The National PD Programme in England Scottish Personality Disorder Network

1. The National PD Programme in EnglandScottish Personality Disorder Network “Progress, Questions and Looking Ahead”

2. 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 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 Policy and aims

3. Why…… • 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

4. Because…. • 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

5. Aims of a Pilot Programme A pilot approach seeking • 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

6. Progress - the range of developments • 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? • Training and education programmes through CSIP/NIMHE RDCs • Local and national evaluation initiatives • Service user participation at local, regional and national levels • Commissioning national curriculum and framework with Royal Colleges; and forensic training module • Personality Disorder Capacity Planning exercise • Requirements for mental health services - Autumn Assessment

7. New approaches – improving outcomes - 1 • 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 • Developing and testing a range of treatment/intervention models and pathways • Establishing the importance of assessment-formulation- intervention. • Providing support to Multi Agency Public Protection Panels

8. New approaches – improving outcomes - 2 • 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

9. 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

10. Outcomes for Personality Disorder – professional?

11. Outcomes – Service users? PD Service Modernisation Targets • 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

12. Strengthening capabilities • 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.

13. Improving capacity - 1 • 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

14. Improving capacity - 2 • 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

15. 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

16. Where are we now? Moving forward? • 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

17. 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??

18. Where are we now? Or marking time? • 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’?

19. The Current Challenges Threat or opportunity? • 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?

20. Outstanding Questions • 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?

21.  National referrals  Tier 6: DSPD Units Key NOMS  • 2 High Security Hospital pilots • 3 Prison Service pilots Non-forensic services Regional referrals Forensic services   Regional referrals Tier 5: Secure and Forensic PD Services Relative volume of need  NOMS Case management & pathway planning Gatekeeping using shared protocols Tier 4: Specialist, Inpatient and Intensive Services  NOMS Tier 3: Intensive Day Services, Crisis Support and Case Management      Tier 2: Community-based Treatment & Case Management Specialist Services      Tier 1: Consultation, Support and Education      Locality Locality Locality Locality Locality Personality Disorder NHS and NOMS Services: The Vision

22. Looking Ahead • 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