CAPA in Child and Adolescent Mental Health Services An independent evaluation by the Mental Health Foundation 2009 National CAMHS Support Service

The Choice and Partnership Approach CAPA is a clinical system that brings together the active involvement of young people and their families, demand and capacity ideas and a new approach to clinical skills and job planning It was developed in Richmond and East Herts CAMHS by Ann York and Steve Kingsbury It is used in many teams across the UK and in New Zealand, Western Australia and Belgium

Evaluation In January 2009 the Department of Health Commissioned the Mental Health Foundation to undertake an independent evaluation of the CAPA to : –Examine how well CAMHS in England have adopted the components of CAPA in their practice –Assess the degree to which the intended outcomes of CAPA are being achieved –Understand the impact of adopting CAPA for services and families –Enable future decision making

Method Phase 1 –1a audit of CAMHS teams in England –1b audit of implementation of 11 components –1c audit of pre and post CAPA data Phase 2 –Visiting selected CAMHS teams (n=6) Staff Children, young people and their families

Findings – Phase 1 Phase 1a (n=213) –92% had heard of CAPA –97 teams implementing CAPA Phase 1b (n=53) –Highest CAPA score = 10.5 out of 11 –Lowest CAPA score = 1 out of 11 –Mean CAPA score = 6 out of 11 components implemented Phase 1c (n=7) –Difficult to get pre and post CAPA data from teams –Before implementation waits were between weeks for a first appointment after implementation they were between 5-12 weeks.

The 11 Key Components of CAPA 1.Leadership 2.CAPA language 3.Importance of handling demand 4.Choice framework 5.Full booking 6.Selecting appropriate clinicians 7.Extending clinical skills 8.Job plans 9.Care planning 10.Peer group supervision 11.Away days

Findings – Phase 2 The benefits implementing teams reported were: –Reduced waiting times –Reduced demands on the service –More formalised team working –Better planning and greater transparency for staff and families

Impact on families Waiting lists - surprised at how quick they could get into the service Care planning - none explicitly said that they had been involved at all in a ‘care plan’; however they knew what care they were receiving and why and were involved in deciding about their care

Impact on waiting times In services that were high implementers of CAPA components 92% of families were seen within 13 weeks Compared with the rest of CAMH services in England using CAMHS mapping data where 78% of families were seen within 13 weeks

Main benefits of CAPA Reduced waiting times Reduced demands on the service More formalised team working Better planning infrastructure Greater transparency

Main challenges of CAPA Internal waits for partnership appointments due to not implementing full booking Confidence in doing choice appointments Capacity planning Clarity of staff roles within CAPA Letting go of more complex cases and understanding that the aim is to see who needs to be seen as long as they need it, but not continuing the see a family when there is no need for specific work

Strengths and limitations of evaluation Strengths –Excellent response from staff –Mixed methods used Limitations –Difficulties in engaging families for their feedback –Difficulty obtaining tangible CAPA instruments eg. Capacity plans and before and after data

National recommendations An enhanced training package should be developed to facilitate successful implementation of CAPA. This should include training on conducting Choice appointments for clinicians, job planning and capacity planning for managers. The training and support package should address commonly held misunderstandings of the CAPA model, particularly how the system can be applied to complex cases. This will help to ensure that the implementation process becomes more standardised across teams. A national online network and directory of CAPA implementers from a variety of contexts could be developed allowing professionals to share information and solve problems.

Local implementer recommendations To realise the benefits of CAPA facilitative team management is crucial. In line with the first component of CAPA there should be an informed manager, a clinical lead, and an administrative lead. They should be well respected within the team, educated and trained in CAPA prior to implementation. Appointing a number of champions to help oversee and standardise implementation within an area. These champions should be a mixture of clinicians and managers with experience of implementing CAPA already. More formalised mechanisms need to be in place to facilitate effective team-working eg. peer group supervision.

Local implementer recommendations Continued Children’s Trusts should hold extensive, up-to-date directories of all local children’s services. CAMHS teams should use these directories to enable them to engage in multi-agency work or to signpost families to appropriate services. Monitoring and feedback are integral prior to, during, and after the implementation phase. Teams should engage in robust, transparent data collection and analysis processes that will allow them to monitor the following; outcomes for families, user experiences of the service, waiting lists, internal waits, capacity, flow and discharge.

Next Steps The Department of Health has asked the National CAMHS Support Service to prepare a costed options paper that considers possible responses to the findings of the evaluation and the recommendations made by the Mental Health Foundation.