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Chapter 6: Conclusions
In this final chapter we summarise the key findings of the research and consider the implications of these findings for the operation of Transitional Care. Although, as indicated in Chapter One, the Transitional Care initiative was discontinued in July 2005, there are lessons to be learned from its experiences of delivering throughcare to prisoners with identified drug problems that can inform the new arrangements that have been put into place from August 2005.
Summary of findings
This chapter of the report summarises the findings from the monitoring data and considers some of the broader issues that appear to have impacted upon the operation of the Transitional Care Initiative. Some of these issues were external to the initiative but nevertheless had implications for its operation while others were intrinsic to it. The fact that we focus here on some of the areas of difficulty should not be seen as a criticism of Transitional Care. The Transitional Care initiative was complex and ambitious and it was therefore inevitable that some aspects proved challenging.
Aims of Transitional Care
All respondents were very clear about the aims and objectives of Transitional Care and defined the concept in terms of identifying prisoners' needs and linking individuals with existing services in the community. Respondents commented that Cranstoun had made significant efforts to ensure that everyone involved in providing Transitional Care was aware of its objectives. It was noted however that 'disparate organisations' with different agency remits in the community (for example, whether they were drug services or provided services in other areas such as employment) were likely to approach these objectives from slightly different perspectives.
Community-based agencies that had been sub-contracted to provide a Transitional Care service clearly shared the objectives of reducing drug-related deaths and linking people into services on release from prison. For practitioners, reducing drug-related harm appeared to be the main reason why agencies were interested in Transitional Care. Sub-contracted agency managers noted that there were various reasons for their involvement with the service though financial incentives predominated. All sub-contracted agency managers believed that their service had something to offer Transitional Care.
Organisation and management
The management structure for Transitional Care was acknowledged to be complex. Relationships and communication between the different agencies was reported to be good but it was suggested that this might be further improved if Cranstoun had more direct management of the service. Some respondents believed that the staffing structure could undermine continuity of service from prison into the community. There was initially perceived to be a lack of co-ordination within and between prison and community services, though the transmission of information between prison caseworkers and Transitional Care workers improved over time.
The training provided for staff involved in the initiative was generally viewed positively and offered an opportunity to contribute to the ongoing development of Transitional Care. However, the arrangements for monitoring were regarded as time-consuming and incapable of reflecting the actual work undertaken with clients. There were also acknowledged to be inconsistencies in the manner in which the forms were completed.
Other agencies were said at times to have been somewhat hostile towards the initiative, which they feared might 'poach' their clients, or, conversely, increase their caseloads. A lack of early consultation with statutory agencies was thought to have resulted in a lack of co-operation, especially from social work departments.
Pre-release contact
In terms of engagement with Transitional Care, it was expected that the worker who would have contact with the client in the community should attend at least one pre-release case conference with the client. One of the aims of this was to increase the likelihood of the client attending appointments post-release. In practice, these meetings did not always happen with around one third of ex-prisoners indicating that they did not see their Transitional Care worker while they were in prison. Interestingly, and contrary to expectations, those who had seen their worker in prison were no more likely to attend after release than those who had not. This suggests that the potential for these meetings to motivate and encourage take-up of Transitional Care by emphasising its potential benefits for prisoners had not been fully exploited.
Monthly reviews were conducted for those deemed to have high complex needs. Otherwise most clients were seen two or three times over the course of their sentence. Remand clients tended to be seen only once for assessment. They were usually given the telephone number of the Transitional Care scheme and sometimes an appointment but the onus was on them to contact Transitional Care. This issue was addressed through the changes that were implemented from April 2004 which included the introduction of 'crisis' Transitional Care for remand prisoners and those serving up to 31 days (see Chapter Three).
More generally, one-to-one work in the prison seemed to be affected by targets and time constraints. Initial targets for the numbers agreeing to be referred to Transitional Care and for attendance at case conferences and pre-release meetings were acknowledged to have been overly ambitious and were subsequently reviewed. Case conferences were seen as crucial though there was a definitional issue with respect to what constitutes a case conference (for example, whether the prisoner was or was not required to participate). Pre release meetings were also seen as good practice but arranging them placed additional demands upon caseworkers. Instead, community-based Transitional Care workers arranged pre-release meetings themselves through the agents visits system.
Having caseworkers integrated into prison addiction teams appeared to ease communication and process issues. Caseworkers could and did co-ordinate the referral process to Transitional Care but it was unclear who had overall responsibility for co-ordination of clients' service provision whilst in prison. This was perceived to result in gaps and duplication in the linking between prison and the community. Some Transitional Care agencies visited 'local' prisons only while others sent a team member to cover. Whilst it was considered preferable to send the actual worker who would be allocated the case rather than another team member, distance, budget and time constrained this.
Publicity/Information
Nine of the 37 respondents who took part in the qualitative interviews could not recall having received any publicity about Cranstoun 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 respondents suggested that it could be improved. This might include the provision of further information prior to and upon release about the services that Transitional Care could and could not provide.
Assessments
The CAART assessment tool was viewed by staff who used it as a general tool that was not able to address the needs of specific groups of clients such as women and young offenders and that generated too much administration. Doubts were also expressed over whether it was being used systematically to identify and address gaps in service provision: identified needs were said often to be geared to what was available in prison rather than reflecting needs for services (such as counselling) that were not widely available. Caseworker assessment targets were said to encourage an emphasis on quantity rather than quality and there was perceived to be some duplication of the assessment and referral process, partly because of a lack of co-ordination of the work undertaken by external agencies in prison.
The majority of ex-prisoners 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. However it was noted by ex-prisoners that it would be useful for assessments to be tailored to individual needs rather than focusing upon pre-defined areas. More alarmingly, it was a common view amongst the qualitative interview respondents that raised expectations with respect to access to services in the community that could not subsequently be fulfilled.
Engagement with the service post-release
Prisoners who were of No Fixed Abode and those deemed vulnerable were considered a priority and generally seen on the day of release (as were other prisoners where it was practical to do so). The mode of response by Transitional Care workers appeared to impact on first appointment attendance (speed, on client terms/territory, ability to provide client needs, home visit, client can go in car). A more proactive, client-centred approach was perceived to result in a better take-up of Transitional Care. Most Transitional Care workers met and occasionally took clients to their first appointment. Where staff endeavoured to meet with clients in 'neutral venues' difficulties were encountered in locating suitable venues. More generally, Transitional Care was perceived to work better if staff were able to advocate and mediate on their clients' behalf, accompany them to appointments with other agencies and generally assist them to negotiate bureaucracy.
Attendance rates were initially low (28%) at Transitional Care meetings and decreased sharply across the potential appointments, though voluntary take-up rates of services by this client group are widely acknowledged to be low. Where reasons for non-attendance were known by staff, a return to custody and/or being arrested accounted for the majority of cases.
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 remand or prison sentence. There were reports of clients being liberated, engaging with services and making progress and then finding themselves up at court a year 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 services.
The amount and quality of pre release work was perceived to impact on attendance for the first post-release appointment. While there was no significant difference between those who had met their worker pre-release and those who had not in terms of whether they attended all their appointments, those who had not met their worker pre-release were more likely to say their reason for not attending was that they had not received an appointment (21 of the 33 individuals who had not met their worker compared with 34 of the 94 who had). Women were as likely as men to attend at least one Transitional Care appointment but the take-up of Transitional Care was lower among young offenders. Many staff felt that the 'model' of intervention was not the most appropriate for young people with substance misuse problems who were less likely to recognise that they had a problem. However, the form that alternative models might take was not specified.
Attendance rates were also lower among those who were of no fixed abode. This suggests that consideration needs to be given to ways of engaging with these clients as soon as possible after their release from prison.
Formal and informal contact between Transitional Care workers and potential clients was considered important in increasing take-up of the service. It was thought that ex-prisoners would be more likely to attend an appointment with someone they had already met while in prison and through this contact had a clearer notion of what Transitional Care could offer. Some penal establishments were able to allow Case workers and Transitional Care staff greater access to prisoners than others. On release there would appear to be an association between attendance figures and the geographical accessibility of the Transitional Care service.
According to ex-prisoners, the single most common reason for non-attendance was simply not receiving an appointment (regardless of meeting the worker pre-release). This suggests that the process for engaging the client in prison and immediately following release 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.
In summary, it seems that it was not one factor that determined attendance rates for Transitional Care but, rather, a combination of factors. These included accessibility of Transitional Care within the prison and after release, ex-prisoner lifestyle and attitudes (especially age-related) and outstanding charges and further offending. In addition, the availability of relevant community-based resources into which ex-prisoners might be linked is also likely to have influenced whether or not prisoners were willing to take up the offer of Transitional Care.
Prisoners' needs on release
Overwhelmingly the two most frequently identified needs of clients were support in relation to substance use (appointment with a drug agency) followed by accommodation issues (an appointment with a housing officer). 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. 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. In relation to needs, there were few differences between those who attended Transitional Care appointments and those who did not.
Linking clients into services
Overall, it appears that Transitional Care is reasonably effective in linking clients with services. However, there was no evidence that it was linking clients with services they would not otherwise have made contact with by some other means: there was no significant difference in the level of 'unmet needs' (needs not met by the Transitional Care worker or anyone else) between those who attended and those who did not. Data from both the survey and qualitative interviews, for example, suggest that many of those not making use of Transitional Care on release were, nevertheless, making contact with other agencies and valuing the services they received.
Three appointments were considered to be insufficient to effectively link clients into services. Instead, it was suggested that clients needed more intensive support in first week following release. It was proposed that appointments should be based on need rather than being fixed to three. Most areas were considered to have an adequate range of services, but these did not have the capacity to deal with client demand. Waiting lists for substitute prescribing varied from 6/7 weeks to over one year and clients were reported often to be back in prison before they had been effectively linked into services. Housing services were thought to have improved as a result of recent legislative changes, however there remained a lack of secure, supported temporary accommodation and a lack of housing support workers
Health outcomes
There were no differences in the mean number of physical symptoms, or symptoms of depression, reported by those who had attended Transitional Care appointments and those who had not. However, those who had attended appointments reported more anxiety symptoms at four months (though not at seven) than those who had not, possibly because those who were more anxious on release from prison were more likely to take up the service. There was a reduction in Christo scores over successive appointments among those who attended Transitional Care, suggesting some 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.
Drug use
When qualitative interview respondents were asked whether their drug/alcohol use had changed between the period before going into custody and since being released from custody, a small majority felt that their use of substances had reduced. However, from the survey responses 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 were using drugs, 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, those attending Transitional Care appointments were no more likely to be on a methadone script (or a buprenorphine or lofexidine script). 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.
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 alcohol in the past 30 days. 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 since release and 49% of respondents at the seven-month stage said they had offended in the past month.
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 how long they expected to be staying 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 compared to those who had not attended (35% of attendees felt unsafe compared with 11% of non-attendees). This may be because some of those who attended Transitional Care did so because they regarded their current accommodation as inadequate.
There were no differences between those who attended Transitional Care and those who did not, at any level of comparison, in relation to economic activity (whether in employment, unfit for work, in education etc.).
Implications for future practice
Although there are many caveats attached to the data presented in this report, the following would appear from the data available to represent aspects of practice that were likely to encourage ex-prisoners to engage with Transitional Care:
- Proactive engagement with clients as soon as possible following their release
- Availability of a range of relevant agencies and service providers with sufficient capacity to meet client demand.
- Prioritisation of needs according to their importance for ex-prisoners in the immediate period following release.
- Scope for more intensive engagement with clients as determined by needs.
- Accessibility of staff inside and outside the prison and their willingness to advocate on behalf of and support clients in a variety of ways.
- Mechanisms for effectively linking clients with services as a source of longer-term support.
- Similar indicators of good practice and similar difficulties with respect to the provision of services prior to and following release were also identified in Burrow et al.'s (2001) study of drugs throughcare in England and Wales.
Conclusion
The effectiveness of Transitional Care was affected by a number of internal and external factors such as outstanding charges, the complex management and staffing structure and the amount of administration that was required. It was also constrained by the availability and accessibility of services in the community. It appears that Transitional Care was reasonably effective at linking clients with services, although the extent to which it linked them with services they would not have accessed by some other means was unclear and there were no apparent differences in short-term outcomes among those who attended Transitional Care and those who did not. Those who attended appointments were positive about the workers and the service they received. However, the take-up rate of initial appointments was comparatively low, especially among young offenders and those of no fixed abode, suggesting that the process for engaging ex-prisoners needed to be improved and the appropriateness of the model for certain groups of ex-prisoners reviewed.
It was inevitable that an initiative as complex and ambitious as Transitional Care would encounter some challenges. Throughout the period of the evaluation the initiative evolved to take cognisance of emerging issues identified by the research and by the various stakeholders involved in its operation. As understanding of the challenges of providing throughcare services to short-term prisoners with drug problems developed, the need for a new approach was identified. This resulted in the replacement of the Transitional Care initiative with a new national Throughcare Addiction Service. It is hoped that this report, though identifying some of the difficulties faced by the Transitional Care initiative and through identifying areas that were perceived to enhance effective practice, will enable future throughcare services for prisoners involved in substance misuse to be strengthened and improved.
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