The National Personality Disorder Development Programme

1. The National Personality Disorder Development Programme Personality People & Pathology 1 June 2005, Friends Meeting House, Oxford Rex Haigh & Steve Pearce

2. The National Personality Disorder Development Programme Aims: • To develop new approaches to treatment and care of people diagnosable with PD • Strengthen the capabilities of the workforce through education and training • Reduce social exclusion

3. Two Government publicationsNational Institute for Mental Health for England (NIMHE)

4. Deliberate variety of approaches All involve many stakeholders Working together to provide new type of service Service users help in planning Care pathways approach Very strong control over finances & governance Emphasis on evaluation, outcome & dissemination Results in 2005-7 Government money: services

5. The National Personality Disorder Development Programme Rex Haigh Consultant Psychiatrist in Psychotherapy, Berkshire Healthcare NHS Trust Personality Disorder Development Consultant, NIMHE South East Personality Disorder Service User Consultation Lead, Department of Health

6. Two Government publicationsNational Institute for Mental Health for England (NIMHE)

7. New Government Money • Started as “crumbs from the DSPD table” • Personality disorder: the “DSPD” units • £128m (£100m capital + £28m revenue) • For a few hundred people • eg £0.5m per patient per year at Broadmoor • Personality disorder: community programme • £18m • For ~5% of the population (3,000,000 people) • Equals £6.60 each case per year (or 33p per head of population) • Intention to coordinate across 4 “silos”

8. Four “silos” • New pilot projects • 2 years funding thence PCT • National specialist commissioning • Henderson, Main House and Webb House • DSPD units • 4 in prisons, 6 in forensic and 4 womens units • Training initiatives • Divided amongst 8 NIMHE regions

9. What “No Longer a Diagnosis of Exclusion” is funding: the 11 new community pilot services • Deliberate variety of approaches • All involve many stakeholders • Working together to provide new type of service • Service users help in planning • Care pathways approach • Very strong control over finances & governance • Emphasis on evaluation, outcome & dissemination • Results in 2005-7

10. What “No Longer a Diagnosis of Exclusion” meanswww.publications.doh.gov.uk/mentalhealth/personalitydisorder.pdf • 2004-2007 • 11 new pilot projects • Learning from diversity • 4 “big ones” • 2 managed networks • 2 predominantly SU-led • 1 early intervention • Different therapeutic models, some mention none

11. The 11 pilots • A quick tour, giving: • Who submitted bid • Who manages it (=owns it?) • Clinical model • Distinguishing features

12. Leeds • Submitted by Tom Mullen, Leeds Mentally Disordered Offender Development Coordinator, Leeds MHTT • Provider: Leeds MHTT • Managed clinical and service network • Core team working across agencies • Providing • Assessment • Clinical Services • Care coordination • Largest urban project

13. Nottinghamshire • Submitted by Helen Scott, Executive Director, Nottinghamshire Healthcare NHS Trust (MHT) • Provider: Nottinghamshire Healthcare NHS Trust (MHT), and local advocacy groups • Coordinated network with new clinical services • 3 levels of provision • L1= advice and information • L2= “stop and think” CBT • L3= therapeutic community • With satellite services across the county • Integrated team • Wide range of stakeholders • Large population (>1m) and budget

14. Coventry • Submitted by Coventry PCT • Provider: Coventry PCT • New clinical services • “community psychotherapy team” • group-based programmes for simple, complex, & severe PD • Integrated with new NSF-aligned psychiatric services • New building • Most favourable funding to population ratio

15. Thames Valley • Submitted by Drs Rex Haigh & Steve Pearce, consultant psychiatrists in psychotherapy • Providers: 3 MHTs - Berks, Bucks & Oxon • Hub and spokes • 3 hubs • Approx 10 spokes • New 4 tier clinical services • Assertive assessment (XBX) • Local treatment provision • 3 day TCs • Recovery tier (XBX-led) • Multiple agencies involved • Integrated with training • Largest area & population (>2m)

16. Camden & Islington • Submitted by Stephen Pilling, Consultant Clinical Psychologist, Camden and Islington Mental Health and Social Care Trust • Providers: Charitable Trust (“Umbrella Ltd”), two PCTs and the MH/SC Trust • Provision of two services: • Primary care: early recognition and brief treatment, DBT-based • Voluntary sector: helping people to reengage in work and be active citizens • Small project • Small population • Inner city

17. NE London • Submitted by Dr Janet Feigenbaum, Consultant Clinical Psychologist • Provider: NE London MHT • Dual Diagnosis Assessment and response Team: “DDART” • Dual diagnosis – PD & substance misuse • Provision of • Assessment • Interventions • DBT based • group & individual • with outreach • Case management

18. SW London • Submitted by Dr Steve Millar, Consultant Psychiatrist in Psychotherapy • Provider: SW London & St Georges MHT • Service User Network (SUN) • To set up 4 local networks to • Support SUs • Improve access to services • Large urban population • Small staff numbers

19. Colchester • The Haven Project Ltd • Voluntary sector • Drop-in day services • Features of therapeutic community • Also short term crisis beds

20. Cambridge & Peterborough • Submitted by Annette Newton (Area Director and MH Policy Lead, MHT), Prof Geoff Shepherd (Director of Partnerships and Service Development, MHT) and Dr Chess Denman (Consultant Psychotherapist) • Provider: Cambridge & Peterborough Mental Health Partnership Trust • No theoretical approach specified in bid • Services provided in two “hubs” • Assessment • Interventions • Case management • Development workers = spokes, to work across agencies and promote recovery model

21. North Cumbria Submitted by Dr Mike Rigby, Consultant Psychiatrist in Psychotherapy Provider: North Cumbria MHT “Itinerant therapeutic community” Intensive day service model Aspatria RC & Carlisle Closely integrated with training programme Large rural area Low population

22. Plymouth • Submitted by Phil Confue, Director MH & LD, Plymouth PCT • Provider: Plymouth PCT • Early intervention model • Young people (<25) engaged through youth enquiry service • Social inclusion focus: “to prevent career as psychiatric patient” • Delivered in partnership with voluntary agencies • Includes DBT treatment

23. Local as described in individual bids cooperation emerging National Imperial College London Mike Crawford, Dorothy Griffiths, Tim Weaver, Deborah Rutter, Peter Tyrer Mental Health Foundation Iain Ryrie, Jan Wallcraft University College London Anthony Bateman, Gerhart Knerer, Peter Fonagy Institute of Psychiatry Paul Moran University of Liverpool Jonathan Hill Multi-method evaluation A macro-level organisational evaluation of the context, form, function and impact of pilot services A micro-level cohort study examining changes in health, social outcomes and direct costs of care among a cohort of people using these services A micro-level qualitative study of service quality from the perspective of service users A Delphi exercise to examine the level of consensus among academics, service users and providers about lessons that can be learnt for future service development Evaluation of the 11 pilots

25. What do they cost? • Smallest – SUN - £254,000 • Largest – Thames valley - £1,006,335 • Full year effect • Including capital expenditure and management costs • Excluding local contributions

26. Cost to NIMHE per project

27. How many new staff? • In original bid (possibly amended since) • Minimum: Carlisle = 6 • Maximum: Thames Valley = 30.5

28. Number of staff per project

29. Less than half a million Waltham Forest DDART Coventry North Cumbria Essex Haven Camden and Islington Plymouth Over a million Thames Valley (Berkshire, Buckinghamshire and Oxfordshire) Nottinghamshire Population covered

30. Population served by each project

31. Calculation: money spent per “case” Assuming 5% of total population “have” PD: • MAXIMUM – Coventry - £56 • MINIMUM – SW London SUN - £6.52 • MEAN - £17.75 • REST OF ENGLAND in PCT baselines - £4.01

32. Spend per case for each project

33. Calculation: “cases” per new staff member • MAXIMUM – SW London SUN – 7662 • (14 minutes each per year = 19 sec weekly) • MINIMUM – Coventry – 701 • (2hr 37mins each pa = 3 mins 25 sec weekly) • MEAN - 2311

34. “Caseload” per project

35. Calculation: cost of each new staff member • MAXIMUM – North Cumbria – £70,883 • MINIMUM – Leeds – £31,852 • MEAN - £41,038 • Note: does not include contribution of volunteers, service users or ex-service users if unpaid.

36. Cost per new staff for each project

37. Summary of “new money” • For 11 new pilot projects from NIMHE: • £6.8m for 7.5m population = £17.75 per case • Into PCT baselines 2004-5 • £8m (England only) = £3.20p per case • Into PCT baselines 2005-6 • £10m (England only) = £4.01 per case • For training programme 2004-5 & 2005-6 • £2m = £250K per NIMHE region

38. More “new money”? • To bring England up to average level of pilot projects would cost • £868m • This represents increasing current funding by 52x • Or current funding is 1.93% of what is needed • Awaiting announcement from spending round (March 05?) • But most will need to come from service remodelling

39. Forensic Service Developments DSPD services • 2 new 70 bed units at Broadmoor and Rampton operational from 2005/6 • Two new prison pilot sites at Frankland and Whitemoor are operational from 2004 • Planned womens DSPD prison pilot at Lower Newton • 6 pilot forensic services for people with PD who present a risk to others • Women's high support community services (residential core and cluster services for women leaving high secure care)

40. Forensic Service Developments Pilot services provided by: • South London and Maudsley • Nottingham Healthcare Trust (Rampton) • East London Mental Health Trust • West London Mental Health Trust (Broadmoor) • Oxleas Trust • Newcastle, North Tyneside and Northumberland Trust • Merseycare Mental Health Trust

41. Forensic Service Developments Pilots include: • Dedicated PD units within high secure services • Dedicated PD units within medium secure services • Associated hostels in three pilots • Community Team in six

43. Personality Disorder Capability Framework – Breaking the Cycle of Rejection • Comprehensive approach to improving capabilities of the workforce across many agencies responding to people diagnosable with PD • Total of £2m for 2004/5 allocated to 8 NIMHE Regional Development Centres for new initiatives to implement the framework.

44. Personality Disorder Capability Framework – Breaking the Cycle of Rejection Training initiatives reflect partnership between WDDs, HEIs, NIMHE RDCs. National bodies (NHS University, Royal Colleges etc.), committed to joint work to establish training initiatives consistent with Capability Framework Learning networks will ensure dissemination of learning from pilot services. Training and education programme will be independently evaluated

45. Personality Disorder Capability Framework – Breaking the Cycle of Rejection Current training and education initiatives include: • mapping/scoping exercises and training needs analyses • stakeholder consultation • “PD awareness cascade” courses • PD basic training modules to be incorporated in pre and post reg training • multi-agency modular training approaches • exploring training needs of commissioners. Local multi-agency training is also included in many of the service development pilots

47. TRRT – training, research and recovery team • 4th team of TVi • TRAINING – to deliver this course and other events using XBXs and Agents • RESEARCH – to undertake national data collection and local evaluation of TVi • RECOVERY – to make service user, ex-service user and expert by experience partnerships essential • AND – external relations etc etc…

48. TRRT: who, where, when? • 3.3 wtes: • Sue Robinson Team Administrator 1.0wte • Clare Stafford Project Manager 0.5wte • Fiona Blyth Training Coordinator 0.5wte • [vacant] Team Researcher 0.5wte • Sheena Money Expert by Experience 0.3wte • Yolande Hadden Expert by Experience 0.3wte • Rex Haigh Programme Director 0.2wte • Managed by OMHT through CS • Located on Warneford site • Phase 1 – setup – y1 • Phase 2 – provide – y2 • Phase 3 – the future – y3+?

49. TRRT and training • To coordinate all training offered • To “capacity-build” SU, XSU & XBX involvement (STARS) for training and clinical function • To provide (very limited!) funding for training activities – alongside NIMHE funding • To provide (more substantial) funding for XBX input • To get it onto secure financial footing

50. SE Training Plan – aka “network course” – aka “awareness cascade” Development of new services MH managers PD Treatment Facilities commissoners Service advocacy Policymakers XBX pool Dynamic teams Seminars, conferences, short courses, workshops, etc Input into course philosophy, structure and content mental health services mental health services A&E Qualification Primary care A&E housing Awareness cascade probation police Further training prisons 1 year PD network course probation PD agents police prisons Primary care Social services Voluntary organisations Voluntary organisations Social services Interested recruits housing