Friday, 30 May 2014

Lords help us...

Given the Government’s commitment to parity of esteem for mental health, could the minister please explain:

Why Oxford’s flagship service for personality disorder (PD), developed in response to the ‘No Longer a Diagnosis of Exclusion’ policy in 2003, is having its budget cut by two thirds now that central funding (£750K) has been devolved to local Clinical Commissioning Groups (who will only fund £250K)? It is a small service with growing demand and robust evidence of effectiveness and cost benefit. This cut will mean that about 450 patients per year will need to receive suitable treatment elsewhere in already threadbare mental health services; how will this be managed?

Back story:
"Oxford Health", the sexily-named NHS foundation trust for mental health (and community health services) in Oxfordshire and Buckinghamshire, has told its 'Complex Needs Service' that it needs to make immediate plans to cut its budget by two thirds, with almost immediate effect. The patients in the middle of their intensive therapy were informed of this earlier this month (May 2014), and are anxious, angry and determined to do what they can to fight against the cuts in service.

The service was started in 2004 with central funding (directly from the government) of £950K per year for Oxon and Bucks, plus a £200K contribution from Buckinghamshire PCT – total £1,150,000 - and this continued until this year. The intention of the National PD Development Programme had always been to carefully plan the handover of funding (over several years if necessary) – but, despite much work and detailed negotiations since 2009, this has failed. The PCTs, and now CCGs, have failed recognise the value of the service and cooperate in the orderly handover of funding, so the finances have reached the end of the line and ‘hit the buffers’: the mechanisms for central funding which existed in the days of the national programme no longer exist in the structures of NHS England. 

All the funding for the complex needs services therefore now needs to come from the local Clinical Commissioning Groups (CCGs). Oxfordshire CCG has agreed to 'find' £250K, and Buckinghamshire will find nothing extra, but continue to contribute the £200K that has been there since the beginning. The way this has been presented to the public [CEO comments - click here] is somewhat disingenuous, and tries to portray the commitment of the CCG to personality disorder services, and their generosity in providing a sum which would mean impossibly severe cuts to the service.

Whether the NHS and Health and Wellbeing Boards recognise the ubiquity, severity and treatability of PD; the social and economic costs of failing to treat it; and the range of ground-breaking work undertaken by the National Personality Disorder Development Programme (NPDP) between 2003 and 2011 to work with it in new ways? Has the government effectively disowned this substantial body of ‘quality, innovation, performance and prevention’ (QIPP) orientated work? Could the government comment on clinicians’ and service users’ view that the Improving Assess to Psychological Treatment (IAPT) programme, where the development work is currently placed, is inadequate and unsuitable to manage the complexity, risk and cross-agency nature of PD and its treatment?

Back story:

In 2003, the government published ‘Personality Disorder: No Longer a Diagnosis of Exclusion’ – a policy guide that formally recognised PD as a condition deserving NHS treatment, with funding to set up eleven innovation-focussed pilot projects and to develop national training programmes to improve staff skills and reduce stigma. 

The ‘Thames Valley Initiative’ was the largest of the eleven pilot projects, covering a population of 2.1m in the then Thames Valley Region: Berkshire, Buckinghamshire, Milton Keynes and Oxfordshire. As NHS Foundation Trusts started to function as competing businesses, early hopes for a coordinated clinical network across the whole region soon faded, as Berkshire and Milton Keynes went their own way – and the separate mental health trusts in Oxfordshire and Buckinghamshire merged with each other, and with community services, to form ‘Oxford Health Foundation Trust’, in which the complex needs services were a tiny part of the budget and for which any organisational memory of the intentions of working across county borders was soon lost.

The National Programme was shut down (in March 2011) and a detailed clinical review, ‘Innovation in Action’, was commissioned and written – but never published. It describes the success of the pilot projects and was intended to be the official document marking the end of the programme, much as ‘No Longer a Diagnosis of Exclusion’ marked the beginning. The unpublished draft is available online:

With considerable reduction in all government budgets, the only remaining national mental health programme was ‘Improving Access to Psychological Treatment’ (IAPT, also known as ‘Talking Therapies’). This was a large, highly organised and widely implemented programme conceived to deliver cognitive behavioural therapy (CBT) at primary care level for people with mild to moderate depression and anxiety, in order to get them back to economic productivity. This programme has now been expanded to cover ‘serious mental illness’, part of which is personality disorder. However, it is much more restricted in its scope – and uses therapeutic methods and measures which fit a ‘psychological model’ of mental disorder rather than the ‘biopsychosocial’ one required for comprehensive treatment of personality disorder. Specifically, it cannot address the complexity of presentation of many people diagnosable with personality disorder, it does not have the mechanisms to engage people who are hostile to services because of previous bad experience, it cannot manage the high and randomly variable levels of risk inherent in a PD population, and it has no brief to work across agencies and sectors (most people with PD do not present in an orderly way to mental health services).

How the new NHS England commissioned specialist services (tier 4) can hope to effectively coordinate with local (tier 3) services in the light of NHS England’s policy to commission ‘self-contained’ tier 4 services, with no joint working across the local/specialist divide - while the CCGs are actively disinvesting in tier 3 (as in (1) above)? Is NHS England being specifically asked to give greater priority to administrative structures which will facilitate the growth of disconnected independent sector provision, than to satisfactory service user experience, coherent clinical care and ‘joined-up’ patient pathways? If this is done without advising and influencing CCGs to provide satisfactory tier 3 services, is it recognised that serious gaps in service provision for this very risky and vulnerable population will be created?

Back story:
NHS England is responsible for all specialist services in the NHS, of which there are about 130. One of these is ‘Severe Personality Disorder’, also known as ‘tier 4 PD’ (tier 1 is primary care and voluntary sector provision; tier 2 is local mainstream mental health services, such as community mental health teams and crisis services; tier 3 is local specialist services, as described above for the NPDP pilot services; tier 4 is for non-forensic specialist services beyond the scope of local provision; tiers 5 and 6 are for rarer cases where there is significant risk to others and history of offending – tier 5 is ‘medium secure’ and tier 6 is ‘high secure’. 

The divide between tier 3 and tier 4 has always been a problem, and there have been various attempts to build a bridge across it (so patients experience a coherent pathway, clinical communication is good, staff training is comprehensive, quality is defined and improved, and integrated research is possible).

Now that the funding arrangements have an absolutely sharp division between those that are nationally funded through NHS England (tier 4 and above) and those funded by local CCGs (tier 3 and below), such bridges are more difficult to build.

However, the NHS England policy of demanding specialist service specifications which do not include any possibility of establishing formal links or joint working with locally commissioned services – in order that they are open to ‘any qualified provider’ – has made these bridges well nigh impossible to build.

It does not take a great leap of imagination to think that this could be related to the government’s intention for the new NHS to have a much higher level of private provision. It is easy to see how fragments of disconnected service are much more likely to be profitable than those which offer coherent pathways and continuity of care. 


  1. I'm very grateful, as a GP in W Oxon, for this information; illuminates a lot of dark corners.

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