).

Similarly, both attendees and non-attendees reported slightly more symptoms of depression at seven months than they had at four. However the change in the reporting of these symptoms over time was the same for both attenders and non-attenders.

Those who had not attended Transitional Care reported slightly more symptoms of anxiety at seven months than they had at four months. There was no significant difference in the levels of anxiety at each stage reported by those who had attended Transitional Care appointments.

Drug use

Again, a version of the MAP instrument was used to measure drug use. There were no statistically significant differences - at four months alone, seven months alone, or differences over time - between those who had attended Transitional Care appointments and those who had not in terms of whether they had used any drugs in the previous month, the mean number of days they had used each drug in the previous month or in the amount of money they were spending on drugs.

Similarly, at all levels of comparison ²⁶, those attending Transitional Care appointments were no more likely to be on a methadone script (or a buprenorphine or lofexidine script) than those who did not attend.

There was also no difference in injecting behaviour (at any level of comparison): there were no differences between those who had attended and those who had not in terms of whether or not they had injected in the past month or in the mean number of days they had injected.

When qualitative respondents were asked whether their drug/alcohol use had changed between the period before going into custody and since being released from custody, most believed that their use of substances had reduced or had remained unchanged.

An issue identified by a few respondents was the possibility that liberation grants may well be spent on drugs or alcohol immediately on release, unless alternative, constructive opportunities are made available to ex-prisoners:

"They should have people, [who know] what people need when they get out… when I came out, I didn't feel part of any circle, know what I mean? I was wanting to leave the old one, the criminal [circle] and I couldn't fit into anywhere else, ending up just drinking… so I dinnae feel I could walk into a shop buy clothes with a clothing grant. I walked into all the sports shops and just had to walk out because I know everybody was looking at me as if to say 'aye, he's into stealing', know what I mean? That's the way I think, so I ended up just spending my grant on drink".

"… you go to prison, they'll do nothing for you. You come out of prison, you get a lib grant in your hand. Where do you go? You go and buy drugs. I do it, 99% of the people do it and it's just your routine. A couple of weeks and you're back in the jail again".

Given that the majority of women in prison report having a history of drug use, the number of women who could be recruited into the sample was disappointingly low. Both women who were interviewed in depth indicated that they needed and asked for help with their heroin addiction in prison but neither heard from Transitional Care on release, even though they expected such contact to occur. Both also suggested that the prison-based caseworkers appeared to place greater emphasis upon housing issues (which they considered less relevant) than upon drugs.

Alcohol use

An adapted MAP was also used to measure alcohol use. There was no significant difference, at any level of comparison, between those who had attended Transitional Care appointments and those who had not in terms of the mean number of days they had been drinking in the past 30 days. ²⁷ There was also no significant difference between the groups in the mean number of units of alcohol drunk (by those drinking at least once a week).

Offending

There were no differences between those who had attended and those who had not (at any level of comparison) in relation to whether or not they said they had committed any crimes in the previous month. In total, 41% of respondents at the four-month stage said they had committed a crime/crimes and 49% of respondents at the seven-month stage said had offended in the past month.

Qualitative interview respondents were asked whether they felt their level of offending had reduced since they had been released from prison compared with their offending prior to admission to prison for the sentence under study. Most reported they had not re-offended since leaving prison or that they were offending less (see Table 27).

In line with recent studies of desistance from offending, respondents suggested that they had become disillusioned or 'burnt out' as a result of their involvement in the criminal justice system to date. This was a major impetus to them reducing or stopping offending. The numbers who attended Transitional Care on release were too small - and the intensity of that contact was too minimal - to be able to suggest that Transitional Care had an impact on this sample's offending behaviour.

Many respondents suggested they were grateful for the advice that they had received from Cranstoun caseworkers in the prison in which they had been held. Whilst one young man suggested that being "banged up for four and a half months basically" had impacted on his reduced offending, he nevertheless felt that Cranstoun's pre-release support had also had a positive impact:

"Somebody comes and speaks to you and maybe kinda… put a different point of view in your heid… about how drugs work and they even tell you about how your pals have got you in the jail and you think about it. They've obviously been speaking to folk and they ken what they're talking about."

Although drug-related advice was not generally considered sufficient to make a difference, longer-term contact and support prior to release was valued and in some cases was thought directly to have reduced the likelihood of drug-related offending. Even so, the challenges posed on release could be significant:

"If you want to stop people re-offending, if you put them back into their own housing scheme where they grew up causing trouble, they are going to do it again, so I don't see the sense in it. If they want to stop me from re-offending, they should move me to a quiet place out of [home town] where I can settle down and go to college".

This suggests that the housing needs of ex-prisoners should be a key priority for housing and other agencies concerned with the re-settlement of prisoners.

Accommodation and economic activity

There were no significant differences, at any level of comparison, between those who had attended Transitional Care appointments and those who had not in relation to the type of accommodation they occupied ( e.g. whether house or flat, bed and breakfast, hostel, staying a few days here and there with friends or relatives) or in relation to how long they expected to be in their current accommodation. There were also no differences in relation to ratings of the safety of their belongings.

At the four-month stage, those who had attended Transitional Care appointments were more likely to rate their personal safety in their accommodation as being 'very' or 'fairly' unsafe those who had not attended (35% of attendees felt unsafe compared with 11% of non-attendees).

There were also no differences between the two groups, at any level of comparison, in relation to economic activity (whether in employment, unfit for work, in education etc.).

Christo Inventory scores

The Christo Inventory is used as a professional audit/evaluation tool, providing an indication of the degree to which a client's substance misuse impacts on their psychological and social well being. It is administered by practitioners, who make an assessment based upon the presentation of the client. In the context of Transitional Care, it was intended to provide a measure of client progress in the period following release from prison.

The Christo Inventory requires client contact for its completion and requires such contact on at least two separate occasions in order that any changes in scores can be measured. Only 331 clients attended three appointments and in only 292 cases were Christo scores available for each appointment. However, comparison of mean scores reveals a gradual reduction in scores from first (2.3) to second (2.0) to third (1.8) appointment ²⁸. This suggests that clients' social situation and substance misuse behaviour had generally improved over the post-release contact time. However, whether and to what extent these improvements could be attributable to Transitional Care cannot be determined from the available data.

Perspectives on the effectiveness of Transitional Care

Ex-prisoners' views about the service received

Those ex-prisoners who did attend Transitional Care appointments were positive about the service they received. Responses to a series of statements about the service are shown in Figures 2-5. ²⁹

Figure 3: Level of Agreement with Statement "The Transitional Care Worker Always Understood the Kind of Help I Wanted"

Base: 48 (All those who saw TC worker post-release)
Source: 4mth data

Figure 4: Level of Agreement with Statement "The Transitional Care worker has helped motivate me to sort out my problems"

Base: 48 (All those who saw TC worker post-release)
Source: 4mth data

Figure 5: Level of Agreement with Statement "I have liked all of the Transitional Care meetings I have attended"

Base: 48 (All those who saw TC worker post-release)
Source: 4mth data

Figure 6: Level of agreement with statement "I have not had enough appointments with the Transitional Care worker"

Base: 48 (All those who saw TC worker post-release)
Source: 4mth data

Interview respondents mostly described Transitional Care as an advisory and support service, along the following lines:

• To help offenders whilst in prison and to meet them once back in their communities.
• To help with drug problems [only].
• To help with drug and alcohol problems, employment and housing.
• To help people to lead different lives.
• For offenders or ex-prisoners.
• Someone to talk to and to offer help if needed.
• To help you to access necessities or support on release.

The aspect of the service most appreciated by those who had direct experience of Transitional Care both within the prison and on release were the workers' friendly and courteous approach, the fact that they made one feel comfortable, and the sound advice they gave on drug and alcohol problems. For those who had contact in the prison but not on release, the main aspect most appreciated was the fact that the worker was someone they could talk to and seek advice from when required. It was also suggested that they could 'back up' individuals who were dealing with other agencies (and one respondent in this respect suggested that they put in a good report for him at court, which resulted in him getting probation rather than a further custodial sentence).

Managers and practitioners suggested that the aspects of Transitional Care that were most effective included the links which could be established for clients between prison and the community, the advocacy role which clients could access and the general 'helping hand' which was made available to individuals following release. There was considerable optimism among professional respondents about the ability of Transitional Care to reduce drug-related deaths. Respondents were more cautious about the potential to reduce drug use or re-offending, although it was acknowledged that this could be affected in the longer-term. However it was also acknowledged that Transitional Care does provide an opportunity to identify where services are lacking and hence has the potential to move services towards better strategic planning.

Young offenders in particular often appreciated constructive help from agencies in negotiating, not only substance misuse programmes, but also benefits, housing, employment and other related services, often finding the red tape difficult to deal with. One young man highlighted the effectiveness of Transitional Care in by-passing such bureaucratic procedures:

"It was quite good 'cos like usually you need to wait a week or so for an appointment for the Job Centre and stuff like that, eh. So they got us that straight away as soon as I got out."

The aspect of the service least appreciated by respondents was that Transitional Care does not necessarily 'deliver' on its promises, a criticism cited by several of the sample. Three respondents also suggested that caseworkers' line of questioning was too intrusive, pressurising or 'fussy' and a fourth respondent thought that they lacked organisational skills.

A number of factors were thought by professional respondents to have prevented the Transitional Care Initiative from being more effective. These included a concerns by some agency managers that insufficient emphasis was being placed upon quality; ex-prisoners' failure to attend appointments and engage with services; and a low proportion of women taking up the service. Concern was also expressed about clients being placed on waiting lists rather than being offered an immediate service and that prison-based caseworkers, by making promises which could not be delivered, were not giving clients realistic expectations of what could be made available on release. Some respondents suggested that the restrictions placed on the amount of client contact were too inflexible, with workers indicating that they would like the opportunity to do more intensive work with clients beyond the limited three-month period. The lack of integrated care in the drugs field was also seen as a problem:

"There are gaps there in the services and the whole idea, I think, is for addiction to have a seamless service and we're not quite there yet. I think we're all working very hard to achieve this in the service but there are definitely gaps where the people can fall through the net and we in fact lose the continuum."

"Commonsense joined-up social policy would assume some sort of link between clinical services within prisons where people have had an enforced detox and when they've been released into the community …But their immediate need - the one thing that's likely to kill them is going straight into street drug use. So substitute prescribing for people pre-release from prison would probably do a lot more to reduce overdose, address recidivism than any other single factor."

The prison-based caseworkers had also formed views about the effectiveness of Transitional Care. Many felt that if the Transitional Care agency had the ability to be mobile, to meet clients on their terms, to attend appointments with them and to advocate for them, it was more likely that clients would take up the offer of Transitional Care. A few suggested that engagement with the service might be further enhanced if Transitional Care workers could meet clients at the gate when they were released from prison, but they also acknowledged that this would be expensive and not practical in most cases. The caseworkers were of the view that three post-release appointments were unlikely to be sufficient in most cases and that many clients would be in need of three appointments within the first week of release. They also felt that 12 weeks was probably too short and suggested that Transitional Care agencies were struggling to link clients into existing service provision within the 12-week time frame. Caseworkers perceived housing and drugs services to be in highest demand and, like the Transitional Care workers, thought that, with the exception of young offenders, education, training and employment were for most clients long-term aims.

Turning to a comparison of experiences and views among ex-prisoners who were returning to different areas on release, none of the seven respondents from Fife had contact with Transitional Care on release. In contrast, three of the four Dumfries and Galloway respondents were in touch with the service on release ³⁰. It appears that the Dumfries and Galloway scheme - by locating the Transitional Care staff within the prison - was better able to offer a constructive, consistent and continuous service to offenders both pre- and post-release. The Cranstoun worker within the prison was spoken of highly by these respondents.

Only two of the 20 respondents from Glasgow had contact with Transitional Care on release, although a further five had been contacted or given an appointment on release but failed to keep it. Most apparently left prison to no official support or throughcare arrangements, even though they all identified multiple problems during the Transitional Car assessment process in prison.

Several respondents were under a possibly misguided impression that Transitional Care staff could and could not do certain things within their remit. Whilst the following misconceptions may be considered one-off, individual viewpoints, they are worth noting because, although only one person may have made each of these remarks, these assumptions may in turn have been received by word of mouth or conveyed to other potential clients by word of mouth:

• Transitional Care cannot work with people whilst they are on probation.
• Transitional Care does not provide services in certain geographical areas.
• Transitional Care only works with homeless people.

Another respondent said that Transitional Care staff had tried to refer him to SACRO on release but that SACRO were unable to help him whilst he was wearing an electronic tag.

Respondents in the qualitative interviews offered suggestions as to how Transitional Care might be improved. Prior to release these included:

• the provision of specific/concrete help and advice during assessment
• greater contact with caseworkers and Transitional Care workers prior to release
• shorter delays between requesting an receiving a prison-based appointment
• increased written publicity about Transitional Care (and possibly a video on induction)
• greater autonomy for Cranstoun caseworkers (including, for example, in relation to facilitating meetings between prisoners and community-based workers)
• the provision of groupwork programmes for young offenders
• improved co-ordination of harm reduction and treatment between Cranstoun and SPS
• the creation of prisons for drug users or for non-drug users, to minimise the likelihood of 'contamination'.

Following release they included:

• provision of fixed appointments as soon as possible following release, to maintain motivation and build on support offered within the prison
• recreational activities for younger offenders
• avoid raising expectations with respect to what can and cannot be offered inside and outside the prison to levels that cannot be achieved. For example, four respondents specifically mentioned - although several others implied - that Transitional Care should 'deliver on promises' and not raise expectations unduly in terms of what they can provide both in and outside the prison: "They say they're gonna help you and they don't. They don't deliver".

Cost effectiveness

Views on cost-effectiveness varied between organisations. The smaller agencies based in the voluntary sector believed that the service was cost-effective. Larger sub-contracted agencies considered that there were probably ways of making the service more cost-effective ( i.e. gearing it towards those individuals who wanted it). This was also linked to geographical location. One Cranstoun manager commented that

"I think it's very cost effective in the city, I don't think it's cost-effective at all in the rural areas. I think there are some areas where there are people sitting being paid to deliver a service that they're not".

SPS respondents did not consider the service to be particularly cost-effective:

"In terms of the outputs that are being achieved, I don't think it's resource compatible, for the work that has been put in and what has been achieved".

However, several respondents commented on the importance of making changes in people's lives that could not be measured in monetary terms:

"…if I was to look at it myself, if we can help ten people live a better life and stay alive then it's more than met its cost."

Cranstoun managers were, moreover, clear that changes that were introduced following the review and renewal of the contract in 2003 (for example through increased use of spot purchasing) had made the service more cost effective.

Summary

The Cranstoun monitoring data indicated that health (drug and alcohol) (63%) and housing needs (58%) were most commonly identified by staff among those who attended at least one appointment, followed by benefits/financial needs (34%), education/training (26%) and employment (22%). Women were more likely than men to have identified housing needs while men were more likely to have needs identified in relation to employment. Compared with those aged 25 years or older, younger prisoners were more likely to be identified as having needs related to education and employment. A very similar pattern of needs was obtained from the 4-month ex-prisoner survey data. Seven months after release housing was the most commonly identified need (51% of respondents) followed by education, training or employment (42%).

The effectiveness of the Transitional Care initiative depended on the extent to which it facilitated ex-prisoners' access to community services. Examination of whether or not the required action to meet identified needs (usually making an appointment with a relevant agency) had been achieved within the 12-week post release period suggested that the appropriate action had been taken in between 51% and 69% of cases. However there was no evidence of different levels of unmet need between those who attended Transitional Care appointments and those who did not.

There were no differences in drug use, injecting behaviour, alcohol use and offending among survey respondents who attended Transitional Care and those who did not. There was a significant reduction in mean scores on the Christo Inventory over successive appointments which would suggest an improvement in psychological and social well-being. However the number of cases was comparatively small and in the absence of an appropriate comparison group it is not possible to attribute changes to Transitional Care.

Ex-prisoners were generally positive about their experience of Transitional Care, valuing the advice they received, the friendly and courteous approach of the workers and, in particular, the assistance they received in negotiating bureaucratic processes to access they services they required. Some, however, were critical of Transitional Care for failing to deliver on its promises, reflecting, it appears, the difficulties reported by staff in accessing services in different parts of the country.

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