8 provocations for designing the future of health and care services

Recently, I’ve been reflecting over our last few years leading and designing better health and care services. These experiences have led to a lot of learning about what does and doesn’t work to enable teams to deliver better outcomes.

As part of our work to lead and support the design of better health and care services, we’ve developed eight provocations for teams to work with as they identify problems and shape opportunities in health and care.

Whether you work in health and care or like to try and transfer learning to other social issues, I hope you find these provocations helpful to:

• scope out and define design opportunities for change
• set approaches and methodologies to designing and delivering change
• unblock challenges through a process of design and change
• think about the right collaborators to convene and involve through your process
• shape roadmaps to deliver against the Long Term Plan

1. Put people at the heart

We always talk about the importance of putting people first — patients, carers and staff — and that’s also the first NHS Design Principle. But do we really know what this means, and do we really do this? Putting people first doesn’t just mean patient participation forums, staff surveys and consultations. It means that we do the hard work to really get to know people, putting their needs first and foremost when making decisions and designing the future of health and care services.

When working with NHS Digital to redesign the future of digital urgent and emergency care, we outlined a set of criteria to define what ‘impact’ means in this context, prioritising opportunities to design the future state. Our top three criteria put people at the heart:

• improve patients’ health outcomes
• increase patients’ trust and reassurance
• improve conditions for staff so they can provide the best care to patients

The insights we gathered showed us that we cannot improve urgent and emergency care services without focusing on people’s emotional, practical and clinical needs. We found that the reason people bounced between different urgent and emergency care services was not necessarily because their clinical needs weren’t being met. Rather, we found that people were not feeling reassured, trusting the advice or care offer, or asked to do things that were not practical for them.

By putting people and their emotional, practical and clinical needs first, we can design services that meet these needs holistically at the first point (or as few points) of interaction. Undeniably, other indirect and equally positive outcomes will emerge from this effort — such as improved productivity and cost efficiency — but that’s not where the change journey starts. That’s where it ends.

2. Consider needs and assets hand in hand

A design approach promotes a needs-based mindset. What problems are we trying to solve? What are the needs that must be met? And what can we do to meet these needs? There is definitely value in this deficit-based approach to identifying an opportunity or gap for change. However, there is even more value in bringing together both a needs-based and asset-based mindset, focusing on the strengths (rather than weaknesses) that exist in a system, organisation or community, and what we can mobilise or harness (rather than fix or eliminate) to deliver change.

When we were tasked with co-producing a five-year programme to address health inequalities in Tower Hamlets, we weren’t quite sure where to start. Tower Hamlets is the tenth most deprived borough nationally with the fastest growing population in London. There’s a six to eight year variation in life expectancy between the most and least affluent neighbourhoods. A needs-based approach would have driven the team down the rabbit hole of a long set of unrealistic and unfocused social interventions to address all of these systemic challenges.

Instead, we asked local residents and community-led organisations about their strengths; the things they were proud of, and their dreams for themselves, their family and their neighbourhood. We then focused all our energy on working with communities and other parts of the system (services, the council and providers) to mobilise existing assets that can turn these dreams to reality.

“I want to feel safe locally.”

“I want to see our children have a good life; to be successful and happy.”

“I want to feel a sense of community unity.”

In one case, we worked with a group of girls to improve their sense of safety, confidence and connectivity in the local community; all of which we know is linked to better wellbeing. By introducing girls-only days and involving girls on governance boards, we removed the stigma around youth centres being a place for boys only. We also worked with a local provider to run self-defence classes for girls and a train the trainers approach so they can continue to run classes themselves.

3. Start with prevention

Prevention is better than cure. But from what I’ve seen, most of the investment in health and care goes into troubleshooting further downstream. Focusing on prevention and upstream work has many benefits, from better health outcomes to a better return on investment. But it’s also harder to do because it comes with a lot of uncertainty and the impact cannot always be seen immediately. I like to compare any work that doesn’t start with prevention to a hamster on a treadmill. Lots of energy (or money) is spent, but the hamster (or the problem) isn’t going anywhere.

Adult social care in Essex faced a challenge like this, where people who went into hospital were 20% more likely to leave with a social care package compared to the rest of England. These packages were often more than what was wanted or needed. Looking further upstream to working with patients in hospital before discharge care packages were considered, we could reduce inappropriate assessments, discharge delays, repeat admissions and the cost of inflated care packages.

This was the start of Home and Healthy, a hospital-based service supporting patients and their families to work collaboratively with their clinical team to find and arrange the right quality care in a way that is personalised, consistent and meets their needs. One hypothesis we’re interested in testing further is moving Home and Healthy even further upstream into primary care, to assess the needs of elderly patients and reduce hospital admissions.

4. Drive system-wide collaboration

One of the biggest fallacies is that health and care is one challenge that’s addressed by one National Health Service. This is problematic because there are many interdependencies between health and care challenges and other social challenges — or what we refer to as the wider determinants of health. Poor housing and high levels of pollution, social isolation, low educational attainment and many other factors all have an impact on the health conditions, caring arrangements and access to information and services.

To add to that, there isn’t any single organisation solely responsible for mandating, regulating, commissioning, supporting and delivering health and care services. The landscape is so complex that across the country, often thousands of organisations have to work together to deliver a single standard national service.

When we were designing the future of digital-first urgent and emergency care, we needed to consider the roles, activities, challenges and motivations of over 19,300 organisations responsible for delivering this type of unscheduled care; from central bodies to commissioners and local and regional services.

To effect any change in health, we need to think about and collaborate with different parts of the system who share or own the problem and who have a role in solving it. Most of the time, these players sit at different levels of the systems, in dispersed geographic locations, and sometimes outside of health.

5. Innovate in the open

Teams across the country are working to address some of the same health challenges, many doing and trying similar things. So there’s so much value in innovating in the open; sharing work as it evolves, showing mistakes and learnings and creating solutions that others can use, build on and adapt. Innovating in the open pulls everyone together to solve shared problems and improve solutions, rather than pottering away and duplicating efforts in siloes. It’s exciting to see the recent focus of the Future of Healthcare Vision and NHSx on creating open standards that can facilitate and drive this sort of open innovation and interoperability between different parts of the system.

Our open innovation approach to children’s social care services is a good example. We know that social workers spend 80% of their time on administration and only 20% with families and children — which is where the real value and impact of their practice lies. Working collaboratively with three west London councils, we designed FamilyStory, making the best use of digital technology to put interactions between practitioners and families back at the heart of social work. We’re piloting FamilyStory with three Child Protection teams and working towards open standards and a co-owned trust arrangement to scale FamilyStory across other local authorities and children’s services.

6. Fix the same problems once

There is a constant push and pull between national scalable solutions and locally tailored solutions. But it’s hard to argue against the benefit in fixing some shared problems once, where the local context is less relevant or where a solution is flexible enough to be tailored locally.

For example, patients across the country need to book appointments, request prescriptions and access health records. These are the exact shared needs that the NHS App is trying to meet once and for all. However, when we don’t think strategically about which problems we need to solve at national level, and which problems are best solved locally, we end up creating a chaotic market of solutions. The result is wasted investment, ineffective competition for a patient’s attention and the danger of retrofitting a national solution locally without considering the context.

When we started working with Public Health England to identify opportunities for digital weight management, it was apparent that nearly half of all local authorities cannot afford to provide a face-to-face child weight management service. Where they do exist, uptake is low and impact is variable. Additionally, there are next to no digital weight management solutions on the market that target young children and their families. Fixing this problem once made sense.

We designed and tested Our Family Health, a whole-family digital weight management service that families can personalise to meet their needs, and local setting, and that can be used anytime, anywhere, alongside an existing face-to-face service or on its own. This meant that we could work towards a vision where 100% of families could access a weight management service at a fraction of the cost to the public health system. The Department of Health and Social Care’s green paper recently shared the ambition to continue to work on developing Our Family Health.

7. Deliver results quickly

Facing funding challenges and systems constantly in flux, it’s imperative that design work delivers results quickly. Ambitious two to ten year roadmaps for change are meaningless. In that considerable time, the problem will most likely have become obsolete, the funding gone, or the conditions for change altogether different. We need to be designing change that can be delivered quickly at a small scale, supported by a process of constant feedback, iteration, adaptation, spreading of learning and scaling up (or down).

Affecting change at a social and environmental level is challenging to do in the short-term, but by working closely with local systems and stakeholders, we are able to identify a few interventions that are quick to implement, but also quick to deliver results. We worked with the Healthy London Partnership on the Healthy Communities programme, to improve social and environmental conditions that would make a healthy lifestyle choice easy for families. Working with local families, schools, policy-makers, businesses and entrepreneurs, we created Make Kit, which took three months to deliver from concept to community. It’s a healthy, affordable and easy to prepare recipe box that families can pick up at the school gates or on housing estates. The 6-week pilot showed that 73% of the families using Make Kit were eating fewer ready meals and 83% felt more confident cooking healthy meals.

8. Build capabilities and shift mindsets

FInally, it’s critical that those working on policy, commissioning, or delivery of health and social care are equipped with the design and digital skills needed to shape the future of services in a digital age. Most of these provocations require a modern way of thinking and working that does not come naturally to many in traditional policy-making, clinical and delivery settings. These are settings that focus on scholarly evidence over patient needs, best practice over experimentation, risk-averse randomised control trials over rapid prototyping and technology implementation over understanding the problem we’re trying to solve.

The work that Health Education England and NHS England are doing on the back of the Topol Review to create a digital-ready workforce cannot be better timed. As well as regularly building capabilities through the work we deliver with health partners, we’re excited to have been involved in specific programmes such as NHS Digital Academy, NHS Digital Pioneers, and the Topol Digital Fellowship to shift mindsets to designing the future of health and care services.

I hope you find these provocations helpful in shaping your work and decisions. Any feedback, comments, or suggestions for moving these forward is always welcome!