Treating Personality Disorders – Solution lies in integrated care pathways

The prestigious Mental Health Today exhibition at the Business Design Centre in Islington in December 2009 marked ten years of the ‘National Service Frameworks for mental health’. It featured a programme of seminars covering all aspects of mental health policy and practice. One of the most popular presentations was from the Ansel Group focusing on the integrated provision, commissioning and service user experiences of personality disorder care. Richard Broughton, Consultant Advisor to the Department of Health, spoke about developments in integrated Personality Disorder service pathways, emphasising that personality disorders evolve as a response to circumstances and are not simply an illness ‘to be treated with a pill’. He confirmed that this is a surprisingly common condition. Recent research, he noted, suggests that up to 4% of the general population – some 2 million people, could be said to have a personality disorder (PD) that would require some level of support. The homeless and offender populations have particularly high incidences with estimates as high as 70% of the prison population considered to present with a diagnosable personality disorder.

Although the government has delivered significant policy support aimed at driving improvement in the service provision and care of people with a personality disorder, to a large degree this remains an underserved and marginalised group of vulnerable and challenged individuals. Substantive gaps in both the availability and quality of appropriate assessment, treatment and care and support remain.

Richard believes a solution to address this lack of suitable provision lies in the development and delivery of Integrated Care Pathways (ICP’s). ICP’s emphasise coordinated, consistent and appropriate delivery of client focused services across the care pathway aimed at providing meaningful and effective long term outcomes for individual service users. The particular virtue of ICPs’ in the treatment and support of people with a personality disorder is the promotion of consistency in respect of therapeutic interventions and through this enabling service users to make life-changing progress.

Richard finished by emphasising that sustainable processes and structures will have a positive impact on outcomes for people with a personality disorder. An integrated strategic approach is also far more likely to deliver good health, social and economic benefits. He concluded by saying that achieving a comprehensive spectrum of services is a significant challenge which may take many years to achieve and requires a long-term strategic commissioning approach informed by improved knowledge of the condition, knowing what works clinically and driven by patient focused and coordinated activity.

Tom Burns, Group Chief Executive of Ansel, followed Richard’s presentation. His presentation ‘Commissioning Guidance – What does it mean in practice?’ offered a critique of the commissioning process and a ‘tool kit’ to help drive forward effective commissioning of services for people with a personality disorder.

Tom confirmed that currently there is little agreement on what constitutes treatment for a personality disorder and that there is actually no consensus on what a ‘personality disorder’ is. Consequently, many people with a personality disorder, he went on to say, are in the wrong place, such as prisons or forensic mental health services and receiving either very little or indeed no appropriate clinical treatment and support. The general lack of knowledge about personality disorder and the confused service environment for the patient population makes the commissioning of effective treatment and meaningful support very difficult.

The DoH produced two documents in 2008/9 – ‘Beyond Local Services’ and ‘Recognising Complexity’, which describes a tiered service delivery and commissioning framework for people with a personality disorder. The documents outline that provision of services within the upper tiers of that framework (tiers 6-4) focus on low volume, high cost services generally procured regionally by specialist commissioning groups on behalf of PCT’s.

Typically tiers from 4-1 (i.e. those moving towards high volume, low cost services) will be commissioned at PCT level. However, the day to day realities associated with the actual commissioning of services within the tiers can be confused, especially at tier 4 where centralised and localised commissioning interfaces. This confusion is compounded by a lack of knowledge of the disorder, lack of information regarding patients in the higher tier services and a real issue with accessing objective and independent information regarding the competency and effectiveness of available services.

Tom outlined  key elements of good practice in respect of effective service delivery. These include a strategic framework, robust communications, client involvement at all levels, agreement of attainable objectives and the capacity to reliably deliver effective, integrated services over an extended period. These requirements are echoed by the service users themselves, who cite lack of consistency and poor basic planning as major problems in the service they receive.

Tom suggested that accreditation, using an external proof of competence, may be the way forward to raise the standards of service delivery and help support commissioners in driving change for those with a personality disorder. Introduction of such a system will take time to develop and clearly the needs of commissioners and service users need to be addressed now.

Tom concluded therefore, that whilst enabling strategic change commissioners in the interim should approach the needs of individual patients by designing, commissioning and implementing tailored packages of care focused on service user need and a robust assessment of available provision to find a best fit on a case by case basis.

The Ansel Group were also delighted to welcome Kath Lovell of Emergence – the leading PD service user representative organisation – to speak at the seminar. Kath is a national voice and advocate for service users and a key adviser to Government healthcare, justice and educational policy development and delivery teams in respect of personality disorder services. Ansel was founded on the philosophy of full service user engagement in service development, delivery and appraisal and look forward to continue to work with Emergence in driving this forward.

In addition to delivering their seminar, The Ansel Group also exhibited at the event and were pleased with the large number of mental health professionals and service users who visited their stand. Ansel’s unique approach to treatment, using a social therapy framework around which to build personal and outcome focused interventions and support, will be driven forward at the Ansel Clinic Nottingham and was of considerable interest. The Ansel Group anticipates playing a leading role in the developing treatment of personality disorder and complex needs in this country and was pleased to be able to continue to drive forward their specialist service delivery agenda at the conference. 
 

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Commissioning for Mental Health & Wellbeing - Hallam Conference Centre - 28th January 2010

Tom Burns - Seminar Presentation - Download