What are the Demand and Capacity ideas behind the Core and Specific separation?

A key part of why CAPA works is using demand and capacity theory in how we organise CAMH services. The two key ideas that relate to Core and Specific work are:

Segmentation

This is separating everyone who comes to the service into smaller groups that need similar processes. This allows their care pathway to be separated along their whole journey with the aim of keeping flow through any bottleneck points constant. A non - CAMHS example would be a post office having a counter for parcels (which have a longer task time) and one for stamps - this smoothes flow by separating high frequency, shorter task time processes (stamps) from the longer, less frequent ones (parcels).

In CAMHS, the variation in number of appointments needed tends to be wide, maybe 1 to 100 or more! If staff just took each case as it came they would experience wide variability in their caseload and activity. Separating clinical journeys into predictable paths smoothes the journey for the young person and family. This separation (segmentation) should be based on duration and skills needed. Some problems/pathways are predictably long and intensive (anorexia nervosa; psychodynamic psychotherapy), or very short (psychometric assessment). Many will be of average duration and need a range of threshold level skills. We know that the average number of times families come to CAMHS is around 7 (national surveys and local audits, see The Numbers chapter in Implementation) so, in CAPA, we segment average duration interventions into Core Partnership and longer or shorter term into Specific.

Although we know that the average duration of interventions in CAMHS is around 7 appointments, we tend to remember those that are way longer than this. Those families we see for years or very intensively. But these are the tail of the distribution (in Richmond audit showed these to be around 10%). In fact Herts audit (2009) suggests that 60% of our capacity is used up by 30% of the families. An example: Steve recently discharged two young people on the same day- one had been seen twice in Core Partnership – a young lad referred for anger management that seemed to get better on his own and another that he had seen 15 times – a young woman with a sustained anxiety and separation anxiety disorder. Both were Core work as he had used Core threshold level skills – CBT and systemic – but the durations varied widely. Probably both from the same average distribution, just from either end.

Segmented clinics

This is when you group clinical skills together around a Care Bundle (see the 7 HELPFUL Habits) to smooth flow by ensuring that the clinical skills for a particular group are available. These segmented clinics need to be protected time in a job plan to ensure the clinicians that need to work together can do so. An example could be a segmented eating disorder clinic for anorexia nervosa- grouping dietetics, systemic and other skills together. Anorexia has a predictable time course and needs a predictable set of skills. Grouping them in a clinic thus facilitates the work.

The skills needed in segmented clinic may not be at specialist level of competence. They may be threshold level skills that can be grouped together e.g. a parenting work for oppositional behaviour problems, including driven by ADHD.

Capacity reservation

There will be some specific skills and tasks you need to make sure your CAMHS team has available. If you did not reserve this clinical capacity more common and high volume tasks might erode it. A child psychiatrist needs to have flexible time to be able to do mental health assessments at fairly short notice. Without planning for this the job plan might be used up by less urgent tasks such as ADHD medication reviews. If you only have one psychotherapist in the team, you may not be able to afford to use them for Core work.