Engager

The Engager project was a five-year project to develop and evaluate a collaborative care intervention for offenders with common mental health problems, near to and after release.

Overview

Engager was a novel intervention for supporting prisoners with common mental health problems to achieve their goals.

University and peer researchers developed a system of care that aimed to help people in prison, leading up to and following their release. We wanted to know how well this package of care was working and whether it could be improved.

Problems to be addressed

Offenders suffer from a range of health problems, both while in prison and after their release. More than half have a mental health problem of some kind. While prison healthcare has improved over the last decade, mental healthcare is minimal except for those with the most severe problems. Additionally, care after leaving prison is particularly lacking for those serving short sentences. Addressing offenders’ mental health problems could lead to considerable gains: to the offenders’ own health; to the wellbeing of their families and communities; along with wider economic and social benefits due to reductions in reoffending.

Aims

The aim of the Engager project was to develop a way of organising care for men with common mental health problems as they approached release from prison. We proposed that the intervention would act as a bridge between a range of services this group did not normally access, both inside and outside of prison. An Engager practitioner worked with each person to develop a shared understanding of their individual goals, and worked with them to engage with services that helped them work towards achieving them.

The research

The project was divided into two phases:

Phase one (months 1–24)

We developed and tested the collaborative care intervention (Workstream 1). We also created a set of outcome measures and the methodology to evaluate the intervention in a Randomised Controlled Trial (RCT) (Workstream 2). In addition, we developed an economic model to assess the potential costs and benefits of the intervention (Workstream 4).

Phase two (months 25–60)

We undertook a RCT to evaluate the intervention (Workstream 3).

For the RCT, prisoners were asked to take part before leaving prison and then followed up with in the community. Half of the group received the intervention, while the other half received the care normally available. In this large scale trial, we examined whether there was a significant difference between those who did, and did not, receive the intervention.

The research results told us whether the Engager intervention improved prisoners’ common mental health problems and had wider social and financial benefits.

The intervention

Who was it for?

The Engager intervention was intended for men serving a prison sentence of up to two years who were within 4–12 weeks from release and who experienced common mental health problems (depression, anxiety, PTSD), with or without comorbid substance misuse and personality disorder.

The original intention was to develop an intervention to fill a gap in the provision of services to offenders. As such, the intervention was not designed to cater for men with serious mental illness, those with significant functional impairment, or those with severe personality problems, as these groups already have specialised services to address their specific needs.

What did we hope it would do?

The Engager intervention was designed to engage with individuals with common mental health problems who were close to release and to set up a pathway of care in preparation for discharge and for up to 16 weeks out in the community. The intervention aimed to overcome a set of challenges that had been identified as being problematic for this group including:

• transition between prison and community
• fragmented services based on diagnosis (e.g. substance misuse, depression) and social problems (homelessness, unemployment) rather than the reality of people with multiple and complex needs
• offenders’ reluctance to trust services (or see themselves as having mental health problems).

How was it delivered?

The intervention was delivered by practitioners supported by supervisors (senior health workers with experience of therapeutic work). They worked with offenders both pre and post-release. This work included:

• developing a shared understanding between the practitioner and the offender and producing a plan for achieving individualised goals
• actively liaising with relevant services to support need based on a shared plan
• working with offenders in preparation for the ending of support.

Impact

• The study was reviewed and given a favourable opinion by the National Research Ethics Service (NRES). It was also reviewed and approved by the Research and Development Offices of the appropriate NHS Trusts and the National Offender Management Service (NOMS)
• The Engager approach was adopted and implemented by West Midlands Combined Authority Mental Health Commission
• The Engager model was taught on the Plymouth GP vocational training scheme and to community and practice nurses in training
• The Engager team received ‘highly commended’ in the NIHR CRN Mental Health McPin MQ Service User and Carer Involvement in Research Award 2018

Patient and Public Involvement (PPI)

Engager found that people serving sentences in the Criminal Justice System (CJS) often have substantially different backgrounds and life experiences from the general population. PPI of ‘seldom heard’ groups brings valuable lived experience, and enhances research by driving its relevance.

A Peer Researcher (PR) group was set up to ensure that Engager 2 was relevant to those who would receive the intervention. The PR group consisted of eight men, and meetings were held at a local substance misuse charity. They were fortnightly meetings, usually lasting around two hours. The PRs were involved in all aspects of the project, up until the start of a Randomised Controlled Trial (RCT). Most notably, they helped to refine research documents, ensuring that their language and length were acceptable.

***

This research, based at sites in the North West and South West of England, was a collaboration between PenARC, the Faculty of Health at the University of Plymouth and The University of Manchester. It was funded by the National Institute for Health and Care Research (NIHR) Programme Grant for Applied Research (PGfAR) and supported by the Peninsula Clinical Trials Unit (PenCTU)