Introduction
Personality disorders (PD) are common and challenging to treat. Studies have revealed that 1 in 20 people in the UK have a diagnosis,1 and prevalence is much higher in healthcare settings. Approximately a quarter of patients that attend primary care2 and 40% of those in community mental health services meet the criteria for PD.3 Estimates of prevalence in psychiatric inpatient settings range from 36% to 67%.4 People with PD experience poor quality of life5 and have a significantly shorter (19 years for women and 18 years for men) life expectancy than the general population.6 They are at high risk of self-harm7 and suicide.8 9
People with PD have more extensive involvement with psychiatric services than those with major depressive disorder,10 tend to have both a higher number of readmissions and shorter time between readmissions11 and more frequently attend emergency departments.12 However, there is substantial and long-standing evidence that services fail to meet the needs of this patient group. In 2003, the National Institute for Mental Health in England published ‘PD: No longer a diagnosis of exclusion’, a formative paper that drew attention to the inadequacies of PD care in healthcare services and called for improvements.4 Specifically, it called for dedicated PD services, clear care pathways and a substantial improvement in the skills, expertise, and training of mental health professionals in this area. The report also stated that people with PD were often stigmatised, both within mental health services and wider society, and that many mental health professionals were reluctant to work with them.
Dedicated services for PD are now more widely available,13 but problems remain. Patients are still not receiving care consistent with the National Institute for Health and Care Excellence guidelines14 and do not have equal access to dedicated services.13 Patients, carers and staff still believe that being given a PD diagnosis can be stigmatising, which may, in turn, lead to exclusion from services; staff may even be reluctant to make a diagnosis of PD for fear that this will disadvantage the patient.15 16 Care pathways are often unclear and fragmented, with patients falling into a gap between primary and secondary services, leading to inappropriate reliance on the emergency department at times of crisis. Staff’s negative attitudes and lack of understanding of PD continue to be stressed by patients and carers, and indeed by staff themselves. In many organisations, psychological therapies are not readily available to all patients and there is a lack of collaborative whole system working.14–18
PD care is a major focus of the recent National Health Service (NHS) ‘Five-Year Forward View for Mental Health’19 and ‘Long Term Plan’.20 However, improving PD care can be difficult due to a wide range of issues across the system and the absence of a distinct clinical pathway to guide system redesigns.14 Locally, many Trusts have carried out PD pathway/service reviews, strategies and redesigns.21 These are broadly described in various documents, but few give sufficient detail to enable others to follow their methods. An exception is a redesign reported by the Yorkshire and Humber Region, which used various methods including staff and patient focus groups, a literature review, analysis of referral and admission data for specific services and involvement events.22 Yet, the majority of work reported has not detailed their methodology, which severely limits wider learning and replication of the approach.
Oxford Health NHS Foundation Trust (OHFT) recently received funding from the NHS Long Term Plan’s Community Mental Health Framework to improve PD care across Buckinghamshire. Oxford Healthcare Improvement (OHI) carried out a comprehensive system-wide diagnostic assessment of gaps in the provision of care for working age adults (18–65) with PD. It produced a list of recommendations to aid future improvement work. Our primary aim was to use a robust and systematic approach, including a range of quality improvement (QI) methods, qualitative approaches and an in-depth quantitative analysis of services.23 This paper summarises this mixed-method approach to show how a complex mental health system can be assessed, as well as presenting potential areas of improvement for the care and treatment of patients with PD.