Title: An investigation into aftercare planning for those remitted to prison from secure services: a mixed methodology exploratory study
Funder: Department of Health and Social Care

Abstract: Research question How can the remittal to prison care pathway from secure psychiatric services be improved to ensure entitlement to aftercare is upheld? Background Remittals to prison from medium secure services increased in 2010/11 and were observed to represent over 20% of all discharges. This transition is a time of elevated risk and vulnerability and up until recently, it was unclear what degree of aftercare was available in the prison estate for those returning following treatment. We have just conducted the first study both nationally and internationally to examine the remittal care pathway from secure psychiatric services (SPS s) to mental health in reach services (MHIT s). We found that that just 18% of patients remitted to prison had their care managed through the Care Programme Approach upon return to prison. At present, there is no formal mental health care-pathway or national targeted post-discharge service for prison remittals in the United Kingdom, and no comprehensive guidance for effective remittal exists. Aims and objectives The study will use a mixed methods approach to achieve the following objectives: To identify current national discharge/after-care-planning processes and procedures in SPS/MHIT s for prison remittals in England and Wales. To gain insight into clinicians experiences of managing discharge/after-care-planning for prison remittals. To develop guidelines for future clinical practice regarding discharge/after-care-planning for prison remittals from SPS s. Methods We will adopt a sequential-explanatory mixed methodological design which incorporates both quantitative and qualitative research methods. This consists of three separate pieces of work, each with clearly defined aims and anticipated outcomes: Phase 1: National survey to identify current discharge/after-care-planning process and procedures for prison remittals in SPS/MHIT s in England and Wales (objective 1 &ndash; months 1 - 8). Phase 2: Qualitative interview study of clinicians , criminal justice professionals and experts by experience (EE s) to explore discharge/after-care-planning for prison remittals (objective 2 - months 4 - 12) Phase 3: Stakeholder nominal-consensus groups to develop guidelines for future clinical practice regarding discharge/after-care-planning for prison remittals from SPS s (objective 3- months 11 - 16) Anticipated impact and dissemination Our findings will have an important impact on NHS policy in England and Wales. For the first time, data will be available on discharge and aftercare planning practices for prison remittals in England and Wales. Good practice guidance will be produced. A comprehensive strategy will be employed to ensure that findings are disseminated to key stakeholders and a wide range of professional and patient groups. Key outputs will include; good practice guidance; peer-reviewed articles in high impact journals and conference presentations at key academic and policy events. All anticipated outputs have the potential to promote prison remittals rights to aftercare, and should optimise the processes required for this to be achieved. Any uptake of the guidance produced will be a step towards achieving equivalent access to care for remittals to prison compared to people discharged to the community. We plan to apply for subsequent external funding to establish the feasibility, and acceptability of guidance key components and to implement and evaluate the impact of this guidance.

Lay abstract: Aim: We will study the process of returning to prison from secure-hospitals. This will include looking at; 1) how secure-hospitals plan for the return of prisoners and, 2) how prison-services make sure that returners receive the right after-care. Background: Over the last twenty years, the number of people transferred from prison to secure-hospitals for mental health care has increased. As a result, the number of people returning to prison after treatment has also increased. People who are transferred from prison to secure-hospitals for mental health treatment are entitled to free after-care when they leave hospital. This also includes those ordered to go to hospital for treatment by the courts. Those directed to hospital by courts for assessment only do not have this entitlement. This is called Section 117 after-care, which is designed to reduce the chances of their condition getting worse. This care should be designed and managed through the Care Programme Approach (CPA); a personalised plan which is coordinated by a mental health professional. The first study to look at people returned to prison from secure-hospitals found that just 18% were having their care managed through the CPA process in prison. The study also found that many people are vulnerable when returned to prison and that they often stop getting their after-care when transferred between prisons and when released to the community. This is concerning as earlier studies have found that poor access to after-care is associated with mental health relapse, violence, re-offending, suicide and other causes of death. There is need to look at the responsibilities of secure-hospitals and prison-services to make sure that prison returners get their legal right to after-care. We want to develop guidelines for the design of a robust pathway of care for people returning to prison from secure-hospitals. Methods: To do this we will use the following 3 steps: Step 1: Survey current services, discharge planning and after-care arrangement practices in medium secure-hospitals and prison-services in England and Wales. Step 2: Interview clinicians, criminal justice professionals and experts by experience to explore experiences of the Section 117 discharge/after-care process for people returning to prison. Step 3: Expert group meetings to develop Good Practice Guidance for return to prison from secure-hospitals. We will work with patients and people who have experienced returning to prison. They will help to decide how the study will be done, how the findings will be shared and the design of national guidance to be tested in future research. We then plan to design a follow-on study where we try-out the Good Practice Guidance within local medium secure-hospitals. This will help us to determine how practical the guidance is and how it may need to be modified across different regions.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;7.1 INDIVIDUAL CARE NEEDS
Health categories: MENTAL HEALTH