Guidance

Guidance for improving continuity of care between prison and the community

Updated 30 November 2018

1. Summary

An integrated care pathway from prison to the community is crucial for supporting recovery from substance misuse and reducing reoffending among people leaving custody. The 2017 evidence review of drug treatment in England highlights the risk of relapse and reoffending among substance-misusing prisoners and their vulnerability to drug-related death in the first few weeks following release. The Drug strategy 2017 also recognises the need for better continuity of treatment for offenders on release into the community.

Supporting access to and continuity of care through the prison estate, pre-custody and post-custody, into the community is one of 3 shared objectives in the 2018 to 2021 National Partnership Agreement for Prison Healthcare between the Ministry of Justice, Her Majesty’s Prison and Probation Service, the Department for Health and Social Care, NHS England, and Public Health England (PHE).

Public Health Outcome Framework (PHOF) indicator 2.16 is a national indicator that measures continuity of care for people with a substance misuse treatment need who are released from prison and are referred to, and subsequently engage with, a community treatment provider.

Continuity of care of substance misusing offenders between prisons and community treatment is also a key service outcome in Service Specification 29 (Public Health Services for Children and Adults in Secure and Detained Settings in England) and is therefore one of the performance indicators in the public health functions agreement (Section 7A) to which NHS England is held to account.

Current PHOF indicator 2.16 and section 7A data provides evidence that successful transfer of offenders to substance misuse treatment in the community is low (30%).

PHE London established a project to specifically look at the barriers to engagement in treatment following release from prison. The project was supported by the Alcohol, Drugs and Tobacco division in PHE and the South East PHE Centre National Drug Treatment Monitoring System (NDTMS) team. The substance misuse treatment provider in one London prison, along with community treatment providers in the 5 highest receiving boroughs, agreed to participate in a one-off audit of prisoners leaving custody with a treatment need. The audit tools outlined in this toolkit were used and tested in this project. The audit identified weaknesses in the pathway between custody and the community, including:

• almost half of the referrals made by prison treatment services were not received by the community treatment services
• limited opportunity to make referrals with unplanned releases from court and no joined-up working with probation services during release planning
• low attendance at appointments or drop in clinics in the community following release from prison
• limited follow-up of individuals who did not attend

The audit also found that treatment services visiting or phoning clients in prison before release were much more likely to engage in treatment in the community. Successful engagement of these clients was almost 3 times higher than for those not contacted before release.

This guidance is based on the audit findings and discussions with stakeholders during the project, and includes:

• recommendations for commissioners and service providers who want to improve the transition from prison to community treatment services
• an overview of the audit approach used in the PHE London project
• tools which can be used by prison and community-based providers to investigate the barriers to continuity of care for offenders returning to the community who need substance misuse treatment

Performance on the PHOF 2.16 and 7A continuity of care indicator relies on accurate and good quality NDTMS data from treatment providers. So the document also includes a section on NDTMS data recording of clients transferred from treatment services in prison to the community and recording of clients successfully engaging in structured treatment on release.

2. Introduction

2.1 Continuity of care is a priority for government

The 2018 to 2021 National Partnership Agreement for Prison Healthcare between the Ministry of Justice, Her Majesty’s Prison and Probation Service, The Department of Health and Social Care, NHS England, and PHE has 3 shared objectives. One of these is supporting access to and continuity of care through the prison estate, pre-custody and post-custody, into the community.

Continuity of care is important to the National Probation Service (NPS) and community rehabilitation companies (CRCs), since both coordinate the resettlement of offenders. CRCs also play an important role in the treatment pathway as they are responsible for the supervision of all low and medium-risk prisoners who are released on licence conditions.

The Public Health Outcomes Framework (PHOF) provides the overarching vision for public health, the outcomes to be achieved and the indicators that monitor how well we are improving and protecting health. PHOF indicators are reported at national level and for each local authority. PHOF indicator 2.16, one of the health improvement indicators, measures the continuity of care for people released from prison with a substance misuse treatment need that are referred to, and subsequently engage with, a community provider.

Continuity of care of substance misusing offenders between prisons and community treatment is also a service outcome in Service Specification 29 (Public Health Services for Children and Adults in Secure and Detained Settings in England) and is therefore one of the performance indicators in the public health functions agreement (Section 7A) to which NHS England is held to account.

Both the 2.16 indicator and the Section 7A indicator on continuity between prison and community services are measured using data submitted by service providers to PHE for NDTMS. Current 2.16 data (2016 to 17) provides evidence that successful transfer from substance misuse treatment in prison to the community is low nationally (30%).

2.2 PHE London project to identify barriers to continuity of care

PHE London established a project in summer 2017 to identify the barriers to continuity of care from substance misuse treatment services in prison to those in the community. One of the main parts of the project was to undertake an in-depth analysis of the data recording and operational delivery processes for continuity of care of substance misusing offenders leaving prison. To support this, commissioners and providers of substance misuse treatment in one London prisons and 5 boroughs agreed to participate in a one-off audit. The audit was conducted between June and August 2017 and looked at a group of clients transferred from substance misuse treatment services in the prison to services in the community over a 6 month period.

The project also involved a series of meetings with a range of strategic and operational stakeholders to understand the local pathways from custody to community and to provide a qualitative analysis of the processes behind the audit results.

The audit and analysis was led by the Alcohol, drugs and tobacco division in PHE and the National Drug Treatment Monitoring System (NDTMS) team in the South East PHE Centre. A set of tools were developed for the audit, and participating treatment providers in the prison and community were supported to undertake the work. The London audit was an opportunity to test the tools and the auditing approach. This guidance is based on the approach taken for the case file audit and the tools used.

2.3 Barriers to continuity of care

A number of barriers and gaps in continuity of care were identified as a result of the audit work in London. In summary these were:

• only around half of referrals from the prison substance misuse treatment service were received in the community
• there was a lack of two-way communication between the prison and community treatment providers – referrals were mainly faxed to the community and there was no checking or confirmation of receipt
• the client’s release date was not communicated in almost a quarter of the referrals received – the longer the individual remained in prison the more likely the release was communicated
• there was limited opportunity to make referrals to the community in some cases, for example unplanned releases from court
• attendances at appointments in the community following release were low
• there was limited follow-up of individuals who did not attend their appointment in the community
• the challenges of following up individuals newly released from the prison were compounded by a lack of contact details for the clients, especially those with no fixed abode
• only a very small proportion of clients referred were flagged on the referral form as having a mental health need; housing was flagged in a quarter of cases
• very few clients transferred to community treatment services were known to have a licence condition to attend treatment on release and there was limited co-ordination between CRCs, the NPS and community treatment providers

There was little evidence of interaction between the community treatment services and the people transferred to them during the time the clients were in prison. However, where clients were contacted prior to release engagement rates were high (80%). The majority of these were visited in custody by a dedicated prison in-reach team within the local treatment service, and some were telephoned.

The London audit was also an opportunity to compare the post-release engagement rates derived from the local audit work and the rates calculated from nationally-held NDTMS data for the Section 7A and PHOF 2.16 indicator for the prison and partnerships who participated in the audit. While there was some variation between the participating boroughs, the rates derived from the audit returns and those calculated by PHE using NDTMS data were comparable overall.

3. Recommendations for improving continuity of care

A number of gaps and barriers were identified in the audit work in London (see introduction). Many of these issues will be similar in other local treatment systems so these recommendations will be relevant to all providers and commissioners who want to strengthen their local pathway from custody to the community.

Recommendation 1: develop a standard referral form

Prison treatment services should consider the development of a standard referral form for sharing with community services, where this is not already in place. As a minimum the form should include a description of the client’s assessed substance misuse needs plus any other needs that may impact on recovery (for example mental health and housing needs). The forms should describe the treatment the client received in prison, the expected date of their release and their contact details in the community to enable community providers to follow-up any non-attendance. The form could also include details of any contact with resettlement services in prison and whether the client has a licence condition to attend drug or alcohol treatment on release. An example referral form is included in this toolkit.

Recommendation 2: agree a referral protocol

Local treatment systems should agree a referral protocol with their main feeder prisons, which includes the minimum information to be shared with the community services (ideally via a standard referral form). It should include sharing planned release dates with the community provider, and stipulate that the community provider should be notified as soon as possible of any changes to a prisoner’s expected release date, for example early release from court. The referral protocol should outline the method of communication between the services, which should be secure (see recommendation 7), and the expectation of two-way communication (including the community provider formally acknowledging their receipt of a referral from the prison treatment provider).

Recommendation 3: in-reach by community providers

In London, in-reach from the community provider significantly increased the likelihood of a prisoner engaging in treatment in the community. Local commissioners should consider providing or expanding in-reach provision and drawing on mutual aid, peer and family support networks to support release plans and help the prisoner engage with treatment.

Recommendation 4: review and communicate what community treatment offers

Community treatment systems should review their offer to prison leavers to ensure it meets their needs. Community providers should communicate what their treatment services offer to their main feeder prisons, so that the prison service can describe the treatment and recovery support available in the community to prison leavers. Prison and community treatment providers may wish to consider more integrated working to encourage engagement on release, for example invite community services in to run pre-release groups with prisoners.

Recommendation 5: improve links with related services

Prison treatment services should review their links with resettlement services and jointly coordinate referrals and appointments arranged for the community (for example to avoid appointments clashing). Community treatment services should review their links with the community rehabilitation companies (CRCs) and the National Probation Service (NPS) to encourage and support newly released prisoners’ engagement in treatment.

Recommendation 6: provide single point of contact details

Local community treatment and recovery support services should ensure that their main feeder prisons are aware of the community single point of contact (SPOC) and that the published SPOC details are up to date by informing PHE of any changes in the SPOC details (for example an email, phone or address change or a change in provider) by emailing SPOC@phe.gov.uk.

Recommendation 7: share personal information securely

Faxing referrals is still a common communication method between prison and community treatment services. Faxing is not a secure way to communicate patient data and runs the risk of a personal data breach because messages cannot be encrypted and it can’t be guaranteed that the information is only seen by the intended recipient. For more information see the Information Commissioner’s advice.

Faxing or posting information to the wrong recipient was the most common form of data security breach in the heath sector in 2017-18. So services should only communicate personal information via a secure method, such as secure email (for example, using Criminal Justice Secure Mail (CJSM) email accounts).

Recommendation 8: record treatment data accurately

Recording of treatment data directly impacts on the PHOF 2.16 and 7A continuity of care local performance figures. Treatment providers in prisons and other secure establishments, and in the community, should ensure that their NDTMS data is recorded in line with NDTMS guidelines (see section 6 on data recording). This will ensure that that local post-release engagement rates accurately reflect the true picture of continuity of care for prisoners returning to the community.

4. Understanding the local pathway

A meeting between local commissioners and treatment providers from the community and the prison can help them to fully understand the referral pathway between treatment services in prison and those in the community. This will provide an opportunity for all parties to better understand the challenges faced by each provider and establish an ideal model for referrals.

Meetings should be established in the early stages of the audit and repeated throughout the process as and when the need arises. For example, in the initial stages of the project it would be beneficial to discuss the current pathway and challenges for continuity of care, obtain support and agreement to undertake an audit and agree its parameters (who, what, when, how). At a later stage in the project it would be useful to meet to discuss the audit findings and to agree recommendations and action planning. PHE Centres may be able to facilitate or support such meetings.

Meetings could aim to gain an understanding of:

• how referrals are made and whether this differs by partnership or provider (depending on how many localities and providers are involved)
• whether there are clear points of contact for making referrals
• when referrals are made and by whom
• whether referrals are documented (at point of transfer and/or at point of receipt)
• what information is shared – an information sharing protocol to standardise this may be appropriate
• whether and how appointments are made with the community provider and how these are communicated to the client
• if appointments are not made what instructions are given to the client and how?
• whether the CRC is informed of or involved in the client’s release planning
• what the process is for clients with a licence condition to attend treatment
• how referrals are recorded on NDTMS locally - are the correct processes being followed?

5. How to conduct a continuity of care audit

5.1 Introduction

PHE developed and piloted a set of tools for a one-off audit conducted between June and August 2017 in London. The tools used in the audit have been further developed to form a set of auditing tools and guidance. These tools are for service providers who want to do an audit of their own to better understand their prison to community referral pathway and the points where clients drop out. Engagement from the treatment services in the secure setting and in the community, along with support from both sets of commissioners, is essential to ensuring this process is successful.

5.2 Purpose and benefits of undertaking an audit

The main purpose of undertaking an audit is for providers and commissioners to understand the reasons behind the low pick-up rate by community treatment providers of clients released from prison. Reasons for this low pick up rate could include data recording, referral pathway and process issues.

A case file audit will provide commissioners, providers and PHE with a better understanding of how these issues impact on the pick-up rates and help to identify solutions to address these. The ultimate aim is to improve continuity of care for offenders with ongoing treatment need at release and to see this reflected in the performance indicators.

5.3 Audit stages

The audit should comprise of the following stages:

Stage 1: create a list of clients

The secure setting treatment service should create a list of clients in their NDTMS records who were transferred to community treatment on release.

Stage 2: complete an audit for each client

Community providers should check their local records or case files for each client on the list and complete a standard audit template (spreadsheet) based on a set of audit questions developed by PHE and sense-checked by community providers involved in the London audit.

Stage 3: analyse the audit data

The community provider should analyse the completed audit and identify the findings, including gaps in the pathway and what works well. Where multiple local authority providers are involved it is important to work out early on who will be responsible for analysing the audit data. If an overarching analysis is being conducted, the row level data should be anonymised before being shared between organisations and information governance should be thoroughly considered.

Stage 4: share the findings

The community provider should share their findings with local authority commissioners, secure setting providers and secure setting substance misuse commissioners, to develop a local action plan to address gaps.

Stage 5: monitor changes

Providers and commissioners monitor the impact of any changes implemented (for example by monitoring the PHOF 2.16 or metric 7A indicators).

5.4 Tools to support a local audit

PHE has developed a set of tools to support treatment services in prisons and in receiving partnerships to undertake Stages 1 and 2. These include:

• a data extraction protocol to assist the secure setting treatment service to obtain an extract of ‘transferred’ clients to share with community providers participating in the audit
• an audit template (spreadsheet) for completion by the community services which contains a standard set of questions for each client referral – completing the spreadsheet can be coordinated by the SPOC for local substance misuse services for clients released from prison
• an audit checklist to support community services in collating the information required to complete the audit template

5.5 Determining who and what to audit

When undertaking an audit it is important to select the most appropriate secure setting and local authority combinations and the most appropriate time period to ensure that a comprehensive and representative group of clients is audited without over-burdening.

The audit may involve one secure setting and either one or multiple receiving local authorities; or one local authority and one or multiple referring prisons. The combination will depend on the numbers of prisoners transferred, the commitment of local stakeholders and the focus of the project.

For example, in the London project, one prison was selected along with the 5 local authorities who received the highest number of clients transferred by that prison. All parties were fully engaged with the audit process.

The PHOF 2.16 companion report, produced by PHE using NDTMS data, can be filtered by prison or local authority, so the reader can see the main referring prison establishments to a local authority area or the main receiving areas from a given prison, along with the corresponding pick-up rates.

This report can be found on the Report Viewer available through NDTMS.net (for partnerships and commissioners) or NDTMS V2 (for providers).

The PHOF 2.16 companion report should be used to inform decisions in relation to which local authorities and prisons the audit should include.

The auditor should engage with the providers in the desired local authorities and prisons to obtain their support and cooperation with the audit. The regional NDTMS team may be able to assist with obtaining the contact details of providers based in secure settings.

Although it is relatively quick for a substance misuse team in a secure establishment to extract a list of transferred clients from NDTMS; it’s far more time consuming for the community provider to research each of these clients, complete the audit template and analyse the audit data. The community provider’s capacity should be used to gauge the optimum number of clients to audit.

The period audited in the London project was 1 October 2016 to 31 March 2017. 6 months’ worth of clients transferred from the prison to treatment services in the 5 local partnerships was deemed to provide a comprehensive and representative sample of clients transferred from the prison to the community. For other prison and partnership combinations a longer or shorter time period may be required depending on the volumes of clients transferred.

5.6 Guidance for undertaking an audit

This section describes the steps to take when undertaking an audit, taking into account a number of different scenarios. A quick summary of the steps is available separately.

One prison treatment provider and one community treatment provider

This is the most straightforward type of audit. In this scenario, the prison treatment provider should take an extract of all clients with:

• a discharge reason of ‘transferred not in custody’
• an exit reason of ‘released’
• an exit destination of the specified local authority
• an exit date in the relevant time period from their NDTMS system

This information should be used to populate the ‘prison NDTMS data’ section of the audit template spreadsheet. The spreadsheet should then be shared with the community SPOC or treatment provider in a secure way. Once received, the community treatment provider should complete the audit.

One community treatment provider and multiple prison treatment providers

In this scenario each prison treatment provider should take an extract of all clients with:

• a discharge reason of ‘transferred not in custody’
• an exit reason of ‘released’
• an exit destination of the specified local authority
• an exit date in the relevant time period from their NDTMS system

This information should be used to populate the ‘prison NDTMS data’ section of the audit template spreadsheet. This should then be shared with the community treatment provider in a secure way. The community provider should be aware that they will receive an audit spreadsheet from each secure setting. These should be audited and analysed separately, as well as in combination, to ensure that differences between referral pathways and processes are identified to identify good practice.

One prison treatment provider and multiple community treatment providers (across several local authorities)

This was the format used in the London audit. In this audit the secure setting should take an extract of all clients with:

• a discharge reason of ‘transferred not in custody’
• an exit reason of ‘released’
• an exit destination of the specified local authorities
• an exit date in the relevant time period from their NDTMS system

The extract should be separated into each of the different local authorities to ensure that each community treatment provider only receives information about clients that were referred to them.

This information should be used to populate the ‘prison NDTMS data’ section of the audit template spreadsheet (one spreadsheet for each community treatment provider). The relevant spreadsheet should then be shared with each community provider in a secure way, ensuring that each provider only receives a spreadsheet of the clients referred to them.

This will result in one audit spreadsheet to be completed by each community provider. These should be analysed separately, as well as in combination, to ensure differences between referral pathways and processes are identified. Who takes responsibility for analysis will need to be agreed between the different parties and everyone will need to be clear about information governance in relation to access to data. For example, data will need to be anonymised to ensure that information shared between providers does not breach information governance guidelines.

The regional NDTMS team can support the prison treatment service to take an NDTMS data extract and filter it to identify clients recorded as transferred to a particular local authority within a particular time period. The manipulation of the data extract should be based on the extraction protocol included in this toolkit. The extract can then be copied into a blank audit template spreadsheet by the prison treatment provider prior to sharing with the community provider.

Secure data sharing

Before any data is shared all parties should ensure that the relevant information sharing protocols are in place and that data can be shared securely.

The audit spreadsheet populated with the prison NDTMS data must only be shared with the community provider in a secure way (for example, CJSM email with additional encryption such as 7-zip). This is because the file will contain client personal data. It must not be emailed to the community provider because this is insecure and would be a data breach.

Prison treatment providers should ensure that they are only sharing with each community service information about the clients that were referred to that service and therefore have already consented to the sharing of their information.

Once the prison NDTMS data has been securely shared with the community provider the community provider may then complete the questions in the audit spreadsheet for each client transferred. The questions are focused on the referral process and engagement of the client post-release. The questions are also contained in the audit checklist available in the toolkit. Depending on how case files are stored by the community service provider it may be preferable to complete an individual checklist for each client in the prison extract and then input the information into the audit spreadsheet ready for analysis. Alternatively it may be more efficient to enter the information directly into the spreadsheet, particularly if case records are to hand electronically.

If a client had more than one referral during the period covered by the audit (due to more than one prison stay), the community provider should complete the questions for each separate referral as each ‘transfer’ could have potentially resulted in post-release engagement with the community service and would therefore be counted in the denominators for the PHOF and 7A indicators.

5.7 Analysis and findings

Once the audit questions have been completed for all clients included in the audit the community service provider may then analyse the data.

Where community providers from multiple local authorities have been involved each service should conduct their own analysis. The various parties should consider how they will compare and contrast results across the different local authorities and how best to summarise the overall findings.

During the analysis the main attrition points to be examined would include:

• how many of the referrals were received from the prison?
• how many referrals were not appropriate to the local service? (for example, if the client did not have a structured treatment need, they should have been referred to a different service)
• were appointments made for the referrals received?
• were clients that did not attend their appointment followed up?
• what was the impact of in-reach work?

The audit analysis could investigate whether the number of referrals received and the engagement rates differed for different groups of clients. The number of referrals to the community and engagement rates may vary depending on the referred clients’ problem substances (for example, opiate or non-opiate clients), or by the length of time the clients spent in custody (for example, engagement rates may be lower for clients who had short stays in custody).

In the London audit, the length of time in custody was determined by the number of days between a client’s initial reception and their prison release (exit date). For analytical purposes, clients were also grouped into the 4 substance groups commonly used by PHE in NDTMS reporting (opiates, non-opiates only, non-opiates and alcohol, and alcohol only), based on their top 3 problematic substances recorded in the prison treatment data extracted for the audit.

5.8 Action planning and monitoring

Once the audit return has been analysed and the key findings are shared with local stakeholders, commissioners and providers should convene to discuss the barriers to continuity of care and identify actions which would address these. They could also explore good practice which appears to result in better engagement in community treatment after release, to adopt it more widely or consistently in their area.

If any changes to practice are implemented in the prisons or the community, or along the pathway, the impact of these can be monitored using the PHOF 2.16 companion report This report is updated quarterly, but contains rolling annual figures; so it may take some time for positive changes in local engagement rates to be evident in the reporting.

6.Data recording guidance

6.1 Introduction

One of the possible reasons for the PHOF indicator showing a low rate of clients being picked up by community services post-release is local data recording issues. Data should be correctly and accurately recorded to ensure the PHOF figure is accurate. This section of the toolkit outlines some of the most common data recording issues and describes the correct NDTMS data process to follow when clients are transferred from treatment in a secure setting to a community service.

6.2 Common data recording issues affecting performance indicators

This section outlines some of the most common problems that have been identified when recording information about clients transferring from a secure setting to a community service (or vice versa) on NDTMS.

Client attributors are mismatched

When PHE analysts match transferred clients in the data, they use the client attributors (client first initial, second initial, date of birth and sex). If any of this information is inconsistent between the community and the prison data, PHE is unable to match the client between the prison and community NDTMS data sets.

Differences may occur because a different name has been recorded for the client (for example, Bob instead of Robert) or because a mistake has been made when the data has been entered. To reduce the risk of this occurring, it is important that both community providers and secure setting providers take additional care when entering these important fields on NDTMS. Service providers should also check the name of their client on referral and if there is a possibility that it could have been recorded differently by the community or prison treatment provider, they should double check before entering the data so that the information is consistent.

Prison exit date

It is important that the date that the client was released from the prison (the prison exit date) is recorded accurately on NDTMS. When linking the prison and community NDTMS data, PHE looks for a triage date within 21 days of the prison exit date for a client who has been transferred to the community. If the client was not triaged within 21 days of leaving prison then they are deemed to have not engaged as a result of that particular transfer.

If the prison exit date is recorded as being earlier than the client’s actual release, then the 21-day window will not be accurate and may result in no match between the datasets, even if the client did engage in that time.

Alternatively, if the prison exit date is recorded late, the client may have been triaged in the community before they are recorded as having left the prison, and this will not be picked up in the data.

So it is very important that the treatment service in the secure setting correctly records the exit date and that this is communicated to the community service as part of the client’s referral.

Secure setting discharge reason

It is important to remember that NDTMS only collects data on clients in structured treatment.

PHE will look for all clients with a prison discharge reason of ‘transferred – not in custody’ in the prison NDTMS data. If the client does not start a structured treatment episode in the community upon release, they will not be counted as having engaged in treatment, measured by the PHOF or 7A metrics , even if they do engage but only start a non-structured intervention.

Therefore it is vitally important that the prison assesses the client’s ongoing treatment need at the point of discharge and use the appropriate discharge reason:

• if the client has an ongoing need for structured treatment, use the discharge reason ‘transferred – not in custody’
• if the client only requires a non-structured intervention or recovery support, use the discharge reason ‘treatment completed’

A referral for non-structured or recovery support can still be captured in the referral on release status as ‘referred to recovery support only’. By recording clients with no structured treatment need as ‘transferred – not in custody’ the denominator used in the PHOF 2.16 calculation will be inflated, resulting in a lower recorded pick-up rate.

Prison treatment providers will be helped to select the most appropriate discharge reason if there is:

• a good understanding of what is offered by the community service
• a strong relationship with the community treatment provider
• two-way communication with the community provider at the point of transfer

A definition of structured treatment can be found in the appendix.

Previous community episode

When a client who is in community treatment goes into prison it is important that the community episode of treatment is closed (interventions must have an end date and exit status and a discharge date and discharge reason should be entered). If the episode is not correctly closed, then even if the client presents to the community service on release from prison, PHE will not be able to recognise this in the data.

If a client returns to the community service within 21 days of going into prison (due to a short custodial stay) then the community service may remove the discharge date and discharge reason from the previous episode but new interventions must be started. If the client returns to the community service after more than 21 days, then a new episode must be created.

No intervention started or non-structured intervention only

For a client to be recognised in the data as having started or restarted their community treatment after leaving prison, they must have a structured treatment intervention which started within 21 days of their prison exit date.

If no intervention is recorded, if only a recovery support intervention is recorded, or if a structured intervention is recorded but more than 21 days after their prison exit, they will not be identified in the reports as having started treatment in the community.. So it is important that transferred clients commence a treatment episode in the community within 21 days of their exit from prison and that this includes a structured treatment intervention start date.

6.3 Recording transfers from a secure setting to a community provider

Secure setting services’ data recording

This data process should be followed to ensure that the number of clients being transferred from a secure setting to a community provider is not overinflated in the data. If a client is engaged in structured treatment in the secure setting, and is coming up to release, the prison treatment service will need to consider their discharge reason. They may encounter 5 main scenarios:

1. The client requires ongoing structured treatment in the community

In this scenario:

• their discharge reason should be recorded as ‘transferred – not in custody’ (see the NDTMS business definitions for the secure settings discharge reason definitions)
• the referral on release status should be ‘referred to structured treatment provider’ or ‘referred to structured treatment provider and recovery support’ as appropriate
• the appropriate discharge date must be completed
• the client should have a prison exit reason of ‘released’ and the prison exit date should be the date that they left the prison
• the exit destination should be populated with the local authority that the client is being transferred to
• two-way communication should take place between the prison provider and the community provider to ensure that opportunities for continuity of care are maximised

See the appendix for the definition of structured treatment.

2. The client requires ongoing structured treatment but does not want to engage with a community service

In this scenario:

• their discharge reason should be recorded as ‘incomplete – onward referral offered and refused’
• the ‘referral on release status’ is likely to be ‘no onward referral’
• the appropriate discharge date must be completed
• the client should have a prison exit reason of ‘released’ and the prison exit date should be the date that they left the prison
• the exit destination should be populated with the local authority that the client is being released to

3. The client requires ongoing non-structured recovery support treatment only

In this scenario:

• their discharge reason should be recorded as ‘treatment complete – drug free’, ‘treatment complete – alcohol free’ or ‘treatment complete – occasional user (not opiates or crack)’
• the referral on release status would be ‘referred to recovery support service’
• the appropriate discharge date must be completed
• the client should have a prison exit reason of ‘released’ and the prison exit date should be the date that they left the prison
• the exit destination should be populated with the local authority that the client is being released to
• by recording the transfer in this way PHE will be aware that a referral to a recovery support service has been made but the client will not count towards the denominator or numerator for the PHOF 2.16 or 7A continuity of care metric

4. The client does not require any further treatment or support in the community. They have completed all elements of their care plan and are drug and/or alcohol free

In this scenario:

• their discharge reason should be ‘Treatment completed – drug free’ or ‘Treatment completed – alcohol free’
• the referral on release status would be ‘no onward referral’
• the appropriate discharge date must be completed
• the client should have a prison exit reason of ‘released’ and the prison exit date should be the date that they left the prison
• the exit destination should be populated with the local authority that the client is being released to

5. The client was unexpectedly released from court, and therefore the prison treatment provider has been unable to transfer the client’s care to the community provider in a planned way

In this scenario:

• their discharge reason should be ‘Incomplete – client released from court’.
• the referral on release status would be ‘no onward referral’
• the discharge date should be the last face to face contact with the client
• the client should have a prison exit reason of ‘released’ and the prison exit date should be the date that they left the prison
• the exit destination should be populated with the local authority that the client was released to

There will be variations on the above scenarios. If you are unsure as to which options to select please contact your regional NDTMS team.

A client should only be recorded as ‘transferred’ on NDTMS if they have an ongoing structured treatment need. If a secure setting treatment provider records the NDTMS discharge reason as ‘transferred’ for clients that have only been referred for recovery support, PHE will not be able to match them in the NDTMS data. This means they will still appear in the denominators for the PHOF and 7A indicators and will reduce the successful transfer rate from the prison to the community in those indicators.

For definitions of the different NDTMS data items, please refer to the NDTMS Business Definitions for secure settings and/or community adult treatment providers.

6.4 Community treatment services’ data recording

Community treatment services also have a responsibility to ensure that they manage the data for clients transferring in to and out of prison in the correct way. This will help ensure clients are identified as re-engaging with community services on their release from prison.

When a client is transferred into prison, the community service should ensure that the client’s treatment episode in the community is closed. This includes entering intervention exit date(s), intervention exit status(es), and discharge date and discharge reason.

A final Sub-Interventions Record (SIR) and an exit Treatment Outcomes Profile (TOP) should also be completed.

If the client comes back to the community provider within 21 days of their discharge date from the community service (for example, due to a prison short stay) the old episode can be re-opened, by deleting the discharge date, discharge reason and exit TOP record.

However it is very important that new interventions are opened (with new start dates) to show that the client has returned to the service. Without new interventions PHE will not be able to identify that the client has re-engaged with the service.

If the client should come back to the community provider after 21 days of their discharge date from the community service, the previous episode should remain closed and a new episode of treatment opened. A start TOP form should be completed within the first 14 days, and a post-prison exit TOP should also be completed between day 28 and day 56 of their prison exit date.

It is imperative that the community service ensures that the new community interventions start within 21 days of the client’s prison exit date. It is also important that the community service ensures that the attributors of the client (first initial, second initial, date of birth and sex) all match the prison data, by checking client details against the prison referral and in two-way communication with the prison substance misuse team. This is how PHE will match the client’s treatment journey. If any of the attributor information if different, PHE will not be able to identify the client as the same person in both sets of data.

7. Appendix: structured treatment definition

If one or more pharmacological interventions and/or one or more psychosocial interventions are delivered, the treatment package is a structured treatment intervention, if the following definition of structured treatment also applies.

This definition of structured treatment is taken from the Secure setting drug and alcohol treatment business definitions.

Structured drug and alcohol treatment consists of a comprehensive package of concurrent or sequential specialist drug and alcohol-focused interventions. It addresses multiple or more severe needs that would not be expected to respond, or have already not responded, to less intensive or non-specialist interventions alone.

Structured treatment requires a comprehensive assessment of need, and is delivered according to a recovery care plan, which is regularly reviewed with the client. The plan sets out clear goals which include change to substance use, and how other client needs will be addressed in one or more of the following domains: physical health; psychological health; social well-being; and, when appropriate, criminal involvement and offending.

All interventions must be delivered by competent staff, within appropriate supervision and clinical governance structures.

Structured drug and alcohol treatment provides access to specialist medical assessment and intervention and works jointly with mental and physical health services and safeguarding and family support services according to need.

In addition to pharmacological and psychosocial interventions that are provided alongside, or integrated within, the key working or case management function of structured treatment, service users should be provided with the following as appropriate:

• harm reduction advice and information
• blood-borne virus screening and immunisation
• advocacy
• appropriate access and referral to healthcare and health monitoring
• crisis and risk management support