Transcript Slide 1

Changing CAMHS
Choice and Partnership
Dr Steve Kingsbury
[email protected]
Introduction
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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
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Who am I?
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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
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Also the Medical Advisor for CAMHS to the
English Department of Health
Been involved in CAMHS service Change
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CAMHS Network
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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
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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
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Plan for today's talk
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Present some of the English Quality
standards
Talk about user choice
– Do a small exercise in the room!
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Discuss user involvement
How to encourage reflection in teams
Finish on time!
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Standards for Better Health
(DH, 2004)
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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.
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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.
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Our Choices in Mental Health
(CSIP, 2005)
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Enabling systems to provide informed
choice
Choice points:
– Life Choices
– Access and Engagement
– Assessment
– Care Pathway
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You’re Welcome Quality Criteria
(DH, 2005)
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Accessibility
Publicity and Information
Involvement
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Summary
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Clearly CAMHS is being asked to
– Offer CHOICE and
– INVOLVE users in
– ACCESSIBLE and appropriate settings
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How Health or Traditional
CAMHS works…
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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
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Choice and Partnership
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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
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Values of CAPA
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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
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Interior decorator exercise
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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
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Choice and Partnership
Approach
The first contact with the service:
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Choice appointment
focuses on engagement
facilitation of informed choice
using aspects of assessment, risk evaluation
and shared initial formulation
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Key Choice to explore
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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
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To reach a Choice Point
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Choice: A Directed
Conversation
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Conversation
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Follow the families’ process and thinking
Non-hierarchical and process focussed
Engaging, motivating and respectful
HUMAN
Directed
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Goal Focused as we have to actively
Reach an understanding about the issues
That considers risk
And any appropriate diagnostic frameworks
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Choice details
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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
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Choice Admin
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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
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Introduction (can be omitted)
History / Discussion
Formulation / Understanding
Action
 Includes what we will do and
 What the family will do
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Partnership
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This is what we call the treatment or ongoing work
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With a different clinician from the Choice clinician
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Why change clinician?
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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.
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Facilitates choice completion
Allows Partnership onset with “right” therapist
Engagement with their change not with clinician
Helps capacity management
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How to involve users?
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In
In
In
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their care planning
service evaluation
service design
information strategies
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In their Care Planning
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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)
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Reviewing regularly the goals and care plan
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In Service Evaluation
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Seek out user feedback on your clinical
service
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Satisfaction questionnaires
Specific service audits
E.g. in Herts. we found
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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
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In Service design
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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?
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In Service planning
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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
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In appointment interviews
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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.
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Reflective Practice
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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
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The ability to think together facilitated by
– Supervision / consultation and
– Team meetings and away days
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Supervision / consultation
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To be reflective and creative we all need time to
think about our work
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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
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Small Group supervision
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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!
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Team meetings
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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
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Team away days
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A central part of reflective practice
Work is often very busy leaving little
reflective time
Away days allow the team to
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Discuss clinical issues
Develop clinical practice
Be creative in future work and
Have fun together
We have them at least quarterly
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Summary
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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
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