Save Derbyshire NHS Psychotherapy

Save Derbyshire NHS Psychotherapy

Last Night, November 21st 2018, more than 80 people attended the Candle Lit Vigil outside Derby Council House to Save Derbyshire NHS Psychotherapy. Folk then asked questions of the Council, about the threatened closure of the Dept by Southern Derbyshire CCGs and how this discriminates against most vulnerable people.
The leader of Labour City Councillors, Louise Eldret made a magnificent speech in support of this vital Derbyshire NHS Psychotherapy Dept

46517492_2165523810353380_9042793169141366784_nIn the picture , photo credit Marcus R James Derbyshire NHS SOS, the leader of Labour City Councillors Louise Eldret made a magnificent speech in support of this vital  NHS Derbyshire Psychotherapy Dept.

Candle-lit vigil in support of the Derby Adult Psychotherapy Service: 21st of November 5.15 pm, outside the full meeting of Derby City Council, Corporation Street.

Candle-lit vigil in support of the Psychotherapy Service:

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Candle-lit vigil in support of the Psychotherapy Service:

Wednesday, 21st of November 5.15 pm,  outside the full meeting of Derby City Council, Corporation Street.

Then listen from the public gallery from 6:00 pm onwards, while campaigners question the council.

Cut Threatened to NHS Adult Psychotherapy Service in Derbyshire

Cut Threatened to NHS Adult Psychotherapy Service in Derbyshire

What is this about? NHS Commissioners for Derbyshire want to cut a Psychodynamic Psychotherapy Service provided by the Derbyshire Healthcare NHS Foundation Trust (DHCFT). The public consultation on this proposal is running from 10th October 2018 until 11th January 2019 and Commissioners have produced a consultation document and questionnaire to accompany it (http://www.southernderbyshireccg.nhs.uk/have-your-say/consultations/psychodynamic-psychotherapy/).
This proposed cut would remove a crucial source of help, leaving people in Derbyshire without access to a well- respected, proven and in- demand therapy.
So who does this psychotherapy service help? The Psychodynamic Psychotherapy Service provides therapy to adults profoundly affected by traumatic childhood experiences such as physical abuse, sexual abuse and neglect, with severe and enduring effects on their mental health. For many this includes self-harm, suicide attempts and multiple use of services.
Psychotherapy can help treat their distress and move them towards recovery. Therapists know through feedback how highly the service is valued. For many people it has been a literal life line. Many move out of the mental health system following therapy.
Nowhere in their consultation document do Commissioners
• acknowledge the gap that would be left if they cut this service
• answer how people in such distress would, in the future, find the therapy they need

What is the demand for this service? Demand for Psychodynamic Psychotherapy is very high. The Service is only able to accept one in three suitable referrals as accepting all would result in unacceptably long waiting lists. The result is that many people whose needs are fully appropriate are already turned away.
If the service is cut, surely there are others who can see such people in future?
There is nowhere else in the already over-stretched mental health services for these patients to go for the type of therapy they require. Many people who are referred to the service have already tried alternative therapies and, for them, this Psychodynamic Psychotherapy Service is the only realistic and appropriate option.
Is there a problem with the consultation process?
Commissioners have produced this proposal and begun this consultation without taking advice.
But they do not have the kind of detailed knowledge of psychotherapies in Derbyshire that would allow them to make for themselves, without assistance, well informed judgements about what services are needed and what gaps a cut like this would create.
And they have failed since 2005 to carry out a thorough review of the range of therapies, the role each type of therapy plays and the gap that would be left if any one therapy service was cut.
And they have failed since 2011 to create a service plan for psychotherapies in Derbyshire.
NHS Psychotherapy services in Derbyshire have been hindered in their development for several years now by the lack of clear Commissioner engagement and joint planning.
How long has there been this threat to the service? Commissioners conducted the same consultation in 2011 and the outcome was very positive for this service. So, UNITE does not understand why Commissioners are now repeating this consultation.
In September 2017 Commissioners announced they planned to start a public consultation. Since then four potential starting times for the consultation have come and gone. By the time this Consultation has closed and a decision reached in March 2019, the service will have been under threat for 18 months.
Commissioners seem, at the very least, insensitive to the effects on the Service, both on the people who come for therapy and on their therapists, of such a long and protracted threat to therapies.
UNITE understands that Commissioners are now planning to engage in a review of all therapies in Derbyshire, a review that might lead to the development of new proposals, different to this one.
Clinicians, Unions and Health Service Managers have asked Commissioners to withdraw this proposal and wait to see what more informed and evidence- based proposals emerge from a full review.
So it is unclear: ‘why are we still having this consultation?’

How well do Commissioners understand the needs of people who use this service?
Commissioners describe the Psychodynamic Psychotherapy Service as a ‘nice to have’ but not ‘must do’ service. This inappropriate and insensitive language suggests that Commissioners do not adequately understand the depth and intensity of the work that people do in this type of therapy, in which the painful experiences of sustained childhood trauma and its severe and enduring effects are worked with and associated risks are managed. This proposal has created immense anxiety and insecurity among the 136 people who currently attend for therapy, increasing for some the risk of self-harm. Current care has been compromised unacceptably. Commissioners seem to lack awareness of the crucial importance for any therapy of a sufficiently stable environment in which this demanding and challenging work can be done.Therapists and those who attend for therapy deserve better than this insensitive, insufficiently informed and unnecessarily protracted process.

How important is it to have a choice of therapy? Commissioners are proceeding with this consultation as if it is optional to offer people a choice of the type of therapy they will receive. In fact, denying people such a choice runs contrary to clear guidance and evidence.
People coming for therapy need the opportunity to be matched to the therapy best suited to their needs. This is a crucial factor in the successful outcome of any therapy. If this service is cut, then meaningful choice will have been removed.
Is there a problem with equal access to the service across Derbyshire?
This service is not as available in the North of the County as it is in the South of the County and this is a reason Commissioners have put forward for cutting the service. Commissioners appear to be saying that, in the interest of equality, everyone in Derbyshire should be equally deprived of this service. This cannot be the only option. Commissioners could explore ways of making the service more available in the North of the County.
What about the financial cost of this service?
Any short- term savings made by cutting this service would be outweighed by increased long term costs.
This is because this service helps people to move towards recovery, facilitates them to remain in work or return to work, reduces demands on wider mental health services and GPs and supports the mental health of families and children. The Service aims to produce lasting change in people’s lives.
The potential length of therapies is vital in preventing the kind of ‘revolving door’ experience many people have in which help that is too short in length results in their needing to keep coming back. The effectiveness of the work is demonstrated through a variety of outcome measures that the service uses.
Is there an evidence base for this therapy?
The summary of research evidence provided by Commissioners seriously misrepresents what NICE guidelines say about Psychodynamic Psychotherapy. There is clear evidence that this type of therapy is effective and makes a difference to peoples’ lives.
In fact, Commissioners appear to agree because, at a meeting of County Councillors in July 2018, Commissioners stated that they accepted that the service has an evidence base for its work and, as a result, Commissioners would no longer be arguing that it should be cut due to a lack of evidence.
Is more money being spent on Psychological therapies in Derbyshire?
While funding has increased over the past four years for short term therapies, funding has decreased for people whose therapies need to be longer than six sessions due to the extent of their childhood trauma. Now, this proposal would see their specialist therapy service cut altogether.
There are three questions that UNITE believes Commissioners need to be challenged to answer:
1. When did those in the most need become a lesser priority for funding?”
2. Where are such people to go in future for the therapy they urgently need if the service is cut?
3. With all that we now know from the media about the extent and effect of the historic abuse of children, can this really be the time to cut a therapy service that specialises in treating adults so profoundly affected by their childhood trauma?
In summary, UNITE cannot see the sense of Commissioners:
….seeking to cut this psychotherapy service before conducting, in partnership, a full review of all NHS psychotherapies in Derbyshire out of which more informed and evidence-based proposals could emerge
….cutting a valued service which is in high demand and has an excellent record of helping adults whose mental health has been profoundly affected by childhood trauma
….failing to address anywhere in their consultation document the gap in therapy services that this cut would create
….failing to put forward any ideas about how such people with severe and enduring needs would find the therapy they need in the future
….treating people in most need as a lesser funding priority compared to those whose needs might be me in short term therapies.
….resolving inequity by ensuring everyone in Derbyshire is equally deprived of the service
….making savings in the short term that will lead to increased costs in the long term
….taking away from people the opportunity to be matched to a therapy that suits their needs.
So, what can I do?
Sign the petition: https://you.38degrees.org.uk/petitions/save-derbyshires-nhs-specialist-psychotherapy-service
Complete the Commissioner questionnaire https://www.surveymonkey.co.uk/r/PPtherapy
Contact your MP: to find your MP follow the link https://www.theyworkforyou.
Contact your Local Councillor: https://www.gov.uk/find-your-local-councillors/
Contact the Chairs of the City and County Committees with scrutiny roles:
• David Taylor, Chair of Derbyshire Improvement and Scrutiny for Health Committee, County Hall, Matlock, Derbyshire. DE4 3AG email: david.taylor@derbyshire.gov.uk
• Jangir Khan, Chair of the Adults and Health Review Board, Council House, Corporation Street, Derby. DE1 2FS. Email: jangir.khan@derby.gov.uk
Contact the Lead Commissioner to raise your concern: Dr Chris Clayton, Derbyshire Clinical Commissioning Group, 1st Floor North Point, Cardinal Square, 10 Nottingham Road, Derby. DE13QT. Tel: 01332 888080 email sderccg.enquiries@nhs.net

Current or former therapy patient? HealthWatch Derbyshire would like to hear your views and will present a summary on your behalf to Commissioners at the end of the consultation. Contact details: Suite 14, Riverside Business Centre, Foundry Lane, Milford, Belper, Derbyshire. DE56 0RN Tel: 01773 880786 Enquiries@healthwatchderbyshire.co.uk
If you feel able to share your views or experiences of the value of Psychodynamic Psychotherapy with local newspapers or TV, please contact me. I can help you set up the contact so that your voice can be heard. Interviews can be anonymous.
Please feel free to copy me into any correspondence you send to MPs or Councillors or Commissioners so that UNITE can keep an overview of the feedback they are receiving.
Want more information?

Its available at:
Website https://savederbynhspsychotherapy.blog
Twitter @DerbyPsychothe1
Facebook: https://www.facebook.com/SaveNHSDerbyPsychotherapy/

Maureen Scott-Douglas
maureen.scott-douglas@unitetheunion.org
2 Pride point Drive, Pride Park, Derby DE24 8BX
Tel: 01332 548 400

UNITE’S FORMAL COMPLAINT TO DERBYSHIRE NHS COMMISSIONERS IN RESPONSE TO THEIR CONSULTATION DOCUMENT AND THE MISLEADING SUMMARY OF EVIDENCE. THE PSYCHODYNAMIC PSYCHOTHERAPY SERVICE AND ITS EVIDENCE BASE

THE PSYCHODYNAMIC PSYCHOTHERAPY SERVICE AND ITS EVIDENCE BASE
UNITE’S FORMAL COMPLAINT TO DERBYSHIRE NHS COMMISSIONERS IN
RESPONSE TO THEIR CONSULTATION DOCUMENT AND THE MISLEADING
SUMMARY OF EVIDENCE
PRESENTED BY UNITE ON BEHALF OF THE SPECIALIST PSYCHODYNAMIC
PSYCHOTHERAPY SERVICE – A SERVICE PROVIDED BY DERBYSHIRE HEALTHCARE NHS
FOUNDATION TRUST
NOVEMBER 2018
THE PSYCHODYNAMIC PSYCHOTHERAPY SERVICE AND ITS EVIDENCE BASE
EXECUTIVE SUMMARY OF FORMAL COMPLAINT
NICE recommendations:
• Nice strongly recommends the provision of psychological therapies for Service Receivers who are diagnosed with Personality Disorder.
• NICE states that Psychodynamic Psychotherapy has an evidence base for this kind of work that is equivalent to that of other therapy approaches.
• NICE recommends commissioning services that allow for Service Receivers to exercise choice and be matched to the type of therapy that suits their needs
• NICE requires Commissioners to avoid discrimination and promote equal opportunity
• NICE describes the necessary characteristics of a personality disorder service
• NICE recognises there is already a shortage of trained NHS therapists for this work
Commissioner’s proposal would run contrary to these clear recommendations from NICE in the following ways:
• Commissioners have wrongly asserted Psychodynamic Psychotherapy has a lesser evidence base for this work than other therapies
• Cutting the Psychodynamic Psychotherapy Service would prevent Service Receivers exercising choice and being matched to the therapy that suits their needs.
• Cutting the Psychodynamic Service would disproportionately affect those in the most need, particularly women severely abused as children
• Commissioners would be cutting a service that matches the NICE description for a Personality Disorder Service
• Commissioner’s proposal would lead to experienced therapists being made redundant despite a shortage of trained therapists
• Commissioners accepted in July 2018 that the Psychodynamic Service has an evidence base for its work so why is this still a ground for decommissioning the service?
• The extent of misrepresentation of relevant NICE guidelines in the public consultation document has severely compromised the integrity of the consultation
And there are other problems
• Commissioners unfairly require higher standards of evidence from the Psychodynamic Service than other therapies
• Commissioners are making decisions that lack transparency
• It is many years since Commissioners conducted a full review of all Psychological Therapy services in Derbyshire and, as a result, their understanding is out of date
• Commissioners have created this proposal on their own when they should have created it in partnership with Clinicians and Service Receivers and others
• Service Receivers are not being helped enough to put their views to the consultation
UNITE has called on the Commissioners to withdraw their proposal and conduct a full review of all Psychological Therapy Services in Derbyshire out of which more informed proposals can emerge.
Please support our campaign.
Sign the petition at: https://you.38degrees.org.uk/petitions/save-derbyshire-nhs-specialist-psychotherapy-service
Complete the questionnaire: https://www.surveymonkey.co.uk/r/PPtherapy
See the campaign website: https://savederbyshirenhspsychotherapy.blog
THE PSYCHODYNAMIC SERVICE AND ITS EVIDENCE BASE
A FORMAL COMPLAINT TO COMMISSIONERS
UNITE has lodged a formal complaint with Derbyshire NHS Commissioners about the summary of the evidence base provided by Commissioners in their public consultation document concerning the decommissioning of the Psychodynamic Psychotherapy Service.
This summary seriously misrepresents to the reader the advice given in NICE guidelines about the treatment of Personality Disorder, and Borderline Personality Disorder (BPD) in particular.
It does so in a way that is prejudicial to the Psychodynamic Psychotherapy Service. Due to the importance of the evidence base to this consultation process and outcome, UNITE has provided below an accurate survey of relevant NICE guidelines and highlighted both their implications for this proposal and other flaws in the consultation.
In summary:
• Nice recommends the provision of psychological therapies for BPD.
• NICE states that Psychodynamic Psychotherapy has an evidence base for this kind of work that is equivalent to that of other therapy approaches.
• Commissioners accepted in July 2018 that the Psychodynamic Service has an evidence base for its work
• This proposal would prevent Service Receivers having the choice of therapies that NICE recommends in order to ensure they are matched to the therapy that suits their needs.
• The proposal would disproportionately affect those in the most need, particularly women who were severely abused as children
• NICE recognises there is already a shortage of trained NHS therapists for this work
• In the requirement for evidence bases the Psychodynamic Service is repeatedly being held to a higher standard than other therapies and decisions are made that lack transparency
• The extent of misrepresentation of relevant NICE guidelines in the public consultation document has severely compromised the integrity of the consultation
• In other ways Commissioners have created a flawed process which needs to be acknowledged
• Commissioners need to ensure that future reviews of Psychological Therapies include all relevant stakeholders
NICE produce guidelines not mandates
The public consultation document states that “NICE mandates the commissioning of some specialist psychotherapies which means CCG should really commission them…. but does not mandate the commissioning of Psychodynamic Psychotherapy”.
This is a problematic statement as NICE, in fact, does not produce mandates and so there are no mandated treatments for personality disorder. In a preface to each guideline NICE states, in a section entitled ‘Your Responsibility’;
“it is not mandatory to apply the recommendations and the guideline does not override the responsibility to make decisions……Local Commissioners should do so in the context of local and national priorities …..”.
The message from NICE is that Commissioners have to own their decisions and there are no NICE ‘mandates’ that take this responsibility away from them.
NICE makes recommendations
NICE produces guidelines and makes recommendations based upon a thorough investigation of the evidence.
“NICE applies the term ‘offer’ (or ‘provide’ or similar wording such as ‘advise’ or ‘refer’) to denote a strong recommendation (NICE Review of Guidelines for BPD, 2017)”.
Commissioners have stated in correspondence that, for this consultation, “the judgment here is whether the CCGs are able to afford services that are not mandated therapeutic services but an optional service”.
Can we be clear about this. NICE do not categorise therapies as ‘mandated’ or ‘optional’. Commissioners should not superimpose their own preferred language on to NICE guidelines.
NICE recommendations and summary of the evidence
NICE recommends that “people with borderline personality disorder are offered psychological therapies (NICE Quality Standard QS88)”.
NICE regards this as a strong recommendation, equivalent to ‘provide’, and this recommendation is endorsed by NHS England. The NICE surveillance report (2018) saw no reason to change this recommendation.
NICE describes therapies such as Psychodynamic or CBT or DBT as having an equivalent evidence base for their work with Borderline Personality Disorder (BPD). NICE notes there is, as yet, “an absence of any clear evidence that one treatment or a type of service is more advantageous than another” (Guideline 78:8.5.18).
NICE is not supportive of Commissioner assertions that the Psychodynamic Service has a lesser evidence base for their work with BPD than other types of therapy.
NICE recognises that, “the state of knowledge about current treatments available for Personality Disorder is in a developmental phase rather than one of consolidation….better designed studies need to be undertaken before stronger recommendations need to be made (BPD 5.11)”.
This applies equally to CBT and DBT, not just Psychodynamic Psychotherapy, and reflects, among other reasons, the difficulty of researching more complex psychological problems and their treatment. Instead of seeing this as a reason not to commission such treatments, NICE recommends they are ‘offered’ and describes the kind of research needed in the future to clarify further their effect.
NICE states, “research suggests that psychological therapy programmes such as dialectical behaviour therapy or mentalisation-based therapy as delivered in the studies reviewed for this guideline, may benefit people with borderline personality disorder. However, trials are relatively small and research is generally at an early stage of development with studies tending to examine interventions delivered in centres of excellence (5.13.1)”. Nice calls for more pragmatic studies to be undertaken.
Mentalisation-based therapy is a form of Psychodynamic Psychotherapy. It has now completed a second Randomised Controlled Trial (RCT). Transference focused therapy is another form of Psychodynamic Psychotherapy that now has completed RCTs. This will influence future guidelines.
In an update on the effectiveness of Psychodynamic Psychotherapies (World Psychiatry: June 2015) Peter Fonagy writes: “the strongest current evidence base supports relatively long-term Psychodynamic treatment of some Personality Disorders, particularly Borderline Personality Disorder”. He goes on to recognise that all treatments for Personality Disorder require more quality research in order to clarify further their effectiveness.
NICE emphasises the importance of Service Receiver involvement and choice
NICE asserts that treatment should be tailored to the individual, to the type of personality disorder and the presenting problems. Because of the variety of symptoms and the variation in needs, flexible approaches that are responsive to the needs of each person with personality disorder are important. Involving people with borderline personality disorder in decisions regarding their own care is key for their engagement with treatment.
“It was the view of the Guideline Development Group that specialist services should not be restrictive and should offer more than one type of intervention to meet the predominantly complex needs of service users and allow for flexibility and choice to be exercised” (8.5.18).
“When considering a psychological treatment for a person with borderline personality disorder, take into account the choice and preference of the service user” (1.3.4.1).
“Service Receiver views are paramount” (8.5.14.1).
Service Receiver feedback shows how highly they value the service which many have been referred to after trying other types of therapy with limited effect. Derbyshire Voice produced a very full summary of Service Receiver views for the consultation in 2011 which is available to Commissioners and which provides evidence of Service Receiver views at that time. Commissioners are in clear breach of the Nicholson test (2010) that requires proposals “to demonstrate consistency with current and prospective patient choice”.
Further implications of this proposal for choice and particularly for women
The Service Receivers most disproportionately affected by this proposal will be women who were subjected as children to sustained sexual abuse with severe and enduring effects on their adult mental health. At any one time they can represent up to 75% of Service Receivers who attend the Psychodynamic Psychotherapy Service.
At a time when funding for services for those with mild to moderate psychological difficulties continues to expand, here is a proposal for a serious cut of service for those most in need, with severe and enduring psychological difficulties. UNITE does not understand why these Service Receivers have become a lesser priority to Commissioners.
NICE surveillance report for BPD (2018) states: ‘Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity.’ This proposal contravenes this expectation.
Furthermore, the Gunning principles (1985) states that “Equality assessments should take place at the beginning of the consultation and be published alongside the document”. UNITE has not been able to find a published copy.
There is already an absence of meaningful choice for patients in Derbyshire who need the kind of Specialist Psychological Therapy that allows them to work in depth with the effects of severe childhood trauma. CBT is not commissioned to work with childhood trauma in Derbyshire and Psychologists varied and valuable work is not an equivalent to the work done by the Psychodynamic Service and they have long waiting lists.
Over the past thirty years the Psychodynamic Psychotherapy Service has been the specialist NHS service in Derbyshire to which patients can be referred for sustained and in-depth work on the severe and enduring effects of their childhood trauma.
Cutting the Psychodynamic Psychotherapy Service would not restrict choice so much as leave a huge gap in service, significantly disadvantaging people who suffered serious childhood trauma.
Commissioners make no acknowledgement of this.
NICE description of the necessary treatment service characteristics for BPD
NICE describes the need for more services for personality disorder (not less as this proposal would create) and states that, “the limited availability of such services for people with personality disorder suggests that they should focus on those with severe personality disorder who have greater impaired functioning and may have high levels of risk. In addition, they are likely to have high levels of service utilisation” (8.5.19.5) This is exactly where the Derbyshire NHS Psychodynamic Service is focused.
NICE states that to provide a service for people with BPD, “the following service characteristics should be in place (10.3.4.3):
• an explicit and integrated theoretical approach used by both the treatment team and the therapist, which is shared with the service user
• structured care in accordance with this guideline
• provision for therapist supervision
• do not use psychological interventions of less than three months duration
• twice-weekly sessions may be considered
• when providing psychological treatment to people with borderline personality disorder, monitor the effect of treatment on a broad range of outcomes, including personal functioning, drug and alcohol use, self-harm, depression and the symptoms of borderline personality disorder (1.3.4.7)”.
• “When considering a psychological treatment for a person with borderline personality disorder, take into account the choice and preference of the service user” (1.3.4.1).
The Psychodynamic Psychotherapy Service is the NHS service in Derbyshire that most closely fits this description by NICE. It is focused on Service Receivers with severe BPD who have high levels of impairment, risk and service utilisation. It provides therapies with an average length of 15 months which helps prevent revolving door syndrome whereby Service Receivers keep having to return as previous treatment has been too short in length to address the severity of their needs.
It has an integrated theoretical approach that is shared with the Service Receiver. It provides a structured and stepped care approach, offering once weekly therapies or a more intensive group therapy programme according to need. Therapists have weekly supervision.
Therapies are regularly reviewed with the Service Receiver and a range of outcome measures used. Risk is carefully monitored. A shared care plan within the service and safety plan is negotiated with the Service Receiver and reviewed regularly.
NICE stresses the need to manage, with care, endings and transitions
The BPD guidelines stress the importance of anticipating that “the withdrawal and ending of treatments or services…..may evoke strong emotions and reactions in people with borderline personality disorder” (1.1.7). It calls for careful discussion and planning with service receivers.
In reality, news of the planned consultation became public in April 2018 when the Commissioners attended the Derby City council meeting. However, it was not until October 2018 that Service Receivers were officially informed of the proposal through receipt of a public consultation document which devotes only four lines to addressing their concerns about the future of their therapies and does so in very general terms.
Service Receivers and their therapists need a service that has sufficient stability to support and contain them while they do the difficult work of addressing the on-going effects of childhood trauma. Instead, Commissioners have engaged the service in an appallingly protracted process, now 14 months with more months to run. This has had the effect of paralysing future planning and causing deep insecurity for the 136 current Service Receivers. Vacant posts have been frozen, so the service is now 3.5 posts down and access to the service has now been closed with a waiting list that stands at over 14 months.
For Service Receivers to feel that their views on the proposal are wanted and valued, they needed to have channels set up that met their needs. The format chosen by Commissioners for Service Receivers to contribute their views to the consultation is not adequate to the task. Commissioners did not accept fully the Trust advice on the different ways that needed to be offered to Service Receivers to help them articulate and pass on their views to the Commissioners. Commissioners risk repeating Service Receiver damaging experiences of their views being sought only on someone else’s terms.
Commissioners have not shown the necessary care that NICE recommends.
NICE recognises the shortage of therapist trained to provide treatment for BPD
“In practice, the limiting factor in providing access to psychological therapies {for BPD] is the very small proportion of NHS staff trained to deliver these to a competent standard” (2.5.3). It is does not make sense for Commissioners to cut this therapy service that is staffed by well trained and experienced therapists who would be made redundant and their skills and experience lost to Service Receivers in Derbyshire. They are further needed to provide the kind of training and supervision to other staff in working with BPD that NICE recommends. They provide a service that is consistently assessed as ‘outstanding’ in annual quality inspections.
Commissioners accepted there is an evidence base
Commissioners met with Derbyshire County Councillors on 16th July 2018 to discuss this proposal. They stated to councillors that they now accepted that there is an evidence base for Psychodynamic Psychotherapy and were withdrawing a lack of evidence as a ground for decommissioning the service.
And yet, in October 2018, it is again presented in this public consultation document as a ground for decommissioning.
Why is Psychodynamic Psychotherapy being held to a higher standard?
Despite already accepting the evidence base, Commissioners refer in the public consultation document to there being insufficient evidence, “to suggest that Psychodynamic Psychotherapy is a more effective treatment in comparison to other specialist psychological therapies”. NICE does not set as a criterion for a positive recommendation of a therapy that it has to show it is ‘more effective’ than other therapies.
Can Commissioners explain why they have created this criterion, not found in NICE, and why they are holding only Psychodynamic Psychotherapy to this higher evidence standard? They are presumably not arguing that all approaches should be decommissioned as current evidence suggests none are superior?
NICE guideline notes that the varied nature of the work done by Clinical Psychologists, in their treatment approaches to Personality Disorder, makes it hard to research and as such there is a lack of evidence for the very valuable work that they do. But NICE does not recommend they be decommissioned. Yet, here is a proposal to decommission a Psychodynamic Psychotherapy service that does have an evidence base for its work, an evidence base that NICE acknowledges is equal to other therapy approaches.
The unequal distribution of the Psychodynamic service across the County has been used by Commissioners as a reason to propose decommissioning the service. However, CBT is also unequally spread across the County but is not threatened, as a result, with decommissioning. In this way too, Psychodynamic Psychotherapy is being held to a higher standard.
Commissioners assert that the Psychodynamic Service has failed their test of ‘affordability’. However, they have no criteria against which to judge this. They admit that “the four Derbyshire CCGs do not have a specific commissioning policy which describes how affordability of all services is categorised or ranked”.
How can Commissioners demonstrate that the Psychodynamic Service is any more or less affordable than other therapy services without clear criteria backed up by reliable figures?
Where is the transparency in this process and how can this assertion that the service has failed a test of affordability be subjected to healthy scrutiny outside the walls of Commissioner offices?
Ongoing problems with the proposal and consultation process
The many flaws in this proposal, and the consultation process that accompanies it, reflect the way that it has been developed without the voice of clinicians and other relevant stakeholders. The public consultation document states: “in spring 2017 NHS Southern Derbyshire Clinical Commissioning Group (SDCCG) led a review of specialist psychological therapy provision in the south of Derbyshire”. UNITE asks who was involved in this review? Certainly not clinicians and UNITE is not aware of any other relevant stakeholders who were involved.
This in clear breach of the Nicholson test (2010) which requires Commissioners, “to demonstrate strengthened public and patient engagement. It contravenes clear expectations in the Health and Social Care Act (2012).
This failure to consult appears on the verge of being repeated. In your letter to a Derbyshire MP you write on 22nd October 2018 that: “we are also undertaking a much larger review of all psychological therapy provision and the outcome of this piece of work will be presented to CCG Governing Bodies in the New Year”. Who will be involved in that review? Will it once again exclude clinicians and other relevant stakeholders? It is hard to see how any review, conducted within a 12-week time frame, without real consultation, can be anything other than a cosmetic exercise.
Commissioners continue to act as if Purchasers have nothing to learn from Providers and no obligation to involve them in service wide reviews.
We would ask that Commissioners do not again describe the Psychodynamic Service as a ‘nice to have’ but not a ‘must do’ service. Whatever Commissioners mean by these words, the description of the service as ‘nice to have’ is experienced by Service Receivers and Therapists as deeply denigrating of the work being done in therapy. In therapies Service Receivers confront appalling memories of childhood traumas (which may include sexual or physical abuse and neglect) and the severe and enduring effect this has had on their adult mental health and relationships. They also address the parts of themselves that self- harm and/or are pre-occupied with suicidal thoughts. We would ask Commissioners to use language that is respectful of this work.
Implications for Commissioners
Commissioners need to:
• ‘offer’ psychological therapies to people with borderline personality disorder.
• recognise the evidence base of the Psychodynamic Service is equal to other therapies
• commission therapies that allow Servicer Receivers meaningful choice
• acknowledge that the Psychodynamic Service matches NICE service characteristics
• avoid disproportionate effects on those most in need, particularly women
• organise better ways of helping Service Receivers express their views
• not hold the psychodynamic Service to a higher standard than other therapies
• not add to the shortage of staff trained to work with BPD
• recognise that purchasers need to learn from providers
• ensure that future reviews include all relevant stakeholders
• represent the NICE guidelines fairly and accurately
• recognise that the integrity of the consultation has been seriously compromised
Decommissioning the Psychodynamic Psychotherapy Service would run counter all the above.
In conclusion
UNITE believes that it is unacceptable for Commissioners to misrepresent to the reader NICE research recommendations in this way in a public consultation document. The second Gunning principle (1985) states: “People involved in the consultation need to have enough information to make an intelligent choice and input in the process”. Commissioners risk unjustly undermining service receiver faith in the therapy in which they are engaged and increasing clinical risks among this already vulnerable group.
This misrepresentation, alongside the many other flaws identified in this letter, has damaged the integrity of the consultation process and prejudiced its outcome. It is difficult to see how the integrity of this consultation can now be salvaged.
UNITE urges Commissioners to withdraw this proposal and instead conduct, in full partnership with all relevant stakeholders as required by law, a long overdue review of the range and type of Psychological Therapies in Derbyshire.
Out of this review a more informed overview can emerge that would create a shared understanding of the needs of the people of Derbyshire and the best ways in which psychological therapy services could be organised to meet that need. New proposals could then emerge which are both evidence-based and practice-based.
Maureen Scott-Douglas
Regional Officer
14th November 2018