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.

Service Design vs. Bureaucracy: How Human is Your Business?

This article was published in the international Service Design Network's Touchpoint magazine in October 2010.

From handier tin openers to more intuitive interfaces, the ability of design to humanise ‘things’ is well known and understood. Services, however, in spite of being provided by people in direct contact with users, are often de-humanised by measurements and policies set at an organisational level.

Top-down directives intended to increase revenue, efficiency or measurability can actually undermine experiences for staff and users, and de-couple what organisations aim to achieve from what their users want.

Following are three examples for bridging this gap illustrating how service design can meet such organisational challenges. It affirms that by transforming the front line you can liberate staff, unlock innovation and provide users with the experiences they demand to help ensure that the bottom line looks after itself.

Customer and Organisational Needs

Service users have fundamentally different needs from consumers of products. They seek individual experiences that bring touchpoints and channels together. They require direct interaction (and often human interaction) with the providing organisation.

Organisations inevitably need to divide tasks between departments and as such, develop roles and incentives to keep each of its components moving, employing automation and standardisation to boost efficiency.

These differences in needs and behaviours can cause a gap to appear, diminishing the user’s experience and in turn an organisation’s fortunes.

De-Humanised Services and Market Stalinism

A fixation on operations and efficiencies can mechanise and de-humanise services. Siloed departments can quickly create bureaucratic hoops for customers to jump through. While customers seek customization, longer-term relationships, and largely measure experiences on qualitative grounds, organisations often consider success in quantitative efficiencies and short-term ROI.

Key Performance Indicators would seem to be a happy medium, but can become subverted by target setting and the shortcuts necessary to achieve them. The minutiae of how to achieve something becomes an end in itself, obscuring and even detracting from why you’re trying to achieve it in the first place. Mark Fisher calls this effect Market Stalinism’ [1], after the USSR’s White Sea Canal project. The primary goal of allowing access for large cargo ships and tankers was hijacked by target squeezing, box-ticking and PR concerns. The result was a glorious media review of an efficiently completed canal, but in truth it was only deep enough to accommodate the small tourist steamers on which the journalists sat.

Market Stalinism at work - Wherever you hear these signs.

The above example may be humorous, but this phenomenon is visible from small-scale interactions to life-or-death scenarios.

Gill Hicks, who was injured in the London Tube bombings of 2005, spoke at the NHS Innovation Live conference last year. She explained how it was those who broke the rules, and the moments when rules were broken, which meant the most to her recovery. From rescue paramedics bending resuscitation protocols, to hospital staff later sneaking her out of the ward to improve her psychological well-being, small moments of individual initiative that did not adhere to organisational rules helped her recovery immeasurably.
Although organisations need to have safety procedure and focus on the bottom line to maintain profits and value, being rule-bound can often have the opposite result.

The cost of dissatisfied users is a damaged reputation and a long time spent trying to win their confidence and custom back. By tying the hands of staff with policy, pragmatism, common sense and innovation are stifled and even discouraged.

Re-Humanising Services

Service Design is the vehicle for uniting desirable user experiences and outcomes (bottom-up needs) with operational necessities and efficiencies (top-down needs). Below are three examples illustrating how organisations can be transformed from frustrating empathy-void automatons to empowered, adaptive, innovative helpers.

1. See the design process as an end in itself:
Lewisham Housing Options

Co-creative activities during the process can be as effective as the final deliverables themselves, in establishing the right culture to sustain a service.



Lewisham Housing Options - Transforming services by engaging staff in the design process

ThinkPublic and the Design Council worked with Lewisham Council to understand how they could better serve constituents who required housing, some of whom were in distressed situations and housing emergencies.

Staff members were all given a camera, some training and then went about interviewing people who were waiting for or had just had their appointment.

Through the direct experience of gathering data, footage and insights, the staff were taken away from their desks, databases and forms. Being re-connected with the situations, fears and hopes of those they serve every day, they began literally to see things through a different lens, asking different questions and getting to the heart of customers’ problems in a personal, human way.

2. See services as constantly in “beta”:
Passenger Personas

Transferring tools and knowledge through workshops, training and method sharing is an often-overlooked activity. It greatly improves the sustainability of a service by equipping front-line staff and management with the tools and processes to improve and evolve the service.

One European airport group has an established protocol for understanding and improving their passenger experience.

‘Greeter’ staff are on hand to help and direct passengers as they arrive in the terminal. At quiet times, this staff put themselves in the shoes of a passenger persona, select a destination, and set off through the airport identifying gaps in wayfinding, accessibility or even maintenance and upkeep. Issues are dealt with swiftly, making the job more satisfying for staff and the experience more pleasant for passengers.

Embedding design and empathy tools creates a strong link between an organisation and its users, ensuring needs are understood. Empowering those who have the grass-roots knowledge of a situation to take action to fix problems means solutions are more informed and services are built coherently, not on an ad-hoc basis.

3. Refrain from imposing common sense guidelines:
Just A Routine Operation

Generic guidelines inhibit staff from trying anything new or different. They cannot best serve individual customers, nor fulfil their role as ‘silent designers’ – observing and changing the system incrementally.

Just A Routine Operation from thinkpublic on Vimeo.

This documentary, created for the NHS Institute for Innovation and Improvement, follows a man's experiences during the sudden death of his wife, who suffered complications after a minor operation.

Rather than encapsulate what was observed through the film into another ‘framework for communications protocol' or a 'critical situation checklist', the film has simply been screened to 2,000 NHS staff. By more directly experiencing the situation the staff can draw their own conclusions, which mitigates the need for 'guidance' because skills and empathy are developed more directly.
To those who may balk at a lack of control, consider Nordstrom, a US department store renowned for its customer service. Until recently, its staff guidelines consisted of just 75 words, including:

“Rule 1: Use best judgement in all situations. There will be no additional rules.” [3]

This laissez-faire approach has empowered Nordstrom sales associates to go to the extremes of customer service. By increasing autonomy and lightening the touch of administration, barriers to common sense, ideas and action are removed, enabling a culture of innovation.

Conclusion

By using Service Design to address organisational challenges, you can create direct and dynamic links between operational necessities and what users want are created, reducing waste and increasing demand.

How well this is done is most apparent at the ‘front line’ where staff and users interact. Organisations need to trust and support the people they hire, so that they can efficiently provide effective services that are meaningful and desirable to people. That is true return on investment.

References

[1] Fisher, M (2009) Capitalist Realism: Is There No Alternative? (esp. p39, 43)
[2] Just A Routine Operation (2008, Thinkpublic)
[3] Spector, R. (2000) Lessons of the Nordstrom Way
With thanks to Thinkpublic and Sean Miller for case studies and images.

Designing the Future of Knowledge Transfer

I'm proud to report that a project I have been leading at Prospect to deliver a vision for Unlocking Knowledge Transfer (KT) in the UK on behalf of the Creative Industries Knowledge Transfer Network (CI KTN) is now complete, and the Unlocking Knowledge Transfer Executive Summary can be downloaded. It summarises three robust reports illustrating a number of new services, spaces and tools that will help bring academia and the creative industries closer together.

The three reports can be found in my Projects section - I recommend starting with the third of the three Opportunities for Unlocking Knowledge Transfer and digging further if that whets your appetite.

Summary

CIKTN needed a robust vision of the future of knowledge transfer between the creative industries and academia in the UK. We engaged a wide audience through workshops, online surveys and an online platform to develop future scenarios which inspired a number of new opportunities for KT.
Over the course of five months, hundreds of people contributed to inform the three reports which map out the future of KT in the UK, with 16 opportunities (actionable initiatives, services, spaces and roles) for improving KT in the creative industries.

Problem

Now, more than ever, businesses are investing in the knowledge economy to catalyse innovation. The UK's academic institutions are world leaders in creating knowledge and ideas. The Creative Industries Knowledge Transfer Network (CIKTN) invited Prospect to lead a strategic project exploring the future of creating, sharing and applying this wealth and better connecting academia and business.
Historically, the Creative Industries have not engaged with 'knowledge transfer' (KT) on the same scale as industries such as sciences and engineering, for example. Add to this a harsh economic climate and the increasing overlapping and competition between business and academia and you have a knotty problem; one that design is ideally suited to solve.

Solution

We used a holistic design approach and methodologies in a way that would engage a broad spectrum of people, and make sense of a diverse range of reactions, comments and ideas. This collaborative, co-creative process not only helped us gather information and insights from these stakeholders, but also encourage them to generate new solutions to possible developments in the future.

The project pivoted around the creation of four future scenarios, based on economic, social, cultural and environmental trends amongst other factors. These were designed to challenge and provoke participants and ask; 'How would you thrive in this new world?'; 'What do you fear?'; and 'What needs to be done?'.

Impact

Online surveys, expert interviews, future scenarios and five workshops conducted around the UK informed the three reports delivered through the project. The first, Baselines, documents today's landscape of knowledge sharing between the UK's creative industries and academia. The second, Scenarios, illustrates possible futures and documents how our participants reacted to them. The third, Opportunities, presents a series of robust reccomendations for future services, spaces and initiatives, balancing a wealth of views with feasibility and sustainability, realised through a powerful strategic design process.