East Herts CAMHS

East Herts map

Service description

We are a Tier 3 Specialist CAMHS for East Hertfordshire, part of the Hertfordshire Partnership Foundation Trust (a mental health trust). Our whole population is about 320,000 in an area 20 by 12 miles or so. We think of ourselves as one large team (i.e. a whole team meeting every week) but we have three sites or clinics with staff being based primarily in one although many clinicians work in more than one. We have a clinical FTE of around 19.5 with 4 FTE admin and receive around 1400 referrals a year.

In the beginning...

CAPA, or what it was then, began for us in the summer of 2004. We had 10-month waits, felt very beleaguered and knew we had to do something.

We had, in the past, in 1993 and 1995, (which a few of us remembered!) carried out new patient assessment weeks where each of us had seen 4 new patients a day for 4 days seeing about 70 new families. We then discussed them all on the Friday and allocated according to priority and clinical problem. In fact we noticed, even then, that the workload from these weeks seemed less than we expected but could never figure out why. Now we have some ideas but a key part was separating the treatment from the assessment as well as seeing a lot of new families in one go allowed streaming according to need and urgency (smoothing flow and segmentation).

However the number on the waiting list seemed too big for such a blitz 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 teams capacity for the Royal College. 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.

Team photo

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. These details are based on the Hoddesdon team (the one I work in; Steve) 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 180,000 with about 6 FTE and 4 FTE vacancies.

In October 04 we had 224 families and young people on the 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.

Team photo

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. The issue that consistently caused the most anxiety was the transfer from Choice to 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 Partnership to thinking about when was it good to offer to stay with the young person and family. This is within the broad idea that selecting a new clinician brings advantages. They still need a choice of course.

More recently

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

We have also got more detailed about the job planning and I have been developing 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 has encouraged us to define ‘big’ admin more clearly and realise that each job plan needs to have a developmental aspect as well as a service aspect, for each clinician.

At the time of writing we are also exploring the idea that clinicians who have a high percentage (>50%) of their job plan in Core seem to be busier that those who have a lower percentage. So for the moment (Jan 09 onwards) we are trying a sliding scale for the Partnership Multiplier. Watch this space I guess [July 09: seems to be helpful].

Team photo

Finally

CAPA and its way of working seems to be very embedded in out 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 managers and as a whole our team feels very coherent and united. Over the years we have been remained in balance with short waits to Choice and Partnership - less than six weeks to both with a more usual average of 2-4 weeks. Only once (summer 2007) did we get close to a breach in CAPA terms for booking to Partnership but just agreed to make more of an effort to rebook unused Partnerships and we came back in to balance.

We think CAPA works so well for us because we all understand and completely buy into the philosophy of CAPA and we do the ‘whole thing’ in terms of the components which maximises the gains for us, the young people and their families and the service.

Photos

The 3 large photos are of our sub-teams: Bishops Stortford, Hoddesdon and Welwyn Garden City. A few staff could not be present due to illness and leave.