Users in health — A UK perspective
A lot of work within the NHS.uk service draws upon the work done with the Government Digital Service (GDS). GDS was set up around 5 years ago to transform the way government digital services are used by the citizens of the UK. NHS.uk (Through Discovery, and Alpha) was set up in 2016 with the aim to transform how users manage their health and care.
How does GDS look at users?
Central to GDS methodologies is the concept of the user, the person or business accessing a service in order to complete a task. “Understanding user needs” is point 1 of the Government digital service standard. This (rightly) shows their importance in successfully designing a government digital service. Service assessments (the internal assessment that allows a service to move from various stages of publication until full release) help reinforce this view by making user needs a key part of any assessment.
Users of government services seem relatively straightforward to understand. According to GDS, they are any person or business that access a service in order to complete a task. This definition is both distinct in both description and action. By description they are can be an individual or group, or an entity. By action, their goals a defined clearly enough to be a task that can be completed.
With the recent release of the Government Transformation Strategy to 2020, there is explicit government ambition for joined up services that cross departmental boundaries and supports a broad definition of ‘user’. From citizens, to agents, to businesses. This echoes a broader definition of ‘User’ in Health: From patients to clinicians to Health Care professionals. In some cases users cross large organisational/sectoral boundaries such as between health and social care.
Government Services should be verbs.
The recently released Government Transformation Strategy listed 20 digital services that will be publicly accessible by 2020. The scan of just the titles already shows a difference in thinking between health and other digital services.
Out of the 20 only 1 is health: NHS.uk. Almost all of the non-health services use verbs in their name. Users can ‘apply’, ‘check’ and ‘get’ or ‘want’. In most cases, it’s easy to understand what a user is expected to get at the end of the transaction. They will receive a divorce, a fishing licence, or a new passport.
Almost all of them suggest a focus on the single citizen, although they will involve other organisations. NHS.uk, (the bit I am working on), at this stage, is initially focused on 2 main areas. Symptoms and conditions content, and accessing services in (primarily) primary care (GP’s, walk in services and Pharmacies).
It doesn’t have a verb in its title. There is no identifiable thing that a user will get at the end of using this service. This may not always be the case. The future may hold health services with verbs such as ‘wanting a European health card’ or even ‘Get an insulin pump’.
Regardless of an increasingly complex user landscape, there is and may always be a focus on the citizen accessing the service. This is reflected in how the services are named, and in my experience of government, how services are currently designed.
Users in healthcare are different to users of government digital services.
In many cases there are similarities between a typical user of a government service and that in health. For example, Health journeys are often proxy journeys. In many cases they are done for someone else, such as booking an appointment for an older relative.
Within health and care, and digital health services generally, I believe the concept of the user is different enough to be worth unpacking. Seeing how a user in health is different from the one that underpins a government service will impact not only how we design, but how we judge the impact of digital health services.
Health journeys are unsystematic…
The research that the team has conducted suggests that user journeys in health are often characterised by their unsystematic nature. Especially for symptoms and conditions, where users may not know what they have nor know what is their best route of action is. Users tend to move across a lot of information channels, both digital and analogue. From web services to asking friends for advice. Traversing many Information networks for knowledge acquisition is key method in how a user orientate themselves to their symptoms or condition.
There is usually no single transactional route with a beginning middle and end. Even if symptoms are simple and presented typically, health users are not clinicians and can’t be expected to interpret the presentation of symptoms in a typical way. They repeatedly access different services and often the same service multiple times, in order to orientate themselves to their symptom and condition in order to work out what to do next.
This orientation and action was described by John Boyd as the OODA loop (Observe, Orientate, Decide and Act). A concept he formulated to describe the series of observations and actions fighter pilots use to assess combat situations. Peter Jones (Design for Care, Jones 2016) suggests the OODA loop is a better descriptor of the haphazard, multiple entry point nature of health seeking.
….and often repeated
Whereas other government services may be single transaction, Within health seeking, the exact nature of the ‘transaction’ is more difficult to pin down. There may be many transactions (registering with a GP, booking an appointment) alongside orientating oneself with a symptom or condition. The heterogeneity of interactions means there is no ‘end-state’ as typified by interactions with other government services. By engaging in a service one will not receive state of ‘wellness’ at the conclusion of the transaction.
This repeated journey, whose value increases over time is very different to the aim of government digital service to reduce friction in transactions which ultimately avoids “unnecessary contact with government, which will mean that in the future, the number of digital transactions should decrease.” (Government Transformation Strategy, 2017)
Users within the system impact other users of the system.
Healthcare in the UK is a finite resource, characterised by multiple stakeholders interacting with multiple services in multiple sectors (Jones 2014, p12). For a patient, the majority of interactions are with clinicians and other healthcare professionals. However, less recognised interactions are with other patients. Even for simple health services that mimic simpler government interactions, there is always the underlying structure of the interrelated nature of how different users within the system effect one another.
I’ve heard this verbalised through concerns such as “I don’t want to drain the system’ or ‘it usually takes two weeks to get an appointment’ or in the case of symptoms and conditions content, it could be ‘my friend had something similar and got this from the pharmacy’.
Health benefits are not immediately realised
In many cases in Health, the benefit it is often a deferred. As Jones points out, this is very different to service design methodologies that government services rely upon, whose benefit is realised in the ‘delivery and active acceptance of expected service’ (Jones 2014).
In health, a service user may only realise a benefit at a much later date, especially in clinical settings. Booking an appointment to the GP, should be recognised as one piece in a potentially very long health journey. The end state of ‘success’ may be hard to define. Focusing on a small aspect without understanding the larger system may adversely affect the design of such services.
The success of a services isn’t a reduction of in user interaction but should be measured around health outcomes.
Users in health are different than users of other UK government digital services. Their journeys are haphazard and often repeated. Their relationship with other actors in the system makes their interactions impact on others. The benefit of this interactions, may only be truly realised at a much later date. This high level of interactions, rather than being a sign of failure this could well be an indication of high engagement. In some cases, it should be encouraged. There are many actors in health and their relationship to one another will impact on how we define ‘user’ within the methodologies set out through the UK Government transformation agenda. Re-looking at user in health will help us create better health specific journey which ultimately support better health outcomes.
References
Jones, Peter. Design For Care. 1st ed. [Place of publication not identified]: Rosenfeld Media, 2013. Print.
Gov.uk. (2017). Government Transformation Strategy: business transformation — GOV.UK. [online] Available at: https://www.gov.uk/government/publications/government-transformation-strategy-2017-to-2020/government-transformation-strategy-business-transformation [Accessed 23 Feb. 2017].
Gov.uk. (2017). Start by learning user needs — Service Manual — GOV.UK. [online] Available at: https://www.gov.uk/service-manual/user-research/start-by-learning-user-needs [Accessed 23 Feb. 2017].
Stephens, A. and Downe, L. (2017). Taking service design to Parliament | Government Digital Service. [online] Gds.blog.gov.uk. Available at: https://gds.blog.gov.uk/2016/07/22/taking-service-design-to-parliament/ [Accessed 23 Feb. 2017].
