The National i-THRIVE Programme team spoke with Helen Taylor, Clinical Psychologist and Clinical Lead with Wirral CAMHS about implementing the THRIVE Framework for system change (Wolpert et al., 2019) in services for children and young people.
15th September 2017
Q: What has been your role in implementing the THRIVE Framework?
A: I am the Clinical Lead for the new primary mental health team which began in October 2016. Before coming into that post, I attended a National i-THRIVE Community of Practice event and I started to think about how to implement the THRIVE Framework. I had previously been involved in setting up Wirral’s single point of access which follows Choice and Partnership Approach (CAPA) principles, so we call it the CAMHS Choice Clinic. [See i-THRIVE Implementation Story here.]
Q: How is implementation of the THRIVE Framework structured locally?
A: Implementing the THRIVE Framework is central to the delivery of the local Future in Mind Transformation (FiM) plan. The Future in Mind steering group includes commissioned services for the children’s workforce including social care (early help and other social care services), education representation, public health, health and the Clinical Commissioning Group (CCG) and provides a fantastic forum for the types of conversations and innovations that help a THRIVE Framework work.
We were successful in the bid for FiM monies in 2016 and had to set up and deliver the CAMHS part of the project fairly rapidly – this meant we didn’t do some of the initial wider mapping activities early in the project – however that is something we are now addressing.
Q: Which aspects of the THRIVE Framework did you feel were already in place?
A: Wirral was in a good position to start with implementing the THRIVE Framework because we had developed our tool for shared decision making, the Next Steps cards [See i-THRIVE Implementation Story here], we had used CAPA, are a CYP IAPT site, we were trained and had experience in using Quality Improvement methodology and were successful in bidding for Future in Mind funding.
Already in place were good local links with other agencies, embedded Routine Outcome Measures (ROMS) in CAMHS electronic note systems and we had experience of partnership working.
Q: What changes have you made towards becoming more THRIVE-like?
A: We moved to a single point of access which has allowed better data collection. We have seen waiting lists decrease and the numbers of risk assessments for self-harm decrease. Providing an advice line has enabled us to be more accessible and dismantle the tiers in our service. The advice line provides consultations over the phone with schools, parents and carers and other professionals – anyone with a concern about a local young person’s mental health. The line is staffed by the primary mental health workers and specialist CAMHS workers, all of whom who are really experienced. They have amazing backgrounds in specialist Children and Adolescent Mental Health Services (CAMHS) and lots of mental health experience. The workers can fill in a referral form whilst on the phone with all of the necessary information. I think this is a good example of getting rid of tiers because children and young people get quick access to the advice and care they need, and we have frontloaded these initial conversations with very experienced staff to provide quality assured advice. An initial worry with setting up the advice line was that it might lead to an increase in the number of referrals coming in to CAMHS but this has not been the case and in fact referrals to CAMHS and referrals to the local A&E for deliberate self-harm, have reduced.
We have training in schools which is infused by the THRIVE Framework ethos by reducing the fear and mental health stigma in the education workforce.
We are also working on evidence based care pathways for Getting Help and Getting More Help needs based groupings. We are working on making the pathways more explicit and clear. We will be looking at mapping the skills and time of staff. CYP IAPT and CAPA have helped with being able to do this.
Our transformed primary mental health team launched in October 2016, on World Mental Health Day. The team is made up of six primary mental health workers who work closely with schools and other professionals to ensure children and young people receive the help they need when they need it and can access specialist services when they are required. The six primary mental health workers work across the 150 schools in Wirral and provide training and consultation to the schools and other organisations. To date, 1000 education staff have been trained and over 1000 consultations have been undertaken on the phones.
Q: What are some of the barriers you have faced in implementing the THRIVE Framework so far?
A: One of the barriers has been communication. Different terminology is used across organisations to talk about mental health. A local survey before the transformation, had revealed that there weren’t good relationships between CAMHS and schools and there was the perception that it was difficult for children and young people to access CAMHS. This has changed with the help of the training events that started from January 2017 in schools. Each year this training is made available to another sector, social care will be the next part of the children’s workforce to be trained. The training and advice-line have been well-received by schools and that helped to improve the credibility of CAMHS. They have had good feedback from schools on the experience of using the advice line.
Another barrier has been a fear of dealing with mental health in other agencies but the training and advice line have helped us to contain and support those organisations to be able to address the issues.
At the beginning of developing the primary mental health team the existing waiting list for CAMHS was a barrier to improvement. The service worked hard to reduce their waiting list and we estimate that by April 2018 the service will meet national guidelines on timescale from referral to first appointment.
The primary mental health team faced the difficulty of being a small team with a huge task. It required a culture shift, and now the primary mental health workers are very enthusiastic about the work and are an amazing team.
Q: What are some of the facilitators you have faced so far in implementing the THRIVE Framework?
A: If staff are resistant to change then bringing the conversation back to what children and young people need and what they have said that they want helps people to refocus on why change is needed. The training and the advice line by the primary mental health team have been facilitators in building capacity in schools.
The aim of our work with schools is to support them in promoting whole school approaches to mental health, measuring outcomes and getting young people’s voices heard in schools. Identifying ‘accelerator schools’ to share best practice in promoting mental health and wellbeing in schools has facilitated engagement with this work. The school workforce will listen to what other schools have to say.
As a lead for implementing the THRIVE Framework, being positive and enthusiastic and containing anxieties from health, social care, children and their families is necessary for driving change. Being practical and having a clear plan facilitates buy-in. Project management was key because it helped to be able to show a project plan with a rationale.
The fact that a few of the CAMHS service team have had training in Quality Improvement methodology including LEAN thinking and being able to conduct PDSA cycles (Plan-Do-Study-Act) has been useful because if people do not think that a particular change will work you can say, well let’s try it and see if it works. If it doesn’t work then we will change it to make it better.
Having CAPA already in place also helped. It has been a tool for planning service transformation because it gave us a useful language for communication with commissioners by allowing the service to provide objective data about the service’s capacity given staff skills.
Q: What has been the area so far which has required the biggest culture change in implementing the THRIVE Framework?
A: I think it has been organisations outside of the health service having a greater acceptance that they are part of the solution for the mental health crisis facing children and young people. The anti-stigma initiatives and projects in mental health nationally seem to be trickling down and it now feels like we have reached a very exciting tipping point.
Another area of culture change has been in really, genuinely listening to what young people want instead of it being a token exercise. I’m really excited about the co-production possibilities in the future.
The primary mental health workers have had to be brave to lead trainings and move towards having more phone consultations and fewer face-to-face contacts which has required workforce development.
The next step in culture change for us will be around When to Stop Treatment. This is the next step in improving the flow of young people through CAMHS. This will involve changing supervisions to talk about endings from the beginning and using routine outcome measures more often. The waiting list decreasing will help with this because it is easier for clinicians to discharge when they know it will be easy for the young person to re-access specialist help if necessary.
Q: What are you focusing on in the next six months?
A: We will be conducting a mapping exercise over the next few months. The exercise will identify local provision of emotional well-being support across the whole CYP workforce, map the pathways and flow through the system, detail the thresholds and identify the data available at each point. The purpose of the mapping exercise is to ultimately create a better journey for children and young people. Young people want to receive help where they ask for it rather than being referred on.
A second purpose of the pathway mapping exercise is to engage the wider local area in the THRIVE Framework because it is health driven at the moment.
In six months it is hoped that there will be a vision for the THRIVE Framework across local areas, accelerator schools will be sharing best practice, the advice line may be widening the support offered to parents and the flow will improve in CAMHS pathways.
Q: Have you used any of the i-THRIVE Toolkit from the website?
A: We have used pathway mapping tools and used diagrams from the slide sets. We have used the colours in designing our Getting Advice and Signposting booklet. We also often come back to the original THRIVE Framework publications and the case studies are helpful. I have been in contact with Helen Brasnett regarding the parent consultation service implementation story.
Q: Do you have any developments you would like highlighted to the Community of Practice?
A: I’d like to highlight our THRIVE Framework based signposting resource pack. In addition, the Next Step cards to anyone who hasn’t seen them yet.
Q: Is there anything you would like to ask the National i-THRIVE Community of Practice?
A: I would like to ask whether other sites have materials for communicating the THRIVE Framework across sectors and for examples of using pathway mapping exercises for the purpose of achieving culture change across agencies? In addition, work on When to Stop Treatment.
Would you like to participate in a Q&A?
If you would like to take part in a Q&A to share your experiences in relation to implementing the THRIVE Framework and using the i-THRIVE Approach to Implementation, please get in touch with the team at ithriveinfo@tavi-port.nhs.uk.