Choice and Partnership in CAMHS

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Re: Choice and Partnership in CAMHS

Post by miriam »

What is Choice and Partnership?

Choice and Partnership is a way of managing supply and demand in CAMHS work. The idea is to avoid allocation meetings and waiting lists, and for referrals to be told to phone in and choose an appointment from a list. The first appointment, which is called the Choice appointment, aims to do a brief assessment of the familiy's concerns, their strengths, and where they can get information and support from. Where appropriate, families are then offered a Partnership clinician (again, straight away, from a diary of available appointments) who will do any generic work agreed at the Choice appointment and ensure that the family access any specialist parts of the service that are appropriate (eg particular assessments or types of therapy, medication or groups).

This is a more open and accountable way of working, and ensures all members of the team carry an equal responsibility for meeting the demands of the work, though the balance between Choice, Partnership and Specialist work will vary from professional to professional.

According to the number of referrals, the amount of Choice appointments per month and then the amount of new Partnerships required can be calculated. This means the team know exactly what the turnover needs to be, and each clinician then does a job plan that leads to a number of Choice appointments they will offer, and the number of new Partnerships they will take on each month - and they have to managed their caseload in a way that allows them to meet this demand, although they can still choose to work for as many or few sessions with any referral that seem necessary.

CAPA is based on some simple assumptions:
1) a full-time clinician should make an average of 16 appointments about named referrals per week (whether these are to do assessment, follow-up, specialist work, consultation). Each appointment is about an hour long. The rest of the time is to fit in the admin, telephone calls, meetings, supervision etc that we all do. In general they think of doing two appointments and all related admin per half day, and having one day per week of work-related commitments that are not related to a named referral.
2) The capacity of a service is based on the number of staff (counted in terms of whole-time-equivalents) multiplied by this figure of 16 appointments per week.
3) The demand for the service is based on the number of referrals we receive which are offered and attend an appointment.
4) They allow for 80% efficiency, and working 45 weeks a year (to allow for leave, sickness and CPD), which means this is realistic maths (I worked it out for our service, and in we seem to fit within the figures, and the idea of wasting less time on allocation meetings and freeing it up for mutual support and case discussion is inherently appealing).

So, why does it feel like demand exceeds supply?
1) We are suffering from “churn” whereby there are lots of routes to get prioritised or specialist services and those that don’t fit with this become “sediment” where they sit in a secondary waiting-list which grows more quickly than cases are picked up.
2) So, the visible signs of demand (high referral numbers, and secondary waiting list) give us lots of guilt but don’t show the whole picture (that lots of people don’t opt in or DNA, and that most of the work is actually quite short).

So, what do CAPA recommend?
1) Handle Demand
2) Extend Capacity
3) Let go of Families
4) Process Map and redesign the service
5) Flow Management
6) Use Care Bundles
7) Look After Staff

1) Handle Demand
According to CAPA we should have clear eligibility criteria that are always applied, and be clear about which services are better offered by another agency. We should aim to help commissioners, referrers and other agencies to understand what we do. They also recommend only having “emergency” and “non-emergency” priority ratings – the former containing only cases that need to be seen within the next 48 hours (eg psychosis, extreme weight loss, self-harm with risk of death) and the latter containing everybody else.

We can also increase user choice and satisfaction by offering a choice of first appointments, as soon as possible after the referral is made, and then passing people smoothly into treatment pathways without an additional wait. So, enough Choice appointments need to be offered to meet demand (an this might mean providing more choice appointments at busy referral times, or if there is ever an increase in referrals) and enough Partnership appointments offered to meet the demand for follow-ups. (This might require members of the team to do less specialist work to meet demand for Partnership).

The Choice appointment should be thought of as “single session treatment” clarifying any issues (without waiting for correspondence to clarify these issues before seeing the family), establishing what the family want and their resources for change, and recommending sources of support (local organisations, books, leaflets) and starting a process of change. A written summary of the appointment should go to the family an referrer within 48 hours of the choice appointment, so the admin process needs to be really clear and simple.

2) Extend Capacity
Waiting lists correlate much more with what we do with the families we work with than the number of referrals received. Therefore, we can manage to meet demand by changing what we supply (even if these changes are only subtle). Under CAPA clinicians are expected to take on new Partnerships at a set rate, and this means they need to manage their own caseloads to meet this rate of through-put. This means having an attitude whereby there has to be a reason for each appointment, and where we also actively think if some of the roles we take on can be done elsewhere (can the nurse at the GP practise monitor height and weight for children on stimulant medication, or offer an appointment to check how things are going a month or two after discharge instead of the clinician offering a final review appointment?). The expectations and the amount of work being done should be visible to the whole team and regularly reviewed through audit of the attendance data. They also believe in reducing the amount of time wasted in meetings (if all ten of us meet for two hours per week to do allocations, that is at the cost of 500 Choice or Partnership appointments a year, compared to one or two clinicians doing paper screening and everything else going into Choice appointments). We should also be identifying where there are demands in order to flag up the need to fill them (eg is there a long wait for one part of the service? Can anyone change their role to meet it? Or do we need to recruit or train someone to have those skills?).

3) Let go of Families
Plan endings as soon as possible – contract with families for a set number of sessions from the start of Partnership and where possible write a care plan. Review and discuss with other team members any Partnership cases that remain open for over a certain length of time (6 months/1 year) whilst accepting that some kinds of work do take longer (for example, some eating disorders and complex trauma cases). The service needs to make decisions about lifelong or long-lasting conditions, and these need to be applied consistently – we don’t offer long term support, we should offer goal-directed treatment.

4) Process Map and redesign the service
Consider the user-experience of the service: What would they like to know before they come to their first appointment? What choices would they like to have? Who defines the problem to be worked on, the patient or the professional? Don’t just give user-involvement lip-service, really listen to what they have to say. Collect outcome data and feedback – and act on it! Every member of staff should have a job plan, with time for each role clearly marked out (Choice, Partnership, Specialist, admin, etc) and everyone should know what everyone else does!

5) Flow Management
Identify any bottle-necks within the service: if there are internal waiting lists then you need to create more of that part of the service, if there is a lack of rooms or resources then practical changes might resolve this. Don’t make referrals wait for an allocation meeting, paper-screen them ASAP and then send the letter asking them to phone in to pick a Choice appointment (in fact, they suggest a daily paper-screen which also acts on emergencies – remembering this is only a 15 minute job, as referrals are only “emergency” or “non-emergency” and all of the latter group get offered Choice appointments). Specialist services should only exist if they reflect demand and there is sufficient capacity to provide them. Families should agree tasks to work on in-between Choice and Partnership, and there should be resource packs that Choice clinicians can draw on to give relevant materials to families to read prior to Partnership.

6) Use Care Bundles
This means knowing the evidence base of what works for which types of problems, so that we can have local pathways that work and can be audited. For example, we could think about common presenting problems (eg What should we offer for families where a primary school aged child has behaviour problems? Would the menu normally be screening of the child for diagnosable conditions and then a parenting skills group?) Having a standard care bundle can increase efficiency.

7) Look After Staff
Instead of all our time being spent discussing cases that are newly referred or awaiting allocation, we can spend time getting to know what other members of the team do, providing mutual support and case discussion, and planning and reviewing service development. CAPA should give time for regular team and service away days, which make staff feel appreciated and enthused, as well as prepared for any changes.

So, what are the practicalities?
In order to implement CAPA, every member of the team needs to draw out a job plan - what they do with the sessions that they work, and which of these are already committed to specialist work, and which can be used for the generic work of CAMHS. The team then need to pick out enough Choice appointments to meet the rate of referrals, and a time for a Choice session for the team (eg if the team gets 10 referrals per week, then five clinicians need to put aside a session, eg Monday morning, for Choice, each doing 2 Choice appointments, writing the summary forms and then meeting as a team to discuss them, during that session). The team then need to find enough new Partnership appointments to meet the demand for follow-up work, and this works out at needing to allocate 8 times the number of referrals received per week during every 3 month period (so in the team above that gets 10 referrals per week, they would need 80 new Partnerships per quarter). This is done by each clinician offering to pick up cases according to how much generic time they have in their job plan. For every uncommitted session, the person is expected to pick up 3 new cases per quarter (which equals one new case per month). They think in quarters as the person is expected to make the figure every quarter, even if they vary from month to month because of annual leave, CPD, etc.

So, a nurse who is full-time and does one session dedicated to eating disorders, and one session of a team meeting and supervision, might have a job plan with 1 Choice session per week, and 6 sessions for partnership, and would be expected to pick up 18 new cases per quarter, or 6 new cases per month. A psychiatrist who mostly does management and medication and emergency cover might have two sessions per week of generic time and decide to do one Choice and one Partnership session per week, and would be expected to pick up 3 cases per quarter (one per month). It would be up to the clinician to work out how to discharge enough cases to keep up with this rate of referral, but they could keep some cases open long-term if other cases were turning over more rapidly.

CAPA is based on an average of 8 contacts with families that turn up at least once, and around 65% of referrals leading to some follow-up after the Choice appointment (the rest will either DNA, think one appointment and the materials offered is sufficient, or be directed to a more suitable agency) and again, I've checked with our service data, and this does fit with "real life" as only 5% of referrals lead to long-term work. The biggest debate in my experience was whether some staff are all specialist, and others all generic - and therefore expected to pick up a lot of this work. Some people got quite protective about their longer-term models of working, and we ended up having to have peer reviews to justify cases open for more than 12 contacts, and manager reviews for all cases open more than 16 sessions, otherwise there wasn't enough capacity and some staff became the therapy equivalent of bed blockers in inpatient management.

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Content checked by qualified Clinical Psychologist on 26/01/2024
Last modified on 26/01/2024

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