1. PSYCHOLOGICAL THERAPIES
DEMAND AND CAPACITY
FOR
PSYCHOLOGICAL THERAPIES
2.30
Mike Henderson Consultant Clinical Psychologist
Mental Health Collaborative

2. New Jargon - Demand Capacity Activity and Queue
Demand is not how many people are referred or our waiting list
Capacity is not the number of staff we have
Activity is what we do within our capacity
Our waiting list is actually a Queue
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3. Why are Demand and Capacity Important?
Knowing more about our demand and capacity means we can make informed changes:
“If you always do what you have always done,
you will always get what you always got.”
2.32

4. Psychological Therapy for Psychological Therapy Services
Let’s try CBT
A few Negative thoughts..
evidence needed
2.33

5. No-one understands me Possibly true Do we understand ourselves?
lets tell ‘them’ about us
Do we understand ourselves?
do we know enough about our service
What are our problems?
can ‘they’ help?
2.34

6. ‘They’ want me to work harder ‘They’ are snooping – don’t trust me
‘They’ are not psychological therapists
‘They’ don’t know:
what I do
what to measure
what the problems are
Neither do I!
Maybe ‘they’ could help me work less hard 
2.35

7. I don’t have enough staff
To do what?
Evidence:
what are they doing?
can they learn to do it better?
do they need to do it?
can someone else do it?
what do I need more of?
what do I need less of?
who do I need to train?
to do what?
2.36

8. Demand and Capacity should be equal….
If give impression that we are coping – increase flow.
As demand exceeds capcity – more desperate measures can come into play
From GP point of view – reducing a waiting list – initiative used – refer more as they see apparently more capacity
and also
Ask for more to be seen urgently – chocolates coming in first grabbed, leaving longer waiters to not be dealt with.
Can anyone else see a parallel with their service? t
2.36 – 2.40
Important to match demand with capacity.
When faced with excessive demand – people go to great lengths to try and cope
In-accurate reporting of ability to cope with demand – does not help.

9. The Sweet Demand and Capacity Game
Your table is a psychological therapies team
you have some cases to treat
the cases are either ‘hard’ or ‘soft’
Each table has the same number of cases and the same number of staff
If people do not want to, or cannot eat the sweets, then they are on ‘study leave’. They can sit back and observe
The cases are in the bags – please wait before opening bag

10. The Sweet Demand and Capacity Game
Tables 1 and 2 have a helper (Paul/Louise – wave)
DO NOT START UNTIL I SAY ‘GO’
Please treat every case with ‘respect’:
thorough treatment for all - chew or suck properly before ‘discharge’
early discharge before treatment is completed is not appropriate professional behavior
in this type of work – ‘group’ work – treating more than one case at a time is not allowed for dignity reasons

11. Your Team
Your team is mixed with two High Intensity therapists (HI) and the rest Low Intensity (LI)
ONLY HI therapists can treat hard cases
Nominate a team leader
Identify who has had what level of training
2 High Intensity (HI) the rest Low Intensity (LI)
READ INSTRUCTIONS
Indicate when ready to start your service
START WHEN the MH (Mike H) Board says GO
STOP when all LI are treated and all HI either treated or ‘in therapy’ – call out and hold up number

12. Learning Points Same number of cases, but some take longer to treat
number of cases referred/waiting is not accurate measure of demand
Same number of staff, different time to treat same number cases
there are different ways of using capacity with different effects on total demand
travel, meetings, assessment, case allocation and appropriate use of levels of training all impact

13. Measuring Demand
Demand is the total work required to undertake the clinical service needed
Different types of referrals will require different inputs that last for different periods of time.
brief therapy referral may take 4 hours of Low Intensity therapist input
complex psychotherapy referral may need 100 hours of expert psychotherapy
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14. Measuring Demand Proportion by “Type”
Number of sessions anticipated for each “Type”
Duration of and number of each different type of appointment
Assessment
Therapy
Review
New to follow-up ratio
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15. Help from The MATRIX 2.58 TYPE OF DEMAND TIME DEMAND CAPACITY REQUIRED
Level of Therapy
TYPE OF DEMAND
Patient Group / Severity
Treatment delivered
TIME DEMAND
Training required / competencies
CAPACITY REQUIRED
Low Intensity
Patient Group: Common Mental Health Problems – Stress/Anxiety/Depression
Severity: Mild/moderate, with limited effect on functioning
(1 to 3 hours)
5-10 day training
intensive, ongoing clinical supervision:
Level of competence: must meet the ‘Skills for Health’ ‘Low Intensity’ competences
High Intensity
Patient Group: Common Mental Health Problems
Severity: Moderate/severe with significant effect on functioning.
(6 to 16 hours)
Diploma level
Normally at least 24 days formal teaching, 24 days of CBT in the workplace, plus intensive supervision over at least 1 year of training.
Level of competence: must meet the ‘Skills for Health’ ‘High Intensity’ competences
High Intensity - Specialist
Patient Group: Moderate/Severe mental health problems with significant effect on functioning-Specialist areas
E.g.: Schizophrenia, Personality Disorder, Bi-polar Disorder, Eating Disorders, Substance Misuse etc
Severity: Moderate/Severe with significant effect on functioning
(16 to 20 hours)
Diploma level CBT training, plus further training in application of CBT techniques to specialist area. Further knowledge and skills may be acquired through formal training or through specialist supervision.
Level of competence: must meet the ‘Skills for Health’ ‘High Intensity’ competences
Highly Specialist
Complex, enduring mental health problems with a high likelihood of co-morbidity, and beyond the scope of standardized treatments.
Severity: Highly Complex
(20 + hours)
Specialist knowledge of a range of theoretical and therapeutic models
Ability to formulate complex problems using a range of psychological l models, taking into account historical, developmental, systemic and neuropsychological processes.
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16. Influencing Demand Step One - have clear eligibility criteria
Step Two - reduce unnecessary demand that is created because didn’t do things right the first time
this step is really all about focusing on the quality of the service you provide – and making sure it reliably delivers the right care to the right person at the right time
2.59

17. Influencing Demand
Step three - reduce unnecessary demand that is created because of unnecessary actions in the process
steps that don’t add any value
effective caseload management and review systems in place
use a matched care model
where it is clinically appropriate, use group work
3.00

18. Effective Caseload Management and Review
The number of times a patient is seen has a greater impact on demand than number of referrals
With 3,120 hours a year of staff time available for patient work
Average 1 assessment and 7 follow up = 390 new referrals a year
Reduce average follow up contacts to 6 = 445 new referrals
55 more without doing any more clinical hours
3..01

19. SMART Working
Build in case review: A healthy psychological therapy service has a system that automatically builds case review into a patient’s journey. This would include:
Building in discharge from the outset
Contracting an initial number of sessions
Setting a review date
Revise aims/reformulate if needed
Not routinely offering ‘check up’ appointments

20. SMART Working
S.M.A.R.T.
Specific – Treatment goals should be specific.
Measurable – Therapist and patient should be able to measure whether they are meeting their goals.
Achievable – Are the goals set, achievable and attainable?
Realistic – Can you realistically achieve the goals with the resources available? (includes therapist and patient resources and external factors.)
Time – When do you want to achieve the set goals?
3.02

21. Understanding Your Team Capacity
What percentage of time is spent on direct clinical work?
What else do we spend our time on?
Let’s look at what happens to a “typical” clinician
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22. Ruth Spreadsheet

23. Influencing Capacity Using our time differently
WARNING – this may endanger sacred cows
Referral Meetings
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24. Why do work on service capacity?
Create a better working environment
Highlights opportunities for releasing more time for patient care
Allows us to see if our capacity is enough to meet our demand
If you do need more staff – you have a better case
More efficient than more staff

25. Measuring Capacity Harry Sally Thelma Louise Totals
Direct Clinical work 20 6 19 64
Clinical admin 2
CPD 4 10
Supervision 1
Supervising 3
Referral meeting 8
Team meeting
1.5
Travel 5 16
37.5
18.5
131

26. A few wee changes: Supervison Travel
Sally decides to do group supervision – saves her 2 hours
Travel
For one clinic Thelma and Harry find a room at base,– saves 1.5 hours for Thelma and 1 hour for Harry
Louise moves a remote weekly half day clinic to a fortnightly day long clinic – saves 2 hours

27. A few wee changes: Meetings
The referral meeting stops, Louise and Sally meet for an hour a week to check referrals against criteria and allocate – saves 6 hours
Sally spends half-an-hour preparing for the team meeting and is supported in chairing the meeting more efficiently so now all business done in one hour – saves Harry, Thelma and Louise .5 hours each

28. After changes: Harry Sally Thelma Louise Totals Direct Clinical work
(20) 23
(6) 8
(19) 22
(64)75
Clinical admin
(6) 6.5
(2) 3
(6) 6 22
CPD
Supervision
Supervising
(3) 1 1
Referral meeting
(2) 0
(2) 1 2
Team meeting
(1.5) 1
4.5
Travel
(5) 4
(4)3.5
(6) 4
12.5
37.5
18.5
131

29. The saved time is allocated to direct clinical work
Before
After
Difference
Direct Clinical Hours per Week 64 75
+11
Clinical Hours Per Year (*42)
2688
3150
+462
New Patients Per Year (New:f/u =1:7)
336
394
+58

30. Releasing Capacity is more efficient than increasing staff numbers
If a team spend 50% of time on clinical work
ONE hour redirected to clinical work = 2 hours of new staff time
Say What???
your team needs 20 hours more clinical time
BUT 50% of a staff members time is spent on non clinical work
so you need 40 hours more time to get 20 hours of clinical work
If you can create that 20 hours by current staff stopping doing something else
then you only need to find 20 hours
and you have not employed a full-time staff member

31. Extend Capacity Skill Mix Training
do you have highly graded staff doing work that someone on a lower grade could do just as effectively?
changing skill mix means more clinical time = cost.
Training
can you redesign and extend roles through training to increase your capacity?
and reduce demand..

32. Capacity and Activity Competencies
Are these being used at right level?
Rooms: Clinic Space, Group Rooms
Are they available
Equipment : (BtB), Tests
Enough? In the right place?
Admin support is ESSENTIAL
Managing appointments – DNA etc
Electronic diaries – first and f/u appoints
Filling Gaps
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33. Any Questions???
3.30

34. And finally – to take away
what will you do next?
what information about demand and capacity do you have?
write down three aspects of your service that you want more data on
what help might you need?
who will you find to help you?
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35.  DON’T LEAVE WITHOUT YOUR GUIDES 