The National PD The National PD Programme in EnglandProgramme in EnglandScottish Personality Disorder Scottish Personality Disorder

NetworkNetwork““Progress, Questions and Progress, Questions and

Looking Ahead”Looking Ahead”

Policy and aims Policy and aims

Managing Dangerous PeopleManaging Dangerous Peoplewith Severe Personalitywith Severe PersonalityDisorder (DSPD) 1999Disorder (DSPD) 1999

Personality Disorder: No LongerPersonality Disorder: No Longera Diagnosis of Exclusion 2003a Diagnosis of Exclusion 2003

Breaking the Cycle of Rejection:Breaking the Cycle of Rejection:The personality disorderThe personality disorderCapabilities framework 2003Capabilities framework 2003 Social Exclusion Action Plan 2005Social Exclusion Action Plan 2005

Developing newDeveloping new approaches to treatmentapproaches to treatment and careand care Improving outcomes forImproving outcomes for patients/prisonerspatients/prisoners Strengthening the workforceStrengthening the workforce Improving the capacity ofImproving the capacity of whole systems whole systems Improving social inclusionImproving social inclusion Improving public protectionImproving public protection Establish early interventions for Establish early interventions for

emerging PDemerging PD

Why……Why……

Manifesto commitment on public protectionManifesto commitment on public protection Overall, service provision was minimal and variable (surveys Overall, service provision was minimal and variable (surveys

2000, 2002, and local investigations 2003)2000, 2002, and local investigations 2003) 28% of Trusts “…..do not see the provision of services for 28% of Trusts “…..do not see the provision of services for

personality disorder as being part of their core business.”personality disorder as being part of their core business.” PD patients in high secure services waiting many years for PD patients in high secure services waiting many years for

appropriate placements elsewhereappropriate placements elsewhere People with personality disorder seen to ricochet around the People with personality disorder seen to ricochet around the

service system; particularly in crisesservice system; particularly in crises

Because….Because….

Very limited services for patients with personality disorders in NHS secure Very limited services for patients with personality disorders in NHS secure settingssettings

Limited therapeutic services available for offenders with personality Limited therapeutic services available for offenders with personality disordersdisorders

Many people with personality disorders in the community receiving services Many people with personality disorders in the community receiving services from social care, voluntary sector and housing agencies ill equipped to from social care, voluntary sector and housing agencies ill equipped to respond effectivelyrespond effectively

“…“…..people with personality disorder are treated at the margins….They have people with personality disorder are treated at the margins….They have become the new revolving-door patients, with multiple admissions, become the new revolving-door patients, with multiple admissions, inadequate care planning, and infrequent follow-upinadequate care planning, and infrequent follow-up”. (PIG 2004)”. (PIG 2004)

Lack of shared basic assumptions:- what people with personality disorders Lack of shared basic assumptions:- what people with personality disorders should expect; what we should expect to provideshould expect; what we should expect to provide

Psychiatric services in considerable confusion about PDPsychiatric services in considerable confusion about PD

Aims of a Pilot ProgrammeAims of a Pilot Programme

A pilot approach seeking A pilot approach seeking

Evidence of effectivenessEvidence of effectiveness Innovation in service design and practice Innovation in service design and practice

modelsmodels Challenging social and service exclusionChallenging social and service exclusion Modelling capacityModelling capacity Testing practicabilityTesting practicability Organising sustainabilityOrganising sustainability Informing future policy initiatives Informing future policy initiatives

Progress - the range of Progress - the range of developmentsdevelopments

New investment in 11 community based pilot services; and 5 forensic pilot services; 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 3 pilots in prisons (1 for women); 2 pilots in High Secure Hospitals; 4 new MST sites; a prison clinic?sites; a prison clinic?

Training and education programmes through CSIP/NIMHE RDCsTraining and education programmes through CSIP/NIMHE RDCs

Local and national evaluation initiativesLocal and national evaluation initiatives

Service user participation at local, regional and national levelsService user participation at local, regional and national levels

Commissioning national curriculum and framework with Royal Colleges; and Commissioning national curriculum and framework with Royal Colleges; and forensic training moduleforensic training module

Personality Disorder Capacity Planning exercisePersonality Disorder Capacity Planning exercise

Requirements for mental health services - Autumn Assessment Requirements for mental health services - Autumn Assessment

New approaches – improving New approaches – improving outcomes - 1outcomes - 1

High Secure Hospital pilots developing and testing appropriate clinical modelsHigh Secure Hospital pilots developing and testing appropriate clinical models

Forensic community services pilots: seeking to model a service system and Forensic community services pilots: seeking to model a service system and progression pathways for those posing a risk to othersprogression pathways for those posing a risk to others

Medium secure inpatients and community based managed residential units and case Medium secure inpatients and community based managed residential units and case management teamsmanagement teams

Developing and testing a range of treatment/intervention models and pathwaysDeveloping and testing a range of treatment/intervention models and pathways

Establishing the importance of assessment-formulation- intervention.Establishing the importance of assessment-formulation- intervention.

Providing support to Multi Agency Public Protection Panels Providing support to Multi Agency Public Protection Panels

New approaches – improving New approaches – improving outcomes - 2outcomes - 2

Community services pilots; exploring different Community services pilots; exploring different approaches; different client groups; and network approaches; different client groups; and network modelsmodels

Providing essential support/capacity building for allied Providing essential support/capacity building for allied service systems as well as direct services to clientsservice systems as well as direct services to clients

Strong emphasis on modernised delivery, case Strong emphasis on modernised delivery, case management, and “recovery” – not just treatmentmanagement, and “recovery” – not just treatment

MainstreamingMainstreaming Network buildingNetwork building

New approaches – improving New approaches – improving outcomes - 3outcomes - 3

Experience and learning from pilot servicesExperience and learning from pilot services The workforce has to be grownThe workforce has to be grown Engagement/therapeutic alliance is keyEngagement/therapeutic alliance is key Case management of itself has a positive impact on individuals and Case management of itself has a positive impact on individuals and

systemssystems A range of therapeutic approaches and service models work; - “the A range of therapeutic approaches and service models work; - “the

trick” is in clarity/focus; fidelity; the how of delivery; culture and trick” is in clarity/focus; fidelity; the how of delivery; culture and worker attributesworker attributes

Peer group support can be effective with a positive impact on Peer group support can be effective with a positive impact on individuals individuals

Outcomes for Personality Outcomes for Personality DisorderDisorder – professional? – professional?

1.1. Effective ProcessEffective Process

essential essential

prerequisitesprerequisites

Recognition Recognition Engagement Engagement Case Management/ “holding”Case Management/ “holding” Assessment and formulationAssessment and formulation Pathway planningPathway planning

2.2. Mental Well–Being Mental Well–Being and and

Pro-social Pro-social BehavioursBehaviours

Improved and stable behaviour patterns – Improved and stable behaviour patterns – reduced reduced

impulsive behaviours such as suicidal, self impulsive behaviours such as suicidal, self

harming, aggressive or violent behavioursharming, aggressive or violent behaviours Reduction in risk to the publicReduction in risk to the public Reduced incidence of crisesReduced incidence of crises Reduced incidence of inappropriate service useReduced incidence of inappropriate service use Improved mental well-being – reduction inImproved mental well-being – reduction in

symptoms of mental distress and use of symptoms of mental distress and use of

medicationmedication Improved hopefulness and self-determinationImproved hopefulness and self-determination

3.3. Recovery and Recovery and Longer term Social Longer term Social

FunctioningFunctioning

Sustaining or improving personal relationships Sustaining or improving personal relationships Improved stability in social environment and Improved stability in social environment and

lifestyle (housing, finances etc) lifestyle (housing, finances etc) Positive steps towards valued activity through Positive steps towards valued activity through work, work,

education, employment preparation, recreation education, employment preparation, recreation etc. etc. Improved self management and self Improved self management and self determinationdetermination

Outcomes – Service users?Outcomes – Service users?

PD Service Modernisation TargetsPD Service Modernisation Targets

Recognition within mental health and CJ servicesRecognition within mental health and CJ services Access to services by right of needAccess to services by right of need Interventions that are:Interventions that are: - Truly psycho/social- Truly psycho/social

- Reliable & appropriate - Reliable & appropriate - Effective & coherent - Effective & coherent - Provide continuity overtime - Provide continuity overtime

Management that supports recoveryManagement that supports recovery Participation that supports autonomyParticipation that supports autonomy The potential for life-long pathwaysThe potential for life-long pathways

Strengthening capabilitiesStrengthening capabilities

Range of multi-agency training programmes delivered through 8 Range of multi-agency training programmes delivered through 8 NIMHE/CSIP regional developments centres; some 5000 people NIMHE/CSIP regional developments centres; some 5000 people trained by April 2006trained by April 2006

Work in progress to commission and implement a national Work in progress to commission and implement a national Knowledge and Understanding Framework for staff in all non Knowledge and Understanding Framework for staff in all non forensic settings and roles and to commission and implement a forensic settings and roles and to commission and implement a comprehensive forensic education and training programmecomprehensive forensic education and training programme

www.personalitydisorder.org.ukwww.personalitydisorder.org.uk – providing wide range of – providing wide range of

resources; dissemination of training products etcresources; dissemination of training products etc..

Improving capacity - 1Improving capacity - 1

Evaluation research studies on services and training Evaluation research studies on services and training disseminating lessons for the future; training programme study disseminating lessons for the future; training programme study completed and others due for completion in 2007 and 2008.completed and others due for completion in 2007 and 2008.

Comprehensive service user participation through policy work; Comprehensive service user participation through policy work; programme design and monitoring; service development and on programme design and monitoring; service development and on going service delivery; service commissioning; shared learning going service delivery; service commissioning; shared learning activities; research studiesactivities; research studies

Facilitating investmentFacilitating investment Winning ‘Hearts & Minds’ across the systemWinning ‘Hearts & Minds’ across the system Raising the PD profileRaising the PD profile

Improving capacity - 2Improving capacity - 2

Personality Disorder Capacity Plans produced in 2005 providing Personality Disorder Capacity Plans produced in 2005 providing an analysis of existing service provision in regions and plans for an analysis of existing service provision in regions and plans for the futurethe future

No region has anything like a comprehensive spectrum of No region has anything like a comprehensive spectrum of services (across a 6 Tier model)services (across a 6 Tier model)

Ensuring mainstream services provide for people with Ensuring mainstream services provide for people with personality disorder – a major issuepersonality disorder – a major issue

Models for future services development are still embryonic and Models for future services development are still embryonic and depend on resources for investment; but some small scale depend on resources for investment; but some small scale developments are progressingdevelopments are progressing

Reducing inappropriate service use – acute psychiatric care; Reducing inappropriate service use – acute psychiatric care; placements etc. widespread and costlyplacements etc. widespread and costly

Progress on capacity…Progress on capacity…

Assessment of response to personality disorder through NSFAssessment of response to personality disorder through NSFAutumn Assessment - NSF Autumn 2005 self assessmentAutumn Assessment - NSF Autumn 2005 self assessment Less than 20% of LITs rated green for dedicated personality Less than 20% of LITs rated green for dedicated personality

disorder services within mental healthdisorder services within mental health Less than 20% of LITs rated green for access to a range of Less than 20% of LITs rated green for access to a range of

psychological therapiespsychological therapies 60% rated green on eligibility for services and social inclusion60% rated green on eligibility for services and social inclusion 62% of LITs currently developing services62% of LITs currently developing services 2006 assessment:- Strategy; dedicated service provision; and 2006 assessment:- Strategy; dedicated service provision; and

response through mainstream mental health servicesresponse through mainstream mental health services

Where are we now?Where are we now? Moving forward?Moving forward? First stage policy objectives largely delivered…First stage policy objectives largely delivered… Greater hopefulness – no longer a diagnosis of Greater hopefulness – no longer a diagnosis of

despair? despair? Growing body of experience, evidence, thinking on Growing body of experience, evidence, thinking on

prognosis, treatability and effectivenessprognosis, treatability and effectiveness Improved understanding of personality disorder; what Improved understanding of personality disorder; what

works; response; – across agencies, practitioners, works; response; – across agencies, practitioners, commissioners and plannerscommissioners and planners

Better understanding of service user participation – Better understanding of service user participation – where, how, what - and why it is importantwhere, how, what - and why it is important

Where are we now?Where are we now?Moving forward?Moving forward? Priority and profile – local and national agendas; Priority and profile – local and national agendas;

interest and “buzz”; improved motivation to do interest and “buzz”; improved motivation to do somethingsomething

Growing resource of services specifically providing for Growing resource of services specifically providing for people with personality disorders ANDpeople with personality disorders AND

Improving response in mainstream mental health Improving response in mainstream mental health servicesservices

Improved understanding of what services can deliver – Improved understanding of what services can deliver – what changes and benefits are possiblewhat changes and benefits are possible

Movement towards broader policy concepts – social Movement towards broader policy concepts – social exclusion agenda; emerging personality disorder in exclusion agenda; emerging personality disorder in young people - addressing primary prevention??young people - addressing primary prevention??

Or marking time?Or marking time? Hopefulness; understanding; motivation – still very patchy and Hopefulness; understanding; motivation – still very patchy and

variable across the country and in localitiesvariable across the country and in localities Service provision, both specific services for people with pds Service provision, both specific services for people with pds

and response in mainstream services – still very patchyand response in mainstream services – still very patchy Fragile approach to a “critical mass” of service provision Fragile approach to a “critical mass” of service provision

threatened as existing and new services vulnerable to threatened as existing and new services vulnerable to cuts/savingscuts/savings

Lack of a capable workforce still proves a barrier to Lack of a capable workforce still proves a barrier to development – need to continue to develop capabilities and development – need to continue to develop capabilities and capacitycapacity

A cross governmental ‘Personality Disorder Project’?A cross governmental ‘Personality Disorder Project’?

Where are we now?

The Current ChallengesThe Current Challenges Threat or opportunity?Threat or opportunity? Challenging financial realities. Potential impact on mainstream Challenging financial realities. Potential impact on mainstream

mental health services; innovative service development; mental health services; innovative service development; interagency collaborationinteragency collaboration..

Complex and changing NHS commissioning infrastructure Complex and changing NHS commissioning infrastructure NOMs commissioning still in development. Collaboration still NOMs commissioning still in development. Collaboration still embryonic. The complexities can be a barrier to developing embryonic. The complexities can be a barrier to developing whole systems and pathway developments.whole systems and pathway developments.

Policy streams currently diverse and disparate – greater Policy streams currently diverse and disparate – greater integration/cohesion needed across forensic and mainstream integration/cohesion needed across forensic and mainstream mental health; personality disorder; social inclusion; criminal mental health; personality disorder; social inclusion; criminal justice; equalities agendas.justice; equalities agendas.

Clinical and organisational ambivalence – caution or resistance? Clinical and organisational ambivalence – caution or resistance?

Outstanding QuestionsOutstanding Questions

How does PD and the development of How does PD and the development of psychological therapies fit together?psychological therapies fit together?

Inclusion - a political or clinical objective?Inclusion - a political or clinical objective? Tier 4 ½?Tier 4 ½? Concept of ‘High Harm’ – a risk to self and a risk Concept of ‘High Harm’ – a risk to self and a risk

to other and the difficulties of the ‘D’ word?to other and the difficulties of the ‘D’ word? Are we commissioning pathways or services?Are we commissioning pathways or services? Need for local, regional and national drivers in a Need for local, regional and national drivers in a

devolution environment? devolution environment? Value For Money (VFM)?Value For Money (VFM)? Can we establish a workforce?Can we establish a workforce?

Personality Disorder NHS and Personality Disorder NHS and NOMS Services: The VisionNOMS Services: The Vision

Non-forensic services

Forensic services

Relative volume of need

Case management & pathway planning

Gatekeeping using shared protocols

Key

Tier 5: Secure and Forensic PD Services

Regional referrals

NOMS

Tier 6: DSPD Units

• 2 High Security Hospital

pilots• 3 Prison Service pilots

National referrals

NOMS

Tier 2: Community-based Treatment & Case ManagementSpecialist

Services

Tier 4: Specialist, Inpatient and Intensive Services

Regional referrals

NOMS

Tier 3: Intensive Day Services, Crisis Support and Case Management

Locality

Locality Locality Locality Locality

Tier 1: Consultation, Support and Education

Looking AheadLooking Ahead

PD as a Cross Governmental ProgrammePD as a Cross Governmental Programme Mainstreaming PD and managing without more Mainstreaming PD and managing without more

moneymoney Early intervention programmesEarly intervention programmes Broadening and deepening the PD networkBroadening and deepening the PD network Differentiations MI and PD – maintaining a discourseDifferentiations MI and PD – maintaining a discourse Developing the workforce(s)Developing the workforce(s) Developing PD Leadership/championsDeveloping PD Leadership/champions Supporting user participation and voiceSupporting user participation and voice Being courageous about design, innovation and a longer term Being courageous about design, innovation and a longer term

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