Choice Detail and Admin
Ideally, referrals should be attended to daily, using clear eligibility and core criteria (Key Component 2, Handle Demand). This can be done by one clinician, a rota, or by a pair. You decide. Then the client is contacted and invited to book an appointment. You could contact them by letter or phone – in both our services we use a letter. Choice appointments are therefore ‘fully booked’ in this system, meaning that the person is offered a choice of at least 2 appointments. We aim for this Choice appointment to be available within 6 weeks of referral, according to service user preference. We chose 6 weeks as user feedback (Richmond [Ann]) showed this to be suitable and sooner is hard for many people to organise. In practice this means that, at the point they phone to book, an appointment is often available within the next 2 weeks or so. Of course, you can set the time scale to be whatever suits you locally. In some mental health systems referral is made to a central referral point or single point of access. If this happens locally ensure that delays for the client are avoided and that referrals are still actioned daily.
In both East Herts CAMHS and Richmond CAMHS the letter invites them to phone in and book a Choice appointment. Along with the letter they we enclose a leaflet that explains CAPA and the purpose, and duration, of the Choice appointment. It emphasises that the clinician they see may not be the one they see if they decide to return. The opportunity to explore what they need and find out about the service is highlight- ed. When they ring they are offered all the free appointments in the Choice diary (see Implementation for creating one of these) and then sent a confirming letter with the date and time for the appointment they have chosen.
Clients can choose which clinician they want to see if they have come before and want to specifically see – or avoid – that person. This may mean a longer wait but this is their choice.
Many service users are able to use such a booking system. However, some could be disadvantaged as they may find it hard to get organised to phone in or are unable to read. Some may have found it hard to engage previously, or are vulnerable teenagers such as those Looked After. You need a system for them. We allow them the same opportunity to book in, but if they don’t we ensure we take steps to phone them or ask the referrer to help them book in (and maybe come with them). We may offer a wider range of venues to be seen in, including home visits.
In both our teams, emergencies and overdose/ hospital self harm referrals are not handled using this full booking system. Our emergency criteria are tight and few, ensuring clarity of determination of what need a same day or up to 48 hour response (in Richmond the criteria are suicide attempt, BMI under 15 and psychosis). However, the key principles of choice are retained as the philosophy in emergency appointments. The same paperwork is used.
Emergency work can be managed in different ways. Most services using CAPA find that they have far fewer emergencies, as waiting times are short. See the Chapter 7: Job Planning for more details.
The Choice appointment itself
Choice appointments usually last around an hour. In practice they tend to last anything from 45 minutes (usually these are with families who are well known and have clear goals) to 90 minutes. We allocated 90 minutes to the Choice slot – if it is shorter than this leaves time for beginning the Choice admin.
A number of clinicians can work together for all or part of a half-day session (a Choice clinic), meeting at the end to discuss the cases and complete rating scales etc. This team discussion is not to decide what to do, as this has already happened with the service user, but is useful for learning, to share ideas about resources that can then be sent to the client if needed. It also reduces variation in practice.
For example East Herts used to have a Choice clinic on a Monday afternoon. It had two slots –1.30 and 3.00. Some staff did both, others only one and then we all met for a 4.00 discussion slot. There was a rough half-hour gap between the two slots for admin but some admin from the second slot carried over to Big Admin time. There are more details in Implementation section. If you offer Choice appointments on different days and sites then the team discussion needs to happen at another time in the week, say linked to the weekly team meeting (the system used in both Richmond and East Herts).
Now, due to increasing admin time from our electronic patient record Choice and its admin take a little longer. So we only see one Choice for part of the afternoon or morning and have one meeting in the team diary for post-Choice discussion.
What if you can’t decide?
Sometimes it can be hard to be sure what you think will be helpful despite coming to a joint formulation with the service user. Then it’s OK to say “I’d like to talk to my team and then I’ll get back to you”. Note that this is to get more opinion / ideas to share with the client and not to decide with the team and inform the person after!
It isn’t always possible to reach a Choice Point in one Choice appointment (for us, maybe 10% of the time). If so, then you just arrange one or more further Choice appointments (Choice Plus) in your own or the Choice diary until you do. It’s the initial Choice clinician’s responsibility to continue until a Choice point is reached.
Full booking to Partnership
Following the Choice appointment, if the client chooses to return to the service, then they are booked into Core Partnership with a clinician with the right skills, style and personality to help them reach their goals. This is full booking – this is not waiting to make the decision until the post-choice meeting!
Partnership work continues to enhance the Therapeutic Alliance and it continues to focus on choices, goals and outcomes through Core work with additional Specific work as needed.
It is this separation of the clinical work into Core and Specific pathways that we will describe further in Chapter 6: Core and Specific Partnership Work.
We believe that the use of routine outcome measures is part of collaborative practice and effective goal setting and is thus a key part of CAPA. So our teams currently use measures from the
Children and Young People’s Improving Access to Psychological Therapies programme.
You choose what you would find useful.
At the end of each appointment a written communication is sent to the person, referrer and agreed network summarising the nature of the issues, choices discussed and chosen and actions. This includes what they will do to help themselves, goals and what services are needed. If they have chosen to return to the service then details of the key worker/care co-ordinator, Partnership appointment and Partnership clinician/s are given. This can be done in a letter (as in East Herts) or as a structured form (as in Richmond) , Care programme Approach or equivalent pro- cesses.
The clinical notes should contain any other information that would be helpful to the clinician at Partnership, that isn’t in the letter. Bear in mind ‘if I were to take on this person at Partnership would the letter and notes tell me all I need to work effectively?’. Remember, as is true for all records, these can be made available to the client if they want.