Transcript The past the present the future Naiotnap Perosnality

The National PD
Programme in England
Scottish Personality Disorder Network
“Progress, Questions and
Looking Ahead”
Policy and aims
Managing Dangerous People
with Severe Personality
Disorder (DSPD)
1999
Personality Disorder: No Longer
a Diagnosis of Exclusion 2003
Breaking the Cycle of Rejection:
The personality disorder
Capabilities framework
2003
Social Exclusion Action Plan 2005
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Developing new
approaches to treatment
and care
Improving outcomes for
patients/prisoners
Strengthening the workforce
Improving the capacity of
whole systems
Improving social inclusion
Improving public protection
Establish early interventions for
emerging PD
Why……
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Manifesto commitment on public protection
Overall, service provision was minimal and variable (surveys
2000, 2002, and local investigations 2003)
28% of Trusts “…..do not see the provision of services for
personality disorder as being part of their core business.”
PD patients in high secure services waiting many years for
appropriate placements elsewhere
People with personality disorder seen to ricochet around the
service system; particularly in crises
Because….
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Very limited services for patients with personality disorders in NHS secure
settings
Limited therapeutic services available for offenders with personality
disorders
Many people with personality disorders in the community receiving services
from social care, voluntary sector and housing agencies ill equipped to
respond effectively
“….people with personality disorder are treated at the margins….They have
become the new revolving-door patients, with multiple admissions,
inadequate care planning, and infrequent follow-up”. (PIG 2004)
Lack of shared basic assumptions:- what people with personality disorders
should expect; what we should expect to provide
Psychiatric services in considerable confusion about PD
Aims of a Pilot Programme
A pilot approach seeking
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Evidence of effectiveness
Innovation in service design and practice models
Challenging social and service exclusion
Modelling capacity
Testing practicability
Organising sustainability
Informing future policy initiatives
Progress - the range of
developments
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New investment in 11 community based pilot services; and 5 forensic pilot
services; 3 pilots in prisons (1 for women); 2 pilots in High Secure Hospitals;
4 new MST sites; a prison clinic?
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Training and education programmes through CSIP/NIMHE RDCs
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Local and national evaluation initiatives
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Service user participation at local, regional and national levels
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Commissioning national curriculum and framework with Royal Colleges; and
forensic training module
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Personality Disorder Capacity Planning exercise
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Requirements for mental health services - Autumn Assessment
New approaches – improving
outcomes - 1
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High Secure Hospital pilots developing and testing appropriate clinical models
Forensic community services pilots: seeking to model a service system and
progression pathways for those posing a risk to others
Medium secure inpatients and community based managed residential units and
case management teams
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Developing and testing a range of treatment/intervention models and pathways
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Establishing the importance of assessment-formulation- intervention.
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Providing support to Multi Agency Public Protection Panels
New approaches – improving
outcomes - 2
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Community services pilots; exploring different
approaches; different client groups; and network
models
Providing essential support/capacity building for allied
service systems as well as direct services to clients
Strong emphasis on modernised delivery, case
management, and “recovery” – not just treatment
Mainstreaming
Network building
New approaches – improving
outcomes - 3
Experience and learning from pilot services
 The workforce has to be grown
 Engagement/therapeutic alliance is key
 Case management of itself has a positive impact on individuals and
systems
 A range of therapeutic approaches and service models work; - “the
trick” is in clarity/focus; fidelity; the how of delivery; culture and
worker attributes
 Peer group support can be effective with a positive impact on
individuals
Outcomes for Personality
Disorder – professional?
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Effective Process
essential
prerequisites
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Mental Well–Being
and
Pro-social
Behaviours
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3.
Recovery and Longer
term Social
Functioning
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Recognition
Engagement
Case Management/ “holding”
Assessment and formulation
Pathway planning
Improved and stable behaviour patterns – reduced
impulsive behaviours such as suicidal, self
harming, aggressive or violent behaviours
Reduction in risk to the public
Reduced incidence of crises
Reduced incidence of inappropriate service use
Improved mental well-being – reduction in
symptoms of mental distress and use of
medication
Improved hopefulness and self-determination
Sustaining or improving personal relationships
Improved stability in social environment and
lifestyle (housing, finances etc)
Positive steps towards valued activity through work,
education, employment preparation, recreation etc.
Improved self management and self determination
Outcomes – Service users?
PD Service Modernisation Targets
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Recognition within mental health and CJ services
Access to services by right of need
Interventions that are:
- Truly psycho/social
- Reliable & appropriate
- Effective & coherent
- Provide continuity overtime
Management that supports recovery
Participation that supports autonomy
The potential for life-long pathways
Strengthening capabilities
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Range of multi-agency training programmes delivered through 8
NIMHE/CSIP regional developments centres; some 5000 people
trained by April 2006
Work in progress to commission and implement a national
Knowledge and Understanding Framework for staff in all non
forensic settings and roles and to commission and implement a
comprehensive forensic education and training programme
www.personalitydisorder.org.uk – providing wide range of
resources; dissemination of training products etc.
Improving capacity - 1
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Evaluation research studies on services and training
disseminating lessons for the future; training programme study
completed and others due for completion in 2007 and 2008.
Comprehensive service user participation through policy work;
programme design and monitoring; service development and on
going service delivery; service commissioning; shared learning
activities; research studies
Facilitating investment
Winning ‘Hearts & Minds’ across the system
Raising the PD profile
Improving capacity - 2
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Personality Disorder Capacity Plans produced in 2005 providing
an analysis of existing service provision in regions and plans
for the future
No region has anything like a comprehensive spectrum of
services (across a 6 Tier model)
Ensuring mainstream services provide for people with
personality disorder – a major issue
Models for future services development are still embryonic and
depend on resources for investment; but some small scale
developments are progressing
Reducing inappropriate service use – acute psychiatric care;
placements etc. widespread and costly
Progress on capacity…
Assessment of response to personality disorder through NSF
Autumn Assessment - NSF Autumn 2005 self assessment
 Less than 20% of LITs rated green for dedicated personality
disorder services within mental health
 Less than 20% of LITs rated green for access to a range of
psychological therapies
 60% rated green on eligibility for services and social inclusion
 62% of LITs currently developing services
 2006 assessment:- Strategy; dedicated service provision; and
response through mainstream mental health services
Where are we now?
Moving forward?
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First stage policy objectives largely delivered…
Greater hopefulness – no longer a diagnosis of
despair?
Growing body of experience, evidence, thinking on
prognosis, treatability and effectiveness
Improved understanding of personality disorder; what
works; response; – across agencies, practitioners,
commissioners and planners
Better understanding of service user participation –
where, how, what - and why it is important
Where are we now?
Moving forward?
 Priority and profile – local and national agendas;
interest and “buzz”; improved motivation to do
something
 Growing resource of services specifically providing for
people with personality disorders AND
 Improving response in mainstream mental health
services
 Improved understanding of what services can deliver –
what changes and benefits are possible
 Movement towards broader policy concepts – social
exclusion agenda; emerging personality disorder in
young people - addressing primary prevention??
Where are we now?
Or marking time?
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Hopefulness; understanding; motivation – still very patchy and
variable across the country and in localities
Service provision, both specific services for people with pds
and response in mainstream services – still very patchy
Fragile approach to a “critical mass” of service provision
threatened as existing and new services vulnerable to
cuts/savings
Lack of a capable workforce still proves a barrier to
development – need to continue to develop capabilities and
capacity
A cross governmental ‘Personality Disorder Project’?
The Current Challenges
Threat or opportunity?
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Challenging financial realities. Potential impact on mainstream
mental health services; innovative service development;
interagency collaboration.
Complex and changing NHS commissioning infrastructure
NOMs commissioning still in development. Collaboration still
embryonic. The complexities can be a barrier to developing
whole systems and pathway developments.
Policy streams currently diverse and disparate – greater
integration/cohesion needed across forensic and mainstream
mental health; personality disorder; social inclusion; criminal
justice; equalities agendas.
Clinical and organisational ambivalence – caution or
resistance?
Outstanding Questions
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How does PD and the development of
psychological therapies fit together?
Inclusion - a political or clinical objective?
Tier 4 ½?
Concept of ‘High Harm’ – a risk to self and a
risk to other and the difficulties of the ‘D’ word?
Are we commissioning pathways or services?
Need for local, regional and national drivers in a
devolution environment?
Value For Money (VFM)?
Can we establish a workforce?
Personality Disorder NHS and NOMS
Services: The Vision
National referrals
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Key
Tier 6: DSPD Units
• 2 High Security Hospital
pilots
• 3 Prison Service pilots
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Regional referrals
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Regional referrals
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Non-forensic services
NOMS
Forensic services
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Case management
& pathway planning
Tier 5: Secure and Forensic PD Services
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Gatekeeping using
shared protocols
NOMS
Tier 4: Specialist, Inpatient and Intensive Services
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NOMS
Tier 3: Intensive Day Services, Crisis Support and Case
Management
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Tier 2: Community-based Treatment & Case
Management
Specialist
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Locality
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Services
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Tier 1: Consultation, Support and
Education
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Locality
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Locality
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Locality
Relative volume of
need
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Locality
Looking Ahead
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PD as a Cross Governmental Programme
Mainstreaming PD and managing without more money
Early intervention programmes
Broadening and deepening the PD network
Differentiations MI and PD – maintaining a discourse
Developing the workforce(s)
Developing PD Leadership/champions
Supporting user participation and voice
Being courageous about design, innovation and a longer term
commitment