Introduction: Service Design in the NHS… designing which service?
In digital health and public sector, many people including clinicians, engineers, designers, and managers use the word service – to describe very different things. Typically in service design, a service is something that helps someone to do something. I started by adapting this definition for the health and care context in order to make clear what my designs address and how this is different from clinical workflows or user journeys or software development for example:
In health and care, a service is the health and care system’s response to the patients’ journeys and needs. A whole end-to-end service is everything that happens on the NHS front-stage and back-stage during a patient's journey.
This includes an admin typing up a letter to be sent out to a patient to a specialist performing surgery to a scheduler booking in appointments to someone taking blood tests to the lab. This is different from a clinical workflow, it does not describe the steps individual clinicians perform in a patient's care, or even the steps or experience individual patients go through, or even the NHS interactions that relate directly to the patients. It describes all actions and processes, everything that helps the patient to achieve their goal and everything the system needs to achieve a health outcome - the whole service.
The NHS is a hugely complex and important service that needs to work for everyone. Of course, understanding and designing for all the above sounds like an impossible task to do for each and every person journey or ailment the NHS deals with. This is why I developed the “pathway design system” together with service design colleagues. It focuses on service patterns - models, standards and components that are proven to be good and reusable.
What are service patterns?
A service pattern is a repeatable design solution for a common problem, designed based on standards of 'what good looks like’. Service patterns in health and social care are sets of practical guidelines for building services (or bits of services) that are repeated many times across the system - something like getting a referral, being informed of treatment options, getting discharged.
From a clinical point of view, individual NHS specialties of course do difficult, complex, and very different work with different names and different purposes - for instance treating heart disease is completely different to treating colon cancer. However, if you take more of a bird's-eye view and look from the service perspective, they amount to the same thing, consisting of three basic steps: consultation-investigation-treatment.
The service pattern concept has been used very successfully at Government Digital Service (Reference):
"Though they had many different names - permits, exemptions, certificates, accreditations - and different purposes - registering the birth and death of cattle, movement of livestock, getting a fishing license - they all amounted to the same thing. They were all licenses, of a sort. They all involved someone or something getting permission from the government to do something (or not do something). But each user journey was different, many were complicated and not user-centred. What became clear was that we could improve the way licenses were granted, and in doing so articulate a service pattern which could be used in other contexts."
Applying this approach to health and care as a service can be hugely powerful, and transform how we organise the NHS and its pathways around people – both patients and staff. I have developed this approach over the last years working as a designer in digital health, and now understanding and articulating service patterns has become part of the development of the National Digital Platform at NDS. We have named this the Pathway Design System.
Introducing the pathway design system
This is similar to design systems used in user interface design: a set of base components such as buttons, navigation elements, fonts and colours etc which are then combined in defined ways to create consistent, usable interfaces. Instead of combining UI components leading to screen designs based on guidelines and templates, the pathway design system combines service steps using guidelines and templates. It can create whole service pathways, and categorise and cluster similar experiences of services across health and care. There are three levels to the pathway design system:
Level 1: Service components
The service components are the smallest unit of the Pathway Design System. They are high level events in a journey through healthcare. I initially identified these during 12 months of co-design and research through the Scottish Access Collaborative (see here), and now developed and validated them further in the last 12 months at NDS. The service components do not aim to represent the ideal future state but are a way of mapping the current pathways and finding patterns.
Important steps recurring in most NHS pathways include consultation, investigation, treatment, transition of care (referral / discharge). From a patient’s perspective only some of these components will be visible and someone’s life and health journey of course includes much more than these steps. From a pure clinical perspective some of these steps will not be detailed enough as they do not reference clinical workflows. From a service perspective however, these are recognisable and formalised foundational blocks that NHS pathways can easily be broken down into. By acknowledging them and making them visible, I am able to redefine and redesign them based on the needs and experiences of all their users.
Level 3: Current service pathways
I know, I have jumped from level 1 to level 3, but bear with me. Since introducing this approach, me and my colleagues have used the service steps to map a variety of existing NHS pathways, including the interactions of people, places, technologies and tools involved. They have been excellent tools to draft and build narratives, highlight challenges and identify leverage points across the system. Using a similar language cross-project allows us to easily compare pathways too.
Level 2: Service Patterns
Now that we have mapped the current state of several different NHS pathways, we can start identifying and designing for service patterns - the actual building blocks that form most NHS pathways. When combined into patterns, the high level generic components suddenly have purpose, and focus on commonalities of jobs-to-be-done and user needs.
For example, a GP referring their patient to a specialist team is a fairly common pattern. It can differ in workflows, activities, and timings depending on health condition or health board guidelines. The needs and ‘jobs to be done’ around making a referral to a specialist however are in essence similar. We call these “verbs”. Identifying common verbs is a long-term task in itself and will require user research and co-design engagement with users. Here are initial examples I have been working on at NDS:
GP referral to access a specialist consultation: looking at this pattern across cancer and endocrinology services allowed us to see similarities and differences between patients’ experiences. Referrals to specialist cancer services are timely monitored, meaning the person will usually get a prompt referral to see a specialist in secondary care. Instead, identifying an endocrinology related conditions often requires more time and investigations in primary care. Looking at what ‘good' looks like across these two patient experiences might help us understand what type of digital service support can be provided in the waiting experience during the referral process alongside clinical support.
Making decisions on what treatment fits best with the person: making a decision about the right treatment involves more than clinical choices. It requires understanding of the experience that could impact the rest of a person’s life. It requires patients and their family and carers to be appropriately informed based on their understanding of their own health. Recognising that third sector and social care are often in support of this phase in a person’s journey is also an interesting factor that could have a strong reflection in the way we support decision making in the products we build at NES Digital Service.
Post-treatment follow-up shared between patients, primary care and secondary care clinicians: looking at the endocrinology and the cancer contexts, is clear that this is a very complex space where patients are often asked to do a lot of self-assessments and administration to connect with the right people, services and technologies while having understandably little understanding of how the back end of the health system works. This may be burdensome on patients, especially if you are desperately trying to get back into care. Designing technologies optimised for models of shared care is a well overdue pattern in many different NHS pathways.
The Opportunity
Looking at NHS pathways by using the pathway design system is not a linear process, but rather a mental model to help think of patient journeys as both a cohesive whole and a collection of parts at the same time. Design patterns guide us. They help us to create a consistent, but not uniform experiences of NHS pathways. By isolating processes within a service, we can improve the way these component parts work. They remove duplication of effort and improve interoperability between services and are crucially - generated from experience and iterated through the Scottish Approach to Service Design and other good practices of design that ensure co-design and inclusion. Like other design patterns, service patterns can be isolated, tested, and iterated on.
Services like I have described above, are repeated hundreds of times across NHS Scotland in completely different ways, with completely different technology, guidelines, clinical pathways and operational processes underpinning them. The service pattern hypothesis is that by identifying and refining what good looks like for these types of service, it will make it quicker and easier to build better and more inclusive services that focus on patients and clinicians and easier to link these services across NHS to meet their needs. The opportunity therefore is for service patterns to become consistent standards for the way repeated activities should work, both for patients and clinicians, and connect with matching technical architecture, interface designs, and product experience being developed at NDS.
What people said about this project:
This approach provides a clear 'science' style approach - which counterbalances the critiques I hear about coproduction that it is based on flawed 'intuition or individual stories'
NHS Participant
The language is so accessible, [service patterns] will resonate with people across health and social care services. These components could be easily adjusted to apply in social care and social work settings as well.
Healthcare Improvement Scotland Participant