Personality Disorder: No Longer a Diagnosis of Exclusion

Thames Valley Personality Disorder Initiative`Personality disorder: no longer a diagnosis of exclusion’Application for national development fundsApplication submitted by… Dr Steve Pearce and Dr Rex HaighTitle/organisation… Personality Disorder Initiative, Thames Valley Strategic Health Authority (TVSHA)To which NIMHE RDC… South East (SEDC)Agencies involved… Service: Oxfordshire, Buckinghamshire and Berkshire Mental Health NHS Trusts, Service User Reference Group (SURGE) - Thames Valley branch, Oxfordshire Mind, Connection - the floating support team, Elmore Community Services, Social and Health Care Directorate of Oxfordshire County Council, REAP resettlement agency, ReadingTraining and staff support: HMP Grendon, Broadmoor DSPD Directorate, Milton Keynes Primary Care Trust Commissioning: Thames Valley Strategic Health Authority, Primary Care NHS Trusts (PCTs) in Oxon, Bucks & Berks Lead organisation…Oxfordshire Mental Healthcare NHS TrustTitle of proposed service development… Thames Valley Personality Disorder InitiativeGeographical area and population covered by proposed service The overall project covers the three counties of the Thames Valley: Oxfordshire, Buckinghamshire and Berkshire, and Milton Keynes: population 2.05m. The major service developments proposed are for Oxfordshire, population 770,000. Ethnicity figures are 5% non-white (10% in Oxford City), and IMD (Index of Multiple Deprivation) scores of 35% in the lower two quintiles for Oxford City. It is zero in six of the fifteen Thames Valley PCT areas. Buckinghamshire and Milton Keynes’ population is 686,000 with 4.6% non- white in Bucks and 10.1% in Milton Keynes, and IMD scores of 27% in the lower two quintiles for Milton Keynes. Berkshire’s population is 800,000 with 8.4% non-white (31.2% in Slough and 9.2% in Reading), and highest deprivation IMD scores of 44% in the lower two quintiles for Slough and 31% for Reading.Final page 1 19 January 2018 Thames Valley Personality Disorder InitiativeBetween 62% and 68% of the population in all areas covered are aged between 18 and 64. Final page 2 19 January 2018 Thames Valley Personality Disorder InitiativeCONTENTS ...... 21. Planning and preparation ...... 31.1 What process have you used to develop a broad understanding across agencies, of the current services provided for people with personality disorder, the resources deployed, and gaps in service provision? ...... 31.2 Please describe your multi-agency plans to redesign services across all agencies, to improve effectiveness and response to need...... 71.3 How have local growth monies been applied to implement these plans? ...... 91.4 In what way have service users and carers been involved? ...... 102. Service development proposals ...... 132.1 How does the proposed service development build on work already undertaken (as you have described in section 1 above)? ...... 132.2 What are the aims and objectives of the service development? ...... 182.3 Please describe how the proposed development will operate; what services will be provided; for which population groups; where, when and how...... 202.4 How does the development meet the objectives and standards set out in guidance? ...... 332.5 Please provide detail of the anticipated outcomes of the service development. NB clear, quantified projections are required; these will be used to evaluate the progress and effectiveness of service developments...... 352.6 Has any training programme been included within this proposal? If not will this be covered by an application for training funds? ...... 372.7 How will staff be supervised and supported? ...... 392.8 Please provide detailed costs for the service development proposed, any training which has been included, the amount of national funding sought, and any exit strategies agreed locally with commissioners...... 402.9 Have you identified who will undertake the development work? ...... 442.10 What inter-agency process will be used to oversee the development of the service? ...... 452.11 Please provide details of governance arrangements for the service development...... 463. Learning and further development ...... 483.1 How will you disseminate learning and the development experience from this pilot initiative, regionally and nationally? ...... 48Final page 3 19 January 2018 Thames Valley Personality Disorder Initiative3.2 What process do you plan to use to ensure continued development and improvement in services for people with personality disorder? ...... 494. Agency endorsements ...... 50Final page 4 19 January 2018 Thames Valley Personality Disorder Initiative1. Planning and preparation1.1 What process have you used to develop a broad understanding across agencies, of the current services provided for people with personality disorder, the resources deployed, and gaps in service provision?The three counties of the Thames Valley Strategic Health Authority (TV SHA), Oxfordshire, Buckinghamshire and Berkshire, are an area with considerable expertise in managing personality disorder in different settings. This includes Grendon Prison in Buckinghamshire (established as a prison programme for PD over 40 years ago); the NHS mental health (MH) services in Berkshire (with the Winterbourne unit, which has run a therapeutic community for about 35 years), and in Oxford the Elmore Team (a voluntary sector organisation with considerable expertise in helping an urban socially excluded population) and the Park Hospital (a Child and Adolescent Mental Health Service with a specialist unit for comprehensive assessment of disturbed parenting and with links to maternity services). More recent developments were the Oxfordshire Mental Health Trust’s agreement in principle to a new PD service and the development of a pilot service (see section 2.1) in Oxfordshire, with the appointment of a new consultant there in 2001 following a multidisciplinary initiative by clinicians in the Trust in 2000-01 embracing all relevant Trust services; the opening of a ‘DSPD’ unit at Broadmoor Hospital in 2003, which is one of three national pilot units; and several local PD initiatives in Berks and Bucks (see section 2.1).With this in mind, and knowledge that central NHS work was being undertaken on PD, TV SHA held regular meetings of senior clinicians with experience of PD work, and mental health service managers, which started in autumn 2001. This was called the ‘Thames Valley Personality Disorder Initiative’. It started its work with a ‘mapping and gapping’ exercise across the three counties. The services cited above, and several others with relevant expertise, were identified in the early phase of this work. Prominent gaps were in (a) mental health services (b) other health services (c) other agencies as detailed below, and (d) public health considerations. In mental health services, local teams were unable to offer a good service to those diagnosable with PD, and acute inpatient wards often had intractable problems in providing a suitable service. In other health services, in areas such as encounters with casualty officers in A&E or receptionists in GP surgeries, normal protocols are often unhelpful and staff find such situations difficult. People diagnosable with PD often do not present to NHS services, but frequently have difficulties in their relationships with other agencies (such as housing, social services or the criminal justice system). They are often vulnerable, with considerable unmet health and other needs, but their condition prevents them effectively obtaining the help required. Discussions with the Oxford University’s Institute of Health Sciences Public Health Resource Unit (PHRU) confirmed that Personality Disorder was not recognised as a public health problem that would attract NHS support at that time (before the publication of the NIMHE guidance). Preliminary discussions with the Director of Public Health in Milton Keynes have identified a need for awareness and basic level training in personality disorder work, particularly in general mental health, forensic psychiatry and custodial settings.In November 2002 a multiagency meeting was convened by OMHT to obtain views from the other agencies on the plans for a PD service. Agencies attending and inputting into the plan included Probation service, Police, Social Services, Voluntary sector, University counselling, Final page 5 19 January 2018 Thames Valley Personality Disorder InitiativePrison and housing bodies. User groups involved included Rethink and Mind housing. In Oxfordshire, members of these organisations are now involved in an ongoing steering group to guide PD developments: the ‘Local Strategy Forum’ (see section 2.10).In October 2001 a personality disorder audit was carried out on two of the adult acute wards on the Littlemore site in Oxford (Phoenix and Ashhurst). Of 43 patients 38 were judged by ward staff as having severe and chronic difficulties which were not limited to episodes and which caused significant impairment of functioning. Of these, staff thought 16 would benefit from a specialist personality disorder service, which was 37% of the inpatients at that point in time. These 16 had been admitted a total of 99 times between them over the previous 5 years, accounting for 6,085 inpatient days. More recently an audit has been carried out of overall OMHT admissions from April 1995 to November 2003. 5% of individual patients admitted had been given a diagnosis of personality disorder. These patients had had an average of 141 contacts, compared to an overall average of 74 contacts. Their average duration of inpatient stay was 45 days. This equates to 12 inpatients in Oxfordshire at any one time with a PD diagnosis.A survey of the number of patients with borderline personality disorder in contact with community mental health teams and outpatient services in the Mid-Bucks locality of the Buckinghamshire Mental Health Trust was conducted in June 2002. Roughly 10% of patients had received a diagnosis of Borderline personality disorder. Earlier, an audit of inpatient admissions to the Tindal Centre in Aylesbury, a psychiatric inpatient facility, had been conducted for the period January to December 2000. 13% of the 263 patients admitted during this period were diagnosed with personality disorders. Patients with a diagnosis of borderline personality disorder (BPD) comprised 60% of this group, and 8.4% of the total inpatient sample. Their length of stay ranged up to 7 ½ months, amounting to a total of 1481 inpatient days. Almost half (45%) of this patient group had multiple admissions, While being treated on an outpatient basis, 57% of this patient group attended the Accident & Emergency (A & E) Department at the local acute hospital. Half of the patient group engaged in deliberate self-harm while an inpatient. After the preliminary work was undertaken, the TV group developed its early plans, with ex- service users and other agencies included in discussions, and in the proposed organisation of future developments. Other agencies welcomed the prospect of collaboration in addressing what they unanimously saw as a considerable unmet need.One of the first practical outputs from the TV initiative has been a 2003-4 multi-agency introductory PD course, for approximately 30 participants from the three counties (details in section 2.6). This is intended as the first stages of forming a practitioner network in the area, including specific learning methods which require the sharing of clinical experiences, attitudes and understanding of PD work across different agencies. This proposal aims to have both ‘horizontal’ and ‘vertical’ reach: the former is to spread awareness and basic information about PD and the new services wide and thin; the latter to provide deep hubs with specialized and intensive treatment facilities.Partnerships have been established with a number of statutory and non-statutory agencies, including the Social and Health Care Directorate of Oxfordshire County Council, the Elmore Final page 6 19 January 2018 Thames Valley Personality Disorder InitiativeTeam, Connection and Oxfordshire Mind. As BMHT is an Integrated Health and Social Care provider, Buckinghamshire County Council is also a partner in the proposal.Brief descriptions follow of some of these stakeholders with whom agreement on joint working has been reached.ELMORE TEAM The Elmore Team was founded in 1968, and was originally concerned with the rehabilitation, support and resettlement of ex-offenders. It is now an independent, voluntary sector resource set up to work with ‘difficult to place’ clients wherever they may be in the community. The Team also provides an outreach service to people sleeping rough in Oxford City who have multiple problems. ‘Difficult to place’ clients are defined as those people with chronic, multiple needs who do not fit within the existing range of services and are likely to be behaving in a disordered or challenging way. They will have a combination of problems such as mental health problems, learning difficulty, physical health problems, offending, substance misuse, self-harm, accommodation problems, and chaotic/bizarre behaviour.The Elmore Team’s service is tailored to each individual’s needs. This might include practical help (for example, with benefits or accommodation or simply help with keeping appointments), emotional support and a good trusting relationship, advocacy (for example, with court appearances), re-engaging individuals with services that are specifically aimed at helping with specific, focused needs (normalising), often involving liaison with a mental health key worker, social worker or probation officer. The Team has developed strong links with most statutory and voluntary agencies in Oxford and is also approached to advise or supply information in a consultancy role. A high proportion of the Teams clients are likely to be diagnosable with personality disorder. It is Elmore's belief that a secure base (i.e. accommodation) is essential in order to contain people in therapy and maximise their ability to change or move forward personally. Elmore is also currently working closely with English Churches Housing Group in investigating the feasibility of developing complex needs housing in Oxfordshire. Note: one of the authors of this bid is a trustee of Elmore Community Services (SP).CONNECTION - THE FLOATING SUPPORT TEAM Connection - The Floating Support Team, is an organisation which works across Oxfordshire and Buckinghamshire to enable people from disadvantaged groups to survive and thrive in their local communities. The work has always included a clear focus on people with mental health problems and continues to receive funding for this mental health focused work from the Oxfordshire Department of Social and Health Care and Partnership Development Fund in Buckinghamshire. A significant proportion of service users have had a diagnosis of personality disorder at some stage. While the service is holistic in nature and support planning is done with the service user at the centre of the process, there is always some focus on housing issues, with many service users having had serious problems around housing which are likely to recur without support. Connection works closely with a range of other professionals, including Community Mental Health Teams, and has links with the development work around Dual Diagnosis in Oxfordshire. Risk assessment and line management principles rigorously inform Connection’s approach.Final page 7 19 January 2018 Thames Valley Personality Disorder InitiativeOXFORDSHIRE MIND The aim of Oxfordshire Mind is to promote good mental health through the provision of high quality services with active user participation, together with lobbying & campaigning for positive change. Oxfordshire Mind has been engaged in developing and running mental health provision since 1977 and, other than the NHS Trusts and Social Services, is the largest provider of mental health services in the county.The organisation manages a network of fifteen day services, five housing projects, a crisis line, an information service, and a relative’s support group. Since 2000 Mind have developed a new housing project with the Oxford City Assertive Outreach Team, created a new floating support service for vulnerable women, launched the ‘Opportunities Project’ to improve access to work and training, and set up a new service for black and minority ethnic women. In addition Mind work with a psychologist seconded from Oxfordshire Mental Healthcare Trust to provide a programme of therapeutic groups within the community, now redesigned as a personality disorder worker. Mind are committed to improving services for people considered as having a personality disorder and working together with other agencies to achieve this aim.Oxfordshire Minds work is based on belief in:  Valuing the knowledge and expertise of mental health service users.  Working alongside people to help them realise their potential.  The importance of striving to make mental health services more human.  Acknowledging and challenging discrimination and stigma.  The importance of community and the benefits of mutual support.REAP RESETTLEMENT AGENCY REAP Resettlement Agency works across the Thames Valley and Outer London area with single vulnerable people, usually without dependents, in need of housing and support, helping them access appropriate accommodation and providing a community support service to sustain their housing and live independently.We help access a number of housing options from emergency accommodation for clients who are literally homeless, through to assisting with moves from temporary or inappropriate housing into more permanent homes. Our caseworkers provide resettlement and community support to meet the needs of our client group, which includes those with multiple support needs and often chaotic lifestyles. Many will require ongoing, longer-term help to sustain their tenancy, and independent living, and prevent future homelessness.REAP provides both emotional and practical support to clients. Client –focussed support planning involves partnership working with other specialist statutory, support and advice agencies. Clients most commonly have mental health, general health, substance misuse issues, and / or offending behaviour. Many have multiple support needs, including personality disorder. It is in the latter area that we feel we need to develop and build on our working relationships with local professionals, in order to more effectively access appropriate support and advice, and achieve robust joint working. There has been no clear access to training or local professionals working in this field, and we welcome the opportunity to develop these links. Final page 8 19 January 2018 Thames Valley Personality Disorder Initiative1.2 Please describe your multi-agency plans to redesign services across all agencies, to improve effectiveness and response to need.(see also section 2.1 for details of plans already being put into action)Agencies identified in the early work for this proposal were . NHS – mental health: including inpatient wards, community assertive outreach and crisis teams, drug & alcohol services, child & adolescent MH services, forensic units, deliberate self-harm services. . NHS – general health: including A&E, GPs, GP receptionists, practice counsellors, health visitors, midwives, general hospital liaison services. . Criminal Justice – probation, prison mental health, prison offending behaviour programmes, young offenders’ institutions, MAPPPs, courts. . Social Services - child protection teams, mental health. . Voluntary sector – housing associations, homelessness charities, social exclusion projects, mental health charities (Mind, Rethink, Richmond Fellowship, MHF) . Other – university and college health & counselling, occupational health & counselling.All are likely to be settings where people with personality disorders present with problems related to their condition, and which may be exacerbated if it goes unrecognized or they are handled insensitively. Members of all six broad groupings above have been involved in the discussions leading to the preparation of this proposal.In the first instance, services need to be redesigned to break the cycle of rejection which can be perpetuated in any of these settings. The Thames Valley plan is to train up professionals from different agencies and locations, working closely with ex-service users, to form a network of ‘PD agents’ around each of whom ‘awareness training’ and ‘service advocacy’ groups could be developed. These would be supported by the Thames Valley-wide networks of expertise and interest, through CPD and further specialist training events using seminars, conferences, work discussion groups, private internet forums and other settings as requested by participants. (See section 2.6)The ‘awareness training’ groups will undertake basic training activities with workers of all seniority in all settings. They will be organized in accordance with the capabilities framework and specifically targeted at different groups, with support from senior staff. Those who developed a special interest in PD work would be encouraged to undertake the regional basic training (section 2.6), and become ‘PD agents’ themselves. All these activities will include service user input, with some being organized and run by ex-service users themselves - according to the needs of the target groups. The ‘service advocacy’ groups will be coalitions of local enthusiasts who are willing to press for more suitable services for people diagnosable with personality disorder. In each area, it is envisaged that they will develop around a nucleus of interested mental health clinicians and service users, but in locally sensitive ways and with different alliances between relevant agencies. In organisational terms, it will require a broader view of “Health Services” than the NHS alone, and one that includes non-statutory bodies. This is a challenge which will need innovative planning and some change of organisational culture to allow it. Final page 9 19 January 2018 Thames Valley Personality Disorder InitiativeEstablishment of outreach capacity will encourage joint working at tiers I and II of the service delivery model (see section 2.3) in different settings. An example of this in the costed proposal is the ‘Therapeutic Risk Assessment Course’ for parents undergoing child protection proceedings: this particular service would require collaborative working between PD services, child and adolescent mental health services, social services and the courts. Staff from the first three will all be directly involved with the clinical programme and supervised together. This represents secondary prevention, by lessening the adverse consequences of existing personality disorder (see section 2.3 for more details).In the longer term (beyond the timescale of this proposal) it is hoped that primary preventative work would also be undertaken as part of the Thames Valley-wide initiative to pool relevant expertise and coordinate projects with similar underlying aims. This could involve maternity units, schools, workplaces, church groups and other settings, and concentrate on development of parenting skills and ‘emotional intelligence’. It is likely that this work would need to be undertaken mostly through collaboration with charitable projects.One example of preliminary work in this area is the development of plans for a “creative community” which will build a safe environment for therapeutic activities and learning opportunities, drawing on ideas from traditional cultures, community values and the power of relationships. It will build on NHS work already undertaken in West Berkshire (see section 1.4, para 3) and function as a self-referral day unit for personal growth on an organic farm.Thames Valley Mental Healthcare NHS Trusts joint workingOxfordshire Mental Healthcare NHS Trust and The Social and Health Care Directorate of Oxfordshire County Council have integrated management arrangements in place for adult mental health services. A joint commissioning team and pooled budget will be in place from April 2004. This framework for the commissioning and delivery of adult health and social services will support the development of PD patient pathways across the care system and will also support the delivery of system-wide training. Buckinghamshire has similar lead commissioning and integrated provision arrangements in place. Berkshire has six localities for adult mental health services, which are co-terminous with the unitary authorities and PCTs, and have local collaborative management and commissioning arrangements.Joint working is already taking place between the Oxfordshire and Buckinghamshire MH Trusts in the areas of Forensic Services, Eating disorders, Tier IV CAMHS, and Mother and Baby services. Berkshire also engages in joint working in Forensic Services. The aim is for PD working across the Thames Valley to follow a similar model where access will be according to need and appropriateness rather than location of domicile or GP.Final page 10 19 January 2018 Thames Valley Personality Disorder Initiative1.3 How have local growth monies been applied to implement these plans?The development of the PD initiative is seen as a key priority in developments within mental health services and is strongly supported by Oxfordshire PCTs as having an impact across the whole system. In accordance with this Oxfordshire PCTs have agreed to support the development of personality disorder services as part of the whole system of mental health care; growth money allocated to mental health in 04/05 will fund personality disorder services alongside other developments. Agreement will be reached between the PCTs and OMHT around monitoring processes to ensure that the impact of the personality disorder work on other services can be measured and reinvestments resulting from this are transparent. If the national bid is not successful discussions will take place between commissioners and OMHT to arrange funding at a level and in line with other priorities to safeguard the at present unfunded pilot PD service. The Three PCT's in Buckinghamshire, through the lead commissioning PCT (Wycombe), have all previously confirmed that PD services development is a key priority for the County Services. Additionally, they have all committed appropriate resources as part of the LDP for 2004 -2006, which contains an allocation amounting to the Bucks PCT contribution in proposed service costings (s2.8). They are therefore now keen to endorse and support this proposal.They have also signalled their willingness to become involved in the evaluation process thus ensuring that positive lessons and all significant outcome measures that are developed are shared across the primary care services in a way that further promotes improved collaboration and integration between specialist mental health and general primary care services.In Berkshire, the recovery plan for a substantial budget deficit which came to light in early 2003 threatened closure of Winterbourne Therapeutic Community and associated services in Reading. These are longstanding services which are well recognized for their experience and expertise in outpatient and day care for those diagnosable with personality disorder: the therapeutic community is cited as a “gold standard service” and “notable practice site” in the NIMHE policy guidance. After several months’ negotiations the proposed cuts were reduced to a level which did not threaten the viability of these services through an agreement between the SHA and Berkshire PCTs which means that £300,000 will be available to support Winterbourne Therapeutic Community’s ongoing work. Although this is not specifically ‘growth money’, it could be described as ‘money to prevent contraction’ of already established PD services. The Berkshire PCTs have agreed that this is not for general mental health services, but for personality disorder work. Final page 11 19 January 2018 Thames Valley Personality Disorder Initiative1.4 In what way have service users and carers been involved?Involvement leading up to these proposalsService users at Grendon and Winterbourne have long been involved in teaching and training, and have established democratic procedures for managing many aspects of the therapeutic programmes. Service users are involved in multi-professional seminars at Grendon, and various activities at Winterbourne House in Reading, including a 2001-2002 Deanery supported project ‘Patients Teaching Doctors’. In the formulation of this proposal, members of this local network have had regular meetings with Thames Valley Mental Health staff since late 2002. Initially, this was to discuss different ideas for developing training, services and research in the PD field. Since the publication of the requirements for bids, the meetings were specifically to draw up the proposals such as collaborative crisis support work, joint engagement and assessment programmes and multi- agency awareness training. These are outlined in section 2.3 and budgeted in section 2.8. In the county services, ex-service users are also already participating in the Oxford Local Strategy Forum (see section 2.10) in which role they can directly influence the planning of that service. Improved services for Personality Disorder has been the Buckinghamshire users and carers agenda for the past two years. The development of a service aimed at changing the treatment options for people with a personality disorder has been discussed at both user and carer conference meetings in 2002/2003 where concerns were expressed about the appropriateness and quality of services currently available for those with personality disorder. Particular concerns were expressed about the appropriateness of admission to acute psychiatric wards. Proposals to change this were welcomed.Service User Reference Group for England (‘SURGE’)- Thames Valley BranchSURGE evolved from the Department of Health focus groups looking at Personality Disorder services and examples of best practice. These focus groups supplied service user input into the Policy Implementation Guidelines for Personality Disorder Services. SURGE is an informal network of those from the DoH focus groups wishing to undertake further activities as ‘experts by experience’, and others recruited at conferences and teaching events around the country who have expressed an interest in joining the mailing list. This includes several of the organising members of Borderline UK, the only national user-led support group for borderline persons, which works mostly through the internet.The Thames Valley branch has a strong affiliation to a local group set up by ex-service users for people who have completed a recognised path of therapeutic treatment, for personality disorders, to provide ongoing contact and social support. This group has a mailing list in excess of 50 members many of whom have an interest in becoming actively involved in using their experiences to support training and development of services. This closely dovetails with the ex- service user areas being considered by this proposal. A number of the committee members of Final page 12 19 January 2018 Thames Valley Personality Disorder Initiative this group are members of the Berkshire Users Group which has representation from all areas of Berkshire particularly Slough, Windsor and Maidenhead, West Berkshire, Reading and Bracknell.One of the committee members has developed a thriving user group in Newbury (West Berkshire locality), called People Like US (PLUS). Members of PLUS are actively involved in local service developments, with members on the Local Implementation Team, and nationally in various SURGE events. PLUS is an example of how an ex-service user can be employed to support and empower service users, who in turn support others and move back into mainstream life, such as education and employment. The members of SURGE have been involved in discussion groups, seminars, and conferences on current personality disorder treatments and their effectiveness.Integration throughout PD servicesAs Service User Reference Group for England (Thames Valley) we see our work as running through all aspects of the overall proposal. We see service user and ex-service user involvement as an integral part of the whole, with us working in a collaborative manner with the professional and voluntary agencies. We envisage having a flexible structure that would be developing and evolving according to changing needs. Requirements and arrangements for service user involvementInitially we would work with two part time salaried workers and administrative support; other people in the group would choose the extent and nature of their participation. Related support needs of the service users and ex-service users involved would be catered for, as would requirements for expenses and fees for participation. This would have similarities to “training support agencies” which have been formed elsewhere in the country.We promote a recovery model whereby people are initially paid at a level to allow them to remain on benefits; as skill levels, confidence and participation increase we would support people back to employment or education. We are basing these ideas on those used by Reading’s ‘Mental Health Resource Centre’ (Resource), which has a history of encouraging individuals to look at what they are able to do and achieve, rather than see themselves as ill and unable.As the service user group, we would receive training and education to help us to participate fully and with confidence. We could then become involved in planning, delivery, monitoring and evaluation of training for staff, voluntary workers as well as other service users and carers. This would largely be done on a consultancy basis so that service users can choose the level and nature of their involvement and fit it in with their individual needs, abilities and interests. The participants in these activities will be encouraged to work in groups to provide mutual support, and associated social activities would be important to form a cohesive team. Service users and ex-service usersThe reason for being very clear in stating ‘ex-service users’ is due to our recognition and belief in the recovery model. Although it is possible and often beneficial for service users to be actively Final page 13 19 January 2018 Thames Valley Personality Disorder Initiative involved while in treatment, this must be recognised as a part of the treatment itself, which requires the overall ‘containment’ of a properly structured and staffed programme. For the model we are proposing for input into the Thames Valley initiative, those who have completed a treatment programme and who wish to become involved can subsequently have the opportunity to move into paid employment using their experiences, as part of the various project teams. We would all have completed a recognised treatment in order that we have moved on enough to achieve sufficient objectivity to be able to look beyond our own therapeutic needs. The support and social element of the group would be available to people immediately after treatment, but involvement in training, planning and other paid work would not occur until six months after the end of treatment, in order to support people to move on from therapeutic attachments. Final page 14 19 January 2018 Thames Valley Personality Disorder Initiative2. Service development proposals2.1 How does the proposed service development build on work already undertaken (as you have described in section 1 above)?Oxfordshire pilot PD serviceFollowing the negotiations and processes described in section 1, in mid 2002 the Executive board of Oxfordshire Mental Health Trust gave the go-ahead for staff to be seconded to a PD pilot service. Eight staff have given time, between one and four half-days. Three of these are attending the regional PD introductory course (see section 2.6). Seconded staff include occupational therapists, clinical nurse specialists, community psychiatric nurses, ward nurses, psychotherapists and psychiatrists. All patients entering the service complete a comprehensive test battery measuring symptoms, risk, functioning, self-harm and suicidality, service use, and an instrument to provide a formal measure of personality disorder status.The pilot project now runs for two days a week, all year round. Assessments commenced in October 2002, and the first patients joined the service on January 6th 2003. There are 16 spaces, the programme runs for one year and is based on exploratory, experiential and problem focussed group work within a therapeutic community structure. There are currently 14 patients in the service, fulfilling criteria for between 2 and 5 personality disorder diagnoses each.The pilot service is intended to build gradually, forming the basis of a comprehensive PD service for Oxfordshire once funding becomes available. Local referrers are becoming used to the idea that there is something that can be offered to this group, local expertise is being developed, and a group of staff with competence and enthusiasm in this area has been identified with a view to the future expansion of the work. Staff seconded to the service have already been asked to run teaching sessions, provide supervision, and now facilitate a group for relatives of people who self-harm with a user organisation (Rethink). Team members also provide a consultation service, at present mostly to Community Mental Health Teams and inpatient units.The pilot service has established strong links with the parenting assessment unit at the Park Hospital in Oxford, which provides a parenting assessment service for the whole of the Thames Valley, and the services have patients in common.Other work in OxfordshireProvision for personality disorder services has been recognised as essential for the Mental Health Trust to achieve key performance targets. PD service provision is provided for in the current estates reprovision strategy.The Oxfordshire PD working party was invited to convene workshops at both the November 2002 and January 2003 DoH Launch Conferences for the PD Policy Implementation guidance, entitled ‘Local Implementation’. The workshops were presented jointly with a group from Leeds in order to contrast the two approaches, which broadly demonstrate the two models outlined in the guidance – in Oxfordshire a hub and spokes model comprising a specialist PD team based Final page 15 19 January 2018 Thames Valley Personality Disorder Initiative around a day unit, in Leeds a clinical network. This has led to a proposal for the two sites to cooperate in a comparative evaluation to demonstrate the respective strengths and weaknesses of the two models if successful in bidding for national pilot site status.In 2001 the Oxfordshire Trust employed a Consultant Psychiatrist with a specific brief to develop PD services. The OMHT business case was put together by a multidisciplinary working party from within the Trust. It has been costed by Trust accountants, and in mid 2002 was approved by the Trust Psychological and Social Therapies Committee, a scientific committee charged with scrutinising proposed psychological and social interventions, equivalent to the Drugs and Therapeutics Committee. Shortly thereafter the business plan was adopted by the Trust Board. Over the following months (autumn 2002) the Trust’s plan was presented to and endorsed by the central NSF Local Implementation Team (LIT) and the Mental Health Task Force along with the Oxfordshire PCT Commissioning Board. The plans have had the benefit of Board and Chief Executive support from the earliest stages.In November 2003 a vacant Psychology post seconded to Oxfordshire Mind to facilitate the development of a county-wide programme of group work in accessible environments was recast as a PD worker and advertised with a brief for making the already established groupwork programme accessible to people diagnosable with PD. In this way it is becoming possible to take them in a local setting so they do not need to travel out of their own area. In addition, recent redesign of psychological therapies services has led to the pilot PD service operating as part of an integrated psychological therapy service using a multi-disciplinary approach to deliver services at primary, secondary and tertiary levels. This serves to maximise opportunities for cross working, training and cooperation.Accident and Emergency provision by the liaison psychiatry service at Oxford Radcliffe Hospitals NHS Trust, the Oxfordshire acute trust, is due to be reviewed in 2004. The review will be informed by the PD policy implementation guidance document, and members of the Oxfordshire PD group have been invited to participate. A brief intervention service for deliberate self –harm is a core part of the liaison service, and represents existing Tier I work in the Thames Valley model detailed in section 2.3; at present 25% of patients engaged by the liaison service after deliberate self harm receive a PD diagnosis. Buckinghamshire pilot PD serviceIn January 2001, Buckinghamshire Mental Health Trust set up a PD Project, chaired by the Aylesbury Psychotherapy Team Lead and comprising of a multi-disciplinary team of clinicians with interest and experience in PD work. The remit for this project group was to ascertain the need for a PD service, to address clinical practice issues and to implement agreed proposals. An audit of PD users of acute in-patient services was undertaken for the preceding year. The project reported to the project board, comprised of senior managers and professional leads. Proposed developments were endorsed and supported by this group and by the Director of Strategic Planning and the Director of Operations. In July 2002, following the plan outlined by the TV wide project group in April/May 2002, which had been tasked with this by the SHA wide Specialist Commissioning Team, a submission to Final page 16 19 January 2018 Thames Valley Personality Disorder Initiative develop a personality disorder service was approved by the MH Trust Board. These Board papers were sent to all PCG/PCTs, as well as to Buckinghamshire County Council (BCC) for information, and the initiative was presented to the PCT in January 2003. The proposal is part of the current BMHT LDP.Steps have been taken by MH staff to change practice and develop a more appropriate service for personality disorder. Psychotherapists and psychologists provide supervision and support to acute inpatient areas, semi-secure units eg Woodlands House, units providing rehabilitation services for difficult to manage patients, the Day Hospital and Day Services and to CMHT workers. The supervision and support focuses on difficult to manage patients, many of which have a primary or secondary diagnosis of PD.A twice-weekly group analytic PD treatment accommodating 8 patients has been successfully established by the Aylesbury Psychotherapy Department. This will form the basis of a developing therapeutic programme as part of the proposed PD service. In addition the Frith Ward project, "Consistency in Care - developing in-patient services for people with borderline personality disorders", won a Foundation of nursing studies award in 2002. It is planned to roll this model of good practice out to other in-patient services. Other work in BuckinghamshireThe main thrust of the MH strategic plans for Buckinghamshire Mental Health Trust has been to exploit every opportunity for partnership working. To this end the Trust has over the past two years already established a number of key collaborations with a range of non-statutory local partners including Buckinghamshire Association for Mental Health (BAMH), Aylesbury Vale Advocates, People’s Voices, Buckinghamshire Carers Centres, Crossroads, and a number of Housing Associations. In addition, the Trust has invested considerable energy in developing and consolidating a range of partnerships with services in the statutory sector. These have included Buckinghamshire County Council, Local District Councils, Thames Valley Police Service, Probation Service and Prison Services (Grendon and Aylesbury YOI). Significant amongst these partnerships has been the one that has evolved with the County Council. The Trust now has a formal Section 31 Agreement with Buckinghamshire County Council that results in the BMHT being the integrated provider of both health and social care services for users and carers of mental health services within the county of Buckinghamshire. This provider agreement will soon be followed by an integrated commissioning agreement that is underpinned by having a pooled budget for commissioning MH services within the county. Because of the position that the County Council hold within the community, and the co-ordinating role it plays in relation to District Councils and other agencies, the formal agreement with the Buckinghamshire County Council has meant that the Trust (and others) have been able to benefit from a wide range of opportunities for developing shared (agreed) priorities on a range of important topic areas. These have included housing provision, community safety (information sharing), local Policing policy, Youth offending policy, domestic violence, vulnerable adults, working with vulnerable young people, education and special needs services, Supported living schemes, employment and pre- employment support, social inclusion and leisure & recreation.Central to this proposal is the recognition that the contribution able to be made by this range of partners, especially the collaboration with and through Buckinghamshire County Council, is a Final page 17 19 January 2018 Thames Valley Personality Disorder Initiative significant plus and a key opportunity in enhancing the range and variety of players that are able to participate in and benefit from the proposal. The Section 31 agreement includes all Trust and BCC provision/services in Adult Mental Health, CAMHS Services, Older Peoples MH services, as well as Drug and Alcohol services. The total BCC budget covered by the agreement is in the region of £5m. Buckinghamshire County Council are full participants and supporters of this proposal.Further collaborations are planned over the next three to five years and the creation of the sort of integrated PD service that is proposed by this submission will be a major feature of those developments. Most, if not all of the agencies mentioned above are eager to become even more involved in developing these specialist services and all will have a major contribution to make to their effective operation. All are likely to be significant beneficiaries of getting such a service established, well co-ordinated and, where possible, fully integrated.The Trust PD project group is part of the Thames Valley PD Initiative, which has been working on the development of PD services. Staff from Buckinghamshire contribute to the Thames Valley introductory training in PD and several staff from within the Trust were identified and are undertaking this training in preparation for the development of a PD service. Current discussions regarding closer collaboration between Oxfordshire and Buckinghamshire Mental Health Trusts are likely to bolster the plans for close collaboration between the two Trusts in the area of PD work detailed in this bid. In addition to the above, it has been agreed that some clinical roles can be adjusted to incorporate a PD role that will be utilised within the identified clinician’s current team and which will allow some input to a PD service. Many of the psychological therapists and some of the nurses within the Trust have expertise in working with PD patients and can be utilised to provide a more effective service. These are identified staff who already carry a high PD caseload. It is also envisaged that newly created posts within the organisation separate from this bid – a lead development nurse and a bed manager at operational level - will positively impact on delivery of appropriate services for PD.The Trust are in the process of recruiting posts for prison in-reach into Aylesbury Young Offenders’ Institution. The prison has a high incidence of PD within the inmate population, and has a specific programme run on therapeutic community principles. The prison in-reach team will be involved in providing and advising on appropriate treatments for these prisoners. It is planned that prisoners with a diagnosis of PD who are ultimately released into the local community will be able to link into the local PD service. This will provide continuity of care and address potential housing and employment problems. Strong links with probation services will be established to enable a comprehensive and containing service.The Trust has also been establishing links with Grendon Prison through the Psychotherapy Department. There have been preliminary discussions between the Prison Governor, the Director of Therapeutic Communities, the MH Trust Director of Strategic Planning, the chair of the prison in-reach project and the psychotherapy professional lead for mid Buckinghamshire around the potential for future prison inreach services. Final page 18 19 January 2018 Thames Valley Personality Disorder InitiativeA detailed request for accommodation for the proposed PD service has already been lodged with the estates project group. Accommodation will be made available.Work already undertaken in BerkshireBerkshire has a non-residential therapeutic community (TC), Winterbourne, at the centre of its PD services, which was recognised as a “Notable Practice Site” in the NIMHE guidance. There are places for 36 members, with 18 in the preparation phase and 18 in the daily programme. The preparation lasts 1 - 12 months and the intensive treatment programme itself for a maximum of 18 months. Winterbourne TC has been in existence for over 30 years, and during that time has led the field in both treatment for PD and user involvement. Following publication of the NIMHE guidance, a multi-disciplinary group with service user input was convened to develop Berkshire’s strategy for personality disorder in early 2003, in line with it. Shortfalls identified in the service were inadequate provision of specialist facilities for those not suitable for the Winterbourne House programmes, and a lack of training, support and supervision available to practitioners who are managing these clients, often with difficulty, in other settings. A local ‘borderline workshop’ has been instigated as well as participation in the Thames Valley-wide introductory PD training.Thames Valley preparatory workUser involvement Working closely with service users to scrutinize and change internal aspects of programme structure is a feature of therapeutic community work, which has been taking place at Winterbourne and Grendon for many years. The experience and capabilities for building and maintaining the collaborative relationships that this requires are therefore well understood. At Winterbourne, this has developed into training, research and consultancy work in the last few years; this was the precursor of ‘SURGE’ (see section 1.4). An active nucleus of ex-service users from Winterbourne, with some from elsewhere, would now be prepared to formalize some of these activities in line with the Thames Valley proposal. It would require provision of administrative infrastructure, fee-for-item-of-service remuneration arrangements, and a small amount of clinician support.Parenting risk assessment. The work undertaken for the parenting programme involved liaison between Child and Adolescent Mental Health Services, Child Protection Teams, Court Welfare Officers and clinicians involved in both Winterbourne’s PD programme and Broadmoor Psychotherapy Department. A proposal was prepared in January 2002, but initial attempts to obtain start-up funding from the statutory sector were not successful, and efforts to raise it from the voluntary sector were not pursued at that time.Final page 19 19 January 2018 Thames Valley Personality Disorder Initiative2.2 What are the aims and objectives of the service development?AIMS:  To develop new services, to improve existing services, and to discourage harmful services for people diagnosable with personality disorder in Oxfordshire, Buckinghamshire and Berkshire, in line with the NIMHE guidance.  To build on a unique resource of local treatment experience, and to use this to expand PD resources across the Thames Valley.  To provide consultation, supervision, outreach and engagement functions for mental health services, primary care, housing, social services, probation, and voluntary sector and user groups.  For all staff in relevant agencies to be aware of the condition and show due sensitivity in dealing with it: to bring about attitude change in the Thames Valley towards this group of people.  To put into place a personality disorder strategy formulated, monitored and overseen by a multiagency group including ex-users.  To set up a network of agencies working with this group to enable quick and efficient access to services.  To form an effective and supportive network across the three counties, for those working in this field and ex-service users: to include opportunities for learning, quality improvement and research.  To ensure minority groups with personality problems have equal access to services.  To learn and share best practice within and beyond the Thames Valley  To reduce inappropriate presentations and admissions across the system, and to reduce Extra Contractual Referrals (ECRs) of PD patients out from Thames Valley Mental Health Trusts.OBJECTIVESService  For the administrative arrangements for ex-service user collaboration to be in place by July 2004.  To engage service users and ex-service users in Buckinghamshire by July 2004.  For the multi-agency local strategy fora to be functioning for all three counties by September 2004.  To have agreed evaluation processes and procedures to monitor effectiveness and participation of minority groups by November 2004.  To start a daily treatment programme (tier 3 – see section 2.3) in Oxford by the end of 2004.  To start a day therapeutic programme in Buckinghamshire by end 2004.  To start tier 1, 2 and 4 programmes, in collaboration with ex-service users, for Oxfordshire by February 2005.  To start tier 1,2 and 4 in Buckinghamshire by February 2005.  To have expanded Oxfordshire Mind groupwork provision with an emphasis on PD-type problems and presentations by February 2005  To start the therapeutic risk assessment course for parents by April 2005.Final page 20 19 January 2018 Thames Valley Personality Disorder Initiative To start other specific clinical programmes in Banbury, Didcot, Witney, Aylesbury, High Wycombe, Newbury, Wokingham, Bracknell, Windsor/Maidenhead and Slough by July 2005.  To have instigated contact with all relevant agencies across the three counties by July 2005, and followed it up as required by the end of 2005. Training  To finish the 2003-4 ‘Personality: People and Pathology’ course in April 2004  To recruit at least ten course graduates to be ‘PD agents’ in their own geographical/disciplinary area by July 2004 (see section 1.2).  To instigate a regular forum, at least quarterly, for interested course graduates to develop their practice and ideas, by July 2004.  To adapt and repeat the course annually, starting in September 2004.  To find an academic institution to be a partner in delivery of the course, and to help develop it further, by the end of 2004.  To have arrangements for training placements agreed, with Oxfordshire, Buckinghamshire and Berkshire services; and Grendon Prison, Broadmoor DSPD unit and voluntary sector agencies by July 2004.  To develop a small set of standards based on the NIMHE guide, by the end of 2004.  To start a process for staff and service users to visit each other’s services by July 2005. To hold an annual conference/meeting/event to which all stakeholders are invited, starting in Summer 2004Final page 21 19 January 2018 Thames Valley Personality Disorder Initiative2.3 Please describe how the proposed development will operate; what services will be provided; for which population groups; where, when and how.Overall structureThe Thames Valley PD Initiative group established an overarching structure for PD services in the area, which is represented in diagrams 1 to 3 at the end of this section (2.3). The proposal is for a functionally and geographically tiered service. The first tier will emphasise education, attitude change, engagement, and bringing under control problematic symptoms such as drug use or self harm that are likely to interfere with later treatments. This tier will operate as close to the service users’ domicile as possible. The second tier will be a ‘spoke’ tier, geographically distributed to cater for those who cannot travel far, or who for reasons of severity or because of employment or childcare do not need or cannot attend the more intensive third tier intervention. The third tier will be a Therapeutic Day Service operating from a central position in each county, as a hub for the service as a whole. Referrals for the treatment elements of the service will be accepted from as wide a variety of sources as possible, including all departments within the mental health trust, primary care, the acute trust, social services, housing, probation, the voluntary sector, and self referral. In each county the service and network will be overseen and receive strategic direction from a multiagency ‘Local Strategy Forum’ comprising representatives of stakeholders, as outlined in section 2.10.Oxfordshire Tier I: Secondary prevention and network working  Supervision, Outreach, Consultation Inreach and Training will have a high profile in this tier. Due to the high prevalence of PD, the majority of sufferers will inevitably remain outside the mental health treatment part of the service, and case supervision and consultation are in great demand within the Trust, in Primary Care, in the acute trust particularly Accident and Emergency, in the Independent sector, social services, probation and housing. Workers in the service will both undertake training themselves and help provide training to other workers across agencies. Tier I: Assertive community engagement People with PD are difficult to engage, often having difficulties maintaining stable accommodation, relationships and employment. These problems make engagement the lynchpin of a successful PD service. This tier will consist of the following elements.  Contact with single workers or pairs of workers to establish rapport and engagement. This is likely to be in the community, in clients’ homes or on neutral ground where clients feel comfortable.  A regular welfare clinic in collaboration with stakeholder partners.Final page 22 19 January 2018 Thames Valley Personality Disorder Initiative An engagement group where people can begin to make links with other sufferers. This serves to introduce the idea of group work, which is anxiety provoking for some sufferers, provides an opportunity for learning from others with similar problems, and a chance to consider which of the treatment options in the three tiers might prove useful.  Initial assessment, often jointly with ex service users (see section 1.4 for details). Assessment will continue in Tiers II and III.  Targeted therapies designed to bring problematic behaviours under control. Behaviours that are dangerous or likely to interfere with treatment in later tiers are particularly targeted, for example addictions and deliberate self-harm. Links will be made with departments and practitioners in the Trust with expertise in these models in terms of training and supervision. These therapies are likely to include: o Cognitive Analytic Therapy (expertise in Psychological Therapies Service) o Cognitive Behaviour Therapy (expertise in CBT for deliberate self harm in Barnes Unit, acute hospital Psychiatric Liaison service and Psychological Therapies Service) o Dialectical Behaviour Therapy (developing expertise in Eating Disorder service and Child and Adolescent services) o Psychodynamic Interpersonal Therapy (expertise in Psychological Therapies Service)  A series of groups in Mind day centres and other venues around the county targeting specific problems such as assertiveness, anxiety management and self-harming. These will be facilitated or co-facilitated by Mind group workers, in association with the seconded PD worker detailed in s2.1 and this section, providing an accessible setting and format away from traditional mental health settings, which can prove a barrier to access and feel stigmatising.  There will be co-working of cases with Connection floating support workers. Floating support teams provide a particular link around the provision of housing and the difficulties raised in independent living, which can cause breakdown of housing and expense to the public purse. The incorporation of floating support provision in this bid makes use of the reputation Connection have established with housing providers who are often sceptical about housing people with support needs and not confident in providing a housing management service to them. We intend to develop this partnership further.  Close liaison will be maintained with other services to address co-morbid problems, or issues that would be likely to compromise treatment. Examples would include Specialist Community Addictions and Eating Disorder services.  Close liaison will be maintained with other agencies, including Housing, Social Services and Probation. Co-working with The Elmore Team will allow a more seamless integration across agencies.  Clients engaged in this tier for up to 12 months. Some will progress rapidly on to tiers II or III, others will require a longer time for effective engagement and other activities and therapies in this tier.Tier II: Intensive outpatient treatment Treatment in this tier will be for two days each week and last for up to 18 months. Three centres are planned situated in the North, East and South of the county in towns without good public transport links to Oxford. Some patients will be appropriate for this intensity of treatment by Final page 23 19 January 2018 Thames Valley Personality Disorder Initiative virtue of the severity of their problems. For others the realities of childcare or employment will make a five times weekly (Tier III) therapeutic day unit impossible. Still others will lack the ability to get to Oxford five times a week.This tier will run along psychoanalytically oriented lines after the Halliwick Day Hospital model in London, and will consist of psychoanalytic individual and group work. Treatment duration will be for up to 18 months. Each of the three projects will have 18 patients, and will take referrals on the same basis as Tier III. In tiers II and III an out of hours self-help network will be established. Close links will be maintained with the crisis resolution team to monitor and resolve out of hours contact.Tier III: Therapeutic Day Unit Treatment in this tier will be for five days each week and last up to 18 months.  A central hub service located in Oxford city, to contain and treat the most severely disabled and distressed. 24 places.  This tier will run as a group-oriented Therapeutic Community, running a variety of groups tailored to the needs of the membership at that time.  The mainstay of the service will be analytic small groups and Community groups. Additional specialist groups might include social skills training, specialist therapies (such as cognitive/behavioural and social skills groups), practically oriented groups (housing and welfare, occupational therapy), patient business meetings, and practical task groups. Individual interventions and family therapy will be used where appropriate.Tier IV: Step-down group Patients from Tiers II and III will be offered a step down group upon completing therapy, which will consist of a once or twice weekly outpatient exploratory group, overlapping with the closing stages of more intensive treatment. Up to 25 graduates of the programme will be able to attend for up to 18 months. Close liaison will be maintained with other agencies (eg college, employment) to aid a rapid re-entry into work or study, and the tier will be developed in collaboration and with the participation of ex service users and SURGE.Accommodation The Oxford hub service and the Thames Valley umbrella functions will ideally share easily accessible accommodation in Oxford, which is the town with best road and rail communication to all parts of the region. It will require the stable and long-term use of suitable premises to allow the continued development of PD services. Although it does not form part of this bid, it is understood that opportunities may be forthcoming for allocation of capital funds. The options will be considered if the bid is successful. Many users of these services are single parents, and lack of or inadequate childcare facilities can be a hurdle to regular attendance at therapeutic services. This proposal includes a small sum to start a crèche, for one to two days per week (section 2.8); this will be developed in partnership with statutory and voluntary services when an accurate assessment of need has been made.BuckinghamshireFinal page 24 19 January 2018 Thames Valley Personality Disorder InitiativeIt is intended that the existing collaborative working between Oxfordshire and Buckinghamshire to jointly provide services in specialised areas, such as Eating Disorders, Forensic services, CAMHS tier IV and Mother and Baby Services, will be extended to include PD. This will provide a more comprehensive service with greater scope while still allowing for local service delivery.There will be a Core PD Team operating at a specialist level at the hub of the local service. This team will have a remit to: Provide support, supervision and education to multi-agency services  Provide specialist consultation, assessment and treatment of patients with Personality Disorder  Oversee, coordinate and assist in delivering a day therapeutic community.  Establish and maintain close links with Grendon prison, the inreach team for Aylesbury Young Offender’s prison, probation and Housing.  Establish and maintain a virtual team around the core team, comprising identified psychological therapists and nurses with expertise in PD who will feed into Tier III and act as specialist agents to assist in the provision of Tier I within Mental Health, building on existing work in this area.Tier I  Supervision, consultation and training to all areas of Mental Health Services.  Access to and collaboration with assertive outreach and crisis teams.  Liaison, consultation and training to primary care, A&E, Drug and Alcohol Services, Voluntary Sector organisations.  Close links and liaison with Housing. Connection, the Floating Support Team is a key link between the provision of housing and the difficulties raised in independent living, which cause breakdown of housing and expense to the public purse. The incorporation of floating support provision in this bid makes use of the reputation Connection have established with housing providers who are often sceptical about housing people with support needs and not confident in providing a housing management service to them. We will further develop this partnership.  Close links and liaison with Grendon prison, the Aylesbury Young Offenders Prison inreach team, Marlborough House secure unit and probation.  Close links with Connection, “The Floating Support Team”.Tier II Many PD patients are already users of MH Day Services and of therapeutic and supportive programmes provided by the voluntary sector. Some of the groups already established in Mental Health day services are particularly appropriate for PD patients eg Art for Change, Assertiveness training and Drama therapy. These areas can be supported in providing an appropriate level of care through consultation, liaison and supervision from the core team. Members of core team link into Day Services which incorporates the Day Hospital programme, therapeutic and educational groups and which maintain close links with the voluntary sector.Final page 25 19 January 2018 Thames Valley Personality Disorder Initiative Engagement with voluntary sector organisations providing day, evening and weekend therapeutic and supportive activities to difficult to manage patients eg “Wings”, a local Buckinghamshire project. This engagement will be accessed through the Day Services manager.  Clinical Consultation and initial assessment.  Patients may also be receiving individual or group Psychodynamic, Cognitive Analytic or other therapies in this tier.Tier III The hub service will be located in Aylesbury, where there will be a specialist day programme for patients for whom this is judged most appropriate. This tier will run on a 3 day a week programme along psychoanalytically orientated lines. It will incorporate individual and group psychodynamic and psychoanalytic therapies and cognitive educational groups aimed at reducing self harming and acting out behaviours. Each day will end with a community meeting. Treatment in this tier will be for 18 months.This service will be staffed by members of the Core Team with sessional input from identified psychological therapists and nurses skilled in specialised treatments. The Crisis team will be utilised for out of hours crisis.Close working links will be maintained with the Eating Disorder team and the Drug and Alcohol teams for those patients with Dual Diagnosis. Tier IV Step down group. Patients completing Tier III treatment will have the opportunity to attend a once weekly exploratory/support group to enable a smoother transition to normal functioning. Close liaison will be maintained with other agencies the patient is involved with.Milton KeynesMilton Keynes is a unitary authority where mental health services are managed and delivered by the Milton Keynes Primary Care Trust; it is in the process of taking responsibility for health service provision to Woodhill Prison and the new Oakhill Young Offenders’ Institution. The PCT does not have a specialist personality disorder service. As preliminary discussions with the Director of Public Health identified a need for awareness and basic level training in personality disorder work, (particularly in general mental health, forensic psychiatry and custodial settings), the initial work will be through participation in the training aspects of the project, by recruiting enthusiastic clinicians to be part of the Thames Valley network, who can then deliver awareness training and form advocacy alliances in Milton Keynes. As interest develops, and support from the PCT is gained, it is hoped that clinical services in line with the NIMHE guidance will be developed through collaboration with the other Thames Valley centres.Currently people with a personality disorder are being maintained in mainstream services across all the agencies by a number of therapeutically trained and committed workers. However Final page 26 19 January 2018 Thames Valley Personality Disorder Initiative without a specific service for people with personality disorder services are patchy and unable to provide the most appropriate treatments for this group of service users. As a result the PCT is making specialist placements out of area and committing a lot of money outside Milton Keynes. By participating in the training aspects of the project Milton Keynes can begin to raise the knowledge and skill capacity within the system locally which will in turn result in more appropriate treatments and less dependency on out of area placements. This will allow service redesign and development by freeing up resources to develop a local treatment service that will further reduce the need to make out of area placements.At this point in time a full time day service forming a 'hub' would not be appropriate for Milton Keynes as the demand is too small. In the future it is likely that a local service development would combine Tiers 2 and 3 because of the compactness of Milton Keynes as a geographical area. However links to this Thames Valley project will be vital to maintain continuing professional practice, service development and effective treatment models.BerkshireIntroductionThe Trust has formulated proposals for the development of a well-structured, integrative Trust- wide service for people who present with the difficulties associated with the diagnosis of Personality Disorder, formulated by the Trust Wide Strategy for Personality Disorders. Primary tasks of the service are Education & Training, Supervision, Staff Support, Clinical in-put, Holding Boundaries, Ensuring successful operation of the protocols. Berkshire already has a 5- day Therapeutic community for people diagnosable with PD situated in Reading, the Winterbourne Therapeutic Community. This will form Tier III of the service. In addition there is a weekly engagement group also running in Reading which will form the basis of Tier I in the county.Tier I Winterbourne House, in addition to the therapeutic community, runs an extensive outpatient psychotherapy service, and many of the people seen in this part of the service will also be diagnosable with personality disorder. A comprehensive assessment service, for different forms and formats of psychotherapy, is a major part of the work. Detailed liaison with referrers takes place when necessary.In 2002, an ‘Inreach’ service was started, with two WTE therapists undertaking liaison and consultative work at the general psychiatric hospital (Fair Mile in Wallingford relocated its services to Prospect Park Hospital in early 2003). This involves supporting ward staff in acute units, holding inpatient therapy groups and various other ways of raising staff awareness about establishing and maintaining therapeutic environments. Links with REAP, a resettlement agency based in Reading, have been established. Collaborative working will be established with oversight of the Local Strategy Forum Final page 27 19 January 2018 Thames Valley Personality Disorder InitiativeExperts by experience from the SURGE group will participate in joint assessments as part of the activity described in section 1.4. They would be able to provide a positive mentor for people coming into the services, and for helping to explain and facilitate future therapeutic work.Tiers I & II A personality disorder coordinator role will be established with a county-wide remit to provide supervision to the locality personality disorder services, in each of the six localities across the county. This will ensure co-ordination of the services, equity of access, shared standards and maintenance of the quality of service provision across the localities. Locality-led working systems will be developed to coordinate the overall county hub, and protocols will be developed with the local services.The six localities will all have appropriately trained personality disorder specialists allocated to them; their professional base will be in the hub service but they will spend a substantial proportion of their time in the locality settings. They will work closely with the county coordinator in developing protocols and suitable local systems. In the localities they will be responsible for:  Direct provision of clinical services (assessment and therapy)  Liaison with case managers over practical issues and crisis beds  Supervision and support  Education and trainingIn each locality Tier I overnight crisis bed facilities will be opened, a 24-hour helpline will be set up, and twice weekly Tier II groups will start. The crisis beds will be community based, accessible by CMHTs, the local PD specialist and A&E departments; they will be managed by the CMHTs with the local PD specialists. Clear protocols for their use will be established.The 24-hour helpline will be operated by service users and staff (Winterbourne have many years’ experience in operating a similar system for the members of the intensive programme), and be a tier I point of entry into services as a self-referral. Suitable training and support will be provided, and clear protocols will govern its use.The twice weekly tier II groups will be a locally available, personality disorder specific service for people unable to travel to the hub service, or as part of a longer pathway of care (see diagram 2 at the end of this section)..They would be conducted jointly by the local PD specialist and CMHT staff. Tier III Winterbourne Therapeutic Community in Reading provides an 18-month intensive day programme run along group-oriented Therapeutic Community lines, and will form the hub of the proposed Berkshire PD service. It has been established for more than thirty years and has a stable therapeutic culture; it is a training base for pre-registration nursing staff, and for basic and specialist psychiatrists, and provides opportunity for clinical placements for researchers and Final page 28 19 January 2018 Thames Valley Personality Disorder Initiative others. It is the founding member of a national lottery-funded quality network for therapeutic communities, run by the Royal College of Psychiatrists Research Unit, and has now completed its second audit cycle of the project. In recent years, it has provided training placements for staff setting up day units elsewhere in the country, and it is hoped that this, and other ways to share good practice involving service users and ex-service users, will enable continuing growth and development for Winterbourne itself and its sister units across the Thames Valley.Tier IV Ex-service users will be equal partners in strategic development of suitable options for those leaving the intensive programme. This would be with the intention of including facilities to explore training and employment opportunities, and future developmental needs in a socially supportive environment that is not specifically therapeutic.Thames Valley ServicesThe therapeutic risk assessment programme for parents whose children are undergoing statutory child protection procedures is a group-based programme which will also act as an introduction and preparation for further psychological treatment.The project will run as a pilot scheme for one year, and will take place on one afternoon per week, in three terms of 10 weeks. The framework will be that of a Therapeutic community, where different therapeutic approaches are used within a programme which emphasises the development of personal and collective responsibility for behaviour, emotions and relationships.Those referred to the programme (by Courts, Local Authorities, Probation, Mental Health Services or Primary Care) will undergo detailed psychological assessment, and be offered a place in the therapeutic programme which might include individual preparation sessions. Commitment to regular attendance will be expected, without overt coercion to participate. The programme will contain elements including psychosocial relationship formation, structured activities, psychoeducation and small group therapy, as well as groups in which the risk assessment reports will be formulated. Other requests for reports from Courts and other statutory agencies will be dealt with within the group format.Detailed evaluation of individuals’ progress will be carried on throughout the programme, at its end and at follow-up. For those finishing the programme who wish to undertake more prolonged therapy, appropriate pathways to other PD services will be available.A Clinical Psychologist and nurse will undertake parenting assessments, supervised under the established programme at the Park Hospital in Oxford, for parents on the Therapeutic Risk Assessment course.Elmore Team involvementFinal page 29 19 January 2018 Thames Valley Personality Disorder InitiativeElmore is committed to the local PD service development strategy, and sees advantages in strengthen the Team’s links to mental health services, for whom clients with this diagnosis are often not top priority. Elmore also has a different approach to people with mental health difficulties, from which statutory services might benefit in the ongoing process of attitude change to which the bid partners are committed.In addition the developing PD service is likely to have a lot to gain from Elmore’s 'flexibility' and speed of response to referrals, while maintaining Elmore’s independence and differences, and remembering that clients are entitled to choices.Details of joint working will be as follows:  The Oxford PD hub service and the Elmore team will swap workers for a period of time, likely to be between 8 and 12 weeks.  Elmore support workers will have discounted access to the PD introductory course; one of the workers is a participant in the current course. Elmore identifies it as a core training need. Nobody else is providing a comparable training locally.  Close collaboration will ensure that people's basic needs are met first, like housing, in order to provide a stable personal environment for work. Helping people with chaotic lifestyles will enable an otherwise hard to reach group to engage in therapeutic and other kinds of work which might otherwise be closed to them. Elmore has this expertise along with the local knowledge and connections to make this possible.  Elmore is planning to develop inreach work into Bullingdon Prison in Oxfordshire, which takes prisoners from the county and, particularly on remand, from further afield. This would complement the mental health inreach service which is being developed by Oxfordshire Mental Health Trust. A PD service is critical in view of the volume of in- mates with severe PD (greater than 50%), so this network would prove very valuable. The Elmore/PD element of this work would link into and overlap the other joint working detailed above with an emphasis on trying to engage with the hard to reach client.  The Elmore Team will join the Local Strategy Forum for PD services in Oxfordshire in order to ensure that services develop in ways that are responsive to the needs of their client group and build on developing joint working.Social and Health Care (SHC) Directorate of Oxfordshire County Council (Note: Oxfordshire Mental Health Trust and SHC are already integrated in terms of delivery of adult services.) The proposed PD service framework for the Thames Valley fits with the whole thrust of the government white paper on Children's services and the need to provide more preventative services. Oxfordshire SHC deals with a significant number of adolescents and administers frequent agency placements; most of these clients have the beginnings of personality disorders following very disruptive and disturbed beginnings. We plan to explore the relevance of this work for younger clients, generally older than 14, but possibly even younger. Work with parents is also extremely important and the SHC would fully endorse the work proposed in the bid for Therapeutic risk assessment course (TRAC) to cover the Thames Valley area.General details of collaborationFinal page 30 19 January 2018 Thames Valley Personality Disorder Initiative Joint training and extending the scope of the Thames Valley PD training at all three levels for younger clients i.e. 14 to 18. SHC commits to making staff available for the Thames Valley PD trainings.Details of joint working will be as follows:  Joint assessments which will include ongoing risk assessments to ensure the continual safety of the children, as well as assessment of long term parenting capacity, both in collaboration with the TRAC program.  Assessments and interventions for adolescents: exploration of treatment programmes for more disturbed and disaffected young people who fail to access current services.  Fast track access to consultation/supervision and assessment from the PD service for social services.  Active joint intervention with SHC staff and cross supervision. This would fit with the direction of the CAMHS strategy i.e. to provide support, consultation and supervision to front line staff from more specialist staff in order to improve capacity/competence of these workers.  Close collaboration on particular cases.  Oxfordshire SHC will join the Local Strategy Forum for PD services for Oxfordshire in order to ensure that services develop in ways that are responsive to their client group, and respond to needs as they arise.  SHC will invite the PD initiative to collaborate in looking at the reconfiguration of SHC adolescent services.Connection – the floating support team Details of joint working will be as follows:  Joint working will provide Connection caseworkers and team managers with opportunities for further reflection and learning around some of the most challenging situations that are faced by the people supported by Connection. This is especially the case for people who have multiple needs or have a personality disorder diagnosis. Connection has arranged for such input from local professionals on a goodwill basis in the past; however we are keen to develop this on a sounder footing. This would take the form of regular supervision from workers in the PD service and access to the Thames Valley PD introductory training.  Access to support and co-working between Connection workers and members of the PD team.  Quick access to consultation and advice for Connection Caseworkers from members of the PD team.  Connection will join the Oxfordshire and Buckinghamshire Local Strategy Fora for PD services in order to ensure that services develop in ways that are responsive across services.Oxfordshire Mind Details of joint working will be as follows:  Matched funding from Oxfordshire Mind in the form of administrative support, supervisory backup, access to Mind training programme, and guaranteed premises and office space from Oxfordshire Mind.Final page 31 19 January 2018 Thames Valley Personality Disorder Initiative Three-session secondment of a PD worker to Oxon Mind to dovetail with work already being undertaken by recently restructured PD Psychology post seconded to Oxfordshire Mind (see section 2.1). This will enable o An expansion of groupwork in accessible settings around the county, work led by Mind workers who will gradually become increasingly skilled (see section 2.3, Oxfordshire, Tier I for details). o Supervisory and consultative backup to workers already working with clients diagnosable with PD in Mind Day services and Housing Projects, an area which workers find extremely challenging, time consuming and stressful.  Access to Thames Valley PD training to skill-up Mind workers at low cost. Oxfordshire Mind has committed to backfilling for workers undertaking PD trainings.  Oxfordshire Mind will join the Local Strategy Forum for PD in Oxfordshire in order to provide strategic direction to the initiative.REAP resettlement agency Details of joint working will be as follows:  Joint working will provide REAP caseworkers and Service Managers with opportunities for learning, and increasing their understanding of situations involving clients with multiple support needs and / or personality disorder label.  Access to the Thames Valley PD introductory training at low cost.  Access to support, and co-working between REAP caseworkers and local PD professionals.  Improved access to consultation and advice for REAP caseworkers from local PD professionals.  REAP will join the Berkshire Local Strategy Forum for PD services to ensure the strategic, responsive and needs-led development of innovative PD services across the area.For all stakeholders:  Participation in annual development conference to review the progress of the PD network and deepen links between agencies. Final page 32 19 January 2018 Thames Valley Personality Disorder InitiativeA hub and spokes PD service for the Thames Valley: a clinical service model 1. The four tiers of deliveryTier 1: Assertive engagement and active assessment NOTES  Tier 1 has similarities to assertive Various Numerous activities in outreach combinations of services. different days for different settings, different referral one common weekly ‘drop-in’  It needs to be groups, iin different organised with locations engagement group for informal numerous meeting and agencies at information locality level. sharing t=up to 12  Individual and months. joint Shared care with consultations referrers Tier 2: Outreach, inreach and ‘access to therapy’  Includes a weekly non- exploratory group Different activities at Could  Tiers 2 and 3 different times in include require larger the week, for weekend geographical different programmes coverage for populations, in for those in formation of different full time appropriate locations work or groups n=18 per project education t=12-18 months  They also provide many opportunities for staff Tier 3: Day programme: definitive treatment training  Tier 2 can be district, Whole-time daily regional or programme as supra-regional. service base, with different activities,  Tier 3 (daily therapies and programme) groups. Considerable user- needs to be involvement. Also locally training base. accessible n=24; t=18 months  Either mixture of individual and group therapies, or Tier 4: Leaving process – graded disengagement only groups Tier 4 primarily Half day per week group, but with (or less), with overlap into last specific weeks/months of consultations tier 2 or tier 3 for particular programme. In individuals liaison with other according to agencies (eg each person’s college, needs. employment). Normally back to GP care only.  To include n=25; t=up to 18 therapy with months families and Final page 33 19 January 2018 Thames Valley Personality Disorder Initiative2. Care pathwaysSamarit Univ & ans College Occupatio health & nal health NHS counselling S Self- Direc Priso Hs refer t ral Liaison ns psychia try CAMHS A& E H MAPP eg SS P V Ps parents Ds C Young G with PD offender P Court services divert Adult mental Probati schem health: on es CMHTs, IP, Forensi crisis c services, stepdo Homeles assertive wn s Drugsoutreach services & Housi Alcoh ng ol units Various RF , combinations MIND of different etc days for different Referral to referral groups, more suitable iin different services: For those with specific issues, locations occasionally geographical or time limitations, or not to out-of-area suitable for daily programme nationally funded residential units (e.g. Henderson Hospital) or for suitable patients to outpatient For those psychological suitable for day For those able and willing to go on therapies. programme. to a more intensive treatment programmePlanned discharg e Planned discharg eFinal page 34 19 January 2018 Thames Valley Personality Disorder Initiative3. Thames Valley-wide relationshipsMilton Keynes Grendon Prison PCT / Local Authority Assessment Therapy MIN Wing F Wings A, D B, C, D, G Elm CON ore NE- Thames Valley Oxfords CTIO Strategy Forum Socia hire N & ‘Axis 2 CON NE- l Local Institute’ Servi CTIO Strateg Training functions only Bucking- ces N y Forum (grey arrows) hamshire Strategy fora to Local V coordinate services Strategy a AND training Forum ri functions (blue o arrows) u Includes administration V s of service user input a c (throughout) ri o located in one trust or as o part of SEDC / TVSHA m Parentin u strategic links with other b g s region-wide agencies i Assessm c Oxon Axis 2 Service liaison with other regions n ent o a LocalProject MH m ti services b o i Bucks Axis 2 n n Service s a o ti Local MH f RE o d V n services AP if a s ri f Berksh o e o f ire r u d s Local e Broadmoor if n c Strate f t o gy Hospital: e d m Forum Psychotherapyr & a b DSPD units e y i Local MH n Berks nAxis 2 Service s services t f a d o ti a r o y d n s if s f f o o e f r r d d e if if n f f t e e r r r e Final e page 35 19 Januarye 2018 f n n e t t r d r r a e a y f l s e g f r r o r o r a u d l p if g s f r , e o ii r u n e p d n s if t , f r ii e e n r f d e e if n r f t r e l a r o l e c g n a r t ti o l o u o n p c s s a , ti ii o n n d s if f e r e n t l o c a ti o n s V a ri o u V s a c ri o o m u b s i c n o a m ti b o i n n s a o ti f o d V n if a s f ri o e o f r u d e s if n c f t o e d m r a b e y i n s n t f a d o ti a r o y d n s if s f f o o e f r r d d e if if n f f t e e r r r e e e f n n e t t r d r r a e a y f l s e g f r r o r o r a u d l p ifThames Valley Personality Disorder Initiative g s f r , e o ii r u 2.4 Hown does the developmente meet the objectives and standards set pout in guidance?d n s if t , f r ii Paragraphe numbers from “Guidancee on the development of service models” (pp 30-36) n r f d e e if n r f Specialistt Team r e l a r o l e 68 c Each mental healthg trust in the Thames Valley would have a specialist team to delivern the a r t servicesti described. o l 69 o The specialist teamsu would each form a hub, with the development of outreach serviceso p (for example,n tier 1 and 2 in Oxfordshire) as spokes into different geographical areas and crelevant s s a agencies. , ti ii 70 A multidisciplinary team approach is used throughout, led by appropriately experiencedo n n clinicians; exclusion criteriad will be agreed by all stakeholders, not solely by those clinicianss providing specialist treatments.if f 71 Care will be sharede between team members who will link to other agencies as required. 72 A bio-psycho-socialr model underpins the proposed approach. e 73 The specialist teamsn would develop from existing psychological treatment departments. The best management arrangementst will be actively evolved as the project develops. A key aim l will be to provide flexible ando active service delivery, not only based in one physical unit. 74 The services will operatec a policy of ‘assertive inclusion’, by which it is seen as the a service’s responsibility to maketi itself acceptable to all those with PD – subject to suitability criteria agreed and protocolso developed by the strategy fora (i.e. all stakeholders) 75 The specialist teamsn would be responsible for delivering coordinated and theoretically s coherent care, which includes direct clinical work, consultation, staff support, supervision and training. Links with forensic services are good (also para 82), and ex-service users have considerable familiarity with out-of-hours crisis arrangements (a longstanding and successful system at Winterbourne), and have pioneered locality-based self help networks (in Newbury).Taking on patients for assessment and treatment76 Protocols for referral will be developed through the strategy fora; comprehensive and innovative assessment forms the core of tier I services 77 From experience in Winterbourne, those likely to be taken on would have considerable distress and difficulty in many areas of their lives. Information would be handled within the current legal framework. 78 The types of treatment in this proposal are highly structured with a clear focus and explicitly coherent theoretical framework, which is available to both clinicians and patients. It is relatively long term (tier I may be as short as a month, but progress through the whole clinical system will generally take more than 2 years), and experience at Winterbourne would indicate that considerable efforts by staff and service users achieve good adherence. The proposed services allow different types of treatment as part of the ‘whole system’: the system’s fundamental properties are establishing a collaborative relationship with potential service users, providing a safe environment for therapeutic work, and offering specialist therapy according to their needs and capacities. All five specific psychological therapies cited in the Final page 36 19 January 2018 Thames Valley Personality Disorder InitiativeNIMHE guide (p24) will be available in different parts of the Thames Valley, and expertise will be shared through staff development and educational activities.Providing consultation and support, supervision and training79 Consultation and support protocols will be drawn up in the three strategy fora. 80 Consultancy and support would be a major function of the ‘outreach’ part of the service, 81 It would include access to supervision and training for staff from different settings and agencies.Other service guidance points83 User-support networks are an explicit part of the core clinical model. 84 Out-of-hours arrangements will be linked to existing and developing services. 85 Day units will form three main hubs (one in each county); these will be closely linked to outpatient services. 86 No provision of beds is required. From experience at Winterbourne, for those in an intensive programme, crises can generally be managed without needing inpatient admission. 87 Where appropriate, a small number of people may be referred to one of the five national PD residential units, with whom good relationships already exist.Final page 37 19 January 2018 Thames Valley Personality Disorder Initiative2.5 Please provide detail of the anticipated outcomes of the service development. NB clear, quantified projections are required; these will be used to evaluate the progress and effectiveness of service developments.Outcomes will have a high profile in the proposed service for the purposes of monitoring performance via audit. Outcome measures will cover formalised PD diagnosis, service usage, self harming and suicidal activity, symptoms and risk, functional level, and social and interpersonal functioning. The measures being used in the current Oxfordshire pilot service have been chosen with this in mind, and this will serve as a pilot for outcome measurement for the whole Thames Valley initiative.In addition it is intended that a formal trial of the treatment will be implemented. Links have already been established with the Leeds group with a view to comparing the two models (see section 2.1). It is important that we should share knowledge gained from such developments as we progress, not only between both sites but also with other interested parties. We would therefore factor in to our developments time for the production of regular written progress reports and to present findings/reflections to others, including an annual event addressing best practice and models of care for working with personality disorder. Outcome measures would be agreed in collaboration with NIMHE and other relevant partners and these would include site -specific measures which reflect our different paths and shared outcome measures which may be more generally applicable. In addition we intend either to conduct a local trial with support from the Oxford University Department of Psychiatry, or as part of a wider multi-centre trial. We have been involved in the proposed Medical Research Council multi-centre Therapeutic community trial correspondence (TACIT), as well as discussions about being a centre for a replication trial of the psychoanalytically-orientated partial hospitalisation model (as at Halliwick, see section 2.3, Oxfordshire tier II) . The Professor of Social Psychiatry at Oxford University is interested in developing an academic post with a particular focus on PD research, which might be linked to the PD service.The Thames Valley Strategy Forum will prioritise outcomes for evaluation, drawn from the list below.Treatment outcomes:  Reduced suicidality and self harm (Acts of deliberate self-harm inventory)  Symptom reduction eg depression, anxiety, dissociation, psychotic phenomena (by self- report questionnaires such as SCL, BSI)  Social functioning improvement (simple measures such as stability of housing, more detailed qualitative interviews; self-report questionnaires – SAS, IIP, PROQ)  PD features reduction (research interview schedule – SCID-II; self-report - PDQ4+)  Composite scales showing clinically and statistically significant change (eg CORE system, Euroqol EQ-50, HONOS)  Qualitative outcome evaluation by ex-service users involved in tier IV  Service users and ex-service users report useful changes (qualitative – interview or open questionnaire)Environmental outcomes:Final page 38 19 January 2018 Thames Valley Personality Disorder Initiative Improved therapeutic environments where consultation and supervision has been implemented  Defining and describing positive (and negative) features of the new psychological environments: ethnographic qualitative study  Numerically demonstrable establishment and maintenance of therapeutic environments: staff & service user reporting questionnaires – WAS, COPES, CAS  Acceptable architectural and physical features: Structured RESPII instrument.Training and awareness outcomes  Increased proportion of staff in different settings have (i) awareness of the condition of personality disorder and (ii) capabilities in line with ‘vocational education’ in the framework document.  Increased proportion of mental health staff have (i) capabilities in line with ‘professional training’ in the framework document and (ii) knowledge of local services and referral pathways.  Recruitment to introductory course above 20pa, with above 10pa going on to develop the work in their own areas (numbers TBC)  Positive feedback from course participants  Positive feedback from others at their place of work  Positive feedback from service usersSystem outcomes  Economically demonstrable benefit: cost offset demonstrable through less use of expensive but inappropriate services – health and other (particularly out-of-area referrals); ideally also showing reinvestment in more suitable services  Improved working in stakeholder teams  Ex-service-user-led qualitative assessment of the “extent to which we are being heard and valued” in the local and Thames Valley strategy fora.  Staff in other MH settings report useful input from the service (questionnaire or semi- structured interview)  Staff in other general health settings report useful input from the service (questionnaire or semi-structured interview)  Staff in other agencies report useful input from the service (questionnaire or semi- structured interview)  Low sickness and staff turnover rates in PD services  Increased staff morale in services previously ill-equipped to manage PD, but expected to do so.  Increased investment in further PD services, training and research.  Decrease in Extra Contractual Referrals (ECRs) of PD patients out from Thames Valley Mental Health Trusts.Final page 39 19 January 2018 Thames Valley Personality Disorder Initiative2.6 Has any training programme been included within this proposal? If not will this be covered by an application for training funds?A training alliance has been formed between mental health trusts in Oxfordshire, Berkshire and Buckinghamshire, along with Grendon Prison and Broadmoor (see diagram 2, section 2.3) with a view to providing a locally accessible training for PD practitioners. This is designed to be accessible to workers from all agencies and at all levels of education and competence. Three levels of training have been identified: awareness, basic and specialist. These correspond to the ‘training escalator’ training stages in the NIMHE capabilities framework.‘Horizontal reach’ (section 1.1) is required for awareness: so all staff having contact with people diagnosable with personality disorder are aware of the existence of the condition and the services available. This needs to be across all agencies, and across the geographical area served. Basic training is suitable for any professionals whose day-to-day work involves substantial contact with PD. Specialist training is for those who work, or who aspire to work, in PD services: the ‘vertical reach’ of section 1.1, describing pockets (or hubs) of specialist expertise and intensive treatment.A basic training course was started in June 2003: ‘Personality: People and Pathology’. This is a multidisciplinary one year, one afternoon per month series of seminars, workshops, lectures and experiential groups. It is held in a hotel in Wallingford; a hotel to avoid atmosphere of hospital institutionalization, and in Wallingford because this is closest to the geographical centre of the three counties. The course is designed for anyone working with clients with PD-type problems, specifically including mental health clinicians; social workers; criminal justice professionals (probation officers, prison officers & YOI workers); voluntary sector staff; housing sector workers; homelessness team members; addictions workers; psychotherapists and counsellors. It provides  A theoretical base to understand the nature and clinical features of personality disorder  An understanding of the effective ways of working with people suffering with PD, and the evidence base for specific treatments  Skills and strategies to help deal with the particular stresses of this work  Teaching from experienced specialists in the field  Experience of user input to training  A chance to experience group work first hand and gain skills of self observation and awareness, essential in work with this client group  A casework discussion and supervision group  The basis for further training in PD work  Contact with a peer group of professionals from different backgrounds working with similar clients27 participants have joined, from across the Thames Valley and beyond, with numerous backgrounds including mental health nursing, social work, probation, general practice, voluntary sector and psychiatry. Several more have put their names down for the next annual cycle. The course is run from a charitable account held by Berkshire Shared Services Organisation; fees have been met in various ways including a block booking from Oxfordshire supported by the WDC. Final page 40 19 January 2018 Thames Valley Personality Disorder InitiativeThe vision for the course is for students to become advocates in their workplaces for a different way of working and a better understanding of this group of patients/clients. The course will emphasise attitude change and the practicalities of the work. The intention is that graduates of this course will maintain links with each other, and the course team, but undertake PD development work in their own areas and agencies. Encouragement and practical help will be offered so that this is in collaboration with ex-service users, and will be two-pronged: awareness training (as ‘horizontal reach’ and as in the Capabilities Framework) and forming the nuclei of local advocacy networks (to make the case for better PD provision in that particular area and agency). A range of regional secondment opportunities for all those involved in personality disorder work will also be set up.Specialist training is an area to be developed later. Initially, external specialist courses will be recommended for those who are keen to undertake further formal training. Many suitable courses exist, such as training in specific therapies, and a few are now targeted specifically at working with PD. In the longer term, a modular course is envisaged where relevant parts of various other training activities can be incorporated, together with relevant theoretical input and work experience gained in the Thames Valley services, to certificate and diploma level. A University partner and Workforce Development Confederation support will be sought in 2004. It will also be important to gain the support of the WDC for supporting training places for non- NHS staff, perhaps backed by matched support from other sources such as the Prison Service and Local Authorities.It is anticipated that the Thames Valley plans for incorporating basic PD training into pre-existing schemes will mesh into this work. We are developing a pool of willing graduates of the basic course and ex-service user collaborators who will be able to mount different training events in various formats, according to need.Final page 41 19 January 2018 Thames Valley Personality Disorder Initiative2.7 How will staff be supervised and supported?Suitable staff supervision and support is a requirement for working with PD, and will take place at three levels: Thames Valley-wide, Hubs, and Spokes.The Thames Valley-wide supervision will be offered to (i) senior staff working in the three county ‘hubs’, in Grendon and the DSPD unit at Broadmoor, (ii) graduates of the basic training course who have become involved in the awareness training and local advocacy networks, and (iii) other staff with special interest and responsibility for PD in different settings. It will be coordinated centrally, and involve regular meetings (at least quarterly plus an annual stakeholder conference) with a clinical focus. Other methods of communication across the three counties will also be available and developed as technology, funding and willingness permits, such as dedicated websites and discussion boards, messenger services and virtual private networks, telephone and video-conferencing. It is also envisaged that participants will form their own peer and external supervision systems, as suits their different requirements. Posts in the new services will have built-in CPD time for suitable supervision, with travel and study leave funding available. Other staff with special PD responsibilities will be supported to ask for similar dedicated time and expenses.The supervision from the hubs will be for those in local mental health services and other agencies (external) and for those directly undertaking the specialist assessments and treatments (internal). The external supervision will take different forms, such as work discussion groups, complex problem seminars, and individual case supervision groups – according to the needs of the different local mental health services and the service protocols agreed at the strategy fora. The internal supervision arrangements will be in accordance with the requirements for trainees and trained staff in the specific therapies used; this may be peer supervision for qualified staff, supervision by senior staff or external supervision where there is a specific need. Supervision ratios will be established and audited (for example 1:10 for qualified staff and 1:6 for trainees). A weekly staff support group for all hub staff will be expected. Training and CPD time with expenses will be available for all hub staff. Participation in teaching, research, management and non-clinical activities will be encouraged to maintain a healthy balance between face-to-face clinical work and other activities. HR policies to encourage a healthy working environment and a positive work-life balance will also be actively supported.The supervision and support of numerous staff in disparate agencies across the area will be tackled indirectly, through the awareness training events and spin-offs from them (for example, GP receptionist peer support groups with monthly ex-service user participation), and through the local advocacy networks (to put the case for formal supervision where it is needed). All relevant agencies will need to be made aware, at different levels of seniority, that dealing appropriately and sensitively with those diagnosable with personality disorder is no longer a luxury, but an expectation and a necessity.Final page 42 19 January 2018 Thames Valley Personality Disorder InitiativeFinal page 43 19 January 2018 Thames Valley Personality Disorder Initiative2.9 Have you identified who will undertake the development work?Clinical leads for Mental Health Trusts in the three counties along with heads of service of stakeholders will form a Thames Valley wide steering group (the ‘Thames Valley Strategy Forum’) to oversee the development of the work. This group will initially comprise:1. Steve Appleton, Head of Modernisation: Mental Health, Substance Misuse and Prison Healthcare, Thames Valley Strategic Health Authority 2. Yolande Hadden and Sheena Money, Convenors, Service User Reference Group for England, Thames Valley Region 3. Rex Haigh, Consultant Psychiatrist in Psychotherapy and Convenor of Thames Valley Personality Disorder Initiative 4. Jenny Connelly, Mental Health Lead Commissioner for Oxfordshire PCTs, representing PCTs across the Thames Valley Initiative area. 5. Gwen Adshead, Consultant Psychiatrist in Psychotherapy, Broadmoor Special Hospital and lead on Thames Valley PD training initiative for Broadmoor 6. David Jones, Assessment Wing therapist and lead on Thames Valley PD training initiative for HMP Grendon 7. Steve Pearce, Consultant Psychiatrist in Psychotherapy with specialist responsibility for people with personality disorder in Oxfordshire, Overall Clinical lead on bid 8. Manager, Elmore Community Services (currently vacant) 9. Patrick Taylor, Director, Oxfordshire Mind 10. David Jones, Consultant Psychiatrist, Child and Adolescent Mental Health Services, OMHT 11. Maddy Podichetty, Consultant Psychiatrist in Psychotherapy with specialist responsibility for people with personality disorder in Berkshire 12. Alex Esterhuyzen, Consultant Psychiatrist in Psychotherapy with specialist responsibility for people with personality disorder in Buckinghamshire 13. Marion Panchkowry, Non-medical Consultant Psychotherapist, Project Clinical Lead, Buckinghamshire 14. Mark Thompson, Director, Connection 15. Fran Fonseca, Service Manager with a lead on Child and Adolescent Mental Health Services, Social and Health Care Directorate of Oxfordshire County Council 16. Mike Chew, Deputy Chief Executive and Director of Mental Health Services, Milton Keynes Primary Care Trust 17. Rita Nath-Dongre , Director, REAP Resettlement AgencyFinal page 44 19 January 2018 Thames Valley Personality Disorder Initiative2.10 What inter-agency process will be used to oversee the development of the service?In June 2003 the multidisciplinary Oxfordshire PD working party that drafted the Summer 2002 business plan, members of which attended the Thames Valley PD Initiative meetings, was replaced by a multi-agency PD steering group to guide the development of the service and provide strategic direction. The membership of this Local Strategy Forum is as follows: Primary care and PCT representative  2 Ex User representatives  Voluntary sector representative (Manager of Oxford Night Shelter)  Specialist services manager  PD development clinical lead (Steve Pearce)  Addictions service representative  Child and Adolescent services representative  Social services representativeThis group also operates as the National service framework implementation group for PD services in Oxfordshire. This group meets quarterly and has the following functions: Development of care pathways and clinical protocols  Supporting local training functions  Defining protocols and procedures for consultation and external supervision functions  Establishing good communication with local health economy  Providing input into recruitment procedures for PD service staffProcesses for reviewing membership and terms of reference will be agreed with South East Development Centre (SEDC) and TV SHA.Similar fora are being established in Buckinghamshire and Berkshire to steer service developments, and representatives from the three will meet regularly together for wider liaison as the Thames Valley Strategy Forum, with the SHA, SEDC and other strategic bodies.Final page 45 19 January 2018 Thames Valley Personality Disorder Initiative2.11 Please provide details of governance arrangements for the service development.Clinical leads for each of the three parallel projects will be responsible for implementing the service and governance model and demonstrating key deliverables.Clinical governance From the outset of the project each of the three hub and spoke services will be subject to normal clinical governance arrangements within the host Mental Health Trusts. In addition clinicians working within each of the three parallel services will be clinically accountable to the local clinical head of service in each county as specified in section 2.9. As this is an innovative project which will involve close working with Voluntary sector services and ex-service users, the appropriateness of these arrangements will be kept under review by the Thames Valley Strategy Forum, and new governance arrangements may need to evolve as the project develops.The following principles will govern the application of clinical governance in the Thames Valley PD service.Risk management  Positive risk management  Principle of interdependence: shared responsibility between disciplines  All professions involved  Structured care planning and pathways  Principles of Care Programme Approach adapted as necessary to the needs of the service and periodically reviewed by the strategy fora.Staffing and management  staff of all seniorities will be expected to undergo an annual appraisal  this will be linked to a personal development plan, and  integrated with Thames Valley objectivesUser involvement  Thames Valley consultative and training function  User-driven treatments  User-driven service planning  Letters to and by patients  Transparency of structures  Links with other user groups Education and training  Capabilities Framework - based  Study leave and expenses for hub staff and others with PD responsibilities  Integration with Thames Valley objectives Clinical effectiveness  Development of stakeholder-agreed protocols  Shared care with other agencies according to agreed formatFinal page 46 19 January 2018 Thames Valley Personality Disorder Initiative Joint assessments in tier I  Cross-county and cross-agency links through TV focus on training and staff support networks  Explicit use of existing evidence baseClinical audit  A Quality network will be developed  Staff workload and supervision will be specifically audited Research and development  Stakeholder-agreed local evaluation will be undertaken  We will participate in wider research programmes as detailed in section 2.5Use of information  There will be differentiation between statutory, therapeutic, audit and research data  We will put in place protocols for the circumstances in which information is shared, in agreement with the strategy fora.  We will work towards paperless systemsResearch governance All research will be governed by the ethics committee approval procedures of the appropriate research institution, and conform to research governance procedures in place. The Thames Valley Initiative will aim to sponsor research investigations, and anticipates requests for research activity from trainees across the disciplines. Research and Development leads in each contributing Trust will take an overview of all research undertaken.Corporate governance Responsibility for overall strategy of the project will be shared by the partners listed in section 2.9, and overseen by the National Institute for Mental Health in England through the South East Development Centre. SEDC will not be responsible for performance monitoring, nor administering financial matters. Training governance/quality assurance Links are being explored with academic partners in order to provide quality assurance for PD training at all three levels in the Thames Valley.Final page 47 19 January 2018 Thames Valley Personality Disorder Initiative3. Learning and further development3.1 How will you disseminate learning and the development experience from this pilot initiative, regionally and nationally?At the outset of the project, we will hold a launch conference, including all the stakeholders in the programme, and invite all interested colleagues and service users from the region and nationally. At that event we will also launch a project website, with discussion boards, where information on all aspects of the development will be regularly posted, and feedback sought.Locally, one of the first service user activities to be organised will be a ‘roadshow’ type of seminar, which will offer to visit mental health units across the South-East NIMHE region with a half-day training session on PD in general, and the aims of the project. It is envisaged that this will develop into a quality network, with a regular schedule of activities and visits. Nationally, senior members of the project team and service users will establish links with colleagues undertaking other NIMHE pilots and collaborate on various issues to ensure that the different projects do not all need to reinvent the wheel for themselves – but that sharing of best practice and ideas is instituted from the outset. This work has already started, in that a national group with a particular focus on training has already formed and met, and proposes to continue doing so once the projects are under way.Numerous national conferences already take place in this field of work, and when calls for abstracts are received for those which seem particularly relevant – posters, papers and workshop submissions will be prepared. This will be done through the Thames Valley strategy forum, with participation of all stakeholders.Papers will be written for peer reviewed academic journals (for example Journal of Personality Disorders), professional journals (such as Nursing Times, Health Service Journal and Psychiatric Bulletin) and other publications (such as Open Mind and On the Border). If there is sufficient interest, selected journalists from the national press will be invited to come and see the project and discuss it. The project will actively participate in the Parliamentary PD awareness event which is being planned for 2004-5 by the national SURGE group and Borderline UK.Final page 48 19 January 2018 Thames Valley Personality Disorder Initiative3.2 What process do you plan to use to ensure continued development and improvement in services for people with personality disorder?Targets for personality disorder service development are unlikely to be set for PCTs, so from the outset strong relationships will need to be forged with them. Interested representatives will be invited to the launch event, and their views sought on the ways in which the PCTs should be kept abreast of the developments. They will continue to be invited to the annual development conference, which will be designed as an interesting, lively and thought-provoking event. It will be of utmost importance to demonstrate to them, with robust evidence, that these services are performing a valuable function – economically, clinically and ethically.Momentum for continual developmental change, both within the project and beyond it, will result from the action research methodology underlying the quality network: through a system of engagement in active reflection about services, and collaboration in bringing about improvements, by involving all those with an interest. Specifically, it will involve a scheduled programme of visits between different units so that participants will be able to share and discuss best practice. Particularly strong pressure to continue developing and improving services is likely to come from service users and ex-service users who are involved, who will be working closely with the ‘PD Agents’ in the local advocacy networks.The way in which the training is structured – particularly by training interested staff to train others – will have a cascade effect, which will establish active nuclei in different areas of the Thames Valley. These will be ‘special interest groups’ relating to their own sectors, agencies, professional groups and wider local population. All those involved will be invited to share their different experiences by having opportunity to present them at the annual development conference, and publish them on the project’s website.The early emphasis on attitude change, and openness to innovation such as more often seen in the voluntary sector, should make further development inevitable. In the longer term, also developing an emphasis on primary prevention will recruit other interested agencies into the growth of a radical and self-sustaining momentum.Final page 49 19 January 2018 Thames Valley Personality Disorder Initiative4. Agency endorsementsPlease provide signature endorsements for all agencies that are partners to the application, including the Chief Officer of the lead agency. Applications submitted by NHS trusts should be endorsed by the local Primary Care Trust and Strategic Health Authority.[Signature sheets are appended following list of signatories]Thames ValleySteve Appleton, Head of Modernisation Mental Health: Substance Misuse and Prison Healthcare, Thames Valley Strategic Health Authority Yolande Hadden and Sheena Money, Convenors, Service User Reference Group for England, Thames Valley BranchRex Haigh, Consultant Psychiatrist in Psychotherapy and Convenor of Thames Valley Personality Disorder InitiativeGwen Adshead, Consultant Psychiatrist in Psychotherapy, Broadmoor Special HospitalTony Maden and Jessica Williams, WLMHT Broadmoor DSPD Directorate Peter Bennett, Governor and Michael Brookes, Director of Therapeutic Communities, HMP GrendonMark Thompson, Director, ConnectionMilton KeynesNicholas Hicks, Director of Public Health, Milton Keynes Primary Care TrustMike Chew, Deputy Chief Executive and Director of Mental Health Services, Milton Keynes Primary Care TrustOxfordshireJulie Waldron, Chief Executive, Oxfordshire Mental Healthcare NHS TrustMike Hobbs, Medical Director, Oxfordshire Mental Healthcare NHS TrustJenny Connelly, Mental Health Lead Commissioner for Oxfordshire PCTsFinal page 50 19 January 2018 Thames Valley Personality Disorder InitiativeSteve Pearce, Consultant Psychiatrist in Psychotherapy with specialist responsibility for people with personality disorder in Oxfordshire, Overall Clinical lead on bidMark Hammond, Chair, Elmore Community ServicesPatrick Taylor, Director, Oxfordshire MindDavid Jones, Consultant Psychiatrist and Acting Clinical Director, Child and Adolescent Mental Health Services, OMHTFran Fonseca, Service Manager with a lead on Child and Adolescent Mental Health Services, Social and Health Care Directorate of Oxfordshire County CouncilBerkshirePhilippa Slinger, Chief Executive, Berkshire Mental Health TrustPhilip Burgess, Mental Health Lead Commissioner for East Berkshire PCTs, Chief Executive, Windsor, Ascot and Maidenhead PCT Janet Fitzgerald, Mental Health Lead Commissioner for West Berkshire PCTs, Chief Executive, Reading PCT Maddy Podichetty, Consultant Psychiatrist in Psychotherapy with specialist responsibility for people with personality disorder in Berkshire Rita Nath-Dongre, Director, REAP Resettlement AgencyBuckinghamshireJill Cox, Chief Executive, Buckinghamshire Mental Health Trust Alan Webb, Wycombe PCT, Mental Health Lead Commissioner for Buckinghamshire PCTsAlex Esterhuyzen, Consultant Psychiatrist in Psychotherapy with specialist responsibility for people with personality disorder in Buckinghamshire Marion Panchkowry, Non-medical Consultant Psychotherapist, Project Clinical Lead, BuckinghamshireFinal page 51 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Thames Valley……………………………………………………………Steve Appleton, Head of Modernisation Mental Health: Substance Misuse and Prison Healthcare, Thames Valley Strategic Health Authority Final page 52 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Thames Valley……………………………………………………………Yolande Hadden, Co-convenor, Service User Reference Group for England, Thames Valley Branch…………………………… DateFinal page 53 19 January 2018 Thames Valley Personality Disorder InitiativeFinal page 54 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Thames Valley……………………………………………………………Sheena Money, Co-convenor, Service User Reference Group for England, Thames Valley Branch…………………………… DateFinal page 55 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Thames Valley……………………………………………………………Rex Haigh, Consultant Psychiatrist in Psychotherapy and Convenor of Thames Valley Personality Disorder Initiative…………………………… DateFinal page 56 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Broadmoor Psychotherapy Department and TV Parenting Programme……………………………………………………………Gwen Adshead, Consultant Psychiatrist in Psychotherapy, Broadmoor Special Hospital Crowthorne, Berks…………………………… DateFinal page 57 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Broadmoor DSPD Service……………………………………………………………Tony Maden, Consultant Forensic Psychiatrist and Clinical Director, DSPD Service Broadmoor Special Hospital, Crowthorne, Berks…………………………… Date Final page 58 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Broadmoor Special Hospital……………………………………………………………Jessica Williams, Manager, Broadmoor DSPD Directorate West London Mental Healthcare NHS Trust …………………………… DateFinal page 59 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Milton Keynes……………………………………………………………Nicholas Hicks, Director of Public Health, Milton Keynes Primary Care TrustFinal page 60 19 January 2018 Thames Valley Personality Disorder Initiative…………………………… DateFinal page 61 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Milton Keynes……………………………………………………………Mike Chew, Deputy Chief Executive and Director of Mental Health Services, Milton Keynes Primary Care Trust…………………………… DateFinal page 62 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: HMP Grendon……………………………………………………………Peter Bennett, Governor , HMP Grendon……………………………Final page 63 19 January 2018 Thames Valley Personality Disorder InitiativeDateSignatures: HMP Grendon……………………………………………………………Michael Brookes, Director of Therapeutic Communities, HMP GrendonFinal page 64 19 January 2018 Thames Valley Personality Disorder Initiative…………………………… DateSignatures: Voluntary Agencies……………………………………………………………Mark Thompson, Director, ConnectionFinal page 65 19 January 2018 Thames Valley Personality Disorder Initiative…………………………… DateSignatures: Oxfordshire……………………………………………………………Julie Waldron, Chief Executive, Oxfordshire Mental Healthcare NHS TrustFinal page 66 19 January 2018 Thames Valley Personality Disorder Initiative…………………………… DateSignatures: Oxfordshire ……………………………………………………………Dr Mike Hobbs, Medical Director, Oxfordshire Mental Healthcare NHS TrustFinal page 67 19 January 2018 Thames Valley Personality Disorder Initiative…………………………… DateFinal page 68 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Oxfordshire……………………………………………………………Jenny Connelly, Mental Health Lead Commissioner for Oxfordshire PCTs…………………………… DateFinal page 69 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Oxfordshire……………………………………………………………Steve Pearce, Consultant Psychiatrist in Psychotherapy with specialist responsibility for people with personality disorder in Oxfordshire and overall clinical lead on bid…………………………… DateFinal page 70 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Voluntary Agencies……………………………………………………………Mark Hammond, Chair, Elmore Community Services…………………………… DateFinal page 71 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Voluntary Agencies……………………………………………………………Patrick Taylor, Director, Oxfordshire Mind…………………………… DateFinal page 72 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Oxfordshire……………………………………………………………David Jones, Consultant Psychiatrist, Child and Adolescent Mental Health Services, Park Hospital, Oxford…………………………… DateFinal page 73 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Oxfordshire……………………………………………………………Fran Fonseca Service Manager with a lead on Child and Adolescent Mental Health Services, Social and Health Care Directorate of Oxfordshire County Council…………………………… DateFinal page 74 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Berkshire……………………………………………………………Philippa Slinger, Chief Executive, Berkshire Mental Health Trust…………………………… DateFinal page 75 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Berkshire……………………………………………………………Philip Burgess, Mental Health Lead Commissioner for East Berkshire PCTs Chief Executive Windsor, Ascot and Maidenhead PCT …………………………… DateFinal page 76 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Berkshire……………………………………………………………Janet Fitzgerald, Mental Health Lead Commissioner for West Berkshire PCTs Chief Executive Reading PCT Final page 77 19 January 2018 Thames Valley Personality Disorder Initiative…………………………… DateFinal page 78 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Berkshire……………………………………………………………Dr Maddy Podichetty, Consultant Psychiatrist in Psychotherapy with specialist responsibility for people with personality disorder in Berkshire …………………………… DateFinal page 79 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Berkshire……………………………………………………………Rita Nath-Dongre Director, REAP Resettlement Agency…………………………… DateFinal page 80 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Buckinghamshire……………………………………………………………Jill Cox, Chief Executive, Buckinghamshire Mental Health Trust …………………………… DateFinal page 81 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Buckinghamshire……………………………………………………………Kate Kennally, Executive Manager, Integrated Commissioning on behalf of Alan Webb, Wycombe PCT, Mental Health Lead Commissioner for Buckinghamshire PCTs…………………………… DateFinal page 82 19 January 2018 Thames Valley Personality Disorder InitiativeFinal page 83 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Buckinghamshire……………………………………………………………Dr Alex Esterhuyzen, Consultant Psychiatrist in Psychotherapy with specialist responsibility for people with personality disorder in Buckinghamshire …………………………… DateFinal page 84 19 January 2018 Thames Valley Personality Disorder InitiativeSignatures: Buckinghamshire……………………………………………………………Marion Panchkowry, Non-medical Consultant Psychotherapist, Project Clinical Lead for Buckinghamshire…………………………… DateFinal page 85 19 January 2018

Personality Disorder: No Longer a Diagnosis of Exclusion

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