28 January 2019

Improving access and flow within Child & Adolescent Mental Health Services

Graeme Lamb, Clinical Director for Children’s services, and Jamie Stafford, Improvement Advisor, reflect on the journey of teams who took part in a learning system to improve access and flow within the Child and Adolescent Mental Health Services directorate. Over the coming weeks, we will be sharing some of these teams’ stories.

Graeme Lamb

Since June 2017, we have been using Quality Improvement to try and improve access and flow across Child and Adolescent Mental Health Services (CAMHS) community services in ELFT. Across the five services in the trust, seven separate teams set out to better understand their demand and capacity, and to improve an aspect of the quality of care they provide. They were asked to consider what matters to them and their service users, and were encouraged to use QI to make meaningful and impactful changes.

The seven pathway teams that participated have come together regularly to learn from each other, and to reflect on the progress being made. Although leading and supporting this work across the directorate has been challenging at times, it’s been fantastic to see teams come together in the spirit of collaboration, and to hear them talk passionately about how it has felt to make positive changes within their pathways. With some projects now showing great outcomes too, I look forward to hearing and celebrating the stories of the projects in our weekly series.

I’d like to thank all of the staff and service users who have been involved in these projects for your dedication and thoughtful hard work. While demand and capacity continue to be a challenge for CAMHS both locally and nationally, your keenness to improve quality, use data effectively, try new ideas and work together have helped the Trust start to address these issues, whilst at the same time ensuring that we continue to provide the highest standard of care.

Read all of the recent CAMHS stories below:

Improving access and flow within CAMHS: the ADHD service story

‘Mission Improvable’: an entirely factual and anonymous blog

Newham Child and Family Consultation Service in: The Busy Bees

City & Hackney CAMHS: Access and Flow project

Improving access and flow: Luton CAMHS story

Tower Hamlets Neurodevelopmental CAMHS pathway

Developing a Learning System to support improvement work across CAMHS

Jamie Stafford

On the commencement of the ‘Access and Flow’ projects in CAMHS we faced a simple question – with seven teams looking to improve, how can they work together?

The pathways that were selected were geographically dispersed, had different internal structures, and provided a range of different clinical functions. Despite this, some of the challenges to providing quality of care across CAMHS were shared. Using the learning system framework devised by the IHI (Provost, 2013), we considered the seven components that would support shared learning.

  1. Clarity of your healthcare system

Each team began their projects by developing a process map of their pathway, and collecting and reviewing data describing demand and capacity. This allowed teams to consider their pathways through a different lens, and to start to identify quality issues that they wanted to work on, and theories for how they might improve. Teams were asked to find a meaningful focus for their improvement projects, and many worked with service users and families to think this through.

For greater depth, some teams modeled the demand and capacity of their pathway, highlighting variation and showing how their clinical capacity is currently used.

An example of the output and analysis is as follows:

Where C&H ADHD clinical capacity is used (click to enlarge).

  1. System level measures

A dashboard of key relevant measures was developed to allow teams to monitor data while they test changes in their pathway to determine whether they were improvements. The dashboard comprised of some data collected manually by teams and some pulled directly from electronic patient records (RiO). For the teams involved, the data is still available here.

For all teams combined, the following shows the overall impact on waiting times for appointments across the specialist pathways that were involved in the learning system:

The improvements seen across the teams continue to be maintained, with the changes in data aligning with teams’ process mapping and testing changes in their pathways

  1. Explicit theory or rationale for system changes

Each team created a meaningful aim statement using their knowledge of their pathway combined with information from service users, available data, and literature sources regarding flow (Mayer and Jensen, 2009). They used Nominal Group Technique and Affinity Diagrams to build Driver Diagrams. They were encouraged to learn from each other and steal ideas shamelessly!

The following high-level driver diagram encompasses the individual project level theories of change:

  1. Appropriate segmentation of your patients

The CAMHS Directorate Management Team invited services to express an interest to work on demand and capacity. Pathway teams met with members of the QI team to initiate their project charters.

  1. Sequential learning methods

Project teams democratically selected change ideas to test using multi-voting. They based their decisions on their prediction of potential impact. They reviewed data and other feedback loops to determine whether changes were improvements, and to explore the broader impact of changes. Some teams were able to have service users as regular attendees in team meetings.

Using PDSA cycles, teams tested their change ideas, incrementally building confidence in their effectiveness.

  1. Multiple feedback loops and regularly scheduled learning events

The QI team supported the running of a 6-weekly learning set bringing the teams together with the directorate leadership for co-learning and co-coaching. The content was designed with the CAMHS leadership in response to how teams were progressing, and was an opportunity to develop a learning community around the projects.

We published a 6-weekly newsletter circulated to all CAMHS staff keeping them updated of progress. Each project was registered on the ‘Life QI’ web platform making data, driver diagrams and updates visible to all trust staff. This helped develop a community around the project. Team leads added monthly updates which formed a monthly report to sponsors.

  1. Leadership to keep the organization focused on learning

In addition to the learning system and coaching support, each project had the support of a local sponsor, a directorate sponsor (Clinical Director – Graeme Lamb) and an executive sponsor (Chief Operating Officer – Paul Calaminus). These people ensured that teams were supported to overcome barriers, but also to create the right conditions for the improvement projects to flourish.

While some teams saw fantastic improvements, as can be seen in the dashboard above, it is certainly true that QI projects rarely progress without bumps in the road. Indeed failure is a fundamental part of trying new things, without which we would struggle to learn. The role of leadership is to understand the value in learning from failure, and ensure we are testing in as safe an environment as possible.


Provost, L. (2013) Building a Learning Health Care System. Available from: http://app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-10006/Document-7652/Lloyd_Provost.pdf [Accessed 21st July 2018]

Mayer, T. and Jensen, K. (2009) Hardwiring Flow: Systems and Processes for Seamless Patient Care. Pensacola: Fire Starter Publishing.


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