All our services are in the process of change. National influences and local pressures mean we have all had to think about how to make our- selves responsive and effective. Since 2004, we have been privileged to be asked to talk about the ideas in the Choice and Partnership Approach (CAPA). We have worked with several thousand clinicians, managers and commissioners. We quite often hear things that make us realise that CAPA is misunderstood!
So what are the Myths about CAPA?
f you are trying to implement CAPA and feel it is inflexible, then you are probably not doing it in the spirit in which we intended. Yes, there are guiding principles that need to be in place (the 11 Key Components) but within these you can do it as suits both you and your service users. You decide how to do assessments, what interventions to offer and who does what.
You can see clients for as long or as short a time as they need, and as frequently as they need. We hear that some people think there is a limit to the number of sessions, but there isn’t. We do know that the average number of appointments per family/young person is approximately 7.5 in many countries. This figure is used in the CAPA capacity calculations for Core Partnership. Other services with a clearly different Core average will use that number. But this does not mean you need to see people only 7 or 8 times, it may be much more. The range may be wide.
Whilst it is true that clinicians do give up some of their diaries, it is a small amount. The average would be, say, less than 3 appointments per week for a full timer (perhaps 1-2 Choice appointments and 1 initial Partnership). The rest, and all the non-clinical work in the week, remains under the clinician’s control.
We believe all specialities are valuable and necessary. We wish to privilege them alongside clinicians with extended skills in core work. How- ever, clinicians and services should consider their use of specialised time as it can use up clinical resources without necessarily adding significant value, or seeing the majority of referrals.
We think of the first Choice session as an opportunity to think about what resources a person needs to help them with their problems. This is a combination of resource identification, motivational interviewing, assessment and single session therapy. Thus it is much more than classic triage, as that simply sifts for urgency and eligibility.
Choice appointments can take as long as necessary. The shortest is probably 45 minutes with the client, especially if they have previously been known to the service, are clear about what they want and the referral came with lots of information from other agencies. You may well need more than one Choice appointment (Choice Plus) especially if not everyone in the family came (such as the referred adolescent or a separated father). People cannot make an informed choice if they are not present! The longest Choice appointments can take up to 90 minutes – and the CAPA numbers allow for this. It is up to you. [I find that I take about 15 minutes longer than I used to as I spend this time working with the family over their specific goals and what they can do to help themselves… Steve].
Choice only ends when the service user has been able to decide what they want to work on. If the right people do not come to the first Choice appointment (e.g. the adolescent) then you need to have a Choice Plus with them to allow them to make an informed choice. You could find you need up to 3 Choice sessions- one with the parents, one with the adolescent and one all together, or with a referrer or partner agency.
In fact, it is the other way around. We start with the idea that they don’t need specialist services and that they have the resources to manage. If they then choose not to return to Partnership it’s because they feel they positive about the plans they have made, without the need for services.
Sometimes people seem to think that there is no assessment in Choice appointments! This is untrue. It is not possible to help a service user understand their difficulties, and make choices about what to do about them, without assessment, including risk assessment. The stance is active, collaborative and open. We use our expertise to help them understand. Then together we reach a view of what to do next. The process of the Choice appointment should feel like a conversation and not us dragging them through a passive (for them) assessment interview.
Where does this myth come from? We think there is a significant misunderstanding about what goes on in a Choice appointment. A simplistic view of a Choice appointment is that it is a cosy chat with a client, focused on finding out what they want, without comment or opinion, and agreeing to it. This is not what should happen in a Choice appointment.
Choice involves an active conversation between the service user and people important to them and us. We are interested in what they want and we use our expertise to facilitate the formation of a joint understanding. And consideration of risk is a part of that.
The key reason for including risk in a Choice appointment is that the goal is to reach a joint understanding. If risk is present then it has to be openly talked about and included in the Choice Care Plan. Any risk will be central to the current situation and thus a key focus in Choice.
The stance in CAPA is collaborative, open and transparent. Talking about risk in Choice will be conversational in style but in such detail as needed to agree a safety plan. A relaxed, conversational style will gather more accurate information and engage the person better than asking a list of questions that does not follow their processes. This does mean that the clinician needs to be confident and experienced in basic risk assessment and have a structured approach in their head to apply.
Following the Choice appointment we continue to be aware of risk throughout Partnership. It is particularly important that it is clear who is the key worker, especially for those clients who see someone different in Partnership. Ensure rapid completion of written communication and Care Plans, copied to the service user and network. We aim for this paperwork to be sent out within 48 hours.
Skills in risk assessment and management are included in the concept of assessment as an ex- tended skill CAPA- the A of the Alphabet skills.
…but it is true that you will not have waiting lists. CAPA enables you to fix your first appointment (Choice) waiting time to whatever your service users need (we find 2 to 6 weeks from referral for non-urgent cases is ideal). As Choice appointments are fully booked, the person is never put on a waiting list. Partnership appointments are fully booked at the end of the Choice appointment and, ideally, should be within 2 to 6 weeks of Choice. Again, no one goes on a waiting list.
However, if you truly have too much demand for your Partnership capacity (and you can calculate this by team job planning) then the wait between Choice and Partnership will gradually lengthen. You will not have enough Partnership appointments to cope with your referral demand. This is when you will have to have discussions in the team and with managers about what the root cause is.
We sometimes hear that services are putting their least experienced clinicians in Choice. We believe that you need particular skills and a degree of experience to do Choice well. You need to know the local services, the skills of individual team members and be able to assess and formulate using a variety of models. You need to feel confident in discussing evidence based practice and be able to engage people in change in a way that feels empowering and non-hierarchical. You need to think carefully in your team as to who is best placed to do Choice, bearing in mind these skills.
We find that traditionally hard to engage clients value the stance in CAPA. It helps them to choose what will work for them and to be fully informed about what CAMHS is all about. It is easy to do Choice appointments with partner agencies to help this process. Hard to reach service users can be helped to book appointments by their refer- rer. Choice appointments can be held with the referrer and in a variety of venues to suit a family. CAPA is all about engaging people in change.
We are not sure where this myth comes from! You can do as much long-term work as a person needs – as long as the goals are clear, regular multidisciplinary reviews are held and the service user is in agreement that this is what is needed. CAPA is about doing the right things with the right people, at the right time. This may include long-term work.
Although in our services, the majority of the time, one clinician sees a family in Choice. However,
you can decide that this is two, if this is what is needed. Similarly, Partnership involves as many clinicians as needed- the key is having the right skills. Co-work is considered in the CAPA numbers.
Clearly not! They can chose within constraints of what is available and what is likely to work. They cannot choose an unsafe intervention or some- thing not available. They cannot choose to ignore risk or child protection concerns.
… if they have the right skills, the client wants to stay with them and there is a Partnership appointment at a suitable time! But the Choice appointment must be done as though you will not be the partnership clinician to encourage enough curiosity.
These ideas developed over many years of service redesign in Richmond and East Herts CAMHS. We have clarified how the model works in terms of demand and capacity theory and written in system free language. Other services have found it helps them manage and work more effectively. We have received no funding to develop or implement this model apart from some seconded time to the London Development Centre in 2006. The book and website are all self-funded and the time we spend running Workshops either comes out of annual leave or costs are paid to our employers.
It is true that CAPA is focused on improving outcomes for the service user by agreeing goals to be worked on. We agree how this will be done and review progress towards those goals. It does aim to identify strengths and be directed towards the outcome the client wants. Some practitioners may use Solution Focused Therapy techniques, especially in Choice. However, the therapy/intervention is up to the service user and clinician to decide on.
If you are trying to implement CAPA and feel it is inflexible, then you are probably not doing it in the spirit in which we intended. Yes, there are guiding principles that need to be in place (the 11 Key Components) but within these you can do it as suits both you and your service users. You decide how to do assessments, what interventions to offer and who does what.