touc hp o in t the jo u rn al of s ervice d es ign

24 touc hp o in t the jo u rn al of s ervice d es ign

By Julia Schaeper, Lynne Maher and Helen Baxter Designing from within: Embedding Service Design into the UK s health system The National Health Service (NHS) is the national healthcare provider in the UK. It is the fourth largest organisation in the world employing 1.3 million people through a wide range of organisations including hospitals, General Practise surgeries, and ambulance services. The NHS is used by millions of people everyday who value its expertise, its staff, and its ability to make them feel better. It is often referred to as a national treasure yet at times it does not provide the best service that it could to all of the people who need to use it. This results in inefficiencies, safety issues, a lack of personal care, and dissatisfaction. To make things worse, in the current economic climate it is suggested that the NHS will face its greatest financial challenge of its entire history a 15 billion funding gap over the next decade 1. This means the need for strong leadership and increased productivity has never been greater. Time is short and experience of previous spending crises tells us that failing to rise to this challenge now will have serious consequences for the NHS, its patients, and staff. Work to deal with this unprecedented challenge is needed now, with the support of NHS staff, policy makers, and the public. One ambition over the next years is to radically innovate within the health system, changing it so that it consistently provides more choice, more personalised care and more meaningful involvement of the recipients of the service. Without doubt, this is a bold ambition and one that needs innovative tools, techniques and methods to help it succeed. It is an ambition that in our opinion can benefit from some of the tools, techniques, and methodologies found within the emerging discipline of Service Design. Better by design Of course, it has sometimes been a challenge to explain how design methodologies can improve the delivery of public services. As the Design Council noted not so long ago: design is a problemsolving process but it is difficult to think of what problems it can help you solve when all you really know about designers Julia Schaeper Service Designer, NHS Institute for Innovation and Improvement Lynne Maher Head of Innovation Practise, NHS Institute for Innovation and Improvement touchpoint the journal of service design 25

is that they make nice gadgets like ipods or will have created the graphics for that attractive label on your tin of baked beans. 2 Although still fairly unknown as a discrete discipline or specialist profession, Service Design reflects the understanding that techniques, which evolved from the production lines of the 20th century, can be applied not only to products, but also to fields from communications to business strategy, from sustainability to services. 3 In the wider public sector, several recent initiatives for example, Dott 07 4 and the Design Council s programme Public services by design 5 have helped make clear that Service Design can make a valuable contribution to tackling some of the social and economic challenges we are facing today. And in healthcare we are also beginning to see change, as increasdesigning from within By Julia Schaeper, Lynne Maher and Helen Baxter Helen Baxter Associate, NHS Institute for Innovation and Improvement ing numbers of health experts have come to recognise the value of Service Design in terms of offering a methodology for turning ideas into high quality results that are cost-effective and productive whilst delivering the right experience for the patient. 6 Within health policy development, we are seeing a tangible focus on personalisation of care and a higher level of patient and carer involvement in designing health services. The Operating Framework for the NHS in England for instance, set out that everything we do must be geared towards improving the patient experience of NHS services and clinical outcomes of care. 7 This has led health organisations like ours to seek out new ways of working closely with patients to better understand their experiences and redesign services to better meet their needs. To do this, we are util- The ebd approach (experience-based design) The ebd approach has been developed based on the work that the NHS Institute has done with Service Designers to focus on improving patient, carer, and staff experience of health services. The approach provides a framework to capture and understand health experiences and then work together with staff and patients to design better services. A critical aspect is to really understand the challenges from the perspective of those who use the service in order to gather insights and themes, from which we can gain ideas as to how you might identify the appropriate solutions for the challenges. Experiencebased design is helping transform services at all levels, from management to front line staff. The methodology is transferable to diverse areas, for example; commissioners who might want to understand a whole patient pathway to GP practises. 26 touchpoint the journal of service design

ising Service Design as an improvement methodology and are embedding the approach alongside existing processes. Embedding Service Design as a fundamental principle of how we work At the NHS Institute we started this journey by working with a number of Service Designers who like NHS staff strive to make things better for people. We began to understand that design might be useful to healthcare improvement work and that we could gain considerable benefit from involving patients, as well as healthcare practitioners, in the design process shaping services that meet the needs of those using or delivering them. Most importantly, we also began to understand the public s expectations of healthcare as a service an interaction with a person or organisation from which you expect to gain value. Clearly the NHS is such a service but it is one whose value has traditionally been defined in terms of clinical outcomes. And while healthcare organisations have demonstrated that they can improve the performance and reliability of services producing tangible changes in how patients access care and how safe that care is, these same organisations have not always placed equal focus on how it feels to use or be part of the service. So we started to understand that seeing health provision as a service means considering the experience of care for all users patients, carers, and staff and that we now have the opportunity to focus on that. We first started to apply Service Design when we developed our very own way of»one ambition over the next years is to radically innovate within the health system, changing it so that it consistently provides more choice, more personalised care and more meaningful involvement of the recipients of the service.«doing things. Inspired by Service Design and looking at how other innovative organisations work, we developed our own Work Process a systematic but flexible process we use to convert concepts and ideas into new solutions that can make a real difference. It allows us to take appropriate risks something at the heart of all innovation while ensuring our end solutions are relevant, fit for purpose, and actually wanted by staff and patients. A core component of this new approach involved using tools from the design sphere to bring new insight to the organisation. For example, observation forms a core part of our own innovation process. While, clearly, observation is already a well-established clinical tool, we brought touchpoint the journal of service design 27

designing from within By Julia Schaeper, Lynne Maher and Helen Baxter a more anthropological approach to bear, learning about patients experiences and the context in which healthcare staff go about their work. Another important principle drawn from Service Design is that of co-design the understanding that in order to improve healthcare, we need to bring patients and staff much closer together than we had previously done in order to see the problems from their perspectives and to actively share the role of re-designing health services. We also found evidence for the need of co-design outside of the design world. The National Audit Office for instance promotes the role of customer insight in particular in healthcare situations. They suggest that to be successful, innova-» design is a problem-solving process but it is difficult to think of what problems it can help you solve when all you really know about designers is that they make nice gadgets like ipods or will have created the graphics for that attractive label on your tin of baked beans. «28 touc hp o in t the jo u rn al of s ervice d es ign tive projects could only be delivered by meaningfully involving service users and citizens. Supporting NHS improvements through Service Design In one instance, the application of these techniques resulted in patients, NHS staff, and designers making over 40 changes to one clinical pathway alone. While the pathway in question had previously scored 98% in a patient satisfaction survey, our work revealed that people s actual experience of the service fell short of the high level implied by the survey result. This helped us understand that there is a fundamental difference between an overall service satisfaction and a great experience and that working with satisfaction surveys alone is simply not good enough. In order to encourage widespread uptake of Service Design approaches, we have learnt from designers and translated some of the tools and techniques internally. Having first designed our internal work process, we then created some programmes to support the NHS in developing capability, capacity, and confidence for example the ebd approach (experience-based design), the Observation Tool and the Innovation Practitioner Programme. These products are designed to challenge current NHS practise of starting improvement projects simply by jumping straight to a solution. Instead we advocate spending time up-front to identify and delineate problems more systematically so as to be able to then design a more appropriate, effective solution.

Innovation Practitioner Programme We soon realised that, to build innovation capability in NHS staff, we had to cast these tools and individual products in a broader framework. Although many of the Institute s design-led programmes and products have been widely absorbed, NHS staff often requested support in using these tools and delivering their goals. So we started to think about how we could best build capability within the NHS and empower individuals to become change agents themselves, knowing that people would be the best vehicles to spread and scale new ways of working. We developed the Innovation Practitioner Programme a programme that supports individuals build the skills, knowledge, and understanding of what it means to be an Innovation Practitioner. In a practical sense, the programme enables NHS staff to work in innovative ways and to learn employ design-led tools and techniques as part of a chosen live project within their own work context. Over a period of several months we support an Innovation Practitioner cohort through a series of workshops, inspirational seminars and tutorials and in creating a strong peer-to-peer network. While the private sector has used similar approaches for years, these tools and programmes are new for the NHS. Where they have been used in the health service, they have amazing results, delivering the sort of care pathways that leave patients feeling safer, happier and more valued whilst making staff feel more positive, rewarded and empowered. However, introducing design-led approaches was not without its challenges. The greatest hurdle has been convincing healthcare staff of the value that design can bring to their services. We were often faced with the comment but designers design chairs, don t they?. The design industry was not really considered an obvious partner to help in our scientific world of health services. There was also a distinct language barrier between the two professions with new phrases such as co-design or insight gathering and the use of highly visual communications being foreign to health workers. Equally the slang and abbreviations used within the NHS culture were at times unfathomable for Service Designers! touchpoint the journal of service design 29

designing from within By Julia Schaeper, Lynne Maher and Helen Baxter»Service Design can play a role in re-shaping health services, and to ensure the continued spread and adoption of its tools and techniques in the NHS.«Moving forward Never before has the NHS needed innovation in service delivery in the same way and, clearly, there is still a lot of work to be done. We believe that design thinking as an improvement strategy has great potential to help many health organisations bring about change. In combination with other improvement methodologies we believe Service Design helps pursue our prevailing political objectives of personalisation, participation, and co-production, as well as supporting the health priorities of quality, innovation, productivity, and prevention (QIPP). 8 But it will take time to win acceptance from healthcare professionals for the idea that Service Design can play a role in re-shaping health services, and to ensure the continued spread and adoption of its tools and techniques in the NHS. Designers moving into the public sector can start facing that challenge now helping to ensure that design thinking and principles become part of the everyday work of public service delivery. The design profession needs to become widely recognised as having evolved beyond form giving and material production into a sphere of making people and services more resourceful in themselves. 9 At the NHS Institute, we have the opportunity to look at things with fresh eyes which means we can bring design in at an early stage, and encourage a dialogue before we develop any aspects The Observation tool The tool is an exercise designed to be used by NHS front line staff to show the value of observation from a more anthropological perspective than their predominant skill set of clinical observation which links symptoms, behaviour and diagnosis. It has helped teams understand the value of observation in understanding the challenge or issue. Design principles are encouraging NHS teams to consider more than a benchmarking or measurement of how their service is doing against another observing of what is actually happening from a variety of perspectives. It helps teams think outside of their usual parameters for solutions. 30 touchpoint the journal of service design

of our work in more detail. By championing design techniques as an intrinsic part of healthcare innovation, we hope to support the development of better, more efficient services right when they are needed most. What is it like to work as a Service Designer with the NHS? The traditional approach for public sector organisations would be to commission Service Designers to undertake specific work. But, increasingly, the public sector is recognising the value of having Service Design skills available in-house. At the NHS Institute for Innovation and Improvement for instance, we initially commissioned design support but have more recently employed a full time Service Designer as a core member of our interdisciplinary innovation team. Whilst we continue to work with Service Designers on some of our key programmes, we also recognised that in order to create a platform to expand Service Design to the NHS (and the NHS to Service Design) we had to have our own, institutional Service Design expertise. Even so, the role of the Service Designer within a health organisation remains similar to working in a design consultancy context. Clearly, this is a new professional working context for the Service Designer with new challenges and slightly different skill requirements. As with all Service Designers, the job entails finding as well as solving problems. In-house Service Designers still facilitate collaborative design processes, enabling people to develop and implement solutions together. The job still requires expertise in using a»it is important to remember that working within a health organisation places the designer at the pulse of making change happen. It allows one to experience first-hand the impact Service Design approaches can have in people, ways of working and their outcomes.«visual language for breaking down complexity and communicating intangible relationships and interactions between people. And the role still demands the ability to create a more holistic picture, fitting all various elements together on a more strategic level to remodel entire business structures. But moving to the public sector requires adaptation to a very different organisational culture. For one, working within an interdisciplinary team of health experts, former practitioners, psychologists and researchers means the in-house Service Designer needs to develop quickly an understanding of the bigger picture, and crucially the political drivers and policies involved. Practical design work has still to fit within the broader strategic touc hpoint the jour nal of se rvi ce desi gn 31

designing from within By Julia Schaeper, Lynne Maher and Helen Baxter Julia Schaeper is a Service Designer and Associate at the NHS Institute for Innovation and Improvement, UK. Before joining the NHS Institute, Julia worked as a Service Designer at Engine, helping private and public sector clients innovate their service offering. She has worked on service innovation projects for several companies including Mercedes-Benz, Norwich Union, Orange, AA and Dott 07. Julia has also lectured and run seminars on Service Design at several universities across Europe. objectives set out by the government, and has to be grounded in the specialised terminology used in the healthcare sector, if it is to remain engaged and relevant. This can be quite a challenge, given that few designers have direct experience of the policy arena. It is essential to have at least some understanding of the culture and key issues faced in the healthcare sector. Secondly, working in-house means that the Service Designer has to deploy their skills across a much wider scale of potential applications. Projects might range from working closely on the ground with a GP to improve aspects of a surgery or patient experiences, to working on a much more strategic level, remodelling internal business structures or translating the newest policy documents into actionable opportunities for change. Facilitation skills, enthusiasm and tenacity are crucial, as it can take some time to gain acceptance for new ideas and approaches. Even so, the internal design expert should remain a champion for the application of design as an integral component of healthcare innovation within the Institute and wider NHS. A large part of the work will consist of finding solutions that build the capacity and capability to innovate within healthcare providers, as well as coaching front line staff to use design techniques, transforming them into a new cohort of change agents. Importantly, Service Designers positioned within a public service organisation can help shape people s associations and understanding of design, championing design as a problem-solving process rather than an exercise in making things look nice. They can bridge the gap between the design industry and health provision. For that, designers might need more training in translating their skills appropriately. Also, feeling comfortable with a certain ambiguity, dropping design terminology and accepting to work within the more political context of the health sector is important. Whilst the scope of change might be limited by political and cultural realities as well as slow step-by-step progress at times, it is important to remember that working within a health organisation places the designer at the pulse of making change happen. It allows one to experience first-hand the impact Service Design approaches can have in people, ways of working and their outcomes. 32 touchpoint the journal of service design

footnotes 1 The NHS Conferderation, Dealing with the downturn, June 2009, http://www.nhsconfed. org/publications/documents/dealing_with_the_downturn.pdf 2 Design Council, Public services by Design, http://www.designcouncil.org.uk/en/design- Council/1/What-we-do/Our-activities/Public-services-by-design/ 3 RSA Design & Society, Social Animals: tomorrow s designers in today s world, Sophia Parker, July 2009 4 Dott 07 (Design of the times 07) explored what life in a sustainable region could be like and how design could help us get there, http://www.dott07.com 5 Public services by design was set up in response to the Government Innovation Nation White Paper to help government create services that are not only cost-effective but that connect the public with the heart of policy making, http://www.designcouncil.org.uk/en/ Design-Council/1/What-we-do/Our-activities/Public-services-by-design/ 6 See various examples where different teams in the Institute used Service Design support for their programmes; see the Open door Project Grimsby, www.managing-innovation. com/case_studies/open%20door.pdf; see HealthConnect a design project with London based Service Design Agency Engine and Bucks County Council, see Alzheimer 100 project, www.alzheimer100.co.uk/ 7 The Operating Framework for the NHS in England 2008/09 8 The NHS set out to deliver its quality and efficiency commitments through a greater focus on quality, innovation, productivity and prevention (QIPP). This will allow the NHS to drive up quality whilst improving productivity - a challenge which means harnessing and spreading innovation and new ideas. QIPP will be key to building upon the success and progress made in implementing the commitments set out last year in Lord Darzi s High Quality Care for All. http://www.dh.gov.uk/en/news/recentstories/dh_101712 9 RSA Design & Society, You know more than what you think you do: design as resourcefulness & self-reliance, Emily Campbell, July 2009 Lynne Maher is the Head of Innovation Practise at the NHS Institute for Innovation and Improvement, UK. She leads work on innovation specifically focusing on the design and redesign of health services and processes to support the NHS. Lynne is a member of the Innovators Council formed by the Cabinet Office, a Fellow at the Health Service Management Centre, Birmingham University and a Fellow of the Royal Society of Arts. She is a reviewer for the British Medical Journal and Institute for Healthcare Improvement and an advisory board member for the Design Council. Helen Baxter leads on the experience based design approach and the Innovation Practitioner Programme for the NHS Institute, as well as working with the team to develop and explore the application of novel processes, tools and techniques for the NHS. Helen completed an MSc in Continuing Professional Development (Health) at the University of Greenwich in 2005. Helen is a trustee at a local hospice, leading on the implementation of strategy and workforce planning and development. www.institute.nhs.uk touchpoint the journal of service design 33