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

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