Since our vision for One Big Front Door for children’s services was successful in the 2023 round of Q Exchange projects, our team has been working to help bring this vision into reality.

Where we’ve seen success has been in patient engagement and empowerment, visibility of waiting times across the service and culture change leading to better co-operation between teams. What we’ve learned is that communication is key, visibility of problems is needed before you can tackle them and digitally enabled projects come with their own particular set of challenges.

Understanding the problem

When we began this project, we knew from feedback from service users that families were finding it difficult to navigate children’s services.

One child might have four different referrals, drawing on support from a range of clinicians from community paediatricians and children’s nurses to therapy services for speech and language to physiotherapy to podiatry.

Parents told us they were being signposted but not referred on to the services they needed. Inappropriate referrals could lead to delays and poorer long-term health outcomes. Families said they often felt they were being passed ‘from pillar to post’.

In a service that receives about 1000 referrals a month, spread across a huge geographical area with multiple clinical teams, bringing referrals under one virtual roof was a huge challenge.

Seeding cultural and behavioural change

Apart from the technical and digital change needed to create a single system for referrals and treatment across the service, this was really a cultural and behaviour change project.

It was especially challenging in an environment of already stretched services, system complexity and increasing demand.

Clinicians and staff were rightly concerned about data protection and changing ways of working in a system under pressure. Having to tell families how long they would be likely to wait was also a concern.

Hearing from families

It was feedback from families that strengthened our resolve to do this.

We went around a number of parent forums and groups in Southampton, Portsmouth and the Isle of Wight. We used learning from Healthwatch and were in regular contact with a range of community engagement groups, including, for example, Portsmouth Parent Voice.

We appointed a parent expert by experience to join our project group, feeding into the steering group. We also had lots of feedback from staff, many of whom were also engaged with our services as families.

Everyone was supportive of the vision. Families wanted us to be child-centred, so instead of us seeing multiple referrals they wanted us to see their one child.

They wanted clear signposting – the right support at the right time. And they wanted acknowledgement of receipt of referral because they often weren’t getting a communication to say when their child had been referred to our services.

We had built a significant presence on a variety of digital sources but mostly families didn’t know about these so we knew we needed to raise awareness about the services on offer and how to access these services. It was clear that people also wanted to have their expectations set about wait times.

Tackling inequalities

As clinical lead, it was really important for me to reduce the inequality across localities where there may be a significant variance in waiting times for the same service, which was only due to where you lived.

This came down to visibility of referrals and waiting times across services and localities – something we didn’t have. Whereas in the past, all referrals would go a location list, we wanted to have all locations in a single system.

Working with digital systems

This meant we had to look at our systems and it was here that we faced major challenges. The way our patient record systems worked meant that everything was organised in separate units.

Paediatricians, therapies (physiotherapy, occupational therapy, speech and language therapy and podiatry) and localities amounted to four separate systems. When it came to new referrals into the service, paediatrics couldn’t see what was happening in the therapies system and vice versa.

There were initial concerns but we realised that the only way to include paediatrics in a single referral system was to have a separate unit just for triage.

Using PDSA cycles

We used Plan, Do, Study, Act (PDSA) cycles to co-create the new services, starting with new triage templates.

With input from parents, we narrowed down seven core categories of referrals from 30-40 different lists.

The new triage template would record why a child was being referred and this reason could relate to multiple services. For example, ‘I’m referring in because I’m worried about a child’s communication’.

The seven categories for referral were:

• communication
• eating and drinking
• physical
• school skills
• independence
• musculo-skeletal
• multiple needs.

We also created a template referral outcome letter to go out immediately to families once a child had been triaged.

Alongside this we provided waiting well advice via a telephone advice line and are developing information on the Family Assist application, which is a local information portal developed within the health visiting service.

Part of the project aim was to bring together a central team, repurposing clinical time to bring clinicians together.

There was anxiety about how this would affect triages for local teams so we didn’t do this in cycle 1. Instead, we supported local teams through training and Q&As and created a Teams channel for a large number of clinicians doing triage. This uncovered a great deal of variance in practice.

We had to recognise that our ambitions were limited by the capabilities of our digital systems.

Feedback from staff from PDSA cycle 1 was that there were some successes and some real challenges. The challenges were particularly around the digital system, and we had to make some considerable adaptations for PDSA cycle 2, including moving away from the single triage system.

This felt a bit like backtracking on our original goal but were important for supporting our staff with staying with this project.

The power of visibility

The visibility of what’s going on across the service has massively improved. With the new centralised waiting lists you can now very easily see how long children are waiting for triage and if there are differences across localities.

This was a big cultural change. Some clinicians were very anxious about triaging children outside of their base locality. While there was a consensus that families would like to be contacted with information after triage, there was also anxiety about the time that this would take, and particularly about communicating with families how long they are likely to wait for their first appointment.

However, the cultural and behavioural change is happening, support is now being offered across different localities and families are now routinely being advised via a digital letter of the outcome of their triage (including waiting well advice and expected wait times).

It’s helped us to see what standards we should be setting in the long term and to set goals for improvement based on where we are at the moment.

Knowing when to compromise

The integrated therapies team is very large – they receive 95% of referrals. Having a separate system for triage was cumbersome and time-consuming for admin and clinicians so for PDSA cycle 2 we’ve compromised on a single point of access for everything.

Instead, there’s a single point of access for therapy services and we are continuing to work with our colleagues in community paeadiatrics to develop an ‘interconnecting door’ between paediatrics and therapies.

We plan to develop a robust system where a clinician can transfer referrals between teams rather than bouncing referrals back to families and referrers.

What next?

For PDSA cycle 2 we were looking for a downward trend in wait times and an upward trend in communication and satisfaction. A questionnaire is being sent out to a large group of families to determine the success of this.

We won’t stop doing PDSA cycles. There’s so much we want to do.

This includes improving our digital resources for waiting well and raising awareness about how to access services.

We’re hoping the project will lead to more consistency across areas as to how they do those initial appointments. We want to look at the potential for virtual clinics and giving patients the choice.

We also want to explore the concept of a care navigator. We’re looking at how care navigators and volunteers can work together to enable this type of service for families.

Ultimately, the project has become less about bringing people in through one front door and more about ensuring seamless care under one roof.

Submit your ideas for Q Exchange funding

The next round of Q Exchange is open to new project ideas until Tuesday 27 February 2024. We are looking for proposals that involve two or more parts of the health and care system and focus on improving the quality and efficiency of the interface between different sectors.

This year’s theme is: How can we improve across system boundaries? Find out more and submit your ideas on the Q Exchange page.