An unusual change project drafted in anthropologists to explore patients' experiences. Stuart Shepherd takes a look
The similarities between the NHS and the BBC run deep. Both are publicly funded national institutions with a strong, defining ethos. Each is riding the wave of intense and, at times, politically motivated scrutiny.
In a recent leadership fellows talk at the Health Foundation, research designer Martin Bontoft suggested that another feature the two share is that they used to describe what 'good' looked like - a position no longer assured in either case.
The BBC has seen its position challenged by the rise of digital technology and user-generated content, Mr Bontoft pointed out. New consumers want media on demand, not in schedules, and will take it from wherever they can find it and, when they can't find it, are happy to make it themselves.
At first, the BBC's response was simply to offer more choice. But it is now engaging with a wide community of developers and users to experiment with new ideas for online and programme content.
'The BBC has recognised that a significant amount of innovation is possible and indeed desirable from outside the organisation,' Mr Bontoft says.
In many instances the NHS has also gone down the 'more choice' route, he says, but without necessarily delivering more health. Where this is the case, the resulting complexity makes navigating through the service far from straightforward.
There are of course only minor consequences to missing an episode of your favourite soap because you can't find the channel. Struggling to find the right people to give you prompt and appropriate care, however, can be distressing.
Mr Bontoft says that 'although there are exceptions, the NHS has yet to realise the extent to which looking outside the organisation could benefit the number, inventiveness and crucially the acceptability of the services it offers'.
Matter of experience
Those exceptions are few but notable, as in the case of Luton and Dunstable Hospital foundation trust and its head and neck cancer services. In 2006 managers, staff and patients at the services worked together on the Your Experience Matters project. Sponsored and supported by the NHS Institute for Innovation and Improvement and using experience-based design principles, the project team - which also included a service design consultancy and anthropological researchers - co-produced a new approach to receiving and delivering head and neck cancer care.
NHS Institute head of innovation practice Lynne Maher says: 'The fundamental difference to what we might describe as typical service improvement methods is the depth to which we look at experience and emotions. A designer will challenge your preconceived ideas of doing that in a very sensitive and considered way. Rather than making changes to a service based on interpretations of patient and staff views this is about really understanding what their story is.'
Experience-based co-design, described in detail in the recently published book Bringing User Experience to Healthcare Improvement by Paul Bate and Glenn Robert, identifies 'touchpoints', those moments and places where people connect with the service in a way that elicits a strong emotional response. Where that is negative, it clearly marks a problem.
'The people using and working in the service then got together with the project team to think about how to redesign it and set some targets for action,' says Dr Maher. 'I think the fear is that when patients do something like this they will be asking for gold taps in the washroom. That couldn't be further from the truth. They understand the restraints and often the ideas they have about redesigning a service are little things you can do today.'
One example was simply moving scales away from the view of the waiting area - bringing an end to being weighed as a spectator sport.
Luton and Dunstable service improvement project manager Elaine Hide says: 'The experience of engaging the public that a designer adds to this kind of work, with branding, ideas logs and disposable cameras, helps the staff to have a better sense of the process and to encourage participation from a much broader group of patients.'
Design principles and processes also brought new approaches to problem-solving - a greater use of prototyping and testing for example - and a reminder that solutions can be counter-intuitive. A clinician may think the patient should be told everything about their condition and treatment from day one, but it can be more helpful to provide a steady flow of information.
'Staff now show an equal concern for both a patient's health and their experience of using the clinic,' says Ms Hide. 'The trust has taken a lot from this way of working and thinking and is incorporating it into reviews of several pathways, including stroke and hip replacement.'
At Salford Royal foundation trust, consultant in kidney medicine Janet Hegarty has just started to work with Mr Bontoft and the Centre for Health Innovation Management at Leeds Business School on a review of a satellite haemodialysis service in Wigan, using co-production principles.
'We know higher phosphate levels are associated with early mortality,' says Dr Hegarty, 'but we're not always good at getting them down. So we have invited people with the skills to drill down to people's mental maps and work out how they think and what motivates them, to offer us more rounded and collaborative ideas that we can also tie up with something measurable and deliverable.'
The risky bit, Dr Hegarty acknowledges, is that nobody quite knows what will come out of it.
'In a post-Wanless era, people are realising that the huge numbers of people with long-term conditions can't continue to be treated in the same way,' says Mr Bontoft. 'There is no lack of innovation in the NHS, and co-production is a very good means of bringing those ideas to the fore. The challenge is seeing what gains traction.'