Transcript Personality Disorder Service – one year on

Putting the person
back into personality
disorder
Improving services for people
with Personality Disorder
Dr Christine Leaman
North Staffordshire Combined Healthcare NHS Trust
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
1
Aims for today’s talk
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Talk about developing a local service –
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Specially where there is no psychotherapy lead
Insufficient funding/will to set up a therapy service
Can you do anything worthwhile that is less
than a therapeutic service?
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
2
Aims for today
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Introduce myself and local service
Describe method of setting up local service
Refer to relevant evidence-base and
guidelines
Strengths and weaknesses of the model
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
3
Who am I?
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Consultant psychiatrist
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Practitioner in Cognitive Analytic Therapy
Work in a community mental health team in
Stoke on Trent
And in a hub and spoke model Personality
Disorder Service
Lately Clinical Director for Adult Services
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
4
Where is Stoke on Trent?
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
5
North Staffordshire Combined
Healthcare NHS Trust
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Small, traditional Trust
CAMHS, Adult and Older
People’s Services
Learning Disability Services
Joint health and social care
Trust
Work with many partners in
local health economy
Local service user’s group –
North Staffs Users Group
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
6
North Staffordshire Combined
Healthcare NHS Trust
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Harplands Hospital –
Community beds at 4
(out of 5) local
Resource Centres
Adult services
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CMHT’s
In-patients
Crisis Home Treatment
Functional teams
Used to have a
therapeutic day service!
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
7
Services for people with
personality disorders … in 2004
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Routine care
Psychological therapies service –
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Non-specialist for personality disorder
Open to all service users
Care Programme Approach
People with personality disorders struggled to get
appropriate care
Out of area referrals for therapy
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CALeaman
Main House – NHS regional therapeutic communtiy
Private services
North Staffordshire Combined Healthcare NHS
Trust
8
What happened in 2003?
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Drivers towards improving services for people
with ‘personality disorders’
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Increasing evidence of treatability for some
personality disorders
Evidence re effective treatment models
In England & Wales
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CALeaman
DoH and NIMHE promotion of evidence-based
models
North Staffordshire Combined Healthcare NHS
Trust
9
The impetus for developing
services
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
10
What happened regionally?
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Regional Strategic Health Authorities were
given central funding to promote
development of personality disorder services
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A capacity plan
A regional network – service users and
professionals
Main House residential DTC
The Olive Tree – one of the 11 pilot study
sites – day service
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
11
Developing a local service 2006
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Meetings within the Trust
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Meetings with Commissioners
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Psychological therapies service
Managers
Clinical leaders
Executives
Stoke and North Staffordshire
Meetings with service user groups
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
12
What was the response?
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Range of responses from bewilderment and
disinterest to active encouragement
One set of Commissioners supportive
So ...
Audit of in-patient services
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CALeaman
Nice Guidelines was not currently available
Used Integrated Care Pathway to set standards
Audit demonstrated significant short-falls in
current practice
North Staffordshire Combined Healthcare NHS
Trust
13
Developing a service – the
principles
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Evidence-base for what works
Examples of good practice – a visit to The
Olive Tree Local good will
Regional network support
But
Insufficient funds –
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
14
Developing a service – the
resources
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Funding from commissioners
£ 44,000 for first year (subsequently £45,000
recurring)
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Psychological therapies input - 0.15 sessions per week (6
hours!)
Part-time admin post 12 hours per week
Part-time service user network co-ordinator 11 hours per
week
Resources from within Trust
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CALeaman
3 consultant sessions plus up to 4 sessions of an
experienced senior nurse
North Staffordshire Combined Healthcare NHS
Trust
15
How does this compare with
other services in the region?
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Main House – tertiary and local service – closed in
2009
Birmingham & Solihull – therapeutic day service and
hub and spoke model using ‘Stop and Think’
Coventry and Warwickshire – the Olive Tree
therapeutic day service
Shropshire and South Staffordshire – lone worker
doing education and awareness training
Several other small services eg DBT, MBT
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
16
Think
personality!
Putting the person back into
personality disorder
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
17
Core Team and Champions
model
Innovative model
 Based on evidence and good practice
principles
 Adapted for local services
 Economical
But
 It has limitations
 It does not deliver a therapeutic service (yet)
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CALeaman
North Staffordshire Combined Healthcare NHS
Trust
18
Core Team and Champion
Model
CMHT
IP teams
Champion
CMHT
AOT
CORE Team
Rehab
EIT
CIT
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
19
Core Team - membership
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Management team:
CAL
Julie Elden
Sue Imlack/Sheila
Sheltie
Heather Creasey
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CALeaman
Consultation team:
CAL
Julie Elden
Karen Mason
Carl Woolliscroft
Christina Fitzgerald
Cat O’Callaghan
Graham Breeze –
independent supervisor
North Staffordshire Combined Healthcare NHS
Trust
20
What does the team do?
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Consultation to NSCHT teams and to
partnership organisations
Education and awareness training
Service user forum
Carer forum
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Put the person back into personality disorder!
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CALeaman
North Staffordshire Combined Healthcare NHS
Trust
21
What does the team do?
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A lot of (self)-promotion eg
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CALeaman
Link on Trust web-site
Entered for Trust Innovation competition
Survey Monkey survey to staff
On the Trust training programme
Attend local health and social care economy
meetings
Links with third sector organisations
World Mental Health Day, hosting a local
conference …. logo competition …
North Staffordshire Combined Healthcare NHS
Trust
22
What else does the team do
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Data collection
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Consultations
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Immediate satisfaction feedback
Data on service use by consultation – historical and
prospective use of CRHT, in-patient bed days, number
of admissions etc
Education and training feedback
Current audit of CMHT management of
people with personality disorder (in line with
Nice Guideline)
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
23
The Personality Disorder Service
Putting the Person back into
Personality Disorder
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
24
The NSCHT PDS main
functions
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Consultation to teams
Service user involvement
Education and awareness training
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
25
Consultation is ...
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A widely used model for developing good
practice
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CALeaman
Professionals’ meeting with PD Core Team input
A space to reflect
To address difficult issues
To contribute to care-planning
To develop team ownership of care-plans for
complex needs
To share positive risk-taking
North Staffordshire Combined Healthcare NHS
Trust
26
Consultation
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What is consultation?
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A consultation is a professionals’ meeting of all
involved individuals, meeting together with members
of the Core team, to discuss & think about the
service user, their needs, the challenges for the
team and individual staff members of working with
them, with the aim of using a more informed
understanding to develop care planning, risk
management and positive strategies
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
27
What makes a good
consultation?
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Time – usually 90 minutes
Attendance – best results if all the people
involved face-to-face can be there
Supported by managers
Augmented by representatives from other
agencies or teams
Acting in – everyone’s impressions and
contributions are valuable
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
28
Consultation activity – year
one
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Total number of consultations:
Total number of service users:
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CALeaman
23
19
2 clients had one follow-up consultation
1 client had two follow-up consultations
North Staffordshire Combined Healthcare NHS
Trust
29
Consultation occurrences
5
4
3
Consultations, incl. F-Ups
2
1
0
CALeaman
Apr08
May08
Jun- Jul-08 Aug08
08
Sep08
Oct08
Nov08
Dec08
Jan09
Feb09
Mar09
North Staffordshire Combined Healthcare NHS
Trust
30
Numbers Present at Consultations
11
10
9
8
7
6
5
4
3
2
1
0
Numbers Present
1-3
CALeaman
4-6
7-9
Mode: 3
North Staffordshire Combined Healthcare NHS
Trust
31
Themes – what was useful?
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‘professional and objective discussion and
outcomes’
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‘supervision element helped to identify
patterns of behaviour and also suggestions
regarding how to progress’
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‘Helped to refocus and clarify needs of client’
Multidisciplinary discussion and ‘outside
perspective’’
‘reaffirming current input is appropriate’
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
32
Themes – what was least
useful?
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‘No further treatment strategies identified to
help with management of client because all
available options have been offered and tried’
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Feelings that the interventions for PD ‘are so
ineffective’
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‘that the Core Team were unable to give ‘the
answer’’
‘there are no easy answers on how to care for this
type of client’
‘the client may sabotage outcomes’
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
33
Team Feedback – Core Team
Was the Consultation Useful?
None
0/
21
Some
6/
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Quite
12/
21
Very
Core Team feedback
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
3/
21
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Feedback – Comparison
12
11
10
9
8
7
6
5
4
3
2
1
0
Core Team
Care Coordinator / Team
Some
CALeaman
Quite
Very
North Staffordshire Combined Healthcare NHS
Trust
35
Could the Core Team identify
features of a personality disorder in
the patient?
Features of PD identified in patient
(based on Core Team’s feedback) 17/19
Cluster A: 1
Cluster B: 14
Cluster C: 3
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
36
Consultations feedback
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Useful to be listened to
All team members contributed
Recognition of ongoing risks
No short-term solution
Looked at joint working
Supportive, non-judgmental approach
Off-load main concerns, feelings & frustrations
Empowerment of client
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
37
Core Team analysis
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Main problems brought by the MDT
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CALeaman
Patient disengagement or lack of taking
responsibility
Professional conflict within team
Escalating risk
Lack of support for Care Co-ordinator
Pressure from carers/family/other agencies
Splitting
Boundary issues
North Staffordshire Combined Healthcare NHS
Trust
38
Core Team analysis
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Main problems brought by the MDT
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CALeaman
? referral to therapeutic service or another team
(eg rehab or assertive outreach)
Issues re MDT’s shared understanding and
communication issues
Unrealistic expectations eg re time-scale
Feeling stuck and pessimistic re outcome
Staff needing reassurance
North Staffordshire Combined Healthcare NHS
Trust
39
As discussed in Core Team
supervision ...
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Underlying issues
Lone Care Co-ordinator
getting tired
Team splitting
Needs of service user not
central
Information not being
considered
Unrealistic aims
Emotional responses not
being recognised
No team discussion
CALeaman
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Positive outcomes
Improved
communication
Shared risk
management
Person-centred
approach
Involving service user
more in planning
North Staffordshire Combined Healthcare NHS
Trust
40
Main agreed outcomes
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Increased support for the Care Co-ordinator
Information sharing within consultation
Clarity for team members about their roles
Confirming principles of working with people
with PD
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CALeaman
Eg setting boundaries
Shared management of risk
Communication
Using team supervision
North Staffordshire Combined Healthcare NHS
Trust
41
In summary
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Re consultations
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CALeaman
Consultations are being requested for the right
client group
The feedback is that the consultations are positive
and useful
Repeat consultations are often useful – specially
for teams struggling with strong emotions evoked
by working with PD clients
Some teams require/request increased training
North Staffordshire Combined Healthcare NHS
Trust
42
Setting up the Core Team …
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Core Team – 3 workshop days with external
trainers
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Team-building, agreeing principles, finding a
common theoretical framework
Supervision (with an independent supervisor)
Ongoing training – external and internal –
some jointly with Champions
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CALeaman
Theoretical, practical – eg developing training
skills
North Staffordshire Combined Healthcare NHS
Trust
43
A very simple model of
borderline pd
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Borderline pd occurs in people who have early
difficulties (before age 3 – attachment difficulties)
PLUS trauma in childhood
They have disrupted development
They have difficulties in managing their emotions,
having a sense of self, impulse control, relationships
(specially trust)
Everyone gets stuck in repeating patterns of
behaviour – for people with personality disorder this
can be more harmful and more difficult to change
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
44
Treatment models – the
principles
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Accessibility
Flexibility
Consistency
A coherent theoretical model
Supervision
Consultation
Education
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
45
Nice Guidance for
Borderline Personality
Disorder
78
Treatment & management
Issue date Jan 2009
Developed by National Collaborating
Centre for Mental Health
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
46
The Personality Disorder Service
Putting the Person back into
Personality Disorder
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
47
The Champion network
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What is a Champion?
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Interested in working with PD people
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One of more in each team
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Extra training with Core Team mandatory
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‘Champion’ PD
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Liaise with Core Team- practical role
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Can develop skills further – on the training escalator
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
48
PD Champion role
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Help teams to Think Personality!
Help care co-ordinators think about benefits
of consultation
Help arrange consultations
Be a link with the Core Team
Training – for Champions and with Core
Team
Support network
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
49
Selecting champions
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One to one interviews
Agreement with line manager to release time
for working with PDS and to go to Champions
network and training
Champions network meets monthly
Ongoing training opportunities – external and
internal
Commitment to three training sessions in first
year and two thereafter
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
50
The Champions
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22 in 13 teams – CMHT’s, IP wards, CRT,
functional teams, SW duty team
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CALeaman
All disciplines
People who volunteer
Have an interest in PD
Want to learn more
Want to develop skills
North Staffordshire Combined Healthcare NHS
Trust
51
The Service User Network
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Service user forum - aims
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CALeaman
To develop awareness of personality disorder
locally among service users
To inform re local services and opportunities for
development
To contribute to service development
To contribute to planning and delivery of
awareness training and education
Potentially to become a supportive network
North Staffordshire Combined Healthcare NHS
Trust
52
Service User Network
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Run by service user network co-ordinator
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Successful launch day in January 2009
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Monthly meetings in a non-NHS setting
Wide publicity
Agenda set each session
Developing a newsletter to go out in The Voice
Contributing to Trust PPI days
Participants in KUF training
Quarterly carers’ meetings
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
53
What else does the team do?
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Education and awareness training:
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Education – to MDT’s, services and professional
groups
Training – to partnership organisations
Undergraduate and postgraduate teaching
Professional groups
Primary care
All training opportunities are taken up
All Core Team members contribute
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
54
Training developments
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Champion training on-going
Penetration to other teams
Delivery of further training in NSCHT
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understanding causes of BPD
attachment
what works in teams
‘Feeling shattered – dealing with ‘splitting’’
Using supervision
Trust training programme
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
55
Knowledge & Understanding
Framework for PD
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DOH sponsored scheme
Developed by a consortium
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Personality Disorder Institute (Pdi) at Nottingham University
Tavistock & Portman NHS Trust
Borderline UK (part of Emergence CIC)
Open University
Training escalator – from basic awareness to
doctorate level training re personality disorder
Awareness training – e-learning supported by
a virtual learning environment & local training
by teams
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
56
West Midlands KUF
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Three PD Services won tenders to deliver
Awareness level training
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CALeaman
Birmingham, Coventry and Warwick and NSCHT
Personality Disorder Virtual Learning Awareness
(VLA) Programme
6 e-learning modules
Supported by 3 experiential workshop days –
jointly led by a professional and a service user
Currently training to deliver in 2010-2011
North Staffordshire Combined Healthcare NHS
Trust
57
In summary
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Our aim remains to develop a therapeutic day
service
In the meantime we have a service which
delivers parts of the Nice Guideline
recommendations
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CALeaman
Education and awareness training
It supports CMHT’s in delivering Nice Guideline
It supports the organisation in delivering Nice
Guideline
North Staffordshire Combined Healthcare NHS
Trust
58
In summary
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We have put together an effective Core Team
which is ready to develop a therapeutic
service
We have a service user forum which makes
links locally and regionally
We have increasingly well-trained staff who
are able to ‘champion’ personality disorder
service user needs ...
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
59
Think
personality!
Putting the person back into
personality disorder
CALeaman
North Staffordshire Combined Healthcare NHS
Trust
60