Martyn Perks, Maja Kecman, Lynne Maher, Jason Mesut and Alastair Donald, 20 October 2009
Introduction: Martyn Perks, design consultant; speaker and writer on design, technology and innovation
It has emerged recently that the yearly influx of newly-graduated doctors could be responsible for an increase in hospital death rates (1). Although the evidence is unclear, the story does not help the government’s latest plan for improving the NHS by measuring its effectiveness based on patient happiness rather than focusing on medical science. Ever since the previous health secretary Alan Johnson argued that the future of the NHS was going to be based around providing personalised services (2), patients appear to be the new drivers of change. In Lord Darzi’s wide sweeping review last year, High Quality Care For All (3), he insisted it is the ‘patient experience’ that will drive NHS reform. Current health secretary Andy Burnham confirmed this more recently: ‘How you are spoken to, how you are dealt with, whether you are treated in a friendly way — these things can be as important as your medical care’ (4). In other words, failing to keep patients happy could prove costly for those providing care.
If you remain unconvinced, don’t worry. A new breed of designers believes they have the skills to put things right. These so-called ‘service designers’ argue that traditional top-down thinking is insufficient to reform such a burdensome institution. For them the NHS’s command-and-control allocation of resources is the wrong way to go about things. Instead they argue the answer lies with putting those with the greatest need at the heart of the process ie, the patient. Their strategy is a simple one: design around the patient’s needs and let that dictate what is provided. This is a big change in approach. Just as Burnham argues for a new balance between care and cure, here designers argue the principle of universal provision should be balanced with a new set of ideas that tailor services around specific ‘user-need’.
Service designers argue that only when the patient’s needs are understood can you create good, efficient services. One of the ways they do this is by mapping each step of the customer or patient ‘journey’ against relevant services, information and support they would ideally need at each point along the way. The goal is to understand and define each set of services that when put together will answer the original need. Today they argue, many of those steps are missing, so the patient rarely receives a complete and satisfactory level of care.
In practice this approach could help myriad problems such as when patient records get lost or in situations where there is a breakdown of communication between doctor’s surgery and another healthcare unit—all of which results in unnecessary delays and complications. Technology can play a key role in streamlining how these systems can talk to one another and help patients access everything online. All of this does sound good.
But let’s not forget: designers have their own motives, as they are themselves in a tough spot. When they are blamed for too much consumption, contributing to there being too much ‘stuff’ in the world, as leading designer Tom Dixon says, service design helps designers regain lost ground and keeps them ‘relevant and economically viable’ (5). In a climate where the government is searching for new ways to target state spending and at the same time overcome its own marginalisation, service design can too easily fit an agenda not of its own making. Apart from helping government pinpoint bad services, service design is also being used to encourage wider participation in the government’s own agenda, which is not always good news for the very people they want to help—the patient.
In reality, collaboration between doctors, patients, managers and advocacy groups can end up putting the patient’s own experience under the microscope. The customer journey is no longer an open-ended tool but one that means consciously guiding patients into making the right choices. Put another way: getting them to behave. Service design agency Live¦Work, who work in various areas including health, explain this when they say ‘[W]e need to support people to lead healthy lives, stay out of hospital and feel good. We need services designed to help people stay well’ (6). Here spurred on by the cost-cutting agenda, the design of services can so easily become one based upon consciously re-engineering provision that veers on being a coercive process. This is no longer about patient autonomy as such and is instead about a process that encourages people to live healthier lives. But what if they choose not to heed such advice? Could they become at risk of being demonised as a burden and a strain on resources? Maybe.
Likewise Tim Brown, who leads one of the world’s leading design consultancies IDEO whose work also includes healthcare, makes a similar point: ‘we must become more engaged with our health, including living lives that promote health and wellness rather than encourage the onset of chronic disease’ (7).’ His answer of how he thinks design can help alleviate unhealthy lifestyles is through the creation of ‘platforms that encourage participation’.
Two examples of how this could work are e-medical records and Health Savings Accounts (8). Both are American ideas that let people keep records of their healthcare and also provide a platform for providers and government to intervene with pertinent advice including about insurance and nutrition to a wealth of other related services. The more direct benefit for the person with the record is they get advice and support that recognises their changing circumstances—including if they get ill or are in need of treatment. But as Brown puts it, the effect of encouraging participation means more opportunity to influence patients’ behaviour: ‘I think they offer an opportunity for the government to significantly change our attitudes towards health.’
But in a culture where all aspects of our personal lives are under constant scrutiny—whether it is smoking, eating, drinking or our sexual health—the risk of all these design initiatives is that many of their positive sentiments get sidelined by an agenda that wants to dictate and regulate what we can and cannot do. So although designers do make the lives of many people better, for example by establishing better support around the needs of Alzheimer’s sufferers (9), other people and communities might do well to duck when hear the knock of the designer on their door. Whether all of this will help make us happier or healthier is another question when each new attempt of the designer to cure our ills only adds more weight of responsibility on our shoulders.
Is design’s intervention in healthcare a good thing, or will it ultimately make matters worse—especially for those in greatest need of a cure?
RESPONSE 1: Maja Kecman, senior associate, patient safety group, Helen Hamlyn Centre, Royal College of Art; industrial design engineer and consultant
Designers can bring about a true understanding of real user needs.
A common failing of healthcare reform is that new measures rely on assumptions, rather than detailed observation or analysis, of user needs. As designers, we have expertise in taking a different approach to understanding and solving problems, beginning with a focus on uncovering unarticulated or hidden user needs. By observing and focusing on the user, designers can derive important insights with the potential for meaningful and even radical solutions. This approach, applied to healthcare, will help us to better understand the experience that we are trying to create, and better design the delivery model that is needed to reach there.
Designers can help translate and transfer healthcare and wellness from clinic to home.
Recent years have seen a significant power shift away from the priesthood of the physician, to the patient as an active consumer of healthcare. This change has been influenced by a number of factors, from the proliferation of available medical information, to new methods of care delivery. Certain health interventions, once the domain of the skilled physician, can now be delivered and administered by patients themselves. The designer has a key role to play in the process of translating and transferring healthcare from clinic to home. In this way, design innovations can lead to cheaper, faster and more accessible health services. In addition, we will see wellness, prevention and predictive care leave the physicians office completely and be administered by people anywhere and anytime.
Collaboration is needed and designers are positioned to lead and facilitate.
With designers increasingly in demand across a range of industries, effective interdisciplinary working has become an essential component of any successful design project. The pressing issues in healthcare require the involvement of all stakeholders, including patients, families, communities, clinicians, managers and policy makers. The complexities are almost overwhelming, and taking a single view on any one issue outside the context of everything will fail to satisfy the healthcare system. Designers can lead as facilitators in this collaborative process; understanding the needs of all groups, and then guiding stakeholders through the difficult decisions needed to generate successful models of care.
RESPONSE 2: Lynne Maher, interim director, innovation, NHS Institute for Innovation and Improvement; author, Making a Bigger Difference NHS guide
Health and well-being are precious commodities. The NHS, as the UK’s biggest health care service provider, is facing an unprecedented financial challenge over the next five years, and has an ambition to increase quality while reducing cost. How do we do that? We need to redesign for today and redesign for the future if we want the NHS to provide high quality care for all. Designers have massive expertise in solving problems, patients and their families have massive expertise in how it feels to be a patient; both should be involved in redesigning health services.
There are a lot of wasted resources in the NHS, too many unnecessary appointments, too many steps in the process, people doing the wrong thing at the wrong time, people accessing the service with preventable conditions. If not controlled this situation will break the NHS. This is a problem- designers are experts in solving problems and should help to design mechanisms to support us, the public in choosing healthy lives and the professionals to provide high quality care at lower cost. Already the methods used by designers have been copied and ‘translated’ for use in hospitals, GP surgeries and within community health services. A growing number of health care staff are using the skills of service design particularly. This demonstrates an unmet need designers have been slow to fill the gap.
Over the past 60 years the predominant culture of health services has been paternalistic, with the professional knowing best and patients being grateful. Health care services have been designed around the professionals mental model of what is needed rather than based on understanding and designing around the experience of care. Other industries use this method and it should be used in the NHS- why wouldn’t you want to get a great service?
RESPONSE 3: Jason Mesut, experience director, The Team; design specialist, healthcare user experience, NHS and private sector
I’m glad that designers are interested in helping make the world a better place through their craft. My concern is that these eager designers have their energies focused on areas more challenging and more complex than they can handle - whether it is global warming, obesity, economics, or even our government’s hollow policies for the NHS.
The latest policy ‘plat du jour’ seems to be that of ‘patient experience’ - a new area for measurement within NHS. Let’s try to forget that for a while that a focus in this area may have detrimental effects to the medical care that a patient might receive, and that most doctors think a new ‘patient experience’ target is a bad idea. Instead, let’s think about how we improve patient experience. The new wave of ‘service designers’ has some answers: watch how people use the service and get served; speak to them and the staff about their experience; co-design new service ideas together; and put in an action plan for delivering these services. This seems logical, after all, it’s just good design. Something that NHS hasn’t seen a lot of in the past, as millions gets spent on number crunching management consultants who deliver lots of proof, but very little progress.
So what’s the problem, then - lots of work, lots of opportunity to make a difference. My concern, however, isn’t the process, it’s the naivety of the designers. Making the change happen takes time, energy, and a lot of politics. I strongly believe that most of the designers working in this space simply don’t have the patience to follow through on the sort of change they come up in their workshops or brainstorms. It’s relatively easy to do the early parts of the process, but as any single discipline designer knows, the devil is in the detail, and getting the product, poster, booklet or building out to market. Changing areas of the NHS is even harder, especially on the holistic scale that some are talking. The real problem is one of people, all with different views, jaded by previous attempts at reform.
If service designers are to really make a difference in this space, they are going to need to join forces with those who can crunch the numbers and prove improvements as a result of their ‘service concepts’. And be incredibly patient, so they hang around to drive their ideas through. Alternatively, my advice would be to focus on the areas that they can make a more tangible difference - the systems and the products that healthcare professionals use. Make things easier for them, and maybe you’ll reduce clinical errors, give them more time to give better care, and ultimately give patients the medical care they need, rather than the customer experience which government thinks they want.
Response 4: Alastair Donald, urban designer, postgraduate researcher, Min-Max-Cities Group, Martin Centre for Architectural and Urban Studies, University of Cambridge
The Maggie’s Centre in Hammersmith, London, picked up the prestigious architecture award the Stirling Prize this year for the building adjudged to have made the greatest contribution to British architecture. Designed by the Lord Richard Rogers-led practice Rogers Stirk Harbour, the centre confirms the importance currently attached to redesigning the delivery of healthcare, and suggests a considerable shift in emphasis in the design of healthcare.
With a budget of £2 million, Maggie’s Centre is small fry compared to the billions currently being invested in a revamped NHS estate. Yet, the centre has been the focus of considerable attention since it was opened last year by Nigella Lawson and Sarah Brown - the latter who returned recently with Michelle Obama in tow.
The centre is one of a series named after Maggie Jencks, a victim of cancer who had the idea of providing sanctuaries that provide a retreat for those affected by the disease. With its ‘warm’ orange wraparound walls, angular ‘floating’ roof canopy, and landscaped terrace, the design of the centre is a stark contrast with its immediate neighbour the 1970s high rise Charing Cross hospital, the existence of which the centre seems designed to blot out.
It is certainly true that many post-war NHS buildings have a deserved reputation as dysfunctional and relatively austere environments. But the RIBA judges’ description of the Maggie’s Centre as a ‘the antithesis of a hospital’ is revealing. A new generation of healthcare buildings are designed not just to improve the quality of the physical spaces. The important transformation is in the values of healthcare from an emphasis on the treatment of disease, to the provision of ‘empathetic’ or caring environments. At a time when complementary medicine takes precedence over medical science, and nurses are encouraged to become ‘dignity champions’ who enhance the patient experience, designers are now charged with creating buildings that boost self esteem and well-being.
Today - a time when we live longer, healthier lives than ever before - the preservation of the self seems to take ever more of our energies, suggesting that the pursuit of health has become about far more than the treatment of disease. The role that many designers seem to have accepted is one of helping us to rediscover ourselves and society through the medium of our health. Richard Rogers illustrates this when he argues of his Maggie’s Centre that ‘it’s like church without religion - you go in to find yourself, and try to understand who you are’. In fact the role of health as increasingly central to our identities reflects an anxious society that is unable to conceive of shaping a better future. Centring society around the new emotional patient centred approach to health not only downplays the benefits of medical science over emotional experience of disease, but will reinforce our anxieties and sense of powerlessness over the future of society.
Click on authors’ names for biographies.
1) ‘Deaths rise’ with junior doctors, BBC News, 22 September 2009
2) Johnson wants ‘personalised’ NHS, BBC News, 2 March 2008
3) High Quality Care For All, Lord Darzi, 2008 (PDF)
4) Hospitals to be told to make patients happy, The Sunday Times, 13 September 2009
5) Tom Dixon pushes service design agenda, Design Week, 25 September 2009
6) Service Thinking, live|work website
7) Participating in health care, Tim Brown, Design Thinking, 2 May 2009
8) Health savings accounts explained on Wikipedia
9) Think Public in Alzheimer’s Society service design task, Design Week, 3 September 2009
"The Battle of Ideas goes from strength to strength. The intensity, variety and depth of debate, sustained for an entire weekend, makes for a unique experience charging the intellectual batteries for the rest of the year."
Raymond Tallis, emeritus professor of geriatric medicine, Manchester University