CALeaman

1. CALeaman North Staffordshire Combined Healthcare NHS Trust 1 Putting the person back into personality disorder Improving services for people with Personality Disorder Dr Christine Leaman North Staffordshire Combined Healthcare NHS Trust

2. CALeaman North Staffordshire Combined Healthcare NHS Trust 2 Aims for today’s talk Talk about developing a local service – 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?

3. CALeaman North Staffordshire Combined Healthcare NHS Trust 3 Aims for today 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

4. CALeaman North Staffordshire Combined Healthcare NHS Trust 4 Who am I? Consultant psychiatrist 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

5. Where is Stoke on Trent? CALeaman North Staffordshire Combined Healthcare NHS Trust 5

6. CALeaman North Staffordshire Combined Healthcare NHS Trust 6 North Staffordshire Combined Healthcare NHS Trust 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

7. CALeaman North Staffordshire Combined Healthcare NHS Trust 7 North Staffordshire Combined Healthcare NHS Trust Harplands Hospital – Community beds at 4 (out of 5) local Resource Centres Adult services CMHT’s In-patients Crisis Home Treatment Functional teams Used to have a therapeutic day service!

8. CALeaman North Staffordshire Combined Healthcare NHS Trust 8 Services for people with personality disorders … in 2004 Routine care Psychological therapies service – 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 Main House – NHS regional therapeutic communtiy Private services

9. CALeaman North Staffordshire Combined Healthcare NHS Trust 9 What happened in 2003? Drivers towards improving services for people with ‘personality disorders’ Increasing evidence of treatability for some personality disorders Evidence re effective treatment models In England & Wales DoH and NIMHE promotion of evidence-based models

10. The impetus for developing services CALeaman North Staffordshire Combined Healthcare NHS Trust 10

11. CALeaman North Staffordshire Combined Healthcare NHS Trust 11 What happened regionally? Regional Strategic Health Authorities were given central funding to promote development of personality disorder services 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

12. CALeaman North Staffordshire Combined Healthcare NHS Trust 12 Developing a local service - 2006 Meetings within the Trust Psychological therapies service Managers Clinical leaders Executives Meetings with Commissioners Stoke and North Staffordshire Meetings with service user groups

13. CALeaman North Staffordshire Combined Healthcare NHS Trust 13 What was the response? Range of responses from bewilderment and disinterest to active encouragement One set of Commissioners supportive So ... Audit of in-patient services Nice Guidelines was not currently available Used Integrated Care Pathway to set standards Audit demonstrated significant short-falls in current practice

14. CALeaman North Staffordshire Combined Healthcare NHS Trust 14 Developing a service – the principles Evidence-base for what works Examples of good practice – a visit to The Olive Tree - Local good will Regional network support But Insufficient funds –

15. CALeaman North Staffordshire Combined Healthcare NHS Trust 15 Developing a service – the resources Funding from commissioners £ 44,000 for first year (subsequently £45,000 recurring) 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 3 consultant sessions plus up to 4 sessions of an experienced senior nurse

16. CALeaman North Staffordshire Combined Healthcare NHS Trust 16 How does this compare with other services in the region? 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

17. CALeaman North Staffordshire Combined Healthcare NHS Trust 17 Think personality! Putting the person back into personality disorder

18. CALeaman North Staffordshire Combined Healthcare NHS Trust 18 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)

19. CALeaman North Staffordshire Combined Healthcare NHS Trust 19 Core Team and Champion Model

20. CALeaman North Staffordshire Combined Healthcare NHS Trust 20 Core Team - membership Management team: CAL Julie Elden Sue Imlack/Sheila Sheltie Heather Creasey Consultation team: CAL Julie Elden Karen Mason Carl Woolliscroft Christina Fitzgerald Cat O’Callaghan Graham Breeze – independent supervisor

21. CALeaman North Staffordshire Combined Healthcare NHS Trust 21 What does the team do? Consultation to NSCHT teams and to partnership organisations Education and awareness training Service user forum Carer forum Put the person back into personality disorder!

22. CALeaman North Staffordshire Combined Healthcare NHS Trust 22 What does the team do? A lot of (self)-promotion eg 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 …

23. CALeaman North Staffordshire Combined Healthcare NHS Trust 23 What else does the team do Data collection Consultations 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)

24. CALeaman North Staffordshire Combined Healthcare NHS Trust 24 Logo of our service designed by service user (Fiona) (Wczasek [Fits-ass-ick]) Logo of our service designed by service user (Fiona) (Wczasek [Fits-ass-ick])

25. The NSCHT PDS main functions Consultation to teams Service user involvement Education and awareness training CALeaman North Staffordshire Combined Healthcare NHS Trust 25

26. CALeaman North Staffordshire Combined Healthcare NHS Trust 26 Consultation is ... A widely used model for developing good practice 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

27. CALeaman North Staffordshire Combined Healthcare NHS Trust 27 Consultation What is consultation? 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

28. CALeaman North Staffordshire Combined Healthcare NHS Trust 28 What makes a good consultation? 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

29. CALeaman North Staffordshire Combined Healthcare NHS Trust 29 Consultation activity – year one Total number of consultations: 23 Total number of service users: 19 2 clients had one follow-up consultation 1 client had two follow-up consultations

30. CALeaman North Staffordshire Combined Healthcare NHS Trust 30 Consultation occurrences

31. CALeaman North Staffordshire Combined Healthcare NHS Trust 31 Numbers Present at Consultations

32. CALeaman North Staffordshire Combined Healthcare NHS Trust 32 Themes – what was useful? ‘professional and objective discussion and outcomes’ ‘Helped to refocus and clarify needs of client’ ‘supervision element helped to identify patterns of behaviour and also suggestions regarding how to progress’ Multidisciplinary discussion and ‘outside perspective’’ ‘reaffirming current input is appropriate’

33. CALeaman North Staffordshire Combined Healthcare NHS Trust 33 Themes – what was least useful? ‘No further treatment strategies identified to help with management of client because all available options have been offered and tried’ ‘that the Core Team were unable to give ‘the answer’’ Feelings that the interventions for PD ‘are so ineffective’ ‘there are no easy answers on how to care for this type of client’ ‘the client may sabotage outcomes’

34. CALeaman North Staffordshire Combined Healthcare NHS Trust 34 Team Feedback – Core Team

35. CALeaman North Staffordshire Combined Healthcare NHS Trust 35 Feedback – Comparison

36. CALeaman North Staffordshire Combined Healthcare NHS Trust 36 Could the Core Team identify features of a personality disorder in the patient?

37. CALeaman North Staffordshire Combined Healthcare NHS Trust 37 Consultations feedback 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

38. CALeaman North Staffordshire Combined Healthcare NHS Trust 38 Core Team analysis Main problems brought by the MDT 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

39. CALeaman North Staffordshire Combined Healthcare NHS Trust 39 Core Team analysis Main problems brought by the MDT ? 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

40. CALeaman North Staffordshire Combined Healthcare NHS Trust 40 As discussed in Core Team supervision ... 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 Positive outcomes Improved communication Shared risk management Person-centred approach Involving service user more in planning

41. CALeaman North Staffordshire Combined Healthcare NHS Trust 41 Main agreed outcomes 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 Eg setting boundaries Shared management of risk Communication Using team supervision

42. CALeaman North Staffordshire Combined Healthcare NHS Trust 42 In summary Re consultations 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

43. CALeaman North Staffordshire Combined Healthcare NHS Trust 43 Setting up the Core Team … Core Team – 3 workshop days with external trainers Team-building, agreeing principles, finding a common theoretical framework Supervision (with an independent supervisor) Ongoing training – external and internal – some jointly with Champions Theoretical, practical – eg developing training skills

44. CALeaman North Staffordshire Combined Healthcare NHS Trust 44 A very simple model of borderline pd 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

45. CALeaman North Staffordshire Combined Healthcare NHS Trust 45 Treatment models – the principles Accessibility Flexibility Consistency A coherent theoretical model Supervision Consultation Education

46. CALeaman North Staffordshire Combined Healthcare NHS Trust 46 Nice Guidance for Borderline Personality Disorder Treatment & management Issue date Jan 2009 Developed by National Collaborating Centre for Mental Health

47. CALeaman North Staffordshire Combined Healthcare NHS Trust 47 Logo of our service designed by service user (Fiona) (Wczasek [Fits-ass-ick]) Logo of our service designed by service user (Fiona) (Wczasek [Fits-ass-ick])

48. CALeaman North Staffordshire Combined Healthcare NHS Trust 48 The Champion network What is a Champion? Interested in working with PD people One of more in each team Extra training with Core Team mandatory ‘Champion’ PD Liaise with Core Team- practical role Can develop skills further – on the training escalator

49. CALeaman North Staffordshire Combined Healthcare NHS Trust 49 PD Champion role 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

50. CALeaman North Staffordshire Combined Healthcare NHS Trust 50 Selecting champions 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

51. CALeaman North Staffordshire Combined Healthcare NHS Trust 51 The Champions 22 in 13 teams – CMHT’s, IP wards, CRT, functional teams, SW duty team All disciplines People who volunteer Have an interest in PD Want to learn more Want to develop skills

52. CALeaman North Staffordshire Combined Healthcare NHS Trust 52 The Service User Network Service user forum - aims 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

53. CALeaman North Staffordshire Combined Healthcare NHS Trust 53 Service User Network Run by service user network co-ordinator Monthly meetings in a non-NHS setting Wide publicity Agenda set each session Successful launch day in January 2009 Developing a newsletter to go out in The Voice Contributing to Trust PPI days Participants in KUF training Quarterly carers’ meetings

54. CALeaman North Staffordshire Combined Healthcare NHS Trust 54 What else does the team do? Education and awareness training: 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

55. CALeaman North Staffordshire Combined Healthcare NHS Trust 55 Training developments Champion training on-going Penetration to other teams Delivery of further training in NSCHT understanding causes of BPD attachment what works in teams ‘Feeling shattered – dealing with ‘splitting’’ Using supervision Trust training programme

56. CALeaman North Staffordshire Combined Healthcare NHS Trust 56 Knowledge & Understanding Framework for PD DOH sponsored scheme Developed by a consortium 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

57. West Midlands KUF Three PD Services won tenders to deliver Awareness level training 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 CALeaman North Staffordshire Combined Healthcare NHS Trust 57

58. In summary Our aim remains to develop a therapeutic day service In the meantime we have a service which delivers parts of the Nice Guideline recommendations Education and awareness training It supports CMHT’s in delivering Nice Guideline It supports the organisation in delivering Nice Guideline CALeaman North Staffordshire Combined Healthcare NHS Trust 58

59. In summary 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

60. CALeaman North Staffordshire Combined Healthcare NHS Trust 60 Think personality! Putting the person back into personality disorder