Wednesday, 10 August 2016

“How do I know?”: Some thoughts on PBS accreditation



High quality delivery of evidence-based practices is a good thing

There are evidence-based, “consumer”, and likely economic arguments for ensuring that any approach to intervention/support is implemented with fidelity. By fidelity here, I am primarily thinking about high quality delivery of an intervention. Any evidence-based practice needs to be delivered with a high degree of quality (i.e., “done properly”) to have the best outcomes and to deliver anything like the promise of any more tightly delivered original research-based evaluations of that practice. That’s the evidence-based/research argument.

My “consumer” argument is simple and actually is the most important. In this case, people with intellectual disabilities and their families and carers deserve high quality support and intervention. Thus, they also deserve access to the highest quality Positive Behavioural Support.

The economic case derives from the first point about achieving better outcomes with better implementation (higher quality delivery of supports and intervention). These days, there is considerable interest in an “invest to save” perspective: if services can invest in wider scale implementation of evidence-based practices of various kinds, the high costs of picking up serious problems later might be avoided. In the case of people whose behaviour is described as challenging, perhaps this could include avoiding high cost placements in inpatient settings, shorter stays in such settings, shorter term use of high staffing ratios, and making sure people can stay in their own local community with security of residence (thus avoiding the costs of multiple moves between services and settings). Please note that any simplistic economic case being made here is not in my view the most important, but it is a reality we have to address.

Any economic models for investment in new services, in training for support staff, or the delivery of evidence based practices generally assumes at least a reasonably effective impact from the services, training or intervention. Basically, there is an assumption that whatever is done will be done well.

Current “standards” for Positive Behavioural Support

There may be several ways to improve the chance of high quality implementation of evidence-based practices, but the key features identified in the research literature relate to organisational commitment, good quality training of staff and ongoing expert supervision, and the articulation of clear standards for individuals and services/teams to meet.

How does this relate to the current situation in the UK around PBS? The key is in the answer to some apparently simple questions: How do I know that this practitioner is an expert in PBS? How do I know that this PBS training course will ensure I develop high quality PBS competencies? How do I know that this service/this team “does” high quality PBS?

The answer to these very important questions at the moment is that you have to decide for yourself/work it out yourself. The PBS Academy has produced a very detailed framework describing PBS competencies (see: http://pbsacademy.org.uk/pbs-competence-framework/). An answer to the “How do I know?” questions could be linked to this framework such as: “I received training based on the PBS competencies framework”, or “This training course is mapped onto the PBS competencies framework”. Unfortunately, this does not tell us very much because we naturally then need to ask something like “but who says it was any good?”. The PBS Academy has also published series of resources that help different stakeholders work out the answers to the “How do I know?” questions themselves. Thus, there are tools for people with intellectual disabilities, for family carers, for support staff, for service providers, for commissioners, and soon for people charged with inspecting the quality of services.

Personally, I think that these PBS Academy resources are helpful not least because they were produced with people from each of the stakeholder groups and are designed to address the particular nature of their “How do I…?” questions. These resources are in any case produced under a Creative Commons license so that they can be easily taken on board and amended by anyone who wants to use them. As I have said before, please do use and adapt these resources to make them work for you.

In terms of individuals delivering PBS, some professionals will point to the international Behavior Analyst Certification Board (BACB) and their levels of certification. These are indeed clear standards, and you should expect anyone with these credentials to know all about the Applied Behaviour Analysis aspects of PBS. However, behaviour analysis certification is not UK-based nor necessarily sensitive to the UK context, it is not specific to PBS, and of course ABA is a core part of PBS but not the whole of PBS. So, this may be useful but I do not think that it is a full solution and it primarily addresses the highest level expert practitioner only. There are University courses in ABA in the UK at postgraduate level in particular. Graduates from these programmes are likely to understand much more of UK context and may also meet the BACB certification requirements.

Interestingly, some UK Universities from 2016/17 are bringing in new PBS-specific routes through their postgraduate training in ABA, and others (some of the same ones too) have been delivering “challenging behaviour” courses for several years. Other PBS/challenging behaviour training courses have been developed that are accredited against a relevant UK qualifications framework. All of this training is delivered by respected education providers and is “accredited” somewhere within the UK public education provider/system. Although this is a good thing and they are undoubtedly good courses, there is a still no nationally agreed standard for PBS training against which these existing training courses can be tested. In addition, there are many PBS training providers who offer their own quality assurance (and several take this seriously) but they are conflicted as training providers, and there is no national standard for PBS training against which they can be checked.

UK accreditation for Positive Behavioural Support

Currently, in the UK, there are no nationally agreed standards for PBS. Does this matter? My argument is that it certainly does. First, PBS is recommended as a part of the plans going forward to address the Transforming Care agenda. It is not the whole solution to the challenge of challenging behaviour, but it is a part of it. Second, NICE guidance and quality standards are also clear about the need for functionally-based approaches (essentially, PBS). Thus, it is important to ask about quality and standards of PBS as a recommended approach.

Some may argue that setting standards and then having an accreditation process will cost money and that we cannot afford this. This is likely true – accreditation does cost money. How else though can we set proper standards and ensure high quality without such a process? Relying on people to sort it out for themselves (the current situation) is not appropriate. What is needed is a national accreditation process that can be trusted so that people do not have to sort it out themselves.

What if it does cost more money? Don’t the people affected by the transforming care programme and care scandals deserve high quality supports? In addition, if we can raise standards and somehow ensure higher quality supports we won’t have to use the sticking plaster high cost responses that we use when things go wrong. In the end, we may have invested and indeed saved!

The good news is that the PBS Academy has secured some funding and contributions of time from people to write/develop PBS accreditation standards for individuals, providers/services, and for PBS training courses. Thus, we’ll get on with this writing process using a similar methodology to that we have used before. The resulting standards will also be released as always using a Creative Commons license – hopefully by Spring 2017. This will mean that whoever might be tasked with PBS accreditation in future will have a head start. If the powers that be do not finally see the wisdom in commissioning PBS accreditation nationally, then at least the standards will be there for those committed to high quality PBS to use as a community.

16 comments:

  1. Is there anything we can learn from how it is regulated who practices CBT? This isn't too distant a field of practice and must have had similar concerns of people claiming to offer CBT without the right training/competence.

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    1. Indeed Jonathan, in the end there would need to be an accreditation body established. This could look a lot like the BABCP who accredit cognitive and behavioural therapists in the UK.

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  2. Loved the Blog Professor Hastings. Some great points. I'll have to look more into the PBS competency framework to let this guide our practice as social care providers. thank you.

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    1. That's good to hear, and do check out all the other PBS Academy resources connected to the competence framework.

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  3. In commissioning services, there needs to be the understanding of who needs PBS, there are those who think everyone needs PBS (including panel members on CTR's). This can encourage services to promote their high cost services because they do 'PBS' and dilutes the quality, or fidelity further.
    What all people need is to be treated with dignity and respect and to have their wants, needs and wishes acknowledged, valued and achieved.
    I'm in total agreement with the PBS academy and the need for national agreed standards, without them how do we know that services are delivering the right support and people are in receipt of the quality of support and treatment they deserve?

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  4. Thanks for the comments Paula. Indeed, how do we know!

    I very much agree that "all people need is to be treated with dignity and respect and to have their wants, needs and wishes acknowledged, valued and achieved". This is the core and then we have to ask what are some ways we can sensibly deliver just those things.

    I do think we need to be careful about saying either everyone needs PBS or not everyone does. The issue is that PBS is not a one size "treatment" for all, but a framework for personalising the supports that someone with, or at risk of, behaviour that challenges needs. PBS for person A is likely to look different to person B. So, in some senses, all of this group of people do need PBS - what they don't need is exactly the same PBS-based supports.

    I'm not convinced that enough people are getting this in terms of what PBS actually is...

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  5. This comment has been removed by the author.

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  6. I think the confusion comes about because the key principles of PBS, are what most of us would consider to be the expectations within person centred and capable service delivery:

    Behaviour is understood (from an FA/scientific perspective)
    The needs of the person and their carers are recognised with the goal being to achieve the best possible quality of life
    The individual is supported to have the skills to meet their own needs using active support, creative approaches and positive risk taking.

    I've often heard people say 'it's not rocket science' in relation to PBS and I think that's a disservice to the practitioners out there who are delivering on the core competencies. It also supports the idea that anyone can do it. The understanding of the function of the behaviour is the bit people miss out, instead of understanding why a person needs to behave in the way that they do they attempt to stop the behaviour with approaches that don't match.

    It's about values and beliefs, high quality leadership and raising expectations so that the people using these services achieve their potential and lead happy and fulfilling lives, as all of us want.

    The CQC report on Mendip House this week (The National Autistic Society), highlighted negative culture, poor leadership, environments engineered to meet staff needs rather than service users needs, lack of care and appropriate communication strategy's and so much more, all the opposite of what a capable environment would look like.

    There are so many angles to think about this from, I'd like to see more accountability for commissioners coming through the national standards when they are in place, the guidance for them on what a PBS service should look like is as clear as day so how do situations like Mendip House continue to be exposed?

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    1. Excellent points Paula, thanks. Also thank you for the example that clarifies one reason why it is crucial to have high standards - that it does indeed matter for people's lives.

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  7. Hello ProfHastings

    Would it be possible for me to get a copy of your papers: "I'm not a patient, I'm a person" and the review of carer research "He's hard work, but he's worth it"?

    Many thanks

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    1. Yes of course just email me
      R.hastings@warwick.ac.uk

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