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Peer-supported Open Dialogue Bulletin

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Welcome to the POD Bulletin

Read on to be updated on the huge project to research POD in the UK National Health Service, as well as to hear all about travelling to Norway for an Open Dialogue conference, the workings of an experienced Open Dialogue team in Southern England, and the pioneering use of Open Dialogue in an Intellectual Disability team.

But first, find out all the details about the upcoming National POD conference in Torquay, just below...

Enjoy the read!

2019 National POD Conference!

The 2019 Peer-supported Open Dialogue conference is upon us.

The world's largest trial of Open Dialogue is now underway in the UK. Devon is a key site in that trial so we will be holding our conference this year in sunny Torquay. We have a lot to report on with the launch and progress of the trial this year. You'll hear from clinicians, family members, service users and academics about the story so far, as well as plans for the future of Open Dialogue in the NHS.

Mon, 19 August 2019

14:00 – 17:00 BST

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Riviera International Conference Centre



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Conference tickets
Tickets are on a donations basis – so pay as much or as little as you like – and it all goes towards promoting Peer-supported Open Dialogue in the NHS. The event is sponsored by NELFT NHS  Foundation Trust, and its Open Dialogue inspired national referral service, Dialogue First.
Russell Razzaque
Consultant Psychiatrist and Director of Research, NELFT; Visiting Professor, LSBU

We are now full swing into the ODDESSI trial and it is indeed a trial. Implementing Open Dialogue requires many levels of agreement and cooperation - between managers, directors, clinicians and commissioners - but on top of that, we need to engage in an additional level of very complex organisation and governance for the research. Randomly selected areas will receive Open Dialogue and compared to treatment as usual in other randomly selected areas in the same locality. This means we need to position our POD teams and staff very specifically and recruit people to the study based on that.

For this reason, before starting the mean trial, our funder - the National Institute of Health Research - required us to conduct a feasibility study. We were awarded our £2.4 million grant on the basis that the feasibility demonstrates that in 2 pilot sites Open Dialogue can indeed be implemented as a full service model and, furthermore, that we can recruit subjects formally to a trial - gain their consent and start to measure some outcomes - from that service. Only if we hit all our targets in these areas would the study be allowed to continue. If not, the rest of the money would be taken away. This is what's known in the research world as a "stop-go" trial.
The two pilot teams were based in Havering in NELFT (my own team) and Canterbury in Kent. We kicked off last Summer and started network meetings for all those in our designated areas who were referred in crisis. We worked closely with our tireless research assistants from UCL who then interviewed and followed up all these clients as well as those in the treatment as usual arm. Team members were also interviewed and sessions taped to test whether or not it was actually Open Dialogue - with all of the fidelity and adherence criteria - that was happening. We had to deliver on quantity as well as quality, therefore. 
As we approached Christmas, with only a month or so left, referral numbers in both sites - just by chance - dropped. We didn't know if we'd have enough to complete all the measures in a sufficiently valid way. Anxiety grew in UCL and Steve Pilling (our Chief Investigator) and I would confer regularly about the latest state of play. The teams continued to do their best and, through the Winter, we carried on with the work, knowing the whole future of the trial rested on our shoulders. I have to say a huge thanks here to Allison Crane and Yasmin Ishaq, the managers of the 2 pilot teams for their focus and dedication at this time. 
In January it started to become clear that our numbers were getting closer and the targets were in sight. Steve and I then had a meeting with the committee overseeing our trial, along with the NIHR (called a Programme Steering Committee). Steve told me he was nervous before going in. Half an hour into the meeting, however, the trio of Professors on the panel made it clear that they were very impressed. They could see we had delivered on all the essential questions, proved that we could implement Open Dialogue in these pilot sites and evaluated people who were receiving it. They wrote a glowing recommendation to the NIHR decision makers and a matter of days later we got the "go". The rest of the trial can now continue to completion.
A moment of relief and celebration was followed very quickly by a new focus. Now we have to replicate this across a further 5 teams - in addition to the original 2 - and run it for several years. In April the leads from each prospective team met so we could learn from the pilots and plan the launch of the new teams alongside us. We agreed launch dates across the Summer to Autumn of 2019 and are now all learning, liaising and developing our protocols and systems together. 
The next phase of our joint ODDESSI is now well and truly underway. 
At the same time an international collaboration has also been funded that will see a large number of similar smaller trials around the world launched and evaluated alongside ODDESSI - in a kind of hub and spoke model, where they all share our methods and data sets wherever possible - so that we can build an international evidence base together. Steve and I are traveling to Rome in early July to help kick it off, which will hopefully cement a global research movement to evaluate and, if all works out, disseminate Open Dialogue internationally. 
Watch this space. It's getting a whole lot bigger.
Debbie Greenhill
OD Practioner, Barnet, Enfield and Haringey Mental Health Trust

With the ODDESSI trial due to start imminently in Haringey, a colleague and I thought it would be helpful (and fun) to travel to Norway to attend the 9th Nordic Open Dialogue conference in Trondheim, Norway.

I was struck by the peace and traquility of the city in contrast to the tension that is often present in many cities in the UK.

The conference venue was a museum of music history, established in the 1950's at the beginning of the rock n roll era - an added bonus for me, as music is my passion.

Both days started with powerful presentations of song and dance movement, conveying messages around self hatred, personal growth and empowerment.

Presentations from the Netherlands, Norway and the East Midlands (UK), were informative and inspiring, demonstrating the success and growth of Open Dialogue around the world.

I was particlarly inspired by the presentation of an Open Dialogue public health project implemented in Norway, where an online forum using Open Dialogue brings together young people to discuss the issue of fatalities amongst young people from a trend for fast, reckless driving. The results after a two year period demonstrated that by providing a forum for these previously unheard voices to be heard, the number of fatalities had decreased notably.

So pleased and proud to have been there.
Yasmin Ishaq
Kent Open Dialogue Service Lead

The Kent Peer Supported Open Dialogue Service became operational in February 2017. As the 1st team in the country to start delivering a service with a new approach adapted from the Finish Open Dialogue Approach, we found ourselves having to consider many challenges which were not easily resolvable within the existing mental health NHS system. These included pathways for urgent referrals and working across existing boundaries. It also included where we should benchmark care coordinated caseloads to allow sufficient flexibility and mobility whilst also maintaining continuity of care, two of the main principles for the Open Dialogue approach.

Whilst developing the new operational systems, the team started to take referrals from the Canterbury and coastal area of Kent. This locality is also the site for the ODDESSI trial and whilst ensuring operational and governance systems were in place to meet organisational standards there was also a process in place to complete what was required for the research protocol.

The team has been through a process of not only being an innovation within the Kent and Medway Health and Social Care Trust but also seen a beacon for other trusts to learn from in terms of successes and challenges. To this end there have been many visitors to the site from national and international colleagues, practitioners and others interested in the work being undertaken.

The operational team, who have all had a minimum of 1 year training in Open Dialogue, have continued to learn as a team. Relationships have been challenged and strengthened through the dialogical way of working, particularly the focus on a relational way of being and working with family/network systems. This has been rewarding but also at times difficult in terms of managing time and availability whilst ensuring continuity.

Practitioners in the team have used weekly reflective clinical supervision to understand at a deeper level the use of self, and how the polyphony of voices that inhabit us all raise issues and reflections when working with each other and network members. The process of ‘shared decision making’ has taken on a new level of meaning, with consideration of the different levels of power within a network meeting openly discussed and where possible decisions made collaboratively and inclusively. Team learning and away days happen every 3-5 months to support the continued development of the service and self work.

The team have had 400 referrals over the last 26 months and currently have an active Open Dialogue caseload of 120. The team work flexibly over the working week up to 8 pm in the evenings, to give increased choice for individuals and their families/networks over meeting times. There is an aspiration for the team to move to a 7 day a week operation.

The feedback from people using the service has been overwhelmingly positive, with regular comments of “feeling heard”, “given time to explore what has happened”, “not feeling rushed” and “feeling all voices are heard and validated”.

There has been national recognition of the teams work since it started and over the last year the team have been Highly Commended by the Positive Practice in Mental Health Collaborative and won Adult Team of the Year at the Royal College of Psychiatrists Awards 2018 (see picture below).

In some respects the team still feels in its infancy, in terms of working dialogically and systemically within a strong psychosocial framework. Learning is continuous and it is likely that there will not be an end point to developing and learning. We learn constantly from each other, from people we work directly with and from the reflections of others. The openness to new experiences and new ideas remains an important aspect of how the team is evolving, as is the focus on the importance of all voices in the team being heard and validated.
The team won Adult Team of the Year at the Royal College of Psychiatrists Awards 2018
Dr Lisa Monaghan, Alexis Stevenson, Jason Vosa-Baigrie, Lucy Ihezie & Dr Bini Thomas
Havering Learning Disability Team, NELFT

In many parts of the UK there are specialist teams that serve the intellectually disabled population. Over the last 20 years these have been integrated teams consisting of health (NHS staff) and social care (local borough authority staff); professionals from multiple disciplines. For those of us working in intellectual disability specialist services, multi-disciplinary working practices and systemic models are familiar and seen as vital to good practice of care.

Much of our work is considered to be “joined up” working that considers the whole person and not just symptoms, care needs or disorders. The people that access these services are heterogeneous having a wide variation in presentation, complexity, ability and need. For this and many other reasons, (stigma & injustice being just two of them), people with an intellectual disability (PwID) are often excluded from research trials and models are often developed without effective consideration about how it might be applied to this population.

We work in The Havering Learning Disability Team (HCLDT), which is one of four such teams in NELFT. Lisa is a Clinical Psychologist, Jason is a Nurse, Lucy is a Social Worker, Bini is a Psychiatrist and Alexis is a Speech & Language Therapist. We have all had varying degrees of training in Open Dialogue (OD) and Systemic therapy but our team is not included in the RCT trail that our mainstream colleagues are involved in. The authority we work in is also trialling a model called “Better Living” which has many of the principles of OD. As OD appeared to be a natural extension of the way our team already works (see table below), we decided to undertake a small scale trial in order to look at the adaptations needed to use this approach with our clients.
Using the principles of Open Dialogue in the ID team (LD = Learning disability; LT = long term; SU = service user)
We had no extra funding and already have highly pressurised workloads with limited capacity. We already know that family therapy is cost effective compared to individual therapy for certain presentations, especially ‘high utilisers of care’ (Law, Crane & Mohlman-Berge, 2003). There is also a national target to reduce inappropriate use of services and a performance target, upon which trusts are assessed.

Due to our limited capacity we chose one clinical case study that fit this category. This would limit any added pressure on the normal duties of staff, enabling us to problem solve adapting the model to PwID, assess organisational obstacles and understand any financial implications for both social care and health targets. Clients categorised by the team as 'high utilisers of services' were reviewed (30 in total).

The person with the highest risk and most immediate concerns was chosen for this trial; ‘Leon’*. There was a reported increase in hearing voices and frequent use of emergency services.

Over the course of 8 months, the team undertook 12 network meetings with Leon, with 30 individual appointments agreed outside of this to cover physical health needs, social care reviews and a communications assessment. Leon’s family and support workers attended the network meetings. Various visual communication tools such as pictures, talking mats and whiteboard diagrams were used in the meetings to enable Leon to fully participate and comprehend. Sessions were usually around an hour to allow him to concentrate throughout.

Leon’s use of emergency services reduced from 3-4 weekly to once in the final month, which was necessary for physical health concerns. The costs of his weekly visits were approximately £3000+ prior to this intervention.

Leon described his sessions as “good different”, his family who had concerns that the meetings would exacerbate his presentation were surprised at the positive results, and his support workers reported that “Leon always wants to come and reminds me they are happening”. In addition, the team was able to model helpful interactions to support staff and to proactively highlight issues in care as they arose.

Bakhtin, (1984) stated:

“To live means to participate in dialogue: to ask questions, to heed, to respond, to agree and so forth. In this dialogue a person participates wholly and throughout his whole life: with his eyes, lips, hands, soul, with his whole body and deeds.”

For our client group, many of whom struggle to communicate, it is important to note that the model stresses the need for professionals to attend to ‘non-verbal’ communication cues. In this way, this model is highly suitable for working with PwID and does not need a great deal of professional change to implement it. It was possible to integrate the model into our team and enabled us to adhere to our aim of good person-centered planning. It also fits well with national strategies of care such as The Winterbourne report, where failures in care were partially due to lack of communication and inclusion of a person and their networks.

There are issues with the model from an organisational point of view. For example, currently 8-12 weeks is the average time for social care allocations and reviews in this team. However, Lucy, our social worker, was able to review Leon immediately and assess his care package when concerns were raised in the network meeting about how it was being used; this is not something that can be sustained in the current system and will cause a detrimental impact on the progress made in network meetings.
This trial of Open Dialogue has shown that good integrated multi-disciplinary interventions work well for the clients & their families as well as the teams involved. However, lack of funding and resources mean it is difficult to fully incorporate the model at this time. Further research and case studies are needed to assess the effect of the open dialogue model in this population. Our hope is that we can use the model for our crisis work while we build a case for further funding.
*names changed for confidentiality
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Peer-supported Open Dialogue UK · NELFT NHS Foundation Trust offices · 137-145 Church Road · Harold Wood, RM3 0SH · United Kingdom

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