Designing Services in a Changing NHS

This article was first published on the Prospect website.

An Opportunity for Preventative Healthcare

Prospect joined GPs, NHS representatives, academics and other service designers last week for an event hosted by Imagination Lancaster, who recently released their report 'Design In Practice' to discuss the effects of the most radical changes facing the NHS since its foundation in 1948.

The event at the Design Council explored how service design can help GPs, local authorities and the public make the most of their new roles and responsibilities and facilitate change for the better.

1. Liberating the NHS

The Coalition Government's white paper 'Liberating the NHS' heralds the replacement of an entire stratum of NHS management with consortia of GPs. It aims to empower those in direct contact with patients to design, procure and provide new, better services. It also re-iterates the need to better integrate local authorities, social services and other partners to provide more holistic, localised and preventative care.

The two challenges on the surface are to help GPs gain insight into the wellbeing and behaviours of their local population to better meet their needs, and facilitating diverse groups of stakeholders to create joined-up and preventative services centred around people.

This is Service Design's back yard‚ and there is much the discipline can offer the NHS. However, this article also explores more complex organisational issues of this radical change programme, and calls for the application of strategic design thinking to resolve them.

2. Removing barriers to innovation and improvement

The removal of PCTs may well reduce bureaucracy and barriers to innovation, allowing GPs to more efficiently set up primary care services that can reduce the number of patients who end up in hospital and more costly secondary care treatments.

But as Dr. Mohammed Ali reflected in his talk, "GPs are a particular type of person; evidence-based, and if you can prove it, you can do it." Such caution is understandable for those in medicine, but it does not bode well for the culture of experimentation and risk-taking necessary to produce innovative new services.

However, using service design methodologies can integrate qualitative and quantitative to leverage new projects, and exploit the direct contact between GPs and patients to produce more appropriate services. Ethnographic-based research uncovers behaviours and service expectations that can inform and define new solutions. Iterative cycles of prototyping and testing allows for performance data, as well as qualitative feedback to be quickly gathered from patients and providers to ensure they are on the right track.




The NHS Institute for Innovation and Improvement has successfully combined such qualitative, experience-based methodologies with the quantitative data and evidence base required to leverage new projects and develop a business case for change.

3. Taking a longer view for a healthier population

The logic is clear for focusing more effort on preventative healthcare in order to reduce future demand for secondary care. As a representative from the Royal College of General Practitioners

"The lower down the food chain you are, the more difference you can make - we (GPs) have always known this. So much money is spent on intensive surgery procedures... if you took some of that budget and spent it on getting people to live more healthily, you would reduce the number of people who need surgery."


One such example is Activmobs. Developed by RED, a department of the Design Council, it encourages communities and groups to self-organise and live healthier, more active lifestyles. It incentivises everyday activities such as dog walking or aerobics groups for the elderly and augments them with nutritional advice, information and guidance, rewards and even the support of a personal trainer.




Such schemes can reduce the prevalence (and cost) of serious conditions such as cardiovascular diseases and type 2 diabetes, as well as improving the mental wellbeing and productivity of the population. It reverses the cycle of increasingly costly treatment.

4. Fewer patients, but little patience for the long view

The rationale is obvious, but when secondary care funding is based on to the number of people who go through its wards and operating theatres, there is little incentive for secondary care managers to seek to reduce the supply (or ill people as they are also known), as a consequence is reduced budgets, closing facilities and job losses.

The new remit of GPs, however, will empower them to take that direction, scaling down secondary care in order to implement more primary care alternatives. GPs must go further and look 'upstream' - where the conditions from which chronic illnesses emerge - and invest in community care and longer term healthy population strategies to take the pressure off all services.

Measuring the outcomes and quality of experience of those who become ill is complex, but measuring the value of spending on preventing illness is near paradoxical: How many people would have become ill? What might their treatment have cost? Which of the many schemes the population will have interacted with can claim responsibility and secure funding, and how far in the future will they have to wait for their impact to be proven?

5. Shifting from Secondary, to Primary, to Community, to Preventative

The NHS was configured in 1948 with a focus on coping with accidents and injuries, communicable diseases, and provide palliative care. Since then NHS provision has fallen out of step with the needs of the population, and its demographic composition. Less healthy lifestyles have caused a large increase in long-term chronic illnesses; many of them preventable if healthier behaviours can be introduced early enough.

The 'Nicholson Challenge' of finding £20bn in cost savings in the next four years is daunting, to say the least. But the answer isn't found in simply scaling back the NHS and opening up markets to the private sector to occupy the vacuum.

The real challenge of the NHS in the 21st century is to reduce the need for the NHS by encouraging and facilitating a healthier population.

International studies have shown that where primary care is strongest, hospital activity is reduced and the supply of GPs in a region is associated with fewer hospital admissions (Source: RCGP). Data on health populations reducing the need for primary and secondary care is more difficult to produce and obtain.

How the health of a population is measured, monitored and improved requires an holistic approach which reaches beyond the NHS to better co-ordinate with local authorities, social services, police and hospices alongside private and third sector bodies.




The NHS atlas maps variation of healthcare, but also indicates different health challenges faced in different areas.

6. People at the Heart of Services

The Government endorses 'integrated care' as described above. The NHSi recommends the use of a 'Compact' - a more detailed agreement to outline relationships between clinical commissioners and community and partner organisations.

Imagination Lancaster goes further still, to endorse 'Community-Centred Commissioning', which also includes community leaders and public representatives to give their user's view of healthcare provision.

With a diverse group of stakeholders, a user-centred strategy can provide focus, aligning the objectives of different providers and ensuring that services dovetail without any gaps along the user journey.

Co-creative sessions, where designers facilitate the stakeholders to design services themselves, can be used to prioritise issues and collaboratively generate ideas for new services, which can be quickly prototyped, tested and improved.

Source: Design in Practice, Lancaster university

Such inclusive processes help instil a sense of ownership in participants and overcome resistance to change, and can even help mitigate conflicting supplier interests. By understanding the patient's experiences, and combining qualitative evidence such as ethnographic research outcomes with quantitative data, GPs gain the leverage required to justify replacing some secondary care with primary care, and some primary care with community and preventative care.

A user-centred approach to designing services can also filter out un-necessary targets. Over the years these have multiplied to obscure the primary objective of maintaining the well being of the population and staff, instead distracting care providers with the minutiae of meeting abstract targets, which can often get in the way of using good common sense to do their job well.

Conclusion: A Call to Service Design

The Imagination Lancaster event provided an optimistic view of the difference Service Design can make in this period of change to the NHS. However, it also uncovered deeper systemic issues and a labyrinth of entrenched and conflicting incentives and business models.

With the Government's announcement that PCTs are to be phased out, they have already begun dismantling before the Health and Social Bill has gone through Parliament. Those who remain are dis-incentivised to pass on their knowledge, and GPs will consequently have greater difficulty in grappling with these management challenges.

It's time for service design to step up, and apply its design thinking to develop new, balanced, sustainable and user-centred business models. Nothing short of a new proposition is required for the NHS - shifting away from, as one GP put it, "The public perception of the National Hospital Service," and towards encouraging preventative healthcare and a healthier, happier population.