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The Eric Shepherd Unit: A Model of Effective Service Delivery Findings From a Long Term Outcome Study.

Aims. To give a description of the service

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The Eric Shepherd Unit: A Model of Effective Service Delivery Findings From a Long Term Outcome Study.

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    1. The Eric Shepherd Unit: A Model of Effective Service Delivery? Findings From a Long Term Outcome Study. Dr Christopher Bennett Consultant Clinical Psychologist Dr Sujeet Jaydeokar Consultant Psychiatrist

    2. Aims To give a description of the service & treatment approach To present main findings from a 13 year follow up study To give preliminary data from third phase of study on outcomes using HoNOS LD

    3. Eric Shepherd Unit Medium Secure Unit 30 Medium secure beds, 6 continuing treatment beds All male Age 18 – 60 (flexible) All detained under a section of the Mental Health Act, mostly criminal sections Average length of admission: 2 – 4 years Admission criteria: Learning disability (flexible definition – needs led) Mental Health Issues Personality Issues Drug & Alcohol Issues Complex Cases Offending behaviour ( not necessarily convicted)

    4. Legal Status and Legal Category

    5. Eric Shepherd Unit Sources of Referrals: Nationwide London = 23 (64%) Hertfordshire = 6 (17%) Other = 7 (19%) Prison Service Probation Service Police High Secure Hospitals Community teams

    6. Eric Shepherd Unit The Team: 2 Consultant Psychiatrists 2 Clinical Psychologists (B grade & A grade) 1 Assistant Psychologist 1 Integrated Arts Psychotherapist 3 Junior Doctors (SpR, SHO, Staff Grade) 1 Social Worker 2 Teachers (Seconded from local college) 5 Clinical Team Managers (Senior Nurses) 2 Discharge Liaison Nurses Learning Disability Nurses

    7. Eric Shepherd Unit Aims & Objectives ‘The service aims to respond to the individual needs of patients and to plan and deliver treatment according to those needs through: Focusing on the individual but also acknowledging the contribution of carers, families and friends. Rehabilitating and re-settling patients back into the community within the shortest period possible, whilst being mindful of the need for public safety. Supporting community services and other agencies through sharing experience and advising of the management of forensic issues. Through thorough risk assessment, to ensure a service which is safe, and through thorough risk management plans to promote patients’ independence and personal responsibility.

    8. Eric Shepherd Unit Treatment Approach Developmental Model Creating & fostering a safe & secure therapeutic environment where change is possible (providing a secure base/attachment) Fostering an appropriate staff approach where trust and valuing of the individual provides positive therapeutic relationships (limited re-parenting model) Provision of appropriate psychological therapies (individual & group), purposeful occupation, educational opportunities, & leisure opportunities Working with the wider system – families, carers, referrers Review and monitoring of medication ‘The therapeutic & treatment approach adopted in the unit comprises five elements which aims to resolve acute problems, modify behaviours and address issues underlying the presenting difficulties.’ ‘The therapeutic & treatment approach adopted in the unit comprises five elements which aims to resolve acute problems, modify behaviours and address issues underlying the presenting difficulties.’

    9. Long term outcome from a Medium Secure Learning Disability Service Crouch K, Halstead S, Alexander, RT & Piachaud (In Press) Permission by Jack Piachaud (Former Clinical Director of ESU)

    10. Outcome Study Aims: To describe long-term outcome for a cohort of patients discharged from the ESU over a 12 year period. 1st September 1987 – 31st December 2000 Based on two cohorts: 1987 – 1993 (n = 34) & 1994 – 2000 (n= 40) Third Cohort: 2000 – 2004 (currently being investigated) Used case note analysis & structured interview with key informants.

    11. Outcome Study All patients had received at least one year’s treatment at ESU. Total sample size = 74 Information for 64 patients available at this follow up. Followed up for 13 years maximum & 1 year minimum.

    12. Diagnostic Categories

    13. Comparison of current residence & place of admission Current Residence

    14. Main Findings 19 patients (30%) involved with the police 6 patients (9%) reconvicted Of these, 4 had PD 7 patients (11%) received cautions 38 patients (58%) displayed at least one offending behaviour Offending behaviour most prevalent during first 5 years post discharge 23 patients (37%) relapsed 19 patients (30%) readmission to hospital 16 had mental health problems, including PD 3 had no specified mental health problem other than LD No association between diagnosis of schizophrenia & readmission Of 41 patients reaching 5 years post discharge, 14 had readmissions 34 patients (53%) remain under powers of MHA

    15. Outcome Compared to general forensic services: Maden et al. (1999) 24% of discharges reconvicted over similar time period. (Compared to 9%) 67% moved from MSU to some other form of hospital treatment. (Compared to 27%) Buchanan (1998) – High Security Hospitals 26% reconvicted after 5 ˝ years 34% reconvicted after 10 ˝ year

    16. Conclusions Reconviction rates good when compared to general forensic services Behavioural problems (including offending behaviours) continue for many years Majority of these managed without recourse to criminal justice system Patients with a diagnosis of schizophrenia less likely to have police involvement, relapse, re-offend or be readmitted

    17. Conclusions Less good outcome was associated with: Younger age History of acquisitive offences Higher IQ Absence of mental illness Presence of Personality Disorder Several changes of residence

    18. Outcome Studies Few outcome studies Many case studies and case series No studies using HoNOS or HoNOS-LD Some treatment outcome studies in community as well as inpatient set up. Longer term out come studies Recidivism Risk of offending highest during the year following discharge Outcome better with longer inpatient treatment

    19. Reed Report Set up an agenda for research in Forensic psychiatry including for people with learning disabilities Move away from the traditional outcome measures Need for development of new outcome measures

    20. Health of Nation Outcome Scale (HoNOS) Department of Health recommends use of HoNOS as an outcome measures Development of HoNOS – as a routine measure of outcomes in mental health HoNOS – secure HoNOS – LD HoNOS – CA HoNOS – 65 HoNOS - ABI

    21. HoNOS - LD 18 measures Rating over the past four weeks Rated as no problem to very severe problems Covers a wide range of variables from challenging behaviour to the activities of daily living and mental health Broad nature of the instrument – may be less suited to detect subtle changes in chronic conditions

    22. HoNOS - LD No outcome studies using HoNOS-LD in a Forensic Learning Disability set up No valid outcome measures in the Forensic LD set up. Most follow up studies using conventional outcome measures like recidivism, readmissions etc.

    23. Aim Use of HoNOS – LD as a baseline measure so as to measure changes against it during the inpatient stay and after discharge from a medium secure unit for people with LD Compare HoNOS – LD against traditional outcome measures in a Forensic set up to establish its usefulness. Compare follow up outcome of 3rd cohort with previous two cohorts

    24. Paired sample t-test

    25. Paired sample t-test

    26. Changes in Mean Score over one Year

    27. Difficulties Analysis of the data Changes not necessarily reflect changes in the risks Important Forensic outcomes missing Low frequency – high risk behaviours Sex offending

    28. HoNOS – secure Developed for Forensic set up 7 item Security scale e.g. risk of harm to others, vulnerability etc. 12 item mental health scale Not necessarily useful for Forensic LD set up Need for development of more specific outcome measure for Forensic Learning disability

    29. Next Step On going data collection Post discharge follow up of the third cohort Compare the third cohort with previous two cohorts Examine role of HoNOS – LD as an outcome measure Development of outcome scale Compare HoNOS scores with other outcome measures like EPS, symptom checklist - 90

    30. Summary ESU plays significant role providing forensic services for people with LD Previous follow up studies at the ESU– good outcomes on follow up Lack of follow up studies with appropriate outcome measures. No outcome studies using HoNOS LD Preliminary data shows significant improvement on HoNOS LD ( more significant at the end of 2 years than 1 year) HoNOS LD has its limitations as an outcome instrument Need for development of outcome instrument for clinical use as well for research purpose. On going piece of work at the ESU

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