Tell us a bit about your project…

"Over the last few years, we have noticed a change in the type of referrals we receive to Talking Therapies, mainly a reduction in the amount of people referring for ‘step 2’ intervention, compared to a ‘step 3’ intervention. Someone who might benefit from a step 2 intervention is someone who might benefit from Low Intensity CBT/Guided Self Help sessions within our service. These are short-term (between 6-8) weekly therapy sessions delivered by a Psychological Wellbeing Practitioner (PWP) aimed at providing service users with CBT-based tools and techniques to support with mild-moderate mental health difficulties such as depression, anxiety, phobias, stress & insomnia, whereas clients who might benefit from a ‘step 3’ intervention tend to experience moderate-severe mental health difficulties such as social anxiety, PTSD, health anxiety or severe depression. We also notice there are certain client groups in the community who are under-represented in our referrals to step 2, mainly perinatal clients, older adults (65+) and clients of the global majority. It is important to ensure we are able to increase referrals for these client groups and to step 2 in general as early intervention and supporting service users with their mental health difficulties when they first develop, or are still mild, may then prevent the symptoms from worsening and someone requiring longer term support.

This is a complex problem with many different factors that have led to the current low referral numbers, we wanted to explore this using QI tools to then be able to produce change ideas to try to address this problem and increase referral numbers at step 2 to ensure we are supporting the population of Camden & Islington and are able to help those who would benefit the most form our interventions."

What tools did you use to better understand the system surrounding your project? Were all the tools useful?

"We found using the stakeholder matrix helpful for understanding the different groups of people impacted by the current low numbers of referrals, and therefore who would benefit if referral numbers did increase. We also used this to think about those who could potentially contribute to increasing referrals and who we would need to keep involved/informed.

We also submitted questions to our service user focus group to gain feedback on the current referral processes and to think more about how the service users became aware of our service in the first place. This was useful to hold in mind before going into the process mapping session to consider our perspective as a service, but also the perspective of service users.

We also obtained data on referral numbers over the last year and explored this further to think about the data for each of the target groups, this was useful, however it was more useful to review this data following the process mapping session to try to narrow down our aim and which parts of the data we wanted to focus on."

How did you find using Process Mapping / Fishbone Analysis?

"Process mapping allowed us to take a step back with some of our identified stakeholders and think about the current systems and how they may be contributing to low referral numbers. It was helpful to do this in person and be able to visually map out the different processes. It was also helpful to have members of the QI team facilitating this as they could ask questions from an external point of view and allow us to think about challenges and opportunities for change, we might not have considered before. It allowed us to explore the problem broadly, to then be able to narrow this down through the fishbone analysis. 

The fishbone analysis was invaluable in allowing us to identify the wider themes leading to the lack of referrals and the specific problems within each theme. We were then able to use this to think about which parts of the problem we wanted to focus on. We regularly refer to the fishbone diagram now we have moved onto the next stage of the project. It is also clear and concise and easy to share with others who are interested in the project or want to clearly see our process and how we narrowed down the aim."

Was there anything that surprised you when you were exploring the problems?

"One thing that surprised us was the wide variety of factors contributing to the problem. Through exploring the problems, it also became clear that others were working within the service to try to address some of the difficulties we identified already, e.g. one of the problems we identified through the process mapping was out of date referral forms being used by GPs and other professionals, but this is something that is already being addressed by our Communications Team. This again allowed us to narrow down our aim to think about which problems were not currently being addressed."

What top tips would you give people that are at Stage 2 in their project journey? 

"Don't exclude anything! Even if a factor contributing to the problem feels too broad or outside the remit of the project, it is still best to include it in the fishbone analysis/driver diagram as it may relate to some of the other difficulties you are exploring as part of your project. Don’t be put off if your aim shifts and changes as you explore the problem in more depth."

If you could start over, what would you do differently?

"I would spend longer speaking to others in the service about work already being carried out and how this might overlap with the aims of the project."