Ute Schauberger and Giulia Fiorista: October 06, 2020
In this post, NDS designers Ute Schauberger and Giulia Fiorista introduce the idea of service patterns and how they can be effectively used to support good health and care technology as well as good experience for clinicians and patients.
WHAT DO WE MEAN BY SERVICE?
First things first, let's go all the way back to what us service designers mean when we talk about service. as this is another one of those words clinicians, engineers, designers, and others at NDS use differently.
Simply put, a service is something that helps someone to do something.
We have adapted this a little to health and care, as the wording "helping to do something" can be difficult to apply in our context.
A service is the health and care system’s response to the patient journey and needs (note also how this is different from a clinical workflow).
A whole end-to-end service is everything that happens on the NHS front-stage and back-stage during a patient's journey. So from an Administrator 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 is all the actions and processes happening, everything that helps the patient to achieve their goal and everything the system needs to achieve a health outcome - the whole service.
If 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, we have good news. We are working on approaching our pathway work at NDS by looking at service patterns. Just like in many other specialties, service patterns are models, standards and components that are proved to be good and reusable.
WHAT ARE SERVICE PATTERNS & WHY ARE THEY SO USEFUL?
A service pattern is a repeatable design solution for a common problem, designed 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 across the sector - something like getting a referral, being informed of treatment options, getting discharged.
From a clinical point of view, individual NHS specialties do complicated, complex, and very different work with different names and different purposes - for instance treating heart disease is very 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, namely consultation-investigation-treatment.
This Government Digital Service blogpost illustrates this very well when explaining their approach to designing services related to granting licenses:
"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."
Inspired by this and NHS Digital framing service patterns as as important in health and care as technical architecture, here at NDS we have started to develop our articulation and understanding of service patterns as part of our overall development of the National Digital Platform.
This is summarised in what we call the NDS Pathway Design System.
INTRODUCING THE PATHWAY DESIGN SYSTEM
You may be more familiar with the idea of a design system when it comes to user interfaces - 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 - (and NDS in parallel to this work is also developing one of those).
The pathway design system is the same, but instead of combining UI components leading to screen designs based on rules, we combine service steps to create whole service pathways using rules.
If you are comfortable with user journeys or service blueprints visualisations, our pathway designs are a level more abstract, and because of that are also extremely handy to categorise and cluster similar experiences of services across health and care.
There are three levels to the pathway design system and if you’re familiar with atomic design, we’ve put the corresponding level in brackets.
Level 1: Service components (the Atoms)
The service components are the smallest unit of the Pathway Design System. These are high level events in a journey through health care, and have been identified through a year of research through the Scottish Access Collaborative workshops, and have also been developed and validated further in the last 9 months at NDS. The service components don’t try to represent the ideal future state, but are a way of mapping the current pathways and finding patterns.
To date we identified 5 essential steps:
From a patient’s perspective, only some of these components will be visible, from a pure clinical perspective some of these steps won’t be detailed enough. But from a service perspective, these are recognisable and formalised foundational blocks that NHS pathways can easily be broken down into.
By acknowledging them and making them visible in first place, we think we will be able to re-define them as required by all the users experiencing them.
Level 3: Current service pathways (the Organisms)
Yes we’ve jumped from Level 1 to Level 3 but it’ll make sense why shortly!
We have used the service steps to map a variety of existing NHS service pathways, through the interaction of people, places, technologies and tools involved. They have been excellent tools to draft and build narratives, highlight challenges and leverage points across the system. Using a similar language cross-project allowed easy comparison too. Here a couple of examples of how we have used these to map end-to-end services in the context of cancer and endocrinology services.
Cancer Service Pathway
Endocrinology Service Pathway
We have also experimented with physically mapping out pathways during conversations with clinicians and other stakeholders:
Service pathway tool - paper prototype
Level 2: Service patterns (The molecules)
Once we’ve mapped the current state of several different NHS pathways, it is then possible to identify and design for service patterns - the actual building blocks that form pretty much all NHS pathways.
When combined into patterns, the high level generic components (the atoms) suddenly have purpose, and focus on commonalities of needs and 'jobs to be done' across different NHS pathways.
For example, a GP making a referral 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. The Government Digital Service defines these recurring 'jobs to be done' as verbs.
Identifying these verbs is a long-term task in itself and will require user research and co-design engagement with users. Here some examples and early articulation of service patterns that have been identified across projects at NDS.
Service pathway example made of service patterns
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 condition 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, it 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.
Looking at NHS pathways by using the atomic design framework is not a linear process, but rather a mental model to help us think of our patient’ s 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 SAtSD 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 we’ve shared 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 NDS 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 more inclusive services that focus on patients and practitioners 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 associated technical architecture and product experience.
We look forward to sharing more in the coming months about the development of this work and how it applies to specific areas of work NDS is engaged in.