HITTING THE TARGET IN TAYSIDE: SUCCESSES AND FAILURES PRAISE FOR THE ACHIEVERS NOT SEARCH FOR THE GUILTY Professor Kevin Power Head of NHS Tayside Psychological Therapies Service

BACKGROUND PROBLEM: LENGTHY WAITING LISTS LARGE NUMBERS OF PATIENTS TAYSIDE BACKGROUND PROBLEM: LENGTHY WAITING LISTS LARGE NUMBERS OF PATIENTS WHY: - GROWING EVIDENCE BASE - PATIENT PREFERENCE - SHORTAGE OF APPLIED PSYCHOLOGISTS - INEQUITY OF SERVICE PROVISION - SERVICE INEFFICIENCY - INCREASE IN REFERRAL RATE

TAYSIDE Population per 1wte of all clinical staff in psychology services in NHS Scotland in 2002, by Health Board area. <8, 000 8, 000 – 9 ,999 10, 000 – 14, 999 15, 000 – 19,999> 1. Fife (6306) 3. Borders (8522) 5. Greater Glasgow (10335) 2. Dumfries & Galloway (7379) 4. Ayrshire & Arran (9609) 6. Grampian (10452) 7. Lothian (11174) 8. Forth Valley (11950) 9. Argyll & Clyde (12537) 10. Tayside (13279) 11. Lanarkshire (13652) 12. Highland (13946)

5. Greater Glasgow and Clyde (5 704) TAYSIDE Population per 1wte of all clinical staff in psychology services in NHS Scotland at 30th September 2009, by NHS Board. <6, 000 6 ,000 – 7, 999 8 ,000 – 9 999 10 ,000> 1. Dumfries & Galloway (4 101) 7. Lothian (6 972) 9. Grampian (8 683) 11. Forth Valley (10 695) 2. Fife (4 664) 8. Lanarkshire (7 009) 10. Highland (9 807) 3. Tayside (4 990 ) 4. Borders (5 662) 5. Greater Glasgow and Clyde (5 704) 6. Ayrshire & Arran (5 761 )

TAYSIDE TAYSIDE PSYCHOLOGICAL THERAPIES SERVICE Annual Referrals 2003 – 2009 (Apr – Mar) Specialty 2003/ 2004 2004/ 2005 2005/ 2006 2006/ 2007 2007/ 2008 2008/ 2009 Dundee Primary Care 540 446 369 649 922 894 Dundee CMHT 86 81 88 144 161 180 Perth Primary Care /CMHT 263 353 570 859 1078 1150 Angus Primary Care/CMHT 617 385 489 762 1390 1033 Child & Adolescent 163 47 184 407 438 Older People 63 73 167 244 362 256 Learning Disabilities 285 288 275 261 314 303 Eating Disorders --- 22 60 Addictions Service 11 28 137 115 Forensic 66 37* 0 ** Health Psychology 171 253 447 376 539 516 Neuropsychology 229 114 146 183 173 208 TOTAL 2794 2156 2609 3756 5505 5153 *Service commenced in Nov 07 **Forensic service suspended due to Maternity Leave Nov 07 – Jan 09

TAYSIDE Total number of patients waiting, number waiting beyond 18 weeks and longest wait (wks) at July 2004 and Jan 2010 by Specialty   July 2004 Jan 2010 Specialty Total Nos +18 wks Longest Wait + 18 wks Dundee Primary Care 798 567 112 125 15 Dundee CMHT 86 51 104 Perth Primary Care & CMHT 240 156 2 4 Angus Primary Care & CMHT Child & Adolescent 203 107 60 18 Older People 29 7 24 41 Learning Disabilities 58 22 11 Eating Disorder - Addictions Forensic TOTAL 1414 910 201

TAYSIDE Total number of patients waiting, number waiting beyond 18 weeks and longest wait (wks) at July 2004 and Jan 2010 by Specialty July 2004 Jan 2010 Specialty Total Nos +18 wks Longest Wait + 18 wks Dundee Primary Care 798 567 112 125 15 Dundee CMHT 86 51 104 Perth Primary Care & CMHT 240 156 2 4 Angus Primary Care & CMHT Child & Adolescent 203 107 60 18 Older People 29 7 24 41 Learning Disabilities 58 22 11 Eating Disorder - Addictions Forensic Health Psychology 246 183 530 383 82 Neuropsychology 81 9 32 85 54 TOTAL 1741 1102 816 437

WAITING LIST MANAGEMENT TAYSIDE WAITING LIST MANAGEMENT NO SINGLE ACTION RESPONSIBLE FOR IMPROVEMENTS VARIETY OF SERVICE SPECIFIC DEVELOPMENTS COMMITMENT FROM ALL STAFF

ADULT PSYCHOLOGICAL THERAPIES REVIEW (2003) TAYSIDE ADULT PSYCHOLOGICAL THERAPIES REVIEW (2003) LEVEL 2 (PRIMARY CARE) DISPARATE SERVICE PROVISION - COUNSELLORS - CBTS - CLINICAL PSYCHOLOGISTS AMALGAMATION OF SERVICES MORE COHERENT AND COMPREHENSIVE APPROACH LEVEL 3 (CMHTs) CLINICAL PSYCHOLOGISTS EMBEDDED WITHIN TEAMS

REVISED OPERATIONAL POLICIES AND ELIGIBILITY CRITERIA TAYSIDE REVISED OPERATIONAL POLICIES AND ELIGIBILITY CRITERIA CONJOINT REVISION OF LEVEL 2 AND LEVEL 3 ELIGIBILITY CRITERIA FOR ALL SPECIALTIES WITHIN PSYCHOLOGICAL THERAPIES PROVIDES CLARITY FOR REFERRING AGENTS AND ENABLES MANAGER TO BETTER PREDICT ANTICIPATED REFERRAL RATE ALSO IDENTIFIES GAPS IN SERVICE PROVISION

REVISED OPERATIONAL POLICIES AND ELIGIBILITY CRITERIA (cont’d) TAYSIDE REVISED OPERATIONAL POLICIES AND ELIGIBILITY CRITERIA (cont’d) ENGAGEMENT OF LEVEL 1 (VOLUNTARY) SERVICES TO PROTECT AGAINST INAPPROPRIATE REFERRALS REDUCE NOS OF INAPPROPRIATE REFERRALS - UNFAIR TO PATIENTS - RAISES FALSE EXPECTATIONS - WASTE OF CLINICAL TIME - ONGOING MONITORING OF ALL SERVICES e.g. LEVEL 2 : 12%, 13% & 19% LEVEL 3 : 0% CMHT : + 25%

TAYSIDE ENHANCED SKILL MIX INTRODUCTION OF MASTERS LEVEL CLINICAL ASSOCIATES IN APPLIED PSYCHOLOGY ENABLES CLINICAL PSYCHOLOGISTS TO FOCUS ON MORE SEVERE AND COMPLEX CASES COMPATIBLE WITH MATCHED CARE MODEL INITIATIVE: SUCCESS IN PRIMARY CARE EQUIVOCAL IN CAMHS AWAITED IN OLDER ADULTS

TAYSIDE STAFF ENGAGEMENT STAFF AT ALL LEVELS ENCOURAGED TO LEAD ON SPECIFIC PROJECTS e.g. TRAINEES: SERVICE INNOVATION - EVALUATE ACCEPTABILITY, UPTAKE AND EFFECTIVENESS OF cCBT FOR OLDER PEOPLE e.g. CAAPS: SERVICE EVALUATION - CORE SKILLS GROUPS - SOCIAL PROBLEM SOLVING GROUPS 8 WKLY vs 2 x 0.5 DAY - ANGER MANAGEMENT : CD-ROM + DVD

STAFF ENGAGEMENT (cont’d) TAYSIDE STAFF ENGAGEMENT (cont’d) STAFF AT ALL LEVELS ENCOURAGED TO LEAD ON SPECIFIC PROJECTS e.g. CLIN PSYCH, CAAPS, CBT : cCBT CHAMPIONS - LEAD ON MARKETING OF cCBT ACROSS GENERAL PRACTICE - LEAD ON EVALUATION AND DELIVERY OF MINDFULNESS TRAINING BY NURSING STAFF IN OLDER PEOPLE SERVICE

STAFF ENGAGEMENT (cont’d) TAYSIDE STAFF ENGAGEMENT (cont’d) STAFF AT ALL LEVELS ENCOURAGED TO LEAD ON SPECIFIC PROJECTS e.g. CONSULTANTS: SERVICE REDESIGN - WORKING THROUGH OTHERS - DISSEMINATION OF BEHAVIOURAL FAMILY THERAPY TRAINING (RELAPSE PREVENTION) - IN-PATIENT/CMHT STAFF TRAINING, e.g. Personality Disorder Childhood Sexual Abuse Survivors Challenging Behaviour From Assessment to Formulation

PATIENT APPOINTMENT SYSTEM TAYSIDE PATIENT APPOINTMENT SYSTEM TO REDUCE FAILURE TO ATTEND RATES WAITING LIST TAIL – STILL NEED TO BE SEEN FIRST APPOINTMENT CONFIRMATION DEFAULT PATIENTS CONFIRMATION STILL NEED TO BE SEEN TOPAS - PROVIDES MANAGER WITH GREATER CONTROL OF SERVICE RESOURCE - ABLE TO LOG ALL STAFF ACTIVITY - SCRUTINY OF MONTHLY CONTACT FIGURES - ENHANCED THROUGHPUT - REDUCED WASTAGE

RECONSIDER ALLOCATION MEETINGS TAYSIDE RECONSIDER ALLOCATION MEETINGS CONSULTANT ALLOCATION OF CASES NOT RELIANT ON GOODWILL AND HONESTY OF STAFF WORK AVOIDANT vs OVERCOMPLIANT STAFF REQUIRES MANAGER TO BE AWARE OF STRENGTHS AND WEAKNESSES OF STAFF REQUIRES MANAGER TO BE AWARE OF DEMANDS ON STAFF REQUIRES AGREEMENT BETWEEN MANAGERS AND STAFF ON MODAL CONTACT FOR PATIENTS REQUIRES REAL ACCEPTANCE OF CAPACITY MODELLING IN PRACTICE AND ACTIVITY AUDIT

Percentage of time all clinical staff in TAYSIDE Percentage of time all clinical staff in psychology services in NHS Scotland (excluding trainees) spent on the listed activities during a 2-week time period Activity Overall Tayside Direct Clinical Care: Attended Individual. Attended Group. DNA, Direct Patient Contact, Indirect Patient Contact, Psychology Consultation with other staff, Patient Related Admin, Receiving Clinical Supervision, Giving Clinical Supervision, Business Travel 70.1% 75.6% Supporting Activities Research: CPD : Providing teaching/lecturing /staff training NHS Meetings & Supporting Activities (non-clinical) Service Planning & Management. 20.1% 15.9% Other Duties Personal Admin non-NHS meetings other 9.9% 8.6% Total 100.0%

NEW MODELS OF SERVICE DELIVERY TAYSIDE NEW MODELS OF SERVICE DELIVERY SELF HELP MATERIALS e.g. MOODJUICE BOOKS ON PRESCRIPTION COMPUTERISED CBT : 18 MNTHS APPROX 300 + REFERRALS (74 FTA) SUPPORTED SELF HELP WORKERS

CAPACITY MODELLING IN PRACTICE TAYSIDE CAPACITY MODELLING IN PRACTICE INTRODUCED AT INTERVIEW ABILITY TO COUNT APPRECIATION OF UNIT COST JUSTIFICATION OFEXPENDITURE

CAPACITY MODELLING IN PRACTICE TAYSIDE CAPACITY MODELLING IN PRACTICE CONSULTANTS / HEAD OF SERVICE - ENHANCED POLITICAL AND STRATEGIC AWARENESS WITH REALISTIC VISION FOR THE FUTURE - SKILL DEVELOPMENT IN PRESENTING A BUSINESS CASE AT SENIOR MANAGEMENT LEVEL - SKILL DEVELOPMENT IN OPTION APPRAISAL AND FLEXIBILITY - CAPACITY MODELLING AND BENCHMARK COMPATIBILITY - MEMBERSHIP OF RELEVANT DECISION MAKING BODIES - LEADERSHIP SKILLS TO ENSURE DELIVERABLES

SERVICE FAILURES IN THE PAST TAYSIDE SERVICE FAILURES IN THE PAST ISOLATIONIST / ISOLATED LACK OF STRATEGIC AWARENESS FAILURE TO EMBRACE SKILL MIX OBSTACLES TO SERVICE REVIEW INCONSISTENT ELIGIBILITY CRITERIA FAILURE TO NETWORK INABILITY TO PRODUCE CONVINCING BUSINESS CASE GROWING WAITING LISTS DIFFICULTY IN FILLING VACANCIES

TAYSIDE SUCCESS SUMMARY ACHIEVED IN COLLABORATION WITH ALL CLINICAL AND SUPPORT STAFF FACILITATED BY LEAD CLINICIANS ENCOURAGED TO TAKE A STRATEGIC VIEW EMPHASIS ON BEST USE OF REALISTIC RESOURCE PROVISION SERVICE REVIEW AND REDESIGN IN PHASED MANNER IN CONTEXT OF EVIDENCE BASED PRACTICE NEED FOR CONTINUAL MONITORING AND SERVICE IMPROVEMENT TO ENSURE PATIENTS PROVIDED WITH APPROPRIATE INTERVENTION OR TREATMENT AT EARLIEST OPPORTUNITY

SUCCESS SUMMARY STAFF MORALE HIGH RETENTION RATE OF STAFF IN TAYSIDE HITHERTO SHACKLED BY WAITING LISTS

SUCCESS SUMMARY STAFF MORALE TAYSIDE SUCCESS SUMMARY STAFF MORALE EFFECTIVE MANAGEMENT OF WAITING LISTS, REMOVES SHACKLES AND PROVIDES OPPORTUNITY FOR INNOVATION TOWARDS A MENTALLY FLOURISHING WORKFORCE