The Experience of Implementing CAPA

Below is a description of some of the comments in a focus group in the East CAMHS team in 2006 and their experience of the implementation of CAPA. We have found these themes to be common in other teams.

Before starting CAPA, what did clinicians worry about?

That it may not work

‘Planning was scary, everyone worried about the work they would need to take on.’

‘Brave jump in.’ ‘people worried that it was going to create work.’

‘…when we got over the first hurdle and we began to see where it was going’

‘…there were worries …about when we got rid of the waiting list then are we going to get inundated…’

Adapting to a new way of working

‘…some people have taken to this model more easily than other people and I think it’s been easier for some people to do the one off session and not continue work…’

What helped in getting things started?

Vision

‘Not so much the new system but the idea of getting rid of the waiting list.’

Leadership

‘I sort of felt there was a coming together as a team really but I think it demanded really good leadership.’

Commitment

‘I think there was something very important about people having enthusiasm for the idea, so therefore being prepared, because in January and February there was a lot of extra work. ‘

Planning

‘Big lead up to change, number of team meetings, discussing as a team how it would be done.’

What did clinicians think it was like for families?

Focused on what they wanted

‘Think this system allows much more for that and for people to choose. Part of what we need to discuss with them is do you want more work or is this enough for you? Quite a lot of people do choose ‘that’s enough’, they can go away with some ideas’ ‘I think that gets back to this bit about choice, patients might read the NICE guidelines [evidence based guidelines in England] and then read up on CBT but you need to have the knowledge that you bring with some kind of expertise to be able to think with people about what actually is most help.’

Made it easier to ensure CAMHS was the right service

‘… [Choice] is one-off stand alone session which we say very clearly to the family at the beginning…it’s for them to assess us as a service as well as for us to assess what we might offer them’

‘You don’t necessarily need a solution or answers but focus of what you’re exploring.’

How did it change clinicians’ practice?

Working in a more focused way

‘Well you can’t just go on in a sort of vague way with the family yourself, you are actually having to give a focus of work to the next person taking it on and if the family haven’t got any recollection of what is the focus of work then you know it’s not worked’

Thinking more clearly (in appointments and in letters)

‘I used to find I waffled on and that we didn’t really put down a formulation, more tentative and just ideas.’

Having a more collaborative stance

‘I suppose the onus is on us to explain our thinking and be much more overt about it, so it begins to make sense to the family as well’

‘I think that is they’ve found the Choice appointment really freeing knowing that I don’t have to have the answers, really freeing and exploring with families and that’s been really nice actually.’

Developing a shared language with colleagues from other disciplines

‘You have to have a shared language don’t you … in terms of how you formulate within the team

…I think it’s also true that we are developing that more.’

But are there any problems?

Sometimes a sense of missing something by not having done the Choice

‘In [Partnership] session you miss all the bits of subtle information that you get from [Choice] that you would ask but wouldn’t put in the letter.’

More awareness of how others work and they of you.

‘…probably effecting the team dynamics because we are seeing each other’s work much more and

in a different way to co-working because somebody has worked with a [Choice] and then you

see them for the [Partnership]…’

What was important in the Choice to Partnership transfer process?

A clear formulation and the right skills!

‘We’ve talked about this, I’ve had a formulation given to me that I don’t even understand let alone have the skills to implement, but it was too late and I took the [Partnership] and started the work…with my own skills…’

It was important to fine-tune the system

‘We (in Clinic x) have decided to set up one Choice appointment each week as a joint appointment.’

Iterative process helped

‘The beauty is that it has been an evolving system. So it started off as one idea, maybe as the triage idea and then it was kind of re-thought and came out as the …model and then ..[Choice/Partnership] and… call it CAPA, evolving all the time and changing.’

Flexibility about co-working was good

‘Although …it is set up that one appointment each week is a joint appointment.’

What else did clinicians really like?

Pride in having changed to a system that worked

‘One word has come to mind, there has been sometimes a sense of real pride I think for me, I’m not sure if others felt that , certainly in our team, to do with the team and pride in the team.’

‘Not having a waiting list to worry about.’

‘One of the good things, it got rid of the waiting list which is amazingly freeing and freed up us to close cases more easily than before.’

Referrers pleased no waiting list

‘… I’ve heard people are delighted they hadn’t realised there was no waiting list, absolutely delighted, GP’s, schools.’

What was important in making CAPA work?

Monitoring of the process

‘Those numbers, for me it is really important to know, I have confidence in someone keeping a handle on those numbers because I’m not very good with numbers.’

Formulation with the family

‘Passing it on, so [Partnership] therapist has a clear sense of where the focus of work might be.’

Flexibility and adapting the system

‘There has to be that flexibility in the system, it can’t be rigid otherwise it would only fit certain families.’

Team discussion

‘And I think that’s absolutely crucial, I don’t think you could do this model in a team were you weren’t able to have ongoing discussion.’

Trust within the team

‘It relies on trust between you and the team ‘

‘I suppose it felt like as a team there are all the skills there but not necessarily all in one person so it’s about learning from each other and talking about it’

What other things would help?

Getting a resource file together

‘What we haven’t done also is about accumulating knowledge of resources and we talked a lot about it, creating a resource file.’

Adapting it

‘…there needs to be an element of flexibility for complex families or other situations’

So overall…

We learnt that clinicians were anxious about change, understandably, but adapted and felt proud of what they were doing. Vision, leadership, planning and monitoring were seen as important in managing the change.

Openness about their own and each other’s work was one of the newer experiences for clinicians, as was the need to develop a shared language. Clear formulation with the family that was transmitted between the Choice and Partnership clinicians was important in a successful transfer.