Richmond CAMHS

Richmond map

The service

I (Ann) work in Richmond. The Child and Family Consultation Centre is a Tier 3 multi-disciplinary service in South West London. We are in a Mental Health Trust. Our catchment population is just under 180K. Current staffing is 11.3 FTE, including posts in YOT, 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- borough on call system.

Referrals have increased annually and are now 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 and similar to Partnership (with 11.3 FTE and around 800 referrals).

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!

1999

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 were seen for 3 sessions or less, 19% for 4 to 8 sessions and 9% for more than 8 sessions.

CAPA rating: 9%

2000

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!

Then we:

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’.

CAPA rating: 23%

January 2001

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, neurodevelopemental, 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!

CAPA rating:64%

2002

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.

2003

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 Partnership clinics so different and inequitable waits developed for each clinic.

CAPA rating:73%

2004

We then introduced full booking from Choice to Partnership in Jan 2004 in 2 of the 3 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 Partnership clinics. By June 2004 we had Choice and 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 rating 86%

2005

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 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.

2006

Routine discussion of cases open over 1 year began in 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!

CAPA rating 77%

2007

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 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 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.

CAPA rating: 90%

2008

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.

CAPA rating: 86%

2009

75% of the team have been in post less than 3 years, and some have only been with us a few months. The team that piloted Partnership clinics all those years ago and introduced Choice have mostly moved on. This has produced new opportunities and challenges. Reducing variation in practice and remembering (or learning) what our systems are has required special attention in away days. Not all new staff have yet had their job plan completed and we need to map individual skills again to make effective use of booking in to the right person in Core Partnership.

We use a standardised form for Choice and standardised Care Plans with outcome measures. 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), Neurodevelopmental Disorders, ADHD medication, Specific Family Therapy and Adoption/attachment work. We run a next up system for psychiatry and Specific CBT. We 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.

What helped us?

Having a vision and someone to keep the show on the road Continual audit and evaluation, adjusting the system to cope with whatever the current challenge is Allowing time to change Realising that making a change does not mean it continues to happen- you need to monitor what is going on and check processes are working- revising them if not (but don’t assume they are not working! In our experience it is more often that we aren’t following the processes!) 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.

Finally

Team photo

So that is how Richmond did it- and continues to do it. CAPA works well. We have learnt is that leadership and monitoring is crucial, and never underestimate the impact of a major organisational procedural change! CAPA will not run itself, everyone needs to understand how the system works and play their part. Access continues to be very good and user feedback extremely positive. We have had a very good external peer review (QINMAC). We are looking forward to major re-organisation in our partner agencies, which has already led us to pilot some new models of partnership working. Financial constraints continue to bring challenges but the culture of creativity and flexibility in the team will help us continue to move forward.