Sometimes I get into interesting email conversations with
people I have never met, or from a long time ago. Here’s one from a medical psychotherapy
colleague wanting some background on the National PD Programme for a talk. To
save any embarrassment, I have redacted any identifying details. For me, it
reminded me of how sad it was to lose a government programme that was really
trying to introduce the idea of relationships - at group and society level as
well as for individuals - being more important than ‘therapy products’. With a
little more time and nurture, it could have introduced some truly radical
thinking into mental health services for some of the most dispossessed. But
perhaps this conversation shows that I may be feeling more bleak about it than
I need be…
Colleague:
Remember me? Its been a few years. I wonder if I
could pick your brains about services for BPD and IAPT. I’ve been asked to step
in and give a talk about IAPT for SMI and BPD, and I am going to talk about
relational therapies. I just wanted some info about the wider picture, and how
IAPT could improve access to services for people with BPD.
Hope you are well!
Me:
Of course I remember you – those research
conferences were one of the most formative experiences of my career! Good to
hear from you.
But you do ask the most sensitive
questions…
My personal view is that IAPT does not
have, in its leadership at least, a good enough understanding of the ‘complexity agenda’
that was the defining feature of the DH’s National PD Development
Programme until its effective demise in 2011. This was specifically defined as
cross-agency working, service user partnership at all levels, no exclusion
criteria if diagnosable as PD, multiplicity of suitable therapeutic approaches
often arranged in complex group programmes, whole-system interventions, staff
attitude change, and a research agenda including the social sciences.
The programme had £6.9m annually (2002-11),
and set up 11 Imperial-researched pilot sites across England (using different
models) as well as the ‘Knowledge and Understanding Framework’ online awareness
training plus a BSc and an MSc. What was the national PD programme has now effectively
moved to the Ministry of Justice (where excellent work is being done, for
example, on setting up therapeutic environments in prisons and training
custodial staff in ‘relational security’) and DCLG (where there are similar
champions for the housing and homeless sectors).
I suppose the underlying conflict - laid
bare by the recession and thus the need to shoehorn any future PD work into
IAPT - is that the DH’s PD programme was trying to do innovation and exploratory
work in a very messy field that crosses almost all sectors and government
agencies, and IAPT was ‘rolling out’ a precise delivery and measurement model
for treatments that had already been through the ‘evidence mill’. And those of
us in the PD programme were left feeling that IAPT was an entirely different
type of thing, that would not well serve the needs of our service users -
particularly the angry BPD people who were (I believe justifiably) outraged at
the scandal of the poor treatment they have always had in the NHS, except in
very few places.
But when we (the ‘PD exiles’) are feeling
less aggrieved and more philosophical, we hope it is simply a matter of time
scale. BPD treatment is so much less researched than anxiety, depression and
all the common mental disorders, that we will need years to catch up. And -
fundamentally - it is not yet possible, and may never be, to prescribe a simple
suitable evidence based treatment programme for people diagnosable with PD, and
all the relationship (dare I say transference) problems they bring…
Do get back if you want more info, or a
phone chat, etc.
Colleague:
Hi. That's
great. Glad I asked you!!!
I'm basically
standing in at a talk which was going to be on CBT and personality disorders,
and the need to adapt it. I'm going to review relational therapies instead.
The latest I've
picked up from IAPT is the view it's about increasing access rather than
recreating the wheel. But I'll summarise what you've told me.
Is essentially
money being taken out of existing services? And diverted to IAPT or prisons?
Best wishes
Me:
What an interesting conversation!
In answer to your questions, the money that is being taken out
of exisiting services is the pilot funding (£6.9m) which was always DSPD money,
and meant to be picked up by PCTs (and now CCGs) once the pilots had shown
their worth. Some of them have been taken on by local commissioners (often with
substantial cost savings imposed, or requirements to ‘income generate’), but
others are still needing the central funding to prevent closure. The idea is to
reduce the central funding to zero over the next 3 years or so (although that
is the message they have been given for several years now).
The bigger problem, in my book, is that only 12% of the English
population was ever covered by the pilots - so 88% never had a bean (for local
specialist non-residential PD services - what is called Tier 3. Tier 2 is as
part of existing mainstream services - such as a small DBT clinic - which is
more widespread, I think). Obviously in areas with powerful champions like
Anthony Bateman, or commissioners with a particular understanding, Tier 3
services have developed - but most of the country is still a desert for
people with BPD. Reading (where Jane and I set up Winterbourne TC in the 90s)
was rather reluctantly incorporated into the big 'Thames Valley Initiative'
pilot, and still struggles on quite successfully (clinically) in an
unsympathetic milieu and hard-nosed health economy .
Back in the early days of the PD Programme (2004-5-6) the
expectation was for more funding to roll out the successful models across the
country, with a continuing R&D
programme to support it: but it never happened. Maybe it was the recession and
inevitability of hard times, by my feeling is that there was a deeper
resistance - maybe denying the size of the PD problem, or the diagnosis itself,
or the messy uncertainty and chaos that goes with the territory, or (my
favourite) that people with PD challenge authority and the established order in
a way that is just not tolerated. Many stories to tell there, over a beer or
two, if we ever get the chance!
Another interesting piece of the jigsaw is ‘Tier 4’ provision -
which has been grumbling on as an unresolved issue since the Henderson and its
replicates were shut down. The commissioners involved did recognise that there
is a severe unmet need - particularly for those people uncontainable in
non-residential services, who tend to cause chaos in acute wards and often end
up in expensive and un-therapeutic long-term forensic care. So that has now
re-emerged as a workstream of the National Commissioning Board, and last I
heard they were looking at something like £33m revenue for 500 people in
treatment at any one time in up to 10 regional centres - but they will be very
different from the Henderson model - with a lot of emphasis on outreach,
forensic liaison, consultation and training, and – under ‘Any Qualified
Provider’ – are likelier to be run by independent, non-NHS, providers. And -
even more important maybe - to exert leverage on CCGs to provide better Tier 3
services in the localities (our experience in Thames Valley is that the need
for BPD referral to a residential out-of-area unit is rare when good local
services are in place).
As you might gather - PD services have been my main
preoccupation (and headache) for the last few years!
Colleague:
Thanks again
for all your thoughts. Amazingly helpful! Not sure how it will end up but the
people involved with PD at IAPT seem very aware of the complexity issues. And
IAPT seems to be the only bus in town at the moment.
I think it's a
big ask ....... but I think it depends on the evaluation from the demo
sites. If some show clear savings... better chance of leverage with CCGs.
A beer would be
great some time. You need to run for president of the college. We haven't had a
psychotherapist since Fiona Caldicott.
You've got my
vote!
And
then, after the meeting, to several of us who had helped.
Hi
This
is just to say thanks to you all for your helpful comments, thoughts, data etc.
I
thought I'd just give some feedback:
Their
remit appears to be to implement IAPT for SMI including PD, and are keen to get
away from the idea that IAPT services will deliver treatment as they have done
for the adult primary care initiative. But they appear to recognise the
complexity of the problem and also that there are therapists and resources out
there who have trainings that could be utilised to treat people with BPD.
The
meeting was attended by a mix of people but mainly heads of psychology services
and senior managers.
The
main issue was about how commissioning and resources could be both protected
and strengthened for people with BPD. No clear answers !
I
suggested a strong case could be made for funding on the back of potential cost
savings and there was evidence in relation to this both from RCTs and
comparative and before and after studies. Presumably when Imperial report their
findings re the 11 pilot sites there may be some additional evidence.
I
also made the point that the relational therapies did not need to be 'adapted'
for treatment for BPD as they were either initially designed or developed for
people with BPD or were tailored for use with BPD many years ago. I also
suggested that there is a wealth of experience re treatment of BPD within CAT,
PIT and MBT therapists, and that CAT in particular had an established training
and system of accreditation which was popular and accessible to a wide range of
psychological practitioners.
People
are grappling with how services can be organised and how any therapists
undertaking work with people with BPD can be supported and assimilated into
current support and treatment networks. Clearly the current IAPT stand alone
model won't work.
It's
quite interesting standing outside the psychotherapy system and seeing and
hearing people's concerns. RAID had a transformational effect on liaison
services, together with a variety of policy and strategy documents. So if
there are significant savings demonstrated from some of the 11 pilot services
and these can independently verified, that's likely to have most effect with GP
commissioners.
Cross references:
- Has CBT killed the human spirit? (June 2012)
- CBT rules in the House of Lords (October 2012)
- Alphabetti spaghetti therapies (June 2008)
