Engager

Developing and evaluating a collaborative care intervention for offenders with common mental health problems, near to and after release
Engager

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. Access the full study protocol. 

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.

The Engager project was a five-year project, funded by the National Institute for Health and Care Research (NIHR) Programme Grant for Applied Research (PGfAR), to develop and evaluate a collaborative care intervention for offenders with common mental health problems, near to and after release.

This project was supported by the NIHR ARC South West Peninsula (PenARC).

The project was based at two sites, one in the North West and one in the South West of England.

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 being released from prison. We proposed that the intervention would act as a bridge between a range of services inside and outside of the prison, which this group did not normally access. 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 these goals.

The research

The project was divided into two phases. During 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). During phase two (months 25–60), we undertook an RCT to evaluate the intervention (Workstream 3).

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

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

This study has been reviewed and been given a favourable opinion by the National Research Ethics Service (NRES). It has also been reviewed and approved by the Research and Development Offices of the appropriate NHS Trusts as well as the National Offender Management Service (NOMS).

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.

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.

<p>Engager 2 montage</p>

Engager Peer Researcher film

A video telling the story of what it meant to the Peer Researchers to be involved in Engager, and the advice they would give to someone else considering being involved in a research project.

<p>Engager team</p>

The South West team

The Northwest team:

Professor Jenny Shaw, University of Manchester 
Principal Investigator – Northwest Site

Dr Charlotte Lennox, University of Manchester
Senior Research Fellow; Project Manager for Northwest site

Caroline Stevenson, University of Manchester
Research Assistant

 If you wish to find out more please contact us at primarycare@plymouth.ac.uk or +44 1752 764230.

Collaborators: Exeter University

Health Economics: 

Statistics and Trial Design:

Realist Review:

Qualitative Methodology:

Collaborators: other institutions

Professor Susan Michie
Director, UCL Centre for Behaviour Change

Dr Nat Wright
Associate Medical Director Specialist Services and Vulnerable Groups
Leeds Community Healthcare
n.wright@leeds.ac.uk 

Professor Mike Maguire
Professor in Criminology
University of South Wales

Dr Alex Stirzaker
IAPT Advisor and Specialist in PD and SMI
Avon & Wiltshire Mental Health Partnership NHS Trust
alex.stirzaker@nhs.net 

Dr Mark Haddad
Senior Lecturer in Mental Health
City University London

Dr Graham Durcan
Associate Director, Criminal Justice
Centre for Mental Health 
graham.durcan@centreformentalhealth.org.uk

Rachael Hunter​
Senior Research Associate
UCL

Dr Christine Brown
Consultant Forensic Psychiatrist 
Devon Partnership Trust
christinebrown1@nhs.net 

Dr Tirril Harris
Former Senior Research Fellow
King’s College London.

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