Changing CAMHS

1. Changing CAMHS Choice and Partnership Dr Steve Kingsbury Steve.kingsbury@hpt.nhs.uk

2. Introduction • Asked to talk about service change, creating self-reflective teams and demand and capacity ideas using my range of experience • Don’t know your services well enough to be exactly sure what I can say that will be helpful • Like a buffet where you can choose ideas that interest you and ignore the others

3. Who am I? • Child and Adolescent psychiatrist working in a local community CAMHS team just north of London • Patch of 180,000 with 8 FTE • Range of disciplines: psychiatry, psychology, family therapy, social work, play therapy • 650 referrals per year • Also the Medical Advisor for CAMHS to the English Department of Health • Been involved in CAMHS service Change

4. CAMHS Network • Dr York and myself have devised • A demand and capacity framework for CAMHS called the 7 Helpful Habits of Effective CAMHS and • A clinical system called the Choice and Partnership Approach which • Removes waiting lists • Engages families and young people in their choice and • Works with them in Partnership • Details on the Website www.camhsnetwork.co.uk • Since 2004 trained 2000 CAMH staff and visited with 200 CAMH teams

5. Plan for today's talk • Present some of the English Quality standards • Talk about user choice • Do a small exercise in the room! • Discuss user involvement • How to encourage reflection in teams • Finish on time!

6. Standards for Better Health (DH, 2004) • Patient 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 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.

7. Our Choices in Mental Health (CSIP, 2005) • Enabling systems to provide informed choice • Choice points: • Life Choices • Access and Engagement • Assessment • Care Pathway

8. You’re Welcome Quality Criteria (DH, 2005) • Accessibility • Publicity and Information • Involvement

9. Summary • Clearly CAMHS is being asked to • Offer CHOICE and • INVOLVE users in • ACCESSIBLE and appropriate settings

10. How Health or Traditional CAMHS works… • Patients attend with a problem • This is diagnosed by an expert • A treatment plan is recommended • The patient agrees • Little choice and often uninformed • Passive and hierarchical

11. Choice and Partnership • To address these and other demand and capacity issues myself and Dr Ann York devised the • Choice and Partnership Approach • This is being implemented in many teams nationwide (and New Zealand) but the principles can be adapted to any setting

12. Values of CAPA • Users are at the heart of the process • “Led by them and guided by us” • “I’m the expert but you’re the boss” • Shift in clinician stance to • Facilitator with expertise rather than expert with power • Key shift in language • Not assessment or treatment • Key shift in beliefs • Away from pathology • Towards family, child and social setting resources

13. In pairs For 5 minutes discuss a room in your house you would like to change One person act as decorator and the other as client Decorators aim is to extract the clients vision as well as any resource constraints: i.e. how practical? As you do this consider how it compares to a traditional assessment Interior decorator exercise

14. Choice and Partnership Approach The first contact with the service: • Choice appointment • focuses on engagement • facilitation of informed choice • using aspects of assessment, risk evaluation and shared initial formulation

15. Key Choice to explore • Clarify with the family their hopes for change • Discussing whether CAMHS had a role to play • Identifying what the family could do for themselves • Focus on strengths and promoting independence • In other words • For CAMHS to explore the choices of the child and family and for the • Family to choose what services they wanted • To reach a Choice Point

16. Choice: A Directed Conversation • Conversation • Follow the families’ process and thinking • Non-hierarchical and process focussed • Engaging, motivating and respectful • HUMAN • Directed • Goal Focused as we have to actively • Reach an understanding about the issues • That considers risk • And any appropriate diagnostic frameworks

17. Choice details • Single therapist (not determined by seniority but aptitude) • 45 minutes to 1 hour long • Patients are seen by whoever they book in with • Choice appointments organised into Choice clinics of 3-5 staff doing 2-3 Choice in a half day (session) • At end of session mini-team discussion / supervision re decisions and for debriefing

18. Choice Admin • Each therapist after Choice writes a letter or completes a form, promptly, to the GP and copies it to the family and network. • Now use a letter that has specific, titled sections of • Introduction (can be omitted) • History / Discussion • Formulation / Understanding • Action • Includes what we will do and • What the family will do

19. Partnership • This is what we call the treatment or ongoing work • With a different clinician from the Choice clinician

20. Why change clinician? • Encourages curiosity • Frees family and clinician to make good use of session • 89% families and 93% adolescents felt more open knowing wouldn’t see Choice clinician again. • Facilitates choice completion • Allows Partnership onset with “right” therapist • Engagement with their change not with clinician • Helps capacity management

21. How to involve users? • In their care planning • In service evaluation • In service design • In information strategies

22. In their Care Planning • Begins with understanding their choices and wishes • Working within the constraints of what they think is possible • Giving them enough information to make and informed choice • Having care plan that they contribute to and has the actions they will undertake • (active agency) • Reviewing regularly the goals and care plan

23. In Service Evaluation • Seek out user feedback on your clinical service • Satisfaction questionnaires • Specific service audits • E.g. in Herts. we found • 92% of the teenagers felt they had been treated well • 82% they had been listened to and • 71% felt they had been given enough information about what service or help was available

24. In Service design • Many services use process mapping to examine or learn about their patient and data flows • Process mapping charts every step of the journey • Showing this to user groups for their comment helps keep the focus on what is added value to the user rather than helpful for professionals • E.g. in your ambulatory care what user views have been sought?

25. In Service planning • If you are developing new service involve users in the care pathway mapping • Consider questions such as • What information will they need? • What choices will be available to them (compared to other health service choices)? • Do they want every step as planned

26. In appointment interviews • This is the hardest for CAMHS to organise as it brings into focus ideas about who is our user, how young can they be etc. • We haven't solved it yet • But have been in other setting education where it works really well.

27. Reflective Practice • What things promote reflective practice? • The whole Choice framework reminds us, as professionals, that • we have to work together and • not be solely driven by our assumptions • The ability to think together facilitated by • Supervision / consultation and • Team meetings and away days

28. Supervision / consultation • To be reflective and creative we all need time to think about our work • It helps maintain focus and creativity • Reduces families getting “stuck” • In our services we have 3 sorts of supervision / consultation • Individual with professional line manager • In a small teams at the end of Choice and Partnership clinics • And small group supervision in the team

29. Small Group supervision • Many CAMHS teams have large group case discussion • We found this to be fairly aversive as you often heard of all the creative things you hadn't done! • So we started in our weekly team meeting t breaking up into small groups (3 or 4 staff) • We do this randomly to avoid cliques • Lasts for an hour and • There is an expectation we all talk about a case each week • Works really well!

30. Team meetings • Team meetings are important for culture and working together • Helps if all the meetings are “fit for purpose” • Some services spend a lot of time discussing referrals that haven't come yet rather than on-gong work • One reason we recommend daily referral screening • To leave time for other things such as CPD

31. Team away days • A central part of reflective practice • Work is often very busy leaving little reflective time • Away days allow the team to • Discuss clinical issues • Develop clinical practice • Be creative in future work and • Have fun together • We have them at least quarterly

32. Summary • Significant change occurs in CAMHS when we • Involve users in their Choice • Involve users in our service design and evaluation • Allow time to talk and think together • Allow time to create things together • And have fun! Thanks - Dr Steve Kingsbury