Background and Aim

In 2017 a green paper on Transforming Children and Young People’s (CYP) mental health (MH) 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 wating 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.

In 2018 South Warwickshire were chosen to be one of twelve four-week wait pilot areas. The pilot activity ran from 2028 until 2020.

Approach

The 4WW pilot was based upon the foundations of the RISE model where access and intervention were the primary focus. The RISE team provides services for Coventry and Warwickshire and includes all targeted and specialist CYP mental health services. RISE includes not only CAMHS but a wider umbrella of services including multi-disciplinary teams, community eating disorder service, youth offending team, looked after children and crisis response.

At the start of the pilot, the team reviewed and developed activity across the whole pathway to implement change. This included looking at the front door of the service and the access and referral process. The team also looked at how to improve operations and flow while improving patient and staff experience.

Access and Engagement  

• The 4WW pilot allowed the team to develop their navigation hub (front door) to the service. Band 7 staff were brought in and supported to lead on accepting referrals for specialist services and triaging the needs of CYP. This was put in place to ensure the right assessment and or intervention pathway was identified. Childrens Wellbeing practitioners (CPW’s) trained under CYP IAPT recruit to train programme also worked alongside professional mental health clinicians to create an enhanced triage experience and link in with the core services to enable a seamless journey for CYP.
• The benefits of enhanced triage meant efficient access and engagement, CYP having a voice, reducing CYP retelling their stories, having clear data, and reporting and an overall better experience for CYP and families.
• The team developed their Access and Engagement team (AET) to include staff with various skills and expertise. The development of the AET model allowed for collaborative working with the navigation hub (front door). It supports decision making at assessment and formulation stage which reduces variabilities locality teams can bring and led to a more consistent offer.

Operations

• The Integrated Pathway Hub (IPH) was developed as a waiting list team consisting of clinical and non-clinical staff, who provided dedicated resource to support CYP during their wait for intervention as part of the 4WW pilot
• Setting up IPH involved lots of groundwork at the start. During the pilot, the team reviewed all young people (YP) who were in the service and those waiting for services to understand what patient intervention they were waiting for. This helped the team to review waits by intervention rather than by service and to also understand their longest waits.
• The initiative successfully supported capacity and demand across the core services, which resulted in the team’s expansion in both clinical and non-clinical resource.                                                                                                                                                                                               
• Rise developed and demonstrated a seamless patient flow process, with the aim of holding the CYP during all contact points. The aim was to give reassurance to the individual and their support network. The involvement of clinical staff members allowed reviews and intervention amendments to be actioned, improving the onward care and support of the CYP.
• The team also used a case management weighting tool. It was used by all clinicians to aid discussion and identification of case complexity. The tool promotes a consistent approach to case management reducing variation in individual approaches to defining case complexity.

Collaborative working

• The RISE service provided accurate intelligence of the demands and length of waits for the core services allowing greater collaborative working with commissioners to appropriately plan and respond to service users.
• The team developed a Knowledge Hub that supported greater transparency of wait times at each stage of a CYP’s journey. Further benefits include risk management of CYP who do not access interventions when they are contacted.
• To better support and align staff working across the pathway the team made use of job planning, capacity and demand modelling and reviewed staff skills mix.
• Multi-Disciplinary Team (MDT) focus was put in place to support flow across teams and with system partners. This reduced the number of “hats” the core team were finding themselves wearing. The aim was to increase CYP flow, reduce inefficient process and increase staff morale.

Result and Impact

• The updates to the navigation hub, access and referral team lead to more efficient access and engagement, CYP having a voice, reducing CYP retelling their stories as well as having clear data and reporting.
• The IPH and operational changes implemented meant that the team were able to demonstrate a seamless patient flow process.
• CYP being held by dedicated waiting team resource rather than just a “duty” line, allowed for YP and families to have a point of contract whilst waiting and throughout their treatment journey.
• Use of demand and capacity modelling, job planning, reviewing skills mix and taking an MDT approach not only increased CYP flow but also increased staff support and moral.
• The principle areas developed during the 4WW pilot including navigation hub, IPH and work on improving flow have stayed and been sustained.

Challenges and Key Learning

• Initial work mobilising a different approach with regards to access and engagement was a key challenge.
• Learning from the 4WW pilot and from the Covid-19 pandemic allowed the team to further develop their digital offer and blend with their in person clinical offer. The team were also able to increase the ways they engage with YP and families.
• Waiting list processes were reviewed which evolved into the intervention pathway hub approach.

The team aimed to improve the waits for young people with neurodiversity. This included aiming to hold autism waits to 48 weeks. A key issue the team has had in achieving this is that YP have co-morbidity in ½ of cases. The service has a trajectory to reduce Autism waits as well as CYP presenting with MH and co morbidity needs. This will be in line with the expected 4 WW NHSE access and waiting times standards.

Next Steps

• The team have recently started to weave the i-THRIVE model into their work.
• The team recognised that they need to continue to engage with young people to improve the service. They have started working with a local theatre to co-deliver participation work Transformation project to support accurate recording of clinical data through clinical/service pathways aligned to SNOMED coding and ROM’s.
• Mapping of pathways to support quality improvement

Improved data and CYP patient flow with expansion of dedicated patient flow team for all services.