Blog / Barriers to access – the inter-relationships between service design, equalities and health literacy

Blythe Robertson: December 07, 2020

Back in 2019, the Government Digital Service (GDS) wrote a thought-provoking blog post called “understanding all the barriers service users might face”. Since then, the work has been collaboratively developed, further barriers proposed and explored, and aspects of their approach influenced and updated.

At NDS, we’ve been impressed with how considering barriers to access shifts conversations from “what is wrong with these users” to “what is wrong with my proposed product or service and where does it put up unnecessary barriers for people?” This approach is an easy-to-use, practical tool for making research insights useable to directly inform design and decision making in digital health and care.

Why is this important for building (digital) services in health and social care?

First and foremost, providing services that meet everyone’s needs is a core role of the health and care system. Design means building end-to-end services in collaboration with whatever organisations necessary and delivery across whatever channels necessary. The focus is building services that work well for everyone in Scotland and are organised around people and their needs across whatever channel, interface or provider involved.

Secondly, an inclusive service causes less problems to the organisation which runs it,  is cheaper to run, involves less interactions and more successful outcomes, and translates into more time and money for both users and organisations. There really are few excuses for not putting in the work of making your service work well for everyone.

But how do we go about understanding and designing for all these users and user groups? How do we divide them into manageable groups without blocking our efforts to build a service that works well for everyone?

Traditionally, the answer has been segmenting or grouping users by demographic – for example age, protected characteristic such as disability, a diagnosis, or gender. Of course, this is vital, and includes offering the best pronoun options when asking for someone’s gender, or making sure services are not structured in a way that might exclude or alienate BAME people.

However, and especially in health, we then face the challenge of an infinite list of different conditions, diagnosis or characteristics, or ever more granular ways of describing how people are different from each other. In a service that aspires to work for everyone, it is simply not possible or practical to ‘cover’ or ideally involve everyone necessary in its design at all stages.

Another approach has been to segment users by the channel they are using – for example digital user, non-digital user, accessibility related user. From a design perspective however, this can quickly result in a circular argument. If digital channels are designed in a way that does not work for certain people, but we then label those people non-digital users, this will never help us to actually improve our digital channel and make it work for everyone.

Increasingly, what we are finding is that what works best is segmenting the reasons for why someone is struggling with a service rather than segmenting the people who experience them. This is what we call the universal barriers to access.

GDS has over time received a lot of phone calls from people who struggled to use part of it. They have collected a large amount of data which has led to the identification of these 11 universal barriers:


The barriers are a great tool to bring insights about real people and their needs into our design process in a way where it is useful and practical, and directly informs design decisions the team are making. Of course, the best way to do so is designing with people who will be using our services or products. This is not a replacement. In fact, asking people you are designing with to describe which barriers they would be experiencing when using an existing service or a prototype is a really valuable way to use the barriers!

What have we each done?

At around the same time as this work on barriers was emerging, we started some cross-team work on how better to articulate the links between our service design and equalities work. For NDS team members Blythe and Helen on the equalities side, this was largely a voyage of discovery into exactly what service design looked like in practice.

For Giulia and Ute in the Design team, once they had reinforced the case that equality and diversity are at the very heart of service design, it became more about using the barriers approach as part of their range of design tools when working with people.

Ute has led the development of our work on the barriers in collaboration with GDS, and a wider cross-public sector group of designers and user researchers.

Giulia has experimented using the barriers in the design process of a digital product related to cancer services, by first thematically organising research insights, quotes and stories of people accessing cancer services against the barriers framework, and then plan a co-designed workshop with people around the key barriers that people face, to ultimately design actions and ideas around these.

Helen incorporated the barriers as a way of structuring our equality impact assessment. She did this by seeking to understand the implications of barriers through research to gain insight and explore what these meant in practical terms, how would these impact and what challenges would they pose for people to engage with the services being developed.  Data was reviewed from a wide range of academic and social research, third sector and public bodies, to consider the barriers both in general terms for digital health technologies and specifically for care planning and ophthalmology.

Blythe has incorporated it into various presentation he’s been giving recently, including to the Health Literacy Group UK. This group, which brought together academics and practitioners in the health literacy field across the UK and worldwide, saw the approach as a really good way of articulating the impact that improving health literacy responsiveness can have across the wider system.

What comes next?

At NDS, we are using barriers to access in a range of different contexts. We’ll continue to embed it in our equality and design thinking. We’re increasingly using it in our interactions with third sector partners as a way of bringing together their existing and emerging insights to better inform our work. Over time, we think it has great potential to inform how we evaluate impact.

We think this is a really rich and inclusive approach, so look forward to further exploration.

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