annual forum 2008 28 march 2008 introduction: past, present and future rex haigh, project lead
TRANSCRIPT
Annual Forum 2008
28 March 2008
Introduction: Past, Present and Future
Rex Haigh, Project Lead
Who
are
you
all?
3
Where are delegates from?
10415
29
10 3 4
ADTC Non-Mem CYP College Add LD
4
Past
Now we are six
Good Old Days
Land of milk and honey
Adrian’s unwelcome advice
Excitement of the new
Present
The different networks and membership
How the TCs are doing
Accreditation
The antidote to regulation
Our review of what we offer
The London office team
What we cost and need to charge
Regulatory frameworks and us
5
Future
The new core standards and value base
The new breed of ‘modified TCs’ and Mini TCs
Realignment of the UK foundation charities for TCs
Accreditation trial in social care sector
European and Australasian initiatives
Therapeutic Environments
TC research network and our evidence base
6
Present
The different networks and membership 1: “Old CofC”
8 54 Full Members and 2 Guests
The different networks and membership2: The new sectors
Year 1 = 16 Members
Year 2 = 31 Full Members 38 Guests (37 Addictions and 1 C&YP)
After this year...
We will be running all the networks as a single network
Theoretical reasons – “fusion model”
Financial reasons – economy of scale
Practical reasons – pool of lead reviewers etc
Educational reasons – more to learn from diversity
Eg children’s communities, community within community; LD
Nature of this learning: tolerance and curiosity required
We are not impressed with a “we know best” attitude!
It is not a league table or a competition...
...but we will still aim to give choice of peer reviews
10
How the TCs are doing1: core standards cycles 5 & 6
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How the TCs are doing2: core standards in the different networks
12
How the TCs are doing3: core standards - interesting findings
13
1. Slight variations between cycles 5 & 6 but no overall trend
2. Children & Young People’s TCs consistently score higher
3. The best met were CS1 and CS15:
- The whole community meets regularly
- Positive risk taking is seen as an essential part of the process of change
4. The worst met were CS4, CS11 and CS 13:
- All community members share meals together
- All community members are involved in some aspect of the selection of new
staff members
- The whole community is involved in making plans for a client member when
he or she leaves the community
Addiction TCs
Their first cycle of operation
Using the core standards
And six groups of different quality improvement standards
(the addictions TCs have an extra section on “treatment programme”)
Anonymised (with silly names!)
Interesting to think about what the individual ‘fingerprints’ mean
14
How the TCs are doing4: a comparison between 10 different TCs
Pilot Cycle: UK Addiction TC
Overall Percentage Scores of Met Standards by Section
0%
20%
40%
60%
80%
100%
CoreStandards
PhysicalEnvironment
Staff J oining andLeaving
TherapeuticEnvironment
TreatmentProgramme
ExternalRelations
Section
%
AlphaCentre
Beta House
Crisis Lodge
DeltaServices
EasyTherapy
Fire andBrimstone
GhostsGone
HopefulHaven
Intentions RUs
JiggeryPokery
Picked out as poor and declining performance
More discussion in the annual report
16
How the TCs are doing4: things to be concerned about?
Issues for Adult Democratic TCs and Comparisons
Erosion of Informal Time?
Issues for Adult Democratic TCs and Comparisons
Leaving the TC
Issues for Adult Democratic TCs and Comparisons
Staff selection
Issues for Adult Democratic TCs and Comparisons
Are TCs stopping eating together?
Suggestions about how to improve things
...are always included individually in each TC’s report
This is our first main attempt to look at it across ALL TCs
4 interesting findings from the recent cycles
More detail and discussion in the annual report
21
Addiction TCs
Their first cycle of operation
Using the core standards
And six groups of different quality improvement standards
(the addictions TCs have an extra section on “treatment programme”)
Anonymised (with silly names!)
Interesting to think about what the individual ‘fingerprints’ mean
22
How the TCs are doing5: a comparison between 10 different TCs
Pilot Cycle: UK Addiction TC
Overall Percentage Scores of Met Standards by Section
0%
20%
40%
60%
80%
100%
CoreStandards
PhysicalEnvironment
Staff J oining andLeaving
TherapeuticEnvironment
TreatmentProgramme
ExternalRelations
Section
%
AlphaCentre
Beta House
Crisis Lodge
DeltaServices
EasyTherapy
Fire andBrimstone
GhostsGone
HopefulHaven
Intentions RUs
JiggeryPokery
Accreditation in the NHS is now in place
First TC to gain this was Acorn Unit at the Retreat in York
Now several have been through the process: Mandala TC, Nottingham
Manzil Way, Oxford
Winterbourne TC, Reading
Henderson Hospital, London
Main House, Birmingham
2 are in progress, 1 is deferred and 2 have had developmental accreditation visits
All were deferred in their progress towards this
...an important task looms before too long:
to review the commissioning standards
24
Accreditation in the prison TCs
Now in its 4th year
12 prison TCs have had their accreditation peer reviews
Accreditation decisions will be made on 23 April
25
The antidote to regulation
Paul Lelliott (personal communication, c 2005):
quality networks as the antidote to accreditation
Always our hope and intention to steer a middle way - since the
1998 debate at Windsor
Up to our members to keep us on track (neither to “sell out” nor fail to
appreciate the adaptations we need to make to survive)
And certainly not to bend with every wisp of the wind
Establishing our integrity through what? -1 strong network of participating communities;
- 2 solid backing of long-renowned professional organisations like ATC;
-3 extensive archive of the field’s work;
-4 evidence base and research ...
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Our internal review of what we offer
A short audit of ‘how we were doing’
(one of many processes to maintain our own standards)
Done by semi-structured telephone interviews
Undertaken by Kelly Davies
Most immediate finding:
...how busy everybody is and how difficult it is for staff to spend
time talking to Kelly
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Our internal review of what we offer: SELECTED RESULTS
n=10
9/10 “helped us improve our service”
10/10 “helped us communicate the value of our service”
All found accreditation standards helpful
7/10 found (old) core standards useful
10/10 found accompanying lead reviewer of high quality
Worst scores:
30% “very satisfactory” for information for visiting another TC
50% “very satisfactory” for information pre-own peer review
50% “very satisfactory” national reports
50% “very satisfactory” information sheets
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Verbal comments:
“very supportive at every stage”
“usually very interesting and always very
helpful”
“feel sense of belonging to a larger
network”
“raised managers’ understanding”
“helped us evolve during a steep learning
curve”
“it’s helped us speak to commissioners”
“it shows we are not a Mickey Mouse
operation”
“prison TCs were very isolated before”
“it has given us a voice and made our
practice more evidence-based”
“the frequency of reviews could be a bit
less”
“6 weeks intense work”
“money – including the cost of getting to
the Forums etc”
“lack of recognition of mini-TCs”
“the logistics of it are huge”
“there can be a temptation to feel that
your TC is being interrogated”
“people come to us without enough
information”
“money”
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The London office team
30
Personnel
Rex Haigh – Project Lead
Adrian Worrall – Head of CCQI
Sarah Paget – Programme Manager
Katherine Larkin – Quality Improvement Worker
John O’Sullivan – Quality Improvement Worker
1 Vacant Posts (included in budget forecast )
likely to be cut
1 Vacant Post - cut
What we cost and need to chargeThe Headlines
We are not currently charging enough to survive
We have lost 2 staff who will not be replaced
We need a new invigorated ATC – as the only organisation in the
field with paid staff, we end up taking on roles we can no longer
afford to
The level of service to members will not be noticeably different
We will be increasing our fees
After much agonising about many different formulae, we are
having a flat fee plus fee per place
In the future we are looking to better coordinate this with
membership of ATC, CHG and maybe other TC organisations.
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Finance
Since 2002 Community of Communities has aimed to become self-financing but has remained dependent on funding
In order for Community of Communities to survive it needs to cover the cost of delivery from members subscriptions
The cost of delivering the service is a minimum of £2000 per TC and is not relative to the size of the TC
On the basis of the current way we calculate fees the average cost per TC is £1361
Similar CCQI project fees range from £2300 to £3500 per service
Actual and Budget Forecasts to 2010 – Annual Fee increasing by 8%
Description average fee of £1440 Actual 2006 Actual 2007
Jan-Dec Activity 2008
(Budget)
Jan-Dec Activity 2009
(Budget)
Jan-Dec Activity 2010
(Budget)
85 TCs @ average fee
of £1440
90 TCs @ average fee of £1586
95 TCs average fee of £1807
Opening Balance 37,870.05 59,015.11 49,921.20 48,302.70 -13,438.46
Income:
Registration Fees:Annual Forum 3,800.00 7,317.12 8,500.00 8,500.00 8,500.00
Members Fees 125,248.89 122,707.72 153,799.90 189,971.58 212,156.82
Grants 129,333.00 122,125.00 94,182.00 10,106.00 0
Total Income 258,381.89 252,149.84 256,481.90 208,577.58 220,656.82
Expenditure
Staff Costs 146,269.91 146,472.38 136,815.34 147,053.93 155,237.17
Running Costs 36,478.07 55,967.88 64,100.00 61,600.00 62,800.00
Overhead Charges 54,488.85 58,803.49 57,185.06 61,664.81 65,199.10
Total Expenditure 237,236.83 261,243.75 258,100.40 270,318.74 283,236.26
Balance Carried Forward 59,015.11 49,921.20 48,302.70 -13,438.46 -76,017.90
The challenge
It costs about £270K to run CofC
This calendar year we have £94K lottery income, next calendar year £10K, then none
We need to substantially increase fees if we are to survive
We need to make being part of the process affordable to marginal members
2008 fee increases require membership to remain around 50-90 (including the new networks)
Income will be reviewed in October’s advisory group
The Changes to Membership and Fees
Three New Membership categories:
Associate Membership
Full Membership
Accredited Membership
Associated Membership:
Self-review and report plus other benefits of membership; no peer-review; no use of the logo to signify quality (self-review not ratified).
Expectation to participate in peer-reviews of others (details in ‘types of membership’ document)
£600 per community
Full Membership:
Members fully participate in annual cycle (as since the beginning of CofC) and have use of standard logo to demonstrate quality.
£600 per TC plus £70 per available client places (no cap)
Accredited Membership:
Members undergo accreditation process appropriate to their sector, hold accredited status (on Royal College website) and have use of “accredited TC” logo
£1200 per TC plus £70 per available client places (no cap)
The nitty-gritty:
Joining form
40
Regulation and Government Department news
Ministry of Justice – has now reorganised their ‘DSPD’
programme as ‘DSPD and Prison TCs’ programme
Work continuing on developing coherent pathways to and through
offender programmes
Particular lack of ‘step-down’ into non-custodial sector
CofC standards are recognised in the national contract for
preferred providers as a key performance indicators for
therapeutic childcare
Continued involvement in various DH working groups, committees
and professional networks, including NICE.
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Sarah’s ‘Good Things’
Increased use of discussion forum – interesting exchanges across different TCs
Accredited TCs Increasingly recognised process – Standards for Children and
Young People recognised as part of the National Contract KPIs for Children's Services and HMP TCs Increasing number of TCs in the NHS Increased interest in TC approach – Therapeutic Environments European interest in standards and methods – addiction
standards adopted by all EFTC members all of whom are signed up as guest (no money for full membership)
Learning Disability Communities coming on board – will lead to widening out the process to increasing number on coming year
Future
The new core standards: 1: value base
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CV1 Attachment Emotional dependency is necessary for independence
CV2 Belonging In order to encourage personal growth, individuals need to have a sense of value and worth in relation to others
CV3 Relationships Individuals are defined by their relationships and understanding these relationships leads to a better understanding of ourselves
CV4 Communication All behaviour is a form of communication; effective communication is about putting things into words
CV5 Citizenship Each individual has responsibility to the group and the group in turn has responsibility to the individual
CV6 Responsibility Personal well-being stems from the capacity to positively influence ones’ environment and relationships
CV7 Interdependence
Personal well-being is determined by one’s ability to develop appropriate relationships with others which recognises mutual need
CV8 Containment An individuals ability to risk change is possible only within a safe and nurturing environment
CV9 Potential Difficult experiences and problems are accepted, and recognised as necessary for personal growth of the individual and the community
CV10 Democracy Participating in decision making encourages shared responsibility and ownership
CV11 Structure Clearly defined boundaries and meaningful structure enables the community to be effective
CV12 Process There is value in accepting that there is not always an answer and it is sometimes useful to reflect rather than act immediately
CV13 Enquiry Learning about oneself and others is dependant on asking questions
CV14 Respect Everybody is unique; individuals are not defined by their problems or their qualifications
CV15 Organic The balance of creative and destructive processes promotes change
The new core standards: 2: Draft standards
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CS1 Community members develop meaningful relationships
CS2 Community members work, relax and eat together
CS3 Community members consider their attitudes and feelings towards each other
CS4 Power in relationships is used responsibly and is open to question
CS5 Community members can discuss aspects of life within the community
CS6 Disturbed behaviour and emotional expression is challenged and discussed in the community
CS7 Community members take a variety of roles and levels of responsibility
CS8 The community has a clear set of boundaries, limits or rules
CS9 Community members share responsibility for each other
CS10 Community members create an emotionally safe environment for the work of the community
CS11 The community enables risks to be taken to bring about change
CS12 Community members make collective decisions that affect the functioning of the community
CS13 The community meets regularly
CS14 Strong leadership enables the community’s democratic processes to be effective
CS15 Relationships between staff members and client members are characterised by informality and mutual respect
Therapeutic Environments
based on TC theory & the derived core values and standards
for quality assured therapeutic environments
A much simplified set of standards
To move towards kite-marking like “investors in people”
for services in all sectors
(health, social services, criminal justice, education)
for all client groups
and maybe others (certain categories of employer?)
who wish to be gain recognition for having a “healthy
environment”
46
The new breed of ‘modified TCs’ and ‘mini TCs’
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Key: pink = planned; orange = future uncertain;red = existing & stable
The new breed of ‘modified TCs’ and ‘mini TCs’
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Mini Therapeutic Communities Parent organisation Starting date Number of members (normal - max)
Days (hours) per week
Length of programme
Premises Notes
Intensive Psychological Treatment Service (IPTS), Southwark & Lewisham Guys Hospital MHT
C20 10-16 1d 12m Acute hospital As stand-alone OR follow-up to day TC
IPTS, Tower Hamlets 2007 ? 1d 12m Is it a mini-TC?Witney Group
Thames Valley Initiative (TVi) & MHT
2006 9-14 4½h 18m Community Centre
Banbury Group 2006 12-14 4¼h 18m CMHT
Wallingford Group 2004 12-14 1½d 18m Community Centre
Abingdon Elders 2007 ?-10 3h 18m Community Hospital
Slough Group 2008? ?-16 tbf May be CAT-based
Amersham Group 2008? ?-14 Friends Mtg House
High Wycombe Group 2008? ?-14 Friends Mtg House
Milton Keynes mini-TC 2008? ?-24 2d 18m Community Centre With Borderline UK
Diverse Pathways, Leeds
TC Services North (TCNS) + MH Trusts ± Local Authorities
2004 12-16 1d Mon MHT comm service
15, Manchester 2004 9-15 1d Mon 12m Psychotherapy Dept Poss 12m agreed
Rotunda, Liverpool 2004 1d Community Centre Local Authority
North Pennine DTC, Oldham & Bury 2008 7-15+ 5½h Thu 12m Vol on old MH site
Taste, Stockport 2007 10-15+ 1d Tue 12m Community Centre
174, Bolton 2007 Close integration
2B, Blackburn & Burnley 2008
Aspatria Itinerant TC N Cumbria PD Pilot & MHT
2004 2d Rugby club
Barrow/Kendal Itinerant TC 2009? 2d tbf
Mandala, Worksop Notts PDDN & MHT 2005 2-8 1½d 18m MIND Relaunch in 2008
St Andrews, York MHT ~2007 ?-16 3½d 12m Psychotherapy Dept In PCT
Bridger House, Birmingham Main House & MHT 2006 ?-16 PD service OP dept
Jasmine Centre, Leicester FDL & MHT 2006 ?-10 Women-only
Realignment of the foundation charities in UK
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Accreditation trial in social care sector
We now have rigorous and robust accreditation processes in
prisons (4 cycles) and NHS (2 cycles)
Social Care sector has a very heavy burden of regulation and
inspection
We need to develop similar processes for them, and hopefully
help make some of it more meaningful
CHT (London) and Threshold (Belfast) have agreed to help us run
a pilot year with their 10 communities
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European and Australasian initiatives
EFTC - conference Ljubljana June 2007
ATCA - conference Melbourne, November 2007
Numerous workshops and presentation on the standards
Including work for core values
Much support for the standards
Process continues to develop overseas membership
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TC research network and our evidence base
TCRN: 5 Founder members = Mandala Nottingham, Winterbourne Reading,
New Horizons Aylesbury, Manzil Way Oxford, FDL Leicester
All collecting agreed baseline and outcome dataset, using well-
recognised and validated self-report questionnaires
Google Group discussion forum over last year, including 2 staff
and ≥2 service users, to agree all procedures
Other guest members – will become full data-collecting members
when whole process is working smoothly
To be online like Norwegian network; CofC could become the data
collection hub
Come to our workshop this afternoon!
“Oxford Science Meeting” next Monday and Tuesday
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Aims for CofC in 2008-2009
Become financially viable without need for limited-term grants Concentrate on Core Business = effective use of more limited
resources to maintain current level of service and day to day support to members
Support members to use CofC membership to the best effect within their organisations and superordinate structures
Reduce the burden of inspection for members: continue to pursue recognition under the national concordat agreement
Promote CofC benefits to wider audience: senior managers, commissioners etc. – You can help. Tell us who to contact.
Develop accreditation for TCs in social care – piloting a process in three TCs in voluntary sector in coming year
Develop ‘Therapeutic Environment’ kite mark
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Meet the Man from NICE
Questions emailed to Dr Tim Kendall,
National Collaborating Centre for Mental Health,
NICE
For Community of Communities Annual Forum,
London, 28 March 2008
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1 NICE process
Who gets appointed to Guideline Development
Groups?
How do you make sure you have proper representation from all
stakeholders? (for example, senior women)
How can others with a particular interest get involved?
Does it make a difference being an organisation or an individual?
At the consultation stage, does it help to be a well-funded drug company,
to have your voice heard?
How do you prevent bias from powerful lobby groups?
Questions from Jan Birtle, Chris Holman
57
2 Methodological issues: complexity & uncertainty
How does NICE deal with ‘unstable diagnoses’ and
‘complex interventions’?
For example, where diagnosis is uncertain, where clinicians disagree about it, or
where it changes over time? Or with comorbidity?
How can distorting influences such as volition, will, intention, motivation and
hope be controlled for in experimental studies?
How does NICE take account of ‘non-specific factors’ in psychological therapies,
which have been shown to be at least as important as specific methods?
How does NICE evaluate complex systems of care? (such as TCs, but also
inpatient wards, community teams and many others)
Would TCs be better evaluated as a ‘Health Technology?’
Questions from David Kennard, Stephanie duFresne, Michael Brookes
58
3 Methodological issues: experimental design
Is it inevitable that TCs must be subject to a
randomised trial to be considered evidence-based?
Despite a history of unhelpful attempts at RCTs?
And although qualitative work is preferred by many practitioners and
service users? And some researchers claim that ‘the seriousness of
science is compromised by RCTs’?
Why does good qualitative research receive such low priority in NICE
processes?
How does NICE manage treatments that are adapting and changing so
fast that published studies do not reflect current practice?
Questions from Gary Winship, Jan Birtle, Chris Holman
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4 The Power and The Evidence
Is NICE too certain, and too powerful?
Because so many people and organisations hang on to NICE’s every word
and phrase, does this make the guidelines an ‘ultimate authority’ which they
were not intended to be?
Does this ‘amplification’ contribute to the problem where, for example,
commissioners tend judge a treatment with no evidence as being of no use?
How can the inevitable uncertainties and imprecisions be best
communicated?
Is its systematic review process only suitable for drugs, where conditions
such as dose and length of treatment are precisely controllable?
Questions from Jan Birtle, Chris Holman, Stephen Blunden
60
5 Social discourse
Why is it appropriate to use the technology of
biological science to a social setting?
Where social meaning is an important and seriously confounding variable?
Where ‘subjects’ are necessarily co-authors of their own experience – and
using positivistic science is ‘like using a microscope to look for ships on the
horizon’?
Is this paradigm problem not as undermining to individualistic theory as the
observer effect of the uncertainty principle is in quantum mathematics?
Is scientific truth the most important truth? What matters, and why?
Does the quest for ‘evidence’ replace holistic forms of evidence, such as
collective wisdom and memory, with atomised fragments of data - which
create a permanent revolution and conditions of instability which damages
children?
Questions from John Gale, Chris Holman, Robin Johnson, Stephen Blunden