Title: Personality Disorder and the MS Pilots is there learning and direction for the future
1Personality Disorder and the MS Pilots is there
learning and direction for the future?
- John Levy
- PD Team Wellington House
- Department of Health
2PD - Specific background
- National context
- Department of Health (2005) Self Care A Real
Choice, Self Care Support A Real Option. - Department of Health (2006) Our Health, Our Care,
Our Say. - Personality Disorder (2003) No Longer A
Diagnosis of Exclusion. - The Capabilities Framework (2004)
- The development of Capacity Plans (2005)
- Central Response to the Capacity Plans (2006)
- Review of Capacity Plans (2007)
3Initiatives
- PD Training funds 250K per CSIP Region
- In 2004 10.9 million allocated over 2 years for
11 new community pilots (Nationally 8 million in
PCT baseline 2004/05) - Following evaluation of pilots the recurrent
funding 6.8 million devolves to PCTs - NSCAG specialist tertiary PD Services shadowed
then devolved to PCTs in 2006 7.5 million
4Commissioning responsibility
- Commissioners (2005) were seen to need to
- Ensure allocated PD resources from DH continue
to be used for PD - Work with agencies to support whole systems
services - Support the specialised commissioners in
understanding local needs - Ensure all key players develop an informed
understanding of PD - Re-consider access to services to promote
inclusion - Consider the impact and implication of proposed
changed to the MHA (1983)
5The current position
- Need to establish/develop local services (circa
140K per PCT) - Seen as a 2 to 3 year development
- Viability of services for every PCT are currently
the exception not the norm - Experience and expertise is scarce
- Collaborative commissioning seems most likely
positive outcome
6Personality Disorder NHS Services The Vision
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National referrals
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Key
Tier 6 DSPD Units
NOMS
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- HMP Grendon
- HMP LowNewton
Non-forensic services
Regional referrals
Forensic services
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Regional referrals
Tier 5 Secure and Forensic PD Services
Relative volume of need
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NOMS
Case management pathway lanning
Gatekeeping using shared protocols
Tier 4 Specialist, Inpatient and Intensive
Services
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NOMS
s
Tier 3 Intensive Day Services, Crisis Support
and Case Management
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Tier 2 Community-based Treatment Case
Management
Specialist services
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Tier 1 Consultation, Support and Education
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Locality
Locality
Locality
Locality
Locality
7The mental health care pathway is complex and
multidirectional with a number of points of
access to services
Specialist services
Forensic Services
Severity
Secondary / Tertiary interface
Assertive Outreach Team
Community Mental Health Team
Psychiatric Intensive Care Unit
In-Patient
Crisis Resolution Home Treatment
Crisis Beds etc
Early Intervention in psychosis
Primary / Secondary interface
AE Liaison Team
Primary Care Mental Health Liaison Team
Primary Care
Acuity
8Acute care what does success look like?
Source Healthcare Commission 2007 acute
inpatient assessment framework which has 59
indicators underpinning the 4 criteria
9First steps
- Form 4 groups and
- List the 3 major challenges for local (EoE) for
generic personality disorder services - List the 3 major opportunities for local (EoE)
for generic personality disorder services
10Feedback
11Training development (KUF) a national
initiative for tender 2007
- The Knowledge Update Framework was tendered and
successfully won by the partnership of - Personality Disorder Institute
- Borderline UK Ltd
- The Tavistock and Portman NHS Foundation Trust
- The Open University
12- The Goals of the KUFs Successful Tender
- Designing accessible, relevant and quality
assured developmental pathways making Breaking
the Cycle of Rejection a practical reality - Raising awareness and shifting attitudes
- Applying skills and knowledge to make a real
difference - Building on service user experience
- Ensuring informed and responsive leadership and
management - Improving interagency and interprofessional
collaboration
Goals to achieve
13December 2007
April 2009
Overview of the project
14 Criminal Justice Health Local Government
Forensic
Non Forensic
Management and leadership
Expert/higher
Improving psychological well-being and increased
awareness
Core
Assessing and managing risk to self and others
Core/Foundational
Promoting Social Functioning/ Obtaining Social
Support
Building on the capability framework
15- At a National level, a number of key themes
emerged from the regional capacity plans
including - Recognition of the need for a robust and coherent
conceptual model to support personality disorder
(PD) capacity plans and strategy - The importance of partnership approaches across
the many agencies involved in providing support
to people with a personality disorder - The need to develop appropriate and robust
commissioning arrangements for PD services - The importance of engaging with primary care to
support an improved response for people with PDs - The essential role of mainstream mental health
services in providing for people with PDs - The importance of staff attitudes and skills
within current mainstream services in ensuring
appropriate provision for people with PDs - Exclusionary practice still operates in many
mental health services (secure, forensic and
community) and there is a need for a clear steer
and guidance from the Centre - From Update of PD Strategy Eastern Region (2007)
16The 3 Pilot Medium Secure PD Services
- DH agreed 3 pilot sites following concerns
regarding the quality parameters for PD Services
(funding service evaluation) - South London Maudsley NHS Foundation Trust
(SLaM) has Forensic Intensive Psychological
Treatment Service (FIPTS) (comprising of MSU the
Tony Hillis Unit, a community team residential
service). - East London the City MH Trust (ELCMHT) has
Millfield Unit (in-patient, modified TC model)
a residential service managed by Housing
Association. - Newcastle, Tyneside Wear MH Trust (NTW) has
Oswin Unit (in-patient MSU and a community team).
17Principles for MSU PD
- To provide new treatment services that improve
psychological health outcomes and reduce risk - Better public protection
- Improving the evidence base about what works in
the treatment and management of individuals with
personality disorder who are at high risk to
others - Developing an appropriately skilled workforce
- Providing better pathways between services
18Second steps
- Medium secure PD Services
- Go back to the same groups and revisit the 3
challenges and 3 opportunities and - What is now the difference?
19Principles for MSU PD
- Treatment of PD offenders
- General PD treatment literature
- Some meta analysis undertaken but inconclusive
when considering any one stand alone treatment
(Perry et al, 1999) - Bateman Fonagy (2000) found major short comings
in psycho-therapeutic treatment of PD - Warren et al (2003) found that although a number
of studies suggested potential effectiveness
reliable long-term effectiveness was extremely
limited.
20Principles for MSU PD
- 2. Correctional treatment literature
- The primary goal of correctional paradigm is to
reduce criminal behaviour. - Some evidence that CBT skills programmes have
been useful (Andrews, 1998) e.g. enhanced
thinking programmes (prison/probation) RR
(Reasoning Rehabilitation). - Sex offending programmes run in prisons and
therefore significantly address criminogenic
factors, some use CBT (Hanson, 2002).
21Principles for MSU PD
- 3. Literature on treatment of PD Offenders
- Crassati et al noted a range of treatments, of
which CBT combined with training in social skills
problem solving (thinking skills) sex
offender treatment programmes offered greatest
generalisability and efficacy. - Stigma remains a significant issue for those with
PD it was accepted that there was not sufficient
services for those with PDs.
22Principles for MSU PD
- 4. DSPD Specific Programmes
- The management of those posing serious risk of
offending is linked to severe disorders of
personality led to DSPD programmes. - Involved approx 300 new high secure places at
Whitemoor Frankland Prisons as well as Rampton
Broadmoor Hospitals. - The DSPD was to achieve five principles
23Outcomes from the 3 MSU Pilots
- Organisational outcomes common trends
- noted include
- Clear inclusion/exclusion criteria
- Significant work was on diminishing risk
- Assessment processes were long and on-going
- Differing models exist TC for ELCMHT VR for SLaM
CB based for NTW - Psychological interventions were core in every
service - MDT approaches were central to all services
24Outcomes from the 3 MSU Pilots
- Organisational outcomes differences noted
- Include
- The core components of the services
- The extent of external training provided.
- The level of integration between components of
each service. - The extent of S/U involvement (all encouraged SU
involvement in their own care but involvement
beyond that varied considerably).
25Commissioning for Outcomes Outcomes for
Personality Disorder
26Taking a Mainstream Approach
- All mental health services have inclusive
eligibility criteria that translate into practice
that includes people with PDs - All services have information systems that allow
identification and tracking of people with PDs - Systems are in place to identify people with more
serious needs - Systems in place to ensure effective assessment
and case management for the most severe /risky PD
cases - Essential role of skilled case management in
terms of pathways engagement appropriate
treatment recovery - Co-ordinated access to appropriate accessible
engaging longer term psychological therapy
programmes for moderate/severe PD - Appropriate assessment and gate keeping of such
treatments other intensive care packages and
out of area placements - Appropriately trained staff at key points in the
system with recognised roles in relation to PD
27- John Levy
- jlo8_at_btinternet.com
- John.levy_at_dh.gsi.gov.uk
- Mobile 07974 440969
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