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NHS Inform + New Partnersh






























hi s o

ross m

Engineering Design+ Design Innovation and Citizenship

h w c


Sociology & Criminology + Design Innovation and Citizenship

silvia ca nt

alupi Product Design+ Design Innovation and Citizenship

u ro

alice b ghton Art History + Design Innovation and Citizenship


INTRO For this project, we were asked to respond to a brief for the NHS 24 platform. NHS 24 is Scotland’s national telehealth service that makes up one of the seven health boards under the NHS umbrella. It is primarily an out-of-hours service for advice and information when general practices are closed. NHS 24 includes several helplines, both general and specific as well as a set of online resources. Our part of the brief was to investigate new partnerships that NHS 24 could work with to relieve strain on their resources and open up new services and

touchpoints they could provide to the people of Scotland. As the population ages and more healthcare services are required, it is important to think of new and innovative ways to deliver these needed services. For example, we were particularly inspired by the partnership between the Health and Social Services Departement (HSSD) and the Jersey Postal Service where, thanks to the Call and Checkš service, postal workers check up on vulnerable people as they go about their post route. This puts together two services in a new way and allows them to work alongside each other in useful ways.

Before entering in the detailed aspects of our project, here is above its overview, showing the most important steps we took. Following the timeline - divided in ten weeks - we can find in the upper part the key points of our research, while in the lower part are aligned

critical reviews and presentations. The coloured area represents the quantity of the qualitative knowledge/insights we collected: as it can be noticed, the area grew until the middle of the ninth week to then condensed itself into the final proposal.

Our particular focus for this project as citizen designers was to think about the underlying social aspects that relate to how we interact to health care services. We found it important to think about the social aspects of this project, making sure that they influenced how we went about any new partnerships. Health care is inherently social and in order to expand the current health care services, it would be important to understand the social aspects that influence the system in order to use partnerships in a socially minded way.




«Your zip code is a better predictor of your health than your genetic code.»

DESK RESEARCH We collated and analysed a varying amount of literature for our desk research stage in order to gain an appropriate understanding of the subject area and seek out potential narrative directions. We started by looking at the wider area of telehealth, analysing the main themes and debates. We then looked at NHS 24 strategy reports and objectives. This also gave as an understanding as to how the organisation works internally. Thanks to this analysis, we were able to organize our data into an NHS 24 services map (on the left), ordering them into if they were more phone or web based. Other important literature we looked at were reports that identified the key future objectives for the NHS 24. This helped us get an understanding of how the organisation was progressing. We noticed a big milestone is the roll-out of e-medical cards in 2020: this new service will allow people easy access to medical records through the NHS 24 online system. The wish of NHS24 to grow up and become something more than a simple out of hours service is also shared with the Realistic Medicine², report from the Chief Medical Officer’s Annual Report 2014-2015, written by Catherine Calderwood and hugely important for its role in shifting Scotland’s overview on healthcare, bringing a new approach to the medical system. Combining this initial desk research³ with the last part of Realistic Medicine – the Executive Summary of the Health of Nation – and our personal interest, we decided to position ourselves on a patient centred project (according also to NHS24 aims), particularly focusing on health inequalities due to environmental and social contexts. Following the idea that “Your zip code is a better predictor of your health than your genetic code.”⁴ and looking into the phenomenon called “the Glasgow Effect”, we focused our starting research on finding new partnerships in different sectors, keeping preventative care our core theme.


DESK RESEARCH Currently, food choices have a large economic impact on the NHS generally, which trickles down to services such as NHS 24, including NHS Inform. Right now, lifestyle choices cost the NHS 16 billion pounds a year, which is more than the government spends on the fire and police services⁶. And the problem is only getting worse - the NHS predicts that by 2050 the cost to society around obesity will be 50 billion pounds a year. For many of the health consequences around obesity, access to a variety of healthy choices and a change in diet can drastically change one’s health. A study done at Newcastle University showed that those with type 2 diabetes were able to reverse their conditions by drastically changing their diet over two months⁸. However, it is not as simple as just encouraging people to change their diet. Often times the discrepancies based around healthy food choices are related to food and health inequalities. The level of deprivation where one lives can drastically affect the food choices that one has access to. In fact, the level of obesity in children who live in deprived areas is almost twice that of those who do not. Because of this, policies and services must target a specific community and their circumstances when it comes to access around food choices. Rather than seeing these as drastic changes in one’s lifestyle, successful campaigns see these changes in the realm of nudge theory, where one’s behavior is influenced through indirect means and positive reinforcement rather than negative means. Right now, there are several organizations that are working on community food and health both in Scotland and around the world. There seems to be a large impetus currently around changes in food policy to make access to healthy food easier and this would be a perfect time for an organization like NHS Inform to become involved in these efforts to provide a health care perspective and the backing of a large governmental institution.



«Lifestyle choices cost NHS 16 billion £ a year. By 2050 the cost to society around obesity will be 50 billion £ a year.» 9




























STAKEHOLDERS From our desk research we uncovered a number of institutions that we felt could further progress the development of our project and reached out to a number of them. When researching community food and health, there is a considerable number of organisations that span many different industries. Once we collated all of our data and identified our key stakeholders, we planned to implement our framework in a way that could showcase the variety of institutions. The result of our affinitisation of stakeholders was best displayed when dividing them between third sector and government, and whether they were more medically or socially inclined. This allowed us to see where there may be a lack of support and where there could be an implementation from NHS 24. Specifically, we found a gap between the social and governmental areas.




«It’s not about changing mindsets, it’s asking what are the reasons for health inequalities in the first place.» As part of our research, we secured an interview with Linda Carson, the Programme Manager of The Food Shelf at Hennepin County Medical Center (HCMED). HCMED addresses hunger and food insecurity amongst its patients and families, with a longterm vision of a hunger-free hospital and community where all families have the healthy food and nutrition they need. This is the only programme that is entirely grant funded and is the only one of its kind in the Hennepin County. We compiled some open ended questions for the interview. We found it particularly important that the programme operates on inclusivity i.e. they do not make people fill out forms, making it a safe space for vunerable people. In addition, similar programmes require a registration and consultation with a doctor before you are able to use the services while the Food Shelf does not. This is important because Linda noted that “every time you put up more obstacles in front of someone it makes engagement much harder” so reducing these obstacles are important for access.. 12

We also were able to talk to Mary Sinclair who works on community food at Senscot, which is an organisation that connects community enterprises. They have a network focused specifically on community food and health and they work on connecting enterprises across Scotland to share their best practices. They see it as important to understand ways in which community food enterprises can work together and learn from each other to procure funding and sustain themselves. Senscot believes that there is space and possibility for sustainable enterprises in community food if people work together. Additionally, Mary talked about how they view food, not so much about ‘changing habits’ but rather introducing new options and using what people currently do but finding healthier alternatives. In general, she sees the value of using accepting language rather than commanding Senscot, in addition to promoting these concepts to their network of social enterprises also works towards bringing food up in the national agenda through their partnerships with governmental bodies, demonstrating the need for someone like NHS 24 to make community food a priority.


«People’s relationship to food is very important… people need extra external support to live in the food environment that the live in . » Although not directly linked to ‘engagement with food’, we thought it would be interesting to interview a third sector organisation, in this instance a spokesperson from Diabetes Scotland, who is currently working with NHS 24 in order to distribute information via telephone and online channels. We conducted a face-to-face interview with Linda, the Engagement Manager at Diabetes Scotland, asking her a series of opened ended question. One of the most interesting insights was around people having more control or agency over their ‘health data’, stating ‘It’s difficult to get people to access their data and monitor their health but it would be useful for both individual patients and the larger NHS data collection and outpatient care.”

We also talked to Fiona Comrie who works at Food Standards Scotland. We thought it would be good to hear how they are legislating around food in Scotland. They told us that their main output was the Eatwell Guide, which is a set of diet recommendations for people living in Scotland. Whilst many people subscribe to these guidelines, Fiona spoke about how it was difficult for people to see the eatwell guide as the primary resource for healthy food information. There is a lot of information out there nowadays around food and when you google for these resources, the Eatwell Guide is not the first thing that comes up. 13

EVENTS We were fortunate enough to attend two community food and health events that were put on by Community Food and Health Scotland. The first was Community Food & Social Enterprise Networks, in partnership with Sensescot, an organisation which looked at how to gain and sustain funding for community food and health organisations. From this event we were able to gain contacts that were working on social enterprises related to food. The second event we went to was Cooking Community Skills – evidence and networking, organised by NHS and Community Food and Health Scotland. We chatted and exchanged our insights and researches with a lot of different people actually working on our core project themes, and we were able to collect some interesting insights, especially from Martin Caraher, Professor in Food and Health Policy at the School of Arts and Social Sciences of City, University of London. From him we learnt that it becomes much easier to deliver services related to health for many communities in a socially based environment (“The best way to get cooking skills is from a mother and grandmother but it’s really hard to make legislation for that.”) and that a lot of localized organizations are working on community food, but they aren’t connected to one another.


ENGAGEMENTS We also created a series of ‘cultural probes’ for our interviews. One of these were ‘Health CVs, which stemmed from our key insight - ‘having agency/control over one's health data.’ It was a way for us to understand what sort of information and control people had over their health and whether they wanted more. We thought that this might act as a bridge between ‘what people know’ and ‘what people don’t know.’ The findings confirmed that many of the interviewees did not know the basics when it came to their basic health i.e. blood pressure status, blood group and BMI.

We also hosted a workshop called Journey with Food at the Monday evening Woodlands Community Café, to ask people when, during their lifetime, their relationship with food has changed. We did it to verify our assumptions and also to have the chance to see if our current concepts were helpful and, if not, how we could eventually change/integrate them. The workshop was a way to verify and validate it, making us more sure of what we were proposing as final delivery. 15

INSIGHTS After our interviews, we started assessing how we could distribute information and engagement around food. In addition, we looked at the main social behaviours around food. We found that the main themes surrounding food behaviours as it stands are: economic determinants such as cost; physical determinants such as access, education, skills and

time constraints; social determinants such as class and social contex; cultural influences; attitudes, beliefs and knowledge. From our interviews and engagements we came up with several insights about the current landscape of community food and health. We found these as important in highlighting the current situation in community food and health.

1. Health and food inequalities and

environmental situations highly affect the way in which people are able to access food choices. “Every time you put up more obstacles [to healthy food], it makes it harder.” -Linda, The Food Shelf at HCMED

Because of this, we want our project to have democratic access so people can have better access to food choices.

2. It is difficult to get people to access their

data and monitor their health but it would be useful for both individual patients and the larger NHS data collection and outpatient care. “If people don’t have access to their information how can they be empowered?” -Linda, Diabetes Scotland

As such, we believe it is important for our program to give people agency over their own health data. 16


A lot of localized organizations are working on community food, but they aren’t connected to one another. “If you have three projects linked, you have more benefit… Jamie Oliver isn’t successful because it’s a ‘parachuted in program’ without any community base.” -Doctor Martin Caraher, Professor, Central London University

As such, we find it important to work with existing organizations because they will allow us an in with the community that we wouldn’t get otherwise and can make sure we link to other organizations doing this work.

It becomes much easier to deliver services

4. related to health for many communities in a socially based environment.

“The best way to get cooking skills is from a mother and grandmother but it’s really hard to make legislation for that.” -Doctor Martin Caraher, Professor, Central London University

We found that cooking and food in general is very social, so a successful program must be socially-based.

NHS 24 is not manifested as a common

5. occurrence as people’s lives.

“There’s no common script, there’s a lot out there that people can just google but if you google healthy eating, you don’t find the eatwell guide.” -Fiona Comrie, Food Standards Scotland

As such, we find it’s important to increase physical touchpoints for NHS 24, because then it people can see it as a source of reliable information around healthy food choices. 17

AIMS From our insights and conversations with relevant stakeholders, we then came up with a set of aims relevant to our framework. The first set of aims were what we thought it was important for everyone to have access to when it comes to healthy food choices. These included the following:

Cooking skills and meal preparation; Increasing the social aspects of food; Developing access to knowledge networks; Increasing awareness of food and nutrition habits relating to health; Seeing NHS 24 as part of their community; Providing longitudinal advice and support around food to people throughout their entire lives.


AIMS We also thought it was relevant for there to be a set of aims that were things that NHS Inform would want to achieve with this project and framework. These would be things that would be accomplished through implementation of this framework and would allow for a certain amount of soft power that NHS Inform would gain by becoming more constant in people’s lives. These aims include the following:

Presenting themselves as the “go to” source for nutrition information; Positioning NHS 24 as preventative as opposed to reactive; Developing a constant physical presence in the community; NHS 24 leading the NHS towards championing preventative care through food and nutrition advice. 19

FRAMEWORK In order to integrate healthy food information into people’s everyday lives, we thought about times in one’s life when they change their food habits. We found that during these moments, there is certain information or resources that one needs but often there isn’t a verified source to distribute resources and because of that, it is difficult to know what the best practices are for that particular food choice.


We believe NHS Inform has a responsibility to position themselves as a reliable source for healthy food information during these life changes around food. Additionally, because of the unique situation that Scotland currently is in regarding their changing food policies, we find right now to be an important time for NHS 24 to tap into

existing schemes to provide a broad democratic vision around healthy food choices, showing to the public that the health care sector sees food as a priority. The following is a ‘Lifetime with Food’ that we created through engagements with individuals at the Woodlands Community Cafe. Each moment occurs at a general age range and somehow influences the food choices that one is

FRAMEWORK making. The touchpoints that we have designed focused primarily on starting school, starting work, and having children because through our engagements we found these to be especially important regarding changing food choices and affect one’s later life drastically. We have three concepts - a mobile space, HR incentive scheme and baby box - each of which target one of those changes. We have also a fourth

concept that is an overarching concept - a physical touchpoint - that serves as the cornerstone for this framework as it brings people together socially around food and creates a longitudinal relationship that individuals can have with a more physical manifestation of NHS 24. In this way, we have imagined a set of touchpoints that engage people around

food throughout their lives. Through these concepts we hope that NHS 24 can provide useful information throughout the course of someone’s life and make NHS 24 a constant presence for food and health information. In the following pages our concepts will be discussed in greater detail as well as the interaction between them.



A community food and health organisation and a school School-aged children Informed choices, seeing NHS as a part of the community, awareness of habits, longitudinal support Positioning NHS24 as preventative as opposed to reactive, championing preventative care through food and nutrition

The NHS24 mobile site offers a way for school-aged children to explore opportunities surrounding food and lifestyle. When a child is at this stage, it is the first time they are exposed to new food choices or given the chance to explore them. The mobile site is an opportunity for initial exposure to healthy food habits and lifestyle choices. The mobile site will be equipped to deliver experiential modules for school-aged children in a safe environment. A school and a community food and health organisation would partner with one another. Together they would set up an interaction between the children at the school and the mobile site. A representative from the community food and health organisation would conduct a number of activities in the mobile space where the children could learn about the benefits of healthy food choices and lifestyle decisions. The mobile site offers a physical manifestation of NHS24 that children can relate to throughout their life. This 22

increases the value of NHS24 and its approachability. The advantage of the mobile site means that there are positive experiences available in an environment which is safe and conducive to learning.


HR software company Office workers Access/agency/tracking of health data through incentives Acquiring valuable health data from large demographic, getting people to take control and monitor their health statistics

A major life event is entering the workforce. With retirement ages getting longer this can take up a considerable portion of someone’s life. In addition, there has been lots of attention in recent years to promoting health within the workplace, particularly within sedentary office environments. With this in mind, we looked into existing systems and services rolled out within workplaces to potentially partner with. We started thinking about both effective and personal ways of reaching people in the workplace and this led us to the area of HR.

employees’ health) and for employers (who will be awarded an incentives for engaging in the scheme). The integration would also link to the NHS 24 inform website, where people sitting in front of their screens could easily access health information. NHS 24 Inform training would be offered to HR departments of companies part of the scheme, so the physical presence of the NHS 24 continues within the workplace.

Many smaller companies now use HR software or apps. We started to think about the possibilities of partnering with such a system in order to roll out an ‘ an NHS 24 add on service.’ Through the ‘add on service’ within the existing HR software, the employee would be able to build their own NHS 24 profile, where they would able to input health and food data i.e a ‘food diary at work’. Health incentive schemes at work have proved hugely popular in recent years being part of a scheme is beneficial to employer (they are engaging in their



Baby Box Scotland New parents Access to knowledge networks, informed choices, awareness of habits, meal preparation Positioning NHS24 as preventative as opposed to reactive, championing preventative care through food and nutrition

Baby boxes in Scotland have proven to be an extremely successful initiative which has been substantially appreciated since it was first introduced. Having children creates a number of new considerations to be made when caring for a newly born baby, with food and nutritional choices playing a vital role. We envisage adding a layer on the baby box under the remit of forming a ‘healthy at home’ mentality. There would be materials such as recipes that contain the correct nutritional requirements for their child, how to make their own baby food, an invite to see a NHS nutritionist (to help understand what options they have and to determine the best way to approach their baby’s diet), and access to information regarding food and nutritional opportunities in the local area (such as community food organisations, fresh produces grocers etc.). If this initial proposition had positive results we would also like to develop the healthy at home box concept further. We imagine the creation of a new box tailored to individuals who have 24

just been diagnosed with a specific condition. This personalised box would include information on how best to regulate their health through their food choices and lifestyle approach. It would also contain tools such as a food diary and meal preparation planner. When first being diagnosed with a health condition it can be a lot to take in and at the simplest of tasks or acts that are taken for granted, now have risks and consequences. The healthy at home box offers help and support to a situation in order to help the individual cope with what is going on. The box offers a physical presence of NHS24 in the home. It helps formulate the notion of preventative care because it shows an effort not just to treat sick people but to help them greatly cut down the chances of ever becoming sick.


Community Spaces Everyone Access to knowledge networks, informed choices, awareness of habits, longitudinal support, cooking skills, meal preparation, increasing social aspects of food, seeing NHS24 as part of the community Presenting NHS 24 as the ‘go to’ source for nutritional information, positioning NHS 24 as preventative opposed to reactive, developing a constant physical presence within the community, leading the NHS towards championing preventative care through food and nutrition

The NHS24 physical space is a culmination of the aims we are hoping to achieve from this project. It is space that offers support, exploration, learning, leisure and increased social connection. This particular concept is available to the whole community. The mobile site, HR system, and healthy at home box will all offer some way of connecting to this site. This infrastructure would act as a pillar for the food and lifestyle development within every community.

of cooking facilities for both teaching classes and preparing meals for social occasions. There would be a wall library where one could access cookbooks and individual recipes, as well as the option to borrow cooking utensils that they may require for a specific meal. There would also be a dedicated space where one on one appointments could be conducted with a nutritionist to receive advice and to answer questions.

Partnering with local community spaces means that the site could be developed in a place that is already familiar to the local area. Peoeple involved will already be supporting the community and would be aware of the individuals who would be utilising it. The site itself would consist of a number of constructs that aid positive interaction with food and lifestyle. The space would consist 25

PHYSICAL TOUCHPOINT The physical space we are proposing would be integrated into an existing civic space that has the capacity to host events, workshops and resources linking to the new NHS 24 initiative. We envisage the physical being manifested with community centres, town halls and/or Parish Council sites.


It would include the following: 1/Event space - used by community food organizations to host events (right now it’s difficult for them to find the space) such as cooking classes or nutrition habits workshops,. Many community centres are being closed down or re-

purposed so organizations are losing the places where they would normally hold events so this space would offer for them a reliable space to host their events ; 2/Kitchen space - used for cooking classes and for the cafe to make their food;

PHYSICAL TOUCHPOINT 3/Café - to host weekly community meals to get the community together around food and healthy ways of living; 4/Library - of tools, spices, herbal remedies (not perishable) to borrow or take in small quantity. For many people in more deprived areas, after they go to a

a cooking course they don’t have or can’t affordthe equipment to actually make those meals at home, so NHS 24 could serve as a steward for this equipment and show its support for these sorts of cooking classes by allowing people to rent out tools or spices for a short period of time;

5/Nutritionist space - an office space for more one-on-one counciling with a nutritionist; 6/Creche area for children - to allow parents to utilise the space for their own needs without worrying about looking after their children.


SCENARIO The following storyboard was developed to showcase how interactions occur between the different touchpoints. The scenario depicts the experience of a new mother named Jane who utilises the concepts in order to progress her understanding of food choices and the support offered to her.

1/ Jane receives her Baby Box that she was given by the Scottish government for free when her midwife signed her up.

4/ Jane goes to the New Mums Cooking Class where she has the chance to learn about healthy meals for children and how to make your own baby food. She enjoys the class and has a new interest in different baby food recipes..

8/ When making her way out of the community space, Jane notices a new mums group that she could go along to.


5/ She decides to look further into baby food recipes on the NHS Inform page. She finds a recipes that she likes but realises she does not have the food processor or some of the spices required.

9/ She goes home to prepare the meal she planned and thinks about joining the Mums and Kids CafĂŠ at the center.


2/ Amongst the materials in the box there is an invite to a New Mums Cooking Class.

6/ Jane heads back to the Community Space..

10/ She decides to go to the CafĂŠ which allows her to connect socially with a group of people in similar positions as her. Jane frequently visits and eventually volunteers to help run the group.

3/ This cooking class is held in the NHS Inform +food touchpoint within the Woodlands Community Centre in Glasgow and run by Irina from Woodlands Community Food.

7/ She uses the wall library to take out a food processor for a 36 hour period and also accesses some spices. The wall library allows Jane to have access to materials that she may not usually be able to get and in turn explore new positive food choices.

11/ As Jane’s child gets older, he starts school and interacts with the NHS Mobile site. This showcases the longitudinal, generational support that solidifies NHS 24 as a pillar in the community as a reliable resource for healthy food information. 29

BENEFITS We don’t imagine that this project exists on its own. Rather we see it as part of an extended delivery of services that NHS 24 can roll out around healthy lifestyle choices. Food choices alone do not drastically affect one’s health, but combined with choices around exercise and other lifestyle habits can be even more

successful. As such, we’re imagining that this framework could be expanded to include those aspects as well. Additionally, we hope that if this framework proves successful, then the larger NHS will see lifestyle choices as an important part of their services and make it an important part of their outcomes. In general, this could lead to

people seeing health care as something that is not ‘just in time’ but rather much more preventative, and realize that food choices are an extremely important part of that preventative care. The following is a timeline that shows how we imagine this framework to influence the larger health care system:

In general, we are hoping that NHS 24 is able to see the value of food choices and the influence that they can have in this sector. As there are many changes happening at the current moment and policy is at a turning point around food in Scotland, we find this an important time for NHS 24 to decide to take an initiative around healthy food choices and position themselves as the leader in resources and information, bringing together people and organizations working in community food and allowing them a space to make lasting change under NHS 24. 30

REFERENCES 1/ Call & Check. A friendly face. A helping hand. Available at: [Access 23rd May 2018] 2/ Calderwood C.,(2016). Realistic Medicine - Chief Medical Officer’s Annual Report 2014-2015, Edinburgh: APS Group Scotland. 3/ Audit Scoltand, (2012). Health Inequalities in Scotland. Available at: [Access 23rd May 2018] 4/ Roeder, A. (2014). Zip code better predictor of health than genetic code. Harvard T.H Chan – School of Public Health. Available at [Access 23rd May 2018] 5/ Public Health England, (2017). Guidance. Health matters: obesity and the food environment. Available at [Access 23rd May 2018] 6/Hughes, L. (2016). More spent on treating obesity-related conditions than on the police or fire service, says NHS Chief. The Telegraph [online]. Available at: [Access 23rd May 2018] 7/ Dr Aujla, R. (2018). Food is medicine – so why aren’t our doctors trained in the science of nutrition?. The Telegraph [online]. Available at: [Access 23rd May 2018] 8/ New Castle University Press Office. (2015). Diet reverses Type 2 Diabetes. Available at: [Access 23rd May 2018] 9/Graphics source: Scot PHO - Public Health Information for Scotland (NHS Health Scotland), (2017). Obesity and health inequalities in Scotland. Summary Report. Avalaible at: [Access 23rd May 2018]


NHS Inform plus Food  
NHS Inform plus Food