The key difference between Mersey Care PD Hub and other NHS PD services is that we have translated our philosophy, that community care promotes better service user recovery, and is more effective and less damaging than inpatient psychiatric care, into the care of those service users with complex and severe PD. As a result, we have been able to minimise both local psychiatric hospital admissions and Out of Area Treatments (OATs), compared to other mental health trusts.
Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.
The key difference between Mersey Care PD Hub and other NHS PD services is that we have translated our philosophy, that community care promotes better service user recovery, and is more effective and less damaging than inpatient psychiatric care, into the care of those service users with complex and severe PD. As a result, we have been able to minimise both local psychiatric hospital admissions and Out of Area Treatments (OATs), compared to other mental health trusts.
What makes your service stand out from others? Please provide an example of this.
Generic psychiatric care can be ineffective and damaging for people with PD. Service users with BPD typically engage in deliberate self-harm (DSH) as a way of demonstrating and managing their own emotional distress. As these acts generate anxiety in the professionals caring for them, staff can then become overly focused on managing acute risks through admitting service users into hospital. Unfortunately, psychiatric admissions can be harmful in a number of ways: (i) they can promote regression as responsibility is relocated away from service users and placed with the staff team (ii) service users can learn maladaptive and dangerous behaviours from one another (copycatting) (iii) whilst initially being focused on “seeking care” through admission, the dynamics between a service user and inpatient staff team can become more antagonistic, when a service user starts to experience the control and restrictions that are inevitable on an inpatient unit (iv) as staff start to prepare for discharge, service users can feel rejected and engage in more extreme and dangerous behaviour, in an attempt to elicit more staff care.
All of these negative consequences can leave the staff team feeling despondent and that the only hope is for the service user to be transferred to a different team or specialist service. Requests OATs, ie PICU, low secure and rehabilitation services can follow and the service user begins a journey to higher levels of support, increasingly further away from being helped to take responsibility for themselves and living in the community. As such within the NHS many patients with severe PD are sent out of area, as local trusts do not feel able to manage the risks locally, despite many of these specialist providers actually adding little to recovery beyond “warehousing”.
Service users in OATs are living at distance from their family and communities, dislocated from any local community recovery pathways and are expensive to the original trust sending the person out of area. The PD Hub has significantly reduced out of area placements and local admissions by establishing a local specialist PD Hub service. Mersey Care was able to repatriate all those service users who were previously in OATs (in 2016 this was 7 service users) to live in the community locally in Liverpool, and there have been no new service users sent out of area. There has also been a significant reduction in utilisation of local beds with days spent in hospital reducing from 170.8 to 34.1 (80%) and the average length of stay from 40.7 to 10.7 days (74%). As such service users who had spent many years in locked environments are now living in the community with much greater personal freedom. Using estimates of £200k for an OAT and £350 per OBD, this equates to savings of £1.4 million for OATs and £1.26 million for local beds. We would therefore argue that the PD Hub model of care has provided a “win-win” situation, in terms of both a better quality of care for service users and also significant financial savings.
How do you ensure an effective, safe, compassionate and sustainable workforce?
The PD Hub has been set up over the past two years and we have just completed recruitment of the full complement of staff. We recognise the importance of helping new members of staff both develop the appropriate psychological skills necessary to work with PD but also the need to support staff to remain resilient to the challenges of this. Given the personal and clinical challenges that may arise in working with this service user group it is critical that staff have the time and space for both individual and team-based reflection, debriefing and planning. Working with service users with PD can illicit strong negative feelings in staff members when faced with challenging behaviour and it is important that these feelings are recognised and processed so that staff responses are thoughtful. Thus the PD Hub has provided a range of different psychological training opportunities as well as providing ongoing clinical supervision. Psychologically informed clinical supervision: As the PD Hub has grown around an established psychotherapy service there are senior psychotherapy staff available to provide supervision and reflective spaces. As well as running a weekly multi-disciplinary meeting, all the clinical staff receive weekly psychologically informed clinical supervision in small groups, this being in addition to line management supervision.
Additionally, the whole staff team meets weekly for a large reflective practice group to process any challenging events that have occurred. In terms of continuing professional development some members of staff have been trained in certain evidence based psychological models of therapy appropriate for PD (eg. MBT, DBT). However, the whole staff team has been trained in Structured Clinician Management (SCM), an evidence-based intervention for generalist mental health professionals, and this model provides the main form of intervention the staff team deliver. Senior practitioners have also been trained in Eye Movement Desensitisation Reprocessing (EMDR) to provide individual therapy for those with complex trauma. Within the PD Day Service, service users are actively involved in the running of the service in two important ways. Firstly, each Friday afternoon we have a joint meeting with staff and service users to plan the running of different aspects of the service. Secondly, many of the Day Service groups are co-facilitated by a service user volunteer (eg. registration group, psycho-education group, walking group) as this provides a good opportunity for growth and development for more senior service users.
Who is in your team?
Consultant Psychiatrist (lead clinician and supervisor) 0.5 wte PD Hub Manager, band 8a x 1 wte PD Case Manager, band 6 x 4 wte PD Crisis Service Lead, band 7 x 1 wte PD Day Service Lead, band 6 x 1 wte PD Day Crisis/Day Practitioner, band 5 x 4 wte PD Support Worker, band 3 x 6 wte Art Therapist, band 4 x 0.1 wte Psychotherapist (supervision and reflective practice), band 8a x 3, 0.1 wte Service User Lead/Chair, band 3 x 2, 0.5 wte
How do you work with the wider system?
Publication of a BPD policy for use within the wider Trust The PD Hub developed a Local Services Division policy that was published in June 2017. This supports clinicians across the whole division in taking appropriate positive/therapeutic risks, so members of staff feel less anxious about managing acts of DSH in the community and so potentially unnecessary/harmful admissions are avoided. The BPD policy requires the completion of two key documents: Extended Care Plan: This provides a formulation, agrees how problematic behaviours might best be manged and is shared collaboratively with patients. The senior members of staff from the PD Hub frequently attend these professional meetings, usually within inpatient settings to help the inpatient and CMHT staff plan the care of the most complex cases being manged in the Trust’s other services. A local audit of the use of these Extended Care Plans indicated that they reduced admissions by 70%. Admission Checklist: This is completed when an admission is being considered, asking staff members to consider whether previous admissions have been helpful, if there might be potential harm as well as benefits to an admission and to create a plan for the admission, including any contract of good behaviour for the admission. Close working with external organisations
Some service users regularly attend A&E or make frequent contact with the police or ambulance services. If this is the case “frequent attender” meetings are organised and we plan with the police and ambulance staff how our services might best respond to these. Similarly, we work closely with accommodation providers, sharing the Extended Care Plan (described above) and ensuring it covers any difficulties at the service user’s accommodation to support the practice of the staff there. Additionally, we are working closely with Liverpool City Council to help them expand the number of accommodation providers willing to house service users with severe PD (eg. in April 2018 we attended the Provider Forum to publicise our service and promote joint working). Within the Trust the PD Hub is currently engaged in an ongoing programme to train each of the CMHTs in SCM so that they can introduce a lower level 12-month clinical pathway to provide this intervention to new service users referred into the Trust with less severe PD. Additionally, we run an introductory level (based on the National Knowledge and Understanding Framework for PD) as a generic primer in PD for all staff and an advanced level theoretical course in PD for more senior clinical staff and for accommodation provider managers.
Do you use co-production approaches?
Service users have been integral at every stage of the development of the PD Hub service, from lobbying as we sought funding to establish the service, to the current running of the service and also currently helping with researching our outcomes. The PD Day and Crisis services are run as a Therapeutic Community: The PD Hub Day and Crisis Services have been established and are run on the principles of a Therapeutic Community, which sees service user involvement in the delivery and running of the services as a fundamental part of each service user’s recovery. Each Friday afternoon we have a 90-minute meeting, with a rolling programme over the month (First week: business meeting, second week: research meeting, third week: communication meeting, and fourth week: service user support meeting) involving both members of staff and service users to review and consult on the running of the different aspects of the service.
These are all chaired by the lead service user. In order to keep the therapeutic environment of the PD Hub safe, the service user membership have developed an “Acceptable Behaviour Procedure”, which is the handbook of rules that new members have to agree to abide by when registering with the PD Hub (eg. no self-harm or aggression on the premises). If a service user infringes one of these “rules’ a Community Meeting is called, with an open invitation to anyone registered with the community to attend. During these meetings incidents are discussed and it is decided how best to apply any sanctions needed (eg. suspension for one week). Additionally, service users work as co-facilitators leading some of the Day Service groups, developing their own confidence and sharing their experience to encourage the development of others.
Do you share your work with others?
Sharing our model with other NHS trusts: Based on the good local reputation of the Trust’s PD Hub in repatriating patients previously sent out of area, in 2017 NHS England asked the PD Hub to undertake a specialist consultation to a nearby trust, who had over a dozen PD patients in OATS, and one particular patient who was being refused admission nationally by locked wards. We were able to work with the local teams to develop a plan to return this lady to the community, generating our Trust £3000. Additionally, four other trusts have visited to learn and copy from our initiatives. Also the Liverpool Coroner, who investigates local suicides in the Merseyside area, has been so impressed by the Trust’s response to previous deaths, through the development of the PD Hub and the BPD policy that he wrote to NHS England expressing his view that similar services be implemented nationwide. Publication: After 12 months of operation our first outcome data for the PD Case Management Team became available in 2017 (for details see question 8 below) and we have since written and submitted the following paper to the journal “Personality and Mental Health” in February 2018. This is currently under review: Support in leaving the Asylum: using money spent on Out of Area Placements to develop a Local Community Care Pathway for personality Disorder to reduce hospital stays. A preliminary service evaluation of a Personality Disorder Case Management Service.
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
Outcome data for the PD Case Management Team after 12 months of operating In 2017 the PD Case Management team, that offers 100 weeks support to divert those 40 patients with the most severe presentations from hospital, had been operational for a year and comprehensive data was available. Reducing hospital admissions for patients with BPD is important clinically for two reasons, firstly to minimise iatrogenic harm (see answer to question 2 for a more detailed explanation of this) and secondly to ensure efficient expenditure of financial resources, so we were keen to examine any reduction in days spent in hospital. After 12 months of care from the PD Hub all seven patients who had spent many years in OATs (up to six years) had been returned to live in the community locally and no new patients were sent out of area. Utilisation of local beds saw a significant reduction in days spent in hospital from 170.8 to 34.1 (80%) and the average length of stay from 40.7 to 10.7 days (74%). Using estimates of £200k for an OAT and £350 per OBD, this equates to savings of £1.4 million for OATs and £1.26 million for local beds. To date we have not had any suicides. Routine measures used for those service users receiving therapeutic interventions For those service users entering one of our formal psychological interventions (MBT, DBT, SCM, EMDR, Day Therapeutic Community) we have been using a range of routine psychological measures.
To measure therapeutic change between the start of a psychological intervention and it ending, we use the CORE OM which is a before and after measure widely used within NHS Psychotherapy Services. To track any changes that might be occurring as each therapy sessions continue we use both the CORE 10 and the Sessional Rating Scale (SRS) mapping these live with patients at the beginning and end of sessions respectively. These measures are of important clinical use, as: i. the CORE 10 can help inform if the service user is deteriorating clinically, possibly as a result of the psychological intervention. About 1 in 20 people deteriorate in therapy and terminating should be considered ii. the SRS monitors whether there is a robust therapeutic alliance. If this measure indicates that the alliance is deteriorating, prompt action needs to be taken (rupture repair skills) by the clinician before that session ends, to ensure that the service user does not drop out. These measures are important clinical tools for our individual clinicians to use collaboratively with service users but outcomes are not collated for statistical analysis at a service level.
Has your service been evaluated (by peer or academic review)?
Since September 2017 the PD Hub has been involved in an ongoing two-year research collaboration with Liverpool University, through a National Institute for Health Research (NIHR) process called the Collaborations for Leadership in Applied Health Research and Care (CLAHRCs). The collaboration will be a larger scale research project combining both a quantitative (clinical outcome measures and service utilisation figures) and qualitative investigation (what do service users report as their personal experience and any benefits from using the PD Hub). Service users have been heavily involved in all aspects of this project, attending the research training days with the University alongside the staff leads and defining the research questions to be investigated. The project design has been completed and service user interviews and staff/service user focus groups are scheduled to start this summer 2018. Service users will lead the interview of participants. The CQC visited and inspected Mersey Care NHS Foundation Trust in March 2017 giving the Trust a rating of “good” across the breadth of its services, the only mental health trust nationally to receive this level. However, they did not specifically visit the PD Hub to evaluate our service.
How will you ensure that your service continues to deliver good mental health care?
Through engaging with the financial pressures facing the Trust and looking to help with reducing expenditure the PD Hub has been valued within the organisation. The PD Hub has just received its first external referral for care from another trust and will likely be taking this service user on for case management. This step into income generation will bring added financial security to the PD Hub (£60K per year). The Local Services Division’s primary care referral and assessment gateway (Access Team) is currently at the beginning of a process of transformation, to extend gateway assessments into brief interventions. The plan is that there will be a further expansion of services offered by the PD Hub, with our service leading in the development and provision of a Crisis Therapeutic Community supporting those service users referred in from primary care in crisis, through the provision of a series of three to four group meetings over the week.
What aspects of your service would you share with people who want to learn from you?
The key messages the PD Hub would look to share with others interested in our developments would be: (1) Making the financial argument that redirecting money previously spent on Out of Area Placements is a useful way of developing local services. (2) Using the evidence base from our PD Hub and other similar services to lobby that similar developments should be supported within other trusts. (3) Take the step to be become a leader “championing” the need for better care for service users with personality disorder.
How many people do you see?
The different components of the PD Hub work slightly differently. The PD Case Management Service has a closed capacity of 40 service users, offering a two-year pathway of care before discharge. People prioritised for this service are those with the most complex and severe presentations. Often this is those service users currently out of area, for example being discharged from low secure units or graduating from CAMHs Tier 4 locked services. Local service users are selected on need, with our data team providing information on which service users are currently utilising the most resources in terms of days in hospital and presentations to A&E. The PD Day and Crisis Service is open to direct referrals from CMHT and psychiatrist, as well as those service users receiving or completing PD Case Management. This service has been operational for just over 12 months and the current number of people registered is around 125.
How do people access the service?
The PD Hub has a single combined referral form, shared with the Psychotherapy Service. Referrals are received from the CMHTs within the Trust. As a tertiary mental health team with a focus on the most complex and severe service users with PD we do not receive direct referral from primary care or self-referrals. Once a referral is received it is screened in our weekly referrals meeting and then an assessment is offered by a member of staff either for the PD Case Management Team or the PD Day and Crisis Service. For those joining the PD Day and Crisis Service we have a two week welcome “Readiness Group” that greets service users to the service, explains what is on offer and how the service works. This group is co-facilitated by an experienced volunteer service user, so they can share their valuable insights. To support those service users with PD who do not reach the threshold for our service and remain under the care of CMHTs, the PD Hub is currently in the process of delivering training in Structured Clinical Management to each CMHT team.
How long do people wait to start receiving care?
The PD Case Management Team has a closed case load of 40 patients receiving care for two years. Currently there are no waits for the PD Day and Crisis Service. We look to offer an assessment within six weeks, which is in keeping with NHS guidance for psychological interventions.
How do you ensure you provide timely access?
We have a weekly referral meeting to discuss requests for the different services within the PD Hub and look to offer assessment within six weeks of receiving a referral. We prioritise those with the most complex and severe presentations for the PD Case Management Service (eg. OATs and those utilising our inpatient and A&E services the most), with those with less complex presentations being considered for the PD Day and Crisis Service. We also support inpatient and CMHT teams with their management of cases solely under their care by attending professional meetings and offering consultations. As we have been setting up the two PD Hub services we have been in the process of recruiting staff for the past 2.5 years. We have just recently reached the point where all but one of the Band 3 posts is filled.
What is your service doing to identify mental health inequalities that exist in your local area?
The PD Hub was set up as a result of identifying a local health inequality, namely poor local services for people with PD. Until the PD Hub was established the Trust had no specialist service for service users with PD and as such those with this diagnosis were at risk of being excluded from care, especially ongoing CMHT services. This was despite significant numbers of crisis presentations to A&E and inpatient units and high numbers of service users in OATs.
What inequalities have you identified regarding access to, and receipt and experience of, mental health care?
Through the role the PD Hub has as acting as gatekeeper for PD OATs, we have become aware that a significant number of service users with a combination of both mild/borderline learning disability and PD have been placed in OATs and form a subgroup that fall between services and therefore without equal access to community care pathways. Our PD Hub service accepts people with co-morbid mild LD and PD. In our service there is a disproportionate ratio of female to male service users (10:1), likely a reflection of a similar bias across the Trust’s population. This is in keeping with more females receiving the diagnosis of BPD than men, but also likely because males are more likely to be seen in prison or forensic services.
What is your service doing to address and advance equality?
The BPD policy that the PD Hub has authored is compliant with equality legislation. The PD Hub is open to service users with mild/borderline learning disability and male service users. We run specific groups aimed at trying to engage male service users (eg. sports and gym groups) and have male members of staff who can act as role models.
How do you identify the needs of a person using the service ?
Service users share their life stories and current difficulties, and clinical staff use their weekly supervision with one of the qualified psychotherapists to develop psychological formulations, which are then shared and re-worked with service users. We use Cognitive Analytic Therapy tools for this process. Our aim is to help service users move from a formulation of their problems into a psychological intervention to address the needs/problems identified. Once service users are judged to be sufficiently stable they are encouraged to undertake one of the psychological interventions we offer, predominantly Structured Clinical Management.
This combines individual sessions to teach the skills of problem solving with attending a group to learn skills in managing feelings, impulsivity and relationships. When service users have their care transferred to the PD Hub, many families find the change in culture and ethos of our service different and confusing. The best level of care can only be delivered through a partnership of families, service users and professional services. When service users start, both the PD Case Mangers and Consultant Psychiatrist meet regularly with family members to explain the philosophy of care and the rationale around positive risk which can appear paradoxical.
How do you meet the needs of people using the service and how could you improve on this?
We offer a wide range of interventions that cover the various intensity of needs different people have. Those with the most severe presentations are offered the intensive support of PD Case Management, as well as access to the PD Day and Crisis Service. Those service users with less intense needs, and who are pre-contemplative for therapy, can be supported by the PD Day and Crisis Service. Finally, those service users who are furthest on their journeys to recovery can access specific NICE recommended therapy for PD, namely DBT, MBT, CAT. Arrival:
The initial transfer of care from CMHTs has sometimes been unsettling for service users due to the very different culture of care provided – a shift away from paternalistic inpatient care towards being supported to be more independent and autonomous in the community. Leaving: The period of care under the PD Case Management Service is two years, with most service users graduating to a further period of care from the PD Day and Crisis Service. The existence of the PD Day service significantly reduces the impact of the Case Managers withdrawing and in most cases has prevented the need for service users to return to care under the CMHTs.
What support do you offer families and carers?
We run a family and carers group to support family members. The emphasis of this group is on introducing psycho-educational material around the diagnosis but also in helping family members process their own feelings about living with someone with PD and learning how to be more effective in supporting their family members.
Monday to Friday 9.00 – 22.00, Saturdays 11.00 – 19.00
Population details
Brief description of population
Liverpool is a metropolitan city with a large and very diverse population. In 2011 the UK Census recorded population of the city was 466,400. In 2015 Liverpool was ranked the fourth most deprived local authority area on the Index of Multiple Deprivation. It was third most deprived on the Health Deprivation and Disability domain and fifth on both on the Income Deprivation and Employment domains.
Size of population and localities covered:
Mersey Care NHS Foundation Trust serves a local adult population of 511,000, covering the geographical areas commissioned by Liverpool, Sefton and Knowsley CCGs.
Commissioner and providers
Commissioned by (e.g. name of local authority, CCG, NHS England): *
Liverpool, Sefton and Knowsley CCGs
Provided by (e.g. name of NHS trust) or your organisation: *
