At the beginning of the year I attended a two day training course: “Advanced Clinical Reasoning and Effective Clinical Decision Making”, facilitated by Kate Malcomess. It was an intense two days, at the end of which my brain hurt!

Kate talked a lot about risk, which she defines as, “the degree to which harm is foreseeable.” This led us to think about who can best manage a child’s risk, which is linked to the three levels of care: universal, targeted, and specialist. At the universal level—that is, for all children—we should be supporting parents to enable them to manage their child’s risk.

We discussed clinical risk, “the degree to which foreseeable harm can be managed by your intervention,” which you can think of as effectiveness. Then there’s clinical need, “the input needed to reduce risk and achieve predicted outcomes, ” which approximates to the amount of clinical input needed. Kate suggests using a clinical risk vs. clinical need grid, to prioritise workload and increase throughput.

Let’s consider a child who has both high clinical risk and high clinical need. An SLT can effectively reduce risk for this child, but a large amount of input is required. In contrast, a child who has high clinical risk but low clinical need, requires only a small amount of input for risk to be effectively reduced.

If we prioritised these high clinical risk, low clinical need children we would increase throughput: the number of children moving through the system, i.e. the children whose referrals are accepted, are assessed, offered intervention and then discharged. Currently it seems like most children are stuck at the intervention stage—we don’t discharge many, so throughput is small. If we could increase throughput, we would reduce waiting times, which may lead to more cheerful parents (and therapists!).

This way of thinking turns the traditional model, that I’m used to, on its head—there is no mention of using severity to make these types of decisions.

So how do we start? Kate talked about caseload profiling as a first step: looking at where on the risk vs. need grid we would place the children currently on the caseload. Then we can work on throughput, while keeping a record of unmet needs, to show to our commisioners. It’s going to be a lot of work, but I’m looking forward to the challenge, and want to start making some changes… I’ll keep you updated!