Northumberland Four Week Wait Pilot

Background and Aim
In 2017 a green paper on Transforming Children and Young People’s mental health provision was published by the Department of Health and Social Care and the Department for Education. A key part of the paper involved developing 12 ‘four week wait’ pilot sites to inform approaches to measuring and improving waiting times for access to CYP mental health services.
The 4 week wait (4WW) pilots were set up to test approaches that could deliver a 4WW time for access to NHS support, ahead of introducing new national waiting time standards for all children and young people who need specialist MH services.
Northumberland were selected as one of twelve four-week wait pilot areas. Pilot activity ran from October 2018 to December 2020. The team at Northumberland developed their pilot with the aim to implement changes across the whole pathway from referral through to discharge and to improve how they worked with wider community partners to best meet needs of young people and families.
Approach
At the start of the pilot the team reviewed service specifications to clarify their offer, considered ways tackle long waits and reviewed the business case for the neurodiversity pathway. The team’s approach considered the whole pathway from front door to discharge. This allowed the team to continue activity that worked well and make changes to improve their support offer for young people, community partners and for their staff teams.
Access and Referrals – the Northumberland pilot developed their front of house access and referral team. This included:
- The team utilised senior clinicians with more experience to offer initial assessments via front loading enabling right care at right time with the most appropriate clinical skill set, but also clinical oversight via supervision as the CYP moved into treatment to improve referrals. Bringing in Band 7 staff to undertake assessments helped the team to complete more through assessments and meet the needs of young people.
- The team also brought in a referral team researcher whose role involved reaching out to schools and families. This work also contributed to improving assessments by having a more complete picture of each young person’s circumstances. In addition, the researcher also captured information on wider offers in the system and signposted young people to appropriate services.
- The team worked to improve the team communication and admin functions to ensure more consistent messaging with partners including schools and VCSE.
- The team have also undertaken work to engage with partners in the wider system (VCSE, education) so that all partners know who and how to contact for support. This has meant more consistent responses and better flow for young people between services.
Operations – to improve waiting times the team implemented new processes to help with throughput. This included:
- The team reviewed their appointments process and implemented news ways of working. The team now map and allocate appointments for clinicians for 6 months in advance. Appointments were allocated with the aim of young people being seen within 2 weeks for face-to-face initial assessment, and weeks to treatment.
- The team also undertook an exercise to review clinicians’ expertise which enabled them to allocate appointments for YP with clinicians with the relevant expertise to meet their needs. This process has helped clinicians especially if they are busy and to better manage their time. It also helped clinicians as they could see when they have new cases coming up.
- Job planning and supervision for staff was put in place to help review caseloads. As part of this staff have been asked to undertake 17 clinical hours per week.
Discharge – alongside changes to the access and referral team and operation processes, the pilot activity also supported the end of treatment.
- The team created a forum meeting for clinicians who were struggling to discharge YP. The aim was to build skills and support for staff to ensure effective and safe discharge. This process was successful and is now undertaken on a case-by-case basis with staff that might need support discharging a YP.
- The team also offer their staff peer support if cases take longer than 12 weeks. This supports clinicians to manage their upcoming appointments, workloads and with difficult or complex cases.
- The team added Band 7 staff who provide supervision and support for staff in Band 6 and under. This helps more junior staff with their delivery and to enable them to support YP with more risk.
- The team engaged staff throughout the process and staff were aware of expectations around clinical hours and also know when they have new cases coming up. Support is in place through supervision and training if any clinicians are struggling with caseloads.
Partners – the team have taken an integrated approach to working with partners. This includes:
- The team are part of a graduated system response and work with community partners. The aim is for partners to provide early intervention work with YP and help address emotional difficulties and lower-level needs.
- During the pilot the team attended weekly interfaces with partners including schools, primary care, crisis, social care to discuss referrals. Since the pilot this meeting is now more focused on peer support because the system is more streamlined.
Results and Impact
- Approaches taken in the referral and assessment team have led to better working relationships with community refers and partners. The team are completing more thorough assessments and are better able to meet YP needs through use of the Band 7 staff in the assessment team and through the researcher role.
- Operational changes from the pilot have allowed the team to improve systems by allocating appointments 6 months in advance. Staff now match YP with clinicians with the expertise to meet their needs. This has allowed the team to reduce wait times.
- Job planning and supervision has meant the team have the right systems in place to effectively support staff teams to deliver the agreed 17 clinical hours per week.
- The team have put in place effective systems and support mechanisms to support effective and safe discharge. This allows the team to take on new YP and helps to reduce and or avoid a backlog of YP waiting for support.
- The team have also ensured that they work more effectively with community partners including those who refer YP into their services, community providers and also support a multi-disciplinary approach when needed. The impact of this is that system partners and heath are working together in a streamlined and effective way.
Challenges and Key Learning – whilst the pilot has been successful and helped the team, they still face some challenges. These include:
- As seen in many pilot areas the team in Northumberland have seen an increase in referrals and acuity since the Covid-19 pandemic. The team have some longer waits especially for young people waiting for neurodiversity services.
- The team have had ongoing challenges in providing support for young people with neurodiversity needs and co-occurring mental health needs.
- Whilst the team in Northumbria have been successful in implementing changes to reduce waiting times. They haven’t been able to replicate this success in other teams in the region. Work is ongoing to continue to learn from the pilot but also test and trial what might work within other teams as solutions are not one size fits all.
Next Steps
The pilot has been successful, and the team have continued many elements that had been implemented during that time. This includes how they work with partners, their access and referral team structures and how they allocate clinical time and provide support for their staff team.
The team are keen to share the learning and key achievements from the pilot and support other teams in their region / area to make changes and improve their waiting times.
- The team are revisiting service specification.
- A service name change proposal has been submitted
- Targets have changed from wait to assessment/treatment to accessing help/advice (this is a culture change from face-to-face initial assessment to help/advice)
- The ADHD/Autism assessment pathway instead of initial assessment now offer a welcome event which can often involve seeing 50 parents in a day (evaluation underway at this time)