Personality Disorder and the MS Pilots is there learning and direction for the future

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Personality Disorder and the MS Pilots is there
learning and direction for the future?

• John Levy
• PD Team Wellington House
• Department of Health

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PD - 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)

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Initiatives

• 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

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Commissioning 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)

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The 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

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Personality Disorder NHS Services The Vision
?
National referrals
?
Key
Tier 6 DSPD Units
NOMS
?

• Broadmoor
• HMP Whitemoor

• HMP Grendon
• HMP LowNewton

Non-forensic services
Regional referrals
Forensic services
?
?
Regional referrals
Tier 5 Secure and Forensic PD Services
Relative volume of need
??
NOMS
Case management pathway lanning
Gatekeeping using shared protocols
Tier 4 Specialist, Inpatient and Intensive
Services
???
NOMS
s
Tier 3 Intensive Day Services, Crisis Support
and Case Management
?
?
?
?
?
Tier 2 Community-based Treatment Case
Management
Specialist services
??
??
??
??
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Tier 1 Consultation, Support and Education
???
???
???
???
???
Locality
Locality
Locality
Locality
Locality
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The 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
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Acute care what does success look like?

Source Healthcare Commission 2007 acute
inpatient assessment framework which has 59
indicators underpinning the 4 criteria
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First 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

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Feedback

• What is emerging
• And now

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Training 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

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• 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
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December 2007
April 2009
Overview of the project
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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
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• 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)

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The 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).

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Principles 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

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Second 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?

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Principles 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.

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Principles 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).

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Principles 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.

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Principles 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

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Outcomes 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

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Outcomes 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).

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Commissioning for Outcomes Outcomes for
Personality Disorder
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Taking 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

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• John Levy
• jlo8_at_btinternet.com
• John.levy_at_dh.gsi.gov.uk
• Mobile [phone]

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