Annual Forum 2008

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

11

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 ...

26

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

27

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

28

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”

29

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.

32

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.

41

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

44

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

45

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’

47

Key: pink = planned; orange = future uncertain;red = existing & stable

The new breed of ‘modified TCs’ and ‘mini TCs’

48

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

49

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

50

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

51

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

52

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

54

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

56

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

59

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