Springbank ward is one of only two specialist personality disorder units in the NHS. It has developed a pioneering approach at managing severe borderline personality disorder without the use of restrictive and coercive practices. It has attracted the attention of the national media and is one of the only positive stories by the BBC about an NHS ward in the last 20 years (https://www.bbc.co.uk/news/health-47393050). The aim of the team is to help our patients find a life worth living. We use a compassionate and recovery-focussed approach that combines psychosocial interventions and targeted pharmacotherapy to achieve this goal
Webpage for service (if available): https://www.cpft.nhs.uk/Springbank/
From start: Yes
During process: Yes
In evaluation: No
PP Collaborative: Yes
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Dr Jorge Zimbron - Consultant in General Adult and Rehabilitation Psychiatry
Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.
Springbank ward is one of only two specialist personality disorder units in the NHS. It has developed a pioneering approach at managing severe borderline personality disorder without the use of restrictive and coercive practices. It has attracted the attention of the national media and is one of the only positive stories by the BBC about an NHS ward in the last 20 years (https://www.bbc.co.uk/news/health-47393050). The aim of the team is to help our patients find a life worth living. We use a compassionate and recovery-focussed approach that combines psychosocial interventions and targeted pharmacotherapy to achieve this goal. The team has collected data to show that the treatment provided is safe, effective, efficient, and caring. The ward’s results and ethos have been shared with professionals across the UK through various conferences and teaching events with the aim of sharing and promoting good practice.
What makes your service stand out from others?
Springbank’s new approach has led to a 95% reduction in restrictive practices, with only 1 incident of rapid tranquilisation in the last 4 years. Springbank supports the Mental Health Safety Improvement Programme (MHSIP) by the Royal College of Psychiatrists, and was used as an example of what can be achieved at the launch of the programme (London, 23.11.18 https://www.rcpsych.ac.uk/improving-care/nccmh/reducing-restrictive-practice/rrp-launch-event). The aim of MHSIP is to reduce restrictive practices in 42 wards by a third. Springbank’s results outperform even this ambitious goal.
How do you ensure an effective, safe, compassionate and sustainable workforce?
The team’s leadership promotes a flat hierarchy and a distributed leadership model. This is essential in high-risk environments where the transfer of information between team members is crucial to maintaining safety. Everyone is encouraged to take a leadership role on service improvement initiatives, ranging from developing a carers group, gardening, and organising social events, to taking a lead in dialectical behaviour therapy, collecting outcome measures, or presenting at international conferences. Ongoing professional development and looking after the wellbeing of the staff are crucial in providing an effective, safe, and compassionate service. All staff receive weekly supervision. There is a weekly programme that includes 1 hour of reflective practice, 1 hour of case discussions, and 1 hour of teaching. All staff receive training in DBT skills and all staff, band 5 and above, receive the full DBT training to become individual DBT therapists. There is an additional 2.5 hour weekly group supervision for all those providing 1:1 DBT therapy. The ward holds 2 away days per year and regular social events to promote positive relationships within the team. We also hold regular group challenges, for example, we walked from London to Cambridge to raise money for charity in a walk that took 27 hours! The ward and the Trust regard lived experience of mental health problems as a desirable criteria in all job applicants. Therefore, in addition to our peer support workers, there is lived experience at all levels in the team. This collective wisdom helps with the provision of a compassionate service.
Springbank interacts with multiple services within the Trust, as well as with other trusts and allied services outside the NHS. One of our main roles as a specialist service involves providing supervision and teaching for other services. People diagnosed with a personality disorder interact with multiple organisations, but the staff working in these settings are not always trained to deal with the complex situations faced by this patient group. Springbank staff provide regular supervision and teaching for the local acute psychiatric wards, as well as teams at Addenbrooke’s hospital (our neighbouring Trust), such as the emergency department and plastic surgery. We have also provided training to non-NHS organisations like Metropolitan Housing and students at the Anglia Ruskin University. In addition to training and supervision, we also provide second opinions and help other services develop management plans for complex cases by attending multi-disciplinary meetings, including for patients outside our organisation. We see a real need to promote a non-restrictive approach for the management of personality disorders and are happy to share our experience with anyone that requires it.
Do you use co-production approaches?
The service underwent major changes in 2015 and co-production with patients played a key role in designing the structure and content of the new therapeutic programme, as well as in abolishing rules and setting values to guide behaviour (respect, recovery, and safety). Co-production continues and our programme is constantly changing according to the needs of the cohort of patients that we have. We have 2 ‘community meetings’ per day to facilitate this. All staff and patients meet at the start of the day to discuss any issues and all patients meet at the end of the day to evaluate changes and discuss issues to bring to the wider group on the following day. Patients are also encouraged to take a lead in running groups, such as cooking, arts and crafts, and knitting. Some of our patients have also set-up their own groups in other services as volunteers, sharing the skills they have gained on the ward. Finally, our patients are empowered to make decisions about their environment and take an active role in decorating their rooms and the communal spaces on the ward. Patients are also involved in promoting a non-restrictive approach by sharing their experiences at national and international conferences, together with staff (BIGSPD, 2018, Cardiff; Restraint Reduction Network conference, RCPsych, 2019; Human Right Dilemmas in PD, London 2019). Families and carers are play a very important role in the co-production of our services. We engage carers and families before, during, and after a patient’s admission. Two nurses have taken the lead on this and contact carers on a weekly basis. In addition, we offer a monthly carers group on weekends (to make it easier to attend for those who work), and provide input to the local Service User Network that runs a monthly group for carers of people in the community. Co-production has improved the quality of the service we offer and this has been reflected in the results of our outcome measures and monthly surveys of patient and carer satisfaction. It has also made the ward a better environment to work in, which has helped with staff recruitment and retention.
Do you share your work with others? If so, please tell us how.
We have multiple sources of evidence that we are providing an effective treatment programme that benefits not only patients, but also the staff and carers looking after them. In addition to the teaching we provide, we share our work through presentations at national and international conferences. A peer-reviewed publication of our findings is under way. Furthermore, professionals from other organisations regularly visit the ward in order to learn about the work we do. Below is a list of some of the conferences we have presented at and some of the visitors we have shared our work with: Presentations ********************** National – Recovery conference, Tees Esk and Wear Valley NHS Foundation Trust, Durham, 2017 – Mental Health Safety Improvement Programme (MHSIP), London, 2018 23.11.18 https://www.rcpsych.ac.uk/improving-care/nccmh/reducing-restrictive-practice/rrp-launch-event – Restraint Reduction Network conference, Royal College of Psychiatrists, London, 2019 5.2.19 http://restraintreductionnetwork.org/. – Human Rights, Dilemmas & Solutions in Personality Disorder, London, 2019 https://www.forumsandevents.co.uk/human-rights-dilemmas-solutions-in-personality-disorder International: – World Psychiatric Association, Cape Town, South Africa, 2016 – British and Irish Group for the Study of Personality Disorders conference (BIGSPD): * Inverness, 2017. * Cardiff, 2018. * Durham, 2019. – Royal College of Psychiatrists, Birmingham, 2018 – ENMESH – the European Network for Mental Health Service Evaluation conference, Lisbon, Portugal, 2019 Visitors ********************** – Dame Dido Harding, Chair of NHS Improvement, 01.11.17. – Prof. John Gabbay and Prof. Andree Le-May, Univeristy of Southampton, 17.09.2018 – ‘Mind’ mental health charity (National Branch), 11.02.19 – Dr Rex Haigh, Berkshire Healthcare NHS Foundation Trust & Dr Anando Chatterji, Bangalore, India, 14.03.19 – Sean Duggan, CEO, Mental Health Network, NHS confederation. 09.04.2019 – Dr Andrew Nicholls, HPFT Head of Recovery and Psychological Services, 03.05.19 – Dr Simon Graham and Team, Mersey Care NHS Foundation Trust, 13.05.2019
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
The ward has collected outcome and experience measures since it opened in 2011. There have been 2 distinct periods for the ward using different treatment models: The original treatment model focused on risk containment (May 2011 – May 2015). There was no pre-defined treatment duration and many of the patients were under a section of the Mental Health Act and on enhanced observations. This is the most common way of managing patients with chronic suicidality across the UK. The new treatment model focuses on recovery and positive-risk taking (May 2015 onwards). The treatment duration is of 1 year. We have not had anyone on enhanced observations for over 3.5 years and the use of the Mental Health Act is extremely rare and only for short periods of time. One way we use outcome measures is to compare the two treatment approaches (old vs new). We now have 4 years of data to suggest that the new model is safer and more effective. All our outcome measures are collected electronically to ensure complete data sets and avoid transcribing errors. Below is a list of the outcome measures we collect and some of the results we have achieved: Datix incidents: Any incident on the ward is categorised and reported electronically on a daily basis. There has been a 60% reduction in incidents and a 95% reduction in incidents involving physical restraint since the new programme started. This reduction has been maintained for over 3.5 years. Patient and carer satisfaction questionnaires: We carry out monthly surveys using the ‘friends and family test’. Patient and carer surveys consistently show that between 90% – 100% are satisfied with the care they receive and would recommend the unit to a family member. The highest score in the old model was 25%. Clinical outcome measures:
Since the new model started we have collected clinical data using 9 validated outcome measures. Measurements are taken on admission, 6 months after admission, and on discharge. All outcome measures show improvements at the point of discharge, compared to scores on admission. This includes improvements in symptomatology (Difficulties in Emotional Regulation Scale [26% improvement], GAD 7 [23%], Personality Assessment Inventory for Borderline personality disorder [14%], PHQ-9 [34%]), quality of life (Short Warwick Edinburgh Well-being Scale [46%]), and recovery (Process of Recovery Questionnaire [86%], Reasons for Living Scale [38%]). Service use data: Our electronic systems collect data on any contact our patients have with secondary care. This allows us to compare the service use of our patients before and after completing the Springbank programme. A service use analysis before and after admission showed a 92% reduction in acute admissions/year and a 60 – 90% reduction in contacts with other services. A cost-utility analysis suggests that the programme is cost-effective, with the incremental cost effectiveness ratio (ICER) being £32,000/QALY (quality adjusted life-years) at a 10 year horizon. This was presented at an international conference in Durham (BIGSPD, 2019).
Has your service been evaluated (by peer or academic review)?
The service was externally evaluated by CQC during an unannounced visit on 20th August, 2018. They provided us with very positive feedback. The reports they obtained from patients are particularly relevant here and are quoted below: “Patients told us: • Springbank ward was an excellent place to be. It was the best hospital they had ever been in. It was much better than anticipated. • They could go out whenever they wanted unless staff thought they were unsafe. The detained patient had leave with staff and could go out most times when they asked. • It was good being able to visit and meet people before admission. During the admission visit they did not take everything in but they were given information booklets. • The locked doors were a nuisance but did not feel restrictive. • The ward was not restrictive at all. It was very relaxed. Lighters and razor blades were restricted but they could keep most other things. • When they came back from leave staff asked if they had anything to hand in. It was all about trust. There were no searches. • Everything about their treatment was inclusive. If the doctor suggested changes the final decision was with the patient. • They helped to create their care plans. • The whole team were amazing. They were all approachable and knowledgeable. Any staff could help in a crisis. The staff never made them feel useless or a nuisance. • The nurses challenged them all the time. They made the patients think of ways round problems. • One really good thing was that everyone wanted to be there, the staff and the patients. • The communication between the nurses could be improved slightly. • The treatment was definitely helping. • There was a good ratio of staff to patients so there were no problems getting support at any time. • There was nothing to complain about. Two patients told us if they did have any concerns or worries about anything on the ward they could raise it with the ward manager. • Community meetings were useful. They could talk about things like keeping the ward tidy and other niggles without getting into an argument. • The WiFi on the ward was not very good. • The food was all right. They used the other kitchen to cook for themselves. • Springbank ward has been a life changer” Souce: CQC report 2018
How will you ensure that your service continues to deliver good mental health care?
We believe that there are 3 key components to ensure the unit continues to provide excellent care: 1) Maintaining the culture of the ward through the shared values of respect, recovery, and safety. Staff and patients share these values and our behaviour and treatment is guided by them. We regularly review what these values mean to everyone. 2) Looking after staff. This requires regular supervision, training, and providing a supportive environment. We have an annual allocated budget for training and we encourage staff to develop their own interests for the benefit of our patients. 3) Demonstrating to the Trust and the clinical commissioners that the treatment we provide is caring, effective, and good value for money. We do this through the ongoing collection and analysis of outcome measures.
What aspects of your service would you share with people who want to learn from you?
The following are some important lessons we have learnt from developing the service, which may be transferable to other settings: If the behaviour of a particular patient group is proving to be ‘difficult’, it is often more useful to think about what aspects of the environment are contributing to that behaviour (and change things accordingly) than to blame and coerce individuals. Having a shared set of values is more useful at promoting positive behaviour than having a long list of rules. For any major change in service provision it is essential to have support from all levels of management. This is particularly relevant if the changes involve a significant level of risk to the organisation.
The following questions are an opportunity for you to provide further details on how you implement positive practice in your service delivery and how you ensure your service is advancing access and equalities. Answers to these questions will not influence how your PPiMH awards application is assessed, however any responses received may contribute to the potential inclusion of your service/team as a positive practice example within published guidance developed by NCCMH and NHS England.
How many people do you see?
We have 12 beds for women aged 18 – 65. Our treatment programme is 12 months.
How do people access the service?
Referrals come from secondary care services from all over the UK. All local admissions are discussed and agreed with the personality disorder community service.
How long do people wait to start receiving care?
We do not have a waiting list, so the main factor that delays admissions is waiting for funding panels to agree funding for out of area patients.
How do you ensure you provide timely access?
Referrals are all screened by the consultant prior to assessment. The volume of referrals we have, given the specialist nature of the unit, is low, so prioritisation is not usually an issue.
What is your service doing to identify mental health inequalities that exist in your local area?
Mental health inequalities are investigated at a directorate level (Adult and Specialist Directorate). All services have been reviewed recently to identify inequalities in service provision. Springbank ward was part of that review. Our staff helped to collect data and provide input at meetings with other services.
What inequalities have you identified regarding access to, and receipt and experience of, mental health care?
There are no personality disorder units for men. In addition, there is little service provision and guidance for personality disorder types which are not borderline personality disorder. Only a small minority of people with personality disorders receive treatment within secondary care.
What is your service doing to address and advance equality?
Our role in promoting equality is to teach other services about better ways of managing personality disorders. This helps reduce stigma and raise awareness that people with personality disorders can make a good recovery when they receive appropriate treatment.
How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?
People being admitted to our service undergo a detailed assessment by a consultant psychiatrist and a clinical nurse specialist prior to admission. Information from family members, carers, and other services is reviewed and patients complete the validated outcome measures mentioned above. This information is used to identify their needs and form an action plan. Outcome Measures: Baseline, 6 months, 12 months Reasons for living scale The CORE Outcome Measure (CORE) The Difficulties with Emotion Regulation Skills (DERS) Generalised Anxiety Disorder 7 item scale (GAD 7) The Kentucky Inventory of Mindfulness Skills (KIMS) Personality Assessment Scale for Borderline Personality (PAI-BOR) The Patient Health Questionnaire (PHQ-9) Process of Recovery Questionnaire (QPR) The Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS) EQ-5D-5L
How do you meet the needs of people using the service and how could you improve on this?
We use evidence based treatments advocated by NICE guidelines, such as DBT, and medication for specific symptoms or co-morbidities that is supported by randomised controlled trials. We begin planning for discharge shortly after admission and our aim is to be able to discharge our patients to the care of their GP without any secondary care involvement. As the discharge date approaches, our patients begin spending longer periods of time in the community, in order to setup a routine with meaningful activities. We could improve by offering more types of psychological therapies, for those who may not benefit from DBT. There are funding and staffing implications that make this difficult to achieve.
What support do you offer families and carers? (where family/carers are not the service users)
As discussed above, we have nominated team members that contact carers and families on a weekly basis, provided that our patients consent. We also offer a monthly carers group during a weekend, as well as provide input for the local community carer’s group. We have written information about our service and the treatments we offer, which is freely available at the ward’s main entrance.
Is there anything else you want to share about what makes you an example of positive practice?
We train medical and nursing students throughout the year. These students are based on our ward and are experiencing a completely different approach to managing personality disorders. We hope that this will reduce stigma against this patient group and promote good practice. Three of our former nursing students have joined the ward as permanent members of staff. Students were not allowed on the ward under the previous treatment programme (pre-2015), as it was felt that the experience would dissuade them from continuing their career in psychiatry. This is another example of how much things have changed.
Brief description of population (e.g. urban, age, socioeconomic status): Women with severe personality disorders across England.
Size of population and localities covered: CPFT (900,000) covering Cambridgeshire, Peterborough, Huntingdon, and Fenland. Also accepting referrals from across England.
Commissioner and providers
Commissioned by : Cambridgeshire Clinical Commissioning Group
Provided by: Cambridgeshire and Peterborough NHS Foundation Trust