Many people in prison have severe mental health problems, but what is being done to help these individuals resettle when released? And how can policy and practice reduce reoffending rates, while ensuring prison leavers with mental illnesses are given the support they need to reintegrate into the community? Here, Dr Jane Senior, Professor Jennifer Shaw, and Dr Charlotte Lennox outline their research into Critical Time Interventions, and what the evidence says about how best to help prisoners get back into society.

• Without bespoke and ongoing support, many prisoners with mental health needs lose contact with community services when released.
• Critical Time Intervention is one model for helping these prison leavers reintegrate into communities, and has been shown to lead to better outcomes.
• A more joined-up approach to prison resettlement is needed for leavers with mental health needs, which could help lower rates of reoffending, and ease pressure on the NHS and community health services.

Since the 1999 Future Organisation of Prison Healthcare report, attempts at healthcare for prisoners has been delivered as a partnership between the NHS and the Prison Service. And since 2013, responsibility for commissioning all healthcare services for prisoners in England – with the exception of emergency and out-of-hours services – has rested with NHS England. Within the community, Integrated Care Boards (ICBs) are responsible for commissioning the majority of healthcare services for prison leavers, having inherited this responsibility from the now defunct Clinical Commissioning Groups.

But how is the handover between prison and community services managed?

Earlier research led by The University of Manchester found that, of 53 prisoners who had been in touch with in-reach services, and who had severe and enduring mental health conditions, just 4 were in contact with community mental health services six months after release. The study concluded that there “is a need for robust discharge planning and proactive through care for prisoners with mental health problems”.

What else can be done – and what works?

Critical Time Intervention

Critical Time Intervention (CTI) is an American model of care, designed for people in psychiatric hospitals who were discharged as homeless. It involves the development of holistic discharge packages, to organise all the services and needs that patients have said are a priority to them. This includes funding, accommodation, education, and employment alongside healthcare needs. CTI managers (who are clinicians, routinely nurses) work with patients both before and for a short period following their discharge, to ensure they have stable pathways and support in place.

A review of CTI in the US found that patients who received support from this model were less likely to be homeless, and spent less time using emergency care facilities, than the ‘treatment as usual’ (TAU) group.

Researchers from The University of Manchester wanted to know if this model could be applied to prisons. They adapted the training manual for CTI managers, to cater to the needs of prison leavers. They were as follows:

• Ensuring prisoners on remand were able to attend court dates with arrangements in place (such as medication supplies, appointment with community services) should they be released.
• Registering prison leavers with GP services in the areas they were discharged to.
• Liaising with statutory and third sector organisations, plus families and other community links, around providing accommodation, where this was possible.

Findings

It was found that people who went through CTI were significantly more likely to remain in contact with mental health services, and to be concordant with their medication, than those who didn’t. This was true at 6 and 12 months after release. However, a loss of contact following 12 months will lead to CMHT and NHS incurring significant further costs and pressures, and demonstrates that CTI alone is no magic bullet. Prisoners with severe mental health issues require the same kind of life-long support that would be provided to any patient with these conditions, and this must be recognised in a joined-up strategy between the Ministry of Justice, and the Department for Health and Social Care.

Researchers also found that, in addition to better outcomes, CTI was liked by both prison leavers and staff, with a common notion that it was the ‘right thing to do’, and that working in this intensive way provided ‘proper’ mental health care. CTI participants were less anxious about release, and reported receiving more support with housing, access to services, and community reintegration, than during previous periods of incarceration, due to being closely supported by their CTI manager.

However, it is reasonable to expect that, when moved to the status of receiving routine Community Mental Health Team (CMHT) support, with less frequent contact and intensive CTI management, contact and engagement will wane, potentially leading to continued mental illness and criminality. As such, the move from prison to the community should include wider CTI training for CMHT services. CMHT staff will need CTI training, and the time and resources to dedicate to their clients. This could be done by having CMHT staff who have reduced caseloads of only CTI clients, or giving all CMHT staff a small number of CTI clients along with a reduced ‘normal’ caseload.

Recommendations

CTI has not been widely adopted to date, in part due to higher costs than the standard model of release. However, given that it showed significantly better outcomes for prison leavers with severe mental health issues, it is likely that its use could lead to net savings overall, through wider economic benefits to public services through lower use of emergency care, better community integration, and reduced rates of reoffending.

• The Ministry of Justice should commission research to investigate the wider health economics of CTI.

CTI is no universal solution – a related model (‘Engager’), when trialled found that, for prisoners with more mild mental health conditions, the results were mixed. However, for those prisoners with the greater mental healthcare need, the evidence shows that CTI has the potential to be a powerful asset in the wider toolkit for improving community resettlement, and helping prison leavers to lead fulfilling lives outside the justice system.