In Halton, Change Grow Live’s criminal justice team have achieved a 90-100% rate of continuity of care for people leaving prison – surpassing national targets and making sure no one is left behind.
Reconnecting with your community after leaving prison can be a daunting process, with countless obstacles to overcome. For people receiving treatment and support for their substance use, it can be especially difficult to maintain a continuity of care.
People face many barriers to support as they reintegrate into their community, from inadequate housing to a lack of communication between different agencies. Without careful planning and a joined-up approach between agencies, individuals can easily fall through the cracks.
In Halton in Cheshire, Change Grow Live’s Integrated Recovery Service has been working to break down the barriers people face, with significant success.
Last year the service achieved an impressive 90-100% rate of continuity of care – well above national targets. By ensuring that everyone who leaves prison needing ongoing treatment and support can access it, they are making sure no one is left behind. Here’s how they reached this remarkable milestone.
A challenge turned opportunity
In 2022, the Government’s National Drug Strategy introduced an ambitious new target for continuity of care: to ensure 75% of people leaving prison could access treatment within three weeks. The criminal justice team in Halton has surpassed this target by a wide margin.
It started with a clear vision: to make sure that no one fell through the cracks. The team formed close partnerships with local prisons (HMP Styal and HMP Altcourse), Cheshire Probation, and Cheshire Police. Together, they redefined how support for prison leavers was structured and delivered.
Charlotte Roberts, Service Manager at Change Grow Live in Halton, emphasised the importance of creating a culture that prioritises individualised support over numbers: “We wanted to make sure that when someone walked out of prison, they didn’t feel abandoned. Continuity of care isn’t just about statistics; it’s about giving people hope and the resources they need to succeed. We’re saying: ‘We see you. We’re here for you. Let’s rebuild together.’”
Innovation and empathy
The Halton team took an approach that directly addressed all the barriers people face to accessing care – from the build up to their release, to their reintegration into the community.
Prior to someone’s release, networking with the prison teams begins.
“Alerts sent by the prisons give us an indication of when people have entered prison and when they are to be released,” explained Clare Lunt, who leads the service’s criminal justice team. “Our team then holds weekly release meetings so we can individually plan each person’s release and support plan.”
She continued, “Our aim is to start that support prior to release, by attending the prison estates so we can meet those wishing to engage with us and find out what they want to achieve in terms of their recovery. Communication is key with everyone involved—from the person in prison, to the prison teams, police, probation, and housing.”
Key to this was the Cheshire Prison Leavers Project: a 12-month initiative funded by the Ministry of Justice that saw the introduction of three prison link workers who assessed people’s needs in the build up to their release. The prison link workers worked closely with housing providers such as Emerging Futures to make sure people had a place to stay after their release.
A stable home can make all the difference for someone leaving prison, and the team even arranged calls between people due to leave prison and their future housemates, to help ease their anxiety.
Support in the community
The service’s success is also a testament to the efforts of its recovery champions – people with lived experience who meet people at the prison gate and make sure they have a supportive, friendly face waiting to greet them.
Clare said, “We have found our gate collection offer to be hugely successful, with fantastic feedback.”
“We are engaging with people at a high-risk time in terms of tolerance and overdose risk. Gate collections provide us with the time in transit from the prison back to our site to give individuals harm reduction advice, overdose prevention, naloxone training, and information on local drug alerts.”
Once people have left prison and are settling back into the community, they can also benefit from the service’s Kitchen Table Café as a central hub for many of their first appointments.
When people leave prison, their ongoing support may involve a wide range of services based at different locations. The more separate appointments someone has to attend to receive support, the more likely they are to disengage and fall through the cracks.
At the café, individuals can access the various services they need in a single location and a welcoming environment. Charlotte noted, “When people come to the café, they’re greeted with warmth and understanding. It’s not just about services – it’s about making them feel valued from day one.”
The team’s holistic, empathetic approach to supporting people through their journey back into the community has even helped them to respond to unexpected new situations.
When the government launched its early release scheme in 2024 to tackle overcrowding in prisons, the team rose to the challenge and maintained its 90-100% continuity of care rate.
Charlotte added, “We’ve built strong relationships with local prisons, so when surprises happen, we can act quickly. The key is communication—being in constant dialogue with everyone involved.”
A model for the future
Halton’s success highlights the importance of collaboration, adaptability, and an empathetic approach to tackling health and social issues. But above all, it shows that success lies in seeing each individual as more than just a number.
The criminal justice team’s achievements in continuity of care are not just about numbers and targets – behind those numbers are real people who are being supported to reconnect with their communities in a dignified and empowering way.
“We’re not perfect, and we’re always learning,” said Charlotte. “But what we’ve built here in Halton is a community of care. And that’s something I’m incredibly proud of.”