Written evidence from TMR Health Professionals
FUTURE PROVISION FOR VICTIMS IN NORTHERN
IRELAND
— Currently there is no clear commitment
to long term funding policies that would embed the range of trauma
services into core health and social care provision.— The
CGP Report recognises the need for a specialist trauma service
as conflict-related trauma is a "major public health issue".
— TMR Health Professionals have provided
through government funding, a "gold standard" service
for NI conflict-related trauma by embedding Primary Care Link
Workers in GP Practices/health centres in the Northern area (two-year
pilot project):
— Eye Movement Desensitisation and Reprocesing
(EMDR) was evaluated as cost effective and clinically effective
to provide individual assessment and treatment plans to meet individual
need.
— Over 1,000 clinical sessions and
74% patients completed treatment.
— GPs reported decreased prescribing of
drugs for anxiety and depression.
— This approach is an integral part of
the OFMDFM Victims Unit 10 year Strategic Plan and also the
Work Plan of the Commission for Victims and Survivors.
— A GP practice has elected to continue
on the Primary Care Link Worker Service.
— The Medical and Dental Training Agency
have adopted our specialist training for GPs in screening for
PTSD (as designed by TMR Health Professionals).
1. The future for all citizens of Northern
Ireland rests on each person who has been affected by the legacy
of the past having access to the necessary services to enhance
their overall health and wellbeing. The Report highlights a number
of key issues in regard to the future needs and concerns of victims
and survivors that need addressed as a matter of urgency.
2. The Report recognises the value of the
work already undertaken by the myriad of non-statutory groups
and many of the statutory organisations but this has, overall,
been a very "piecemeal" approach. The approach was revenue
dependent and the DHSSPS and local government agencies never fully
addressed the level of commitment to long term funding policies
that would embed the range of trauma services into core health
and social care provision.
3. The Report highlights the issue of "Understanding
and Responding to Trauma" (pg 87) and outlines that "for
many people experiencing a traumatic event has resulted in an
array of conditions such as alcohol, drug dependency …"
it goes on to say "those who work with people who
have suffered (trauma as a result of conflict related incidents)
need the opportunity to deal with these through the availability
of specialist trauma services. This is somewhat more critical
given that the authors of the Report have identified "conflict
related trauma as a major public health issue" (pg 88)
4. The report states that "the healthcare
system was portrayed as, at time, inflexible and unduly wedded
to certain therapeutic responses, some of which may not be the
the most effective…." (pg 88) At TMR Health Professionals
we have been at the forefront of service provision, offering a
broad spectrum of care services and therapeutic approaches for
victims and survivors of the conflict and people who have the
range of co-morbid conditions as a result of conflict related
experiences. We have a major success rate with the provision of
EMDR (Eye Movement Desensitisation and Reprocessing as a therapeutic
intervention programme for PTSD and related conditions. The success
and effectiveness of this therapeutic response is well documented
in our practice and in clinical research (see Annex 1). At the
forefront of our multi-disciplinary clinical team we have two
European recognised specialists in EMDR (Drs. Paterson and Miller).
We raise this issue within this document to highlight the effectiveness
of this approach on a number of different levels and to address
directly the problem of healthcare providers being wedded to a
single approach which is neither cost efficient in terms of value
for money nor clinically effective in terms of providing individual
assessment and treatment plans to meet individual need. We can
provide documentary evidence to support the outcome effectiveness
of this treatment as a way of addressing the issue of "trauma
being a major public health issue" (pg 88) and we would
like to take the opportunity through this response paper to demonstrate
that we are in a position to address this situation.
5. In 2002 we were commissioned by
the Northern Area Trauma Advisory Panel on behalf of the Department
of Health and Personal Social Services and Public Safety (DHSSPS)
and the Victims Unit of the Office of the First and Deputy First
Ministers Office to provide a Primary Care Link Worker Service
as a two year pilot project. The essence of this Service was to
provide an effective, community-based therapeutic service for
adults who had experienced emotional and psychological trauma
as a consequence of the political and community conflict in Northern
Ireland (colloquially and euphemistically referred to as "The
Troubles").
6. The Project included the placement of
a clinically trained psychotherapist (a Primary Care Link Worker)
in each of three GP practices/medical centres in the NHSSB area.
The pilot sites were identified within a socially acceptable and
non-stigmatised environment of a primary healthcare setting. The
Primary Care Link Workers were supported and supervised throughout
the Project by a Consultant Psychiatrist (who also provided training
and advice to the GPs on pharmacological medication for the treatment
of PTSD (Post-traumatic Stress Disorder) and a Consultant Clinical
Psychologist. The Service benefited from the availability and
direct access to these senior clinicians for medical and psychological
advice on specific issues for providing holistic care plans for
patients.
OUTCOMES
7. Almost 1,000 clinical sessions were
provided over the two-year period of the Project with 74% of patients
completing the full treatment programme. This is a significant
figure as people who receive psychological trauma treatments often
fail to attend after the first few visits.
8. GPs in the pilot sites for the service have
indicated that as a result of the training designed and provided
by TMR Health Professionals they have developed their capacity
and competency to screen for post-traumatic stress conditions
and prescribing the most appropriate pharmacological medications
for such conditions. They have also identified the need for funding
to be made available to provide this model of service as an essential
part of core provision in primary care settings. One GP practice
has continued with the Primary Care Link Worker service by generating
the funding themselves.
9. There is clear evidence from the evaluation
outcome that the Project has reduced the level of subsequent costs
for prescription drugs for other conditions (such as depression,
anxiety etc) for those patients who used the service. Additionally,
the Project has provided evidence-based information to support
the view that people who have experienced trauma are more likely
to develop one or more of the main mental health conditions such
as anxiety, depression, addiction etc. It is a well-recognised
fact that these conditions have been an underlying cause for many
physical conditions and also the main reason for the significant
rise in prescription drugs and, in some cases, alcohol dependency.
10. The Project has been identified as a
gold standard model of good practice by the key government healthcare
agencies, Victims Commissioner, Office of the First and Deputy
First Ministers Office (Victims Unit), The Medical and Dental
Training Agency, the Department of Health and Personal Social
Services and the Northern Ireland Health Committee. The Primary
Care Link Worker Service Model is an integral part of the OFMDFM
Victims Unit 10 year Strategic Plan and also the Work Plan
of the Commission for Victims and Survivors.
11. A full report on this Project is being
sent by mail. It shows an outline of the clinical value of the
Project as well as providing the individual, social and contextual
dimension in which the Project was designed and implemented.
12. At TMR Health Professionals we would
suggest to the Northern Ireland Public Affairs Committee that
this unique and evidence based effective Service is given consideration
with acuity of mind accordingly.
Annex 1
13. EMDR was developed initially as a treatment
for Post Traumatic Stress Disorder and was found to be successful
with veterans of the Vietnam War and survivors of rape. In 2000,
EMDR was recognised by the International Society for Traumatic
Stress Studies as an effective treatment for PTSD. The Northern
Ireland Department of Health subgroup, CREST, followed suit in
2003 and the National Institute of Clinical Excellence (NICE)
in the UK in 2005. EMDR has also been considered highly effective
and supported by research in the practice guidelines of the American
Psychiatric Association (APAA, 2004) and the US Departments of
Defense and Veterans Affairs.
14. Spector (2007) states, "Results in randomised
controlled comparison studies overwhelmingly show an effect for
EMDR with a trend towards greater efficiency when compared to
traditional exposure procedures." For example, the greater
efficiency was demonstrated in a study commissioned by the Scottish
Office (Power et al, 2002) which showed EMDR to be, on average,
two sessions quicker in obtaining remission from PTSD.
REFERENCESAmerican
Psychiatric Association (2004). Practice Guideline for the
Treatment of Patients with Acute Stress Disorder and Posttraumatic
Stress Disorder. Arlington, VA: American Psychiatric Association
Practice Guidelines
CREST (2003). The management of post traumatic
stress disorder in adults. A publication of the Clinical Resource
Efficiency Support Team of the Northern Ireland Department of
Health, Social Services and Public Safety, Belfast.
NICE (2005) www.nice.org.uk/nicemedia/pdf/CG026publicinfo.pdf
Power, K G, McGoldrick, T, Brown, K, (2002). A controlled
comparison of eye movement desensitization and reprocessing versus
exposure plus cognitive restructuring, versus waiting list in
the treatment of post-traumatic stress disorder. Journal of
Clinical Psychology and Psychotherapy, 9, 299-318.
Spector, J (2007). Eye Movement Desensitisation
and Reprocessing (EMDR). In C Freeman & M Power (eds)
Handbook of Evidence-based Psychotherapies: A Guide for Research
and Practice. Wiley.
April 2009
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