East Herts CAMHS, UK

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Story supplied by Steve Kingsbury, Child Psychiatrist

A Long time ago…

The beginning to this was in 1993 when I was first a consultant. We had a fairly long waiting list and few staff. For some inexplicable reason we decided to try a waiting list week. In this every member of staff saw 4 new cases every day (standard pre-CAPA assessments) and on the Friday we all met to discuss them and allocate interventions. The weird thing was that the amount of work that was allocated seemed to be much less than we expected.

In 1995 we repeated a similar week with a few more joint assessments. This time I audited it to try and figure out what had happened the time before. The same thing did happen i.e. much less follow up work that we expected and worried about but I didn’t understand it!

In retrospect I think I can guess that two factors had a strong influence:

  1. The pressure of seeing so many at once meant we thought more about what CAMHS “should do” rather than what it “could do” and
  2. Knowing we were going to allocate to someone else meant we had to come to a clearer, agreed idea of what would help (the roots of why a Choice point and selecting a Partnership clinician are so effective)

Over the next few years we explored various service innovations but the significant step was the demand and capacity training both Ann and I undertook in the early 2000’s. Now we knew why some things did and didn’t work.

The Change…

Then in the summer of 2004, we had 10 month waits, felt very beleaguered and knew we had to do something.

However the number on the waiting list seemed too big for one of the previous week blitz’s and we needed a solution at least as big as the problem and so I suggested we implement the model that Richmond CAMHS was using.

Ann and I knew each other well and had been talking for years about how to have effective services, new patient clinics etc. as well as writing documents on CAMHS team’s capacity. In fact if we think about our service then and the 11 components of CAPA we had in place…

  • Leadership, I was the clinical director, Duncan Law, a consultant psychologist, was the team manager and admin were actively involved,
  • Team away days, we’d been having these quarterly since 1993,
  • Small group peer supervision weekly and
  • The rudiments of job planning in that everyone had a new patient target. Although then of course the assessment and treatments weren’t separated.

So from the summer of 2004 we spent the next 6 months talking in almost every team meeting about how to implement the Richmond model, planning the waiting list blitz and trying to figure out the maths to have individual activity targets for clinicians. Our style as a team was to implement things in one whole go and then review. Not a pilot and review type group!

The waiting list blitz…

We started by deciding to start the blitz on Jan the 1st 2005 and the “Richmond” model at the beginning of March 2005. Our first step was to write to all those who had been waiting over 10 weeks to ask them to opt in again if they still wanted to come. We assumed (for the sake of simplicity) that all those who had been referred less than 10 weeks ago would want to come.

Then, as now, East Herts CAMHS was one large team for a population of 320,000 which worked as three smaller teams based around Hoddesdon, Welwyn Garden City and Bishops Stortford. This example is based on the Hoddesdon team (the one I worked in) and although the whole service carried out this blitz the numbers for Welwyn and Bishops Stortford teams are lost in the mists of time.

The Hoddesdon catchment population in 2004, was 160,000 with about 7 FTE.

In Oct 04 we had 224 families and young people on waiting list. We asked the 162 who had been waiting over 10 weeks to opt in and 66 did. These plus the 61 who had been waiting less than 10 weeks made 127 families we would need to see in our Blitz.

Of course we weren’t entirely sure at the start how many slots we would need as the opt-ins came in gradually. So we guessed each week on how many we needed. We didn’t allocate any set number to clinicians just asked everyone to find what they could. As the intervention – Partnership – was not owned by the Choice clinician, staff were happy to offer any spare slot. We also said we’d fund part-timers doing more hours if they wished. We also devised a form for Choice clinicians to fill out and photocopy to referrer and family to cut down on admin time.

Then we called these appointments not Choice and Partnership but TIC’s (treatment inquiry consultation) and TOC’s (treatment onset consultation)!

It was a fairly manic time but there was a great team spirit with some clinicians from one team (Welwyn) even going out another site to help out there.

So we were fully underway by spring 2005.

The first couple of years

I think the team took the model on with some enthusiasm and it went well. Looking back we had most of the 11 components in place except few written care plans although Choice letters did have goals in them. We also carried out a focus group to hear about the clinicians’ experiences – see in the Evaluation chapter.

The issue that consistently caused the most anxiety was the transfer from Choice to Core Partnership. In our quarterly away days, where we chose our own topics, the transfer issue was talked about every time for about 18 months. So over time we moved from a rigid rule that the clinician must be changed to Core Partnership to thinking about when was it good to offer to stay with the family within the broad idea that selecting a new clinician brings advantages. They still need a choice of course.

The middle years

We were still running full CAPA at all 3 sites: flexing our Choice capacity and had no waits for Choice, averaging 2 -4 weeks. We also had a good percentage of our service in Core work – 40% plus – yet we continued to develop specific clinical interventions. This means that the waits to Partnership were always less than 6 weeks and again more usually 4.

We also got more detailed about job planning and I have been developed a spreadsheet to automate this. This has forced us to think more clearly about how job plans are structured as well as being fair between managers. I.e. were we applying the “rules” consistently. This encouraged us to define Big Admin more clearly and realise that each job plan needed to have a developmental aspect as well as a service aspect, for each clinician.

In 2009 we explored the idea that clinicians who have a high percentage (50%) of their job plan in Choice and Core Partnership seemed to be busier that those who have a lower percentage. So our local modification to CAPA is that the partnership multiplier attenuates the more Core Partnership time you do (see www.capa.co.uk).

Up to date

Since 2009 we have continued to run CAPA with a full implementation. We have had lots of staff changes but the culture and our enthusiasm has remained. Despite the change we have held the gap to the first Choice appointment to within 6 weeks for the last 7 years (just at times!) and the gap to the Partnership onset also to 6 weeks (again just at times). One of the factors in staying in balance was not only CAPA and the gains it has brought but it also allowed us to understand and plan our capacity across the three sites and then flex capacity as needed.

We have in recent times, partly because of our team coherence, been selected as one of the first wave sites for Children’s CYP-IAPT (this required transformed service), a local pathway trial and now a site for the Department of Health (England) pilot on Payment by Results and pathways.

All these new innovations have been very challenging on our capacity but CAPA has allowed us to quantify and respond in a timely manner.

Finally

CAPA and its way of working is very embedded in our team. We like the clarity of Choice, the support and learning of the peer group supervision and the creativity of our regular away days. We actively job plan and seem able to balance core work with specific activity. We have had very good leadership in the team from our clinical manager and as a whole our team feels very coherent and united.

Over the years and now we have been in balance with short waits to Choice and Core Partnership. Only once (summer 2007) did we get close to a breach in CAPA terms for booking to Core Partnership but just agreed to make more of an effort to rebook unused Core Partnerships and we came back in to balance.

Finally the clarity of the job planning and team capacity resulted in the trust agreeing for locum cover for a maternity leave (twice now!!)!

Practice Point: a CAPA waiting list blitz is a fairly simple thing: you plan CAPA completely including Choice and Core Partnership activity. From when the blitz begins (maybe 2 months before) all new referrals are offered a Choice from the CAPA start date. All those on the waiting list are seen in Choice as a part of the blitz in the gap between the blitz starting and CAPA beginning. All those that need Core Partnership Appointments are offered one in the pre-existing slots in the CAPA plan. When those are all in the Core Partnerships from the CAPA Choice appointments can be booked. See Waiting List Blitz in this webiste.