Improving Health and Care Services Through Design
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We can improve the way that we commission and create services if we alter our model. Using Design Thinking we can create services that meet user needs but are also cheaper.
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Improving Health and Care Services Through Design
- 1. Darren Wright Improving Outcomes Through Design
- 2. Using data, from individuals, to describe communities and demonstrate outcomes 1. Using Design Thinking we can create better services that meet the needs of people 2. Data has a social value beyond proving contracts are working 3. Using data we can describe the communities we live in and co-produce services 4. Demonstrating outcomes in terms of national policy allows data to be aggregated for social benefit
- 3. We all love the idea of measuring outcomes rather than activity
- 4. Challenges with Measuring Outcomes • Attribution – Did you cause that outcome? • Complexity – Especially in preventative services • Why are you doing it? • Contract specific outcomes can change a service • Place vs service
- 5. There is no shortage of Outcome Frameworks
- 6. Being Busy vs Being Effective
- 7. Built environment – 10% Clinical care – 20% Healthy behaviours – 30% Socio-economic factors – 40% Contributors to Overall Health Outcomes Source: Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute
- 8. There are two types of outcome 1. Systemic outcomes – e.g. A&E attendance, GP appointments 2. Individual outcomes – measurable improvement in health and social situation
- 9. A focus on outcomes should fundamentally change the way we commission and design services
- 10. By focussing on measuring the system we miss the opportunity of human-centric design
- 11. Challenges With Commissioning • The difference between commissioning and procurement • Co-designing services is more expensive • What if the public don’t agree? • Where do you get your data from?
- 12. What do we commission against? • QOF Data • Open Exeter Data • National Data Sets (Atlas - life expectancy, infant mortality) • Local data sets? • Mosaic? • Community data on service design?
- 13. Traditional Commissioning Model This often the point where we start getting involved Build service model Test model with patient/user groups Decide on some metrics Go out to contract Measure metrics
- 14. What is the purpose of collecting data? Is it purely to measure transactions?
- 15. Wisdom Knowledge Information Data The Wisdom Hierarchy of Data Value
- 16. Alternative Service Design Model Set out problem to be solved Go out to contract Define user needs Identify data to meet user needs Design service Adapt service Test service against user needs Prove the problem is being solved
- 17. Tracey is 24. Tracey grew up in Chelmsley Wood until she was 21. She lived at home until she fell out with her family and came to stay with friends in Birmingham. After a couple of months it was obvious there wasn’t enough room in the one bedroom flat she was staying in and without anywhere else to go she ended up in a hostel in Birmingham. It’s not a great part of Birmingham and Tracey doesn’t feel safe walking around there. Tracey can’t stay in the hostel during the day so spends a lot her days in friend’s flats. During the day her, and her friends, watch TV and usually drink quite a lot of vodka. She has completed over 2000 levels of Candy Crush Traceyple
- 18. Tracey: ● In debt ● Socially isolated ● Lives in a hostel ● Been to see GP 7 times in 3 months ● Stressed and anxious ● Attended A & E on two occasions with alcohol related alcohol related issues ● Smokes ● Misuses alcohol ● Poor diet ● No exercise Traceyple Socio-economic factors Clinical factorsHealthy behaviour
- 19. The danger of the microscope Defining people by the services they use, and the data we choose to collect on those services, leads to data reductionism
- 20. Not understanding the person can lead to Solutionism:- The providing of a solution or solutions to a customer or client (sometimes before a problem has been identified)
- 23. Challenges with Measuring Outcomes Attribution – Did you cause that outcome to happen? Place vs service
- 24. Integration around the individual GP A&E Smoking Cessation Alcohol Services Job Centre Money advice Gym Housing Health Trainer Collective Outcomes
- 25. Data Collection is Structured to Match the Life Course Starting Well Data Dictionary Developing Well Data Dictionary Working Well Data Dictionary Living Well Data Dictionary Ageing Well Data Dictionary Diabetes Data Dictionary But also service specific Mental Health Data Dictionary Supported Housing Data Dictionary End of Life Data Dictionary Domestic Abuse Data Dictionary We have identified 93 common risks and issues. Each has been defined and is monitored for any change in policy. We are adding to this list all of the time.
- 26. Living Well Data Dictionary Personal Circumstances: • Domestic Abuse • Homeless • Temporary Accommodation • Unsuitable Accommodation • Vulnerable Adult • Financial Hardship • Social Isolation - Loneliness • Environment - Noise • Environment - Outdoor Spaces Behaviour: • Very Low Fruit & Vegetable Intake • Low Fruit and Vegetable Intake • Significant Fried and Processed Food Intake • Excessive Sugar • Nutrition - Iron • Physical Activity - Moderately • Physical Activity - Inactive • Alcohol Misuse • Smoking • Substance Misuse Status: • Weight - Overweight • Weight – Obese • Mental Health – Low Reported Wellbeing • Mental Health - Stress and Anxiety • Sexual Health - Unwanted Pregnancy • Sexual Health – Sexually Transmitted Infections • Pre - Diabetes: Non - Diabetic • Screening - Increased Blood Pressure • Screening - High Blood Pressure
- 28. Household income is >60% of UK average Reduce households where neither parent is in work Healthy Child Programme The family can afford food and clothing items Social Justice Outcomes Framework Department of Health Department of Work and Pensions Financial Hardship After required fuel costs the family remains above the poverty line Improving Outcomes Supporting Transparency Reduce the proportion of those on work-related benefits The number of working age adults engaged in work related activity
- 29. Data has value Continuous service improvement Wider social value
- 30. Continuous service improvement Value Identify data Gather data Analyse data Identify service improvement Implement service improvement Wisdom Knowledge Information Data
- 31. Social Issues Can be Aggregated and Mapped
- 32. Our tips to designing services Start with the person Think about data that is relevant to the person Be broad in the data you collect Make data collection as simple as possible Iterate regularly If the data says the service isn’t working then change the service
Editor's Notes
- Four orders, graphic artefacts, products, processes, services (and systems)
- 2012 saw a systemic shift to outcomes from activity. Largely supported by people. But…… what’s the breakdown of outcomes vs activity? Typically we fund that it breaks down to 95% activity and 5% outcomes. Frequently things labelled as outcomes are actually activity.
- Do you routinely use these frameworks to assess progress? In the main frameworks are the domain of commissioners but aligning with these frameworks make you a more attractive provider.
- The challenge of moving to a focus on outcomes means the metric of success is no longer how busy you are but how effective you, and your services are. The move to a qualitative approach from a quantitative approach means that you frequently have to make more fundamental changes if the data tells you a service isn’t working. If an activity based contract is failing then just do more, if an outcome based contract is failing then doing more of the same is a really bad idea.
- The main focus of investment is in clinical care. It costs more money, it requires significantly more long term investment and is less effective. Traditionally services in the bottom two tiers have struggled to demonstrate their worth to the people with money.
- There is a disconnection in priorities. Providers (and not surprisingly individuals) prioritise individual outcomes. Commissioners tend to focus on system outcomes. They are related. Systemic outcomes are relatively easy to achieve. Cynically you could achieve them through deteriorating the quality of service. That wouldn’t mean an improvement in overall health and wellbeing.
- Such a fundamental change in emphasis needs to be supported in a change to the way we carry out service design. Doing what we used to do and just changing the reports that people complete won’t work.
- Putting the people that use a system at the heart of the design process mean that you can create a service that can be empirically tested as effective By putting continual challenge at the heart of your service you create something that is agile and can respond to changes in need.
- We don’t incorporate failure into our commissioning model. If a service fails what do we do? Do we allow the service to redesign in line with patient expectations, even if this creates a different model to that specified in a contract? Or do we just wait out the contract length and then no recommission? This approach creates dead money in the system. Agile service design can create effective services but also efficient services.
- I’ve never come across anyone systematically using community data in service design or commissioning.
- Data shouldn’t be an after thought. It should run through your service design process from the very beginning.
- We need to think about why we collect data. Does it facilitate supporting the individual? Does it prove your contract is working? Does it support how your service works? Have you considered how the data can be used? How it can be analysed? What information it creates? Have you thought about the technology implications of data collection and data protection?
- Knowledge is the part where you get insight. Wisdom is where it becomes actionable. Can you validate all of the data you collect against this model? Do you collect data to create value as a matter of course.
- Iterative process remove, or at least mitigate, the need for the dreaded evaluation When you test service against user needs to remember to test the data and the emotional response.
- This is persona made up of user interviews. Notice that none of this relates to services. This the person. Personas need to be at the heart of all service design.
- If we see someone accessing a smoking cessation service as purely a smoker we miss the complexity that might be contributing to why someone smokes.
- Solutionism can lead us to decide on a service design that we like and then make us start to look for the data that will support it.
- The system is complex but Tracey doesn’t need to know this. Tracey has three needs. 1) To get services to integrate around her 2) To be able to navigate the system without friction 3) To know her personal data is being used productively and securely Every element of this system has a data need from Tracey. They rarely co-ordinate that need
- Particular problem of services that are removed from direct client interventions. For example if a social prescribing project refers to an exercise class and a person begins exercising who owns that outcome?
- If Tracey goes to a money advice service and a smoking cessation service these could impact each other. Giving up smoking could free up a lot of weekly money for Tracey but does that mean the money advice agency has achieved an outcome. At the end of the day does it really matter how it happened? Alliance contracting provides a model to properly measure collective impact.
- This should be fundamental to how you manage services. Every month can you identify a tangible service improvement and implement it?
- Aggregating data across services allows us to truly gain insight into neighbourhoods and means data provides social value.
- Holistic approach support integration. The adversarial form of commissioning is ending Simplicity in data collection minimises data protection issues and increases compliance and accuracy