Dr Asha Gowda I’m Dr Asha Gowda. I’m a  Consultant Psychiatrist at Portsmouth CAMHS.   I’m also the Chair for ACAMH Southern Branch,  and on behalf of our branch, I would like to   take this opportunity to welcome you all to our  Annual Research and Service Innovation session. Now, today, we are going to be discussing two  topics, I think which is really very relevant   to our daily practice. Our first topic is going  to be about care co-ordination in busy teams,   and the second one is about addressing the  unscheduled care through the STaR project. Before we start this session, a few  housekeeping rules. First of all,   the session is set up as a webinar, so you’re  not going to have access to your cameras or   your microphones, but this will be opened up  during the Q&A session, or the Q&A pane. So,   we hope to have about ten minutes after each  discussion where you can ask your questions,   and our presenters will be able to answer those  questions. We would like to actually encourage   you all to post your questions and queries  using the Q&A function only, please. So, no,   kind of, general conversations in the Q&A box, so  we can actually curate the questions for after the   sessions. For any other conversations, please feel  free to use the chat function on your screens. We want you to participate as much as possible  and we would love your active involvement,   because we feel that this is the best way for us  to share our thoughts and learn from each other.   So, please, please keep posting your thoughts  and your questions as they come through. We   hope to keep to time as much as possible, so  we hope to finish by three, but if we do run   over by five minutes or ten minutes, I hope  you can stay with us for the conversations. Now, let’s begin our session by introducing  our speakers to you. Our first speaker is Dr   Anu Devanga and Mr Dave Smallman. Dr Anu is – she  is a Consultant Child and Adolescent Psychiatrist   for Pan-Dorset Intellectual Disability  CAMHS service. She’s been a Consultant   since 2017 in this service and she’s the  Lead Consultant for Core CAMHS since May   2020. She’s the sole Consultant for a service  covering the county of Dorset, with clinical   bases in Dorchester and Southport, and she’s  also a part of the multidisciplinary service,   consisting of Nurses, NMPs, Psychologists,  Senior OTs, mental health practitioners,   clinical support workers, sleep practitioners  and the rest of them. I’m not going to actually   list all of them, but there are quite a few  multidisciplinary staff in this service. Now, the service works closely with  partner agencies, such as the social care,   children’s social care, education, schools,  Paediatricians and adult mental health services,   amongst others. Now, most of her work takes place  in community and schools and relevant assessments,   interviews, take place at clinics. Anu  completed her core training in psychiatry   in Northamptonshire and when it was part of the  Oxford Deanery. She has also completed her higher   training in Midlands Deanery. Her first role  as a Consultant was in West Midlands Hospital   and her areas of interest can – were – include  ND conditions and looked after children. She   has worked as a Consultant Psychiatrist across  independent specialist residential schools in   Dorset, Hampshire and Gloucestershire and  has a wealth of experience and expertise. With that, I’m going to introduce you to Mr Dave  Smallman. He is a Nurse Therapist and a Registered   Nurse in a Learning Disability Team. He’s also  an Art Psychotherapist by background. He – since   qualifying in 1999, he’s worked within a range  of inpatient and community services. He’s now   the Team Leader for ID Service CAMHS, which works  with children with an intellectual disability,   experiencing severe emotional and behavioural  difficulties. Mr Smallman’s interests include   using positive behavioural support and functional  analysis, for which he completed his training at   the Tizard Centre. He also uses creative  therapies in supporting young people with   neurodevelopmental conditions, works with groups  and interested in delivering psychoeducation   for parents. He’s interested in developing  solution-focused management forums within   the teams and across agencies. Now, with that introduction,   I’m going to hand it over to Anu and  Dave to start off their presentation. Dr Anu Devanga Thanks, Asha, for that  introduction. But I’d like to say at the   start that my contribution to this meeting  is to get Dave here to talk about his work   and presentation. I’ve been involved in the work  in terms of, as you heard in the introduction,   I’m the only Psychiatrist for the service,  the Pan-Dorset service, and I think I wrote   the introduction with a view that I was part of  the service when I first joined and probably for   the first three years. Our team doesn’t look  like that. And probably, that was one of the   reasons why the caseload reviews and to this –  the context of the presentation comes in. So,   I’ll hand you over to Dave, who will take  us through the work that we did and the   presentation, and I’ll come in wherever it’s  relevant for me to chip in. Thank you, all. Dave Smallman Okay, thank you, Anu.  Okay, I’m just going to check that the   slides move on when I click this. Uh-huh,  yes. So, good afternoon, everybody. So,   yeah, I’m going to present some work that we  did around developing an audit tool just to   think about processing and to manage differing  demands of identital – and identify trends in   our core work. And I’ll just go into a bit  of background about our team. Excuse me. So, just a little bit of background about who we  are. So, we are – the ID-CAMHS team are part of   the learning disability service, but we also  link in with our mainstream CAMHS offer. So,   we’re a multidisciplinary team of nursing, OT,  speech and language therapy, family therapy,   social work, Social Workers, psychology,  psychiatry, psychological wellbeing   practitioners and Support Workers.  So, the aims of our service. So,   we work with and empower families  to lead the care of their children,   and we work in partnership to improve the  quality of life and enhance the experience   of those children with an intellectual disability  and mental health needs in all settings. And we’re   a pan-Dorset service and there are currently two  teams based in the East and West of the county. So, the service works with children  and young people with a diagnosis   of an – diagnosed intellectual disability and  in addition, present with the following. So,   significant aggression, challenging behaviours and  putting the child or others at risk, and mental   illness or significant mental health issues.  And our service principle is the assessment   and treatment of mental heal – mental dis – health  disorders, illness in children and young people up   to the age of 18 who have an intellectual  disability and a mental health need. So, what we did and why. So, thinking about, kind  of, the purpose of our presentation today. So,   our caseload review days were organised  in response to a series of changes in   the composition of the team, and that was  really as a result of Clinicians, often who   possess a specialist interest, an additional  training, moving out of the team. Recruitment   of several new Clinicians, going through  induction and probationary periods. Changes   in existing Clinicians’ jobs roles, referral  rates increasing in relation to discharge rates,   and an increasing number of patients required to  stay open to the team due to medication regime   they were on. And I think the really important  context behind this is, I think, relatively,   we’re only really a small team compared  to some of our teams that we, kind of,   link in with. So, any of these significant  changes can make a real impact on the way   that we work and some challenges in how  we recruit new Clinicians into the team. So, as some Clinicians had left the service, our  Care Co-ordinators were asked to pick up cases   alongside their existing caseload. This might  resonate with some of your experience as you’re   listening today, and as new recruits started their  jobs and another CCO returned from maternity leave   between October 22 and February 23, the team had  a full cohort of Care Co-ordinators again. So,   we’d been through this period of change  and then, we started to get up to our,   kind of, full team capacity again,  following a period of challenge. So,   this enabled a process of group reflection on  the Clinicians’ caseloads, and we were abe – I’m   able to identify the number of patients,  the nature of engagement and support,   cases for new recruits, cases which needed  review of input and cases that we could   close. And it seemed to – important to  focus on the team sharing this process. So,   Clinicians felt less isolated after the trend  towards lone working following the pandemic. So,   people started to come back into the unit and work  together and spend time with each other again. In the additional compli – context to this  was, like, in terms of creating an audit   tool that really, kind of, could extract  what we needed to know. I think a lot   of the audit tools that often, we’re  working with at the moment are about   examining compliance and performance.  And I think what we really needed to,   kind of, find out was what our core work was  and where everybody was with their cases and   their caseloads and how that was being managed  and how we could, kind of, move things around   and make things feel more manageable as the team,  kind of, came back together to work together. And so, we – very straightforward. We created a  data collection tool on Excel to examine caseloads   and the nature of engagement. We colour coded it  so we could look at the nature of involvements and   the possible actions as an outcome of that. So,  it was very straightforward in that respect. So,   the codes were, for cases that be – could be  closed, consider transfer to another Clinician   as new Clinicians join the team. We thought about  stuck cases, where perhaps a formulation meeting   was required in cases that we’d worked with  for a long time. And I think this was, again,   particularly in the context of coming out of the  pandemic, where maybe some of the direct work had   been less possible and a lot of the support  had been delivered via video consultation,   essentially, throughout. We weren’t able to  always see young people and families. So,   I think we are – sort of, collectively, we felt  we had an array of cases that might have felt   a little bit stuck and we needed to think about  how we could work that and move things forward. We thought about cases that were  at the point of initial assessment,   or at a point of transfer to another Clinician. We  thought about cases where there were medications   and the management of medications and review of  medications, but fairly infrequent contact. So,   patients that were quite stable, where they didn’t  need to be seen particularly frequently. And then,   cases where there was more complexity,  there were more shifts in presentation   and a lot more frequent contact with families  and the Multidisciplinary Team. And then,   cases where there was an ongoing episode of  thera – or therapeutic intervention. Anu… Dave Smallman …I don’t know if  you want to reflect on any of…? Dr Anu Devanga No, I think it’s going –  so far, I don’t have any questions on this. Dave Smallman So, we came together  three times throughout that first   year and we spent the whole day together. And  what we hoped to do was this information could   be used to consider collectively, if our current  resources could manage the demands that we were   under and what else might be available  to support the team as a return to more   conventional ways of practice and engagement  following the pandemic. And the audit tool   provided both a valuable overview of the team’s  workload in relation to individual and team   capacity and also, a chance to see which areas  of core business were drawing the most focus. And I think that’s really important, because I  think there was shifts in some present peo – young   people’s presentation, and I think really,  even now, a couple of years later, we’re still,   kind of, feeling the effects of that, for sure.  So, you know, where perhaps young people had   been more stable and contact had been less  frequent, there were young people that had   really struggled with the lack of structure or as  maybe education fell away during that period, all   the different challenges that everybody faced. I  think we needed, really, to, kind of, re-evaluate   where we were at with a lot of our young people  and with our cases and how they were managed. Dr Anu Devanga Yeah. Dave Smallman So, it was really – it felt like  a really useful and important time to, kind of,   do this piece of analysis with my casework,  and particularly around core business. Again,   I think there were some shifts and  changes in young people’s presentation,   and I think perhaps we were working – the  proportion of young people who perhaps we   were working with who were experiencing some  anxiety or where there’d been some behavioural   change in response to all the things that had  happened throughout that period. We needed to,   kind of, re-evaluate where we’re  at with a lot of young people. So, the kinds of evidence the team identified to  help, sort of, identify trends in workloads were   thinking about the complexity. So, we considered  by – this by frequency of planned and unplanned   contact and medication and monitoring. The  team also identified other information that   would be useful, so looking at things like  referrals, the rates and the reasons why   young people were being referred. How many cases  had declined and why and how many revolving door   cases and reasons for re-referral. So,  really, kind of, digging into, kind of,   what was happening in respect of the reasons  for referral and our engagement. And obviously,   there are other ways to extract this data,  but it felt that there – doing this as a   collective and as a team, we could, really, kind  of, really get to grips with it and understand it. So, another consideration was the nature of the  conditions being reported at referral and how   this might provide a focus on future CPD events  and training and appraisal. So, things that we,   kind of, picked up were things like issues around  the need for desensitisation or graded exposure   training, looking at managing risk in self-injury,  where there was an element – a forensic element to   the presentation, a challenging behaviour that  may be criminalising, sexualised behaviours and   ARFID. All things that, kind of, seemed to be,  kind of, coming through at this particular time. Okay, so, sort of, managing the patient’s  journey through the service. So, through   the review process, we identified three stages at  which progress through ID-CAMHS, from referral to   discharge, when per – potential issues could  arise. So, at referrals and screening, what   we found was high rates of referral in context of  high caseloads and slow discharge rates. So, that   was the difficulty that we identified, as a team,  which speaks for itself, really. We were getting   lots and lots of referrals. We already had high  caseloads and relatively slow discharge rates. So,   our caseloads were growing, our capacity  wasn’t changing in response to that. So,   we, kind of, had – it helped to, kind of,  identify that and it’s helped later on,   when we’ve obviously had to talk to our Senior  Leaders about, kind of, what our team might need   in the future to support that. So, it’s helped  to, kind of, do this bit of data collection.  So, we thought – and at this point, as well, we  thought about potential management tools. So,   more awareness of waiting times and planning  timeframes, by which assessment and then   treatment phase might be achieved, and then  deliver effective care. So, thinking about   how long were – people were waiting for treatment  and how that impacted on their engagement with the   service. Effective signposting to partner  organisations, information and resources,   which I think that’s something we’ve definitely  got better at since we did this piece of work. I think often, our reaction, because  we’re kind people and we want to help,   would be often, just to, kind of, process  the referral and take it forward. But I think   we’ve been more mindful and thinking more  about what other signposting we could do,   what other partner organisations need to be  involved, what information and resources we   can signpost to. So, I think that’s been really  – a really important part of how we’ve changed. And we’ve done a lot of work with our Gateway  Team, because that’s something that they do,   that they’re really proficient at, so  we’ve, kind of, linked in with them   more. More effective information gathering at  referral. We’ve reformatted our referral form,   and there’s more onus on the referrer  to find and share information. So,   what we found was the referrals would sometimes  be not as much information, perhaps, as we need,   or we’d like. Sometimes they weren’t on our  referral forms. Sometimes there just wasn’t   enough detail. There was no information about  frequency. There was an assumption that we might   be able to work with certain scenarios that  perhaps were best placed by other agencies. So, what we felt was that we just  needed the referrer to take that   responsibility around the quality of the  information being shared at referral stage.   Still can pose a challenge sometimes,  but it’s something that we, you know,   we keep going back to, and I think people  are frequently making referrals. You know,   they’re starting to understand that’s something  that we would want from them, really, and expect. And to offer consultations to referrer,  so via telephone or Teams. Obviously,   they were – obviously telephone, obviously, there  was – existed before the pandemic, but Teams was a   new format that we could use, and we could offer  a consultation and use that consultation, again,   around signposting, gathering more information.  And I think that’s been useful, as well, to,   kind of, offer consultation, rather than to open  the referral and get on with the work and then,   kind of, find out that perhaps we’re not always  the best placed service, or that certainly,   we need to draw other services in. So, that’s  something that – all those things, I think,   have shifted over time. I think doing this  piece of work has really helped in, kind of,   focusing on making sure that we’re doing  this and we’re – it’s part of our process. And so, thinking about formulation and  goal-focused intervention and evaluation.   So, the difficulty, so, limited availability of  partner – particular Clinicians that can deliver   certain interventions. So, what we found is that  after a period of relative stability in the team,   we had people that left that had very particular  areas of interest or skills or training, such as   particularly around sensory integration  therapy and psychological therapies. So,   it became a challenge, ‘cause  obviously, we had young people   open to our service and there was an expectation  out there in the world that we could deliver   some of this. And we wanted to, and in  some degree, we were commissioned to,   but we were unable to during this period of  time, which is a real pressure on some of our   other existing Clinicians that are still in  the team to, kind of – how to work with that. So, we thought about potential  management tools. So, obviously,   thinking about our CPD training and making it more  targeted, making sure that we’re skilling people   up and it’s considered as part of our – through  our PDRs. So, we’re reinstating parenting groups,   which I think was really important part of,  kind of, meeting some of those needs, timely   reviews and assessment of needs. So, don’t allow  drift in cases that demand less attention. So,   I think that’s something that we found could  happen at times, where perhaps there were   certain case – especially when caseloads  are big, certain cases can draw a lot of   attention and then, there can be drift when,  you know, there’s a lot of demand on the team. And so, NICE guidelines, clinical guidelines  and directive/protocols around timeframes for   assessment, really important to try and stick to  those and management of presenting difficulties.   So, really, kind of, thinking about where we  start in terms of creating our formulation,   agreeing our formulation and then getting on with  our goal-faced – goal-focused intervention and   evaluation. Sometimes, we could find ourselves  instantly recognising what the issue was and   trying to get an intervention in place as quick  as we could, because we were just almost, like,   sort of, responding to difficulties. We had to,  kind of, very much focus back on our process. Using formulation reviews and we’ve developed  a criteria for use of a formulation meeting,   to have those regularly. Use the caseload review  days. Caseload distribution amongst Clinicians   monitored in relation to experience and working  hours. So, really, kind of, help – you know,   making sure that people don’t become overwhelmed,  if maybe they’re only working part-time hours or   if they – you know, their experience doesn’t,  sort of, cover some really more complex cases. And then, at the point of discharge. So, the  difficulty we found was there’s a buildup of   long-term case involvement for young people  on medication and the hard to close cases,   so resistance from systems or parents for  ID-CAMHS to close a case. So, again, we had   to really think about our clarity of expectation  of service criteria and involvement at the point   of referral. So, really getting that right at the  very beginning, what the expectations are around,   at what point we might close a case to  a – to the team. And encourage revolving   door episodes of support. So, make sure that  people know that they can come back if things   become difficult again and we can reflect on and  review the advice that has been given previously. So, those are the, kind of, things that we  identified as difficulties and potential   management tools or solutions  to those difficulties. Again,   it was really useful to do that as a team, to get  everybody’s feedback, to get everybody’s thoughts,   to get everyone to take ownership. I think that  was a really important part of what we did. Yeah, so just thinking about other  bits of audit we did to support it. So,   with the support of our Operational Business  Manager, we were able to develop an additional   tool to identify further trends in intervention  and clinical presentation. So, we were able to,   kind of, extract, by going over the details of  people’s caseloads, like – so, our total caseload   at this point in time, which was probably about  14 months ago, was 257 cases. And you can see,   from just, kind of, going through the data there,  so we looked at the main clinical pathway and we   could identify from that what the main focus  of our work was, the core business was. So,   in many respects, it was looking at things  like positive behavioural support planning   was really high. Long-term mana – the ‘LTMR’  is long-term medication review and management. So, the next slide, kind of, shows that in  a bit more det – a bit more clearly. So,   you can see the majority of our case management  was around challenging behaviour, and secondly,   anxiety and low mood. Then there were – initial  assessment stage was, like, next. Then other,   which would be on the previous slide,  other issues that were presenting   and trauma/PTSD fairly low in comparison  to the other areas of focus and then,   attachment, again, a relatively  small part of our core business. So, we looked at our main interventions,  again, extracting it from that previous data   collection. So – excuse me, so again, scoring  really high was positive behavioural support   planning and long-term management – medication  reviews. Then we were looking at, really,   working around communication issues and sensory  difficulties and yeah, I don’t know what else you   can, sort of, extract from that yourselves.  But again, psychological therapies scored   around – moderately, again with, like, sleep  difficulties. So, those were the – looking at,   kind of, the main interventions. So,  again, really, this is just about, kind of,   thinking about our core business, thinking about  CPD, thinking about the skills of the team and   matching the core business and the demands on  the service with the skills that the team have. So, yeah, we had a bit of feedback from our team  on the caseload review days. So, they said that   they – the reviews were “effective, productive and  they aid flow.” “They allow opportunity to revisit   the care plan, risk assessment, explore the  causes for stuckness and review the formulation.”   “They provide a sense of direction and they can  feel onerous, especially if Clinicians are not   prepared for the discussion.” Which I think was  fair, because, you know, there is an element of   exposure when we’re looking at people’s work. But  again, I think the benefit of this particular way   of working as a team, around our collective  caseload, was it’s not really looking at   performance and compliance. It’s looking at – as a  nice balance of objective and subjective data that   we’re, kind of, drawing from that. ‘Cause I guess  stuckness can be subjective and it might be that   we’re thinking about does somebody else perhaps  need to think about this case now? Is this – is it   time for a change of Clinician? And it’s a – and  when people are busy and caseloads are high, that   can be a difficult discussion to think about, kind  of, swapping somebody else in, but it, again it’s   really important, if that’s going to be effective,  to, kind of, take that difficult decision. And some say they feel “scrutinised, hence  caseload reviews need to have a positive focus,   alongside identifying areas of need.” And we  did make sure that we balanced this with some   – lots of consider about – consideration about  people’s wellbeing and it being very much about   our collective and individual wellbeing  and recognising this was about meeting   some of the pressures, and that’s hard – and  that’s really important. And doing that again,   as a collective, doing it together, sharing that. Some more feedback. So, “Although the  stated context for the review is internal,   I was wondering about external factors/wider  contextual influences, like the change in   social care criteria, the local/national  SEND challenges in funding provision,   third sector funding changes. Don’t know if  that’s viewed as being too political.” So,   really interesting that somebody had, kind of,   made connections with that – the wider systems  around young people that we’re working with. Someone else said, “I think it was important that  you were there in the reviews as a Clinician,   as well as a Team Lead. I’ve been part of  these review processes in the past in C-CAMHS,   where it was external people to the  team asking questions/making decisions,   which didn’t feel collaborative  and felt critical at times. These   are systemic dilemmas, not  about individual Clinicans.” So, again, some really important feedback,  thinking about how we make ourselves part   of these reviews. And I think audits  happen and they’re important, but again,   this wasn’t about compliance. It wasn’t about  performance. It was very much about, kind of,   figuring out how to move on with some difficult  management of demands on the service. And “Some   of the figures, I was wondering about the overlap  of family therapy and psychological therapies and   the criteria for the latter.” So, again, thinking  about the overlap between different approaches. Okay, “As well as formulations meetings, I  was wondering about the role of supervision   in the process.” So, again, just, kind  of, bringing in the idea of supervision.   “As a new member of the team, I felt there  was a supportive atmosphere at the caseload   review where I attended.” That “Whilst there were  ongoing challenges regarding demand on the service   and Clinicians’ capacity, Clinicians offered  each other practical and emotional support,   for example, adopting cases that required a  new CCO, a general acknowledgement and naming   that the whole team were under pressure due  to demands.” “It may have been said already,   but the days were a great opportunity  to reflect on the work we do as a team   and how we could make improvements.” So,  again, some really positive feedback there. Okay, so that’s, kind of, got me  to the “Any Questions?” slide,   so I can probably stop sharing  now and we can go to the Q&A. Dr Asha Gowda Okay, thanks, Dave. Actually,   it was really an informative talk, and I think  I’m not going to be alone in saying that,   actually, a lot of the things you’ve talked  about, it resonates with a lot of us in this   group. ‘Cause I think we have all had similar  experiences of the demands increasing,   but the resources still remaining the same, or  sometimes actually decreasing and still having to   manage expectations, both internal and external  expectations, from others about our services. And I think for me – I’m just looking at the  questions. There are no questions as of yet,   but while we wait for people to think  about questions, I have got something that   I wanted to comment on. Is that one of the  tools you talked about, especially, I think,   some of the stuck cases or being able  to swap cases and things, as a service,   do you actually do some joint working, when  it’s two Clinicians working with the same case   and having one as the primary case holder?  So, I see a lot of nods, so I think that’s… Dave Smallman Yeah. Dr Asha Gowda …happening. Dave Smallman Yeah, it does happen, but I would  say that it got to a point that even that became   a challenge, because it would mean, yeah, that  – yeah, I don’t know. I think we try to do that,   and I think well, some people work like that  better than others, or more so than others.   Some people prefer to be more independent,  I guess, and – Anu, you’ve got your hand up. Dr Anu Devanga Yeah, I think it’s a reflection.  So, I’ve been with the service for the last   seven years and what the team looked like when  I interviewed for the job and when I started,   and for the first maybe six months, is completely  different to what the team looks like now. There   are a few of us who have stayed on, and I  think prior to that, you’re talking about   a lot of consistency and stability within the  team, largely, people staying on for longer   periods. And I think it was a combination  of, you know, the phase of life we are in,   or stage of life. So, it’s personal circumstances,  whether it’s career progression, retirement,   losing people prematurely to illness and the  pandemic. So, we went through a phase where   we lost a lot of Senior experienced Clinicians.  We’re talking about, you know, Band 8a Clinical   Psychologists, non-medical prescribers, and it’s  so difficult to run a Pan-Dorset service as a   sole Consultant if you don’t have your, you know,  rocks who, sort of, help you do all of the work. So – and I think particularly, it makes it very  difficult, because some of the Senior Clinicians   offer that containment, that space for reflection,  supervision, case-based discussions, formulation,   without it necessarily going into always some  therapeutic support or coming from medications.   And I think the trend we started to see was I  generally am the last person to see a family,   as you would see in most of the teams, unless,  you know, there’s an acute mental illness or   it’s a highly complex situation. But we went  through a phase where – well, I still do,   I know pretty much every child who’s open  to the service, but very closely as well,   because I became the contact person between,  you know, some of the Band 6/7 Nurses,   and we have a very good working relationship. So, pretty much everybody in the team can, sort   of, have those discussions, but it became more and  more. It came very quickly on and not just that,   the referrals were, like, even sometimes for three  to five-year-olds not wanting – not about wanting   to come into the service for support, but directly  asking to see a Doctor, see a Psychiatrist, want   medications. So, there’s loads of things that  we have to deal with whilst we were, sort of,   trying to tide over some of these significant  changes. And I think the point I’m trying to   make is you always want a phase where you, you  know, stormed and formed, normed and perform,   and we’ve had very small periods of where we’ve  been able to perform and it’s been forming,   norming, but we’ve had our fair share of  storming over the last three years. And yes,   it does shake the team quite a bit when  you have some people who’ve been with the   service for 20 odd years/ten years,  not being present there, so, yeah. Dave Smallman Yeah, I think that… Dr Asha Gowda Thanks a lot. Sorry, go on, Dave. Dave Smallman Sorry, I was just going  to say there’s a couple of questions in   the chat. I was just going to respond  to those. So, is that okay, yeah? So,   Michael’s asked about “keeping the day on  track” and it “not being potentially too   hard,” which is a really good point about  it being “arduous,” because, like I said,   it is – it – sometimes it’d be quite – it can  be arduous to, kind of, turn the spotlight on   oneself, or collective self. So, we didn’t  initially be – and that was really – but we   very much used the – why I asked people to  prepare their, kind of, their review tools,   Excel sheet, prior to the day and then spent  time, kind of, going through that together. I think it was probably more useful to think about  stuck cases or – and we put time aside for people   to think about cases that could be closed. Or I  think recently, probably the focus has been more   on the cases that – where we haven’t had contact  for a while and maybe there’s been some drift. So, I think really, each day has been slightly  different, with a slightly different focus,   but yeah, that’s a really important thing to  consider, kind of, how to structure it. I think   it was a balance of really, kind of, coming  together, looking at everyone’s, kind of,   Excel sheets and identifying, kind of, what their  particular issues are and then some time to,   kind of, go away and work on some of that.  So, that was partly how we structured the day. Again, a question from, I think, Mandy,  about, kind of, how we “engage the team”   and the “trust within the team” was really  important. It’s a – it is a really close   team. People have worked together for a long  time and new people coming into the team. So,   we’re very, very lucky in that respect. So, yeah,  that’s a yes, but we’re a relatively small team,   too, so that’s an advantage, so we all know each  other quite well, spend a lot of time together.   But then, I would say, also, there’s been new  people that have joined the team, have had less   opportunity to build those working relationships  because there’s a lot of remote working now. So,   I can’t speak for everybody, so I’m not going  to, but yeah, we are lucky in that respect. Dr Asha Gowda But then, you, kind of, hit the  nail on the head, Dave, with sometimes when the   teams are smaller, you have lot more opportunities  to build those relationships and you have. And the   question about ‘trust’, and I think I did make  a note in my thing there, for Mandy, who posted   the question is, think of a – it’s all based on  the trust and confidence to – in this service or   the team to think that they have got your back.  And that sense of being contained is so important   within services to be able to do the work that we  do. And I think smaller teams are great, but also   – which means that your service, particularly,  is a smaller service and looking at the number   of referrals, I was thinking when it comes to  Core CAMHS who have about 1,000 and odd cases   open to their services, how do you do it? But the  idea of then grouping them into smaller teams… Dave Smallman Yeah. Dr Asha Gowda …but also integrating them  back as a whole service, the challenges   that come along with it. Dave Smallman Yeah, yeah,   it would be – it – I could imagine it  would be trickier with a bigger team,   for sure, yeah. It would need a – you’d need  to think about that structure, I think that… Dr Asha Gowda Yeah. Dave Smallman …as Michael was pointing  out, how to keep that structured. Dr Asha Gowda Yeah. Anu, you’ve got your hand up. Dr Anu Devanga Yeah, I think there were.  The reflections were on all of the questions,   you’re right, Dave, that’s what I have  felt. It’s a very cohesive team and I   think up until a certain point, I  was the newest member of the team,   and I think – I don’t think it took me a  – you know, long to just be part of that   service and that’s what I saw. Very passionate  and enthusiastic people, they’re highly skilled,   wanting to do the best for each other  and all the children and young people. And the knowledge that you have about individuals,  not just professional life, but personal, in that   sense, as friends, friendships or relationships,  helps you to pick up at certain times when people   are not in the best frame of mind. But people  also feel abe – or they have felt able, largely,   to be able to receive the support, and I think  majority of the times, that’s what we have,   sort of, found. And sometimes people can’t ask, or  don’t ask, but they want somebody to pick it up,   you know, and offer that support and  I think they have seen that go well. And you’re right, it is a small service, but – and  I think that’s the work that’s gone in, because   we – there was a time when we were receiving  a lot of referrals. The number of referrals,   sometimes, you couldn’t even do that in one  screening meeting. It took several things to   be able to give a good enough, you know, sort of,  reasons why we are not expect – accepting someone,   but we would always give them something to, sort  of, work on in terms of signposting resources. So,   that took a long time. It was never just, like, a  rej – you know, a referral rejected, even amongst   those times when we didn’t have capacity. And the number that you saw is for the East   team. It’s not the Pan-Dorset. The other  side has 100 cases, which some of, like,   Clinicians in the East are not involved with,  but there are some who work Pan-Dorset. So,   there’s another bit of team. So, the – again,  getting that consistency between the two teams’   offer, because there were differences even there.  So, we have wor – been working on that as well,   so that our East and West offer is consistent,  and wherever possible, drawing upon people for   supporting in terms of CPD and case discussions  and formulations and supervision. And that’s how   we’ve, sort of, pulled through when we  haven’t had Clinicians in the East. And   there is work going on to make it a little bit  more, sort of, joined up in that sense, yeah. Dr Asha Gowda Thanks, Anu. I’m  just wondering if anybody else,   other delegates, have any questions or  thoughts and reflections that you want   to share with the group [pause]?  It’s a very quiet group, isn’t it? Dave Smallman Yeah. Dr Anu Devanga I was trying to see if I  do recognise anybody and I’m sorry if we   have met before and I can’t, but I do reme –  recognise one name. I met her recently at the   CADA Conference, so I would like to say hello  to Priyanka and hello to everybody else there. Dr Asha Gowda I know Michael Hann, I think. Julie  Owens, I think I might actually know Julie Owens,   but may not be. If I can see the faces, probably  I can recognise, but the cameras are off... Dr Anu Devanga Well, I do… Dr Asha Gowda …and so… Dr Anu Devanga …know Jenny and  Mandy. I didn’t mean in that sense. Dr Asha Gowda Anyway, I think if we do not have  any more questions for the speakers at this point   in time, we could move onto the next talk. I’m  going to give you another chance. So, going once. Dr Anu Devanga I just… Dr Asha Gowda Oh… Dr Anu Devanga I wanted… Dr Asha Gowda …one of you have got a hand up. Dr Anu Devanga Oh, I wanted to thank Dave for the   work he put into that and for the  presentation that he put together,   which we went through the team if they wanted  to add something to it. And it was – we are   grateful for the feedback we received and thank  you, Dave, for coming and presenting it here. Dave Smallman No, no, it’s really – yeah, thank  you, and thanks for the great questions. So, yeah,   thanks for having me, yeah. And I think – you  know, I’d just like to ext – even though they’re   not here, extend my thanks to the team, ‘cause  I think their really candid feedback was really   important. And I think there’s an authenticity to  the process that we did that felt really – it felt   good to go and take the team through that. So,  yeah, it’s – and it’s nice to be able to, kind of,   share it with you and I hope you’ve, kind of,  taken something useful from it. So, thanks… Dr Asha Gowda And thanks, Dave. Dave Smallman …thanks for listening. Thank you. Dr Asha Gowda Thanks, Dave. Actually,  Priyanka has put her hand up, so let’s go to… Dr Priyanka Palimar Hello. Dr Asha Gowda …Priyanka, then. Dr Priyanka Palimar Yes, and thanks so much.  Yeah, it was really good. I didn’t – not sure   I cast all – caught all the questions at the  end, but I listened to all of your presentation,   Dave. It was, yeah, an amazing piece of work  and obviously, a lot of work went into that. I just wondered, actually, whether  it rubbed off on Core CAMHS,   just because they tend to have a longer  waiting list in most areas? Yeah,   so, I wondered how it, kind  of, rubbed off on other areas? Dave Smallman Ah, that’s a  good question. I don’t know,   to be honest. It’s not something that  we’ve, kind of, shared with Core CAMHS. Dr Priyanka Palimar Hmmm hmm. Dave Smallman It might be something that,  yeah, we have an opportunity at some point   in the future. I think there’s a very  def – very different structure, sort of,   but similar pressures. It’s difficult to know how  they would – how that team might find that useful   process to go through. I guess it’s fine margins,  I think, with small teams, isn’t it? You know… Dr Priyanka Palimar Hmmm. Dave Smallman …and I think that’s like Anu was  saying about, you know, you can have tens – you   can have a quiet month with referrals,  you can have maybe two or three and then,   you can have maybe ten. And that’s half of  – that’s half a reasonably sized caseload   and when you’ve only got a small team of  Clinicians, that’s – that feels quite a   lot. But I guess if you’ve got a bigger team and  you’re, kind of, able to absorb that a bit better,   maybe do some more, sort of, targeted work. And I think working with young people with   intellectual disabilities, there’s so much  complexity to their presentation, sometimes,   and not that there isn’t with other young people,  but I think there’s other factors that we have to,   kind of, take into account, people’s  communication and their educational   needs and social care needs. So, yeah, it  feels like there’s more complexity, but then,   I’ve been in this team forever, so I haven’t got  much experience of Core CAMHS, so that’s not my… Dr Priyanka Palimar I do a bit… Dave Smallman …area of expertise. Dr Priyanka Palimar …of Core  CAMHS. I cover a bit of Core CAMHS,   as well, and I’d say the complexity is  different, but it’s still very much there. Dave Smallman Yeah. Dr Priyanka Palimar And with the education  problems, with the – especially with the   autism group of young people who are no longer,  kind of, fitting into mainstream a lot more now. Dave Smallman Yeah. Dr Priyanka Palimar Social issues. But I think  it’s – I think your – I think the point was also   the capac – not the capacity, the number of  Clinicians in a team, the size of the team. Dave Smallman Yeah. Dr Priyanka Palimar It’s like all  these discussions are facilitated by   the fact that you are a close – pretty close  team. It was felt very easy to – and open,   obviously, people – for people to, kind of, share. Dave Smallman Yeah. Dr Priyanka Palimar Whereas with Core CAMHS,   I think just the number of people, the  – I’m not sure that always hits. But   I think it would be really useful,  actually, because I think there’s… Dave Smallman Yeah. Dr Priyanka Palimar …something  about not – people not feeling,   as you said – people feeling criticised  for holding onto cases when genuinely,   I can see from the inside why  they’re stuck with that or… Dave Smallman Yeah, yeah. Dr Priyanka Palimar …why they  feel they could not discharge. Dave Smallman And it might be you’d need  more of maybe, like, a workshop format. Dr Asha Gowda Hmmm. Dave Smallman Or to, kind – yeah, to,  kind of, try and put it into, kind of,   more manageable chunks. I don’t know how  it would work. But it is really useful   just to bring people together, I  think, and again, that, sort of,   objective experience of managing their  caseload, I think it’s just really helpful. Dr Priyanka Palimar Thank you. Dave Smallman Mandy? Mandy Yeah, just on the back of that point,  really. I think our service currently has a   huge caseload. It’s about 11,000 youngsters on our  caseloads and lots of different teams as part of   that, locality teams and specialist teams. But  some of the work that we’ve been doing has been   looking at how difficult it is to discharge people  and actually, it takes a lot of work to discharge   youngsters off your caseload. You have to put  a lot of energy into that and supporting them… Dave Smallman Yeah, yeah. Mandy …in their recovery and stepping them  off different pathways and giving them an   opportunity to embed some of the skills that  they’ve developed and learnt as a result of the   intervention. And I think it’s no coincidence,  I think certainly, in community CAMHS services,   that when people either go off on maternity leave  or leave the service or go off sick, there’s a,   sometimes, a review of people’s caseloads and  you’ll find that just because that’s happening,   all of a sudden, quite a few youngsters are closed  from their caseload. And there’s really active   involvement around discharge. So, I think that the  concept of reviewing caseloads, I think, is really   an important one, which is why I was asking about,  you know, the groundwork that you did beforehand. Dave Smallman Yeah. Mandy I think there is an issue  for all of us that we do – you know,   it is – it takes a lot of energy and  sometimes, when you’re leaving a service,   then you’ve got some motivation to address some  of that. And I do think it’s really important… Dave Smallman Yeah. Mandy …in the current context of  all of our services that we are   consistently looking at that part of the process. Dave Smallman Yeah, and if you’re  protecting some time to reflect on that,   maybe people wouldn’t have to leave to get that. Mandy Yes. Dave Smallman Make that happen.  Yeah, there’s a couple of hands up. Dr Asha Gowda I think Anu was first. Go on and... Dr Anu Devanga Yeah, I think that my – I put  my hand up when Priyanka asked that question   and I think that was a very, sort of, good  question to ask. In terms of – I think in   my other role as the Medical Lead for CAMHS, I’m  aware that caseload reviews do happen and – but   I think it happens for different reasons.  And some people have found it helpful,   and I think it’s not necessarily the  caseload review tool that we have used. The Trust came up with a caseload review  tool which had the compliance with Rio,   which feels like a bit more of a pressure. And  we are talking about caseloads of – in some of   the rural teams, it is probably similar to ours  or a bit less. But there are the urban teams,   like Poole – Bournemouth/Christchurch, who  have three times the caseload that we have,   or two and a half. And maybe Clinicians, the  numbers are probably a bit more than ours,   but not everything fully recruited. So, the  pressure on them to do those reviews is a lot. But I – in view of what Mandy said, I think it  should be part of our job plan, and wi – you know,   to have – to be doing that as part of our clinical  work, to give us a sense, reflection on the work   that we have done, what more we need to do. For  who do we need to do what and when? And then,   what is a – how can you progress to closing them  or signposting and all of it? Because it’s not   very often that we leave or we’re trying to go on,  you know, all sorts of different kinds of leave   and if we are dependent on that, then it really,  sort of, becomes a huge bit of work. So – and I   think it’s easier said than done. It always comes  to time capacity, but teams who do that regularly,   or individuals who do that regularly, for  whatever reason, because of their – the way   that they organise things, it’s always beneficial,  and that’s my personal experience, as well, yeah. Dr Asha Gowda Thanks, Anu. Thank you both,  actually, Dave and Anu, for, like I said,   quite an important topic. This is so  relevant to our working practices. And   I’m just going to make one last comment  and then, we’ll move onto the next talk,   and the comment that I had was to say  that just earlier, you were saying,   Dave, that you’re setting expectations for  patients as to what the service can offer and   what needs – you know, and how we can actually  start planning discharge from the word go. And I   think the same principles need to be thought about  for new members coming in, or even for the staff,   thinking you start as you want to continue.  So, you set the service as we want to continue. The expectation that there are going  to be caseload reviews regularly,   whether it’s in the form of line management,  you know, one-to-one line management,   or as a team that we are going to review cases.  And that there is the expectation this is going   to happen fre – regularly, so at those agreed  time intervals. And I think when that is set up,   it’s far more easier to follow the pattern, rather  than actually feeling like, oh, I was not aware of   that expectation and now feeling like you’re being  under scrutiny. And I think that’s something that   I’m just going to take back for our service  and thinking that, yeah, this is something. Dr Anu Devanga The take home message, yes. Dr Asha Gowda Yeah. Dr Anu Devanga I like that line, “Start  as you want to continue.” Good one, Asha. Dr Asha Gowda So… Dr Anu Devanga Thank you for that. Dr Asha Gowda With that, I thank you both.  I’m going to introduce our other two speakers,   and they are Jacqui Tyson and Megan Fowler.  I’m going to lower my hand, first of all. Now,   Jacqui is a qualified Registered Mental Health  Nurse since 1993 and has over 30 years of   experience working in many health settings. She  has worked across all ages, and she has qualified   as an Approved Mental Health Professional as  well, since 2012. She has achieved her MA in   Advanced Mental Health Practice in 2017. She is –  has an expertise in operational and organisational   management. She works to develop services and  has created innovative projects to link with   her clinical practice and social justice. She’s  very passionate about her work, from per – a   person-centred perspective, to improve the  quality of life for children and young people. And Megan Fowler, she is an Occupational Therapist  by background, who has had over five years of   experience in CAMHS. She has also worked across  all age groups. She is an Assistant Team Manager   and has an interest in the recovery model and she  is a Clinical Supervisor for the STaR workers.   Now, without much ado, I’m going to hand it over  to both of them to present their talk. Thank you. Jacqui Tyson Hi, thank you, and thank you  for your interest in attending today to hear   about our enquiry-led quality improvement  project on Support, Time, Recovery Workers,   and how we have recently started using this  role to support with managing unscheduled   care and improving efficiencies within the  community CAMHS teams in Hampshire. So, today,   Megan and I are going to be talking with you  about actually, what is unscheduled care and   how we use the QI methodology in the development  of the STaR worker role. What the recovery model   and poverty model interventions look like  in CAMHS and where we are and what next? So, the context behind this is it was  being recognised through supervision,   line management, clinical supervision, appraisals,  leadership meetings and staff conversations,   particularly following COVID, that there was a  change in the demand and complexity associated   with the open caseload of the locality CAMHS young  people. And the term ‘unscheduled care’ began to   be used by Clinicians really frequently  to describe this challenge and complexity   in delivering of the services and providing  the care that they were expected to deliver. So, what did we know? We’re thinking about  what’s – where did this come from? So,   we looked at NHS benchmarking, which showed  that Hampshire CAMHS was providing a higher   number than average clinical contacts to  other CAMHS services. I think it was we   were providing an average of 23 contacts,  where the national average was much lower,   at around nine. And at the same time, we were  seeing a significant rise in staff leaving   the service, both within the Hampshire CAMHS,  but I note – think more widely within the NHS,   and particularly Psychologists and  Psychological Therapists often were   citing that they were going to set up in their  own practice or work in another care setting. So, when seeking to understand this, we  undertook a review of the exit interviews   in more detail. These exit interviews were  actually reported as being quite emotional,   with staff expressing feelings of being quite  sad and upset about feeling that they wanted   to leave and – but citing difficulties associated  with the work that they were needing to deliver,   outside of what they considered  to be their therapeutic role. This was the unscheduled care that they  were talking about, which they described   as being work that they didn’t feel appropriately  trained or that they were actually employed to be   delivering. And they felt this negatively impacted  on both their moral and their ability to deliver   the treatment they were expected to deliver. So,  we were really curious to understand this, both   as Operational Managers and professional leads and  we wanted to understand and address this concern. So, thinking about change, with the  quality improvement and the QI methodology,   we asked the following questions. We  had identified a notion of unscheduled   care as being a key factor in which – in  what was the challenge or what was wrong,   but we needed to be clear about what we wanted  to accomplish and understand what actually is   unscheduled care? There’s a lot of talk about  what is unscheduled care, but we didn’t really   understand what that was and how we would  use this to improve the service delivery,   in particularly addressing the number of contacts  needing to be delivered by the Therapist. It was also really un – important to understand  from the beginning what a change improvement   would look like, so that we remained focused  and we could measure the success and make any   necessary changes to the plan as we learnt.  We’ve had, again, qualitative data that can   be gathered to understand the patient journey,  along with staff experience and quantitative data   to examine contacts, both who was delivering the  intervention and how many contacts were required,   enabling us to manage the success. So, the  strategy we developed was what – this is   what we did, and there are four aspects. We  undertook a Community Team survey, and staff   focus groups were held and we used a co-produced  approach and undertook a literature review. The findings were interesting. Five out of the  seven Community Teams responded to the survey,   and we had some really interesting results in  relation to the number and types of activities   which were considered to be unscheduled. Some  examples that were given were “a significantly   high level of contacts involving networking  with schools and children’s services.”   “Crisis containment interventions” were  cited and “the need for contact and   liaison outside of the planned therapeutic  clinical appointment, to support with delivering   the intervention.” Interestingly, there was some  secondary learning also associated, in that some   of the activities to be – that were perceived as  being unscheduled, could indeed, be job planned. We further explored who needed to undertake  these activities, questioning, did the activity   require the allocated Therapist, or could  it be done by another qualified Clinician,   or possibly an unqualified worker? Staff  focus groups were held to further explore   what we had identified within the staff survey as  unscheduled care and unstructured conversations,   thinking about what might work, were held. Here,   we focused on the – some of the challenges and  the reality around recruitment and the need to   do something different. We wanted to ensure  there was co-production from the beginning. There were some challenges with this. We  had poor uptake from the young person and   carer group that we had tried to engage.  However, we did recruit a young adult who   had previously accessed services to join us and  share her story and experiences. Interestingly,   the key message from her experiences were  associated with her care being delivered   with a person-centred approach, which for her,   was not necessarily being seen in the clinic room  and also, having a future focus, which was about   accessing education and a goal of, her words  were, “Being normal and getting on with my life.” The themes that we gathered from undertaking this  piece of work are from the focus groups and the   young person’s experience, identified that there  was a need for additional care activity outside of   that planned clinical treatment intervention, that  didn’t necessarily require a qualified Clinician   to deliver. These activities were grouped together  as either practising or reinforcement of therapy   skills, advocacy for both the young person  and possibly their parents, task-focused,   not therapy interventions, and additional contacts  outside of the planned therapy time to reinforce   these skills, addressing accessibility,  en – and engagement issues. And supporting   with – and like I said, being previously  talking about those safe supported endings. This led to us identifying and thinking about  what we understood as a recovery approach,   which could be an alternative model to be used  alongside the care being delivered and whilst   accessing treatment on an existing care pathway.  At this point is where we undertook the literature   review to explore the evidence around the recovery  approach and the recovery model and looked at it   in terms of its application into a CAMHS service.  Not surprisingly, it was found that the evidence   in the literature mostly had an adult focus.  However, there was a strong history of positive   outcomes related to recovery orientated  clinical practice in those adult services. I think nevertheless, the recovery orientated  approaches, although not well established within   the children and young people services, were  actually equally supported within the literature,   with evidence indicating that the recovery  approach can be used to formulate best   practice for young people when combined along  with a psychological therapeutic intervention.   And this supported the idea of unscheduled  care being accessed as an additional care   intervention, alongside the treatment being  delivered by the allocated CAMHS Therapist. So, what did the literature tell us about recovery  in this context? Well, it was broadly defined as a   recovery, as a transformation from a negative  identity to a positive state of psychological   wellbeing. And within this, the model  identified four key areas social/environmental   accessibility, the development of autonomy  and responsibility, the importance of roles   and responsibility that enable an experience  of belonging and meaning, and an aspect of   acceptance of the difficulty of experience  and how to promote wellbeing. And thinking   about all of that, about the application of  that, and here, I’ll hand you over to Megan,   who’ll be able to talk about this application  of the model into our clinical practice. Megan Fowler Thank you. So, from all of  this, we identified a role of a Support,   Time and Recovery worker, or what we call in the  service as a STaR worker. So, the STaR workers   use this recovery model and we’ve applied this  model into being used within a CAMHS service. So,   Jacqui already spoke about our solution  needing to be viable. So, therefore,   we gained commissioning for two full-time  equivalent Band 4 STaR workers in each of the   locality-based Community Teams. We had a piece  of work to do around identifying how we would   implement a recovery model and create an identity  for those workers, and we also needed to introduce   the role and the model to the Community Teams, as  this is a new way of working within our service. The STaR workers, alongside Lead Clinicians,  maximise the work being completed and so, they’re   working directly with children and families, that  can be either individually or within groups. So,   their work is predominantly community-based,  as opposed to the majority of the CAMHS work,   which is done based in the clinic. This is in  line with that recovery model, as the role is   about engaging with the local area, engaging  with those local peers, those local networks   that exist outside of the CAMHS service, and so,  it’s really best placed to be in the community. And part of what we have been finding from COVID  and in relation to the recovery model, was that   Clinicians were often experiencing that children  and families either weren’t re-establishing those   connections following COVID, that had been,  kind of, previously lost when everybody was   within their houses, or they were experiencing  that actually, those young people and those   families weren’t developing those connections.  And in the service, a lot of the talk was about   young people and families ending up relying more  heavily on CAMHS services for a lot of support. So, thinking about the STaR worker role and  adapting this for the children and young people   and applying it in practice into a CAMHS service.  So, a STaR worker will have a young person that’s   referred to them. There’ll be a pre-meeting  between the Lead Clinician, the young person,   the STaR worker and if appropriate, their family,  and when they’ve been referred, they will have   already been identified the care plan that follows  the areas of the recovery-focused intervention.   And at the pre-meeting, there should be a specific  goal that is identified. We’ve thought about the   STaR worker intervention being around six to  ten weeks and then, there’d be a review at the   end so that – and from that review, they  would be discharged from the STaR worker. In the service we haven’t set a limit to the  amount of times that a young person could access   a STaR worker, as long as there’s another  recovery intervention that’s identified for   that young person. And then, we’ve thought  a lot about how we develop the identity of   the STaR workers and support each other. So,  for their professional identity to develop,   they have group clinical supervision and that’s  with myself, as an Occupational Therapist,   and then, their line management is completed  within their team. And we wanted those two   different approaches so that clinically, they  had a professional identity together and that   was in line with the recovery model, but outside  of that, they were lined managed within their team   so that the STaR worker and the team are sharing  the ownership of those interventions and the young   people that they’re working with. And particularly  thinking about it’s a really short intervention,   so we needed to make that cases, young people,  were being opened and closed effectively. So, when we were thinking about how the cases  should be allocated, this is something that   we’re still partly developing, as we’ve now  recruited to some of the posts. But cases   are really identified by Clinicians that are case  holding or doing therapy with those young people,   identifying them perhaps in their MDT, or  perhaps to the STaR worker themselves. And then,   the STaR worker would bring that case  to be discussed within supervision. The Line Managers and the Clinical Supervisors  within the teams also have a big part to   play in this, as when they’re providing that  supervision to the staff members in the teams,   we would be hoping for them to be looking at that  caseload management and how they can support cases   for the STaR workers, particularly looking  at that throughput of work or complexities. It was spoken about quite a lot in the  last presentation about complexities   or those cases being ‘stuck’. So, within  those discussions that people are having,   we’d be expecting them to be considering  whether there was a role for a STaR worker   to either help with that patient flow  or perhaps to support a discharge. So, I’ll think a little bit about what potentially  a STaR worker might be care planned for. So,   we’ve broken this down into the areas of  those recovery focuses and thought about   what interventions would fall within those care  plans. And to bring to life, we’ve tried to think   of a few examples of what our STaR workers are  already doing. So, the first area will be thinking   about those roles and relationships, so that’s  both for the young person and their families   and thinking about how we can engage – we can  enable that engagement with services or networks. So, areas that we’ve thought about could be  direct sessions to support engagement when we   think – when we’re thinking about whether a young  person or family are ready to engage and what   support they might need to access a service. So,  this could be informing a Lead Clinician of how   we adapt a service to deliver that person-centred  care, or it might be developing an understanding   of the barriers to engagement. Another area that  is – might think about might be about supporting   that informed discharge. So, necessarily, when  we’re exploring that engagement, perhaps it is   decided that actually, this isn’t the right  time, or for whatever reason, this isn’t the   intervention that we want to follow, and actually,  we might then discharge from the service. The second area that we thought about could  be that direct work with the young person or   their families and so, thinking about  how we can support their voice to be   heard in different areas. So, that could  be working with a young person or family   to really explore the areas of need  and then, supporting them to attend,   or attending with them maybe a meeting,  perhaps with schools or other professionals,   and really helping them amplify their voice of  what needs and support they have in other areas. And finally, within this area of developing  roles and relationships, we’ve thought   about psychoeducation and perhaps a STaR worker  could spend additional time with a young person   or a family to support their understanding about  different aspects of their mental health needs.   So, this could be a standalone piece of work,  or it could be in addition to the therapy. So,   for example, if it was additional to a therapy,  somebody might be already having therapy around   anxiety, but perhaps there’s a real piece of work  to be done around psychoeducation about perhaps   the physical sensations of anxiety and how that –  how we can develop their understandings of that so   that they can use that within their therapy.  Or it could be a standalone piece of work,   so perhaps thinking with a young person or  a family, perhaps some sessions around the   teenage brain and that development, to really  enhance their understanding of the young person. The second area of care planning is around  the social and environmental conditions around   resources and safety. So, we’ve got lots of  different areas within this topic that we   think that a STaR worker could provide support  for. So, our first area would be thinking about   that direct work to return to school. So, this  is often an area where we get young people that   have been out of education for a really long  time, or perhaps something has happened which   has meant that they’ve had a temporary period  where they haven’t been in education and need   that support to get back in. So, the STaR worker  might establish a relationship with the SENCO in   the school and they might work with a young person  to identify areas of need and then, support that   young person and the school in planning about how  they would be managed or supported in the school. So, when we’re thinking about this,  we’re thinking about somebody, maybe,   that is going into a different provision  following mainstream education, or perhaps   thinking about the therapy that they’re having  and how that relates to school and the context   around that, and what impact, perhaps,  it’s having within the school environment.  Another area we thought about particularly  that we’re finding an increase in recently   is young people that have difficulties  around disordered eating and the impact   that that can have when they’re at school.  So, the STaR worker might become involved   to really think about that area of need  and identify what can be put in place in   school to enable them to continue attending  school, but also to be safe within school. Our second area that we’ve thought about is about  direct support for that ‘therapy homework’ we’ve   called it. So, it may be, perhaps, particularly  if parents aren’t that psychological minded   or perhaps the young person would just really  prefer to not do that work with a parent. So,   we’ve thought about two different areas.  So, this could be either applying skills   from the therapy in the community whilst  they’re having that therapy work. So,   they might be set those home practice or homework  tasks to happen in between sessions and a STaR   worker could really support them alongside  that therapy, to go out and do the homework. Or the other bit might be perhaps after a piece  of therapy work, that perhaps during the therapy,   they’ve created a graded exposure hierarchy or  they’ve created a behavioural activation schedule.   And once that therapy is nearing completion, or is  complete, then perhaps a STaR worker is allocated   to work through that outside of the therapy  room. So, we do have a STaR worker currently   who’s working through a graded hierarchy  with a young person who’s situationally mute   and they’ve had a block of therapy and they’ve  finished that and created this graded hierarchy,   which our STaR worker is now doing to  support the discharge from the service. And our third area of need, we’re thinking about  STaR workers supporting young people to re-engage   in those meaningful activities. So, this is really  in line with my interests as an Occupational   Therapist, but it could be about helping  those young people make connections in their   local communities or re-engaging with perhaps  those activities that they lost when they were   unwell. It could be supporting them to find  work. It could be supporting them with a new   hobby. It could be thinking about a Saturday  job with them. All different range of areas,   but actually, getting them into that  meaningful activity outside of the therapy.  We’ve also thought about STaR workers  having part of their role when a young   person is open to a Child in Need or a child  protection meetings, that the STaR worker,   when they’re working with that young person, could  also attend those CIN or those child protection   meetings and present the report on behalf of the  Clinician that’s working with that young person. We’ve thought about recovery – wellness recovery  action planning. So, when a young person is coming   to the end of their care, perhaps there’s a  piece of work that a STaR worker could do to   really support that positive ending. So, it’d  be thinking about the – how the young person   can access care and support outside of CAMHS and  what would actually indicate a need to come back. Another area we’ve thought about is those  communical – community networks, sorry,   and informal support. So, what we want our STaR  workers to be able to do is develop a bit of   a resource base within the community and create  links with other services that work around side   us. So, maybe thinking about the Prince’s Trust,  or we’ve got a local provision of a Sport in Mind,   or those MD support groups with Autism Hampshire.  And we really view the STaR workers as having   a role of helping families and young people  become linked in with these other organisations. And our final area that we’ve considered within  this is that direct support to engage or attend   therapy sessions, or I guess, thinking about those  times when we get young people that, kind of,   don’t engage with the services. And actually,  what we think would be really useful for a STaR   worker would be to be allocated to explore that  more. So, where they can have a bit more of that   flexibility to work really creatively with  the young person to identify what CAMHS maybe   needs to do to support that engagement.  So, we’re thinking about that, kind of,   outreach style work, really working  in that person-centred way to support   them being seen by that specialist  Clinician to do a piece of therapy. The other areas that we’ve thought about is  thinking about maybe our teenagers, where   parents and young people have really different  views about what they want CAMHS to provide   and have really different views on whether the  young person should be engaging with CAMHS. And   actually, our STaR workers can be allocated to do  a piece of work with that young person and that   family to, I guess, try and figure out what’s  happening with that young person. And actually,   if they are making a choice that they just  don’t want to engage with CAMHS, then actually,   that piece of work can really support making  that a safer discharge from the service. And our final area of care planning is  around those reasonable adjustments. So,   supporting the autonomy and empowerment  for the young person and their family and   doing that direct work with them. So, when we’re  thinking about supporting reasonable adjustments,   we’re thinking about making sure any work is  accessible and any adjustments are made for   any identified diversities. So,  this could be neurodiversities,   cultural diversities, perhaps  parents with their own needs. An example that we’ve thought about  this is the autism assessment process,   that it’s quite complex, there’s quite a lot of  stages to it. There’s the assessment process,   there’s the feedback appointments, there’s the  report and then having to create a plan of what   happens next. So, potentially, there’s an  area that we thought particularly about,   where actually, a STaR worker could be  allocated to really support people to understand   what’s going on, particularly  if they’ve got additional needs,   and particularly around creating that plan of  what happens next after that autism assessment. We also have parents with their own  neurodiversities or mental health   needs that perhaps their needs impact the  child’s attendance on CAMHS and that might   be an area where there might need to be  some extra support to engage that child. We’ve thought about the direct and indirect work  to support complex transfer of care planning. So,   we’re thinking really about – here, about  transitioning to adult services. So, that could   include the MyCareMyView [means MyCareView] tool  and completing that with a young person to help   them identify what needs they want, kind of, met  within adult services and the support around that.   And it could also involve that practical support  with those transition appointments and going to   a new service for the first time. We’ve thought  about perhaps this could be a graded discharge   from CAMHS, as well. So, maybe in supporting  them to have a therapy break from a Clinician   and doing some of that reinforcement work in  the community, to then support the discharge. A third area that we’ve thought about is  that parallel parent work. So, in all of our   care plans, we identify what parents will do to  support a young person with their mental health,   and we’ve thought about how STaR workers could be  allocated to support a parent to implement that.   So, again, we’re thinking of particularly those  parents that maybe aren’t that psychologically   minded or have their own personal barriers to  them implementing that and actually helping   them to get onboard and do some of that work  within the community with the young person. And the final areas that we thought about within  this recovery focus is about that direct crisis   work. So, supporting those parents or the young  person when they’re in an acute stage of crisis.   So, that could be establishing regular contact  with parents when a young person is in crisis,   or perhaps provide an increased contact to  the young person to help both the parent   and the young person feel more managed and  contained whilst in that period of crisis. So, moving onto our implementation plan. So,  we’ve had a project plan around recruitment.   We have recently, TUPE’d over to being part  of Southern Health and so, we have had delays   in our recruitment process, but we’re really  excited that we’ve had several rounds of   recruitment now. So, we’ve had involvement in  our recruitment process from the young adult   that Jacqui spoke about earlier and who’s  got lived experience of CAMHS services. So,   they were involved in developing those  interview questions with us and they   also sat on the interview panel and in – have  interviewed every single applicant with us,   and we’ve found that really valuable, actually,  haven’t we? So, particularly having them part of   the interview panel, as they would often have  different views to us and they would often be   looking at different aspects of a candidate  than we were looking at. And it was really   useful to have their feedback and we were – we  really took that onboard, actually, didn’t we… Jacqui Tyson Hmmm hmm. Megan Fowler …in all those interviews? When – we thought we’d speak a little bit about  some of the, maybe, challenges we’ve had. So,   we have had a mixed – a mix of interests in the  applicants that we’ve had apply. So, generally,   we’ve identified areas that we’ve had quite  a lot of significant interest in. So, that’s   been from psychology graduates, people working  in education, perhaps as Teaching Assistants,   people that have worked in CAMHS but perhaps  in non-clinical posts and people with lived   experience. So, at the moment, we’ve  recruited five out of the 12 vacancies,   but we’re about to go into our third round  of recruitment. I was just thinking what   round we’re on. Our third round of  recruitment and we’ve actually got   15 interviews lined up over the next two  and a half weeks, which is really exciting. Some of the limitations we’ve found is that  we’ve had people that have had a lot of academic   knowledge, but perhaps they’ve been less able  to link that knowledge to practice into the   recovery model. Or we’ve had people that have got  some healthcare experience or some other relevant   experience, but actually, we felt they  weren’t able to work to that Band 4 level,   because that does come with a level of  autonomy and actually, that – you’re   going out and working in the community on  your own with young people and families. Since we’ve been under Southern Health, we  have had some additional support and hopefully,   we’re thinking that that’s what’s led to us  having a really successful round of applications,   and we’re hoping that we can recruit from  our 15 people that we’re going to interview. So, the other area of our implementation  plan has been around the training. So, again,   our young person with lived experienced supported  us to help identify what training these workers   would need coming into CAMHS. So, the initial  group of workers had a three-day induction,   where we provided, I guess, a bespoke induction  to them. So, we introduced them to the service,   we thought a little bit more about the model  and we provided some really bespoke safeguarding   training and training around community  work, ‘cause that was what we identified   they might need quite quickly coming in. We’ve also thought about the training for the   teams. So, that’s been around the role of the STaR  worker, but also around the recovery model. So,   Jacqui and I have visited each of the teams  that have had STaR workers or are due to have   STaR workers, to help un – help them understand  the process around developing these roles and   to also really think about that model and how  they can support – how this can support with the   current work that they’re doing. And we’ve also  provided some support around allocation. So, we’ve   had discussions with Managers and Supervisors and  the Clinicians to think about, within their teams,   what cases they have that they could be starting  to refer to the STaR workers once they have them. So, going into our summary. So, we’re quite a  way through this process and we have already   had our first quarterly review meeting. So,  the STaR workers gave some really positive   feedback on the three-day induction, and they  also had a – had some ideas of how we could   develop that. We reviewed what their local  induction had been like and there have been   some challenges in this. We recognise that this  might have partly been that they were recruited   about two weeks before we TUPE’d over to  Southern Health. So, perhaps the teams   were having some unique challenges within the  teams of different work that they were doing and   those changeovers to those new systems. So,  there was a bit of a varied local induction   process for the STaR workers, which we’ve  obviously gained that feedback from and can   do some learning for the next recruitment  of STaR workers that we have coming in. Generally, the STaR workers have fed back that the  recovery – the understanding of the recovery model   is still developing within those teams and there’s  needed to be some more support around identifying   appropriate cases that are in-keeping with the  recovery model. So, from that, we’ve gone back   out and we’ve done more pieces of work with the  teams and thinking about with the Supervisors   around really working with them to identify those  areas that they could be picking up young people,   kind of, identifying those young people  that might be suitable for a STaR worker. When we’ve been thinking about our outcome  measuring, so we’ve developed a specific code   within our electronic notes system so that we  can record the work that the recovery workers   are doing and then, that can form part of our data  that we collect. And we’ve also got a plan – so,   we’ve got a plan to monitor those clinical  contacts with both the Therapists and the   STaR workers, and what we hope to start seeing  is a positive trajectory. There have, again,   been some challenges with our data collecting due   to that TUPE over and there’ve been new  processes and new systems being place. We’ve set up goal-based outcomes on – to  be our ROMS and so, at the start of the   work that the STaR workers are doing, we’re  expecting them to complete that goal-based   outcome and complete that throughout their work  with them and that final review and that can be   another area that we’re going to gain some  data from. And then, the other area that   we expect to see some difference in is those  exit interviews and those STaR surveys. So,   this is an area that we’ll really take the  evaluation of how the teams are feeling   it’s going from what messages we’re now getting  from the staff that are involved in these teams. That is the end of our presentation,  so thank you very much for listening. Jacqui Tyson Thank you. Megan Fowler And we’d be really  happy to answer any questions. Dr Asha Gowda Thank you, Megan and Jacqui, for  such an interesting talk and I think it’s quite   a lovely project that you’ve started. I must  say the recovery college or the recovery model,   it’s so common in the adult world, but  it’s gradually seeping into the CAMHS   world. And recently, I had attended a training  somewhere in London on motivational interviewing   and things and there were quite a few STaR  workers in that training. And part of – it   was interesting how London had invested a lot  of money in those STaR workers, compared to,   I think the rest of the country are still  catching up. But it’s lovely to see that   actually, in Hampshire, you’ve already  have started this work. Good to see. Now, has anybody got questions yet? Or if not,  I’ve got a few questions that I wanted to start   off with. Huh. While others come up with their  questions, one of the questions I had written   down was, “What was the, kind of, training or  qualifications you expected?” And I think you   answered the question. There was some people from  teaching background, Assistant Psychologists and   other people with either lived experience and  things. But the other thing was I was wondering,   has your experience shown that the level of  work or the quality of work that they offer,   or the effectiveness that they’re bringing  to your project, depends on their level of   training prior to becoming STaR workers? Or  do you think actually, there’s no difference   in terms of their training or background,  or professional background or whatever? Jacqui Tyson There wasn’t a – when we  were going through the recruitment process,   we had – we did have a lot of interest… Megan Fowler Hmmm. Jacqui Tyson …on each round and so, we  had a lot of choice about who we actually   took forwards into the post. So, a lot of people  that – like I said, they were – they had – were   graduates or had worked in health services  for a number of years and were interested in   doing this type of work. There were also,  and I think it’s quite relevant, as well,   a lot of people that were looking at gaining more  experience ‘cause they were looking at further   qualifications, either wanting to go into nursing,  occupational therapy or social work themselves, so   were wanting that level of experience. So, there  were – we had quite an interest in the posts. In terms of the quality of the work. The  work is tas – a task-focused intervention   and it was found that it – we didn’t  need a qualified worker to necessarily   deliver those interventions. I don’t know if  we’ve had any specific feedback around that. Megan Fowler Hmmm. Jacqui Tyson But the work being done before,  I think the staff were feeling pressured and   not able to have time to invest or to do the  work in a way that they wanted to do it. So,   now we’ve got somebody to do this  in a dedicated way, they can spend   the time and the investment, to have that  relational aspect, do that outreach type work,   build those connections and have  the relational aspect with the   families. And as – that has been reported  as being really beneficial and supportive. Megan Fowler And I think, as well, that we’ve  started off the STaR workers are having weekly   supervision, because acknowledging that this is  really new and obviously, some of them are coming   into healthcare with different experiences. So,  actually, we’ve been doing weekly supervision   with them where we’re discussing cases.  And I think where we expect there to be a   Lead Clinician working with the young person,  actually, they’re able to get some guidance   from the Lead Clinician as well, and that – the  task that they’re doing is really quite clear. Jacqui Tyson And care planned. Dr Asha Gowda Hmmm, thank you.  Actually, I think it, kind of,   speaks to the idea that that  supervision and holding, again… Jacqui Tyson Yeah. Dr Asha Gowda …containing with the key Clinician… Jacqui Tyson Yeah, yeah. Dr Asha Gowda …and that’s quite important.  Dave has posed a question. He said,   “Important to get the correct balance of  STaR workers and Clinicians in the team.”   And also, has made a comment saying, “It sounds  like a good opportunity for career pathways.” So… Jacqui Tyson Hmmm hmm. Megan Fowler Hmmm. Jacqui Tyson So, we’ve got two – we’ve got –  we have two STaR workers in each of the team,   is the plan. Dr Asha Gowda So,   two STaR workers for a community  team, which holds how many cases? Megan Fowler My team – I – so, I’m from one   of the locality teams and we  have about 1,200 open to our… Dr Asha Gowda Okay, and… Megan Fowler …service here. Dr Asha Gowda Which, kind of, leads me  to the next question, and I was thinking,   is there a limit that you’re going then draw  to say these are the number of cases that   there can be referred at any given time,  because there are only two STaR workers… Megan Fowler Yeah, so, we’re saying… Dr Asha Gowda …for the whole service? Megan Fowler …that each STaR worker, kind of,   up to 15. Obviously, that’s going  to vary. It’s community-based,   so they’re going to need a proportion of their  time to travel, but we’re saying up to 15. Dr Asha Gowda Okay. Megan Fowler So, that would – per  worker. So, I guess that would be 30. Dr Asha Gowda Hmmm. The other thing that I  had, kind of, put down and I know I’m going   on in asking questions here, because I haven’t  seen anybody’s hand up or any other questions   in the chat, so I’m just going to ask. Now, in  terms – it – as we all know, when you recognise   there is a need, you set up a service, the demand  goes up, okay, as people get to know, the demand   often goes up. What is the, kind of, safeguards  you’ve got or have thought about in making sure   that the STaR workers feel contained? And one is  you’ve got your limits in terms of the caseloads,   but also, making sure that they’re not going to  become overwhelmed, just like the Clinicians did,   at any given point? So, what are your  safeguards that you’re going to put in place? Jacqui Tyson So, they’re having weekly  supervision. They also have a – like,   we talked a bit with you about developing  an identity. So, there’s that element of   peer support and understanding a shared  learning that they’re having. They’re not   lone working in the sense of they’re not doing  this piece of work on their own. They’re doing   a piece of work that’s been care planned, or  prescribed, if you like, by the Lead Clinician,   that has a start, a middle and an end clearly  defined and care planned from that beginning. And in terms of thinking about who – you know,  so they’re not overwhelmed with the numbers,   this very much is about identifying who will  benefit from this recovery time, but it’s a   specific intervention. It’s about, you  know, an identified need and a piece of   work that doesn’t continue. So, it will end  and work – you know, it could be revisited,   but it – I think those were the key  safeguards that we thought about. Megan Fowler And I think, as well, in the initial  setting up of it, we’ve been quite – we’ve had to   be quite boundaried around what – there’s have  to have been times where clinical supervision,   they’ve brought cases and we’ve looked at it and  we’ve said, “Actually, that just is not a role for   a STaR worker.” They’re trying to be eked into the  other, maybe, areas of need within the team that   maybe the team was struggling with. So, actually,  I think creating that boundary around what is the   task, what is the – what’s the care plan here,  has been really helpful in protecting them. Jacqui Tyson Hmmm. Dr Asha Gowda Thank you, and I think  we’ve got two questions. Anu and Jenny,   I think I’m going to leave you to ask the  questions, given you’ve got time to discuss the,   sort of, reading of the questions. Anu,  do you want to go first, given you’re…? Dr Anu Devanga Sure. I’m just having  a look once again. ‘Cause I don’t know,   for some reason, I cannot see the questions. Dr Asha Gowda Oh. Dr Anu Devanga Is it the… Dr Asha Gowda Oh. Dr Anu Devanga …one in the chat? Dr Asha Gowda Yeah, they’re all in the chat and… Dr Anu Devanga Oh, they’re all in the  chat. Okay, so I think this is the one,   the one that’s come from Jenny? Dr Asha Gowda Yeah, so… Dr Anu Devanga Sorry, go on, Asha. Dr Asha Gowda No, I was just  saying, you have got a question,   so do you want to come up with your question  and then, Jenny can ask her question? Dr Anu Devanga What do I have? Dr Asha Gowda So… Dr Anu Devanga Where do I have a… Dr Asha Gowda It says… Dr Anu Devanga …question? Dr Asha Gowda I think there  is a question which says,   so, “Would we be able to estimate  throughput given the six-week input?” Dr Anu Devanga Oh, no, no, no. Dr Asha Gowda Would that be…? Dr Anu Devanga So, no, Mandy was writing that. Dr Asha Gowda Oh, no, that’s what Mandy’s… Dr Anu Devanga Mandy is sending… Dr Asha Gowda Oh, that was Mandy’s question. Dr Anu Devanga …a direct message to  me, so I was posting it in the chat. Dr Asha Gowda Okay. Mandy Yeah, Jacqui, Megan, you were  saying about the throughout, weren’t you,   and the caseload? So, is the plan that  you’ll be able to get a sense from the   team about how many cases per year that they  could work with? Just wondering about that. Jacqui Tyson Yes. We haven’t got any clear data  yet that we’ve been able to run to look at those   contents – contacts and look at those outcomes,  but that is absolutely the plan. We plan to look   at from the point of the – you know, that  – those three point, point from referral,   the review and the ending, to look at the  contacts both in terms of the numbers that   the qualified Clinician will have, the numbers  that the STaR worker will have and to look again   at the discharge rates following that. Dr Asha Gowda Thank you. Jenny,   do you want to ask your question? Jenny Yeah, mine was just I know that,  kind of, the CAMHS teams have been, sort of,   diversifying over the last few years and there’s  already, kind of, Healthcare Support Worker roles   within locality CAMHS teams and healthcare  supportive roles within the home treatment   teams. And I was just wondering how it’s, kind  of, decided where and when, who will do what? Jacqui Tyson Good question. I think from  within the community teams at the moment,   the – definitely, the Healthcare Support  Workers are often job planned to do duty,   ADHD clinic and supporting in those types of  roles. This fits to a specific recovery model   with – and a specific way of working, and I  don’t know, Megan, if you want to enhance a   bit more? It’s not about taking on just some of  those functions that don’t need to be done by a   qualified Clinician. There’s something here about  that, as we talked about, that re-engagement,   that meaningful activity and that – developing  that sense of self outside of the mental health   difficulty that they’re experiencing, to aid  in recovery and to discharge from service. Dr Asha Gowda Thank you. Oh, I have a question,  Jacqui and Megan, is that some of the work you’ve   talked about, that, kind of, building rapport,  doing that one-to-one work or aiding the therapy,   those are – and I’m not – and probably it’s  just me, I see it as some of the interesting   part of the work we do with the young people.  ‘Cause the rest of the job is quite heavy and   it’s quite, oh, word, resource intense, but also  emotionally draining for staff. Is this, kind of,   activities taken away from the Clinicians, but  focused by the STaR workers, does it then lead   the Clinicians – and so, what’s your experience?  Are the Clinicians feeling like some of the easy   part of my job has been taken out, or are they  happy, actually, this has been removed from their… Megan Fowler I think it would be… Dr Asha Gowda …job description as such? Megan Fowler …a balance of both. I think that  the STaR workers will get to do some of the nice   fun bits that Clinicians will think, oh, I wish  I could do that. But also, the STaR workers will   probably do some of the bits that people would say  were the really challenging part of their roles,   as well. So, I guess partly, this came from those  Clinicians that were in therapy roles, saying,   “We’re just not doing the therapy.” Like, “I’m  just not doing CBT because I’m having to meet   with the school every week and I don’t have the  time to do the actual therapy that I’m trained   and qualified to do.” So, actually, some of  it will be that the STaR worker will go and   get to do the school bit, that they’ll go  off, they’ll be working with the school and   the young person, and the Therapist can do the  therapy role. So, I think it will be a balance.   I don’t know what you think, but I think some  bits will be that they’ll get to do the nice   bits and go to the nice, meaningful activities  and those bits will be – I think Clinicians will   be slightly jealous of, and I think there’ll  be the bits where it’s like oh, well, “Yes,   you go do that bit and I’ll do what I’m trained  to do.” So, yeah, I think it will be a mix. Jacqui Tyson Hmmm. Dr Asha Gowda Ah. So – and that’s,  kind of, nice to hear that there feel   like give and take from both sides, from  both the STaR workers and the Clinicians. The other aspect I was just thinking was a  lot of the things that you have described as   being the role of a STaR worker falls under  the banner of care co-ordination, as well,   doesn’t it? It’s about liaising –  attending those child protection   meetings or Child in Need meetings and  representing there, or being able to,   kind of, provide that advocacy for the  young person and families. How much do   you think that actually, again, should be  part of the STaR working – StaR workers or   should be part of the care co-ordination,  as such? When do you decide who does what? Jacqui Tyson Yeah. I mean, I think that’s  really interesting to think about, and one   of the challenges that we have within the service  is having someone to do that care co-ordination   role. The reality is, is that with a lot of  limited staff, having both a Therapist allocated,   delivering along the care pathway, and having a  separate Clinician alongside that, is often – is   a real challenge in terms of that allocation and  be able to deliver that. Which I think is what   the feedback we discussed in the beginning, with  staff saying they don’t have the actual ability to   be able to do that role, which is when we broke  it down, was looking at what parts of that role   need to be done by a qualified Clinician. ‘Cause  certainly, there are some aspects that do need   to be done by a qualified Clinician, but there’s  certain aspects that don’t and that that’s a, you   know, that’s a much better use of some – of  a qualified Clinician’s time to be focusing   delivering that specialised therapy. They’re  delivering, you know – they’ve had a lot of   training to deliver that, using their time to do  that, rather than some of those network meetings. Dr Asha Gowda Thank you. I don’t want  to make this a one-man show, but – yeah… Jacqui Tyson Yes. Dr Asha Gowda …so, Anu, thank you… Dr Anu Devanga I did… Dr Asha Gowda …you seem... Dr Anu Devanga …put one… Dr Asha Gowda You have… Dr Anu Devanga …and you probably have discussed  this before and I may have missed listening to it. Dr Asha Gowda I think Jenny asked that question… Dr Anu Devanga And I think it was… Dr Asha Gowda …by the sounds of it. Dr Anu Devanga …in the context. Jacqui Tyson Yeah, so, the – in terms  of the Healthcare Support Workers,   we do have – the Healthcare Support  Workers come in at Band 3 and tend   to sit in clinic with job plans around  specific functions. This is a different   function that they will be delivering and  we’re seeing their work being majoritively   undertaken within a community setting to support  re-engagement with outside agency or interest. Dr Asha Gowda Thank you. I think  Michael has made a comment. Michael,   do you want to actually come online and say it? Michael Roberts No. Dr Asha Gowda No? Michael Roberts Yeah, I just really like  this model. I think I’ve seen it in adults,   and I just wondered whether – do they always  need to have a qualified Care Co-ordinator,   so – as the, sort of, primary case holder,   or are you thinking that they can, you know,  offer an independent piece of intervention? Jacqui Tyson I think that’s a good way of  thinking about it. The way that we’ve gone   with it, and Megan, chip in, is that because  of the purpose of this was to support with   patient flow and to thinking about the roles  that the Therapists were actually wanting to   undertake and deliver, it was to enable  that process to happen. I think it would   be interesting to see if there’s something  standalone that they could do on their own. Megan Fowler Hmmm. Jacqui Tyson Or even if you could have  some unqualified recovery workers within   teams that could undertake maybe some of  that more complex work and some of those   care co-ordination roles. Maybe that’s  something to think about in the future. Michael Roberts I just really like the  group supervision. I think, you know,   they get the one-to-one line management. I really  like the group supervision, I think, and that,   sort of, team around the worker, sort of, style,  that actually, if they’re getting that oversight,   I can really see how they could really make some  inroads into some of the cases that have quite   a complex community presentation that isn’t  just based around their mental health. So,   yeah, I’m really – it’s exciting.  I’ve taken lots of notes, thank you. Jacqui Tyson Thank you. Dr Asha Gowda Thanks, Michael. Anu? Dr Anu Devanga Yeah, I think I don’t know what is  the practice within other services? And if Dave,   you’re listening to me, perhaps you can help me  out. So, within our service, at one point we had   four Clinical Support Workers, we are down to two  now, where they would do this kind – they’re not   called STaR workers, but this is what they work  as. But I think it was perhaps two/three years ago   where they were representing the Care – Clinical  Care Co-ordinator and attending important meetings   and stuff and there was, sort of, a policy that  was brought in that Support Workers can’t go to   some of these meetings, like child protection  conferences, and also some of these reviews,   without the Clinical Care Co-ordinator. And also  – they can go with them, but also, when they’re   making notes, a Rio cannot have an entry from  them alone, unless that’s validated by a CCO. So, it’s just about looking at is it  different for STaR workers and how does   that work? Because it – I totally agree  with Michael, because that would be – or,   like, in – building the resources within your  team, you don’t have – need two people to do the   same, and as long as there’s supervision,  but just wondered what happens elsewhere. Jacqui Tyson So, in terms of thinking  about some of the statutory work, no,   they would not be writing any reports or –  for child protection meetings or Form 1s,   for example, any – or anything  that went forward like that,   they wouldn’t be doing those sorts of roles.  But they might be going there to advocate or   to be the voice of the young person or  the worker. I mean, it’s – you know,   I don’t think it’s about their view, as such.  They are representing the young person or the... Dr Anu Devanga The young person. Jacqui Tyson …at that point. Dr Anu Devanga Thank you. Jacqui Tyson Do you know about Rio? Megan Fowler No, no. Jacqui Tyson No. Megan Fowler Hmmm. Yeah, so, about Rio,   I don’t know that I’ve got – we’ve got an  answer. That hasn’t been what we’ve come… Jacqui Tyson No. Megan Fowler …up against. Jacqui Tyson So, the care  plans and risk assessments are… Megan Fowler Yeah. Jacqui Tyson …all done by the allocated  Clinician, which is why they don’t work   independently and what they’re delivering  is very clearly care planned prior to them   being delivered and is reviewed at  the end by the qualified worker. Dr Anu Devanga Thank you. Dr Asha Gowda I think just carrying on  with the theme that Anu raised, and I had,   kind of, a similar question, is that if –  and I’m probably making assumptions here,   right? So, you’re going to have to correct  me. The STaR workers, because they’re coming   – it’s they are at that stage where they  haven’t actually got a lot of experience   working within CAMHS or health services,  as such. Yes, they’ve got some experience,   but they had the least experience, or are the  least trained, staff. If there was an expectation   for them to attend Child in Need Meetings or  represent CAMHS or the CAMHS’ thinking in that,   especially statutory meetings, child protection  meetings, is that safe, is one question? Second thing is, I think if that was happening,  have we got feedback from the STaR workers to   say are they feeling contained enough to  do – represent? Because I can only imagine,   sometimes, staff saying, “Oh, my God, this  is above my pay grade, and I’m being asked   to do things that I should not be doing, and  I don’t feel safe.” So, how do we actually,   kind of, create a balance which is safe  for the service that we are offering,   so you as a service is not going to  be questioned, but also safe for the   Clinician who is going to go and represent  and for the families, for that matter? Megan Fowler I think the – probably  some of that, I think CIN meetings and   CP meetings are probably different and I  think some of this is what we have ideas   upon. And we haven’t had a STaR worker yet  go to a CP meeting and I think actually,   you’d want them to be an established member of  staff, wouldn’t you? You don’t want someone,   within their first six months, to be going up to a  child protection meeting, of course. But I – yeah,   I don’t know, I think that this is an area that  we want to explore. Certainly, CIN meetings,   I think, are a little bit different, aren’t  they, than child protection meetings? Jacqui Tyson Yeah. Megan Fowler But yeah, I think  we need to be think – yeah,   good points. We need to be thinking about that. Dr Asha Gowda Thank you so much to both of  you. I think – and Michael has made a point,   saying there, “Could this be part of professional  development as part of their career pathway, such   as eyes on practice and part of working towards  becoming qualified staff?” Any thoughts on that? Jacqui Tyson I think certainly that  the linking with professional leads,   thinking about that and thinking about some of  the opportunities going forward, absolutely. Dr Asha Gowda Fantastic, and I  think we’ve got a project that   we can all aspire to start looking at in  our own services. Anu, go on. You also… Dr Anu Devanga Yeah, I didn’t want to  interrupt you, Asha, upset your flow. I   think it’s an – and in the background of that  in terms of we’ve known Support Workers who   have then gone onto do their nursing training  and OT, psychology, and I think it’s been a   pleasure to work with them, you know, when they  have come with that. Because for me, personally,   I consider my Clinical Support Workers to be  worth their weight in gold. The help that you get,   the connection they build with the young person  and also, the families, it’s unmatched. It’s – you   don’t – you sometimes don’t get that same  alliance. So, it’s great to have them,   so yeah, it’s an excellent initiative and I  can – we should have more Support Workers,   Bright Start and the Healthcare Support  Workers that we do have, definitely. Jacqui Tyson Thank you. Dr Asha Gowda Thanks, Anu. If we don’t have any  other questions, it’s 3 o’clock and before we end,   we would really, really love to get your feedback.  So, there is a link in the chat. Please, please   complete your feedback. One last question and I’m  going to wrap this up, is from Dave. So, Dave,   you’re asking, “Is there scope to create a bank  of STaR workers that can work in different teams?” Jacqui Tyson That would be good, wouldn’t it?  I think that’s something maybe to aim towards. Dr Asha Gowda Okay, good. So, thank  you all, and to the speakers and also,   to the delegates who are here. Thanks to Dalia,  first of all, for sorting out the IT and also,   organising our event, and thank you to  all the panellists, as well. Thanks for   being here. We hope to see you again soon  at our other events. We have got an event,   an in-person event on the – Anu, remind  me, Anu, Jenny and Mandy, who is…? Dr Anu Devanga 18th of September. Dr Asha Gowda Yeah, 18th of September on  trauma, on the spectrum of difficulties   that come with trauma and their treatment. So, we  look forward to seeing you all soon, as well. So,   please complete your feedback forms and we  hope to see you soon. Take care. Thank you.