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6. RETURN TO THE COMMUNITY

6.1 Prisoners with severe and enduring mental health problems are likely to require to continue to receive treatment, interventions and other support when they return to the community, either from prison or hospital. The nature of this provision, and the continuity of care will have an impact upon their future experiences, and this chapter examines the nature of the treatment, interventions and other support which are provided to them at that stage, and any issues arising with this.

PRE-RELEASE

6.2 Prisoners face a range of issues as they approach their return to the community. Some described the general stress and worry of being released, and also felt that their mental health problems could increase. The importance of accessing support, where this was the case, was noted:

"Some mental health problems are quite scary and you worry about when you do get out if it [the mental health problem] does come back what to do."

6.3 There is a need for support of different types, particularly access to hospital treatment. Accommodation is also a key issue, with a lack of housing linked to increased stress. Other forms of support which are required include social work support, family support, benefits help and access to the services required. More generally, one prisoner stated that:

"If I was given a bit of help then I could get on with my life, I could manage."

Preparation for Release from Prison

6.4 Work is being carried out in all prisons to assist prisoners in preparing for their release and in accessing support for mental health issues. Most have a Links Centre, within which connections are made to a range of services as prisoners approach liberation. The nature of this varies between prisons, and the work highlighted below comprises examples of the types of preparation which can take place.

6.5 One of the areas of variation is in the level of formalised planning undertaken with prisoners with severe and enduring mental health problems. Some prisons conduct relatively formal processes of assessment prior to release. These include the use of case conferences or pre-release meetings, sometimes involving the mental health team, and sometimes involving services from the community. However, this does not generally take place for all prisoners.

6.6 In some cases, addressing mental health needs may take place as part of the Integrated Case Management process, or as a specific component of throughcare and the general liberation planning process. While most prisons have some ICM practice in place, it is varied in the nature and extent to which mental health needs are taken into account of, and whether ICM Co-ordinators sit on MDMHTs, the use of case conferences, and approaches to information.

6.7 One prison stated that everyone gets a Community Integration Plan "of sorts", and that all of the prisoners known to have mental health problems get help with planning for their release. A small number of prisons mentioned the use of the MAPPA process, or the Care Programme Approach as part of planning for release. The voluntary sector organisations also recognised that there was some relevant work being done through Community Integration Plans ( CIP) and Integrated Case Management, but it was also noted that there is variation between services and areas in terms of whether or not they are willing to engage with prisoners prior to release. The value of more formalised arrangements was highlighted.

6.8 In terms of making contact with specific services, one of the key sources of support for people with mental health needs is the continuation of healthcare support, and almost all prisons provide assistance with accessing GP provision. Some prisons also alert a prisoner's GP on their release, and a number provide a discharge letter to the GP. One prison highlighted the fact that no one with mental health needs leaves the prison without a doctor being available. Others noted that they would try to link to doctors in the community in relation to medication, or notify the local health centre.

6.9 Assistance is also provided, through the MDMHT, the prison psychiatrist or the health centre, with arranging mental healthcare on release. Appointments for prisoners are arranged at the time of release. For some prisoners, a link may be made with a CPN in the community or a community mental health team, and the CPN may also assist in arranging appointments.

6.10 Some prisons have good links with social work services, and social work teams may take responsibility for organising a care package. Community social work staff may also come into prison to help some prisoners prepare for release and assist in making relevant arrangements, although not all prisoners have an allocated supervising social worker in the community before they are released.

6.11 Some housing services also come into prisons to assist with housing issues in preparation for release, and all but one prison noted that assistance is provided with this. If specialist housing is required, prisons may be able to assist in accessing this.

6.12 Some other aspects of general preparation for release were also felt to be particularly relevant to mental health needs, particularly "life skills". In one case, a support group was involved from the start of the sentence in planning how prisoners would cope on release.

6.13 There has been a general improvement in contacts with outside agencies in recent years, and prisons are trying to build upon existing work and develop this further.

6.14 Some voluntary organisations also suggested that throughcare has been much improved, with developments to their role in the process. Again, however, there is variation within and between prisons with one providing the example of a prisoner with mental health problems being liberated with a range of multi-agency support in place, while another from the same establishment had been liberated with no support.

6.15 Home leave prior to release provides an opportunity for prisoners to make contact with services.

6.16 A number of prisoners with severe and enduring mental health problems are released from prison into homeless accommodation or may not have a GP. In these instances throughcare is very difficult to organise.

Preparation for Return to the Community from Hospital

6.17 Return to the community directly from hospital for people who have been transferred from prison is relatively common. In these cases, there is a more systematic and consistent formal process for making arrangements to ensure that mental healthcare continues.

6.18 Preparation for return to the community from hospital involves a relatively formal discharge planning process, which includes relevant staff identifying all of a patient's needs. The Care Programme Approach requires co-ordination of care and implies input from a number of services.

6.19 Hospitals also identified the MAPPA process being in place for some individuals where there is a significant risk to the public. In these cases there would also be likely to be specific links to the police and criminal justice social workers.

6.20 Through these mechanisms, hospitals generally make contact with all of the relevant service providers and try to enable smooth transition to community support, linking individual patients to appropriate services, and inviting service providers to the hospital as appropriate. One hospital identifies service providers, develops confidence in the service providers, as well as providing some follow up support themselves. The whole process of treatment and care involves a progression from illness through treatment, management, rehabilitation and discharge.

RETURN TO THE COMMUNITY

Release from Prison

6.21 Although some preparatory work is carried out prior to liberation both in prisons and in hospitals, and there appears to have been developments in this work, the actions taken at the point of release can have a key impact upon the subsequent experiences of an ex-prisoner. The actual point of release, and the period following this, are crucial stages in the continuity of care, and there are a number of problems which can affect ex-prisoners at this time.

6.22 Prisoners being released from prison with severe and enduring mental health problems need to get from the prison to the area in which they will live, secure their accommodation, settle in, and take all of the actions necessary relating to their health, housing and finance. The services which they will access also need to know about them. In many cases, ex-prisoners have to approach these organisations at their own instigation, or, where appointments have been made previously, to approach the organisations and attend these appointments with little or no support.

6.23 In terms of continuity of health care, some prisons give ex-prisoners a short-term supply of medication upon release. Thereafter they will need to gain access to this in the community. Similarly, where appointments have been made, prisoners will be informed of these and will need to attend.

6.24 The types of services available upon release, vary between areas, but include statutory services (health and mental health; housing; and social work) and voluntary sector provision (in these areas, and in relation to other forms of specialist support, such as organisations working with ex-offenders; abuse issues; addictions; befriending; and other forms of issue-based work).

6.25 A small number of initiatives to provide support with making or attending appointments was identified. One involves a "Routes Out of Prison" initiative, with "life coaches" providing assistance to released prisoners from the earliest stage, who can help them to access services and accompany them to appointments. The initiative is only available in certain areas.

6.26 One prison ensures that people who are high risk and on Act2Care receive specific support on release, such as having someone to collect them or take them to their local GP. Similar provision is made in another case where "health information advocates" accompany prisoners to register with doctors, and to hospital appointments. Social workers might sometimes accompany ex-prisoners to appointments.

6.27 One prison set up a multi-disciplinary approach for someone who was struggling without support, in which the individual was placed on a three-month supervision order to try to ensure support. Prisoners who had experience of support in the past were very appreciative of it.

6.28 The prison can also contact family members, if they can be identified, where a person is unwell, and ask the family to meet the ex-prisoner at the gate.

6.29 For many, however, there is no such support in place:

"They're just giving me a grant and showing me the gate."

Return to the Community from Hospital

6.30 In terms of the provision made for patients leaving hospital, those who have not committed violent or sexual offences are generally transferred to the care of community medical services. One hospital noted that people were unlikely to be released without any form of referral from the hospital, and some identified that they had a community service which works with ex-patients, or that they would continue to respond to emergencies. Social work services can also fund packages of care for particular patients.

6.31 The provision of assistance with housing and other support was also highlighted. For example, some have access to facilities provided by support organisations (such as SACRO, Barony, and the Richmond Fellowship), which can provide accommodation and care.

6.32 Patients returning to the community from a high security facility within the mental health system generally do so via a rehabilitation unit, which ensures their ongoing support in the community.

The Risk of Re-offending

6.33 Although people with severe and enduring mental health problems who are otherwise fairly well, and have support outside prison can, and often do, survive for long periods of time in the community, some have difficulties in securing continuity of care and access to appropriate support - which increases the risk of their re-offending. Prison staff made the following point:

"Before release they'll tell you they'll be back because there's nothing for them out there."

The voluntary sector also made the point that:

"People fall through the gaps, and that's why they go to prison and then they come out and it's the same gaps."

Prisoners agreed with this:

"You're put out and left to fend for yourself … if you get no support and you've nowhere to go, you're back in here and that's a vicious circle."

6.34 Prisoners also suggested that re-offending can be the result of "masked" mental health problems, and examples were given of them taking alcohol and drugs to help them cope. One prisoner pointed out that he had had to commit another offence before he got help, and others suggested that some would stop taking their medication after release, as a way of ensuring that they returned to prison.

Issues and Problems with Continuity of Care and Return to the Community

Gaps in Preparation for Release

6.35 As well as the issues raised in relation to the variation in the level of preparation for release within and between prisons, some additional gaps in preparation for release were highlighted, including that:

• It is difficult to make arrangements for release for short-term prisoners.
• There is a lack of formalised throughcare focusing specifically on mental health issues. Although some of the processes, such as ICM offer a move to an holistic approach, the extent to which these address mental health is unclear, and there is still a focus on statutory services. The processes also depend on mental health needs being identified.
• There can be a lack of provision of information to prisoners about how to access mental health services when they leave prison.
• Prisoners do not always engage with the process of pre-release planning.
• The prison Links Centre will not necessarily receive the information required in relation to a prisoner's mental health needs.
• Organisations working with prisoners to address related needs such as housing and employment will not always know that prisoners have mental health problems, and this can make it difficult to work with them.
• There can be a reluctance for some services in the community to assess prisoners while they are still in custody.
• It can be difficult for some prisons which act as a national facility to link to local services in a prisoner's home area.
• It can be difficult for local prisons to arrange healthcare where a prisoner lives outwith the local NHS area.
• Prisoners may not have a release address sufficiently in advance to make local arrangements.
• There can be a lack of communication between community mental health services and prison.
• When services such as CPNs and social work do assist with preparation for release, time spent with a prisoner can be very limited.
• Prisoners are not always seen by a doctor prior to release.
• The perceived impact of mental health problems on a prisoner's liberation date can lead to the prisoner hiding his or her other issues, which makes it more difficult to ask for support.
• It can be more difficult to make provision for women because of complexity of their needs.
• There is a lack of an holistic approach to addressing needs approaching release, and there can be a lack of partnership working and co-ordination.

Access to Services

6.36 Some issues were raised related to perceived difficulties in securing access to services following release:

• Some prisoners are not registered with a GP.
• There can be difficulties in accessing a hospital bed for some ex-prisoners, including where someone has been stabilised but is seen by prison-based staff to present a high risk.
• There can be problems securing appropriate housing, with homelessness having a negative impact upon mental health, and hostels seen to be inappropriate for "vulnerable" people.
• It can be difficult for ex-prisoners to access treatment programmes.
• There is variation in the availability of different kinds of services in the community in different geographical areas, and some support may not be available.
• There can be specific gaps in services in the community such as a lack of suitable accommodation and effective treatment for pregnant women.
• Particular groups of ex-prisoners may have specific difficulties in coping or accessing support in the community, including people with addiction problems; homeless people; people with learning disabilities; sex offenders; and foreign national prisoners.
• Mental health and addictions services in the community are not always linked.
• Services in the community, including NHS primary care services for people with chronic mental health conditions, are stretched and may be unable to meet ex-prisoners' needs, or there may be a lengthy waiting period.
• Some services will not work with people on release who are from outwith their designated geographical area, but some ex-prisoners do not want to return to their previous address.
• Some services may be unwilling to work with ex-prisoners: "you get doors shut in your face with mental health problems".
• There is a lack of a "joined-up" and holistic approach to meeting an individual's needs. Some people's needs may fall between services.
• There is a lack of focus on preventive work in the community and some ex-prisoners become involved with services only at the point of crisis.
• Some ex-prisoners will present a risk in the community if their mental illness is not treated.

Circumstances of Release/Timing Issues

6.37 A small number of issues related to the circumstances of release, or timing issues which may exacerbate the difficulties in accessing support was highlighted:

• Sometimes prisoners are liberated from court, against the recommendation of psychiatrists. One hospital noted that sometimes nurses will be despatched to court with prisoners to ensure that they can be detained in the event that they are no longer detained as prisoners.
• When prisoners are liberated at short notice or unexpectedly it can cause problems in arranging support.
• When people go to court from hospital and are liberated, they must return to collect their personal items, as RCS will not have transferred these.
• Even when community appointments have been made for individuals on release, prisoners may worry about how they will cope between their release and the appointment: "it's making me ill and it's getting harder every sentence I do". Ex-prisoners may struggle even with the journey to their home area. One ex-prisoner sat at a bus stop all day following release.
• Prisoners may have to "start all over again" with their treatment on release, and may have to go back on a waiting list.

Lifestyle and Community Issues

6.38 Some of the problems were highlighted as affecting continuity of care on release related to aspects of prisoners' lives in the community:

• Ex-prisoners' lives outside prison are sometimes chaotic, and although they may have been stabilised in prison, they may return to such a lifestyle on release.
• Some will not attend appointments.
• Many ex-prisoners do not have personal support in the community.
• Some ex-prisoners are banned from services because of their previous behaviour.
• Ex-prisoners who are homeless face specific issues in hostel provision: "what do you do with someone who is getting released and who doesn't have an address - they go to a hostel. That condemns them to link to friends who will take them down a different road."
• Prisoners face a range of other problems in the community relating to issues such as education, employment and benefits. Although these are issues for most prisoners, they are exacerbated by mental health problems.
• Some prisoners identified continuing stigma and inappropriate attitudes from other people in the community as having an impact on their overall mental health.

CONCLUSIONS

6.39 In terms of preparation for release and release of people with severe and enduring mental health problems, the main conclusions are as follows:

6.39.1 Prisoners face a range of issues prior to liberation, and accessing support is very important.

6.39.2 Some work is being carried out in prisons to assist prisoners in preparing for their release and in accessing support, but the nature of this varies between prisons, particularly in relation to the level of formalised planning undertaken.

6.39.3 Mental health is not regularly considered as part of the ICM process.

6.39.4 A more systematic, formal, process for making arrangements to prepare people for return to the community and to ensure that their care continues is in place in hospitals. This generally involves a relatively formal discharge planning process, which includes relevant staff in identifying all of a patient's needs.

6.39.5 In many cases, prisoners being released from prison have to approach organisations in the community at their own instigation, with limited external support available, although a small number of initiatives were identified.

6.39.6 In terms of the provision made for patients leaving hospital, those who had not committed violent or sexual offences would generally be transferred to the care of community medical services.

6.39.7 The point of return to the community, particularly from prison, is a key area of concern in terms of securing continuity of care. One hospital stated that, when prisoners have been transferred to the mental health system, the problems are no greater than those faced in planning the discharge of any other patients. A number of problems can arise, however, when individuals with a mental disorder are in prison, and are being released directly into the community.

6.39.8 Some prisoners with severe and enduring mental health problems are, incredibly, liberated from prison with few if any links to continuing support in the community, and without any arrangements for the continuation of any work which had started in prison.

6.39.9 There are some specific gaps in preparation for release such as a lack of focus on throughcare specifically for prisoners with severe and enduring mental health problems and the lack of an holistic approach.

6.39.10 Some prisoners do not engage with pre and post-release planning, in some cases arising from a fear that disclosure of needs may delay their liberation date.

6.39.11 There is a number of perceived difficulties in securing access to services upon release ( e.g.GP services, hospital services and housing) and issues for some specific groups. There are also difficulties in gaining access to an in-patient bed when this is required.

6.39.12 There are issues relating to geographical variations and capacity of services, as well as a lack of communication between agencies.

6.39.13 Women may find it more difficult to access services due, in some cases, to the relative complexity of their needs.

6.39.14 Other groups who may also face problems include drug and alcohol users; homeless people; people with learning disabilities; sex offenders and foreign nationals.

6.39.15 There is a small number of issues relating to the circumstances of release, or timing issues which may exacerbate the difficulties in accessing support.

6.39.16 Some of the problems experienced on release relate to aspects of prisoners' lives in the community: chaotic lifestyles; behaviour; drug and alcohol use; lack of support and access to economic and social participation; and stigma. These may also impact on their likelihood of being able to access support services.

6.39.17 In some cases, the problems faced by ex-prisoners in these circumstances increase the likelihood of their re-offending.

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