Annual Forum March 2008 Introduction: Past, Present and Future Rex Haigh, Project Lead

Who are you all? 3

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 membership 2: 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 doing 1: core standards cycles 5 & 6 11

How the TCs are doing 2: core standards in the different networks 12

How the TCs are doing 3: 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 doing 4: a comparison between 10 different TCs

Pilot Cycle: UK Addiction TC

 Picked out as poor and declining performance  More discussion in the annual report 16 How the TCs are doing 4: 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 doing 5: a comparison between 10 different TCs

Pilot Cycle: UK Addiction TC

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 4 th 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 charge The 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 2006Actual 2007 Jan-Dec Activity 2008 (Budget) Jan-Dec Activity 2009 (Budget) Jan-Dec Activity 2010 (Budget) 85 average fee of £ average fee of £ TCs average fee of £1807 Opening Balance37, , , , , Income: Registration Fees: Annual Forum 3, , , Members Fees 125, , , , , Grants 129, , , , Total Income258, , , , , Expenditure Staff Costs 146, , , , , Running Costs 36, , , , , Overhead Charges 54, , , , , Total Expenditure237, , , , , Balance Carried Forward59, , , , ,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 (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 organisationStarting date Number of members (normal - max) Days (hours) per week Length of programme PremisesNotes Intensive Psychological Treatment Service (IPTS), Southwark & Lewisham Guys Hospital MHT C d12mAcute hospital As stand-alone OR follow-up to day TC IPTS, Tower Hamlets2007?1d12mIs it a mini-TC? Witney Group Thames Valley Initiative (TVi) & MHT ½h18mCommunity Centre Banbury Group ¼h18mCMHT Wallingford Group ½d18mCommunity Centre Abingdon Elders2007?-103h18mCommunity Hospital Slough Group2008??-16tbfMay be CAT-based Amersham Group2008??-14Friends Mtg House High Wycombe Group2008??-14Friends Mtg House Milton Keynes mini-TC2008??-242d18mCommunity CentreWith Borderline UK Diverse Pathways, Leeds TC Services North (TCNS) + MH Trusts ± Local Authorities d MonMHT comm service 15, Manchester d Mon12mPsychotherapy DeptPoss 12m agreed Rotunda, Liverpool20041dCommunity CentreLocal Authority North Pennine DTC, Oldham & Bury ½h Thu12mVol on old MH site Taste, Stockport d Tue12mCommunity Centre 174, Bolton2007Close integration 2B, Blackburn & Burnley2008 Aspatria Itinerant TC N Cumbria PD Pilot & MHT 20042dRugby club Barrow/Kendal Itinerant TC2009?2dtbf Mandala, WorksopNotts PDDN & MHT ½d18mMINDRelaunch in 2008 St Andrews, YorkMHT~2007?-163½d12mPsychotherapy DeptIn PCT Bridger House, BirminghamMain House & MHT2006?-16PD service OP dept Jasmine Centre, LeicesterFDL & MHT2006?-10Women-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  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 ed to Dr Tim Kendall, National Collaborating Centre for Mental Health, NICE For Community of Communities Annual Forum, London, 28 March 2008

56 1NICE 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 2Methodological 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 3Methodological 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 4The 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 5Social 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