Changing the System for Adolescents and Young Adults

Dr Aarthi Ravishankar, GP with interest in Paediatrics and Clinical Adolescent and Transition Improvement Lead at London North West University Healthcare NHS Trust, reflects on her Darzi Fellowship experience last year of improving Adolescent and Young Adult Care at the Trust

By meganpeng · September 27, 2022

Working in this role, I have learned so much about trying to make large scale change and I am lucky to have been supported by an incredible team at London North West University Healthcare NHS Trust. My work focused on improving the quality of care for Adolescents and Young Adults. As child health professionals we know that investing in young people will lead to long-term individual and societal benefits1. Historically, however, young people have not been well represented in health care policy2.

So how do you get started with trying to improve a system of care for a population?

Here’s what I have learned (with plenty of mistakes made along the way!)

To change the system, you need to get to know the system

Understand the” macro-, meso- and micro-” context

Go wide


Be curious and let go of bias, assumptions and agendas

Collaborate and engage

  • Understand the” macro-, meso- and micro-” context: What is happening at a national and regional level that influences the issue you are trying to change? What is happening at the organisation? And what do the patients and families think? For example, this may take the form of reviewing national policy documents, looking at your organisation’s CQC report and reviewing previous patient feedback.
  • Go wide: Speak to as many people as you can including patients, families and professionals to understand the system from their perspective. This includes those from outside the health setting which in my case included education, social care and the voluntary sector. This creates opportunities to look for wider patterns which may be influencing the problem. If possible, go beyond your organisation and reach out to teams who are doing good work elsewhere.
  • Data: Data is critical to understanding the context and the needs of the population. Traditionally as healthcare professionals, we tend to focus on quantitative data but qualitative data is equally as important. This is why it is so important to hear the perspectives of staff, patients and families – all of these conversations hold important data points which will help to understand the reality of the problem you are trying to improve.
  • Be curious and let go of bias, assumptions and agendas: Taking the time to speak to as many patients, families and professionals in the system as possible whilst putting aside your own biases, assumptions and agendas allows for never-before considered ideas to emerge that could be part of the solution.
  • Collaborate and engage: Engaging a wide range of people often leads to identifying those who may want to collaborate with you and offer support for the cause. Attempting to make large-scale change is impossible to do single-handedly!

Developing a plan

Synthesis and reflect

Shared purpose

Develop a ‘Theory of Change’

Resource plan

Evaluation plan

This paper is particularly helpful for the following section3:

  • Synthesis and reflect: Review and reflect on all the data you have collected and look for common themes.
  • Shared purpose: A clear shared purpose which helps unite stakeholders can be a very powerful motivator and provide direction. In times of doubt, revisiting the purpose can help things get back on track.
  • Develop a ‘Theory of Change’: With complex change, it is likely that a variety of interventions are needed to tackle the issue. Your context study and common themes will help you to think about what structures, processes and beliefs are influencing or “driving” the problem and the change interventions which may help to act on these and help achieve the shared purpose. This is also known as a “theory of change”. A driver diagram is a way to display this visually and can be useful for communicating your plan. The Institute for Healthcare Improvement has some fantastic resources and examples4.
  • Resource plan: Advance planning of your resources will pay dividends as you decide on your interventions and implement your plan. In addition to those who may want to collaborate with you, try and find out if you have other resources. This may include funding, administrative time or business intelligence.
  • Evaluation plan: Ask yourself, “how will we be able to tell that a change has been an improvement?” It can be challenging to decide on process and outcome measures for complex change work but doing it before implementation is crucial. Reach out to your local QI or Transformation team or even your local academic department for help with formulating an evaluation plan.

Discover more about QI methodology and children and young people’s engagement in our QI Central resources section.


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Clark, H., Coll-Seck, A. M., Banerjee, A., Peterson, S., Dalglish, S. L., Ameratunga, S., Balabanova, D., Bhan, M. K., Bhutta, Z. A. and Borrazzo, J. (2020) A future for the world’s children? A WHO– UNICEF–Lancet commission, The Lancet, 395 (10224), pp. 605-658.


Shah, R., Hagell, A. and Cheung, R. (2019) International comparisons of health and wellbeing in adolescence and early adulthood research report (2019) London: Nuffield Trust & the Association for Young People’s Health (Ayph)


Shah, A., Aurelio, M., Frasquilho, F. and Fradgley, R. (2021) Quality improvement in practice— part three: Achieving the triple aim through the systematic application of quality improvement, British Journal of Healthcare Management, 27 (10), pp. 1-10.


Institute for Healthcare Improvement (n.d) Driver Diagram (Last accessed 16/09/2022)