Supporting system change in an integrated children’s mental health service
Situation
Tavistock Consulting was approached by a children’s mental health service that was established to provide holistic, equitable response to children and young people experiencing mental health difficulties. Despite this ambition, the service struggled to achieve its intended outcomes. Demand for specialist services continued to rise, waiting lists grew, and staff morale declined. Senior leaders within a strategic planning group commissioned support from the National i-THRIVE Programme to help the system use existing resources more effectively while retaining its focus on integrated care.
An initial exploratory phase involved interviews with stakeholders across agencies, including practitioners, managers, and service users. These conversations revealed persistent fragmentation, heavy reliance on specialist health services, and widespread anxiety about risk, responsibility, and accountability.
Our Approach
The work of two Tavistock pioneers, Menzies-Lyth1 and Bain2, emphasises the importance of analysing organisational change through three interdependent lenses: roles, culture, and structure. This case study examines how the work of the National i-THRIVE programme supported a large-scale transformation within a children and young people’s mental health service, drawing on this framework.
Role
Thinking about the main objective that an organisation is established to achieve, often referred to as its “primary task,” is a valuable starting point for working with organisations. Establishing a consensus on the organisation’s primary task and ensuring that behaviour aligns with it is typically the first step in addressing some of the more complex dynamics involved in the work.
Clarifying an organisation’s primary task is essential for understanding how roles are taken up3. In this system, the stated (normative) primary task was to “bring partners together to take collective responsibility for improving children and young people’s mental health and reducing inequalities.” However, applying Lawrence’s4 distinctions revealed significant misalignment.
The primary task, as experienced by the staff and referred to as the “existential primary task,” was focused on accessing mental health support through a specialist health provider. This was further emphasised by the “phenomenological primary task,” which was evident in everyday behaviour. Referrals were typically directed to individual agencies based on categories listed on referral forms, with little to no collaborative assessment or shared decision-making involved.
This misalignment resulted in role confusion and defensive positioning. Although many practitioners expressed a desire for collaborative working, their behaviour reflected a system organised around protecting professional and organisational boundaries. Teams had very strict criteria that determined whether young people could access their services, and decisions were made solely based on referrals. This approach hindered more collaborative efforts, which involve discussions between agencies to identify the most suitable services for families. Ideally, one agency would offer liaisons or consultations to another, allowing them to cross professional boundaries and provide a more holistic service to young people and their families.
The screening function was largely carried out by junior administrative staff whose role was limited to processing and redirecting referrals. Tasks were highly fragmented, repetitive, and offered little scope for judgement or autonomy. Bain notes that such task splitting can result in workers becoming disconnected from the meaning of their work, fostering dependency and disengagement.
Bion 5 has made a significant contribution to our understanding of how groups work when they are on task, and some of the mechanisms groups use to defend against the difficult feelings the work creates. The pattern described above reflected what Bion describes as a dependent group, in which responsibility of the group is unconsciously located in an idealised authority figure—here, the specialist mental health service. Administrative staff frequently described themselves as “not responsible for providing help” reinforcing a split between “doers” and “thinkers” within the system.
The emotional weight of working with children and young people at high risk further intensified these dynamics. Menzies-Lyth’s work on social defences in nursing organisations is particularly relevant: splitting tasks into impersonal components functioned as a defence against anxiety associated with potential harm, loss, and failure. In this case, high levels of youth suicide and staff vacancies heightened anxiety and reinforced defensive role behaviours.
To address role confusion, cross-agency workshops were facilitated to explore values, motivations, and experiences of the work. Participants were encouraged to reflect on why they entered the field and how systemic pressures shaped their behaviour. Making explicit the gap between values (normative task) and practice (existential task) enabled staff to recognise the limitations of the existing system and increased openness to change.
Practical role redesign followed. The screening role was expanded to include initial contact with families, welfare checks with schools, and identification of existing professional involvement. This increased task significance, improved morale, and enhanced the quality of information feeding into decision-making processes.
Additionally, a series of cross-sector Action Learning Sets were facilitated to encourage practitioners to act beyond traditional professional boundaries—for example, supporting families to access community or preventative resources rather than defaulting to clinical pathways. This represented a shift away from dependency on specialist services toward shared responsibility.
Culture
Bain defines organisational culture as the observable patterns of assumption and behaviour that may be conscious or unconscious. Despite the formal creation of an “integrated” service, the culture remained siloed. Agencies used distinct languages, acronyms, and commissioning arrangements, reinforcing separation rather than collaboration.
To counteract these dynamics, Tavistock Consulting introduced structured spaces to think for senior leaders through reflective practice groups. Leaders brought live dilemmas and explored them collectively, supporting reflection on both task and role. Participants reported reduced isolation and increased awareness of shared challenges.
While these interventions did not dismantle deeply embedded cultural defences, they created pockets of reflective practice that began to challenge siloed thinking and normalise uncertainty and difference.
Structure
Tavistock Consulting’s structure analysis highlighted significant problems with the ways that team managed the flow of work into and out of the service. The specialist mental health service was overwhelmed by fluctuating referral volumes and lacked authority to regulate what work came into them. As a result, waiting lists grew, staff turnover increased, and morale declined. There were also problems with the way teams allowed work to flow out of them, with clinicians struggling to discharge families due to limited onward support and fear of risk escalation.
A key structural intervention was the introduction of twice-weekly multi-agency intake meetings involving health, social care, education, and community services. Rather than allocating referrals automatically, the group jointly determined lead responsibility and drew on a wider range of system resources. This created a single, firmer external boundary around the service, with more flexible internal boundaries between agencies.
Attention was paid to dual group membership, acknowledging practitioners’ loyalty to their home organisations while supporting collective responsibility. This structural shift significantly reduced pressure on specialist services and improved shared ownership of risk.
An additional initiative—a post-discharge “health passport” offering rapid re-access to services—had limited uptake by families but provided containment for clinicians and services users, supporting safer discharge decisions.
Impact
This case study illustrates how role, culture, and structure are deeply interdependent in system change. Addressing role dissatisfaction without altering structural boundaries would have been insufficient, just as structural reform without cultural containment would likely have failed.
Role redesign increased staff engagement and improved information flow. Structural changes redistributed responsibility and reduced dependency on specialist services. Cultural interventions, while slower to embed, created reflective spaces that challenged defensive patterns of behaviour.
Consistent with Menzies-Lyth’s work, splitting and dependency operated as social defences against overwhelming anxiety. Moving toward more integrated, sophisticated functioning required creating conditions in which anxiety relating to the high risk presented by the population the team were working with could be thought about rather than defended against.
The case raises the importance of protected reflective spaces for multi-agency systems while they hold the emotional weight inherent in work with vulnerable children and young people.
Header image: Jelleke Vanooteghem Unsplash
- Menzies, I. E. P. (1960), ‘A case study in the functioning of social systems as a defence against anxiety. A report on a study of the nursing service of a general hospital’, Human Relations, 13 pp. 95–121 ↩︎
- Bain, A. (1982), The Baric Experiment. London: Tavistock Institute. Occasional Paper No. 4. ↩︎
- Rice, A. K. (1963) The Enterprise and its environment. Tavistock Publications, London ↩︎
- Lawrence, G. (1977) ‘Management development…some ideals, images and realities’, in Colman, A. D. and Geller, M. H. (eds) Group Relations Reader 2, Washington, D. C.: A. K. Rice Institute Series, 1985.
↩︎ - Bion, W. R. (1961), Experiences in groups and other papers. Tavistock Publications, London. Chapter 6, pp.115-126. ↩︎