The Children’s Mental Health Service
At a glance
-
1. Discovery
Desk research, contextual inquiry and extensive interviews were used to understand the end-to-end user journey within the CAMHS Service.
The team conducted:
2 x days of in-situ observations
14 x interviews with 4 user groups
-
2. Analysis and Definition
Use of thematic analysis and user journey mapping made it clear that there were many different pain points for different user groups.
The biggest digital pain point was that the referral point of entry was not fit for purpose for GPs and CAMHS staff.
Also communication, signposting and expectation management were some pain points for parents and schools engaged in the service.
-
3. Presentation and Outcomes
The discovery was presented to designers and key stakeholders.
Talks began to discontinue use of the existing referral solution.
Insights and recommendations were taken forward with service design and quality departments.
Background
CAMHS is primarily responsible for accepting and processing referrals for children with Mental Health and Neurodevelopmental concerns. The service accepted referrals from GPs and Schools via a third-party web portal form, and via post. They also used an internal electronic patient record system and third-party outcomes measuring software. The referral portal was also used and shared by the Children’s Family Health Service (CFHS) which focuses more on physical complaints in children and young people. The CFHS used a full version of the web portal to process referrals whereas CAMHS used it only as a means of receiving referrals. The digital teams undertook the project to evaluate whether CAMHS would benefit from ‘upgrading’ to the full version of the web portal.
Please note: brand names and specific service names have been redacted.
Set-up
The design team were tasked with mapping out the workflow of CAMHS to identify where support can be offered from a technological standpoint and improve the experience of the users. They were given this brief as well as key stakeholders and user groups to map out.
Users:
Clinicians and admins in the service
Referrers (GPs and Schools)
Children and Young People (CYPs)
We set out a research plan to ensure all the user groups and stakeholders had a part in the discovery and design process.
Research Objectives:
Identify the pain points and inefficiencies in the referral receipt and processing phases.
Establish the key issues for referrers throughout the end-to-end process.
Evaluate the viability of expanding the use of the current web referral portal and if it will improve the user experience.
Desk Research
There was already a wealth of information within the organisation that gave insight into the existing situation, process and pain points. We were able to learn more by:
Reviewing process maps and Standard Operating Procedures
Gathering formal complaints made to CAMHS
Conducting internal meetings with team members with experience of the service
Reviewing legacy research
From this research we were able to design a research plan and establish some research hypotheses. This was circulated and signed off by key stakeholders.
Hypotheses
-
GP Referrals
General Practitioners (GPs) do not have enough time to complete the require web referral forms.
-
Integration
Full integration of the existing web portal solution would provide advantages to the team and the referrers.
-
Diganosis vs Support
Children being referred for Neurodevelopmental needs are seeking help and support but the service is geared around diagnosis.
Primary Research
Contextual Inquiry
A day in the office
Myself and one other researcher travelled to the offices of the CAMHS team and observed their processes. We observed and conducted interviews with:
3 x clinicians
1 x service lead
1 x admin
1 x assistant pschologist
Observation
We were able to see the admins and clinicians interact with their existing systems and observe the process end-to-end. Observation opened the way for us to understand exactly what users do, even sub-consciously.
We took detailed noted highlighting the pain points and the reasons for them.
Interviews
Interviews gave us the opportunity to learn what users think and feel. They elaborated on each step of the process describing exactly where the frustrations lay.
High-Level Process Flow
From this, I was able to visualise a high-level process flow. The referral is made at a GP (or school), sent to CAMHS for processing by admins and then triaged by clinicians. Any referrals for Neurodevelopmental needs would also have a secondary screening by an Assistant Psychologist.
The high level process for a referral in the CAMHS service
Interviews with Referrers
Question guide for GPs/Schools:
Do you make referrals to CAMHS?
Who else is involved in the process?
What tools or methods do you use?
Tell me about the last time you made a referral.
When you made the referral what did you expect to happen?
Question guide for Parents:
What are your perceptions of the CAMHS service?
Tell me about the experience of your child being referred. What help did you and your child receive?
What do you wish CAMHS could have done differently?
The initial discovery with the CAMHS team made it clear that pain points for them started early in the process (i.e. on referral). Therefore, the referrers needed to be engaged to fully understand the end-to-end journey.
To empathise with these user groups I conducted 1 on 1 interviews with them using a discussion guide, while also letting the conversation flow. I gathered the information we needed and explored tangents to get to the bottom of the real concerns of the participants.
GPs
I interviewed 5 GPs via Microsoft Teams. Using in-depth questions I was able to discover the GP’s experiences creating referrals, their motivations for doing so and their perceptions of the service.
Parents
Schools
Parents, though unable to refer their children to CAMHS, were an invaluable source of information regarding the end-to-end process from referral to discharge. Parents were the most willing to talk about the issues, therefore I interviewed 7 about their experiences.
School Special Educational Needs Coordinators (SENCOs) are primarily responsible for ensuring the educational needs of children in the school with ND and Mental Needs are being met. I interviewed 2 SENCOs and reviewed notes from legacy research and learnt about their experiences referring children to CAMHS.
Findings & Analysis
Web Portal Form Review
Common complaints and pain points that arose from this phase of research revealed that the web portal form used for referrals caused many issues down the line in the referral processing.
I walked through the portal form and discovered numerous pain points and usability issues. These issues were able to be grouped into themes:
Most referrers feel unequipped to answer the questions either because they lack clinical knowledge (schools) or they did not spend enough time with the child to learn all the information required (GPs).
The configuration of the form makes it too long for referrers (especially GPs) to complete yet still doesn't provide all the information needed for CAMHS to process the referral.
The form is blended with the referral form for CFHS meaning pathways are confused and referrals can be incorrectly routed to each service. CFHS allows for parental referrals yet CAMHS does not. Due to the forms being mixed together situations arose where parents accidentally referred to CAMHS which would have to be rejected.
User Journey Mapping
The design team met at the office in person and undertook a collaborative user journey mapping session to visualise the pain points and design recommendations at each stage of the referral process.
This enabled discussion with the designers to brainstorm ideas for solving the pain points presented.
The analogue map was then translated into a formal, digital process map with each step outlined and overlayed with the associated pain points.
Personas
I synthesised the insights from all the interviews and observations into personas for each user group. Each persona reflected the goals, needs and pain points of each user. They also featured some direct quotes from users that well illustrated the problem space.
-
CAMHS Clinician
-
CAMHS Admin
-
GP
-
Special Educational Needs Coordinator in Schools
-
'Ordinary' Parent
-
'Professional' Parent
Thematic Analysis
The pain points in the process were listed, coded and categorised into a digital catalogue. They were sorted and synthesised into overarching themes. To effectively explain the problem space I separated each theme into Issue, Reason, Impact and Design Implication.
From this exercise it was clear a pattern was emerging:
The referral web portal as an entry point is the main cause of issues for the CAMHS service and the GPs.
However, the Trust had spent a lot of money on this digital solution to facilitate referrals to the service. In fact, one of the objectives of the discovery was to establish if expanded use of the web portal would improve the experience.
Therefore, to fully illustrate the pain points associated with the web portal form, I presented this summary to the key stakeholders.
This pie chart, along with the other deliverables, was presented to key stakeholders and proved very impactful. Immediately, discussions began about discontinuing the use of the third-party web solution instead of expanding the use of it.
How Might We?
-
Must
How might we reduce the amount of time referrers spend entering ‘administrative’ details?
-
Must
How might we reduce the amount of admin work the CAMHS admin team require to process the referral?
-
Must
How might we ensure that referrers only refer from the right clinical commissioning area?
-
Must
How might we enable the referrer to provide the correct clinical information in an efficient way that meets CAMHS’ requirements?
-
Must
How might we make it easier for parents to answer the questionnaires appropriately?
-
Should
How might we make it easier for parents to fill in and return diagnosis questionnaires?
-
Should
How might we ensure that referrals aren’t closed simply because a diagnosis questionnaire hasn’t been received?
-
Should
How might we redesign questionnaires (or the process overall) so that they are answered more ‘truthfully’?
-
Should
How do we improve the communication/updates for parents?
-
Should
How might we ensure that everyone that is looking for support, gets that support, regardless of intervention/diagnosis?
-
Should
How might we better design the referral pathways to take into account complexity and co-morbidities without sending CYPs through different pathways and different clinical teams?
-
Should
How might we better manage the expectations of families and carers?
-
Could
How might we ensure the children being referred are involved (or at least better perceived to be involved) in the screening and triaging process?
-
Could
How might we better manage the expectations of referrers on what their responsibilities are?
-
Could
How might we provide better sign-posting information for GPs, within their referral form (web portal or other)?
Conclusion
CAMHS
There are a number of pain points experienced by both the admin and clinicians at CAMHS. Some are related to the internal system and other to third-party digital solutions.
However, the largest pain points within the CAMHS workflow stem from issues within the doorway to it i.e., the web referral form (approximately 70% of the pain points). The priority in this project to reduce pain points for CAMHS Admins and Clinicians would be to make the needed changes to the web referral form or remove it entirely.
Referrers
The further discovery research completed, provided further insight into the referrers’ experience (both GPs and schools), some potential design questions arose:
How might we improve the referral form to work better for BOTH CAMHS and referrers?
Is the web referral form still the only option for referrals to CAMHS? Are there better referral solutions that do not involve the existing web formal?
However, the discovery of the GP and School processes and experiences revealed that to make design improvements for any of the referral route, it needs to be viewed holistically.
“The problems for AAT, the GPs, the schools and the parents start as soon as the CYP begins to present.”
There are a number of pain points experienced by referrers. Some are related to the overall referral process and some are more specifically caused by the RIVIAM Portal Form. Generally, for the 3 main groups I interviewed, I could differentiate between them and summarise the findings as such:
GPs are extremely unhappy with the web referral form. It simply takes too long, makes GPs fill in loads of admin information, and doesn’t fit with their way of working.
Schools have slightly different frustrations - while the form is not perfect, and they spend even more time on them than the GPs, they do not complain about the length of time it takes or the amount of information that is asked of them. Rather they struggle with how to fill in the form appropriately, how much information is required, and what the expectations are of them. At the end of the day, their dealings with the family and child is not just during a consultation - it is a long-term relationship before and even way after, the referral is made.
Parents and carers do not use the form so their frustrations are not about the form – but rather it is more about the way the service/referral pathway is structured, the expectations they have, and the communication that they experience. These raise big questions, that go beyond a digital platform. They also struggle with the wording, framing and logistics of the questionnaires.
Impact
-
Designer Hand-Off
The deliverables from the discovery were handed off to the designers to brainstorm improvements that can be made from a digital perspective. The primary focus is the referral entry point.
-
Management Stakeholders
Findings were presented to service leads and digital managers. Interestingly, despite the project aim being to explore the expansion of the web referral portal, moves were made to decommission the portal immediately after discovery.