Choice and Assessment

At a recent consultants meeting in Hertfordshire we spent some time thinking about Choice appointments and, as i discovered, some continuing myths about the role of assessment. First off let me state the myth: that Choice appointments do not contain any assessment – it is just offering a range of Choices. I can see where this myth comes from as Ann and i talk a lot about Choice and the need to work with the users wishes, hopes and wants. As well as our recommendation that we stop calling the initial contact “Assessment” (as we think this word is not collaborative) and to call it something else, maybe “Choice”.

BUT we also say that our job is to “facilitate their choices using our expertise”. In other words we have to do think about both assessment and risk to be able to have conversations with the young person in a collaborative and informed manner. The trick is to move away from an expert assessment that makes the young person and family feel passive to being able to do our assessment and risk thinking in a conversational manner that both gives us the information we need and keeps the young person and family active and engaged.

In fact it is this open and honest conversation with the young person and their family using my ideas as well as their hopes and wishes that I find so rewarding in a CAPA service!

A Team Away Day – Xmas version!

Today we had one of our team away days. These are part of the full CAPA model and should occur at least 4 times a year (see the 11 components). A key part of away days are that they are not set by management but that the content is devised by and delivered by the team – I thought it might be interesting to post about today.

We started with a warm-up. We thought it might be good to do something appreciative so we each took a piece of paper, wrote our name on the bottom, and passed it to our left. We then all wrote an appreciative comment or comments about that person, folded the paper over – so no-one could see what was written — and again passed it to our left. Eventually the pieces of paper returned to their owners. It was quite moving to see what had everyone had written.

Then, up till coffee, we talked about the recent GP audit and thought about ways we could improve the referral process, let them know about the good things we were doing and reflected on the choice letters. The plan is to then meet with the local GP lead and think it through with them.

After coffee, up till lunch, we looked at the CYP-IAPT measures for every session monitoring and tried some out. These changes are going to be HUGE but in the end i think really good.

After lunch we thought about shared decision making and young peoples experience of the service. We thought both about how to make our clinic rooms more welcoming and what posters or positive messages we wanted on the walls. We then went on to think about a user experience project about how young people and their families experience the choice letter.

Tea came and then we had an exercise where we walked round the room looking at 6 Xmas pictures (snowman, mistletoe, Rudolf, present, tree, scrooge) and choose the one we thought best represented our view of the CYP-IAPT process. After we’d all selected we talked in the round why we’d picked them. After that we reflected on the hopes and fears we had written down 3 months ago. Interesting to find we had moved on and were maybe more positive and working together as a team.

Finally to cool down, we had a Xmas quiz run rather madly by Simon. A fun end to a really good day of working together.


CAPA-ccino and other beverages…

We visit and hear about lots of teams who say they are doing CAPA but when we look closely they are doing some but nowhere near all of the 11 CAPA components. Our experience is that this CAPA-lite model really doesn’t work very well! In fact this was a key finding of the Mental Health Foundation of English CAMHS and CAPA, that there were many partial implementations often due to myths about CAPA (MHF report).

At a recent conference a delegate suggested that we should call such a service not CAPA-lite but CAPA-ccino! It has less coffee, is covered with a frothy top and suggests it is more substantial than it is.

More extreme even was when we came across a service that said they were dong CAPA and had merely converted their first appointment into triage, called it Choice and nothing else! As another delegate suggested this should be CAPA Zero.

So if you think your service is meant to be doing CAPA but it isn’t a full and satisfying double espresso, check out the self rating scale…

A CAPA limerick

I have to credit Andrew, a systemic therapist, in my team for this…

Said a CAMHS statistician / clinician
“To end waiting lists is my mission.
With a partnership quota
We’ll be lean – like Toyota !
My ambition will come to fruition.”

Excellent and had to post it!


CAPA travels to Canada!

Warm people, cold weather. Cars that stop to let you cross. Experts in clearing snow (we could learn a thing or two here!). We had a wonderful time running CAPA training in Halifax, Nova Scotia 26 Nov to 1st Dec.

We were very excited when Sharon (Clark) from IWK invited us to run CAPA training at the Chocolate Lake Hotel.  No Willy Wonka in sight though! Day 1-2 was for clinicians and 3 for managers and others from the Province. Sharon had heard of CAPA from one of their clinicians who had worked in a CAPA team in New Zealand. The world is a very small place it seems!

IWK is the main provider of mental health services in Nova Scotia. We were struck by their enthusiasm about the service transformation CAPA can bring. The current services, although developed in good faith, are no longer able to provide responsive, quick access that they crave. Anxiety about their waits to non-urgent appointments had felt overwhelming until now…

The wonderful Maureen MacDonald, Health and Wellness Minister, opened the first day and we were struck by her resolute commitment to the project. She is a fantastic champion for children’s mental health- her praise for the hard work of the staff was particularly welcome. Then the day spurred on, tailored to people’s needs as we went. We talked about a focus on what people want, how to offer choices and let go when enough has been done. We were filmed (will we ever dare watch this!) and interviewed by a news journalist from the Chronicle Herald.

In Day 3 we worked with paediatricians, child and adult mental health practitioners, managers and the Department of Health. We focused on different viewpoints and system-free CAPA. How does CAPA help the service user, manager, clinician, administrator and funder? Everyone took something away.

Breakfast with the psychiatrists (the biggest plate of pancakes you ever did see!), bring and share supper at Sharon’s on Tuesday evening and a Q&A lunch before we went. A packed visit. Can’t wait to hear how things go for Nova Scotia!

Thank you for having us! We loved being with a new ‘family’.


CAPA implementation and leadership

Question: The issue of who should lead CAPA within our teams is currently being discussed as is the issue of what the tasks of a CAPA lead actually are in the first year. We are uncertain whether our leadership model should be based on one person or indeed whether carefully differentiated tasks should be delegated to a small number of people within each team. We do not have an overarching team leader and this is not something that is currently up for debate. Moreover, we need to ensure we have the appropriate CAPA leads to take us through this first year

Steve and I advise that teams have a CAPA leadership team of manager, CAPA clinical lead and Admin lead. The main tasks in the first year are to keep things on track – and this means monitoring what is going on, checking Away days have supportive content, reviewing job plans, co-ordinating any service audit that is happening etc.

The clinical lead role can rotate of course, and this can be helpful so that the ownership is not located within one person. The skills and knowledge needed are enthusiasm and knowledge about CAPA and ability to work with others to take it forward. All the actual work – such as job planning, audit can be delegated within the team.


Adult Eating Disorders: new steps…

I met with the manager of the my trust adult eating disorders team yesterday. They are joining two local teams and were looking for a service model to bring the services together. She had heard of CAPA in CAMHS in my trust and wanted to know if it might help.

Initially we talked about the numbers and how to work out treatment (Partnership) activity. As that maths is simply based on the number of contacts a clinician can do if a half day and the average treatment duration, finding the right multiplier for her service would be fine

She could see that the collaborative stance with patients, the peer group discussion and layering skills in her particular service into the specific specialist skills and extended core versions of these would really make a transparent, open service. It’s really exciting to work with a new team and service area and to work more on not translating CAPA into adult mental health but thinking about the principles of CAPA and how they work in a wide range of services – system free CAPA!

I’m going to go to the next team meeting to talk with everyone as a taster.



FAQ: how long does it take to do a Choice appointment?

Q: Hi- I am wondering how long it takes to do a Choice appointment?  I have heard that sometimes it takes 20 minutes and sometimes several hours! Which is right? I am worried someone will tell me I have to do them in 20 mins.


Both! The aim of the Choice appointment is to reach a Choice Point ie to have a joint understanding with the family/service user about what is going on, what goals and outcomes are being sought and how these can best be met.

If the family is well known to CAMHS e.g have been before and lots is known AND the goals are clear, then it may take only 20 minutes to work out what is needed together. E.g. a family who move back into the area bring their child who has previously been on medication for ADHD. They want to restart. All the assessment and background is known from before so what is needed is an update- what is going on now? What do they need help with and how can this be done? Any risks?  The intervention in Partnership may then be rapidly agreed.

Similarly, someone coming back with another bout of OCD- the focus may be on what are the symptoms now and how can they restart all the things they learned previously plus an update about circumstances, including any risks.

For brand new service users, the conversation will take longer- getting to know them, what they want, how they see things. If someone key in their system is not at the Choice appointment (e.g. the adolescent did not come, only parents, or dad needs to be included, or the social worker) then a Choice Plus appointment needs to happen to reach the Choice Point.

Timetabling in CAPA generally allows of 2 appointments in a clinical half day so you can spend 90 minutes if needed.

Of course, how many Choice appointments you can do in a half day depends on your admin system. If quick and easy it may only take 30 mins. Since moving to an Electronic Care Record the team I am in need 2 hours to complete the admin in addition to the 1 hour admin staff need.



FAQ: Do Choice numbers factor in leave?

Question: Hi! I wonder if you would kindly answer a question about the CAPA model that is causing some confusion here. The confusion surrounds a practitioner’s choice and partnership in the quarter when they are on holiday.

 Q: If a practitioner has 15 choices to undertake in a quarter and they go on holiday, do they still have to do all 15 choices in that quarter? If they still have to do all 15 Choices, should they be made up in that quarter or the next?

 Hope this makes sense!

 Answer: Hi! OK first to answer a question you didn’t ask (!). The partnership numbers are based on job plan and the multiplier of 3 already accounts for holidays so whatever their number is, that is what clinicians need to do.

 However this isn’t the case for choice. Choice can be organised however suits the team and is reasonable and doable.

 The top rule is that total number of choice offered must equal what is required for the whole team. This total number can be divided up amongst the team in a number of ways:

  •  A quota per person – either prorata, based on FTE, or same number each (or another way!). E.g. a team needs 100 Choice and has 10 FTE. This equals 10 per FTE per quarter. So a 0.5 FTE would need to offer 5 in the quarter (next 3 months).
    The number that this produces then is job planned. E.g. if 10 per Q and each choice takes say 2 hrs including admin then 10 x 2 = 20 hours / 13 weeks = about 1.5 hours per week in job plan.
  • A fixed weekly rota e.g. 1 every week there (= 11.5 per Q – accounting for leave). This does factor in leave as there would not be an expectation to do choice when on leave or to make up when back.

It’s whatever suits the team and delivers the right number so leave doesn’t come into it directly.



FAQ: How to manage ASD?

Question: My clinic started CAPA in July 2010. CAPA has helped to reduce waiting list and time to be seen. However, many of our referral and choice seen came out with the possibility of ASD. How to run CAPA with many potential cases are ASD? We don’t have neurodevelopmental team available.

Answer: Hi. You sound like the service I am in- we have a lot of neurodevelopmental in Choice.

We manage this in the team I am in by having a neurodevelopmental Partnership clinic. So if this type of assessment is needed they are booked in from Choice – screening is done in Choice. We don’t just assume such an assessment is needed from the referral. So that means those doing Choice need neuro screening skills. The Partnership multiplier we use in the neuro clinic is still 3 as we have found the session average is still around 7.

We have trained up clinicians to do Neurodevelopmental assessments – and so we have a subteam made up of a range of professional backgrounds. We don’t have SLT or OT in the service so these assessments are not included in our ND assessment. However, if they are indicated as a result of our assessment then we refer to the relevant service locally. We used to have SLT who joined us but this has been withdrawn due to cuts a few years ago.

Everyone doing the assessments is able to do basic social communication assessment with the child – we have been given help from the SLT who used to work with us to do this- i.e. have extended our skills in this area. However, if they need a CELF or such like then we could not do this.

So you have various options: Your SLT and OT could be in Partnership, joining the assessments for Specific Partnership work and you could ask them to help extend your skills so you can do some assessments, bringing them in for the more complex ones- probably a more efficient option

A final thought is also not to assume what ASD referrals want. Often we feel they need a thorough assessment (whatever that is). They may be more pragmatic.

Ann (and Steve)