Needs Assessment for people with Borderline Personality Disorder
and Antisocial Personality Disorder in Derbyshire County and Derby
City
Dr Elizabeth Orton, Specialist Trainee in Public Health
1 Introduction - What is the issue?
The term Personality Disorder (PD) can be used to describe “the problematic way of coping
with everyday life and dealing with self, others and the world which result from the interplay
between genetic and environmental factors and disrupted early development”1.
Because of the complex nature of PD, both in terms of recognising symptoms, the frequent
presence of co-morbidities or dual diagnosis with drugs and alcohol problems, people with PD
are often diagnosed after a prolonged period of contact with medical, social and/or criminal
justice services. Diagnosis can take a long time and is often via a process of elimination of
other psychiatric morbidities. Commissioning appropriate PD services therefore is a complex
matter that requires joint working across agencies. In addition, simply viewing the
epidemiological evidence of PD prevalence, if used in isolation, can give an unhelpful
perspective in terms of need, since people with PD may go through phases of receptiveness
to treatment and may need several episodes of treatment in their lifetime2,3.
1.1
The scope of this document
For the purposes of this options paper, two main categories of personality disorder are
considered: Borderline Personality Disorder (BPD) and Antisocial Personality Disorder
(ASPD). BPD is characterised by significant instability of interpersonal relationships, selfimage and mood, and impulsive behaviour. It is often associated with suicidal thinking and
self harm with a high risk of suicide4. ASPD is characterised by high negative emotionality,
low conscientiousness and associated behaviours including irresponsible and exploitative
behaviour, recklessness and deceitfulness5. PD is generally not diagnosed in young people
since characteristics can be confused with those demonstrated during adolescence, however
there is some evidence that early indicators of adult PD can be identified in young people and
so the NICE guidance calls for integrated working between adult mental health services and
children and adolescent mental health services (CAMHS).
This paper does not include the provision of services for those with a severe personality
disorder who present significant risk of harm to others (dangerous people with severe
personality disorder – DSPD) or the provision of early intervention for children and young
people, although this should be considered through additional work.
1
Department of Health. Recognising complexity: Commissioning guidance for personality disorder services
(2009)
2 Tyrer, P. Personality disorder and public mental health. Clinical Medicine v8(4) (2008)
3 Gyles Glover, North East Mental Health Observatory personal communication.
4 National Institute for Health and Clinical Excellence clinical guideline 78, 2009
5 National Institute for Health and Clinical Excellence clinical guideline 77, 2009
1
1.2
The policy context
Over the last 10 years there has been a significant change to how people with PD are viewed in terms
of their health and well-being needs. Below are the key policy papers that have been instrumental in
this change.
1) Managing Dangerous People with Severe Personality Disorder (1999)6. This document
addressed the lack of treatment available for those people with sever PD who present a
danger to the public.
2) Personality Disorder: No longer a diagnosis of exclusion (2003) 7. Prior to the
publication of this document people with Personality Disorders (PD) were frequently unable to
access appropriate care in secondary mental health services. This document confirmed that
PD services should be part of the core business of mental health trusts. It suggested that
specialist multi-disciplinary PD teams should be established for people with PD in significant
distress, with difficulties or complex needs and the development of specialist day patient
services in areas with high morbidity from PD. Consideration was given to how forensic
services develop expertise in the identification and assessment of PD offenders, with the
development of a small number of centres nationally and regionally for the assessment,
treatment and management of PD offenders. In addition it acknowledged the need for
additional professional training in PD.
3) Breaking the Cycle of Rejection: The Personality Disorder Capabilities Framework
(2003)8. Focuses on the training of staff in health and social care in relation to PD.
4) Reaching out: An action plan on social exclusion (2007)9. This work focuses on a
prevention agenda aimed at socially excluded people, including young people with personality
disorder.
5) NICE guidelines10,11 (see below)
6) The Bradley Report (2009)12. This review highlights the need for the early identification of
people with mental health problems or learning difficulties entering the criminal justice system.
It sets out recommendations in the context that custody may exacerbate mental illness and
may not be the right environment for such people to be in. In doing so, recommendations are
outlined for appropriate timely intervention.
7) The PD Knowledge and Understanding Framework (2008). This report provides an
analysis of training that is available nationally on PD and defines a future training framework.
8) Recognising Complexity: Commissioning guidance for personality disorders (2009)13.
In June 2009 commissioning guidance was published that recognised the complex needs of
people with PD who may be vulnerable children at risk, people with substance misuse
problems, women with complex needs or offenders. In doing so, it recognises the need for
integrated commissioning of PD services across health, social care, children’s trusts,
substance misuse services, the police and criminal justice agencies.
6
Department of Health/Home Office (1999)
National Institute for Mental Health in England (2003a).
8 National Institute for Mental Health in England (2003b)
9 Cabinet Office (2006)
10 National Institute for Health and Clinical Excellence Clinical Guideline No77 (2009)
11 National Institute for Health and Clinical Excellence Clinical Guideline No78 (2009)
12 Department of Health (2009)
13 Department of Health (2009)
7
2
1.3
The epidemiology of PD
Prevalence estimates from national survey data – general population
Using DSM-IV, the adult psychiatric morbidity in England survey 2007, estimated the
prevalence of ASPD from age 18 and BPD from age 16. Results are shown in Table 1. The
study estimated that ASPD is more prevalent in the younger adult male population (1.5% in
18-34 year old men compared to 0.4% of women) whereas BPD is more prevalent in the
younger adult female population (1.4% of 16-34 year old women compared to 0.3% of
men). Prevalence is significantly reduced in the higher age categories.
Table 1 Age-specific prevalence (% of sample population) of antisocial (ASPD) and
borderline (BPD) personality disorders in people aged 16/18-74 and living in England, 2000
and 200714.
Type of PD
Men
ASPD
BPD
Women
ASPD
BPD
All adults
ASPD
BPD
Age group
16/18-34
%
35-54
%
55-74
%
All aged 16/18-74
%
1.5
0.3
0.2
0.2
0.4
0.6
0.3
0.4
1.4
0.5
-
0.1
0.7
1.0
0.8
0.1
0.4
0.2
0.4
0.5
Adapted from table 6.2 Adult psychiatric morbidity in England, 2007 p117
Prevalence estimates from national survey data – prison population
In 1998 the APMS prisoners’ survey15 estimated through a screening tool (SCID-II) and a
sample of clinical interviews using DSM-IV the prevalence of Personality Disorders. The
results are shown in Tables 2&3.
Table 2 Prevalence (%) of Personality Disorders in Prisoners in England and Wales.
Type of PD
Any Personality Disorder
ASPD
BPD
Male remand
78%
63%
23%
Prison group
Male sentenced
64%
49%
14%
Female prisoner
50%
31%
20%
Source: APMS Prisoners’ survey 1998
14
McManus S, Meltzer H, Brugha T, Bebbington P, Jenkins R (Eds) (2007) Adult Psychiatric Morbidity in England,
2007 Results of a household survey
15 Singleton N, Meltzer H, Gatward R, Coid J, Deasy D (1998) Psychiatric Morbidity among Prisoners GSS
3
Table 3 Prevalence (%) of Personality Disorder combinations in Prisoners in England and
Wales.
Combination of PD
Prison group
Male sentenced
30%
20%
15%
Male remand
28%
35%
15%
ASPD only
ASPD and other
Other only
Female prisoner
11%
20%
18%
Source: APMS Prisoners’ survey 1998
This is significant for Derbyshire given the presence of HMP Foston Hall HMP Sudbury (see
below).
1.4
Epidemiology extrapolated to Derby City and Derbyshire County
Using prevalence estimates from the 2007 adult psychiatric morbidity survey, the number of
cases of PD for Derby City and County is presented in Table 4.
Table 4 Expected number of prevalent cases in 2007 based on mid year population size estimates
Derby UA
Amber Valley CD
Bolsover CD
Chesterfield CD
Derbyshire Dales CD
Erewash CD
High Peak CD
North East Derbyshire
CD
South Derbyshire CD
Derbyshire County
Derbyshire inc Glossop
Derbyshire County PCT
Glossop
Total (excl Glossop)
16-34
99
38
24
33
19
37
29
30
31
241
482
230
252
329
Men BPD
35-54 55-74
64
86
36
55
22
33
29
42
21
37
32
47
29
40
28
28
224
448
213
235
277
49
37
339
678
326
353
412
Women BPD
16-34 35-54 55-74
451
159
174
90
113
55
153
74
77
52
177
82
134
73
-
Men ASPD
18-34 35-54 55-74
445
64
165
36
105
22
147
29
83
21
161
32
127
29
-
133
142
1104
2208
1050
1158
1501
130
133
1052
2104
1003
1101
1448
72
69
567
1134
539
595
698
-
28
28
224
448
213
235
277
-
Women ASPD
18-34 35-54 55-74
116
44
29
39
19
45
34
33
36
278
556
264
291
380
-
-
Source; 2007 mid year population estimates and 2007 general psychiatric morbidity survey estimates.
4
Graph 1 shows the number of cases expected grouped into the two main personality
disorders by sex.
Graph 1 PD prevalence estimate based on 2007 mid year population
estimates
6000
Number of people
5000
4000
3000
2000
1000
0
total men BPD
total women BPD
total men ASPD
total women ASPD
Grand total
Type of PD
Source: 2007 mid year population estimates for Derbyshire and PD prevalence rates from the 2007 psychiatric
morbidity survey
Epidemiology extrapolated to the prison population – HMP Foston Hall
Foston Hall closed women’s prison has an operational capacity of 290, including up to 80
women on remand. Each month there are approximately 60 new receptions16. The age
distribution of prisoners is skewed so that approximately 60% are below the age of 34.
Table 4 illustrates, based on an estimated 50% prevalence of PD (using the AMPS survey
data) the number of people potentially in need of PD specialist services in Foston Hall prison
Table 4 – the expected numbers of PD cases in HMP Foston Hall per year and for each
month of receptions
Point prevalence of PD at any one point in time
Of these:
the number estimated to have ASPD only
the number estimated to have ASPD with another PD
For each month of
the number with ASPD only
new receptions:
the number with ASPD with another PD
Number
145
32
58
7
12
Extrapolated from the HMP Foston Hall HNA, Robyn Dewis, 2007
16
Health Needs Assessment Foston Hall Prison, 2007. Robyn Dewis Derbyshire County PCT.
5
Epidemiology extrapolated to the prison population – HMP Sudbury
Sudbury open prison for men has an operational capacity of 572 men with 60-120 new
receptions per month17. Over a one year period, the prison can come into contact with 1400
men. The age distribution of prisoners is skewed so that nearly 70% are between the ages of
21 and 39.
Table 5 illustrates, based on an estimated 64% prevalence of PD (using the lower of the two
prevalence estimates for remand and sentenced men in the AMPS survey data) the number
of people potentially in need of PD specialist services in Sudbury prison.
Table 5 the expected numbers of PD cases in HMP Sudbury per year and for each month of
receptions
Point prevalence of PD at any one point in time (64%)
Of these:
the number estimated to have ASPD only (30%)
the number estimated to have ASPD with another PD (20%)
For each month of the number with ASPD only (30%)
new receptions
the number with ASPD with another PD (20%)
(60-120):
366
172
114
18-36
12-24
Extrapolated from the HMP Sudbury HNA, Jonathan Gribbin, 2008
Therefore, in both Foston Hall and Sudbury there are a significant number of people who
have a clinical need but no access currently to a specialist PD service. Whilst not all of these
people could be diagnosed during their stay at the prison, given the short period of time that,
particularly those on remand, may stay, however there is potential for everyone to receive PD
screening as part of their initial mental health assessment, using for example the SCID-II tool
used in the APMS study.
Population projections 2006-2031 (thousands)
In order to predict the future demand for services it is important to understand the population
projections for Derbyshire. As shown in the two graphs below, there is an expected increase
in population size over the next 10 years in the age-group with the highest prevalence of PD
(i.e. 16/18-34) in both Derby City and Derbyshire County
17
Health Needs Assessment HMP Sudbury, 2008. Jonathan Gribbin Derbyshire County PCT.
6
Derby City population projections, Males and Females age 16-34, 2006-2031
37.0
Males
Females
Population (thousands)
36.0
35.0
34.0
33.0
32.0
31.0
30.0
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
29.0
Year
Derbyshire County population projections Male and Females age 16-34, 2006-2031
92.0
90.0
Males
Females
Population (thousands)
88.0
86.0
84.0
82.0
80.0
78.0
76.0
74.0
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
72.0
Year
This equates to the following increases over the next 10 years as shown in Table 5.
Table 5 Increases in population size over the next 10 years
Males Derby City
Females Derby City
Males Derbyshire County
Females Derbyshire County
2009
33.6
32.6
82.3
79.6
2019
36.1
34.1
90.2
85.3
Increase (thousands)
2.5
1.5
7.9
5.7
7
2 What services are currently provided in Derbyshire?
Derbyshire County and City does not currently have a discrete specialist service or agreed
Derbyshire-wide clinical pathways for people with personality disorder. Current services
provided differ between the north and the south due to historic commissioning arrangements.
2.1
Primary Care and Community Mental Health Teams
PD cases are referred by primary care as routine or urgent appointments through the clinical
assessment service (CAS) into the community mental health teams (CMHTs) or crisis teams
as appropriate. Usual liaison between primary care and CMHTs should occur although there
is no prescribed pathway.
2.2
In-patient beds
There are currently no in-patient beds commissioned specifically for PD, although there are
people with PD in out of area in patient beds (see below) and in general psychiatric beds
although the number of the latter is not clear.
2.3
Out of area placements
There a number of private providers of specialist PD beds and on the 18/9/09 there were 18
women and 11 men in low secure, medium secure, PICU, rehab and mother and baby
facilities out of area.
2.4
Psychological Therapies
There is currently an inequity of access to PD psychological therapy services for residents in
the north and south of the county.
DBT is a NICE recommended therapy for people (particularly women) with BPD who self
harm and are at high risk due to this and/or impulsive behaviour. Group therapies are
probably more appropriate for people with serious problems but lower risk. The differing
therapies target people with variations in levels of risk which might reflect different parts of the
care pathway i.e. they could move from one therapy to another as needs are addressed.
There are also other therapeutic interventions which are relevant to this client group at
various points in the care pathway, e.g. EMDR (for trauma), anger management (NICE
recommended for ASPD), Mentalization Therapy (NICE recommended for relationship issues
in PD)18. Currently only DBT and group therapies are available in any consistent
arrangement as outlined below.
The North
 Dialectical Behavioural Therapy (DBT)
In the north there is a small team of 3 trained and currently 1 untrained members of staff
delivering Dialectic Behavioural Therapy to residents of High Peak and Dales, Chesterfield,
18
Mathew Littlewood, mental health trust, personal communication.
8
Clay Cross, Bolsover and Killamarsh. There will soon be one more untrained person joining
the team and both untrained members of staff will then undergo training. Each person in this
team works 0.2 wte sessions on DBT.
Awaiting data on service use/capacity.
The South
 Dialectical Behavioural Therapy (DBT)
A community psychiatric nurse and 2 other members of the MHT have been identified in the
south of the county to undertake DBT training and provide a service in the future.
Awaiting confirmation of what the service capacity will be
 Group Therapy
A group psychological therapy programme is currently offered at the Duffield Road clinic, run
by a team of 4 Group and 4 Cognitive Behavioural Therapists.
Awaiting data on service use/capacity.
Offender mental health services
Specialist services for people in the criminal justice system with PD are not currently
commissioned.
People entering police custody suites, courts or the prison service (include people on
remand) are screened for mental health problems more generally. Plans are in place to
ensure that people in the probation service are offered a screening service also.
2.5
Ongoing training
Currently there is no ongoing workforce training commissioned or provided in relation to PD.
However, there has been awareness training provided for 300 staff across agencies in the
health community previously.
2.6
Managed Clinical Networks
Although the NICE guidance document promotes the development of managed clinical
networks at a supra-PCT and/or regional level, these do not currently exist in the East
Midlands. Work to establish fully functional clinical networks is however underway.
3 The NICE guidance on BPD and APD
Below is a short summary of the key recommendations set out in the NICE guidelines for
BPD and ASPD.
9
3.1
Borderline Personality Disorder (BPD)
1) Mental health trusts should develop multidisciplinary specialist teams and/or services
for people with PD that:

Are responsible for the routine assessment, treatment and management of people
with BPD, including diagnosis when general psychiatric services are in doubt

Provide consultation and advice to primary and secondary care services and
training programmes on the diagnosis and management of BPD

Provide and/or advise on social and psychological interventions

Work with CAMHS teams to govern transition into adult services

Develop clear communication with primary and secondary care including the
establishment of information sharing protocols among different services (including
those in the forensic setting)

Are involved in the development of new treatments for people with BPD nationally
and locally
2) Service users should have their individual needs and preferences taken into account
when developing the multidisciplinary treatment and care programme. The guidance
sets out the requirements of the care plan, the importance of promoting choice,
developing a trusting relationship between patients and people who work with them
and in planning endings and transitions
3) Psychological treatment services should have an explicit and integrated theoretical
approach with the provision of therapist supervision. Brief interventions (less than 3
months’ duration) should not be used specifically for BPD
4) Drug treatment should not be used for BPD or individual symptoms e.g. repeated self
harm.
3.2
Antisocial Personality Disorder (ASPD)
1) Develop non-judgemental, trusting relationships with staff
2) Offer cognitive problem solving skills training for children aged 8 and older
3) Offer assessment in forensic or specialist PD services should routinely used a
standardised measure of the severity of ASPD e.g. the PCL-R or PCL-SV
4) People with co-morbidities should receive treatment for these even if they are
receiving treatment for ASPD
5) Group-based cognitive and behavioural interventions should be available that focus
on reducing offending and other antisocial behaviour
6) Clear pathways should be in place so that effective multi-agency care is provided with
agreed criteria for the transfer of people with ASPD between settings
7) Establish ASPD networks that play a role in training, provide specialist support and
supervision for staff, help develop standards and monitor the effectiveness of the
clinical pathways.
10
4 Information not currently available
There is little information currently available in Derbyshire on the following aspects of the PD
care pathway:
1) The amount of drug treatment being prescribed for PD currently by GPs or the MHT
(drug treatment is not recommended by NICE in the management of PD unless there
are comorbid conditions that require it).
2) PD is a spectrum with the vast majority being managed in primary care, although it is
not part of IAPT programme (Improving Access to Psychological Therapies) for people
with depression and anxiety disorders. The current level of awareness of PD in
primary care, or current management/treatment strategies are not know.
3) The need for knowledge and skills training around PD has not been comprehensively
reviewed, although it is likely to be substantial since there isn’t an ongoing training and
awareness raising programme.
5 Gaps in service provision
1) At present there is no specialist service for PD. Given the numbers of people who are
estimated to have PD in the county, both in the general and criminal justice
populations, there is likely to be a significant unmet need currently.
2) Given the lack of training provision historically on awareness and understanding of PD
and the necessary skills to deal with PD, there are likely to be significant training
needs for primary and secondary healthcare, social care, police and criminal justice
staff.
3) There are no agreed clinical pathways in the general and forensic settings specifically
for PD
4) Crisis teams need to respond to people with PD and the mental Health Trust is
reviewing this.
5) There is a lack of choice and inequitable choice between north and south of the
county with regards to psychological therapy options.
6) There is a lack of written information on PD available to clients.
7) There are no regional clinical or user networks for PD although there are efforts
underway to establish a regional-level clinical network through the East Midlands
Development Centre and the Mental Health Trust is setting up a network of clinicians
that will also re-engage with service users also. Given the complex and cross-cutting
issues around people with PD, it may be helpful for service development to be
considered in a multiagency Derbyshire-wide forum that involves for example, health,
social care, police and criminal justice system.
11
5.1
General principles
Any service options should be based on the assumption that they will all take into account the
following guiding principles:
1) That there is equitable access to services in the north and south
2) That options include work to identify workforce training needs. A sustainable,
multiagency strategy should then be commissioned to deliver training that enables:
- the improvement of early identification and diagnosis of PD or emerging PD
-consistent diagnosis, treatment and care management
- appropriate signposting or referral to therapeutic and other services (e.g.
housing, employment etc
Training may be delivered across agencies to staff in primary care, the criminal justice
system, the police, social care and other agencies as identified by need.
3) That improvement of PD services requires a joint approach from health, social care,
police, criminal justice system and voluntary sector
4) That improvement of PD services has service user involvement.
5) That there are limited unallocated funds available to support service developments
12
Appendix 1
Draft options from author’s perspective following limited discussion and to
inform future planning
Option A - Do nothing
Given the national NICE guidance for PD, the number of PSA targets that it crosses and
these extreme inequities that exist with current services in Derbyshire, this option is not
advisable. There is a significant number of people with PD in Derbyshire who have unmet
need and who receive support and treatment in an ad hoc fashion. There is no information
currently available on the additional wider costs incurred due to the current lack of provision
but NICE estimate that implementation of their guidelines may reduce the admissions due to
self harm, reduce the use of A&E services and result in a reduction in the number of drugs
prescribed to patients with BPD.
Outstanding gaps
This option would result in the PCTs not meeting NICE guidance on the provision of specialist
services, integrated care pathways or treatment options. Services are not currently
commissioned to meet the needs set out in this paper and they are inequitable and
inconsistent across the County/City. There is a lack of information around current practice
with regards to PD in primary care and CAMHS or training needs.
Option B – Improve existing services
1) Agree integrated PD pathways and referral criteria for the existing arrangements with
primary care and general mental health service provision.
2) Commission DBT services in the south and group therapy in the north to meet capacity
and ensure that equitable access to these services exists.
4) Ensure current service provision is monitored/audited.
Outstanding gaps
This option does not meet fully the NICE guidance to provide a specialist service with a range
of therapeutic options including a crisis service. Expertise in diagnosis, treatment and
management may be insufficient and limit the effectiveness of the service, increasing the risk
of late identification and ineffective management. Early identification and intervention in
young people and transition from CAMHS to adult services will continue to be insufficient as
will access to psychological therapies for people within the criminal justice system.
Option C – Improve the offender mental health services
1) Commission PD screening at contact points in the offender pathway with referral pathways
to DBT and group therapy as required.
2) Commission access to appropriate psychological therapies (e.g. DBT and Group Therapy)
for people in prison or on remand.
3) Ensure PD is included in development of court diversion activity.
13
Outstanding gaps
See above for option B, excluding the last comment.
Option D
This is a combination of B+C
Option E – Commission a whole-population specialist service
(see Figure 1)
Tier 1 would continue to provide mainstream community services for people with PD,
ensuring access to appropriate help with housing, employment, training etc. This would be
provided by mainstream (and in-reach) community mental health services with specialist
support/advice if needed from Tier 2/3 specialist PD services or hubs.
Primary Care or screening in the forensic services would have a key role in the identification
or recognition of PD symptoms and refer to Tier 2 for assessment. Primary care may then
maintain case management or share with general or specialist CMHTs.
Tier 2 functions include the provision of specialist assessment, treatment and case
management in the community and prison setting, for people who do not pose a serious risk
to others.
Delivery may be through specialist PD CMHTs or via GPs with access to specialist
expertise/advice from Tier 2/3 specialist PD services (or hubs).
Tier 3 functions include the provision of specialist assessment, treatment and case
management for those needing more intensive community-based treatment or who have a
higher level of risk to self, or offenders who present a limited risk to others. In-patient
admissions may be considered on a short-term basis. This would also include a full day
service programme, crisis service and respite care beds.
Tiers 2 and 3 would provide a variety of psychological therapies, including Cognitive
Behavioural Therapy (CBT), Dialectical Behavioural Therapy (DBT), Cognitive Analytical
Therapy (CAT), group analytical approaches and therapeutic community (TC) models as
outlined in the NICE guidance. Clinical supervision would be available.
Tiers 2/3 may be provided by 2 main ‘hubs’ located in Derby City and one in the County that
then respond to need in the community through ‘spokes’.
Tiers 4 and 5 are regionally-based services – would require further needs assessment work
to establish the requirement.
Tier 6 nationally-based services – would require further needs assessment work to establish
the requirement.
.A full health needs assessment would need to be undertaken in order to assess capacity
requirements at each stage.
14
Service user involvement is important in defining future service configurations and functions.
Consider involvement/role of the voluntary sector.
There would need to be agreement about the commissioning outcomes and who should
deliver on them. These might include process outcomes (recognition, case management,
pathway planning, community services partnership) and clinical (assessment and
engagement, MH wellbeing and pro-social behaviours, recovery and longer-term social
functioning)
Outstanding gaps
Further work would be needed to ensure that the service is fully integrated across agencies
including substance misuse services and CAMHS. There would also need to be participation
in the establishment of regionally-based clinical networks and a user network. Further work
on the reduction of stigma associated with PD could be undertaken at a PCT or regional level.
Option F – Option E + a longer term strategic approach
1) Enhance pathways to become fully integrated across mental health, substance misuse,
CAMHS (including early intervention), offender health and criminal justice system, social care,
primary care services (including IAPT) and to include development of Tiers 4 and 5.
2) Deliver training/social marketing to – reduce stigma, increase staff retention, enable earlier
identification, enable a more appropriate relationship with the criminal justice system
3) Focus further on forensic services to – ensure more appropriate sentencing, reduce
reoffending as described in the Bradley report.
4) Establish staff retention strategies.
5) Establish or participate in regionally-based clinical networks and user network.
Outstanding gaps
It is anticipated that option F would satisfy the requirements of the NICE guidance, subject to
further publication of guidance, and provider-recommended service provsion19.
Benefits and savings
NICE has published a costing report for the implementation of a specialist BPD service.
However they do not provide a costing template since there is thought to be so much
variation currently in what PD services are provided that the implementation of the guidance
will have different cost implications for each PCT. Estimating the costs of PD services is
further complicated by the significant level of comorbidity in this group.
See report to the strategic commissioning group for Derbyshire 23 October 2008 ‘Discussion paper for
developing a personality disorder service in Derbyshire’. Derbyshire Mental Health Services NHS Trust
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In their costing and commissioning reports NICE and the Department of Health do however
estimate that implementation of the guidance will result in costs savings due to a reduction of
health service use in A&E and due to self harm in women in particular. There may also be
cost reductions in the criminal justice system and in terms of community safety with regards
to better services for people with ASPD also.
There will be costs associated with training professionals to recognise, diagnose and treat
people with PD. Also, there will be an increase in service use due to greater awareness of
PD and better diagnosis. However, as discussed in the opening paragraphs of this report,
not all people with PD will actively seek or accept treatment at any one time, although there
will need to be systems of surveillance in place to judge when they are ready for treatment.
The current DH Commissioning guidance for PD services estimates the following service
costs for commissioning tiers 1-3 (non-offending population).
Awaiting further clarification around these costs from the Department of Health
Approximate population
catchments
300,000-1,000,000
Optimum service/client capacity
(and other indirect services)
70-120
Approximate cost range
(£000 p.a. at 2005/6 prices)
500-900
Source: DH Recognising complexity: commissioning guidance for PD services June 2009 p30
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