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Table 1 Leverage points ‘Meadows ladder’ or places to intervene in a system 1

From: Soliciting stakeholders’ views on the organization of child and adolescent mental health services: a system in trouble

Label Explanation meadows Systemic problems in Belgian CAMHS
12) Numbers Constants and parameters such as subsidies or taxes. • Lack of financial resources
• Inappropriate allocation of resources to CAMHS relative to the investment in mental health services for adults
11) Buffers Sizes of stabilizing stocks relative to their flows. These are aggregates of various types (people, finances, materials) that determine the system’s behavior. Buffers that are small relative to their flows may lead to system instability. Large buffers may compromise the adaptiveness of a system. • Lack of a workforce (provider network) that is prepared to provide state-of-the-art services and supports
10) Stock-and-flow structures Physical systems and their nodes of intersection. This concerns the capacity of infrastructural elements that sustain a flux or flow in a system. • Lack of service capacity
• Limited range of service
• Lack of home and community-based services
• Overreliance on inpatient services
9) Delays Lengths of time relative to the rates of system changes. Delays in feedback processes can significantly determine the behavior of a system, often leading to instability (oscillations) if they are out of synchronisation with the speed with which the system changes. • Lack of capacity and saturation of services and resultant significant waiting lists for care
8) Balancing feedback loops Strength of dampening feedback loops relative to the impacts they try to correct. These are dynamic forces that keep the system near equilibrium, in much the same way as a thermostat keeps a room’s temperature near a desired temperature. • Reliance on inappropriately services due to lack of service capacity
• Pockets of excellence in service delivery approaches that are not adopted and implemented system wide
• Isolated services created to reduce pressure on the CAMHS system that result in additional fragmentation
• System inertia and resistance to system reform
7) Reinforcing feedback loops Strength of reinforcing, driving loops. These are dynamic forces that move the system away from an equilbrium (leading typically to phenomena of exponential growth). • Continued growth in children and families’ demand for mental health services
• Lack of coordination within and between sectors and both the system and service delivery levels exacerbate capacity problems and compromises clinical and functional outcomes for young persons and their families
• Waiting lists lead to users’ demand-inflating strategies to access the system
• Reinforcing demand-driven dynamic of increasing specialization and fragmentation in care services for young people.
• Lack of strategies to address cultural and linguistic differences and disparities in access to and the quality of services
6) Information flows Structure of who does and does not have access to information. Information flows are fairly obvious and easy to understand (whilst not necessarily easy to remedy) determinants of a system’s performance and behavior. • Fragmentation at the system and service delivery levels
• Lack of structured and coordination flows of information
5) Rules Incentives, punishments, constraints, typically embodied by regulations of all sorts. • No clear focal point of responsibility, management, and accountability at all levels
• Systemic focus on “beds” and hospital-based services rather than a full range of services and supports
• Lack of data for data-based decision making and continuous quality improvement at both the system and service delivery levels
4) Self-organization Power to add, change or evolve system structure. This essentially concerns system features that allow it to learn and to adjust its structure and functioning to outside disturbances. • Fragmentation of services both within the mental health sector and across other child-serving sectors
• Focus on the child in isolation rather than in the context of the family and the wider environmental context
• Lack of training of mental health professionals on a family focused and “ecological” approach to service delivery
3) Goals Purpose or function of the system. This refers to the explicit or implicit goal(s) espoused by the actors working in and governing the system. • No clear, agreed-upon goals for the CAMHS system
• Lack of clear, agreed-upon desired outcomes for the CAMHS system
• Lack of an appropriate focus on young persons across the developmental spectrum
• Lack of a balance between treatment for young persons with identified mental health conditions and a “public health approach that also includes mental health promotion, prevention, and early identification and intervention
• Lack of specification of a value-based practice approach for the entire CAMHS system
2) Paradigms Mindset out of which the system arises (its goals, structure, rules, delays, parameters). This refers to the basic norms and values which give meaning to the system’s goals and functioning. • Lack of family and youth partnerships at the system and service delivery levels
• Lack of family-driven, youth-guided care
1) Transcending paradigms Which is the ability to move flexibly between paradigms2. Not applicable
  1. 1The 12 ‘places to intervene in a system’ are usually presented in an inversely numbered way (ordered from the less systemic to the more systemic).
  2. 2We have chosen not to include this level in the analysis as it goes beyond the scope of this study.