These are challenging times for the NHS. It has some 1.4 million employees. It currently costs around £100bn. to run and it is expected to shoulder £15bn. in spending cuts over the next 2-3 years while also increasing quality. Some argue that the UK government’s 2012 Health and Social Care Act, with its opening up NHS services to competitive tender, is a privatisation by stealth campaign against the country’s most valued institution. Meanwhile, recent news of poor hospital service undermines confidence.
It was not without irony that Lynne Maher was addressing us one week into her (early) retirement from the role of Director for Innovation and Design at the NHS Institute for Innovation and Improvement. Yet another shake up of NHS organizational structures has meant that it has lost one of its leading modernizers just when you’d think she was needed most. Lynne Maher has spent 35 years in the NHS, having trained as a nurse aged 17; so she knows this complex, fascinating but also, at times, frustrating organisation inside out. Undoubtedly she will not be short of offers from other countries for her expertise. But a key issue for now is preserving and disseminating the learnings from her labours.
During the seven years that Lynne Maher has been employing innovation methods in reviewing and reworking various corners of NHS delivery, service design thinking has become a key element of her approach. In particular, her work has focused on changing the episodic experience of care to one of flow. Time and time again in her talk, Lynne showed how the disconnection between various actors and sectors within the NHS was resulting in wasteful practices. Solutions are often disarmingly simple. Stroke patients need toilet rolls on both sides of the cubicle (with one side of your body paralysed, you run the risk of falling off the toilet as you reach across). Hospital porters need quick and easy access to wheelchairs (otherwise they waste much time looking for them). In all of the examples given there are material interventions which establish connections between previously separated domains within healthcare.
At the heart of work carried out by the NHS Institute for Innovation and Improvement is experience-based design. Healthcare design has tended to focus on performance, which incorporates evidence-based decision making on utility (how well does something carry out its task) and engineering which involves how reliable something is. (Within performance focused design, I think that the work of Professor Roger Ulrich, who was a senior advisor to the NHS in 2005-6, is particularly noteworthy.) The third domain of design that has, until recent years, received less attention is that of the aesthetics of experience. How does it ‘feel’ to engage with a healthcare service? While putting a toilet roll on both sides of the cubicle addresses a very practical need of stroke patients, this is also a ‘physical, sensual, cognitive, emotional, kinetic and aesthetic’ factor (Bate and Robert 2006).
For my money, this attention to aesthetics in its broadest sense isn’t fluffy. It isn’t just about making hospitals pretty. It is about placing greater emphasis on the material and human encounters of the setting. In this, design is not regarded just as form-giving to discreet elements; rather, the ‘fit’ of elements and the narrative of the visit or stay has to be orchestrated. Lynne Maher explained how she asked the question ‘what are the analogies in customer services to draw from’. All use service design, consciously or not, was the answer. And in focusing on the user experience, she discerned that patients wanted to talk about the emotional journey that is undertaken through healthcare. Q.E.D., paying attention to this journey and shaping it to be efficient and experientially sound is paramount.
In providing an expert response, Yashu Reddy of Healthbox, asked the important question of how you engender the levels of innovation in the NHS that one finds among SMEs. Several similar questions tumbled out of the plenary discussion. How do you disseminate innovations? What is the opportunity for building capability in the NHS around these issues? How do you transfer thinking? And so on.
One might focus on patient journey and experience of the service. But innovations in themselves have to be integrated across the service providers. There has to be shared and agreed ownership of potential changes in procedures and settings. This is why, as Lynne explained, it is productive to involve all levels of NHS employees in the design process, from management through to frontline deliverers.
Much of the challenge is, however, in giving permission for change. It seems to me that actors are often involved in a stand-off with noone willing to concede to what they really want. The culture of the NHS is, for good reasons, risk-averse. This is why planned risk where the learnings are monitored and reviewed can be opened out, Lynne argued.
Anyone who has had any dealings with the NHS find it both a comforting and frustrating experience. The comfort has invariably been in the dedication, care, attention and concern of its employees. The frustration has sometimes been in the waiting, the repetition or the miscommunications. (My personal aggravation was, once, while going through a pre-operation set of examinations, I was asked exactly the same questions by three different hospital staff through the afternoon. Eventually on the third go I pointed out to the junior doctor that all the answers to the questions he was putting to me were already recorded in the notes that had been handed on to him. (He couldn’t read the handwriting, though.) The comfort was that the surgeon and staff were dedicated and brilliant.) These can often be designed out as Lynne Maher’s talk amply demonstrated.
Ultimately, though, — and I’m going off-discussion here – I personally think that if we are to have a sparkling healthcare system that is beautiful, compelling and high functioning in every way, we need it to be reflexive. In this, I mean that its machinations and structures have to be readable and understandable. It has to know itself, be self-critical and analytical of how its procedures and settings — and their design — function. Design itself should be reflexive, otherwise, confusion or bedazzlement reign. Subsequently, both experts and users can contribute to it and feel ownership of it. The NHS is, after all, ours.