Personality disorders: borderline and antisocial NICE quality standard 88
Issued: June 2015
NICE quality standard 88
guidance.nice.org.uk/qs88
© NICE 2015
Personality disorders: borderline and antisocial NICE quality standard 88
Introduction
This quality standard covers treatment and management of borderline and antisocial personality disorders. For borderline personality disorder, this quality standard applies to adults aged 18 and over and young people post puberty. For antisocial personality disorder, this quality standard applies only to adults aged 18 and over. NICE quality standard 59 covers antisocial behaviour and conduct disorder in children and young people under 18 years. For more information see the personality disorders topic overview.
Why this quality standard is needed
NICE was asked by NHS England to develop a quality standard on 2 specific personality disorders, that is, borderline personality disorder and antisocial personality disorder. Borderline and antisocial personality disorders are 2 distinctive conditions that affect people differently and have different care pathways. The diagnosis affects how the condition is managed and the interventions and services that are appropriate. The 2 disorders have been grouped into 1 quality standard to reflect similarity in approaches, not to imply that the 2 conditions are the same.
Antisocial personality disorder can only be diagnosed in adults, whereas borderline personality disorder can also be diagnosed in young people post puberty. For borderline personality disorder, statements within this quality standard apply to young people post puberty as well as adults recognising that young people would be supported by age-appropriate services (child and adolescent mental health services).
Borderline personality disorder
Borderline personality disorder is characterised by significant instability of interpersonal relationships, self-image and mood, and impulsive behaviour. There is sometimes a pattern of rapid fluctuation from periods of confidence to despair, with fear of abandonment, rejection, and a strong tendency towards suicidal thinking and self-harm. Borderline personality disorder is often comorbid with depression, anxiety, eating disorders, post-traumatic stress disorder, alcohol and drug misuse, and bipolar disorder (the symptoms of which can often be confused with borderline personality disorder).
Borderline personality disorder is present in just under 1% of the population. It most commonly presents in early adulthood, with women presenting to services more often than men. It is not usually diagnosed formally before the age of 18 years, but features of the disorder can be identified earlier.
Most people with borderline personality disorder show symptoms in late adolescence or early adult life, although some may not come to the attention of mental health services until much later. With formal psychiatric assessment and appropriate treatment, symptoms improve sufficiently so that at least 50% of people no longer meet the criteria for borderline personality disorder
5–10 years after diagnosis.
Antisocial personality disorder
Traits of antisocial personality disorder include impulsivity, high negative emotionality, low conscientiousness and associated behaviours, including irresponsible and exploitative behaviour, recklessness and deceitfulness. As a result of antisocial personality disorder, people may experience unstable interpersonal relationships and may disregard the consequences of their behaviour and the feelings of others. The disorder may also result in a failure to learn from experience and in egocentricity. Antisocial personality disorder is often comorbid with depression, anxiety, and alcohol and drug misuse.
The prevalence of antisocial personality disorder in the general population is 3% in men and 1% in women. The prevalence among people in prison is around 47%, with serious crimes being less common than a history of aggression, unemployment, and unstable and short-term relationships.
The course of antisocial personality disorder is variable and although recovery is achievable over time, some people continue to experience social and interpersonal difficulties.
Most people with antisocial personality disorder receive the majority of their care outside the health service. They may be supported by education, social care and housing services and, as result of offending, by the criminal justice system.
Care for people with borderline and antisocial personality disorder
Although borderline and antisocial personality disorders are both associated with significant morbidity and increased mortality, the care people receive is often fragmented. Borderline and antisocial personality disorders are frequently misdiagnosed because of comorbid conditions, and people are often prescribed medication or therapies that are unsuitable for them. Sometimes they are excluded from health or social care services because of their diagnosis or their behaviour. This may be because staff lack the confidence and skills to deal with these conditions or have negative attitudes towards people with borderline or antisocial personality disorder.
Some topic experts and people with personality disorder feel that the stigma attached to borderline and antisocial personality disorders still prevails even within mental health services.
In 2011, the government published its mental health strategy, No health without mental health, which set out long-term ambitions for transforming mental healthcare and the way people with mental health problems are supported in society as a whole. The strategy was built around 6 objectives:
more people will have good mental health
more people with mental health problems will recover
more people with mental health problems will have good physical health more people will have a positive experience of care and support
fewer people will suffer avoidable harm
fewer people will experience stigma and discrimination.
The quality standard is expected to contribute to improvements in the following outcomes:
quality of life for people with serious mental illness service user experience of health/care services
excess under 75 mortality rate in adults with serious mental illness employment of people with mental illness
experience of integrated care.
How this quality standard supports delivery of outcome frameworks
NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – patient safety, patient experience and clinical effectiveness – for a particular area of health or care. They are derived from high-quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 3 outcomes frameworks published by the Department of Health:
Adult Social Care Outcomes Framework 2015–16
NHS Outcomes Framework 2015–16
Public Health Outcomes Framework 2013–16.
Tables 1–3 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.
Table 1 Adult Social Care Outcomes Framework 2015–16
Domain Overarching and outcome measures
| 1 Enhancing quality of life for people with care and support needs | Overarching measure
1A Social care-related quality of life* Outcome measures People manage their own support as much as they wish, so that they are in control of what, how and when support is delivered to match their needs 1B Proportion of people who use services who have control over their daily lives Carers can balance their caring roles and maintain their desired quality of life 1D Carer-reported quality of life People are able to find employment when they want, maintain a family and social life and contribute to community life, and avoid loneliness or isolation 1F Proportion of adults in contact with secondary mental health services in paid employment** 1H Proportion of adults in contact with secondary mental health services living independently, with or without support* 1I Proportion of people who use services and their carers, who reported that they had as much social contact as they would like* |
| 2 Delaying and reducing the need for care and support | Overarching measure
2A Permanent admissions to residential and nursing care homes, per 100,000 population |
3 Ensuring that people have a positive experience of care and support
Overarching measure
People who use social care and their carers are satisfied with their experience of care and support services
3A Overall satisfaction of people who use services with their care and support
3B Overall satisfaction with social services of carers 3E Effectiveness of integrated care
Outcome measures
Carers feel that they are respected as equal partners throughout the care process
3C The proportion of carers who report that they have been included or consulted in discussion about the person they care for
People know what choices are available to them locally, what they are entitled to, and who to contact when they need help
3D The proportion of people who use services and carers who find it easy to find information about support
People, including those involved in making decisions on social care, respect the dignity of the individual and ensure support is sensitive to the circumstances of each individual
| 4 Safeguarding adults whose circumstances make them vulnerable and protecting them from avoidable harm | Overarching measure
4A The proportion of people who use services who feel safe** Outcome measures Everyone enjoys physical safety and feels secure People are free from physical and emotional abuse, harassment, neglect and self-harm People are protected as far as possible from avoidable harm, disease and injuries People are supported to plan ahead and have the freedom to manage risks the way they wish 4B The proportion of people who use services who say that those services have made them feel safe and secure |
| Aligning across the health and care system
* Indicator complementary ** Indicator shared |
|
Table 2 NHS Outcomes Framework 2015–16
| Domain | Overarching indicators and improvement areas |
| 1 Preventing people from dying prematurely | Overarching indicator
1a Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare Reducing premature death in people with mental illness 1.5 Excess under 75 mortality rate in adults with serious mental illness* |
| 2 Enhancing quality of life for people with long-term conditions | Overarching indicator
2 Health-related quality of life for people with long-term conditions** Improvement areas Ensuring people feel supported to manage their condition 2.1 Proportion of people feeling supported to manage their condition** Enhancing quality of life for people with mental illness 2.5 Employment of people with mental illness**** |
| 4 Ensuring that people have a positive experience of care | Overarching indicators
4a Patient experience of primary care 4b Patient experience of hospital care Improvement areas Improving people’s experience of outpatient care 4.1 Patient experience of outpatient services Improving hospitals’ responsiveness to personal needs 4.2 Responsiveness to inpatients’ personal needs Improving people’s experience of accident and emergency services 4.3 Patient experience of A&E services Improving the experience of healthcare for people with mental illness 4.7 Patient experience of community mental health services Improving people’s experience of integrated care 4.9 People’s experience of integrated care** |
Alignment across the health and social care system
* Indicator shared with Public Health Outcomes Framework (PHOF)
** Indicator complementary with Adult Social Care Outcomes Framework (ASCOF)
**** Indicator complementary with Adult Social Care Outcomes Framework and Public Health Outcomes Framework
Table 3 Public health outcomes framework for England, 2013–16
| Domain | Objectives and indicators |
| 1 Wider determinants of health | Objective
Improvements against wider factors that affect health and wellbeing and health inequalities Indicators 1.6 ii – % of adults in contact with secondary mental health services who live in stable and appropriate accommodation 1.7 – People in prison who have a mental illness or a significant mental illness 1.8 iii – Gap in the employment rate for those in contact with secondary mental health services and the overall employment rate 1.13i – % of offenders who re-offend from a rolling 12-month cohort 1.13ii – Average number of re-offences committed per offender from a rolling 12-month cohort |
| 2 Health improvement | Objective
People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities 2.15i Successful completion of drug treatment – opiate users 2.15ii Successful completion of drug treatment – non-opiate users 2.18 Alcohol-related admissions to hospital |
| 4 Healthcare public health | Objective |
| and preventing premature | Reduced numbers of people living with preventable ill health |
| mortality | and people dying prematurely, while reducing the gap between |
| communities | |
| Indicators | |
| 4.09 Excess under 75 mortality in adults with serious mental | |
| illness | |
| 4.10 Suicide rate |
Service user experience and safety issues
Ensuring that care is safe and that people have a positive experience of care is vital in a high-quality service. It is important to consider these factors when planning and delivering services relevant to people with borderline or antisocial personality disorder.
NICE has developed guidance and associated quality standards on patient experience in adult NHS services and service user experience in adult mental health services (see the NICE pathways on patient experience in adult NHS services and service user experience in adult mental health services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and are supported to understand their options and make fully informed decisions. They also cover the provision of information to patients and service users. Quality statements on these aspects of patient experience will not usually be included in topic-specific quality standards. However, recommendations in the development sources for quality standards that impact on service user experience and are specific to the topic are considered during quality statement development.
Coordinated services
The quality standard for borderline and antisocial personality disorders specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole borderline or antisocial personality disorder care pathway. A person-centred, integrated approach to providing services is fundamental to delivering high-quality care to people with borderline or antisocial personality disorder in a range of settings.
The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high-quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high-quality borderline or antisocial personality disorder service are listed in related quality standards.
Training and competencies
The quality standard should be read in the context of national and local guidelines on training and competencies. All health, public health and social care practitioners involved in assessing, caring for and treating people with borderline or antisocial personality disorder should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development sources on specific types of training for the topic that exceed standard professional training are considered during quality statement development.
Role of families and carers
Quality standards recognise the important role families and carers have in supporting people with borderline or antisocial personality disorder. If appropriate, health and social care practitioners should ensure that family members and carers are involved in making decisions about assessment, care planning and provision of treatment.
List of quality statements
Statement 1. Mental health professionals use a structured clinical assessment to diagnose borderline or antisocial personality disorder.
Statement 2. People with borderline personality disorder are offered psychological therapies and are involved in choosing the type, duration and intensity of therapy.
Statement 3. People with antisocial personality disorder are offered group-based cognitive and behavioural therapies and are involved in choosing the duration and intensity of the interventions.
Statement 4. People with borderline or antisocial personality disorders are prescribed antipsychotic or sedative medication only for short-term crisis management or treatment of comorbid conditions.
Statement 5. People with borderline or antisocial personality disorder agree a structured and phased plan with their care provider before their services change or are withdrawn.
Statement 6. People with borderline or antisocial personality disorder have their long-term goals for education and employment identified in their care plan.
Statement 7. Mental health professionals supporting people with borderline or antisocial personality disorder have an agreed level and frequency of supervision.
Quality statement 1: Structured clinical assessment
Quality statement
Mental health professionals use a structured clinical assessment to diagnose borderline or antisocial personality disorder.
Rationale
Borderline and antisocial personality disorders are complex and difficult to diagnose. Even when borderline or antisocial personality disorder is identified, significant comorbidities are frequently not detected. People often need support that goes beyond healthcare and this makes care planning complex. Carrying out a structured assessment using recognised tools is essential to identify a range of symptoms, make an accurate diagnosis and recognise comorbidities.
Quality measures
Structure
Evidence of local arrangements to ensure that mental health professionals use a structured clinical assessment to diagnose borderline or antisocial personality disorder.
Data source: Local data collection.
Process
Proportion of people with a diagnosis of borderline or antisocial personality disorder who had the diagnosis made by a mental health professional using a structured clinical assessment.
Numerator – the number in the denominator who had the diagnosis made by a mental health professional using a structured clinical assessment.
Denominator – the number of people with a diagnosis of borderline or antisocial personality disorder.
Data source: Local data collection.
What the quality statement means for service providers, mental health professionals, and commissioners
Service providers (mental health trusts) ensure that mental health professionals are trained and competent to carry out a structured clinical assessment to diagnose borderline or antisocial personality disorder.
Mental health professionals carry out and document a structured clinical assessment to diagnose borderline or antisocial personality disorder.
Commissioners (clinical commissioning groups, NHS England local area teams) ensure that they commission services with mental health professionals who are trained and competent to carry out and document a structured clinical assessment to diagnose borderline or antisocial personality disorder.
What the quality statement means for service users and carers
People with possible borderline or antisocial personality disorder have a structured assessment by a specialist in mental health before they are given a diagnosis. The results of the assessment are written in their records. This means that the diagnosis is accurate and that their needs and other health problems are identified from the outset.
Source guidance
Antisocial personality disorder (2009) NICE guideline CG77, recommendations 1.3.1.1 and 1.3.1.2
Borderline personality disorder (2009) NICE guideline CG78, recommendation 1.3.1.2
Definitions of terms used in this quality statement
Structured clinical assessment
Structured clinical assessment should be undertaken using a standardised and validated tool. The main tools available for diagnosing borderline and antisocial personality disorders include:
Diagnostic Interview for DSM–IV Personality Disorders (DIPD–IV) Structured Clinical Interview for DSM–IV Personality Disorders (SCID–II) Structured Interview for DSM–IV Personality (SIDP–IV)
International Personality Disorder Examination (IPDE) Personality Assessment Schedule (PAS) Standardised Assessment of Personality (SAP).
[Adapted from Borderline personality disorder (the full guideline CG78), Antisocial personality disorder (the full guideline CG77)].
Equality and diversity considerations
People with borderline or antisocial personality disorder frequently experience a range of comorbid conditions. These may be physical as well as mental health problems. Those working with people with borderline or antisocial personality disorder should always assess all of their needs and offer support accordingly. Diagnosis of borderline or antisocial personality disorder should never exclude people from receiving the help they need.
Quality statement 2: Psychological therapies – borderline personality disorder
Quality statement
People with borderline personality disorder are offered psychological therapies and are involved in choosing the type, duration and intensity of therapy.
Rationale
The NICE guideline on borderline personality disorder recommends psychological therapies for managing and treating the disorder. Because of the variety of symptoms and the variation in needs, flexible approaches that are responsive to the needs of each person with personality disorder are important. Involving people with borderline personality disorder in decisions regarding their own care is key for their engagement with treatment.
Quality measures
Structure
- Evidence of local arrangements to ensure that psychological therapies are available to people with borderline personality
Data source: Local data collection.
- Evidence of local arrangements to ensure that people with borderline personality disorder are involved in choosing the type, duration and intensity of psychological therapies that they
Data source: Local data collection.
Process
- Proportion of people with borderline personality disorder who received psychological therapies.
Numerator – the number in the denominator who received psychological therapies.
Denominator – the number of people with borderline personality disorder.
Data source: Local data collection.
- Proportion of people with borderline personality disorder who chose the type, duration and intensity of psychological therapy they
Numerator – the number in the denominator who chose the type, duration and intensity of psychological therapy they received.
Denominator – the number of people with borderline personality disorder who received psychological therapies.
Data source: Local data collection.
Outcome
Evidence from experience surveys and feedback that service users feel actively involved in shared decision-making.
Data source: Local data collection.
What the quality statement means for service providers, healthcare professionals, and commissioners
Service providers (mental health trusts) offer people with borderline personality disorder psychological therapies that are defined by the service user in terms of type, duration and intensity.
Healthcare professionals offer people with borderline personality disorder psychological therapies that are defined by the service user in terms of type, duration and intensity.
Commissioners (clinical commissioning groups, NHS England local area teams) commission services that have sufficient resources to provide psychological therapies for people with borderline personality disorder that are defined by the service user in terms of type, duration and intensity.
What the quality statement means for service users and carers
People with borderline personality disorder are offered psychological therapies that help them manage their condition. They can choose the type, the length of the sessions, treatment and frequency of the therapy they receive.
Source guidance
Borderline personality disorder (2009) NICE guideline CG78, recommendations 1.1.3.1,
1.3.4.1 and 1.3.4.3
Equality and diversity considerations
Adults within the prison population who present with symptoms of borderline personality disorder should have equitable access to services received by people in the community.
Specialist mental health services should ensure that culturally appropriate psychological interventions are provided to people from diverse ethnic and cultural backgrounds and that interventions address cultural and ethnic differences in beliefs regarding biological, social and family influences on mental states and functioning.
Quality statement 3: Psychological therapies – antisocial personality disorder
Quality statement
People with antisocial personality disorder are offered group-based cognitive and behavioural therapies and are involved in choosing the duration and intensity of the therapy.
Rationale
The NICE guideline on antisocial personality disorder recommends psychological therapies for managing and treating the symptoms and behaviours associated with antisocial personality disorder. Group-based cognitive and behavioural therapies help to address problems such as impulsivity, interpersonal difficulties, and antisocial behaviour, and can help to reduce offending behaviours. Because of the variety of symptoms and the variation in needs, flexible approaches that are responsive to the needs of each person with the disorder are important. Involving people with antisocial personality disorder in decisions about their own care is key for their engagement with treatment.
Quality measures
Structure
- Evidence of local arrangements to ensure that group-based cognitive and behavioural therapies are available to people with antisocial personality
Data source: Local data collection.
- Evidence of local arrangements to ensure that people with antisocial personality disorder are involved in choosing the duration and intensity of group-based cognitive and behavioural therapy that they
Data source: Local data collection.
Process
- Proportion of people with antisocial personality disorder who received group-based cognitive and behavioural
Numerator – the number in the denominator who received group-based cognitive and behavioural therapy.
Denominator – the number of people with antisocial personality disorder.
Data source: Local data collection.
- Proportion of people with antisocial personality disorder who chose the duration and intensity of group-based cognitive and behavioural therapy they
Numerator – the number in the denominator who chose the duration and intensity of the group-based cognitive and behavioural therapy they received.
Denominator – the number of people with antisocial personality disorder who received group-based cognitive and behavioural therapy.
Data source: Local data collection.
Outcome
Evidence from experience surveys and feedback that service users feel actively involved in shared decision-making.
Data source: Local data collection.
What the quality statement means for service providers, healthcare professionals, and commissioners
Service providers (mental health trusts) offer people with antisocial personality disorder
group-based cognitive and behavioural therapies that are defined by the service user in terms of duration and intensity.
Healthcare professionals offer people with antisocial personality disorder group-based cognitive and behavioural therapies that are defined by the service user in terms of duration and intensity.
Commissioners (clinical commissioning groups, NHS England local area teams) commission services that have sufficient resources to provide group-based cognitive and behavioural therapies for people with antisocial personality disorder that are defined by the service user in terms of duration and intensity. They also ensure that referral pathways are in place for people with antisocial personality disorder to be referred to these services.
What the quality statement means for service users and carers
People with antisocial personality disorder are offered group therapy that helps them manage their condition. They can choose the length of the sessions, treatment and frequency of the therapy they receive.
Source guidance
Antisocial personality disorder (2009) NICE guideline CG77, recommendations 1.1.3.1, 1.4.2.1, 1.4.2.2 and 1.4.2.4
Equality and diversity considerations
Consideration should be given to the provision of services for adults within the prison population who present with symptoms of antisocial personality disorder.
Specialist mental health services should ensure that culturally appropriate psychological interventions are provided to people from diverse ethnic and cultural backgrounds and that interventions address cultural and ethnic differences in beliefs regarding biological, social and family influences on mental states and functioning.
Quality statement 4: Pharmacological interventions
Quality statement
People with borderline or antisocial personality disorders are prescribed antipsychotic or sedative medication only for short-term crisis management or treatment of comorbid conditions.
Rationale
No drugs have established efficacy in treating or managing borderline or antisocial personality disorder. However, antipsychotic and sedative medication can sometimes be helpful in short-term management of crisis (the duration of treatment should be no longer than 1 week) or treatment of comorbid conditions.
Quality measures
Structure
- Evidence of local arrangements to ensure that people with borderline or antisocial personality disorder are prescribed antipsychotic or sedative medication only for short-term crisis management or treatment of comorbid
Data source: Local data collection.
- Evidence of local arrangements to ensure that when people with borderline or antisocial personality disorder are prescribed antipsychotic or sedative medication, there is a record of the reason for prescribing the medication and the duration of the
Data source: Local data collection.
Process
- Proportion of people with borderline or antisocial personality disorder prescribed antipsychotic or sedative medication in a crisis or to treat comorbid
Numerator – the number in the denominator who were prescribed the antipsychotic or sedative medication in a crisis or to treat comorbid conditions.
Denominator – the number of people with borderline or antisocial personality disorder prescribed antipsychotic or sedative medication.
Data source: Local data collection.
- Proportion of people with borderline or antisocial personality disorder prescribed antipsychotic or sedative medication in a crisis and who had it prescribed for no longer than a
Numerator – the number in the denominator prescribed antipsychotic or sedative medication for no longer than a week.
Denominator – the number of people with borderline or antisocial personality disorder prescribed antipsychotic or sedative medication in a crisis.
Data source: Local data collection.
Outcome measure
Antipsychotic and sedative medication prescribing rates.
Data source: Local data collection.
What the quality statement means for service providers, healthcare professionals, and commissioners
Service providers (GPs and mental health trusts) ensure that staff only prescribe antipsychotic or sedative medication for people with borderline or antisocial personality disorder for short-term crisis management or treatment of comorbid conditions.
Healthcare professionals only prescribe antipsychotic or sedative medication for people with borderline or antisocial personality disorder for short-term crisis management or treatment of comorbid conditions.
Commissioners (clinical commissioning groups, NHS England local area teams) commission services that only prescribe antipsychotic or sedative medication for people with borderline or antisocial personality disorder for short-term crisis management or treatment of comorbid conditions.
What the quality statement means for service users and carers
People with borderline or antisocial personality disorder are only prescribed antipsychotic or sedative medication for a short time if they have a crisis or if they have another condition that needs that medication.
Source guidance
Antisocial personality disorder (2009) NICE guideline CG77, recommendations 1.4.3.1 and 1.4.3.2
Borderline personality disorder (2009) NICE guideline CG78, recommendations 1.3.5.1, 1.3.5.2, 1.3.5.3 and 1.3.5.4
Definitions of terms used in this quality statement
Short-term crisis management
Using sedative or antipsychotic medication for short-term crisis management means using it cautiously in a crisis as part of the overall treatment plan for people with borderline or antisocial personality disorder. The duration of treatment should be agreed with the person, but should be no longer than 1 week.
Crisis may be suicidal behaviour or intention, panic attacks or extreme anxiety, psychotic episodes, or behaviour that seems out of control, or irrational and likely to endanger the person or others.
[Mental health crisis care concordat, Department of Health (2014) and expert opinion]
Quality statement 5: Managing transitions
Quality statement
People with borderline or antisocial personality disorder agree a structured and phased plan with their care provider before their services change or are withdrawn.
Rationale
Once in treatment, people with borderline or antisocial personality disorder may build a strong attachment with practitioners and services that support them. Any change to the familiar arrangements is likely to cause anxiety and be associated with an increased risk of crisis.
Self-harming behaviour and suicide attempts often occur at the time of change. Discussing changes in advance and coming up with a structured and phased plan acceptable to the service user, gives them a greater sense of control and reduces associated anxiety. People with borderline or antisocial personality disorder also need to know that they can access services easily in time of crisis. Integrating services is important to establish clear pathways for transitions between services and agencies, and facilitating well-organised services, care and support.
Quality measures
Structure
- Evidence of local arrangements that people with borderline or antisocial personality disorder agree with their care provider a structured and phased plan before their services change or are withdrawn.
Data source: Local data collection.
- Evidence of local arrangements to ensure that people with borderline or antisocial personality disorder can easily access services in time of
Data source: Local data collection.
Process
Proportion of changes to services or service withdrawals that have been planned and agreed beforehand by people with borderline or antisocial personality disorder and their care provider.
Numerator – number in the denominator planned and agreed beforehand by people with borderline or antisocial personality disorder and their care provider.
Denominator – changes to services or service withdrawals for people with borderline or antisocial personality disorder.
Data source : Local data collection.
Outcome
- Service user experience of integrated
Data source: Health and Social Care Information Centre 2014 Adult Social Care Outcomes Framework
- Frequency of crisis situations linked to
Data source : Local data collection.
- Evidence from experience surveys and feedback that service users feel actively involved in shared decision-making.
Data source: Local data collection.
What the quality statement means for service providers, health and social care practitioners, and commissioners
Service providers (mental health trusts, primary care services, social services, care homes, probation and prison services) ensure that systems and processes are in place for people with borderline or antisocial personality disorder to agree with their care provider a structured and phased plan before their services change or are withdrawn. This should include plans for accessing services at times of crisis.
Health and social care practitioners ensure that they agree with people with borderline or antisocial personality disorder a structured and phased plan before their services change or are withdrawn. This should include plans for accessing services at times of crisis.
Commissioners (clinical commissioning groups, local authorities and NHS England local area teams) commission services that allow people with borderline or antisocial personality disorder to agree with their care provider a structured and phased plan before their services change or are withdrawn. This should include plans for accessing services at times of crisis.
What the quality statement means for service users and carers
People with borderline or antisocial personality disorder agree with the people providing their care a plan setting out how their services will change before any changes happen. The plan includes what will happen if services are stopped and how they can get help if they have a crisis.
Source guidance
Antisocial personality disorder (2009) NICE guideline CG77, recommendation 1.6.1.1 Borderline personality disorder (2009) NICE guideline CG78, recommendation 1.1.7.1
Definitions of terms used in this quality statement
Changes to services
Changes to services include but are not limited to:
transition from 1 service to another
transfers from inpatient and detention settings to community settings
transition from child and adolescent mental health services to adult mental health services
discharges after crisis
withdrawal of treatment or services ending of treatments or services changes to therapeutic relationship.
Any changes need to be discussed, agreed and documented in a care plan written in collaboration with the service user to enable smooth transitions. The care plan should clearly identify the roles and responsibilities of all health and social care practitioners involved for each person with a personality disorder.
[Adapted from NICE guideline CG77 and NICE guideline CG78]
Equality and diversity considerations
Specialist mental health services should ensure that interpreters and advocates are present if any changes need to be discussed with a service user who may have difficulties in understanding the meaning and implications of these changes.
Quality statement 6: Education and employment goals
Quality statement
People with borderline or antisocial personality disorder have their long-term goals for education and employment identified in their care plan.
Rationale
The symptoms of borderline and antisocial personality disorders can often be improved with a range of interventions yet people still find it difficult to live well in the community. Health and social care practitioners develop comprehensive multidisciplinary care plans in collaboration with service users, which identify short-term aims such as social care and housing support. However, these care plans should also look at long-term goals for education and employment.
Quality measures
Structure
Evidence of local arrangements to ensure that people with borderline or antisocial personality disorder have their long-term goals for education and employment identified in their care plan.
Data source: Local data collection.
Process
Proportion of people with borderline or antisocial personality disorder who have their long-term goals for education and employment identified in their care plan.
Numerator – number in the denominator who have their long-term goals for education and employment identified in their care plan.
Denominator – number of people with borderline or antisocial personality disorder.
Data source: Local data collection.
Outcome
Proportion of people in contact with secondary mental health services who are able and fit to work and are in paid employment.
Data source: Health and Social Care Information Centre 2014 Adult Social Care Outcomes Framework
What the quality statement means for service providers, health and social care practitioners, and commissioners
Service providers (mental health trusts, primary care services, social services, care homes, probation and prison services) ensure that systems are in place for people with borderline or antisocial personality disorder to have their long-term goals for education and employment identified in their care plan.
Health and social care practitioners ensure that people with borderline or antisocial personality disorder have their long-term goals for education and employment identified in their care plan.
Commissioners (clinical commissioning groups, local authorities and NHS England local area teams) commission services that ensure that people with borderline or antisocial personality disorder have their long-term goals for education and employment identified in their care plan.
What the quality statement means for service users and carers
People with borderline or antisocial personality disorder have a care plan that sets out their goals for education and employment.
Source guidance
Antisocial personality disorder (2009) NICE guideline CG77, recommendation 1.3.1.1
Borderline personality disorder (2009) NICE guideline CG78, recommendations 1.3.1.2 and 1.3.2.1
Equality and diversity considerations
Services should work in partnership with local stakeholders, including those representing minority ethnic groups, to enable people with borderline or antisocial personality disorder to stay in work or education or access new employment, volunteering and educational opportunities.
Some people may be unable to work or may be unsuccessful in finding employment. In these cases, other occupational or education activities should be considered, including pre-vocational training.
Quality statement 7: Staff supervision
Quality statement
Mental health professionals supporting people with borderline or antisocial personality disorder have an agreed level and frequency of supervision.
Rationale
Some mental health professionals may find working with people with borderline or antisocial personality disorder challenging. People with personality disorder can experience difficulties in communication, building trusting relationships and respecting boundaries. This can be stressful for staff and may sometimes result in negative attitudes. Mental health professionals have a varied remit when supporting people with borderline or antisocial personality disorder. This means that the level and frequency of support and supervision that mental health professionals receive from their managers needs to be tailored to their role and individual needs.
Quality measures
Structure
- Evidence of local arrangements to ensure that mental health professionals supporting people with borderline or antisocial personality disorder have an agreed level and frequency of supervision.
Data source: Local data collection.
- Evidence of local arrangements to ensure that the level and frequency of supervision of mental health professionals supporting people with borderline or antisocial personality disorder is monitored.
Data source: Local data collection.
Process
Proportion of mental health professionals supporting people with borderline or antisocial personality disorder who have an agreed level and frequency of supervision.
Nominator – number in the denominator who have an agreed level and frequency of supervision.
Denominator – number of mental health professionals supporting people with borderline or antisocial personality disorder.
Data source: Local data collection.
Outcome
- Staff retention among mental health
- Job satisfaction among mental health
Data source: Health and Social Care Information Centre (2014) NHS Outcomes framework and NHS Staff Survey
What the quality statement means for service providers, mental health professionals, and commissioners
Service providers (mental health trusts) ensure that mental health professionals supporting people with borderline or antisocial personality disorder have an agreed level and frequency of supervision with their managers. This is recorded and reflects the individual professional’s needs.
Mental health professionals supporting people with borderline or antisocial personality disorder have an agreed level and frequency of supervision with their managers. This is recorded and reflects the individual professional’s needs.
Commissioners (clinical commissioning groups and NHS England local area teams) commission services that ensure that mental health professionals supporting people with borderline or antisocial personality disorder have an agreed level and frequency of supervision with their managers. This is recorded and reflects the individual professional’s needs.
What the quality statement means for service users and carers
People with borderline or antisocial personality disorder are supported by mental health professionals who are supervised by their managers to make sure they provide a good level of care.
Source guidance
Antisocial personality disorder (2009) NICE guideline CG77, recommendation 1.6.3.4 Borderline personality disorder (2009) NICE guideline CG78, recommendation 1.1.9.2
Definitions of terms used in this quality statement
Staff supervision
Staff supervision can be focused on monitoring performance, supporting the individual professional or a mix of both these objectives. Staff supervision should:
make use of direct observation (for example, recordings of sessions) and routine outcome measures
support adherence to the specific intervention
promote general therapeutic consistency and reliability counter negative attitudes among staff.
[Adapted from Antisocial personality disorder (2009) NICE guideline CG77]
Using the quality standard
Quality measures
The quality measures accompanying the quality statements aim to improve the structure, process and outcomes of care in areas identified as needing quality improvement. They are not a new set of targets or mandatory indicators for performance management.
We have indicated if current national indicators exist that could be used to measure the quality statements. These include indicators developed by the Health and Social Care Information Centre through its Indicators for Quality Improvement Programme. If there is no national indicator that could be used to measure a quality statement, the quality measure should form the basis for audit criteria developed and used locally.
See NICE’s what makes up a NICE quality standard? for further information, including advice on using quality measures.
Levels of achievement
Expected levels of achievement for quality measures are not specified. Quality standards are intended to drive up the quality of care, and so achievement levels of 100% should be aspired to (or 0% if the quality statement states that something should not be done). However, NICE recognises that this may not always be appropriate in practice, taking account of safety, choice and professional judgement, and therefore desired levels of achievement should be defined locally.
Using other national guidance and policy documents
Other national guidance and current policy documents have been referenced during the development of this quality standard. It is important that the quality standard is considered alongside the documents listed in development sources.
Information for the public
NICE has produced information for the public about this quality standard. Service users and carers can use it to find out about the quality of care they should expect to receive; as a basis for asking questions about their care, and to help make choices between providers of social care services.
Diversity, equality and language
During the development of this quality standard, equality issues have been considered and equality assessments are available.
Good communication between health, mental health and social care practitioners and people with borderline or antisocial personality disorder is essential. Treatment, care and support, and the information given about it, should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People with borderline or antisocial personality disorder and their families or carers (if appropriate) should have access to an interpreter or advocate if needed.
Commissioners and providers should aim to achieve the quality standard in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations. Nothing in this quality standard should be interpreted in a way that would be inconsistent with compliance with those duties.
Development sources
Further explanation of the methodology used can be found in the quality standards process guide.
Evidence sources
The documents below contain recommendations from NICE guidance or other NICE-accredited recommendations that were used by the Quality Standards Advisory Committee to develop the quality standard statements and measures.
Antisocial personality disorder (2009) NICE guideline CG77 Borderline personality disorder (2009) NICE guideline CG78
Policy context
It is important that the quality standard is considered alongside current policy documents, including:
Department of Health (2014) Closing the gap: priorities for essential change in mental health
Emergence (2014) ‘Meeting the challenge – making a difference’: a new personality disorder practitioner guide
Department of Health (2012) No health without mental health: implementation framework
Department of Health (2011) No health without mental health: a cross-government mental health outcomes strategy for people of all ages
Definitions and data sources for the quality measures
Health and Social Care Information Centre (2014) Adult Social Care Outcomes Framework
Health and Social Care Information Centre (2014) NHS Outcomes Framework
Antisocial personality disorder (2009) NICE guideline CG77
Borderline personality disorder (2009) NICE guideline CG78
Related NICE quality standards
Published
Alcohol: preventing harmful alcohol use in the community (2015) NICE quality standard 83 Psychosis and schizophrenia in adults (2015) NICE quality standard 80
Antisocial behaviour and conduct disorders in children and young people (2014) NICE quality standard 59
Anxiety disorders (2014) NICE quality standard 53
Smoking cessation – supporting people to stop smoking (2013) NICE quality standard 43 Self-harm (2013) NICE quality standard 34
Drug use disorders (2012) NICE quality standard 23
Service user experience in adult mental health (2011) NICE quality standard 14 Alcohol dependence and harmful alcohol use (2011) NICE quality standard 11 Depression in adults (2011) NICE quality standard 8
In development
Bipolar disorder in adults. Publication expected June 2015.
The full list of quality standard topics referred to NICE is available from the quality standards topic library on the NICE website.
Quality Standards Advisory Committee and NICE project team
Quality Standards Advisory Committee
This quality standard has been developed by Quality Standards Advisory Committee 3. Membership of this committee is as follows:
Dr Alastair Bradley
General Medical Practitioner, Tramways Medical Centre/Academic Unit of Primary Medical Care, University of Sheffield
Ms Deryn Bishop
Public Behaviour Change Specialist, Solihull Public Health Department
Jan Dawson
Registered Dietitian
Dr Matthew Fay
GP, Westcliffe Medical Practice, Shipley, West Yorkshire
Dr Malcolm Fisk
Co-Director, Ageing Society Grand Challenge Initiative, Coventry University
Ms Margaret Goose
Lay member
Dr Madhavan Krishnaswamy
Consultant Clinical Oncologist, Southend University Hospital NHS Trust
Mrs Geeta Kumar
Clinical Director, Women’s Services (East) Betsi Cadwaladr University Health Board
Mrs Rhian Last
Clinical Lead, Education for Health
Dr Hugh McIntyre (Chair)
Consultant Physician, East Sussex Healthcare Trust
Mrs Mandy Nagra
Cancer Drug Fund and Individual Funding Request Manager, Specialised Commissioning, NHS England
Ms Ann Nevinson
Lay member
Dr Jane O’Grady
Director of Public Health, Buckinghamshire County Council
Mrs Jane Orr-Campbell
Director, Orr-Campbell Consultancy, Bedfordshire
Professor Gillian Parker
Professor of Social Policy Research and Director, Social Policy Research Unit, University of York
Mr David Pugh
Independent Consultant, Gloucestershire County Council
Dr Eve Scott
Head of Safety and Risk, The Christie NHS Foundation Trust, Manchester
Dr Jim Stephenson
Consultant Medical Microbiologist, Epsom and St Helier NHS Trust
Mr Darryl Thompson
Psychosocial Interventions Development Lead, South West Yorkshire Partnership NHS Foundation Trust
Mrs Julia Thompson
Strategic Commissioning Manager, Sheffield City Council
Mrs Sarah Williamson
Clinical Quality Assurance and Performance Manager, NHS Stockport Clinical Commissioning Group
The following specialist members joined the committee to develop this quality standard:
Mrs Annette Duff
Nurse Consultant, Cognitive Behavioural Psychotherapist, Approved Clinician, Norfolk and Suffolk NHS Foundation Trust
Professor Peter Fonagy
Head of the Research, Department of Clinical, Educational and Health Psychology, University College London
Ms Victoria Green
Lay member
Professor James McGuire
Professor of Forensic Clinical Psychology, Institute of Psychology, Health and Society, Department of Psychological Sciences, University of Liverpool
Dr Paul Moran
Clinical Senior Lecturer and Consultant Psychiatrist, Institute of Psychiatry, King’s College London
Miss Katherine Spivey
Service and Development Manager, Bridging the Gap PD Services, Doncaster
NICE project team
Mark Minchin
Associate Director
Craig Grime
Technical Adviser
Anna Wasielewska
Lead Technical Analyst
Rachel Neary-Jones
Programme Manager
Esther Clifford
Project Manager
Jenny Mills
Co-ordinator
About this quality standard
NICE quality standards describe high-priority areas for quality improvement in a defined care or service area. Each standard consists of a prioritised set of specific, concise and measurable statements. NICE quality standards draw on existing NICE or NICE-accredited guidance that provides an underpinning, comprehensive set of recommendations, and are designed to support the measurement of improvement.
The methods and processes for developing NICE quality standards are described in the quality standards process guide.
This quality standard has been incorporated into the NICE pathway on personality disorders.
NICE produces guidance, standards and information on commissioning and providing
high-quality healthcare, social care, and public health services. We have agreements to provide certain NICE services to Wales, Scotland and Northern Ireland. Decisions on how NICE guidance and other products apply in those countries are made by ministers in the Welsh government, Scottish government, and Northern Ireland Executive. NICE guidance or other products may include references to organisations or people responsible for commissioning or providing care that may be relevant only to England.
Copyright
© National Institute for Health and Care Excellence 2015. All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE.
ISBN: 978-1-4731-1247-6