Can you really transform a Child & Adolescent Mental Health Service in a week using LEAN?

Can you really transform a Child & Adolescent Mental Health Service in a week using LEAN? Dr Ian Dufton Consultant Child & Adolescent Psychiatrist Clinical Lead Bolton CAMHS

First I really need to celebrate our camera shy CAMHS team in Bolton

Introducing LEAN to Bolton CAMHS Reality Check Introducing LEAN has not been easy Initial CAMHS Value Stream Exercise 2008 was a failure and led to no further LEAN activities for 12 months Right moment The wider organisation in the right place to move with LEAN ideas Adversity provided an opportunity for change resulting in the change of Clinical Lead and the possibility of a new direction Early examples of success with LEAN (or BICS as we call it in Bolton) A breakthrough or rapid improvement event around the use of medication improved patient care, sustained a reduction in drug spend over 18/12 (%) and won the UK Lilly Award for Reflective Practice in Attention Deficit Hyperactivity Disorder

Can you really transform a Child & Adolescent Mental Health Service in a week using LEAN? Of course you can t there a number of preceding steps A3 boxes 1-3

Can you really transform a Child & Adolescent Mental Health Service in a week using LEAN? Of course you can t there a number of preceding steps A3 boxes 1-3 Step One: Specialty Specific Strategic Review: We all recognised the need to change but what, all, some? And to achieve what ends? focused the service by asking What are our distinctive strengths in service management & delivery, clinical & systemic innovation etc. Can we demonstrate clinical outcomes? Can we demonstrate adherence to clinical guidelines? Can we demonstrate we are adequately staffed and with the right skill mix? Are we sustainable? Are we affordable? How will demand evolve in the future? What are the risks?

Demand Evolution? 2000 Referral Rate Predictions Numbers 1800 1600 1400 1200 1000 800 referral Deflects 600 Pre- Redesign Predicted Service Capacity 400 200 0 2009-2010 2010-2011 2011-2012 2012-2013 2013-2014

2. Initial state - (b) Responsible Use of Resources Go No Go 1 Achieving Cost Improvement Programme 2 3 CAMHS overall budget approximately 1.3 million Met ISP for financial year 2010-11 Surplus in direct costs 42,000 Combined direct / indirect cost surplus approximately 80,000 Bolton CAMHS National Cost Reference Index is 87 i.e. 13% cheaper than the national average Challenges; Block Contract arrangements Limited options % Time 10to Action Measures at Service Standard Aim to develop an aggregate a number of Time to Action Measures ( Time to Choice, Time to CBT, Time to Parenting, Time to Day Unit, Time to ADOS (5), Time to Pathways 1 8 *, Time to IPT*, Time to EMDR* *to come on-line by July 2011 ) At present time from referral to 1 st Contact elevated and continuing to do so despite increase approx 40% NC activity in 2010 11 Capacity not matched to demand Service NC cap 860 Demand 1000+ 30 25 20 15 5 Patient Involvement in Strategic Activities Level of patient involvement in the development of service delivery (baseline Jan 2011) 100 75 Recruitment 50 Interviews 25 Involved in RIE / VSA 0 2010/11 Target* * Target from prior Strategy and Vision 2009 2014 Waiting Time Serv Spec Target Reflections: Dashboard data tracking time to action measures in last 7 months 22 out of CAMHS 28 @ target agreed CAMHS target standard, equals 79% Metric Goal Red Flag Sep Oct Nov Dec Jan Feb Mar Source /Actions / Comments (SLA Target) Cognitive Behaviour Therapy No. Referrals * 1 9 18 29 31 24 33 22 No waiting * 2 3 6 19 30 32 34 41 Total Referrals * 3 99 117 146 177 201 234 316 Longest wait * 4 4 9 12 16 10 8 < 8 > 8 4 ACTION: Recruited Bolton Uni students *waiting time standard * (uinc cap) changed to 12 / 52 at Feb Monitor 2011 Review activity of ccbt and GSH clinics Explore C&Y- IAPT opportunities 20 10 0 0 Apr June Aug Oct Dec Feb Waiting Time Serv Spec Target CAMHS target Waiting Time to 1 st Contact following Referral 2010-11 ADOS assessments No. Referrals* 1 6 2 5 1 7 3 8 No. Waiting* 2 0 0 0 0 1 0 1 Total Referrals 32 34 39 40 47 50 58 Longest wait* 4 < 6 > 6 2 2 2 2 3 4 CAMHS Tier III+ Day Unit Occupancy 97% 97% 98% 98% 98% 98% 99% Longest wait < 8 Apr May June July Aug Sep Oct Nov Dec Jan Feb Mar > 8 11 Weeks 6 5 7 8 6 Parenting Interventions No. Referrals* 1 12 15 26 10 12 17 11 No. Waiting* 2 12 15 26 10 12 17 2 Waiting Time to 1 st Contact following Total Referrals* 3 Referral 85 100 2010 126 136 148-165 11 176 Longest wait* 4 < 10 > 10 5 4 5 5 5 5 2 Due to changes in LA provision this will 6 8

2. Initial state - (b) Responsible Use of Resources Go No Go 1 Achieving Cost Improvement Programme 2 3 Initial Time to Action measure and primary target in the first phase of redesign Waiting 25 time to first contact CAMHS overall budget approximately 1.3 million Met ISP for financial year 2010-11 Surplus in direct costs 42,000 Combined direct / indirect cost surplus approximately 80,000 Bolton CAMHS National Cost Reference Index is 87 i.e. 13% cheaper than the national average Challenges; Block Contract arrangements Limited options % Time 10to Action Measures at Service Standard Aim to develop an aggregate a number of Time to Action Measures ( Time to Choice, Time to CBT, Time to Parenting, Time to Day Unit, Time to ADOS (5), Time to Pathways 1 8 *, Time to IPT*, Time to EMDR* *to come on-line by July 2011 ) At present time from referral to 1 st Contact elevated and continuing to do so despite increase approx 40% NC activity in 2010 11 Capacity not matched to demand Service NC cap 860 Demand 1000+ 30 20 10 0 20 15 5 0 Apr June Aug Oct Dec Feb Waiting Time Serv Spec Target CAMHS target Waiting Time to 1 st Contact following Referral 2010-11 100 75 50 25 Patient Involvement in Strategic Activities 0 Metric Level of patient involvement in the development of service delivery (baseline Jan 2011) 2010/11 Target* Goal (SLA Target) Escalating despite Recruitment Interviews Involved in RIE / VSA * Target from prior Strategy and Vision 2009 2014 Waiting Time Reflections: Dashboard data tracking time to action measures in last 7 months 22 out of CAMHS 28 @ target agreed CAMHS target standard, equals 79% Red Flag Sep Oct Nov Dec Jan Feb Mar Source /Actions / Comments Cognitive Behaviour Therapy No. Referrals * 1 9 18 29 31 24 33 22 No waiting * 2 3 6 19 30 32 34 41 increase in Total activity Referrals * of Longest wait * 4 < 8 > 8 4 *waiting time standard * changed to 12 / 52 at Feb 2011 99 117 4 146 9 177 12 201 16 234 10 316 8 3 40% in 2010 11 ADOS assessments No. Referrals* 1 6 2 5 1 7 3 8 No. Waiting* 2 0 0 0 0 1 0 1 Total Referrals 32 34 39 40 47 50 58 Longest wait* 4 < 6 > 6 2 2 2 2 3 4 CAMHS Tier III+ Day Unit Occupancy 97% 97% 98% 98% 98% 98% 99% Longest wait < 8 Apr May June July Aug Sep Oct Nov Dec Jan Feb Mar > 8 11 Weeks 6 5 7 8 6 Parenting Interventions No. Referrals* 1 12 15 26 10 12 17 11 6 8 ACTION: Recruited Bolton Uni students (uinc cap) Monitor Review activity of ccbt and GSH clinics Explore C&Y- IAPT opportunities No. Waiting* 2 12 15 26 10 12 17 2 Waiting Time to 1 st Contact following Total Referrals* 3 Referral 85 100 2010 126 136 148-165 11 176 Longest wait* 4 < 10 > 10 5 4 5 5 5 5 2 Due to changes in LA provision this will Serv Spec Target

Getting the reasons for change right A3 boxes 1-3

Getting the reasons for change right A3 boxes 1-3 Developing the True North goals, A3 & its Metrics

Getting the reasons for change right A3 boxes 1-3 Developing the True North goals, A3 & its Metrics Developing the framework for the re-designed service and remembering it s an experiment, we have to prove it works better

Getting the reasons for change right A3 boxes 1-3

Better Care for Better Health To provide effective and high quality child and adolescent mental health services to the population of children with significant mental health problems in Bolton A3 boxes 1-3 A SET OF METRICS TO MATCH THE SERVICE GOALS OUTCOME focused: Triad of measures CORC Strength & Difficulties Questionnaire Intervention Specific Measures % outcomes above the research standard Commission of Heath Improvement (CHI) Service Experience Questionnaire

Getting the reasons for change right A3 boxes 1-3

Responsible Use of Resources To become a patient driven service where effective user involvement, strong clinical leadership and continuous improvement drive the responsible and sustainable provision of mental health care. A3 boxes 1-3 A SET OF METRICS TO MATCH THE SERVICE GOALS OUTCOME focused: Triad of measures Cost Improvement Programme Patient involvement in strategic activities % time to action measures e.g. new case contact, treatment interventions

Getting the reasons for change right A3 boxes 1-3

Valued, respected & Proud To be a CAMHS service that actively supports, challenges and develops its workforce while contributing to the wider development of the national CAMHS workforce in a positive and forward thinking manner within environments fit for purpose. A3 boxes 1-3 A SET OF METRICS TO MATCH THE SERVICE GOALS Evaluation focused: Triad of measures CAMHS temperature check (or equivalent) % Job Plan / Appraisal rates Improvements implemented per month

A3 boxes 1-3

Re-designing the service along LEAN principles A3 boxes 1-3 2011: Austerity hits and the need to achieve 5% improvement savings becomes reality EVENT week April 4 th 8 th 2011 Redesigned Service started week commencing 11 th April 2011 Redesign Service Model A service where patients are stepped up to the right level of care rather than a tiered provision and flow through the service Small team based rather than individually case managed Model Pathways provide evidence based and NICE compliant interventions Whole service is a model service matching capacity to demand with agreed standards for the equity of care.

The re-design week was divided into three sections: A3 boxes 1-3 Section One: Going over again WHY we were making this change for now and the future openly, addressing each and every staff question Section Two: Designing our version of Choice & the Pathways (including reviewing evidence base, collecting information for young people and families, leaflets, review of current process and developing new process that focuses on adding value and use of effective evidence based interventions, identifying interventions, creating processes for clinics, proformas to guide standard working, evaluation methods) Section Three: Continually attempting to address anxieties and problems as they arose through daily morning forums

What the staff said about the re-design week? Really hard work, but we got so much done that has been waiting to be done the sense of achievement from getting tasks done has been great. Everyone has pulled together to achieve something we could not have done alone. We would have benefited from more understanding before event to reduce anxiety. However very productive week. It is to all our credit that we got so much done and were able to disagree in groups without falling out!- great team work. More breaks next time please! Helpful thinking about re structuring an already existing service, involving such a big team. Impressed with the amount of positive work which was done in a space of one week. Would be helpful thinking about process over time with involving team right from the start, looking at objectives and goals for the service and ways of achieving this. Positive team work. Pleasure to have been a part of it.

80 : 20 Model Service A.D.H.D. Relationship & Behaviour Eating Disorders & Paediatric Liaison Emotional Disorders Social Communication LD & Challenging behaviour Psychosis Brief Intervention L.A.C. 9 Pathways that support Routine CAMHS work

Entry Jan: 72 Feb: 126 CAMHS LEVEL 1 LEVEL 2 LEVEL 3 A.D.H.D EMOTIONAL BEHAVIOUR / RELATIONSHIP Social Communication LD Challenging Behaviour Psychosis Brief Intervention Eating Disorders / Paediatric Looked After Children Standard Assessment tools Standard Correspondence points Standard Evidence Based Interventions Standard Outcome Points EXIT exit toolkit Recovery EXIT Jan: 89 Feb: 99

Re-designing the service along LEAN principles A3 boxes 1-3 Within the broader model there need to be discrete cells or pathways that are able to: Match Capacity to Demand Deliver agreed standards of care & evidence based interventions (NICE) Tasks need to be done in the right place at the right time Information is there when needed

Re-designing the service along LEAN principles A3 boxes 1-3 Our Version of CHOICE & it s continuous improvement Presently we provide Choice or at least first contact appointments five days per week, 4 mornings, 1 afternoon, 2 localities Standard format and operating procedure Choice Rapid Improvement Event Real Time Monitoring of a Choice Clinic in Action Time waiting in reception for families Adherence to the standard work of the clinic Clinical Support Team Activities, interruptions and durations Semi-structured interview following the observations with the young people and families

Refining the CHOICE Clinic Processes to enable flow Clinical Support Team Choice Clinician Pre RIE Rate Post RIE Rate

Clinical Support Team Choice Clinician Pre RIE Rate Post RIE Rate

Reduced WASTE Waiting Clinical Support Team Choice Clinician Pre RIE Rate Post RIE Rate

Reduced WASTE Waiting Clinical Support Team Reduced DEFECTS Choice Clinician Pre RIE Rate Post RIE Rate

Reduced WASTE Waiting Clinical Support Team Reduced DEFECTS Choice Clinician Reduced DEFECTS Pre RIE Rate Post RIE Rate

Our Efforts at Visual Management - final component of a LEAN cell

Re-designing the service along LEAN principles A3 boxes 1-3 Pathways that have demonstrated improvements in Patient Flow To deliver an A.D.H.D pathway that integrates two separate services and delivers timely NICE compliant assessment, intervention and monitoring

: A.D.H.D. Pathway

: A.D.H.D. Pathway ADHD Pathway Team Lead - Noreen Ryan, Consultant Nurse Cath Ashworth, Nurse Steve Worswick, Nurse Pete Birchill, Nurse Dr Giovanni Arsiwals, Paediatrician Anita Wood, Clinical Support

: A.D.H.D. Pathway 170 cases per annum ADHD Pathway Team Lead - Noreen Ryan, Consultant Nurse Cath Ashworth, Nurse Steve Worswick, Nurse Pete Birchill, Nurse Dr Giovanni Arsiwals, Paediatrician Anita Wood, Clinical Support

: A.D.H.D. Pathway 170 cases per annum ADHD Pathway Team Lead - Noreen Ryan, Consultant Nurse Time from Choice to 1 st Diagnosis Point Cath Ashworth, Nurse Steve Worswick, Nurse Pete Birchill, Nurse Dr Giovanni Arsiwals, Paediatrician Anita Wood, Clinical Support

: A.D.H.D. Pathway 170 cases per annum ADHD Pathway Team Lead - Noreen Ryan, Consultant Nurse Time from Choice to 1 st Diagnosis Point 10 Cath Ashworth, Nurse Steve Worswick, Nurse Pete Birchill, Nurse Dr Giovanni Arsiwals, Paediatrician Anita Wood, Clinical Support Reduced Use of Complex Assessment (CAMHS Day Unit) Improved Waiting Time to Complex Assessment

Re-designing the service along LEAN principles A3 boxes 1-3 Other Pathways that have demonstrated improvements in Patient Flow and / or improved Quality

Re-designing the service along LEAN principles A3 boxes 1-3 Other Pathways that have demonstrated improvements in Patient Flow and / or improved Quality L.A.C. pathway achieved the extremely positive comments from the recent Ofsted review: Looked After Children CAMHS provides good consultation and advice to social workers and carers to equip them with the knowledge and skills to support young people who have experienced high levels of trauma and loss in their lives. Social Communication Pathway for the assessment and diagnosis of young people with autism or autistic spectrum disorder. The impact of this work is seen in a number of areas including improved attendance at school, reduced self harming or offending and a strengthening of their placement arrangements. Social Communication Pathway

Social Communication Pathway Team ----- Dr Alison Dunkerley ----- Andrew Lee Noreen Ryan Hilary Strachan

Social Communication Pathway Team ----- Dr Alison Dunkerley ----- Andrew Lee Noreen Ryan Hilary Strachan Introduction of the integrated pathway in line with the 80:20 design model Time to ADOS (Autism Diagnostic Observation Schedule) Interview 14/52 to 8/52 Time to Diagnosis from 1 st contact 52/52 to 19/52

Re-designing the service along LEAN principles A3 boxes 1-3 Pathways that developed REAL problems in Patient Flow and were not providing improved Quality

Re-designing the service along LEAN principles A3 boxes 1-3 Pathways that developed REAL problems in Patient Flow and were not providing improved Quality Relationship & Behaviour Pathway for young people with oppositional defiant & conduct disorder and/or attachment disorder Initial demand and capacity calculations incorrect Resulted in unacceptable waiting times from Choice (12 18/52s) Pathway design inflexible and didn t promote flow

: Behaviour & Relationship Pathway

: Behaviour & Relationship Pathway Recent RIE clarified requirements to match Capacity to Demand

: Behaviour & Relationship Pathway Recent RIE clarified requirements to match Capacity to Demand 120 cases per annum 2 Sessions per week Family Therapy 1 Sessions per wk Parent Child Game 5 Sessions per wk Behaviour Management 8 Sessions per wk Complex 2 Sessions per wk

: Behaviour & Relationship Pathway Re-deployed time and skills within the pathway team rapid re-job planning crucial Recent RIE clarified requirements to match Capacity to Demand 120 cases per annum 2 Sessions per week Family Therapy 1 Sessions per wk Parent Child Game 5 Sessions per wk Behaviour Management 8 Sessions per wk Complex 2 Sessions per wk

Re-designing the service along LEAN principles A3 boxes 1-3 Pathways that developed REAL problems in Patient Flow and were not providing improved Quality

Re-designing the service along LEAN principles A3 boxes 1-3 Pathways that developed REAL problems in Patient Flow and were not providing improved Quality Emotional Pathway for young people with depression, anxiety, obsessive compulsive disorder, PTSD Initial demand and capacity calculations incorrect Time from Choice to 1 st Contact 2-3 but Limitations in Psychological Therapy provision mean lack of timely access

: Emotional Pathway

: Emotional Pathway 280 cases per annum

: Emotional Pathway 280 cases per annum Choice to 1st pathway contact = 3

: Emotional Pathway Time to Guided Self Help, Behavioural Activation & computerised CBT = 4

: Emotional Pathway Time to Guided Self Help, Behavioural Activation & computerised CBT = 4 Time to Family Therapy = 6

: Emotional Pathway Time to Formulation based &Trauma CBT= 16 Time to Guided Self Help, Behavioural Activation & computerised CBT = 4 Time to Family Therapy = 6

: Emotional Pathway Time to Formulation based &Trauma CBT= 16 Time to Guided Self Help, Behavioural Activation & computerised CBT = 4 Time to Family Therapy = 6 Time to EMDR = 26

: Emotional Pathway Matching Capacity to Demand is challenging Initial projections underestimated demand Time to Formulation based &Trauma CBT= 16 Time to Guided Self Help, Behavioural Activation & computerised CBT = 4 Time to Family Therapy = 6 Time to EMDR = 26

Does It Work? 80:20 Model Service

3. Target State (a) Better Care for Better Health Go No Go 1 CORC Strength & Difficulties Questionnaire 2 Commission of Health Improvement Service Experience Questionnaire Information & initial state available. Data on small numbers only, annually presented allowing slow response time to any necessary change 3 45% A bit better 40% 40% Much better 55% Intervention Specific: % Outcomes @ Research Standard Limited and variable data: Psychopharmacological outcomes: Stimulants / Non Stimulants: Standard questionnaires used to assess effectiveness (Connors & Short Connors / Adverse events (ADHD SEQ) but not collated SSRIs: Standard questionnaires available / Adverse events (SSRI SEQ) No standard use agreed for questionnaires / Adverse events Psychological outcomes: Parenting groups- available (DASS & SDQ & Parenting Scale) Individual Behaviour Management (DASS & SDQ & Parenting Scale) Riding the Rapids available ( ccbt available via MFQ data Not yet defined Research Standards Initial outcome state: Evidence of improvement but weak data and less than change identified by rest of CORC* *note this is a consortium of 44 groups not a national average "Good help" Score % "Recommend to friend" Score % "Convenient location" Score % "Convenient appointments" Score % "Comfortable facilities" Score % "Working together" Score % "Given enough explanation" Score % "Know how to help" Score % "Views and worries" Score % "Treated well" Score % "Easy to talk to" Score % "Listened to" Score % Parent n=42 Child n=18 10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%100.0% Percent "Recommend to friend" Score % "Convenient location" Score % "Convenient appointments" Score % "Comfortable facilities" Score % "Working together" Score % "Given enough explanation" Score % Reflections: CHI SEQ & SDQ information sparse IT support Data frequency weekly to monthly to quarterly to annual 1 2 3 4 "Good help" Score % "Know how to help" Score % "Views and worries" Score % "Treated well" Score % "Easy to talk to" Score % "Listened to" Score % Certainly True Statements on Bolton Adapted CHI SEQ 85% ---Views & worries taken seriously --- 85% 85% --- Recommend to a friend --- 85% 85% --- Convenient Appointment --- 85% 85% --- Enough Information --- 85% 10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%100.0% Percent 85% --- Parent / Child CHI SEQ Average --- 85%

3. Target State (a) Better Care for Better Health Go No Go 1 CORC Strength & Difficulties Questionnaire 2 Commission of Health Improvement Service Experience Questionnaire Information & initial state available. Data on small numbers only, annually presented allowing slow response time to any necessary change 3 45% A bit better 40% 40% Much better 55% CORC Intervention Outcome Specific: % Outcomes data analysis @ Research Standard pending Limited and variable data: Psychopharmacological outcomes: Stimulants calendar / Non Stimulants: month Standard questionnaires this year used from to assess 2-5% effectiveness (Connors & Short Connors / Adverse events (ADHD SEQ) but not collated SSRIs: last Standard year) questionnaires available / Adverse events (SSRI SEQ) No standard use agreed for questionnaires / Adverse events Psychological outcomes: Parenting groups- available (DASS & SDQ & Parenting Scale) Individual Behaviour Management (DASS & SDQ & Parenting Scale) Riding Intervention the Rapids available ( specific data patchy at ccbt available via MFQ data Not yet defined Research Standards Initial outcome state: Evidence of improvement but weak data and less than change identified by rest of CORC* *note this is a consortium of 44 groups not a national average (Increased T 2 returns to 18 21 % per present (Full introduction of Session by Session monitoring with IAPT-CY will improve this in year 2 3 hopefully) "Good help" Score % "Recommend to friend" Score % "Convenient location" Score % "Convenient appointments" Score % "Comfortable facilities" Score % "Working together" Score % "Given enough explanation" Score % "Know how to help" Score % "Views and worries" Score % "Treated well" Score % "Easy to talk to" Score % "Listened to" Score % Parent n=42 Child n=18 10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%100.0% Percent "Good help" Score % "Recommend to friend" Score % "Convenient location" Score % "Convenient appointments" Score % "Comfortable facilities" Score % "Working together" Score % "Given enough explanation" Score % Reflections: CHI SEQ & SDQ information sparse IT support Data frequency weekly to monthly to quarterly to annual 1 2 3 4 "Know how to help" Score % "Views and worries" Score % "Treated well" Score % "Easy to talk to" Score % "Listened to" Score % Certainly True Statements on Bolton Adapted CHI SEQ 85% ---Views & worries taken seriously --- 85% 85% --- Recommend to a friend --- 85% 85% --- Convenient Appointment --- 85% 85% --- Enough Information --- 85% 85% --- Parent / Child CHI SEQ Average --- 85% 10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%100.0% Percent

Target State: (a) Better Care for Better Health: Service User Experience Commission of Health Improvement (adapted) Questionnaire Responses: Parent (%) Certainly True Partly True Not True Don't Know Standard (Cum) Certainly True > 80% 92 Standard (Feb) Certainly True > 80% 93 My views & worries were taken seriously 96 3 1 The appointment was at a convenient time 87 11 3 If a friend or professional needed similar help I would recommend they come here 92 5 1 2 I have been given enough information about the help available here 92 6 1

Target State: (a) Better Care for Better Health: Service User Experience Commission of Health Improvement (adapted) Questionnaire Responses: Parent (%) Certainly True Partly True Not True Don't Know Standard (Cum) Certainly True > 80% Standard (Feb) Certainly True > 80% 92 93 Achieved stretch target >85% My views & worries were taken seriously 96 3 1 The appointment was at a convenient time 87 11 3 If a friend or professional needed similar help I would recommend they come here 92 5 1 2 I have been given enough information about the help available here 92 6 1

Target State: (a) Better Care for Better Health: Service User Experience Commission of Health Improvement (adapted) Questionnaire Responses: Parent (%) Certainly True Partly True Not True Don't Know Standard (Cum) Certainly True > 80% Standard (Feb) Certainly True > 80% 92 93 Achieved stretch target >85% My views & worries were taken seriously 96 3 1 The appointment was at a convenient time 87 11 3 If a friend or professional needed similar help I would recommend they come here 92 5 1 2 I have been given enough information about the help available here 92 6 1 Sample size is currently 345 (51%) respondents

Target State: (a) Better Care for Better Health: Service User Experience Commission of Health Improvement (adapted) Questionnaire Responses: Child (%) Certainly True Partly True Not True Don't Know Standard (Cum) Certainly True > 85% 85 Standard (Feb) Certainly True > 85% 84 My views & worries were taken seriously 88 6 24 The appointment was at a convenient time 75 12 7 6 If a friend or professional needed similar 87 5 2 7 I have been given enough information 88 6 24

Target State: (a) Better Care for Better Health: Service User Experience Commission of Health Improvement (adapted) Questionnaire Responses: Child (%) Certainly True Partly True Not True Don't Know Standard (Cum) Certainly True > 85% Standard (Feb) Certainly True > 85% 85 84 Almost achieved stretch target >85% My views & worries were taken seriously 88 6 24 The appointment was at a convenient time 75 12 7 6 If a friend or professional needed similar 87 5 2 7 I have been given enough information 88 6 24

Target State: (a) Better Care for Better Health: Service User Experience Commission of Health Improvement (adapted) Questionnaire Responses: Child (%) Certainly True Partly True Not True Don't Know Standard (Cum) Certainly True > 85% Standard (Feb) Certainly True > 85% 85 84 Almost achieved stretch target >85% My views & worries were taken seriously The appointment was at a convenient time If a friend or professional needed similar 75 88 87 12 6 24 7 6 5 2 7 Except here <85% I have been given enough information 88 6 24

Some of the things Young People & Families said about the service 12 months after the redesign Speedy service second time round Have felt involved, lots of information given been through the old way and CHOICE, felt better this time did get appointment quicker, was used to all the questionnaires, good sharing of correspondence, this was very important and should continue Appointment times not always convenient but when moved to pathway they bent over backwards to accommodate sessions so it became positive

3. Target State - (b) Responsible Use of Resources Go No Go 1 Achieving Cost Improvement Programme 2 3 CAMHS overall budget approximately 1.3 million Met ISP for financial year 2010-11 Surplus in direct costs 42,000 Combined direct / indirect cost surplus approximately 80,000 Bolton CAMHS National Cost Reference Index is 87 i.e. 13% cheaper than the national average Challenges; Block Contract arrangements Limited options 10 % Time to Action Measures at Service Standard Aim to develop an aggregate a number of Time to Action Measures ( Time to Choice, Time to CBT, Time to Parenting, Time to Day Unit, Time to ADOS (5), Time to Pathways 1 8 *, Time to IPT*, Time to EMDR* *to come on-line by July 2011 ) At present time from referral to 1 st Contact elevated and continuing to do so despite increase approx 40% NC activity in 2010 11 Capacity not matched to demand Service NC cap 860 Demand 1000+ 30 25 20 15 5 Patient Involvement in Strategic Activities Level of patient involvement in the development of service delivery (baseline Jan 2011) 100 75 Recruitment 50 Interviews 25 Involved in RIE / VSA 0 2010/11 Target* * Target from prior Strategy and Vision 2009 2014 Waiting Time Serv Spec Target Reflections: Dashboard data tracking time to action measures in last 7 months 22 out of CAMHS 28 @ target agreed CAMHS target standard, equals 79% Metric Goal Red Flag Sep Oct Nov Dec Jan Feb Mar Source /Actions / Comments (SLA Target) Cognitive Behaviour Therapy No. Referrals * 1 9 18 29 31 24 33 22 No waiting * 2 3 6 19 30 32 34 41 Total Referrals * 3 99 117 146 177 201 234 316 Longest wait * 4 4 9 12 16 10 8 < 8 > 8 4 ACTION: Recruited Bolton Uni students *waiting time standard * (uinc cap) changed to 12 / 52 at Feb Monitor 2011 Review activity of ccbt and GSH clinics Explore C&Y- IAPT opportunities 20 10 0 0 Apr May June July Aug Apr June Aug Oct Dec Feb Sep Oct Waiting Time Serv Spec Target Nov Dec CAMHS target Waiting Time to 1 st Contact following Referral 2010-11 Jan Feb Mar Apr ADOS assessments No. Referrals* 1 6 2 5 1 7 3 8 No. Waiting* 2 0 0 0 0 1 0 1 Total Referrals 32 34 39 40 47 50 58 Longest wait* 4 < 6 > 6 2 2 2 2 3 4 CAMHS Tier III+ Day Unit Occupancy 97% 97% 98% 98% 98% 98% 99% Longest wait < 8 > 8 11 Weeks 6 5 7 8 6 Parenting Interventions No. Referrals* 1 12 15 26 10 12 17 11 No. Waiting* 2 12 15 26 10 12 17 2 Waiting Time to 1 st Contact following Total Referrals* 3 Referral 85 100 2010 126 136 148-165 11 176 Longest wait* 4 < 10 > 10 5 4 5 5 5 5 2 Due to changes in LA provision this will May June July Aug Sep Oct Nov Dec Jan 6 Feb 8

2. Initial state - (b) Responsible Use of Resources Go No Go 1 Achieving Cost Improvement Programme 2 3 Response to introduction of 80:20 model choice component on Waiting 25 time to first contact CAMHS overall budget approximately 1.3 million Met ISP for financial year 2010-11 Surplus in direct costs 42,000 Combined direct / indirect cost surplus approximately 80,000 Bolton CAMHS National Cost Reference Index is 87 i.e. 13% cheaper than the national average 20 Challenges; Block Contract arrangements Limited options 15 10 % Time to Action Measures at Service Standard 100 75 50 25 Patient Involvement in Strategic Activities 0 Level of patient involvement in the development of service delivery (baseline Jan 2011) 2010/11 Target* Recruitment Interviews Involved in RIE / VSA * Target from prior Strategy and Vision 2009 2014 Waiting Time Serv Spec Target Reflections: Dashboard data tracking time to action measures in last 7 months 22 out of CAMHS 28 @ target agreed CAMHS target standard, equals 79% Aim to develop an aggregate a number of Time to Action Measures ( Time to Choice, Time to CBT, Time to Parenting, Time to Day Unit, Time to ADOS (5), Time to Pathways 1 8 *, Time to IPT*, Time to EMDR* *to come on-line by July 2011 ) At present time from referral to 1 st Contact elevated and continuing to do so despite increase approx 40% NC activity in 2010 11 Capacity not matched to demand Service NC cap 860 Demand 1000+ 30 5 Metric Goal Red Flag Sep Oct Nov Dec Jan Feb Mar Source /Actions / Comments (SLA Target) Cognitive Behaviour Therapy No. Referrals * 1 9 18 29 31 24 33 22 No waiting * 2 3 6 19 30 32 34 41 Total Referrals * 3 99 117 146 177 201 234 316 Longest wait * 4 4 9 12 16 10 8 < 8 > 8 4 ACTION: Recruited Bolton Uni students *waiting time standard * (uinc cap) changed to 12 / 52 at Feb Monitor 2011 Review activity of ccbt and GSH clinics Explore C&Y- IAPT opportunities 20 10 0 0 Apr May June July Aug Apr June Aug Oct Dec Feb Sep Oct Waiting Time Serv Spec Target Nov Dec CAMHS target Waiting Time to 1 st Contact following Referral 2010-11 Jan Feb Mar Apr ADOS assessments No. Referrals* 1 6 2 5 1 7 3 8 No. Waiting* 2 0 0 0 0 1 0 1 Total Referrals 32 34 39 40 47 50 58 Longest wait* 4 < 6 > 6 2 2 2 2 3 4 CAMHS Tier III+ Day Unit Occupancy 97% 97% 98% 98% 98% 98% 99% Longest wait < 8 > 8 11 Weeks 6 5 7 8 6 Parenting Interventions No. Referrals* 1 12 15 26 10 12 17 11 No. Waiting* 2 12 15 26 10 12 17 2 Waiting Time to 1 st Contact following Total Referrals* 3 Referral 85 100 2010 126 136 148-165 11 176 Longest wait* 4 < 10 > 10 5 4 5 5 5 5 2 Due to changes in LA provision this will May June July Aug Sep Oct Nov Dec Jan 6 Feb 8

2. Initial state - (b) Responsible Use of Resources Go No Go 1 Achieving Cost Improvement Programme 2 3 Response to introduction of 80:20 model choice component on 10 % Time to Action Measures at Service Standard Patient Involvement in Strategic Activities Level of patient involvement in the development of service delivery (baseline Jan 2011) Waiting 25 time to first contact CAMHS overall budget approximately 1.3 million Achieved less than 12/52 target Met ISP for financial year 2010-11 Surplus in direct costs 42,000 100 (service specification) Combined direct / indirect cost surplus approximately 80,000 Bolton CAMHS National Cost Reference Index is 87 i.e. 13% 75 cheaper than the national average Recruitment 20 50 Interviews Challenges; Block Contract arrangements Limited options 25 Involved in RIE 0 / VSA 15 2010/11 Target* * Target from prior Strategy and Vision 2009 2014 Waiting Time Serv Spec Target Reflections: Dashboard data tracking time to action measures in last 7 months 22 out of CAMHS 28 @ target agreed CAMHS target standard, equals 79% Aim to develop an aggregate a number of Time to Action Measures ( Time to Choice, Time to CBT, Time to Parenting, Time to Day Unit, Time to ADOS (5), Time to Pathways 1 8 *, Time to IPT*, Time to EMDR* *to come on-line by July 2011 ) At present time from referral to 1 st Contact elevated and continuing to do so despite increase approx 40% NC activity in 2010 11 Capacity not matched to demand Service NC cap 860 Demand 1000+ 30 5 Metric Goal Red Flag Sep Oct Nov Dec Jan Feb Mar Source /Actions / Comments (SLA Target) Cognitive Behaviour Therapy No. Referrals * 1 9 18 29 31 24 33 22 No waiting * 2 3 6 19 30 32 34 41 Total Referrals * 3 99 117 146 177 201 234 316 Longest wait * 4 4 9 12 16 10 8 < 8 > 8 4 ACTION: Recruited Bolton Uni students *waiting time standard * (uinc cap) changed to 12 / 52 at Feb Monitor 2011 Review activity of ccbt and GSH clinics Explore C&Y- IAPT opportunities 20 10 0 0 Apr May June July Aug Apr June Aug Oct Dec Feb Sep Oct Waiting Time Serv Spec Target Nov Dec CAMHS target Waiting Time to 1 st Contact following Referral 2010-11 Jan Feb Mar Apr ADOS assessments No. Referrals* 1 6 2 5 1 7 3 8 No. Waiting* 2 0 0 0 0 1 0 1 Total Referrals 32 34 39 40 47 50 58 Longest wait* 4 < 6 > 6 2 2 2 2 3 4 CAMHS Tier III+ Day Unit Occupancy 97% 97% 98% 98% 98% 98% 99% Longest wait < 8 > 8 11 Weeks 6 5 7 8 6 Parenting Interventions No. Referrals* 1 12 15 26 10 12 17 11 No. Waiting* 2 12 15 26 10 12 17 2 Waiting Time to 1 st Contact following Total Referrals* 3 Referral 85 100 2010 126 136 148-165 11 176 Longest wait* 4 < 10 > 10 5 4 5 5 5 5 2 Due to changes in LA provision this will May June July Aug Sep Oct Nov Dec Jan 6 Feb 8

2. Initial state - (b) Responsible Use of Resources Go No Go 1 Achieving Cost Improvement Programme 2 3 Response to introduction of 80:20 model choice component on 10 % Time to Action Measures at Service Standard Patient Involvement in Strategic Activities Level of patient involvement in the development of service delivery (baseline Jan 2011) Waiting 25 time to first contact CAMHS overall budget approximately 1.3 million Achieved less than 12/52 target Met ISP for financial year 2010-11 100 Surplus in direct costs 42,000 (service specification) Combined direct / indirect cost surplus approximately 80,000 Bolton CAMHS National Cost Reference Index is 87 i.e. 13% 75 cheaper than the national average Recruitment 20 50 Interviews Challenges; Block Contract arrangements 25 <8/52 Involved in RIE Limited options Further improvement / VSA 0 15 Failed to achieve our target of required 2010/11 Target* * Target from prior Strategy and Vision 2009 2014 Waiting Time Serv Spec Target Reflections: Dashboard data tracking time to action measures in last 7 months 22 out of CAMHS 28 @ target agreed CAMHS target standard, equals 79% Aim to develop an aggregate a number of Time to Action Measures ( Time to Choice, Time to CBT, Time to Parenting, Time to Day Unit, Time to ADOS (5), Time to Pathways 1 8 *, Time to IPT*, Time to EMDR* *to come on-line by July 2011 ) At present time from referral to 1 st Contact elevated and continuing to do so despite increase approx 40% NC activity in 2010 11 Capacity not matched to demand Service NC cap 860 Demand 1000+ 30 5 Metric Goal Red Flag Sep Oct Nov Dec Jan Feb Mar Source /Actions / Comments (SLA Target) Cognitive Behaviour Therapy No. Referrals * 1 9 18 29 31 24 33 22 No waiting * 2 3 6 19 30 32 34 41 Total Referrals * 3 99 117 146 177 201 234 316 Longest wait * 4 4 9 12 16 10 8 < 8 > 8 4 ACTION: Recruited Bolton Uni students *waiting time standard * (uinc cap) changed to 12 / 52 at Feb Monitor 2011 Review activity of ccbt and GSH clinics Explore C&Y- IAPT opportunities 20 10 0 0 Apr May June July Aug Apr June Aug Oct Dec Feb Sep Oct Waiting Time Serv Spec Target Nov Dec CAMHS target Waiting Time to 1 st Contact following Referral 2010-11 Jan Feb Mar Apr ADOS assessments No. Referrals* 1 6 2 5 1 7 3 8 No. Waiting* 2 0 0 0 0 1 0 1 Total Referrals 32 34 39 40 47 50 58 Longest wait* 4 < 6 > 6 2 2 2 2 3 4 CAMHS Tier III+ Day Unit Occupancy 97% 97% 98% 98% 98% 98% 99% Longest wait < 8 > 8 11 Weeks 6 5 7 8 6 Parenting Interventions No. Referrals* 1 12 15 26 10 12 17 11 No. Waiting* 2 12 15 26 10 12 17 2 Waiting Time to 1 st Contact following Total Referrals* 3 Referral 85 100 2010 126 136 148-165 11 176 Longest wait* 4 < 10 > 10 5 4 5 5 5 5 2 Due to changes in LA provision this will May June July Aug Sep Oct Nov Dec Jan 6 Feb 8

3. Target state - (b) Responsible Use of Resources Go No Go 1 Achieving Cost Improvement Programme 2 Patient Involvement in Strategic Activities 70 100 60 50 40 30 20 10 Recurrent Non-Recurrent % Achieved 90 80 70 60 50 40 30 20 Recruitment RIE / VSA 0 Year 1 target Year 1 achieved 10 0 2010-11 2011-12 target 2011-12 achieved 3 % Time to Action Measures at Service Standard At 'Time to Action' Standard Primary (Initial measure monthly) time from referral receipt to appointment 81 Waiting Time to 1 st Contact following targets 2011-2012 80 25 20 15 10 5 0 Waiting Time Serv Spec Target CAMHS target 79 78 77 76 75 74 Baseline* 2011-12 target Feb 2012 achieved At 'Time to Action' Standard Apr Aug Dec Apr Aug Dec Benefits to customers: :

3. Target state - (b) Responsible Use of Resources Go No Go 1 Achieving Cost Improvement Programme 2 Patient Involvement in Strategic Activities 70 100 60 50 40 30 20 10 Achieved Target Recurrent Non-Recurrent % Achieved 90 80 70 60 50 40 30 20 Recruitment RIE / VSA 0 Year 1 target Year 1 achieved 10 0 2010-11 2011-12 target 2011-12 achieved 3 % Time to Action Measures at Service Standard At 'Time to Action' Standard Primary (Initial measure monthly) time from referral receipt to appointment 81 Waiting Time to 1 st Contact following targets 2011-2012 80 25 20 15 10 5 0 Waiting Time Serv Spec Target CAMHS target 79 78 77 76 75 74 Baseline* 2011-12 target Feb 2012 achieved At 'Time to Action' Standard Apr Aug Dec Apr Aug Dec Benefits to customers: :

3. Target state - (b) Responsible Use of Resources Go No Go 1 Achieving Cost Improvement Programme 2 Patient Involvement in Strategic Activities 70 60 50 40 30 20 10 Achieved Target Recurrent Non-Recurrent % Achieved 100 90 80 70 60 50 40 30 20 No Recruitments in 2011-12 Recruitment RIE / VSA 0 Year 1 target Year 1 achieved 10 0 2010-11 2011-12 target 2011-12 achieved 3 % Time to Action Measures at Service Standard At 'Time to Action' Standard Primary (Initial measure monthly) time from referral receipt to appointment 81 Waiting Time to 1 st Contact following targets 2011-2012 80 25 20 15 10 5 0 Waiting Time Serv Spec Target CAMHS target 79 78 77 76 75 74 Baseline* 2011-12 target Feb 2012 achieved At 'Time to Action' Standard Apr Aug Dec Apr Aug Dec Benefits to customers: :

3. Target state - (b) Responsible Use of Resources Go No Go 1 Achieving Cost Improvement Programme 2 Patient Involvement in Strategic Activities 70 60 50 40 30 20 10 Achieved Target Recurrent Non-Recurrent % Achieved 100 90 80 70 60 50 40 30 20 No Recruitments in 2011-12 Recruitment RIE / VSA 0 Year 1 target Year 1 achieved 10 0 2010-11 2011-12 target 2011-12 achieved Achieved Target 3 % Time to Action Measures at Service Standard At 'Time to Action' Standard Primary (Initial measure monthly) time from referral receipt to appointment 81 Waiting Time to 1 st Contact following targets 2011-2012 80 25 20 15 10 5 0 Waiting Time Serv Spec Target CAMHS target 79 78 77 76 75 74 Baseline* 2011-12 target Feb 2012 achieved At 'Time to Action' Standard Apr Aug Dec Apr Aug Dec Benefits to customers: :

3. Target state - (b) Responsible Use of Resources Go No Go 1 Achieving Cost Improvement Programme 2 Patient Involvement in Strategic Activities 70 60 50 40 30 20 10 Achieved Target Recurrent Non-Recurrent % Achieved 100 90 80 70 60 50 40 30 20 No Recruitments in 2011-12 Recruitment RIE / VSA 0 Year 1 target Year 1 achieved 10 0 2010-11 2011-12 target 2011-12 achieved Achieved Target 3 % Time to Action Measures at Service Standard At 'Time to Action' Standard Primary (Initial measure monthly) time from referral receipt to appointment 81 Waiting Time to 1 st Contact following targets 2011-2012 25 20 15 10 5 0 Waiting Time Serv Spec Target CAMHS target 80 79 78 77 76 75 74 Baseline* 2011-12 target Feb 2012 achieved Achieved Target At 'Time to Action' Standard Apr Aug Dec Apr Aug Dec Benefits to customers: :

3. Target State (c) Valued, Respected & Proud Go No Go 1 % of staff achieving the annual Job Plan Appraisal Cycle 2 CAMHS Temperature Check 50 100 95 90 85 40 30 20 10 Very Dissatisfied Dissatisfied Satisfied Very Satisfied 2011-12 target 2011-12 achieved 0 Baseline 3 Improvements Implemented per Month Proxy Measure 2011-12 8 6 4 2 0 April May June July August September Oct Nov Dec Jan Feb Mar Days devoted to improvement events First year use proxy measure, years 2 through to 5 introduce Improvements implemented model. Consider: Weekly monitoring Award / reward scheme Identification of improvement of the month etc. 14 12 10 8 6 4 2 0 Improvements per month 1 2 3 4 5 6 7 8 9 10 11 Improvements per month

3. Target State (c) Valued, Respected & Proud Go No Go 1 % of staff achieving the annual Job Plan Appraisal Cycle 2 CAMHS Temperature Check 50 100 Achieved Target 95 90 85 40 30 20 10 Very Dissatisfied Dissatisfied Satisfied Very Satisfied 2011-12 target 2011-12 achieved 0 Baseline 3 Improvements Implemented per Month Proxy Measure 2011-12 8 6 4 2 0 April May June July August September Oct Nov Dec Jan Feb Mar Days devoted to improvement events First year use proxy measure, years 2 through to 5 introduce Improvements implemented model. Consider: Weekly monitoring Award / reward scheme Identification of improvement of the month etc. 14 12 10 8 6 4 2 0 Improvements per month 1 2 3 4 5 6 7 8 9 10 11 Improvements per month

3. Target State (c) Valued, Respected & Proud Go No Go 1 % of staff achieving the annual Job Plan Appraisal Cycle 2 CAMHS Temperature Check 50 Not yet repeated 100 Achieved Target 95 90 85 40 30 20 10 Very Dissatisfied Dissatisfied Satisfied Very Satisfied 2011-12 target 2011-12 achieved 0 Baseline 3 Improvements Implemented per Month Proxy Measure 2011-12 8 6 4 2 0 April May June July August September Oct Nov Dec Jan Feb Mar Days devoted to improvement events First year use proxy measure, years 2 through to 5 introduce Improvements implemented model. Consider: Weekly monitoring Award / reward scheme Identification of improvement of the month etc. 14 12 10 8 6 4 2 0 Improvements per month 1 2 3 4 5 6 7 8 9 10 11 Improvements per month

3. Target State (c) Valued, Respected & Proud Go No Go 1 % of staff achieving the annual Job Plan Appraisal Cycle 2 CAMHS Temperature Check 100 Achieved Target 95 90 85 50 40 30 20 10 Not yet repeated Expectation that this target will not be reached Very Dissatisfied Dissatisfied Satisfied Very Satisfied 2011-12 target 2011-12 achieved 0 Baseline 3 Improvements Implemented per Month Proxy Measure 2011-12 8 6 4 2 0 April May June July August September Oct Nov Dec Jan Feb Mar Days devoted to improvement events First year use proxy measure, years 2 through to 5 introduce Improvements implemented model. Consider: Weekly monitoring Award / reward scheme Identification of improvement of the month etc. 14 12 10 8 6 4 2 0 Improvements per month 1 2 3 4 5 6 7 8 9 10 11 Improvements per month

3. Target State (c) Valued, Respected & Proud Go No Go 1 % of staff achieving the annual Job Plan Appraisal Cycle 2 CAMHS Temperature Check 100 Achieved Target 95 90 85 50 40 30 20 10 Not yet repeated Expectation that this target will not be reached Very Dissatisfied Dissatisfied Satisfied Very Satisfied 2011-12 target 2011-12 achieved 0 Baseline 3 Improvements Implemented per Month 8 6 4 2 0 Proxy Measure 2011-12 April May June July August September Oct Nov Dec Jan Feb Mar Days devoted to improvement events Struggled to find a practical & effective way to monitor this First year use proxy measure, years 2 through to 5 introduce Improvements implemented model. Consider: Weekly monitoring Award / reward scheme Identification of improvement of the month etc. 14 12 10 8 6 4 2 0 Improvements per month 1 2 3 4 5 6 7 8 9 10 11 Improvements per month

LEAN or BICS & CAMHS: Reflections LEAN TECH: A3 boxes 1 & 3 (a) (b) 2012: It remains the approach we plan to use to continuously improve our service at this time of cost savings and disinvestment in CAMHS in the UK generally It isn t easy and its not a quick fix, this is a long game Sustaining change over time and managing the operational processes that achieve that improved quality and performance is critical, an area we have struggled with We believe our model pathway approach will be successful and allow adaptability to demand and the context but WE ARE A LONG WAY FROM THERE YET!