National Personality Disorder
Development Programme
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National Personality Disorder
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Final Summary Report of PDTI in South East Region
A number of factors relating to PDTI in the region have influenced this process:
- The existence of the Thames Valley PD Service Delivery Pilot, in a fairly advanced form from early on, has helped to provide both a clinical approach and a training model that is a basis for much of the region’s work. In the TV SHA itself the Pilot has provided some key training inputs and an important admin base.
- Despite the large nature of the region and the geographical spread (from the Cotswolds to the Kent coast) there has been a surprising coherence about the views on training and on PD services and this stems in part from shared clinical experiences, traceable back to various key people having worked or trained together in the early days of the Winterbourne Project in Reading (a key example of the new style of PD practice).
- Although the PD Training Leadership role is split (between Judi Mallalieu and Rex Haigh) there seems to have been enough trust between them to manage a complex set of roles in which Rex did much of the early development work and gradually handed over the overall management to Judi, whilst Judi kept on top of budgets and finances and accountability.
- In many respects, the region is an artificial creation, and much of the time things operate at SHA level with permeable boundaries into other regions (e.g. Capacity Planning is not done regionally but in four different networks each of which includes a patch of what would otherwise be another region, service delivery boundaries are permeable on the Dorset side of Hampshire and between Portsmouth and Sussex, between Surrey and London and Kent and London, and between Bucks and Northants). It was therefore decided early on not to have a regional stakeholder group but rather a slimmed down steering group (subsequently referred to as the Training Implementation Group). This has had the effect of speeding up delivery of training at SHA level, but it has left developing stakeholder links to be worked on in the SHAs once the Training Co-ordinators were in post. This has now proved problematic.
- The various SHAs enjoy slightly different funding situations so that in the early phases the courses in Hampshire, Thames Valley and Kent were able to charge something for the training and so store up some funds for the second stage, whilst the financial difficulties in Surrey and Sussex meant that funds were used up more quickly and a financial crisis in the Sussex PCTs means that there are not the funds to manage a second stage at all. Other differences include the extent to which Trusts were able to part-fund the initiative by not recharging for staff time and the variable costs of venues and access to suitable large low costs venues at the right locations.
The Thames Valley Pilot Programme had funded a 10 half-days modular course over 10 months in 2003-2004 for about 24 professionals from a range of settings and agencies. It was this model which became the template for a specification which the Steering Group put out to each SHA inviting them to submit proposals. In each of the three other SHAs a small team of NHS clinicians (led either by a Psychiatrist/Psychotherapist or a Clinical Psychologist) came forward with a proposal which matched the specification and allowed a tranche of money to be released to them. There were some slight variations in the different programmes (e.g. two of the programmes were much bigger with 35-40 participants; two of the programmes opted for meeting fortnightly with one completing in six month, one opted for monthly full sessions with a monthly local small group session in between).
The basic model was well-thought-out in terms of the overall approach, with an inter-agency “network course” to skill up “change agents” and then an “awareness cascade” in terms of in-house or local short events for a wider group of staff. It also envisaged a sequencing of activities: with feedback on the Thames Valley pilot course being used to shape the regional roll-out, a process to appoint Training Co-ordinators half-time in each SHA, and then to support the cascade, widen agency engagement and seek further sources of funding. This strategy was articulated in some quite complex diagrams, but I suggested at an early stage that the region might need to spell out their approach in simpler terms and in a variety of ways in order to get their message across into the wide stakeholder network.
Whilst the main courses in each SHA were being run in 2004-2005 the Thames Valley SHA was able to test further the ideas of the cascade approach by working with the cohort of “graduates” from their pilot course – the “PD Agents”. A significant decision was taken to link the 2004-5 course attendees with these PD Agents and get everyone thinking about projects and awareness-raising in localities and agencies early on. This has led to some very useful work at local levels in Oxford and Bucks and some testing of the support needed for sustaining PD Agents in this type of model. The development of the “Change Agents” approach is necessarily at an earlier stage in the other SHAs, but there is emerging evidence of some significant project work being done in Surrey/Sussex and Hampshire.
Another significant feature of the region has been the well-developed model of engaging with Service Users built up over time in the Thames Valley SHA. This originated in the therapeutic community model of Winterbourne House and the subsequent group processes of the TV Pilot in Oxford, so that there was a lot of experience of working with ex-users and providing them with support to undertake training roles. There is a good understanding of the process of progressing from patient to “expert” and the levels of support needed – much of it provided by networks of other experienced service users. This is a dedicated PD network, not just an off-shoot of a general MH Service Users Group. Two ex-service users are now employed by the TV Pilot in training and support roles and a small group of service users are regularly involved in paid sessional work in training or leading groups. This aspect is not so well-developed in the other SHAs and there has been more of a struggle to provide enough ex-users with sufficient experience to contribute; but that process is underway in each SHA and would be sustained if the programmes continued.
Finally, the other overall factor has been the appointment of the Training Co-ordinators. This was always part of the strategy, but it took noticeably longer than expected – perhaps because the technical work of drawing up job descriptions and person specifications had been under-estimated and perhaps due to the complexities of negotiating who would actually employ these people and where they would work. In the event the interviews for these posts did not take place until the spring of 2005. Although a half-time post was initially filled in each SHA, difficulties over the details proved problematic in the Kent and Hampshire cases, leading to the posts not being filled and then not re-advertised because the continuation of funding could not be assured. The Thames Valley post was filled largely because of co-operation by the TV Pilot and the Surrey/Sussex post was filled by the SEDC directly employing the co-ordinator on a short-term contract. The disappointing feature of this was that the different individuals deliberately brought different aspects to these posts and as a team would have been well-rounded, whereas to expect the two half-time appointees to cover all the ground between them was unrealistic. The balance between their local roles (within their SHA) and their developmental roles (across the region) is now unclear and not sustainable.
Thus, what has been on the whole a very effective regional strategy has ended up with reduced effectiveness because of the non-renewal of central funding at a critical time in the roll-out of the strategy and at a point when only two co-ordinators are in post and support by Trusts in Surrey/Sussex is reduced (due to general NHS funding issues). Preliminary indicators (in terms of feedback on the programmes conducted and evidence of the impact in terms of projects and follow-up work) suggest that the strategy was a good one for this region and showed every sign of bearing further fruit soon. Another year of funding would have made all the difference and there is considerable frustration and disappointment after all the efforts made by so many people.
The main course has been run and completed twice in Thames Valley, and once in each of the other SHAs. It has recently begun another round in Hampshire/IOW, Kent and Thames Valley, but not in Surrey/Sussex. The course has slightly different titles in each location:
Thames Valley: “Personality: people and pathology – a course introducing key concepts and approaches to working with personality problems and personality disorder.”
Surrey/Sussex: “Personality: disorder or challenge? - a course introducing key concepts and approaches to working with personality problems and personality disorder.”
Hampshire/IOW: “Personality Disorder: Building Awareness and Skills – An introductory course designed to help those working with or coming into contact with people who have a diagnosis of personality disorder as part of their working day.”
Kent: “Working with Personality Disorder: Promoting good multi-disciplinary and multi-agency practice in the understanding, care and treatment of clients with Personality Disorder.”
Each course has an adapted version of the aims for the original TV course, although these are expressed as “Intended Learning Outcomes” (in Kent) as “Course Aims” (in Surrey/Sussex and Hampshire/IOW) and as “What the course provides” (in Thames Valley). As these have been grouped together in slightly different ways in each case they vary from a list of 6 in Hampshire/IOW to 10 in the Surrey/Sussex case. In all cases they could be clustered under three headings:
· Information, theory and models of new approaches to PD Practice
· Raising self-awareness, reflection and confidence in dealing with PD in these new ways
· Establishing inter-agency and local networks for projects and plans on raising awareness.
Most of the courses consist of some mixture of input by a variety of visiting and course tutors, reflection and awareness in small groups often with some user input, planning and development of implementation plans for projects etc. The courses can be quite demanding of tutor input with typically 4-6 tutors present throughout (although Kent and Hampshire have more slimmed down tutor teams and greater visitor input) and some involvement of “local action group” facilitators (sometimes the same tutors, sometimes other “PD champions”) and a varied degree of additional led-reflection (Thames Valley has employed a group-process specialist for one regular slot).
Venues have varied: the PD Treatment Unit in Kent, the Friends Meeting House in Oxford, a Social Services Centre in Southampton, the University of Brighton in Sussex. There have been issues about what is the ideal accessible location (in terms of transport for participants and avoiding journeys of over an hour and a half each way, and in terms of having the variety of rooms needed for small group work and few interruptions).
Looking at the list of trainers they appear to have considerable experience between them and to include a mix of disciplines, but all of the main tutors are NHS employees or freelance practitioners used to NHS work. There is considerable involvement of service users for some input and some group leadership, but few examples of tutors or speakers from other agencies. Tutors seem to have been approached individually locally by course leaders.
Participation in these programmes has been positive in two respects: it has generally involved a range of agencies beyond the NHS and after some small drop out in the first few weeks it has usually been sustained at a level of 75-85% of the original course list. There have been Prison Service staff on several of the programmes, police participation on most of them, and Social Services and Voluntary Organisation engagement with all of them. This level of mix has not been without its difficulties: isolated singleton participants from particular agencies can find it hard to work out the relevance of materials and may be overwhelmed by some of the more detailed inputs. At one point it was suggested that it would be helpful, if possible, to secure participants in pairs and/or arrange for isolated participants to get support outside the sessions (perhaps from those in their own agency who had been on the original course?) but all of this is difficult to arrange. On the whole experience has suggested that, where a lone participant has put their head above the parapet to come on a programme like this, it is because they feel isolated in their role within their own agency as a specialist and therefore find support from the common interest on the course despite the difficulties. Were the programme to be able to continue then there would be a case for building up the support networks for such singleton participants.
Recruiting was done for the courses by way of fliers distributed locally. The courses in Hampshire and Surrey/Sussex were originally over-subscribed. Selection for the Surrey/Sussex course was prioritised in terms of dividing places up between the six Trusts in the SHA and having a balance of participants. There was an interesting experiment in one Trust area of not advertising but instead selecting one sub-area and identifying a local slice of roles and agencies to have a network that worked together. (I have not received feedback on whether that paid off and it’s worth checking up.) In Hampshire the over-subscription was dealt with by looking at the personal statements on the application forms and choosing those who showed a good basic grasp of PD practice and the nature of the course. These experiences led to a useful discussion about the impact of criteria for selection and the subsequent writing of the Evaluation Team Website paper on Selection of Participants.
None of the programmes are accredited by an HEI and there was general agreement in the Training Implementation Group that the target group was “one level down” from most accredited courses and a wish to “work upwards” to a more in-depth accredited programme in 3-4 years time if possible. The current programme might be a building block for that. The one difference was that the Kent course was run by tutors familiar with teaching programmes on the University of Kent CPD programme and provision was made from the start to keep open the option of accrediting the programme at some point. To this end the design and delivery in Kent reflected other modules on the Masters Programme in Public Mental Health and the programme was 18 sessions long (rather than 10 like the others) and delivered in six termly blocks at fortnightly intervals. In the absence of a recent Kent report I can’t say how that has worked out in terms of impressing those responsible for accreditation.
The current position is that Thames Valley has just started a third course, Hampshire has started a second and it is believed the Kent second one started last month. The Surrey/Sussex Course stalled during recruitment and is suspended pending decisions about funding. There are some interesting differences in the pattern of charging:
Thames Valley: Charged £350 last year; is charging £750 this year – but this course includes a weekend residential which is focussed on processes and group interactions and is not replicated on other courses. They have used remaining central funding to provide bursaries to 50% fund those from voluntary and non-NHS agencies.
Hampshire: Charged £100 last year; is charging £150 this year. Hampshire have lower venue costs.
Surrey/Sussex: No charge was made in the first year; found that trusts could not contribute this year and so not running. Surrey/Sussex have struggled to find a suitable low cost venue.
Kent: Charged £500 in last year; is charging £300 this year.
No extensive mapping exercise was undertaken, although an early meeting of the Steering Group quickly established what was currently on offer in the region: very little. The individual programmes did take account of local tutor groups’ knowledge of local provision in terms of service delivery. For instance, the Hampshire programme reflects the fact that there is no therapeutic community or group based provision in the SHA (unlike the three other SHAs) and therefore the emphasis is on what is available. Each programme team also knew what was on offer by way of CPD events at Universities (especially Southampton and Brighton) and the focus this has on doctors (especially GPs) rather than community mental health teams.
Comments about the strategic training plan have been made in the Introduction to this report. My main observations would be:
As indicated, the Thames Valley Programme has a good track record of working with Service Users in delivering training. Service users have been involved in the design and review of all the programmes. In Thames Valley particular members of the STARS network (Support, Training and Recovery System) and XBXs (Experts by Experience) have been part of the teaching team and group leaders present throughout. The other programmes have been able to have Service Users present most of the time, but not always the same Service Users. Surrey/Sussex had problems the first time around because one of the Service Users became unwell and dropped out. It had not been established how this would be dealt with in terms of someone else being found by the Service User organisation. In the review at the end of the programme the Service Users’ representative accepted that this needed to be seen as an organisational commitment in future. Plans were in place for Service users to be full members of the tutor team in the re-run course at the point that it had to be postponed. In Hampshire there has been some Service User involvement and the level of this is being increased on the second run of the course, although there are issues about not having a specific PD Service Users group or the experience of working in the way that group or therapeutic communities would do. Kent drew on recent members of the local therapeutic group programme and initially encountered difficulties in sustaining this when patients too recently out of treatment suffered relapses – especially as the training was in the same building as the patient services.
The value of the level of support provided to users in Thames Valley was evident when I participated in two half-day workshops for PD Agents and Service Users at which local projects, awareness training plans and support for service development were all discussed. A mixed group of participants from the first and second course and a number of members of the STARS group all worked together in a constructive and supportive way where the contributions of each group was recognised and valued. It was also evident that the small scale awareness raising workshops, usually run by a partnership of STARS members, XBXs and PD Agents, had been particularly valued because of the powerful personal inputs of the Service Users. I was interested in the fact that often the Service Users didn’t reveal their past history until the end of a training event they were delivering – saying that the impact was the better for not depending on any kind of “sympathetic hearing”. If funding were to continue then building up this kind of Service User presence in other SHAs would be a priority if this model of training is to be sustained at a local level.
Detailed Evaluation Reports have been presented by Surrey/Sussex and Hampshire, a summary report has been done in Thames Valley, and the Kent Evaluation is awaited. The Surrey/Sussex Evaluation is perhaps the most thorough of these and I can speak more about that having taken part in two stages of it. Close track was kept on attendance and attrition, but only after the arrival of the Co-ordinator (with a Social Services training background) did issues about P/T workers, race, gender surface. (There was then an interesting discovery that the handful of black participants worked in the most over-stretched parts of the area and were therefore the more likely to miss sessions because of competing demands. This discovery highlighted how few black participants, or indeed black MH staff, there were in the other SHAs.)
40 people were given places on the Surrey/Sussex course; one never attended and the maximum who came on one day was 37. There were a core of 35 participants who stayed with the programme and a breakdown of patterns of participation has been done with encouraging findings about the overall high level of participation. The programme used a detailed feedback form on the content of sessions and methods used. There was a good system for reflecting on these at the end of each session and picking up any messages that need attending to there and then. There was also a thought-out approach to feeding back comments to visiting speakers. There was then an end of course evaluation form which sought to get an overall impression and to look at how far personal learning objectives had been achieved and what action plans they had. The response rate on these was not so good (18 out of a possible 33) but they were rich in information which has been worked on in detail by the tutors and summarised in the final Evaluation Report. In addition there were two other methods used for evaluation:
· The penultimate session was a debate on overall approaches to PD service delivery and which had to be prepared by participant groups over the preceding five weeks. This was a chance to draw together all the learning of the programme and was conducted in such a way as to evidence new learning and change of attitudes.
· The final session was a presentation of plans and activities by the Local Application Groups and this evidenced the extent of local networks being formed and some progress already with improvements in service delivery and/or awareness-raising.
I have described this Surrey/Sussex Evaluation Report in more detail because it seems to me to be many-layered. The tutors are aware that there are improvements to be made in the design of the feedback forms, in the engagement with the overall review and in finding other measures of attitude change. They would also like to involve the managers of participants in evidencing the learning and activities arising from the programme. The quality of this particular exercise owes much to the data collection and analysis of the recently appointed Training Co-ordinator and would not be possible without that resource.
The Hampshire programme used session feedback forms, a half-way review and a pre- and post-course awareness questionnaire to demonstrate change. This exercise merits further follow-up if the programme is sustained. The questionnaire was designed by the lead clinician on the course and it has 10 questions with a five point Lickert scale for answers. It has not been validated, although she feels it replicates some aspects of other longer questionnaires that have been validated. The final evaluation shows considerably increased knowledge and confidence in working with PD and a reduction in the sense of stress induced by such patients. The use of this approach and the detailed report in Hampshire has been largely due to the rigourous research-based approach of the Consultant Clinical Psychologist heading up the tutor team.
The Thames Valley programme used a much simpler 3 question attitude enquiry before and after the course to show some movement in beliefs about the possibility of change and the hopefulness with which participants approached PD work. The absence of a detailed TV Programme Report is due to the recent extended illness of the TV Administrator who has access to all the data. This should be rectified shortly.
All of the programmes would like to do some further follow-up on activities since training. In some respects the Thames Valley pilot has got that information through the reports of the PD Agents’ Network and there is a commitment to follow-up all of the programmes this winter to see how things have gone six months after the programmes.
There is currently no overall regional evaluation report and, in many ways, a recent presentation to Maria Duggan has performed some of the function of that exercise.
References have been made above to attempts to evaluate the impact of training. Both Thames Valley and Hampshire would seek to present some evidence of their assessment of trainees’ newly acquired capabilities – although this relates to changes in attitudes and knowledge rather than behaviour. The project work from all the programmes gives evidence of changes in practice and/or service delivery as shown above. The Thames Valley first programme would provide evidence of promotion to new roles as several of the participants have moved into specialist posts in the last 18 months. There is an interesting off-shoot of the first Thames Valley course in the shape of two participants who now regularly teach sessions on PD on an undergraduate nursing course run in Buckinghamshire by the University of Luton. This is recognised as having potential in other places.
The national PD team has visited the region twice and I was present at both visits. I was
given the impression that they were very pleased with what they found. Even at the recent visit, this was accompanied by some general promises to attempt to ensure the continuation of the programme. The links with the Regional Development Centre are very good and the PD lead has agreed to put some extra funding into supporting the Hampshire Programme follow-up in the absence of an appointed Training Co-ordinator.
My impression is that within the SHAs the programmes are as well-linked with local Trusts as can be, given the time constraints on tutors. The plan was that the Training Co-ordinators would now focus on other local links, with social services, voluntary groups, criminal justice agencies etc. There are some small difficulties and tensions in some places where either Trusts are being re-organised (Surrey/Sussex) or services are under strain (the Isle of Wight), but the region copes well with local variations, so that for instance some Sussex staff close to Southampton attend the Hampshire programme, as do some Berkshire staff from Newbury.
There have been some useful discussions about engagement with managers and there is an interest in applying some of the points in the National Evaluation Team’s website paper on Engaging with Managers should an extension of funding allow this.
The Training Implementation Group has met every 2-3 months with representatives of each tutor team, the two PD Training Leads, the training Co-ordinators, the TV Administrator and myself present. This has served to keep the scheme on track. In the last two meetings there has been a risk that the Kent operation has not been kept in focus and the lead tutor has reported a sense of carrying this on his own with little local support following the failure to appoint a co-ordinator. On the whole the PD Training Leads can be relied on to follow up issues like this and the RDC member keeps a good but light hand on accounting for the money spent, reporting to the RDC Director as well as Maria Duggan.
Overall I think the structure and management of the initiative regionally has delivered extraordinary results in a very short time. The special factors referred to at the start of this report help to explain this success, although the good personal dynamics in the region, the “activist” approach and the clear strategy have all helped. If the region had the opportunity to start again I suspect they might either have expedited the appointments of the Training Co-ordinators or have ensured these important resources were used in a slightly different way. I believe the efforts to adapt the original Thames Valley model have worked well, reflecting each SHA’s character and ensuring the course is owned by each tutor group. I think the round of evaluations done this summer have worked well and give a good platform to build on, both in terms of shaping the next round of courses and in improving the evaluation system for next time. I hope the region will take the chance soon to spell out their Evaluation Strategy. Like the Training Strategy it is “emergent”, but would merit being set down in writing at this point and they have some pointers to how that might be done. If the funding for the National Evaluation Team were to be extended there would be scope for completing that piece of work, for developing the evaluation tools across the SHAs and working at the follow-up to courses in terms of the “cascade” approach. There would be scope to gather evidence of impact through an account of the projects and development work done by those on the courses and there is an interest in the region in exploring the development of the Service User roles in ways which learn from the Thames Valley experience whilst recognising the differences between SHAs.
Continuation of the training funding would allow the Surrey/Sussex course to run for a second time, would support the search for sustainability in local stakeholder links and help to complete the task of building training capacity. The vision is that 3-5 runs of the course in each SHA might bring the local networks to the point where they could achieve a great deal of impact that could be self-sustaining. Another year of funding would have taken them close to successfully implementing that vision.
Peter Lewis
PDTI National Evaluation Team
17 October 2005
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