1. CAPA- Choice and Partnership Approach: the 4 Big Ideas and the 11 key components Steve Kingsbury and Ann York Steve.Kingsbury@hertspartsft.nhs.uk Rowe.york@btinternet.com www.camhsnetwork.co.uk

2. The Basics What are they?

3. What is CAPA? …the Choice and Partnership Approach  a clinical system that evolved in Richmond CAMHS from 2000  developed and implemented wholesale in East Herts CAMHS 2005 and  now being used in many CAMH teams across the UK, New Zealand and parts of Australia

4. Ancestors of CAPA Demand and Capacity Theory 7 HELPFUL Habits of Effective CAMHS 10 High Impact changes User accessible services Evidence Based practice Choice and Partnership Approach Our Choices in Mental Health New Ways of Working You’re Welcome Standards

5. What are the 7 HELPFUL Habits?  Broad framework that can guide service redesign  Evidenced based in terms of theory and clinical experience  Mix of Lean Thinking/demand and capacity techniques and quality parameters  Meets most standards that we need to apply  Can be done in steps or as one

6. 7 HELPFUL Habits H andle Demand E xtend Capacity L et Go of Families P rocess Map F low Management U se Care Bundles L ook after staff CAPA is a system that integrates these…

7. What CAPA is…and isn’t… It is about  Doing the right things  With the right people  At the right time By applying the majority of the 7 HELPFUL Habits Myths  CAPA prescribes clinical interventions - NO  CAPA is time-limited - NO  CAPA is classic Triage - NO  It is rigid – NO  You have to give up your whole diary – NO  Choice appointments have to be done in 45 min – NO  No specialist work allowed – NO  A plot by the Government - NO

8. Values of CAPA  Users are at the heart of the process  “Led by them and guided by us”  Shift in clinician stance to Facilitator with expertise rather than expert with power

9. The CAPA system…

10. The 4 Big Ideas What are they?

11. The 4 Big Ideas 1. Choice 2. Core and Specific work 3. Selecting clinician to Partnership 4. Team Job Planning

12. 1 st Big Idea: Choice Choice philosophy: throughout Partnership  Choice appointments: first contact with the service

13. Aims of Choice  Find out what they they want  Use our knowledge to jointly form an understanding  Together choose what will be helpful

14. Interior Decorator  Explore what the client wants  Offer some advice (as an expert)  Reach a decision together

15. Curiosity Honest Opinion Joint Formulation Alternatives Choice Point Engagement Tasks in the Choice appointment/s

16. Choice: A Directed Conversation  USER: Conversation Follow the families’ process and thinking Non-hierarchical Engaging, motivating and respectful HUMAN Process Focussed  PROFESSIONAL: Directed We reach an understanding about the issues That considers risk And any appropriate diagnostic frameworks ACTIVE Goal Focused

17. 2 nd Big Idea: Core and Specific work  Key idea of separating our clinical work into core and specific work streams  Core work is bulk of what we do All clinicians Extended clinical skills Manages most families  Specific work Specific therapy, assessment or skill Additional to Core work Often done in a more formal way

18. Why have separate core and specific work?  Many can be helped by threshold level work  Extended core skills reduces bottlenecks to specifc work  Extended core skills increases clinical flexibility (fewer queues into ‘specialised’ streams)  Allows us to identify AND PROTECT specific team / individual capacity for specific work  Segments and so helps flow

19. Key concept: extending clinical skills  ABCD’S Skills Clinicians (Alphabet skills) Clinicians who have extended their skills to include the core competencies of:  Assessment  Behavioural  Cognitive  Dynamic.  Systemic

20. Threshold Specialist Skill level Specialist skills pattern

21. Threshold Specialist Skill level Core Extended threshold skills

22. So what does a typical clinician look like?  Range of extended Core clinical skills  Able to work flexibly between these skills  Some Specific skills that are job planned  Receive internal referals for…  Spend time (job planned) doing both Core and Specific

23. Specialist Threshold Common team pattern

24. Team skill issues Question: How does the distribution of these skills affect the team?

25. A Possible Pattern… Effects? Specialist Threshold

26. A Possible Pattern… Effects? Specialist Threshold

27. A Possible Pattern… Effects? Specialist Threshold

28. CBT: core threshold vs specialist skills example Core CBT:  Core/basic work- explain model, structure sessions, using homework, reviewing homework Specialist CBT: All the above PLUS  Socratic questioning/guided discovery  Automatic thoughts/assumptions/beliefs  Problem specific competencies eg in ERP for OCD Could you manage a bottleneck to CBT by extending clincal skills to increase capacity at threshold/core level? Ref: The competencies required to deliver effective cognitive and behavioural therapy for people with depression and with anxiety disorders. Dept of Heatlh 2007.

29. 3rd Big Idea: selecting clinician This is  At the end of the Choice appointment  With the young person’s and family’s goals in mind  Selecting a clinician in Partnership who has the  Skills to work towards those goals and  A personality that matches the young person and family  Fully booking them in using the Partnership diary

30. Why?  Allows Partnership onset with right clinician with the right skills  Frees family and clinician to make good use of session as encourages curiosity  Allow families and adolescents to feel more open (user feedback)  Engagement with their change not with clinician and  Helps capacity management!!

31. How does it help with Capacity?  Separating the Choice from the Partnership work allows  Choice activity to be based on referral rate  Partnership activity to be based on reasonable job plans  This means that Staff are happy to flex Choice (as no follow-up work burden) Low risk of overload as Partnership activity rates set (and do-able) Can use staff who are leaving by moving their capacity into Choice

32. How do you find someone with the right Core Partnership skills?  Need to have mapped team skills  Need to know each other  Need extended skills in Core work  Need to have done team job planning to have new Core Partnership appointments to book in to

33. 4 th Big Idea: Team Job Planning This is  Each individual having a job plan that describes their work: core, specific, choice, admin etc  This plan being written with team needs in mind  All the individual plans integrated into one team plan

34. Why?  Plans activity for the whole service  Calculates capacity  Makes work load manageable  Flexibility to move and build resources  Transparent monitoring  Set standards for activity as well as protects staff from over activity

35. Key task  Defining different types of clinical work Choice Core Partnership Specific Partnership

36. Core vs Specific work in job plan Core work  Tends to be of standard duration- on average 7 sessions  Uses threshold level extended skills (ABCDS) Specific work  specialist level skill used to complement the core work e.g specific assessment or intervention  May be shorter (e.g. Specialist assessments) or longer duration (e.g. high intensity interventions)

37. Specific work protected in job plan You decide as a team what you need to protect. Examples could be... Shorter duration  ASD assessment  WISC Longer duration  psychodynamic psychotherapy  EMDR  Specialist level/’high intensity’ CBT

38. How do we job plan Core and Specific work? Need to identify: 1. Core work- using extended threshold level skills 2. Specific work- using specialist level skills Using: Competencies ideas  Threshold and specialist level Alphabet skills  This helps work out what to put in job plans and how much And information on Flow rates  shorter term vs longer term durations  This helps work out new activity rates/capacity

39. Things to think about...  Can a specialist do Core work?  What about Long term core work?  Anorexia nervosa- is it always specilaist?

40. Team Job Planning How to do it...

41. Team Job Planning in CAPA  Each individual has a job plan that describes their work in various ways  Combined to form a team job plan  Useful to managers and clinicians as describes predicted activity  Can show effects of losses  Contains activity for clinicians  Based on “do-able”numbers

42. Job plans include… Supporting work: admin, management, CPD Other: consultation, YOT, LAC

43. You need to work out 1. What is everyone doing at the moment? ie. current job plans 2. How many Choice sessions need to be added to those job plans to match referrals? 3. What is the capacity for Core Partnership in the job plans? 4. Managers: is the team in balance? 5. Do job plans need reviewing?

44. Assumptions 1. All referrals that you accept will be guaranteed a Choice appointment within 6 weeks of referral 2. Only 2/3 of those having Choice will continue into Core Partnership work 3. Families and young people who have Core Partnership work need an average of 7.5 appointments 4. You can offer two appointments in a 3.5 hour session / half day 5. Out of 52 weeks of the year, only 45 are actually worked 6. You will design job plans according to what is currently being done

45. Step 1 What is everyone doing at the moment? ie. current job plans

46. Job planning: Blank Diaries MonTueWedThuFri Psychiatrist AmChoice PmPartnership Free SW AmTier 2 PmSpecific Admin Psychlgist AmNon clinical PmTeam meeting Systemic Am PmPm

47. Team Meeting MonTueWedThuFri Psychiatrist AmChoice PmPartnership Free SW AmTier 2 PmSpecific Admin Psychlgist AmNon clinical PmTeam meeting Systemic Am PmPm

48. Admin Time MonTueWedThuFri Psychiatrist AmChoice PmPartnership Free SW AmTier 2 PmSpecific Admin Psychlgist AmNon clinical PmTeam meeting Systemic Am PmPm

49. Specialist and specific time MonTueWedThuFri Psychiatrist AmChoice Free = 3 PmPartnership Free SW AmTier 2 Free = 6 PmSpecific Admin Psychlgist AmNon clinical Free = 4 PmTeam meeting Systemic Am Free = 7 PmPm

50. Other Commitments MonTueWedThuFri Psychiatrist AmChoice Free = 2 PmPartnership Free SW AmTier 2 Free = 4 PmSpecific Admin Psychlgist AmNon clinical Free = 4 PmTeam meeting Systemic Am Free = 4 PmPm

51. Free sessions for Choice and Core Partnership work MonTueWedThuFri Psychiatrist Am 2 Pm SW Am 4 Pm Psychlgist Am 4 Pm Systemic Am 4 pm TEAM TOTAL = 14 sessions Per week

52. Step 2 How many Choice sessions need to be added to those job plans?

53. Team Job Planning Example Anywhere CAMHS...  4 full time staff (4 FTE)  4 referrals per week

54. How many Choice appointments need to be added to those job plans? All accepted referrals are offered a Choice appointment  Number of referrals per week (that are accepted) = 4  They need 4 Choice appointments. HOW?  Each staff member can do 2 Choice appointments in one 3.5 hour session / half day 1.30 pm 3 pm

55. Decide who will do Choice Think skills not profession or seniority  Good at engagement- to service and not clinician  Facilitator with expertise  Knows local services  Can communicate best practice  Confident but not overconfident

56. Choice Clinics MonTueWedThuFri Psychiatrist Am Pm SW Am Pm Psychlgist Am PmCh Systemic Am PmPmCh TOTAL TEAM CAPACITY = 4 Choice appointments per week TOTAL TEAM DEMAND = 4 Choice appointments per week

57. Step 3 What is the capacity for Core Partnership in the job plans?

58. Calculate capacity for each clinician  Count free sessions in job plan for Core Partnership work  Multiply by 3 (Partnership Multiplier)  This is number of new Core Partnership clients each clinician will take on in a period of 13 weeks

59. Andrew Down, systemic therapist Total sessions10 Team meeting1 YOT1 Systemic Therapy clinic1 LAC consultation1 Management1 Admin1 Choice1 Remaining Core sessions 10 – 7 =3 Core Partnership new clients per quarter3 x 3 = 9 MonTueWedThuFri Systemic Am PmPmCH

60. Team Core Partnership CAPACITY per 13 week quarter MonTueWedThuFri Psychiatrist Am Free = 2 Pm SW Am Free = 4 Pm Psychlgist Am Free = 3 PmCh Systemic Am Free = 3 PmPmCh

61. Team Core Partnership CAPACITY per 13 week quarter MonTueWedThuFri Psychiatrist Am 2 x 3 = 6 Pm SW Am 4 x 3 =12 Pm Psychlgist Am 3 x 3 = 9 PmCh Systemic Am 3 x 3 = 9 PmPmCh TOTAL TEAM CAPACITY = 36 new Core Partnerships per quarter

62. Why? Why 3?  In 13 weeks each clinician is there for 11.25 weeks (leave etc)  So for each half day in their diary they do 11.25 half days per quarter  In each half day they can do 2 appointments  So over the quarter they can do 11.25 x 2 = 22.5 appointments  Each family and young person averages 7.5 appointments  This means that the 22.5 appointments divided by 7.5 appointments = 3 children and young people And We know this number works for most UK CAMHS teams But If your session average is more than 7 or you can only do 1 appointment in a half day e.g for LD The multiplier will be less

63. How many fixed appointments does Andrew offer? ie how much of his diary has he given up? 2 Choice appointments a week 9 new Core Partnership appointments over 13 weeks

64. How does he plan his work? Tue am Fri

65. Summary  Choice activity based on referrals (remember to flex…)  Core Partnership based on job plans  The number is 3  Admin time based on core activity  Job plans should be reasonable based on what you and the team NEED to do  Shift to Team Job Planning and activity  May or may not be in balance

66. Core service Percentage It is useful to know what % of the service is given to all Choice and Core Partnership WHY?  40% is the realistic ceiling;  this is challenging and needs excellent clinical and managerial leadership WE FIND: 40% in Choice and Core Partnership works for most teams: This could be... 40% for Choice and Core Partnership work 35% Specific work (i.e. 75% of time is in clinical work) 25% in supporting work e.g. management, CPD etc