In public services there is an increasing focus on the individual needs of service users and an ambition to really personalise services. If we are to achieve this goal we need to introduce new methods and new ways of thinking. In this article, Ben Reason from service design company live|work, applies the core aspects of what he calls service thinking to healthcare.
In his report on the NHS, High Quality Care for All, Lord Darzi identifies three key requirements for NHS services. He asks that they be “clinically effective, personal and safe”. ‘Personal’ is the quality that stands out as a change from the past. Darzi believes that services must be orientated around individuals; that services must be fit for everyone’s individual needs. He also argues that it is time to “move from an NHS that has rightly focused on increasing the quantity of care to one that focuses on improving the quality of care”.
The report recognises that improving quality is not simply a matter of fine-tuning what you were already doing. A shift from increasing the quantity of services to improving their quality represents a change of focus. It involves switching attention from the productive capability of the NHS machine to the ability of NHS services to meet the needs of patients and the public.
As the Darzi Review makes clear, health services that care for people only when they become sick are not enough. We need to support people to lead healthy lives, stay out of hospital and feel good. This requires a shift from the traditional industrial thinking focused on quantity and productivity and a narrow definition of efficiency (how many cancer patients can we treat with these resources?) to a new way of thinking. At live|work we call it service thinking. A service thinking approach focuses on creating personalised services where we think about how to support the individual health needs of each and every NHS patient and help people to maintain their health and overall wellbeing.
We cannot simply be more productive. Service thinking is a response to the fact that everywhere we turn, the industrial mode of production, or ‘product thinking’ - that generated huge material benefits in the twentieth century - is now beginning to strain. The signs are there for all to see; in our overextended financial system, in our threatened environment, in the congestion in our cities and in a National Health Service faced with mass obesity, an aging population and growing chronic illness. We need a smarter approach.
Shifting to service thinking
live|work’s experience of working with NHS trusts and with the NHS Institute for Innovation & Improvement, is that service thinking is effective and highly relevant in improving the quality of health services. Throughout Darzi’s review the need to improve quality is associated with personalisation and with change.
At live|work we see personalisation as a key component of service thinking. Personalisation can have a huge effect on the quality of services. It means that services respond to individuals and that their whole experience is of being a partner in health. But personalisation in the NHS means a new type of engagement with patients and the public. And it means handing over control.
Handing over control
Handing over control is scary. The NHS is extremely used to managing the demands on services through waiting lists and ‘gatekeepers’ who control access to services. Yet personalisation requires that it becomes more responsive to the individual, to their schedule, situation and emotional requirements. In our work with the NHS we have experienced a fear of engaging patients in service design, a fear of asking them about their experiences, what they think and what they might like. This fear is entirely rational. Responding to patients’ needs could very easily create more work for clinicians and staff, stretch the capacity of services or challenge the authority of clinical best practice.
We clearly witnessed this challenge in our work with the kidney dialysis team at Salford Royal Hospital. They were very aware that patients had unmet needs but also that the hospital had no capacity to meet them. There was concern that there would not be sufficient resources to meet the new demands and that opening up to patients risked the painful recognition of shortfalls in service. However, there is a huge opportunity in closer interaction with patients. Serving unmet needs can reduce the strain on other parts of the system – freeing up time, beds, people, and in the long term, money. Personalisation doesn’t have to be an idealized vision of healthcare in the future. It can be a reality now, but will only work if it can improve quality and enable more cost effective service delivery.
Before more effective and high quality services can be realized, we need to switch to a service mindset. We need to move on from seeing quantity and quality as competing. Service thinking can help to identify a number of ways to reduce the demand for services. The evidence exists to prove that a more personal approach, one that actively engages patients, can lead to reduced demands on resources. For example, providing patients with personal information on their health can help them become better able to judge whether they need to see a clinician or not and save unnecessary consultations. A more regular ongoing personal service, perhaps over the telephone, can prevent the need for emergency care.
Service thinking provides health professionals with a structured way to identify new opportunities to improve the quality of care and transform health services.
Through live|work’s involvement in over 200 service innovation and design projects - with clients big and small, public and private – along with our analysis of the best thinking in service economics, management and marketing, we have identified four key elements of service thinking and applied them to our experience of working in the NHS:
1. Personalise services for individuals
Services cannot be mass-produced and be truly satisfactory. Many service providers have adopted industrial approaches in order to improve efficiency or increase output. However, to create great services we need to understand that services are subtly or substantially different for every single service user. Thinking this way encourages us to design services that are flexible and can adapt to satisfy each individual user’s requirements.
For the NHS this means empowering patients to access services when they need them. In our work with Ealing Primary Care Trust, on a project to improve services for people with Multiple Sclerosis, we saw that although many patients attended a monthly clinic, the scheduled time rarely coincided with the patient exhibiting the specific symptoms they needed to discuss. We proposed a telecare service that would enable people to contact an MS expert at their time of need.
2. Design engaging experiences
Once we focus on individuals we can then design the experience they have of a service. The right experience can ensure that a patient engages with the service. This makes the service more productive for all parties as there is less waste caused by mistakes and patients are more able to self manage. A service experience may need to be nurturing or dependable, maybe even exciting, depending on the individual and the situation. A service design approach can make these decisions and design the experience to ensure that users get the value they need from the service.
In Ealing we saw how some patients coped less well than other with their diagnosis of MS and that the period after diagnosis was crucial to their ongoing wellbeing. We saw that the post-diagnosis experience was stressful and lonely. In response we designed post-diagnosis education and support that helped patients understood their condition and how best to live with it. This experience ensured patients were better prepared to cope with their MS and to self manage.
3. Make the right connections with service users
Whilst services can exist in anticipation of a need, they are only delivered at the point when a service user has a need for the service. Creating the right connections between a service and its customers is essential. Service designers must look closely at each interaction between a service and individual service users and design that interaction carefully. If we think of these interactions as the most important aspect of the service, we can then ensure everything else is in place to enable the right kind of interaction. This may mean that we can help the customer self-serve, or that we know when they need specific professional support.
Clinicians working in our team on the MS project noticed that some patients were not getting the medication they needed due to relapses not being properly identified and recorded – there was a missing connection. We proposed giving patients a diary, paper and online, to record the progression of their condition and enable the MS team to better understand the condition of each patients and their requirements.
4. Think about long-term sustainability
Services are temporal but service thinking makes us think about opportunities in the long run. Because resources – time, money and material - are finite we need to think about how to make best use of them. It gives us the opportunity to imagine how we can sustain ourselves in the future.
The Darzi review proposes the piloting of personal budgets in healthcare. In Ealing we found that some patients’ most pressing needs were not medical, but social. People with MS can be very young and need to be able to carry on their normal lives as best they can. Keeping active and in work has a positive health benefit and is key to the whole idea of wellbeing. One of the commissioners we worked with proposed a personal budget for patients to use to buy a range of equipment and services (from wheelchairs to accessible taxis) to help give people the control they needed to make the decisions best for them and sustain their quality of life. Perhaps Ealing can bid for one of Lord Darzi’s pilots.
Achieving Darzi’s goals is a service design challenge rather than a clinical or operational challenge. It starts with understanding patient needs and experiences and then designing new services to meet those needs effectively. Service thinking is essential if we are to achieve the vision of High Quality Care for All.
Let’s make the shift to service thinking, embrace personalization and start designing for Darzi.
Ben Reason (ben@livework.co.uk) is a founding partner of the service design firm live|work.
For more information visit: www.livework.co.uk