Background and Aims

During the Covid-19 pandemic eating disorder services across London and England reported large increases in referral numbers and acuity. This case study highlights the approach taken by a specialist tri-Borough Community Eating Disorder Service (CEDS) for children and adolescents. The service is based at East London Foundation Trust and supports a broad range of diverse East London communities. The impact of the pandemic led to increased wait times from referral to initial routine assessment and also internal treatment wait times. The CEDS team at ELFT saw the average time from referral to routine assessment increase to 17 weeks, which is significantly longer than the 4-week National target and 2-week local target. To address this the team used a Quality Improvement (QI) framework approach and set up a project to address the issues around capacity and flow through the service, with a focus on reducing wait times for young people and families.

Approach

The leadership team at ELFT supported the CEDS leads to use a QI framework as a tool to address and reduce the waiting times for the service. The team used process mapping to understand and highlight areas of bottlenecks, delays and inefficiencies. The team were then able to implement many changes including:

• Reviewing the referral form to make it more informative and stopping extra steps in the referral process.
• Setting up a system to keep oversight on referrals and timely closure.
• Moving from two assessors to one to offer a timelier assessment appointment.
• A proactive recruitment campaign was launched including reviewing job descriptions and having interface meetings with other stakeholders to recruit staff.
• Regular psychiatry clinics were set up to clear the backlog of those waiting.
• The team also set up a more dynamic and collaborative way of working with psychiatry, joining therapists to see families together for reviews, rather than working in silos and operating separate lists.
• Job plans were systematically reviewed, and capacity was discerned for each therapist. This helped to establish a more efficient way to allocate families for therapy.
• The team reviewed therapy interventions with proactive planning towards discharge or setting up referrals to more appropriate service if needed to support flow through the family therapy pathway.

Results and Impact

The average wait time from referral to routine assessment reduced from 17 weeks at the start of the QI work in June 2022 to 2 weeks by June 2023.

Figure 1. X Bar and S Charts demonstrating average wait time from routine referral to assessment from 17 weeks to 2 weeks

The psychiatry wait list reduced from 75 to 0 between September to December 2022. The family therapy wait list reduced from 50 to 0 between September 2022 to April 2023. The service now has shifted in its culture, towards more proactive, young person and family centred approach and has developed a collaborative and dynamic way of working, with no internal waiting lists. Time from referral to routine assessment is stabilised at the local target of 2 weeks, and families access treatment pathways in a timely fashion, usually within 2 weeks.  

More information on the work undertaken by the CEDS team, including a short video, can be found via this link to the story on the ELFT QI website – https://qi.elft.nhs.uk/camhs-east-london-eating-disorders-service-ceds-improving-flow-and-capacity/

Challenges and Key Learning

One main challenges of this piece of work was how to approach and manage change in a service. The team took a considered and curious approach to understanding the landscape and spent time with staff to get their perspective. This helped significantly, as it helped to build trust, support staff buy in and started the thinking in the team around change ideas.

Given that change management can be challenging, one key piece of learning from this work is around using service user feedback to motivate staff to help effect change. The CEDs leads shared feedback from complaints, compliments and other forms of informal feedback with their staff team. By ensuring the young people and families’ voices were heard and discussed in the team provided to be a powerful catalyst toward improvement.

Another lesson learnt from this work was the power in using QI frameworks hand in hand with High Impact Leadership to support positive outcomes for service users, families, and staff. The IHI white paper on High Impact Leadership[i] highlights core behaviours to improve care, improve the health of populations and improve cost including person-centredness, front line engagement, relentless focus, transparency and boundarilessness. These values have been inspirational to the leads of the project and have undoubtedly influenced the approach to the QI work.

The QI framework was used within a context of setting a clear vision for the service, and investing in opportunities to build the will for change and create the capacity to undertake improvement work. This yielded positive results that have been used to shape the culture of the service and to continue to have innovation and systems thinking as key.

Next Steps

Improving capacity and flow through the service by significantly reducing wait times has led to improved young person, family and staff experience. It will make the service more efficient and effective and will help to embed a culture of responsive, reflective and empowered clinicians working collaboratively together and with young people and families, putting them at the heart of what we do. 

It will also allow the team to now focus on embedding a sustainable high quality service.

The team plan to instill a consistent way of obtaining feedback from staff, service users and families. Included in this work will be reviewing outcomes, use of People Participation, the CQC review framework, and ELFT Service User-Led Accreditation to further improve the service. The team have used the Trust Leadership Framework to actively have conversations with the leadership team to ensure high quality service is made sustainable, with continuous learning and improvement a core value held in their culture.

---

[i] Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2013. (Available at ihi.org)