|Contact||Fiona Brand, Oxford Health NHS Foundation Trust|
|Address||4000 John Smith Drive, Oxford Business Park, South Oxford, OX4 2GX|
This project led by Oxford Health NHS Foundation Trust aimed to develop, implement and evaluate a weekly self harm outpatient clinic which will offer outpatient follow up as currently but will also offer a particular service to people who repeatedly self harm.
The clinic, known as BIRSH (Brief Interventions in Repeat Self Harm), provides these patients with an alternative to attending A&E for support.
The emphasis of the clinic is on prevention and problem solving will be central to interventions offered as evidence suggests that this approach is the most effective for repeat self harm (Hawton et al 1998). The approach is enhanced with Cognitive Behavioural therapy (CBT) and psychodynamic influences which is supported through supervision, which is advised by NICE Guidelines CG133: Longer-term care and treatment of self-harm.
The Barnes Unit self harm service is providedby a nurse led team made up of 3.74 Band 7 psychiatric liaison nurses, managed by a Band 8A nurse. The team is currently working at full establishment.
The core business of the team is the psychosocial assessment of patients between the ages of 13 and 65 who come to A&E following acts of self harm. Following assessment the team signpost and/or refer patientsto statutory or voluntary services depending on need and also offer brief outpatient work (generally around 6 sessions) to people who may benefit from problem solving interventions or who require further assessment or containment while awaiting formal referral elsewhere.
People who self harm and frequently come to A&E raise particular challenges for A&E, the Barnes Unitand wider mental health services. This population has a high level of psychological morbidity (Guthrie 2001) and given the strong links between self harm and subsequent suicide (Kapur et al 2008) are a high risk group.
Many people in this patient group present with indicators of borderline personality disorder and in the absence of noncomitant mental illness are not always appropriate for Community MentalHealthTeam(CMHT) caseloads. A significant minority of people who recurrently self harm do not want to engage with the specialist personality disorder (complex needs) service due to the group emphasis or because of work commitments.
Historically the Barnes Unitteam has lacked the formal expertise, supervision and capacity to manage this population on an out patient basis. Thus there exists a vulnerable group of people who remain at high risk of self harm and suicide whose needs are clearly not met and who frequently feel let down and uncared for by the Trust.
From a resource perspective this population is costly both to the mental and community health trust and the general hospital’s trust. Regular presentations to A&E, often with overnight stays, involve administrative, clinical and bed costs. In line with the NICE Guideline on self harm (CG16) (2004), patients should receive an assessment by the Barnes Unit team or out of hours staff on each occasion, which can result in time consuming duplication if various professionals become involved. Service user feedback over time has suggested that whilst these assessments are helpful in the short term, ongoing input from the Barnes Unit team would be moreso.
A person centred approach
Based on this feedback, in 2010/2011 the Barnes Unit team worked with a patient who was presenting to A&E with increasing frequency. Both A&E and the self harm team were struggling to provide her with adequate care and support. The team concentrated on this individual because they felt that if they could help her to manage and reduce her self harming behaviour she would feel more stable, her use of A&E and mental health resource would alleviate and staff would feel less helpless, which in turn might lead to a more positive attitude towards her and similar patients.
The psychiatrist from the complex needs service agreed to help the team develop a care package for this patient and also to provide supervision. Three team members were involved in this work and two out of the three saw the patient on a fortnightly basis.
Although the team members were not trained in specialist approaches for people with borderline personality disorder and had no additional resources, the expert supervision they received, which was based on concepts from transactional analysis, psychodynamic approaches and learning theory, guided them in their reflections, practice and planning of the work that was undertaken with the patient.
Admissions to A&E were significantly reduced during this outpatient work. Other positive outcomes were that the service user reported that she felt supported and stabilised, the team established a robust collaborative relationship with the personality disorders service and they reported that their skills and confidence in working with this client group were much enhanced.
Whilst this work was demanding in terms of our clinical time, the demand was offset by the reduction in A&E presentations, the associated psychosocial assessments and by reduced contact with the crisis team. Furthermore, the outpatient work was structured and consistent, which frequent assessments by various staff members would not have been.
Recent NICE Guidelines CG133: Longer-term care and treatment of self-harm stresses the importance of establishing trusting and supportive relationships with service users over time and to ensure their care is based on their needs and preferences. In line with this, the experience of both the service user and the team outlined above suggests that such an approach should be offered to other patients who repeatedly self harm.
Aims and objectives
- To reduce the incidence of self harming behaviour within a client group known to regularly self harm by providing a preventative component to the Barnes Unit service
- To improve service users’ experiences of care in the context of self harm
- To reduce costs associated with A&E bed usage, crisis team utilisation and self harm assessments of repeat attendees
To achieve these aims, the following objectives were identified
- To develop the Barnes Unit team’s skills and expertise with this client group and to enable them to work proactively with service users as well as being a response service
- To provide interventions that aim to facilitate self efficacy with regards to problem solving and managing self harm
- To offer support and education to carers
- To improve relationships with and to educate and support A&E staff
Project steering group
At the outset of the project, the team decided that it would be beneficial to create a steering group to ensure the clinic had input from multiple sources. The group meets about every 3 months for 1 ½ hours at the Barnes unit.
Initially, members of the steering group and also service users and carers who had utilised our service, students who had been on placement with us, and staff members were asked by the project team to share positive narratives about self harm care. A total of 7 stories were collected from 3 staff members, 2 service users and 2 nursing students. The stories were shared at the first stakeholder meeting/steering group and the positive feedback has influenced the way that the project has been focussed. Looking at the positives from the work that the service has done has been used to inform the basics of an operational policy for the self harm clinic.
BIRSH Draft Operational Policy
- At least 3 presentations to Emergency Department (ED) following self harm in 12 months or 5 presentations in 24 months.
- We would exclude any service users that currently engaged with psychological services or complex needs as it would not be appropriate to engage them in another “therapy” and it may be counterproductive.
- Services users who meet our inclusion criteria and are open to the Community Mental Health Team would be discussed with their care co-ordinator and if it was felt appropriate they would have the opportunity to engage with the clinic.
- Style of work being 1:1 with the assessing clinician.
- Each clinician would have a maximum of 3 repeat clinic services users engaged with them at any one time.
- All clinicians will receive monthly supervision to discuss and ensure that the same approach is being adopted, Supervision will be group and probably provided by Karen Lascelles, ensuring we can adequately measure the efficacy of the intervention.
- All new cases to be discussed in supervision.
- 3 monthly supervision provided by Dr Steve Pearce to focus primarily upon disengagement.
- Self esteem/self worth and Edinburgh and Warwick wellbeing scale to be used at the beginning and end of the 12 weeks.
- Self harm self report and BDI to be used at every session.
- Anonymous patient feedback form with suggestions at the end of 6 sessions
- Collect data on presentations the year prior to, during and the year following intervention (some of this will be outside the scope of the BIRSH supported time).
- Collect self report data regarding acts of self harm.
1st session used to “prescribe” the package with the patient.
The content of the sessions to be 3-4 “core sessions”. These will be focussed around self harm and minimisation, problem solving and coping strategies. Then followed by 2-3 specific sessions based on the particular needs of the individual service user. For example alcohol, personality difficulties, bereavement, etc.