Leeds Personality Disorder Services - Leeds & York Partnership NHS Foundation Trust - HC - #MHAwards19

Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference

The Leeds & York Partnership Foundation Trust (LYPFT) Personality Disorder Service is comprised of:

The Leeds Personality Disorder Managed Clinical Network (PDMCN). A local based service offering specialist care coordination and group work interventions to men and women living in Leeds
The Pathway Development Service (PDS). A regional service offering advice, signposting and case review for men and women belonging to the region who are residing in (or at risk of escalating into) secure hospital beds or where a pathway back to the community from any inpatient setting has not been identified/progressed.
Yorkshire Humberside Personality Disorder Partnership (YHPDP). A regional service working in partnership with the National Probation Service to enhance the criminal justice management of male and female offenders with personality disorder.

Our Personality Disorder Services work in collaboration and partnership with other organisations to enable movement and provide therapeutic opportunities for people who are frequently perceived to behave in a way which is destructive to relational and therapeutic bonds. We are interested in maintaining people as safely as possible in the community and close to their homes. We are interested in making sure that opportunities are unobstructed and that services remain hopeful about pathways which don’t progress as they had planned. We are interested in creating systems which are thoughtful and which manage risk as collaboratively with service users as possible. We are less focussed on ‘treatment’ and more concerned with creating opportunities at every level to think about and understand minds, repair ruptures and to learn. We are ambitious and we want to evolve with the full involvement of all our stakeholders to make sure that we stay relevant and provide a meaningful service to a client group who traditionally are excluded, marginalised, stigmatised and traumatised. To do this we work both locally and across the region to understand individuals through psychologically informed formulations and to use these formulations as a basis for:

1. Providing a series of direct interventions for men and women with a personality disorder presentation within Yorkshire & Humberside. These direct interventions sit at the centre of a network of other, more systemic based interventions and aim to involve the service users as much as possible in their own formulation and therapeutic journey. They include:

Specialist care coordination for men and women who present with a high level of distress and risk of harm to themselves in the community in Leeds
Dialectical Behaviour Therapy Informed Skills Groups. A structured group work programme focussing on developing skills to manage emotional distress, interpersonal difficulties and self-harming/suicidal behaviours
The ‘Journey Programme’. Journey is an occupational therapy group work programme designed for people with personality disorder and is based on the understanding that what people do (occupation) and don’t do in their daily lives has a direct impact upon their health and wellbeing
Intensive Interventions for Risk Management with high risk men (Discovery Service) and women (Compass Service) with offending histories. These are focussed on managing transitions (e.g. out of prison) and on providing both psychological and occupationally based therapeutic opportunities
Mentalisation Based Therapy (MBT) groups for men diagnosed with Anti-Social Personality Disorder

2. Reviewing the cases of men and women detained in hospital across Yorkshire & Humberside whose pathways are identified by NHS England and CCG case managers as being ‘stuck’. We offer recommendations to clinical teams about how these pathways may be progressed

3. Working in partnership with probation services across Yorkshire & Humberside to enhance the criminal justice management of high risk offenders by providing consultation/co-working of complex cases. This work supports the implementation of the national Offender Personality Disorder pathway.

5. Supporting specialist living environments, including two Psychologically Informed Planned Environments (PIPEs) which look to provide a robust psychologically informed relational environment for men with personality disorder leaving prison

6. Working together with third sector partners to provide a specialist Tier 4 inpatient Personality Disorder service in order to develop a more cohesive pathway for women with personality disorder who require secure/inpatient care and treatment

7. Supporting carers of service users with a personality disorder presentation by facilitating co-produced carers groups within Leeds

8. Supporting workforce development across Yorkshire & Humberside, and in relation to Offender Personality Disorder services then also across the North, via the Knowledge & Understanding Framework (KUF) personality disorder workforce development programme

9. Intensive support for Offender Managers (OMs) in the Humberside region around their case management of individuals detained under Indeterminate Public Protection (IPP) sentences. Pathways for this group are highly problematic.

Our services are psychologically informed with systemic working delivering in partnership with service users and other providers being key aspects across all of our service provision (referenced further in later sections of this submission).

We hold the position that the ‘problem’ for many of our service users with regards to moving forward in their lives is not located with them but rather with the wider ‘system’ itself. The service is therefore committed, as indicated in the range of ‘interventions’ outlined above, to making a difference through both direct intervention with service users and systemic working. How we evidence making a positive difference to individual service users will be referenced in the ‘outcomes’ section of this document.

What makes your service stand out from others? Please provide an example of this.

We believe that Leeds Personality Disorder services is different in a number of ways:

Firstly, we believe that at the forefront of our clinical model is an understanding of the importance of the emotional labour which is required in the work that we do. We understand that services get drawn into unhelpful practices which obstruct pathways when the emotional impact of the work is ignored. Below are some examples of how this work has evolved over the past year:
1. Across all service areas we are committed to learning when something goes wrong. For example, in YHPDP, we are committed to examining our practice closely when someone we are involved with commits a serious further offence (as classified by HMPPS). When one of these offences occurs, YHPDP act swiftly to ensure that a fact find report is completed and shared with stakeholders and through governance. We keep a log of actions to ensure that learning is embedded into practice. Over the past year this learning has led to some detailed recommendations about record keeping – and an audit to ensure that standards are maintained. It has also led to a review about the way in which we formulate cases and ensure that our thinking about someone is shared and applied. A full team away day was organised in accordance with the recommendations of a fact find report to review practice around formulations. A new template/process is currently out for comment within the team. Our expectation is that the new process will ensure that one formulation is at the centre of a whole pathway and works to coordinate the practice of multiple professionals.

Secondly, Leeds Personality Disorder services are committed to expanding the definition of what constitutes bold and effective ways of working. Too frequently, personality disorder services are concerned solely with the treatment of individual intra psychic pathology and not enough with other equally valid outcomes and psychosocial phenomena. For example, over the past year we have expanded and developed our work with:
1. Carers:

i. We have co-delivered ‘Cygnus’, a psychoeducational groups for carers, three times this year with excellent carer outcomes and positive feedback. This group has now been manualised for further research and wider dissemination.

ii. ‘Andromeda’, our carers bimonthly peer support group, has steadily grown and 10-12 carers now attended regularly for peer support. This group is facilitated in partnership with Carers Leeds.

iii. ‘Orion’, a new carer involvement group, has been developed with the carers who co-facilitate the psychoeducational group. The group has worked together on developing an information leaflets about the Network for carers, and is now working on developing information to help carers understand and navigate issues around consent and confidentiality.

1. Probation:

i. Over the past year we have increased the number of posts within the service that are occupied by offender managers.

ii. We have worked closely with senior leads in 8 probation clusters to develop local plans for implementing the OPD pathway

iii. We have launched a survey looking at a broad range of offender manager views about the pathway with a view to ensuring that the service adapts and stays as relevant to them as possible

1. Housing and resettlement:

i. We continue to work in partnership with Community Links across all our services to better ensure that our service users have access to stable, secure housing. The psychologically informed framework means that our housing and resettlement workers work closely with housing providers to ensure that some of the interpersonal difficulties that they typically encounter do not prevent them from having somewhere safe to live.

Thirdly, and finally, Leeds Personality Disorder services are focussed on ensuring that, through collaboration and partnership, new knowledge about what works with the client group can emerge. We believe that what works with our clients is not yet properly known or understood and we are committed to enabling a culture of enquiry which supports innovation and evolution.
1. Involvement strategies across all services include the importance of ensuring that outcomes are co-produced wherever possible to ensure that they are meaningful.
2. Service user satisfaction feedback is routinely gathered as part of the PDCN annual review process. Current and recently discharged service users are asked to complete a brief questionnaire about their experiences. Service users are also invited to attend a Service User Involvement Group to provide feedback and to work together with staff to improve services.
3. PDCN group programmes are co-facilitated with experts-by-experience
4. The PDS routinely gather feedback from key stakeholders, including service users, hospital staff and NHSE/CCG Case Managers. This feedback is used to guide service improvement and development.
5. Service users are actively involved in the co-delivery of our PIPE projects and a recent ‘open day’ at one site featured entirely co-produced presentations and workshops
6. We have an active research strategy group which is committed to contributing to the body of national knowledge about what works with the client group.

We hold regular stakeholder events for our partners and ensure that the partnership arrangements are represented at every level (e.g. senior management meetings and governance)

Below are some things that Leeds Personality Disorder services are particularly proud of from the past year:

October 2018: Co-produced films about Network Services were featured on the Trust Website.
November 2018: Alice Holland wins the Trust’s Volunteer of the Year Award. Alice was the first carer co-facilitator of the PDMCN’s Carers’ Group.
November 2018: Transitions Conference – a Co-produced event with PDMCN and PDS service users.
2017-2018: Clinical Innovation – Employment of a Service User Consultant to provide Peer Support to the DBT skills groups.
June 2018: The support and supervision of staff by Dr Ranil Tan, Consultant Clinical Psychologist, Garrow House, to complete the cognitive analytic therapy case management course training, was recognised as an Outstanding Area of Clinical Practice by the CQC.
2018: YHPDP clinical model highlighted as an example of good practice in the BPS publication ‘Power Threat Meaning Framework’ (Johnstone & Boyle, 2018)

How do you ensure an effective, safe, compassionate and sustainable workforce?
Developing and maintaining a highly motivated and effective work force is in our view a key objective for all members of the service but a primary task for the leadership team. Achieving this aim is multi-factorial but we would point to the significance of our established: Values informed recruitment Investment in staff development and support Containing and reflective structures across the service All staff within the service are employed via recruitment panels consisting of staff and service users and once employed staff all staff have individual CPD plans developed and monitored through the appraisal process and access to relevant short and long course training opportunities, aligned to service level training plans. Engagement with high quality and regular supervision is considered to be essential for staff well-being and effective service delivery. This is demonstrated by all staff within the service having both management and individual clinical supervision on a monthly basis. Additional group clinical supervision is provided to support management of group work processes in the DBT and Journey group work programme teams. All clinical supervisors and supervisees have completed clinical supervision training, updated within the past 6 months as a service level quality improvement objective, with the quality of supervision being reviewed through individual and service level feedback questionnaires (relevant action plans then being developed and monitored through clinical governance). All staff attend, as a mandatory requirement, monthly team development days (TDDs) to support team reflection on relevant areas of practice development. The focus for TDDs are developed in consultation with the staff team and facilitated by senior clinicians within the service with additional input from external facilitators as required. Each service area additionally has a weekly ‘clinical review’ forum with mandatory attendance across the MDT where cases are formulated and treatment plans developed/reviewed. As a psychologically led service reflective practice is embedded at all levels of the service. There is a transparent approach to workload allocation with a clear commitment to ensuring that staff caseloads do not exceed those agreed within the team and with commissioners. There are annual team ‘away days’ facilitated for each team across the service with a shared focus of team building and service development. The ‘evidence’ of the structures impacting positively on the staff well being, and crucially therefore on their psychological capacity to continue to work effectively despite the challenging nature of the work, is demonstrated through the positive response to the Trust’s annual survey from staff within the service and in our HR related performance. The service routinely has less than 5% vacancy factor across the service low staff turnover and low levels of sickness absence (typically 1-2%). Responses to the survey this year indicated that: · 100% staff rate appraisal as positive · 100% staff feel they make a difference · 94% staff feel they receive regular updates re the service/service user feedback · 73% feel they can meet conflicting demands of work · 42% feel they work unpaid hours (down 19% after we addressed this following last year’s survey) Other responses which indicated a downward trend in terms of staff satisfaction are the subject of an action plan which is attached to this submission. The action plan has been circulated to all staff. Our belief is that the high level of service user satisfaction is directly related to high level of staff satisfaction within the workplace. A clear and sustained commitment from the leadership within the service to working to this principle is evidenced through the structures outlined above and is prioritised as a standing item for review on the service’s bi-monthly senior management forum.
Who is in your team?	Band/grade	Number	Whole-time equivalent
E.g. Clinical psychologist	8a	2	1

Consultant Clinical Psychologist	–	3	1.6
Principal Psychologist	–	3	2.8
Nurse Consultant	–	1	1.0
Operational Manager	–	1	1.0
Senior Psychologists/Psychotherapists	–	14	12.1
Clinical Team Manager	–	1	0.9
Senior Probation Officer	–	2	2.0
Housing & Resettlement Manager	–	1	0.6
Psychologist/Psychotherapist	–	2	2.0
Occupational Therapist Specialist	–	1	1.0
Occupational Therapist	–	5	5.0
Care co-ordinator	–	4	4.0
Caseworker	–	4	3.6
Housing & Resettlement caseworker	–	5	4.4
Probation Officer	–	3	2.5
Administration Team Leader	–	1	1.0
Service User Involvement (paid)	–	4	2.0
Higher Assistant Psychologist	–	2	2.0
Assistant Psychologist	–	5	5.0
Health Care Assistant	–	1	1.0
Administrators	–	4	2.0

How do you work with the wider system?

Leeds Personality Disorder Services work with a range of key partners and stakeholders. These primarily include:

The National Probation Service
Community Links (3^rd sector housing provider)
Together Women Project
Leeds Survivor Led Crisis Service
Leeds CAMHS
Carers Leeds
Turning Point
Institute of Mental Health
Service User Training
NHSE and local commissioners across the region

We consider partnership working to be essential in providing a suitably complex service for our service user group and systemic work is embedded across all aspects of our service. Indeed supporting pathway planning is the primary task for the PDS. The PDMCN was originally designed using a ‘Managed Clinical Network’ model, with multi agency and multi-disciplinary arrangements being central to the design of the operational model. We are motivated to engage with the psychological and social circumstances of our clients and as such we look to ensure that our work encompasses the widest possible social agenda and involves multiple stakeholders and partners. In addition, our clients are frequently transitioning between services. We know that these transitions are often ill planned or fraught given the level of anxiety they tend to trigger. We are also, therefore, motivated to work closely with other agencies to manage gaps and transitions and ensure that learning about the individual is captured. We strive to be brave and to ensure that we, and those we are collaborating with, manage what often appear to be increases in risk thoughtfully and effectively. As a consequence, we are keen to ensure that partner agencies are involved at every level of our business. Below are just some examples of how we work closely with partners and involve all stakeholders to support service provision across the wider system:

The PDMCN CAMHS transition protocol. We have an established protocol with local CAMHS services which ‘operationalises’ the early identification of young people ‘transitioning’ into adult services who may benefit from our service. Collaborative formulation and joint working prior to the young person’s 18^th birthday is a key component of this protocol and to the development of an adapted/individualised package of support
The PDS led specialist personality disorder inpatient services review. This project, commissioned by NHS England, focuses on the population of Yorkshire and Humber who are currently using, or may be requiring specialist medium or low secure personality disorder services. The review is tasking with:

o Reviewing best practice and the evidence base for the population

o Engaging with service users, staff and commissioners in developing a vision for future service provision

o Reviewing current in-patient services and provision across the whole pathway

o Supporting commissioners to develop a three to five year strategic implementation plan

The Knowledge and Understanding Framework (KUF) personality disorder training programme. The service co-ordinates delivery of personality disorder training from awareness level to Masters level across the Northern region and will deliver over 40 cohorts of training to multi-disciplinary staff across health, criminal justice and 3^rd sector agencies. Supporting workforce development across the whole system is a key aspect of this programme

· Our Humberside based project which is tasked with supporting the case management of high risk individuals who are detained under Indeterminate Public Protection (IPP) sentences is working actively with prison based psychologists and the parole board to ensure that goals are shared and transitions are as smooth and as actively supported as possible for this client group. ‘Progression panels’ are routinely held in this locality through the project ensuring a forum for multi-agency involvement and shared decision making for a client group whose pathways are highly problematic.

· Over the past year we have actively engaged senior probation officers in the development of local ‘cluster based’ plans for implementation of the OPD pathway. This means that each team manager is able to own and oversee a plan for his or her area which is responsive to local need and driven by the relevant workers.

· One of our PIPEs has arranged a 60 minute awareness session with the local GP practice where all the residents attend. The men have communicated what they think the key messages are for the practice about the experience of personality difficulties / disorder and how this influences their response to accessing primary care services.

· Following an incident on another ward in the Trust, the service secured funding for an additional psychology post to support women with needs consistent with a ‘borderline personality disorder’ diagnosis

Do you use co-production approaches?

Personality Disorder Managed Clinical Network

Leeds PDMCN has a long history of service user involvement. However in 2016, a decision was taken to engage in a major review of involvement activity across the service which started with a co-produced event to obtain views and feedback from a range of stakeholders about how we as a service could progress the involvement agenda. Nearly three years later, we have a co-produced Involvement Strategy and Structure; a service user involvement group called ‘Personalities in Action’; a strong service user and carer presence in the delivery of a range of our services and a tool for evaluating involvement activity. There are a wide range of opportunities for current and previous service users to become involved with service development, delivery and improvement. We have consciously striven to implement a ‘ladder of involvement’ continuum methodology, providing engagement opportunities from service user’s experience of directing their own care to paid involvement at a senior governance level. The following section outlines some of the work we have focused on in this last year

‘Your Voice’: An event organised in June 2018, to think about how we might improve our offer and engagement with young adults. The median age of our service group has decreased over the years, with a significant number of services users who we care co-ordinate falling between 18-25. One of the service users who attended this event is now coproducing a training session for junior doctors, in order to improve and enhance their understanding of personality disorder, with a particular emphasis on learning from service user experience.
Re-Imagining Involvement: A bi-annual co-produced conference with attendance from service users, service providers and other stakeholders from across the region. The focus this year was on Transitions, presentation and workshop discussions has resulted in an action plan for both the Network and Pathway Development Service, including the proposal to host organise a City and System-Wide Mental health awareness event for World Mental Health day in 2020 (see attached report).
Evaluation of Service User Consultant Post within DBT Skills Group: The presence of a service user consultant within the group was highly valued by service user and in response to this there is a commitment to continuing with the initiative. The project was presented at BIGSPD 2018. Journey also continues to have service user consultants within the group.
Co-produced Psychoeducational Groups for Carers, “Cygnus”: This six-week psychoeducational group is co-facilitated with Carer Consultants. Outcomes were co-presented at the British & Irish Group for the Study of Personality Disorder (BIGSPD, 2018). This group has now been manualised for further research and dissemination, and coproduced journal articles have been submitted for publication.
A new Carers Involvement Group, “Orion”, has been developed with the carers who co-facilitate the psychoeducational group. The group has worked together on developing an information leaflets about the Network for carers, and is now working on developing information to help carers understand and navigate issues around consent and confidentiality.
Co-produced films about Network Services: Providing easily accessible information about our services on the Trust website.
Co-produced Self-Help information: A coproduced project was completed to support service users in making choices about using self-help materials, leading to a coproduced leaflet
Improved communication: through the use of digital media, including a Facebook page and Twitter account; a new Service User Involvement website is also in development which will be coproduced.
Triangle of Care Self-Assessment: Completed March 2018 and reviewed February 2019. The service action plan focused on the consistent identification of carer information on PARIS; Carer Awareness Training October 2018, co-facilitated with a Carer; developing better information for carers, which has included a short co-produced animated film and a co-produced Information leaflet for carers.
Service User Network: Staff and service users regularly attend SUN to develop pathways of communication and involvement activity within LYPFT.
An annual service user satisfaction survey: Recommendations from the survey results are co-produced with the ‘Personalities in Action’ group and outcomes are fed back to service users using a ‘You Said – We Did’ structure.

Pathway Development Service

A review of involvement activity took place in 2016 which started with a co-produced event to obtain views and feedback from a range of stakeholders about how we as a service could progress the involvement agenda. The PDS have a co-produced Involvement Strategy and Structure and provides a range of opportunities for current and previous service users to become involved with service development, delivery and improvement, ranging from involvement in services user’s own care to attendance at steering groups and clinical governance. The following section outlines some of the work we have focused on in this last year:

Co-produced Involvement training for all PDS staff.
Involvement Steering Group: Held at Garrow House to engage with PDS service users who regularly attend to inform the service’s involvement plan and activities.

· Clear, easy read information leaflets: A new service information leaflet and an Information leaflet have been co-produced with service users to ensure that clear and accessible information is available.

· Glossary of Terms: A glossary of terms has been developed in conjunction with experts by experience and is now included as an appendix to PDS reports. This glossary was developed in response to service user feedback, with the expectation that it would help reports to be better understood and more transparent for service users.

Improved communication through the use of digital media.
A short animated film about the service is being co-produced with service users.
Triangle of Care Self-Assessment: The service action plan focused on Carer Awareness Training October 2018, co-facilitated with a Carer; developing information for carers; and improving service guidance for how family members/carers are involved in the Review Process. The PCMCN Carer groups are also now available to carers of PDS service users.
Re-imagining Involvement – Transitions conference, 2018; which included PDS service users co-facilitating a workshop at the conference.

Yorkshire Humberside Personality Disorder Partnership

PIPE delivery is informed by active service user participation. Below are some examples of the involvement activity which has taken place in our PIPEs over the past year:

We developed the ‘Hoping for Coping’ programme after residents requested. These are psychoeducational sessions which, so far, have focussed on anxiety and sleep
Special support sessions were held following the death of a resident. These looked at loss and trauma
Men requested more information about the PIPE regimes and what the purpose of structured groups were etc. Discussions were held with the men and an information pack for new residents was developed (with input from the men).

The operational model for our Intensive Intervention Risk Management (IIRM) service has changed from a group to an individual model. This was largely based on learning about the interpersonal threats posed to this client group of engaging with groups. As part of this individual model, the programme focusses on bespoke engagement and intervention plans which are developed collaboratively with service users. This means that people are met in places that are convenient to them (e.g. their workplace or probation office) and that the goals for the intervention are informed by individual needs. The work is informed by individualised formulations which take into account the service users life experiences and idiosyncratic life story.

Below are some specific examples of how practice has been informed by listening to service user’s experiences:

· One service user asked his engagement worker to attend his family home to support him to explain the formulation that they had developed. This formulation specifically focussed on his anger (or his “volcanoes”). The engagement worker responded to this and spent time with his family – who were not victims of his from the past – thinking about how they might best support him when his “volcano” was active.

One service user’s anxiety increased when he was moved from a probation hostel to his own property. He asked his housing support worker from the IIRM service to support him to attend his GP to help him explain his anxiety and challenge the GP around his prescribing needs as he had previously been declined medication. This happened and he was prescribed the medication he wanted which helped him to manage this transition.

Do you share your work with others? If so, please tell us how.

Leeds Personality Disorder services are committed to sharing but also learning from others. We are keen to publish our learning whenever possible but also to engage with stakeholders to showcase our work and explore challenges together. As a leading personality disorder service we routinely engage in and contribute to local, regional and national forums which reflect the comprehensive scope of our service provision. Some examples of how we have shared our work and sought to learn from others are:

The BIGSPD conference is an event which Leeds Personality Disorder services regularly has a presence at. We have presented at this conference for the last 5 years. At the most recent event (in April this year) Leeds Personality Disorder services presented 3 posters (which are attached to this submission)
- What pathway ‘success’ looks like for men on indeterminate public protection sentences
- What factors are associated with different pathway outcomes for men on indeterminate public protection sentences
- A co-produced service user guide to Selecting Self-Help

YHPDP have held two learning events for criminal justice and health stakeholders in the region. These learning events combine a series of key note speeches with workshops. The workshops all explore different areas of work which have posed challenges for us and which have enabled us to learn as a consequence. Our goal is to share our learning in the hope that it will help others with similar challenges as well as to provide a space for further discussion and exploration of the issue
We hosted a national conference in October 2018 reflecting on our experiences of service delivery over the past 15 years and considering ‘what next’ for personality disorder services. In attendance were local, national and international speakers, such as Professor John Livesley, reflecting the profile and credibility of the service

Below are a list of publications which have been authored by workers from Leeds Personality Disorder services over the past year:

· Clinkscales, N., Tan, R. & Jones, L. (2018). “What role am I playing?” Inpatient staff experiences of an introductory training in Cognitive Analytic Therapy. International Journal of CAT and Relational Mental Health, 2, 37-49.

· Harvey, D. & Sefton, W. (2018). The use of psychologically-informed warning letters in probation for high-risk clients with personality difficulties. The Probation Journal, 65(2) 170-183.

· Ramsden. J. (2018). ‘Are you calling me a liar’? Clinical Interviewing: more for trust than knowledge with high risk men with anti-social personality disorder. International Journal of Forensic Mental Health, 17(4), 351-361.

· Sutherland, R. (2018). Supporting carers of people with a personality disorder. Published in Innovation, LYPFT Research and Development Newsletter.

· Taylor, P., Perry, A., Hutton, P., Tan, R., Fisher, N., Focone, C., & Seddon, C. (2018). Cognitive Analytic Therapy for Psychosis: A case series. Psychology and Psychotherapy: Theory, Research and Practice.

· Zamir, A. (2018). Development within times of Austerity: an evaluation of the pilot Dialectical behaviour Therapy Groups. Published in Innovation, LYPFT Research and Development Newsletter.

· Zamir, A & Sutherland, R. (2018). Tweet, tweet, who’s there? Social media in Specialist Services for People with Longstanding Difficulties. Accepted for publication in Clinical Psychology Forum, the British Psychological Society.

What outcome measures are collected, how do you use them and how do they demonstrate improvement?

Personality Disorder Managed Clinical Network

Service Users

Since its inception the PDMCN has focused on the collection of clinical outcomes and service user satisfaction data to understand the effectiveness (or not) of our interventions, to monitor treatment progress and to obtain specific feedback about aspects of service user experience. There is a well-established system for the administration, scoring, analysing and reporting on these areas, which results in an Annual Review Report. The report for 2018/19 will be completed by July 2019. Service user involvement is evident throughout the whole process, culminating in co-produced recommendations.

A number of PROMs, which have been agreed with service users, are used. These include:

World Health Organisation Quality of Life measure (WHOQoL)
Clinical Outcomes in Routine Evaluation (CORE-OM)
The Borderline Evaluation of Severity over Time (BEST)
Occupational Self-Assessment (OSA)

In our 2017/18 Annual Review (see Appendix 2), service users within the PDMCN showed modest improvements in terms of psychological distress, interpersonal functioning, and quality of life. 84% of service users felt positively about the Network and the care and treatment received.

Family and Carers

The service delivers six week cohorts of carers’ groups three times per year and at different times of the day including evenings. The group aims to provide education about personality disorder, to support carers in thinking about what caring for someone with a personality disorder might entail, and to consider self-care as an essential part of caring. The first groups in 2016 were co-facilitated by a clinical psychologist and care co-ordinator; groups are now co-facilitated with a Carer Consultant. Outcome measures used include:

The Personality Disorder: Knowledge and Skills Questionnaire (PD-KASQ) adapted specifically for this group. The PD-KASQ measures understanding, capability and emotional responses regarding working with people with a personality disorder.
The Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS) which is a brief self-report measure of wellbeing.
The Carer Satisfaction Questionnaire (Larsen et al.) adapted for this group.

Outcomes suggest that carer knowledge and understanding of personality disorder significantly improves as a result of the group, as does carer wellbeing. Carers also report high overall satisfaction with the group with all responses falling into the ‘very satisfied’ or ‘mostly satisfied’ categories.

Pathway Development Service

The PDS collects routine evaluation data from key stakeholders in order to evaluate the clinical impact of PDS Reviews. Questionnaires are completed by Case managers, Clinical Team members and Service Users following Reviews and Housing and Resettlement Brokerage. This method of evaluation has been ongoing since 2016 and has led to important changes in service delivery, for example:

Improving the clarity of reports and recommendations: A Glossary of Terms have been developed in conjunction with experts by experience which is now included as an appendix to reports.
Improving access: PDS letters have been reviewed to ensure that the referral and review process is clear. A new service information leaflet for service users and carers has been developed in conjunction with experts by experience to ensure that clear and accessible information is available and a short animated film is being co-produced with service users.
Improving Response Rate: The online tool ‘Survey Monkey’ was introduced in September 2017 to provide easier access to the Questionnaires. In addition, recommendations from Market Research have been followed to improve email and written invitations to take part in the evaluation.
Improving clarity of questionnaires for service users: Further consultation with service users has led to changes in wording of questions in the Service User Questionnaire to ensure clarity of meaning.
Increasing contact between PDS caseworkers and wards: PDS staff have arranged time to shadow staff within inpatient units in order to improve understanding of current issues in inpatient services. Similarly, Housing and Resettlement workers have arranged to shadow local ‘wrap around’ teams or other appropriate accommodation services.

Responses from stakeholders are broadly positive, with respondents describing PDS interventions as helpful in supporting team thinking about the needs of service users and in planning suitable care and resettlement pathways. Commissioners and case managers report feeling very satisfied with the service, as do the majority of clinical staff and service users.

Yorkshire/Humberside Personality Disorder Partnership (Offender Personality Disorder Services)

Routine outcome measurement for our IIRM service aims to address outcomes as outlined in the National IIRMS specification. These include: prevention of reoffending and increasing offenders’ awareness of their impact on their victims; harm reduction; recovery; improving wellbeing; rehabilitation and social inclusion.

Global questionnaires measuring engagement, wellbeing and protective factors include measures completed by probation officers (Treatment Engagement Rating Scale (TER) (Drieschner & Boomsma, 2008) alongside self report measures to be completed by participants:

Clinical Outcomes in Routine Evaluation (CORE-OM)
Reflective Functioning Questionnaire (RFQ)
Structured Assessment of PROtective Factors for violence risk (SAPROF)
Occupational Self Assessment (OSA) (v2.2)
Patient Health Questionnaire (PHQ-9)
Generalised Anxiety Disorder Assessment (GAD-7)
Overt Aggression Scale (OAS-M)

The IIRMs teams also complete outcome measures regarding each participant:

Treatment Engagement Rating Scale (TER)

This list is not exhaustive and bespoke, individualised and goal orientated measures may also be

We have learned that it is problematic gathering outcome data for YHPDP and small sample sizes make it impossible for the service to draw any firm conclusions about impact using these measures. The service is, therefore, concerned with co-producing a narrative about what is meaningful for service users so that we can better ensure that we are utilising measures which register real clinical impact.

Has your service been evaluated (by peer or academic review)?

Leeds Personality Disorder services has not been subject to a CQC inspection or a recent peer/academic review following an initial NHS England led PDMCN pilot review. The Yorkshire/Humberside Personality Disorder Partnership is however a pilot site for new quality reporting which will, ultimately, include peer and commissioner reviews.

How will you ensure that your service continues to deliver good mental health care?

We work to ensure sustainability through a clearly defined culture which is value driven and operationally clear. This is to ensure that a strong value led culture should ‘live on’ even when key individuals leave. YHPDP, for example, has a clear set of value statements and examples of how those actions should be ‘lived’. The team was fully involved in the process of developing those value statements and an internal service evaluation project has recently investigated the impact of those statements on practice. This project discovered that the values are felt by the team to still be relevant and to both reflect the culture of the service and guide practice.

We work hard to record what we do, how we’re thinking and what’s important to us in operational policies, annual reports, governance documents and published papers. Again this is to primarily ensure that the service has ‘a memory’ and key principles are sustained both at points of ‘stress’ and change.

We actively work to recruit staff who will continue to contribute to the existing culture and work to its core principles and look to retain staff through investing in followership; collaboratively working with staff to review and critique our processes and our approach. We have a strong record on staff development and low staff turnover. Feedback from our staff in the most recent staff survey (2017) provided clear evidence of staff feeling supported by the management team to provide high quality clinical care.

The service has strong and well established relationships with a range of commissioners and we are consistently requested to contribute to collaborative work with commissioners regarding our own service performance through quarterly contract review meetings and the development of wider service provision. Examples of this are the service being requested to lead on a regional review of inpatient personality disorder services by NHS England and be a national pilot site for the development of personality disorder quality standards for NHS England and HMPPS co-commissioners. We believe that a constructive relationship with commissioners has inherent value in the continued positive development of services for personality disorder but is also integral to the longer term sustainability of our individual service.

What aspects of your service would you share with people who want to learn from you?

Since Leeds Personality Disorder Services began in 2004 there have been many and varied challenges, some forecast and some unexpected. We are not, however, aiming to be a service which doesn’t experience challenges but to be a service which develops and evolves from what we learn when there are pressures, problems and ineffective ways of working. Learning as we grow and evolve is central to the work of Leeds PD Services. Being a learning organisation is enshrined as an approach and we are not afraid to notice and acknowledge when we have made mistakes or worked ineffectively. We are also keen to ensure that our learning helps others.

Things we would want to share include

· The importance of paying close attention to the health of partnerships. Work in partnership is deeply challenging and we have learned that this tends to be due to the obscured authority which is an inherent aspect of partnership work. Negotiating authority and having a narrative about these challenges has enabled us to work restoratively with the difficulties.

· Involving service users meaningfully and effectively is challenging. Our learning would be the importance of clear strategies and of explicit commitments to exploring the potential for involvement in all aspects of the work. We have noticed the anxiety in organisations when it comes to involving people (especially if they have offending histories) and we would share the importance of a clear, comprehensive (collaborative where possible) risk assessment.

· Evidencing the difference we make when the work is often indirect and about a way of being rather than doing is challenging. We would share the importance of thinking differently about outcomes and co-producing them wherever possible.

· Changes to our Intensive Intervention Risk Management service operations. These changes reflect our learning that work with high risk offenders is difficult to achieve in groups. The client group tend to find groups very challenging and when the work is community based and voluntary, it is hard to keep a group sustained. The changes we have made reflect a move more towards individually based work.

· A paper we published in 2016 details the journey we have taken in developing and delivering an Intensive Intervention Risk Management service to women offenders. This paper outlines key challenges which were experienced by the team developing this service and discusses how we have responded to these challenges and learned from them. (Ramsden, J; Hirons, A, Maltman, L & Mullen, T (2016) Finding Our way: Early Learning from the Compass Project, an Intensive Intervention Risk Management service for women. The Journal of Forensic Psychiatry and Psychology. Vol 28 (2))

The focus for us is to maintain a framework which allows us to notice and to think about things that go wrong or things that are difficult. This framework consists primarily of a strong sense of our primary task and clarity about our values and our model.

How many people do you see?

Below is a summary of our activity data for the past year:

Personality Disorder Managed Clinical Network

Referrals

Total n=264 (97: DBT Group, 82: Journey Group* & 84 Care co-ordination)

*Journey Group re-opened to new referrals from 1^st August 2018 only

Demographics

Average approximately 75% female
Average approximately 50% aged 18-25
Average approximately 75% white British

Caseload

Average caseload n=95 (31 DBT Group, 18: Journey Group & 46 Care co-ordination)

Clinical contacts

Year to date n=2,957

Pathway Development Service

Referrals

Total n=40

Demographics

Average approximately 80% female
Average approximately 50% aged 18-25
Average approximately 65% white British

Caseload

Average caseload n=60

Clinical contacts

Year to date n=201 (n=35 review reports completed)

Yorkshire & Humberside Personality Disorder Partnership

Consultation & Formulation Intervention

Consultations provided for Offender Managers: n=753
Psychological Formulations completed for Offender Managers: n=574
Humberside Indeterminate Public Protection Project (HIPPP): caseload n=35 male offenders

Psychologically Informed Planned Environment Intervention (PIPEs)

N=24 male offenders @ Holbeck House Approved Premises (Leeds)
N=21 male offenders @ South View Approved Premises (York)
Average occupancy rate: 85-90%

Mentalisation Based Treatment (MBT)

Average group size: n=6 male offenders
Successfully completed treatment: n=3

Intensive Integrative Risk Management Service (IIRMs)

Referrals

Total = n=51 (21 Female IIRMS & 30 Male IIRMs)

Demographics

Average approximately 40% female
Average approximately 35% aged 18-29
Average approximately 92% white British

Caseload

Average caseload = n=34 (13 Female IIRMs & 21 Male IIRMs)

Clinical contacts

Year to date n=634

How do people access the service?

Referrals processes are different across different service areas. In the PDCN, referrals can come from varied sources including self referral. The PDS accepts referrals from case managers. YHPDP clients are not referred, as such, but are screened in and are, therefore, in scope for the service. Prioritisation for direct work in YHPDP is determined by the matrix (below).

The work of YHPDP is actively promoted within probation and we have employed probation officers who are able to carry the message about the work and seek referrals from their teams.

What inequalities have you identified regarding access to, and receipt and experience of, mental health care?

We are aware of inequalities regarding people from BAME groups.

**What is your service doing to address and advance equality?**

Priorities for us for the coming year are to work more closely with third sector partnership who have a remit to assist people from different communities to access mental health services. We are also keen to work with probation officers to identify people from BAME communities so that we can actively encourage their involvement with our service.

How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?

The service works to establish individualised, psychologically informed formulations. Needs are identified through the process of establishing the formulation.

How do you meet the needs of people using the service and how could you improve on this?

The care we deliver is effective because it is bespoke and responsive to individual need. Within this we are informed by NICE guidelines and quality standards. For example;

Our Mentalisation Based Therapy group for high risk male offenders with Antisocial Personality Disorder is part of a multi-site national Randomised Controlled Trial. The basis for the trial (and the commissioning of the intervention) is evidence regarding the effectiveness of this treatment for individuals with Borderline Personality Disorder (e.g. Vogt & Norman, 2018) and early indications that it is suitable in reducing the symptoms associated with co-morbid Antisocial Personality Disorder (Bateman et al, 2016).
The delivery of our Intensive Intervention Risk Management (IIRM) service is based on national guidelines which highlight the relevance of: Attachment theory (e.g. Bowlby, 1969); Desistance and the ‘Good Lives’ model (e.g. Ward & Brown, 2006).
Elements of the IIRM service are informed by cognitive analytic therapy (CAT) which has an emerging evidence base for working with offenders with personality disorder.
Our case consultation service is building evidence for its effectives (some of which we are involved with). Emerging evidence though would indicate that the process is helpful for offender managers in developing competencies around formulation (Radcliffe et al, 2017) and for developing working alliances with offenders (Shaw et al, 2018)
We offer Dialectical Behaviour Therapy skills groups, which are recommended in NICE guidance for women with a diagnosis of Borderline Personality Disorder who self-harm

What support do you offer families and carers? (where family/carers are not the service users)

Please see information provided about the carer’s group which is an innovation we are very proud of.

Commissioner and providers

Commissioned by (e.g. name of local authority, CCG, NHS England): NHS England, Leeds CCG & HMPPS (Prison & Probation Service)

Provided by (e.g. name of NHS trust): Leeds and York Partnership Foundation Trust (LYPFT)

Size of population and localities covered:

Our services work with different populations:

Leeds managed clinical network: men and women resident in Leeds.
Pathway Development Service: Men and women with GP addresses in the Yorkshire/Humberside region who are often out of area in hospital and identified by case managers as having problematic pathways.
Yorkshire/Humberside Personality Disorder Partnership: Men and women case managed by probation in the Yorkshire/Humberside region.

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Co-Production

Evaluation

Find out more

Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference

What makes your service stand out from others? Please provide an example of this.

How do you ensure an effective, safe, compassionate and sustainable workforce?

Who is in your team?

How do you work with the wider system?

Do you use co-production approaches?

Do you share your work with others? If so, please tell us how.

What outcome measures are collected, how do you use them and how do they demonstrate improvement?

Has your service been evaluated (by peer or academic review)?

How will you ensure that your service continues to deliver good mental health care?

What aspects of your service would you share with people who want to learn from you?

How many people do you see?

How do people access the service?

What inequalities have you identified regarding access to, and receipt and experience of, mental health care?

**What is your service doing to address and advance equality?**

How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?

How do you meet the needs of people using the service and how could you improve on this?

What support do you offer families and carers? (where family/carers are not the service users)

Commissioner and providers

Size of population and localities covered: