Snowball In a team What do you think are the core clinical competencies for a child & adolescent team [choose a particular colour paper]
Potential Risks at Project Level lack of dissemination lack of sustainability Potential benifits Consultants are not responsible for less complex, lower tier work but freed to focus on complex cases Providing a better service in existing resources Clearer roles, clear mechanisms for checking case loads and ensuring staff are operating appropriately Able to concentrate on one area, becoming more experts, the job will be more satisfying (helping with recruitment and retention) Team members will be able to develop and feel more valued and responsible
David Cottrell Psychiatric Bulletin 1993, 17:733-735 In defence of multidisciplinary teams in child and adolescent psychiatry
Introduce Me Introduce each other 3 CAMHS skills/competencies that you have Aims of session : Introduce NWW Introduce NWW CAMHS Leave with thoughts with regard to the future
Look at what we have done – created vast array of programmes, a torrent of funding streams, multiple targets, separate inspections, fragmented accountability And look at the impact on the child - each funding stream its own xxx and gatekeeper nobody has the full picture of the child ’s needs but each xxx the child and the child is passed from agency to agency
Still has great resonance – how close are we to achieving this?
Multi-agency work remains very difficult Audit Commission report (2002 p.52): Snowball Between teams How can we change working practice for Multi-agency work
Snowball On your own What do you think are the core clinical skills for a child & adolescent psychiatrists [choose a particular colour paper]
Levels of levers Patient-driven through choice, voice and competition Commissioner-driven through contracting, contestability and service redesign Nationally-driven through standards, targets, agencies and regulatory approaches
Eg support time and recovery workers, graduate mental health workers, associate practitioners Eg nurse prescribers, clinical pharmacists Eg changing the pattern of working of consultant psychiatrists to make the best use of their expertise
Not a Recipe Needs work More of a approach Cultural change is very difficult tribal nature of professional training a potential barrier Enhance effective person –centred services through new ways of working in multidisciplinary multi agency context 10 Essential Shared Capabilities Distinct Contributions Project plan Project management Time Team based Service users and carers from the outset Clear communication strategy Data demonstration Share experiences [e.g Active Shadowing] DOAS Interest is essential Supportive management structure Board level ‘permission’ HR, finance, governance etc – make use of them Expect problems-revise assumptions Service users and carers from the outset
There are no well worn paths People and services will need to move out of their comfort zones.
CAMHS Specialist trainees management april 2013
MajorCompetency:ManagementApril 2013 ST C&ANorth West Deanery
Personal introduction• Current placement• Management courses/experience• Strengths & weaknesses• Why attending this course?
Whatever happens?• Massive turmoil• Adaptation and innovation• Need the right number of staff with the right skillsin the right place at the right time for the rightprice!• Winners and Losers
Major Competency• Managing a budget• Managing Risk• Handling complaints• Involving service users• Evidenced based practice• Applying good practice standards• Monitoring and analysing outcomes• Audit• Influencing organisations
Managing Yourself• How is your desk & office organised?• What clinical and administrative tasks do youdelegate? e.g. booking appointments, messages,notes & filing.• How do you organise your diary & tasks – paper orcomputer?• How easy am I to work with (this is not only aboutbeing nice)
Managing YourselfExercises• Review weekly job plan & log of activity for oneweek• How much do I cost to employ?• 360 appraisal – exercise or utility• Preparation for next session – will you? Actionorientation or words?
Core Clinical Skills for C&A Psychiatrists• Identification and treatment of psychosis, severe depressiveillness, organic mental states, severe somatoform disorders• Psychopharmacology• Advice in respect of high risk of self-harm, suicide and harmto others• Advice on treatment of severe, complex ADHD, OCD andTICS• Advice on and management of Eating disorders• Identification of, formulation of, and advice in, complex casese.g child protection, LAC, Youth offending• Certain types of paediatric liaison work• Assessment of complex or atypical ASD
Is there clarity?• What we do• What we could do• What we should do• What we are asked to do• How we do it together
Clinical Competencies of a Team• Initial formulation and diagnosis of most cases• Risk assessment of self-harm and harm to others• Formulation and management of most cases of self-harm• Initial ADHD assessment and treatment of cases notneeding medication• Family therapy clinics• Parent management skills• Cognitive-behavioural therapy
Potential Risks at Team Level• The model is not owned by everyone in teamsand services• No appropriate skill mix in teams• Too many interfaces• Isolation, confusion of roles• Lose good practice, especially workingtogether in patch teams• If one is the only specialist in that area whathappen when they are off?
MDT• “One obstacle to the smooth running ofmultidisciplinary teams is the desire of doctors to bein charge.” Cottrell 1993
Departmental Organisation• What are the structures & processes?• Who is in the department?• Who decides what, and where?• What are the lines of management –personnel/clinical?• What are the management/departmentalmeetings – who attends and what is decided?• What arrangements are there for appraisal?
Leadership & Teamworking• Who sets goals & how are these evaluated?• How is activity information used?• Is there a service description & priorities?• Is there a regular development day? How isthis organised & evaluated?• How are new developments planned &agreed?• How is expertise recognised?
Communication & Meetings• What is the remit?• Who attends – and how is this decided?• What is the agenda?• Are minutes kept and distributed?• Focussing on what has to be decided, and what actions areagreed• How are decisions and actions implemented and reviewed?• How to deal with non-attenders, or people who talk toomuch or too little?
Clinical Governance• What are the structures & processes forclinical governance?• How does CAMHS relate to these?• How is audit organised?• What protocols are in place and how arethese reviewed?• What audits have been completed?• How are clinical incidents reported andreviewed?
Conflict & Negotiation• How to manage people who moan (problems)?• How is efficiency & effectiveness monitored?• What about punctuality and absence?• What are the disciplinary processes?• Difficult people e.g. non-participation,critical/hostile
Service Development• What are the departmental processes forgenerating & developing the service?• How are these negotiated within the trust/CCGand with other agencies?• What funds are available for development?• What are the national trends & drivers fordevelopment priorities?
Managing Change• How is change planned & implemented?• Is change negotiated or imposed?• How are team members involved orinformed?• How do people react?
Working in CAMHS“I’m all for progress, it’schange I can’t cope with”Mark Twain
External context• Which trust & directorate? CCG?• CD, MD, CEO, Ch, board: who & how?• When & where? Who represents you?• Multiagency CAMHS planning? Who, when &where?• Health England impact on CAMHS
The overall goal of comprehensive child andadolescent mental health services should bethat of delivering seamless multi-sectoralmental health services for children,adolescents, young people and their families.The services must be effective, sensitive andappropriate to the needs of the localpopulation, and based on achieving the bestfrom partnerships in care.TOGETHER WE STAND, HAS, 1995
GPs, Paediatricians, Teachers, School Nurses,Youth Justice Workers, Health Visitors,Social Workers, Voluntary Agencies etcTier 1Individual Professionals Trainedin Children and Young People’s Mental Healthe.g. Psychiatrists, Psychologists, Therapists etcSpecialist Multi-disciplinaryTeamsTier 2Tier 3Veryspecialistservices, incl.children away from home Tier 4The 4-tier model for CAMHSPrimaryMentalHealthWorkersetcHealth Advisory Service, 1995. Together We Stand
National Service Framework forNational Service Framework forChildren, Young People and MaternityChildren, Young People and MaternityServicesServicesNSF Standard 9:The Mental Health and Psychological Well-beingof Children and Young People
“All children and young people, frombirth to their eighteenth birthday, whohave mental health problems anddisorders have access to timely,integrated, high quality multidisciplinarymental health services to ensureeffective assessment, treatment andsupport, for them, and their families.”NSF Standard 9:The Mental Health and Psychological Well-beingof Children and Young People
• Services are shaped by their histories andorganised for the convenience of the provider notthe client (Cabinet Office, 2001).• Audit Commission report (2002): a generalconsensus that agencies need to work more closelytogether to meet the needs of young people, butdifferent spending priorities, boundaries andcultures make this difficult to achieve in practice• Interagency working of such services tend tounderlap rather than overlap and agencies canignore the complexity their clients presentMulti-agency work
BarriersProfessional barriers – different professional culturesleading to different perceptions of role and priority anddisagreement about assessment and intervention withyoung personCommunication barriers - often different professions anddifferent organisations approach the same issue from adifferent perspective and use different terms;Organisational barriers - different organisations mayhave different goals, priorities and structures;Resource barriers - there may not always be sufficientmoney or time to support joint working.
So what are users saying theySo what are users saying theywant?want?• What children, young people and their families andcarers want is often quite simple.• They want consistent relationships with people whocan help and to be treated with dignity and respect.CAMHS Review 2008
Features of effective services – as defined byFeatures of effective services – as defined bychildren, youngchildren, youngpeople and their parents and carerspeople and their parents and carers• Awareness• Of mental health and how to deal with it• Trust• Build a trusting relationship• Regular contact with the same staff• Clarity over confidentiality arrangements
Features of effective servicesFeatures of effective services• Accessibility• Convenience• Accessible information and advice available• Single point of entry to specialist mental health services• Age-appropriate services• Communication• Being listened to, given individual attention• Straightforward, no technical jargon
• Involvement• Being valued• Opportunity to discuss what services and interventionsare available• Support when it’s needed• Available when the need first arises, not when thingsreach crisis point• Support and follow upFeatures of effective servicesFeatures of effective services
• Holistic approach• services that think about you as an individual; for example,providing help with practical issues and addressing yourphysical health as well as your mental healthSummary of key findings from Focus groups and interviews withchildren, young people, parents and carers, conducted specifically forthe Independent CAMHS Review Expert Group.Features of effective servicesFeatures of effective services
Some Levers for Change• Users and carers [Families]• NSF Change for Children - Every Child Matters• Comprehensive CAMHS• Workforce challenge• NHS Modernisation• Commissioner-driven through contracting,contestability and service redesign• Performance indicators• Activity data• Waiting times
“All models are wrong butsome are useful”W Demming
How to develop a service?• Developing new roles, to bring new people intothe mental health workforce• Developing the roles of existing staff, to enablethem to take on more or different tasks• Ensuring that the skills of all staff are beingused in the most efficient and effective way
Key lessons and actions• No single blueprint for CAMHS• Small changes can be easy wins• Change one role and change all• Leadership to support change is essential bothfrom clinicians and managers• There is more shared in common that distinctbetween professions [ Ten Essential SharedCapabilities]• Will involve cultural change
Solutions [AIMS]• Child & Family input into service design• Clarity about realistic roles• Recognise finite capacity and capabilities andavoid wishing unrealistic demands upon them• Vertical and horizontal integration of services• Clarify corporate responses
Solutions [ACTIONS]• Use explicit plans and protocols for demandmanagement• Re-organise services to respond to need notdiagnostic labels• Consider information needs of all stakeholders• Recognise concept of burden and impact• Complexity means multiple respondents may beneeded• Matching between wants, needs, evidence ofeffectiveness and availability of expertise• Supportive information systems
There are no well worn paths….…. People and services will needto move out of their comfortzones.
Preparing For AConsultant Post• What kind of post are you looking for?• What posts are currently available in the NorthWest?• Ways to appraise a vacant post