Autumn In-Brief 2018 V10 FINAL - Flipbook - Page 9
Continued from previous page.
This structured approach puts an end to what can be an
escalating cycle of rejection that is wasteful of resources.
Rather it engages the service user and staff in a clear and
consistent therapeutic relationship. At the heart of this
This trust is similar to others we have studied. The data
approach is ‘structured clinical management’ which can be
suggests a significant demand on trust resources but with used during crisis, assessment and socialisation
many people still having crises and therefore not
/stabilisation. Large numbers of staff can attend two day
benefiting in the way NICE guidelines says they should. courses delivered by qualified practitioners.
We found patients in cluster 8 had about one third more
contacts than other patients and only a few people
accessed psychological therapy.
Designing your local pathway
Step 2 – Demand and capacity modelling – what is the
When collecting baseline information on your services it is level of demand now and how will this change as the
also helpful to look at:
service matures? What staff will be needed and what will it
cost? In the past a few staff, mainly clinical psychologists,
• Referral and discharge activity to examine ‘flow’
have done the specialist DBT or MBT training but have
through services of people in cluster 8. Establishing
found it difficult to implement in practice within a system that
variation in flow over at least one year, preferably
is not structured and consistent. These staff can then be
three, enables forward planning for demand and
seen as an expensive ‘extra’ rather than being at the heart
capacity.
of a different cost-effective system.
• Serious untoward incidents for people in cluster 8.
• Community team workforce (and cost) by profession
We have developed several tools to model future demand
and grade, and details of relevant training in
and capacity flows. The central features of a basic model
psychological therapies.
need to include:
Step 1 – Design the concept with clinicians in the lead
with frequent reference to service users and front line
staff and their managers. The model starts with a whole
organisation response to helping people with BPD, i.e.
from the Board to the receipt of services. The principles,
based on the delivery of evidenced-based therapy as per
NICE guidance are likely to be:
1. Based on past demand how many new referrals for
assessment?
2. Assume 75% go on to the stabilisation phase.
3. Assume 25% enter treatment.
4. Estimate capacity required for staff to provide 50:50 mix
structured clinical management or DBT/MBT – once
weekly 1:1 appointment and a group session.
5. Estimate net cost – remove demand and capacity from
•
Structured care – clear purposeful expectations for
current community team service and compare to new
service users and staff.
structured PD service. This assumes staff/posts could
•
Timed care - clear goals/outcome monitoring,
move from current teams to new service.
treatment starts and ends.
These factors, and additional ones, can all be modified until
•
Resilience, self management focus.
a balanced model is achieved. Clinicians and managers
•
Connectivity (social inclusion).
•
Efficiency in access – easy in, easy out – reducing need to be involved to ensure that the new structured
service is viable and does not increase pressure on generic
exclusion and over caring.
community mental health teams.
The pathway is for all people on cluster 8 with BPD. The
overall pathway is likely to last up to two years to be
Implement and monitor
effective. It is likely that fewer than half the people
Change of this nature requires project management,
referred will need, or want, the whole programme. Those communication, training and regular monitoring. What is the
who do not engage will be discharged but can easily re- feedback from service users and frontline staff? Have crisis
engage, but there is only one clinical offer. In addition,
events such as inpatient care and incidents of self harm
based on risk, there will need to be a ‘safety valve’ of
reduced or increased? Is the service able to achieve
short term crisis stabilisation and brief admission to
discharge when the patient has finished treatment? Is the
hospital, using the NICE guidance.
service accessible to referrers and service users? A
structured approach to implementation is as necessary as
the structured approach to service delivery for people with
BPD.
Dr Richard Ford, RMN, BSc, MSc, PhD is a Niche
Associate. Email: Richard.ford@nicheconsult.co.uk
With thanks to Dr Mark Sampson - Consultant Clinical
Psychologist, North West Boroughs Healthcare NHSFT.
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