Changing CAMHSChanging CAMHS

Choice and PartnershipChoice and Partnership

Dr Steve KingsburyDr Steve Kingsbury

Steve.kingsbury@hpt.nhs.ukSteve.kingsbury@hpt.nhs.uk

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IntroductionIntroduction

Asked to talk about service change, Asked to talk about service change, creating self-reflective teams and creating self-reflective teams and demand and capacity ideas using my demand and capacity ideas using my range of experiencerange of experience

Don’t know your services well enough to Don’t know your services well enough to be exactly sure what I can say that will be be exactly sure what I can say that will be helpfulhelpful

Like a buffet where you can choose ideas Like a buffet where you can choose ideas that interest you and ignore the othersthat interest you and ignore the others

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Who am I?Who am I?

Child and Adolescent psychiatrist Child and Adolescent psychiatrist working in a local community CAMHS working in a local community CAMHS team just north of Londonteam just north of London– Patch of 180,000 with 8 FTEPatch of 180,000 with 8 FTE– Range of disciplines: psychiatry, psychology, Range of disciplines: psychiatry, psychology,

family therapy, social work, play therapyfamily therapy, social work, play therapy– 650 referrals per year650 referrals per year

Also the Medical Advisor for CAMHS to Also the Medical Advisor for CAMHS to the English Department of Healththe English Department of Health

Been involved in CAMHS service ChangeBeen involved in CAMHS service Change

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CAMHS NetworkCAMHS Network

Dr York and myself have devisedDr York and myself have devised– A demand and capacity framework for CAMHS called A demand and capacity framework for CAMHS called

the 7 Helpful Habits of Effective CAMHS andthe 7 Helpful Habits of Effective CAMHS and– A clinical system called the Choice and Partnership A clinical system called the Choice and Partnership

Approach whichApproach which Removes waiting listsRemoves waiting lists Engages families and young people in their choice andEngages families and young people in their choice and Works with them in PartnershipWorks with them in Partnership

Details on the Website Details on the Website www.camhsnetwork.co.ukwww.camhsnetwork.co.uk

Since 2004 trained 2000 CAMH staff and visited Since 2004 trained 2000 CAMH staff and visited with 200 CAMH teamswith 200 CAMH teams

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Plan for today's talkPlan for today's talk

Present some of the English Quality Present some of the English Quality standardsstandards

Talk about user choiceTalk about user choice– Do a small exercise in the room!Do a small exercise in the room!

Discuss user involvementDiscuss user involvement How to encourage reflection in teamsHow to encourage reflection in teams Finish on time!Finish on time!

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Standards for Better Health Standards for Better Health (DH, 2004)(DH, 2004)

Patient focusPatient focus– Health care is provided in partnership with

patients, their carers and relatives, respecting their diverse needs, preferences and choices, and in partnership with other organisations (especially social care organisations) whose services impact on patient well-being.

Accessible and responsive careAccessible and responsive care– Patients receive services as promptly as

possible, have choice in access to services and treatments, and do not experience unnecessary delay at any stage of service delivery or of the care pathway.

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Our Choices in Mental Our Choices in Mental Health (CSIP, 2005)Health (CSIP, 2005)

Enabling systems to provide Enabling systems to provide informed choiceinformed choice

Choice points:Choice points:– Life ChoicesLife Choices– Access and EngagementAccess and Engagement– Assessment Assessment – Care PathwayCare Pathway

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You’re Welcome Quality You’re Welcome Quality Criteria (DH, 2005)Criteria (DH, 2005)

AccessibilityAccessibility Publicity and InformationPublicity and Information InvolvementInvolvement

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SummarySummary

Clearly CAMHS is being asked toClearly CAMHS is being asked to– Offer CHOICE andOffer CHOICE and– INVOLVE users inINVOLVE users in– ACCESSIBLE and appropriate ACCESSIBLE and appropriate

settingssettings

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How Health or Traditional How Health or Traditional CAMHS works…CAMHS works…

Patients attend with a problemPatients attend with a problem This is diagnosed by an expertThis is diagnosed by an expert A treatment plan is recommendedA treatment plan is recommended The patient agreesThe patient agrees

Little choice and often uninformedLittle choice and often uninformed Passive and hierarchicalPassive and hierarchical

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Choice and PartnershipChoice and Partnership

To address these and other demand To address these and other demand and capacity issues myself and Dr Ann and capacity issues myself and Dr Ann York devised theYork devised the

Choice and Partnership ApproachChoice and Partnership Approach This is being implemented in many This is being implemented in many

teams nationwide (and New Zealand) teams nationwide (and New Zealand) but the principles can be adapted to but the principles can be adapted to any settingany setting

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Values of CAPAValues of CAPA

Users are at the heart of the processUsers are at the heart of the process ““Led by them and guided by us”Led by them and guided by us” ““I’m the expert but you’re the boss”I’m the expert but you’re the boss” Shift in clinician stance toShift in clinician stance to Facilitator with expertise rather than expert Facilitator with expertise rather than expert

with powerwith power Key shift in languageKey shift in language Not assessment or treatmentNot assessment or treatment Key shift in beliefsKey shift in beliefs Away from pathologyAway from pathology Towards family, child and social setting Towards family, child and social setting

resourcesresources

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Interior decorator exerciseInterior decorator exercise

In pairsIn pairs For 5 minutes discuss a room For 5 minutes discuss a room

in your house you would like in your house you would like to changeto change

One person act as decorator One person act as decorator and the other as clientand the other as client

Decorators aim is to extract Decorators aim is to extract the clients vision as well as the clients vision as well as any resource constraints: i.e. any resource constraints: i.e. how practical?how practical?

As you do this consider how it As you do this consider how it compares to a traditional compares to a traditional assessmentassessment

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Choice and Partnership Choice and Partnership ApproachApproach

The first contact with the service:The first contact with the service:

Choice appointmentChoice appointment focuses on engagement focuses on engagement facilitation of informed choicefacilitation of informed choice using aspects of assessment, risk using aspects of assessment, risk

evaluation and shared initial evaluation and shared initial formulationformulation

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Key Choice to exploreKey Choice to explore

Clarify with the family their hopes for changeClarify with the family their hopes for change Discussing whether CAMHS had a role to playDiscussing whether CAMHS had a role to play Identifying what the family could do for Identifying what the family could do for

themselvesthemselves Focus on strengths and promoting Focus on strengths and promoting

independenceindependence In other wordsIn other words

– For CAMHS to explore the choices of the child and For CAMHS to explore the choices of the child and family and for thefamily and for the

– Family to choose what services they wantedFamily to choose what services they wanted

To reach a To reach a Choice PointChoice Point

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Choice: A Directed Choice: A Directed ConversationConversation

ConversationConversation– Follow the families’ process and thinkingFollow the families’ process and thinking– Non-hierarchical and process focussedNon-hierarchical and process focussed– Engaging, motivating and respectfulEngaging, motivating and respectful– HUMANHUMAN

DirectedDirected– Goal Focused as we have to activelyGoal Focused as we have to actively– Reach an understanding about the issuesReach an understanding about the issues– That considers riskThat considers risk– And any appropriate diagnostic frameworksAnd any appropriate diagnostic frameworks

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Choice detailsChoice details

Single therapist (not determined by seniority but Single therapist (not determined by seniority but aptitude)aptitude)

45 minutes to 1 hour long45 minutes to 1 hour long Patients are seen by whoever they book in withPatients are seen by whoever they book in with

Choice appointments organised into Choice clinics of Choice appointments organised into Choice clinics of 3-5 staff doing 2-3 Choice in a half day (session)3-5 staff doing 2-3 Choice in a half day (session)

At end of session mini-team discussion / supervision re At end of session mini-team discussion / supervision re decisions and for debriefingdecisions and for debriefing

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Choice AdminChoice Admin

Each therapist after Choice writes a letter or Each therapist after Choice writes a letter or completes a form, completes a form, promptlypromptly, to the GP and , to the GP and copies it to the family and network.copies it to the family and network.

Now use a letter that has specific, Now use a letter that has specific, titledtitled sections ofsections of– Introduction (can be omitted)Introduction (can be omitted)– History / DiscussionHistory / Discussion– Formulation / UnderstandingFormulation / Understanding– ActionAction

Includes what we will do andIncludes what we will do and What the family will doWhat the family will do

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PartnershipPartnership

This is what we call the treatment or ongoing This is what we call the treatment or ongoing workwork

With a With a differentdifferent clinician from the Choice clinician from the Choice clinicianclinician

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Why change clinician?Why change clinician?

Encourages curiosityEncourages curiosity Frees family and clinician to make good use of Frees family and clinician to make good use of

sessionsession– 89% families and 93% adolescents felt more open 89% families and 93% adolescents felt more open

knowing wouldn’t see Choice clinician again.knowing wouldn’t see Choice clinician again. Facilitates choice completionFacilitates choice completion Allows Partnership onset with “right” therapistAllows Partnership onset with “right” therapist Engagement with their change not with Engagement with their change not with

clinicianclinician Helps capacity managementHelps capacity management

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How to involve users?How to involve users?

In their care planningIn their care planning In service evaluationIn service evaluation In service designIn service design In information strategiesIn information strategies

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In their Care PlanningIn their Care Planning

Begins with understanding their choices and Begins with understanding their choices and wisheswishes

Working within the constraints of what they Working within the constraints of what they think is possiblethink is possible

Giving them enough information to make and Giving them enough information to make and informed choiceinformed choice

Having care plan that they contribute to and Having care plan that they contribute to and has the actions they will undertakehas the actions they will undertake– (active agency)(active agency)

Reviewing regularly the goals and care planReviewing regularly the goals and care plan

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In Service EvaluationIn Service Evaluation

Seek out user feedback on your clinical Seek out user feedback on your clinical serviceservice

Satisfaction questionnairesSatisfaction questionnaires Specific service auditsSpecific service audits

E.g. in Herts. we foundE.g. in Herts. we found 92% of the teenagers felt they had been treated 92% of the teenagers felt they had been treated

wellwell 82% they had been listened to and82% they had been listened to and 71% felt they had been given enough 71% felt they had been given enough

information about what service or help was information about what service or help was availableavailable

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In Service designIn Service design

Many services use process mapping to Many services use process mapping to examine or learn about their patient and examine or learn about their patient and data flowsdata flows

Process mapping charts every step of the Process mapping charts every step of the journeyjourney

Showing this to user groups for their Showing this to user groups for their comment helps keep the focus on what is comment helps keep the focus on what is added value to the user rather than helpful added value to the user rather than helpful for professionalsfor professionals

E.g. in your ambulatory care what user views E.g. in your ambulatory care what user views have been sought?have been sought?

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In Service planningIn Service planning

If you are developing new service If you are developing new service involve users in the care pathway involve users in the care pathway mappingmapping

Consider questions such asConsider questions such as– What information will they need?What information will they need?– What choices will be available to them What choices will be available to them

(compared to other health service (compared to other health service choices)?choices)?

– Do they want every step as plannedDo they want every step as planned

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In appointment interviewsIn appointment interviews

This is the hardest for CAMHS to This is the hardest for CAMHS to organise as it brings into focus ideas organise as it brings into focus ideas about who is our user, how young can about who is our user, how young can they be etc.they be etc.

We haven't solved it yetWe haven't solved it yet But have been in other setting But have been in other setting

education where it works really well.education where it works really well.

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Reflective PracticeReflective Practice

What things promote reflective practice?What things promote reflective practice? The whole Choice framework reminds us, The whole Choice framework reminds us,

as professionals, that as professionals, that – we have to work together and we have to work together and – not be solely driven by our assumptionsnot be solely driven by our assumptions

The ability to think together facilitated byThe ability to think together facilitated by– Supervision / consultation andSupervision / consultation and– Team meetings and away daysTeam meetings and away days

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Supervision / consultationSupervision / consultation

To be reflective and creative we all need To be reflective and creative we all need time to think about our worktime to think about our work

– It helps maintain focus and creativityIt helps maintain focus and creativity– Reduces families getting “stuck”Reduces families getting “stuck”

In our services we have 3 sorts of In our services we have 3 sorts of supervision / consultationsupervision / consultation

1.1. Individual with professional line managerIndividual with professional line manager

2.2. In a small teams at the end of Choice and In a small teams at the end of Choice and Partnership clinicsPartnership clinics

3.3. And small group supervision in the teamAnd small group supervision in the team

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Small Group supervisionSmall Group supervision

Many CAMHS teams have large group case Many CAMHS teams have large group case discussiondiscussion

We found this to be fairly aversive as you We found this to be fairly aversive as you often heard of all the creative things you often heard of all the creative things you hadn't done!hadn't done!

So we started in our weekly team meeting t So we started in our weekly team meeting t breaking up into small groups (3 or 4 staff)breaking up into small groups (3 or 4 staff)

We do this randomly to avoid cliquesWe do this randomly to avoid cliques Lasts for an hour andLasts for an hour and There is an expectation we all talk about a There is an expectation we all talk about a

case each weekcase each week

Works really well!Works really well!

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Team meetingsTeam meetings

Team meetings are important for culture and Team meetings are important for culture and working togetherworking together

Helps if all the meetings are “fit for purpose”Helps if all the meetings are “fit for purpose” Some services spend a lot of time discussing Some services spend a lot of time discussing

referrals that haven't come yet rather than referrals that haven't come yet rather than on-gong workon-gong work

One reason we recommend daily referral One reason we recommend daily referral screeningscreening

To leave time for other things such as CPDTo leave time for other things such as CPD

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Team away daysTeam away days

A central part of reflective practiceA central part of reflective practice Work is often very busy leaving little Work is often very busy leaving little

reflective timereflective time Away days allow the team toAway days allow the team to

– Discuss clinical issuesDiscuss clinical issues– Develop clinical practiceDevelop clinical practice– Be creative in future work andBe creative in future work and– Have fun togetherHave fun together

We have them at least quarterlyWe have them at least quarterly

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SummarySummary

Significant change occurs in CAMHS Significant change occurs in CAMHS when wewhen we

Involve users in their ChoiceInvolve users in their Choice Involve users in our service design Involve users in our service design

and evaluationand evaluation Allow time to talk and think Allow time to talk and think

togethertogether Allow time to create things togetherAllow time to create things together And have fun!And have fun!

Thanks - Dr Steve KingsburyThanks - Dr Steve Kingsbury