An Introductory Guide For Clinicians & Service Managers CAPACITY FOR PSYCHOLOGICAL THERAPIES SERVICES By The Mental Health Collaborative
01/02 Introduction This guide provides a basic introduction to capacity and ways to ensure services make the best use of their current resources. It is part of a series of introductory guides for psychological therapies services. These guides cover four areas: Demand, Capacity, Goal Setting/Case Review and Clinical Administration. There is also an introductory guide called Start Here that looks at how to implement change in the midst of uncertainty about what will work.
This is a beginners guide to capacity theory as it applies to psychological therapy services. The intention is that it will plant a few seeds of interest and hope to help you with your own service. For the purposes of this guide, a Psychological Therapy Service is any local service providing psychological therapies. Examples might include: Primary Care Mental Health Teams, Community Mental Health Teams, Clinical Psychology Service and Psychological Therapies Services.
03/04 What is capacity? Capacity is the total resource you have available to do the work. It includes staff and any equipment needed (such as rooms). Not all of the clinical staff time will be available for direct service user contact. This is because time will be spent travelling, on leave, at meetings etc. It is important to take this into account when looking at your service capacity. For this guide we will focus on available clinical hours. This is not determined solely by the number of Whole Time Equivalent (W.T.E.) staff you have. Your service capacity is the total number of clinical hours you have available and will primarily be limited by current job plans. If you don t yet have job plans, don t worry, we will come to that. Why work on service capacity? There are a number of good reasons for working on service capacity: Highlights opportunities for releasing more time for patient care. Working on service capacity is not about getting people to work longer or harder. It is about ensuring time is used appropriately. If you ask them, most clinicians would rather spend less time looking for patient records, booking care reviews or going to badly chaired and focused meetings. They would prefer to use the time they save for clinically related activities. Creates a better working environment The feedback from clinical services who do this work is that most clinicians are happier afterwards as their working lives are more in control.
Enables analysis of whether the service has enough staff to meet the demand. If you have also worked on demand, then doing work on capacity means you can analyse whether you have enough resource in place to meet your demand. Helps you make effective bids for additional resources. Can you demonstrate to the organisation that you are using your current capacity as efficiently as you can? Are you effectively managing demand? If the answer to these two questions is yes and you still don t have enough staff to do the work, you will have a really strong case for additional resources. More efficient than more staff. If your team only spend 50% of their time on clinical work (not unusual for a CMHT) then every additional hour you can redirect to clinical work is the equivalent of 2 hours if you bought it in as new staff time. Why is that? Well, lets say you ve worked out that your team needs 20 hours more clinical time. You couldn t just employ someone part time for 20 hours as you know that 50% of a staff member s time is spent on non clinical work; so you would have to employ 40 hours more time to get the 20 hours of clinical work. But if you can create that 20 hours by stopping doing something else, then you only need to find 20 hours.
05/06 What is our service capacity? Okay, so you understand that capacity is the total hours you have available. Now you need to know how to break this down so it is meaningful and can be matched to demand. Step 1 Write down a list of all your clinical staff and how many hours they work. Name Professional Hours Harry CPN 37.5 Sally Psychologist 18.5 Step 2 Ask each member to keep a record of their work for two weeks. Use this to work out the amount of time (in hours) spent on direct clinical work. Also record: meeting time, clinical admin, supervision, CPD/training, travelling and any other relevant categories (for instance if you spend a couple of hours a week doing a piece of improvement work). For example, Harry, who is contracted to a 37.5 hour week, spends two weeks keeping a record of what he does. He allocates hours spent to a few main categories as follows:
Harry s record of work Hours (2 weeks) Average hours spent per week Direct clinical work 40 20 Clinical admin 12 6 Training/CPD 4 2 Supervision 2 1 Referral meeting 4 2 Team meeting 3 1.5 Travel 10 5 Totals 75 37.5 Step 3 Adding it all together to get the teams capacity The following table shows the results of all team members record of their average weekly time allocation. Harry Sally Thelma Louise Totals Direct clinical work 20 6 19 19 64 Clinical admin 6 2 6 6 20 CPD 2 2 4 2 10 Supervision 1 1 1 1 4 Supervising 0 3 0 0 3 Referral meeting 2 2 2 2 8 Team meeting 1.5 1.5 1.5 1.5 6 Travel 5 1 4 6 16 Totals 37.5 18.5 37.5 37.5 131
07/08 Doing Capacity Sums Now you need to use the information you have collected to work out how much time you have available to see clinical work. The easy way is to use the Mental Health Collaborative DCAQ Tool. You put the data in, it does all the sums for you, and gives you the answer at the other end. Information on how to access this is available at: www.scotland.gov.uk/topics/health/nhs-scotland/ delivery-improvement/1835/74 However, we know that some of you will want to know how to do the sums yourselves, so we ve included the following example. Application Tip Calculating how much time you have available to see clients No-one works 52 weeks a year. To calculate your capacity you first need to take into account annual leave, sick leave and special leave. On average one day per week is already accounted for by annual leave and sickness. It can help to remember this when you are thinking about your capacity: a full time staff member is only there for an average of 4 days a week, not 5 days. We will do all our calculations in the following examples based on a 42 week year as we ve made the following capacity assumptions: 8 weeks leave and 2 weeks sickness (4%) per annum.
Application Tip (continued) At its simplest, the team s clinical capacity is the sum of the clinical hours. So using our example above, we have 64 clinical hours per week which equates to 2688 a year (64 x 42) and 224 hours a month (2688/12). If the average number of appointments per case is 8 and each appointment takes 1 hour then the average demand per case is 8 hours. This means we have a total team capacity of 28 new cases a month (224/8). HELP! That sounds complicated Let s break that down then step by step Each referral is seen an average of 8 times for one hour a time. This means in total each referral has 8 hours (8 x 1) of clinical contact time. You ve got 224 hours a month of staff time available to see patients (you ve already adjusted for time spent doing other things). So to work out how many new cases you can see a month simply divide the total amount of clinical time you have (224) by the total number of clinical hours you spend with each referral (8). This equals 28 new cases a month. HELP! That still sounds complicated We ve already mentioned the new DCAQ tool that will help you with this, all you need to do is to enter the data you have collected and it will do all the sums for you.
09/10 But there is a big difference between how much time I spend with each referral. That is true, but averages are fine. You may be surprised when you work out your average numbers. In the Borders, when they looked at average contacts for all clinicians, they were surprised to find that there was not as much variation as they predicted. Most therapists who they thought saw people for longer (including the author), did not have significantly more contacts per patient than those they predicted were quicker. Ok, so I am measuring my capacity, what next? There are two main ways you can use this information about capacity to help you. You might be surprised by the data and how much time you are spending on non-clinical activities. The data might indicate where there are opportunities for redesigning how you run the service so you can release more time for clinical work. If you have also completed work on your service demand, then you can use this data to see if you have enough resource to meet your demand.
Increasing capacity without working harder Releasing time for clinical work Sometimes you can create extra capacity for clinical work by reducing the amount of time you spend on other activities. Looking at how your team spends their time helps you think together about opportunities for redirecting time to clinical work. This is not about getting people to work faster or harder or even longer, it is about using your time smartly. Neither is it about stopping the things we do that add value, for instance, time spent in supervision is important. However, we all know the frustration of ending up doing things we don t think are the best use of our time. How often have you sat in poorly chaired meetings that have been going over the same ground for the last three years? Looking at how your team spends their time helps you think about opportunities for redirecting time to clinical work.
11/12 Example of releasing time for clinical work Doing capacity work helps teams to talk openly about how their time is spent and whether they are making the most effective use of it. It might lead you to redesign some of your admin processes to release time for clinical work or you might want to look at how effectively your meetings are chaired so you can release time for clinical work. The summary of how people spend their time is an essential starting point for looking at ways of increasing capacity. Our staff are contracted to work a set amount of hours, we are NOT expecting anyone to work longer hours! To see how this might work, let s try a few small changes with an example team. Supervison Sally decides to do group supervision saves 2 hours a week Travel Thelma and Harry find a clinic room at base, and no longer travel for one clinic saves 0.5 hours for Thelma and 1 hour for Harry Louise moves a remote weekly half day clinic to a fortnightly day long clinic saves 2 hours driving Meetings The referral meeting is changed to just Louise and Sally meeting for an hour a week to check referrals against criteria and allocate saves 6 hours Sally spends half-an-hour preparing for the team meeting and is supported in chairing the meeting more efficiently so now all business is done in one hour saves Harry, Thelma and Louise 0.5 hours each. The saved time is allocated to direct clinical work (with some additional time for associated clinical admin).
After the changes: Harry Sally Thelma Louise Totals Direct Clinical work 23 8 22 22 75 Clinical admin 6.5 3 6 6.5 22 CPD 2 2 4 2 10 Supervision 1 1 1 1 4 Supervising 0 1 0 0 1 Referral meeting 0 1 0 1 2 Team meeting 1 1.5 1 1 4.5 Travel 4 1 3.5 4 12.5 Totals 37.5 18.5 37.5 37.5 131 The result: Before After Difference Direct Clinical Hours per Week 64 75 +11 Clinical Hours Per Year 2688 3150 +462 New Patients Per Year 336 394 +58 That is 58 more new patients a year, more than one additional new referral a week. No-one is working more hours, there are no new staff, and we have not reduced time for CPD, supervision or clinical admin. This is the equivalent of employing at least another half time person for the team.
13/14 Actually we have added more than a half-time person to our team as we have not yet factored in time for annual leave, travel and so on. We need to use the assumptions we have about how clinicians spend their time, but backwards this time. As we lose so much of a persons time to travel, leave etc every hour you get to reallocate to clinical time is usually the equivalent of employing 2 additional hours. Opportunities for releasing capacity for clinical work In the above example we ve highlighted some areas for consideration to release capacity for clinical work. The following table summarises issues you might want to think about.
Issue Travel Time Meetings Allocation Meetings Clinical Admin Detail Some community services spend a lot of time travelling and there may be opportunities to reduce this. For instance: Is there a need to spend an hour a week travelling to a particular meeting? Would a telephone conference call be just as effective and achieve the same outcome? Can you reduce the amount of time spent travelling to remote locations by doing longer clinics less frequently? Badly managed meetings can waste a lot of time. Some of the most common problems are: Lack of focus and clarity on the purpose of meeting/agenda item; Issues being discussed at length only to defer a decision till a later date due to a lack of information or key people being unavailable; Lots of people sitting through a discussion that is only relevant to two people. Is it necessary for the whole team to attend the allocation meeting? Could the allocation of referrals be done differently? Do your admin procedures involve duplication such as: Duplicate assessments of patients; Typing up notes, only to have admin retype them into a template; Entering the same information into two or more systems? Writing notes of meetings that are then typed up (why not take a laptop and get someone to type the notes straight in).
15/16 Issue Detail Skill Mix Absence Rates Are your highly skilled/specialist staff deployed appropriately? If not, then reviewing your skill mix may mean you are able to utilize existing resources more effectively. You will have an organisational policy for how to manage sickness absence and this will be based on best practice. Are you following it? These are just some ideas, you will probably have a lot more. But remember, this is not about making staff work harder; it s about working smarter. This is about reducing the time spent on unnecessary activities, with all of the negative emotion that goes with that. It s about removing the day to day frustrations we all experience when wasting time fixing problems or spending time doing something unnecessary.
Keeping it Right - Individual Job Planning Everyone should have a job plan which sets out the percentage of time they are expected to spend on the activities relating to their job. This plan should be reviewed regularly and will be central to personal development planning and appraisal. All the individual job plans for team members can be combined to form a Team Job Plan. This will act as a summary of the capacity of the whole service. It allows the team to look at their total capacity, as well as seeing clearly what the impact of changes to the way their time is used. We ve already mentioned the MHC DCAQ tool. This will let you model the potential changes to practice, so you can see the impact of reducing the amount of time spent in meetings or the impact of managing to reduce time spent travelling. The capacity to undertake levels and types of work needs to match the demands on the service. This should inform team and individual job planning and personal development plans.
17/18 We need more capacity Your team has spent time looking at working patterns, all your staff have job plans and unproductive time has been greatly reduced. You ve done everything you can think of to reduce your demand BUT it still exceeds capacity. Now what? Clearly, if by analysing demand your team can see that 30% of clinical time is needed for guided selfhelp, then the team capacity for guided self-help must match this. If the hours you have for guided self-help are less than the demand, capacity for self-help will need to increase. Otherwise your waiting lists will just continue to grow. If after increasing capacity by the methods outlined above, there is still a shortfall, then more staff need to undertake self-help. Is this where we ask for more staff?
Not quite yet. First you need to make sure there aren t resources that could be moved from other parts of the system. So, if there are staff elsewhere who are not working to capacity (and yes this does sometimes happen, one set of staff running around like headless chickens and another set of staff with not enough work to do) then you will need to move resources around. This may mean you have to provide additional training. Alternatively, you may also have some staff working very hard, but at the wrong thing (i.e. delivering a therapy that is not evidence based, or doing work that someone at a much lower grade could do). This is another opportunity for moving resources around. You do all of this and there is still not enough capacity to meet the demand, now what? Well now you have an excellent case to put forward for additional resources. You will be able to prove that you have done everything you can to manage the problem within existing resources; and you will have the data to show that, without additional resources, the waiting lists will continue to grow.
19/20 Summary The following checklist will help you decide whether you are making effective use of your current capacity. Rather than a simple yes/no choice you can select partly, as we recognise that most services will be in the process of looking more closely at what they are doing. If you can answer yes to every question in this checklist, then you are probably doing everything you can to make the most effective use of your current capacity. If you answer no or partly to questions, then this indicates an area where you could do further work.
Yes Partly No Do you know how team members currently spend their time and how much of this is on clinical work and how much on other activities? Do you know what your team s capacity is in terms of number of new referrals you can see and number of interventions you can provide? Do you manage sickness effectively? Are community visits well organised so they minimise time spent travelling between places? Are you certain you have the right people doing the right things? (or do you have highly skilled / specialist staff spending lots of time on work that other staff could do just as effectively?) Are your staff appropriately trained so they have the skills needed to do the work that presents? Are your meetings well run so they are an effective use of time? Have you removed all duplication and unnecessary steps from your clinical admin procedures?
21/22 Summary of Data to Measure Capacity A number of times in this guide we have referred to the DCAQ tool. This is a spreadsheet based application. To use this tool for capacity analysis, you will need to know certain pieces of information. These are described in more detail in the MHC DCAQ Tool guide at: www.scotland.gov.uk/topics/health/nhs-scotland/ delivery-improvement/1835.74 This guide also tells you why you need this information. The following table summarises the data that the DCAQ tool will need. Data needed for CAPACITY analysis Currently Collect Number of staff in each professional category. Annual Leave (average days per person) Special Leave (percentage) (Special leave covers leave such as carer s leave, parental leave and compassionate leave.) Sickness Absence (percentage) Time spent travelling per week (average hours per staff member) Hours spent on training per week (average hours per staff member) Hours spent at meetings per week (average hours per staff member) Hours spent in supervision per week (average hours per staff member)
Capacity and Demand two sides of the same coin Looking at your capacity is only one side of the coin, you also need to look at how you manage your demand. You might find you have more control over it than you realised. See Demand for Psychological Therapies Services for more information on this.
Crown Copyright 2010 These booklets have been produced by the Scottish Mental Health Collaborative. For further information about the work of the Scottish Mental Health Collaborative please visit its website: www.scotland.gov.uk/psychologicaltherapiesservicesintroductoryguides/ Capacity These booklets are a series of five. These are listed below: Improving Access to Psychological Therapies Services Capacity for Psychological Therapies Services Demand for Psychological Therapies Services Clinical Administration for Psychological Therapies Services Goal Setting & Case Review for Psychological Therapies Services PDF copies of these booklets can be assessed at the Scottish Government website: www.scotland.gov.uk APS Group Scotland DPPAS10060 05/10 ISBN: 978-0-7559-9343-7 Further copies are available from: BookSource 50 Cambuslang Road Cambuslang Investment Park Glasgow G32 8NB Telephone: 0845-370-0067 Fax: 0845-370-0068 Email: scottishgovernment@booksource.net 9 780755 993437