Well its been a time of rapid progress for me. Over the last week I’ve appointed my staff team! I now employ (or will within a month or so) a full-time AP, a full-time newly qualified CP, a part-time admin and a part-time techie. The office is all set up, and I’ve bought laptop computers, a digital dictation kit and a printer/copier. I’ve had legal and financial and business advice. I’m in the process of setting up a limited company and trademarks, and I now know what my obligations as an employer will be, and how to keep the books in a way that will allow my accountant to do the payroll and tell me what tax to pay.

I now need to focus on laying out what services I am going to offer, and updating my website and printing some information leaflets to reflect this. In the next month I’m also doing lots of presentations at conferences and meetings, both locally and nationally. I’ve also got lots of court work ongoing, including lots of appearances to give evidence, so it will be quite a busy time!

Importantly, so far I am enjoying it and have no regrets. It feels like breaking out of the restrictions of the NHS has allowed me to be more creative and create a much better quality of working environment and way of doing my psychological business.

Two weeks later: Well, I am now the Director of a Limited Company. I have had a little bit of a complex path to achieve that, as someone else had registered the name I wanted to use at company’s house, however, I managed to negotiate successfully. I now need to get my trademark registered, set up a bank account for the business and get the right employee indemnity insurance, before I officially have employees (who start on 1st September).

The AP post is going to be key in ensuring I can do more, so I am glad to have that in safe hands. The admin seems like a good bet as she has loads of NHS experience and will start of on an ‘as and when required’ basis and grow with us. The newly qualified CP I met with is still considering the post, as I think non-NHS work is still quite anxiety provoking for most people to contemplate.

Its been a bit of a new thing to have to get my head around the business side of things, but I hope that it is the right move in terms of expanding my private work. At least my accountant is going to do all the VAT registration, payroll, PAYE, and tax returns for me.

I’ve made a ‘menu’ of what the business can offer, with prices, and I’ve started to think about who I need to show that to. I’ve also been formally offered an honorary lectureship from a good university and I’m being considered for a visiting fellowship at another. Having academic links will help my access to SPSS and journal articles, give me a few teaching sessions and hopefully ensure I write up papers and bid for research grants.

I now have public liability insurance, employee liability insurance and professional indemnity insurance.

Interestingly, I’ve been approached by some other local NHS-experienced professionals who would like me to manage them within a social enterprise structure. This is another new horizon to consider, as I am not sure I know enough outside of my own area to know how to pitch for work for them…

October 2011: Looking back, I think the idea was scarier than the reality, as I haven’t missed the post I left at all! In fact it has been a remarkably positive experience. I know that it would be much harder without an existing court-work business, but to be honest I was thinking about it and its the best decision I never made. I can’t envisage myself going back to being a salaried employee with so little autonomy and so much burdensome process again, so my career goal has evolved from head of child psychology in an NHS trust to running a psychological business employing as many staff as a typical child psychology department (though maybe with a wider scope than CAMHS as families also contain adults and I think there is potentially a lot of work with parents that currently falls into a service gap).

Its actually still evolving so much that lots of things have changed since I last posted:

I didn’t take on a newly qualified person yet, though I certainly have capacity to employ someone competent to share some of the court work. I reverted to using my NHS secretary in her private time via email. Her knowledge of me and capacity to turn around typing are incomparable really, and we had no need for reception or other admin apart from typing yet. The office is working out really well, its a great working environment in an accessible location, with reception staff who are the right balance of friendly and professional. I’ve done a few appointments there and it has worked well. The colleagues from other health professions are still dithering about whether to join me or just rent a room to share, but are scared of the commitment of a year-long lease (strangely I think £500+VAT per month is a bargain and not much of a gamble at all for a great working environment with security and staffed reception, with endless pens/tea/coffee/chilled water, especially as I can offset it against tax and claim back the VAT). We have a business bank account complete with chequebook and debit card in the company name.

The AP has started and is awesome. I’ve been formally offered the honorary lectureship and visiting fellowship, and I have been made a trustee of a pilot project which is set to have a national roll-out. I’ve presented at the child faculty conference and ACAMH LAC SIG with positive feedback and advance expressions of interest from some key people if we set up some training. I’ve got two potential sources of therapy referrals lined up and we’ve started submitting papers for publication. The only problem is finding time to fit everything in as I’m drowing in requests for (very well paid and interesting) court work!

Well, I’m now 3 weeks away from leaving the NHS. I’m actually only going to be doing 6 more days in work, so its running out very quickly, especially as I have said I will do a demand-capacity paper and clear my room out in that time.

I’ve sent an email round to colleagues to say that I’m going to take a career break, and giving a brief outline why (my ‘openess’ surprised my managers, it seems). I sent it both to the camhs mailing list and to other colleagues in various agencies; paediatricians and managers in my prior trust, EPs, commissioners, social workers and anyone I feel I have a working relationship with. Its been really nice to be sent well-wishes, and a lot of people have said they have similar feelings and wish they could do likewise. Of course there are people trying to read into it things I didn’t intend (for example I said “I will miss lots of you” which referred to the fact that I don’t really know some people on the camhs mailing list, but someone thought implied I was making a point there were some people I actively dislike). It has also made me realise the ’empty chairs’ in my professional network – two deaths and many people who have left the service over time that I have enjoyed working with.

So where am I starting my grand adventure in the real world?

At the moment my non-NHS work has been offering expert assessments of parenting, children’s needs and attachment relationships for the family court, in the context of Care Proceedings and complex custody disputes. I spend around 15 hours per week of my time on it, plus the same of an AP and some ad hoc admin. I currently turn away a lot of work by only accepting two small or one large case per month, so this has some scope to expand. I am a preferred expert for quite a good geographical patch, and get regular work from the same sources as well as many new enquiries. I have a good reputation and positive feedback about my work. However, I feel quite disorganised at the financial side – my invoicing is behind and I am poor at chasing unpaid invoices, so a lot of income is outstanding. Nonetheless I make enough for our family to live on with this work alone, so its my foundation from which to expand.

The areas I want to look at more are training, consultation, assessment, interventions, audit and research.

In terms of training, I have received very positive feedback for past training events, and have scope to offer training on various topics. The most easy/marketable being training others to deliver a group intervention I devised to support non-birth parent carers with ‘managing behaviour with attachment in mind’. I can also train social workers to do better assessments of children and adults when planning placements, whether foster or adoptive. I can also lecture/teach on issues such as the impact of trauma and poor early care, neurodevelopmental disorders, differential diagnosis between neurodevelopmental disorders and the impact of trauma and poor early care, transgenerational transmission of attachment issues, assessment/formulation, childhood mental health issues, etc. I’ve been invited to lecture for a chamber of barristers who have an interest in family law, and have some interest from Local Authority and private agencies locally, which I need to explore.

In terms of consultation, I need to pitch to Local Authorities about the value of this in choosing when to use experts and what to ask them, but also in terms of allowing social workers to evidence their thinking for care plans and court documents. This is something I am often asked to do, so I just need to work out the details and then ensure that I get people enthused enough to contract with me.

In terms of assessment, I think there is scope to offer detailed psychological assessments outside of care proceedings. These might be to private providers of residential and foster placements, or to Local Authorities. I just need to lay out a menu of what I can offer, and at what cost, and ensure that it is seen by the right people. My initial feedback has suggested there is a viable but niche market for this.

In terms of interventions, I am keen to offer my psychoeducational group for adoptive parents and foster carers to the market, as I believe there are funders who would consider this good value in supporting placements (and I enjoy delivering it). I’d like to also scope whethere there is a market for highly specialised attachment-focused interventions, as I believe that there is a gap between the time-limited and somewhat generic interventions offered in camhs and social care, and the intensive but hugely expensive packages offered by places like Family Futures.

In terms of audit, I am interested in how private providers of placements monitor their efficacy and whether they can show ‘added value’ through specialised outcome measurement. I also have a norm group for the knowledge and style of Local Authority residential care staff against which to compare more specialist providers. Again, it needs scoping, but the potential market is there, and when I have mentioned it I’ve had positive feedback.

In terms of research I am keen to build links with one or more local university, to write up papers, bid for research grants and continue to keep an academic strand in my professional life. I have about ten research papers which I have part-written and would like to submit to peer reviewed journals but have never had time. I may also pick up some teaching sessions, or supervision of post-graduate research. I’m in discussions about ‘visiting fellowship’ or ‘honorary fellowship’ or ‘research consultant’ type roles with a few academic centres. I just need to tidy up and update my academic CV and submit this for scrutiny to complete the process.

So, what about the pragmatics?

At the moment the plan is to have more of my own time (maybe 25 hours per week), plus an AP post which builds up to full-time, plus a half-time admin/business support role (again with the potential to build up over time), and one or more newly qualified CPs to allow me to expand the court work and build up all the other strands. I’ve got people in mind for some of the posts, and people to meet for others. I don’t want to end up with the burdens of being an employer too early, so my current thinking is to initially form a cluster of self-employed people with a cooperative aim, and then get it legally drawn up as a partnership in which I am the senior partner and hold the majority share. So, the staff I take on will be ‘junior partners’, contracted to the business but not employees (with the incentive of a small profit share, a christmas meal, and Costco membership, to compete with the NHS pension LOL). However, in the longer term I may form a ‘social enterprise’, though I may keep the court expert work separate from that because of the need to be independent and being uncertain it would fit the social enterprise model as well as the other aspects.

In order to have a base, I am going to rent an office. I haven’t quite worked out whether this will be a serviced office in a big office complex which provides reception and waiting areas and facilites, or whether to rent a small set of rooms with some other health colleagues (eg above a shop). At the moment I am swayed toward the former option as it appears more flexible.

I’ve got 3 weeks to sort everything out! (Actually, I’m not increasing my court work or taking on staff until September, so I’ve got a month of exploration after I leave the NHS as well, but I’m trying to prepare as early as I can).

Addendum 1: Today was my leaving lunch. We did it as a ‘bring and share’ in one of the group rooms at work. A colleague in my team, my supervisor/head of service and I all made short speeches. I was actually suprisingly touched when my colleague said that she considered my leaving a sadder event for her and the team than being moved to the other trust after we lost the tender for the CAMHS contract. I got a card, some paint your own Russian dolls (which I use as a metaphor in my work all the time) and a spa treatment day as my leaving gifts. More importantly I got several sincere hugs and good wishes, and very personal messages. I felt like it was an ending with no bad feelings, which was great. I do feel sad to be leaving my team though, we’ve been very close under the adversity of increased demand and I’ve really valued them, and the sense of humour we share as a means of managing the stress.

On the other side of the coin, I have arranged confidential waste paper disposal, and signed a contract for a new office in a serviced block. I’ve designed a business card and I’m going to print name badges, to match my private practise letterhead. I’ve picked out what furniture I want in my new office, and I’ve begun to think about equipment. I’ve written job descriptions and contracts for the 3 posts I am contracting (the band 5 equivalent AP, the band 4 equivalent 20 hour per week admin/business post, and a band 7 equivalent qualified CP post) and the first of those people has been interviewed and appointed, with people to meet and interview who I hope might fit the other posts. I’ve formed links to two local universities that will let me use facilities such as journal access and SPSS, and arranged with my trust to be able to keep my research data to write up in a way that meets ethics and data protection. I’ve also been thinking about the things my business can offer, and the potential market. I’ve had really encouraging noises about people wanting me to offer training or lecturing to them or their organisation, but its hard to know what of that will develop into genuine paid work. A surprising number of colleagues are also going off into the private sector and there are a few amongst them who will be useful network connections to hold onto.

The amazing post-script on this process though is that my trust are considering offering me redundancy! It feels like such a gift, when the likelihood was that I was going to leave anyway. I’ve got to get it in writing and then get legal advice, but it would really take the pressure off to leave with some extra cash in my pocket!

Addendum 2: I’ve had some legal advice and things are pressing forward. I’ve agreed to leave my trust permanently, and the paperwork is going through. I’ve also discovered that I can’t make a partnership as my business structure, as that pretty much relies on people only earning a predetermined profit share, when I am not in a position to predict turnover yet. So given what I want is to pay people an hourly rate plus profit-related-bonus, it looks like I am going to have to register as a limited company and then take on employees. This feels much further out of my comfort zone than I expected, as it means I’ll have to pay my employees’ tax and NI, and get employer’s liability insurance. That’s not to mention having to have contracts and policies and stuff. So it will be interesting to see what happens in the next few weeks. A lot will rest on the kind of work I can bring in, and whether the CPs I could employ seem like the kind of people who would be enough of an asset to my company to go through all that rigmarole!

Well, its been a year full of twists and turns, and I’ve spent half of it on maternity leave. However, I still feel like the other trust winning the competitive tender was the death knoll for a brilliant CAMH service. I am now employed by a load of managers and medics who seem to care more about the figures than the people who use and work for the service.

In a devious bit of manouvering I was told I could keep my Consultant banding and post if I agreed to manage the LAC service. What they didn’t say was that I would never get to do any of the work I was appointed to do, as the Specialist Attachment Intervention Team has yet to be funded by commissioners and therefore doesn’t exist. Also, that they’d make it very hard for me to recruit a locum to cover my maternity leave, that the other psychologist in the team would also go on maternity, and that they would delay and then absorb 2 of the remaining 4 posts, leaving me with less team to offer a service to the whole county than we had to offer the service to half the county before the tender.

So, I’m being pressured to pick up bits of work in order so that the service doesn’t cave in. I already read all my emails, write the strategic documents, deal with recruitment, and supervise the other team members from home, but now they want me to offer a fortnightly consultation morning, and a monthly complex case clinic.

I feel so let down. The job I loved has become something so different I can hardly recognise it. Add to that the fact that some key colleages are no longer with us (my main link to social services, and inspiration around adoption has died, the social worker I linked most with has left to join a private provider, the 8B in the office next door me moved out of area and won’t be replaced, etc etc). Makes me wonder whether the NHS is all I thought it was as an employer 😥

Post script: I’m less negative about the situation today. I met with the CAMHS manager, and we have resurrected one of the band 7 posts, which will be out to advert in two or three weeks – hooray! In the end I used one day a week of the funding from my own post to make the difference, as I intend to work part-time for at least the next few years. Also, we are likely to absorb a few staff from a social services run team for placement support that is being reconfigured. They are also reassuring me that the bid for the attachment team is still live, and something high on the agenda for commissioners. Most importantly, there are shifts happening amongst the senior and management staff, which might put the people I hold in higher regard in places of more power, and lose some of the people I feel are less attuned to this being about people (staff, service users). Maybe by the time I return it will be a service I want to be part of after all!

18 months after that:

Well, 18 months on from my last post on this thread, 3 years on from losing the tender, and I still don’t like my new employing organisation. My team has shrunk from 8 WTE to 2.5 permanent and 1.5 temporary staff, despite having massively increased referrals (partly due to massive cuts in the parts of social services we used to link up with). We no longer have a named link medic and have to negotiate case by case with the 8 sector consultants in tier 3 camhs. We are in a new building which is lovely but half the size we need so most people have to sit in a ‘call centre’ of a shared office where people don’t even have their own desk or computer. My allocated (shared) office space has no internet or telephone access 14 months after we moved in to that room. You reach it by swiping out of the CAMHS offices into the fire exits, then swiping into the adjacent building, then going along a neglected corridor to the very end. If you don’t book a room in advance for every appointment it is not possible to find anywhere to see people. I feel like I am between a rock and a hard place – as a senior clinician I feel a responsibility to protect my team from burnout and to offer the clients a good service but I don’t feel like I can do either. I’m being asked to do many things yet not given the authority to get on with them. I feel like I am being asked to climb a cliff and no-one will take the handcuffs off. It doesn’t suit me to be grumpy and pessimistic when I am normally so enthusiastic and creative. And it is beginning to affect my health and the frame of mind I bring home to my family.

So, I’m going to take a career break from the NHS. It will be a year in which to explore other options. I’m quite excited about it. And if other people are curious I might just continue to blog about it here and report back how my foray into the brave new world goes…

Well, I finally met the new head of CAMHS and I like him. He seems to mix honesty and pragmatism with empathy. He also has enough common sense to know that his first task is to contain the anxiety and uncertainty that has built up in the service over the last few months. He has worked previously in social services and CAMHS, so he seems genuinely grounded in providing good quality services and I am reassured that he values LAC services.

Last week we had a ‘service development day’ in a local golf club, combined with a xmas lunch, which was finally what should have happened on 8th August (or That Friday, as it is now known). We have been assured that our voices will be heard, and there will be proper consultation about how the service evolves, with any changes being negotiated. If any changes have to be imposed on us, eg change of role or band, this will be after informal and formal consultation, and our pay will be protected for 3 years and that clock will not start ticking any earlier than June 2009. We started talking about how we develop a unified service and get the best from both models. Within the group I was in there was actually fairly good levels of consensus about prefered models of service delivery, and where we wanted to expand good services from each half of the county. This is being fed into a working group (with CP representation within it) to explore how to take things forward.

I’ve been asked to explore where there is scope for CAMHS to tender for other service areas that would benefit from CP input (for example, training staff in private organisations, or doing court work). I think there is a sense that CP needs to justify its high price tag by being able to income generate. At one level that is ridiculous, as no-one makes such requirements of the medics, despite their even higher price-tags, but at another level I think that it is a challenge that we can rise to, and doing this kind of work would be worth it if it creates additional CP posts rather than allowing posts to be put at risk.

The proposed service structure has been changed again, and has two Tier 3 CAMHS teams for each half of the county, a PMHW service split over the county, an intensive support/home treatment service (with a Tier 4 inpatient CAMHS unit being built in the near future). The current plan is for the LAC team to be a targetted specialist service, but managed within Tier 3 CAMHS. And reassuringly the professionals I most respect are being given greater influence in the process, and some of those I was concerned about have already moved on.

So, I think all told I am feeling a litte bit more positive.

But the secret boosting my mood was that, given the unwelcome welcome to the new service structure I had decided that I’d never be less loyal to the NHS, and that it was time to come off contraception, and I had found out I was pregnant before this meeting, although I didn’t say so at the time!

Well, my contract is now owned by a new trust. They cancelled the welcome event, so we feel unwelcome and uneasy. Communication is all indirect and via an email ‘newsletter’ not by being able to have proper conversations in which we can ask questions and hear answers. We’ve had to fill in more forms than I could have predicted – new payroll registration forms, new car registration forms, induction booking forms, CRB forms, etc etc. Every one of us is having to have a new police check and do the full 3 day induction progam as if we have never worked in the NHS before. That wastes the equivalent of 6 months of staff time by my calculations (maybe worth £25,000?), when they could just have done a one day ‘what’s different here and welcome’ day.

On our ID badges (for those of us that they have managed to print them for, and after they were returned to have the title Dr added) it says above the photograph “improving your working life”. Everyone I’ve asked so far has said “they haven’t done anything for mine yet”.

We are told there will be no change until the new year, maybe until next summer. Yet I have no role clarity as they haven’t advertised my old post, or guaranteed my new post, so I feel like I am juggling both. I’ve found it impossible to scope a new service in light of all of this, yet I know if I don’t create what I want with enough certainty others will have more scope to impose on me from above. Its rather demotivating. I find myself counting the future as “training this month, a holiday next month, then xmas and then we will see”.

The IT changes have been a nightmare – lots of problems getting email set up and no access to my old email address, lots of problems getting access to my documents, lots of problems even signing in! I’ve had to spend two whole afternoons chasing and then sitting with IT staff until things that worked before work properly again, which has eaten up all my admin time. And being unable to access the patient database has meant chaos for the admin staff, who can’t even find out who to put people through to when they call, or check when future appointments are!

Its really downheartening. Everyone looks tired and glum. There is a palpable atmosphere of pessimism emerging, and no-one is seems to want to do more than they are oblidged to for this new ‘business’. We are told they have appointed a new head of service, but he’s going to have his work cut out for him when he starts next month!

Addendum: I’m actually feeling a little more optimistic now than when I wrote the above. I guess I’ve got it clear in my head that I don’t have to stay if I don’t want to, as I’ve got the option of my private work or jobs elsewhere. So, with that in mind I can set out my stall. I was quite inspired by a talk I heard at a regional network meeting about how to market the value of CP to commissioners. I finally understood the language of creating a competitive marketplace and why services are being put out to tender. It added to my feeling that with chaos and change comes opportunity – as there is scope to put good ideas out there as an easy option for those in power to grab when the alternative is doing the legwork themselves. I like the idea of publicising and interweaving the service amongst local stakeholders, so that if it were changed or cut there would be other people to complain apart from me.

Apart from that I’ve also been to two nice CPD events, had the parking ticket I was issued at work rescinded, and had a positive conversation with my head of service who seems to be singing from the same songsheet as me. Oh, and I’m going on holiday soon. So the world looks more rosey

Well, we seem to have been quite proactive as a department. Our department met with the head of HR in our current trust on Wednesday, and today we met with the hospital union rep.

It seems like there are three things going on almost at the same time that really have to happen in sequence to be legal. First of all we have to TUPE over to the new employer (with no other change to our role or contract) then there has to be negotiations to establish equality of terms of employment with new and old employees, and then there will be a process of organisational change to configure the new service structure. Each process is supposed to involve a formal consultation process, and protection to our existing job role, pay, and terms and conditions. Interestingly they can’t go into the former process with a predetermined outcome in mind for the latter process, as that would not involve the requisite level of consultation or openess to negotiation.

It seems like they will either have to offer us a continuation of our current posts at the same band and with the same remit, or offer redundancies, or offer a reconfiguration in which people are offered “suitable alternative” positions (which are supposed to retain the same status, and be within the skill set of the person involved) with a guarantee of no reduction in salary for a 3 year period (the length of this is dependent on length of continuous service, and in our trust is 3 years is for staff with more than 7 years continuous service like myself).

So, the union are very curious about how they can be saying that they are TUPEing me across, but that my post doesn’t exist unless the commissioners pay more for it (as TUPE has to be with the intention of the person continuing to do the same job). They are also surprised by the implicit threat that some people will lose their jobs, and a number of other places where the process has already deviated from the expected protocol.

There are also lots of issues about the time-scale of the change, and whether it will be possible to sort out payroll, transfer of patient records, etc legally within the time proposed. I can just imagine a worst case scenario in which from 1st October (a mere 6 weeks away) we have to get written consent from each service user to carry their records over to the new trust, and otherwise having to start new files with no history of our involvement and no access to our database…

Update: The union have put in a grievance and the new trust seem to have partially retracted their “non-negotiable” plans (though not in a legally binding way), but we are all set to transfer to the new employer on 1st October. So, I’m guessing the next few weeks will be critical in seeing whether they are going in with an attitude of prioritising the quality of the service we provide, or of saving costs.

The commissioners have agreed to pay more to ensure the survival of the projects outside of the core tender, which is good as it protects my post but bad as it means the two tenders were not considered on a like-for-like basis (as one included these projects, and the other is now being paid more for them, when it seemingly won the tender by being cheaper).

We’ve been told that the expectation is that all current employees will still have jobs within the service in a year from now (but with no guarantees about structure or grading).

So, its a bit of a watch this space. What I can say is that the process of change is disabling in itself. I don’t feel like I can plan ahead, and I feel too overwhelmed to be very productive. I also feel my loyalty to the service has been seriously undermined.

Well, we had the initial meeting with the new bosses yesterday. They called it a CAMHS conference, which is a ridiculous name as it implies some CPD function, not being told about the plans for all of our jobs. I wrote it in my diary as “CAMHS job briefing” which felt like the most neutral name I could give it. It also started with a sandwich buffet and a chance to network with members of the two CAMHS teams that are becoming one, which was really strange because it was far too tense and ambiguous for anyone to be doing proper social networking.

Then we got moved into the main room, where the power players of the new organisation stood at the front and talked about the new service structure, with PowerPoint slides. This varied from being full of management speak, budgets and acronyms, to being snide and patronising about how “other people might be sitting there and think they know best how to run a CAMHS service, but we know better, and this is now publically proven as we won the tender, so they need to stop thinking that and accept we are going to do it our way”. A lot of the digs seemed to be aimed at the clinical leads from my service.

There were some reassurances that nothing will change on the ground until January, except for the appointment of the new CAMHS manager and the 4 team managers, but that we should expect to be in new premises and working within a new structure by April. However, they haven’t yet identified where the new premises will be. There were also reassurances about job security for most people: “there will be more jobs overall than there are now, so no-one, except five or six psychologists, needs to worry about their job security, and for the most part we think we can maintain people’s job bandings”. Nonetheless, as they kept changing their phrasing about who these 5 or 6 posts were, everyone wanted to check that they weren’t “at risk”.

Interestingly for me, I was clearly named as one of the 5 or 6 posts that are at risk (along with two other colleagues who offer paediatric psychology) in front of 60 or so peers, without ever having been formally told this prior to this point. They said that as my new project was not included in the map of CAMHS for which they tendered, it would not be something they continued unless they received additional funding, though they were keen to secure this. In the meanwhile, to assume that I’d be TUPE’d over with everyone else and that I’d hear by October, probably, whether this funding was to be added.

On each table were only 3 copies of a sanitised and abridged version of their tender document (no budgets, numbers of posts or gradings included, and no appendices) to share between 12 members of staff! They presented a diagram of the service structure on their PowerPoint that was different from the diagram in the tender document on the table, and different again from the diagram in the CAMHS manager post that is currently up on NHS jobs. Whole posts that were in some versions were out in others (eg a nurse consultant post) and some had reference to heads of professional groups being involved in a “CAMHS seniors group” that didn’t exist in others. Nonetheless they told us that the service structure was “already finalised” and “not up for consultation or further discussion” (which the union rep thought conflicted with the idea that all organisational change requires full consultation with existing employees).

We then split into groups for each new managment cluster (the plan seems to be to have 4 teams, loosley arranged about the tiers of delivery, with my team in with Tier 2) and were asked to make notes of our concerns, questions, ideas and suggestions. My most obvious question was why put Tier 2 and LAC together, as one is about early preventative interventions and the other about the most complex and entrenched multi-agency interventions. However evidently this fell into the “because we say so, and its non-negotiable” category. Their justification was that each manager would then have a similar amount of staff to manage, and that it wouldn’t mean there was any integration between the services. However it made me wonder whether actually it was because they were both areas that were of interest to a manager who was involved in shaping their bid. It doesn’t say much about whether they sincerely want to use the skills of the (much larger and more experienced) teams and managers in the south of the county though.

I also read the section in their tender document about LAC services. Interestingly, even though to my perception (having offered a county-wide LAC service for several years, with the agreement of both sets of management, despite them getting half the funding) they have been extremely avoidant of this client group, they claim to have proven success with LAC. They are also proposing to buy in psychological consultation, training and supervision from a private fostering agency that I have provided training to, whilst placing my job (which offers all of this) at risk! This led to an interesting conversation between me and the Executive Director (who asked “How can I help you darling?” and replied “If you think you can do better cheaper, love, you knock yourself out” which felt rather patronising) and the Clinical Director (who I found arrogant and defensive) about LAC services and the fact that they clearly had no clue about what was already being delivered.

I left feeling quite annoyed. The event felt badly organised and disrespectful towards the people who have led and developed our service. There was no awareness of process issues, and it followed too long a delay without communication. Their approach came through as dictatorial rather than supportive (and very different to the approach that I’d have expected if the outcome had been reversed).

I really felt for my head of service and the other senior colleagues that I have grown to respect over my 6 years in this department. It made me realise that my loyalty to this job is really loyalty to them as people and professionals, and to the clients we offer a service to, rather than to the organisation. I took this job because I liked my supervisor and the culture of innovation and support. Change that and I’ll have no interest in staying.

P.S. Whilst typing that I got a phone call from my supervisor to check how I was feeling after yesterday and consult about how to take things forward. That would be a good example of how you earn staff loyalty!

I am in the somewhat unknown position of having my contract and that of my whole service transferred to another NHS trust. I thought I might write a blog to document how that pans out, in case it was of interest to other people.

So, how did this happen?

I work for a CAMHS service which covers the southern half of a county, and I am employed by a hospital trust. A ‘competitior’ CAMHS covers the northern half of the county, employed by a mental health trust. The whole county has a single social services and education service, and there was some frustration that the service people could access from CAMHS was different depending on which side of the county they lived. I suspect each CAMHS would claim their service was superior, but for different reasons.

Its hard to compare another service to the one you work in, but it is my impression that in the north of the county, CAMHS is managed by managers and medics, has a tight remit for mental health and is one unified resource. In the south, CAMHS is managed mostly by the lead clinicians from each profession, has a looser remit that accepts a wider range of presenting problems, and has developed a lot of specialist service areas (eg a DBT team, a LAC team, a high dependency team, school and community-based primary mental health team, etc).

I don’t know how it feels in other service areas, but as part of the LAC team I know that no equivalent dedicated resource exists in the north patch, despite funding for LAC being split equally between the two services. As such, we’ve had to extend some of our training/consultation to make it county-wide, and we often get requests to see kids in their area who wouldn’t otherwise get a service. We’ve also had a lot of positive feedback from professionals and service-users that our service is valued, and many requests for a similar service to cover the other half of the patch.

So, commissioners decided in their wisdom, that the way to resolve this was to put the contract for supplying CAMHS to the whole county out to public tender. They designed a basic specification for the service and then asked for a 50 page document (plus appendices) from any interested parties explaining how they would deliver the service. As I understand it, the two existing CAMHS both entered a bid, as did another local NHS trust and a private provider. Each bid took hundreds of hours from clinicians and managers to prepare. They then went and presented their plans to a panel of commissioners who then picked a winner. The criteria for judging the bids have never been clear to me, but seem to have included wider business issues (such as financial contributions to an inpatient unit and land to build it on), rather than only the quality of the service being delivered and the future plans for CAMHS.

In this case the winner was the other CAMHS in the county, and it means that they will be given all the CAMHS funding and expected to provide the whole service from 1st October. All contracts of staff in our CAMHS will be transfered over to them on this date. No details have yet been provided about the service planned, and we haven’t been allowed to read the winning bid document.

We’ve been told that there will be no immediate change to services and no redundancies, though there was a comment about hoping for some natural attrition (which makes me worry that the current vacancies, including the post I have just left, might not be re-advertised). However, although the words are somewhat reassuring, the same mental health trust made 12 CPs redundant in its reconfiguration of adult services 18 months ago, and tends to view us as overpriced compared to other mental health professions. Currently we have 3 times as many CPs in our patch, and a much wider spread of bandings, and a culture of being able to play to our strengths. The feeling is that this makes us an obvious target for cuts. Unsurprisingly morale is at an all time low.

So, I’m a bit anxious to find out how the dust is going to settle. Its likely that in a year from now I’ll be in a different office (as I currently have a room in the hospital) and that will take me away from many friends who are colleagues outside of CAMHS that I currently see quite a lot of. However what is really important to me is how much the job remit and team I work with from day to day will change, and that remains the big unknown. The reason I’ve stayed in this service for 5 1/2 years is because I like my colleagues and supervisor, and because I like having some autonomy in the way I prioritise the demands on my time. If that changes, then I’ll be increasingly looking to explore other options (such as starting a family, or expanding my private practise, or moving elsewhere in the country). In the meanwhile, living with such uncertainty is rather discomforting.

It seems typical of the way the NHS is headed, competitive commissioning and increasingly business-like. I’m reassured by discovering I’m not the only that doesn’t like it. The NHS was supposed to be about being part of a national non-profit-making public sector organisation that gave you career stability, which was why I accepted lower pay than in the private sector. I feel like if I was going to work in a market economy then I’d go entirely private and have full autonomy. This policy of asking NHS trusts to act like businesses sits somewhere in between, without offering me the advantages of either option.

In a lot of ways I get more positive strokes for my private work – more pay, more feedback, more respect given to my opinions and of course you get free choice of what you choose to do (or not do) and how you arrange it. However, you don’t get the same sense of being part of a team, you have to negotiate your own supervision, and you don’t get the protection of sick pay, maternity, pension, and PAYE (tax has to be calculated by an accountant, and paid in two painful large lump sums).

It makes me wonder if the way forward is making private agencies of CPs that contract to deliver services into the NHS, without the weight/expense of NHS trusts above them, or whether in fact this is an uncomfortable middle ground that lacks the advantages of either NHS employment or private-sole-practitioner autonomy. I guess I’ll soon find out!