T1 Total Referrals T2 Total Referral
Service delays and time to discharge
Table 10: Service delays time period 1
Delay Coding N Minimu m Maximu m Mean (days) SD Missin g Appt offered - Appt
attended Total Service Delay 2991 0 475 52.79 46.98 0 Appt Delay 2671 0 338 7.1 28.02 350 Total Appt Delay 2668 0 419 56.63 52.28 328 Overall Delay 936 4 458 153.53 107.60 2081
Appt offered - NOT
attended Total
Service
Delay 347 5 277 65.91 50.53 0
Appt Delay 0 n/a n/a n/a n/a 350
Total Appt
Delay 0 n/a n/a n/a n/a 350
Overall Delay 350 12 467 131.9 106.23 5 0
The average delay from assessment to appointment (service delay) was 52.8 days for those who attended and 65.9 days for those who DNA’d the appointment. In time period 2, the delays to first appointment were slightly less with the mean delay of 51.0 days for those offered appointment who attended and 40.6 days for those offered an appointment who DNA’d. Referrals were discharged more quickly (overall delay figure) in Time 2 as opposed to time 1; the mean time to discharge was almost half that of the first 6 months.
Table 11: Service delays time period 2
Delay Coding N Minimu m Maximu m Mean (days) Std. Deviation Missi ng Appt offered - Appt
attended Total Service Delay 3045 0 287 51.02 53.70 0 Appt Delay 2244 0 222 2.46 11.05 350 Total Appt Delay 2210 0 189 35.04 34.29 4954 Overall 356 6 186 64.74 45.90 2538
Delay
Appt offered - NOT
attended Total Service Delay 196 7 282 40.56 39.71 840 Appt Delay 0 196 Total Appt Delay 0 4954 Overall Delay 196 11 182 54.25 45.773 2538
Priority of appointments
Data shown are for both those who attended an appointment and those who DNA’d an appointment.
Table 12: Priority of appointment in time period 1, attended
Appt offered - Appt attended
Appt Attend Frequency Percent
Awaiting Further Information 2 0.1
Crisis 207 6.9 Normal 1 0 Query ED 3 0.1 Query EI 6 0.2 Routine 1232 40.8 To be Assessed 1000 33.1 Unknown 3 0.1 Urgent 567 18.8 Total 3021 100
Table 13: Priority of appointment time period 1, not attended
Appt offered - NOT attended
Appt Off No Attend Frequency Percent
Awaiting Further Information 1 0.3
Crisis 10 2.9
Routine 141 40.3
To be Assessed 147 42
Urgent 51 14.6
Table 14: Priority of appointment in time period 2
Appt offered - Appt attended
Appt Attend Frequency Percent
Awaiting Further Information 51 1.7
Crisis 412 13.4 Query ED 41 1.3 Query EI 64 2.1 Query Perinatal 19 0.6 Routine 984 31.9 To be Assessed 1150 37.3 Urgent 363 11.8 Total 3084 100
Table 15: Priority of appointment in time period 2
Appt offered - NOT attended
Appt Off No Attend Frequency Percent
Awaiting Further Information 16 8.2
Crisis 15 7.7 Query ED 8 4.1 Query EI 5 2.6 Routine 97 49.5 To be Assessed 46 23.5 Urgent 9 4.6 Total 196 100
Of note is that there were less appointments coded as “routine” and more coded as “crisis” in time period 2 than in time 1.
Appendix 2: Implementing CAPA
According to the originators of CAPA, “There are eleven key components and CAPA is most effective if all eleven are in place. Implementation, quality and sustainability will be impaired if they are not.”
CAPA component
Key features What happens if this is not in place
1. Leadership There is a working group including
1) a manager 2) either a clinical leader or clinician/s 3) an admin lead.
The service is highly unlikely to get change going, or to sustain it.
2. Language Move from ‘assessment’ and ‘triage’ to ‘choice’ and ‘partnership’.
Teams that continue to use
‘assessment’ and ‘treatment’ find it harder to think about clients’ goals. Published young person and family feedback reports they get too much assessment and no-one helps them enough.
3. Handle Demand
Service users can chose an initial Choice appointment when their referral is accepted i.e. full-booking. The service flexes Choice capacity in line with referral demand to prevent a waiting list.
If there are too many priority streams (emergency, urgent, soon, routine are common ones) referrers learn how to get someone prioritised (‘this 4 year old is suicidal’)! ‘Routine’ clients may never get seen. Limiting the number of priority streams means everyone is seen more quickly by minimising multiple queues; reducing variation and smoothing flow
4. Choice Framework
All clinicians work in a Choice framework. Clinicians complete
appropriate tasks for clinical governance and risk
management.
Service users are likely to feel less involved and passive in front of an expert. This is likely to lead to their experience being worse and their engagement, therapeutic and task alliance and motivation will be lessened.
5. Full Booking
Service users leave the Choice appointment with a booked Partnership
appointment with the selected clinician/s. This requires a Partnership diary and no internal waiting list.
The team will lose some capacity and is likely to develop internal waiting lists. Many teams have good systems to manage first
appointments but then put clients on treatment waiting lists.
6. Selecting Clinician
All clinicians select the Partnership clinician according to the skills needed: so the appropriate clinician for Partnership work is chosen based on the service user’s goals and chosen therapy style.
The client may not get the
intervention they want and the goals and care plan might be vague. Motivation, alliance and focus may be reduced. Treatment might be less effective and not directed to their goals. DNAs may increase.
7. Core and Specific Work
The majority of clinical work is carried out with the general principle of Core Partnership work first with Specific Partner- ship work added if required
The client experience is likely to be poor as their problem needs to fit the intervention, no matter what their preferred style or co-morbidities are.
8. Job Plans Each clinician will have an individual plan containing their Choice activity, Core Partnership targets for each quarter, their defined
Specific Partnership work and non-clinical activities.
Teams will lose capacity
9. Goal Setting
These are service users’ goals using care planning. There are regular reviews that clarify the service user’s preferences and choices.
Work becomes unfocussed; clients and clinicians are not clear about what they are both working towards. Things drift.
10. Peer group Discussion
Small group multi-
disciplinary discussion (no more than 4 staff) to consider on-going work.
If supervision is only focused along professional lines, opportunities for learning and the challenge that comes from other professional perspectives is lost.
11: Team Away Days
Regular Team away days in which the agenda is set by the team and involves content to facilitate clinical learning, team relationships and business planning.
You are unlikely to ever implement substantial change, or if you do, it will be hard to sustain. You will not generate a strong and flexible team culture. Staff may leave, vote with their feet and carry on doing what they normally do, and clinical risk may increase. http://capa.co.uk/what- is-capa/11-key-components/
Ann York and Steve Kingsbury CAPA website accessed November 2017 http://capa.co.uk/what- is-capa/11-key-components