Better performance with a reduced workforce, is it possible?

by Stefan Mieczkowski and Jeremy Walsh

14 March 2018

At the mental health workforce forum that took place in February Stefan Mieczkowski, client director, SSG Health and Jeremy Walsh, director, South London Mental Health and Community Partnership, presented a case study on workforce restructure at South West London and St George’s Mental Health NHS Trust. Stefan was appointed to support the change process.

Is it possible to create a service model capable of handling the same workload or more, but with reduced workforce? South West London and St George’s Mental Health NHS Trust (SWLStG) restructured its child and adolescent mental health services’ (CAMHS) workforce to meet a more than £1m cost improvement programme challenge while transforming service delivery.  The lessons learnt can be applied to many frontline service change projects. 


Three years ago South West London commissioners were unhappy with the performance, quality and cost of the specialist CAMHS service. It was also unaffordable for the provider. A triangulated approach to diagnosis (interview, observation and analysis) revealed that the service was well resourced, but underperforming and that there was indeed scope for savings.

There are some typical operational and workforce challenges that lie behind underperforming community based services and many of these were true in the South West London case:

  • Often there are inadequate structures and systems for performance management resulting in variation between teams and weak service delivery
  • The absence of a graduated approach to demand – limited multi-disciplinary triage before signposting to specialist assessment and poor throughput into treatment
  • Clinical skill mix can evolve ‘out of step’ with evidence-based modern skills and practices.
  • Community models have a tendency towards staff travelling rather than service users travelling
  • Services struggle with electronic patient record systems that are unsuited to the clinical, operational or measurement tasks implied by the clinical model.


These challenges in South West London required fundamental service redesign and reorganisation – revolutionary rather that evolutionary change. There are many good reasons to be wary of undertaking revolutionary change in any field of healthcare care provision, let alone in children’s services. Stakeholders are risk averse, local media are highly attuned to stories of cuts, and service users and their families are rightly vocal in the face of uncertainty about services upon which they rely. 

Revolutionary change has its advantages. If designers are diligent and uncompromising the new service will be efficient, evidence based and ‘future proofed’.  If the revolutionary change is well executed, the period of intense disruption ‘buys’ the provider many years of stability, growth and staff retention. If stakeholders are effectively engaged they will see the possibilities for other parts of their system, own the change (eventually) and invest further.

This was all true of South West London. A significant reduction in waiting times and a CQC rating of ‘good’ awarded soon after, gave stakeholders the confidence to invest.


So, what is key to undertaking revolutionary change in local health services? You need the right ‘change team’ combining clinical, operational leadership and experienced human resources partnership. The trust chose these key people well.

Many organisations also see the benefit of appointing an external change partner to inject operational skill and resource. You should also agree and hold onto a clear vision of how service users – in this case children, young people and their families – should experience care. 

Design based on Lean principles, ensure accuracy in everything that is produced and drive constant and consistent communication with stakeholders – especially staff whose jobs are at risk and service users.  Finally, be firm but responsive in the face of human emotions and insist on genuine consultation to win staff over with ‘what is new and better’ about the future model.  

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