CAPA: myths and realities

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Myths
Natural Anxieties
 

We quite often hear things that make us realise that CAPA can be misunderstood!

 

So we thought we would write our view of the myths and correct them!

 

So what are the Myths about CAPA?

 

  1. CAPA is inflexible. 

  2. CAPA is a limited session model

  3. Clinicians lose all control of their diaries

  4. CAPA abolishes specialist work

  5. CAPA is triage by another name

  6. Choice appointments have to be done in 45 minutes

  7. Choice is always done in only one appointment

  8. Successful Choice appointments are about “turning away” children and families

  9. Choice appointments do not include assessment

  10. CAPA means you will never have long waits

  11. Choice appointments can be done by inexperienced people

  12. CAPA does not work for hard to engage families

  13. There is no long term work in CAPA

  14. CAPA abolishes joint work

  15. The family/young person can chose anything they want

  16. The Choice clinician has to transfer the family to another clinician in Partnership

  17. It is a plot by the government to change / control services

  18. Doing CAPA means you accept all referrals

 

We also hear how not to implement CAPA...

 

What are the Realities?

 

  1. CAPA should NOT seem inflexible. 
    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 (full booking; choice; informed consent; care planning; capacity planning) but within these you can do it as suits you and your users. You decide how to do assessments, what interventions to offer and who does what.

 

  1. CAPA is NOT a limited session model.
    You can see families for as long or as short a time as they need, and as frequently as they need. We think some people think there is a limit of sessions, as we do know that the national average number of appointments per family/young person is approximately 7.5. This figure is used in the maths in CAPA.

 

  1. Clinicians DO NOT lose all control of their diaries
     Whilst it is true that clinicians do give up some of their diaries, it is a very small percentage. 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 (about 13) and all the non-clinical work in the week, remains under the clinicians’ control.

 

  1. CAPA does NOT abolish specialist work
     We believe all specialities are valuable and necessary and we wish to privilege them alongside clinicians with extended skills in core work. We do challenge clinicians and service’s however to be considered about their use of specialised time as it can use up clinical resources without seeing the majority of the referrals.

 

  1. CAPA is NOT triage by another name
     We think of the first Choice session as an opportunity to think about what resources a family needs to help with their problems. This is a combination of resource identification, motivational interviewing, assessment and one session therapy. Thus it is much more than classic triage, as that simply sifts for urgency and eligibility.

 

  1. Choice appointments DO NOT have to be done in 45 minutes
     Choice appointments can take as long as are needed. The shortest is probably 45 minutes with the family, 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- especially if not everyone in the family came (such as the referred adolescent or an estranged father). People cannot make an informed choice if they are not present! Sometimes its possible to do so but more often it can take an hour or even up to 90 minutes. It is up to you. I personally find [SK] 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.

 

  1. Choice DOES NOT have to involve only one appointment
     Choice only ends when the family have been able to decide what is needed 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.

 

  1. Successful Choice appointments are NOT about “turning away” children and families
     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 needs for CAMHS.

 

  1. Choice appointments DO include assessment.
    Sometimes people seem to think that there is no assessment in Choice appointments! This is completely untrue. It is not possible to help a family formulate their difficulties and make choices about what to do about them without assessment, including risk assessment. The stance is active, collaborative and open, using our expertise to help the family understand and come together come to a view of the way forward. The process of the Choice appointment should feel like a conversation and not us dragging them through a  (for them) passive assessment structure.

 

  1. CAPA DOES NOT mean you will never have long waits
    …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 users need (we find 4 weeks from referral for non urgent cases is ideal) and, as Choice appointments are fully booked, the family is not ever put on a waiting list. Partnership appointments are fully booked at the end of the Choice appointment and, ideally, should be within 2 to 4 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 as 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 about what the root cause is.
     

  2. Choice appointments can NOT be done by inexperienced people
    We sometimes hear that services are putting their least experienced clinicians in Choice. We believe that you need particular skills and experience to do Choice well- you need to know the local services, the skills if individual team members, be able to assess and formulate using a variety of models, be confident in discussing evidence based practice and be able to engage families and young 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.
     

  3. CAPA DOES work for hard to engage families
    We find that traditionally hard to engage families value the stance in CAPA- of helping them to choose what will work for them and to be fully informed about what CAMHS is about. It is easy to do Choice appointments with partner agencies to help this process and hard to reach families can be helped to book appointments by their referrer. 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.

 

  1. There CAN BE long term work in CAPA
     We are not sure where this myth comes from! You can do as much long-term work as a family needs- as long as the goals are clear, regular multidisciplinary reviews are held and the user is in agreement that this is what is needed. CAPA is about doing the right things to the right people at the right time, and this may always include long-term work.
     

  2. CAPA DOES NOT abolish joint work
     Although in our services the majority of the time one clinician sees a family in Choice- 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.

 

  1. The family/young person can NOT chose anything they want
    Clearly not! They can chose within constraints- of what is available and what is likely to work. They cannot choose an unsafe intervention or something not available. They cannot chose to ignore risk or child protection concerns.

 

  1. The Choice clinician DOES NOT have to transfer the family to another clinician in Partnership
    … if they have the right skills and the family wants to stay with them and there is a Partnership appointment at a suitable time!
     

  2. It is a plot by the government to change / control services
     These ideas developed over many years of service redesign in Richmond and East Herts CAMHS. We have clarified how the system works in terms of demand and capacity theory and written in the language of CAMHS. 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 our costs are paid to our Trusts.
     

  3. Doing CAPA doesn't means you accept all referrals
    We advise having a clear set of eligibility criteria but that once these have been met see the child if you are uncertain rather then engage in letter tennis. For example in both our teams we required the referrer to have actually seen the child.

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Hints for successfully implementing CAPA

 

We also have heard of some of the ways NOT to implement CAPA so we thought we’d also list some of those…Avoid them! They won’t work!

 

·     Stating CAMHS has no need for specialist sessions and demanding everyone work only in core clinics sets yourself up to fail. We need specialist work in CAMHS. But we also need to use it wisely and well.

 

·     Setting the same activity number for everyone without using a thoughtful job plan will make CAPA unworkable and stressful. Take time to work out a proper team job plan that includes a realistic plan for each person.

 

·     Not fully booking into Partnership allows waiting lists to develop and waiting lists are EVIL! There is no added value for families to go onto a waiting list. Full booking (even if this means a wait) means they know when and who they will see and allows them to focus on working on issues themselves until seen. Referrers know what is in progress and when the next contact will be.

 

·         Completion of long and “comprehensive” assessment proforma’s may be unnecessary and not follow the needs of the user. Whilst there is a certain amount of core information that you need to collect, some areas need to be explored more than others- and this takes skill and experience. Partnership may involve detailed specialist assessment or it may be that sufficient assessment has been done in Choice. Every contact with a family involves assessment, intervention and revised formulation. Rigid separation of assessment and intervention can lead to a belief that assessment is ‘complete’. This can lead to new information not being correctly evaluated and formulations not being revised and shared.

 

·     Not having time to manage change in the team and not planning things well will doom CAPA to failure! You need lots of team away days, talking together, deciding who does what. And you need a system of monitoring and revaluation of your changes. If it’s not working for you, work out why, tweak it and monitor again!

 

 

So we could say more and often do, but we hope this helps…

 

 

Steve and Ann

 

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