The reality of designing services in the NHS.

NHS waiting room for TIA.

I’ve been doing some really interesting work recently via Videha Sharma and the Genomics Network of Excellence. Earlier this year we focused on using user research and design methods to explore how to scale pharmacogenomics (personalised prescribing based on testing your genes) off the back of a research trial. This work looked at both the detailed interactions and strategic moves that would need to be made to enable the implementation of new services within the NHS that allowed people to be tested at scale to inform prescribing.

We were fortunate that the publication of some new NICE guidance coincided with the conclusion of our work. This guidance recommends genetic testing to guide treatment for people who have just had a stroke or TIA (transient ischemic attack or ‘mini stroke’). This was an exciting change because genetics has previously been used only for rare conditions or cancer. What this guidance provided was the impetus needed for the NHS to implement the first pharmacogenomics service for people with a common condition. 

We proposed a pilot project to work with four hospitals to design a minimum viable service together, share learnings between the sites then run and evaluate the service for three months before iterating and producing guidance for scaling. We’re right in the middle of this work as I write and I’m sure I’ll have more to say soon. 

At this point, I wanted to share what this work is bringing up for me with regard to using design methods to implement new services in a healthcare system that is running on empty. 

Over the last two weeks I’ve had the privilege to visit stroke wards in three different hospitals. I’ve shadowed their ward meetings, spoken with people from different disciplines and led multi-disciplinary mapping sessions in doctors offices. Every single person I’ve met has been helpful, enthusiastic and willing to take time out of their clearly hectic day to help us figure this thing out. This is the work I hoped I would be doing when I joined NHS Digital five years ago. Sadly that never transpired but getting to do this work now has been really rewarding.

It’s also been super interesting to observe the culture and conditions of the system from the point of view of a designer. Since my NHS Digital days I’ve always been curious about how services get designed at a local level. With budgets at breaking point it’s never going to be an option to have user centred design roles tied to hospitals or even trusts. It’s also clear that designers are not heros in capes that can swoop in and fix everything. However, I do think there is value designers, and a design led approach, can bring if applied with care and consideration.

What’s been great about this work has been the close partnership Videha and I have formed. He with the medical background and gravitas as an ex-surgeon and NHS England aligned employee, and me as a designer with an unbiased perspective and the ability to think systematically and creatively at both a strategic and detail level. This combination has been important and this project wouldn’t have worked without both of these skillsets working in tandem. This partnership has allowed us to build trust with the clinical staff we’ve met and navigate the local context while remaining open and unbiased to how we might design a service that is scalable.

It’s also been interesting to observe how hierarchical the healthcare system is. As a designer my inclination is to get everyone involved in delivering the service in the same room to work it out together. However, that’s not the usual way. People in certain roles, at certain levels, are usually just told how to deliver something. They are not used to having a say, and more senior people are not always used to involving them. 

This top down culture affects people even in the most senior roles. They are not used to being shown mock ups of forms that they will be using and asked for their feedback. Clearly people are used to being given things that don’t really work for them and finding ways around it to make it work. It takes a fair amount of digging and prompting to get people to the point where they are honest with us about what works and what doesn’t.

Showing the results letter to a pharmacist.

There are also parts of the service, like local labs for example, that might be outsourced and provided by another organisation. This leads to conversations like “who is going to pay for the postage and envelopes to send the tests to the national lab.” A very real and important question.

This approach to designing a minimum viable service and piloting it first is new for most of the people involved. What’s been really difficult has been getting the hospital staff to see this as a live service implementation and to work with us to design a realistic version of the service. Consultants especially have wanted to treat this as a project. Some have wanted to wrap the service in cotton wool and do everything themselves to make sure it goes well. However that’s not reality, consultants are one of the most highly paid roles on the ward and to design a realistic and scalable service we need to be honest about who will actually be taking the blood and filling out the forms once this testing is integrated into routine care. 

It’s fairly unusual to take the time to design, test and iterate what is a minor service on the face of it (although it’s definitely more complicated than it looks). One blood test, on one gene, to inform whether or not to prescribe one drug. To some in the system this might seem like overkill so it will be interesting to not only deliver a service that works but demonstrate the value of the approach.

I’ve also been reflecting on my role as a designer in all this. The wonderful people we’ve met in the hospitals know their world inside out, I can be a facilitator for them providing time, space and an approach for them to come together to design the service, but largely, they’ve got this. What I feel is really valuable about this work is the connection we are making between frontline service delivery and strategic level planning and commissioning. That is largely what I see my job as and having the opportunity to take this approach right at the start is fairly unique. 

This project will be continuing into 2025 with the pilot phase beginning in January and the guidance for wider implementation being published in the spring. I’ll be writing more as we go.

Videha and I are also developing a talk about this work on the value of designers and doctors collaborating, and the reality of designing and delivering new services. If you have an audience for this talk please get in touch: hello@designforjoy.co.uk