Transcript Mike Cooke - Nottinghamshire Healthcare

Personality Disorder Pathways
– Creating Coherence
The Personality Disorder Service
Nottinghamshire Healthcare
NHS Trust
A disjointed discharge….
High Secure 1977 – 1985 (5 years) Medium Secure 1985 – 1988 (3 years) conditional discharge
Re-offended 1994 High Secure 1994 --------- Discharged 2006
2000
Completed
psychological
treatment
2002
Referral
made to
MSU
2003
2004
6 months
from
assessment
completed –
decision
received
Offered a
bed
Not
suitable
2005
2006
Other PD
placements
with borough
agreements
reviewed –
not
successful
Commenced
discharge
No clarity
regarding
future
placement
Move to
predischarge
area in
high
secure
Will need
independent
sector due to
needs
Recommenda
tions made
Patient coped
well &
adhered to
recommendat
ions
Will need
long term
MSU
MSU not
suitable
following
orientation
visit
Funding
issues with
out of area
placement
5 YEARS &
9 MONTHS
MHRT –
not to
discharge
Request
made for
assessment
from
independent
sector
Granted
deferred
conditional
discharge
MHRT
suggest a
conditional
discharge,
preference
for MSU
What the research tells us
When transferring patients with a diagnosis of PD
from high to medium secure services, the
reasons for unsuitability are cited as:o Too much treatment
o Too little treatment
o Too reliant on high secure structures
o Has a personality disorder
o Lack of resources/ facilities
o Needs long stay facility
The Pathway and beyond..
HIGH SECURE
The Peaks & Male Personality Disorder
OTHER
HIGH
SECURE
22 ( 23% )
2 ( 2% )
21 ( 22% )
6 ( 8% )
14 ( 25% )
34 ( 35% )
59 ( 76%)
LOW
SECURE
NON NHS
MEDIUM SECURE
NHS
MEDIUM SECURE
NON NHS
8 ( 11% )
2 ( 3% )
(LOW
SECURE) &
COMMUNITY
3 ( 4%)
MEDIUM SECURE
Arnold Lodge
PRISON
OTHER
HOME
ADDRESS
COMMUNITY
NON
FORENSIC
FORENSIC
PROBATION
COURTS
POLICE
MAPPA
Data based on discharges from 2007 - 2011
The rationale for a PD Pathway
Organisations work autonomously
Fallon – Lottery
Duplicated / disjointed treatment
Variable admission criteria
A Journey Through Services
from a service user perspective
My Journey
by Steven King
Time….my journey…..my life….
March 1996 – April 2010 ………14 years
 1996 to 1998 – Prison
 1998 to 2005 – Rampton Hospital
 2005 to 2010 – Kemple View – Medium Secure
 2010 – Step down accommodation – supported
 September 2010 – Commenced BA (Hons) in Fine Arts at
University
 2011 – “Living in my own flat!”
Treatment and treatment…..
HIGH secure
 Psychological assessments
 Anger Management
 Men Talking
 D.B.T. – (group) 2 years
 D.B.T. – (individual)
 Thinking Skills
 VOTP & Substance Misuse
 Commenced Schema work
(completed at Kemple View)
 1:1 VOTP work
 1:1 psychology work
MEDIUM secure
 12 week psychological
assessments (again) 1 year to
complete – must be complete
prior to commencing treatment
 VOTP – waited 18 months to
commence, 13 months to
complete
 Substance Misuse
 Schema work
 Life Manage Violence group
All similar/same to treatment
completed in High Secure
Services
What helped me
 Doing the Life Manage Violence again
 Utilising DBT skills helped normalise situations
 All treatments as it helped me to look at the
consequences of my behaviour
 Was able to be tested in Kemple View
 Recognising when I got stressed & my early warning
signs & talking to someone about them
 Knowing what I can & can’t deal with – where my cut
off point is
 Being part of a small clinical team – knowing I could
trust this small team
What I wasn’t prepared for
 Money
 How to use a phone
 Learning to use a mobile phone
 Benefits – waiting for them to
be sorted
 Waiting for my money to be
sorted
 What I was entitled to
 Having to so things for myself
 Patients cash always did this
 Starting new relationships with
staff & peers
 Having ground leave
 Greater restrictions
 Poor communication
 What the environment would be
like, what was there
 Home visit information
Repeating Social Work visits
 Changes in medication
 Repeating treatment
 Gaps in time – having to
manage this myself
 Budgeting
 Buying food
 The wards were different to
what I had visited
 Staff attitude
 Patients different
What would be helpful for patients
moving on from High Secure services
 Need to know what to expect – a brochure about the next service
 Learning how to be more self sufficient – more access to OT to
learn about budgeting and cooking skills etc
 Knowing how to structure my life & making use of my time
 How to budget
 Knowing about bank accounts, filling in forms, applying for things
such as a bus pass
 Dealing with knock backs
 Having to wait for things such as an appointment at the GP
 Dealing with issues such as care-coordinator being off sick
 Knowing what treatment you will be expected to complete in the
next service
The PD Care Pathway
A Systematic Approach
Emma Sly
Systems & principles
Needed look at the individual services as a
system rather than as individual services
All parts of the “system” should follow the same
principles. i.e. admission to a service and
transferring to another service
These principles should apply whether transfer
is to a health establishment or prison
establishment
The key functions
PD Pathway…
PD Pathway
REFERRAL
Decide on appropriate tier for
admission assessment
DISPUTE
Re-evaluate
Stay in service or move to
another
Health / prison
Assessments completed
Using OPB & agreed
assessment tools
Formulation developed
Update formulation
Complete any pre- treatment
measures
Assessment & treatment
targets discussed &
negotiated with lower tier
Re-negotiate if necessary
Commence treatment as
agreed with other service
Pre- treatment measures
Continue treatment as
agreed with other service
REVIEW
What risks are presented
What tier appropriate for
assessment?
Engage in
treatment
Relevant
pathway
ICP
Treatment
RISK
targets
Assessment &
Factors
NEGOTIATED Formulation Management
& AGREED
Reduction
PD Pathway
Panel
Guiding principles
End of treatment report, link
to RISK & OPB , post
treatment measures
completed.
End of treatment report, link
to RISK & OPB , post
treatment measures
completed.
PD panel
Referral and admissions
Decisions agreed regarding appropriate “tier”
Resolution of disputes
Offers opportunity to maintain open
communication & discuss difficult presentations
Opportunity to share “lessons learned”
Risk issues shared
Assessment, formulation
Agreement reached regarding assessment tools
to be used across all services
Formulation key when identifying treatment
targets
Agreed to use offence paralleling behaviour
model to measure behaviour changes
Agreement reached regarding formulation being
updated when transferred to other services, not
redone
Development of a portfolio of information
Treatment and targets
Agreement reached regarding treatment targets
negotiated & agreed
Joint process, communication key, shared goals
and responsibility
Appropriate treatment in the appropriate
service
Assistance required determining direction
Engagement in treatment
Treatment
Individual pathways
Clearer understanding of each others service
Shared training
Shared clinical supervision
Working together across services
Review, update, refer .. transfer
Clinical review following treatment intervention
Review risk
Enables a discussion to take place
Resolution of disputes
Open communication
Allows appropriate questions to be asked
INTEGRATED CARE PATHWAY FOR
MALE PATIENTS WITH PERSONALITY
DISORDER
JAY SARKAR
Consultant Forensic Psychiatrist
Personality Disorder & Secure Women’s Service
East Midlands Centre for Forensic Mental Health
Arnold Lodge, Leicester
Common difficulties
 Clinical teams: Burn-out, deskilling
○ Difficult patient group with long-term risks, therapy
interference, intense scrutiny
○ Denial, deception and dismissive of need for treatment
 Institution: ‘Splits’
○
○
○
○
○
○
Teams, services, pathway
Barriers to effective communication
sN37’s without MOJ controls – Trust bears all risks
‘Independent’ pathways available, ‘patient choice’, QIPP
Costly legal battles, subpoenas
Tribunals recommend risky transfers/discharges
Solutions and the context
Experience from contested MHRTs or failed
‘trial leaves’ over last 4 yrs
Multiple assessments, goal-setting and repeated
reviews, sometimes with managerial input
Criteria have been legally ‘field-tested’:
Tribunals now upholding criteria recommended
by trust clinicians rather than independent
‘experts’
Commissioners rely on these clinical judgements
Aware: What & Where
INSIGHT DEVELOPMENT
 Broad-spectrum view and
therapies
 Schema, CAT, Individual work
 Offence-specific work
 Denial/defensiveness
APPLICATION OF SKILLS
•CBT-based specific pieces of work
•Life and Social Skills training
•Relapse prevention work
•Capacity to work with others, groups
SUPERVISABILITY
•In community, hostels, etc.
•High risk situations, moods, thoughts
•Crisis-intervention/plans
•Willingness to comply
HIGH
MEDIUM
LOW/COMMUNITY
Agree: Entry & Exit criteria –“MAPPING”
Treatments to be completed at different stages
and to be agreed between clinicians and
patients.
It can be informed by, but not dictated to by
those who do not have the responsibility of
managing risks and addressing needs.
Take a Whole System View from an
organisational perspective and not from
individual viewpoints.
Thresholds and criteria
Stage I – Stage of liaison (CPA)
Stage 2 – Stage of formal referral (Assessment)
Stage 3 – Readiness to transfer (Interim reviews)
Stage 4 – Managing Transition (Criteria for
return to higher level of secure care)
Compare & Contrast
Multiple challenges by legal teams
No consultation with medium security
Parallel assessments
Precipitous transfer to low security (GD)
Lack of awareness of risks and its management
Worryingly discharged to community (LP)
Media spotlight and risks
Future challenges to ICP
Needs ‘buy-in’ and changes to ‘usual practice’
Take broad perspective, not local
Legal challenges to ‘agreements’
Organisational support to individual teams
Fully ‘integrated’ implies patient movement in
both directions
Locating and sharing skills & knowledge
throughout the ‘system’
The Nottinghamshire Community
Forensic Service
A Crucial Point within the PD
Pathway
Jeremy Resnick
Clinical Director
The Nottinghamshire Community
Forensic Service
Two equal sized teams (City & County).
Not PD specific (45 PD, 80 other)
Manage 150 through-care patients
450 new community referrals each year : 4050% have PD primary or secondary diagnosis
and problems/risks relating to PD.
No bespoke community forensic PD service
No low secure PD service
Pilot PD clinic based in county team
2007 –The Way We Were
 PD services are fragmented, different models operating
across the PD service affects patients
 Need to integrate clinical models of service provision
across Trust PD services inclusive of health, Prisons
MAPPA & probation services
 Some community patients not suitable for PD Network
due to risk issues identified
 Developed Specialist Registrar in medical Forensic
Psychotherapy providing leadership in PD services
 Continued need to provide outpatient assessment and
treatment of Forensic PD patients
2007 Proposal: A Community & Low
Secure Forensic PD Service
 Meeting the needs of PD patients in the community,
inpatient settings, prisons, probation service as well as the
needs of commissioning services
 Assess & treat patients returning to the community from
OAT placements & medium secure services
 To offer choice for patients on the pathway
 Manage blocks in services
 Share expertise between available services
 Cater for the unmet needs of patients who are not suitable
for other services within the Trust i.e. PD Net
 Clarity regarding shared/ joint agreements
 Appropriate provision for discharged patients
Managing the Risk
Responding to serious and untoward incidents
Recognise the risk associated with this patient
population
Assistance with managing risks with limited
specialist resources in the community
Development of the pathway between services
Increased communication between services
Local PD pathway initiative
Improved licensing conditions with probation
The Current System
A limited pilot PD clinic in County – not
available to City patients
Informative review established the clinical need
of our PD caseload this will assist in future
service design
Managing referrals in a more responsive way
Inter-agency working where possible
Recognising when needs are not currently being
met
The Future
 Build the vision of a new system of care for PD patients
that includes community forensic and offender patients.
 To evolve as a service & provide a range of services to
support, treat & reduce risk
 With an equitable pathway across services
 Continue to recognise & respond flexibly to the
differing needs of this population
 A pathway that supports patients; and systems which
support staff
 Acknowledge & work with the necessary changes in
practice and provide expertise in treatment and risk
management
OFFENDER HEALTH
Dr Adarsh Kaul
CLINICAL DIRECTOR
HMP Wakefield
Lindholme IRC
HMP Lindholme
Integrated Care
HMP
Category
Nottingham
C Mental Health
CapacityCategory
1010 B Local
Capacity
549
(Imigration Removal
Centre)
HMP Whatton*
Integrated
Care
Mental Health
Category
Category
IRC
C
Capacity
Capacity
124
841
Trusted partnership
HMP Stocken**
Primary Care
HMP&YOI
CategoryDoncaster
HMP Ranby
HMP&YOI Moorland
(Closed)
HMP Lowdham
Integrated Care
Grange
Category
Mental Health
Category C
Capacity
B Closed Training
Prison 785
Capacity
564
Mental Health
Category
A
Capacity
751
HMP
Moorland(Open)
Integrated Care
Category
D
Capacity
260
C Integrated
Mental Health
Care
Capacity Category
Category
806
CB-Local
- Training
Capacity
Capacity
1098
1178
HMP&YOI
New Hall
Mental Health
Category
female
Capacity
446
HMP Nottingham Population
1060 male remand and sentenced prisoners
OBJECTIVE
EQUIVALENCE
PREVALENCE Of PD
SINGLETON et al , 1997
63% OF MALE REMAND P. – ASPD
49% OF MALE SENTENCED P.– ASPD
29% OF MALE REMAND P.– P.P.D.
20% OF MALE SENTENCED P.– P.P.D.
23% OF MALE REMAND P. – BPD
14% OF MALE SENTENCED P - BPD
PREVALENCE HMP NOTTINGHAM
–
BELSHAW & KAUL (2007)
SAMPLE REFERRED TO IN-REACH SERVICE
30% OF REFERRALS – PERSONALITY DISORDER
AND MENTAL ILLNESS
60% OF THOSE SEEN BY IN-REACH SERVICES HAD
PERSONALITY DIFFICULTIES AS ONE OF THE
PRESENTING PROBLEMS.
75% OF REFERRALS TO IN-REACH SERVICE HAD
BEEN IN CONTACT WITH PSYCHIATRIC SERVICES
AT SOME POINT.
ASSESSMENT
VERY FEW WITH ASPD ONLY
ASPD + PPD + E.U.P.D
COMORBID MINOR PSYCHIATRIC CONDITIONS
COMORBID MAJOR PSYCHIATRIC CONDITIONS
COMORBID SUBSTANCE ABUSE
WHO SHOULD WE TREAT?
AND
HOW ?
TIERED
PROVISION
TIER 4
Tier 3 nonresponders
Specialist prisons
Secure Hospitals
TIER 3
Tier 2 non-
Individual Psychology
responders
Moderate / Severe disorders
Medication,Psychoed,
Supportive Psychoth,
Stop & Think
TIER 1
Crisis Intervention
TIER 2
Mild disorders
TIER 1
Organisational
Healthy Prison
Mental Health Awareness
Patient Related
Crisis Intervention
Self-Help
TIER 2
Medication as appropriate
PD Psychoeducation module
Supportive Psychotherapy
Stop and Think
APPROPRIATE MEDICATION FOR AXIS
1 AND AXIS 2 DISORDERS.
SUPPORTIVE PSYCHOTHERAPY
EMPIRICALLY BASED THERAPY PROMOTING A
SUPPORTIVE THERAPUTIC ALLIANCE, ENHANCES
COPING SKILLS AND STRENGTHS, REDUCES
SUBJECTIVE DISTRESS AND BEHAVIOURAL
DYSFUNCTION, ACHIEVES THE GREATEST
DEGREE OF INDEPENDENCE FROM PSYCHIATRIC
PROBLEMS AND AUTONOMY – NOVALIS et al 2005
SOCIAL PROBLEM SOLVING THERAPY
IMPROVES SOCIAL COMPETENCE BY
DISCOVERING SOLUTIONS TO PROBLEMS IN
LIVING AS SOCIAL DYSFUNCTION IS A MAJOR
PROBLEM FOR PEOPLE WITH P.D. – SKODOL et al
2005.
HELPS BY COUNTERACTING IMPULSIVITY,
DEFINING PROBLEMS, GENERATING SOLUTIONS,
ENCOURAGING CONSEQUENTIAL PLANNING AND
ACTION – D’ZURILLA & NEZU, 1999.
TIER 3
Individual Psychological Treatment
PTSD
Developmental Trauma and Abuse
Attachment Problems
OCD
Coping with Voices
Coping with Paranoia
Self-Harm ( ? DBT )
TIER 4
NHS Secure Hospitals
Grendon Underwood
Dovegate
Gartree
Prison DSPD Programmes
DOES IT WORK?
DO NOT KNOW …………BUT
MOST BECOME PSYCHOSOCIALLY STABLE IN
PRISON ENVIRONMENTS
- MARKED REDUCTION IN DISTRESS
- MARKED REDUCTION IN BEHAVIOURAL
DISTURBANCE
- MARKED REDUCTION IN CRISIS
- ENGAGEMENT WITH PRISON WORK /
EDUCATION
- BETTER ENGAGEMENT ALL AROUND
FAILED RETURNEES FROM SECURE HOSPITALS
PATHWAY PROBLEMS
-INTERFACE WITH REST OF THE DIVISION AND
TRUST
-MAINTAINANCE TREATMENT & FOLLOW UP
 - SIMILAR TO ANY CHRONIC CONDITION WITH A
BIO-PSYCHO-SOCIAL AETIOLOGY
 - NOT ROCKET SCIENCE
 - RESOURCE INTENSIVE ( CAREWORKERS WITH
CASELOADS SIMILAR TO ASSERTIVE OUTREACH )
REVOLVING DOOR
HELPING YOU OUT
PRISON BASED OUT-REACH SERVICE
Successful reintegration
back into the community