Peer Supported Open Dialogue Service (POD) - Kent & Medway - HC - #MHAwards18 & #MHAwards19

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

POD is an innovative psycho-social approach that involves working with the whole family/network at the point of crisis using the knowledge, assets and strengths of all involved. It places shared understanding and ‘shared decision making’ for treatment decisions at the centre of the work. In February 2017 the Kent POD team was the 1st team in the country to become operational and has led the way in measuring outcomes in the 1st year via an internal portfolio study (support by a Health Foundation grant). Kent are co-applicants in the NIHR £2.4m RCT ODDESSI trial. The service is an alternative to the current crisis/community pathway and provides support at the point of crisis through to recovery/ discharge without the transition between a CRHT and CMHT.

The approach is an adaptation of the Open Dialogue model from Western Lapland, Finland. Practitioners have trained for a year in the approach including psychiatrists, psychologists, social workers, nurses, OT and Peers. The core principles of Open Dialogue are; 1. Immediate help 2. Social network/family perspective 3. Flexibility and Mobility 4. Responsibility 5. Psychological continuity 6. Tolerance of Uncertainty 7. Dialogism In essence the approach is a way of delivering services where the first meeting is held within 24 hours of contact. The service user decides who will attend- family, friends and any relevant professionals. The same clinicians remain throughout care and meetings take place as often as needed during the phase of crisis. Hasty decisions about treatment are avoided and there is a distinct form of therapeutic conversation call ‘dialogic practice’. The clinicians reflect in the presence of the family and all decision are made in front of and with all present at the network meeting. The approach elicits multiple view points and includes at times psychotic utterances which are normalised. The approach uses a relational focus in the dialogue to create new meaning and understanding of ‘what has happened’ rather than “what is wrong with you”.

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

Effective leadership. A steering group was set up in 2014 to ensure the governance of the training and development of a business case for a pilot team. The steering group has reported to the different operational service groups and executive leadership group. Prof Kinane (former medical director) has supported the strategic fit of the service development to ensure it meet the Trust objectives and it has formed a component of the development of innovations within the organisation. Leadership has come from operational and clinical leadership but also from ensuring that the steering group had service user and carer input as equal participants at all stages of development. All members of the operational team have been trained at a foundation level in Open Dialogue. In addition 2 practitioners have undertaken additional trainers training in dialogical practice in Helsinki to enable further training to develop both within and outside the organisation. To ensure clinical adherence to the model the team have reflective clinical supervision weekly and attend a CPD day approximately every 3 months.

Engagement of service users and carers. The team receive regular qualitative feedback from service users and families with themes of being heard and included in decisions being identified as important and key to the relationships formed.

The outcome measures used in the previous section have ensured there is continued feedback from service users and carers/families/networks. Continuous service development is based on feedback and outcomes alongside the peer and carer lead contributing to the strategic development. Service users and families have actively engaged in presentation and workshops both internal and external to the organisation and are valued as equal voices at all levels of service development. The service development has attracted interest from other mental health organisations both nationally and internationally with invitations to share the service development at national and international forums. The team also won an award at Royal College of Psychiatrists annual Awards in 2018 for Team of the year in Adult Mental Health services.

How do you ensure an effective, safe, compassionate and sustainable workforce?
The Multidisciplinary Team (MDT) has undertaken specific training in the model, sought funding opportunities for development and disseminated their work widely. The belief is that the model delivers best quality care with continuity of professional within the service user and their network in a chosen place by the network making all the difference to outcomes in terms of effectiveness, safety and experience. The team has expanded since it became operational in February 2017 and to date there has been no turnover of staff indicating high satisfaction with the current roles and responsibilities. To enhance the delivery of the work additional training has been undertaken with a member of the team undertaking trainers training in Dialogical practice in Helsinki for 2 years. Also two practitioners have undertaken training at an intermediate level in Family Therapy to enhance the focus of remaining family and network focused for ongoing work. Clinical Reflective supervision takes place every week and the focus is on the practitioners’ thoughts and feelings about their practice and relationships rather than what is to be achieved with service users. This helps to ensure decisions are not made about interventions without the individual and/or their network present. Currently the team has 3 practitioners with lived experience contributing to the delivery of the service who have received, care from the mental health system or have been a family member working with mental health services.
Who is in your team?	Band/grade	Number	Whole-time equivalent
Open Dialogue Service lead/social worker/psychotherapist	8b	1	1
Consultant psychiatrist		2	1
Peer Workers	3/6	3	1.4
CPNs	6	4	3.68
Occupational Therapists	6	3	2.68
Consultant Psychologist/principle investigator	8d	1	0.2
Research Assistant	5	2	2

How do you work with the wider system?

The Health Foundation Grant was awarded in 2016 for an innovation from another country transferred to a UK setting and enabled the set up of the service with an evaluation process embedded from the beginning to support it development. Heath Education Kent Surrey and Sussex supported the project with £120,000 for training and educational development of the approach. The service has worked with over 200 referrals and routine outcomes have been collected and analysed as part of the internal portfolio study. The final outcomes and results of the 1^st year of service should be finalised by the end of summer 2019 with 3 articles due for publication.

As this is a service innovation there has been significant work undertaken with other parts of the organisational systems to ensure that care is never compromised, but that the innovation is understood in terms of its differences to how treatment is delivered in CRHTs and CMHTs.

The growing interest in working dialogically with families and network systems has generated significant interest nationally and internationally. This has included other mental health care providers, carer and service user groups, national charities (e.g. Rethink), MHFA England, Social Care providers, and attendance at national and international forums.

Much of the interest in this innovation has centred on how the approach can be incorporated into an NHS mental health setting, in particular understanding the challenges of moving away from holding the expert position to working more relationally to co-create new meaning and understanding of emotional distress and crisis.

In addition to the external interest the service has also recently been filmed by a Canadian film company to contribute to a documentary about alternatives to traditional mental health services in Canada. The documentary is likely to be screened in 2020.

Workshops and training opportunities have also developed in the last year with requests for training increasing.

Do you use co-production approaches?

Using Open Dialogue as an approach to care implicitly involves a co-productive delivery of service with the service user and their family/network. As mental health clinicians, the ability to step away from holding the expert position to being a more curious member of a network enables all voices to be treated with equal value and importance. Understanding of what has happened and what may be helpful becomes more of a co-created process and the generation of dialogue is central to this process. This way of working has reduced the feeling of exclusion that is often experienced by families and feedback often comments on feelings of inclusion and valued participants.

As stated above service users and cares have been involved in all stages of development of the service and several have generously given their time to co-present at workshops, training events and on film. The voice of lived experience remains central to working in this approach.

A current service user has contributed to a chapter in an ISPS book on lived experience published 2019.

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

Articles have appeared in Context (family therapy magazine), Nursing Times and Community Care. There are currently 3 articles being prepared for publication focusing on the 1st year outcomes including staff wellbeing.

As above a current service user has written a chapter for a book about his lived experience and work with the Open Dialogue Service.

Members of the team, service users and carers have presented at workshops/conferences across the UK, in New York, Egypt, Wales and Scotland. Visitors to the service in Kent have come from other UK mental health trusts, Australia, Egypt, Canada and Holland.

What outcome measures are collected, how do you use them and how do they demonstrate improvement?
The National research trail – “Open Dialogue – Development and Evaluation of a Social Network Intervention for Severe Mental IIlness (ODDESSI)” has 5 work packages over a 5 year period starting in 2017; • 5 year programme, NIHR Programme Grants for £2.4. • Comprehensive evaluation with 5 work packages, including a multi-centre cluster RCT • 5/6 NHS Trusts across UK signed up as study sites • Majority of OD staff teams, including peer support workers, will be trained. • Feasibility study started late 2018 and completed February 2019 • Actual recruitment to full trial starts July 2019 The outcome measures used for the Kent and Medway internal portfolio study were the; – Mental Wellbeing (SWEMWBS) – Work and Social Adjustment (WASAS) – Carer Support Scale (CWSS) – Clinical improvement (HoNOS) – NHS Community Mental Health Survey The table below show some of the early outcomes from the NHS mental health survey. Full year results will be presented at the end of summer 2019. Early indication is that the results are similarly better than treatment as usual.
		Question from the Community Mental Health Survey	2017 National Score	2017 KMPT Score	2017 POD Score at 6 m
	Overall	Overall, on a scale of 0 (I had a poor experience) to 10 (I had a good experience)	7.03	6.51	9.38
	Contact	In the last 12 months, do you feel you have seen NHS mental health services often enough for your needs?	6.12	5.39	8.83
	Family	Have NHS mental health services involved a member of your family or someone else close to you as much as you would like?	6.80	5.78	9.62
	Listening	Did the person or people you saw listen carefully to you?	8.12	7.81	10.00
	Help	Do the people you see through NHS mental health services help you with what is important to you?	6.36	5.62	9.62
	Time	Were you given enough time to discuss your treatment and needs?	7.54	7.24	10.00
Has your service been evaluated (by peer or academic review)?
The service has worked with over 200 referrals and routine outcomes have been collected and analysed as part of the internal portfolio study. In the Friends and Family survey between 80=90% of those surveyed stated they were highly likely to recommend the service.. Articles have appeared in Context (family therapy magazine), Nursing Times and Community Care. There are currently 3 article being prepared for publication focusing on the 1st year outcomes including staff wellbeing. Involvement in research as above.

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

The POD service has now been operational since February 2017. Ongoing funding for a standalone team has been secured for at least the period of the 5 years of research trial.

As above, outcomes continue to be good compared to treatment as usual and the National trial will measure qualitative and quantitative outcomes including use of impatient care, relapse, economic evaluation, satisfaction surveys and social recovery.

The POD service has to maintain national standards required of all community mental health services. However the delivery of the standards are qualitatively different with a focus on using assets and strengths of individuals and their networks rather than on deficits and an “illness” understanding of distress. The model is strongly relational using the strength of relationships to support recovery.

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

The Kent POD service actively encourages interest in the work undertaken with this innovation and put on workshops as and when requested.

The POD service openly welcomes other services both nationally and internationally to visit the team and service users/carers to learn about what is working well and also where there are organisational challenges to developing a new and innovative model in the UK NHS system. Teams and individuals have visited from Leicester, North East London, Barnet, Enfield and Haringey, SLAM, Australia, Egypt and Holland.

The team presentations have included;

· attended the international ISPS conference in Liverpool 2017 and presented in 2 workshops

· presented at the Welsh Early intervention conference in Cardiff

· presented to the Scottish Alliance in Edinburgh

· Presented to Mersey Care in Liverpool

· Presented to social work forums in Birmingham, Bedford and London

· Presented to Canterbury Christchurch University x3

· Presented a Workshop in Crawley Sussex

· Presented a workshop in New York on a dialogic training programme

· Presented at 2 workshops in Cairo and Alexandria

How many people do you see?

· In the 1^st 2 years of operation the team have actively worked with over 200 people and their networks. The current working caseload is over 100.

How do people access the service?

Referrals to the service come via an urgent or crisis route. This is usually via the Single Point of Access, CRHT or Inpatient Services. The mental health presentation has to be one that requires an immediate response within 24 hours.

How long do people wait to start receiving care?

Contact is made within 24 hours and agreement to when a meeting should take place is confirmed with encouragement that people important to the person of concern also attend to assist the practitioners understand from multi voice perspective what has happened and what may be helpful going forward. What is important is the individual or their network determine where, when and what time would be most helpful for the first meeting and subsequent meetings.

How do you ensure you provide timely access?

As above with the team meeting daily first thing in the morning to ensure the response is timely and continuity of care is maintained

**What is your service doing to identify mental health inequalities that exist in your local area?**

Need is understood from a family/community perspective and involving the network helps ensure that assumptions are not made about individuals or the families/communities.

Understanding individuals within their social/cultural context ensures that social determinants are given equal understanding in terms of how they contribute to the current distress and crisis.

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

Inequality in terms of benefit entitlement has been a major stressor impacting on families’ ability to meet their financial obligations. Recognising this often affects a whole network and not just individuals. Inviting advocacy organisations from specialist social providers to network meetings enables timely access to social support.

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

The Open Dialogue approach is inherently destigmatising in its approach as it normalises human distress rather than labelling it and pathologising understandable responses to adverse life events. The normalising approach give more hope for recovery because the distress is seen within a context that makes sense for all involved.

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

The Open Dialogue Approach uses dialogue within a family/network meeting to generate understanding of what has happened, listening non judgementally to all voices and building a joint understanding of what has happened. This type of dialogical approach can enable the not yet said to be spoken about in a safe forum. When the co-created understanding of need is identified the network will also offer suggestions of what may be helpful without being prescriptive or directive. This offers individuals real choice about what they feel will be helpful including ideas and suggestions from family and or friends. This helps the focus move away from a predominantly medicalised response unless it is agreed to be helpful. This includes social and psychological interventions and medication if needed. Offers of support are always tentative to support an individual and their network to feel empowered to make the decisions.

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

The Open Dialogue approach has less transitions of care and the importance of the therapeutic relationship with the network is given priority over identifying solutions/interventions too quickly. As this has been a new way of working practitioners are still developing their skills in dialogical practice. The regular feedback from some of the outcome measures will offer intelligence about what is working well and what can be improved. The national trial will start to give much broader understanding on the efficacy of the model within the next couple of years and the Kent service will contribute to developing National Standards if the results are positive. As the national trial is a RCT on a large scale it is anticipated that positive outcomes may lead to the approach being included in national guidance such as NICE.

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

This model offers an approach that involves family/friends and networks from the 1^st point of contact. Galvanising the knowledge, assets and strengths of an individual’s network ensures all voices are heard and support offered as appropriate to all involved in an individual’s care. Importantly families and carers are viewed as central to someone’s recovery and the approach practices an inclusive way of working where all voices have equal value and importance

Is there anything else you want to share about what makes you an example of positive practice?

This innovation into the UK was developed by a group of interested practitioners, service users and carers/families. It has emerged from the ground up and is now attracting national interest as an approach that could improve the pathways of care in mental health with an emphasis on collaboration, shared decision making and inclusivity of all involved. The approach is relational, humanistic and normalising of adverse experiences to create a much broader understanding of mental distress and what may help in recovery.

If results remain positive and the national trial provides robust research evidence the current transformation may be scaled up to provide a national pathway for care in mental health services in the UK.

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Peer Supported Open Dialogue Service (POD) – Kent & Medway – HC – #MHAwards18 & #MHAwards19

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