“Is CAPA all that lean has to offer CAMHS?”

Dr Ian Dufton

Consultant Child & Adolescent Psychiatrist & Clinical Lead Bolton CAMHS

Dr Hilary Strachan

Consultant Child & Adolescent Psychiatrist

“…or alternatively are ‘Service’ & ‘Redesign’ really two ugly words?”

Dr Ian Dufton

Consultant Child & Adolescent Psychiatrist & Clinical Lead Bolton CAMHS

Dr Hilary Strachan

Consultant Child & Adolescent Psychiatrist

What we hope you get put of this workshop?

• Share our redesign experiences– We agreed to do this at the end year one of our redesign– Year 2 really has been living in interesting times…

• Consider the implications of the service transformation movements of…– Austerity– IAPT – CYP– No Health without Mental Health

• Create an atmosphere of sharing designs & collaboration– What about a CAMHS service redesign network?

• “A beginning is always a difficult time…” – What were our problems?– Introducing LEAN to Bolton CAMHS– What is required for transformation?– Getting the reasons right for change– Resistance?

• Redesigning the service along LEAN principles Part I– How we went about redesign– Bolton’s 80:20 Choice & Pathway Design

• Redesigning the service along LEAN principles Part II– Adapting ‘Choice’ & continuous / rapid Improvement Events (RIEs)– ADHD pathway and further applications of RIEs– Eating Disorder Pathway and the application of standard work

Workshop structure (if all goes to plan)

• Where pathways fall down?– The Emotional Pathway…

• And then there are factors outside anyone’s control…– Demand escalation beyond sense– The old chestnuts sickness and performance– Cost savings, cuts and vacancy freezes

• So where next?– What are your thoughts, experiences?– Can we afford to not transform?

And because it never does go to plan…

Knowing that do you want to get out of this session?

“A beginning is always a difficult time…”

• Same Problems as any other CAMHS– Challenging Waiting Times– Limitations in availability of interventions– Attempts to widen the remit of CAMHS

• Shrinking resources– Cost improvement programmes– Reductions in provision from Social Care & Education– Reductions in 3rd Sector schemes

• Increasing demand– Escalation of referrals

Bolton CAMHS is not a ‘good’ CAMHS

• A level playing field– Real and meaningful integration of the traditional disciplines in CAMHS– Multi-disciplinary leadership structures– Extensive clinical and support staff engagement in transformation–

• A methodology for transformation and continuous improvement– LEAN

• Supported throughout the organisation (BICS Team)– Standards (National [NICE, CCQI], and Local) PDSA, Audit cycles

• Supporting Structures– Adaptable resources (via job planning etc.)– Effective and trusting relationships with the wider organisation (Child Commissioner, Chief

Executive, Trust Board, Division)– Autonomy over budget

• Information– Data that’s good enough to help understand the performance and functioning of the service

What is required to ‘transform’?

• Reality Check– Introducing LEAN has not been easy

• Initial CAMHS Value Stream Exercise 2008 was a failure and led to no further LEAN activities for 12 months

• Right moment– The wider organisation in the right place to move with LEAN ideas– Adversity provided an opportunity for change resulting in the change

of Clinical Lead and the possibility of a new direction

• Early examples of success with LEAN (or BICS as we call it in Bolton)– A breakthrough or rapid improvement event around the use of

medication improved patient care, sustained a reduction in drug spend over 18/12 (25%) and won the UK Lilly Award for Reflective Practice in Attention Deficit Hyperactivity Disorder

Introducing LEAN to Bolton CAMHS

Getting the reasons right for change…

Getting the reasons for change right… A3 – boxes 1 - 3

Getting the reasons for transformation right… A3 – boxes 1 - 3

Developing Shared ‘True North’ goals, A3 & its Metrics

Getting the reasons for transformation right… A3 – boxes 1 - 3

Developing shared ‘True North’ goals, A3 & its Metrics

Developing the framework for the re-designed service and

remembering it’s an experiment,we have to prove it works better

(and harder still we have to believe…)

A3 – boxes 1 - 3

A SET OF METRICS TO MATCH THE SERVICE GOALS

A3 – boxes 1 - 3

Better Care for Better Health• To provide effective and high quality child and adolescent

mental health services to the population of children with significant mental health problems in Bolton

OUTCOME focused: Triad of measures• CORC Strength & Difficulties Questionnaire• Intervention Specific Measures

• % outcomes above the research standard• Commission of Heath Improvement (CHI) Service

Experience Questionnaire

A3 – boxes 1 - 3Getting the reasons for change right…

A SET OF METRICS TO MATCH THE SERVICE GOALS

A3 – boxes 1 - 3

Responsible Use of Resources• To become a patient driven service where effective user

involvement, strong clinical leadership and continuous improvement drive the responsible and sustainable provision of mental health care.

OUTCOME focused: Triad of measures• Cost Improvement Programme• Patient involvement in strategic activities• % time to action measures @ standard e.g. new

case contact, treatment interventions

A3 – boxes 1 - 3Getting the reasons for change right…

A SET OF METRICS TO MATCH THE SERVICE GOALS

A3 – boxes 1 - 3Valued, respected & Proud• To be a CAMHS service that actively supports, challenges

and develops its workforce while contributing to the wider development of the national CAMHS workforce in a positive and forward thinking manner within environments fit for purpose.

Evaluation focused: Triad of measures• CAMHS temperature check (or equivalent)• % Job Plan / Appraisal rates• Improvements implemented per month

What about resistance?

Resistance

• Most change encounters some form of opposition which costs time, money, emotional effort…and may derail the change

• Literally means a restraining force that attempts to maintain the status quo of the current situation

• Often perceived negatively but rather arbitrary to label on behaviour an act of control or power and the other an act of resistance

• Tends to create cycles of resistance and counter resistance

The Challenge for Quality Improvement

Improvement -> Change

Change -> Threat to security

Threat -> Resistance

Resistance -> Emotion or logic?

Four Forms of Resistance

1 Parochial Self Interest Believe they will lose something they value; focus on own best interests not those of total organisation

2 Misunderstanding/Lack of Trust

Believe they will lose more than they will gain but have actually misunderstood; catches managers by surprise

3 Different Assessments Interpret facts / information differently or have access to different sources of data to those initiating change. Managers may miss out on learning opportunity here if assume all resistance negative

4 Low tolerance for change

Anxiety and fear: don’t have / can’t learn new skills and behaviour required

Source: Kotter & Schlesinger, 1979

Reframing Resistance

• Is resistance always wrong?

• Can you make it worse through trying to ‘overcome resistance?’ via:– Selling the benefits

– Discouraging the voicing of negative responses

– Solving the resistors issues to restore calm

– Making light of possible difficulties

• Engaging with resistance is about listening, asking good questions, coaching and acting appropriately

Redesigning the service along LEAN principles Part I:

A3 – boxes 1 - 3

“Are there steps to transforming a CAMHS?”Don’t know … All we can

do is tell you what we did…

A3 – boxes 1 - 3

“Are there steps to transforming a CAMHS?”All we can do is tell you what we did…

Step One: Specialty Specific Strategic Review:

We all recognised the need to change but what? All? Some? And to achieve what ends?

A3 – boxes 1 - 3

… focused the service by asking

What are our distinctive strengths in service management & delivery, clinical & systemic innovation etc.Can we demonstrate clinical outcomes?Can we demonstrate adherence to clinical guidelines?Can we demonstrate we are adequately staffed and with the right skill mix?Are we sustainable? Are we affordable? How will demand evolve in the future? What are the risks?

Step One: Specialty Specific Strategic Review:

We all recognised the need to change but what? All? Some? And to achieve what ends?

“Are there steps to transforming a CAMHS?”All we can do is tell you what we did…

Current distinctive strengths of our service:

“what we’re good at?”

Service management and delivery

• An Integrated service across Psychiatry, Psychology and other allied disciplines which differs from neighbouring CAMHS with a multi-disciplinary lead clinician group.

• Deploy whole service management, • Robust standardised job planning across all staff

• ensures effective skill deployment• develops skills and deploys these creatively and

beyond traditional roles • e.g. nurse prescribers, psychologists providing risk

assessment• Priority managed waiting list that achieves the national 18

week standard*DoH improving access...2009

• Dedicated to the provision of Evidence based, NICE Compliant interventions

Assessment of current viability:

“Are we safe?”

Can we demonstrate satisfactory clinical outcomes?

1. CORC – Strength & Difficulties Questionnaire• 78% of parents met the significant difficulties criteria and

at 6 months only 46%

2. CAMHS Day Unit – pre/post HoNOSCA*• Reduction in all post HoNOSCA scores

3. CAMHS Day Unit – Educational Outcomes*• ‘Good’ Ofsted rating• Non school attendees 100% back into education• 100% sat GCSEs

4. Intervention Specific measures – ASSIST*, Riding the Rapids*, Parenting (Group Triple P), Individual Behaviour Management

• Parenting groups reductions in post SDQ & post DASS

Yes

Assessment of current viability:

“Are we sustainable?”

Can we demonstrate we are adequately staffed with staff of the right skills?

Skill mix –• Broad mix of core generic and specialist skills identified via job

planning and PDP process • Possess the majority of skills required, • Gaps already identified –

• areas of limited resources (IPT, validated attachment assessment skills etc.)

• areas of lack Family Therapy, FFT (see earlier)

Absolute numbers: 31.36 wte (25.21 Clinical Staff) ***• RCPsych recommendations 39.4 wte up to 16, 52.48 wte up to 18, • Average 2006/7 13.3 wte

Current model and current job planning – capacity 650 vs. predicted 915 NC contacts (1 : 6 NC:FU ratio)

• Increase in new OP activity of 38% in 2010 – 2011, still under capacity• risk of ‘burnout’ with present staff numbers and model increased• At present sickness and turnover rates are lower than compared with

divisional average

Maybe

What were our problems and what did we do?

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2009 -2010 2010-2011 2011-2012 2012-2013 2013-2014

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Referral Rate Predictions

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Pre- Redesign Predicted Service Capacityd d d

“Demand Evolution?”