The CLASS clinic is a multidisciplinary diagnostic service for adults suspected of having an Autistic Spectrum Disorder (ASD). Earlier in April 2019, for World Autism Month, the CLASS clinic launched a new library to help the community. Although CLASS is currently not commissioned to provide post-diagnostic support, the team works closely with local partners and the National Autistic Society (NAS) to facilitate access to appropriate recognition and support once individuals have been diagnosed. A key objective for 2019 is to involve autistic individuals, their families and carers so that CLASS continues to deliver the best possible service. Sue Hart, a CPFT volunteer has worked alongside staff to organise existing books, CDs and DVDs into a library that provides resources and reading materials for families, patients and staff to learn more about autism
Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.
The CLASS clinic is a multidisciplinary diagnostic service for adults suspected of having an Autistic Spectrum Disorder (ASD). Earlier in April 2019, for World Autism Month, the CLASS clinic launched a new library to help the community. Although CLASS is currently not commissioned to provide post-diagnostic support, the team works closely with local partners and the National Autistic Society (NAS) to facilitate access to appropriate recognition and support once individuals have been diagnosed. A key objective for 2019 is to involve autistic individuals, their families and carers so that CLASS continues to deliver the best possible service. Sue Hart, a CPFT volunteer has worked alongside staff to organise existing books, CDs and DVDs into a library that provides resources and reading materials for families, patients and staff to learn more about autism. The autism library opened on 2 April 2019, on World Autism Awareness Day and a launch event was held at the Chitra Sethia Autism Centre. This was supported by Harry Specters chocolates, a local business creating employment for young people with autism, and Niche Comics run by the Makey family in Huntingdon, who also have lived experience of autism, and are winners of the 2016 Great British High Street Award. The launch event also attracted staff working in other teams in the Trust who wanted to know more about the service and the resources available. The library is run by our volunteer Sue and is open two mornings a week currently to help anyone caring for or working with the autism community.
Service-users, community groups, health and social care professionals and education and employment organisations across Cambridgeshire and Peterborough are invited to come and browse and borrow books and resources. Individuals and their families are also invited to use the library before or after their diagnostic assessment, to help them make sense of the outcome and the next steps that may be helpful to them. As well as running a busy clinic the part-time clinicians have taken time to promote the library locally by writing press releases, producing a short film for a local TV company and to talk about the library, and autism more generally, on local radio. Since opening, the library has lent out books and invited people to provide book reviews and suggestions for improving the library further. Five new titles have been ordered on these recommendations and book reviews have been made available for other library users to read. It is hoped that the library will be a next step in improving service user engagement in the diagnostic service by providing a base for autistic individuals, their family and carers to stay in touch with the clinic, and provide feedback to improve the diagnostic pathway and resources available. It is also hoped that the books and information will help other professionals working with the autism community, and be a source of support to improve their understanding and training in autism. The CLASS clinic want to ensure that autistic individuals are met with understanding and appropriate support wherever they come into contact with services.
What makes your service stand out from others? Please provide an example of this.
The CLASS service works closely with the National Autistic Society (NAS) and the Autism Research Centre (ARC) at the University of Cambridge to ensure that people get the information and help they need from statutory services, the voluntary sector and the wider autism community organisations. Use of the Chitra Sethia Autism Centre is shared with the local NAS group, and CLASS are involved in setting up some service user engagement groups with the NAS, to find out more about how we can improve the library and signposting services in the future. CLASS also want to find creative ways of making the resources available across the county, for individuals who cannot travel to Cambridge, and to recruit more volunteers to help extend the opening hours. Our next project is to improve the resources available on the laptop in the library, and create a better ‘landing page’, with lots of helpful information about autism as well as local and national services.
How do you ensure an effective, safe, compassionate and sustainable workforce?
The CLASS team is very small and all clinicians are part-time. We are involved in peer supervision and reflective practice as part of team meetings and during professional supervision. We also host a neurodevelopmental peer supervision meeting for psychologists working in other areas in the Trust with autistic individuals or wanting advice and support around diagnostic assessments. The team is taking part in external supervision to ensure that clinical practice in the use of diagnostic tools is reliable and accurate. The team has trained a number of multi-disciplinary colleagues in the Trust in the use of diagnostic assessment so that they can use these skills in their own services, and also offers advice and support for colleagues in the Trust working with patients who have already been diagnosed with autism. Clinicians are members of the local Autism Board(s) as part of the Local Authorities in the county, and we take part in networking meetings, and sharing of good practice, with the regional Managed Clinical Network for Autism Services. In addition to attending national and international conferences, clinicians in CLASS are actively involved in research and are working with the Autism Research Centre at the University of Cambridge to update the Adult Asperger Assessment (AAA), a NICE recommended gold standard assessment tool, to meet new diagnostic criteria under DSM-5.
Who is in your team?
Service Manager – Learning Disabilities and Neurodevelopmental Teams (full-time) Team Lead – CLASS and ADHD Service (0.4 wte) Consultant Clinical Psychologist – CLASS (0.2 wte) Clinical Psychologist(s) – CLASS (0.8 wte) Consultant Psychiatrist – CLASS (0.2 wte)
How do you work with the wider system?
The CLASS team of psychology, nursing and psychiatry professionals works closely with the National Autistic Society (NAS) and the Autism Research Centre (ARC) at the University of Cambridge to ensure people get the information and help they need from statutory services, the voluntary sector and the wider autism community organisations. In addition to running a busy clinic, the team works to improve the experience of the autism pathway by sharing information and resources for service-users, families and carers. We also work with staff across CPFT to raise awareness and improve skills, so that individuals from the autism community can be understood and have their needs met when they access all services. Like many services across the Trust, clinicians in CLASS are active in research and finding ways to optimise outcomes for individuals and improve care services.
Do you use co-production approaches?
The autism library at CLASS is the service’s first project to involve service users in giving feedback about resources and the diagnostic pathway. The team is also working with the National Autistic Society to engage service users and the autism community in helping CLASS to improve the service, and support and information provided, while waiting for an assessment and post-diagnostically.
Do you share your work with others? If so, please tell us how.
Clinicians in CLASS are members of the regional Managed Clinical Network for Autism Services and share good practice at these networking meetings with other diagnostic services across the East of England. Clinicians are regularly involved in research and one of our team recently presented a poster about her research, looking at the predictive qualities of screening questionnaires for autism, at the International Society for Autism Research conference in Montreal. The event highlighted the neurobiology of autism and the need to improve identification and assessment of autism around the world.
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
The CLASS team collects post-assessment feedback via anonomised online surveys and these provide valuable information about the aspects of the process that are working well and those elements that should be addressed. The team is also interested in finding out more about the impact of getting a diagnosis for individuals, and whether it helps in accessing appropriate support e.g. from education or employment. We intend to share the outcome of this feedback to help influence the commissioning of post-diagnostic support in the future.
Has your service been evaluated (by peer or academic review)?
Research by Dr Janine Robinson, Consultant Clinical Psychologist at CLASS which was supported by NIHR CLAHRC EoE has been submitted to a peer reviewed journal and presented at an international conference in Canada this year. The research is about screening measures in autism and has used data collected at the clinic.
How will you ensure that your service continues to deliver good mental health care?
The service is commissioned to provide diagnosis only currently, however we are actively working with commissioners and partners, such as the local authorities and the National Autistic Society to raise awareness of the gaps in post-diagnostic support, particularly in people who also have comorbid mental health difficulties, and to try to influence future commissioning arrangements. Currently the service is commissioned to provide a number of assessments a year, which is less than a quarter of the number of referrals that the clinic receives, and therefore there is a lengthy waiting list. CLASS works hard to ensure that referrals are screened carefully, using nationally recognised measures, and to prioritise referrals so that the waiting list can be managed. The library at the CLASS clinic is an attempt to help offer resources and information to individuals and their families while they are waiting for an assessment and to signpost to other services that may be able to help with specific issues.
What aspects of your service would you share with people who want to learn from you?
Ways to creatively share limited resources to help support individuals and their family and carers while waiting for diagnostic assessment and post-diagnosis. Partnership working with non-statutory organisations such as the National Autistic Society. Research outcomes into autism screening measure and how these can help assessment.
How many people do you see?
is commissioned to provide 100 diagnostic assessments a year. From April 2018- end of March 2019 the CLASS clinic received 452 referrals.
How do people access the service?
Referrals to CLASS are via GP or NHS clinicians. Most referrals have been assessed by a Primary Mental Health clinician in the first instance to determine that they are appropriate for the service. All referrals are screened by CLASS clinicians and a range of information is used to prioritise, including scores on screening questionnaires, risk issues, comorbid mental health issues and impact of difficulties on the patient’s life including in employment, education and relationships. Patients are asked to complete self-report questionnaires and to ask a relative to complete a questionnaire about their early development. Support is provided for individuals who cannot complete questionnaires independently. Due to the amount of information collected as part of the screening process, when individuals attend for an assessment, it is usually a one-off meeting and the outcome is communicated on the same day. This avoids further lengthy assessment or information collection, and ensures that advice and recommendations can be given on the same day.
How long do people wait to start receiving care?
The service is diagnostic only. Assessment starts when questionnaires are sent out by the service and information is gathered to determine whether face-to-face assessment is appropriate. All referrals are prioritised and some seen early. Therefore the average waiting time for a face-to-face assessment is 12 months but some non-urgent referrals wait over 2 years.
How do you ensure you provide timely access?
All referrals are screened by CLASS clinicians and a range of information is used to prioritise, including scores on screening questionnaires, risk issues, comorbid mental health issues and impact of difficulties on the patient’s life including in employment, education and relationships. Individuals are informed about the outcome of the screening process and whether they are on the waiting list. They are invited to inform us if their circumstances change while they are waiting. Some GPs request that referrals are expedited if circumstances change for their patient. All requests to expedite referrals are discussed by the clinical team and decisions made as a team.
What is your service doing to identify mental health inequalities that exist in your local area?
The service is collecting data from referrals and post-diagnostic evaluation from patients to inform the Trust and commissioners about issues.
What inequalities have you identified regarding access to, and receipt and experience of, mental health care?
We are aware that some autistic individuals have found some traditional treatments for anxiety and depression unhelpful e.g. cognitive behavioural therapy. There is a need for further training for mental health professionals in adapting traditional treatments to the needs of autistic individuals.
What is your service doing to address and advance equality?
CLASS provides individualised recommendations to individuals diagnosed with autism about their rights under the Autism Act 2010 and the Equality Act 2010 with respect to reasonable adjustments at work and in employment. We also work closely with the National Autistic Society who provide advocacy and support to autistic individuals post-diagnosis.
How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?
GPs and Primary Mental Health Professionals use the AQ10 and clinical questions on the CLASS referral form. As part of the screening assessment at CLASS the clinic uses the Autism Spectrum Quotient (AQ50), the Empathy Quotient (EQ) and Relatives Questionnaire (RQ) which is a retrospective version of the Childhood Asperger Syndrome Test . These are all published screening tools. Diagnostic assessment employs the Adult Asperger Assessment (AAA) and/or the Autism Diagnostic Observation Schedule (second edition) ADOS:2. These are all NICE recommended and widely used assessment tools.
How do you meet the needs of people using the service and how could you improve on this?
We regularly audit the service against NICE recommendations (using the baseline assessment tool for NICE guideline on Autism in adults (CG142). In the last audit in 2018 the service met 91% of the recommendations made. We also collect information from patients following their assessment at CLASS using anonomised questionnaires to find out their experience and improvements that we can make. From this information we know that patients are highly satisfied with their assessment itself but they find the long waiting times unacceptable and completing the paper questionnaires difficult. We are addressing these issues by attempting to apply for monies to make the screening questionnaires online and engaging with commissioners and the Trust around the high numbers of referrals to the service and resources available to manage these.
What support do you offer families and carers? (where family/carers are not the service users)
The autism library is an attempt to provide more information to families and carers about autism and the support and resources available.
Is there anything else you want to share about what makes you an example of positive practice?
The CLASS service is a very small service and is currently only commissioned to provide diagnosis. We work collaboratively with a range of organisations, to try to provide a clear pathway for adults seeking an assessment for possible Autism Spectrum Disorder, and information and resources to help them on the next step following assessment. We think that our autism library is a creative and innovative solution to improving the autism pathway within the limited resources available.
Commissioner and providers
Commissioned by (e.g. name of local authority, CCG, NHS England): Cambridgeshire and Peterborough Clinical Commissioning Group
Provided by (e.g. name of NHS trust) or your organisation:Cambridgeshire and Peterborough NHS Foundation Trust
Brief description of population (e.g. urban, age, socioeconomic status): CLASS provides specialist assessment for adults who may have an Autism Spectrum Disorder, without intellectual disability or language delay, following referrals from GPs and NHS clinicians across Cambridgeshire. The county of Cambridgeshire includes the cities of Cambridge, Huntingdon, Peterborough and Ely as well as rural areas in between. The service also accepts referrals from students at the universities of Cambridge and Anglia Ruskin if they are registered with a local GP. Autism is a complex neurodevelopmental condition that involves different patterns of brain development and brain activity. These contribute to social and communication difficulties, and unusual, strong, narrow, repetitive interests. people with autism may have above-average IQ and excellent attention to detail, but the autism spectrum is broad, and the condition affects people to varying degrees. Getting a diagnosis of autism can help people access different services and receive recognition and support for social skills, housing and employment, plus disability benefits, advocacy and mentoring.
Size of population and localities covered: The patient population of Cambridgeshire and Peterborough Clinical Commissioning Group is over 980,000. National and international statistics suggest that 1% of the population is autistic. Locally, it may be that prevalence rates are higher than this due to the changing university populations and presence of science and technology industries, which often employ a higher than average number of autistic individuals owing to the nature of the work. Autism Spectrum Disorders are still under-diagnosed in some populations e.g. women, and comorbidity with other neurodevelopmental and mental health conditions is significant and has led to high rates of referral to the diagnostic service.
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