Richmond Tier 3 CAMHS, UK
Story provided by Ann York, Child and Adolescent Psychiatrist
I work in Richmond. The Child and Family Consultation Centre is a Tier 3 and targeted Tier 2 multi-disciplinary service in South West London. We are in a Mental Health Trust. Our catchment population is just over 190,000. Current staffing is somewhat lower than it was, around 8.8 FTE, including posts in Youth Offending Team, Learning Disability and Children Looked After. We see young people from age 0 to 18 years including children with learning disability. 24/7 out of hours cover provided as part of a 5 – London-borough on call system.
Referrals continue to increase and be more complex- around 800 a year. In 1999, when we began our service redesign, we had 13.4 FTE and 445 referrals a year. Waits were 8 months and rising! Waits are now around 4 weeks to Choice. Waits to Core Partnership creep up and claw back in relation to staff sickness, delays in recruitment and cuts to posts. This is especially true to neuro-developmental work where we have found it hard to recruit to this specific skill set, especial for temporary posts.
We act on referrals daily and flex our Choice capacity weekly.
We started in CAPA in a step-by-step manner from 2000; our service model at that time was a traditional one. We had a weekly team referrals meeting, put accepted referrals on an assessment waiting list and had several internal Specific waiting lists to various professionals.
Our team change style is one of doing small pilots, evaluating and revising and then full roll-out. I have described what we did year on year and retrospectively indicated our CAPA-CRS score on the 11 Key Components as we only developed the CAPA-CRS in 2008!
An audit showed that our waiting time for a non-urgent appointment was 8 months. We introduced a Brief Intervention clinic for those on the waiting list (‘Clinic 4’). We had hoped that this would help but found that this did not reduce waiting times overall, although the solution focused approach was valued by families.
We found that 38% of our team caseload was seen for 3 appointments or less, 19% for 4 to 8 appointments and 9% for more than 8 appointments.
In May 2000 we undertook a clinical governance baseline assessment, which involved a clinical risk profiling exercise that calculated likelihood, severity and cost of adverse events. We compared our waiting times using bench-marking against the recommendations made in Children in Mind (Audit Commission, 1999). Waiting times for first routine appointments was found to be our highest risk area.
We also audited referral pathways for those put on the non-urgent waiting list and found times of:
- 8 months or more for non-urgent referrals
- 12 months or more for Specific assessment of social communication disorders
- 4 to 6 months for psychotherapy treatment
- Same day or 2 weeks for urgent appointments, according to perceived level of risk/ urgency.
Audit of the waiting list showed we could not predict urgency from the referral letter and that some families waited 3 months in our weekly allocation meeting (which was by now approaching 90 minutes!) whilst we tried to get further information. We had a daily rota for ‘waiting list enquiries’ and staff spent nearly an hour a day talking to families on the phone who were waiting, or sometimes, rather guiltily, doing a ‘one-off session’ to cope with their anxiety!!! Urgent cases were queue jumping all the time (Demand and Capacity issue: Churn).
At that point we had, as a team, all got to the point of:
- We couldn’t bear to go on this way (‘The present is intolerable’)
- We wanted to get rid of waiting lists and to offer an accessible, quality, multi-disciplinary service that saw routine families within 4 to 6 weeks (‘Clear vision of the future’)
So we did several things:
- Learnt from our internal audit i.e. deciding who may benefit from Brief interventions based on a referral letter did not help waits.
- Long referral meetings did not help us manage our waits.
- Gathering more and more information to try and help us work out whether families were eligible did not help us decide this and just made families wait.
- We spent a lot of time managing our waiting list- it was better just to get on and see people!
- Looked at published literature to find out what others had done
- Explored triage systems- but decided this just led to internal treatment waits
- Decided we wanted a model that offered assessment and treatment without undue delay
- Worked out our numbers so that we knew how many new appointments we needed a week to manage our demand
- Developed 3 possible models in a Team Away Day and chose one to pilot
- Ran the pilot from October to December 2000.
We evaluated it after 15 weeks and found the model was satisfying to work and helpful for users.
The model was a multi-disciplinary clinic with new appointment slots, follow -up slots and small group multi-disciplinary case discussion. In CAPA language it provided a mix of Choice and Core Partnership. We introduced routine outcome measurement and Care Planning.
Running this successful pilot gave us our ‘manageable first step’.
We jumped off the bridge together and changed the whole service in January 2001 to this mixed clinic system. We called them Starter clinics (standing for See To Assess Review Treat Evaluate Review)- there were 4 a week. Each had a mix of Core work but also Specific add-ins (such as sexual abuse, neuro-developmental, adolescents). We kept to our philosophy of offering mixed, blended psychosocial interventions to the majority of families.
We did not offer full booking to first appointments but did to intervention. We attended to referrals daily and wrote to new families and offered an appointment at that point. Waits reduced to around 4 weeks for non-urgent referrals, primarily as we had got our numbers right and were offering the needed number of appointments.
At that time we had carved-out urgent slots in the 4 clinics and 3 priority streams (emergency, urgent, routine) still with about 10 categories in the urgent one!
Unfortunately we lost local authority and other funding and so 40% of our staff (and thus capacity) and referrals gradually crept up. So by end of 2002 routine first appointment waiting times were approaching 26 weeks. We had reduced the Starter clinics to 3 from 4 as a result of loss of staff. We started a segmented Eating Disorder clinic. We had admin crisis too, with loss of post and long-term sickness.
Audit of the carved-out urgent slots showed under-use, so capacity wasted, and we found we were poor at predicting urgency from the referral letter. We also felt families did not have a chance to find out about our service before committing to it.
We designed Choice clinics (which we called Face2Face) and piloted them from Jan to June 2003. All Choice appointments were fully booked. We also reduced priority streams to 2 (emergency and routine) with only 3 categories within emergency (psychosis, severe suicidality or BMI under 15). This was separate to the self- harm service to the local hospital, which was managed by a rota system. We abandoned carved out urgent slots and moved to a rota ‘next up’ system for emergencies. Choice principles and paperwork were used in the emergency and self-harm contacts.
This worked really well, with good user, clinician and admin feedback. We also had spontaneous positive feedback from referrers, particularly that hard to reach young people were easier to persuade to come to a Choice appointment for a ‘look-see’.
But we were not doing full booking from Choice into the Core Partnership clinics so different and inequitable waits developed for each clinic.
We then introduced full booking from Choice to Core Partnership in Jan 2004 in 2 of the 3 Core Partnership clinics. This worked well, with equal waits in the 2 that were fully booked and lengthening waits in the one that wasn’t! This showed us the importance of full booking.
So full booking moved to all Core Partnership clinics. By June 2004 we had Choice and Core Partnership clinics with full booking to each.
We extended skills for ASD assessments and in CBT. This meant CBT could be offered as core work and bottlenecks to Specific CBT and ASD assessment were widened.
CAPA continued to work well, although we had not introduced team job planning. The segmented Eating Disorders clinic continued.
We began activity targets for clinicians in Core Partnership (but broad and not tailored to their job plan).
As in many CAMHS, we had huge problems ‘Letting go’ of families and found it hard to find time to do routine multidisciplinary reviews of ALL cases- there was anxiety in some of team about such openness.
Our team manager was redeployed following Trust reorganisation and the post remained vacant for a year.
Routine discussion of cases open over 1 year began in Core Partnership peer groups. Team job planning and individual activity targets were implemented. We undertook a New Ways of Working early Implementation project looking at user involvement.
In the summer of 2006 an electronic care record system was introduced and we became a ‘paperless’ service. Unfortunately, we had not anticipated that this change would be as dramatic as it was!!! It certainly added to our admin time. We had hoped that it would save us time but the adjustment was enormous. For several months we struggled to learn a completely new way of working administratively and stopped full booking to Partnership as a way of trying to cope. Surprise, surprise- waiting lists grew rapidly!
Our new manager started and we slowly adjusted to our new computer system. However, despite wonderful advantages such as the notes being in one place (and being able to read them!) and electronic diaries, data entry was time consuming and straining our capacity.
We restarted full booking to Core Partnership and waits reduced again, but because of reduced capacity due to the new care record system we found it hard to maintain our internal quality standard of no more than 4 weeks between Choice and Core Partnership. The process of Choice took much longer due to increased admin time, meaning we had to double the capacity to manage. Instead of being able to offer 2 Choice appointments in a half-day, we could only do one. Having been in demand and capacity balance for a while, we no longer were. Team job planning was revised accordingly.
Having been quite a stable staff group, many senior members retired over the next year. Financial constraints meant that posts were not replaced or were down-graded to try and maintain capacity. Changes in the senior management team meant leadership became more fragmented for a time. New staff had to learn about CAPA and took time to settle in.
75% of the team had been in post less than 3 years and the team that piloted Core Partnership clinics all those years ago and introduced Choice had mostly moved on. This produced new opportunities and challenges. Reducing variation in practice and remembering (or learning) what our systems required special attention in away days.
A new Primary Mental Health Service began as a pilot, jointly commissioned by the local authority and local health commissioners (PCT). This meant a revision of our pathways and referral criteria and the hope was demand to Tier 3 would reduce. This did not happen however, instead Tier 3 referrals increased and were increasingly appropriate. This was great for the families but hard on workloads – through CAPA job plans we could demonstrate that we were becoming more and more out of balance.
Continued financial pressures, long term staff sickness and downgrading of posts were challenges. Our manager successfully maintained our WTE by creative means, but the staff mix changed to an overall less experienced one and temporary staff meant lots of churn to the system trying to manage different skill sets and lengths of contracts.
The PMHW service moved to be temporarily managed by our Trust. CAPA was fully implemented to the PMHS and the pathway from PMHW to Tier 3 worked smoothly.
Commissioners started a review of comprehensive CAMHS locally, and began to develop local pathways. At the end of the year the PMHS reverted to the local authority but they continued with CAPA.
At the time of writing we are excitedly getting ready, preparing for the Children and Young People’s Increasing Access to Psychological Therapies (CYP-IAPT) service transformation – we are doing this jointly with the local authority provided Primary Mental Health Worker Service. Running CAPA is really helping us with planning our backfill for trainees and expanding are usual outcome monitoring to the broader, more frequent CYP-IAPT dataset.
The commissioning review is being finalised and there is acceptance by commissioners that we are under-resourced. We wait to see what changes this brings.
We continue to use a standardised form for Choice and standardised Care Plans. Choice paperwork is used in all parts of the service, including YOT, LAC and emergencies. We have 2 Core Partnership clinics a week, and segmented clinics for Eating Disorders (with a Care Bundle), Neuro-developmental Disorders, ADHD medication, Specific Family Therapy and Adoption/ attachment work. We have Specific Partnership multipliers for all Specific Partnership work. We continue to have whole team Away days every 2 months and sub team away days (e.g. Partnership clinics, management, eating disorders). Referrals are attended to daily.
Our CAPA implementation is weaker in terms of extending skills in core partnership – this is harder to maintain with temporary staff, as is ensuring regular care plan goal setting and review processes. Our IT system does not support review reminders and paper systems require constant maintenance! We hope that CYP-IAPT, with its specific dataset and systems will support us to become more consistent.
What helped us?
- We continually think about how our processes work, or not, for young people and their families
- We think all the time- does this process add value to the clients?
- Ongoing monitoring and challenging of ourselves- aiming to continually improve
- Taking time to help new staff members understand CAPA- and getting them to tell us what has worked in their previous teams so we can get new ideas
- External peer reviews as part of the Quality Network for Community CAMHS (QNCC) has helped us benchmark what we do and learn.
This really long story describes how Richmond did it – and continues to do it. CAPA continues to work well. We can’t imagine not using it – we value the focus on collaborative work with our families too much.
Leadership and monitoring is crucial, for CAPA and for any change. We continue to work in a constantly changing NHS, with pressures from all sides. But having a way of working that puts service users at the heart of what we do and supports transparent communication at all levels really helps us survive.