With thanks to Dr. Andy Wiener, Consultant Child and Adolescent Psychiatrist, from the Tavistock and Portman NHS Foundation Trust who talks about the Tavistock and Portman’s multi-agency approach to delivering ‘Risk Support’ in the THRIVE framework (Wolpert et al., 2016).
What was the problem you were trying to solve?
We wanted to develop Risk Support as part of implementing the THRIVE framework in Camden. We had some CAMHS practitioners working in local authority settings who seemed like the staff who were best placed to specialize in Risk Support, but their work was not well linked up with community CAMHS, i.e. there were not effective care pathways between work done by staff in the local authority and staff based in the clinic. Secondly, there was little multi-disciplinary oversight of the work that was done by local authority CAMHS staff so it was difficult to demonstrate that the work being offered in the ‘Getting Help’ or ‘Getting More Help’ categories was justifiable within the available evidence base and to help multi-agency networks move into a Risk-Support domain of activity. Thirdly, the CAMHS staff in the local authority were not available to all local authority services, rather it was only available in some local authority teams. Finally, a model of practice where the CAMHS work provided was indirect – providing consultation and reflective supervision rather than direct work– was more developed in some areas than others.
What was your solution?
We anticipated that Risk Support would be the approach most commonly needed in families accessing Child in Need and other Local Authority Support Services, e.g. the Early Help Offer. We decided to reconfigure our Local Authority offer and set up a new team co-located with these services. The new team has been called the “Whole Family Team”. This team is primarily for families where there is a multi-agency network and the needs of the family would be best met by CAMHS being an integrated part of the network, rather than providing intervention separately, such as might be the case for families and children ‘Getting Help’ and ‘Getting More Help’.
How does this fit into your i-THRIVE plans?
As a service, we were good at providing ‘Getting Help’ and ‘Getting More Help’, but we found that CAMHS clinicians, once they were involved with a family, were reluctant to come to the conclusion that more help was not really the answer, and that CAMHS may need to step down the intensity of their work and shift towards a focus of working alongside other agencies in an integrated way. The focus would be on broader outcomes such as supporting a family to stay together, or helping a young person to maintain an educational placement and as a multi-agency team working together, limit the ongoing risks as much as possible.
The development of our approach to Risk Support is part of a trust-wide shift towards organizing our work for children, young people and their families in terms of their needs, using the terminology of the THRIVE framework. One part of this will be an addition to the electronic patient record which will allow clinicians to identify which of the THRIVE groups a service user or family belongs to, indicating that a discussion has taken place about their needs.
How did you develop the model?
The local authority leadership had two large work streams which were very concordant with the aims of Risk Support in THRIVE. The first was the Reclaiming Social Work agenda. To achieve this, a big training exercise was provided for social workers and the wider children’s workforce to acquire more intervention skills as well as training from the Tavistock in a model of systemic reflective practice. These trainings took place alongside a drive from local authority senior management that social workers and other practitioners would lead on cases using a “team around the worker” model (such as AMBIT) rather than an “assess and refer on” model. They also redesigned services so that the needs of the whole family could be met rather than just a child in the family or an adult in the family. These changes gave an opportunity for the CAMHS commissioners, in partnership with the CAMHS provider to support this model by:
- Increasing the proportion of CAMHS time dedicated to the consultation/reflective practice offer
- Providing a more even spread of CAMHS staff across Local Authority Services (so the offer was more equitable)
- Adopting a whole family approach with better integration between CAMHS and parental mental health services
How has this approached affected staff and service users?
Lead professionals receive support and supervision from CAMHS professionals who are jointly accountable for the outcomes of the family – and lead professionals have reported that they feel more resilient as a result and feel better able to manage risk without escalating the issue to another team or service. It is hoped that the families sense this in their interaction with the lead professionals and as a result have a better experience.
Staff have expressed concerns that there are not clear criteria to access the Whole Family Team. It is clear that professionals find referral criteria useful to manage work flow, but there is little evidence that families find this approach helpful. Therefore, the team are having to adjust to making decisions based on need rather than access criteria.
How will the Whole Family Team be evaluated?
The Whole Family Team was set up in July 2016. An evaluation of the team has not yet been undertaken. We plan to use the IntegRATE measure with service users who currently use multiple services to find out how integrated they perceive their care to be at the moment. This measure will be repeated in a year’s time to determine whether there have been improvements as a result of the Whole Family Team.
The IntegRATE Measure
1. How often did you have to do or explain something because people did not share information with each other?
2. How often were you confused because people gave you conflicting information or advice?
3. How often did you feel uncomfortable because people did not get along with each other?
4. How often were you unclear whose job it was to deal with a specific question or concern?
Elwyn, G., Thompson, R., John, R., & Grande, S. (2015). Developing IntegRATE: a fast and frugal patient-reported measure of integration in health care delivery. International journal of integrated care, 15(1).
If you would like further information, please contact Dr Andy Wiener, firstname.lastname@example.org
Written December 2017.